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Based on interviews and record reviews, the hospital failed to ensure the medical staff enforced its bylaws as evidenced by preprinted physicians' admission order sheets with options for medications, laboratory specimens, observation levels, Diabetic monitoring, and diet being completed by a Registered Nurse instead of the attending physician for 4 (#2, #4, #9, #10) of 10 (#1-#10) records reviewed for admission orders.

Findings:
Review of the Hospital Medical Staff Rules and Regulations presented as current revealed in part:
Physician Orders:
6.1 All physician orders shall be written or telephone/verbal orders from the attending or consulting physician for any patient(s) admitted to the hospital with regard to any examination, laboratory work, x-rays, EKGs, etc.

Review of the Hospital Policy titled Admission Criteria, Policy 1.5, read in part:
2. All admissions require a written admission order by a psychiatrist with medical staff privileges.

Review of the preprinted document titled "Physician Admit Orders and Problem List" revealed several sections which included the headings: Orders, Consults/Assessments, Medications, Diagnostic tests, and Diabetic. Underneath each heading were multiple choices for orders to be selected by checking a box to the left of the order and some blanks that had to be filled in with a choice. Some of the choices that had to be made under the Orders section were precautions including observation levels, diet, activity level, and smoking privileges. Under the Medication section, 7 choices of PRN (as needed) medications had the option to be ordered including Tylenol, Ibuprofen, Maalox, Milk of Magnesia, Multivitamin, and Dulcolax. Under the Diagnostic Tests section, options included Urinalysis, CMP (Complete Metabolic Panel), Pre-Albumin, Urine Drug Screen, CBC (Complete Blood Count) with differential, TSH (Thyroid Stimulating Hormone), and Therapeutic drug levels. Under the section titled Diabetic, options included a finger stick for BS (Blood Sugar) and the frequency of following blood sugar levels. The section for Diabetic also included a selection for sliding scale insulin and blanks to fill in those ranges and insulin dosages.

Patient #2
Review of the medical record for Patient #2 revealed he had been admitted to the hospital on 2/17/14 at 7:25 p.m. for a diagnosis which included unspecified Psychosis.

Review of the Emergency Department (ED) records for Hospital "B" revealed Patient #2 had been admitted on 2/17/14 at 10:34 a.m. from a group home for being aggressive and destructive. Patient #2's blood glucose level was listed as 183mg/dl (milligrams per deciliter) (Normal values listed as 74-106mg/dl), and he had 3+ glucose (normal value listed as negative) in his urine sample. His active health history had DM (Diabetes Mellitus) listed.

Review of the Physician Admit Orders and Problem List for Patient #2 dated 2/17/14 at 7:25 p.m. revealed the legal status of Patient #2 was a PEC (Physician's Emergency Certificate). His reason for admission was listed as potential danger to self (suicidal), potential danger to others (homicidal), Gravely disabled (psychotic features, severely impaired functions). The diet selected was NAS (no added salt). Under a section titled "Diabetic," an order to finger stick for BS (blood sugar) once on admission was the only choice selected. Further review of the medical record revealed no other orders for blood glucose monitoring or a diabetic diet. The admission orders had been signed by S8RN as a TORB (telephone order read back) x 2 to S4Psychiatrist on 2/17/14 at 7:15 p.m. Further review revealed S4Psychiatrist had not cosigned the order until 2/20/14 at 10:00 a.m.

Review of a document titled Diabetic Flow Sheet for Patient #2 revealed his blood sugar on 2/17/14 at 8:15 p.m. was listed as 266. No further blood glucose recordings were documented in the medical record from 2/17/14 through 2/20/14.

In an interview on 3/5/14 at 8:18 a.m. with S8RN, she said she had written the admission orders for Patient #2. S8RN said she will notify S4Psychiatrist when a patient arrives at the facility and might give a brief history. S8RN said S4Psychiatrist usually orders to continue all home medications, which is what happened for Patient #2. S8RN said she filled out the admission order sheet for patients on admission based on the previous documentation from the transferring hospital. S8RN said she wrote telephone order on the admission orders for Patient #2 and other patients although she did not receive the orders from the physician. S8RN said the nurses selected various orders for diet, labs and level of observation on admission orders based on paperwork from the transferring facility, not from the order of S4Psychiatrist. S8RN said she did not see in the notes from Hospital "B" where Patient #2 was diabetic or had 3+ glucose in his urine. S8RN verified the active problems in the notes from Hospital "B" said Patient #2 had Diabetes Mellitus. S8RN said she never looked at Patient #2 ' s initial blood glucose reading and was never told it was 266 mg/dl or she would have included in the admission orders for Patient #2 to be on ac (before meals) and hs (hour of sleep) blood glucose checks.

In an interview on 3/5/13 at 12:32 p.m. with S4Psychiatrist, he said he was the Medical Director of the Hospital. S4Psychiatrist said he knew Patient #2 was diabetic because he either found it on the record sent with the patient from Hospital "B" or from the previous admission history at this facility. S4Psychiatrist said for admissions of patients, the nurses would call him and after giving him a brief history, he usually just told them to continue the patient's home medications. S4Psychiatrist said sometimes the nurses would go over the medication list with him, but most often they did not. S4Psychiatrist said the nurses filled out the physician's admission order sheet by selecting labs, medications, diets, etc., based on information from the transferring facility. S4Psychiatrist agreed he did not do the physician admission orders on Patient #2, and S8RN charting the physician admission orders as having been a telephone order from him was inaccurate. S4Psychiatrist verified the admission orders for Patient #2 had ordered a no added sodium diet instead of diabetic, and there was only an admission blood glucose ordered. S4Psychiatrist said he knew the nurses were signing the physician admission orders as telephone orders from him, but they truly were not his orders.

Patient #4
Review of the medical record for Patient #4 revealed he had been admitted to the hospital on 2/13/14 as a formal voluntary admission for diagnoses which included Schizoaffective disorder, chronic in acute exacerbation.

Review of the Inquiry Call Form from the transferring facility, dated 2/13/14 at 12:30 p.m. revealed the following, in part:
History of Psychiatric Treatment/Diagnosis: Multiple hospitalizations, Schizoaffective Disorder, Bipolar type and Poly-substance abuse.
Presenting problem: Depression
Medical History: DM II (Diabetes Mellitus, Type II), HTN ( Hypertension)

Review of the Physician Admit Orders and Problem List for Patient #4 dated 2/13/14 at 5:00 p.m. revealed the legal status of Patient #4 was a FVA (formal voluntary admission). His reason for admission was listed as gravely disabled (psychotic features, severely impaired functions). The diet selected was NCS (no concentrated sweets) and NAS (no added salt). Under a section entitled Medications the following PRN ( as needed) medications were checked off: Tylenol, Ibuprofen, Maalox, MOM (milk of magnesia), Multivitamin, Dulcolax (by mouth), Dulcolax suppository; Under a section titled: Diagnostic Tests: EKG on all patients at admission, urinalysis, CMP (complete metabolic profile), CBC (complete blood count) with diff, (differential) checked off; Under a section titled "Diabetic," an order to finger stick for BS (blood sugar) once on admission and daily AC (before meals) & HS ( hour of sleep) were selected. The admission orders had been signed by S19LPN on 2/13/14 at 6:32 p.m. Further review revealed S4Psychiatrist had not cosigned the order until 2/14/14 at 10:00 a.m.

Patient #9
Review of Patient #9's medical record revealed an admission date of 2/1/14 with Diagnoses including the following, in part: Depression, Suicidal Thoughts, Chronic Pain, Gout, CHF (Congestive Heart Failure), Anemia, and GERD (Gastroesophageal Reflux). Further review revealed Patient #9 was admitted for Depression and Suicidal Thoughts.

