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Based on medical record reviews, review of facility policies, review of facility practice and interviews for two of nine patients reviewed for the performance of operative procedures (Patients #10 and #13), the facility failed to ensure that the procedure was performed at the correct site. The finding includes:

1. Patient #10 was admitted to the hospital on 5/21/14 for the removal of a right breast mass following radiology placement of a needle/wire for localization. The breast imaging request (biopsy worksheet) dated 4/30/14 directed mammographic needle localization at the 3 o'clock location for invasive cancer of the right breast. The patient's record identified that "time out" was performed by the Radiologist (MD #2) and the radiology technician prior to the procedure on 5/21/14 at 11:23 AM, in part, for site verification. The needle localization report dated 5/21/14 by MD #2 indicated that the patient returned to the radiology department for a repeat needle localization to the 3 o'clock position as the initial needle localization was incorrectly placed in the 9 o'clock position. Review of the patient's mammogram dated 4/22/14 with MD #2 on 12/2/14 noted that the patient had right breast clips located in the 3, 9 and 10 o'clock positions and an arrow pointed to the 9 o'clock position. Interview with MD #2 on 12/2/14 at 9:10 AM noted that there was a question regarding the correct site as the arrow on the film pointed to the 9 o'clock position instead of the 3 o'clock position and/he she should have clarified the confusion with MD #6 prior to the initial procedure. The facility universal protocol policy directed a "time out" be conducted prior to the procedure to include, in part, verifying relevant images and results are properly labeled and appropriately displayed. Subsequent to the event, the facility submitted a corrective action plan (CAP) on 6/20/14 to include a new requirement for clear annotation of the target lesion by the breast radiologist on each mammogram and staff education. Based on record reviews, and review of facility documentation on 11/26/14 and 12/2/14, the facility was found to be compliant with the CAP as submitted.

2. Patient #13 was admitted to the hospital on 5/6/14 for a right total hip arthroplasty and left knee Cortisone injection. The operative consent signed by the patient on 4/9/14 identified right total hip arthroplasty and left knee Cortisone injection. The intraoperative record dated 5/6/14 indicated that the patient was a difficult intubation and the "time out" was performed prior to the right hip procedure. The record lacked documentation that a "time out" was conducted prior to the Cortisone injection. The operative report dated 5/6/14 noted that PA #1 administered an intra- articular Cortisone injection to the right knee (in error) and then administered Cortisone and Marcaine to the left knee as per the consent. Interview with RN#1 on 11/26/14 at 9:53 AM indicated that the patient's left knee was clearly marked by MD #7; procedures are not initiated until after the patient is intubated and PA #1 was "rushing." Interview with PA #1 on 11/26/14 at 11:45 AM noted that the difficulty of the intubation was a distraction; he/she proceeded with the injection without a formal "time out" and injected the right knee in error. Although the facility universal protocol policy identified that a "time out" prior to each procedure be conducted whenever there is more than one procedure being performed by separate procedure teams, the policy did not address the performance of a "time out " if each procedure was performed by the same team. Subsequent to the event, the facility submitted a corrective action plan (CAP) that included a requirement for a "time out" by the licensed practitioner and the RN prior to all steroid injections in the OR. The CAP also identified that documentation of an additional "time out" will be noted in the intraoperative record and OR staff education. Based on record reviews, review of facility documentation/education the facility was found to be compliant with the CAP as submitted.
The Governing Body Bylaws identified that the Quality Committee shall be a joint standing committee with the Board of Directors and shall provide oversight with regard to the quality of care, patient safety, and customer service provided by the Hospital.

1. Based on review of the clinical record, interview and hospital policy, the hospital failed to ensure the patient's (P#2) safety during an outpatient procedure. The finding includes:
a. Patient #2 was transferred from a skilled nursing facility to the interventional radiology department as an outpatient on 9/30/2014 for a gastrojejunostomy tube exchange, secondary to a malfunctioning jejunostomy port. The patient was transferred from the stretcher to the interventional table with a sliding board. Just prior to the procedure, the patient fell off the table, sustaining a contusion to the left cheek with a laceration to the left eye orbit. The patient was transferred to the Emergency Department where he/she underwent X-rays and a CAT scan of the head. Testing identified that the patient sustained a subdural hematoma and a fracture of the left acetabulum. The patient was admitted to the hospital for several days for observation, and was transferred back to the skilled nursing facility on 10/2/14.

b. During an interview on 12/2/14, Lead Technologist (LRT) #1 stated that the patient was known to the staff of interventional radiology because he/she had other procedures performed there. LRT #1 stated that the patient was non-verbal and never moved on his/her own. The patient had been transferred to the interventional table with a hard plastic sliding board, which had been left under the patient on the table as the procedure was anticipated to be of short duration. Additionally, lucite armboards were added on either side of Patient # 2 by sliding the armboard beneath the mattress of the table but not securing the armboards or the patient to the table. LRT #1 stated that as Patient #2 was prepped for the procedure, the patient moved his/her arm toward the procedure site and LRT #1, who was present with one other practitioner, moved away from the table to get some Kerlix when Patient #2 flipped to the left side and fell to the floor. LRT #1 stated that routinely, outpatients had not been strapped to the table, however, since this accident, straps were now available for both interventional tables utilized for procedures.
c. Review of the hospital's corrective action plan identified that interventional radiology staff were reeducated on safe patient transfers with the removal of the sliding board from beneath the patient, and physical contact with the patient by staff until the patient was securely strapped onto the table.
d. Interview on 12/2/14 with Asst. Director #1, identified that while unannounced observation of patient transfers and securing to the imaging table have occurred, the department had not created a policy to which staff are routinely educated to ensure ongoing security for all patients on the imaging table during procedures.



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2. Based on clincial record reviews, review of facility policies and procedures and interviews with facility personnel for one of three sampled patients who needed constant observation (Patient #15), the facility failed to ensure that suicide precautions were maintained. The findings include:

a. Patient #15 was admitted to the hospital on 1/11/14 after a suicide attempt. Review of the physician orders dated 1/11/14 identified that the patient was on constant observation and a regular diet. Further review failed to identify that that the patient was on suicide precautions and was to utilize plastic utensils. Review of the progress notes dated 1/21/14 identified that the patient complained to APRN #1 that he/she was on suicide precautions and was receiving metal utensils on his meal tray. Review of the physician orders dated 1/22/14 identified that the patient's diet order was changed which included suicide precautions, please use plastic utensils. Review of hospital policy identified that patients on suicide precautions are not to have metal utensils, cans, plastic or glass bottles on their trays. In addition, all trays entering the room must be checked by staff. Interview with the Nursing Director #1 identified that it is the resonsibility for nursing staff to check a patient's tray before giving it to any patient on suicide precautions.


