HospitalInspections.org

Based on interview, record review, and document review, the facility failed to ensure an effective governing body was legally responsible for the conduct of the hospital. The governing body failed to ensure nursing services were furnished in accordance with facility policies and procedures (See Tag A0385).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory mandated care to patients.

Based on observations, the facility failed to ensure patients' privacy in the Emergency Room (ER) during medical care and procedures.

Findings include:

On 6/21/11 at 9:00 AM, a cardiac arrest was in progress in the bed directly behind the nurse's station. The curtain was not pulled around the patient while the staff performed cardiopulmonary resuscitation on the patient. The patient was visible to other patients, family, and visitors who were in the ER at the time.

On 6/21/11 at 11:00 AM, observed staff drawing blood on a Patient #13 in Bed 5. The curtains were not pulled around the patient to promote personal privacy. The patient was visible to other patients, family and visitors who were in the ER at the time.

Based on record review, interview and policy review, the facility failed to maintain medical staff credentialing files according to its policy for 3 of 10 physicians (Physicians #68, #69, and #70).

Findings include:

On 6/23/11, Employee #71 reviewed physician files and discovered the files for Physicians #68, #69, and #70 contained two peer references each.

According to the facility's policy, Article Two: Content of Application Form under section d) Peer References, the facility required at least three practitioners who worked with each applicant to complete peer references.

Based on observation, interview, record review and document review, the facility failed to develop nursing care plans (Tag A0396); failed to appropriately train contracted staff (Tag A0398); failed to dispense medications according to hospital policies (Tag A0404); failed to ensure physicians' orders were documented, dated, and signed by the practitioner (Tag A0406); and failed to administer blood transfusions according to hospital policy (Tag A0409).

The cumulative effect of these systemic practices resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on record review and interview, the facility failed to ensure a nursing care plan was developed for 2 patients (Patients #11, #12).

Findings include:

The facility policy titled, "Care Planning," dated 12/09, stated, "Each patient will have a plan of care developed at the completion of the admission assessment and documented in the medical record."

Patient #11

Patient #11 was brought to the Emergency Room (ER) on 6/19/11 at 12:15 PM, by ambulance after being found down in his apartment. Based on the ER physician's notes, the patient was able to respond yes and no to questions and there was no other verbal response. A workup was completed including a CT (Computerized Tomography) of the brain, which showed an acute subdural hematoma, and a CT of the chest which showed bilateral pulmonary emboli.

Patient #11 was started on IV (Intravenous) fluids, medications to control his blood pressure, and a cardiac monitor. The patient was intubated on 6/19/11 at 13:50 (1:50 PM), and placed on a ventilator. The patient was admitted as ICU (Intensive Care Unit) level of care, but was held in the ER since there was no ICU bed available.

On 6/22/11 in the morning, there was no care plan developed for Patient #11.

Patient #12

Patient #12 was admitted through the Emergency Room (ER) on 6/20/11 at 22:50 (10:50 PM), with complaints of chest pain and gastrointestinal bleeding (GIB). Documentation in Patient #12's medical record revealed the patient had active GI bleeding while in the ER, and was intubated on 6/21/11 at 18:25 (6:25 PM). Patient #12 was admitted as ICU (Intensive Care Unit) level of care, but was held in the ER since there was no ICU bed available.

On 6/23/11 in the morning, there was no care plan developed for Patient #12.

In the afternoon of 6/22/11, the Director of Emergency Services confirmed there were no care plans developed for Patient #11 and Patient #12, and added that the care plans were not usually developed in the ER.

Based on observation, interview, record review and document review, the facility failed to ensure non-employee, licensed nurses were trained adequately and adhered to the facility's policies and procedures.

Findings include:

The facility policy titled, "Medication: Distribution/Administration," dated 7/2010, documented:
- "Wasting Medications:
-1. Medications that are unusable (i.e., removed from their protective seal, broken vial, dropped on floor) or a partial dose of a controlled substance must be wasted.
- 2. To waste a medication:
- ...e. Have a witness enter ID and password for controlled substance ... "

Patient #11

On 6/22/11 at 10:00 AM, a Registered Nurse (RN), Employee #16, was observed providing care for Patient #11. The patient was an ICU (Intensive Care Unit) hold in the Emergency Room.

