HospitalInspections.org

Based on observation, policy review and staff interview, it was determined that for 28 of 28 (100%) rehabilitation unit patients (Patient #'s 1-28), staff failed to ensure the patients' safety and protection from infection. Findings include:

The hospital's "Guide to Visitors and Patient Services" booklet, given to patients at the time of admission, stated, "...Patient's Rights...care...at all times and under all circumstances, provided within a safe...environment..."

The hospital policy entitled "Isolation Guidelines" stated, "...Contact Precautions...Precautions must be used by all persons entering the room...precautions should be maintained to prevent transmission of organisms to others or the environment..."

1. 2nd floor Rehabilitation Unit (Census 14)

1/6/12 between 10:39 AM - 11:40 AM:
During a tour with Clinical Nurse Specialist A, all restroom doors located inside the patients room, were observed to have a posted toileting schedule taped to the door. In addition, two (2) of the patients were observed to be on contact isolation precautions for resistant bacterial infections. Clinical Nurse Specialist A confirmed these findings at the time of discovery.

2. 4th floor Rehabilitation Unit (Census 14)

1/6/12 between 10:40 AM - 11:25 AM:
During a tour of the 4th floor rehabilitation unit with Director of Patient Care Services A, all restroom doors located inside the patients room, were observed to have a posted toileting schedule taped to the door. In addition, one (1) of the patients was observed to be on contact isolation precautions for a bacterial infection. Director of Patient Care Services A confirmed these findings at the time of discovery.

Interviews conducted on 1/6/12 with Employee #'s 1, 2 and 3 between 10:53 AM and 11:45 AM and with Employee #'s 4 and 5 on 1/9/12 between 7:09 AM - 9:15 AM, revealed that the voiding schedule forms were being taken out of all patient rooms, including rooms of patients on contact isolation precautions.

Interview with Nurse Manager A on 1/6/12 at 10:40 AM confirmed that all voiding schedules were reviewed by staff in the office, nursing station or on the door and then discarded/shredded. Nurse Manager A reported that for the patients in contact isolation, the expectation would be that staff review the voiding sheet documentation in the patient's room and then discard in the patient's room.

During a telephone interview on 1/9/12 at 12:45 PM, the observational findings were discussed with the Infection Prevention Manager and Infection Prevention Coordinator. The Manager and Coordinator reported that no papers brought into the room of a patient in isolation/on contact precautions should be removed from the patient's room and that the identified practice was an infection control issue.

I. Based on medical record review, policy review, job description review, staff interview and review of other hospital documents, it was determined that the registered nurse (RN) failed to ensure patient care was provided as ordered by the physician for 5 of 5 (100%) patients (Patient #'s 1, 2, 3, 4 and 5) in the sample. Findings include:

The hospital job description entitled "Nurse, Registered Inpatient Rehabilitation" stated, "...Professional nursing practices, requiring specialized knowledge judgement and skill using the process in accordance with hospital policy, procedure...Collects data using appropriate assessment techniques and instruments...Appropriately documents collected data...documents the plan of care and the patient response to interventions in the clinical record..."

The Elkin, Perry and Potter "Nursing Interventions & Clinical Skills" 4th Edition utilized by the nursing staff to direct care stated, "...Verify physician's orders..."

The hospital policy entitled "Charting Guidelines" stated, "The RN is responsible for orders taken off correctly, whether she/he personally performs the act or not..."

The hospital policy entitled "Medication Administration Procedure" stated, "...physician ordered parameters...Take patients apical pulse (heart rate) before administration of...beta blockers...Take blood pressure prior to administering anti-hypertensives (control of high blood pressure). Hold medication and notify physician if patient's systolic blood pressure is below 100mmHg (millimeters of mercury)..."

The hospital policy entitled "Risk to Fall Program" stated, "...Fall Risk Assessment Tool...Complete assessment to be done at least once every 24 hours...Reassess when there is a change in condition...Moderate Risk = 6-13 Points...6 and above indicates risk to fall protocol..."

