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Based on interview and record review, the hospital failed to ensure one of 39 sampled patients (Patient 37) was informed of their rights in the hospital. This posed the potential for the patient and/or the patient's representative not being allowed to exercise the patient's rights.

Findings:

Review of the hospital's P&P titled Direct Admissions - Acceptance and Transfer of Adult Patients from Outside Facilities reviewed/revised 8/17 showed the purpose of this P&P is to define the requirements for direct admission and acceptance and transfer of adults patients from outside facilities. The procedure section of this P&P showed the admitting/registration responsibilities include to notify bed control of the patient's arrival, obtain the patient's signature on a consent form, and place an arm band on the patient upon the arrival of the patient,

Review of the Conditions of Admission/Clinic Visit form (or the consent form) showed the following:

* The section for medical consent showed the patient agrees to the procedures and treatments that may take place on the patient while the patient was in the hospital.

* The reverse side of the Conditions of Admission/Clinic Visit form showed the list of patient's rights.

* The section for "I AM SIGNING THIS TO SAY I UNDERSTAND AND AGREE TO ALL ABOVE STATEMENT. I HAVE BEEN GIVEN THE CHANCE TO ASK QUESTIONS AND TO HAVE MY QUESTIONS ANSWERED. I AM AUTHORIZED AS THE PATIENT OR THE PATIENT'S REPRESENTATIVE TO AGREE TO THESE THINGS. I HAVE RECEIVED A COPY OF THIS AGREEMENT."

On 4/22/21 at 0920 hours, an interview and concurrent review of Patient 37's medical record was conducted with RN 2 and the Senior Nursing Instructor.

The medical record showed Patient 37 was admitted to the hospital on 4/17/21 at 0510 hours.

Review of the Admission History Adult-Text dated 4/17/21 at 0522 hours, showed Patient 37 was admitted from other acute care facility and arrived to the room on 4/17/21 at 0515 hours.

When asked, RN 2 and the Senior Nursing Instructor stated Patient 37 arrived to the hospital on 4/17/21 at 0515 hours. When asked, RN 2 and the Senior Nursing Instructor could not find documented evidence to show Patient 37 had signed the condition of admission form or received the patient's rights information when the patient was admitted to the hospital on 4/17/21.

On 4/23/21 at 0903 hours, an interview and concurrent record review was conducted with Clinical Nursing Director 1 and Nurse Manager 3. Clinical Nursing Director 1 and Nurse Manager 3 confirmed Patient 37 was directly admitted to the nursing unit on 4/17/21. Clinical Nursing Director 1 stated Patient 37 should sign the condition of admission form when the patient arrived to the hospital.

On 4/23/21 at 1055 hours, during an interview with the COO and Clinical Nursing Director 1, the COO and Clinical Nursing Director 1 confirmed the Condition of Admission form was not completed as per the hospital's P&P when Patient 37 was admitted to the hospital on 4/17/21.

Based on observation, interview, and record review, the hospital failed to ensure the patient's right to receive care in a safe setting as evidenced by:

1. Failure to implement the hospital's P&P related to isolation when Patient 34 who received a steroid medication and did not need any isolation precaution was placed in the same room with Patient 35 who was on the contact precaution.

2. LVN 1 failed to continuously monitoring of cardiac rhythms on 6 West unit as per the hospital's P&P.

These failures created the increased risk to the safety and poor health outcomes to the patients receiving care in the hospital

Findings:

1. Review of the Patient Placement of the Contact Precaution section of the hospital's P&P titled Isolation Policy dated 7/20 showed a single patent room is preferred. When a private room is not available, place the patient in a room with patient(s) who has infection or colonization with the same microorganism but with no other infection (cohorting). When a private is not available, apply the following principles for making decisions on patient placement:

* Prioritize patients with conditions that may facilitate transmission for single-patient room placement.

* Place together in the same room (cohort) patients who are infected or colonized with the same pathogen and are suitable roommates.

* If it becomes necessary to place a patient who requires contact precautions in a room with a patient who is not infected or colonized with the same infectious agent:

- Avoid placing patients on contact precautions in the same room with patients who have conditions that may increase the risk of adverse outcome for infection or that may facilitate transmission (e.g., those who are immunocompromised, have open wounds, or have anticipated prolonged lengths of stay).

Review of the Multi-drug Resistant Pathogen Cohorting Guide for Inpatients revised 11/7/18, showed the contact precaution is required for Extended-spectrum beta-lactamase producing organism (ESBL). The section of precautions for ESBL showed the following:

* Private room (if possible).

* Can be in the same room as patients who do not need isolation. Such patients, however, should not be immunocompromised (i.e. receiving PO/IV steroids).

On 4/22/21 at 0830 hours, a tour of 4 West unit was conducted with the Senior Nursing Instructor, RN 2, and Nurse Manager 3. Room A was observed to have four beds (Beds A, B, C, and D). A signage of contact precaution was observed posted next to the door of Room A. When asked, Nurse Manager 3 stated Room A was a 4-beds room and there were only two patients assigned to Room A currently. When asked about the signage of contact precaution, Nurse Manager 3 stated the patient in Bed C was not on the contact precaution, but the patient in Bed D was on the contact precaution. When asked about the cohorting procedure, Nurse Manager 3 stated the hospital had criteria on how to cohort the patients.

Review of the Printed Patient List dated 4/22/21 at 0825 hours, showed the following:

- Patient 34 was assigned to Bed C.

- Patient 35 was assigned to Bed D.

On 4/22/21 at 1132 hours, an interview and concurrent review medical records of Patients 34 and 35 was conducted with RN 2 and the Senior Nursing Instructor.

* Review of Patient 35's medical record showed Patient 35 was admitted to Bed D on 4/4/21. The physician's order dated 4/7/21 at 0834 hours, showed Patient 35 had a lab result showing ESBL and would be on the contact precaution.

* Review of Patient 34's medical record showed Patient 34 was admitted to Bed C on 4/20/21 at 2241. The patient was on the steroid medication.

RN 2 and the Senior Nursing Instructor confirmed Patient 35 was assigned to Bed D from 4/4/21 to 4/22/21 and was placed on the contact precaution for ESBL on 4/7/21, and Patient 34 was assigned to Bed C from 4/20/21 to 4/22/21. Patients 34 and 35 were assigned to the same room (Room A) since Patient 34 was admitted on 4/20/21.

