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Based on observation, interview, and record review, the hospital failed to ensure the medical staff was accountable for four of 28 sampled patients (Patients 8, 13, 14, and 17) as evidenced by:

1. The progress notes for two sampled patients (Patients 13 and 14) failed to have documentation of the use of restraints.

2. MD 3 failed to ensure the accuracy of the Operative Report for Patient 8 when the wrong date of service and procedure techniques were documented.

3. MD 1 failed to wear the appropriate PPE when in a patient's room designated as a COVID-19 isolation room.

4. Patient 17's blood transfusion order was incomplete.

5. MD 2 failed to document the correct surgical procedure on the Pre-Anesthesia Evaluation form for Patient 8.

These failures increased the risk of substandard outcomes to the patients in the hospital.

Findings:

Review of the General Rules and Regulations of the Medical Staff dated 1/22, Section One, Admission and Discharge of Patients showed the medical staff will be responsible for the medical care and treatment of each patient in the hospital; prompt completeness, legibility, and accuracy of the medical record; necessary instructions; and transmitting reports of the condition of the patient to the referring practitioner and to the relatives of the patient.

1. Review of the hospital's P&P titled Restraint and Seclusion approved date 6/21 showed the attending physician or LIP's progress note must address the need for the continued use of the non-violent restraints every calendar day.

a. On 2/16/22 starting 1300 hours, Patient 13's medical record was reviewed with the Manger of Quality Services. Patient 13 was admitted to the hospital on 2/14/22.

Review of the Physician's Order dated 2/15/22 at 0341 hours, showed to initiate a restraint on Patient 13 for interfering with the medical devices.

Review of the Restraint Patient Assessment dated 2/15/22 at 0400 hours, showed the restraint was applied to Patient 13.

Review of the History and Physical Examination dated 2/15/22 at 1121 hours, failed to show the use of restraint was addressed.

Further review of the medical record failed to show the use of restrain was addressed in the Physician's Progress Noted on 2/15/22.

b. On 2/16/22 starting 1300 hours, Patient 14's medical record was reviewed with the Manager of Quality Services. Patient 14 was admitted to the hospital on 1/25/22.

Review of the Physician's Order dated 2/15/22 at 0050 hours, showed to apply a restraint to Patient 14.

Review of the Restraint Patient Assessment dated 2/15/22 at 2200 hours, showed the restraint was discontinued. However, further medical record review failed to show the use of restraint was addressed in the Physician's Progress Note.

The Manager of Quality Services verified the above findings.

2. Review of the General Rules and Regulations of the Medical Staff Section One, Admission and Discharge of Patients, #4 Operative Reports showed an operative report is written or dictated upon completion of the operative procedure and before the patient is transferred to the next level of care.

On 2/15/22 at 1254 hours, an interview and concurrent review of Patient 8's medical record was initiated with the Manager of Quality Services. Patient A was admitted to the hospital on 2/6/22, for a left hip fracture.

Review of Patient 8's IntraOp Record dated 2/8/22 at 0814 hours, showed the patient received ropivacaine (anesthetic numbing medicine) 0.2% 50 ml, ropivicaine 1% 3.75 ml, epinephrine (vasoconstrictor) 1:1000 0.25 ml, and ketoralac (pain medicine) 30 mg/ml 0.5 ml.

However, review of Patient 8's medical record showed two Operative Reports for the same left hip hemiarthroplasty dated on two different service dates (2/8 and 2/11/22) with the following discrepancies:

* The Operative Report with a date of surgery on 2/8/22, dictated at 0904 hours, showed Patient 8 had a five inch incision made in the left trochanteric curve posteriorly. Patient 8 was injected with platelet-rich plasma harvested from the patient. Patient 8 was also injected with ropivacaine, epinephrine, and ketorolac. An abdominal dressing was applied to the area with tape.

* The Operative Report with a date of surgery on 2/11/22, dictated at 1824 hours, showed Patient 8 had a six inches incision made with a posterior approach to the greater trochanter curve posteriorly. The document showed Patient 8 received an injection of 0.25% marcaine (anesthetic numbing medicine) 20 ml to the wound site. The wound was dressed with a xeroform dressing (occlusive dressing), a 4x4 gauze, and aquacel (antimicrobial dressing).

The Manager of Quality Services was informed and acknowledged the above findings.

3. Review of the hospital's P&P titled Standard Precautions/Transmission Based Precautions approved 8/31/21, Section E. showed in addition to standard precautions, use enhanced precaution for patients known or suspected to be infected with SARS-CoV-2. Healthcare providers entering the room of a patient with suspected or confirmed SARS-CoV-2 must adhere to standard precautions and use NIOSH-approved N95 or higher level respirator, gown, gloves, and eye protection.

On 2/16/22 at 0839 hours, a tour of the 3E Telemetry's COVID unit was conducted with the 3E Nurse Manager, the Manager of Quality and Director of M/S and Telemetry.

MD 1 was observed exiting out of a patient's room in the COVID unit. When asked if the MD wore PPE when in the patient's room, the MD stated, "No, you're right, I'm not wearing it."

The above finding was acknowledged by the 3E Nurse Manager, Manager of Quality, and Director of M/S and Telemetry.