A. Patient #1
1. Review of Patient #1's Fall Risk Assessment completed on 1/3/12 at 2:41 PM revealed that Patient #1 was at a moderate risk for falls with a score of 6.

Review of the 1/4/12 "Post-Fall Documentation Form" revealed that Patient #1 experienced an unwitnessed fall on 1/4/12. Review of the documented incident revealed that at the time of the fall, Patient #1's fall risk was assessed to be at a moderate risk with a score of 10.

Clinical Nurse Specialist A reviewed Patient #1's medical record on 1/10/12 at 2:45 PM and confirmed that Patient #1's initial fall assessment score was incorrect. Clinical Nurse Specialist A reported that Patient #1's fall risk score should have been "11" based on Patient #1's age, mobility, medications and patient care equipment.

2. Review of the 1/4/12 "Post-Fall Documentation Form" revealed that Patient #1 experienced an unwitnessed fall in his room at 7:15 PM.

The "Post-Fall Order Set" dated 1/4/12 at 7:20 PM, included an order for vital signs every hour for 8 hours and then every 4 hours for an unwitnessed fall. Review of "Doctor's Orders" revealed no evidence that the order for vital signs every 4 hours had been discontinued.

Review of "Vital Signs" documentation revealed that staff failed to obtain vital signs every 4 hours as ordered on:

- 1/5/12: Due at 8:00 PM
- 1/6/12: Due at 8:00 PM
- 1/7 - 1/9/12: Obtained daily instead of every 4 hours

Interview with Clinical Nurse Specialist A on 1/10/12 at 2:45 PM confirmed these findings.

B. Patient #2
"Doctor's Orders" dated 12/6/11 at 3:00 PM included the order for staff to encourage the patient to void (urinate) every 6 hours. Patient #2's bladder was to be scanned after the patient emptied his bladder and at least every 6 hours if the patient did not void, to ensure the volume of urine in the bladder did not exceed 300 milliliters (ml). If the bladder scan showed a volume of more than 300 ml, the nurse was to catheterize the patient and "record all volumes".

Patient #2's "Interdisciplinary Care Plan" included the 12/7/11 initiation of Bladder Management. Approaches/interventions included avoiding a bladder volume of greater than 400 ml and if the patient was unable to void or had a bladder volume of greater than 300 ml, the patient was to be catheterized as per physician's orders.

Review of Patient #2's "Flow Sheet" documentation revealed that staff failed to record the volume of urine obtained when Patient #2 was catheterized on:

- 12/9/11 at 8:08 AM and 8:39 PM
- 12/10/11 at 4:24 PM
- 12/12/11 at 7:50 AM
- 12/13/11 at 8:00 AM
- 12/14/11 at 8:00 AM, 6:29 PM and 8:00 PM
- 12/15/11 at 8:05 AM
- 12/20/11 at 8:52 AM
- 12/22/11 at 9:20 PM
- 12/24/11 at 9:00 PM
- 12/31/11 at 9:10 AM

In addition, staff failed to scan the patient's bladder every 6 hours and/or catheterize the patient when the patient's bladder scan showed a volume of more than 300 milliliters of urine on:

- 12/15/11: No evidence in the medical record to support that Patient #2 was scanned and/or catheterized between 8:05 AM and 6:15 PM (a time lapse of 10 hours and 10 minutes); At 6:15 PM, Patient #2 was catheterized for a total volume of 350 ml of urine in the bladder.

- 12/31/11: No evidence in the medical record to support that Patient #2 was scanned and/or catheterized between 6:00 AM and 2:39 PM (a time lapse of 8 hours and 39 minutes); At 2:39 PM, Patient #2 was catheterized for a total volume of 999 ml of urine in the bladder.

On 1/10/12 at 4:00 PM, Clinical Nurse Specialist A reviewed Patient #2's medical record and confirmed these findings.

