HospitalInspections.org

Based on record review, observation and interview, the hospital failed to:
A. provide a safe environment for 11 of 11 rooms (21 beds) in the "geri-psych" unit by not removing ligature fixtures and furniture from the rooms.
B. address and treat patient's pain per hospital policies and procedures.

These failed practices had the potential to cause harm to any patient admitted to the unit with suicidal ideations and cause significant physical and psychological consequences for patients in pain.

Findings:

A. Safe Environment

On 05/22/17 at 3:30 pm, surveyors observed 5 of 11 bedrooms, on the 4th floor "geri-psych" unit with the following ligature and safety risks:
A. Hospital beds were moveable with open side rails
B. O2 wall set up
C. Curtains were not breakaway
D. Two lightweight, open armed chairs in each room
E. Bedside tables. Lightweight
F. Sink cabinets with outside hinges
G. Possible ligature fixtures
H. Footboards with quarter to half dollar sized openings
I. Long plug-in cords and long nurse call light cords (4')
J. End tables with decorative loop hardware
K. Phillips screws, lose or easily removed
L. Extension joint with Phillips screws running the length of the room
M.Bed alarm cords in the cubby spaces
N. Bathroom ligature fixtures

The remaining 6 rooms had been "remodeled" and contained anti-ligature fixtures in the bathrooms.

Surveyors observed in the Seclusion Room the following potentials for harm:
A. Bathroom with no anti-ligature fixtures
B. Screw loose on light fixture
C. Sharp-edged metal light surround coming loose from the ceiling
D. Curtain hardware on tract

Surveyors observed in the Day Room the following potentials for harm:
A. Round door knobs
B. Bathroom with no anti-ligature fixtures
C. Metal light fixtures
D. Sinks with no anti-ligature fixtures
E. Light weight chairs
F. Thermostat not covered
G. TV on pivoting wall mount with no cover
H. Gases access plate was loose
I. Two O2 wall mounts

On 05/25/17 at 10:00 am, Staff G stated a risk analysis of all floors had been started. In January 2017 staff had performed a risk analysis of the "geri-psych" unit identifying areas of routine improvement needed. Six of 11 rooms in the unit were updated with anti-ligature hardware.

B. Management of Pain

Document titled "Patient/Parents/Guardians Rights" showed patients had the right to management of pain, quick response from health providers to reports of pain, and staff committed to pain prevention.

Document titled "Patient Admission Assessment and Reassessment" showed pain should be identified and treated within the organization or referred for treatment.

Document titled "Pain Assessment and Management" showed staff provided pain medication administered relative to pain scale rating.

4 (Patients #3, 12, 19, and 21) of 30 medical records showed nursing staff failed to provide pain medication and other pain control measures for complaints of moderate to severe pain. There were no documented reasons pain medications or other pain control measures were not provided.

On 05/27/17 at 11:05 am, Staff B stated pain control measures should be provided based on patient reports of pain, physician orders for pain control and nursing assessment; and reported staff should notify the physician if a patient's pain remained uncontrolled.

Based on record review and interview, the hospital failed to develop a hospital-wide quality program that measured, analyzed, and tracked patient quality data to improve health outcomes.

This failed practice had the potential for improper or inadequate care and health outcomes.

Findings:

No data collection analysis, trending or action plans were present in the following documents:
1. Meeting Minutes Patient Safety July 18, 2016
2. Meeting Minutes Patient Safety August 11, 2016
3. Meeting Minutes Patient Safety November 11, 2016
4. Meeting Minutes Quality Council April 20, 2017
5. Quality/Performance Improvement Report Department Risk, dated January, February and March 2017

On 05/24/17 at 10:43 am, Staff C stated these elements were not analyzed and trended and action plans were not documented; and reported the Quality Improvement Plan was reviewed every 3 years.

Based on record review and interview, the hospital's Governing Body failed to assume full responsibility for establishing an on-going quality improvement program that included evaluating performance improvement efforts and review of projects annually.

