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Based on record review and interview the facility failed to provide written notice to patients or their representatives regarding the steps taken to investigate a grievance, the results of the grievance process and the date of completion for four (#27, #28, #29 and #30) of four grievance files reviewed. The facility had a census of 404.

Findings included:

Review of the facility policy, "Patient Grievance Policy" showed if an issue is not addressed and resolved the same day, it is deemed a grievance and the patient/patient representative will be informed the investigation is underway and the facility will follow up with a written response. On average responses will be sent within 7 business days.

Further review of the policy showed upon completion of the investigation, a written response will be sent to the patient, or their representative. Issues which take more than 7 business days for investigation and response warrant an acknowledgement letter stating when the patient/patient representative can expect a response.

Review of a complaint form showed the representative of Patient #27 contacted the facility by phone on 7/06/10 with a complaint regarding his/her child's care in the emergency department (ED). Further review of the complaint form showed the Manager of Customer Service Staff AA forwarded the concerns to an ED physician. The ED physician spoke with the complainant on 7/08/10. A letter sent to the complainant dated 7/27/10, twenty-one days after the representative called the facility, does not inform the complainant of the steps taken to investigate the grievance or the date the facility completed the investigation.

Review of a complaint form showed Patient #28 contacted the facility on 7/28/10 with a complaint of care received in the ED. Further review of the complaint form showed the Manager of Customer Service Staff AA forwarded the concerns to an ED physician. The ED physician spoke with the complainant on 8/04/10. Review of the complaint showed a letter to the complainant dated 8/23/10, twenty-six days after the patient called the facility. Review of the facility response to the patient showed no resolution given to the patient. The letter does not inform the patient of the steps taken to investigate the grievance or the date the facility completed the investigation.

Review of a complaint form showed the representative of Patient #29 contacted the facility on 7/29/10 with a complaint of care received in the ED. Further review of the complaint form showed the Manager of Customer Service Staff AA forwarded the concerns to an ED physician for review on 7/29/10. Review showed a letter to the complainant dated 8/23/10, twenty-five days after the patient called the facility. Review of the facility response to the complainant does not inform the complainant of the steps taken to investigate the grievance or the date the facility completed the investigation.

Review of a complaint form showed outpatient Patient #30 contacted the facility on 8/10/10 with a complaint of medication he/she received. Further review of the complaint form showed the Manager of Customer Service Staff AA forwarded the concerns to a pharmacist for review on 8/10/10. Review of a letter from the facility to the patient dated 8/10/10 showed the facility response did not inform the complainant of the steps taken to investigate the grievance or the date the facility completed the investigation.

During an interview on 9/01/10 at 2:50 p.m. the Manager of Customer Service Staff AA said that the grievance responses did not contain all the information necessary and some of the issues in the grievances took more than 7 business days for investigation. Staff AA said that he/she did not send acknowledgement letters for the issues which took more than 7 business days to investigate informing the patient/patient representative when they could expect a response.

Based on review of State statute, observation and interview the facility failed to post or display signs to inform the public of the usage of Physician Assistants in the emergency department and the neuro intensive care unit (unit for patients with neurosurgical and neurological injuries, including stroke, brain hemorrhage, trauma and tumors). The hospital had a census of 404.
Findings included:
Review of Missouri Revised Statutes, Chapter 334 section 334.748 enacted in 1989 showed no Physician Assistant (PA) shall be used in any office of a physician or in a clinic or hospital unless a notice stating that a physician assistant is utilized is posted in a prominent place.
Observation on 8/31/10 of the emergency department (ED) at 2:00 p.m.and the neuro intensive care unit (neuro ICU) at 3:05 p.m. showed no signage informing patients or visitors that Physician Assistants are utilized.
During an interview on 8/31/10 at 2:05 p.m. the nurse manager of the emergency department (ED) Staff D said that the ED utilizes the services of Physician Assistants. Staff D said that there is no signage in the ED informing patients that physician assistants are utilized.
During an interview on 8/31/10 at 3:10 p.m. Staff G neuro ICU physician said that the unit utilizes the services of Physician Assistants. Staff G said that there is no signage in the unit informing patients that physician assistants are utilized.

Based on record review and interview, the facility failed to ensure each patient and/or patient's representative in the emergency department (ED) was offered the opportunity to establish an advance directive. The facility had a census of 404.The emergency department averages greater than 4,000 patient visits per month.