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4. Review of the hospital's P&P titled Blood & Blood Product: Obtaining a specimen; Obtaining Blood from Blood Bank; Administration of Blood Product; Monitoring the Patient review date 12/10/21, showed the Orders for transfusion must include "flow rate or period of treatment."

Medical record review for Patient 17 was conducted on 2/16/22.

Review of Patient 17's medical record showed a physician's order dated 2/15/22, to transfuse one unit of packed red cells, stat (immediately) for an acute upper gastrointestinal bleed with hemoglobin (a protein in the red blood cells that carriers oxygen) below 7 g/dl.

On 2/17/22 at 0745 hours, an interview and concurrent medical record review was conducted with the Manager of Quality Services. The Manger of Quality Services confirmed the physician order for blood transfusion was not complete. The order did not indicate the flow rate.


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5. Review of Patient 8's medical record was initiated on 2/15/22. The medical record showed Patient 8 was admitted to the hospital on 2/6/22.

Review of the physician's order dated 2/7/22 at 1621 hours, showed to verify the consent for the left hemiarthroplasty (a surgical procedure done to replace half of the hip joint) and administration of platelet rich plasma injection (injection of a concentration of the patient's own platelets to accelerate the healing of injured tendons, ligaments, muscles, and joints).

Review of the Pre-Anesthetic Evaluation form dated 2/8/22, showed MD 2 documented the incorrect surgical procedure on the form. The form showed documentation of the left hip fracture as the proposed procedure/surgery instead of the left hemiarthroplasty.

On 2/17/22 at 0820 hours, an interview and concurrent medical record review was conducted with the Safety Officer. The Safety Officer verified the above findings.

Based on interview and record review, the hospital failed to ensure translation services and continuous observation were provided for three of 28 sampled patients (Patients 8, 19, and 20). These failures had the potential for the care needs of the patients not being met and violate the patients' rights.

Findings:

Review of the hospital's P&P titled Interpreters/Translation of Documents dated 11/3/20, showed interpreters should be offered to patients whenever English is not their primary language spoken. This offering should be documented in the medical record. If the patient declines the use of an interpreter, this should also be documented. This offer of an interpreter must include the information that the patient will not be charged for such services. Whenever an interpreter is used, the name must be indicated in the medical record and progress notes, along with the interpreter ID number.

1.a. Review of Patient 8's medical record was initiated on 2/15/22. The medical record showed Patient 8 was admitted to the hospital on 2/6/22. The medical record also showed Patient 8's preferred language was Vietnamese.

Review of the Pre-Anesthetic Evaluation form dated 2/8/22, showed MD 2 had signed the form certifying the anesthesia plan was discussed with the patient; however, there was no documented evidence of the interpreter's name and identification number on the form.

Further review of the medical record showed no documented evidence that a certified interpreter was used when the anesthesia plan was discussed with Patient 8.

On 2/17/22 at 0759 hours, an interview and concurrent medical record review was conducted with the Manager of Quality Services. The Manager of Quality Services verified the above findings.

b. Review of Patient 8's medical record showed the Consent for Treatment and Conditions for Admission was provided to Patient 8 on 2/6/22 at 1030 hours. The form provided was written in Patient 8's preferred language. The form also showed the consent was obtained verbally; however, there was no documented evidence showing an interpreter was provided.

Further review of Patient 8's medical record showed no documented evidence of the hospital offering the use of an interpreter and/or that the patient declined the use of an interpreter.

On 2/15/22 at 1254 hours, an interview and concurrent medical record review was conducted with the Manager of Quality Services. The Manager of Quality Services verified the above findings.


Pruitt, Angela

2. On 2/15/22 at 1257 hours, a tour of the DOU (Direct Observation Unit) was conducted with the Nurse Manager. While touring the unit, an observation was made of a sitter in Room 157, positioned at the foot of the bed between Patients 19 and 20. When asked why the sitter was assigned to observe both patients, the Nurse Manager stated due to both patients' having confusion and attempting to get out of bed alone or do other things without assistance. When asked if the sitter was assigned to observe both Patients 19 and 20, the Nurse Manager stated yes.

A review of the nursing assignment sheet showed CNA 1 was assigned for constant observation for Patients 19 and 20. CNA 1 was speaking in Spanish to Patient 19. Patient 20 was observed in bed with his meal. When questioned him in English, Patient 20 waved his hand. When asked if he understood what being asking, Patient 20 shook his head as no. When CNA 1 was asked how she communicated with Patient 20, CNA 1 stated Patient 20 could understand some English, so she communicated with him in English.

When questioning RN 9 on how she communicated with Patient 20, she stated in English because he could understand some English and was able to respond yes or no when asking him simple questions or giving simple commands. RN 9 stated sometimes the physicians would translate to the nurses for Patient 20. When asked what language the physicians had spoken to Patient 20, RN 9 stated his physicians had spoken to him in his native tongue of Vietnamese. When asked if there were interpreter services used by the hospital for the patients who spoke other languages, RN 9 stated yes, the hospital used the AMN device. When asked if she or other staff was aware of ever using the device for either Patients 19 or 20, RN 9 stated she had not used it before but would start using it from now on. RN 9 was not aware if any other staff had used the device for translation before. When questioned CNA 1 if any interpreter services had been used for Patient 20, CNA 1 stated only the speech therapist used an interpreter last Sunday when she came to visit Patient 20. There was no other documentation to show the interpreter services were offered or had been denied by Patients 19 or 20.

