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Based on record review and interview, the hospital failed to ensure the Emergency Department (ED) direct care staff received the education, training and demonstrated knowledge in the use of nonphysical intervention skills.

Findings:

On 02/03/2020 at 10:30 a.m., an interview with S6RN, ED Nurse Manager, revealed patients who were admitted to the ED with a PEC were assigned to have one-on-one care by a staff member.

Review of the training files for S6RN ED Manager and S5RN ED nursing staff revealed no documented evidence of training in the use of nonphysical intervention skills.

On 02/04/2020 at 3:30 p.m., S2DON confirmed that none ot the staff in the ED have been trained in the use of nonphysical intervention skills.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to record, interpret and document the cardiac rhythm for 2 of 2 patients reviewed who were receiving continuous telemetry monitoring in a total sample of 30 (Patient #4, 11).
Findings:

Review of the policy titled Telemetry Monitoring revealed in part that a rhythm strip record will be kept every two hours on all telemetry patients. The strips will be interpreted every two hours.

Patient #4
Review of the patient's electronic medical record with S2DON revealed an admit date of 02/01/2020 with orders for continuous telemetry monitoring. Review of the medical record revealed that rhythm strips were placed in the record but there was no documented evidence of interpretation of the rhythms. Further review of the medical record, including nursing assessments (every 12 hours) revealed no documented evidence of the patient's rhythm strip interpretation.

Patient #11
Review of the patient's electronic medical record with S2DON revealed an admit date of 12/26/19 with orders for continuous telemetry monitoring due to a diagnosis of chest pain. Review of the medical record revealed that rhythm strips were placed in the record but there was no documented evidence of interpretation of the rhythms. Further review of the medical record, including nursing assessments (every 12 hours) revealed no documented evidence of the patient's rhythm strip interpretation.

On 02/03/2020 at 3:10 p.m., interview with S2DON revealed that the telemetry monitor automatically runs strips every two hours and the ward clerk posts the strips in the patient records. S2DON further revealed that the nurses do not interpret the strips. S2DON confirmed the above patient records did not have documented evidence of rhythm strip interpretation every two hours, according to hospital policy.

On 02/04/2020 at 1:00 p.m., interview with S3ADON revealed that she frequently works on the floor taking care of the patients. S3ADON stated that when she has a patient on telemetry monitoring, she looks at the rhythm strips throughout the shift, but does not document any interpretation of the strips.

Based on record review, interview, and observation, the hospital failed to ensure the nursing staff developed and kept current individualized and comprehensive nursing care plans. This deficient practice was evidenced by failure of the nursing staff to include all identified medical diagnoses and failure to include nursing interventions for 6 (#2, #3, #12, #14, #18, #19) of 15 sampled patients reviewed for care plans of a total sample of 30.

Findings:

Review of the hospital policy titled Care Plans, dated 06/2015 revealed, in part: Policy-Nursing care plans should be formulated based on assessment findings. All care plans consist of three parts: goals or expected outcomes, nursing actions or interventions, and evaluations of established goals. All care plans should be formulated and modified by the registered nurse within 24 hours of admission. Each care plan should be carefully reviewed and modified as necessary every shift by the nursing staff. Purpose-Care plans direct the patient's nursing care from admission to discharge based on the nursing diagnosis. Nursing care plans embody the components of nursing diagnosis: assessment, diagnosis, planning, implementation, and evaluation.

Patient #2
Review of patient #2's medical record revealed an admission date of 01/31/2020 with admission diagnosis of Jaundice, Hepatitis, and Diabetes Mellitus.

Review of patient #2's care plan did not reflect or address Jaundice, Hepatitis, and Diabetes Mellitus.

Patient #3
Review of patient #3's medical record revealed an admission date of 01/31/2020 with admission diagnosis of COPD.

Review of patient #3's care plan revealed identified problems to include Activity Intolerance, Respiratory Infection, and Discharge Planning.

The care plan did not reflect the patients' other diagnosis of Hypertension, and Anxiety.

Patient #12
Review of patient #12's medical record revealed an admission date of 01/20/2020 with admission diagnosis of Abdominal Distention.

Review of patient #12's care plan revealed identified problems to include Constipation, and Discharge Planning.

The care plan did not reflect the patients' other diagnosis of Diabetes Mellitus, GERD, and Hypothyroidism. The patient had orders for Accuchecks AC & HS per S/S.


Patient #14
Review of patient #14's medical record revealed an admission date of 10/20/19 with admission diagnosis of Pneumonia.

Review of patient #14's care plan revealed identified problems to include Skin Integrity, Activity Intolerance, and Discharge Planning.

The care plan did not reflect the patients' other diagnosis of Lung Ca, and COPD. The patient had orders for Fentanyl patch 50mcg/hr. every 72 hours, and MS Contin 15mg every 8 hours for pain.

Patient #18
Review of patient #18's medical record revealed an admission date of 10/20/19 with admission diagnosis of Pneumonia.

