HospitalInspections.org

Based on observation, interview and policy review the facility staff failed perform required check of the Emergency Department (ED) Crash Cart (cart utilized for time sensitive emergencies such as heart attacks). This failure could potentially delay care of critically ill patients. The ED treats about 425 patients per month. The facility census was 8.

Finding included:

1. Observation on 05/23/11 at 2:00 PM showed daily check list for May/2011 of ER Crash Cart Room #2 were not performed on:05/1,05/2,05/3,05/5,05/7,05/9,05/11,05/12,05/13,05/14,05/15,05/17 and 05/20.

2. Record review of facility 's policy titled, "Crash Cart Checks-Emergency Department," revised 2010, showed the following staff direction:
-Check each item on the crash cart against the crash cart check list to assure that all items are present in proper quantity;
-Crash cart checks should be done daily and after each use.

3. During an interview on 05/23/11 at 2:30 PM Staff B, ED Supervisor, stated that the checks should be done every day. Staff B stated that I guess we missed a few days.

Based on document review the facility failed to adopt Medical Staff Bylaws which give only the Governing Body the authority to grant medical staff privileges. This deficient practice affects all patients in the facility. The facility census was 8.

Findings included:

Review of the facility ' s Medical Staff Bylaws, conducted on the morning of 5/24/11 showed the following:

Article V
Section 5.3
Temporary Privileges
The CEO and Chief of Staff jointly shall have the authority to grant Temporary Privileges for 60 days to a physician.

Based on observation, interview, policy and record review facility failed:
-To ensure Dietary Staff appropriately sanitized small kitchen utensils and trays used for patient meal service and Dietary staff failed to wash hands in an appropriate manner;
-To ensure Nursing staff utilized standard precaution for infection control when routine urinary catheter care was performed on one of one patient observed for urinary catheter care.
The facility census was 8.

Findings included:

1. Review of the U. S. Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2005 Food Code showed the following:
-Chapter 2-301.15 Food employees shall clean their hands in a hand washing sink and may not clean their hands in a sink used for food preparation or ware washing.
-Chapter 4-301.12(A) Sink compartment requirements for manual ware washing shall be at least three compartments for manually washing, rinsing and sanitizing.
-Chapter 4-301.12(B) Sink compartment shall be large enough to accommodate immersion of the largest equipment and utensils.

2. Observation on 05/23/11 from 1:39 PM through 2:03 PM showed Dietary department staff used a single compartment sink (the room was previously used as a patient room) for ware washing including small utensils used to serve foods on patient meal trays and the fiberglass trays used to serve patient meals.
During an interview on 05/23/11 at 1:39 PM Staff K, dietary assistant manager stated the following:
-The staff used the single sink to wash and sanitize small wares (serving spoons, scoops, spatulas) and fiberglass patient meal service trays.
-He/she knew the recommended three sink ware washing method was not possible in the single sink.
-Staff had been instructed to wash hands in a sink a few doors down the hall (outside the kitchen).
-He/she could not say staff always washed hands in the sink down the hall.
-Staff sometimes washed hands in the single sink in the kitchen.

3. Record review of facility policy titled, "Foley Catheter Care", revised 5/2005, showed direction for staff to wash hands, clean catheter with soap and water in the event of soiling with drainage or feces but routine daily cleaning of Foley (urinary catheter) is not recommended.

Observation 05/24/11 at 11:45 AM showed Staff A, RN, performed routine urinary catheter care by wiping catheter and urethral area with a moist towelette, without placing gloves on his/her hands.

During interview on 05/25/11 at 9:35 AM Staff G, Infection Control Nurse, stated that he/she is not sure if gloves are needed during routine urinary catheter care. Staff G stated that if the nurse washes his/her hands adequately, before and after, gloves shouldn't be needed.

Based on interview and record review the facility failed to ensure high quality accurate nutritional care was provided to patients in accordance with recognized dietary practice by failing to ensure regular and modified diet menus served to patients were written and planned in advance, approved by the registered dietitian and evaluated for nutritional adequacy. The facility census was 8.

