HospitalInspections.org

30984




31048

Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients.
Findings:

During the hospital tour on 06/10/14 at 1:10 p.m., with SF2DON (Director of Nursing) and SF7Maintanence (Director of Plant Operations) the following observations were made:
Hallway:
a. Twelve hot-air balloons hanging from the ceiling attached with clear-type string (varying approximately 6 to 9 inches in length); balloons were made of paper with several circular wires on the inside of the paper to maintain the shape of the balloons.
Common/Activity Room:
a. Fifteen heart-shaped decorations hanging from the ceiling with 12 to 24 inch graduated strings.
b. Seven Blood Pressure Cuffs, one stethoscope, and a digital thermometer with a plastic coiled wire between the thermometer probe and the unit were in a wire basket attached to the wall in the day room and accessible to patients
c. One 67.6 fluid ounce of Hand Sanitizer (colorless and looked like water) was on a table in the day room used by patients next to a stack of Styrofoam cups.
Patient Rooms:
a.. Exposed plumbing/pipes behind the toilets
b. Interior bathroom door hinges (not anti-ligature)
c. Flanged handles/faucets on the bathroom sinks in patient rooms
d. Screws that are not tamper resistant on hinges in doorways
e. Showers with flanged handles for water/temperature control
Seclusion and Restraint Room:
a. Exposed sharp edge remaining from zipper pull being removed from mattress cover

In an interview on 06/10/14 at 1:20 p.m., SF7Maintanence indicated the equipment/supplies to correct the identified problems had been ordered, but had not come in yet in order to be installed in the hospital. SF7Maintenance also indicated that he was not aware that the exposed plumbing behind the toilets were supposed to be enclosed. He further indicated he was not aware that the flanged sink/shower handles and faucets were a ligature risk.

In an interview on 06/10/14 at 1:20 p.m., SF2DON (Director of Nursing) indicated she was not aware that the exposed plumbing behind the toilets were supposed to be enclosed. She further indicated she was not aware that the flanged sink/shower handles and faucets were a ligature risk.

In an interview on 06/10/14 at 1:45 p.m., SF2DON indicated that she was not aware the wire-framed paper balloons and heart decorations suspended from the ceiling and the blood pressure cuffs were a ligature risk. She also indicated she was not aware that the hand sanitizer located and accessible in the common/activity room was a potential safety risk for patients.

Observation on 06/11/14 at 11:15 a.m. of the area used as outdoor space, with SF2DON present, revealed patients would have to walk down the hall from exiting the psychiatric unit to the public elevator and down several more public hallways to exit the building. Further observation revealed the outdoor space used by the hospital was the unsecured space immediately outside the the rear door of the building that opened to the drive way used by ambulances to enter the Emergency Department of Hospital A. Further observation revealed the area had a partial wooden fence around which was a sidewalk leading to the entrance to Hospital A and a public parking lot for Hospital A and Magnolia Behavioral Healthcare. Observation revealed a wooden bench to the right of the exit that was used by patients that had a missing wooden bench seat on one side with protruding nails that were bent down into the wood and several areas of splintered wood on the top surface of the table.

In an interview on 06/11/14 at 11:15 a.m., SF2DON confirmed the safety risks of the unsecured outdoor space and the wooden bench. She indicated that the hospital had a policy that patients on elopement precautions were not allowed to leave the unit. She further indicated that the hospital did not have a policy that addressed the security of patients and the public when escorting patients to the outdoor space.

Based on review of QAPI (Quality Assessment Performance Improvement) records and staff interview, the hospital failed to ensure the QAPI program was an ongoing program that measured, analyzed and tracked quality indicators as evidenced by failing to develop quality indicators for medical staff credentialing.
Findings:

On 06/10/14 at 2:20 p.m., the credentialing files for SF12APRN (Advanced Practice Registered Nurse), SF13Physician, and SF14Medical Director were reviewed with SF4Credentialist. Review of the credentialing file for S14Medical Director revealed the initial appointment to the medical staff was signed by SF14Medical Director. SF4Credentialist stated SF13Physician was appointed as Vice Chief of Staff so he could sign the approval of privileges and initial appointment for S14Medical Director. SF4Credentialist stated the MEC (Medical Executive Committee) and the Governing Body met on 06/05/14, but S13Physician did not sign the privileges or the initial appointment for S14Medical Director.
Review of the credentialing file for SF12APRN revealed the Governing Body had re-appointed SF12APRN to the medical staff on 06/05/14. There was no documented evidence of an appraisal for SF12APRN. SF4Credentialist stated the Medical Staff had revised the by-laws to include annual appraisals for APRNs on staff, but confirmed an appraisal had not been done for SF12APRN.
Review of the credentialing file for SF13Physician revealed the Governing Body had re-appointed SF13Physician to the medical staff on 08/02/13 and there was no documented evidence of an appraisal prior to the reappointment or since the reappointment. SF4Credentialist stated they had not developed a form for physician appraisals yet and the Medical Staff by-laws had not been revised to include a process for physician appraisals.

Review of the QAPI (Quality Assessment Performance Improvement) plan and data collected revealed no documented evidence of any quality indicators for medical staff credentialing.

In an interview on 06/11/14 at 2:40 p.m., SF2DON (Director of Nursing) verified there were no quality indicators identified or implemented for medical staff credentialing. She verified the deficient practices regarding the medical staff appraisals and the initial appointment for S14Medical Director had not been corrected.

On 06/11/14 at 3:50 p.m., SF4Credentialist provided spread sheets she had developed to track the medical staff credential files. Review of the spread sheets revealed the tracking would not start until 06/23/14. Further review of the spread sheets revealed only the following were tracked: State license expiration, CDS (Controlled Dangerous Substance) license expiration, malpractice insurance date, reappointment date, and 3 references. There was no documented evidence that appraisals were included in the tracking.

During the exit conference on 06/11/14 at 4:30 p.m., SF4Credentialist stated SF13Physician had now signed the Medical Staff Clinical Privileges and the Initial Appointment for S14Medical Director. The signed forms were provided for review and indicated SF13Physician signed the Medical Staff Appointment documents on 06/11/14.

Based on record review and interview the hospital failed to set priorities for high-risk, high volume and problem-prone areas as evidenced by:
1) failing to monitor the hospital process for compliance with the Pharmacist review of the patient's medication profile prior to the first dose of a new medication, and;
2) failing to monitor the hospital process for treatment planning.

Findings:

1) failing to monitor the hospital process for compliance with the Pharmacist review of the patient's medication profile prior to the first dose of a new medication:

Review of the policy entitled First Dose Procedure dated 04/03/12, revealed the following, in part:
I. Policy: It is the policy of this hospital that a pharmacist reviews all medication orders (except in emergency situations) for appropriateness before the first dose is administered.
Procedure: ....Outside of business hours, the RN or LPN will fax and call the on-call pharmacist....Prior to medication administration, all medication orders shall be reviewed by the Pharmacist for therapeutic appropriateness of medication regimen, duplication of medications, appropriateness of drug....

Review of the patients' medical records and the pharmacist on-call log for current sampled patients F1, F3, F5, F7, F8, and F10 revealed new medications were administered with no documented evidence of a review of the patient's medications by the pharmacist prior to the first dose of the medication.

