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Based on staff interviews and facility document review it was determined the facility staff failed to provide Medicare recipients the "Important Message from Medicare" (IMM) at the timeframes required for two (2) of two (2) Medicare recipients' records reviewed for whether IMMs were provided. (Patient #5 and Patient #7).

The findings were:

On 5/16/18 at 1:15 p.m., the Emergency Department's (ED) team lead for Patient Access was interviewed about the process patients experience when registering in the ED and how the IMM was provided. The team lead said that upon admission, patients received a book of information that included patient rights information and Medicare recipients also received the "Important Message from Medicare" that was signed electronically.

1. Patient #5's electronic medical record was reviewed on 5/16/18 at 2:10 p.m. along with an RN (registered nurse) navigator - Staff Member (SM) #21. The patient was a Medicare recipient who had been admitted on 5/01/18 and discharged on 5/07/18. The navigator was unable to find evidence of any IMM provided to Patient #5.

2. Patient #7's electronic medical record was reviewed on 5/16/18 at 4:00 p.m. along with an RN navigator (SM #14). The patient was a Medicare recipient who had been admitted on 5/04/18 and was discharged on 5/08/18. The electronic record contained evidence of the IMM from admission on 5/04/18 but no evidence of a second IMM provided prior to discharge.

On 5/16/18 at 5:15 p.m. at the end of day conference, the administrative team present (Administrative Director of Quality/Patient Safety, Director of Operations, Regulatory Compliance Coordinator, Chief Nursing Executive, and Chief Medical Officer) were informed of the above findings.

On 5/17/18 at 8:45 a.m., the facility's Administrative Director of Quality/Patient Safety updated the survey team regarding Patient #5 and Patient #7's IMMs:
A. Patient #5:
1. The Director provided an email from the case management department that stated the case manager for Patient #5 was "unable to obtain" the IMM on 5/07/18 which would have been for the second IMM due prior to discharge. The Director acknowledged there was no evidence of the first IMM being provided.
B. Patient #7:
1. The Director acknowledged that although there was evidence of the signed first IMM, there was no evidence of the second IMM which would have been due prior to discharge. The Director
stated the facility's Manager of Care Management was under the impression when patients were
discharged to Hospice services (Patient #7 had been discharged to Hospice), the patients would not need the second IMM. The Director of Quality acknowledged he/she could not find evidence of any exception to the second IMM, such as a Hospice admission.

On 5/17/18 at 3:50 p.m., the facility's Team Lead for Outpatient Registration (who also worked in patient access in the emergency department at times) was interviewed about providing patients with the IMM. The team lead provided information from the training that Patient Access employees receive regarding the IMM. The information read in part, "All admitted patients who have Medicare are required to be informed about the Important Message from Medicare. Medicare patients are to review, sign, and receive a copy of the consent form."

On 5/17/18, the facility's policy titled, "Discharge Planning and Process" (last revision date 12-06-16) was reviewed and read in part, "Procedure A. Message from Medicare About Rights Patients with Medicare, Medicare Advantage plans or other managed Medicare plans are provided with the second 'Important Message from Medicare About Your Rights' document according to the CMS guidelines. This document is provided to the patient and/or family no more than 48 hours prior to discharge or less than 4 hours prior to discharge."

On 5/17/18 at 4:40 p.m., the facility's Administrative Director of Quality/Patient Safety and their Regulatory Compliance Coordinator were informed again of the the above findings. No further evidence was provided.

Based on observations, interviews, and facility document review it was determined the facility staff failed to notify patients and family prior to the implementation of the continuous visual monitoring system for patient safety for two (2) of three (3) patients reviewed for privacy education. (Patient #10 and Patient #14).

The findings were:

On the afternoon of 5/17/18, a surveyor visited Patient #10 and Patient #14. The surveyor was escorted by the facility's Nurse Manager of Float Pool, Sitter Pool, Staff and Office Supervisors. Both patients were observed in their private rooms and the facility's system (a TeleSitter [sic] monitoring system used as a nursing intervention to help prevent falls and patient injury. The system monitors, it does not record.) was beside both patients' beds. Both patients acknowledged knowing about the system and denied having concerns about the system.

Patient #10's electronic medical record was reviewed along with the facility's Administrative Director of Quality/Patient Safety on 5/17/18. The record contained evidence Patient #10 began having the monitoring intervention on 5/09/18 at 11:00 a.m. however, the education to the family was not documented until 5/17/18. The progress note dated 05/17/18 at 10:20 a.m., read "Spoke with patient, family is currently not present regarding [monitoring system]. Provided education and pt [patient] agrees to having it in the room."

