HospitalInspections.org

Based on review of records and interview, the hospital failed to provide all patients, who were admitted for hospital inpatient services, with a notice of the patient's hospital discharge appeals rights.

On the morning of 9-12-2017, a tour of the patient registration area was made with Staff #37 and Staff #38. In reviewing the registration process and admission forms, no copies of the Important Message from Medicare (IM) were observed. Later that day, a copy of the admission package was provided. Again, no copy of the IM was observed.

Interview was conducted with Staff #38. Staff #38 stated that the IM form was only given when Skilled Nursing Facility (SNF) patients were discharging. Patients who were admitting to the hospital were not given a copy or the IM.

A review of the Centers for Medicare and Medicaid Services website, https://www.cms.gov/Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices.html, was made as follows:

"Hospitals are required to deliver the Important Message from Medicare (IM), CMS-R-193 to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients. The IM informs hospitalized inpatient beneficiaries of their hospital discharge appeal rights. Beneficiaries who choose to appeal a discharge decision must receive the Detailed Notice of Discharge (DND) from the hospital or their Medicare Advantage plan, if applicable."

Based on observation and interview, the facility failed to ensure patient use oxygen was stored in a safe manner in 1 of 2 areas (Main oxygen storage area).

This deficient practice had the likelihood to cause harm to all patients.

Findings include:



During an observation on 09/12/2017 after 10:00 a.m., the following was found:

Nine oxygen tanks (E-cylinders) were stored in a room and they were not secure to the wall. The chains attached to the walls were not anchored in a way to ensure they were secure. When the chains were pulled on they came out of the wall.

Staff #9 and 36 confirmed the observation.



Review of a facility policy named "SAFETY" with an effective date of 04/26/2011 revealed the following:


..All equipment and supplies must be properly stored ...

According to the National Fire Protection Association (NFPA) Standards 99 Health Care Facilites revealed the following:

"All medical gas cylinders (including E cylinders) must be physically supported, either in a stand or rack or chained or strapped to the wall. This requirement is intended to prevent mechanical hazards caused by a sudden release of gas if a tank falls over."

Based on observation and interview, the facility failed to ensure trash was stored in a manner to prevent the infestation of pest or rodents in 3 of 3 trash dumpsters.


This deficient practice had the likelihood to cause harm to all patients.

Findings include:



During an observation on 09/12/2017 after 10:00 a.m. the following was observation in the area where the dumpsters were stored:

One dumpster was missing a lid and bags of trash could be seen sticking out the dumpster.

One dumpster had a lid that was broken off the metal hinge making it impossible to close it completely.

Another dumpster had lids attached, but staff failed to have them closed.


Staff #9 confirmed the observation.

Based on observation, interview and document review, the hospital's Governing Body failed to demonstrate responsibility for

A.incomplete credentialing,
B. an incomplete Quality program, and
C. no facility wide Patient Safety Program,

from January 2017 through September 14, 2017.


This deficient practice had the likelihood to effect all patients of the hospital.


Findings included.


A. On the afternoon of 9/11/2017 in the office of staff #5, who was the oversight for credentialing, the credentialing records for Medical staff #'s 17, 23, 24, 25, 26, and Allied Professional staff #'s 20, 21, and 22 were reviewed.

By definition found Article I 1.4 "Medical Staff" or "Staff'" means the formal organization of all duly licensed medical and osteopathic physicians, dentists, podiatrist, chiropractors and others practitioners or Allied Health personnel who have been granted privileges pursuant to these Bylaws to attend patients in the hospital. The independent practitioners who constitute the Medical Staff are private practitioners and are not employees or agents of the hospital.

1. Medical staff #'s 17, 23, 24, 25, and 26 failed to reflect documentation of two (2) professional references as required by the Medical Staff Bylaws. Allied Health Personnel staff # 20, 21 and 22 failed to had evidence of two (2) professional references.

Review of the "Medical Staff Bylaws Article VI Procedure for Appointment and Reappointment" revealed, ".1 The application shall include the names of at least two (2) persons who have extensive experience in observation and working with the applicant and who can provide adequate reference pertaining to the applicant's professional competency and ethical character."



2. Medical staff #17 had incomplete delineation of privileges. The only privilege staff #17 had requested was 1) Differential diagnosis and management of general medical problems. There was no documentation the requested privileges were approved.
Medical staff #' 23, 24, 25, and 26 had no delineation of current medical privileges documented. Allied Health Personnel staff #'s 22 had no date documented on the application for staff privileges.

Review of the "Medical Staff Bylaws Article V" revealed, "Clinical privileges Delineated, Every practitioner practicing at this Hospital by virtue of Medical Staff membership or otherwise, shall, in connection with such practice be entitled to exercise only those clinical privileges specifically granted to him by the Governing Board."


3. Medical staff #'s 17, 24 and 25 did not have evidence of current Basic Cardio Pulmonary Resuscitation skills.


"Article IV Procedure for Appointment and reappointment" revealed,

6.8 (d) Documentation of participation in basic cardiopulmonary resuscitation training within the last twelve (12) months for all active medical staff.



4. Medical staff #'s 17, 23, 24, 25, and 26 had no documentation of notification of medical staff privilege or appointment. Allied Health Personnel staff #'s 20, 21, and 23 had no documentation of notice of approval of staff privilege.

"6.6 Final Decision" revealed, "When final action has been taken by the Governing Board, the Hospital Administrator shall be authorized to transmit its decision to the candidate for membership and, if he is accepted, to secure his signature pledging to abide by these Bylaws, Rules and regulations.



5. Allied Health personnel staff #21 did not have a designated physician sponsors documented in his application for privileges.

"5.8 Allied Health Personnel" revealed, "(a) Only Allied Health Personnel (AHP) who are licensed, certified or otherwise approved as required by state law and who document their qualifications, status, clinical duties, training, demonstrated ability, and physical and mental status shall be eligible to provide specified services in the hospital; and that any patient treated by them will receive quality care.

(f) Physician Assistant:

Each applicant must be sponsored by a physician member of the Active Staff who shall act as the applicant's supervising practitioner..."

The above findings were confirmed by staff #5.



B. On the morning of 9/12/2017 in the office of the Director of Quality, staff #5, the hospital's quality program was reviewed. The Director indicated she was not a nurse, she was also the Director of the Medical Records department and was responsible for physician credentialing. She explained her quality program was to collect the information the departments turned into her and then report that information to the Governing Body (GB) and Medical Staff (MS). She indicated she submitted the information but did not attend the GB/MS meetings. The information was presented by the Chief Executive Officer (CEO).

Staff #5 confirmed the departments had project improvements. Some departments had been working on the same improvements projects for the entire year. Staff #5 was asked if there was a process within her Quality program for determining a process or project improvements and how to determine measurable goals. She replied "No". Staff #5 was asked if she had ever been trained on the requirements for a hospital Quality Program (QAPI). She replied "No". When asked if she had a copy of her state regulations for reference she replied, "No". The QAPI program did not receive information from the GB/MS meetings or suggestions for improvements that were communicated back to the departments.

Review of the Quality reports from January, February and March (first quarter) and April, May and June (Second Quarter) revealed the same indicators with the same project improvements.

Staff #5 was asked if the Quality program included review of the incident/accident reports from the Patient Safety Program, a review of the credentialing process, reviewed medication errors, or a review of the over all operations of the hospital. She replied, "No".

On 9/12/2017 in the afternoon, an interview in the conference room with the CEO confirmed he presented the Quality information to the GB/MS. He also confirmed the Quality Director did not attend the meetings. He indicated the GB/MS received a written report approximately one week prior to their meeting which allowed the members of the GB/MS to read the information prior to the actual meeting. The CEO was asked if he realized the Quality program was not active within the hospital and that process/project improvement was not well understood with his hospital. He confirmed discussion had been brought up concerning the need for a Registered Nurse to be involved with the Quality program.

On 9/13/2017, in the afternoon, the Quality Director was requested to accompany the surveyor to round in the dietary department. The Food Service Supervisor (FSS) explained she had identified the cooking pots and pans were showing signs of aging and needed to be replaced. She explained she was replacing the pots a few each month and expected to have them all replaced within the next quarter. The FSS was asked if she had submitted this as a project improvement (PI) to the quality program. She indicated , "No". The Quality Director was asked if she saw this was a complete PI project and she said , "Yes", she understood the process.