Review of the QAPI (Quality Assessment Performance Improvement) plan and data collected revealed the monitoring process that was implemented to ensure the 1st dose review by the pharmacist was a Performance Improvement Report Analysis and Plan for Improvement conducted and reported by the Pharmacist. Also included with the report was a copy of the Pharmacist's on-call log. Review of the report revealed the nurse was to call the pharmacy during normal business hours and the on-call pharmacist after hours to ensure correct verification of medications and this was implemented on 05/21/14. The report revealed the plan was reviewed on 05/23/14 and since implementation of the plan, no further incidences occurred.

There was no documented evidence of any data collection or monitoring process to ensure the nursing staff notified the pharmacist of new medications.

In an interview on 06/11/14 at 2:40 p.m., SF2DON (Director of Nursing) verified the only quality improvement process implemented to address the deficiency in 1st dose medication review by the pharmacist was the on-call log documented by the pharmacist and it was not working. SF2DON verified there was no monitoring in place to ensure the nursing staff were notifying the pharmacist when a new medication was ordered.


2) failing to monitor the hospital process for treatment planning.

Review of the hospital policy titled "Inter-Disciplinary Treatment Planning Overview," policy number NU.706, revised 06/20/12, and presented as the current policy by SF2DON, revealed that each patient admitted shall have a comprehensive, individualized treatment plan which is based on interdisciplinary clinical assessments. Further review revealed the treatment planning process is continuous, beginning at the time of admission and continuing through discharge.

Review of the treatment plans for the current sampled patients (F1-F10) revealed the goals were not measurable and were not individualized for each patient.

Review of the QAPI plan and data collected revealed a plan for improvement was developed to address the failure to individualize the patients' treatment plans. Review of the plan revealed the following Performance Measures were identified:
Staff will document patient specific problems, needs and strengths based on multidisciplinary assessments on the Initial Plan of Care and the Master Treatment Plan. Staff will describe the problems as evidenced by and related to in narrative form. Staff will describe long term goals in narrative form. Objectives will be measurable. Special accommodations will be identified based on patient's needs....

There was no documented evidence that the QAPI plan for Treatment Plans was implemented.

In an interview on 06/11/14 at 2:40 p.m., SF2DON verified the above QAPI plan for treatment plans was developed, but had not been implemented yet. SF2DON stated the only intervention she had done to address the deficiencies related to Treatment Plans was to inservice the staff. SF2DON stated the Treatment Plan forms were still under revision and had not been implemented yet.

Based on record reviews and interview, the governing body failed to ensure that the hospital's Performance Improvement Program reflected the hospital's organization and services as evidenced by not having the hospital's Respiratory Services involved in the Performance Improvement Program.
Findings:

Review of the Respiratory Scope of Services approved by the MEC (Medical Executive Committee) dated 06/05/14 revealed the following services were provided by the hospital: Oxygen delivery, Pulse Oximetry, Oropharyngeal Suctioning, Incentive Spirometry, Intermittent Aerosol Treatment, and CPAP/BIPAP (Continuous Positive Airway Pressure/Biphasic Positive Airway Pressure).

Review of the performance improvement quality indicators and the QAPI reports since the last survey dated 05/01/14 revealed no documented evidence that the respiratory services provided by the hospital were included in the QAPI program.

In an interview on 06/11/14 at 2:40 p.m., SF2DON (Director of Nursing) verified the nursing staff provided respiratory therapy as indicated in the above Respiratory Scope of Services. SF2DON verified there were no quality indicators developed to monitor the respiratory services provided by the hospital staff.

Based on record review and staff interview, the hospital failed to ensure the medical staff conducted periodic appraisals of its members for 2 of 2 (SF13Physician, SF12APRN) credentialing files reviewed for medical staff appraisals out of 5 current credentialed practitioners (SF12APRN, SF13Physician, SF14Medical Director, SF15Physician, SF16APRN). Findings:

Review of the Governing Body By-Laws dated 06/05/14 revealed in part the following, Article VI Medical Staff, Item No. 6.03 Medical Care and Its Evaluation: The Governing Board shall, in the exercise of its discretion, delegate to the Medical Staff the responsibility of monitoring and evaluating the appropriateness of professional care rendered to the Hospital's patients. The Medical Staff shall conduct a continuing review and appraisal of the quality of professional care rendered in the Hospital, and shall report such activities and their results to the Board.
Item No. 6.09 Term of Appointment.... Appointments shall be granted by the Board after the recommendation of the Medical Staff is considered. The following information is considered by the Medical Staff and the Governing Board for appointments, reappointments and the delineation of staff privileges: education, training, experience, current competence, references, peer appraisal, continuing education, health status, moral and ethical qualifications and any other information relevant to the granting of such privileges.
Review of the Medical Staff By-Laws, Rules & Regulations dated 06/05/14 revealed in part the following: Reappointment Process: ....b. Every two years each staff member shall submit a written application for reappointment to the Medical Staff and will be reviewed by the Medical Executive Committee....Written record of the periodic appraisal of the professional activities, and of each member's physical and mental capabilities is included in the permanent file of the Hospital.....All advanced practice professional personnel will be subject to a formal annual reappraisal of their clinical activities by the appropriate department chairperson.

SF12APRN
Review of the credentialing file for SF12APRN revealed the practitioner's Governing Body re-appointment to the medical staff was dated 06/05/14. Review of the credentialing file revealed no documented evidence of an appraisal by the medical staff.


SF13Physician
Review of the credentialing file for SF13Physician revealed the physician was re-appointed to the medical staff by the governing body on 08/02/13. Review of the credentialing file revealed no documented evidence of an appraisal by the medical staff.

In an interview on 06/10/14 at 2:20 p.m., SF4Credentialist stated she had been contracted by the hospital 2 weeks ago to complete the medical staff credential files. SF4Credentialist reviewed the credentialing file for SF12APRN and SF13Physician and verified there was no appraisal by the medical staff for either practitioner. SF4Credentialist stated the Medical Staff had revised the Medical Staff By-Laws to include annual appraisals for APRNs on staff, but confirmed an appraisal had not been done for SF12APRN. SF4Credentialist stated they had not developed a form for physician appraisals yet, and the Medical Staff By-Laws had not been revised to include a process for physician appraisals.

Based on record review and interview, the hospital failed to ensure the RN (Registered Nurse) supervised and evaluated the nursing care of each patient as evidenced by failing to implement physician orders to obtain an EKG (electrocardiogram) for 1 (#F8) of 10 (#F1 - #F10) patient records reviewed for implementation of physician orders for EKGs from a total sample of 10 patients.
Findings:

Review of the hospital policy titled "Electrocardiogram (EKG)," policy number NU.312, revised 05/12/14, and presented as the current policy by SF2DON (Director of Nursing), revealed an EKG is obtained based upon physician order for clients admitted to the psychiatric unit and shall be completed within 24 hours of receipt of the order by a trained staff MHT (mental health tech), RN, or LPN (Licensed Practical Nurse). Further review revealed the MHT admitting and orienting the client to the unit is responsible for completing the EKG as part of the orientation/admission process if ordered by the physician.