Based on observation, interview, and record review, the facility failed to provide the patients and/or their representatives the contact information for filing grievances with the Department. This failure resulted in the patients or the patient's representative not having the information necessary for filing grievances with the Department.

Findings:

1. On 2/15/22 at 0944 hours, a tour of the ED was conducted with the Manger of Quality Services and Clinical Informatics Director.

The observed posting in the ED waiting area were the Patient's Rights, including the information for filing grievances with the Department.

The Department's contact information for filing grievances was incorrect, including the Department's name, address, and telephone number.

On 2/15/22, the facility's document titled Patient Rights provided to Patient 28 upon registration to the ED on 2/15/22, was reviewed. The document showed the Department's contact information for filing grievances was incorrect, including the Department's name, address, and telephone number.

On 2/16/22, the Patient Guide dated December 2021 given to the patients upon admission to the hospital was reviewed and showed, "You have the right to ...File a complaint with the Department ...the phone number and address is ..." The document showed the Department's contact information for filing grievances was incorrect, including the Department's name, address, and the telephone number.

On 2/17/22 at 0830 hours, the Manger of Quality Services was interviewed and acknowledged the findings.


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2. On 2/15/22 at 1104 hours, the L&D unit was toured with the Director of Quality Services and Director of L&D. When asked, the Director of L&D stated there were three triage rooms for pregnant patients who need emergency services.

It was observed the EMTALA signage was posted on the hallway of the L&D unit. The posting included the information for filing grievances with the Department. However, the Department's contact information was observed inaccurate.

The Director of Quality Services and Director of L&D verified the above findings.

Based on observation, interview, and record review, the hospital failed to ensure the patients received care in a safe environment as evidenced by:

1. High flow oxygen equipment was not connected to the emergency outlet for two sampled patients (Patients 15 and 16).

2. The ED restrooms did not have ligature resistant call lights.

These failures created an increased risk of substandard health outcomes to the patients.

Findings:

1. Review of the hospital's P&P titled Standards or Care - ICU dated 10/29/21, showed in order to provide a safe environment, the patient can expect equipment in proper working order and plugged into the red emergency outlets.

On 2/15/22 at 1220 hours, Patient 15 was observed to have a high flow oxygen concentrator. The high flow oxygen concentrator was not observed to be connected to a red emergency outlet.

On 2/15/22 at 1230 hours, the IP was interviewed and stated the oxygen therapy equipment should be plugged into the red emergency outlets.

Patient 15's medical record was reviewed on 2/15/22. The medical record showed Patient 15 was admitted to the hospital on 2/14/22.

Review of a physician's order dated 2/14/22, showed to administer 2 liters of oxygen via nasal cannula to keep the oxygen saturation level greater than 92%.

On 2/17/22 at 0817 hours, the Manager of Quality Services was informed and acknowledged the high flow oxygen device was not connected to the red emergency outlets.

2. On 2/15/22 at 1320 hours, Patient 16 was observed to have a high glow oxygen concentrator. The high flow oxygen concentrator was not observed to be connected to a red emergency outlet.

On 2/15/22 at 1320 hours, RN 8 was interviewed and stated oxygen therapy equipment should be plugged into the red emergency outlets.

Patient 16's medical record was reviewed on 2/15/22. The medical record showed Patient 16 was admitted to the hospital on 1/10/22.

Review of the physician's order dated 2/15/22, showed to administer high flow nasal cannula at 40 liters per minute to keep oxygen levels over 95%.

On 2/17/22 at 0817 hours, the Manager of Quality Services was informed and acknowledged the high flow oxygen device was not connected to the red emergency outlets.

3. The ED's restrooms did not have a ligature resistant call lights.

On 2/15/22 at 0935 hours an observation was made in the Emergency Department restrooms. The E-POD restroom call light was observed to be short. The Risk Manager and ED Nursing Director confirmed the call light cord was too short. The ED Nursing Director stated she did not know who or why someone kept taking the attachment.

The Main ED restroom call light was observed to have an attached cord connected by a small link chain which connected the two cords. While pulling on the call light, it was observed that the cord did not breakaway cord and had to be manually detached by the Risk Manager from the chain section. The Risk Manager later confirmed it could be a potential ligature risk.

Based on interview and record review, the hospital failed to ensure the nurse-to-patient ratios were maintained at all times for two nursing units, ICU and Telemetry unit, as required. This failure had the potential for the care needs of the patients not being met when the staffing ratio were not maintained as required.

Findings:

Review of the hospital's P&P titled Plan for the Provision of Patient Care and Services under Staffing Plan, A. Purpose Statement, #2. Staffing, dated 7/23/21, showed staffing will at minimum comply with the State of California mandated nurse:patient ratios.

The California Code of Regulations, Title 22, Division 5, Chapter 1, Article 3, 70217, (a) showed the following:

(1) The licensed nurse-to-patient ratio in a critical care unit shall be 1:2 or fewer at all times.
(10) The licensed nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times.

1. Review of the hospital's P&P titled Clinical Guidelines: 1:1 (one nurse to one patient) Staffing for Adult Critical Care Patients dated 12/21 showed the patients with the continuous renal replacement (CRRT) require 1:1 staffing until discontinued.