Review of the Physician Admit Orders and Problem List for Patient #9, dated 1/31/14 at 12:40 a.m. revealed the legal status of Patient #4 was a PEC (Physician Emergency Certificate). Patient #9's allergies were listed as ASA (Aspirin), Tylenol, Ibuprofen. His reason for admission was listed as potential danger to self (suicidal). The diet selected was NAS (no added salt). Under a section entitled Medications the following PRN (as needed) medications were checked off: Tylenol, Ibuprofen, Maalox, MOM (milk of magnesia), Multivitamin, Dulcolax (by mouth), Dulcolax suppository; Under a section titled: Diagnostic Tests: RPR (rapid plasma reagin) with reflex, Pre-albumin, Therapeutic drug level: Depakote were selected; Under a section titled "Diabetic," an order to finger stick for BS (blood sugar) once on admission was selected. The admission orders had been signed as TORB (telephone order read back) x 2 per S7RN on 1/31/14 at 12:40 a.m. Further review revealed S4Psychiatrist had not cosigned the order until 2/1/14 at 11:00 a.m.

Review of Patient 9's Admit/Discharge Medication Reconciliation and Order sheet, dated 2/1/14, revealed the following: Allergies: ASA, Tylenol, and Ibuprofen

Review of Patient #9's printed MAR (Medication Administration Record) revealed the following medications: Tylenol and Ibuprofen.

In an interview on 3/5/14 at 12:21 p.m. with S7RN, she explained she had written the orders for the diabetics on the physician admit order form and had filled out the schedule for obtaining CBGs (capillary blood glucose).


In an interview on 3/5/14 at 12:44 p.m. with S4Psychiatrist, he said the Physician Admit Orders & Problem List was not a verbal/telephone order given by him on admission.


In an interview on 3/5/14 at 3:11 p.m. with S7RN, she explained she had been told, since her first day on the job, to complete the physician admit order sheet and to sign it as "telephone order read back and verified." S7RN said she just checked the boxes on the admit orders because they were routine standing orders. S7RN also said the PRN medications were selected because those medications could have been given to anybody routinely. S7RN reviewed the patient's Admit/Discharge Medication Reconciliation and Order sheet, that she had signed on 2/1/14 and confirmed the patient's allergies to ASA (aspirin), Tylenol, and Ibuprofen were listed under allergies. S7RN also confirmed the patient's allergy information was in his admit packet. Upon further review of Patient #9's Physician Admit Orders & Problems List, S7RN also confirmed she had written the patient's allergies to ASA, Tylenol, and Ibuprofen on the form and had then selected both Tylenol and Ibuprofen on the Medications section of the Physician Admit orders. S7RN also said the PRN standing order medications could have been given to Patient #9 prior to receipt of the printed MARs (medication administration record) coming back from pharmacy. She said since the medications were considered routine PRN they would have been hand written on a paper MAR to have been used until the printed MARs came back from pharmacy. S7RN explained receipt of the printed MARs from pharmacy indicated 1st dose review had been performed on the medications by the Pharmacist for potential complications such as medication allergies.

Patient #10

Review of the medical record for Patient #10 revealed he had been admitted to the hospital on 2/17/14 at 2:00 p.m. as a CEC (Coroner's Emergency Certificate) for diagnoses which included Schizoaffective disorder and Overdose of medications.

Review of the Inquiry Call Form from the transferring facility, dated 2/17/14 at 9:45 a.m. revealed the following, in part:
History of Psychiatric Treatment/Diagnosis: Schizoaffective Disorder
Presenting problem: Overdose of medications
Medical History: DM, HTN (Hypertension) and Epilepsy

Review of the Physician Admit Orders and Problem List for Patient #10 dated 2/17/14 timed 2:00 p.m., revealed the legal status of Patient #10 was a CEC. His reason for admission was listed as potential danger to self (suicidal), potential danger to others (homicidal) and gravely disabled (psychotic features, severely impaired functions). The diet selected was regular. Under a section entitled Medications the following PRN (as needed) medications were checked off: Tylenol, Ibuprofen, Maalox, MOM (milk of magnesia), Multivitamin, Dulcolax (by mouth), Dulcolax suppository; Under a section titled: Diagnostic Tests: Urinalysis, CMP (complete metabolic profile), CBC (complete blood count) with diff (differential), RPR (rapid plasma reagin) with reflex, and Pre-Albumin checked off; Under a section titled "Diabetic," an order to finger stick for BS (blood sugar) once on admission was selected. The admission orders had been signed by S20RN on 2/17/14. Further review revealed S4Psychiatrist had not cosigned the order until 2/18/14 at 3:00 p.m.

In an interview on 3/5/14 at 1:35 p.m. with S2DON verified he was aware the nursing staff was actually selecting orders on the admission order sheet instead of the physician. S2DON also verified the preprinted admission order sheet was not a set of standing orders because choices had to be made without policies or protocols. S2DON verified the practice of ordering patient labs, diets and medications was out of the scope of practice for a Registered Nurse and should not be allowed at the facility.

In an interview on 3/5/14 at 9:16 a.m. with S7RN said during admissions, the nurses would look at the intake packet from the previous facility and select the physician admission orders including the diet, labs, and blood glucose frequency. S7RN also verified it was not within her scope of practice to order medications, diets, and labs on patients. S7RN said she was trained that way and that is how all of the nurses fill in the physician admission order sheets at the hospital.

In an interview on 3/5/14 at 8:39 a.m. with S10RN, she said on admission the medications were usually obtained from a medication list from the previous facility. S10RN said the nurses complete the admission order sheet based on their paperwork from the other facility, not from orders from the physician. S10RN said she would call S4Psychiatrist to let him know a patient was being admitted, and he would usually say to admit as routine and continue home medications. S10RN said the Hospital did not have a protocol for what a routine admission was. S10RN said diet and labs were ordered by the nurses based on their knowledge.

In an interview on 3/5/14 at 7:22 a.m. with S3RN, she said the nurses will fill in the physician admission order sheets and the medication reconciliation sheets on admission based on the standard stuff they do and the information from the previous facility. S3RN said they call the physician and notify him that the patient is at the Hospital, but do not go over all of the orders they select on the preprinted physician order sheet with him even though they sign that the orders were telephone orders from the physician. S3RN said the nurses choose which labs and PRN (as needed) medications are selected on the order sheet based on what they usually do at the Hospital, not what a physician orders.

Based on record review and staff interviews, the hospital failed to meet the requirements of the Conditions of Participation for Nursing Services as evidenced by:

1) the RN failed to accurately assess and identify a newly admitted patient as diabetic during the admission process for 2 (#2, #9) of 10 (#1-#10) patients reviewed. This deficient practice is evidenced by Patient #2 (Diabetic) not receiving a blood glucose level beyond admission on 2/17/14 resulting in a transfer to the Emergency Department on 2/20/14 with a blood glucose of 1370mg/dl. (See findings in A-0395)

2) the RN failing to develop and implement a system for obtaining admission orders from a licensed practitioner as evidenced by a RN writing admission orders based on paperwork from transferring facilities for 4 ( #2, #4, #9, #10) of 10 (#1-#10) patients sampled. (See findings in A-0395)

3) the RN failed to follow the hospital approved policy/procedure relative to notifying the physician of a capillary blood glucose level that was above 250 on a patient who was not receiving sliding scale insulin for 3 (#2, #4, #8) of 10 (#1-#10) patients reviewed for blood glucose monitoring.. (See findings in A-0395)

4) The hospital failed to ensure the nursing staff developed and kept current a comprehensive nursing care plan for 4 (#2, #4 #,9, #10 ) of 4 (#2,#4, #9,10) patients reviewed for care plans. (See findings in A-0396)

5) The hospital failing to have orders for drugs and biologicals documented and signed by a practitioner who is authorized to write orders in accordance with State law and hospital policy. This deficient practice is evidenced by having preprinted admission order sheets with options for ordering medications being completed by a Registered Nurse instead of the attending physician for 1 (#9) of 1 (#9) records reviewed for medication orders. (See findings in A-0406)

Based on interview and record review the hospital failed to ensure that the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:

1) the RN failed to accurately assess and identify a newly admitted patient as diabetic during the admission process for 2 (#2, #9) of 10 (#1-#10) patients reviewed. This deficient practice is evidenced by Patient #2 (Diabetic) not receiving a blood glucose level beyond admission on 2/17/14 resulting in a transfer to the Emergency Department on 2/20/14 with a blood glucose of 1370mg/dl.