Patient #11 was on a ventilator, on multiple IV (Intravenous) drips including Propofol for sedation.

a) On 6/22/11 at 9:45 AM, observed several vials of medication and syringes lying on Patient #11's bedside table in his room. The RN was not in the room, but was in a room across the hallway. At 10:15 AM, the RN entered the room to administer Patient #11's medications. The RN touched and shook the patient's shoulder and asked him if he was in pain. The RN explained she was going to give Patient #11 his pain medication.

The RN took a vial from the bedside table and opened it. She withdrew some medication and indicated she was going to dispose of the remainder of the medication in the sharps container in the room. Before the nurse disposed of the vial, the surveyor asked to see the vial and asked the nurse about the medication. The nurse explained she had taken a vial of Morphine Sulfate (MS) 5 mg. from the Pyxis system. She knew she was going to administer only 3 mg. of the medication. She told the nurse in the medication room that she was going to waste 2 mg. of the medication. She then placed the medication vial in Patient #11's room on the bedside table.

At 10:18 AM, the RN administered MS 3 mg. IV to Patient #11.

The print out obtained from the Pyxis system indicated the RN signed out MS 5 mg. from the Pyxis system at 9:35 AM. The printout indicated the RN wasted 2 mg. and was witnessed by RN #2, Employee #62.

On 6/22/11 at 10:40 AM, interviewed RN #2 who explained the facility policy regarding controlled substances. She verbalized when a nurse pulled a controlled substance, such as MS, and knew she will not use the entire vial, the amount wasted must be wasted in the medication room and witnessed by a second nurse. Both nurses should document the amount of medication wasted. When the nurse was asked if she witnessed RN #1 waste the 2 mg of MS, she revealed she did not see the nurse waste the medication, but signed as the witness.

b) Since Patient #11 had an IV of Propofol in progress, RN #1 was asked to explain the timeframes for changing the IV tubing and medication. The nurse explained she had experience with administering Propofol and the timeframes for changing the tubing was different at different facilities. She indicated sometime the timeframe was 12 hours or 24 hours or whenever the bottle was changed. When interviewed if she knew what the policy was for this facility, she indicated she did not.

The RN indicated she was an agency nurse and this was her second day at this facility. She verbalized she had general orientation, but no training specific to this ER or ICU. She added there were staff available to ask if she had questions.


26251


Patient #18

On 6/10/11, the facility admitted Patient #18 with diagnoses of altered mental status, respiratory failure, atrial fibrillation, seizures, sinusitis, and leukocytosis.

On 6/10/11, a physician ordered Morphine Sulfate 1-5 milligrams every hour as needed intravenously.

On 6/19/11 at 3:53 AM, Employee #72 signed out 5 milligrams of intravenous Morphine Sulfate from the Pyxis dispenser.

On 6/19/11 at 4:00 AM, Employee #72 initialed the administration of 3 milligrams of intravenous Morphine Sulfate on Patient #18's medication administration record.

On 6/23/11 at 1:36 PM, the charges and credits report for the Pyxis dispenser lacked documentation of 2 milligrams of wasted intravenous Morphine Sulfate.

Patient #18's file lacked documentation of 2 milligrams of wasted intravenous Morphine Sulfate.

Employee #72 did not appear on the facility's current employee roster dated 6/21/11.

A male charge nurse indicated Employee #72 was an agency nurse, not a facility employee.

Based on observation, interviews, record review and document review, the facility failed to ensure medications were administered in accordance with Federal and State laws and accepted standards of practice for 7 of 34 patients (Patients #11, 12, 16, 17, 18, 26, 27).

Findings include:

1. Patient #12

Patient #12 was admitted through the Emergency Room on 6/20/11 at 22:50 (10:50 PM), with complaints of chest pain and gastrointestinal bleeding (GIB). Documentation in Patient #12's medical record revealed the patient had active GI bleeding while in the ER, and was intubated on 6/21/11 at 18:25 (6:25 PM). Patient #12 was admitted as ICU (Intensive Care Unit) level of care, but was held in the ER since there was no ICU bed available.

a) On 6/22/11 at 2:00 PM, Patient #12 was noted to have a Propofol drip infusing. The IV tubing connected to the Propofol drip indicated: Start 6/22/11 at 12:30 PM, D/C (Discontinue) 6/26/11 at 12:30 PM.

b) On 6/22/11 at 9:45 AM, observed Patient #12 with an Intravenous (IV) of Normal Saline infusing. There was no label on the bag which indicated the date and time the IV bag was hung or the rate of infusion.


