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On the days of the hospital validation survey based on interview, record review, and review of hospital policy and procedures, the hospital failed to ensure patients received their patient rights information on admission to the hospital for 4 of 5 inpatient records reviewed (Patient 1, 3, 4 and 5) and for 2 of 16 discharged patient records reviewed (Patient 8 and 11).

The findings are:

On 3/05/14 at 10:40 a.m., review of Patient 3's open inpatient chart revealed the patient was admitted to the hospital on 03/04/1, but review of the patient acknowledgement for receipt of "Children's Notice of Privacy Practices and Patient Rights" was signed and dated 12/27/11. The hospital had no evidence that the patient had received and signed a more recent "Patient Acknowledgement" form. The finding was verified by Staff Member 15.



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On 03/04/14 at 1:45 p.m., review of Patient 8's discharged chart revealed the patient had a procedure performed on 02/05/14, but the last "Patient Acknowledgement" form was signed and dated 10/18/13. The hospital had no evidence that the patient had received and signed a more recent "Patient Acknowledgement" form

On 03/04/14 at 3:00 p.m., review of Patient 11's discharged chart revealed the patient had a procedure performed on 02/20/14, but the last "Patient Acknowledgement" form was signed and 11/14/13. The hospital had no evidence that the patient had received and signed a more recent "Patient Acknowledgement" form

On 03/05/14 at 10:40 a.m., review of Patient 5's open inpatient chart revealed that the patient had a procedure performed on 03/04/14, but the last "Patient Acknowledgement" form was signed and dated 12/06/13. The hospital had no evidence that the patient had received and signed a more recent "Patient Acknowledgement" form




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On 3/4/14 at 09:30 a.m., review of Patient 1's inpatient record revealed there was no current patient rights and responsibilities information given to the patient. The hospital's Patient Acknowledgement form was signed and dated 9/26/13, and the patient's date of service for surgery was 3/3/14. The hospital had no evidence that the patient had received and signed a more recent "Patient Acknowledgement" form . The finding was verified with Staff Member 22 on 3/4/14 at 10:50 a.m..

On 3/5/14 at 11:00 a.m., review of Patient's 4"s inpatient record revealed there was no current patient rights and responsibilities information given to the patient. The hospital's Patient Acknowledgement form was signed and dated 10/07/13, and the patient's date of service for surgery was 3/4/14. The hospital had no evidence that the patient had received and signed a more recent "Patient Acknowledgement" form. The finding was verified with Staff Member 15 on 3/5/14 at 11:00 a.m..

On the days of the hospital validation survey based on record reviews, interviews, and electronic documentation, the hospital's own staff failed to document when patients are admitted if the patient has an advance directive for 6 of 15 inpatient records(Patient 1, 2, 3, 4, 5, and 14) and 11 of 16 discharged patient records. (Patient 1, 2, 4, 6, 7, 8, 10, 11, 13, 15, and 16)

The findings include:

On 3/4/14 at 10:59 a.m., Staff Member 23 revealed, "Advanced directive information is discussed with the patient and/or parent and is supposed to be documented in the patient's pre-admission planning assessment."

On 03/06/2014 at 2:00 p.m., review of Patient 3's inpatient record revealed that during the admission process, the Registered Nurse(RN) documented, "...Advance Directive: Not applicable due to age...". On 03/06/2014 at 2:30 p.m., the finding was verified with Staff Member 15.

On 03/06/2014 at 2:05 p.m., review of Patient 14's inpatient record that during the admission process, the Registered Nurse documented electronically, "...Advance Directive: Not applicable due to age...". On 03/06/2014 at 2:30 p.m. the finding was verified with Staff Member 15.

On 03/06/2014 at 2:10 p.m., review of Patient 15's discharged chart revealed that during the admission process, the Registered Nurse documented electronically, "...Advance Directive: Not applicable due to age...". On 03/06/2014 at 2:30 p.m., the finding was verified with Staff Member 15.