A document titled "Performance Improvement Plan" dated 4/2015 was provided as the current Quality Improvement Plan. Documents titled meeting minutes for "Medical Staff", "Patient Safety", "Quality Council" and "Quality/Performance Improvement Reports" were reviewed. There was no documentation in any of the documents provided that data collected was measured, analyzed, and tracked to improve health outcomes.

On 05/24/17 at 10:43 am, Staff C stated the Quality Improvement Plan was evaluated with projects reviewed every 3 years and that he/or she was unaware the plan needed to be reviewed annually.

Based on record review and interview the hospital failed to:

A. Ensure patient's pain was adequately controlled, assessed and monitored frequently based on patient condition, and neurological assessments performed on patients with neurological conditions (See Tag A-0395)

B. Ensure nursing staff developed, implemented and revised a care plan by assessing the patient's needs (See Tag A- 0396)

C. Ensure titratable medications administered according to hospital policy and manufacturer's recommendations, and education/competency assessment provided to nursing staff (See Tag A-0405)

Based on record review and interview the hospital failed to:

A. Ensure the registered nurse evaluated that patients were being assessed and monitored according to hospital policy and individual condition.

B. Ensure the registered nurse evaluated pain control measures based on assessment, facilitate regular reassessments and follow-up per hospital policy

C. Ensure the registered nurse evaluated the neurological status of patients with neurological conditions on a regular basis for signs of clinical deterioration

This failed practice had the potential to affect patient safety as diligent nursing surveillance of vital signs and thorough patient assessment can lead to timely recognition of early clinical deterioration.

Findings:

A. Assessed and Monitored

Document titled "Patient Admission Assessment and Reassessment" show initial nursing assessment completed within time frames specified for each unit. Reassessments and vital signs conducted within time frames specific to nursing unit and based on patient's condition.

According to the National Institute for Health and Care Excellence (NICE) it is recommended vital signs be taken as part of the initial patient assessment. Pain is also recommended for routine monitoring depending on the circumstances.

According to the American Stroke Association Guidelines show vital sign monitoring is recommended every 15 minutes during the acute phase of stroke and hourly for intensive care admissions.

Ongoing assessment of vital signs are recommended by the Trauma Nursing Core Course Guidelines.

Standards for Frequency of Measurement and Documentation of Vital Signs and Physical Assessments show the frequency should be based on patient needs/condition. Minimum standards should be set to meet the needs of the majority of patients within the clinical area while allowing for individualizing for each patient.

15 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 19, 20, and 21) of 30 medical records showed vital signs were not recorded in the patient's medical record as performed per health care provider's order or hospital policy.

On 05/25/17 at 10:50 am, Staff S stated vital signs, intake and output and pulse oximetry are at nursing discretion and there is no specific guideline for how often these should be taken.

On 05/25/17 at 11:10 am, Staff Q stated he/or she is not aware of any policy or procedure for the frequency of vital signs. Staff Q stated vital signs should be recorded at minimum every shift; and reported many times nursing staff document vital signs as they find them.

On 05/25/17 at 12:32 pm, Staff P stated vital signs and pulse oximetry for patients on the floor are documented a minimum of every shift unless ordered more often; and reported stated for patients admitted to ICU, vital sign monitors take readings every 15 minutes, and nursing staff are required to document at a minimum every hour in the patient's medical chart.

B. Pain Assessment and Follow-up

Document titled "Patient Admission Assessment and Reassessment" show pain should be identified and treated ...assessment including measure of pain intensity and quality recorded in a way that facilitates regular reassessment and follow-up.

Document titled "Patient/Parents/Guardians Rights" show patient has right to expect state of art pain management and quick response from health providers to pain reports.

Document titled "Pain Assessment and Management" show staff provide prompt assessment and management of pain to optimize comfort. Pain medication administered relative to pain scale rating and assessment of nurse. Cases of unrelieved pain, care provider will consult physician and other appropriate resources.