Review of Patient #F8's medical record revealed she was admitted on 06/10/14 with diagnoses of Psychosis with a component of Delirium, Dementia, Mood Disturbance, Depression, Pneumonia, and Hypertension. Review of her "Physician Admit Certification, Orders and Plan for Therapy" received by telephone order from SF14Medical Director on 06/10/14 at 7:45 p.m. revealed an order for an EKG.

Review of Patient #F8's medical record revealed a copy of an EKG that had been obtained by fax from another facility that was performed on 06/03/14. There was no documented evidence that an EKG had performed at the time of admit.

In an interview on 06/11/14 at 8:30 a.m., SF6Unit Secretary indicated if an EKG's been done within 30 days of it being ordered, the staff did not have to do another EKG if they obtained a copy of the most recent EKG.

In an interview on 06/11/14 at 8:35 a.m., SF5RN indicated that she was going to check with SF13Physician to see if he wanted to do another EKG for Patient #F8. When told by the surveyor that the EKG order was obtained from SF14Medical Director, SF5RN answered, "SF14Medical Director defers to SF13Physician and we have 24 hours to do the EKG." SF5RN confirmed there was no documented evidence that SF14Medical Director had given an order to check with SF13Physician to see if he wanted another EKG done.

In an interview on 06/11/14 at 11:50 a.m., SF2DON indicated Patient #F8's EKG should have been done as ordered, because SF13Physician had just been complaining about it not being done.

Based on record review and interview, the hospital failed to ensure the pharmacist reviewed all first dose medications for appropriateness, duplication, interactions, allergies, sensitivities or other contraindications before the first dose was dispensed and administered to patients for 6 (F1, F3, F5, F7, F8, F10) of 10 (#1-#10) sampled patients.
Findings:

Review of the policy entitled First Dose Procedure revealed the following, in part:
I. Policy:
It is the policy of this hospital that a pharmacist reviews all medication orders (except in emergency situations) for appropriateness before the first dose is administered.
II. Purpose: To ensure medication orders are reviewed by a pharmacist for therapeutic appropriateness of medication regimen, duplication of medications, appropriateness of the drug, dose, frequency, route, and method of administration; real or potential medication-medication, medication-food, medication-laboratory test and medication-disease interactions; real or potential allergies or sensitivities; variation from organizational criteria for use; and/or other contraindications prior to first dose administration to patients.
III. Procedure: A. This hospital maintains a contract with an area pharmacy. Pharmacy hours are Monday- Friday from 8:30 a.m. until 5:00 p.m. A pharmacist may be reached during business hours by dialing 1-985-626-9726 or after hours by dialing the On-Call Pharmacist's contact number provided monthly by the contracted pharmacy.
B. RN or LPN shall fax medication written physician orders to the contract pharmacy by dialing the provided fax number and calling the pharmacy to alert them that orders were faxed. Written orders shall be faxed 24 hours a day. Outside of business hours, the RN or LPN will fax and call the on-call pharmacist.
C. Prior to medication administration all medication orders shall be reviewed by a pharmacist for therapeutic appropriateness of medication regimen, duplication of medications, appropriateness of the drug, dose, frequency, route, and method of administration; real or potential medication-medication, medication-food, medication-laboratory test and medication-disease interactions; real or potential allergies or sensitivities; variation from organizational criteria for use; and/or other contraindications prior to first dose administration to patients....

Review of the "Amendment to Contract Agreement Between Company D and Magnolia Behavioral Health," signed 05/01/14 by SF11Pharmacist (contracted) revealed that all orders were to be verified by a pharmacist before being administered to any patient. Further review revealed that if the new order is after hours the nurse is to call the on-call pharmacist and either fax or scan the order or leave a voice mail on the recorder before the order is administered. There was no documented evidence in the contract that an approval by the pharmacist to administer the medication was to be communicated to the nurse before the medication was administered or the time frame in which the pharmacist was expected to respond to the fax, scan, or voice mail.

Patient #F1
Review of Patient #F1's medical record revealed he was an 80 year old male admitted on 05/29/14 with diagnoses of Dementia, Hypertension, Hypothyroidism, Cardiac Disease, and Hyperlipidemia. Review of his "Psychiatric Evaluation" performed on 05/29/14 by SF12APRN (Advanced Practice Registered Nurse) revealed Patient #F1's Axis III diagnoses included Hypertension, Vertigo, Hyperlipidemia, Hypothyroidism, although at this point in time it does appear that it may be medically induced hyperthyroid, history of Back Pain, Osteoarthritis, and history of Asthma.

Review of Patient #F1's "Physician's Orders" revealed an order written by SF13Physician on 06/08/14 at 3:00 p.m. for Gentamycin Ophthalmic Eye Drops 0.3% (per cent), 2 drops to the right eye every 4 hours for 5 days. Further review revealed a telephone order received from SF13Physician on 06/08/14 at 3:15 p.m. to give Gentamycin eye drops when available.

Review of the hospital's binder of physician orders faxed to pharmacy revealed the order for Gentamycin was faxed on 06/08/14 at 4:07 p.m. Review of the confirmation of the fax receipt revealed the top of the page was dated 06/09/14 at 12:11 p.m. (the day after the order for Gentamycin was received).

Review of the "On Call Log," presented by FS2DON (Director of Nursing) as obtained from Company D, revealed no documented evidence of who wrote the note on the log as evidenced by no signature. Further review revealed that SF13Physician was aware that the pharmacy had Tobramycin and Tobrex ophthalmic eye drops, but he wanted Patient #F1 to have Gentamycin. Further review revealed the order was called to a local drug store who would deliver the medication to the hospital.

Review of Patient #F1's MAR (medication administration record) revealed that he received his first dose of Gentamycin on 06/08/14 at 6:10 p.m., 3 hours and 10 minutes after it was originally ordered.

In an interview on 06/10/14 at 2:15 p.m., SF2DON indicated the nurse speaks with a pharmacist to get approval to administer medication, but there is no documentation of this conversation. She confirmed the hospital had no system in place to show that a first dose drug review had been conducted by a pharmacist prior to the patient receiving their first dose of medication. SF2DON indicated the nurse is supposed to call her if a medication is not administered within 2 hours of the order, and the nurse is supposed to complete an incident report. She confirmed that she had not received a call and an incident report had not been completed in regards to Patient #F1's order for Gentamycin.

Patient #F3
Review of the medical record for Patient #F3 revealed the patient was a 97 year old female admitted to the hospital on 06/04/14 with a diagnosis of Dementia with Behavioral Disturbance.
Review of the physician's orders dated/timed 06/08/14 at 11:00 p.m., revealed a verbal order for Haldol 2.5 mg (milligrams) by mouth or intramuscular injection as needed for agitation. Review of the patient's record revealed the Haldol was a new medication for Patient #F3.
Review of the MAR (Medication Administration Record) dated 06/08/14 revealed the patient received a dose of the Haldol at 11:03 p.m.
Review of the hospital's binder of physician orders faxed to pharmacy revealed the order for the Haldol on 06/08/14 at 11:00 p.m. was faxed to the pharmacy on 06/09/14 at 9:16 a.m.
There was no documented evidence that the nurse called the pharmacy on 06/08/14 to inform the pharmacist of the new medication order prior to administering the medication to the patient.