On 03/06/2014 at 2:10 p.m., review of Patient 16's discharged chart revealed that during the admission process, the Registered Nurse documented electronically, "...Advance Directive: Not applicable due to age...". On 03/06/2014 at 2:30 p.m., the finding was verified with Staff Member 15.










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On 3/4/14 at 10:45 a.m., review of Patient 2's inpatient chart revealed the nurse documented in the advance directive section that advanced directives were "not applicable due to age" during the patient's admission process.

On 3/5/15 at 2:05 p.m., review of Patient 1's discharged chart revealed the nurse documented in the advance directive section that advanced directives were "not applicable due to age" during the patient's admission process.

On 3/6/15 at 2:10 p.m., review of Patient 4's discharged chart revealed the nurse documented in the advance directive section that advanced directives were "not applicable due to age" during the patient's admission process.

On 3/6/15 at 2:15 p.m., review of Patient 2's discharged chart revealed the nurse documented in the advance directive section that advanced directives were "not applicable due to age" during the patient's admission process.

On 3/6/15 at 2:20 p.m., review of Patient 3's inpatient chart revealed the nurse documented in the advance directive section that advanced directives were "not applicable due to age" during the patient's admission process.

On 3/6/15 at 2:20 p.m., review of Patient 4's discharged chart revealed the nurse documented in the advance directive section that advanced directives were "not applicable due to age" during the patient's admission process.

On 3/6/15 at 2:25 p.m., review of Patient 13's discharged chart revealed the nurse documented in the advance directive section that advanced directives were "not applicable due to age" during the patient's admission process.
The findings were verified on 03/06/14 at 2:40 p.m. by Staff Member 15.





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On 03/04/14 at 1:45 p.m., review of Patient 8's discharged chart revealed that the Advance Directive answer selected by the nurse was "Not applicable due to age".

On 03/04/14 at 2:45 p.m., review of Patient 10's discharged chart revealed that the Advance Directive answer selected by the nurse was "Not applicable due to age".

On 03/04/14 at 3:00 p.m., review of Patient 11's discharged chart revealed that the Advance Directive answer selected by the nurse was "Not applicable due to age".

On 03/05/14 at 10:40 p.m., review of Patient 5's inpatient chart revealed that the Advance Directive answer selected by the nurse was "Not applicable due to age".








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On 3/6/14 at 1:30 p.m., review of Patient 1's inpatient record revealed the nurse documented "not applicable due to age" in the section labeled Advanced Directives.

On 3/6/14 at 1:33 p.m., review of Patient 4's inpatient record revealed the nurse documented "not applicable due to age" in the section labeled Advanced Directives.

On 3/6/14 at 1:37 p.m., review of Patient 7's discharged record the nurse documented "not applicable due to age" in the section labeled Advanced Directives.

On 3/6/14 at 1:40 p.m., review of Patient 6's discharged record revealed the nurse documented "not applicable due to age" in the section labeled Advanced Directives.

The findings were verified with Staff Member 15 on 3/6/2014 at 1:40 p.m. during record review.

Review of the hospital's electronic documentation on 03/06/2014 at 2:25 p.m., reads, "... *Advance Directive (bubble) Yes (bubble) No (bubble) Not applicable due to age...".

On 03/06/2014 at 2:25 p.m., the Clinical Coordinator stated "yes" means the nurse asks for documentation if the documentation is not on the patient's record from pre-admission, and "no" means provide information and document if patient wishes to receive further information, "not applicable" means the patient is under 18 and the advance directive is applicable only to 18 and up. If the patient is under 18, the questions are directed to the parent because the child is a minor, and if the child is over 18, the questions are directed to the patient.

On the days of the validation survey based on record review, interview, and review of hospital policy and procedures, the hospital failed to ensure its staff completed the patient's initial pain assessment and assessed and reassessed the patient's pain for 2 of 16 discharged records(Patient 3 and 7) and 1 of 5 inpatient records(Patient 1) reviewed for care and services related to pain.