4 (Patients #3, 12, 19, and 21) of 30 medical records showed nursing staff failed to assess and re-assess pain after the administration of pain control measures and consult care provider when pain unrelieved.

On 05/27/17 at 11:05 am, Staff B stated pain control measures should be provided based on patient reports of pain, physician orders for pain control and nursing assessment; and reported nursing staff should assess effectiveness of pain medication within one hour of administration. Staff B stated staff would notify physician if patient's pain remained uncontrolled.

C. Neurological Assessment

Document titled "Patient Admission Assessment and Reassessment" show initial nursing assessment completed within time frames specified for each unit. Reassessments conducted within time frames specific to nursing unit and based on patient's condition.

Document titled "Neurological Flowsheet" show assessment included vital signs, orientation, speech, method used to awaken patient, nonverbal reaction to pain, ability to move, grip strength and pupillary reaction. Last revision of flowsheet was done in September 2000. No evidence this flowsheet was based on current evidence based practice for neurological assessment.

American Stroke Association Guidelines state neurological assessments using a standardized tool should be performed frequently.

American Heart Association Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient Scientific Statement show neurological assessments should be done frequently.

6 (Patients #8, 11, 25, 26, 28, and 29) of 6 medical records showed patients with neurological conditions had no evidence of a standardized neurological assessment or check performed by nursing staff on a regular basis to determine any clinical deterioration.

On 05/25/17 at 10:50 am, Staff S stated assessment of neurological status for medical/surgical units would be every two hours for the registered nurse.

On 05/25/17 at 11:53 am, Staff N stated vital signs including pulse oximetry in the emergency department are based on the admission order set which is system-wide; and reported he/or she is not aware of any unit specific or diagnosis specific guidelines.

On 05/25/17 at 11:10 am, Staff Q stated he/or she is not aware of a neurological assessment guideline or protocol for assessing patients with neurological conditions; and reported he/or she would do a neurological assessment every two hours.

On 05/25/17 at 12:32 pm, Staff P stated a neurological check or assessment would be standard every 15 minutes to two hours for patients with neurological conditions.

Based on record review and interview the hospital failed to ensure nursing staff maintained a nursing care plan by assessing patient's needs per hospital policy.

This failed practice had the potential to result in delayed recognition and/or treatment of active problems that could influence patient recovery, functional status and quality of life.

Findings:

Document titled "Patient Admission Assessment and Reassessment" show the registered nurse responsible for analyzing patient data and identifying and prioritizing patient needs on the Care ...reassessment conducted within time frames for unit and based on patient condition.

7 (Patient #2, 3, 11, 19, 21, 24 and 25) of 20 records showed no evidence of revising or updating the patient's plan of care based on assessment and prioritized patient need.

On 05/25/17 at 12:32 pm, Staff P stated he/or she would initiate the care plan using the patient admitting diagnosis, then after the patient was assessed would look to see what else needed to be addressed; and reported the care plan can be updated as goals are met, partially met or not met. Staff P stated when a patient is discharged the care plan would be resolved.

On 05/25/17 at 11:10 am, Staff Q stated care plans are generally initiated at time patient admitted unless a registered nurse is not present. In this circumstance the care plan would be initiated on the next shift. Staff Q stated care plans are reviewed at minimum once a shift; and reported the primary diagnosis for patient would influence the care plan. Staff Q stated he/or she would look at what puts patient at risk for 30 day readmission and include this on care plan.

Based on record review and interview the hospital failed to:

A. Ensure all IV titratable medications were administered to patients according to hospital policy and manufacturer's recommendations.
B. Ensure nursing staff were provided education and competency assessment for IV titratable medication

This failed practice had the potential for this patient to have hypotension and tachycardia in the setting of acute ischemic stroke.

