HospitalInspections.org

Based on interview, record review and policy review, the facility failed to inform 11 patients (#33, #34, #35, #36, #37, #38, #39, #40, #41, #42 and #43) of 11 patients reviewed on the Inpatient Rehabilitation Facility (IRF) of their rights upon admission. The facility failed to inform two patients (#53 and #62) of two patients reviewed on the Behavioral Health Unit (BHU) of their rights upon transition from involuntary (court ordered) to voluntary admission. These failures increased the potential for all patients admitted to the facility to be unable to exercise their rights. The facility census was 148 with 11 inpatients at the IRF location and 21 inpatients at the BHU location.

Findings included:

1. Record review of the facility policy, "Patient Rights and Responsibilities," dated 08/01/11, showed all patients will be given a summary of patient rights (Notice of Patient Rights, NPR) upon admission to the facility and documentation of the patient's receipt of the summary will be made by the patient and placed in the patient's medical record.

2. During an interview on 11/19/14 at 2:00 PM, Patient #33 stated that she didn't remember being told about patient rights when she was admitted to the IRF but a copy of it might be in her admission packet.

Record review of Patient #33's admission packet in her room showed no NPR.

Record review of the admission packet given to patients admitted to the IRF showed no NPR.

Record review of the medical records for IRF Patients #34, #35, #36, #37, #38, #39, #40, #41, #42 and #43 did not provide evidence that the patients received the NPR.

During an interview on 11/19/14 at 2:20 PM, Staff JJJ, Director of IRF, confirmed that the NPR was not in the admission packet and could not be located in the patient medical records.

3. Record review of Patient #53's medical record showed he was admitted involuntarily to the BHU on 11/06/14. There was no evidence in the medical record that the NPR was provided to Patient #53 when he became a voluntary admission on 11/13/14.

Record review of Patient #62's medical record showed she was admitted involuntarily to the BHU on 11/06/14. There was no evidence in the medical record that the NPR was provided to Patient #62 when she became a voluntary admission on 11/13/14.

During an interview on 11/18/14 at approximately 3:55 PM, Staff XX, Director of the BHU, stated that patients who were involuntary and became voluntary after the end of their court ordered admission should receive information regarding their patient rights at the time they became voluntary.

During an interview on 11/19/14 at 5:02 PM, Staff XX stated that he expected the medical record to reflect that patient rights were reviewed with the patient.

During an interview on 11/18/14 at 2:10 PM, Staff ZZ, Registered Nurse (RN), stated that patients who were transferred to the BHU from an outside hospital were verbally informed of their patient rights upon admission by BHU nursing staff. When Staff ZZ was asked to recite the patient rights, she correctly verbalized only one, the right to refuse treatment. She stated that patient rights were included in the "Patient Education and Discharge Instructions" folder but were not provided to the patient until discharge.

4. Record review of the "Patient Education and Discharge Instructions" folder showed no NPR, other than Medicare rights, was included in the folder.


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32280

Based on interview, record review and policy review, the facility failed to ensure Medicare patients, or their representative, were notified of their right to appeal being discharged from the hospital when:
-Seven current patients (#12, #20, #21, #45, #47, #58 and #59) and two discharged patients (#13 and #49) had no Important Message from Medicare, (IMM), in their record;
-Four current patients (#11, #19, #46, and #48) had an IMM that was signed after the requirement of within two days after admission and;
-Two current patients (#53 and #62) had a signed IMM in the record that were not dated.

These 15 failures occurred in 25 records that were reviewed for the IMM requirements. This deficient practice could affect all Medicare patients when they, or their representatives were not made aware of their right to appeal being discharged. The facility census was 148 with 11 inpatients at the IRF (Inpatient Rehabilitation Facility) location and 21 inpatients at the Behavioral Health Unit (BHU) location.

Findings included:

1. Record review of the facility policy titled, "Important Message from Medicare," dated 07/2007, showed direction for registration staff to issue to all inpatient Medicare beneficiaries an IMM, that provided detailed information about their hospital discharge appeal rights. Further direction showed that staff should deliver this letter, obtain signature and date, give the patient a copy, and place original in medical record, no later than two calendar days after admission. The policy further directed that case management staff should deliver and explain a second IMM letter, obtain signature and date, give the patient a copy and place original in medical record within two calendar days of the day of discharge.

2. Record review of the medical records for seven current Medicare Patients #12, #20, #21, #45, #47, #58 and #59 did not contain evidence that the patients received the IMM after being admitted into the hospital.

Record review of the medical records for two discharged Medicare Patients #13, and
#49, showed no evidence that the patients received the IMM.

Record review of the medical records for four current Medicare Patients #11, #19, #46, and #48, showed that the patients received the IMM but the patient signature date exceeded the two day requirement.

Record review of the medical records for two current Medicare Patients #53 and
#62, showed that the patients received the IMM but there was no date that indicated when the patient signature was obtained.