The hospital failed to have an on-going effective measurable Quality Assessment Project Improvement process.




C. On the morning of 9/11/2017 the Chief Executive Officer indicated that Patient Safety was divided between staff #8, the Risk Manager, and staff #9, the plant operations Director. Staff #8 handled the patient end of the PSP and staff #9 handled the physical plant maintenance and safety portion.

On 9/14/2017 staff #8 was interviewed and confirmed she was the Risk Manager. She indicated she kept the documentation together until time to report it in the Governing Board meeting. Staff #8 was asked for a policy indicating how the PSP was organized and how incident reports were investigated. She indicated she really only did employee worker compensation. She further indicated each department had their own policy for how they investigated patient (Pt/pt) incidents. She did not get involved with that. There was no documentation from a central committee that evaluated, trended or investigated patient safety incident/accidents within the hospital. There was no documentation for corrective action that might be identified or acted upon.

On 9/14/2017, an interview with the Director of Nurses (DON) confirmed she had a policy that addressed pt accident/incidents. She explained her staff reported to her the pt, event, date and time. A report is completed and she personally investigates the incident and follows up with the pt 24 hours after the incident to insure no other latent injuries were present.

A review of nursing incident/accident reports was conducted with the DON in her office.

Incident report #1, "Pt was found sitting between the toilet and her wheel chair (W/C). Attempted to get up without help." The Follow-up care was noted as: "Put back in W/C and told again to call for assistance before getting".

Incident report #2, "Pt up to use toilet. CNA (Certified Nurses Aide) left to get linens and pt got up on her own and fell. Pt was told by aide not to get up and that she would be right back". The Follow-up care was documented as: monitor for c/o (compliant of) pain.

Incident #3, "Pt hollered (sic) Pt found on floor, leaning against recliner, appeared to have slipped out of chair. Incontinent of urine. Pt assisted x 3 persons to stand and transfer to chair. Chair alarm faulty sounding. Alarm found shoved into chair, then to bed peri-care done and new brief placed on pt. No redness noted. Pt denies any pain/discomfort. Called MD (Medical Doctor)- update given. No new orders received. Bed alarm on. Follow-up care (Nothing documented)."

Further interview with the DON confirmed she assessed the patient for injury and did not assess the circumstances surrounding the patient's incident/accident. She confirmed she submitted totals of like kind incident/accidents to the PSP.

On the late morning of 9/14/2017, an interview with the Radiology Tech confirmed she had a policy for incident/accidents that might occur in her department. The Radiology Tech indicated she would call the nursing department or the Emergency Department for a patient evaluation.

A review of the facility wide Policy and Procedure last reviewed 02/11/2011 read "Policy statement" revealed, "The Hospital (Name of facility) incident report will be used to monitor, evaluate and trend occurrences or incidents involving the safety of patients, students, visitors, volunteers or other individuals associated with the hospital. Staff and employee events are reported via the risk manager.

Identified at Procedure C. Supervisor:
1. Address immediate health/safety/operational issues as applicable to incident. Completed follow-up/additional comments sections of additional comments section (sic)of incident report (On a copy). Explain in detail in this section any corrective actions taken since the event, and/or any follow-up that occurred. Give report to examining physician (if any) for comments and recommendations.

Administrative Managers:
1. Analyze quantitative date supplied periodically by quality improvement and assume responsibility for instituting appropriate policy and procedural changes to address quality of care issues. Report changes to Hospital risk manager for information, and forwarding to quality improvement.
2. All medication related incident reports are reviewed by a member of the Pharmacy Department. All equipment related incident reports are reviewed by the maintenance Department. All fall related incident reports are reviewed by the safety committee.
3. Managers and supervisors submit their investigation and follow-up/action steps to Hospital Risk manager to be included in the system database.

Risk manager:
1. Coordinates risk identified and investigated activities in the quality improvement meeting with the appropriate departments involved and the Medical Centers attorney's (if needed) and hospital's general and professional liability insurance carrier is notified of incident.
2. In consultation with the Chief of Staff and quality improvement, determine if the event meets the definition of sentinel events.

Samples of reportable events:
1. physical harm to a patient or visitor.
2. Unauthorized leave by a patient.
3. accidents in which patients or visitors are injured or die.
4. Drug or alcohol use or traffic form outside the hospital.
5. Medication errors/variances
6. Foreign bodies left in patients.
7. Burns.
8. Nerve damage
9. Mistaken identity
10. Falls or other mishaps, e.g., lacerations bruises.
11. transfusion issues (this excludes routine untoward reaction i.e. the 5% chills. fever etc.
12. Patients ;leaving the hospital AMA.
13. Complications form IV administration (Extravasation, fluid overload, etc) resulting in harm to patient.
14. Pressure sores, burns, other skin injuries.
15. Procedural breakdowns involving a patient, for example, consent for not signed, incorrect I.D. band, wrong patient transported for diagnostic or therapeutic procedure, unavailability of transport for patient, also see confidentiality policy (HIPAA policy).
16. Suicide attempts by patients while in the hospital."


On the late morning of 9/14/2917 an interview with the Quality Director confirmed the PSP was not reviewed as a part of the Quality program. Incident reports were not investigated with the intent to identify actions to reduce the likelihood of repeated future incidents which could cause injury to a patient.

Based on document review and interview, the facility failed to follow it's Medical Staff Bylaws and insure 1(#21) of 3 (#20, #21, and #22) Allied Health Personnel were properly supervised.

This deficient practice had the likelihood to effect all patients of the hospital.



Findings included.


On the afternoon of 9/11/2017, the credentialing records for Allied Health personnel staff #20, #21, and #22 were reviewed. Physician Assistant staff #21, did not have a designated physician sponsor documented in his application for privileges. Documentation implied Staff #21 functioned within the hospital without physician oversight.

Review of the Medical Staff Bylaws 5.8 Allied Health Personnel indicated the following:

"(a) Only Allied Health Personnel (AHP) who are licensed, certified or otherwise approved as required by state law and who document their qualifications, status, clinical duties, training, demonstrated ability, and physical and mental status shall be eligible to provide specified services in the hospital; and that any patient treated by them will receive quality care. All applicants for designation as an AHP shall:

(f) Physician Assistant:

Each applicant must be sponsored by a physician member of the Active Staff who shall act as the applicant's supervising practitioner..."


The above findings were confirmed by staff #5 who was responsible for credentialing and who was also the Quality Assurance Director..

Based on observation, interview and record review the facility failed to:

A. ensure physican orders were obtained before placing patient in restraints in 2 of 2(22-23) charts reviewed.

B. follow policy and procedures on nursing assessment documentation every 15 minutes on behavioral restraints and every two hours for medical restraints in 2 of 2 (22-23) charts reviewed.

C. follow policy and procedure for conscious sedation administration, documentation, and current training in 1(23) of 2(22-23) charts reviewed.

D. obtain consent, explain risks/ benefits of procedure and sedation in a non-emergent situation in 1 (23) of 2(22-23) charts reviewed.

E. failed to have a RN assessment before application of restraints and failed to have a RN assessment for over 24 hours in 1(22) of 1(22-23) charts reviewed.

F. failed to ensure the physicians signed restraint orders within 24 hours in 1(22) of 2(22 and 23) charts reviewed.

Refer to Tag A0274



G. ensure medications were managed in a way to ensure safe and appropriate administration and storage in 3 of 3 areas (Endoscopy area, Main Pharmacy, and Medical nursing unit).

This deficient practice had the likelihood to cause harm in all patients.

Refer to Tag A0276



H. maintain a sanitary environment to control the potential spread of infection in the Emergency Department (ED) and store ultrasound devices in a manner that will protect from damage or contamination.

Refer to Tag A0278




I. have policies and procedures to ensure safety, radiation hazards, infection control, and emergencies for patients and personnel in 5 of 5 (X-RAY, MRI, CT/PET scan, Ultrasound, and Nuclear Medicine) areas of the radiology department, and store ultrasound devices in a manner that will protect from damage or contamination.

Refer to Tag A0283


J. ensure nursing staff were trained on specific nursing competencies in 2 areas (Inpatient and Skilled Nursing Facility) out of 3 areas reviewed (Inpatient, Skilled Nursing Facility, and Emergency Department).

Refer to Tag A0294



K. assess and identify patient specific problems and incorporate them into the nursing plan of care in 2 patients (Patient #6 and Patient #17) of 3 patients reviewed (Patient #'s 6, 17 and 28).