The findings include:

On 03/04/2014 at 2:30 p.m., review of Patient 3's discharged record revealed the patient's pain assessment was not completed by the registered nurse during the patient's initial nursing assessment on 12/03/2013 at 9:50 a.m.. The pain assessment section was blank. On 03/04/2014 at 3:15 p.m., the finding was verified by Staff Member 25.




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On 3/4/14 at 9:30 a.m., review of Patient 1's inpatient record revealed there was no documentation of pain assessment scores prior to the administration of the following medications to the patient:
Morphine 2 milligrams (mg) Intravenous (IV) on 3/3/14 at 2350;
Morphine 2 mg IV on 3/4/14 at 0350; and
Norco 7.5 mg orally on 3/4/14 at 0858.

On 3/4/14 at 2:42 p.m., review of Patient 7's discharged record revealed there was no pain assessment score prior to the administration of the following medications to the patient:
Hydrocodone Elixir 5 mg orally on 12/14/13 at 0715
The findings were verified with Staff Member 15 on 3/4/14 at 2:45 p.m. during record review.

Hospital Nursing Policies and Procedures, titled, "Pain Management", reads "....2. documentation will include pain score assessments on IVIEW, interventions, and patient responses....".

Review of hospital policy and procedures, titled, "...Nursing Policies and Procedures NP-58 Title Nursing Documentation...Review/Revision Date 01/14", reads, "...POLICY: To facilitate clinical documentation that is current, timely, and complete. To provide a consistent standard for nursing documentation in the electronic medical record as well as during downtime. PROCEDURE: A. Admission Assessment Guidelines 1. Upon admission, each patient will be assessed as appropriate to include history, physical, psycho-social, cultural, educational, spiritual needs, pain status and score, fall assessment, home medications and discharge planning needs 2. Admission assessment will be completed within eight hours and prior to a patient having surgery...D. Pain Assessment/Reassessment 1. An assessment of pain is performed for all patients, including an initial pain score and at reassessment...4. Pain is assessed and documented: D. Upon admission or presentation for care E. At least every 12 hours F. At the time of the patient's report of pain G. Within one hour 30 minutes following any intervention provided for relief of pain H. hourly for patients receiving continuous pain medications...".

On the days of the validation survey based on observation and interview, the hospital failed to ensure its own nursing staff properly demonstrated the use of emergency equipment automatic external defibrillator (AED)/Defibrillator) for 1 of 2 Registered Nurses observed in the outpatient clinic. (Staff Member 3)

The findings are:

On 03/03/14 at 12:45 p.m., observations and interview with Staff Member 3 related to code procedures revealed Staff Member 3 stated, "I usually check the equipment in the mornings. I would check the patient's airway, breathing, circulation, check vital signs, call the code, and wait for the code team from Hospital B to arrive. If it takes too long for the code team to arrive from hospital B, then after 2 minutes, I would apply the AED monitor". During demonstration of the AED monitor, Staff Member 3 was not able to verbalize or demonstrate the use of the AED correctly. On 03/03/14 at 12:50 p.m., during observations of Staff Member 3 demonstrating the use of a suction machine, Staff Member 3 was unable to connect the Yankauer to the suction tubing for suction. Then, Staff Member 3 stated to the surveyor, "Can you come back to me. I need to go get the other supplies for connection", but all of the required suction supplies were present. On 3/3/14 at 1:00 P.M., Staff Member 24 verified the findings.

On the days of the hospital validation survey based on interview, record review, and review of hospital policy and procedures, the hospital staff failed to follow physicians orders for medication administration for 1 of 16 discharged patient (Patient 4), and failed to follow the physician's order for the administration of pain medication regulated by the patient's level of pain for 1 of 5 inpatient records (Patient 5), and hospital staff failed to follow hospital procedures when a patient's ordered medications are not administered in acceptable time frame for 1 of 5 inpatient records (Patient 1).