During interviews on 11/18/14 at 2:35 PM and 11/19/14 at 3:05 PM, Staff I, RN, Clinical Analyst, confirmed that the Important Message From Medicare were not in Patients #12,
#20, #21, #45, #47, #58 and #59 medical records..

3. During an interview on 11/19/14 at 3:30 PM, Staff UU, Director of Patient Access (Registration), stated that the IMM process was her department's responsibility. She stated that her staff obtained the required signatures at the time of admission. Staff UU further stated that Case Management would advise her department of expected discharges and her staff would go and obtain signatures and dates on the follow up letters.
During an interview on 11/19/14 at 3:30 PM, Staff TT, Director of Case Management, stated that when she and Staff UU heard there were concerns about the IMM letter process, they checked some inpatient charts and discovered there were opportunities for the process to be "tightened up". Staff TT stated that currently the process was not being monitored or audited.


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32280

Based on observation and interview the facility failed to provide the Inpatient Rehabilitation Facility (IRF) patients or their responsible parties with contact information on how to file a complaint or grievance with the State agency. This deficient practice had the potential to affect all IRF patients to file a complaint or grievance regarding their care. The facility census was 148 with 11 inpatients at the IRF location.

Findings included:

1. Observation on 11/19/14 at 2:15 PM showed the Notice of Patient Rights posted at the end of the hall on the wall in the IRF. The Notice did not contain the name, address or telephone number of the State agency to contact if a patient or representative wanted to file a complaint or grievance.

During an interview on 11/19/14 at 2:45 PM, Staff JJJ, Director of IRF, confirmed that the Notice of Patients Rights did not contain the State agency contact information.

Based on interview, record review and policy review, the facility failed to ensure patients were informed of their right to formulate an Advance Directive for four patients (#53, #61, #62 and #63) of nine patients' records reviewed on the Behavioral Health Unit (BHU). This had the potential to affect all patients on the BHU, by preventing them from making and communicating informed decisions about their health care. The facility census was 148 with 11 inpatients at the Rehabilitation facility location and 21 inpatients at the BHU location,

Findings included:

1. Record review of the facility's policy titled, "Advance Directive," Revised 07/10, showed:
- That individuals have the right and are encouraged to make decisions concerning their care, including the right to accept or refuse medical or surgical treatment, and the right to formulate Advance Directives as outlined by State and Federal Statute and case law.
- The patient has the right to formulate, review, or revise his or her Advance Directive.
- All patients eighteen (18) years of age and older receive information regarding Advance Directives at the time of admission.
- Upon arrival at the nursing unit, the admitting nurse will determine if the patient has an Advance Directive and make appropriate documentation in the medical record.

2. Record review of Patient #61's medical record, showed that the patient had not formulated an Advance Directive. There was no evidence that the patient, or her State appointed guardian, was provided with information related to formulating an Advance Directive upon admission.

Record review of Patient #63's medical record, showed that the patient had not formulated an Advance Directive. There was no evidence that the patient was provided with information related to formulating an Advance Directive upon admission.

During an interview on 11/18/14 at 11:10 AM, Patient #53 stated he was not provided with information related to formulating an Advance Directive at any time. He stated that he didn't know what an Advance Directive was and had never heard of it before.

Record review of Patient #53's medical record, showed that at the time the patient went from involuntary (court ordered) admission (11/06/14 to 11/13/14) to a voluntary admission (11/13/14), there was no evidence that the patient was questioned if he had formulated an Advance Directive, and showed no evidence that the patient was provided with information related to formulating an Advance Directive.

Record review of Patient #62's medical record, showed that at the time the patient went from an involuntary admission (11/06/14 to 11/13/14) to a voluntary admission (11/13/14), there was no evidence that the patient was questioned if she had formulated an Advance Directive, and showed no evidence that the patient was provided with information related to formulating an Advance Directive, when she became a voluntary admission.

3. During an interview on 11/18/14 at approximately 3:55 PM, Staff XX, Director of the BHU, stated that patients who were admitted involuntary, and became a voluntary patient after the end of their court ordered admission, should receive information related to formulating an Advance Directive at the time they became voluntary.

During an interview on 11/18/14 at 2:10 PM, Staff ZZ, Registered Nurse (RN), stated that BHU patients did not receive information related to formulating an Advance Directive until their discharge, when they received the "Patient Education and Discharge Instructions" folder.


32280

Based on observation, interview, record review, and policy review the facility failed to:
- Provide a safe environment for two (#52 and #53) of four patients identified at risk for suicide.
- Make timely 15 minute rounding/observations for one (#55) of one patient observed for timely rounding.
- Complete the precaution section of the Patient Observation forms for every 15 minute rounding for seven current patients (#51,# 52,# 53, #55, #61, #63 and #66) and one discharged patient (#64) of nine Patient Observation forms reviewed. These failures had the potential to place all patients admitted to the Behavioral Health Unit (BHU) facility at risk for their safety. The facility census was 148, with 21 inpatients at the BHU location.