Refer to Tag A0296


L. have a Director of Rehabilitative Services with the credentials to properly supervise, evaluate, and administer the services set forth by the rules of the Texas Board of Physical Therapy Examiners.

Refer to Tag A0299

Based on record review and interviews, the facility failed to:

a. ensure physican orders were obtained before placing patient in restraints in 2 of 2(22-23) charts reviewed.

b. follow policy and procedures on nursing assessment documentation every 15 minutes on behavioral restraints and every two hours for medical restraints in 2 of 2 (22-23) charts reviewed.

c. follow policy and procedure for conscious sedation administration, documentation, and current training in 1(23) of 2(22-23) charts reviewed.

e. obtain consent, explain risks/ benefits of procedure and sedation in a non-emergent situation in 1 (23) of 2(22-23) charts reviewed.

f.) failed to have a RN assessment before application of restraints and failed to have a RN assessment for over 24 hours in 1(22) of 1(22-23) charts reviewed.

g.) failed to ensure the physicians signed restraint orders within 24 hours in 1(22) of 2(22 and 23) charts reviewed.


Review of patient #22's chart revealed he was an 84 year old, brought to the facility ED for constipation, on 6/11/16 at 16:20. Patient has a history of dementia and had not had a bowel movement in 3-4 days. The patient was admitted to the facility for UTI, renal insufficiency, urinary retention, and dementia.

Review of patient #22's physician orders dated 6/12/17 at 18:45 revealed the Licensed Vocational Nurse (LVN) took a telephone order that stated, " May apply bilateral soft wrist restraints per staff #53. Staff #53 (MD) was not the attending physician. Staff #53 did not electronically sign the telephone order until 7/17/16 at 3:47 AM; a month later. There was no documentation that staff #52 (attending MD) was ever notified of the restraint order. This order was found on the electronic record under "Physician Entered Orders."

A second physician order, that was titled, "Physician Order For Restraint" was found. The order was a telephone order on a paper form. The order gave reasons for the restraint;

Reason for Requiring Restraint;
At risk for injury/fall/gait unsteady
Disorientation/agitation
Removing medical devices, IV site and Foley Catheter.

Less Restrictive Measures Attempted;
Schedule toileting
Reorientation
Call light/ personal belongings within reach
Placed closer to Nurses Station
Type of restraint;
Soft wrist right and left remove /loosen restraints, reposition, ROM, toileting, hydration, skin, circulation, modesty and environmental checks every two hours.

Expected Duration;
24 hours."

Patient and family informed;
Was left blank.

In the RN signature area for the order a signature was found of an LVN. There was no RN signature for the restraint orders. There was no physician signature on this order. The facility failed to let the family know of the restraint, have an RN and physician to sign the order.

Review of patient #22's electronic physician orders dated 6/12/17 at 23:02 revealed another restraint order. The order was a telephone order that read, "May add vest restraint to previous restraint order." There was no additional paper order found. There was no documented reason on why the vest restraint order was ordered per staff #53. Staff #53 (MD) was not the attending physician. Staff #53 did not electronically sign the telephone order until 7/17/16 at 3:47 AM; a month later.

Review of the nurses notes dated 6/12/17 revealed the LVN called the physician 6/12/17 at 18:47. The LVN documented, "Called Dr.____ staff #53 to receive an order for possible restraints. Orders received for bilateral soft wrist restraints to keep him from pulling out his IV and Foley catheter.

Review of patient #22's nurses notes 6/12/17 at 20:47,
"Restraint and Seclusion Order; Implemented by: Dr.____#53 Behavioral restraint order renewed q 24 hours.
Type of restraint: soft wrist right and left. Reason for restraint: Confusion, removing of medical devices (Tubes/Lines, Disorientation. Prevent patient from injury to self."

At 20:47," Restraint and Seclusion Order; Type of restraint; soft, wrist, right, left, Vest."

The nurse documented the restraints were behavioral restraints not medical. There was no documentation that the vest restraint was applied and how the patient tolerated the restraint. There was no paper order for the vest restraint.

Review of patient #22's nurses notes for 6/13/17 at 6:42AM revealed the LVN documented, "End of shift. Report given to _____LVN. Resting in bed at this time. No s/s of distress noted. There was no mention of the restraints nor was a RN evaluation noted for the 7:00PM to 7:00AM."

Review of patient #22's nurses notes for 6/13/17 at 9:00AM stated, "Behavioral assessment q 1 hr. wrist soft, right, left." There was no documentation if the patient was still in the vest restraint or when it was removed. At 9:03 LVN documented, "Restraints removed at his time. Pt calm in demeanor. NAD noted. Multiple family in room at his time. Call light in reach."

The LVN documented for the 7:00AM to 7:00PM shift on 6/13/17. There was no RN assessment documented for this shift. There was no RN documentation found for 24 hours.

Review of the policy and procedure, "Restraint Usage" stated, "D. Order for Restraint or Seclusion:
Orders for restrain or seclusion must specify:
a. The reason: to promote medical healing or for violent behavior
b. The type of restraint (limb, vest, seclusion, ect.)
c. The body part to be restrained.
d. The duration for restraint application or seclusion and the date and time
i. Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order.

Any order for restraint shall not be written as a standing order, or PRN basis. The attending physician, or on call physician may order the restraints. If the attending physician did not order the restraint, the attending must be notified, at the earliest possible time, of the restraint use.

Behavioral /Violent & Self Destructive Restraint Use;
b. May be initiated upon order of physician or by a trained RN when the physician is not immediately available. A physician order must be obtained within 30 minutes.

c. A face to face evaluation within 1 hour is required by the physician after restraints are applied.
f. All patients in restraints for behavior/violent reasons will be observed a minimum of every 15 minutes, with attention being given to safety, comfort, nutrition, toileting, ambulation, circulation checks, and position change."

An interview was conducted staff #3 on 9/13/17. Staff #1 stated, " We just dont do restraints that often. We only had 2 for the whole year. I can see where the LVN was not following the policy and procedures." Staff #3 confirmed the above findings and stated that the facility would just have to get the education out there.



Review of patient #23's chart revealed the patient was brought to the Emergency Department (ED) by ambulance on 6/4/17. He was found unresponsive by a bystander.
.
Review of patient #23's physician notes the patient was disoriented, confused, combative, with decreased mental status at 7:50AM. At 8:20 the patient was given Narcan 2mg for suspected drug abuse. The patients' blood work revealed he was positive for THC and Cocaine. Patient #22 became more responsive and was able to tell the physician his name.
Review of the nurse's notes dated 6/4/17 at 0738 stated, "pt arrived via ems with bs 123 non coherent, cardiac monitor in place, pt is combative, soft medical restraints applied to bilat upper extremities. IV started lab drawn sent to lab. Patient soiled clothing bm and urine removed and cleansed. (Sic)"

Review of the physician orders revealed there was no orders for restraints at 7:38AM on 6/4/17. The nurse documented the patient was in bilateral wrist restraint at; 0738,0945,1000,1030,1045,1100,1115,1145,1200,1215,1330,and at 1500 the nurse documented, " see restraint flow sheet."

Review of the electronic physician orders dated 6/4/17 at 15:24 stated, "Type of restraint: soft wrist restraints (see restraint flow sheet). The order did not specify the;
a. The reason: to promote medical healing or for violent behavior
b. The type of restraint (limb, vest, seclusion, ect.)
c. The body part to be restrained.
d. The duration for restraint application or seclusion and the date and time.

Review of the Emergency Department Restraint Documentation Form stated the patient restraint was "initiated on 6/4/17 at 0801."Review of the form stated the restraint type was a safety restraint (non-violent). The form has an area to document the following;

"Time (minimum every 1 hour)
Restraint Location
Released
Toileting Offered/Performed
Nutrition/Hydration Offered
Patient's response to restraint. Documentation of Restraint Necessity or Discontinue."

Review of the form revealed the nurse put in times every hour from 0801 -1900. In the patient response the only information was "bilat radial pulses 2+, cap refill less than 2." The form was blank for "Released, Toileting Offered/Performed, or Nutrition/Hydration Offered.

Review of the physician note dated 6/4/17 stated there was "no one willing to take care of him" and he appears to be having some visual hallucinations in the room and is seen fidgeting his hands as if searching for something." The physician documented the patient had "AMS with substance intoxication." Review of the chart revealed there was no documentation if the patient was suicidal or homicidal.