On 4/22/21 at 1402 hours, an interview and concurrent record review was conducted with Clinical Nursing Director 1 and Nurse Manager 3.

Review of the Unit Staffing Assignment Log dated 4/20/21 (night shift), and the Printed Patient List dated 4/20/21 at 2305 hours, showed Beds B and C in Room A were available to be assigned for a new admission.

Clinical Nursing Director 1 and Nurse Manager 3 confirmed the above information. Nurse Manager 3 stated Bed C was opened when Patient 34 was admitted to Room A. Clinical Nursing Director 1 and Nurse Manager 3 confirmed Patient 34 (who had no infection requiring isolation precautions) should not be assigned to Bed C in Room A when admitted to the floor on 4/20/21.


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2. Review of the hospital's P&P titled Telemetry Patients dated 8/31/14, showed the telemetry box shall be placed on the patient who will be monitored continuously via the central monitoring station. The monitor technician will alert the licensed nurse assigned to the patient of dysrhythmia shown in the central monitor for immediate review and assessment of the patient.

On 4/21/21 at 1029 hours, a tour of 6 West unit was conducted with Clinical Nursing Director 3, the Infection Prevention RN, and Supervisor Staff Nurse 1. Supervisor Staff Nurse 1 stated the nursing station had the centralized telemetry monitoring. LVN 1 was observed sitting in front of the telemetry monitors at the nursing station. The audible and visual alarms were going off for two patients showing on the telemetry monitor screen. However, LVN 1's eyes were not on the screen or making note of the alarms. Supervisor Staff Nurse 1 went to LVN 1 and alerted the LVN to the alarms. LVN 1 immediately asked for help with sending someone to check on the two patients with alerts going off on the telemetry monitor screen.

When asked, LVN 1 stated she was the relief monitor technician while the telemetry monitor technician was on a break. LVN 1 stated she was normally calling the RN if the alarms were going off. LVN 1 stated allowing one minute of alarming for movement interference.

Clinical Nursing Director 3, and the Infection Prevention RN acknowledged the above finding.

Based on observation, interview, and record review, the facility failed to ensure the hospital's P&P was implemented for eight of 39 Patients (Patients 6, 8, 16, 17, 25, 29, 37, and 39) as evidenced by:

1. The nursing staff failed to ensure the EKG strip or tracing were recorded and maintained for Patients 6, 17, and 37.

2. The nursing staff failed to accurately complete the medical records related to the CPR documentation for Patients 16, 17, and 39.

3. The nursing staff failed to perform the cardiac rhythm strip assessments for Patient 25 as per the hospital's nursing standards of practice.

4. The nursing staff failed to ensure the STAT blood draw was performed timely for Patient 29.

5. The laboratory test order was not performed as per the physician's order for Patient 8.

These failures increased the risk of substandard healthcare outcomes to the patients.

Findings:

1. Review of the hospital's P&P titled Daily Patient Care Guidelines revised date 8/31/18, showed six second EKG strips must be printed and placed in the medical record upon admission to a unit, at the beginning of each shift, and when a change in cardiac rhythm occurs. The PR, QRS, and QT intervals must be measured and recorded. ST segments must be measured and recorded on all chest pain patients.

Review of the hospital's nursing standard titled Lippincott Procedures-Cardiac Monitoring revised 8/21/20, showed routine six-second EKG rhythm strips will be obtained on all cardiac monitored patients and placed on the rhythm record form on admission to the unit, within one hour of the beginning of each shift and with any acute change or significant arrhythmia.

a. Medical record review for Patient 17 was initiated on 4/19/21. Patient 17 was admitted to the hospital on 12/31/21, with diagnosis of endocarditis, COVID 19 infection, and heart failure.

On 4/19/21 at 1430 hour, review of the EKG strips and CPR Record dated 1/4/21, and concurrent interview was conducted with RN 1. When asked about the EKG strip recorded on 1/4/21, RN 1 stated there were no EKG strips in the patient's medical record. When asked for the EKG strips from 12/31/20 to 1/4/21, RN 1 stated she would ask for the record.

On 4/20/21 at 1500 hours, review of the EKG strip record with Nurse Manager 1 and Clinical Director 1. When asked about the EKG strips recorded from 12/31/20 to 1/4/21, Clinical Director 1 stated there was no EKG strips in the patient's EHR. Clinical Director 1 stated she would follow up with the HIM. When asked how often the EKG strips should be recorded, Clinical Director 1 stated the EKG strips should be recorded every shift and when a change in condition occurred.

On 4/21/21 at 1500 hours, Clinical Director 1 verified there was no EKG strips records for Patient 17 from 12/31/20 to 1/4/21.

b. Patient 6's medical record was reviewed on 4/19/21. The medical record showed Patient 6 was admitted to the hospital on 1/7/21.

Review of the Rapid Response/Code Blue Records dated 1/12/21 at 0009 hours, showed Patient 6 was found to have PEA on 1/11/21 at 2312 hours.

Review of the Cardiopulmonary Resuscitation Record dated 1/11/21, showed Patient 6's cardiac rhythm was PEA from 2308 to 2325 hours.

However, further medical record review failed to show the EKG strips when the patient had PEA on 1/11/21.

On 4/21/21 at 1320 hours, Clinical Nursing Director 1 and Nurse Manger 2 verified the above findings.

c. On 4/22/21 at 0830 hours, a tour of 4 West unit was conducted and accompanied by RN 2, the Senior Nursing Instructor, and Nurse Manager 3. Nurse Manager 3 stated 4 West unit was the telemetry and progressive care unit with 12 hours shift (0700-1900 hours and 1900-0700 hours) licensed nurses.

Review of Patient 37's medical record was initiated on 4/22/21. The medical record showed Patient 37 was admitted to the hospital on 4/17/21 at 0510 hours.

Review of the physician's order showed dated 4/17/21 at 0511 hours, showed to admit to the telemetry unit.

On 4/23/21 at 0903 hours, an interview and concurrent record review was conducted with Clinical Nursing Director 1 and Nurse Manager 3.

Review of the Patient 37's Patient Summary Report failed to show the EKG rhythm strips were obtained within one hours of the beginning of the shift for the night shift on 4/20/21, and the day shift on 4/21/21. Clinical Nursing Director 1 and Nurse Manager 3 confirmed Patient 37's EKG rhythm strips were not obtained/printed within one hour of the beginning of the shift as per the hospital's procedure.