Findings included:

1. Record review of the facility's policy titled, "Suicide Policy," dated 06/13, showed the purpose was to provide a safe environment for patients at risk for suicide. Procedure guidelines were for patients who presented with suicidal attempts would be placed on every 15 minute suicide precautions.

Although requested the facility failed to provide a policy related to every 15 minute rounding/observation or completion of Patient Observation forms; however interviews with direct care staff and leadership stated that the expectation was for the Patient Observation forms to be completed with the observation levels and precautions for each patient.

2. Observation on 11/18/14 at 11:10 AM of Patient #52 and #53's room #336 showed the following:
- One wooden desk positioned in between patient beds.
- Empty space where bottom drawer had been removed;
- Two visible metal brackets that extended approximately 1" out into empty drawer space;
- Two metal screws that extended approximately 1" out into empty drawer space;
- One removable metal nut inside empty drawer space;
- One removable metal nut on bracket that held desk to the floor and
- Broken plastic thermostat cover easily lifted that exposed two metal screws.
These items are not part of a psychiatric safe room, and therefore could be used by psychiatric patients to injure themselves or others.

3. During an interview on 11/18/14 at 3:40 PM, Staff AAA, Patient Care Technician (PCT), stated that her duties were to round on patients every 15 minutes and "keep them safe." Staff AAA stated that she may visualize a patient at a certain time but she always documented the times onto the rounding forms at the quarter intervals. Staff AAA stated that she was unaware of the broken thermostat cover.

During an interview on 11/19/14 at 10:30 AM, Staff BBB, Facility Services, stated that:
- He did not make routine and/or daily rounds of the facility.
- The housekeepers or other staff would make work orders if something was in need of repair or attention.
- Work orders went to main campus then they were faxed to him at the BHU.
- He currently had one work order that regarded a light repair in a patient bathroom.
- He did not have a work order to repair the plastic thermostat cover.
- If there were sharp edges on something in a patient room he would be called and he would file it down.
- They were in the process of removing the desks out of patient rooms but not all had been removed.

During an interview on 11/19/14 at 11:00 AM, Staff CCC, Assistant Director Facility Services, stated that his expectation was for all staff to be aware of things that needed to be fixed and for a work order to be completed.

During an interview on 11/19/14 at 5:00 PM, Staff XX, Director BHU, stated that he was unaware of the safety issues in a patient room. Staff XX verified that the thermostat cover had been broken and that there were metal brackets and exposed screws on the desk. Staff XX stated that the facility was in the process of removing the desks from patient rooms but not all had been removed.

4. During an interview on 11/18/14 at 11:34 AM, Patient #61 stated, "No one randomly comes to check on me", and added that when staff did patient safety rounds, it occurred between every one to two hours and not every 15 minutes. Patient #61 stated that she didn't feel safe because a "Patient shut the day room door for 15 minutes without any staff" in the room.

5. During an interview on 11/18/14 at 10:35 AM, Staff KKK, PCT, stated that all patients on the BHU were to be observed every 15 minutes, regardless of their observation or precaution level. Staff KKK stated that 15 minute patient observations "get behind at times" because the PCTs may be leading a group activity, assisting with other patients' needs, or because the patient acuity (level of individualized care the patient may require) may be high.

6. During an interview on 11/18/14 at 12:00 PM, Patient #62 stated that patient safety rounds did not occur every 15 minutes, that staff would round on her every two to three hours during the day, and every one to two hours during the night.
7. Record review of Patient #63's medical record showed that the patient was on precautions for safety, elopement, suicide, seizures and falls. Review of an undated Patient Observation Form, showed that there was no observation level or precautions documented on the top of the form.

During an interview on 11/18/14 at 12:20 PM, Patient #63 stated that patient safety rounds were completed approximately every 30 minutes.

8. Record review of Patient #64's medical record, showed that the patient was on precautions for suicide. Review of Patient Observation forms showed there was no observation level or precautions documented on the top of the form for 10/01/14, or on two additional days, in which the forms were undated.

During an interview and concurrent record review of Patient #64's medical record, on 11/19/14 at 3:11 PM, Staff XX, Director of the BHU, verified that the top portion of Patient #64's observation form was not completed. Staff XX stated that the top portion of the patient safety checks form should be completed to indicate the patient's observation level and the precaution level. Staff XX added that ensuring the observation level and precaution level were completed, such as indicating a patient was at risk for "elopement", would indicate to BHU staff to ensure the patient stayed away from the exit of the BHU, to ensure the patient's safety.

9. Record review of medical records on 11/19/14 showed there were also no observation levels or precautions documented Patient Observation forms for:
- Patient #51 admitted on 11/17/14 with elopement precautions ;
- Patient #52 admitted on 11/13/14 with suicide precautions;
- Patient #53 admitted on 11/06/14 with suicide precautions;
- Patient #55 admitted on 11/14/14 with self harm precautions;
- Patient #61 admitted on 11/15/14 with suicide precautions; and
- Patient #66 admitted on 11/18/14 with elopement precautions.