Review of patient #23's nurses notes on 6/4/17 at 1030 stated, " Dr. ____ staff #55 gives medical clearance, pt released from soft restraints up to walk around he is able to walk but running into walls and seeing things and trying to pick up objects that are not present. Pt returned to bed called sister and she said he can't come to her house and he is homeless. 1110 attempted observation on medical floor. CNO_____ staff #3 says no per____ staff #56 RN."
There was no documentation that the ED physician attempted to admit the patient for observation and discussed this with an admitting hospital physician. There was no documentation on why the RN CNO denied the patient admission to the facility.

Review of the chart revealed the ED staff made multiple attempts to send the patient to multiple psychiatric centers including the VA. The VA requested that the patient have a CT of the head before they would accept him. Review of the physician orders revealed the patient had an order for a CT scan on 6/4/17 at 8:19AM. There was no documentation that patient had ever gone to CT until 1700. Nurse documented, "____Staff #55 talked with Dr. ______ VA ER, she request we reattempt CT head cannot get the patient to lie still she will accept but we must let her know.

1735 call Temple VA ER Dr. ____ (VA ER MD) and spoke with her partner that we were unable to get the CT at this time. 1750 VA did not accept patient.

1837 medicated per orders Ativan IVP. Lab at bedside. Pt self- repositioned.

1850 pt to CT via stretcher, EMS at bedside for assistance. Pt unable to lay still new orders received.

1855 pt medicated per orders tolerated well. (There was no nursing documentation on what medication was given.)
1905- pt still moving unable to get CT. MD notified. Pt placed on back board and order to help pt lay still. Pt tolerated well and denies pain. pt still shifting. Pt tolerating well. Denies pain. pt still shifting head procedure. Dr. Vera at pt side new orders obtained."

Review of patient #23's physician orders revealed the patient was ordered Versed 2.5mg inj priority: routine on 6/4/17 at 19:11. 2nd order Versed 2.5mg inj priority: routine on 6/4/17 at 19:22. 3rd order Fentanyl 50mcg IVP priority stat. There was no documentation in the physician notes for the order of the conscious sedation medications or reason for administering these medications. There was no physician documentation found that the physician was involved in the conscious sedation and what type of monitoring was performed.

Review of the nurses notes dated 6/4/17 at 1922 stated, "crash cart, airway box brought to bedside. Ambu bag prepared in case of neg pulse ox. Pt medicated per orders versed and fentanyl IVP. Pt tolerated well. Respiratory unlabored. Pulse ox remains 95%. Pt still struggles to lay still. CT obtained.

Review of the policy and procedure "Conscious Sedation/ Analgesic for Adults" stated, " Define 1.1.1 Combinations of pharmacological agents administered by one or more routes to produce a minimally depressed level of consciousness and satisfactory analgesia while retaining the ability to independently and continuously maintain an airway and respond to physician stimulation and verbal commands.

Pre-procedure
3.1 pre-procedure assessment
3.2 Lab work CBC, BMP
3.3 Consent for procedure and sedation.
3.4 Informed consent with risks/benefits of procedure and sedation.
The nurse is to fill out the "Conscious Sedation Record" that is attached to the policy and procedure.

Nursing staff and CRNA will demonstrate competency annually with a competency check list where skills are observed and will be documented in the employees chart."

An interview was conducted with staff #39 and on 9/13/17. Staff #39 stated she was one of the nurses caring for patient #23 on 6/4/17. Staff #39 stated that this patient had been in their ER multiple times and was known to have a psychiatric disorder and substance abuse. Staff #39 also stated the patient had a CT of the head 8 months ago and was negative. Staff #39 reported the patient was being very difficult and kept trying to get out of the bed and fighting with the staff. Patient #23 was "placed in restraints because he was combative and hallucinating." Staff #39 reported that they could not find any place to take the patient for psychiatric care and that the VA would not take patient #23 "until we got a CT scan on him." Staff #39 stated, "the doctor wrote the orders for the Versed and Fentanyl so we could get him to be still for the CT scan."

Staff #39 was asked if the patient was having an emergency situation that required the CT to be performed or was it used as a behavioral management to obtain a test. Staff #39 stated that "no facility would take the patient without the CT being done but it was not medically emergent." Staff #39 stated, "He was just a handful. We couldn't get him out of our ER if we didn't get him to be still for the CT scan."

Staff #39 was asked if there was a conscious sedation form for this event on patient #23 on 6/4/17. Staff #39 stated she did not fill out a conscious sedation form. Staff #39 was not aware of the form. Staff #39 stated the doctor ordered the medications and we administered the medications as they were ordered.

Staff #39 was asked if she had any training on conscious sedation. Staff #39 stated that she has not had any recent conscious sedation training and could not remember when she last had it. Review of staff #39 record revealed she had no current training for conscious sedation and had no date planned to instruct the staff on concious sedation in the ED.

Review of Procedural Sedation in American Society of Anesthesiologists website stated,
"Updated: Nov 14, 2016

Author: Marc S Orlewicz, MD; Chief Editor: Erik D Schraga, MD

The American College of Emergency Physicians (ACEP) defines procedural sedation as "a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function. Procedural sedation and analgesia (PSA) is intended to result in a depressed level of consciousness that allows the patient to maintain oxygenation and airway control independently.

Moderate sedation/analgesia (formerly called conscious sedation) is as follows:
Depression of consciousness is drug-induced. Patient responds purposefully to verbal commands. Airway is patent, and spontaneous ventilation is adequate. Cardiovascular function is usually unaffected.

Sedation and analgesia introduces an independent risk factor for morbidity and mortality in addition to the procedure itself. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recognizes the risks involved with sedation and analgesia for procedures and mandates that sedation practices throughout an institution be monitored and evaluated by the department of anesthesia. The American Society of Anesthesiologists (ASA) has responded to this challenging responsibility by developing practice guidelines for nonanesthesiologists who provide sedation and analgesia

© 2002 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
Practice Guidelines for Sedation and Analgesia by
Non-Anesthesiologists

Recommendations. For both moderate and deep sedation, patients' level of consciousness, ventilatory and oxygenation status, and hemodynamic variables should be assessed and recorded at a frequency that depends on the type and amount of medication administered, the length of the procedure, and the general condition of the patient. At a minimum, this should be: (1) before the beginning of the procedure; (2) after administration of sedative-analgesic agents; (3) at regular intervals during the procedure, (4) during initial recovery; and (5) just before discharge. If recording is performed automatically, device alarms should be set to alert the care team to critical changes in patient status.

Training of Personnel
Although the literature is silent regarding the effectiveness of training on patient outcomes, the consultants strongly agree that education and training in the pharmacology of agents commonly used during sedation- analgesia improves the likelihood of satisfactory sedation and reduces the risk of adverse outcomes from either moderate or deep sedation. Specific concerns may include:

(1) potentiation of sedative-induced respiratory depression by concomitantly administered opioids;
(2) inadequate time intervals between doses of sedative or analgesic agents, resulting in a cumulative overdose; and
(3) inadequate familiarity with the role of pharmacologic antagonists for sedative and analgesic agents Because the primary complications of sedation/analgesia are related to respiratory or cardiovascular depression, it is the consensus of the Task Force that the individual responsible for monitoring the patient should be trained in the recognition of complications associated with sedation/analgesia."

Based on observation, interview and record review, the facility failed to ensure medications were managed in a way to ensure safe and appropriate administration and storage in 3 of 3 areas (Endoscopy area, Main Pharmacy, and Medical nursing unit).

This deficient practice had the likelihood to cause harm in all patients.

Findings include:



Endoscopy area

During an observation on 09/11/2017 after 11:20 a.m., keys to the medication lockup were found in an unlocked drawer at the nurses station. The medication lock-up was located in an area which did not have a door.
The medication lock-up contained such sedative agents as Ketamine, Xylocaine, Propofol, Versed and Fentanyl.

Staff #27 confirmed the observation.




Main Pharmacy


During an observation on 09/11/2017 after 3:00 p.m., the following was observed:

Open plastic bins were observed with medications stored in them. The bins were soiled with dust and debris.
Open plastic bins were observed with bags of intravenous fluids stored in them. The blue bins were soiled with a build-up of brown spills and old remnant from labels.

The floor tile in front of a filing cabinet and the Pyxis had a buildup of rust. There was no way the floor could be sanitized. There was a build-up of dust and debris on the floor on the side of the file cabinet.