2) the RN failed to develop and implement a system for obtaining admission orders from a licensed practitioner as evidenced by a RN writing admission orders based on paperwork from transferring facilities for 4 ( #2, #4, #9, #10) of 10 (#1-#10) patients sampled.

3) the RN failed to follow the hospital approved policy/procedure relative to notifying the physician of a capillary blood glucose level that was above 250 on a patient who was not receiving sliding scale insulin for 3 (#2, #4, #8) of 10 (#1-#10) patients reviewed for blood glucose monitoring.

4) the RN failed to ensure an admission capillary blood glucose level was performed as ordered for 1 (#9) of 1 (#9) patients reviewed.

5) the RN failed to ensure a system was in place to ensure vital signs collected by MHTs (mental health technicians) were reviewed by a RN for 1 (#2) of 1 (#2) out of 10 (#1-#10) patients reviewed.

Findings:

1) The RN failed to accurately assess and identify a newly admitted patient as diabetic during the admission process for 2 (#2, #9) of 10 (#1-#10) patients reviewed. This deficient practice is evidenced by Patient #2 (Diabetic) not receiving a blood glucose level beyond admission on 2/17/14 resulting in a transfer to the Emergency Department on 2/20/14 with a blood glucose of 1370mg/dl.

Patient #2
Review of Patient #2's medical record revealed an admission date of 2/17/14 and Diagnoses including the following, in part: Unspecified Psychosis, Hypertension, Cerebral Palsy, Mental Retardation, and Hypothyroidism. Further review revealed Patient #2 had a history of Diabetes Mellitus (documented on the patient's Psychiatric Evaluation).

Review of the Emergency Department (ED) records for Hospital "B" revealed Patient #2 had been admitted on 2/17/14 at 10:34 a.m. from a group home for being aggressive and destructive. Patient #2's blood glucose level was listed as 183mg/dl (milligrams per deciliter) (normal values listed as 74-106mg/dl) and he had 3+ glucose (normal value listed as negative) in his urine sample. His active health history had DM (Diabetes Mellitus) listed.

Review of the Seaside Health System hospital admission orders for Patient #2 dated 2/17/14 at 7:25 p.m. revealed the diet selected was NAS (No added salt). Under a section titled "Diabetic" an order to finger stick for BS (blood sugar) only on admission was the only choice selected. Further review of the medical record revealed no other order for blood glucose monitoring or a diabetic diet was located in the medical record.

Review of a document titled Diabetic Flow Sheet for Patient #2 revealed his blood sugar on 2/17/14 at 8:15 p.m. was listed as 266. Further review revealed no additional blood glucose recordings were obtained and documented in the medical record during Patient #2's hospitalization at Seaside Health System from 2/17/14 through 2/20/14.

Review of Patient #2 ' s physicians orders revealed no orders for the administration of insulin and/or medications for the treatment of hyperglycemia even though the psychiatric evaluation indicated the patient had a history of Diabetes and the patients blood glucose level was assessed to be 266 at the time of admission.

Review of the Intake and Output Record for Patient #2 dated 2/19/14 revealed he had eaten 100% of breakfast, lunch and dinner. Review of the Intake and Output Record for Patient #2 dated 2/20/14 revealed the following documentation:
Breakfast: 30% (eaten) Note: Couldn ' t swallow. Morning Snack: Didn ' t eat/swallow Lunch: 0% (eaten), sleep Dinner: 0 % (eaten), sleep
Review of the vital sign record dated for Patient #2 revealed the following blood pressures:
2/17/14 at 8:30 p.m. -126/78; 2/18/14 at 6:00 a.m. -148/88; 2/19/14 at 6:00 a.m. -122/76; 2/19/14 at 5:00 p.m. -116/74; 2/20/14 at 6:00 a.m. -120/76; 2/20/14 at 5:00 p.m. -76/50
Further review of the medical record revealed no repeat of the 2/20/14 at 5:00 p.m. blood pressure or notification of the physician that the blood pressure had dropped.
Review of the nursing flow sheets dated 2/17/14 through 2/20/14 revealed no documentation of physician notification of Patient #2's decreasing activity levels, the initial blood glucose of 266 or the patient's blood pressure on 2/20/14 of 76/50. On 2/19/14 at 7:30 a.m., S7RN documented: " Patient is extremely tired and cannot keep his head up. Will continue to monitor per doctors plan of care."

Review of the nursing note for Patient #2 dated 2/20/14 at 9:30 p.m. revealed an entry by S12RN which stated: " Pt. (patient) did not show up for group. Went to room to assess pt. Pt. breathing through his mouth at rate of 36 bpm (breaths per minute). Skin pink, warm, and dry. Unable to assess radial pulse. No v/s (vital signs) listed this shift. Attempted to assess BP (blood pressure) manual cuff x 3. Unable to assess. Sat (oxygen saturation) 67%. HR (heart rate) = 43. Notified CN (charge nurse) of patient's condition. Orders noted. Paramedics here to transport at 10:00 p.m. Report called to nurse at Hospital "B"."

Review of the documentation on dated 2/20/14 from Ambulance Company "A" revealed they were called by the hospital at 9:58 p.m. because Patient #2 was nonresponsive. His CBG (capillary blood glucose) reading was "Hi" which was indicative of being over 500 mg/dl (milligrams/deciliter). The primary Impression was listed as Unconscious and the secondary impression was listed as Diabetic Hyperglycemia (increased blood glucose).

Review of the medical records from Hospital "B" for Patient #2 revealed he had been transferred there from the facility on 2/20/14 at 10:31 p.m. Review of the Emergency Department (ED) notes revealed the following: 44 y.o. (year old) male with previous medical history of MR (mental Retardation), Cerebral Palsy, DM (Diabetes Mellitus) Type I presents to the ED via Ambulance Company "A" with altered mental status and a high reading on CBG (capillary blood glucose). Unknown exact onset. Ambulance Company "A" says the nursing facility pt resides gave limited history and thinks he may have been decreased level of alertness for half of the day. Pt is non verbal, cannot follow commands, grunts and withdraws from painful stimuli. Review of the labs from Hospital "B" for Patient #2 on 2/20/14 revealed he had a blood glucose level of 1370 mg/dl (normal listed 74-106mg/dl)

In an interview on 3/5/14 at 8:18 a.m. with S8RN, she said she had written the admission orders for Patient #2. S8RN said she filled out the Physician's order sheet on admission based on the previous documentation from the other hospital. S8RN said she did not see in the notes from Hospital " B " where the patient was diabetic or had 3+ glucose in his urine. S8RN verified the active problems in the notes from Hospital "B" said Patient #2 had Diabetes Mellitus. S8RN said she never looked at Patient #2's initial blood glucose reading and was never told it was 266 mg/dl or she would have included in the admission orders for Patient #2 to be on ac and hs blood glucose checks.

In an interview on 3/3/14 at 4:23 p.m. with S2DON, he verified the nursing staff should have rechecked the initial blood glucose level for Patient #2 on 2/17/14 and notified the physician when it was 266 mg/dl. S2DON said he would have expected the staff to be concerned that the urine had a +3 glucose from the labs taken at Hospital "B" before admission on 2/17/14. S2DON also verified Hospital "B" listed the patient in their notes as having Diabetes Mellitus, so the staff at the Hospital should have known during the admission review of the transferring facility records. S2DON said Patient #2 was a previous patient at this hospital, so if the previous admission record had been reviewed, the staff would have known he had diabetes. S2DON said all patients who were diabetic were placed on sliding scale insulin.


Patient#9
Review of Patient #9's medical record revealed an admission date of 2/1/14 and Diagnoses including the following, in part: Depression, Suicidal Thoughts, Chronic Pain, Gout, CHF (Congestive Heart Failure), Anemia, and GERD (Gastroesophageal Reflux). Further review revealed Patient #9 was admitted for Depression and Suicidal Thoughts.