10. Observation on 11/19/14 at 10:00 AM, showed Staff GGG, PCT, made rounding/observation of Patient #55 at 10:02 AM and 10:24 AM, 22 minutes apart. Staff GGG had the Patient Observation forms with him on a clipboard when he was making his rounds.

During an interview on 11/19/14 at 3:40 PM, Staff GGG, PCT, stated that he knew he didn't document the time on the Patient Observation forms in real time. He stated that he tried to round every 15 minutes, but it was hard to do when he had 12 patients to round on. Staff GGG stated that it was easier for him to document time at quarter intervals than in real time. He stated that if Patient Observation forms were left blank or incomplete for observation levels or precautions, he had no idea what he monitored the patient for.

11. During an interview on 11/19/14 at 4:00 PM, Staff YY, RN, stated that the Patient Observation forms were fairly new and that staff had not been given any orientation on how to use them, and felt this contributed to inconsistencies and incomplete documentation.

During an interview on 11/19/14 at 5:00 PM, Staff XX, Director of BHU, stated that his expectation was for the patient observations to be documented in real time on the Patient Observation forms.

12. During an interview on 11/19/14 at 2:30 PM, Staff FFF, Quality, verified inconsistent and incomplete precautions documentation on the Patient Observation form for Patient's #51, #52, #53, #55 and #66. She stated that she wouldn't expect the PCTs to know what to observe the patients for, without the patient's specific precautions documented on the Patient Observation form.


29047

Based on interview, record review and policy review, the facility failed to ensure that a care plan specific to seclusion (to be involuntarily placed in a monitored, secluded room for the safety or self or others), was initiated for one current patient (#63) and one discharged patient (#67), of two patients that had been placed in seclusion on the Behavioral Health Unit (BHU). This had the potential to affect all patients placed in seclusion, by failing to ensure that interventions specific to the health and safety of patients in seclusion were carried out by patient care staff. The facility census was 148 with 21 inpatients at the BHU location.

Findings included:

1. Record review of the facility's policy titled, "Restraints and Seclusion," revised 01/10/13, showed that the use of restraint or seclusion must be in accordance with a written modification to the patient's plan of care.

2. During an interview and concurrent record review of Patient #63's medical record, on 11/19/14 at 10:30 AM, Staff XX, Director of the BHU, stated that the Care Plan "Risk of Violence" should have been initiated when the patient was placed in seclusion on 11/14/14 from 2:08 AM until 3:05 AM.

During an interview and concurrent record review of Patient #67's medical record on 11/20/14 at 12:55 PM, , Staff XX, stated that the Care Plan "Risk of Violence" should have been initiated when the patient was placed in seclusion on 11/05/14 at 4:00 PM until 6:55 PM.

3. During an interview on 11/19/14 at 5:02 PM, Staff XX stated that he could not remember if the review of care plans were part of his monthly medical record audit, that was completed as part of the facility's Quality Assurance & Performance Improvement (QAPI).

Based on observation, interview, record review and policy review the facility failed to ensure that five (#53, #55, #61, #62 and #63) of five current patients, on the Behavioral Health Unit (BHU) were appropriately assessed and reassessed by nursing staff for medical issues. These failures had the potential to adversely affect patients admitted to the BHU with medical issues. The facility census was 148 with 21 inpatients at the BHU location.

Findings included:

1. Record review of the facility's policy titled, "Assessment, Reassessment and Care Planning" revised 11/12, showed that patients would be assessed by a Registered Nurse (RN) within 24 hours of admission. The nursing assessment performed on inpatients shall include physical assessment including pain. Reassessment of each patient should be done as necessary based on the patient's plan of care or changes in condition.

2. During an interview on 11/19/14 at 2:30 PM, Patient #53 stated that he had an abscess (a collection of pus that has built up under the skin sometimes with redness and swelling that are usually caused by a bacterial infection) on his lower left leg upon his admission on 11/06/14. He stated that he thought staff had looked at it but was unsure of how often and he received medication.

Record review of Patient #53's History and Physical (H&P) showed that the patient was admitted on 11/06/14 with Schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real), substance abuse and an abscess to the left lower extremity. The plan was to culture (a test to identify germs such as bacteria or fungus that may be growing on the skin or in a wound) the abscess on the lower left leg and to treat for 14 days with antibiotics.

Record review of Patient #53's medical record showed:
- A photographic wound documentation sheet dated 11/06/14 of a picture of what appeared to be an arm or leg. The remainder of the sheet was blank with no patient identification and no identification of what the picture was or wound description.
- Shift summary notes with no documentation regarding wound assessment for 11 out of 13 shift summary notes reviewed.
- Nursing admission assessment that indicated no need for further assessment/screening regarding medical issues.