Review of the Assignment by Staff Member for ICU dated 8/22/21, for the day shift, showed RN 12 was assigned to care for four ICU patients from 0700 to 1900 hours. RN 13 was assigned for three ICU patients from 0845 to 1900 hours. RN 14 who was assigned to care for CRRT patient was assigned to another CRRT patient from 0700 to 1900 hours, when the required ratio was 1:1 care for the CRRT patient as per the hospital's P&P.

2. On 2/15/22 at 1030 hours, the Telemetry unit was toured with the Director of Quality Services and Director of Telemetry. During the tour, RN 3 was interviewed. When asked, RN 3 stated the unit was out of ratio on 2/12/22.

a. Review of the Assignment by Staff Member for Telemetry dated 2/12/22, for the day shift, showed the following:

* Three RNs were assigned to care for five telemetry patients from 0700 to 1900 hours.
* RN 15 was assigned to care for five telemetry patients from 0700 to 1405 hours.
* RN 16 was assigned to care for five telemetry patients from 0700 to 1705 hours.
* RN 17 was assigned to care for five telemetry patients from 0700 to 1530 hours.

b. Review of the Assignment by Staff Member for Telemetry dated 2/14/22, for the day and night shift, showed the following:

* RN 18 was assigned to care for five telemetry patients from 0700 to 1518 hours.
* RN 19 was assigned to care for five telemetry patients from 0700 to 1700 hours.
* RN 20 was assigned to care for five telemetry patients from 0227 to 0700 hours on 2/15/22.
* RN 21 was assigned to care for five telemetry patients from 0040 to 0700 hours on 2/15/22.

On 2/16/22 at 0954 hours, the Director of Quality Services verified the above findings.

Based on interview and record review, the hospital failed to ensure the nursing staff had evaluated the nursing care for five of 28 sampled patients (Patients 6, 10, 11, 19, and 20) as evidenced by:

1. Nursing staff including RN, CNA, and dialysis nurse were not wearing proper PPE in the contact isolation room for Patient 10 as per the hospital's P&P.

2. There was no documented alarms setting of the continuous cardiac monitor every four hours for Patient 11 as per the hospital's P&P.

3. The RN staff failed to ensure Patient 6 had appropriate monitoring and assessments after an angiogram procedure.

4. The RNs failed to supervise and evaluate nursing care for two of 28 patients (Patients 19 and 20) on the DOU and failed to monitor documentation for close/constant observation by the CNA (sitter).

These failures had the potential for unsafe care to the patients.

Findings:

1. Review of the hospital's P&P titled Standard Precautions/Transmission Based Precautions approved 8/21 showed to don gown on entry into the room or cubicle for contact precaution.

On 2/15/22 at 1001 hours, the surgical unit was toured with the Director of Quality Services and Director of Medical/Surgical unit. It was observed three staff in Patient 11's room not wearing a gown. The Contact Precaution signage was observed in front of Patient 11's room.

Review of the Contact Precautions signage showed, "to prevent the spread of infection anyone entering this room must: hand hygiene, gloves, and gown."

When asked, the Director of Medical/Surgical unit stated the three staff were RN 22, CNA, and dialysis nurse. RN 22 was observed leaving Patient 10's room. When asked, RN 22 stated she was not assigned to care for Patient 10. She stated she parked her WOW and taking it out now.

Patient 10's medical record was reviewed on 2/16/22. The medical record review showed Patient 10 was admitted to the hospital on 2/2/22. Review of the Physician's Order dated 2/2/22 at 0529 hours, showed to initiate the Contact Precaution.

On 2/16/22 at 0954 hours, the Director of Quality Services verified above findings.

2. Review of the hospital's P&P titled Standards of Nursing Practice: Telemetry approved date 4/21 showed the following:

* The rate and alarms will be assessed and documented on admission and each shift. Rate and alarms will be documented every four hours in the central monitor telemetry log.

* Alarms are set for all parameters per default configurations or as appropriate for patients per physician order or nursing judgment.

On 2/15/22 at 1023 hours, the telemetry unit was toured with the Director of Quality Services and Director of Telemetry. Monitor Tech 1 was monitoring for the telemetry patients in the central monitoring room.

Patient 11's heart rate was observed from 135 to 140 bpm on the telemetry monitor. When asked, Monitor Tech 1 stated the default alarm setting was less than 50 bpm and greater than 120 bpm. Monitor Tech 1 stated Patient 11's heart rate was less than 50 bpm and greater than 145 bmp.

On 2/16/22 at 0854 hours, the central monitoring room was toured again with the Risk Manager. When asked, Monitor Tech 2 stated the setting for Patient 11's heart rate was less than 50 bpm and greater than 145 bpm. Monitor Tech 2 was asked when the heart rate setting was changed, Monitor Tech 2 stated there was no record to find out the alarm setting.

On 2/16/22 at 0954 hours, the Director of Quality Services verified the above findings.


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3.a. Review of the hospital's P&P titled Sedation - Moderate or Deep: Care of the Adult, Pediatric and Neonatal Patient approved date 10/1/16, showed post procedure monitoring includes continuous pulse oximetry and cardiac monitoring if the patient undergoes sedation. Fentanyl (opioid pain medication) IV has a duration of 30 to 90 minutes. Fentanyl is a high risk medication for respiratory depression. Versed (strong sedative medication) IV has a high risk for respiratory depression and apnea.