2. Review of the hospital's P&P titled Adult Code Blue and Pediatric Code White Teams reviewed 9/20 showed in part:

* Duties of Nursing during the Resuscitation: the RN who records information during the code will be responsible for documenting interventions and their time during the code. The RN Supervisor ensures disposition is agreed upon prior to completion of the Code Blue procedure.

* The RN who records information during the code will ensure that all code respondents are identified on the Resuscitation Record. She will sign the Cardiopulmonary Resuscitation Record in the appropriate section.

* The Code Leader is responsible for documenting rhythm interpretation, as appropriate, and completing the Physician Summary Section of the CPR record. She/he signs the Cardiopulmonary Resuscitation Record in the Physician Summary section.

a. Medical record review for Patient 17 was initiated on 4/19/21. Patient 17 was admitted to the hospital on 12/31/21, with a diagnosis of endocarditis, COVID 19 infection, and heart failure.

Review of the CPR Record was conducted with the Director of Nursing Quality, Clinical Nursing Director 1, and Nurse Manager 2 on 4/21/21 at 1500 hours. The CPR Record dated 1/4/21, showed the time of event onset at 1217 hours. When asked about the following pulse, cardiac rhythm, and chest compressions recorded on 1/4/21:

- at 1220 hour, the patient's pulse was 78 bpm and the cardiac rhythm section was blank, and the chest compression section had a check mark.

- at 1223 hour, the patient's pulse was 159 bpm and the cardiac rhythm section was blank, and chest compression section had a check mark.

- at 1224 hour, the patient's pulse was 167 bpm and the cardiac rhythm section was blank, and chest compression section had a check mark.

- at 1228 hour, the patient's pulse was 160 bpm and the cardiac rhythm section was blank, and chest compression section had a check mark.

The Director of Nursing Quality stated the check mark for the cardiac compression could be the resuming of chest compression after checking the pulse. Clinical Director 1 stated the nursing staff must have recorded what appeared on the cardiac monitor during the cardiac compressions; however, the staff should not record the pulse when the chest compression was being performed.

Clinical Director 1 verified the findings.

b. Review of Patient 16's medical record was initiated on 4/14/21 at 1430 hours, with RN 1. Patient 16 was admitted to the hospital on 1/7/21, with diagnosis of Shock.

Review of the CPR record dated 1/8/21, showed the CPR was started on 2303 hours. The CPR record showed the following information were left blank: noted by, location of the patient, time of event, activated time for the code blue, code blue arrival time, name of the physician present, recorder's printed name, signature, and date, pharmacist, EKG technician, respiratory therapist, and RNs present during the code blue. The physician summary was left blank, including the provider's name, signature, date, and time.

On 4/21/21 at 1445 hours, the CPR record review was conducted with Director of Quality, Clinical Director 1 and Nurse Manager 2. When asked if Patient 16's CPR record was completed, Director of Nursing Quality and Clinical Director 1 stated no, the staff should have completed all of the information on the CPR record.

c. Review of Patient 39's medical record and concurrent interview was initiated on 4/22/21 at 1245 hour, with the Director of Nursing Quality, Nurse Manager 2, and Clinical Director 1. Patient 39 was admitted to the hospital on 11/28/20 due to COVID 19 infection.

Review of the CPR record dated 4/19/21, showed the time of event was at 0842 hour. At 0842 hour, Patient 39 had the pulse of 126 bpm, BP of 139/105 mmHg, and asystole cardiac rhythm; and the chest compression was checked. The Director of Nursing Quality was asked about the check mark for the chest compression column, pulse of 126 bpm, and BP of 139/105 mmHg. The Director of Nursing Quality stated the check mark could mean the chest compression being performed, was started or resumed. The Director of Nursing Quality was asked whether the chest compression was accurate when the patient's pulse of 126 bpm and BP of 139/105 mmHg, the Director of Nursing Quality stated no. The Director of Nursing Quality was asked whether documenting asystole for cardiac rhythm for the patient with the pulse rate of 126 bpm would be accurate, the Director of Nursing Quality stated no. The documentation also showed at 0843, 0847, and 0849 hours, the pulse sections were left blank, the cardiac rhythm was asystole, and the cardiac compression section was left blank.


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3. Review of the hospital's nursing standard, Lippincott Procedures- Cardiac Monitoring dated 8/21/20, showed the RN or LVN will measure the PR, QRS, QT intervals, and heart rate on each recorded EKG strip.

On 4/21/21 at 1035 hours, a concurrent record review and interview was conducted with Clinical Nurse Director 3 and the Infection Prevention RN regarding Patient 25.

Review of the order Admit to Inpatient dated 4/19/21 at 1829 hours, showed to admit Patient 25 on telemetry monitoring.

Review of the Cardiac Rhythm Analysis for Patient 25 dated 4/19 to 4/20/21, showed the following:

- NSR on 4/19/21 at 2102 hours.
- NSR on 4/20/21 at 0737 hours.
- NSR on 4/20/21 at 1919, 1943, and 1950 hours, .
- NSR on 4/20/21 at 2153 hours.

However, further review of the medical record failed to show the cardiac rhythm measurements were validated by the RN and recorded in the EHR. When asked to review the EKG strips, the strips showed the measurements were automatically generated on the strips; however, they were not signed off and validated by the RN.

Clinical Nurse Director 3 and the Infection Prevention RN acknowledged and verified the above findings.

4. Review of the hospital's P&P titled Laboratory Testing Turn Around Time dated 4/17/14, showed the expected turnaround time for STAT laboratory tests is 60 minutes or less from the time the specimen is received in the laboratory.

On 4/22/21 at 1313 hours, a concurrent record review and interview was conducted with Clinical Nurse Director 3 and the Infection Prevention RN regarding Patient 29.

Review of the physician's order dated 4/20/21 at 2056 hours, showed to draw the blood order STAT.

However, review of the laboratory's Event List for Patient 29 showed the blood specimen was collected on 4/20/21 at 2205 hours, more than one hour after it was ordered.

When asked what considered as STAT order, the Clinical Nurse Director 3 stated 15 to 30 minutes. The Infection Prevention RN stated the STAT order should be performed within 15 minutes.

The above findings were shared and acknowledged by Clinical Nurse Director 3 and the Infection Prevention RN.


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5. Review of the hospital's P&P titled Laboratory Testing Turnaround Time revised 4/14 showed the expected turn around time for daily core laboratory routine tests is four hours or less from the time when the specimen is received in the laboratory.