3. Based on medical record reviews, review of facility policies, review of facility practice and interviews for one of three patients who had a wire/needle localization procedure (Patient #10), the facility failed to ensure that the wire was placed in the correct site. The finding includes:

Patient #10 was admitted to the hospital on 5/21/14 for the removal of a right breast mass following radiology placement of a needle/wire for localization. The breast imaging request (biopsy worksheet) dated 4/30/14 directed mammographic needle localization at the 3 'clock location for invasive cancer of the right breast. The patient's record identified that "time out" was performed by the Radiologist (MD #2) and the radiology technician prior to the procedure on 5/21/14 at 11:23 AM, in part, for site verification. The needle localization report dated 5/21/14 by MD #2 indicated that the patient returned to the radiology department for a repeat needle localization to the 3 o'clock position as the initial needle localization was incorrectly placed in the 9 o'clock position. Review of the patient's mammogram dated 4/22/14 with MD #2 on 12/2/14 noted that the patient had right breast clips located in the 3, 9 and 10 o'clock positions and an arrow pointed to the 9 o'clock position. Interview with MD #2 on 12/2/14 at 9:10 AM noted that there was a question regarding the correct site as the arrow on the film pointed to the 9 o'clock position instead of the 3 o'clock position and/he she should have clarified the confusion with MD #6 prior to the initial procedure. The facility universal protocol policy directed a "time out" be conducted prior to the procedure to include, in part, verifying relevant images and results are properly labeled and appropriately displayed. Subsequent to the event, the facility submitted a corrective action plan (CAP) on 6/20/14 to include a new requirement for clear annotation of the target lesion by the breast radiologist on each mammogram and staff education. Based on record reviews, and review of facility documentation on 11/26/14 and 12/2/14, the facility was found to be compliant with the CAP as submitted.

Based on review of clinical records and review of facility policy, for one (1) of three patient's reviewed for restraints (Patients #14), the facility administered chemical (medication) and physical restraints without conducting a comprehensive assessment of the patient including documentation of alternative measures tried and utilization of the least restrictive device possible. The finding includes the following:


a. Patient #14 presented to the ED on 4/13/14 at 6:00 PM with increased depression, mood swings and was three months pregnant. Review of the physician's physical exam indicated the patient was oriented to person, place, and time, was well nourished, and in no distress. The patient was medically cleared and transferred to the behavioral holding area to await a crisis evaluation. The physician note indicated that the patient ambulated to the behavioral health area, no apparent distress appeared anxious initially but was cooperative, alert, speaking full sentences and asking to go home. The clinical record reflected the patient started screaming at approximately 10:15 PM that s/he wanted to go home, was described as being "unable to listen", became threatening (not described) and spit at the nurse. The patient was subsequently placed in four-point restraints and medicated with Ativan 2 mg IM. The restraint flow sheet indicated that the patient was in four point "limb locked" restraints. The facility administered chemical (medication) and physical restraints without conducting a comprehensive assessment of the patient including documentation of and specific behaviors that posed a risk to self/others that warranted the administration of chemical restraints.


Review of the restraint policy defined a chemical restraint as a drug used to control behavior or to restrict the patient's freedom of movement and is not standard treatment for the patient's medical or psychological condition. The policy indicated that the decision to use restraints should be based on the assessed needs and only when less restrictive measures are ineffective.

Based on clinical record reviews, review of policies and procedures and interviews with facility personnel for one of one sampled patients reviewed for restraint usage, (P#45), the facility failed to ensure that a one to one evaluation was completed with the initiation and/or continuation of restraints. The findings include:

Patient #46 was admitted to the hospital on 11/21/14 an altered mental status. Review of the physician's orders dated 11/22/14 identified that the patient was to have bilateral mitts applied due to pulling at tubes and safety. Review of the progress notes dated 11/22/14-11/23/14 failed to identify that a one to one evaluation was conducted with the placement of restraint and/or the continuation of restraints. Review of hospital policy identified that a physician or licensed independent practitioner must perform a daily face to face evaluation of the patient to assess the need for restraints and the patient's psychological and physiological condition and document in the patient's medical record. Interview with the Medical Intensive Care Unit (MICU) charge nurse on 12/2/14 identified that the face to face evaluation was not completed by the physician.

Based on a review of clinical records and policy review, the hospital failed to ensure that one of three patients reviewed for restraint usage (Patient #55) was assessed within one hour following initiation of restraints in accordance with hospital policy. The finding includes the following:

a. Review of Patient #55's clinical record dated 9/26/14 at 4:55 PM indicated the patient was threatening and aggressive, and a code was called. The patient was placed in restraints with Benadryl 50 mg and Haldol 5 mg IM administered. The clinical record failed to reflect that the licensed independent practitioner (LIP) conducted a face to face evaluation of the patient within the one (1) hour stipulated time frame in accordance with facility policy.
Review of the facility policy indicated a face to face evaluation needs to completed within one hour of restraint application.

Based on a review of hospital documentation and interviews with hospital personnel, the facility failed to incorporate data collected from the compounding area of the pharmacy related to cultures that surpassed the recommended United States Pharmacopeia threshold and required intervention into the hospital's quality improvement program to ensure patient safety and quality of care. The finding included:


During a tour of the Pharmacy on 11/25/14 at 10:00 AM a review of the facility environmental monitoring reports were conducted. It was noted that two independent companies had completed testing of the compounding areas of the pharmacy from June of 2014 through October of 2014 to determine if microbial contamination was present. The reports noted that both surface and air sampling identified levels of bacteria and/or mold growth that required a plan of action. Interview with the Director of the Pharmacy and the Director of Infection Control on 12/2/14 at 1:45 PM indicated all samples were reviewed with MD #11 who was the hospital's infectious disease physician however the information had not been reported to the hospital's Quality Improvement committee. Interview with the Director of Quality Improvement on 12/2/14 at 2:00 PM identified the Quality Committee should have been informed of the testing results in the compounding areas of the pharmacy when the tests were initially conducted and/or when the test results were above the recommended USP 797 threshold as they were in June, August and September of 2014 to determine interventions that may have been needed and/or opportunities for improvement to effectively deliver quality care and ensure patient safety. The hospital's performance improvement management plan directed in part that appropriate systems would be in place to measure and evaluate the effectiveness of care and services. Service lines would be accountable for developing specific performance improvement plans, and for collaborating with senior leadership to achieve the organizations overall goals and objectives. The Quality Performance Improvement team was responsible for collaborating with leadership to develop and implement systems to measure the quality of care, identify and reduce adverse patient outcomes, improve service delivery systems and processes and enhance patient experience.