On 2/15/22 at 1029 hours, a tour of the Cardiac Cath Lab Holding Room was conducted with the Manager of Quality Services and IP. Patient 6 was observed laying in a gurney in a separate room off the main Cardiac Cath Holding Room unit. RN 5 was sitting next to the patient. RN 5 went to Patient 6's gurney and asked the patient to open the eyes. Patient 6 opened the eyes very slowly and closed them again. Patient 6 was not on continuous pulse oximetry or cardiac monitoring. When asked, RN 5 stated only helping out as the RN assigned to the Cardiac Cath Lab to assist in procedures.

On 2/15/22 at 1037 hours, an interview was conducted with RN 6 regarding Patient 6. The RN stated Patient 6 should have been on continuous cardiac and pulse oximetry monitoring as the patient received sedative medications during the procedure. RN 6 stated Patient 6 should also be monitored for bleeding at the insertion site, lay flat in bed, and to have the pedal pulses checked at interval times.

RN 6 went to Patient 6's room and assisted RN 5 in placing the patient on the cardiac monitor and pulse oximeter.

On 2/15/22, review of Patient 6's medical record was initiated. Patient 6 was admitted to the hospital on 2/14/22, for a wound infection on the left leg.

Review of Patient 6's Consent to Surgery showed the patient signed to have a angiogram of the left leg with endovascular intervention on 2/15/22 at 0740 hours.

Review of the Sedation report dated 2/15/22, showed Patient 6 received fentanyl and versed at the following times:

* Versed 1 mg IV and fentanyl 50 mcg IV at 0805 hours.
* Versed 1 mg IV and fentanyl 50 mcg IV at 0844 hours.
* Fentanyl 50 mcg IV at 0853 hours.
* Versed 1 mg IV and fentanyl 50 mcg IV at 0943 hours.
* Versed 1 mg IV at 0947 hours.

On 2/15/22 at 1235 hours, the Manager of Quality acknowledged Patient 6 was not on continuous cardiac and pulse oximeter monitoring in the Cardiac Cath Holding Room at the time of the observation.

b. The Manager stated MD 4 failed to order the post-operative assessment and monitoring parameters for Patient 6. However the hospital had an order set which was approved by the medical staff for angiogram patients. It was to be used at the MD's discretion and preferences, and it could be modified. The order set was a standardized method for monitoring and assessing post angiogram patients.

Review of the hospital-approved Order Set sample for Cardiac Cath - PCI - PTCA - Angioplasty Post-Op showed to perform the following:

* Check catheter insertion site for bleeding or swelling and distal extremity for warmth, color and presence of pulses every 15 minutes x four, then every 30 minutes x four, and then every hour.

Review of Patient 6's Case Synopsis dated 2/15/22, showed the following:

* At 0814 hours, there was a percutaneous stick to the right groin.

* At 0828 hours, a guidewire was inserted.

* At 0850, 0930, 0938, 0949, 0952, and 0956 hours, Patient 6 received angiograms through the insertion site.

* At 0957 hours, the sheath was removed.

* At 0957 hours, the closure device to the insertion site was successful. The procedure was complete.

* At 1022 hours, Patient 6 was received to the Holding area.

However, further review of Patient 6's Case medical record failed to show documentation of the groin site and pedal pulses. For example, RN 11 assessed Patient 6's groin and pedal pulses at 1024 and 1030 hours. However, the patient's groin site and pedal pulses were not assessed again until 1100 hours.

On 2/16/22 at 1014 hours, the above findings were shared with the Manager of Quality Services.


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4. On 2/15/22 at 1257 hours, a tour and observation of the DOU was conducted with the Nurse Manager. Patients 19 and 20 were observed in bed with a sitter stationed between the foot of their beds.

Patient 19 was admitted on 1/27/22. Patient 20 was admitted on 2/11/22.

Review of the nursing assignment sheet dated 2/14/22, the 7 PM - 7 AM shift, showed Patients 19 and 20 did not have a sitter for COO (constant/close observation) assigned to them. When asked if there were any sitters assigned, due to the assignment sheet showing no CNA assigned, the Nurse manager confirmed there were no sitters for Patients 19 and 20 on the night shift of 2/14/22.

On 2/16/22 at 1400 hours, a review of Patients 19 and 20's MD orders and COO Flowsheets was conducted with the Risk Manager.

Review of Patient 19's MD orders dated 2/12/22 at 1542 hours, showed an order for "Close observation." The Risk Manager confirmed the orders were written due to Patient 19 being confused, getting out of bed unassisted, and having poor safety awareness. Review of the Constant Observation Flow Sheet for Patient 19 showed two documented flowsheets, but one of them was not dated. The other flowsheet was dated on 2/15/22, day shift. The Risk Manager confirmed there was no other documentations to show the COO being done for Patient 19.

Review of Patient 20's MD orders and COO Flowsheets were reviewed with the Risk Manager. The MD orders for Patient 20 was dated 2/13/22, for Close/Constant Observation. There was no documented evidence of the CNA Flowsheet for Constant/Close Observation. The Risk Manager confirmed no documentation for close observation could be found.