Findings included:

1. During an interview on 05/23/11 at 1:39 PM Staff K, dietary assistant manager stated the following:
-Staff N, Director of Dietary wrote menus used for patient meal service.
-The menus were not preplanned.
-The menus for regular unrestricted diets served to patient were based on what foods were available.
-The foods served for patients on modified diets such as soft, two-gram sodium and four gram sodium diets (restricted sodium diets commonly prescribed for patients with high blood pressure, heart problems or kidney problems) were based on memory of the dietary staff.
-The menus were not approved by the registered dietitian

2. Review of the current facility menus showed an undated partially completed (many blank sections) hand written single page listing foods without portion sizes and without modification for diets.

3. During an interview on 05/24/11 at 10:45 AM Staff L, Registered Dietitian stated the following:
-Staff N, the Director of Dietary was currently writing the menus used for patient meal service.
-Staff L acknowledged allowing Staff N writing patient menus was not within regulatory requirements.
-Staff L stated there were no written modified diet menus (directing staff to serve a specific type and amount of food per physician orders).
-Staff L had not approved any of the menus.
-There was no nutritional analysis of the menus to ensure patients were served sufficient nutrients (protein, carbohydrates, vitamins and minerals).

Based on interview, position description review and personnel file review facility staff failed to ensure one of two Family Practice Nurses (FNP) maintained current Advanced Cardiac Life Support (ACLS) certification as required by his/her position description. The facility census was 8.

Findings included:

1. Review of the facility position description for the Family Nurse Practitioner (FNP), dated 08/01/03 showed direction that incumbent staff must maintain current ACLS certification (advanced cardiac life support, additional training in application of specific interventions performed during emergencies).

Further review of the facility position description for the FNP showed Staff Q, FNP signed the position description (had knowledge of the requirement).

2. During an interview on 05/25/11 from 10:40 AM through 11:05 AM, Staff R, the Director of Human Resources (HR) reviewed Staff Q's personnel file and position description and stated the following:
-Staff Q had a valid ACLS certification that expired in 03/10.
-Staff Q had last been provided an annual appraisal on 07/13/10.
-The position description directed Staff Q to maintain a current ACLS certification.
-Staff Q personnel file did not show documented current ACLS re-certification.

Based on record review, interview and policy review the facility staff failed:
-To ensure safe administration of blood products by not monitoring patient vital signs according to policy. This failure had the potential to miss timely recognition of patient allergic reaction to transfusion. This occurred on one of one record reviewed for blood transfusion.
-To ensure complete physician authentication (signature, date and time) of verbal admission, medication, therapy and code status orders to a nurse. This failure occurred on four of four (Patient #11, #12, #13,#17) current patient medical records reviewed.
Facility census was 8.

Findings included:

1. Record review of facility policy titled, "Blood Transfusion", revised 2/98, showed the following direction to staff:
-Take pre transfusion vital signs and record on both the transfusion requisition slip and Flow Sheet;
-Begin transfusion, document starting time on transfusion requisition slip, Flow Sheet, and MAR (Medication Administration Record);
-Monitor vital signs before transfusion begins, fifteen minutes after start of transfusion and upon completion of the unit (of blood).

2. Record review of Patient #2's current medical record, Blood transfusion Flow Sheet, dated 05/9/11 showed:
-Baseline Vital Signs were not recorded as directed in policy;
-Transfusion started at 18:00 and vital signs were recorded;
-Next vital signs recorded at 18:35-policy calls for vital signs 15 minute after start, this was 35 minutes after start.

3. During interview on 05/24/11 at 10:15 AM Staff C, Registered Nurse Director, stated that baseline vital signs and vital signs 15 minutes after start of transfusion should have been recorded.

4. During an interview on 05/25/11 at 9:50 AM Staff H, Director of Nursing, stated that baseline vital signs and vital signs 15 minutes after start of transfusion should have been recorded.


18075

5. Review of the facility policy and procedure titled: "Verbal and Telephone Orders" revised and approved on 08/08/07 stated the following:
- All medical orders are to be in writing and signed by the physician.
- When the physician cannot write an order, it is preferred that new orders be faxed to the appropriate unit. All telephone and verbal orders should be co-signed by the physician within 24 hours (or as soon as possible).