In an interview on 06/10/14 at 3:55 p.m., SF2DON (Director of Nursing) provided the on-call log from Company D. Review of the on-call log revealed the pharmacist was called by SF7LPN on 06/09/14 at 5:21 a.m. to report the new medication order for Haldol. SF2DON verified the nurse failed to contact the pharmacist prior to administering the Haldol and verified there was no review of the patient's medication regimen before the first dose was
administered. SF2DON was asked what system the hospital had in place to ensure the pharmacist was notified by the staff. SF2DON stated they did not have a system to ensure the nurse was notifying the physician. SF2DON verified the only monitoring done on this process was the on-call log documented by the pharmacist.

In a telephone interview on 06/11/14 at 2:50 p.m., SF10RN verified she was the RN assigned to Patient #F3 on 06/08/14. SF10RN stated she received the verbal order for the Haldol from the physician. When asked if she notified the pharmacist of the new order, she stated she did not call the pharmacy because no one is at the pharmacy at that time of the night. SF10RN stated she had been instructed to fax the orders to the pharmacy the next day. She stated she reports the new medication to the oncoming shift. SF10RN stated she had not been instructed to call the pharmacist after hours if new medications are ordered. SF10RN stated she took the order from the physician and she had the medication, so why should she call the pharmacist. SF10RN verified she was not familiar with the hospital's requirement to have the pharmacist review 1st dose medications.

Patient #F5
Review of the medical record for Patient #F5 revealed the patient was an 83 year old female admitted to the hospital on 06/04/14 with a diagnosis of Dementia with Behavioral Disturbance.
Review of the physician's orders dated/timed 06/05/14 at 6:00 p.m., revealed an order for Neurontin 100 mg by mouth twice a day. Review of the patient's record revealed the Neurontin was a new medication for Patient #F5.
Review of the MAR (Medication Administration Record) dated 06/05/14 revealed the patient received a dose of the Neurontin at 9:00 p.m.
Review of the hospital's binder of physician orders faxed to pharmacy revealed the order for the Neurontin on 06/05/14 at 6:00 p.m. was faxed to the pharmacy on 06/05/14 at 6:50 p.m.
There was no documented evidence that the nurse called the pharmacy on 06/05/14 to inform the pharmacist of the new medication order prior to administering the medication to the patient.
Review of the on-call log from Company D revealed no documented evidence the pharmacist was called regarding the Neurontin order on 06/05/14 at 6:00 p.m.

In an interview on 06/10/14 at 3:55 p.m., SF2DON verified there was no documentation that the nurse contacted the pharmacist prior to administering the Neurontin. SF2DON verified the only monitoring done on this process was the on-call log documented by the pharmacist.

Patient #F7
Review of Patient #F7's medical record revealed that she was an 81 year old female admitted on 05/16/14 with diagnoses of Psychosis, Impulse Control Disorder, Chronic Insomnia, Dementia with Behavioral Disturbance, and Acute Scabies.

Review of Patient #F7's "Physician's Orders" revealed an telephone order received from SF12APRN (Advanced Practice Registered Nurse) on 06/08/14 at 5:00 p.m. for Valproic Acid 250 mg per 5 milliliters (ml), give 10 ml (500 mg) by mouth twice a day at 9:00 a.m. and 5:00 p.m. Review of the fax transmission revealed the "ok" confirmation that the fax was received was dated and timed as 06/08/14 at 5:26 p.m. Review of Patient #F7's MAR revealed he received Valproic Acid 500 mg by mouth on 06/08/14 at 5:00 p.m. (prior to receiving approval by the pharmacist at 5:26 p.m.).

Patient #F8
Review of Patient #F8's medical record revealed she was admitted on 06/10/14 with diagnoses of Psychosis with a component of Delirium, Dementia, Mood Disturbance, Depression, Pneumonia, and Hypertension.

Review of Patient #F8's "Physician's orders Home Medication Inventory On Admit" revealed SF12APRN gave orders to continue Mucinex 600 mg by mouth twice a day, Zyprexa 10 mg by mouth every night at bedtime, Trazodone 100 mg by mouth every night at bedtime, and Nystatin 5 ml to swish and swallow orally three times a day for 7 days.

Review of the hospital's "Pharmacy Communication Log" revealed SF5RN received approval for Patient #F8's first dose medications on 06/10/14 at 9:10 p.m. Review of Patient #F8's MARs revealed she received Mucinex, Zyprexa, Trazadone, and Nystatin on 06/10/14 at 9:00 p.m. prior to receiving approval from the pharmacist.

Patient #F10
Review of patient #F10's medical record revealed she was a 53 year old female admitted on 06/11/14 with a diagnosis of Bipolar Disorder.

Review of Patient #F10's "Physician's Orders" revealed a telephone order from SF14Medical Director on 06/11/14 at 12:15 a.m. for Geodon 20 mg orally every 4 hours as needed for Psychosis and Agitation; if patient refuses orally, then give Geodon 20 mg intramuscularly every 4 hours as needed for Psychosis and Agitation.

Review of the hospital's "Pharmacy Communication Log" revealed a voice mail was left on 06/11/14 at 2:16 a.m. for the pharmacist, a return call with the message that the pharmacist would call back was received on 06/11/14 at 4:40 a.m., and the approval for the first dose was received from the pharmacist on 06/11/14 at 5:10 a.m., 4 hours and 55 minutes after an order was received for an "as needed" medication ordered for Psychosis and Agitation.

In an interview on 06/11/14 at 11:50 a.m., SF2DON confirmed that the hospital policy and the contract with Company D did not address a time frame for receipt of approval to administer first dose medications from Company D and how to address a delay in receiving approval when medication administration was required.

In an interview on 06/11/14 at 2:10 p.m., SF11Pharmacist indicated orders from the hospital were faxed to the pharmacy and the medication orders were entered into their computer system. Once the orders were entered into the computer system, the nurse had access to the medication through Med-Dispense (an automated medication delivery system). SF11Pharmacist indicated the advertised hours of operation are from 8:30 a.m. until 5:30 p.m., but the pharmacists were usually at the pharmacy until about 7:00 p.m. or 8:00 p.m. Once the pharmacy is closed, there was a pharmacist on call via a cell phone by which the hospital staff can contact a pharmacist for medication issues. All pharmacists have individual laptop computers that operate as the main computer in the pharmacy. The orders can be entered into the laptop and the pharmacist can review the patients' profiles and, if approved, allow access to the Med-Dispense system.
SF11Pharmacist also indicated the pharmacists maintain an on-call log of all calls they receive after hours, but there were no specific guidelines for documentation on the on-call log. He further indicated there was no specified time the pharmacist had to return a phone call if a hospital attempted to contact a pharmacist and received a recording to leave a message. SF11Pharmacist further indicated he reviewed all of the log sheets weekly with the pharmacists.
SF11Pharmacist indicated the procedure in place for after-hour medication needs was the nurse was to call the pharmacist on call and give the new medication orders over the phone and fax the doctor's orders to the pharmacy for the pharmacist to review in the morning. The pharmacy would then fax the order sheet back to the hospital for confirmation that the pharmacy did receive and review the medications.
SF11Pharmacist confirmed the nurses were able to override the Med-Dispense system if they needed to have access to any medications without a pharmacist entering the orders into the Med-Dispense computer system. He also indicated there was an override report printed every morning and reviewed by the pharmacists. He further indicated SF2DON was provided override medication reports.