Findings included:

Review on 8/31/10 of the facility patient rights given to all patients or their representative in the ED showed in part, "To make health care directives and/or choose another person to make decisions about your health care if you are unable to do so."

Record review of the admitting information for current Patient #5 showed the patient entered the ED for treatment on 8/31/10. The review showed no documentation of staff asking Patient #5 if he/she has an advanced directive or if the patient wants information concerning an advanced directive.

During an interview on 8/31/10 at 2:30 p.m. the ED nurse manager Staff D said that the staff doesn't ask the patients or their representatives if they have an advanced directive.

During an interview on 9/01/10 at 3:00 p.m. Staff BB the Director of Governance said that the question regarding advanced directives used to be on the admitting information in the ED. Staff BB said the ED is now using the electronic medical record and Staff BB confirmed there is no information being recorded in the ED regarding the advanced directive.

Based on observation, interview and record review the facility failed to ensure patient's privacy by displaying patient information in patient rooms and on a monitor visible to the public and the facility failed to ensure patients and visitors were provided full disclosure of monitoring cameras located in four of four emergency department behavioral health treatment rooms. The facility had a census of 404.

Findings included:

1. Observation on 8/31/10 at 3:30 PM showed a telemetry monitor within the CVICU (Cardiovascular Intensive Care Unit), which displayed the full names and heart rhythms of patients. Visitors were standing within inches of the monitor and the names were easily readable.

During an interview on 8/31/10 at 3:35 PM, Staff M, CVICU Nurse Manager, said the names were displayed for the convenience of staff so that any patient displaying an abnormal rhythm would be easily identifiable. Staff M agreed that displaying full names failed to provide confidentiality for patients.


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2. Observation on 8/31/10 and 9/1/10 showed on the surgical and medical step down units charge sheets were placed in patient rooms. The charge sheets were labeled with a patient sticker that included the patient's name and date of birth. The charge sheets were accessible to anyone entering patient's rooms.

In an interview on 9/1/10 at 10:10 AM, Staff A, Director of Medical Surgical said the patient stickers should not be displayed in patient rooms.



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3. Observation on 08/31/10 at 2:15 p.m. showed four behavioral health rooms in the emergency department (ED). The facility video monitors all four rooms. The video monitors are located in the ED and in the security department.

Observation of the unit showed no signage informing patients or visitors of possible video monitoring in these four exam rooms.

During an interview on 08 /31/10 at 2:15 p.m. the Nurse Manager of the unit, staff D said that there is no signage informing any patients or visitors of possible camera monitoring.

Review of the admission consent form to the ED showed no disclosure that patients or visitors could be monitored on camera if they are in any of the four behavioral health treatment rooms.

Based on record review the facility failed to ensure physicians sign, date and time telephone medical restraint orders for two of two (Patient #6 and Patient #21) medical restraint records reviewed. The facility had a census of 404.
Findings included:
Review of facility policy Restraint/Seclusion last reviewed 3/02/10 showed in the policy section C, 4 that telephone orders must be countersigned with date and time within 24 hours.
Review of the admitting history and physical for current Patient #6 dated 8/22/10 showed the patient entered the facility 8/21/10 for treatment of right sided weakness and slurred speech. Review of the physician orders showed the following orders:
Four telephone orders dated 8/26/10 at 9:00 p.m., dated 8/27/10 at 9:00 p.m., 8/28/10 at 9:00 p.m. and 8/29/10 at 9:00 p.m. for non violent/non self destructive restraints for airway protection, line/tube protection and healing wound/fracture with acute confusion/disorientation; patient scratches or pulls at wound site; removes dressing; lack of safety awareness. The telephone orders are for a left wrist restraint. All four telephone orders lack a physician's signature.
Review of the admitting history and physical for current Patient #21 dated 8/15/10 showed the patient entered the facility 8/15/10 for treatment of injuries from a motor vehicle accident. Review of the physician orders showed the following orders:
Four telephone orders dated 8/26/10 at 7:00 a.m., dated 8/28/10 at 7:00 a.m., 8/29/10 at 7:00 a.m. and 8/30/10 at 7:00 a.m. for non violent/non self destructive restraints for airway protection, line/tube protection and healing wound/fracture with acute confusion/disorientation; patient scratches or pulls at wound site; removes dressing; lack of safety awareness. The telephone orders are for bilateral (both) wrist restraints. All four telephone orders lack a physician's signature.

Based on observation, interview, facility policy review and record review the facility failed to develop comprehensive care plans with interventions for two patients (#19 and #22) of 25 sampled patients. The facility census was 404.