The following expired medication was found stored on the shelves:

Twenty-four vials of the antibiotic Vancomycin that expired 9/01/2017.

Two containers of anesthetic agent Lidocaine oral solution that expired 08/2017.

One bottle of the antibiotic Erythromycin that expired 04/2017.

One bottle of Sodium polystyrene sulfonate that expired 08/2016.

Staff #30 confirmed the observations.


Review of facility policy with an effective date of 03/23/2011 and named "Expired and Destroyed Drugs" revealed the following:

"1. Expired medications include those medications whose expiration date has passed. An indication of month and year will pertain to the last day of that month. Expired controlled or non-controlled drugs will be removed from active stock and kept in a secured area (last week of each month)."





Medical nursing unit (home medication administration)


During an observation on 09/12/2017 after 9:00 a.m., a bottle of Iron supplement 27 milligrams and a bottle of the non-steroidal anti-inflammatory agent Diclofenac 75 milligrams were found in a medication cart on the nursing unit.


Staff #33 confirmed the medications were home medications belonging to Patient #3.



Review of the clinical record revealed Patient #3 was admitted into the facility on 09/05/2017.

Review of medication administration records from 09/05-12/2017 revealed Patient #3 was receiving both medications.
Review of orders revealed no documentation of a physician order for the medications.

Review of the facility's home medication form named "PHYSICIAN STATEMENT FOR PATIENT HOME MEDICATIONS" revealed the following information needed to be documented:


"DATE:
MEDICATIONS:
NAME OF MEDICATION DOSAGE FORM AMT IN BOTTLE AMT RETURNED"

Patient may use medications from home. Patient medications have been verified
by the physician and physician accepts all responsibility for using patient's
medications in this hospital.

Physician Signature:
Date Signed:
Witness (Nurse):"

Staff #34 confirmed there was no physician's order on the chart. The home medication form that was suppose to be completed was not done.

Staff #30 (Pharmacy staff )confirmed they did not have the initial home medication form.




Medical nursing unit (compounding)


During an observation on 09/12/2017 after 11:00 a.m., Staff #35 was observed to mix a bag of the antibiotic Rocephin. Before mixing, Staff #35 removed the medication from the Pyxis medication storage machine and mixed the medication without using hand sanitizer or any kind of handwashing first.


According to a facility policy with an effective date of 03/22/2011 and named "PREPARING PARENTERAL PRODUCTS OUTSIDE PHARMACY" revealed some the following steps:

"..3. Obtain the basic parenteral solution and additive drugs, syringes, needles swabs, etc.
4. Wash hands ..."

Based on observation and interview, the facility failed to

1.) maintain a sanitary environment to control the potential spread of infection in the Emergency Department (ED).

2.) store ultrasound devices in a manner that will protect from damage or contamination.

A tour of the ED was conducted with Staff #39 on the morning of 9-12-2017. There was an ice machine in the ED that was for used for patient drinks. The door to the ice machine was opened and was visibly soiled on the inside of the door. The scoop used to scoop out ice was stored on a shelf inside the ice machine. The shelf was also visibly soiled.

The Trauma Room had a metal cabinet with glass doors that was being used to store sterile supplies for procedures. When the doors were opened, the lip of the cabinet under the doors was observed to be soiled with drops of dark reddish-brown material. The lip of the cabinet and inside edges of the cabinet were soiled with built-up dirt and dust.

Interview with Staff #39 confirmed these finding areas had been overlooked.



32143

Radiology Ultrasound


During an observation on 09/11/2017, the ultrasound area was found with the following:

One vaginal probe was stored inside a drawer uncovered with cords and instruction manuals. A transducer was also found in a drawer uncovered with cables and a blood pressure cuff.

Staff #11 and 13 confirmed the vaginal probe was currently being used that were stored in the drawer. They confirmed the storage area of the vaginal probe and transducer.

According to CIVCO Medical Solutions (civco.com) article "Store Ultrasound Probes Safely" dated January 17, 2017 the following was documented:

"The Joint Commission issued guidelines on storage for semi-critical devices in 2013:

"Store the device in a manner that will protect from damage or contamination and that is consistent with national guidelines and manufacturers' recommendations such as hanging vertically in a cabinet and storing in a clean environment."

According to the Spaulding Classification , endocavity transducers are semi-critical devices. These transducers include endovaginal, endorectal and transesophageal (TEE) probes.

Here are some key pointers:

DO:

DO SEPARATE CABLES FROM PROBES. Unlike endoscopes, only the probe itself is disinfected. Make sure that the probe's cable and electrical connector do not come in contact with the probe during handling and storage.

DO HANG VERTICALLY. When not in use, hang probes vertically to aid drying and protect the cable.

DO USE HEPA FILTERS. A storage cabinet with a fan and HEPA filtered air provides positive air pressure and facilitates drying.

DON'T:

DON'T PROMOTE MICROBIAL GROWTH. Plastic bags can promote microbial growth - the probe must be completely dry!

DON'T USE THE CASE. The original transducer shipping case should not be used for storage once the probe has been used as it can promote recontamination.

DON'T STORE IN UNSAFE AREAS. Avoid storing in areas where cross-contamination or damage to probe can occur."

Review of the policy and procedures for Radiology revealed a company name other than the facility's name was on the policies. The policy and procedures were very generic and did not have any specific procedures or instructions for the employees of this facility. Interview with staff #11 on 9/11/17 reveled the facility did not have their own policies. Staff #11 stated, "We just use the policy and procedures from the company we get the equipment from." Staff #11 stated it's been like that as far as she can remember."

Based upon observation, record review and interview, the facility failed to:

1.) have policies and procedures to ensure safety, radiation hazards, infection control, and emergencies for patients and personnel in 5 of 5 (X-RAY, MRI, CT/PET scan, Ultrasound, and Nuclear Medicine) areas of the radiology department.

2.) Store ultrasound devices in a manner that will protect from damage or contamination.


A tour of the radiology department was conducted on 9/11/17 at 11:34AM. The following items were identified;

Nuclear medicine:
The Nuclear Medicine department is a contracted service within the facility and is monitored by the facility.
The door to the Nuclear Medicine room was found unlocked. The door was in a hallway used by visitors and was within a few yards of an egress to the outside of the facility.
Review of the policy and procedures for "Nuclear Medicine Item 11. Facilities: Appendix A. The dept. doors will be locked when not attended by the nuclear technologist and /or a using physician."

Review of the policy and procedure, "Access to Radioactive Materials" stated, Cleaning of the nuclear medicine department will only be allowed during normal working hours when the nuclear medicine technologist is present. Cleaning will be allowed after surveys and contaminated wipe tests are completed to assure no contamination is present."
Staff #11 Radiology Director reported the facility's housekeeping comes in and cleans regularly. Staff #11 confirmed housekeeping goes in to clean when no one was present. There was no found evidence of contamination wipe tests done before housekeeping entered. Staff #11 confirmed the facility had no policy and procedures tailored for the facility concerning Nuclear Medicine. Staff # 11 stated, "We just use the contracted company's policy and procedures."

A wooden cabinet was found with a sign that stated, "Caution Radioactive Materials." The cabinet had two doors. The door handles were chained with a combination lock. The chain was so loose the surveyor could put her hand in the cabinet and remove items. In the bottom of the cabinet a metal box was found. The box was used to carry in radioactive medications to be used in procedures.

Next to the cabinet, on the floor, was a large white wooden box. On the front of the box was a sign that stated, "Caution Radioactive Materials." The top of the box had a handle with two hinges. The hinges were broken and the top slid off. The box was lead lined in between the wood that held the box together. The top was wood only. Inside the wooden box was discarded radioactive materials. The materials were touching bare wood that could absorb the contents.

Review of the policy and procedures for "Nuclear Medicine Item 11. Facilities: Appendix A. All radioactive materials will be stored with appropriate shielding. The dept. doors will be locked when not attended by the nuclear technologist and /or a using physician."

Review of the policy and procedures for Nuclear Medicine revealed a letter from the administrator of the facility in 2005. The letter stated, "I authorize the assigned Radiation Safety Officer, complete control and access of the leased area where radioactive materials will be received, used and temporarily stored." Staff #11 (Radiology Director) was unable to provide a name of the Radiation Safety Officer and was unable to show evidence of the Radiation Safety Officer presence in the facility and active participation in the Quality Assurance process.