6. Review of Patient #11's medical record showed the patient was admitted to the facility on 05/12/11 with the admitting diagnosis of a right-sided stroke. The admission orders were dated and timed 05/12/11 at 11:45 AM and included the following:
- Full resuscitation code status;
- Patient to be evaluated by PT (physical therapy), OT (occupational therapy) and speech therapy and treat as needed for post stroke;
- Diet order for diet with nectar thick liquids and a dietary consult;
- Aspirin (blood thinning medication) 325 mg (milligrams) PO (by mouth) daily;
- Docusate (stool softener medication) 100 mg PO daily; and
- Acetaminophen (pain medication) 650 mg PO every four hours as needed.

The above admission orders were written by a Registered Nurse, dated and timed 05/12/11 at 11:45 AM but were not signed by the physician as of 05/26/11.

7. Review of Patient #12's medical record showed the patient was admitted to the facility on 05/02/11 with the admitting diagnosis of abdominal pain, rectal and bladder cancer. The admission orders were dated and timed 05/02/11 at 12 noon and included the following:
- Full code status during transport and discuss code status upon arrival;
- Patient to be evaluated by PT (physical therapy) and OT (occupational therapy) and treat as needed for weakness;
- Respiratory therapy for oxygen at 2 liters per nasal cannula as needed;
- Regular diet as tolerated and a dietary consult;
- Lovenox (blood thinning medication injection) daily; and
- Regenacare wound gel to excoriated buttocks three times daily.

The above admission orders were written by a Registered Nurse, dated and timed 05/02/11 at 12 noon. The physician signed the orders but did not date or time the signature.

In addition, the record review showed orders dated 05/02/11 for the following:
- Acetaminophen 500 mg PO every four hours as needed for pain;
- Morphine 15 mg PO every four hours as needed for pain;
- Morphine 30 mg PO every eight hours (sustained release);
- Prochlorperazine maleate (medication for nausea) 10 mg PO every four hours as needed;
- Invanz (intravenous medication) 1 gram daily (last dose 05/06/11).

The above orders were written by a Registered Nurse, dated and timed 05/02/11 at 12 noon but were not signed by a physician as of 05/26/11.

8. Review of Patient #13's medical record showed the patient was admitted to the facility on 05/19/11 with the admitting diagnosis of a soft tissue injury from a fall at home. The admission orders were dated and timed 05/19/11 at 11:00 AM and included the following:
- DNR (do not resuscitate) code status order;
- Patient to be evaluated by PT (physical therapy) and OT (occupational therapy);
- Oxygen per respiratory therapy to keep oxygen saturation above 92%;
- Regular diet and a dietary consult; and
- Nebulizer (Albuterol 2.5 mg respiratory breathing treatment) three times daily.

The above admission orders were written by a Registered Nurse, dated and timed 05/19/11 at 11:00 AM but were not signed by the physician as of 05/26/11.

9. Review of Patient #17's medical record showed the patient was admitted to the facility on 05/21/11. The admission orders dated and timed 05/21/11 at 8:15 PM and included the following:
- Dietary, PT (physical therapy), OT (occupational therapy) consult and treat, social services consult; and
- May substitute Vicodin (pain medication) 5/500 for Norco 5/325 mg ? - 1 tablets PO every 4 - 6 hours as needed.

The above admission orders were written by a Registered Nurse, dated and timed 05/21/11 at 8:15 PM. The physician signed the orders but did not date or time the signature.

10. During an interview conducted on 05/24/11 at 3:45 PM, Staff C, Registered Nurse Director stated that it was the facility policy for orders to be signed by the physician within twenty-four hours. Staff C stated that this may be more of a problem now that the physician's are writing some orders electronically and may not be signing the written orders in the patient's medical records.

Based on interview and record review facility staff failed to ensure documents in patient medical records were accurate and completed as required in three (Patient #7, #8, #10) of six medical records reviewed for accurate and complete entries. The facility census was 8.

Findings included;

1. Review of the facility Policies of the Medical Records Department, dated 03/02/01 showed direction for staff to perform the following:
-A separate medical record was maintained for each patient.
-The patient medical record was documentation of the course of a patient's illness and treatment during a particular episode of care as an inpatient in the facility.