Review of patient #18's care plan revealed identified problems to include Impaired Gas Exchange, and Discharge Planning.

The care plan did not reflect the patients' other diagnosis of HTN. The patient had orders for Zestril 10mg q day, and Klonopin 0.5mg PO BID.

Patient #19
Review of patient #19's medical record revealed an admission date of 01/28/2020 with admission diagnosis of Pneumonia.

Review of patient #19's care plan revealed identified problems to include Infection, Impaired Gas Exchange, and Discharge Planning.

The care plan did not reflect the patients' other diagnosis of Hyperlipidemia, and Chronic Pain.

Interview on 02/04/2020 at 11:00 a.m. with S3ADON confirmed patient care plans should reflect the total care provided to the patient.

Based on record review and interview, the hospital failed to ensure that drugs were administered in accordance with physician orders as evidenced by failing to administer sliding scale insulin as ordered by the physician for 1 of 1 patients reviewed for sliding scale insulin administration in a total sample of 30 (Patient #2).
Findings:

Review of the physician orders for Patient #2 dated 01/31/2020 revealed blood glucose checks were to be performed before meals and at bedtime with sliding scale insulin ordered. The sliding scale insulin orders revealed they included the following:
Sliding Scale insulin for days - 150-199, give 2 units; 200-249, give 4 units
Sliding Scale insulin for bedtime - 250-299, give 2 units

Review of the patient's MAR revealed the following documentation:
01/31/2020 at 5:57 p.m., blood glucose 181, no sliding scale insulin administered (physician ordered 2 units per sliding scale)
02/01/2020 at 4:00 p.m., blood glucose 178, no sliding scale insulin administered (physician ordered 2 units per sliding scale)
02/02/2020 at 11:00 a.m., no documented evidence that blood glucose was tested
02/02/2020 at 4:00 p.m., no documented evidence that blood glucose was tested

On 02/03/2020 at 3:20 p.m., S2DON reviewed the patient's electronic medical record with the surveyor and confirmed that the physician orders for checking blood glucose levels and sliding scale insulin was not followed on the above times.

Based on record review and interview, the hospital 1) failed to ensure all patient medical records were promptly completed as evidenced by failing to have completed medical records 30 days after discharge and 2) failed to ensure that all medical records were protected from water damage should the sprinklers engage.
Findings:

1) Failed to ensure all patient medical records were promptly completed as evidenced by failing to have completed medical records 30 days after discharge

Review of the Medical Staff Rules and Regulations revealed that all records shall be completed within 30 days of the day of discharge. If records are not completed within 30 days, a letter shall be sent to the delinquent staff member listing the charts that require completion and stating that the records shall be completed without delay.

Review of the policy titled, Delinquent Medical Records, revealed that physicians will be notified on a monthly basis of their number of incomplete and delinquent charts (over 30 days after discharge), by report at the monthly medical staff meeting.

On 02/04/2020 at 10:00 a.m., interview with S4RHIT revealed that there were multiple incomplete medical records stored in a filing cabinet in her office. When asked the number of incomplete medical records or a list of the physicians who had the incomplete medical records, she stated that she was unsure. At that time, observation of the filing cabinet revealed it contained multiple patient medical records. Further review of the cabinet revealed that 19 records were delinquent past 30 days, with the latest discharge date of 09/20/19.

Further interview at that time with S4RHIT revealed that she had not sent any letters to the physicians who had the above delinquent records. She further stated that she had not sent any letters "in a long time".

On 02/04/2020 at 12:45 p.m., interview with S1Administrator revealed that he was unaware of any delinquent medical records.

2) Failed to ensure that all medical records were protected from water damage should the sprinklers engage

On 02/04/2020 at 10:20 a.m., observation in the Medical Records office revealed approximately 75 medical records were stored on S8Medical Records Clerk desk. Further observations revealed sprinkler heads were in the ceiling. Interview with S8Medical Records Clerk at that time revealed the records were originals and needed to be scanned into the electronic medical record. When asked if the records were removed from her desk at night for protection should the sprinklers engage, she stated no.

Based on observation and interviews, the Infection Control Officer failed to maintain a system for identifying and controlling infections and communicable diseases as evidenced by failing to maintain a sanitary hospital environment.

Findings:

On 02/03/2020 at 10:15 a.m., observation during initial tour revealed the following:
The vitals signs cart on the 400 hall contained a digital thermometer which was wrapped with red elastic bandage material (Coban).

On 02/04/2020 at 3:30 p.m., an interview with S2DON confirmed that the presence of the Coban wrap prevented the ability to disinfect the thermometers, and could harbor bacteria.

On 02/04/2020 at 8:45 a.m., observation of Operating Room #2 revealed the surgical stretcher had peeling paint and rust on the metal surfaces.
Interview at this time with S7RN, Surgery Unit Director confirmed the rusted and peeling surfaces were not able to be disinfected and could release particles into the sterile environment.