Findings:

Document titled "Titration/Taper of medications" show prescribers' orders should include the desired parameters for titratable medication. Dose ranges should be known before titration to allow clinical staff to determine how much to increase or decrease the dose ...titration attempts may vary depending on clinical status, medical conditions and other factors.

Document titled "Medication Administration and Documentation" show all orders to titrate should contain specific parameters to maintain the patient. Prescriber should be contacted if information is not given.
Manufacturer's "Full Prescribing Information" shows therapy should begin at a rate of 5mg/hr. If desired blood pressure (BP) has not been achieved at this rate, infusion rate can be increased by 2.5mg/hr every 5 to 15 minutes up to a maximum infusion rate of 15mg/hr. Once BP goal has been achieved can begin to decrease infusion rate to 3mg/hr. Continual monitoring of BP and heart rate (HR) is important during titration to avoid too rapid or excessive drop in BP.

American Stroke Association (ASA) Guidelines for the Early Management of Patients with Acute Ischemic Stroke show to initiate Nicardipine (Cardene) at 5mg/hr IV, titrate up by 2.5mg/h every 5 to 15 minutes with a maximum infusion rate of 15mg/hr. When desired BP reached, adjust to maintain desired BP limits. If BP remains uncontrolled or diastolic BP than 140mmHg consider IV Sodium Nitroprusside.

Patient #28 admitted for acute stroke and eligible for thrombolytic therapy (intravenous recombinant tissue-type plasminogen activator TPA - also known as the "clotbuster"). Order for Nicardipine (Cardene) infusion 5mg/hr once STAT. Nicardipine (Cardene) IV infusion started at 2.5mg/hr per verbal order at 8:37 am. Increased to 10mg/hr at 9:07am. Increased to 15mg/hr at 9:17 am and to 20mg/hr at 9:31mg/hr per physician order.
~ No evidence of specific titration parameters for a titratable medication per hospital policy
~ No evidence titration of medication followed any standard protocol, manufacturer's recommendation or evidence based practice
~ Increase to 20mg/hr exceeded manufacturer's recommended maximum dosage

On 05/24/17 at 12:18 pm, Staff R stated the hospital does have a policy for titratable drugs but Nicardipine (Cardene) is not included in the policy; and reported he/or she is not aware of any orientation, education or competency assessment for Nicardipine (Cardene) or titratable drugs for nursing staff.

On 05/25/17 at 12:32 pm, Staff P stated the hospital does have titration or drip protocols which include the titration parameters; and reported the physician indicates in the order to follow the protocol. Staff P stated not sure if all drips have a protocol; and reported he/or she is not aware of a protocol for Nicardipine (Cardene).

Based on record review and interview the hospital failed to demonstrate the development, implementation and approval process for protocols and standing orders that included the use of current nationally recognized evidence based guidelines.

This failed practice had the potential for inconsistencies in patient care and greater risk of medical errors for all patients.

Findings:

Document titled "Protocols & Standing Orders: Corporate Policy" show protocols based on nationally recognized evidence based guidelines. Medical Executive Committee (MEC) should approve the protocols. Specific criteria for protocols identified and education provided to staff prior to implementation. Annually protocols reviewed and approved by leadership and include relevance, preventable adverse events, intended use, and any additional training.

Document titled "ED Protocols/Standards of Practice - Protocols: Chest Pain, ACS, MI" revised date 03/15. No evidence the protocol:
~ Was revised based on current nationally recognized evidence based guidelines.
~ Defined specific criteria for what circumstances the protocol should be initiated and who was authorized to initiate.

Document titled "ICU Sedation Protocol for Ventilated Patients" no date of approval or revision. No evidence the protocol:
~ Was based on current nationally recognized evidence based guidelines
~ Identified who was authorized to initiate protocol

Document titled "STEMI PROTOCOL for OHI" no evidence protocol has been approved by leadership, based on current nationally recognized evidence based guidelines, defined specific criteria for what circumstances the protocol should be initiated and who was authorized to initiate.