Based on interview and record review, the hospital failed to ensure a standardized process for onboarding travel nurses to work in the patient care areas which included the signed job roles and expectations, timely competency validations, and supervisory oversight to ensure the travel nurses were providing safe and effective care to patients in the hospital. This failure created the risk of substandard of care for the patients receiving care from the travel nurses in the hospital.

Findings:

On 2/17/22 at 0939 hours, an interview and concurrent review of RN 5's personnel file was conducted with the Cardiac Cath Lab Manager.

The Manager was informed of observational findings concerning post-sedation recovery of a patient by RN 5 on 2/15/22 at 1033 hours, in the Cardiac Cath Lab Holding Room. Cross reference to A395 example #3.

When asked if RN 5 should have been independently working as an RN in the Cardiac Cath Lab Holding Room, the Manager stated RN 5 was paired with RN 9. The Manager stated the amount of time that an travel nurse required being paired with another RN was typically one day, but there were times that a travel nurse needed more support. The Manager stated RN 5 should not have been working independently yet as the RN started on 2/14/22. However, RN 9 was not with RN 5 at the time of the observation. The Manager stated RN 9 was most likely on a break.

Review of the 2022 RN Annual Core/Cath Lab/IR Holding Room RN Competency showed RN 5 showed the competency validation on 2/15/22, with a validation method of "D" which stood for "Affective." However, when asked, the Manager stated the form was an ongoing evaluation tool that the staff were given a period of time to complete since specific procedures were not presented at the time. This was typically given to onboarding the regular hospital RN staff as part of their new-hire orientation.

The Manager stated RN 5's experience and competence was validated initially using the travel agency's self assessment tool. However, when asked how the hospital independently validated the RN's competency, the Manager stated using the above validation tool.

When asked to provide a signed job description for RN 5 to work in the Cardiac Cath Lab and Cardiac Cath Holding room, the Manager stated the hospital did not procure a signed job description with the RN for the specialty area.

During an interview and concurrent review of the hospital's documents with the Risk Manager on 2/17/22 at 1025 hours, the Risk Manager stated the travel nurses were often onboarded quickly, especially during critical staffing levels. When asked to provide a standardized workflow for onboarding travel nurses to ensure their competency, none was provided.

The Risk Manager stated the travel nurses were also given a Traveler/Registry Evaluation Packet, which was a checklist of the general competencies regarding the hospital operations, locations, and practices.

However, review of RN 5's Traveler/Registry Evaluation Packet failed to show the packet was completed until 2/16/22. Additionally, there was no evidence of the competency evaluation for specific cardiac catheterization procedures which RN 5 was hired for. When asked for the signed job description of RN 5 other than the general signed job description from the travel agency, none was provided.

The above findings were shared with the Cardiac Cath Lab Manager on 2/17/22 at 1035 hours.

Based on observation, interview, and record review, the facility failed to ensure the hospital's P&P or physician's orders were implemented for four of 28 Patients (Patients 1, 11, 13, and 16) as evidenced by:

1. Failed to implement the restraint P&P for assessment and renew restraint order for Patient 13.

2. There was no physician's notification when the patient's out-of range vital signs as per the physician's order for Patient 1.

3. There was inconsistent documentation of CHG (chlorhexidine) bathing as per the hospital's P&P for Patient 11.

4. There were two conflicting nursing policies for continuous cardiac monitoring.

5. The hospital failed to obtain the Governing Body approval prior to changing and implementing the blood transfusion P&P.

6. The heparin medication was not labeled as per the hospital's P&P for Patient 16.

These failures increased the risk of substandard healthcare outcomes to the patients.

Findings:

1. Review of the hospital's P&P titled Restraint and Seclusion approved date 6/21 showed appropriate interval for re-assessment is based on the patient needs, condition, and type of restraint use. The P&P also showed the real-time documentation of assessment of restrained patient status at every two hours for two point restraints for non-violent or medical support restraint track.

Patient 13's medical record was reviewed on 2/16/22, with the Manager of Quality Services. The medical record review showed Patient 13 was admitted to the hospital on 2/14/22.

a. Review of the Physician's Order dated 2/15/22 at 0341 hours, showed to initiate two points soft restraint to Patient 13 for interfering with the medical devices. When asked, the Manager of Quality Services stated Patient 13 was still on a restraint.

Review of the Restraint Patient Assessment dated 2/15/22 showed the restraint was initiated at 0400 hour, and reassessment was performed every two hours until 2/16/22 at 0500 hours. However, further medical record review failed to show the restraint reassessment between 1200 to 2000 hours (for eight hours) on 2/15/22.

b. Patient 13's medical record was reviewed on 2/16/22, with the Manager of Quality Services. The medical record review showed Patient 13 was admitted to the hospital on 2/14/22. Review of the Physician's Order dated 2/15/22 at 0341 hours, showed to initiate two points soft restraint to Patient 13 for interfering with the medical devices. When asked, the Manager of Quality Services stated Patient 13 was still on restraint. When asked, the Manager of Quality Services stated the restraint order should be renewed every 24 hours.