Radiology MRI, CT/PET, Ultrasound
During an observation on 09/11/2017, the ultrasound area was found with the following:

One vaginal probe was stored inside a drawer uncovered with cords and instruction manuals. A transducer was also found in a drawer uncovered with cables and a blood pressure cuff.

Staff #11 and 13 confirmed the vaginal probe was currently being used that were stored in the drawer. They confirmed the storage area of the vaginal probes.

According to CIVCO Medical Solutions (civco.com) article "Store Ultrasound Probes Safely" dated January 17, 2017 the following was documented:

"The Joint Commission issued guidelines on storage for semi-critical devices in 2013:

"Store the device in a manner that will protect from damage or contamination and that is consistent with national guidelines and manufacturers' recommendations such as hanging vertically in a cabinet and storing in a clean environment."

According to the Spaulding Classification , endocavity transducers are semi-critical devices. These transducers include endovaginal, endorectal and transesophageal (TEE) probes.

Here are some key pointers:

DO:

DO SEPARATE CABLES FROM PROBES. Unlike endoscopes, only the probe itself is disinfected. Make sure that the probe's cable and electrical connector do not come in contact with the probe during handling and storage.

DO HANG VERTICALLY. When not in use, hang probes vertically to aid drying and protect the cable.

DO USE HEPA FILTERS. A storage cabinet with a fan and HEPA filtered air provides positive air pressure and facilitates drying.

DON'T:

DON'T PROMOTE MICROBIAL GROWTH. Plastic bags can promote microbial growth - the probe must be completely dry!

DON'T USE THE CASE. The original transducer shipping case should not be used for storage once the probe has been used as it can promote recontamination.

DON'T STORE IN UNSAFE AREAS. Avoid storing in areas where cross-contamination or damage to probe can occur."

Review of the policy and procedures for Radiology revealed a company name other than the facility's name was on the policies. The policy and procedures were very generic and did not have any specific procedures or instructions for the employees of this facility. Interview with staff #11 on 9/11/17 reveled the facility did not have their own policies. Staff #11 stated, "We just use the policy and procedures from the company we get the equipment from." Staff #11 stated it's been like that as far as she can remember."

Based on review of records and interview, the hospital failed to ensure nursing staff were trained on specific nursing competencies in 2 areas (Inpatient and Skilled Nursing Facility) out of 3 areas reviewed (Inpatient, Skilled Nursing Facility, and Emergency Department).

Review of nursing personnel files revealed there were no specific nursing competencies in the personnel files.

Interview was conducted with Staff #3 and Staff #39. Staff #39 stated she had developed nursing competencies for the Emergency Department, but kept them in a separate file. Documentation of completed competencies was provided by Staff #39.. Staff #3 confirmed that specific nursing competencies had not been developed for the inpatient area or Skilled Nursing area. When asked if there was a performance improvement project with a schedule for completion to include training and follow-up, Staff #3 confirmed that there was not one.

Based on review of medical records and policy, the Register Nurse failed to assess and identify patient specific problems and incorporate them into the nursing plan of care in 2 patients (Patient #6 and Patient #17) of 3 patients reviewed (Patient #'s 6, 17 and 28).

Review of Patient #6's Chart:

History and Physical dated 8/15/2017 noted patient #6 was a 92 year old female and had poor intake due to feeling bad. "Today she became weak beyond her normal."

Nursing Initial Physical Assessment completed on 8-15-2017 Nutrition Scale score total was 6. Risk level assessed as medium risk 5-7 points. Points were given for patient having dentures, diabetes, and lab values.

Problem and Goals for nursing care plan did not include nutritional problems/goals as identified in physician and nursing assessments as poor appetite and medium risk on nutrition scale score.

Physician progress note on 8/17/2017 "She says she is not hungry and doesn't want to eat." "Yesterday she had eaten pretty well, but this morning she had eaten less than 50% of her meal."

On 8/17/2017, Speech Therapy evaluated patient and made recommended changes to care due to results of swallow study. Review of Problem and Goals for nursing care plan did not include nutritional problems/goals as identified by Speech Therapy.

Review of Patient #17's Chart

History and Physical by physician on 03/16/2017 noted that patient #17 was brought to the Emergency Department for breathing difficulty that began when she was choking on food. The patient reported that the choking episodes "had become more frequent and she easily loses her breath." Under "Plan", item #2, the physician lists that Patient #17 is having progressive dysphagia (difficulty swallowing).

Review of the nursing care plan revealed this problem was not addressed on the nursing care plan.



Review of policy titled "Nursing Care Standards", last Reviewed and Revised 11/16/2010 was conducted.

"Item 2.4, Standard IV - Planning (The nurse develops a plan of care that prescribes interventions to attain expected outcomes.)
2.4.1 Measurement Criteria
2.4.1.1 The plan is individualized to the patient's condition or needs."

Based on record review and interviews, the facility failed to have a Director of Rehabilitative Services with the credentials to properly supervise, evaluate, and administer the services set forth by the rules of the Texas Board of Physical Therapy Examiners.

Review of the Rehabilitation Services Department revealed the Director of Rehabilitative Services, Staff #52, was a Physical Therapy Assistant. An interview was conducted with Staff #52 on 9/13/17 and was found to be supervising Physical Therapist (PT), Occupational Therapist (OT) and Speech Therapist (ST). Staff #52 stated she performs and signs the Therapist yearly evaluations. Staff #52 stated she was a PTA and was not a Physical Therapist. Staff #52 stated she did supervise the department and personnel.

Review of the Texas Board of Physical Therapy Examiners revealed,

"§322.2. Role Delineation.

(a) The role of the PT.

(1) The PT holds primary responsibility for physical therapy care rendered under his supervision.

(b) The role of the PTA.

(1) A PTA may provide physical therapy services only under the supervision of a PT (See
§322.3 of this title (relating to Supervision).

(2) A PTA may be assigned responsibilities by a supervising PT to:
(A) Screen patients designated by a PT as possible candidates for physical therapy services (See §322.1(b) of this title (relating to Evaluation and screening) ;

(B) Provide physical therapy services as specified in the physical therapy plan of care
(See §322.1(c) of this title (relating to Physical therapy plan of care development and implementation)) which may include but are not limited to:

(i) Preparing patients, treatment areas, and equipment;

(ii) Implementing treatment programs that include therapeutic exercises; gait training and techniques; ADL training techniques; administration of therapeutic heat and cold; administration of ultrasound; administration of therapeutic electric current; administration of ultraviolet; application of traction; performance of intermittent venous compression; application of external bandages, dressings, and support; performance of goniometric measurement;

(iii) Modifying treatment techniques as indicated in the plan of care;

(C) Respond to acute changes in physiological state;

(D) Teach other health care providers, patients, and families to perform selected treatment procedures and functional activities; and

(E) Identify architectural barriers and report them to the PT.

(3) The PTA may not:

(A) Specify and/or perform definitive (decisive, conclusive, final) evaluative and assessment procedures;

(B) Alter a plan of care or goals;

(C) Recommend wheelchairs, orthoses, prostheses, other assistive devices, or alterations to architectural barriers to persons;

(D) Sign progress notes which design or modify the plan of care."


During an interview with staff # 52 on 9/13/17 staff #52 was asked if she is unable to;

(A) Specify and/or perform definitive (decisive, conclusive, final) evaluative and assessment procedures;

(B) Alter a plan of care or goals;

(C) Recommend wheelchairs, orthoses, prostheses, other assistive devices, or alterations to architectural barriers to persons;

(D) Sign progress notes which design or modify the plan of care. How does she evaluate if the Therapist is appropriately treating the patient and participating in an ongoing plan of care?

Staff #52 stated, "The Medical Director of Therapy Services also looks at the performance but I guess I see what you are saying, and no, I don't have the credentials to monitor the Therapist." Staff #52 confirmed she reports to the CEO and was not supervised by a Physical Therapist.

Based on observation, interview and record review, the facility failed to ensure 3 (#'s 19, 20 and 27)of 27 patients had history and physicals that were completed within 30 days before or on registration prior to surgical procedures.

This deficient practice had the likelihood to cause harm to all surgical patients.


Findings include:


During an observation on 09/13/2017 after 5:30 a.m., Patient #27 was taken into the procedure room for a colonoscopy.

Review of the clinical record revealed a history and physical which was dated 07/27/2017 (over 30 days prior to the procedure).




Review of the clinical record of Patient #20 revealed she presented to the facility on 08/31/2017 for an EGD (esophagogastroduodenoscopy).