Findings included:

1. Review of facility policy titled "Plan of Care - Inpatient Nursing", last updated 10/13/09, gave the following direction (in part):
Planning:
I) The register nurse (RN) develops a plan that prescribes strategies and alternatives to attain expected outcomes. The RN:
a. Develops an individualized plan considering patient characteristics or the situation.

2. Record review revealed Patient #22 entered the facility on 8/23/10. Lab results dated 8/27/10 revealed the patient was positive for MRSA (Methicillin-resistant Staphylococcus aureus).
Review of Patient #22's Nursing Plan of Care revealed potential for infection, but did not address an actual infection or isolation precautions.

Observations showed Patient #22's room posted for contact isolation precautions.

In an interview on 9/1/10 at 10:30 AM, Staff A Director of Medical Surgical said Patient #22's care plan should have included isolation precautions due to the positive MRSA results.

3. Record review revealed Patient #19 entered the facility on 8/31/10. Nursing History/Assessment revealed Patient #19's needed a deaf interpreter.

Review of Patient #19's Nursing Plan of Care did not include impaired communication or the intervention for an interpreter.

In an interview on 9/1/10 at 1:25 PM, Staff X Nurse Manager said Patient #19's care plan should have addressed impaired communication and the need for an interpreter.

Based on record review, interview and facility policy review, the facility failed to ensure physician verbal orders (v.o.) and/or telephone orders (t.o.) are authenticated (signed, dated and timed for the signature) by the ordering physician for three Patients (#24, #3 and #4) of 25 sampled records. The facility census was 404.

Findings included:

1. The facility policy titled Doctor's Orders, Telephone and Verbal, last reviewed on 02/08/10 states the following:
- "Timeliness of Authentication of Telephone/Verbal Orders: A. Telephone/verbal orders for medications, biological, and therapies must be authenticated, dated and timed by the physician who gave the order or another physician responsible for the care of the patient. B. For verbal orders given in person, the physician should authenticate, date, and time the order(s) prior to leaving the unit. C. With all telephone/verbal orders, the physician should authenticate, date and time the order(s) upon the physician's next visit or within 24 hour for Acute Rehab, or within 48 hours for all other orders".
- "Method of Authenticating Telephone/Verbal Orders: Authentication consists of the physician's legible signature at the bottom of the order with the date (and time)."
2. Open medical record review on 09/01/10 at 9:30 AM of Patient #24 showed a t.o. dated by the nurse on 08/28/10 at 9:30 PM for:
1. Oxygen 2Liters by NC (nasal canula)
2. Vantin (an antibiotic) 200 milligrams (mg) BID (2 times a day)
3. Albuterol-ipratropium (Duoneb) (treatment for asthma) 0.5 - 2.5 mg/3 milliliters (ml) - Inhale 3 ml by mouth QID (4 times a day) and PRN (as needed)
4. This supersedes any other orders on the above 2 medications.

The order was not signed, dated or timed by the physician.

Record review further showed a v.o. dated by the nurse on 08/29/10 at 10:00 AM for:
1. Bactroban ointment (antibiotic cream) to sore on foot - cover with dressing daily.

The order was not signed, dated or timed by the physician.

During an interview on 09/01/10 at 10:15 AM Staff L, RN (registered nurse) resource nurse verified the lack of physician signature, date and time on the orders.


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3. Medical record review on 9/1/10 for Patient #3 revealed a t.o. dated 8/28/10 for Metoprolol (heart medication) 5 milligrams intravenous every six hours.

The order was signed by the physician with no date or time to indicate it had been signed within the required 48 hours.

4. Medical record review on 9/1/10 for Patient #4 revealed a t.o. dated by the nurse on 8/28/10 for 500 milliliters of ? normal saline plus 15 milliequivelents of KCL (potassium) over eight hours for potassium of 3.1.

The order was signed by the physician with no date or time to indicate it had been signed within the required 48 hours.

Based on facility policy review, observation, and interview, the facility failed to ensure medications are kept in a locked, secured area to prevent unauthorized access. The facility census was 404.