3. Observation and concurrent interview on 11/19/14 at 10:00 AM showed Patient #55 seated in the activity room with right arm in a sling. He stated that he had broken his collar bone a week ago. Patient #55 stated that he had pain and received pain medication routinely and when needed. He stated that staff had not evaluated the shoulder injury.

Record review of Patient #55's H&P showed he was admitted to the BHU on 11/14/14 for Schizophrenia, Bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels and the ability to carry out day-to-day tasks) and right clavicle (collarbone) fracture.

During an interview on 11/19/14 at 12:00 Noon, Staff DDD, RN, stated that any medical conditions that were present upon admission should be documented on the admission assessment sheet and reassessed every shift. The shift note sheets did not have anywhere to document physical assessment but you could enter that information in the narrative note section at the end. She stated that she was aware that Patient #55 had a shoulder injury and that she had not assessed the injury and that she did not document an assessment of the broken clavicle.

4. Record review on 11/19/14 of Patient #61's medical record, showed a H&P dated 11/15/14, which documented that the patient had a history of asthma (narrowing of the lung airways, resulting in shortness of breath), and used a Ventolin inhaler (inhaled medication to improve breathing) at home as needed for shortness of breath. There was no documentation in the record that the patient's lungs sounds had been assessed upon admission or on a regular basis.

5. Record review on 11/18/14 of Patient #62's medical record, showed a H&P dated 11/07/14, which documented that the patient complained of chest congestion and cough, and used an inhaler (inhaled medications to improve breathing, for people with acute and chronic lung disease) at home. A psychiatric admission note dated 11/06/14, showed that the patient's medical history included Hepatitis C (disease affecting the liver, an organ in the abdomen, which can cause liver failure and death) and asthma. There was no indication in the medical record that the patient's lungs sounds, abdomen or bowel sounds, were assessed on a regular basis.

6. Record review on 11/19/14 of Patient 63's medical record, showed an Admission Assessment dated 11/14/14 (time unreadable), was blank, except for a staff signature. A psychiatric admission note dated 11/14/14 at 6:12 PM, documented that the patient complained of shortness of breath and difficulty breathing. There was no documentation in the record that the patient's lungs sounds were assessed upon admission or on a regular basis.

During an interview on 11/20/14 at 10:47 AM, Staff B, Chief Nursing Executive (CNE) stated that she expected the staff at the BHU to assess patients the same as if they were working on a medical floor and stated "nursing is nursing" and that patients with medical conditions on admission should be monitored and assessed for changes in those conditions throughout their hospitalization and the assessment should be documented as narratives.

During an interview on 11/19/14 at 5:02 PM, Staff XX, Director of the BHU, stated that all hospital forms were changed when the facility was purchased by a corporate company earlier in the year. Staff XX stated that nurses had informed him that there was nowhere to document a patient's skin assessment. Staff XX added that the previous forms allowed the nurses to document the patient's heart sounds, lung sounds and abdomen sounds, but the current forms that were in use did not.



29047

Based on observation, interview, record review, and policy review, the facility failed to develop care plans for nine patients (#2, #4, #6, #30, #53, #55, #61, #62 and #63) of 26 patients' nursing care plans reviewed. These failures had the potential to affect all patients who did not have planned nursing care that focused on nursing care based on the assessed needs of the patients. The facility census was 148, with 21 patients in the Behavioral Health Unit (BHU).

Findings included:

1. Review of the facility's policy titled, "Assessment, Reassessment and Care Planning," dated 11/2012, showed the following direction:
- All patients received nursing assessments upon admission and reassessments as planned and as needed.
- The initial nursing assessments led to the development of the patients nursing care plan (a written plan that includes specific individualized nursing care focused on the patients' problems and identified needs).
- Nursing care plans were updated as appropriate based on ongoing assessments.

2. Record review of Patient #2's nursing admission assessment dated 11/17/14 showed the following assessment findings:
- History of glaucoma (a disease of the eyes that caused vision loss);
- Recent diagnosis of lung and breast cancer;
- Incontinence (loss of self-control of urine and stool);
- Surgical removal of partial left lung October 2014;
- Venous ulcer (a serious wound caused by a leg vein condition) on right lower front leg; and
- A diabetic (disease related to blood sugar metabolism) ulcer (a hard to treat wound caused by complications of diabetes) on her left bottom foot.

During an interview and concurrent observation of Patient #2 on 11/18/14 at 11:15 AM, showed Patient #2 had a very large wound on her back and two abdominal wounds that were not healed. She stated the following:
- Vision loss from glaucoma was significant and limited her abilities greatly.
- She had many questions about her cancer diagnosis.
- She was nauseated and could not eat.
- She had an infection.
- She had a "bad" rash on her buttocks from her bottom being wet for long periods.