Review of Patient 8's medical record was initiated on 4/22/21. The medical record showed Patient 8 was admitted to the hospital's ICU on 12/16/20.

Review of the physician's order dated 1/9/21 at 0404 hours, showed an order for C-reactive protein (CRP) and sedimentation rate (ESR) every 12 hours.

Review of Patient 8's medical record showed the CRP result of 19 mg/L (normal CRP level is less than 10 mg/L) and ESR result of greater than 120 mm/hr (normal ESR level for men under 50 years old: less than 15 mm/hr) on 1/9/21 at 1721 hours. There was no other CRP and ESR result on 1/9/21.

Further review of Patient 8's medical record failed to show documented evidence the patient's CRP and ESR tests were done every 12 hours as ordered on 1/9/21.

On 4/21/21 at 1523 hours, an interview and record review was conducted with the Accreditation Coordinator. The Accreditation Coordination reviewed the patient's medical record and verified the above findings.

Based on interview and record review, the hospital failed to ensure the medications were administered as per the physician's orders for 17 of 39 sampled patients (Patients 1, 2, 3, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16, 23, 24, and 26) as evidenced by:

1. The IV drip medications were not administered as ordered and the associated parameters (RASS, CPOT, MAP, and SBP) for the IV medication titration and administration were not assessed and documented for Patients 1, 2, 5, 6, 7, 8, 11, 13, 14, 15, 16, 23, and 24.

2. The antibiotic and Tylenol (analgesic) medications were not administered in timely manner for Patient 3.

3. The Tylenol medication was administered without the actual temperature reading for Patient 9.

4. The breathing treatment was not administered as ordered for Patient 12.

5. The pain assessments and medication administration were not performed as ordered for Patient 26.

These failures created the risk of medication errors and poor health outcomes to these patients.

Findings:

The hospital's P&P titled Medication Administration revised 3/20 showed administration of medications must be documented on the eMAR. Each dose of medication shall be recorded properly in the patient's medical record, which may include response to medications. Notify the prescribing or covering provider when the following occurs:

- Medication is not administered within their permitted window of time.
- The doses are missed due to the patient being temporarily away from the nursing unit.

1.a. Patient 1's medical record was reviewed on 4/14/21. The medical record showed Patient 1 was admitted the hospital on 1/16/21.

* Review of the physician's order dated 1/16/21 at 1751 hours, showed to titrate fentanyl (opioid analgesic) by 25 mcg/hr every 15 minutes, with a goal of CPOT less than 2.

Review of the MAR showed Patient 1 received the fentanyl drip 25 mcg per hour on 1/16/21 at 1850 hours, with the documented CPOT showing "0." The fentanyl medication was titrated up to 50 mcg/hr at 1900 hours. However, there was no documented evidence to show why the fentanyl drip was titrated up to the 50 mcg/hr at 1900 hours.

* Review of the physician's order dated 1/16/21 at 1751 hours, showed to titrate propofol (general anesthetic) by 5 mcg/kg/min every five minutes to reach a goal of RASS score of -3 (moderate sedation).

Review of the RASS assessment dated 1/16/21 at 1850 hours, showed Patient 1's RASS was -5 (unarousable). However, review of the MAR dated 1/16/21 at 1908 hours, showed the propofol drip was initiated at 5 mcg/kg/min.

Review of the MAR dated 1/16/21, showed Patient 1 received the propofol medication as follows:

- At 1908 hours, the propofol medication was initiated at 5 mcg/kg/min.

- At 1910 hours, the propofol medication was infused at 10 mcg/kg/min.

- At 1915 hours, the propofol medication was infused at 15 mcg/kg/min.

- At 1950 hours, the propofol medication was infused at 40 mcg/kg min.

However, review of the RASS score assessments dated 1/16/21, failed to show the RASS scores assessment at 1908, 1910, 1915, and 1950 hours, when the propofol drip was titrated up.

* Review of the physician's order dated 1/16/21 at 1757 hours, showed to titrate norepinephrine (also known as noradrenaline, used to treat for patient's with very low blood pressure) by 2 mcg/min every five minutes, with a goal of MAP 65 mmHg.

Review of the MAP dated 1/16/21 showed Patient 1's MAPs were less than 65 mmHg from 1930 hours to 2045 hours.

Review of the MAR dated 1/16/21 at 1950 hours, showed the norepinephrine drip was initiated at 15 mcg/min and infused at 30 mcg/min at 2037 hours. However, there was no documentation in the MAR showing how the norepinephrine medication was titrated by 2 mcg/min every five minutes as ordered.

b. Patient 2's medical record was reviewed on 4/21/21. The medical record showed Patient was admitted to the hospital on 1/15/21, and discharged on 2/9/21.

Review of the physician's order dated 1/15/21 at 1618 hours, showed to titrate the esmolol by 50 mcg/kg/min every five minutes, with a goal of SBP less than 140 mmHg.

Review of Patient 2's BP record dated 1/16/21, showed the following:

- SBP 171 mmHg at 2100 hours;
- SBP 163 mmHg at 2115 hours;
- SBP 171 mmHg at 2130 hours;
- SBP 157 mmHg at 2145 hours; and
- SBP 144 mmHg at 2200 hours.

Review of the MAR dated 1/16/21 at 2144 hours, showed no documented evidence of the esmolol infusion started at 2100 hours and titrated every five minutes as ordered when the patient's SBP was higher than 140 mmHg until 2144 hours. The MAR showed the esmolol drip was infused at 50 mcg/kg/min from 2144 to 2245 hours. There was no documented evidence of the esmolol titration every five minutes from 2144 hours to 2200 hours when the patient's SBP was higher than 140 mmHg.

c. Patient 6's medical record was reviewed on 4/19/21. The medical record showed Patient 6 was admitted to the hospital on 1/7/21.

* Review of the Physician's Order dated 1/11/21 at 2341 hours, showed to titrate norepinephrine by 2 mcg/min every five minutes, with a goal of MAP 65 mmHg.

Review of the Patient 6's MAP record dated 1/12/21, showed Patient 6's MAP was lower than 65 mmHg from 0130 to 0200 hours.

Review of the MAR dated 1/12/21, showed the norepinephrine drip was infused at 7 mcg/min at 0120 hours, and at 15 mcg/min at 0145 hours.