C. Patient #3
"Doctor's Orders" dated 12/27/11 at 11:00 AM, included orders to perform a scan of Patient #3's bladder every 6 hours and to catheterize the patient to empty the bladder if the scan showed the bladder contained more than 400 ml of urine. At 11:00 AM on 12/29/11, the physician's order was changed to catheterize Patient #3 if the bladder scan revealed a bladder volume of greater that 300 ml of urine.

Review of the "Flow Sheet" documentation revealed that staff failed to perform a bladder scan and/or catheterize Patient #3 as ordered on:

- 12/27/11 at 8:15 PM
- 1/1/12 at 12:00 AM and 2:00 PM
- 1/4/12 at 12:42 AM

On 1/9/12 at 2:15 PM, Clinical Nurse Specialist A reviewed Patient #3's medical record and confirmed these findings.

D. Patient #4
"Doctor's Orders" dated 1/5/12 at 12:00 PM, included the following medication orders:

1. Hydralazine (used to control high blood pressure) - Administer every 8 hours; Hold for a systolic blood pressure reading of less than 110

2. Metoprolol (used to control high blood pressure) - Administer 2 times daily; Hold for a heart rate of less than 60 or a systolic blood pressure reading of less than 110

Review of the Medication Administration Record (MAR) revealed that staff failed to assess Patient #4's blood pressure and/or heart rate prior to administering the blood pressure lowering medication at the following times:

Hydralazine
- 1/6/12 at 1:06 PM: No recorded blood pressure

Metoprolol
- 1/6/12 at 8:43 AM: Pulse rate of 59 recorded at 6:24 AM; No pulse rate recorded prior to medication administration (pulse rate of 59 would have required that the medication be held according to the ordered parameters)

On 1/10/12 at 11:29 AM, Clinical Coordinator A reviewed the medical record and confirmed these findings.

D. Patient #5
"Doctor's Orders" dated 12/27/11 at 3:00 PM, included the following medication order:

Lopressor (used to control high blood pressure) - Administer 100 milligrams (mg) in the AM and administer 50 mg in the PM; Hold for a systolic blood pressure reading of less than 100 or a pulse rate of less than 50

Review of the MAR revealed that staff failed to assess Patient #5's blood pressure and/or heart rate prior to administering the blood pressure lowering medication at the following times:

- 1/4/12 at 5:06 PM: No recorded blood pressure or pulse rate
- 1/5/12 at 5:00 PM: No recorded blood pressure or pulse rate

On 1/9/12 at 1:51 PM, Clinical Coordinator A reviewed the medical record and confirmed these findings.

II. Based on medical record review, policy review, staff interview and review of other hospital documents, it was determined that for 2 of 5 (40%) patients (Patient #'s 3 and 4) in the sample, the RN failed to clarify physicians' orders. Findings include:

The hospital policy entitled "Medication Administration Procedure" stated, "...All orders must be checked and signed (or co-signed) by a RN...Check each patient's MAR for drug dose..."

The hospital policy entitled "24 Hour Chart Check" stated, "...To ensure accuracy and completeness of the patient's treatment plan...night shift nurse is to complete 24 hour chart check...All orders for the previous 24 hours will be verified by a nurse...(MAR) will be verified for correct...dose...Verify accuracy of each entry on MAR on EMR (electronic medical record) with physician orders..."

The Elkin, Perry and Potter "Nursing Interventions & Clinical Skills" 4th Edition utilized by the nursing staff to direct care stated, "...physician's order...physician writes...The dose (e.g., 5 mg)...As the nurse you are responsible for verifying that the MAR is accurate and up-to-date by comparing each medication to the original order, including, drug name, dose...make sure that the information on your client's MAR corresponds exactly with prescriber's order...Do not give medications that have illegible or incomplete orders..."

A. Patient #3
"Doctor's Orders" dated 12/23/11 at 5:10 (AM/PM not entered), included an order for "Coreg 12.5" (used to control high blood pressure). The physician's order did not include the complete dosage prescription, i.e., mg.

Review of the MAR revealed a Coreg dosage of "12.5 mg".