The findings are:

On 03/04/14 at 2:15 p.m., review of Patient 4's discharged chart revealed physician order dated 01/07/14 at 1:11 a.m. that stated, "acetaminophen (acetaminophen oral liquid) 240 mg (milligram), Q 4 hours, PRN (as needed) for Pain or fever greater than 38.6 C (Celsius)....". Review of nursing documentation revealed Acetaminophen 240 mg oral liquid was administered on 01/08/14 at 5:31 p.m. Review of the patient's chart revealed staff documented the patient's temperature 38.3 degrees and there was no pain assessment documented on 01/08/14 at 5:31 p.m.. There was no documentation of a reason that the Acetaminophen was administered.
Further review of the patient's chart revealed a physician order dated 01/09/14 at 8:00 a.m. for "diazepam (diazepam oral liquid) 2 mg every 6 hours, PRN for: muscle spasms....". Review of nursing documentation revealed Diazepam 2 mg oral liquid was administered on 01/09/14 at 8:12 a.m. and on 01/10/14 at 00:27 a.m.. Review of the patient's pain assessment dated 01/09/14 at 8:10 a.m. revealed the nurse documented, "restlessness - 0, muscle tension-relaxed, facial expression - no frowning or grimacing, composed, vocalization - normal tone, no sound, wound guarding - no negative response, and observation for pain assessment score - 0". The nurse documented a re-assessment of the patient's pain at 8:42 on 1/09/14 as all areas assessed was "0". On 01/10/14 at 00:27, the nurse administered Diazepam 2 mg oral liquid, but documented "restlessness - 0, muscle tension - relaxed, facial expression - no frowning or grimacing, composed, vocalization - normal tone, no sound, wound guarding - no negative response, and observation pain assessment score-0". Pain re-assessment at 00:57 a.m. noted "improved" by nursing staff.
On 1/10/14 at 00:57 a.m., the nurse documented the patient's pain as "improved"..







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On 03/05/14 at 10:40 a.m., review of Patient 5's inpatient chart revealed Patient 5 had a physician order for Bupivacaine 0.125% in NACl(Sodium Chloride) 0.9% 50 ml(milliliters) ordered and an Epidural infusing with acetaminophen-hydrocodone (acetaminophen-hydrocodone 325 mg (milligrams) - 7.5 mg/15 ml elixir) 3 ml, elixir, oral, Q(every) 4 hours PRN(as needed) for: pain or discomfort with physician order comments "Max(maximum) dose 75 mg per kg(kilogram) day not to exceed 745 mg per day. May give 2 ml for pain scores 0 - 3, 3 ml for pain scores 4 - 6. For severe pain (pain scores 7 - 10) please see Morphine order. The Acetaminophen-Hydrocodone 3 ml elixir was administered with the following pain assessments on:
03/04/14 at 11:34 p.m.: Acetaminophen-Hydrocodone 3 ml administered with a pain assessment of "0" and a pain reassessment at 11:04 p.m. of "0".
03/05/14 at 02:16: Acetaminophen-Hydrocodone 3 ml administered with a pain assessment of "0" and a pain reassessment at 11:46 p.m. of "0".
03/05/14 at 06:09: Acetaminophen-Hydrocodone 3 ml administered with a pain assessment of "0" and a pain reassessment at 06:39 a.m. of "0". On 03/06/14 at 11:50 a.m., Staff Member 15 revealed that nurses usually administer the oral pain medication prior to discontinuing the PCA (Patient Controlled Analgesia) pump or Epidural pump during their transition to oral medications for simple pain control. There was no explanation or reasoning given for Patient 5 receiving Acetaminophen - Hydrocodone 3 ml instead of Acetaminophen - Hydrocodone 2 ml for pain of 0 - 3 as ordered by the physician.

Hospital policy, titled, "Pain Management", reads, "....A. Administers pain medication according to MD(Medical Doctor) order and is aware of safe dosage...".