Review of the Physician's Order dated 2/15/22 at 0340 hours, showed to contact the physician for evaluation of restraint renewal. The order also showed to obtain the renewal order by 2/16/22 at 0240 hours. However, further medical record review failed to show the restrain renewal order by 2/16/22 at 0240 hours.

c. On 2/16/22 starting at 1300 hours, Patient 13's medical record was reviewed with the Manager of Quality Services. Review of the Physician's Order dated 2/15/22 at 0341 hours, showed to initiate the two points soft restraint to Patient 13 for interfering with the medical devices. When asked, the Manager of Quality Services stated Patient 13 was still on the restraint.

Review of the Restraint Patient Assessment dated 2/16/22, showed there was no documented evidence of the restraint patient assessment since 0500 hours. The Manager verified there was no real-time documentation of the assessment for the restrained patient status.

2. Review of the hospital's P&P titled Patient Daily Bathing with chlorhexidine Gluconate (CHG) approved 12/21 showed daily bathing with CHG will reduce colonization of MRSA and VRE. Daily bathing with CHG also reduces the risk of healthcare acquired infections such as central-line associated bloodstream infections. CHG prevents infections with a persistent antimicrobial effect; providing up to six hours of protections against bacteria, viruses, and fungi. The P&P also showed to document CHG bath in electronic documentation record. CHG baths do not require an order and should be documented in the Adult ADLs section in I&O/Net.

On 2/15/22, Patient 1's medical record was reviewed with the Director of Quality Services. The medical record showed Patient 1 was admitted to the hospital on 7/22/21, and discharged on 9/26/21.

Review of the CLABSI Drill Down Form showed Patient 1 received the central line insertion on 7/23/21, to the right intrajugular.

Review of the medical record failed to show the daily CHG bathing on 7/25, 7/28, 8/7, 8/19, 8/27, and 9/4/21. The daily CHG bathing was performed to the right intrajugular on 9/5/21.

3. On 2/15/22 at 1023 hours, the telemetry unit was toured with the Director of Quality Services and Director of Telemetry. Patient 11's heart rate was observed to range from 135 to 140 bpm on the telemetry monitor.

Patient 11's medical record was reviewed on 2/16/22. The medical record showed Patient 11 was admitted to the hospital on 2/9/22.

Review of the Physician's Order dated 2/9/22 at 2103 hours, showed to notify the physician/provider if the hear rate greater than 120 bpm and less than 50 bpm.

Review of the Vital Signs from 2/13/22 at 2226 hours to 2/15/22 at 0741 hours, showed Patient 11's heart rate was between 84 and 110 bpm. Further Vital Signs dated 2/15/22 showed the following:

* At 0800 hours, Patient 11's heart rate was 129 bpm.
* At 1049 hours, Patient 11's heart rate was 134 bpm.
* At 1102, 1115, and 1600 hours, Patient 11's heart rate was 130 bpm.

However, further medical record review failed to show the physician's notification regarding the abnormal vital signs as per the physician's order.

4. On 2/15/22 at 1023 hours, the telemetry unit was toured with the Director of Quality Services and Director of Telemetry. Monitor Tech 1 was monitoring for the telemetry patients in the central monitoring room. When asked, Monitor Tech 1 stated the default alarm setting for the telemetry patients was less than 50 bpm and greater than 120 bpm. When asked, Monitor Tech 1 stated she communicated with an assigned nurse to change the alarm setting.

On 2/15/22 at 1044 hours, RN 2 was interviewed. When asked, RN 2 stated the parameter for telemetry monitoring alarm was to be determined by the physician.

Review of the hospital's P&P titled Standards of Nursing Practice: Telemetry approved date 4/21 showed the alarms are set for all the parameters per default configurations or as appropriate for the patients per the physician's order or nursing judgment.

Review of the hospital's P&P Telemetry and Remote Telemetry Monitoring approved date 12/21 showed all telemetry alarm parameters are kept at the default settings or per the physician's orders.

The above two P&Ps for the telemetry monitoring showed conflicting information.

On 2/16/22 at 0954 hours, the Director of Quality Services verified the above findings.


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5. Review of the hospital's P&P titled Blood & Blood Product: Obtaining a specimen; Obtaining Blood from Blood Bank; Administration of Blood Product; Monitoring the Patient reviewed date 12/10/21, showed the following information:

A. Orders for transfusion must include: patient's name, date of birth, medical record number, component needed, any special instructions, number of volume need for transfusion, date/ time of infusion, flow rate or period of treatment.

B. Before beginning any transfusion, two licensed nurses, or a physician and licensed nurse must check the information printed on the Blood Bank Transfusion Record and the information printed on the blood bag identification label against the patient's wristband.

a. Both staff must sign the Transfusion record in the space provided.
b. Record the patient's pre-transfusion vitals signs in the place provided.
c. Take vital signs again and record 15 minute vital signs on the Blood Bank Transfusion Record.
d. At the completion of the transfusion, obtain and record the patient's vital signs again, and sign the transfusion record in the space marked "Transfusion Completed."
e. Note in the space provided on the Blood Bank Transfusion Record if any reaction symptoms have been noted.
f. At the completion of the transfusion be sure the Blood Bank Transfusion Record is completely filled out.

Medical record review for Patient 17 was reviewed on 2/16/22. The medical record showed Patient 17 was admitted to the hospital on 2/15/22.

Review of Patient 17's medical record showed a physician's order dated 2/15/22, to transfuse one unit of packed red cells, stat (immediately) for an acute upper gastrointestinal bleed with hemoglobin (a protein in the red blood cells that carriers oxygen) below 7 g/dl.