2. Patient #11

Patient #11 was brought to the Emergency Room (ER) on 6/19/11 at 12:15 PM, by ambulance after being found down in his apartment. Based on the ER physician's notes, the patient was able to respond yes and no to questions and there was no other verbal response. A workup was completed including a CT (Computerized Tomography) of the brain, which showed an acute subdural hematoma, and a CT of the chest which showed bilateral pulmonary emboli.

The patient was started on IV (Intravenous) fluids, medications to control his blood pressure, and connected to a cardiac monitor. The patient was intubated on 6/19/11 at 13:50 (1:50 PM), and placed on a ventilator. The patient was admitted as ICU (Intensive Care Unit) level of care, but was held in the ER since there was no ICU bed available.

a) Patient #11's medications included:
- Diprivan (Propofol) drip for sedation.

On 6/21/11, Patient #11 was observed to have a Propofol drip in progress.

Documentation on the Medication Administration Record (MAR) did not include the time the Propofol was hung. The ICU nurse's documentation form indicated the specific rate at which the Propofol was infusing on an hourly basis. However, there was no time documented when the Propofol was hung.

On 6/22/11 at 10:20 AM, interviewed the Registered Nurse (RN) caring for Patients #11 and #12 regarding the administration of Propofol. The RN explained she had experience with administering Propofol and the timeframes for changing the tubing was different at different facilities. She indicated sometimes the timeframe was 12 hours, 24 hours or whenever the bottle was changed. When interviewed if she knew what the policy was for this facility, she indicated she did not.

The facility policy titled, "Intravenous Therapy," dated 8/2009, documented: "Replace tubing used for the administration of Propofol is to be in use no longer than 12 hours and should be changed per manufacturers recommendation (sic). "

The manufacturer's recommendations documented on the Propofol insert regarding the administration of Propofol indicated: "The tubing and any unused portions of Propofol injectable emulsion should be discarded after 12 hours because Propofol injectable emulsion contains no preservatives and is capable of supporting growth of microorganisms."

On 6/23/11 at 10:00 AM, the Director of Pharmacy (DOP) was interviewed regarding the timeframe for disposing of Propofol. The DOP reviewed the Propofol insert and confirmed both the tubing and medication should be changed every 12 hours. The DOP added, the RN does not receive the insert with the manufacture's recommendation. He continued, the pharmacy staff did not include any alerts regarding the appropriate disposal of Propofol to the nursing staff when the medication was dispensed from the pharmacy.

b) On 6/22/11 at 10:00 AM, observed Patient #11 with an Intravenous (IV) of 5% Dextrose in .45% Normal Saline with 20 meq (milliequivalents) infusing. There was no label on the bag which indicated the date and time the IV bag was hung or the rate of infusion.

When the Registered Nurse (RN) was interviewed regarding what time the IV bag was hung, the nurse checked the Medication Administration Record (MAR).

The facility policy titled, "Intravenous Therapy," dated 8/09 revealed:
- "All IV bags must be labeled with the name of the patient, the name of all additives to the IV, time and date of initiation, and rate of infusion."
- "Once started, all intravenous fluids shall be completely used or discarded within 24 hours; i.e., KVOs (Keep Vein Open)."

c) Patient #11's medication orders included:
- 6/19/11 15:30 (3:30 PM) Cerebrx infusion, loading dose - Pharmacy to dose, then Dilantin 100 mg IVPB (Intravenous Piggyback) q (every) 8 hours;
The physician's order following this documented:
- 6/19/11 (untimed) - Cerebrx 200 mg (milligrams) IVPB q 12 hours, D/C (discontinue) Dilantin orders.

On 6/21/11, review of Patient #11's medication administration record (MAR) revealed the patient was still receiving the Dilantin 100 mg every 8 hours and had not been started on the Cerebrx.