2. Record review of discharged Patient #7's physician's orders dated 04/22/11 showed staff admitted the patient to Swing Bed status with diagnoses including pancytopenia (decreased platelets, red and white blood cells), fever and elevated liver enzymes (possible indicator of disease, disorder or medication problems).

Record review of the patient's Physician's Orders For Life Sustaining Treatment form showed the physician authenticated the form on 04/16/11 however, a staff nurse obtained information from the patient and authenticated the form on 04/22/11 (the admission date).

During an interview on 05/24/11 at 10:21 AM Staff M, Director of Medical records reviewed the patient's Physician's Orders For Life Sustaining Treatment form stated either the nurse who gathered the information or the physician who authenticated the form six days prior to the Swing Bed admission had dated the form incorrectly.

3. Record review of discharged Patient #8's admission history and physical showed staff admitted the patient on 03/14/11 with chief complaints of weakness, anorexia (persistent lack of appetite) and dehydration.

Record review of the patient's discharge summary showed the patient expired on 03/15/11, a Family Nurse Practitioner (FNP) had authenticated a discharge summary on 05/23/11 and the physician failed to authenticate and complete the discharge summary.

During an interview on 05/24/11 at 10:31 AM Staff M stated the physician had failed to authenticate the discharge summary (done by the FNP) as required and the FNP had failed to authenticate the discharge summary within thirty days as required.

4. Record review of discharged Patient #10's physician's orders dated 02/01/11 showed staff admitted the patient to Swing bed with diagnosis of pneumonia.

Record review of the patient's discharge summary showed the patient expired on 02/03/11 and the physician authenticated the discharge summary on 03/10/11.

Further review of the patient's Death, Release of Body Permit form dated 02/03/11 showed staff notified the Organ Bank as required however, information regarding the decision to donate or not donate organs was not documented on the form and the body was released to a representative of a funeral home however, staff failed to obtain a date and time of the authentication.

During an interview on 05/24/11 at 1:13 PM Staff M reviewed the patient's discharge summary and stated the physician's authentication was not within the required thirty days and Staff M reviewed the patient's Death, Release of Body Permit form and stated staff failed to complete the required information regarding organ donation, date and time of funeral home authentication.

Based on interview and record review facility staff failed to ensure physician's verbal/telephone orders were authenticated within twenty four hours as specified in facility policy for three (Patients #2, #6, #9) of seven medical records reviewed for authenticated verbal orders and staff failed to ensure physician's orders were dated and timed for two (Patients #7, #10) of six patient medical records reviewed for dated/timed physician's orders. The facility census was 8.

Findings included:

1. Record review of the facility policy titled, "Policies for the Medical Record Department" dated 03/02/01 showed direction that all physician's orders shall be dated and timed. Verbal orders should be signed within 24 hours.

Record review of the facility policy titled, "Verbal and Telephone Orders" revised 8/2007 showed direction that all telephone and verbal orders should be co-signed by the physician within 24 hours (or as soon as possible).

2. Record review of current Patient #2's physicians orders showed a verbal/telephone order for admission to the facility in a Swing Bed dated 05/11/11 with a diagnosis of pneumonia.

Record review on 05/24/11 showed that the physician had not authenticated the order with signature, date or time.

During an interview on 05/24/11 at 9:40 AM Staff C, RN Director, stated that he/she would expect the order to be signed, dated and timed. Staff C stated that the order is flagged for authentication by the physician.

3. Record review of discharged Patient #6's physician's orders showed a verbal order for admission to the facility in a Swing Bed dated 04/13/11 with diagnosis including left leg blood clot.

Further review showed the physician's verbal orders for admission were electronically authenticated on 05/09/11.

During an interview on 05/24/11 at 10:10 AM Staff M, the Director of Medical records stated the physician's authentication of the patient's verbal admission orders was not within the required twenty four hours as outlined in facility policy.

4. Record review of discharged Patient #9's physician's orders showed a verbal/telephone order set for admission to the facility in a Swing Bed dated 03/23/11 with diagnoses including end of life care, recent respiratory failure, myocardial infarct (heart attack) and chronic obstructive pulmonary disease (breathing problems).

Further review showed the physician's verbal orders for admission were electronically authenticated on 03/30/11.