Findings included:

1. Review of the facility policy titled Medications: Medication Use Policy, last updated 9/22/09, gave the following direction (in part).
Procedure: 3.d- All medications are to be stored in suitable secure locations.
1) Patient-specific medications, IV (intravenous) admixtures, floor stock medication, and unopened IV solutions are stored in secure medication carts, nurse servers, Diebold Med Select or Pyxis Medstations, secured refrigerators, or other secure unit-designated areas.
2. Observation on 9/1/10 at 9:20 AM showed the door open to a patient room on the medical step down unit. The patient room had been converted to the medication room. The room contained a Pyxis Medstation, bags of IV solution, pre-packaged syringes of normal saline and medical supplies. The door had no locking mechanism.

Interviews revealed:
-On 9/1/10 at 10:10 AM, Staff A Director of Medical Surgical Units said the medical step down unit had been moved for renovations. Staff A said the patient room had been converted to the medication room for the renovations and staff had been asking for a lock for the door.
-On 9/1/10 at 1:00 PM, Staff CC Pharmacist said the medication room should be locked. Staff CC said the facility was planning on placing proximity locks on the medication rooms but they had not been installed yet. Staff CC said building services would need to put some kind of lock on the door till the proximity locks could be installed.

Based on observation, interview and facility policy review, the facility failed to follow facility standards of practice for medication administration for one patient (#24) and failed to follow isolations precautions for three Patients (#17, #22 and #25). This had the potential to affect all patients, staff and visitors. The facility census was 404.


Findings included:

1. Review of facility policy Drugs for Aerosol Administration with a review date of 2/22/10, revealed staff guidance in part:
Procedure:
i. Rinse nebulizer following treatment.

2. Observation on 09/01/10 at 9:05 a.m. showed Staff V, registered nurse (RN) administering care to Patient #24. Staff V administered an inhalant medication to Patient #24. Patient #24 had to enclose the end of the inhaler/nebulizer with her mouth. Staff V failed to clean the mouthpiece after Patient #24's medication administration. Staff V placed the used inhaler/nebulizer in the medication box with other patient medications.

During interview after care observation, Staff V said I did not clean mouthpiece. Staff V then cleaned inhaler/nebulizer mouthpiece with alcohol.



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3. Review of the facility polity titled, "Standard Precautions and Isolation Guidelines," reviewed 2/24/10, gave the following direction (in part):
- All blood and body substances must be regarded as infectious or hazardous, regardless of diagnosis.
- Body substances included all body fluids, excretions, secretions, tissues, sputum or any other drainage from the patient.
- Gloves: Must be removed when the task is completed or before touching public areas that others may contact.

Review of the facility policy titled, "Hand Washing/Hand Hygiene," reviewed, 2/24/2010, gave the following direction (in part):
Use an alcohol-based rub in all other recommended situations below, unless hands are visibly soiled -
- Before and after direct patient contact
- After removing gloves
- After contact with objects and equipment in the patient's immediate vicinity.

4. Observation on 9/1/10 at 10:15 AM showed Staff R, RN (Registered Nurse) removed a urinary catheter from Patient #17. While wearing the gloves used during the procedure, Staff R entered the patient's restroom, flipped on the light switch, and disposed of contaminated materials. While still wearing the contaminated gloves, Staff R flipped off the light switch, then removed gloves and washed his/her hands at the patient's sink. Staff R did not wipe the bathroom light switch with disinfectant wipes.

Staff R then went to the patient's bedside, straightened the patient's bed, and repositioned a urinal on the patient's bedside table. Staff R did not perform hand hygiene before leaving Patient #17's room and returning to the nursing station.

During an interview on 9/1/10 at 10:30 AM, Staff S, Chest Pain Unit Nurse Manager, said Staff R should have wiped down surfaces that had been touched in the restroom while wearing soiled gloves, and should have washed hands or performed hand hygiene prior to leaving Patient #17's room.


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5. Review of the facility polity titled, "Standard Precautions and Isolation Guidelines," reviewed 2/24/10, gave the following direction (in part):
-C. Essential Steps in Applying Personal Protective Equipment (PPE):
1. PPE is based on the task to be completed and should be applied prior to entering the room.
2. In the event complete attire is required, put on gown, overlapping well in back to cover clothing and secure gown.
-D. Contact Precautions: 3. Gown and gloves are required for direct contact with patient or when entering the patient environment.

6. Observation on 9/1/10 at 10:30 AM showed Staff O Certified Nurse Aide enter Patient #22's room posted for contact isolation with a gown in his/her hand and put the gown on inside the patient's room. Staff O walked over to the patient's bed then put on gloves.

In an interview on 9/1/10 at 10:30 AM, Staff A Director of Medical Surgical stated PPE should be on before entering a patient's room if they are on isolation.