However, further review of the MAR failed to show the norepinephrine drip was titrated by 2 mcg/min every five minutes from 0130 hours to 0145 hours, as per the physician's order.

* Review of the Physician's Order dated 1/11/21 at 2330 hours, showed to titrate fentanyl by 25 mcg/hour every 15 minutes, with a goal of CPOT less than 2.

Review of the medical record showed Patient 6's CPOT was 7 on 1/10/21 at 2345 hours, and 1/12/21 at 0000 hours. Review of the CPOT failed to show the CPOT completed from 0015 to 0559 hours. At 0600 hours, Patient 6's CPOT was 0.

Review of the MAR showed the following:

- On 1/11/21 at 2345 hours, the fentanyl medication was initiated at 25 mcg/hr.

- On 1/12/21 at 0000 hours, the fentanyl medication was infused at 50 mcg/hr.

- On 1/12/21 at 0015 hours, the fentanyl medication was infused at 75 mcg/hr.

- On 1/12/21 at 0030 hours, the fentanyl medication was infused at 100 mcg/hr.

- On 1/12/21 at 0045 hours, the fentanyl medication was infused at 125 mcg/hr.

However, further medical record review failed to show the CPOT was completed indicating the need for the fentanyl titration on 1/12/21 at 0015, 0030, and 0045 hours.

* Review of the Physician's Order dated 1/11/21 at 2330 hours, showed to titrate midazolam by 2 mg/hour every 15 minutes, with a goal of RASS score of -3 (moderate sedation).

Review of the RASS score assessment dated 1/12/21, showed Patient 6's RASS score was +2 at 0000 hours, and "0" at 0400 hours.

Review of the MAR showed the following:

- On 1/11/21 at 2345 hour, the midazolam medication was initiated at 1 mg/hr.

- On 1/12/21 at 0000 hours, the midazolam medication was infused at 3 mg/hr.

- On 1/12/21 from 0015 hours to 0400 hours, the midazolam medication was infused at 4 mg/hr.

The midazolam drip was not titrated by 2 mg/hr every 15 minutes to ensure a goal of RASS score of -3 as ordered.

d. Patient 13's medical record was reviewed on 4/20/21. The medical record showed Patient 13 was admitted to the hospital on 12/31/21.

The medical record showed the patient's vital signs were completed on the ICU unit on 1/1/21 at 0157 and 0311 hours.

* Review of the Physician's Order dated 12/31/21 at 2309 hours, showed to titrate propofol by 5 mcg/kg/min every five minutes, with a goal of RASS score of -3.

Review of the MAR dated 1/1/21 at 0233 hours, showed the propofol drip was initiated at 0233 hours.

Review of the RASS score assessment dated 1/1/21, showed no documented evidence Patient 13's RASS scores were assessed and documented when the propofol medication was initiated and thereafter to determine if the medication titration needed.

* Review of the Physician's Order dated 12/31/20 at 2309 hours, showed to titrate fentanyl 25 mcg/hour every 15 minutes, with a goal of CPOT less than 2.

Review of the MAR dated 1/1/21 at 0200 hours, showed the fentanyl drip was initiated at 0200 hours.

Further medical record review dated 1/1/21, showed no documented evidence Patient 13's CPOTs were assessed and documented when the fentanyl drip was initiated and thereafter to determine if the medication titration needed.

e. Patient 14's medical record was reviewed on 4/20/21. The medical record showed Patient 14 was admitted to the hospital on 10/11/20.

* Review of the Physician's Order dated 10/11/20 at 0232 hours, showed to titrate propofol by 5 mcg/kg/min every five minutes, with a goal RASS score of -3 (moderate sedation).

Review of the MAR dated 10/11/20, showed the propofol drip was titrated to 20 mcg/kg/min at 0820 hours, from 15 mcg/kg/min at 0800 hours.

However, the RASS score was not documented for the titration on 10/11/20 at 0820 hours.

* Review of the Physician's Order dated 10/11/20 at 0230 hours, showed to titrate fentanyl by 25 mcg/hour every 15 minutes, with a goal of CPOT less than 2.

Review of the MAR dated 10/11/20 showed the following:

- At 0800 hours, the fentanyl medication was infused at 50 mcg/hr.

- At 0815 hours, the fentanyl medication was infused at 75 mcg/hr.

- At 0900 hours, the fentanyl medication was infused at 100 mcg/hr.

- At 0930 hours, the fentanyl medication was infused at 125 mcg/hr.

- At 1000 hours, the fentanyl medication was infused at 150 mcg/hr.

- At 1030 hours, the fentanyl medication was infused at 175 mcg/hr.

- At 1100 hours, the fentanyl medication was infused at 200 mcg/hr.

Review of the CPOT assessment dated 10/11/20 at 0800 hours, showed Patient 14's CPOT was "0."

However, further medical record review failed to show the CPOT assessment was completed for each above titration.

f. Patient 15's medical record was initiated on 4/20/21. The medical record showed Patient 15 was admitted to the hospital on 12/26/20, and was discharged on 1/6/21.

* Review of the Physician's Order dated 12/26/20 at 0653 hours, showed to titrate propofol by 5 mcg/kg/min every five minutes, with a goal of RASS score of -3 (moderate sedation).

Review of the MAR dated 12/26/20, showed the propofol drip was infused at 10 mcg/kg/min at 1200 hours, and 15 mcg/kg/min at 1215 hours.

However, review of the RASS score assessments showed no documented evidence of the RASS score completed on 12/26/20 at 1215 hours, when the propofol drip was titrated up.

* Review of the Physician's Order dated 12/26/20 at 0653 hours, showed to titrate fentanyl 25 mcg/hr every 15 minutes, with a goal of CPOT less than 2.

Review of the MAR dated 12/26/20, showed the fentanyl drip was infused at 100 mcg/hour at 1230 hours, and at 125 mcg/hour at 1245 hours.

Review of the CPOT assessment dated 12/26/20, showed at 1230 hours, Patient 15's CPOT was 2. However, there was no documented evidence of the CPOT assessment at 1245 hours, when the fentanyl drip was titrated up.

g. Patient 23's medical record was reviewed on 4/20/21. The medical record showed Patient 23 was admitted to the hospital on 12/3/20.

* Review of the Physician's Order dated 12/5/20 at 0605 hours, showed to titrate fentanyl by 25 mcg/hour every 15 minutes, with a goal of CPOT less than 2.