Based on review of the clinical record, review of hospital policies, review of hospital documentation and interviews with hospital personnel for one post-operative patient (Patient #11) who had a Cortrak tube inserted, documentation and interviews failed to reflect that a Cortrak protocol was in place and/or that all providers had been educated. The findings include:

Patient #11 was admitted to the hospital on 5/20/14 and underwent an elective anterior corpectomy of T11 and T12, partial corpectomy of L1 with anterior fusion of T10-L1 on 5/21/14. On post-operative day 2 (5/23/14) a Cortrak feeding tube was inserted by PA #2. Review of the clinical record and interview with PA #3 on 12/2/14 indicated that a follow up x-ray was performed (5/23/14, 12:27 AM) to verify tube placement and was interpreted by PA #2 and PA #3 as being in the correct position. Documentation and PA #3 indicated that auscultation after air insertion into the tube was positive. The patient's respiratory status was stable. However, the radiologist identified the tube was located in the left mainstem bronchus and within left lower lobe (5/23/14, 9 AM). The tube was removed. Review of hospital documentation and PA #3 indicated that the use of the Cortrak tube was initially implemented in 2011. Review of hospital documentation and interview with the Chief of Surgical Critical Care, MD #10 on 11/26/14 failed to reflect that a Cortrak feeding tube insertion protocol was in place at the time of the incident and/or that PA #2 was educated on the Cortrak tube insertion procedure.

Based on clinical record reviews, review of facility policies and procedures and interviews with facility personnel for one of three sampled patients (Patient #1), the facility failed to ensure that the family was notified when the patient had a change of condition. The findings include:

Patient #1 was admitted to the hospital on 9/5/14 with hypotension and diarrhea. Review of the physician progress notes dated 9/6/14 identified that the patient had profuse diarrhea, oliguria and low blood pressure and was transferred to the intensive care unit. Further review failed to identify that the family was notified that the patient had a change of condition. Review of hospital policy indicates that the physician is required to assess and provide interventions when a patient is experiencing a change of condition. Interview with MD #14 (Director of the Hospitalist) on 12/3/14 identified that the physician is responsible for notifying the family when the patient had a change in his/her medical condition.

1. Based on medical record reviews, review of hospital policies, and interviews for two of six patients reviewed for fall risk (Patients #35 and #39), the facility failed to initiate fall precautions as per policy. The findings include:
a. Patient #35 was admitted to the hospital on 11/20/14 with a diagnoses of seizures and a history of paraplegia. The fall risk assessments dated 11/20/14 through 11/23/14 at 7:32 PM identified that the patient was at medium and/or high risk for falls. The plan of care dated 11/20/14 through 11/23/14 indicated that the patient was at risk for falls and interventions included to implement the falls/precautions protocol. Observation on 11/24/14 at 10:05 AM noted that Patient #35 was in the bed with a yellow wrist band and bed alarm on. A yellow magnetic sign to denote fall risk was not posted for fall risk on the patient's doorframe. Interview with Registered Nurse (RN) #3 on 11/24/14 at 10:05 AM indicated that the patient should have a yellow magnet on the doorframe but the magnets could not be located on the unit. Subsequently, yellow fall risk, magnets were obtained for the unit and a magnet was placed on Patient #35's door frame.

b. Patient #39 was admitted to the hospital on 11/12/14 with diagnoses that included pulmonary disease and Clostridium difficile colitis. The fall risk assessment and/or safety plan of care dated 11/13/14 identified that the patient was at high risk for falls and interventions included fall precautions. Observations on 11/23/14 at 1:35 PM noted a enteric precautions sign on the patient's doorframe, the patient in the bed, and bed was at a high elevation from the floor. A yellow magnet to denote fall risk was not observed on the patient's doorframe at this time. Interview with the Nurse Aide on 11/23/14 at 1:56 PM noted that he/she checked the patient's doorframe, the yellow magnet was hidden behind the contact precautions sign, and he/she moved the magnet so that the magnet could be seen.

The facility fall prevention policy noted visual identifiers as a recommended intervention for those patients who are at moderate to high risk for falls to include the yellow magnet/laminated card on the doorframe.



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2. Based on a review of clinical records, interview and policy review, the facility failed to ensure that pain assessments were completed for three of five patients' (21, 22, and 38) in accordance with policy. The findings include the following:

a. Patient #21 was admitted on 11/21/14 with shortness of breath and a history of diabetes and end stage renal disease. The physician's orders dated 11/21/14 directed that Dilaudid 1 mg IV be administered every four hours for pain as needed (prn). On 11/23/14 at 12:00 AM, the patient rated their pain as an eight on a scale 1-10 (10 being the worst possible pain) and subsequently received pain medication. The facilty failed to reassess the patient within one hour to determine if the medication was effective. The clinical record indicated the paint rated pain as a 10 at 3:00 AM, however pain medication was not administered until 4:00 AM.

b. Review of Patient #21's clinical record dated 11/24/14 indicated the patient rated pain as a 9 (scale 1-10) at 1:51 AM and was medicated with Dilaudid IV at that time. The record failed to reflect that the patient's pain was reassessed until 6:00 AM when the pain level was identified as a nine.

c. Patient #22 was admitted on 11/15/14 and subsequently required coronary artery bypass surgery. Review of the care plan dated 11/15/14 identified a problem related to pain with an intervention to assess the patients pain every 30-60 minutes after medication/interventions. The physician's order dated 11/21/14 directed OxyContin 5 mg every four hours prn. The record indicated that the patient received OxyContin on 11/22/14 at 3:56 AM for a pain level of 10, on 11/23/14 at 3:00 PM for a pain level of 7, and on 11/24/14 at 3:23 AM for a pain level of 10. The record failed to reflect the patient was reassessed following the administration of pain medication to determine if the medication was effective.

d. Patient #38 was admitted to the hospital on 11/22/14 with a diagnosis of fractured right hip. Physician orders dated 11/23/14 directed Oxycodone 10 milligram by mouth every 4 hours as needed. The medication record dated 11/23/14 identified that the patient received the Oxycodone medication at 3:24 AM and 6:17 AM. The pain assessment scale dated 11/23/14 indicated that, although the patient's pain was assessed prior to the medication administrations, an assessment of the patient's pain following each medication administration was not documented. Interview with Nurse Manager #1 on 11/23/14 at 1:25 PM noted that following the administration of oral pain medication, the patient's pain should be reassessed in about one hour.

The facility pain assessment policy identified to reassess and document patient pain/pain relief following each pain management intervention within a timeframe allowing the intervention to take effect.