Review of "Doctor's Orders" and other medical record documentation failed to provide evidence that the RN contacted the physician to clarify the Coreg dosage order, or to ensure the order was correctly recorded on the MAR. In addition, no order clarification of the incomplete dosage was recorded by the nurse who conducted the 24 hour chart check.

This finding was confirmed by Clinical Nurse Specialist A on 1/9/12 at 2:35 PM.

B. Patient #4
"Doctor's Orders" dated 1/5/12 at 12:00 PM, included the following medication order:

Metoprolol - Administer 2 times daily; Hold for a heart rate of less than 60 or a systolic blood pressure reading of less than 110

The MAR dated 1/5 - 1/10/12 instructed staff to hold the metoprolol for a diastolic blood pressure of less than 110, contrary to the physician's order to hold if the systolic blood pressure was less than 110.

Review of the vital sign documentation revealed that between 1/5 at 11:08 PM through 1/10/12 at 11:42 AM, all diastolic blood pressure readings were less than 110 (43 to 101). According to Patient #4's MAR, metoprolol was administered with a diastolic blood pressure of less than 110 on:

1/5/12 at 11:08 PM
1/6/12 at 8:43 AM and 9:33 PM
1/7/12 at 9:25 AM and 9:36 PM
1/8/12 at 9:50 AM
1/9/12 at 8:36 AM and 10:05 PM
1/10/12 at 8:35 AM

Review of the medical record revealed no evidence to support that the RN identified the transcription error, systolic versus diastolic, until the medical record was reviewed with Clinical Coordinator A on 1/10/12 at 11:29 AM. Clinical Coordinator A reported that nursing staff:

- failed to identify the transcription error
- failed to clarify the blood pressure parameter order with the ordering physician
- should not have administered the metoprolol based on the MAR parameter order

Based on medical record review, policy review and staff interview, it was determined that for 2 of 5 (40%) patients (Patient #'s 3 and 4) in the sample, the medical record failed to contain accurate or complete information. Findings include:

The hospital policy entitled "24 Hour Chart Check" stated, "...Medications Administration Record (MAR) will be verified for correct patient, dose, medication...It is vital that staff complete the MAR check accurately and completely..."

The hospital policy entitled "Charting Guidelines" stated, "The RN (registered nurse) is responsible for orders taken off correctly, whether she/he personally performs the act or not..."

A. Patient #3
"Doctor's Orders" dated 12/23/11 at 5:10 (AM/PM not entered), included an order for "Coreg 12.5" (used to control high blood pressure). The physician's order did not include the complete dosage prescription, i.e., milligram (mg).

Review of the MAR revealed a Coreg dosage of "12.5 mg".

Review of "Doctor's Orders" and other medical record documentation failed to provide evidence that the RN contacted the physician to clarify the Coreg dosage order, or to ensure the order was correctly recorded on the MAR. In addition, no order clarification of the incomplete dosage was recorded by the nurse who conducted the 24 hour chart check.

This finding was confirmed by Clinical Nurse Specialist A on 1/9/12 at 2:35 PM.

B. Patient #4
"Doctor's Orders" dated 1/5/12 at 12:00 PM, included the following medication order:

Metoprolol - Administer 2 times daily; Hold for a heart rate of less than 60 or a systolic blood pressure reading of less than 110

The MAR dated 1/5 - 1/10/12 instructed staff to hold the metoprolol for a diastolic blood pressure of less than 110, contrary to the physician's order to hold if the systolic blood pressure was less than 110.

Clinical Coordinator A confirmed this finding on 1/10/12 at 11:29 AM.

Review of the medical record revealed no evidence to support that the RN identified the transcription error, systolic versus diastolic or contacted the physician for order clarification until the medical record was reviewed with Clinical Coordinator A on 1/10/12 at 11:29 AM.

Based on medical record review, policy review, job description review, staff interview and review of other hospital documents, it was determined that for 4 of 5 (80%) patients (Patient #'s 2, 3, 4 and 5) in the sample, the medical record failed to include evidence of physician ordered interventions. Findings include:

The hospital policy entitled "Charting Guidelines" stated, "...Documentation of patient care...will reflect patient status regarding needs...nursing interventions and patient response..."