Review of Patient #9 ' s PEC (Physician Emergency Certificate), dated 2/1/14, revealed the following, in part:
Physical findings (medical history, current medications, etcetera):
Hx. (history): DM (diabetes mellitus).

Review of Patient #9 ' s Physician Admit Orders & Problems list, dated 2/1/14, revealed the following, in part:
Diagnosis: Major Depressive Disorder
Fingerstick BS ( blood sugar), on admit: checked

Review of Patient#9 ' s Physician Medical Notes, dated 2/4/14, revealed the following, in part:
57 year old here for psychiatric illness. History of uncontrolled blood sugars on last admit to this hospital.
Assessment and Plan:
Dx. (diagnoses): 1) HTN (Hypertension) 2) CHF 3) DM ? 4) Gout
Plan: 1) Accucheck (capillary blood glucose) AC (before meals) and HS ( hour of sleep), 2) Sliding scale insulin per protocol

Review of Patient#9's diabetic flowsheet revealed the first fingerstick blood glucose was performed on 2/4/14 at 16:30 p.m., result: 143.

In an interview on 3/5/14 at 12:21 p.m. with S7RN, she explained she had written the orders for the diabetics on the admit order form and had filled out the schedule for obtaining CBGs. S7RN said it was policy to obtain an admit blood glucose (CBG) on all new admissions. S7RN said the LPNs would have obtained the scheduled CBGs and should have documented them on the graphic (diabetic flowsheet). S7RN explained the initial CBG should have been documented on the diabetic flowsheet, on the date of admission, and it should have continued forward from that date during the patient's hospitalization if the patient had scheduled CBGs. She reviewed Patient#9's diabetic flowsheet and confirmed there was no documentation of an admission CBG. She also confirmed the patient's CBGs weren't begun until 2/4/14 at 16:30 p.m.

In an interview on 3/5/14 at 1:46 p.m. with S2DON he explained patient problems should have been identified upon admission based upon information contained in their admit packets such as PEC (physician emergency certificates), labs, behavior and past medical history. He further explained until recently (Monday-3/4/14), prior admission patient records had not been readily available for review at night and on the weekends. S2DON said all staff had access to the entire patient admission packet. S2DON said communication between staff members was not as complete as it should have been. S2DON reviewed Patient #9 ' s medical record and confirmed the patient had a past history of diabetes mellitus documented on his PEC. Upon further review of Patient #9's medical record S2DON also confirmed documentation, in the Physician Medical Notes (dated 2/4/14), of the patient ' s history of uncontrolled blood sugars on last admit to this hospital.

2) The RN failed to develop and implement a system for obtaining admission orders from a licensed practitioner as evidenced by a RN writing admission orders based on paperwork from transferring hospitals for 4 ( #2, #4, #9, #10) of 10 (#1-#10) patients sampled.

Review of the Hospital Policy titled Admission Criteria, Policy 1.5, read in part:
2. All admissions require a written admission order by a psychiatrist with medical staff privileges.

Review of the preprinted document titled " Physician Admit Orders and Problem List " revealed several sections which included the headings: Orders, Consults/Assessments, Medications, Diagnostic tests, and Diabetic. Underneath each heading were multiple choices for orders to be selected by checking a box to the left of the order and some blanks that had to be filled in with a choice. Some of the choices that had to be made under the Orders section were precautions (including observation levels), diet, activity level and smoking privileges. Under the Medication section, 7 choices of PRN (as needed) medications had the option to be ordered including Tylenol, Ibuprofen, Maalox, Milk of Magnesia, Multivitamin, and Dulcolax. Under the Diagnostic Tests section, options included Urinalysis, CMP (complete Metabolic Panel), Pre-Albumin, Urine Drug Screen, CBC (Complete Blood Count) with differential, TSH (Thyroid Stimulating Hormone), and Therapeutic drug levels. Under the section titled Diabetic, options included a finger stick for BS (Blood Sugar) and the frequency of following blood sugar levels. The section for Diabetic also included a selection for sliding scale insulin and blanks to fill in those ranges and insulin dosages.

Patient #2
Review of the medical record for Patient #2 revealed he had been admitted to the hospital on 2/17/14 at 7:25 p.m. for diagnosis which included unspecified Psychosis.

Review of the Emergency Department (ED) records for Hospital "B" revealed Patient #2 had been admitted on 2/17/14 at 10:34 a.m. from a group home for being aggressive and destructive. Patient #2 ' s blood glucose level was listed as 183mg/dl (milligrams per deciliter) (Reference values listed as 74-106mg/dl) and he had 3+ glucose (reference value listed as negative) in his urine sample. His active health history had DM (Diabetes Mellitus) listed.

Review of the Physician Admit Orders and Problem List for Patient #2 dated 2/17/14 at 7:25 p.m. revealed the diet selected was NAS (no added salt). Under a section titled "Diabetic" an order to finger stick for BS (blood sugar) once on admission was the only choice selected. Further review of the medical record revealed no other order for blood glucose monitoring or a diabetic diet. The admission orders had been signed by S8RN as a TORB (Telephone Order Read Back) x 2 to S4Psychiatrist on 2/17/14 at 7:15 p.m. Further review revealed S4Psychiatrist had not cosigned the order until 2/20/14 at 10:00 a.m.

Review of a document titled Diabetic Flow Sheet for Patient #2 revealed his blood sugar on 2/17/14 at 8:15 p.m. was listed as 266. No further blood glucose recordings were documented in the medical record from 2/17/14 through 2/20/14.

In an interview on 3/5/14 at 8:18 a.m. with S8RN, she said she had written the admission orders for Patient #2. S8RN said she will notify S4Psychiatrist when a patient arrives at the facility and might give a brief history. S8RN said S4Psychiatrist usually orders to continue all home medications, which is what happened for Patient #2. S8RN said she filled out the admission order sheet for patients on admission based on the previous documentation from the transferring hospital. S8RN said she wrote telephone order on the admission orders for Patient #2 and other patients although she did not receive the orders from the physician. S8RN said the nurses selected various orders for diet, labs and level of observation on admission orders based on paperwork from the transferring facility, not from the order of S4Psychiatrist. S8RN said she did not see in the notes from Hospital "B" where Patient #2 was diabetic or had 3+ glucose in his urine. S8RN verified the active problems in the notes from Hospital "B" said Patient #2 had Diabetes Mellitus. S8RN said she never looked at Patient #2 ' s initial blood glucose reading and was never told it was 266 mg/dl or she would have included in the admission orders for Patient #2 to be on ac (before meals) and hs (hour of sleep) blood glucose checks.

In an interview on 3/5/13 at 12:32 p.m. with S4Psychiatrist, he said he was the Medical Director of the facility. S4Psychiatrist said he knew Patient #2 was diabetic because he either found it on the record sent with the patient from Hospital "B" or from the previous admission history at this facility. S4Psychiatrist said for admissions of patients, the nurses would call him and after giving him a brief history of the patient, he usually just told them to continue the patient's home medications. S4Psychiatrist said sometimes the nurses would go over the medication list with him, but most often they did not. S4Psychiatrist said the nurses filled out the admission order sheet by selecting labs, medications, diets, etc. based on information from the transferring facility. S4Psychiatrist agreed he did not do the admission orders on Patient #2 and S8RN charting the order had been a telephone order from him was inaccurate. S4Psychiatrist verified the admission orders for Patient #2 had ordered a no added salt diet instead of diabetic and there was only an admission blood glucose ordered. S4Psychiatrist said he knew the nurses were signing the admission orders as telephone orders from him, but they truly were not his orders.

Patient #4
Review of the medical record for Patient #4 revealed he had been admitted to the hospital on 2/13/14 at 1:30 p.m. as a formal voluntary admission for diagnosis which included Schizoaffective disorder, chronic in acute exacerbation.