Review of the Physician's Order dated 12/9/20 at 1454 hours, showed the fentanyl order was resumed as to titrate fentanyl by 25 mcg/hr every 15 minutes, with a goal of CPOT less than 2.

Review of the MAR dated 12/9/20, showed the fentanyl drip was infused at 125 mcg/hr at 1212 hours, and 200 mcg/hr at 1656 hours.

Review of the CPOT dated 12/9/20 at 1201 hours, showed Patient 15's CPOT was 1.

Further medical record showed there were no documented evidence of the CPOT assessments and titration process from 1212 hours (at 125 mcg/hr) to 1656 hours (at 200 mcg/hr).

* Review of the Physician's Order dated 12/5/20 at 0607 hours, showed to titrate propofol by 5 mcg/kg/min every five minutes, with a goal of RASS score of -3 (moderate sedation).

Review of the MAR dated 12/9/20, showed the following:

- At 1538 hours, the propofol medication was infused at 5 mcg/kg/min.

- At 1550 hours, the propofol medication was infused at 10 mcg/kg/min.

- At 1600 hours, the propofol medication was infused at 20 mcg/kg/min.

- At 1605 hours, the propofol medication was infused at 25 mcg/kg/min.

- At 1610 hours, the propofol medication was infused at 30 mcg/kg/min.

- At 1615 hours, the propofol medication was infused at 35 mcg/kg/min.

- At 1620 hours, the propofol medication was infused at 40 mcg/kg/min.

- At 2000 hours, the propofol medication was infused at 50 mcg/kg/min.

- At 2100 hours, the propofol medication was infused at 50 mcg/kg/min.

Review of the RASS score assessments dated 12/9/20, showed Patient 23's RASS score was -3 at 1535, 1550, 1600, 1615, 1631, 1656, 1710, 1725, 1745, 1816, 1826, 1845, 1900, and 1908 hours. The propofol drip was titrated up when the RASS score goal was met, or without the documented RASS scores. In addition, review of the RASS score dated 12/9/20 at 2100 hours, showed Patient 23's RASS was -5 (unarousable). However, the propofol drip was not titrated to ensure a goal of RASS score of -3.

h. Patient 24's medical record was reviewed on 4/20/21. The medical record showed Patient 24 was admitted to the hospital on 12/4/20.

Review of the Physician's Order dated 12/4/20 at 1604 hours, showed to titrate fentanyl 25 mcg/hr every 15 minutes, with a goal of CPOT less than 2.

Review of the MAR dated 12/9/20, showed the following:

- At 1500 hours, the fentanyl medication was infused at 225 mcg/hr.

- At 1703 hours, the fentanyl medication was infused at 250 mcg/hr.

- At 1752 hours, the fentanyl medication was infused at 275 mcg/hr.

- At 1815 hours, the fentanyl medication was infused at 300 mcg/hr.

Review of the CPOT score assessment dated 12/9/20, showed Patient 24's CPOT score was "0" at 1700 and 1800 hours. However, there was no documented evidence of the CPOT scores for the above fentanyl titration at 1500, 1752, 1815 hours.

On 4/22/21 starting at 0845 hours, the medical record was reviewed with Clinical Nursing Director 1. Clinical Nursing Director 1 verified the above findings.

i. Review of Patient 8's medical record was initiated on 4/22/21. The medical record showed Patient 8 was admitted to the hospital's ICU on 12/16/20.

Review of the physician's order dated 1/8/21 at 1604 hours, showed an order for fentanyl 1000 mcg/100 ml (50 mcg/hr) to titrate by 25 mcg/hr every 15 minutes and the goal was for the CPOT less than 2; restricted to the management of pain.

Review of the MAR showed Patient 8 received the fentanyl drip at 100 mcg/hr on 1/9/21 at 0600 hours, and 200 mcg/hr at 0746 hours on 1/9/21.

Further review of the patient's medical record showed Patient 8's CPOTs were "0" on 1/9/21 at 0600 and 0800 hours. There was no documented evidence to show why the fentanyl drip was titrated up to 200 mcg/hr at 0746 hours.

On 4/21/21 at 1523 hours, an interview and record review was conducted with the Accreditation Coordinator. The Accreditation Coordination reviewed the patient's medical record and verified the above findings.

j. Review of Patient 11's medical record was initiated on 4/22/21. The medical record showed Patient 11 was admitted to hospital on 9/5/20.

Review of the physician's order dated 9/5/20 at 2052 hours, showed an order for fentanyl 1000 mcg/100 ml (25 mcg/hr) to titrate by 25 mcg/hr every 15 minutes and the goal was for the CPOT less than 2; restricted to the management of pain.

Review of the MAR dated 9/8 and 9/9/20, showed the following doses of fentanyl IV infusion was administered:

- fentanyl 75 mcg/hr on 9/8/20 at 0000, 0100, and 0200 hours.

- No fentanyl infusion from 0320 hours on 9/8/21 to 0243 hours on 9/9/21.

- fentanyl 25 mcg/hr on 9/9/20 at 0243 hours.

- fentanyl 50 mcg/hr on 9/9/20 at 0300 hours.

- fentanyl 75 mcg/hr on 9/9/20 at 0313 and 0400 hours.

Further review of the patient's medical record showed Patient 11's CPOT were "0" throughout the day on 9/8 and 9/9/20. However, there was no documented evidence to show why the fentanyl drip was restarted on 9/9/20 at 0243 hours and titrated up when the patient's CPOT had been zero.

On 4/22/21 at 1039 hours, an interview and record review was conducted with the Accreditation Coordinator and RN 4. The Accreditation Coordination and RN 4 reviewed the patient's medical record and verified the above findings.

k. Review of Patient 7's medical record was initiated on 4/19/21. The medical record showed Patient 7 was admitted to the hospital's ICU on 1/4/21.

Review of the physician's order dated 1/7/21 at 1035 hours, showed an order for fentanyl 1000 mcg/100 ml (25 mcg/hr) to titrate by 25 mcg/hr hour every 15 minutes and the goal was for the CPOT less than 2; restricted to the management of pain.

Review of the MAR dated 1/8/21, showed the following doses of fentanyl IV infusion was administered:

- fentanyl 75 mcg/hr at 0100, 0134, 2130 hours.
- fentanyl 50 mcg/hr at 0115 and 2100 hours.
- fentanyl 100 mcg/hr at 0145, 0500, 0602, 0820, 2200, and 2300 hours.
- fentanyl 125 mcg/hr at 0200, 0400, and 0615 hours.
- fentanyl 150 mcg/hr at 0300 and 0700 hours.
- fentanyl 25 mcg/hr at 2000 hours.