The hospital job description entitled "Nurse, Registered Inpatient Rehabilitation" stated, "...Professional nursing practices, requiring specialized knowledge judgement and skill using the process in accordance with hospital policy, procedure...Collects data using appropriate assessment techniques...Appropriately documents collected data...documents the plan of care and the patient response to interventions in the clinical record..."

The hospital policy entitled "Medication Administration Procedure" stated, "...physician ordered parameters...Take patients apical pulse (heart rate) before administration of...beta blockers...Take blood pressure prior to administering anti-hypertensives (control of high blood pressure). Hold medication and notify physician if patient's systolic blood pressure is below 100mmHg (millimeters of mercury)..."

A. Patient #2
"Doctor's Orders" dated 12/6/11 at 3:00 PM included the order for staff to encourage the patient to void (urinate) every 6 hours. Patient #2's bladder was to be scanned after the patient emptied his bladder and at least every 6 hours if the patient did not void, to ensure the volume of urine in the bladder did not exceed 300 milliliters (ml). If the bladder scan showed a volume of more than 300 ml, the nurse was to catheterize the patient and "record all volumes".

Patient #2's "Interdisciplinary Care Plan" included the 12/7/11 initiation of Bladder Management. Approaches/interventions included avoiding a bladder volume of greater than 400 ml and if the patient was unable to void or had a bladder volume of greater than 300 ml, the patient was to be catheterized as per physician's orders.

Review of Patient #2's "Flow Sheet" documentation revealed that staff failed to record the volume of urine obtained when Patient #2 was catheterized on:

- 12/9/11 at 8:08 AM and 8:39 PM
- 12/10/11 at 4:24 PM
- 12/12/11 at 7:50 AM
- 12/13/11 at 8:00 AM
- 12/14/11 at 8:00 AM, 6:29 PM and 8:00 PM
- 12/15/11 at 8:05 AM
- 12/20/11 at 8:52 AM
- 12/22/11 at 9:20 PM
- 12/24/11 at 9:00 PM
- 12/31/11 at 9:10 AM

In addition, staff failed to record the performance of bladder scans every 6 hours and/or catheterizations when the patient's bladder scan showed a volume of more than 300 ml of urine on:

- 12/15/11: No documentation in the medical record to support that Patient #2 was scanned and/or catheterized between 8:05 AM and 6:15 PM (a time lapse of 10 hours and 10 minutes); At 6:15 PM, Patient #2 was catheterized for a total volume of 350 ml of urine in the bladder.

- 12/31/11: No documentation in the medical record to support that Patient #2 was scanned and/or catheterized between 6:00 AM and 2:39 PM (a time lapse of 8 hours and 39 minutes); At 2:39 PM, Patient #2 was catheterized for a total volume of 999 ml of urine in the bladder.

On 1/10/12 at 4:00 PM, Clinical Nurse Specialist A reviewed Patient #2's medical record and confirmed these findings.

B. Patient #3
"Doctor's Orders" dated 12/27/11 at 11:00 AM, included orders to perform a scan of Patient #3's bladder every 6 hours and to catheterize the patient to empty the bladder if the scan showed the bladder contained more than 400 ml of urine. At 11:00 AM on 12/29/11, the physician's order was changed to catheterize Patient #3 if the bladder scan revealed a bladder volume of greater than 300 ml of urine.

Review of Patient #3's "Flow Sheet" documentation revealed that staff failed to record the performance of bladder scans and/or catheterizations as ordered on:

- 12/27/11 at 8:15 PM
- 1/1/12 at 12:00 AM and 2:00 PM
- 1/4/12 at 12:42 AM

On 1/9/12 at 2:15 PM, Clinical Nurse Specialist A reviewed Patient #3's medical record and confirmed these findings.