Review of the Inquiry Call Form from transferring facility, dated 2/13/14 at 12:30 p.m. revealed the following, in part:
History of Psychiatric Treatment/Diagnosis: Multiple hospitalizations, Schizoaffective Disorder, Bipolar type and poly-substance abuse.
Presenting problem: Depression
Medical History: DMII (Diabetes Mellitus, Type II), HTN( Hypertension)

Review of the Physician Admit Orders and Problem List for Patient #4 dated 2/13/14 at 5:00 p.m. revealed the legal status of Patient #4 was a FVA (formal voluntary admission). His reason for admission was listed as gravely disabled (psychotic features, severely impaired functions). The diet selected was NCS (no concentrated sweets) and NAS (no added salt). Under a section entitled Medications the following PRN ( as needed) medications were checked off: Tylenol, Ibuprofen, Maalox, MOM (milk of magnesia), Multivitamin, Dulcolax (by mouth), Dulcolax suppository; Under a section titled: Diagnostic Tests: EKG on all patients at admission, urinalysis, CMP (complete metabolic profile) , CBC (complete blood count) with diff,( differential) checked off; Under a section titled " Diabetic " , an order to finger stick for BS (blood sugar) once on admission and daily AC ( before meals) & HS ( hour of sleep) were selected. The admission orders had been signed by S19LPN on 2/13/14 at 6:32 p.m. with no indication that a physician had been consulted. Further review revealed S4Psychiatrist had not cosigned the order until 2/14/14 at 10:00 a.m.

Patient #9
Review of Patient #9's medical record revealed an admission date of 2/1/14 with Diagnoses including the following, in part: Depression, Suicidal Thoughts, Chronic Pain, Gout, CHF (Congestive Heart Failure), Anemia, and GERD (Gastroesophageal Reflux). Further review revealed Patient #9 was admitted for Depression and Suicidal Thoughts.

Review of the Physician Admit Orders and Problem List for Patient #9, dated 1/31/14 at 12:40 a.m. revealed the legal status of Patient #4 was a PEC (Physician Emergency Certificate). Patient #9 ' s allergies were listed as ASA (Aspirin), Tylenol, and Ibuprofen. His reason for admission was listed as potential danger to self (suicidal). The diet selected was NAS (no added salt). Under a section entitled Medications the following PRN ( as needed) medications were checked off: Tylenol, Ibuprofen, Maalox, MOM (milk of magnesia), Multivitamin, Dulcolax (by mouth), Dulcolax suppository; Under a section titled: Diagnostic Tests: RPR (rapid plasma reagin) with reflex (test for syphilis), Pre-albumin, Therapeutic drug level: Depakote were selected; Under a section titled " Diabetic " , an order to finger stick for BS (blood sugar) once on admission was selected. The admission orders had been signed as TORB x 2 per S7RN on 1/31/14 at 12:40 a.m. Further review revealed S4Psychiatrist had not cosigned the order until 2/1/14 at 11:00 a.m.

Review of Patient 9's Admit/Discharge Medication Reconciliation and Order sheet, dated 2/1/14, revealed the following: Allergies: ASA, Tylenol, and Ibuprofen

Review of Patient #9's printed MAR (medication administration record) revealed the following medications: Tylenol and Ibuprofen.

In an interview on 3/5/14 at 12:21 p.m. with S7RN, she explained she had written the orders for the diabetics on the admit order form and had filled out the schedule for obtaining CBGs.


In an interview on 3/5/14 at 12:44 p.m. with S4Psychiatrist, he said the Physician Admit Orders & Problem List for Patient #9 was not a verbal/telephone order given by him on admission.

In an interview on 3/5/14 at 3:11 p.m., with S7RN she explained she had been told, since her first day on the job, to complete the admit order sheet and to sign it as telephone order read back and verified. She said she just checked the boxes on the admit orders because they were routine standing orders. S7RN also said the PRN medications were selected because those medications could have been given to anybody routinely. S7RN reviewed the patient's Admit/Discharge Medication Reconciliation and Order sheet, that she had signed on 2/1/14 and confirmed the patients allergies to ASA, Tylenol, and Ibuprofen were listed under allergies. She also confirmed the patient ' s allergy information was in his admit packet. Upon further review of Patient #9 ' s Physician Admit Orders & Problems List she also confirmed she had written the patient ' s allergies to ASA, Tylenol, and Ibuprofen on the form and had then selected both Tylenol and Ibuprofen on the Medications section of the Physician Admit orders. S7RN also said the PRN standing order medications could have been given prior to receipt of the printed MARs (medication administration record) coming back from pharmacy. She said since the medications were considered routine PRN they would have been hand written on a paper MAR to have been used until the printed MARs came back from pharmacy. S7RN explained receipt of the printed MARs from pharmacy indicated 1st dose review had been performed on the medications.

Patient #10

Review of the medical record for Patient #10 revealed he had been admitted to the hospital on 2/17/14 at 2:00 p.m. as a CEC (coroner ' s emergency certificate) for diagnoses which included Schizoaffective disorder and Overdose of medications.

Review of the Inquiry Call Form from transferring facility, dated 2/17/14 at 9:45 a.m. revealed the following, in part:
History of Psychiatric Treatment/Diagnosis: Schizoaffective Disorder
Presenting problem: Overdose of medications
Medical History: DM, HTN (Hypertension) and Epilepsy

Review of the Physician Admit Orders and Problem List for Patient #10 dated 2/17/14, at 2:00 p.m., revealed the legal status of Patient #10 was CEC. His reason for admission was listed as potential danger to self (suicidal), potential danger to others ( homicidal) and gravely disabled (psychotic features, severely impaired functions). The diet selected was regular. Under a section entitled Medications the following PRN ( as needed) medications were checked off: Tylenol, Ibuprofen, Maalox, MOM (milk of magnesia), Multivitamin, Dulcolax (by mouth), Dulcolax suppository; Under a section titled: Diagnostic Tests: Urinalysis, CMP (complete metabolic profile) , CBC (complete blood count) with diff (differential), RPR with reflex, and Pre-Albumin checked off; Under a section titled " Diabetic " , an order to finger stick for BS (blood sugar) once on admission was selected. The admission orders had been signed by S20RN on 2/17/14 with no indication the physician had been consulted. Further review revealed S4Psychiatrist had not cosigned the order until 2/18/14 at 3:00 p.m.

In an interview on 3/5/14 at 1:35 p.m. with S2DON verified he was aware the nursing staff was actually selecting orders on the admission order sheet instead of the physician. S2DON also verified the preprinted admission order sheet was not a set of standing orders because choices had to be made without policies or protocols. S2DON verified the practice of ordering patient labs, diets and medications was out of the scope of practice for a Registered Nurse and should not be allowed at the facility.

In an interview on 3/5/14 at 9:16 a.m. with S7RN said during admissions, the nurses would look at the intake packet from the previous facility and select the admission orders including the diet, labs, and blood glucose frequency. S7RN also verified it was not within her scope of practice to order medications, diets and labs on patients. S7RN said she was trained that way and that is how all of the nurses fill in the admission sheets at the hospital.

In an interview on 3/5/14 at 8:39 a.m. with S10RN, she said on admission the medications were usually obtained from a medication list from the previous facility. S10RN said the nurses completed the admission order sheets based on their paperwork from the other facility, not from orders from the physician. S10RN said she would call S4Psychiatrist to let him know a patient was being admitted and he would usually say to admit as routine and continue home medications. S10RN said the facility did not have a protocol for what a routine admission was. S10RN said diet and labs were ordered by the nurses based on their knowledge.

In an interview on 3/5/14 at 7:22 a.m. with S3RN, said the nurses will fill in the admission sheets and the medication reconciliation sheets for patients on admission based on the standard stuff they usually do at the hospital and the information given to them by the previous facility. S3RN said they call the physician and notify him that the patient is at the facility, but do not go over all of the orders they select on the preprinted sheet with him even though they sign that the orders were telephone orders from the physician. S3RN said the nurses choose which labs and PRN (as needed) medications are selected on the order sheet based on what they usually do at the facility, not what a physician orders.