In an interview on 06/11/14 at 2:30 p.m., SF2DON indicated she was notified by the pharmacy if there were any problems with the override reports. She also indicated, if she needed to, she had access to print override reports. SF2DON indicated she was not made aware of any problems with nurses overriding the Med-Dispense system.



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Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiological Services as evidenced by:

Failing to ensure there was a radiologist who was a credentialed and privileged member of the medical staff who supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis. (see findings in tag A-0546)

Based on record review and interview, the hospital failed to ensure there was a credentialed and privileged radiologist who was a member of the medical staff who supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis. Findings:

Review of the list of credentialed physicians on the medical staff list, presented as a current list by SF4Credentialist (Consultant Credentialing Specialist), revealed no documented evidence that a radiologist was credentialed and privileged as a member of the medical staff at the hospital.

Review of the contracts provided by SF2DON (Director of Nursing) revealed the hospital had a contract with Hospital A to provide radiology services to its patients at Hospital A, and a contract with Company B to provide mobile x-ray services on site at the hospital.

In an interview on 06/11/14 at 1:00 p.m, SFDON indicated the hospital does not have a credentialed and privileged radiologist as a member of the medical staff to supervise and oversee radiology services provided at the hospital. She further indicated they have made attempts, and are still making attempts, to get a radiologist to apply for membership of the hospital's medical staff and accept a position as director over radiology services.

Based on record review and interview, the hospital failed to ensure that the scope of diagnostic and/or therapeutic respiratory services was defined in writing and approved by the Medical Staff as evidenced by failure to have the Governing Body By-laws designate Respiratory Services as one of the clinical and ancillary services provided by the hospital.
Findings:

Review of the Governing Body By-laws, revised date of 06/05/14, presented as the current by SF2DON (Director of Nursing), revealed that Respiratory Services was not listed as clinical and ancillary service offered by the hospital.

Review of the Respiratory Therapy Scope of Services document revealed the MEC (Medical Executive Committee) approved the scope of services listed on the document on 06/05/14. The document was signed by SF14Medical Director.

In an interview on 06/11/14 at 10:10 a.m., SF2DON (Director of Nursing) verified the Governing Body By-Laws had not been revised to include Respiratory Services, and stated the only action taken by the hospital was the above Medical Staff approval of the scope of services.

Based on record review and staff interview, the hospital failed to have Respiratory Therapy Technician/s employee/s or contract employee/s to administer respiratory therapy services to patients should they require these services as evidence by failing to ensure nursing staff were trained in respiratory services by a qualified Respiratory Therapist. Findings:

Review of the Respiratory Therapy Scope of Services document revealed the MEC (Medical Executive Committee) approved the scope of services listed on the document on 06/05/14. The document was signed by SF14Medical Director. The scope of services revealed a Respiratory Therapist would be available under contract and the Respiratory Therapist would train and evaluate nursing competency in administering respiratory services. Further review of the contract revealed the RN (Registered Nurse) and the LPN (Licensed Practical Nurse) may administer respiratory therapies after he/she has been deemed competent in respiratory therapy policies by the Respiratory Therapist.

Review of the hospital contract with SF18Respiratory Therapist dated 06/03/14 revealed SF18Respiratory Therapist would provide respiratory training to the hospital nursing staff. Review of the contract revealed no documented evidence of any credentials or license verification for SF18Respiratory Therapist.

Review of the personnel records for SF5RN, SF10RN, SF7LPN, SF8LPN, SF9LPN, and SF17LPN revealed SF18Respiratory Therapist documented a competency evaluation for the provision of respiratory services on 06/06/14.

Patient #F5
Review of the clinical record for Patient #F5 revealed the patient was an 83 year old female with a diagnoses of Dementia with Behavioral Disturbance, Coronary Artery Disease, Hypertension, and Diabetes Mellitus that was currently on as needed nebulizer treatments and Pulse Oximetry every shift.

In an interview on 06/11/14 at 10:10 a.m., SF2DON (Director of Nursing) stated the hospital had contracted with SF18Respiratory Therapist to provide training and competency evaluation of the nursing staff. SF2DON verified the hospital did not have any documentation to verify the credentials of SF18Respiratory Therapist. SF2DON stated she assumed that when human resources obtained the contract, they obtained the credentials also.

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for:

1) Radiological Services as evidenced by:
Failing to ensure there was a radiologist who was a credentialed and privileged member of the medical staff who supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis. (see findings in tag A-0546).

Based on record reviews and interviews, the hospital failed to ensure that the written treatment plan included short-term and long-range goals that were stated as expected behavioral outcomes for the patient and written as observable, measurable patient behaviors to be achieved for 7 (#F1, #F2, #F4, #F6, #F7, #F8, #F10) of 10 (#F1 - #F10) active patients' records reviewed for treatment plan goals from a total sample of 10 patients.
Findings:

Review of the hospital policy titled "Inter-Disciplinary Treatment Planning Overview," policy number NU.706, revised 06/20/12, and presented as the current policy by SF2DON (Director of Nursing), revealed that the discharge goal or long-term goal is defined. Further review revealed that a goal is a "brief clinical, abstract statement of the condition you expect to change in the patient; what you intend to accomplish in general terms, and specify the condition of the patient that will result from treatment. All goals label a set of behaviors that you want to elicit in the patient." Further review revealed that short-term objectives must be realistic, achievable, specific, measurable, and represent a patient's steps toward reaching the long-term goal.

Patient #F1
Review of Patient #F1's medical record revealed he was an 80 year old male admitted on 05/29/14 with diagnoses of Dementia, Hypertension, Hypothyroidism, Cardiac Disease, and Hyperlipidemia. Review of his "Psychiatric Evaluation" performed on 05/29/14 by SF12APRN (Advanced Practice Registered Nurse ) revealed Patient #F1's Axis III diagnoses included Hypertension, Vertigo, Hyperlipidemia, Hypothyroidism, although at this point in time it does appear that it may be medically induced hyperthyroid, history of Back Pain, Osteoarthritis, and history of Asthma.

Review of Patient #F1's treatment plan for "Psychosis With Behavioral Disturbance" revealed the long-term goal was that Patient #F1's thought processes and behavior would be more organized and appropriate by discharge. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F1 had achieved the goal. Further review revealed that the short-term objectives were written as follows and had no documented evidence that they were written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F1 had achieved the goal:
Patient #F1 will establish meaningful communication and trust with others within 7 days;
Patient #F1 will demonstrate no or reduced physical aggression;
Patient #F1 will demonstrate socially appropriate behavior during tasks.

Review of Patient #F1's treatment plan for "Violence" revealed the long-term goal was that he would experience control of behaviors with assistance from others. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F1 had achieved the goal. Further review revealed that the short-term objective was written as "Patient will demonstrate a 90% (per cent) improvement in impulse control..." There was no documented evidence that the goal was written as an observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F1 had achieved the goal.

Review of Patient #F1's treatment plan for "Alcohol Withdrawal" revealed the long-term goal was that he would withdraw from mood altering substances, stabilize physically and emotionally, and then establish a supportive recovery plan. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F1 had achieved the goal.