Review of the record revealed no evidence of a history and physical by the physician.





Review of the clinical record of Patient #19 revealed she presented to the facility on 08/04/2017 for a colonscopy.

Review of the record revealed no evidence of a history and physical by the physician.



Staff #29 confirmed the condition of the history and physicals and reported that she had talked to physicians. She would be coming up with a way for the physician's to make updated history and physicals.



Review of a facility's policy dated 03/01/11 and named "MEDICAL RECORD GUIDELINE FOR PHYSICIANS" revealed the following:

History and physical examination must be on the chart prior to the surgical procedure.

Based on observation and interview, the facility failed to ensure patient information was maintained in a manner to prevent unauthorized usage in 3 of 3 areas (Cardiac rehabilitation, Sleep lab and Nurses station).

This deficient practice had the likelihood to cause harm in all patients.

Findings include:



Cardiac rehabilitation room

During an observation on 09/11/2017 after 11:00 a.m., patient medical records which included their treatment plans and personal identification information were found stored in unlocked files cabinets. The room was empty and doors to the room were unlocked making this information accessible to anyone.

Staff #2 confirmed the observation.



Nurses Station

During an observation on 09/11/2017 after 12:00 p.m., pages of patient medical record information which included treatment plans, medication records and personal identifying information were stored in an open plastic bin. The open bin was underneath the nurses station which was accessible to any one passing by.

Staff #3 confirmed the records were being kept their until they were shredded.


Review of a facility policy dated 03/01/2011 and named "VIOLATION OF CONFIDENTIALITY/SECURITY OR ORGANIZATIONAL INFORMATION" revealed the following:

"POLICY:
It is the policy of (name of facility) to manage data and information with the highest degree of security and confidentiality. All efforts will be undertaken to prevent a breach of this confidentiality and security."






36827

Sleep Lab


On the morning of 9-11-2017, a tour of the Sleep Lab was made with Staff #2 present. The office door to the Sleep Lab in the main hallway was unlocked and provided entry into the Sleep Lab. No staff were present. A plastic box was observed to be sitting on the floor, under the printer table. The plastic box was filled with forms that contained patient protected health information from patient charts.

Interview was conducted with Staff #2. Staff #2 stated he did not know where the Sleep Lab staff member was or when the staff member would return.

Interview was conducted with Staff #3. Staff #3 stated that the hospital is responsible for shredding their own documents. Staff #3 stated that boxes of forms that require shredding are kept in open boxes at all of the workstations so that staff can shred when they have free time.



Review of a facility policy dated 03/01/2011 and named "VIOLATION OF CONFIDENTIALITY/SECURITY OR ORGANIZATIONAL INFORMATION" revealed the following:

"POLICY:
It is the policy of (name of facility) to manage data and information with the highest degree of security and confidentiality. All efforts will be undertaken to prevent a breach of this confidentiality and security."

Based on observation, interview and record review the facility failed to ensure:


A. Hinged surgical equipment was properly sterilized.

B. Esophagogastroduodenoscopy (EGD)) scopes were reprocessed in a timley manner.

C. Rapicide high level disinfectant used for cleansing scopes was changed out as required by the manufacturer.

D. Staff properly performed time outs prior to procedures.



This deficient practice had the likelihood to cause harm to all patients receiving endoscopy and wound care services.

Findings include:




During an observation on 09/12/2017 after 3:00 p.m. the following was observed:



Wound care area


Eight sterile packets of hemostats (equipment used during wound procedures) were found stored on the wound care cart. They were all hinged and had been sterilized in a closed positioned.

Staff #'s 27 and 28 confirmed the observation.


According to the Centers for Disease Control and Prevention (CDC) article, Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, and the Healthcare Infection Control Practices Advisory Committee (HICPAC), page 74, revealed that hinged instruments and instruments that close should be opened during the process of sterilization.




Procedure room


Three endoscopes that they were using for procedures were found stored in a cabinet. They did not have dates logged on them of the last time they were cleaned. There was no hang time logged.


Review of the facility's endoscope "DATA LOG" revealed documentation of when each scope was cleaned. The following was documented:

The EGD (esophagogastroduodenoscopy) scope was cleaned and sanitized on 01/14/2017, 06/15/2017, 06/28/2017, 07/05/2017, 08/03/2017, 08/30/2017 and 08/31/2017. There was no documentation for September 2017 of the EGD scope being reprosessed.

Staff # 27 reported the scopes were cleaned after each use. If one is not used it is cleaned every 30 days from the last time it was cleaned. Staff #27 reported there was no policy addressing the required hang time for the endoscopes.



According to the 2014 Edition of the Association of Perioperative Registered Nurses (AORN) Perioperative Standards and Recommended Practices, page 534 revealed the following:

"Recommendation IX

Flexible endoscopes should be stored in a manner that protects the device from damage and minimize microbial contamination ....

IX.b. Flexible endoscopes should be reprocessed before use if unused for more than five days..

In research studies, flexible endoscopes cleaned and processed as recommended and stored by hanging in closed cabinets have been shown to grow organisms after five days of no use ...."





Staff #27 reported that they were using Rapicide in the Medivator, the equipment used to clean the scopes and changing it out every 30 days.

Review of facility Rapicide instructions revealed the following:

"Rapicide is a 28-day reusable glutaraldehyde-based high-level disinfectant for use in automated endoscope reprocessors (AERs) ..."

Review of the "DISINFECTANT AND FILTER CHANGE LOG" revealed the solution was changed past 30 day timeframe on 12 out of 17 opportunities during the timeframe from April 2016- August 2017.


Staff #27 and 28 confirmed the observation and documentation.





During an observation on 09/13/2017 after 5:30 a.m. the following was observed:


Procedure room

Patient #27 was taken into the procedure room for a colonoscopy. Staff #28, 29, 31 and 32 were in the room. Staff # 28 and #31 were still putting on their surgical gown when Staff #29 called the "time-out". None of the staff in the room stopped and acknowledged the time-out.

Staff #29 reported they did not have a facility policy that addressed the time-out.

Review of facility policy and procedures revealed "Guidelines for Documentation in the Gastrointestinal Endoscopy Setting" by the Society of Gastroenterology Nurses and Associates, Inc. which documented the following:

"Section 2:
Procedure Phase..
19."Time Out" initiated by the physician to confirm the right patient/right procedure ..."



Scope cleaning room


Staff #28 was observed during the scope cleaning process to run water in a sink and put 4 squirts of Enzol (enzymatic detergent).

According to the directions on the bottle staff were to:

"1.Do not add bleach or other chemicals. Add 1 ounce (1 pump) of ENZOL*Enzymatic Detergent liquid concentrate per gallon of water. For equipment with dried-on organic matter, use 2 ounces per gallon of water and /or use warm water ..."

Staff #28 reported she did not measure the amount of water she put in the sink and did not the correct amount of the enzymatic detergent to put in the water.

Based on observation, interview and record review the facility failed to ensure 3 of 27 post anesthesia assessments included all required elements (Patient #'s 19, 20 and 27).

This deficient practice had the likelihood to cause harm to all surgical patients.


Findings include:


Review of post anesthesia assessments on Patient #'s 19, 20 and 27 revealed no documentation of mental status, pain, nausea/vomiting and post operative hydration.

During an interview on 09/13/2017 after 5:30 a.m., Staff #29 confirmed the missing information.




According to the "Practice Guidelines for Postanesthetic Care, Anesthesiology, Vol 96, No 3, March, 2002", provides the recommendations of the American Society of Anesthesiologists for routine postanesthesia assessment and monitoring, including monitoring/assessment of:

"o Respiratory function, including respiratory rate, airway patency, and oxygen saturation;
o Cardiovascular function, including pulse rate and blood pressure;
o Mental status;
o Temperature;
o Pain;
o Nausea and vomiting; and
o Postoperative hydration."

Based on document review and interview the facility failed to demonstrate an effective Quality Assurance program form January 2017 to September 14, 2017.


This deficient practice had the likelihood to effect all patients of the hospital.


Findings included:


On 9/11/2017,in the office of the Director of the Quality Assurance Process Improvement (QAPI) program, an interview with the the Director of the QAPI program, staff #5, who indicated each department submitted there Quality assessment to her. She submitted the quality information to the Administrator. A report was formulated and copies were submitted to the Medical Staff for review prior to the Governing Board/Medical Staff (GB/MS) meetings. She confirmed she did not attend nor did she present her program information at the GB/MS meetings.