Record review of Patient #2's nursing care plan on 11/18/14 at 4:15 PM showed no care plan for the following problems:
- Vision loss;
- Learning needs related to diagnosis;
- Nausea/nutrition;
- Infection;
- Incontinence; and
- Wound/skin care.

3. Record review of Patient #4's nursing admission assessment dated 11/08/14 showed the following assessment findings documented:
- A surgical procedure was performed 11/08/14 to repair a left leg tibia (bone below the knee) fracture.
- Significant vision and hearing loss;
- The patient did not have teeth or dentures.
- The patient required continuous positive airway pressure (CPAP, continuous air blown through a facemask worn over the nose and mouth) during hours of sleep.
- The patient required assistance when bathed, when he ambulated, put on clothes, and when he ate.

Record review of Patient #4's nursing care plan on 11/18/14 showed no care plan for the following problems:
- Wound/skin care related to the left leg surgical incision;
- Communication issues related to vision and hearing loss;
- Eating and nutrition related to missing teeth;
- Use of CPAP during hours of sleep;
- Self-care needs related to bathing, ambulation, dressing and eating.

4. During an interview and concurrent observation on 11/18/14 at 10:50 AM showed Patient #6's left arm and shoulder immobilized in a sling. Patient #6 stated that she fell and hurt her arm, shoulder, hip and had surgery at the facility. Three unhealed large surgical incisions were present on the right leg and one large bandage covered an incision on the right groin.

Record review of Patient #6's nursing care plan on 11/18/14 showed no care plan for the problems and nursing care related to her arm/shoulder sling or wound and skin care.

During an interview on 11/18/14 at approximately 11:30 AM, Staff HH, Director of the Progressive Care Unit and the Surgical Intensive Care Unit, stated that care plans for Patients #2, #4, #6 and all other patients should be individualized and updated as needed and the current care plan process needed improvement.

5. During an interview on 11/18/14 at 3:26 PM, Staff MM, Registered Nurse (RN) assigned to care for Patient #30 in the Women's and Children's Department, stated that Patient #30 was hospitalized due to complications of a 35 week pre-term pregnancy (full term pregnancy is 40 weeks) and received medication therapy to prevent early childbirth.

Record review of Patient #30's nursing admission assessment dated 11/12/14, showed a history of seizures (abnormal electrical activity in the brain) that caused her to become unconscious.

Record review of Patient #30's nursing care plan on 11/18/14 at 4:00 PM showed no care plan for the problems and nursing care related to potential seizures.

During an interview on 11/18/14 at approximately 3:00 PM, Staff JJ, and Staff MM, RNs assigned care to care for Patient #30 stated that nursing care plans are not developed, individualized and updated for medical problems as they should have been.

6. During an interview on 11/19/14 at 2:30 PM, Patient #53 stated that he had an abscess (a collection of pus that has built up in the tissue with redness and swelling that are usually caused by a bacterial infection) on his lower left leg. He stated that he thought staff had looked at it but was unsure of how often and he received medication.

Record review of Patient #53's nursing admission assessment showed that patient had an infected area on lower left leg that was red, swollen and warm to touch. The section for documentation of continued need for assessment/screening of medical issues indicated that the patient had no medication issues and there was no need for continued assessment or screening.

Record review of Patient #53's "Multidisciplinary Treatment Team Plan," dated 11/06/14 showed no care plan for the leg abscess or potential for pain.

7. Observation and concurrent interview on 11/19/14 at 10:00 AM, showed Patient #55's right shoulder and arm immobilized in a sling. He stated that he had broken his collar bone a week before his admission date of 11/14/14. He stated that no staff had evaluated his injury.

Record review of Patient #55's nursing admission assessment and the Master Treatment Plan showed the fractured right clavicle as an identified medical problem. There was no indication in the record that a care plan was initiated to ensure the patient's medical conditions were assessed and monitored for prevention of symptoms or necessary interventions.

During an interview on 11/19/14 at 12:00 PM Noon, Staff DDD, RN, stated that patients on the BHU that had medical concerns upon admission would be monitored for those concerns and those problems should be on the treatment care plan. She stated that the leg abscess for Patient #53 and the shoulder injury for Patient #55, including potential for pain, should have been included on the Master Treatment Plan.

During an interview on 11/19/14 at 2:50 PM, Staff FFF, Quality, verified that Patient #53's Master Treatment Plan did not show his leg abscess or the potential for pain associated with it. She also verified that Patient #55's Master Treatment Plan did not show his shoulder injury or the potential for pain.

8. Record review on 11/19/14 at 9:30 AM, Patient #61's medical record, showed a History and Physical (H&P) dated 11/15/14, which documented that the patient had a history of asthma (narrowing of the lung airways, resulting in shortness of breath), and used a Ventolin inhaler (inhaled medication to improve breathing) at home as needed for shortness of breath. The Master Treatment Plan dated 11/15/14, showed that Asthma was identified as one of the patient's medical problems, but staff failed to modify the Master Treatment Plan to ensure the patient's medical condition was assessed and monitored for prevention of symptoms or necessary interventions.