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On 3/4/14 at 10:25 a.m., review of Patient 1's inpatient medical record revealed the patient had scheduled medications on the patient's Medication Administration Record (MAR) and the medications had not been given as ordered. The following medications were ordered but not administered on 3/4/14:
Lansoprazole 15 mg orally at 0800
CO Q-10 2 tablets orally at 0800
Levocarnatine 3.85 mg orally at 0800
Miralax 17 grams per g-tube at 0900
On 3/4/14 at 10:30 a.m., Staff Member 27 revealed the medications were not administered because the patient refused the medications when they were offered. Staff Member 27 reported that per hospital policy, staff are to document on the patient's MAR within 30 minutes when medications are not administered, and then to schedule the medications for an alternate time for administration. On 3/4/14 at 10:30 a.m., the findings were verified with Staff Member 15.

On the days of the hospital's validation survey based on review of discharged patient charts and review of the hospital's Medical Staff Bylaws and Procedural Rules, the physician failed to complete a discharge summary on 1 of 16 discharged patient charts. (Patient 12)

The findings are:

On 03/04/13 at 3:25 p.m., review of discharged Patient 12's chart revealed the chart had no physician discharge summary 30 days after the patient's discharge. The finding was verified by Staff Members 18 and 26.

Hospital Medical Staff Bylaws and Procedural Rules, reads, "....Discharge order and discharge summary: In order to provide information to other caregiver and facilitate the patient's continuity of care, the medical record must contain a concise discharge summary that includes the following....".

On the days of the hospital validation survey based on observations and interview, the hospital failed to ensure its staff removed expired medications from 2 of 2 patient care medication rooms. (West and East inpatient unit medication rooms)

The findings are:

On 3/3/14 at 1:15 p.m., observation in the West Inpatient Unit medication room refrigerator revealed two (2) - 25 milliliter (ml) 0.9% normal saline mini bags with Cefazolin 320 milligrams (mg) added. The medication had an expiration date of 2/28/14 at 1500. The findings were verified with Staff Member 7 on 3/3/14 at 1:15 p.m..

On 3/3/14 at 1:30 p.m., observation in the East Unit medication room revealed an opened 10 ml vial of 0.9% normal saline that had no label with the date, initials, or time when the solution was removed from the package. The findings were verified with Staff Member 7 and 10 on 3/3/14 at 1:30 p.m..

On the days of the hospital's validation survey based on observations and interviews, the hospital failed to ensure that suction supplies were left packaged prior to patient use to prevent potential cross infection in 1 of 2 examination rooms in the radiology department and in all 18 patient rooms located on the nursing unit on the second floor. (Radiology Examination Room 2 and Rooms 211 through 219 on the nursing inpatient unit) In the Post Anesthesia Care Unit (PACU), the hospital failed to ensure an acceptable level of safety and quality in monitoring the temperatures of 1 of 2 blanket warmers. (Blanket warmer 1)



The findings include:

On 2/04/2014 at 10:00 a.m., random observations of the radiology department's examination room 2 revealed unlabeled suction tubing connected to the wall suction canisters. There was no patient in the examination room. On 2/04/2014 at 10:05 a.m., the Radiology Director reported, "...I do not know when the tubing was changed last...We have not used it (suction equipment) in a while. It (suction equipment) is changed if it is used".

On 3/04/2014 at 12:05 p.m., random observations the nursing inpatient rooms revealed unlabeled suction tubing connected to wall suction canisters in patient room 211 with 3 beds, patient room 212 with 3 beds, patient room 213 with 2 beds, patient room 214 with 1 bed, patient room 215 with 1 bed, patient room 216 with 1 bed, patient room 217 with 2 beds, patient room 218 with 2 beds, and patient room 219 with 3 beds all of which had no patients. On 3/04/2014 at 12:30 p.m., the Clinical Director reported if the suction equipment is used on a patient, the suction equipment is changed when the patient is discharged. If the patient room has multiple beds, then the suction equipment for that patient is changed when that patient is discharged. The Clinical Director reported that he/she could not verify when any of the suction equipment was hung on the patient care unit.