Staff #5 indicated each department submitted what they determined to be their departments Process Improvement or project improvement for the quarter. Staff #5 further confirmed some departments had been working on the same PI project for an entire year. Their numbers were good but no other project had been determined. Staff #5 admitted there were no desired thresholds for most of the departments. They just choose something to work on. So when a department maintained a "met" status for several months they would simply continue collecting data.

Staff #5 was asked if there were policies for the QAPI program. Such as "assess the services or function of a department", "determine a PI and "establish goals or thresholds". Staff #5 confirmed there weren't any to her knowledge. She could not explain how a department chose their PI or how they measured a desired outcome.

Staff #5 was asked if she had received training for the QAPI responsibilities? she indicated "No". She was asked if she had a copy of the regulatory guidelines for QAPI? She replied "No".

Staff #5 was asked if the Patient Safety Program was a part of the QAPI process. She indicated each department handled their patient safety issues but it was not reviewed in the QAPI meetings.

On the morning of 9/13/2017 and interview with the Director of Nurses confirmed she collected the patient incident/accident reports. She would review the reports and in 24 hours she would evaluate as a follow-up to the incident. She confirmed she sent a total of the number and types of incidents to the Patient Safety Officer. But she said incidents and accidents were not submitted a part of her QAPI.

On 9/12/2017 in the afternoon an interview with the Chief Executive Officer, staff #1, confirmed he attended the GB/MS meetings and presented the QAPI report. He further confirmed staff #5, the QAPI Director, did not attend. He also admitted "they", had discussed the possibility of a Registered Nurse assuming the responsibilities of the QAPI program. Staff #1 was made aware the departments were not consistently choosing measurable PI. The departments had not determined thresholds or desired outcomes or established measurement parameters for the PI? He stated he had been a QAPI director in his past and was familiar with the process.

The hospitals departments were collecting information but not acting on the information with the intent of improving the department's services to patients or to the overall function of the hospital. The hospital's QAPI program failed to identify problem prevention measures, Identify corrective action, implement corrective action and measure and evaluate the effectiveness of the action when it was taken.

Based on document review and interview the facility failed to follow its Medical Staff Bylaws for evaluation of physician and allied health personnel services from January 2017 to September 14, 2017.


This deficient practice had the likelihood to effect all patients of the hospital.



Findings included:


On the afternoon of 9/11/2017 in the office of the staff #5, who was the oversight for credentialing, the credentialing records for Medical staff #'s 17, 23, 24, 25, 26, and Allied Professional staff #'s 20, 21, and 22 were reviewed.

By definition found Article I 1.4 "Medical Staff or "Staff' means the formal organization of all duly licensed medical and osteopathic physicians, dentists, podiatrist, chiropractors and others practitioners or Allied Health personnel who have been granted privileges pursuant to these Bylaws to attend patients in the hospital. The independent practitioners who constitute the Medical Staff are private practitioners and are not employees or agents of the hospital.

1. Medical staff #'s 17, 23, 24, 25, and 26 failed to reflect documentation of two (2) professional references as required by the Medical Staff Bylaws. Allied Health Personnel staff # 20, 21 and 22 failed to had evidence of two (2) professional references.

Review of the Medical Staff Bylaws Article VI Procedure for Appointment and Reappointment, ".1 The application shall include the names of at least two (2) persons who have extensive experience in observation and working with the applicant and who can provide adequate reference pertaining to the applicant's professional competency and ethical character."



2. Medical staff #17 had incomplete delineation of privileges. The only privilege staff #17 had requested was 1) Differential diagnosis and management 2) of general medical problems. There was no documentation the requested privileges were approved.
Medical staff #' 23, 24, 25, and 26 had no delineation of current medical privileges documented. Allied Health Personnel staff #'s 22 had no date documented on the application for staff privileges.

Review of the Medical Staff Bylaws Article V, "Clinical privileges Delineated, Every practitioner practicing at this Hospital by virtue of Medical Staff membership or otherwise, shall, in connection with such practice be entitled to exercise only those clinical privileges specifically granted to him by the Governing Board."


3. Medical staff #'s 17, 24 and 25 did not have evidence of current Basic Cardio Pulmonary Resuscitation skills.


Article IV "Procedure for Appointment and reappointment"

6.8 (d) Documentation of participation in basic cardiopulmonary resuscitation training within the last twelve (12) months for all active medical staff.



4. Medical staff #'s 17, 23, 24, 25, and 26 had no documentation of notification of medical staff privilege or appointment. Allied Health Personnel staff #'s 20 , 21 and 23 had no documentation of notice of approval of staff privilege.

6.6 Final Decision, "When final action has been taken by the Governing Board, the Hospital Administrator shall be authorized to transmit its decision to the candidate for membership and, if he is accepted, to secure his signature pledging to abide by these Bylaws, Rules and regulations.



5. Allied Health personnel staff #21 did not have a designated physician sponsors documented in his application for privileges.

5.8 Allied Health Personnel
(a) Only Allied Health Personnel (AHP) who are licensed, certified or otherwise approved as required by state law and who document their qualifications, status, clinical duties, training, demonstrated ability, and physical and mental status shall be eligible to provide specified services in the hospital; and that any patient treated by them will receive quality care. All applicants for designation as an AHP shall:

(f) Physician Assistant:

Each applicant must be sponsored by a physician member of the Active Staff who shall act as the applicant's supervising practitioner...


The above findings were confirmed by staff #5, who had responsibility for credentialing and Quality Assurance for the facility.

Based on review of records and interview, the hospital failed to notify all Skilled Nursing Facility (SNF) residents of specific resident rights, to include services available at the facility and charges for services not covered.

A review of Patient #28's chart was made. Patient #28 had been transferred to the hospital as a SNF resident. In the chart was a form titled, "Advance Directive Admission Form and Checklist - Inpatient Consent". The consent contained a question, asking if the patient had received an "In-Patient Packet" containing patient rights. This question was circled "Yes" and initialed.

The In-Patient Packet was reviewed. This was the same In-Patient Packet that was provided to patients being admitted for acute care medical treatment. The packet did not list specific Resident Rights or contain a list of available services the facility provides or the patient charge for those services, if any.

Interview was conducted with Staff #38. Staff #38 confirmed that there was not a separate admissions package for SNF patients. Everyone received the same package. Staff #38 stated that if the patient was receiving in-patient medical services and transitioned to a Swing Bed, the chart was split into two separate encounters. New consents with patient rights were not provided to the patient at the time of the SNF admission. The inpatient consents with patient rights that had been signed for the inpatient admission were used as consent for SNF services and notice of Resident Rights.

Based on interview and record review, the facility failed to ensure the comprehensive assessments of 2 of 5 Swing bed patients was complete with dental and nutritional status ( Patient #'s 3 and 13).

This deficient practice had the likelihood to cause harm to all Swing bed patients.

Findings include:


Review of the clinical record of Patient #3 revealed she was 69 year old female admitted into the facility on 09/05/2017.

On 09/09/2017 Patient #3 was admitted into Swing bed status. Review of the record revealed the consent to treat and physician's history and physical were dated 09/05/2017.

Review of the comprehensive assessment dated 09/09/2017 revealed no assessment of Patient #3's dental status.





Review of the clinical record of Patient #13 revealed he was a 75 year old male admitted into the facility on 07/23/2017.

Review of a physician's history and physical dated 07/23/2017 revealed Patient #13's chief complaints were dyspnea, anorexia and dehydration.

Review of the comprehensive assessment revealed Patient #13 no documentation of a nutrition assessment or a dietary consult.

Review of nurses notes revealed Patient #13 was discharged from the hospital on 07/28/2017. There was no documentation during the stay of a dietary consult considering the patient was at high risk for nutritional problems.

During an interview on 09/13/2017 after 10:00 a.m., Staff #34 confirmed the missing assessment and dietary consult. Staff #34 reported if the assessment would have been completed it would have prompted a dietary consult.

Based on review of documents and interview, the hospital failed to ensure a dentist was available to all Skilled Nursing Facility (SNF) patients.

A review of contracted services was made. No contract for dental services was found. The contract for Dental Services had ended on December 31, 2014.

Interview was conducted with Staff #2. Staff #2 confirmed that dental services were not available. Staff #2 stated they had not been able to find another dentist in the local area that would contract for services.