Review of the patient's medical record showed Patient 7's CPOT were "0" on 1/8/20. The fentanyl medication was titrated from 25 to 150 mcg/hr on 1/8/21. There was no documented evidence to show why the fentanyl drip was titrated up when the patient's CPOT was zero.

On 4/22/21 at 0940 hours, an interview and record review was conducted with the Accreditation Coordinator. The Accreditation Coordination reviewed the patient's medical record and verified the above findings.

l. Review of Patient 5's medical record was initiated on 4/22/21. The medical record showed Patient 5 was admitted to the hospital's ICU on 1/6/21.

* Review of the physician's order dated 1/6/21 at 1100 hours, showed an order for fentanyl 2000 mcg/40 ml (100 mcg/hr) to titrate by 25 mcg/hr every 15 minutes and the goal was for the CPOT less than 2; restricted to the management of pain.

Review of the MAR dated 1/8/21, showed the following doses of fentanyl IV infusion was administered:

- fentanyl 300 mcg/hr at 0000, 0055, 0100, 0200, 0300, 0400, 0500, 0600, 0751, 0859, 0900, 1000, 1155, 1200, and 1300 hours.

- fentanyl 200 mcg/hr at 1400, 1549, 1600, 1700, 1800, and 1900 hours,

- fentanyl 50 mcg/hr at 2000 and 2300 hours.

Review of the MAR dated 1/9/21, showed the following doses of fentanyl IV infusion was administered:

- fentanyl 50 mcg/hr at 0000, 0100, 0200, 0328, 0400, 0600, and 0740 hours.

- fentanyl 200 mcg/hr at 0700, 0800, 0900, hours.

- fentanyl 100 mcg/hr at 1000, 1100, 1200, 1300, 1400, 1500, 1600, 1700, 1800, 1823, 1900, 2000, 2100, 2200, and 2300 hours.

Review of the patient's medical record showed Patient 5's CPOTs were "0" throughout the day on 1/8 and 1/9/21. However, the fentanyl medication was titrated down on 1/8/21, and titrated up and down on 1/9/21. There was no documented evidence showing why the fentanyl medication was titrated up or down when the patient's CPOTs had been 0 for the whole day on 1/8 and 1/9/21.

* Review of the physician's order dated 1/6/21 at 1114 hours, showed an order for propofol 1000 mg (15 mcg/kg/min) to titrate by 5 mcg/kg/min every five minutes, with a goal of RASS score of -3 (moderate sedation) and recommended maximum rate of 50 mcg/kg/min.

Review of the MAR dated 1/8/21, showed the following:

- at 0000, 0055, 0100, 0200, 0300, 0400, 0500, 0600, 0700, 0900, 1000, 1102, 1200, 1300, 1400, 1544, 1600, 1700, 1800, 1900, 2000, 2011, 2100, 2200, and 2300 hours, the propofol drip was infused at 50 mcg/kg/min.

Review of the RASS score assessment dated 1/8/21, showed Patient 5's RASS score was -5 (unarousable). The propofol drip was maintained and infused at 50 mcg when the RASS score was at -5. There was no documented evidence to explain why the patient's dose was maintained at the maximum rate.

On 4/22/21 at 0942 hours, an interview and record review was conducted with the Accreditation Coordinator and RN 4. The Accreditation Coordination and RN 4 reviewed the patient's medical record and verified the above findings.

m. Review of Patient 16's medical record was conducted with the Director of Nursing Quality, Clinical Director 1, and Nurse Manager 2. Patient 16 was admitted to the hospital on 1/7/21.

* Review of the physician's order dated 1/8/21 at 0023 hours, showed pre-mixed dopamine (medication to improve BP) 800 mg in 250 ml (solution), usual starting rate 5 mcg/kg/min, titrate by 2 mcg/kg/min every 10 minutes, with a goal of MAP 65 mmHg and usual maximum dose of 20 mcg/kg/min.

Review of the MAR dated 1/8/21, showed the dopamine drip was infused at 5 mcg/kg/min at 0047 hours; and titrated as follows:

- 7 mcg/kg/min at 0057 hours,
- 9 mcg/kg/min at 0152 hours,
- 11 mcg/kg/min at 0415 hours, and
- 13 mcg/kg/min at 0423 hours.

However, review of the BPs and MAPs dated 1/8/21, showed Patient 16's MAPs were above 65 mmHg from 0120 hours to 1430 hours. There was no documented evidence why the medication was titrated when the patient's MAPs were above 65 mmHg.

* Review of the physician's order dated 1/7/21 at 2143 hours, showed to administer pre-mixed norepinephrine 8 mg in 250 ml solution, usual initiate rate at 1 mcg/min, titrate by 2 mcg/min every 5 minutes, with a goal of MAP 65 mmHg and not to exceed 30 mcg/min.

Review of the MAR dated 1/7/21 at 2101 hours, showed the norepinephrine drip was started at 30 mcg/min, turned off on 1/8/21 at 0415 hours, then resumed at 1717 hours, with the rate of 4 mcg/min.

Review of Patient 16's BPs and MAPs dated 1/8/21 from 1717 hour to 2143 hour, did not show the BPs and MAPs were consistently measured when the norepinephrine was titrated up at 1730, 1809, and 1821 hours.

* Review of the physician's order dated 1/7/21 at 2140 hours, showed to administer midazolam (narcotic sedative) 100 mg (1 mg/hr) pre-mixed in NS (salt water solution) 100 ml, usual starting rate is 1 mg/hr, titrate by 2 mg/hr every 15 minutes with a goal of - 3 sedation; to titrate by 5 mcg/kg/min every five minutes with a goal of RASS score of -3; and hold if SBP less than 90 mmHg.

Review of the RASS score assessment dated 1/7/21 at 2235 hour, showed the RASS score was -5 (unarousable).

Review of the MAR dated 1/7/21 at 2235 hour, showed the midazolam drip 1 mg/hr was initiated and continued until 1/8/21 at 0700 hours. There was no documented evidence to explain why the midazolam drip was initiated when the RASS score goal was already met.

The findings were verified with the Director of Nursing Quality.