3. Based on a review of clinical records, interview and policy review, the facility failed to ensure that two of four patients (#12 and #14) had vital signs monitored in accordance with policy. The findings include the following:

a. Patient #12 presented to the ED on 5/18/14 at 2:15 AM after drug and alcohol use with suicidal ideation and was triaged as a level three (3). The clinical record indicated that the patient's vital signs were assessed upon triage on 5/18/14 at 12:34 AM then not again until 12:30 PM on 5/19/14, twelve hours later.

b. Patient #14 presented to the ED on 4/13/14 at 6:00 PM with increased depression, mood swings, was three months pregnant and was identified as a triage level three. Review of the clinical record indicated that vital signs were obtained at 6:01 PM and the patient rated his/her pain level as a 10 (scale 0-10). The clinical record failed to indicate that the patient's pain was addressed and/or additional monitoring for pain and/or vital signs after the initial assessment. Interview with the ED medical director on 12/3/14 at 11:00 AM indicated that follow-up assessments should be completed.
Review of the policy indicated that patients will be reassessed approximately every two hours for triage level 1, 2 and 3.

Based on medical record reviews, review of hospital policies, and interviews for 2 of 4 patients reviewed for fall risk and/or skin integrity and/or nutrition (Patients #35 and #39), the facility failed to develop a comprehensive plan of care and/or revise the plan of care. The finding includes:

1. Patient #35 was admitted to the hospital on 11/20/14 with diagnoses of seizures and a history of paraplegia. The initial nursing assessment dated 11/20/14 identified that the patient was admitted with two Stage III pressure ulcers. Observation on 11/23/14 at 11:20 AM noted pressure ulcers to the patient's coccyx and right ischium and treatments were applied to both areas by RN #3. Review of the patient's electronic medical record with RN #2 on 11/23/14 at 10:25 AM indicated that the although the patient had a problem regarding skin integrity, the patient's plan of care did not include this problem to include goals and/or additional nursing interventions.

2a. Patient #39 was admitted to the hospital on 11/12/14 with diagnoses that included pulmonary disease and Clostridium difficile colitis. The fall risk assessment and/or safety plan of care dated 11/13/14 identified that the patient was at high risk for falls and interventions included fall precautions. Observations on 11/23/14 at 1:35 PM noted that the patient was in the bed and that the bed was at a high elevation from the floor. Interview with Nurse Manager #2 on 11/23/14 at 1:35 PM indicated that the patient refuses to keep the height of the bed at its lowest position because it hurts his/her neck to look up at the TV. Review of the patient's record and interview with RN #4 on 11/23/14 at 1:42 PM noted that hourly rounding was conducted routinely on the unit and the patient refuses to keep the bed in the lowest position despite frequent education from staff. Although Patient #39 continued with unsafe behavior related to the height of the bed, the patient's plan of care was not revised other measures to better ensure the patient's safety. The hospital documentation of nursing process and care policy identified that the RN will make changes in the plan of care based on ongoing assessment and change in status.

b. Patient #39 was admitted to the hospital on 11/12/14 with diagnoses that included pulmonary disease and Clostridium difficile (C- diff) colitis. The assessment dated 11/13/14 identified that the patient had a 1.0 centimeter (cm) long by 0.6 cm wide by 0.3 cm deep right groin wound. Dietary notes dated 11/21/14 indicated that the patient had decreased oral intake related to infection. Observations on 11/23/14 at 1:35 PM noted an enteric precautions sign on the patient's doorframe. Review of the patient's record and interview with RN #4 on 11/23/14 at 1:42 PM noted that, although the patient had the C- diff infection, was incontinent of stool, and received treatment for the open groin wound, the problems of altered skin integrity and stool incontinence/C- diff infection were not addressed in the patient's plan of care to include goals and/or interventions.
The hospital documentation of nursing process and care policy identified that based on the initial assessment, the RN will collect data related to the patient's condition and/or needs, document expected outcomes and document a plan of care to achieve the expected outcomes.

Based on clinical record review and interviews for 1 (P#4) of 3 patients reviewed who received intravenous (IV) Acetaminophen (Tylenol), the facility failed to administer Acetaminophen according to manufacturer's recommendations. The findings include:
P#4 was admitted to the hospital on 9/11/14 with a partial small bowel obstruction which required surgery on 9/13/14. According to a discharge summary malnutrition was a concern and a nutrition evaluation for total parenteral nutrition (TPN) was done. P#4's weight on admission was 46.72 kg. (103 lbs.). P#4 had exhibited generalized discomfort and Acetaminophen IV was ordered. According to a physician's order dated 9/12/14 at 1:27 AM Acetaminophen 1000 milligrams (mg.) IV was to be given every 6 hours.
From 9/12/14 through 9/17/14 P#4 received a total of 18 doses of Acetaminophen 1000 mg. IV. On 9/18/14 nutritional laboratory studies suggested liver failure and Acetaminophen toxicity was identified. P#4's Acetaminophen level was 53.5 mcg/mL (Therapeutic level: 10-25 mcg/mL, Toxic level: >200 mcg/mL). P#4 was admitted to the intensive care unit (ICU) and treated for coagulopathy, hypotension and shock from acute liver failure secondary to Acetaminophen toxicity. Treatment included N-acetyl cysteine (NAC). After a complicated hospitalization including acute liver failure/acute kidney failure secondary to Acetaminophen toxicity and respiratory failure requiring ventilator support P#4 was discharged on 10/14/14 to a short term rehabilitation facility. Upon discharge P#4 was alert, oriented and tolerating a regular diet.
During an interview with MD#10 on 12/1/14 at 1:50 PM, MD#10 indicated he/she was the surgical attending for P#4. MD#10 saw P#4 daily and would review his/her current status. MD#10 indicated when reviewing P#4's "active" medication list the Acetaminophen IV did not appear on the list because the medication was only ordered for a 24 hour period and the order had expired. P#4 was additionally on Dilaudid for pain control and the documentation indicated he/she had adequate pain control. MD#10 indicated the Acetaminophen IV was ordered to avoid the use of opiates in an elderly person. Upon surveyor inquiry MD#10 did indicate that P#4 should have received a reduced dose based on his/her weight. MD#10 indicated P#4 had other factors that contributed to the development of Acetaminophen toxicity including a small bowel obstruction, malnutrition and dehydration. As a result of P#4 developing Acetaminophen toxicity practitioners were educated on medication reconciliation and the process for ordering Acetaminophen IV. In addition MD#15 presented formal education on Acetaminophen toxicity to practitioners and the case was reviewed by the department and necessary committees.
During an interview with the Director of Pharmacy on 12/2/14 at 12:30 PM, the Director of Pharmacy identified usual IV Acetaminophen dosage for an adult patient is 4000 mg. over a 24 hour period (1000 mg. every 6 hours) however the recommended dosage for an adult patient weighing less than 50 kg. was a maximum of 3000 mg. in a 24 hour period (650 mg. every 6 hours). The Director of Pharmacy indicated Acetaminophen toxicity develops as a cumulative effect. The Director of Pharmacy verified P#4 weighed less than 50 kg. The Director of Pharmacy indicated when Acetaminophen IV is ordered out of these dosage recommendations a warning appears in the electronic medical record. Acetaminophen IV can only be ordered for four doses in a 24 hour period therefore if the medication is ordered again the order appears as a new order not a reorder. In addition the physician, pharmacist and nurses do not see prior doses administered when viewing the order in the electronic medical record. In P#4's case each time the order was written it was written by a different practitioner, processed by a different pharmacist and therefore the order appeared to be for only 24 hours and felt by the pharmacists not to be an issue. The Director of Pharmacy indicated the hospital is in the process of limiting the number of doses that can be ordered in the electronic medical record "hard stop" and the ordering practitioner would see if the Acetaminophen was previously administered indicating a potential for a cumulative effect. Until that time all pharmacy staff has been educated to not dispense more than four doses of IV Acetaminophen at a time, evaluate if the medication had been previously administered and notify the ordering practitioner.
According to manufacturer's recommendations for injectable Acetaminophen the recommended dose for adolescents and adults weighing less than 50 kg. is 12.5 mg/kg. every 4 hours, or 15 mg. /kg. every 6 hours. Maximum single dose is 750 mg. Maximum daily dose is 3750 mg.