Patient #14's electronic medical record was reviewed along with the facility's Administrative Director of Quality/Patient Safety on 5/17/18. The patient had the monitoring system implemented beginning on 5/16/18 at 5:52 p.m. however, the education was not documented until 5/17/18 at 10:10 a.m. and read, "Tele monitor in patient's room to monitor patient safety, patient is aware. Will discuss with family once they arrive at bedside [sic]"

On 5/17/18 at 9:55 a.m., the facility's policy titled, "TeleSitter, Continuous Visual Monitoring For Patient Safety using [sic]" was reviewed. It read in part, "C. RN Responsibility: 3. Notify patient and family that continuous visual monitoring will be implemented to promote patient safety. 4. Document patient/family education and plan of care in the EMR [electronic medical record]. 5. Obtain TeleSitter monitoring equipment. If unable to locate, notify Nursing Supervisor..."

On 5/17/18 at 4:40 p.m., the facility's Administrative Director of Quality/Patient Safety and the facility's Regulatory Compliance Coordinator were informed of the above findings and both acknowledged there was no further information to provide.

Based on interviews and the review of documents, it was determined the facility staff failed to ensure medications were provided as required for 1 of 14 sampled patients (Patient #8).

The findings include:

1. The facility staff failed to ensure an as needed (PRN) respiratory nebulizer medication was provided in a timely manner. The facility staff also failed to ensure the facility's policy and procedure clearly addressed the timely administration of medications/drugs ordered on an as needed (PRN) basis.

Patient #8's clinical record included an order for levalbuteral nebulizer every six (6) hours as needed (PRN) for wheezing and shortness of breath; this order had a start date of 4/4/18 at midnight.

Nursing documentation for 4/5/18 at 7:34 a.m. indicated Patient #8 had 'scattered' wheezes. Facility documentation indicated facility respiratory staff were first aware of the need for the as needed (PRN) breathing treatment for the patient at approximately 7:45 a.m. but the medication was not available on the unit and had to be requested from the pharmacy. Facility documentation indicted levalbuteral was sent 'via tube' to from the pharmacy on 4/5/18 at 11:15 a.m. although the medication was documented as being administered at 11:09 a.m. The patient's assessment at the time of the treatment was documented as 'wheezing, shortness of breath'.

Review of the facility's "Medication Administration" policy (with an initial date of 5/30/98 and a recent revision date of 11/9/17) failed to provide guidance as to the timeliness of as needed (PRN) medication administration.

On 5/17/18 at 3:15 p.m., the facility's Quality Manager, Director of Pharmacy, and Regulatory Compliance Coordinator reported that there was not a facility policy/procedure providing guidance for the timeliness of PRN medication administration.

The failure of the facility staff to have a policy to address timely administration of PRN medications and the delay in Patient #8 receiving his/her PRN levalbuteral nebulizer treatment was discussed for a final time during a survey team meeting on 5/17/18 at 4:35 p.m. with the facility's Regulatory Compliance Coordinator and the facility's Director of Quality/Patient Safety; no additional information related to these issues was provided to the survey team.

2. The facility staff failed to ensure an eye-drop medication (the patient had been receiving at home) was ordered during the hospital stay.

Review of Patient #8's clinical records with Staff Member (SM) #2 (a registered nurse) on 5/16/18 revealed documentation of the patient receiving timolol eye-drops at home prior to the hospital admission but not having the timolol eye-drops ordered while a patient in the hospital.

A "Pharmacy Clarification of the Prior to Admission Medication Regimen Retrospective to the Admission Medication Reconciliation" document was found in Patient #8's clinical record. This document included the following information: "Recommendations/Findings: The following amendments were made to the patient's active medication list on file at (hospital name omitted): 1) Additions: - timolol (TIMOPTIC) 0.5 % ophthalmic solution ..."

Review of Patient #8's clinical record failed to reveal evidence of a prescriber addressing the addition of timolol eye-drops to the patient's medication list. The facility's Clinical Manager of Pharmacy was interviewed, on 5/16/18 at 4:20 p.m., related to the addition of timolol eye-drops to the patient's medication list; the Clinical Manager of Pharmacy confirmed no action related to the addition of the trimolol eye-drops was documented.

The failure of the facility staff to address an eye-drop the patient was receiving at home but was not ordered during his/her hospital stay was discussed during survey team meetings on 5/16/18 at 5:00 p.m. and 5/17/18 at 4:35 p.m. The facility's Regulatory Compliance Coordinator and the facility's Director of Quality/Patient Safety were in attendance at the aforementioned survey team meetings; no additional information related to these issues was provided to the survey team.