Review of Patient #F1's treatment plan for "Infection" revealed that the long-term goal was that he would demonstrate complete recovery from his right eye infection. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F1 had achieved the goal. Further review revealed that his short-term goal was that he would "demonstrate complete recovery from infection as evidenced by: ________" (blank not filled in).

Patient #F2
Review of Patient #F2's medical record revealed he was a 60-year-old male admitted on 05/28/14 with diagnoses of Psychosis with Behavioral Disturbance, Non-compliance with Medications, Hypertension, Diabetes Mellitus (Type II), Hypothyroidism, and Cellulitis of Left Leg.
Review of Patient #F2's treatment plan for "Psychosis with Behavioral Disturbance" revealed the long-term goal was that Patient #F2's thought processes and behavior will be more organized and appropriate by discharge. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F2 had achieved that goal. Further review revealed that the short-term objectives were written as follows and had no documented evidence that they were written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F2 had achieved the goals: Patient #F2 will be medication compliant; Patient #F2 will report or demonstrate diminishing or absence of hallucinations and/or delusions; Patient #F2 will participate in or attend to hygiene/ADL's (Activities of Daily Living).
Review of Patient #F2's treatment plan for "Non-compliance with Medications" revealed the long-term goal was that Patient #F2 will demonstrate compliance with therapeutic plan of care. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F2 had achieved that goal.
Patient #F4
Review of Patient #F4's medical record revealed that she was an 83 year old female admitted on 06/01/14 with diagnoses if Psychosis with Behavior Disturbance, Urinary Tract Infection (UTI), Hypercholesterolemia, Parkinson's Disease, and Hypertension.

Review of Patient #F4's treatment plan for "Psychosis With Behavioral Disturbance" revealed the long-term goal was that Patient #F4's thought processes and behavior would be more organized and appropriate by discharge. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F4 had achieved the goal. Further review revealed that the short-term objectives were written as follows and had no documented evidence that they were written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F4 had achieved the goals:
Patient #F4 will establish meaningful communication and trust with others within 3 days;
Patient #F4 will demonstrate no or reduced physical aggression;
Patient #F4 will demonstrate no or reduced verbal aggression.

Review of Patient #F4's treatment plan for Infection related to her UTI revealed her long-term goal was that she would demonstrate complete recovery from her UTI. There was no documented evidence of observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F4 had achieved the goal. Further review revealed that a short-term goal was that Patient #F4 would demonstrate complete recovery from infection as evidenced by completing Macrobid 100 mg (milligrams) by mouth twice a day for 10 days. There was no documented evidence of observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F4 had recovered from her UTI.

Patient #F6
Review of Patient #F6's medical record revealed she was a 59-year-old female admitted on 05/29/14 with diagnoses of Major Depression Disorder, Generalized Anxiety Disorder, Hypertension, and Diabetes Mellitus (Type II).
Review of Patient #F6's treatment plan for "Depressed Mood" revealed the long-term goal was that Patient #F6 will exhibit medication compliance and verbalize and/or demonstrate improved mood and feelings of self-worth. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F6 had achieved that goal.
Further review revealed that the short-term objectives were written as follows and had no documented evidence that they were written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F6 had achieved the goals: Patient #F6 will demonstrate compliance with medication regime; Patient #F6 will demonstrate/report improved mood; Patient #F6 will demonstrate/report improved energy; Patient #F6 will demonstrate improved concentration; Patient #F6 will demonstrate improved memory/orientation; Patient #F6 will attend to self-care and ADL's; Patient #F6 will experience diminished or eliminate ruminating thoughts.
Patient #F7
Review of Patient #F7's medical record revealed that she was an 81 year old female admitted on 05/16/14 with diagnoses of Psychosis, Impulse Control Disorder, Chronic Insomnia, Dementia with Behavioral Disturbance, and Acute Scabies.

Review of Patient #F7's treatment plan for "Psychosis With Behavioral Disturbance" revealed the long-term goal was that Patient #F7's thought processes and behavior would be more organized and appropriate by discharge. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F7 had achieved the goal. Further review revealed that the short-term objectives were written as follows and had no documented evidence that they were written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F7 had achieved the goals:
Patient #F7 will establish meaningful communication and trust with others within 5 days;
Patient #F7 will demonstrate no or reduced physical aggression;
Patient #F7 will demonstrate no or reduced verbal aggression;
Patient #F7 will demonstrate socially appropriate behavior during tasks.

Review of Patient #F7's treatment plan for "Violence" revealed the long-term goal was that she would experience control of behaviors with assistance from others. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F7 had achieved the goal. Further review revealed that the short-term objective was written as "Patient will demonstrate a 75% improvement in impulse control..." There was no documented evidence that the goal was written as an observable, measurable patient behavior to be achieved that could be used to determine when Patient #F7 had achieved the goal.

Review of Patient #F7's treatment plan for "Imbalanced Nutrition: Less Than Body Requirements" revealed that the long-term goal was that optimal calorie intake would be maintained. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F7 had achieved the goal.

Patient #F8
Review of Patient #F8's medical record revealed she was admitted on 06/10/14 with diagnoses of Psychosis with a component of Delirium, Dementia, Mood Disturbance, Depression, Pneumonia, and Hypertension.

Review of Patient #F8's treatment plan for "Psychosis With Behavioral Disturbance" revealed the long-term goal was that Patient #F8's thought processes and behavior would be more organized and appropriate by discharge. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F8 had achieved the goal. Further review revealed that the short-term objectives were written as follows and had no documented evidence that they were written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F8 had achieved the goals:
Patient #F8 will establish meaningful communication and trust with others within 7 days;
Patient #F8 will verbalize basic needs within 7 days;
Patient #F8 will report or demonstrate diminishing or absence of hallucinations and/or delusions;
Patient #F8 will demonstrate socially appropriate behavior during tasks.

Review of Patient #F8's treatment plan for "Depressed Mood" revealed that her long-term goal was that she would exhibit medication compliance and verbalize and/or demonstrate improved mood and feelings of self-worth. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F8 had achieved the goal. Further review revealed that the short-term objectives were written as follows and had no documented evidence that they were written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F8 had achieved the goals:
Patient #F8 will demonstrate/report improved mood;
Patient #F8 will demonstrate improved concentration;
Patient #F8 will demonstrate improved memory/orientation;
Patient #F8 will experience diminished or eliminate ruminating thoughts.

Review of Patient #F8's treatment plan for Infection related to Pneumonia revealed her long-term goal was that she would demonstrate complete recovery from Pneumonia. There was no documented evidence of observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F8 had achieved the goal. Further review revealed that a short-term goal was that Patient #F8 would demonstrate complete recovery from infection as evidenced by completing Levaquin 500 mg every day for 7 days. There was no documented evidence of observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F8 had recovered from Pneumonia.

Patient #F10
Review of patient #F10's medical record revealed she was a 53 year old female admitted on 06/11/14 with a diagnosis of Bipolar Disorder.