Based on medical record reviews, review of hospital policies and/or practice, and interviews for 4 patients (Patients #4, #13, #35, and #38) the facility failed to ensure that the medical record was complete and/or accurate. The finding includes:

a. Patient #13 was admitted to the hospital on 5/6/14 for a right total hip arthroplasty and left knee Cortisone injection. The operative consent signed by the patient on 4/9/14 identified right total hip arthroplasty and left knee Cortisone injection. The intraoperative record dated 5/6/14 indicated that the patient was a difficult intubation and was intubated upon the third attempt and with the use of a glide scope. The operative report by MD #7 dated 5/6/14 inaccurately noted that oral endotracheal intubation was achieved without difficulty. An addendum to the inaccurate report was not observed in the patient's medical record. Interview with MD #7 on 12/2/14 at 1:38 PM identified that the operative report was inaccurate and that he/she was not in the room to observe the patient's intubation on 5/6/14. The facility Medical Staff Rules and Regulations identified that when a dictated entry requires correction, the author shall dictate an addendum to the initial report.

b. Patient #35 was admitted to the hospital on 11/20/14 with a diagnosis of seizures and a history of Diabetes Mellitus. Physician orders dated 11/20/14 directed blood glucose monitoring via finger stick before meals and at bedtime (four times a day). Point of care test results (glucose) noted that the patient's blood sugar was tested on 11/22/14 at 12:16 PM, 3:50 PM and 9:47 PM. The point of care test results further noted that, on 11/23/14, an unscheduled blood sugar was obtained by the nurse at 1:02 AM, a scheduled blood sugar testing was conducted by the nurse at 6:18 AM and a second unscheduled blood sugar was conducted by the nurse at 8:28 AM. Review of the patient's record with RN #2 on 11/23/14 at 10:25 AM noted that the record lacked physician orders for the unscheduled blood sugar tests, the patient had not received insulin prior to the unscheduled testing times to warrant any follow-up testing, and nursing narratives did not document why the additional testing had been conducted. The facility policy for documentation of the nursing process and care identified that the RN is responsible for ensuring completeness, accuracy and timeliness of all documentation related to patient care.

c. Patient #39 was admitted to the hospital on 11/12/14 with diagnoses that included chronic abdominal distention, fevers and C- difficile colitis. Dietician progress notes dated 11/21/14 indicated that the patient had inadequate oral intake, refused dietary supplements and a plan to continue inpatient monitoring. Weight records indicated that the patient's weight was not assessed on 11/17/14 and 11/20/14 and weight was assessed all other days from 11/13/14 to 11/24/13. Interview with RN #4 on 11/24/14 at 1:42 PM noted that patient beds were equipped with a scale and patients were weighed upon admission and daily thereafter. Interview with the Director of Quality on 12/3/14 at 10:45 AM identified that, although the hospital did not have a policy that directed the frequency of obtaining patient weights, it was the practice of the unit to obtain daily weights.

d. Patient #12 presented to the ED on 5/18/14 at 2:15 AM with suicidal ideation. Review of the initial physician assessment dated 5/18/14 at 2:17 AM indicated the patient was alert, oriented, had normal range of motion, no edema and no tenderness. The nurse's note dated 5/18/14 at 3:16 AM indicated the patient had a cast on his/her right lower leg, however the note dated 5/18/14 at 6:20 AM reflected the cast was on the patient's left lower leg. A physician's order dated 5/18/14 directed an x-ray of the right tibia fibula, however this order was canceled prior to being completed, and a left tibia fibula x-ray was completed.