3) The RN failed to follow the hospital approved policy/procedure relative to notifying the physician of a capillary blood glucose level that was above 250 on patient who was not receiving sliding scale insulin for 2 (#2, #4 ) of 10 (#1-#10) patients reviewed for blood glucose monitoring.

Review of the hospital policy, entitled True Track Blood Glucose Monitoring System Procedure revealed the following, in part:
Section: Care of Patient
Testing: 5. Record the test results. Glucose levels below 50 or above 250 mg/dl (milligrams/deciliter) may indicate a potentially serious medical condition. Recheck the level with a second machine before notifying the physician. The physician should be notified immediately.

Patient #2
Review of the medical record face sheet for Patient #2 revealed he had been admitted to the Hospital on 2/17/14 at 7:25 p.m. from Hospital " B " with the primary diagnosis of Unspecified Psychosis.

Review of a document titled Diabetic Flow Sheet dated 2/17/14 at 8:15 a.m. for Patient #2 revealed his blood sugar on admission was listed as 266. Further review of the medical record revealed no other blood glucose recordings were documented in the medical record.

In an interview on 3/5/14 at 8:39 a.m. with S10RN, she said she had performed the initial blood glucose of 266 on Patient #2. S10RN said since there was no sliding scale coverage on Patient #2 she should have called the physician. S10RN said she was not aware of the facility policy for calling the physician for glucose levels over 250. S10RN said she got preoccupied with other patients and somewhere she dropped the ball.

Patient #4
Review of Patient#4 ' s medical record revealed an admission date of 2/13/14 (formal voluntary admission) and diagnoses including the following: Depression, Psychosis, Hearing Voices, Hypertension, Diabetes Mellitus-Type II, Hyperlipidemia and frequent infections.

Review of Patient #4 ' s Physician Admit Orders & Problem list, dated 2/13/14, revealed the following orders:
Diabetic: Finger stick BS (blood sugar): On admit: checked; Daily AC (before meals) and HS (hour of sleep): checked;
Call MD if blood sugar is <___or ___> : blank
Regular insulin per subcutaneous injection per sliding scale: blank

Review of Patient #4 ' s care plan for diabetes revealed the following:
Short term Goal: Patient blood sugars will be within normal range by 2/16/14
Approaches: nursing will monitor and record blood sugars as prescribed and PRN (as needed);
Monitor labs as appropriate;
Nursing will administer medications as prescribed, observe for effectiveness.

Review Patient #4 ' s Medication Administration Record revealed the following:
Novolin (Insulin) 70/30- 10 units SQ (subcutaneous) Q (every) morning- breakfast;
Novolin 70/30- 20 units SQ Q evening- Dinner,
Metformin 1000 mg (milligrams) by mouth twice a day

Review of the Diabetic Flowsheet (documenting capillary blood sugar readings) revealed the following, in part:
Note: Use comment section to document physician notification or additional pertinent information.

2/14/14, 11:30 a.m.: 273: coverage: line drawn through space; comments: blank;
3/1/14, 11:30 a.m.: 364: coverage: blank; comments: blank

Review of Patient #4 ' s nurses daily shift assessment notes for 2/14/14 and 3/1/14 revealed no documentation of the patient ' s elevated capillary blood glucose (CBG) levels. Further review revealed no notification of the patient ' s MD of the elevated CBG levels.

In an interview on 3/3/14 at 4:23 pm with Patient#4 ' s nurse, S18RN, she was asked what CBG range was used for notification of the MD of out of range CBG levels. She said the MD would be notified of a blood glucose which would be considered out of range on the sliding scale orders. She reviewed Patient#4 ' s orders and confirmed he was not on sliding scale insulin. She was then asked what was considered a reportable CBG for a patient not on sliding scale insulin sliding scale and she replied below 80 or above 120 consistently. S18RN reviewed Patient #4 ' s chart and confirmed no documentation of notification of the MD of the CBG levels on 2/14/14: CBG: 273 and on 3/1/14: CBG: 364. She also confirmed Patient #4 had received no coverage for the elevated CBGs. She said the RNs generally do not give medications, that is the LPN's (licensed practical nurse) duty. She explained elevated CBG results should have been communicated to her by the LPN. S18RN said there had been a breakdown of communication between herself and the LPN. She also explained there were no safeguards in place for documenting notification. She verified documentation of MD notification should have been noted on the comments section of the diabetic flow sheet and in nurses notes. She said the breakdown in notification of the MD had occurred because the patient was not on sliding scale insulin. S18RN said the fact that the patient was not on sliding scale should have been caught on 12 hour chart checks which had been performed on each shift.

In an interview on 3/3/14 at 3:30 p.m. with S2DON, he was asked when the MD was notified of elevated capillary blood glucose (CBG) results and he replied when patients on sliding scale insulin had a CBG of over 400. He said all diabetic patients admitted to the hospital were placed on sliding scale insulin. He reviewed Patient #4's chart and verified the patient was on 70/30 insulin subcutaneous at breakfast and in the evening. He also verified the patient had no orders for sliding scale insulin. He was asked if a CBG of 190's or above warranted notification of the MD if the patient was not on sliding scale insulin and he said yes. He was asked about the facility's policies on notification of elevated CBGs and he said probably when the patient ' s glucose level was less than 50 or more than 250. S2DON reviewed Patient #4's chart and confirmed no documentation of notification of the MD on any of the occasions when the patient's blood sugar was elevated.

In an interview on 3/5/14 at 7:22 am with S3RN, she said Mental Health Technicians (MHT) take vital signs and LPNs perform CBG monitoring and give medications. She said any abnormality in blood sugar should be reported to the RN and in turn should have been reported to the MD. S3

Based on interview and record review, the hospital failed to ensure the nursing staff developed and kept current a comprehensive nursing care plan for 4 (#2, #4 #,9, #10 ) of 4 (#2,#4, #9,10) patients reviewed for care plans.
Findings:

Patient #2
Review of Patient #2's medical record revealed an admission date of 2/17/14 and Diagnoses including the following, in part: Unspecified Psychosis, Hypertension, Cerebral Palsy, Mental Retardation, and Hypothyroidism. Further review revealed Patient #2 had a history of Diabetes Mellitus (documented on the patient's Psychiatric Evaluation).

Review of Patient #2's current plan of care revealed Hypothyroidism, Cerebral Palsy, Diabetes Mellitus, and Mental Retardation were not identified as problems on the patient's care plan. Further review revealed no documentation to indicate that the nursing staff followed up on the patient's diabetes and elevated blood glucose of 266 at the time of admission to Seaside Health System, the discontinuance of the patient's medications for 24 hours, or the change in the patient's appetite and diet were addressed in the patient's care plan.

Review of Patient #2 ' s physicians orders revealed no orders for the administration of insulin and/or medications for the treatment of hyperglycemia even though the psychiatric evaluation indicated the patient had a history of Diabetes and the patients blood glucose level was assessed to be 266 at the time of admission. Further review revealed the following orders:
2/20/14, 10 a.m. Discontinue all medications for 24 hours;
2/20/14, 2:10 p.m. NAS (no added salt) pureed diet

Review of a document titled Diabetic Flow Sheet for Patient #2 revealed his blood sugar on 2/17/14 at 8:15 p.m. was listed as 266. Further review revealed no additional blood glucose recordings were obtained and documented in the medical record during Patient #2's hospitalization at Seaside Health System from 2/17/14 through 2/20/14.

Review of the Intake and Output Record for Patient #2 dated 2/19/14 revealed he had eaten 100% of breakfast, lunch and dinner. Review of the Intake and Output Record for Patient #2 dated 2/20/14 revealed the following documentation:
Breakfast: 30% (eaten) Note: Couldn ' t swallow. Morning Snack: Didn ' t eat/swallow Lunch: 0% (eaten), sleep Dinner: 0 % (eaten), sleep
Review of the vital sign record dated for Patient #2 revealed the following blood pressures:
2/17/14 at 8:30 p.m. -126/78; 2/18/14 at 6:00 a.m. -148/88; 2/19/14 at 6:00 a.m. -122/76; 2/19/14 at 5:00 p.m. -116/74; 2/20/14 at 6:00 a.m. -120/76; 2/20/14 at 5:00 p.m. -76/50
Further review of the medical record revealed no repeat of the 2/20/14 at 5:00 p.m. blood pressure or notification of the physician that the blood pressure had dropped.