Further review of the patient's physician's orders showed the following:
-Verbal orders dated 03/23/11 for Lorazepam (an antianxiety medication), acetaminophen (pain reliever), fentanyl (pain reliever), morphine PCA (pain reliever given by patient controlled analgesia pump), Morphine oral (oral pain reliever) and Scopolamine transdermal (anti nausea patch) with a physician's electronic authentication dated 03/30/11.
-Verbal order dated 02/23/11 to change the PCA dose with a physician's electronic authentication dated 03/30/11.

During an interview on 05/24/11 at 1:10 PM Staff M reviewed the patient's physician's orders and stated the physician's electronic authentications were tardy.

5. Record review of discharged Patient #7's physician's orders dated 04/22/11 showed staff admitted the patient to Swing Bed status with diagnoses including pancytopenia (decreased platelets, red and white blood cells), fever and elevated liver enzymes (possible indicator of disease, disorder or medication problems).

Further review of the patient's physician's orders dated 04/22/11 showed the physician authenticated the admission orders but failed to date and time the authentication.

During an interview on 05/24/11 at 10:15 AM Staff M stated physicians were required to date and time any authentication in a patient medical record.

6. Record review of discharged Patient #10's physician's orders dated 02/01/11 showed staff admitted the patient to Swing bed with diagnosis of pneumonia.

Further review of the patient's physician's orders dated 02/01/11 showed the physician authenticated the admission order but failed to time the authentication.

During an interview on 05/24/11 at 1:13 PM Staff M stated the physician failed to time the authentication as required.

Based on Missouri State Statute review, personnel record review and interview the facility failed to ensure individuals listed on the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) were not employed by the facility. Record review of eleven (Staff A, B, C, F, G, I, L, M, N, P and Q) of twelve personnel record reviewed showed the facility failed to compare the names of staff on a periodic basis against the EDL. The facility census was 8 patients.

Findings included:

1. Review of the Missouri State Statute RSMO 2003 Section 660.315 directed facilities licensed under Chapter 197 (hospitals) complete not only pre-employment EDL checks but also periodic checks of all currently employed staff against the quarterly updated EDL to ensure no current staff had been recently added to the EDL (The quarterly updated EDLs are available on the Missouri Department of Health and Senior Services web site).

2. Record review of Staff A's personnel file showed Staff A had been employed in the facility since approximately 11/01/58 and had not had any verification that he/she was not on the EDL.

3. Record review of Staff B's personnel file showed Staff B had been employed in the facility since 11/16/77 and had not had any verification that he/she was not on the EDL.

4. Record review of Staff C's personnel record showed Staff C had been employed in the facility since 06/11/04 and had not had any verification that he/she was not on the EDL.

5. Record review of Staff Fs personnel record showed Staff F had been employed in the facility since 05/21/96 and had not had any verification that he/she was not on the EDL.

6. Record review of Staff G's personnel record showed Staff G had been employed in the facility since 09/16/68 and had not had any verification that he/she was not on the EDL.

7. Record review of Staff I's personnel record showed Staff I had been employed in the facility since 09/09/88 and had not had any verification that he/she was not on the EDL.

8. Record review of Staff L's personnel record showed Staff L had been employed in the facility since 01/28/98 and had not had any verification that he/she was not on the EDL.

9. Record review of Staff M's personnel record showed Staff M had been employed in the facility since 02/18/85 and had not had any verification that he/she was not on the EDL.

10. Record review of Staff N's personnel record showed Staff N had been employed in the facility since 04/08/74 and had not had any verification that he/she was not on the EDL.

11. Record review of Staff P's personnel record showed Staff P had been employed in the facility since 05/18/98 and had not had any verification that he/she was not on the EDL.

12. Record review of Staff Q's personnel record showed Staff Q had been employed in the facility since 08/01/03 and had not had any verification that he/she was not on the EDL.

13. During an interview on 05/25/11 at 11:07 AM Staff S, the Chief Executive Officer (CEO) stated that the total number of full time and part time staff was approximately two hundred and twenty persons.

During an interview on 05/25/11 at 1:40 PM Staff R, Director of Human Resources (HR) stated that the facility did not have a policy directing HR to check all current staff against the EDL and the facility had never done periodic checks of all employees against the EDL.