This is a complaint deficiency.

Based on a review of clinical records, facility policies, and interviews, it was determined the hospital's nursing staff failed to perform required nursing assessments/monitoring for possible reactions or adverse outcomes during blood transfusions, for two (2) of two (2) patients sampled who received blood transfusions (Patients #3 and 4).

The findings were:

The surveyor reviewed the hospital's 16 page policy titled, "Transfusion of Blood Components" (Policy Number: BSR 01-03) on 05/16/18. The findings from that review were as listed below.
Section 5.4 "Vital Signs" included (in part) the following requirements for monitoring and assessing the vital signs of patients during blood transfusions:
"Take vital signs in the following intervals from the start of the transfusion:"
1. Within 15 minutes prior to starting blood, then 15 minutes after starting blood.
2. 30 minutes from start time, 60 minutes from start time, 120 minutes from start time, 180 minutes from start time, and 1 hour post-transfusion.
Section 5.4 required the assessments/monitoring be documented in the patient's EHR (electronic health record). The policy at section 5.5 "Adverse Reaction" included (in part), "Closely monitor patient during transfusion for signs and symptoms of adverse reactions." Section 5.5 did not include information to define specific signs and symptoms of adverse reactions. The policy at section 3.3 "Patient/family Education" included (in part), ..."(Adverse Reactions) during transfusion" which listed headache, low back pain, tingling, flushing, fever, chills, itching, hives, rash, hypotension (low blood pressure), hypertension (high blood pressure) as some signs and symptoms to watch for during transfusions.

The clinical records of Patients #3 and #4 were reviewed on 05/16/18. SM #14 (Clinical Care Lead/Registered Nurse-Progressive Care Unit) assisted as the navigator of the EHR (electronic health record). The findings of the record reviews were as follows:

a. Patient #3 received two (2) units of PRBCs (Packed Red Blood Cells) on 05/16/18.
The first unit started infusing at 12:08 a.m. and ended at 2:30 a.m., for a total infusion time of 142 minutes. The patient's vital signs for the transfusion were assessed/monitored late on 4 of 6 required time points, and missed on 1 time point as follows:
· the 15 minutes after were due by 12:23 a.m. and obtained at 12:45 a.m. (22 minutes late),
· the 30 minutes after were due by 12:38 a.m. and were missed,
· the 60 minutes after were due by 1:08 a.m. and obtained at 1:17 a.m. (9 minutes late ),
· the 120 minutes after were due by 2:08 a.m. and obtained at 2:29 a.m. (21 minutes late),
· the 1 hour after transfusion were due by 3:30 a.m. and obtained at 3:53 a.m. (32 minutes late).
The second unit started infusing at 3:16 a.m. and ended at 5:52 a.m., for a total infusion time of 156 minutes. The patient's vital signs for the transfusion were assessed/monitored late on 2 of 6 required time points, and missed on 3 time point as follows:
· the 15 minutes after were due by 3:31 a.m. and were missed,
· the 30 minutes after were due by 3:46 a.m. and obtained at 3:53 a.m. (7 minutes late),
· the 60 minutes after were due by 4:16 a.m. and were missed,
· the 120 minutes after were due by 5:16 a.m. and obtained at 5:28 a.m. (12 minutes late),
· the 1 hour after transfusion were due by 6:52 a.m. and were missed.

b. Patient #4 received one (1) unit of PRBCs (Packed Red Blood Cells) given in the Emergency Department, on 05/15/18. The unit of PRBCs started infusing at 3:30 a.m. and ended at 5:27 a.m., for a total infusion time of 117 minutes. The patient's vital signs for the transfusion revealed the temperature was not assessed/monitored with the vital signs for 4 of 6 required time points, and the vital signs were missed on 1 time point as follows:
· the 30 minutes after vital signs failed to include monitoring of the patient's temperature,
· the 60 minutes after vital signs failed to include monitoring of the patient's temperature,
· the 120 minutes after vital signs failed to include monitoring of the patient's temperature,
· the 1 hour after transfusion vital signs (including temperature) were due by 6:27 a.m. and were missed.

The surveyor met with the hospital's Director of Quality and Patient Safety, and the Regional Compliance Coordinator on 05/16/18 at 2:40 p.m. and discussed the clinical record review findings. The Director of Quality and Patient Safety and Regional Compliance Coordinator were informed the monitoring and assessments of patient's receiving blood transfusions was not identified to be in accordance with the hospital's policy. They both acknowledged the described findings were not in accordance with the hospital's policy and expectations.