2. Review of the hospital's P&P titled Medication Administration showed the interval between the times an order is initially prescribed to the time that administration is started showed the turnaround time for "STAT" order is 15 minutes, "NOW" order is 60 minutes, and "ROUTINE" order would be 120 minutes for the first dose.

Patient 3's medical record was reviewed on 4/19/21. The medical record showed Patient 3 was admitted to the hospital on 12/17/21, and discharged on 1/19/21.

a. Review of the Physician's Order dated 12/20/20 at 2304 hours, showed to administer Tylenol 500 mg every six hours for fever greater than or equal to 38.5 degrees C.

Review of the Temperatures dated 1/11/21 showed Patient 3's temperatures were greater than 38.5 degrees C. from 1900 to 0400 hours.

Review of the MAR dated 1/11/21 at 2055 hours, showed Patient 3 received Tylenol 500 mg. However, Patient 3 did not receive Tylenol 500 mg on 1/11/21 at 1900 hours, when Patient 3's temperature was 39 degrees C; and on 1/12/21 at 0255 hours, when Patient 3's temperature was still greater than 38.5 degrees C.

b. Review of the Critical Care Inpatient Progress Note dated 1/11/21 at 0600 hours, showed to continue vancomycin (antibiotic) as per the pharmacy for bacteremia for seven day course.

Review of the physician's order dated 1/12/21 at 0228 hours, showed to administer vancomycin 1,250 mg IVPB once.

Review of the MAR dated 1/12/21 at 0510 hours, showed the vancomycin medication was to start at 0230 hours. However, the document showed Patient 3 received the vancomycin medication two hours 42 minutes after the order was written.

On 4/22/21 at 0845 hours, the medical record was reviewed with Clinical Nursing Director 1. Clinical Nursing Director 1 verified the above findings.


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3. Review of Patient 9's medical record was initiated on 4/21/21. The medical record showed Patient 9 was admitted to hospital on 8/21/20.

Review of the physician's order dated 9/5/20 at 1923 hours, showed an order for acetaminophen (same as Tylenol) 500 mg one tablet by mouth every six hours PRN for fever greater than or equal to 38.5 degrees C.

Review of the MAR for 9/9/20, showed Patient 9 received acetaminophen 500 mg at 1815 hours. Patient 9's Vital Signs record showed the patient's temperature on 9/9/20, as follows:

- 37.6 degrees C at 1730 hours and 1800 hours.
- 37.3 degrees C at 1830 hours and 1900 hours.

Further review of the patient's body temperature record dated 9/9/20, failed to show documented evidence Patient 9 had a body temperature of greater than or equal to 38.5 degrees C when received acetaminophen 500 mg at 1815 hours on 9/9/20.

On 4/21/21 at 1502 hours, an interview and record review was conducted with the Accreditation Coordinator and RN 4. The Accreditation Coordination and RN 4 reviewed the patient's medical record and verified the above findings.

4. Review of Patient 12's medical record was initiated on 4/21/21. The medical record showed Patient 12 was admitted to hospital on 8/9/20.

Review of the physician's order dated 9/1/20 at 1217 hours, showed an order to administer Atrovent (bronchodilator) 0.5 mg/2.5 ml via nebulizer every six hours and albuterol (bronchodilator) 2.5 mg/0.5 ml via nebulizer every six hours.

Review of Patient 12's MAR dated 9/8/20, showed the entries for Atrovent and albuterol medications as "not done: busy at 1300 hours." There was no documented evidence to explain regarding the entry if the nurse or the patient was busy, or if the physician was notified for not administering the medications as ordered.

On 4/21/21 at 1324 hours, an interview and record review was conducted with the Accreditation Coordinator. The Accreditation Coordination reviewed the patient's medical record and verified the above findings.


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5. Review of the hospital's P&P titled Medication Prescribing dated 6/18 showed the PRN orders for analgesic medications must include the pain level or pain score when more than one pain medication is prescribed. Breakthrough pain is pain that comes on suddenly for short periods of time and not alleviated by the patient's normal pain suppression management.

Review of the hospital's P&P titled Pain Management dated 4/18 showed when pain is present, a detailed assessment will be performed to include the following parameters:

- Pain intensity
- Pain quality
- Location
- Onset, duration, variation, and patterns
- Alleviating and aggravating factors
- Present pain management and its effectiveness

The P&P also showed the assessments will be performed initially, and ongoing as part of the routine assessment or as necessary per the patient's needs. Reassessment will be done as indicated by persistence of pain, and after any interventions provided for pain management.

On 4/21/21 at 1130 hours, a concurrent record review and interview was conducted with Clinical Nurse Director 3 and the Infection Prevention RN regarding Patient 26.

Review of Patient 26's Order dated 4/20/21 at 2119 hours, showed to administer hydromorphone (opioid pain medication) 0.2 mg IVP every four hours for breakthrough pain.

Review of Patient 26's Order dated 4/20/21 at 2123 hours, showed to administer oxycodone (opioid pain medication) 10 mg two tablets by mouth every four hours as needed for severe pain (pain levels of 7-10 on a 0-10 pain scale, with 0 is no pain and 10 is the worst pain).

Review of the Pain Intervention flowsheet dated 4/20/21 at 2340 hours, showed Patient 26 had a stated numeric pain level of "10" in the left leg.

Review of Patient 26's MAR dated 4/20/21 at 2353 hours, showed hydromorphone 0.2 mg IVP was administered.

Review of the Pain Interventions flowsheet dated 4/21/21 at 0008 hours, showed Patient 26's pain level was reassessed as a stated pain level of "10."

However, review of of the medical record failed to show documented evidence of other pharmacological or non-pharmacological pain management interventions provided for Patient 26 until 4/21/21 at 0237 hours, when the MAR showed the patient was given oxycodone 10 mg tablets by mouth.

Further review of the MAR showed Patient 26 was administered hydromorphone 0.2 mg IVP on 4/21/21 at 0618 hours. However, there was no documented evidence of the patient's pain assessment being performed. Additionally, the MAR showed Patient 26 was administered oxycodone 10 mg tablets by mouth again seven minutes later on 4/21/21 at 0625 hours, with no assessment of the patient's pain by the nurse.

Clinical Nurse Director 3 and the Infection Prevention RN acknowledged the above finding and verified Patient 26's inconsistent pain assessments and lack of documentation to support the PRN pain medications were administered as ordered.