Review of Patient 17's medical record showed the Blood Transfusion Audit Report dated 2/15/22. The Blood Transfusion Audit Report failed to show the transfusion stop time, or signs of transfusion reactions.

On 2/16/22 at 1300 hours, an interview and concurrent medical record review was conducted with the Director of Clinical Information. The Director of Clinical Information stated she was unable to find the Blood Transfusion Record in Patient 17's medical record because they longer used the Blood Transfusion Record form since they converted to their the new electronic health system.

On 2/17/22 at 0930 hours, an interview was conducted with the CEO, Director of Quality Services, and Chief Medical Doctor. The CEO stated they reviewed the P&Ps every month, and if there was a change to a P&P, the GB would meet to discuss the proposed changes with the involved work groups before it was approved, and added the GB was responsible for the hospital's P&Ps, and the P&P on blood transfusions had not been revised to show the hospital's current practice.

On 2/17/22 at 0745, an interview and concurrent hospital record and medical record review was conducted with the Manager of Quality Services. The Manager of Quality Services stated the Blood Transfusion Record was no longer in use and added they did not obtain the GB's approval prior to changing and implementing changes to the blood transfusion P&P. The Manager of Quality Services was informed and acknowledged the above findings.


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6. On 2/15/22 at 1215 a tour of the DOU was conducted.

During the tour, an interview and concurrent medical record review for Patient 16 was conducted with RN 8. RN 8 stated Patient 16 was on a heparin drip at 5 ml/hr for atrial fibrillation.

RN 8 stated the heparin bag was not dispensed by the pharmacy. The heparin bags were available in the DOU and stored in the pyxis dispensing cabinet.

RN 8 further stated the heparin bag had to be labeled by the nurse. When asked about the labeling policy for a heparin, RN 8 pointed to a pink label and stated the blanks needed to be filled in.

Review of the pink label showed the following:
- Parenteral Solutions
- Patient
- Room
- Bottle No.
- Date
- Time
- Solution
- Medication Added:
- Rate
- ml/hr
- gtts/min.
- By
- Exp. Date

When asked if the heparin bag currently being administered to Patient 16 had a pink label on it, RN 8 stated it did not.

On 2/17/22 at 0851 hours, the Pharmacy Director was interviewed about the labeling of heparin bags. The Pharmacy Director confirmed the heparin bags should be labeled by the nurses with the pink label.

Based on observation and record review, the hospital failed to ensure the nursing staff administered the medications for one of 24 sampled patients (Patient 12) as per the hospital's P&P, increasing the risk of sub-optimal care for the patient.

Findings:

Review of the hospital's P&P titled Medication Administration, Attachment A approved 4/30/18, showed the patient education includes asking the patient about the medication was ever taken before, and if so, to educate the patient or family on the expected therapeutic outcomes and side effects, and to document the teaching.

On 2/15/22 at 0900 hours, an observation of RN 7's medication pass for Patient 12 was conducted with the Manager of Quality Services, 2E Nurse Manager, Director of M/S and Telemetry, and 3E Interim Nurse Manager in the designated COVID-19 unit on 2 East.

RN 7 was observed with Patient 12's medications in hand, standing outside of the patient's room. RN 7 manually over-rode the patient's barcode scan to verify the right patient and right medications, stating not being able to bring the WOW into the patient's room to scan the patient's arm barcode. The RN scanned each individual medication using the barcode scanner and compared the medication to the MAR. The medication pills were then crushed and placed in a medication cup. The RN mixed the crushed medications in the cup with applesauce.

RN 7 performed hand hygiene and donned PPE before entering Patient 12's room. Patient 12 was sitting upright in bed. RN 7 brought in the patient's label and verified the name, date of birth, and medical record number with the patient and the patient's armband. RN 7 stated to Patient 12, " These are your vitamins," before feeding the crushed medications mixed with applesauce to Patient 12 with a spoon. RN 7 failed to state each medication and ask if the medications were new for Patient 12.

On 2/16/22 at 1000 hours, an interview and concurrent review of Patient 12's medical record was conducted with the Manager of Quality Services. Patient 12 was admitted to the hospital on 2/7/22.

Review of the physician's orders dated 2/8/22 at 0116 hours, showed to place Patient 12 on Continuous Precautions, Enhanced COVID.

Review of the MAR showed Patient 12 was administered the following medications at 0921 hours.

* Ascorbic acid (vitamin C) 500 mg by mouth.

* Cholecalciferol (vitamin D3) 25 mg by mouth.

* Famotidine (reduces stomach acid) 20 mg by mouth.

* Fluticasone (steroid) nasal 0.05 mg/inh spray, 0.1 mg in each nostril.

* Folic acid (B vitamin) 1 mg by mouth.

* Metoprolol (reduces blood pressure) 25 mg by mouth.

* Multivitamin 1 tablet by mouth.

* Thiamine (vitamin B1) 100 mg by mouth.

* Zinc sulfate (mineral & electrolyte) 220 mg by mouth.

The Manager was informed of and acknowledged the above findings. The Manager acknowledged RN 7 failed to state and discuss each medication administered to Patient 12 during the medication pass observation as per the hospital's P&P.