9. Record review on 11/18/14 at 3:10 PM of Patient #62's medical record, showed a H&P dated 11/07/14, which documented that the patient complained of chest congestion and cough, and used an inhaler (inhaled medications to improve breathing, for people with acute and chronic lung disease) at home. A psychiatric admission note dated 11/06/14, showed that the patient's medical history included Hepatitis C (disease affecting the liver, which can cause liver failure and death) and asthma. There was no indication in the medical record that a care plan was initiated to ensure the patient's medical conditions were assessed and monitored for prevention of symptoms or necessary interventions.

10. Record review on 11/19/14 at 11:02 AM of Patient #63's medical record, showed a psychiatric admission note dated 11/14/14 at 6:12 PM, which documented that the patient complained of shortness of breath and difficulty breathing, and that the patient's home medications included Combivent, Advair, and Albuterol (inhaled medications to improve breathing, for people with acute and chronic lung disease). The patient's Master Treatment Plan dated 11/14/14 at 3:05 AM, showed that the patient was admitted for psychiatric disorders, as well as hypertension (elevated blood pressure), seizure (excessive brain activity that may cause violent jerking) disorder, and asthma. There was no indication in the record that a care plan was modified to ensure the patient's medical conditions were assessed and monitored for prevention of symptoms or necessary interventions.

During an interview on 11/19/14 at 5:02 PM, Staff XX stated that staff should initiate a Care Plan to address a patient's medical and psychological concerns, "if we can do anything about it", such as a patient's pain. Staff XX stated that he could not remember if Care Plans were part of his monthly, medical record audit that was completed as part of Quality Assurance & Performance Improvement (QAPI).

During an interview on 11/18/14 at approximately 3:40 PM, Staff NNN, Assistant Director of Nurses, stated that nurse care planning did not show the individual patient problems and were not updated and needed improvement.



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Based on observation, interview, record review, and policy review, the facility failed to ensure staff administered medications and/or fluids through intravascular catheters (IV's, small tubes placed in a vein for administration of medication/fluid into the blood stream) according to policy, and accepted standards of practice for ten patients (#2, #6, #7, #9, #10, #11, #12, #13, #14, and #15)) of ten patients reviewed for safe medication administration. These failures had the potential to cause patient harm by administering IV medication and/or fluids through IV tubing not safe for use. All patients admitted to the facility who received IV medications through unlabeled IV tubing had the potential to be affected. The facility census was 148.

Findings included:

1. Record review of the facility's policy titled, "Medication Administration" dated 07/2013, showed direction for facility staff to follow:
- Nursing standards of care for patient medication preparation and administration;
- Written guidance that assured all delivery systems was safe;
- Infection control standards for medication administration were met.
- The CDC's (Center for Disease Control) Guidelines for the Prevention of Intravascular Catheter-Related (Infections, 2011.

Record review of the facility's undated document titled, "Changing Infusion Tubing," showed direction for staff to change IV tubing for continuous fluid administration at 72-hour intervals , adding that 48-hour tubing changes may be considered under certain conditions. IV tubing was labeled with a marked piece of tape or preprinted label with date and time of tubing change, and attach to tubing below the level of drip chamber.

Record review of The CDC's Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 showed the following recommendations:
- Assess compliance and adherence to guidelines and maintenance of intravascular catheters.
- Replace tubing used to administer fluids containing high concentrations of glucose (also known as dextrose) every 24 hours.
- Maintain optimal infection control standards for medication administration care to prevent intravascular catheter-related infections (CRBSI).

2. Observation on 11/18/14 at 11:15 AM showed Patient #2 with an IV in her right forearm. The IV was connected to tubing and attached to an infusion pump (IV pump, a machine that controls the amount of medication administered through small tubing connected to the patient's IV) that infused 10% dextrose (also known as glucose) solution (a fluid with a high concentration of glucose). The IV tubing was unlabeled and therefore it was not possible to determine when the IV tubing expired.

During an interview on 11/18/14 at approximately 10:40 AM, Staff Y, Registered Nurse assigned to care for Patient #2, stated that IV tubing should be dated and labeled to know when it is due to be changed. She further stated that, the nurses just knew when the IV tubing needed changed.

During an interview on 11/18/14 at 11:15 AM, Patient #2 stated that during her current hospitalization she had received IV medication with glucose several different times. She stated that she did not remember if the IV tubings were changed.

3. Observation on 11/18/14 at 10:50 AM, showed Patient #6 with an IV in her right hand connected to an infusion pump. The IV tubing was unlabeled and therefore it was not possible to determine when the IV tubing expired.

During an interview on 11/18/14 at 10:50 AM, Patient #6 stated that she received many different medicines through the IV tubes and did not remember if or when the IV tubing was changed.