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On 03/03/14 at 1:30 p.m., random observations in the PACU(Post Anesthesia Care Unit) revealed "blanket warmer 1" with no visible temperature gauge or evidence of recordings of blanket warmer 1's temperatures. On 03/03/14 at 1:30 p.m., Staff Member 2 revealed that no monitoring or documentation of the temperatures for blanket warmer 1 was performed from February 23, 2014 through March 1, 2014. On 03/06/14 at 11:30 p.m., Staff Member 2 presented a temperature log for the blanket warmers for the dates of March 3, 2014, March 4, 2014, March 5, 2014, and March 6, 2014. Staff Member 2 reported an infrared gun is obtained from maintenance every morning, and the gun is pointed at the blanket warmers to obtain the temperature because the thermostat does not go up to 110 degrees and is always burning out.

Hospital Policy, titled, "Equipment Management Plan: Environment of Care", reads, "....establish definable and measurable outcomes that support safe equipment management....".

On the days of the hospital validation survey based on interview and review of governing body data and infection control program data, the hospital failed to present evidence of the appointment in writing of its infection control officer.

The findings are:

On 3/3/14 at 1:54 p.m., Staff Member 6 revealed that he/she has been the hospital's Infection Control Officer since 1995. On 3/3/14 at 3:45 p.m., review of the infection control program data submitted by Staff Member 6 had no documentation of the appointment of the Infection Control Officer.
On 3/4/14 at 10:05 a.m., Staff Member 1 revealed there was no documentation in the governing body meeting minutes of the appointment of Staff Member 6 as the Infection Control Officer since 1995. Staff Member 1 stated, "it was just never done."

On the days of the hospital validation survey based on observations, interview, and review of hospital policy and procedures, 1 of 10 hospital licensed staff (Staff Member 19) failed to follow standard infection control measures to prevent potential cross contamination between patients.

The findings are:

On 3/5/14 at 09:08 a.m., observations on the West inpatient nursing unit showed Staff Member 19 failed performed gastric tube care but failed to remove the soiled gloves prior to exiting the patient's room. Staff Member 19 returned to the patient's room wearing the same soiled gloves with a white Styrofoam cup filled with hot water to complete the care of the gastric tube. Upon completion of the care of the gastric tube, Staff Member 19 discarded the supplies, removed the soiled gloves, and cleaned hands with hand sanitizer before exiting the room. On 3/5/14 at 09:23 a.m., Staff Member 19 verified the findings stating, "I didn't even realize I had done that."

Hospital Infection Control Policies and Procedures, titled, Standard Precautions, reads, "....c. gloves should be changed after contact with each patient and hands washed after gloves are removed....".

Hospital Infection Control Policies and Procedures, titled, Handwashing/Hand Hygiene, reads, ".... at minimum, staff will wash hands immediately, or as soon as feasible, after removal of gloves or other personal protective equipment....".

On the days of the hospital validation survey based on interview, review of hospital personnel records, and review of hospital policy and procedures, hospital management failed to ensure that the appropriate patient care staff received training on Organ Procurement Organization (OPO) services for 10 of 10 nursing personnel charts reviewed for OPO training. (Staff Member 2, 6, 10, 15, 16, 18, 19, 20, 21, and 26)

The findings are:

On 03/03/14 at 2:35 p.m., revealed that nurses do not receive training in OPO services. Staff Member 1 reported that nurses are only trained to call the Hospital B Supervisor for any OPO services related to a contract between Hospital A and B. On 03/05/14 at 2:00 p.m., review of 10 personnel charts revealed there was no evidence of in-service training for OPO in the 10 nurses' file.

Hospital policy, titled, "Organ and Tissue Donation Protocol", reads, "....Education; The hospital and the procurement agencies will participate in a cooperative effort to provide education and information about donation to hospital personnel on a regular basis."