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7. Observation on 8/31/10 at 3:20 p.m. in the neuro intensive care unit showed physician Staff G enter Patient #25's room with a contact isolation sign outside the door. The sign directs anyone entering the room to wear gloves and a gown and to wash hands. Staff G placed his/her forearms in the gown. The gown did not cover the upper arms or the upper part of Staff G's chest. Staff G did not secure the neck and/or waistband ties.

Observation on 8/31/10 at 3:25 p.m. showed two visitors enter the same room. Both visitors failed to perform hand hygiene or don gloves.

Based on facility policy review, record review, and interview, the facility failed to ensure staff completed and documented informed consent with date, time, and signature for two Patients (#13 and #16) of 25 medical records reviewed. The facility census was 404.

Findings included:

1. Review of the facility policy titled, "Consents Policy," reviewed 3/3/2010, gave the following direction (in part): "Prior to the start of the procedure the physician shall sign the consent certifying that he/she has explained the procedure to the patient, or if the patient is unable to consent, to the individual authorized to consent."

2. Review on 8/31/10 at 3:45 PM of the acute medical record for Patient #13 showed consents for multiple surgical procedures. The following was noted:

- A form titled "Consent to Surgical or Invasive Treatment" for:
- "Percutaneous Transluminal Coronary Angioplasty (a procedure to open blocked arteries), Coronary Stent (placement of a stent into the arteries of the heart), Atherectomy, Cardiac Catheterization (a procedure to diagnose certain heart conditions)." The form was signed by the physician, but was not dated or timed.
- "Mesenteric Angiogram (a special x-ray of the arteries in the abdomen to show if an artery is blocked or bleeding) with Possible Angioplasty (a procedure to open blocked or narrowed arteries), Stent Placement (a procedure in which an wire mesh tube is inserted into to an artery to hold it open), Atherectomy (a procedure to remove plaque from arteries) and/or Embolization (a procedure to clog small vessels and block the flow of blood." The consent was signed and dated 8/12/10 by the physician, but was not timed.
- "Exploratory Laparotomy (abdominal exploration allowing examination of internal organs), Possible Bowel Resection (a procedure in which a diseased part of the intestine is removed), Possible Ileostomy (a procedure in which a portion of small intestine is attached to the abdominal wall) or Colostomy (a procedure in which a portion of large intestine is attached to the abdominal wall), Tube Gastrostomy (a procedure in which a feeding tube is inserted through the abdominal wall)." The form was signed and dated 8/16/10 by the physician, but was not timed.
- "Removal of Abdominal Wall Vac (vacuum) Device (use of negative pressure to assist with wound healing) and Possible Abdominal Closure or Change of Wound Vac." The form was signed and dated 8/19/10 by the physician, but was not timed.
- "Removal of Abdominal Wound Vac and Possible Abdominal Wound Closure and Gastrostomy Tube Placement." The form was signed and dated 8/21/10, but was not timed.
- "Insertion of Chest Tube (a procedure to insert a tube into the chest wall, allowing lungs to fully inflate)." The form was not signed, dated or timed by the physician.
- "Insertion of Central Line." The form was not signed, dated or timed by the physician.
- "Percutaneous Cholecystostomy Drain Insertion (a procedure to insert a drain tube into the gallbladder)." The form was signed and dated 8/27/10 by the physician, but was not timed.
- "Percutaneous Tracheostomy (a procedure for gaining access to the airway)." The form is not signed, dated, or timed by the physician.

- A form titled "Placement of Peripherally Inserted Central Catheter (a long, thin, flexible tube inserted into a vein near the heart, which is used to give medicines, fluids, nutrients, or blood products over a long period of time)."
- A form was signed and dated 8/13/10 by the nurse, but was not timed.
- A form was signed and dated 8/15/10 by the nurse, but was not timed.

- A form titled "Consent for Anesthesia Services" for general anesthesia.
- A form was signed and dated 8/16/10 by the anesthesia provider, but was not timed.
- A form was signed and dated 8/21/10 by the anesthesia provider, but was not timed.

During an interview on 8/31/10 at 4:00 PM, Staff M, CVICU Nurse Manager, said physicians have been instructed to provide information to the patient and authenticate the forms prior to any procedure.


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3. Review on 8/31/10 of the medical record for Patient #16 showed a form titled "Consent to Surgical or Invasive Treatment" for "Ultrasound guided drainage peritoneal cavity fluid collection" was signed by the physician, patient and witness, but had not been timed.