4. During observations on 11/18/14 at 9:30 AM through 11:30 PM in the the Progressive Care Unit (PCU), Intensive Care Unit (ICU), and Surgical Intensive Care Units (SICU), multiple patients (too numerous to count) showed IV tubing connected to IV infusion pumps with unlabeled tubing.

During an interview on 11/18/14 at approximately 2:00 PM, Staff NNN, Assistant Director of Nursing, stated that while she accompanied the surveyor she observed multiple patients (including #2 and #6) with unlabeled IV tubing and stated that labeling was an area of needed improvement.

5. Observation on 11/18/14 at 1:20 PM showed two IV bags hanging from the IV pole in Patient #7's room. Both IV bags had tubing attached with no labels to indicate the date the tubing was first used and when it was to be discarded.

During an interview on 11/18/14 at approximately 2:00 PM, Staff F, RN assigned to Patient #7's care, stated that the IV antibiotic tubing should have labels to indicate the date the tubing was first used and when it was to be discarded.

6. Observation and concurrent interview on 11/18/14 at 11:15 AM with Staff J, RN, Nurse Manager (NM), showed Patient #13 with three separate IV medications and three separate IV tubes. None of the IV tubing was marked with a date and time. Staff J stated, "Oh, there's no marking on any of them [IV tubing]."

7. Observations on 11/18/14 at 1:30 PM showed Patients #9, #10, #11, #12, #14 and #15 with IV tubing attached to medication IV bags, without the IV tubing labeled with date/time.

During an interview on 11/19/14 at 3:15 PM, Staff M, RN, confirmed that there were no date and time labels on Patient #15's IV tubing. She stated that the nurses were instructed to change and label all of the patients tubing on the floor.

During an interview on 11/19/14 at approximately 10:30 AM, Staff K, Infection Control Officer, stated that she was not aware of specific requirements for IV tubing changes. However, she stated that the facility policy and procedures were developed according to CDC guidelines, and nursing standards of care. She stated that there were no surveillance activities to assess:
- Adherence to guidelines and maintenance of IV tubing;
- Replacement of IV tubing at required intervals;
- Maintenance of infection control standards related to nursing care to prevent intravascular catheter-related infections (CRBSI).

Based on record review, interview and policy review, the facility failed to ensure verbal and/or telephone physician orders, written by persons other than the prescribing physician, were signed by the physician for four patients (#4, #7, #17 and #30) of four patients records reviewed for physician signatures. These failures had the potential to cause harm related to the lack of verification of accuracy of the written order and subsequent authentication by physician signature. The facility census was 148.

Findings included:

1. Record review of facility policy titled, "Verbal and Telephone Orders", dated 07/17/13, showed the prescribing physician (or other authorized practitioner) shall authenticate, and verify verbal and/or telephone orders with a signature within 48 hours after written.

2. Record review of Patient #4's physician orders on 11/18/14, dated 11/08/14 through 11/09/14 showed the following unsigned physician orders :
- 11/08/14 not timed, before surgery procedures;
- 11/08/14 at 11:58 PM, medication to lower blood sugar;
- 11/09/14 at 1:15 AM, medication to prevent blood clots;
- 11/09/14 at 11:40 AM, medication changed.

During an interview on 11/19/14 at 9:15 AM, Staff CC, RN, who had provided care for Patient #4, stated all physician orders except for standing protocols for flu and pneumonia required physician signatures 48 hours after written.

3. Record review of physician telephone orders for medications in Patient #7's medical record on 11/18/14 showed two orders dated 11/08/14 and two orders dated 11/09/14. There were no physician signatures on the orders.

4. Record review of physician telephone orders for medications in Patient #17's medical record on 11/18/14 showed two orders dated 11/13/14. There were no physician signatures on the orders.

During an interview on 11/18/14 at approximately 11:00 AM, Staff D, Nursing Director for the 6th floor, stated that the telephone orders for medications in Patient #7 and Patient #17's medical record should have been signed by the physician within 48 hours after giving the orders.

5. Record review of Patient #30's physician orders on 11/18/14 at approximately 4:15 PM, dated 11/11/14 through 11/14/14 at 8:00 AM showed the following unsigned physician orders:
- 11/11/14 at midnight;
- 11/11/14 at 12:45 AM;
- 11/11/14 not timed;
- 11/12/14 at 3:30 PM;
- 11/13/14 at 3:45 PM; and
- 11/14/14 at 8:00 AM.
The unsigned physician orders represented multiple opportunities for medical errors during a period of four days.

During an interview on 11/18/14 at 3:45 PM, Staff MM, Registered Nurse (RN), who had been assigned care of Patient #30, stated that all verbal and telephone physician orders should have been signed within 48 hours. She stated that staff used to put tabs on the physician order pages in the medical record to flag the unsigned orders. However, she further stated she did not flag orders and other staff did not flag orders and she did not know why they stopped.


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