Based on clinical record review and interviews for 1 (P#4) of 3 patients reviewed who received intravenous (IV) Tylenol, the facility failed to administer medication (Tylenol) according to facility policy. The findings include:
P#4 was admitted to the hospital on 9/11/14 with a partial small bowel obstruction which required surgery on 9/13/14. According to a discharge summary malnutrition was a concern and a nutrition evaluation for total parenteral nutrition (TPN) was done. P#4's weight on admission was 46.72 kg. (103 lbs.). P#4 had exhibited generalized discomfort and Acetaminophen IV was ordered. According to a physician's order dated 9/12/14 at 1:27 AM Acetaminophen 1000 milligrams (mg.) IV was to be given every 6 hours.
From 9/12/14 through 9/17/14 P#4 received a total of 18 doses of Acetaminophen 1000 mg. IV. On 9/18/14 nutritional laboratory studies suggested liver failure and Acetaminophen toxicity was identified. P#4's Acetaminophen level was 53.5 mcg/mL (Therapeutic level: 10-25 mcg/mL, Toxic level: >200 mcg/mL). P#4 was admitted to the intensive care unit (ICU) and treated for coagulopathy, hypotension and shock from acute liver failure secondary to Acetaminophen toxicity. Treatment included N-acetyl cysteine (NAC). After a complicated hospitalization including acute liver failure/acute kidney failure secondary to Acetaminophen toxicity and respiratory failure requiring ventilator support P#4 was discharged on 10/14/14 to a short term rehabilitation facility. Upon discharge P#4 was alert, oriented and tolerating a regular diet.
During an interview with MD#10 on 12/1/14 at 1:50 PM, MD#10 indicated he/she was the surgical attending for P#4. MD#10 saw P#4 daily and would review his/her current status. MD#10 indicated when reviewing her "active" medication list the Acetaminophen IV did not appear on the list because the medication was only ordered for a 24 hour period and the order had expired. P#4 was additionally on Dilaudid for pain control and the documentation indicated he/she had adequate pain control. MD#10 indicated the Acetaminophen IV was ordered to avoid the use of opiates in an elderly person. Upon surveyor inquiry MD#10 did indicate that P#4 should have received a reduced dose based on his/her weight. MD#10 indicated P#4 had other factors that contributed to the development of Acetaminophen toxicity including a small bowel obstruction, malnutrition and dehydration. As a result of P#4 developing Acetaminophen toxicity practitioners were educated on medication reconciliation and the process for ordering Acetaminophen IV. In addition MD#15 presented formal education on Acetaminophen toxicity to practitioners and the case was reviewed by the department and necessary committees.
During an interview with the Director of Pharmacy on 12/2/14 at 12:30 PM, the Director of Pharmacy identified usual IV Acetaminophen dosage for an adult patient is 4000 mg. over a 24 hour period (1000 mg. every 6 hours) however the recommended dosage for an adult patient weighing less than 50 kg. was a maximum of 3000 mg. in a 24 hour period (650 mg. every 6 hours). The Director of Pharmacy indicated Acetaminophen toxicity develops as a cumulative effect. The Director of Pharmacy verified P#4 weighed less than 50 kg. The Director of Pharmacy indicated when Acetaminophen IV is ordered out of these dosage recommendations a warning appears in the electronic medical record. Acetaminophen IV can only be ordered for four doses in a 24 hour period therefore if the medication is ordered again the order appears as a new order not a reorder. In addition the physician, pharmacist and nurses do not see prior doses administered when viewing the order in the electronic medical record. In P#4's case each time the order was written it was written by a different practitioner, processed by a different pharmacist and therefore the order appeared to be for only 24 hours and felt by the pharmacists not to be an issue. The Director of Pharmacy indicated the hospital is in the process of limiting the number of doses that can be ordered in the electronic medical record "hard stop" and the ordering practitioner would see if the Acetaminophen was previously administered indicating a potential for a cumulative effect. Until that time all pharmacy staff has been educated to not dispense more than four doses of IV Acetaminophen at a time, evaluate if the medication had been previously administered and notify the ordering practitioner.

According to manufacturer's recommendations for injectable Acetaminophen the recommended dose for adolescents and adults weighing less than 50 kg. is 12.5 mg/kg. every 4 hours, or 15 mg. /kg. every 6 hours. Maximum single dose is 750 mg. Maximum daily dose is 3750 mg.

According to the Medication Ordering and Administration policy those who administer medications must have knowledge of the drug including the patient's diagnosis, allergies, usual dose, and route of administration, special precautions and contraindications.

1. Based on a review of the facility documentation and staff interviews, the facility failed to ensure interventions were implemented subsequent to the identification of abnormal microbial cultures in the compounding area of the pharmacy. The findings included:

a. Review of the facility documentation dated 6/30/14 and 8/4/14 indicated air and surface samples were conducted in the main pharmacy in the Ante, Clean and Chemotherapy Rooms that identified microbial contamination that surpassed the threshold for the recommended United States Pharmacopeia (USP) 797 guidelines. Interview with the Director of Pharmacy on 12/2/14 at 10:00 AM indicated the action plan in part was to re-educate the staff on proper gowning, hand washing and cleaning of all areas that contained microbial contamination. Further interview with the Director of Pharmacy identified the facility did not complete and/or document staff education as directed in the action plan.

b. Review of the facility documentation dated 8/4/14 and 8/21/14 indicated surface samples were conducted in an off-site campus location in the Ante and Clean Room of the compounding area that identified microbial contamination that surpassed the threshold for the recommended USP 797 guidelines. Interview with the Director of Pharmacy on 12/2/14 at 10:30 AM indicated the action plan in part was to conduct terminal cleaning after each occurrence. Further interview with the Director of Pharmacy identified the facility did not complete and/or document terminal cleaning was conducted on either occasion.

c. Review of the facility documentation dated 9/22/14 indicated surface samples were completed in the main pharmacy within the hood that prepared total parental nutrition (TPN). The surface samples identified microbial contamination that surpassed the threshold for the recommended USP 797 guidelines. Interview with the Director of Pharmacy on 12/2/14 at 11:00 AM indicated the action plan in part was to re-educate the staff on appropriate cleaning of the TPN hood. Further interview with the Director of the Pharmacy identified the facility did not complete and/or document staff education was conducted as directed in the action plan.

d. Review of the facility documentation dated 9/22/14 indicated surface and air samples were completed in the main pharmacy that identified microbial contamination in the Chemotherapy, Clean Room and TPN hood that surpassed the threshold for the recommended USP 797 guidelines. Interview with the Director of Pharmacy on 12/2/14 at 11:30 AM indicated installation of new doors to the entrance of the intravenous room was a planned intervention however, the facility failed to rebalance the doors subsequent to the intervention in accordance with the action plan.

2. Based on observations, staff interview and a review of facility documentation related to compounding within an automated intravenous preparation unit, the facility failed to have knowledge and/or delay entry into the unit to maintain required International Standardization for Organization (ISO) classification and/or failed to ensure accurate information was obtained that identified the ISO classification of the unit and/or failed to ascertain airflow patterns to ensure safety when compounding medications. The finding included:

a. During a tour of the Pharmacy on 11/26/14 at 10:00 AM an observation of Pharmacy Technician #1 was conducted while priming the intravenous tubing in preparation for automated compounding. Although the technician was wearing protective clothing throughout preparation he/she closed the doors to the unit and initiated automated compounding immediately thereafter. Interview with Pharmacy Technician #1 on 11/25/14 at 10:10 AM indicated compounding could begin as soon as the doors to the unit were closed and the ISO classification would not be altered. Subsequent to the surveyor's inquiry the Director of the Pharmacy identified he contacted the manufacturer and was informed that a two minute wait time was required after the doors were closed to ensure the return to ISO five conditions. Further interview with the Director of the Pharmacy indicated he was not aware of the delay time required to ensure the safety of compounding within the automated intravenous preparation unit and would re-educate the staff immediately regarding this directive.

b. Review of the testing and certification report dated 6/17/14 within the automated compounding area and interview with the Director of the Pharmacy on 11/28/14 at 1:00 PM identified airflow patterns were documented as not applicable. The Director of Pharmacy indicated he failed to check with the company that conducted the test to determine the accuracy of the report as airflow testing should have been completed to ensure safe compounding.
c. Review of the certification report dated 6/17/14 for the automated compounding unit and interview with the Director of the Pharmacy on 11/28/14 at 1:15 PM indicated an ISO classification of five (5) and the 9/10/14 certification report identified the ISO classification as four (4). Further interview with the Director of Pharmacy indicated he failed to determine the accuracy of the report or what the required ISO classification should be in accordance with manufacturer's recommendations or USP 797 standards. Subsequent to the surveyors inquiry the Director of Pharmacy provided documentation that identified the automated intravenous preparation unit was classified as an ISO five (5) enclosure device.