On 05/25/17 at 11:30 am, surveyors requested 2016 leadership review and approval of protocols for the Emergency Department that included the determination if protocol was still current or any revisions and use of evidence based practice/guidelines, any adverse events and education of staff. At the time of exit conference no evidence had been provided.

On 05/25/17 at 11:05 am, Staff B stated he/or she was not aware if there is annual review of protocols to determine if protocols are still current with evidence based practice or guidelines, and determine if there any adverse events from their usage.

Based on record review and interview the hospital failed to ensure patient discharge summary was completed per hospital policy and CMS requirements.

Findings:

Document titled "Purpose and Objectives" showed medical record documentation should be appropriate to meet standards of licensing, surveying agencies and hospital bylaws, rules and regulations.

Document titled "Analysis of a complete Medical Record" showed Health Information Management (HIM) responsible for review of medical record for elements in accordance with CMS requirements. Discharge summary required on all inpatient and observation stays greater than 48 hours. No evidence policy requires completion of discharge summary within 30 days of patient discharge.

Patient #7 discharged on 04/02/17 shows no evidence of a discharge summary in the EHR at the time of survey.

On 05/25/17 at 11:05 am, Staff B stated discharge summary reports should be completed in the electronic health record (EHR) within 30 days of the patient's discharge.

Based on observation and interview, the hospital failed to provide a safe environment for 11 of 11 rooms (21 beds) in the "geri-psych" unit by not removing ligature fixtures and furniture from the rooms.

Findings:

See Tag A-0144

Based on record review and interview the hospital failed to:

a. Ensure hospital medical staff identified, reviewed and approved per hospital policy the specific criteria for implementing the criteria for implementing Emergency Department Protocols/Standards of Practice for:
~ Asthma Patient
~ Chest Pain
~ Patient with a Diabetic Emergency
~ Seizure
~ Vaginal Bleeding
~ Pediatric Fever
~ Stroke Team Activation
~ Chest Pain, Acute Coronary Syndrome (ACS), Myocardial Infarction (MI)

b. Ensure Protocols/Standards of Practice in the Emergency Department are current and based on nationally recognized evidence based practice or guidelines.

c. Ensure hospital leadership reviewed Protocols/Standards of Practice annually for any preventable adverse patient events per hospital policy.

This failed practice had the potential for inconsistencies in patient care and greater risk of medical errors for all patients.

Findings:

Document titled "Protocols/Standards of Practice" showed protocols had been approved by the Emergency Department Medical Director and Staff B (CNO) ...may be initiated by hospital and nursing personnel until physician is able to assume direct care.

Document titled "Protocols & Standing Orders: Corporate Policy" show protocols based on nationally recognized evidence based guidelines. Medical Executive Committee (MEC) should approve the protocols. Specific criteria for protocols identified and education provided to staff prior to implementation. Annually protocols reviewed and approved by leadership and include relevance, preventable adverse events, intended use, and any additional training.

On 05/25/17 at 11:30 am, surveyors requested 2016 leadership review and approval of protocols for the Emergency Department. At the time of exit conference no evidence had been provided.

On 05/25/17 at 11:05 am, Staff B stated he/or she was not aware of an annual review of protocols by hospital leadership per hospital policy.

Based on record review and interview the hospital failed to:

A. Ensure staff working in the emergency department (ED) had demonstrated specialized skills and competencies for working in the emergency department

B. Ensure nursing staff in the ED performed regular assessments to meet the needs of the patients.

This failed practice had the potential for all neurological patients who received emergency services to be placed at risk.

Findings:


A. Specialized Skills and Competencies

Document titled "Competency Assessment" showed departmental specific orientation would address department specific competency assessment and annually employees would receive additional education and training including a department specific competency assessment.

Document titled "State of Oklahoma Department of Health Classification of Hospital Emergency Services" effective 07/29/16 identifies hospital as Level II Emergency Stroke Service.