Review of the nursing flow sheets dated 2/17/14 through 2/20/14 revealed no documentation of physician notification of Patient #2's decreasing activity levels, the initial blood glucose of 266 or the patient's blood pressure on 2/20/14 of 76/50. On 2/19/14 at 7:30 a.m., S7RN documented: " Patient is extremely tired and cannot keep his head up. Will continue to monitor per doctors plan of care."

Review of the nursing note for Patient #2 dated 2/20/14 at 9:30 p.m. revealed an entry by S12RN which stated: " Pt. (patient) did not show up for group. Went to room to assess pt. Pt. breathing through his mouth at rate of 36 bpm (breaths per minute). Skin pink, warm, and dry. Unable to assess radial pulse. No v/s (vital signs) listed this shift. Attempted to assess BP (blood pressure) manual cuff x 3. Unable to assess. Sat (oxygen saturation) 67%. HR (heart rate) = 43. Notified CN (charge nurse) of patient's condition. Orders noted. Paramedics here to transport at 10:00 p.m. Report called to nurse at Hospital "B"."

Review of the documentation on dated 2/20/14 from Ambulance Company "A" revealed they were called by the hospital at 9:58 p.m. because Patient #2 was nonresponsive. His CBG (capillary blood glucose) reading was "Hi" which was indicative of being over 500 mg/dl (milligrams/deciliter). The primary Impression was listed as Unconscious and the secondary impression was listed as Diabetic Hyperglycemia (increased blood glucose).

Review of the medical records from Hospital "B" for Patient #2 revealed he had been transferred there from the facility on 2/20/14 at 10:31 p.m. Review of the Emergency Department (ED) notes revealed the following: 44 y.o. (year old) male with previous medical history of MR (mental Retardation), Cerebral Palsy, DM (Diabetes Mellitus) Type I presents to the ED via Ambulance Company "A" with altered mental status and a high reading on CBG (capillary blood glucose). Unknown exact onset. Ambulance Company "A" says the nursing facility pt resides gave limited history and thinks he may have been decreased level of alertness for half of the day. Pt is non verbal, cannot follow commands, grunts and withdraws from painful stimuli. Review of the labs from Hospital "B" for Patient #2 on 2/20/14 revealed he had a blood glucose level of 1370 mg/dl (normal listed 74-106mg/dl)


Patient #4
Review of Patient#4 ' s medical record revealed an admission date of 2/13/14 (formal voluntary admission) and diagnoses including the following: Depression, Psychosis, Hearing Voices, Hypertension, Diabetes Mellitus-Type II, Hyperlipidemia and frequent infections.
Review of Patient #4's current plan of care revealed Hyperlipidemia and susceptibility to frequent infections were not identified as problems on the patient's care plan.


Patient #9
Review of Patient #9's medical record revealed an admission date of 2/1/14 and Diagnoses including the following, in part: Depression, Suicidal Thoughts, Chronic Pain, Gout, CHF (Congestive Heart Failure), Anemia, and GERD (Gastroesophageal Reflux). Further review revealed Patient #9 was admitted for Depression and Suicidal Thoughts.

Review of Patient #9's current plan of care revealed Chronic Pain, Gout, CHF, Anemia, and GERD were not identified as problems on the patient's care plan.

Patient #10
Review of Patient #10's medical record revealed an admission date of 2/17/14 and Diagnoses including the following, in part: Hypertension, Diabetes Mellitus Type II, and Seizure Disorder. Further review revealed Patient #10 was admitted for Schizoaffective Disorder.

Review of Patient #10's current plan of care revealed Hypertension, Diabetes Mellitus Type II, and Seizure Disorder were not identified as problems on the patient ' s plan of care.


In an interview on 3/5/14 at 1:46 p.m. with S2DON he said patient care plans should be all inclusive, including all medical and psychiatric diagnoses and he confirmed patient #2, #4, #9 and #10's care plans had not addressed all of the patients ' problems. S2DON explained patient problems should have been identified upon admission based upon information contained in their admit packets such as PEC (physician emergency certificate), labs, behavior and past medical history. He further explained until recently ( Monday-3/4/14), prior admission patient records had not been readily available for review at night or on the weekends. He said care plans were reviewed once a week during treatment team meetings and they should have been updated during those meetings. S2DON was asked who attended the weekly treatment team meetings and he replied a nurse, S4Psychiatrist, and the discharge planner. He said S5InternalMedicine, who was the MD responsible for medical care of the patients, did not participate in the treatment team meetings and explained the nurse was the medical representative on the team. S2DON said communication between staff members was not as complete as it should have been.

Based on record review (personnel files) and interview, the hospital failed to ensure that nursing competencies and skills were performed and evaluated for 2 of 2 PRN (as needed) nursing personnel in a total sample of 7 nursing personnel files reviewed for nursing competencies and skills performance evaluations. Findings:
Review of the personnel file for S12RN (Registered Nurse) revealed her start date at the hospital was 08/06/13. Further review of the file revealed there were no nursing competencies and skills performance evaluations for S12RN.
In an interview on 03/05/14 at 1:35 p.m., S2DON (Director of Nursing) indicated all nursing personnel upon hire (full-time, part-time, or PRN) should have initial and annual nursing competencies and skills performance evaluations completed. S2DON confirmed S12RN did not have an initial nursing competency and had no skills performance evaluations completed since her start date at the hospital on 08/06/13, and S12RN should have had one.
In an interview on 03/05/14 at 1:20 p.m., S16HR (Human Resource Director) confirmed that S12RN did not have initial nursing competencies and no skills performance evaluations had been completed since her start date at the hospital on 08/06/13.
Review of the personnel file for S15RN revealed his start date at the hospital was on 08/15/13. Further review of the file revealed the last nursing competencies and skills performance evaluation was done on 04/20/11 at another hospital.
In an interview on 03/05/14 at 3:30 p.m., S2DON indicated that all nursing personnel upon hire (full-time, part-time, and PRN) should have initial and annual nursing competencies and skills performance evaluations completed. S2DON confirmed that S15RN did not have an initial nursing competency and skills performance evaluation upon hire to the hospital, and the last one had been completed on 04/20/11 from employment at another hospital. S2DON further agreed S15RN should have had initial nursing competencies and skills performance evaluations upon hire to the hospital.
In an interview on 03/05/14 at 1:20 p.m., S16HR confirmed that S15RN did not have initial nursing competencies and no skills performance evaluations had been completed since his start date at the hospital on 08/15/13.

Based on interview and record review the hospital failed to have orders for drugs and biologicals documented and signed by a practitioner who is authorized to write orders in accordance with State law and hospital policy. This deficient practice is evidenced by having preprinted admission order sheets with options for ordering medications which were being completed by a Registered Nurse instead of the attending physician for 1 (#9) of 1 (#9) records reviewed for medication orders.

Findings:
Review of the Hospital Medical Staff Rules and Regulations presented as current revealed in part:
Physician Orders:
6.1 All physician orders shall be written or telephone/verbal orders from the attending or consulting physician for any patient(s) admitted to the hospital with regard to any examination, laboratory work, x-rays, EKG ' s etc.

Review of the Hospital Policy titled Admission Criteria, Policy 1.5, read in part:
2. All admissions require a written admission order by a psychiatrist with medical staff privileges.