Based upon a tour of the hospital, the facility failed to ensure that the Behavioral Health Nursing Units at St Francis Medical Centers' North Campus were designed and maintained in such a manner as to promote the safety and well-being of patients.

1. On 11/25/14 at 10:00 AM, the surveyor, while accompanied by the Behavioral Health Unit Manager, the Engineering Supervisor and the Director of Engineering observed the following:

a. That the patient rooms throughout the 7-West and 7-East Nursing Units were provided with non-institutional-style electrical box cover (plastic) plates, electrical receptacle cover (plastic) plates, concealed-type sprinkler heads, fire alarm notification devices (a/v's) that posed a potential hanging or potential injury hazard and were not designed or maintained to psychiatric institutional standards or guides;

b. That the patient toilet rooms throughout the 7-West and 7-East Nursing Units were provided with non- institutional-style electrical box cover (plastic) plates, electrical receptacle cover (plastic) plates, concealed-type sprinkler heads, fire alarm notification devices (a/v's), paper towel dispensers (none provided-towels loose on shelf),common porcelain-type toilets with floor flange bolts exposed and basin sinks that were not securely fastened to the walls that posed a potential hanging or potential injury hazard and were not designed or maintained to psychiatric institutional standards or guides;

c. That the patient shower rooms throughout the 7-West and 7-East Nursing Units were provided with non- institutional-style, tamper resistant screws/fasteners in shower curtain tracks, electrical box cover (plastic) plates, electrical receptacle cover (plastic) plates, concealed-type sprinkler heads, fire alarm notification devices (a/v's), paper towel dispensers (none provided-towels loose on shelf),common porcelain-type toilets with floor flange bolts exposed and basin sinks that were not securely fastened to the walls that posed a potential hanging or potential injury hazard and were not designed or maintained to psychiatric institutional standards or guides.

1. Based on observation and review of policy, the hospital failed to ensure that all personnel within the restricted and semi-restricted areas of the operating suite and ancillary areas that complete invasive procedures, wore hair covering that covered the hair of the head and facial beards. The finding includes:
a. During tour of the operating suite on 11/26/14 with the perioperative Director and Manager, observation of staff identified a failure to have adequate containment of hair inclusive of an uncovered full goatee/beard observed at the front desk/scheduling area.
b. Anesthesia personnel traveling in the semi-restricted hallway failed to have bouffant caps pulled down to cover sides and back of the head hair.
c. Hoods utilized by personnel with facial hair, together with the facial mask failed to cover hair growth on the cheeks in both the OR and IR (interventional radiology).
d. Observation of staff at the operative site within active OR's identified bouffant hats pulled behind ears, exposing sideburns and wisps of hairs along the hairline. In some instances, bouffant caps were positioned in such a manner that exposed hair at the front of the head.
A request for hospital policy governing operating room attire identified that the hospital follows AORN Standards. Recommended practices for AORN direct that any personnel who enter the semi-restricted and restricted areas should cover their head, ears and facial hair to completely cover the ears, scalp, sideburns and nape of the neck.
2. Based on observation during tour, the hospital failed to ensure that damaged/worn equipment was removed from use. The findings include:
a. During tour of the Operating Suite on 11/26/14, the mattress utilized on the cysto bed was observed to have edges that were worn down to the mesh and the mattress itself was taped and retaped over the surface, rendering the mattress difficult to disinfect. As the surveyor toured, the mattress was removed and replaced with a new mattress.
b. During tour observation was made of a storage area that identified a hand table that had a hole in one side of the surface the size of a quarter rendering it unable to be disinfected appropriately.
3. Based on observation and policy review during tour of the operating suites on 11/26/14, a partially utilized high level disinfectant solution failed to be dated when stored. The findings include:
a. During tour of the Operating Suite, an alcove containing an automatic endoscope reprocessor was observed with storage of multiple containers of high level disinfectant solution. A one gallon jug was identified as having been opened with contents utilized, however, the jug lacked a recorded date of opening per manufacturer's directions. Manufacturer's directions identify that once opened, the solution remaining in the container may be stored for up to 75 days providing the 75 days does not extend past the expiration date on the container.
Review of the hospital policy identified that the container of CIDEX OPA should be dated and initialed when opened.

4. Based on observation during tour and interview, medication reconstitution failed to be completed according to acceptable standards. The finding includes:
a. During tour on 11/26/14 at approximately 9:10 AM, with the Director and Manager of Perioperative Services, an observation was made in OR #1 of a tray with two vials, one empty and one, with liquid present with a syringe sticking out of the top of the vial. Although a surgical case was pending, the room was not yet set-up and case carts had not been opened. During an interview, a staff member who was present in the room and identified themselves as a nurse stated that the medication was utilized to wash the wires during the surgical procedure however, she/he did not set up the medication for reconstitution or know who had set it up or when.
Review of the CDC guidelines for medication preparation identified, at a minimum, that it is never acceptable to leave a needle inserted into the medication vial septum as it provides a direct route for microorganisms to enter the vial and contaminate the fluid.
5. Based on observation, the floor of one operating room failed to be intact. The finding incudes:
a. During observation of the cleaning of OR #3 (outpatient surgery) on 12/1/14 at approximately 10:26, as the operating table was moved for floor cleaning, numerous cuts and gouged depressions were identified near the foot of the OR table, rendering this part of the floor impossible to sanitize appropriately.
6. Based on observation, the hospital failed to ensure that intravenous (IV) solutions were utilized within one hour of spiking the bag. The findings include:
a. During observation of room cleaning for OR #3, an ambulatory surgery on 2/1/14, it was observed that two spiked 1000 cc IV bags of Lactated Ringers were hanging on a hook behind the anesthesia medication cart.
During an interview on 12/1/14 at approximately 10:26 AM, the anesthetist stated that the premade IV bags were not for the next patient but rather had been made up (spiked) at the beginning of the surgical day and were available just in case they were needed. The IV bags, if not utilized were then discarded at the end of the surgical day.
Review of APIC Standards 2014 identified that IV bags should be hung within one 1) hour of being spiked or otherwise discarded.


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7. Based on observation during tour of the operating room suite, the hospital failed to ensure the operating room corridor (semi-restricted area) was closed to entry from outside avenues and/or that stretcher cushions utilized by patients were in good repair. The findings include:
a. During tour of the recovery room suite on 11/25/14 at 9:30 AM with the Director of Perioperative Services, an unlocked door that led to the inner hallway of the operating room suite was observed allowing access to the restricted corridor.
b. During tour of the recovery room suite, stretcher cushions were observed to be ripped and torn rendering an inability to effectively disinfect the surfaces between patients.