Title 310 Oklahoma State Department Of Health Chapter 667 Hospital Standards Subchapter 59 Classification of Hospital Emergency Services Section 310:667-59-20 Classification of emergency stroke services states a Level II Stroke Center shall be deemed to adhere to primary and secondary stroke recognition and prevention guidelines ...determined by an up-to-date certification as a Primary Stroke Center from CMWS or a Department approved organization that uses nationally recognized guidelines ...staff members trained in the care of the stroke patient.

American Stroke Association (ASA) Guidelines for the Early Management of Acute Ischemic Stroke showed implementation of stroke education is useful in increasing the use of thrombolytic therapy at community hospitals.

American Heart Association Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient Scientific Statement showed emergency personnel should be highly trained in stroke care ...educational programs for physicians, hospital personnel and EMS personnel increase the number of stroke patients who receive timely treatment.

2 (Staff O and S) of 8 personnel files showed no evidence of education and/or competency for care of a stroke patient.

1 (Staff T) of 8 personnel files showed evidence of a training course titled "2011 Population Specific: Stroke" completed on 02/15/11. No evidence of any additional education or competency assessment since 2011.

5 (Staff K, L, M, N, and U) of 8 personnel files showed evidence of a training course titled "Stroke: Know the Early Warning Signs" completed on 01/31/17. No evidence of education or competency in the care of the stroke patient.

1 (Staff N) of 8 personnel files showed evidence of a training course titled "Hospital Quality and Core Measures: Stroke (STK)" completed on 09/26/16.

On 05/25/17 at 11:53 am, Staff N stated not aware of the last time stroke education was completed for staff; and reported there is no current requirements for stroke education training or competency assessments.


B. Patient Assessments

Document titled "Patient Admission Assessment and Reassessment" showed reassessments conducted at intervals within time frames specific to nursing unit and contingent on patient's condition. ED RN assessment include ABC's (airway, breathing, circulation) immediately and triage within 20 minutes. Reassessment should be ongoing. Vital signs as needed as patient's condition dictates and at discharge if in department more than one hour.

Document titled "Neurological Flowsheet" showed assessment of vital signs, orientation, how patient awakens, nonverbal reaction to pain, ability to move to extremities, grip strength and pupillary reaction. Last revision of flowsheet was done September 2000. No evidence this flowsheet was based on current evidence based practice for neurological assessment.

Ongoing assessment of vital signs are recommended by the Trauma Nursing Core Course Guidelines.
Standards for Frequency of Measurement and Documentation of Vital Signs and Physical Assessments showed the frequency should be based on patient needs/condition. Minimum standards should meet the needs for majority of patients within the clinical area while allowing for individualizing for each patient.

American Heart Association Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient Scientific Statement showed frequent neurological assessments should be done frequently.

American Stroke Association (ASA) Guidelines for the Early Management of Acute Ischemic Stroke showed a patient's neurological status and vital signs should be assessed frequently.

5 (Patient #8, 18, 20, 26 and 28) of 20 records showed no evidence of reassessment after initial triage, frequent vital signs based on patient condition and at discharge.

2 (Patient#8 and 28) of 2 records showed no evidence of neurological assessments while the patient was in the emergency department.

On 05/25/17 at 10:50 am, Staff S stated there are no requirements in the ED for neurological assessment and vital signs for stroke, hemorrhage, or trauma; and reported vital signs and pulse oximetry are at nursing discretion and no specific guideline for how often these should be taken.

On 05/25/17 at 11:53 am, Staff N stated neurological assessments for stroke patients generally documented in the medical record or stroke packet that is scanned into the chart; and reported the ED does not have a guideline or policy for the neurological assessment for stroke, head trauma, hemorrhage or other neurological disorders. Staff N stated there is no standardized neurological assessment protocol for the ED; and reported there is no annual education or competency for stroke. Staff N stated vital signs including pulse oximetry in the ED are based on admission order set which is system-wide; and reported he/or she is not aware of any unit specific or diagnosis specific guidelines.