C. Patient #4
"Doctor's Orders" dated 1/5/12 at 12:00 PM, included the following medication orders:

1. Hydralazine (used to control high blood pressure) - Administer every 8 hours; Hold for a systolic blood pressure reading of less than 110

2. Metoprolol (used to control high blood pressure) - Administer 2 times daily; Hold for a heart rate of less than 60 or a systolic blood pressure reading of less than 110

Review of the Medication Administration Record (MAR) revealed that staff failed to record Patient #4's blood pressure and/or heart rate prior to administering the blood pressure lowering medication at the following times:

Hydralazine
- 1/6/12 at 1:06 PM: No recorded blood pressure

Metoprolol
- 1/6/12 at 8:43 AM: Pulse rate of 59 recorded at 6:24 AM; No pulse rate recorded prior to medication administration (pulse rate of 59 would have required that the medication be held according to the ordered parameters)

On 1/10/12 at 11:29 AM, Clinical Coordinator A reviewed the medical record and confirmed these findings.

D. Patient #5
"Doctor's Orders" dated 12/27/11 at 3:00 PM, included the following medication order:

Lopressor (used to control high blood pressure) - Administer 100 milligrams (mg) in the AM and administer 50 mg in the PM; Hold for a systolic blood pressure reading of less than 100 or a pulse rate of less than 50

Review of the MAR revealed that staff failed to record Patient #5's blood pressure and/or heart rate prior to administering the blood pressure lowering medication at the following times:

- 1/4/12 at 5:06 PM: No recorded blood pressure or pulse rate
- 1/5/12 at 5:00 PM: No recorded blood pressure or pulse rate

On 1/9/12 at 1:51 PM, Clinical Coordinator A reviewed the medical record and confirmed these findings.

Based on observation, staff interview and policy review, it was determined that for 17 of 36 (47%) handwashing sinks located on the rehabilitation units, the hospital failed to maintain environmental surface integrity and surface cleanliness in a manner to assure the safety of patients using wheelchairs. Findings include:

The hospital policy entitled "Equipment and Utilities Management Program" stated, "...The Plant Operations Department shall be responsible for the utility systems management program, including inspection, maintenance and/or repair of equipment used within the facility...Utility System Equipment: Any piece of fixed...equipment that is a part of a utility system that supports the patient care environment. This includes...plumbing and piping systems..."

A. 2nd floor Rehabilitation Unit
An environmental tour was conducted with Nurse Manager A on 1/9/12, between 12:38 PM and 1:00 PM. Observation of exposed undersink drain pipes and water supply valves revealed that insulated coverings were soiled, torn or dislodged potentially exposing wheelchair bound patients to extreme temperatures and sharp or abrasive surfaces. These findings were confirmed at the time of discovery. Affected sinks were located in the following rooms: 2023, 2025, 2031, 2033, 2035, 2037, 2039, 2041, 2046, 2048, 2050, Training Bathroom and 2 sinks in the Shower Room.

B. 4th floor Rehabilitation Unit
Continuation of the environmental tour on 1/9/12 with Nurse Manager A, Supervisor of Plant Operations A and Director of Accreditation Services A between 1:55 PM and 2:20 PM revealed sinks with damaged or dislodged drain and water valve coverings in the following rooms: 440, 443 and 444. These findings were confirmed at the time of discovery.

Based on observation, policy review and staff interview, it was determined that the hospital failed to ensure that 1 of 4 (25%) "Temp Plus II" thermometers, utilized on the 2nd floor rehabilitation unit, were properly functioning. Findings include:

The hospital policy entitled "Equipment and Utilities Management Program" stated, "...Plant Operations Department shall be responsible for...inspection, maintenance and/or repair of equipment used within the facility...Medical Equipment...used in the monitoring or direct care of patients. This includes battery-powered equipment and non-electric equipment..."

On 1/6/12 between 10:38 AM and 1:00 PM, a tour of the 2nd floor rehabilitation unit was conducted with Clinical Nurse Specialist A. Findings revealed that 1 of 4 "Temp Plus II" thermometers (Equipment No. 293822) was not functional. This finding was confirmed at the time of discovery.