Based on medical record reviews, review of hospital policies, observations, and interviews the facility failed to ensure that infection control policies and/or manufacturer's recommendations for cleaning were followed in the operating suites and/or dietary department and/or for two of nine patients (Patients #35 and #36) observed for staff performance of hand hygiene. The finding includes:

a. Patient #35 was admitted to the hospital on 11/20/14 with a diagnosis of seizures and a history of paraplegia. The initial nursing assessment dated 11/20/14 identified that the patient was admitted with two Stage III pressure ulcers. Observation on 11/23/14 with Director #1 at 11:20 AM noted that the patient had one pressure ulcer on the coccyx and one pressure ulcer on the right ischium. Observation during the pressure ulcer treatments at this time noted, in part, that RN #3 donned clean gloves, cleansed each ulcer with Normal Saline and a separate 4 by 4, removed the gloves, and donned clean gloves without the benefit of hand hygiene. Review of the dressing change technique with Director #1 on 11/23/14 at 11:35 AM noted that RN #3 should have performed hand hygiene following glove removal. The facility policy for pressure ulcer management identified, in part, to clean the wound with Normal Saline solution, remove gloves, perform hand hygiene, and put on new gloves.

b. Patient #36 was admitted to the hospital on 10/15/14. The urine culture report dated 10/16/14 identified Methicillin- resistant Staphylococcus Aureus infection (MRSA). Physician orders dated 10/16/14 directed contact precautions. Observation on 11/24/14 at 10:45 AM noted a contact isolation sign posted on the patient's doorframe. Further observation at this time identified the housekeeper exited the patient's room, removed his/her gloves in the anteroom area and donned clean gloves without the performance of hand hygiene. Review of the observation with Director #1 on 11/23/14 at 11:35 AM noted that the housekeeper should have washed his/her hands after removing the soiled gloves and prior to donning the second pair of gloves. The facility hand hygiene policy identified, in part, to perform hand hygiene with either waterless hand sanitizer or soap and water after removing gloves.

c. A tour of the dietary department was conducted on 11/25/14 with the Food Service Director. Observation on 11/25/14 at 12:00 PM noted a dietary aide placing items on the food tray. The observation also noted that, although he/she wore a bouffant hair cover, the front of the bouffant was positioned on the middle of his/her head exposing a large amount of hair from his/her mid scalp to his/her forehead. Subsequent to surveyor inquiry, the dietary aide was informed of the improper hair coverage by staff and the bouffant was then adjusted to completely cover the dietary aide's hair. The dietary department uniform dress code identified that long facial hair must be covered with a surgical mask and the approved hair restraint must be worn when on duty.

d. A tour of the outpatient dental clinic was conducted on 12/2/14 with the Director of the Central Sterile (CS) Department. Observation on 12/2/14 at 10:50 AM identified a red basin and a sonic cleaner filled with a blue colored solution in the instrument cleaning room. Interview with Dental Assistant #1 indicated that he/she ran out of the usual enzymatic cleaner used in the red basin, and used one enzymatic tablet per gallon of water in both the red basin and sonic cleaner. He/she further noted that he/she always used 2.5 tablets in the sonic cleaner because it held 2.5 gallons of water. Review of the manufacturer's recommendations for the enzyme tablet with the Director of CS on 12/2/14 at 10:55 AM identified to add two tablets to one gallon of warm tap water. For ultrasonic cleaners, drop one or two tablets, depending on size, directly into the tank.

Based on a review of clinical records, interview and policy review, the facility failed to ensure that a comprehensive discharge assessment was completed for 4 of 5 clinical records reviewed (Patients #7, 72, 73, 74). The findings include the following:


Review of the clinical records for Patients # 7, 72, 73 and 74 failed to reflect that the patient's ability to complete his/her activities of daily living (ADL's) had been addressed as part of the discharge assessment. Interview with the Case Manager on 12/2/14 at 11:00 AM stated patient screening does not include an assessment of the ADL needs unless there is a physical therapy and/or occupational therapy consult. Case Management staff rely on those consults to assist in determining if the patient requires additional services otherwise it is assumed the patient has no discharge needs. Review of the policy indicated that all patients should have a comprehensive discharge plan.

Based on medical record reviews, review of hospital policies, review of hospital documentation and interviews for one of three patients who received a steroid injection, the hospital failed to ensure that the steroid injection was administered in the correct site. The finding includes:

Patient #13 was admitted to the hospital on 5/6/14 for a right total hip arthroplasty and left knee cortisone injection. The operative consent signed by the patient on 4/9/14 identified right total hip arthroplasty and left knee cortisone injection. The intraoperative record dated 5/6/14 indicated that the patient was a difficult intubation and the "time out" was performed prior to the right hip procedure. The record lacked documentation that a "time out" was conducted prior to the cortisone injection. The operative report dated 5/6/14 noted that PA #1 administered an intra- articular cortisone injection to the right knee (in error) and then administered cortisone and Marcaine to the left knee as per the consent. Interview with RN#1 on 11/26/14 at 9:53 AM indicated that the patient's left knee was clearly marked by MD #7; procedures are not initiated until after the patient is intubated and PA #1 was "rushing". Interview with PA #1 on 11/26/14 at 11:45 AM noted that the difficulty of the intubation was a distraction; he/she proceeded with the injection without a formal "time out" and injected the right knee in error. Although the facility universal protocol policy identified that a "time out" prior to each procedure be conducted whenever there is more than one procedure being performed by separate procedure teams, the policy did not address the performance of a "time out " if each procedure was performed by the same team. Subsequent to the event, the facility submitted a corrective action plan (CAP) that included a requirement for a "time out" by the licensed practitioner and the RN prior to all steroid injections in the OR. The CAP also identified that documentation of an additional "time out" will be noted in the intraoperative record and OR staff education. Based on record reviews, review of facility documentation/education the facility was found to be compliant with the CAP as submitted.

Based on clinical record reviews, review of facility policies and procedures and interviews with facility personnel for one of three sampled patients who required non-invasive ventilation (Patient #43), the facility failed to ensure that physician orders for non-invasive ventilation were complete. The findings include:

Patient #43 was admitted to the hospital on 11/25/14 with respiratory distress. Review of the physician orders dated 11/26/14 identified that the patient was to receive Bipap 40% FIO2-12/6 and to titrate the oxygen as needed. Further review failed to identify the range of oxygen needed for the patient. Review of facility policy identified that use of oxygen required a physician order and must specify the titration range in order to maintain stable, specific saturation level or range. Interview with the Director of Respiratory on 11/25/14 identified that the oxygen order was not complete.