Review of Patient #F10's treatment plan for "Psychosis" revealed that her long-term goal was that she would exhibit medication compliance and/or diminished or absent signs/symptoms of active psychosis. There was no documented evidence of observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F10 had achieved the goal. Further review revealed that the short-term objectives were written as follows and had no documented evidence that they were written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F10 had achieved the goals:
Patient #F10 will establish meaningful communication and trust with others within 3 days;
Patient #F10 will demonstrate decreased psychomotor agitation;
Patient #F10 will demonstrate no or reduced verbal aggression;
Patient #F10 will demonstrate socially appropriate behavior during tasks.

Review of Patient #F10's treatment plan for "Depressed Mood" revealed that her long-term goal was that she would exhibit medication compliance and verbalize and/or demonstrate improved mood and feelings of self-worth. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F10 had achieved the goal. Further review revealed that the short-term objectives were written as follows and had no documented evidence that they were written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F10 had achieved the goals:
Patient #F10 will demonstrate/report improved mood;
Patient #F10 will demonstrate/report improved energy;
Patient #F10 will demonstrate improved concentration;
Patient #F10 will demonstrate improved memory/orientation;
Patient #F10 will experience diminished or eliminate ruminating thoughts.

Review of Patient #F10's treatment plan for "Non-Compliance With Medication Regime" revealed that her long-term goal was that she would demonstrate compliance with her therapeutic plan of care. There was no documented evidence that the goal was stated as expected behavioral outcomes and written as observable, measurable patient behaviors to be achieved that could be used to determine when Patient #F10 had achieved the goal.

In an interview on 06/11/14 at 11:50 a.m., SF2DON indicated that she had provided education on the treatment plan development and writing goals. She further indicated that the form had been revised, but it had not been implemented yet. SF2DON indicated the nurses should be writing the goals as observable, measurable patient behaviors to be achieved.

In an interview on 06/11/14 at 2:40 p.m., SF2DON indicated the only intervention she had done to address the deficiencies related to Treatment Plans was to inservice the staff. She further indicated the Treatment Plan forms were still under revision and had not been implemented yet.







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Based on record reviews and interviews, the hospital failed to ensure that each patient's individualized comprehensive treatment plan included interventions relative to the treatment of hypothyroidism/hyperthyroidism for 2 (#F1, #F2) of 10 (#F1 - #F10) active patients' records reviewed for treatment plan development from a total sample of 10 patients.
Findings:

Review of the hospital policy titled "Inter-Disciplinary Treatment Planning Overview," policy number NU.706, revised 06/20/12, and presented as the current policy by SF2DON (Director of Nursing), revealed that each patient admitted shall have a comprehensive, individualized treatment plan which is based on interdisciplinary clinical assessments. Further review revealed the treatment planning process is continuous, beginning at the time of admission and continuing through discharge. Based on intake information and the nursing assessment, the initial treatment plan is developed and addresses the most immediate and obvious needs of the patient. In order to determine the effectiveness of the master treatment plan, weekly reviews are done by the interdisciplinary team. This review will provide valuable information about patient progress, need for continued treatment, and revision of interventions as well as discharge planning.

Patient #F1
Review of Patient #F1's medical record revealed he was an 80 year old male admitted on 05/29/14 with diagnoses of Dementia, Hypertension, Hypothyroidism, Cardiac Disease, and Hyperlipidemia. Review of his "Psychiatric Evaluation" performed on 05/29/14 by SF12APRN (Advanced Practice Registered Nurse) revealed Patient #F1's Axis III diagnoses included Hypertension, Vertigo, Hyperlipidemia, Hypothyroidism, although at this point in time it does appear that it may be medically induced hyperthyroid, history of Back Pain, Osteoarthrosis, and history of Asthma.

Review of Patient #F1's multidisciplinary treatment plan revealed a plan was initiated for Psychosis With Behavioral Disturbance, Risk For Injury/Falls, Violence, Decreased Cardiac Output, and Alcohol Withdrawal. Further review revealed a plan was initiated on 06/08/14 for Infection related to Conjunctivitis.

Review of Patient #F1's "Physician's Orders" revealed an order on 05/29/14 at 1:15 p.m. to hold Levothyroxine until seen by SF13Physician. Further review revealed an order on 05/29/14 at 6:00 p.m. by SF13Physician to hold Levothyroxine for 7 days and then resume at 50 mcg (micrograms), 1 by mouth every day.

Review of Patient #F1's "Weekly Treatment Team Review" for 05/30/14 and 06/06/14 revealed no documented evidence that holding Patient #F1's Levothyroxine and the subsequent change in his dose of Levothyroxine when it was restarted had been addressed. Further review revealed no documented evidence that his treatment plan was revised to address his medically induced Hyperthyroidism.

In an interview on 06/11/14 at 11:50 a.m., SF2DON confirmed that Patient #F1's treatment plan should have been revised to include his medically induced Hyperthyroidism.

Patient #F2
Review of Patient #F2's medical record revealed he was a 60-year-old male admitted on 05/28/14 with diagnoses of Psychosis with Behavioral Disturbance, Non-compliance with Medications, Hypertension, Diabetes Mellitus (Type II), Hypothyroidism, and Cellulitis of Left Leg.
Review of Patient #F2's Psychiatric Evaluation completed on 05/29/14 revealed a diagnosis under Axis III of Hypothyroidism. Review of the Master Treatment Plan Cover Sheet revealed a diagnosis of hypothyroidism in the space allotted for Axis III diagnoses. Review of Patient #F2's Medication Administration Record (MAR) revealed medication for hypothyroidism, Levothyroxine 88 mcg (micrograms) had been ordered by the physician to be given once a day at 6:00 a.m. Review of the MAR revealed that Patient #F2 had been receiving this medication.
Review of Patient #F2's Comprehensive Treatment Plan revealed Patient #F2 did not have a treatment plan developed for the diagnosis of hypothyroidism.
In an interview on 06/11/14 at 2:40 p.m., SF2DON indicated the only intervention she had done to address the deficiencies related to Treatment Plans was to inservice the staff. She further indicated the Treatment Plan forms were still under revision and had not been implemented yet.

Based on record reviews and interview, the hospital failed to ensure that each patient's medical record included adequate documentation to justify the treatment activities carried out for 1 (#F1) of 10 active patients' records reviewed for treatment interventions from a total sample of 10 (#F1 - #F10) patients. Patient ##F1's record had no documented evidence that his oxygen saturation was assessed by the nurse once per shift and as needed for signs of respiratory complications as planned for in his treatment plan for "Decreased Cardiac Output".
Findings:

Review of the hospital policy titled "Inter-Disciplinary Treatment Planning Overview", policy number NU.706, revised 06/20/12, and presented as the current policy by SF2DON (Director of Nursing), revealed that interventions are what you do to help the patient complete the objective. They should be measurable and objective. Interventions are completed by each discipline and should include the specific plan of intervention as well as frequency.

Review of Patient #F1's medical record revealed he was an 80 year old male admitted on 05/29/14 with diagnoses of Dementia, Hypertension, Hypothyroidism, Cardiac Disease, and Hyperlipidemia. Review of his "Psychiatric Evaluation" performed on 05/29/14 by SF12APRN (Advanced Practice Registered Nurse) revealed Patient #F1's Axis III diagnoses included Hypertension, Vertigo, Hyperlipidemia, Hypothyroidism, although at this point in time it does appear that it may be medically induced hyperthyroid, history of Back Pain, Osteoarthritis, and history of Asthma.