Review of the preprinted document titled " Physician Admit Orders and Problem List " revealed several sections which included the headings: Orders, Consults/Assessments, Medications, Diagnostic tests, and Diabetic. Underneath each heading were multiple choices for orders to be selected by checking a box to the left of the order and some blanks that had to be filled in with a choice. Under the Medication section, 7 choices of PRN (as needed) medications had the option to be ordered including Tylenol, Ibuprofen, Maalox, Milk of Magnesia, Multivitamin, and Dulcolax. Under the Diagnostic Tests section, options included Therapeutic drug levels. Under the section titled Diabetic an option was included for choosing sliding scale insulin and blanks were provided to fill in those ranges and insulin dosages. Other options under Diabetic included a finger stick for BS (Blood Sugar) and the frequency of following blood sugar levels.

Findings:
Patient #9
Review of Patient #9's medical record revealed an admission date of 2/1/14 with Diagnoses including the following, in part: Depression, Suicidal Thoughts, Chronic Pain, Gout, CHF (Congestive Heart Failure), Anemia, and GERD (Gastroesophageal Reflux). Further review revealed Patient #9 was admitted for Depression and Suicidal Thoughts.

Review of the Physician Admit Orders and Problem List for Patient #9, dated 1/31/14 at 12:40 a.m. revealed the legal status of Patient #9 was a PEC (Physician Emergency Certificate). Patient #9 ' s allergies were listed as ASA (Aspirin), Tylenol, and Ibuprofen. His reason for admission was listed as potential danger to self (suicidal). Under a section entitled Medications the following PRN (as needed) medications were checked off: Tylenol, Ibuprofen, Maalox, MOM (milk of magnesia), Multivitamin, Dulcolax (by mouth), and Dulcolax suppository; Under a section titled: Diagnostic Tests: Pre-albumin, Therapeutic drug level: Depakote were selected; Under a section titled " Diabetic " , an order to finger stick for BS (blood sugar) once on admission was selected. The admission orders had been signed as TORB (telephone order read back) x 2 per S7RN on 1/31/14 at 12:40 a.m. Further review revealed S4Psychiatrist had not cosigned the order until 2/1/14 at 11:00 a.m.

Review of Patient 9 ' s Admit/Discharge Medication Reconciliation and Order sheet, dated 2/1/14, revealed the following: Allergies: ASA, Tylenol, and Ibuprofen

Review of Patient #9 ' s printed MAR revealed the following PRN medications: Tylenol and Ibuprofen.

In an interview on 3/5/14 at 12:21 p.m. with S7RN, she explained she had written the orders for the diabetics on the admit order form and had filled out the schedule for obtaining CBGs.

In an interview on 3/5/14 at 12:44 p.m. with S4Psychiatrist, he said the Physician Admit Orders & Problem List was not a verbal/telephone order given by him on admission.

In an interview on 3/5/14 at 3:11 p.m., with S7RN she explained she had been told, since her first day on the job, to complete the admit order sheet and to sign it as telephone order read back and verified. She said she just checked the boxes on the admit orders because they were routine standing orders. S7RN also said the PRN medications were selected because those medications could have been given to anybody routinely. S7RN reviewed the patient ' s Admit/Discharge Medication Reconciliation and Order sheet, that she had signed on 2/1/14 and confirmed the patients allergies to ASA, Tylenol, and Ibuprofen were listed under allergies. She also confirmed the patient ' s allergy information was in his admit packet. Upon further review of Patient #9 ' s Physician Admit Orders & Problems List she also confirmed she had written the patient ' s allergies to ASA, Tylenol, and Ibuprofen on the form and had then selected both Tylenol and Ibuprofen on the Medications section of the Physician Admit orders. S7RN also said the PRN standing order medications could have been given to Patient #9 prior to receipt of the printed MARs (medication administration record) coming back from pharmacy. She said since the medications were considered routine PRN they would have been hand written on a paper MAR to have been used until the printed MARs came back from pharmacy. S7RN explained receipt of the printed MARs from pharmacy indicated 1st dose review had been performed on the medications by the Pharmacist for potential complications such as medication allergies.

Based on record review and interview the hospital failed to have medical records accessible in a timely manner once records are transferred from the hospital to the medical records storage facility. Findings:
In an interview on 03/05/14 at 2:00 p.m., S2DON indicated that patients' medical records are kept on site at the hospital for 15 months. After 15 months the medical records are sent to an offsite record storage facility where they are maintained for up to 10 years. S2DON also indicated the retrieval time for obtaining medical records from the storage facility may take from 3 to 10 days.
In an interview on 03/05/14 at 4:00 p.m., S1Administrator agreed there was an issue with retrieving patients' medical records in a timely manner once the records are stored at the medical records storage facility. S1Administrator indicated the hospital was looking into purchasing an electronic medical record system in order to have more timely access and retrieval of patients' medical records. S1Administrator agreed the hospital did not currently have that capability.

Based on record review and interview the hospital failed to have a system of coding and indexing medical records that allowed for timely retrieval by diagnosis and procedure. Findings:
In an interview on 03/03/14 at 11:00 a.m., S17MR (Medical Records) indicated the hospital did not have the capability to access medical records according to diagnosis and/or procedures electronically. S17MR indicated she would have to manually look through the patients' charts to identify patients with certain medical diagnoses.
In an interview on 03/05/14 at 4:00 p.m., S1Administrator agreed there was an issue with indexing and retrieving patients' medical records in a timely manner based on patients' diagnoses and/or procedures. S1Administrator indicated the hospital was looking into purchasing an electronic medical record system that would allow timely access and retrieval of patients' medical records according to diagnoses and/or procedures. S1Administrator agreed the hospital did not currently have that capability.

Based on interview and record review the hospital failed to ensure a therapeutic diet was prescribed by the practitioner responsible for the care of the patient by changing a patient's diet to pureed consistency based upon an order written by the dietician for 1(#2) of 1(#2) patients reviewed for dietary orders.
Findings:
Review of Patient #2's chart revealed an admission date of 2/17/14 with diagnoses including the following: psychosis, hypertension and hypothyroidism.
Review of the Intake and Output Record for Patient #2 dated 2/19/14 revealed he had eaten 100% of breakfast, lunch and dinner. Review of the Intake and Output Record for Patient #2 dated 2/20/14 revealed the following documentation:
Breakfast: 30% (eaten) Note: Couldn't swallow.
Morning Snack: Didn ' t eat/swallow
Lunch: 0% (eaten), sleep
Dinner: 0 % (eaten), sleep
Review of a Physician's Order sheet for Patient #2 revealed an order dated 2/20/14 at 2:10 p.m. that was written as a verbal order from S5InternalMedicine to S11RD. The order was to change Patient #2 ' s diet to a NAS (No added salt) Pureed consistency diet.
Review of the nursing note for Patient #2 dated 2/20/14 at 9:30 p.m. revealed an entry by S12RN. She wrote: Pt. (patient) did not show up for group. Went to room to assess pt. Pt. breathing through his mouth at rate of 36 bpm (breaths per minute). Skin pink, warm, and dry. Unable to assess radial pulse. No v/s (vital signs) listed this shift. Attempted to assess BP (blood pressure) manual cuff x (times) 3. Unable to assess. Sat (oxygen saturation) 67%. HR (heart rate) = 43. Notified CN (charge nurse) of patient's condition. Orders noted. Paramedics here to transport at 10:00 p.m. Report called to nurse at Hospital " B " .

Review of the documentation dated 2/20/14 from Ambulance Company " A " revealed they were called by the facility at 9:58 p.m. because Patient #2 was nonresponsive. His CBG (capillary blood glucose) reading was " Hi " which was indicative of being over 500 mg/dl (milligrams/deciliter). The primary Impression was listed as Unconscious and the secondary impression was listed as Diabetic Hyperglycemia (increased blood glucose).

In an interview on 3/5/14 at 7:54 a.m. with S11RD, she said she changed Patient #2's diet to pureed consistency on 2/20/14 at 2:10 p.m. and signed the order as a verbal order from S5InternalMedicine because a mental health technician (MHT) said the patient was having trouble chewing. S11RD explained she had not actually talked to S5InternalMedicine to receive the order, they just had an understanding. S11RD also said she had not done an assessment on Patient #2 to see if he could swallow because the MHT had done an assessment. S11RD said she had not realized the patient could not eat because he had a decreased level of consciousness.



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