Review of Patient #F1's treatment plan for "Decreased Cardiac Output" revealed that a nursing intervention was to monitor and record Patient #F1's oxygen saturation rate utilizing pulse oximetry one time per shift and as needed for signs of respiratory complications.

Review of Patient #F1's "Nursing Progress Note" for 06/05/14 through 06/09/14 revealed no documented evidence that his oxygen saturation had been assessed by pulse oximetry as planned for treatment of decreased cardiac output.

In an interview on 06/11/14 at 11:50 a.m., SF2DON confirmed that Patient #F1's oxygen saturation should have been assessed by the nurse every shift as stated in his "Decreased Cardiac Output" treatment plan.

In an interview on 06/11/14 at 2:40 p.m., SF2DON indicated the only intervention she had done to address the deficiencies related to Treatment Plans was to inservice the staff. She further indicated the Treatment Plan forms were still under revision and had not been implemented yet.

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Based on record reviews and interviews, the hospital failed to ensure registered nurses (RNs) and licensed practical nurses (LPNs) were trained and evaluated for competency to provide the nursing care necessary under each patient's active treatment program according to hospital policies and procedures. The hospital failed to ensure nursing staff were trained in respiratory services by a qualified Respiratory Therapist as evidenced by having no documented evidence of credentials or current licensure of the respiratory therapist who provided training for 2 (SF5, SF10) of 2 RNs' (SF5, SF10) and 4 (SF7, SF8, SF9, SF17) of 4 (SF7, SF8, SF9, SF17) LPNs' nursing personnel files reviewed for competency evaluations from a total of 20 employed nurses RNs and 11 employed LPNs. The hospital failed to ensure SF10RN who was hired on 05/19/14 and had no prior psychiatric nursing experience had documented evidence of competency evaluations for skills required to provide care to psychiatric patients as evidenced by having all competencies documented as evaluated on the day she was hired.
Findings:

Review of the hospital policy titled "Staff Competency," policy number SD.002, with no documented evidence of the effective date, and presented by SF2DON (Director of Nursing) as a current policy, revealed that the method of assuring staff competency was as follows:
1) Hiring qualifications: education requirements, licensure/certification requirements, previous experience and references;
2) Orientation;
3) Skills Check List, unit and/or population specific;
4) Performance appraisal at three months and annually; and
5) Supervisor observation.

Review of the hospital policy titled "Staff Development," policy number SD.002, revised 06/04/14, and presented as the current policy by SF2DON, revealed that the hospital's policy was that all staff receive regular staff development based on assessed needs identified by Performance Improvement Activities and in-service needs assessments. Further review revealed that formal and informal educational experiences related to orientation, clinical skills, leadership and management, and other appropriate content areas would be included. Further review revealed that Crisis Prevention Intervention (CPI) is required within 30 days of hire.

Review of the hospital policy titled "Hospital Orientation," policy number SD.005, revised 06/04/14, and presented as a current policy by SF2DON, revealed that all employees will receive hospital orientation. Further review revealed that clinical personnel would attend a two day orientation program and will then be oriented in their assigned clinical area for a 2 week period by the Department Head/Nurse Manager.

Review of the hospital policy titled "Clinical Orientation," policy number SD.006, revised 06/04/14, and presented as a current policy by SF2DON, revealed that all clinical employees will participate in and graduate from Clinical Orientation within the month of employment. Further review revealed that each employee would participate in the scheduled orientation for clinical personnel with a note to see attached Orientation Schedule. There was no documented evidence of an attachment to the policy. Further review revealed that specific testing requirements included CPI and a Medication Test, and clinical staff would not participate in seclusion or restraint until they have successfully completed all in-service training and testing on the management of the aggressive patient.

Review of the personnel records for SF5RN, SF10RN, SF7LPN, SF8LPN, SF9LPN, and SF17LPN revealed SF18Respiratory Therapist documented a competency evaluation for the provision of respiratory services on 06/06/14.

Review of the hospital contract with SF18Respiratory Therapist dated 06/03/14 revealed SF18Respiratory Therapist would provide respiratory training to the hospital nursing staff. Review of the contract revealed no documented evidence of any credentials or license verification for SF18Respiratory Therapist.

SF10RN
Review of SF10RN's personnel file revealed she was hired on 05/19/14. Further review revealed her prior nursing experience was providing patient care in Pre-op and Post Anesthesia Care Units in an acute care hospital and ambulatory surgery centers. Review of SF10RN's "General Orientation Checklist" revealed SF19RN Supervisor oriented SF10RN to Human Resources on 05/19/14, Total Quality Management on 05/23/14, Infection Control and Employee Health on 05/20/14, Risk Management on 05/23/14, and the location of hospital equipment on 05/20/14. Review of SF10RN's "Clinical Orientation Checklist" revealed SF19RN Supervisor conducted clinical orientation on 05/22/14. Review of SF10RN's "Core Skills-Knowledge/Competency Assessment" revealed that SF19RN Supervisor performed an "evaluation of his/her clinical skills and knowledge" on 05/19/14 (day of hire) for the following performance: assessment skills; skills related to wound and skin care; skills related to nutrition and hydration, elimination, activity and movement, respiratory function, safety and infection control, management of geriatric psychiatric patients; admissions; specimen collection; skills related to medical emergency care; performing EKGs (electrocardiograms); skills related to patient and unit safety; HIPAA (Health Insurance Portability and Accountability Act) policy and confidentiality; nourishment station and food safety; visitation and phone guidelines; security; skills related to safe medication administration. Review of SF10RN's "Glucometer Competency Assessment" revealed that her competency was evaluated by SF8LPN rather than an RN.

In an interview on 06/11/14 at 12:05 p.m., SF19RN Supervisor indicated that SF10RN did the required tests on the day she was hired. She further indicated that after SF10RN shadowed another RN for 2 night shifts, SF10RN requested 2 more day shifts of shadowing that was approved. SF19RN Supervisor indicated that she completed SF10RN's skills competency after her orientation and didn't know why she dated it 05/19/14. SF19RN Supervisor indicated that she did not personally observe all of the skills listed on the competency checklist that she signed as having assessed. SF19RN Supervisor indicated that she did not observe SF10RN performing medication administration and had not reviewed any MARs (medication administration record) completed by SF10RN. SF19RN Supervisor confirmed that SF10RN's glucometer evaluation was performed by an LPN and not an RN.

In an interview on 06/11/14 at 2:40 p.m., SF2DON (Director of Nursing) indicated the nursing staff provided respiratory therapy as indicated in the Respiratory Scope of Services. She further indicated there were no quality indicators developed to monitor the respiratory services provided by the nursing staff. She also confirmed that she did not have evidence of the credentials or current licensure of the respiratory therapist who performed the education and competency evaluations.

In a telephone interview on 06/11/14 at 2:50 p.m., SF10RN indicated she had been instructed to fax the physician orders for medications to the pharmacy the next day when the order was received after business hours of the pharmacy. She further indicated she has not been instructed to call the pharmacist after hours if new medications are ordered. SF10RN stated she took the order from the physician and she had the medication, so why should she call the pharmacist. SF10RN verified she was not familiar with the hospital's requirement to have the pharmacist review 1st dose medications.





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