On 6/21/11 at 10:35 AM, the Director of the Emergency Department verbalized the order to D/C the Dilantin had not been transcribed and scanned to the pharmacy. Therefore, the Dilantin was still being dispensed by the pharmacy through the Pyxis system, and administered by the nurse. The Director added the night nurse generally reconciled the orders on a daily basis, however this was not done either.

d) On 6/21/11 at 14:30 (2:30 PM), the Director of the ER notified the physician of the problems with Patient #11's medications, Dilantin and Cerebrx. The Director received an order for "Cerebrx 200 mg IVPB q 12 hours starting 6/21/11. Documentation on Patient #11's Medication Administration Record (MAR) revealed Patient #11 received Cerebrx on 6/21 at 3:00 PM and on 6/22 at 3:00 AM.

The next dose of Cerebrx was given on 6/22/11 at 10:00 AM, 7 hours after the previous dose. There was no documented evidence the physician was notified the Cerebrx was given within 7 hours, not the 12 hour interval as ordered.

e) On 6/22/11 at 9:45 AM, observed several vials of medication and syringes lying on Patient #11's bedside table in his room. The RN #1 was not in the room, but was in a room across the hallway. At 10:15 AM, RN #1 entered the room to administer Patient #11's medications. The RN touched and shook the patient's shoulder and asked him if he was in pain. The nurse explained she was going to give Patient #11 his pain medication.

The nurse took a vial from the bedside table and opened it. She withdrew some medication and indicated she was going to dispose of the remainder of the medication in the sharps container in the room. Before the nurse disposed of the vial, the surveyor asked to see the vial and asked the nurse about the medication. The nurse explained she had taken a vial of Morphine Sulfate (MS) 5 mg. from the Pyxis system. She knew she was going to administer only 3 mg. of the medication. She told the nurse in the medication room that she was going to waste 2 mg. of the medication. She then placed the medication vial in Patient #11's room on the bedside table.

At 10:18 AM, the RN administered MS 3 mg. IV to Patient #11.

The print out obtained from the Pyxis system indicated RN #1 signed out MS 5 mg. from the Pyxis system at 9:35 AM. The printout indicated RN #1 wasted 2 mg. and was witnessed by RN #2.

On 6/22/11 at 10:40 AM, interviewed RN #2 who explained the facility policy regarding controlled substances. She verbalized when a nurse pulled a controlled substance, such as MS, and knew she will not use the entire vial, the amount wasted must be witnessed by a second nurse and wasted in the medication room. Both nurses should document the amount of medication wasted. When the nurse was asked if she witnessed RN #1 waste the 2 mg of MS, she revealed she did not see the nurse waste the medication, but signed as the witness.

The facility policy titled, "Medication: Distribution/Administration," dated 7/2010 documented:
- " Wasting Medications:
-1. Medications that are unusable (i.e., removed from their protective seal, broken vial, dropped on floor) or a partial dose of a controlled substance must be wasted.
- 2. To waste a medication:
- ...e. Have a witness enter ID and password for controlled substance ... "


26251



3. Patient #16

On 6/7/11, the facility admitted Patient #16 with diagnoses of hypoxia, chronic obstructive pulmonary disease history, pulmonary embolism, urinary tract infection, dementia history, hypertension, dyslipidemia, osteoporosis history, congestive heart failure history, and atrial fibrillation.

On 6/23/11 at 9:30 AM, Employee #82 washed hands, gloved and prepared Patient #16's medications. Employee #82 brought the medications into Patient #16's room and set them on the bedside table. At one point, Employee #82 dropped supplies on the floor. Employee #82 picked up the supplies with gloved hands and proceeded to administer the medications without removing the gloves to wash hands. Employee #82 used an alcohol wipe to clean an intravenous port with the same gloved hands and administered Maxipine. At one point, Employee #82 emptied crushed medications, putting a gloved finger inside the plastic pouch used to house the crushed medications. The gloved finger was on the same hand used to pick supplies off the floor.

On 6/24/11 in the afternoon, Employee #2 indicated nurses should wash hands and change gloves after handling something off a floor.

On 6/23/11 at 9:30 AM, Employee #82 administered 60 milligrams of Lovenox. Employee #82 indicated the dosing was 1 milligram per kilogram, and the pharmacy adjusted the dose based on the patient's weight.

On 6/8/11, a physician ordered Lovenox (renal dosing) daily subcutaneously.

Patient #16's medication administration record showed a nurse administered the initial dose of 70 milligrams in the emergency room at about 12:18 AM on 6/8/11. Emergency room records showed a stated weight of 72 kilograms.

According to the facility's policy, weights-nursing (last reviewed on 1/2011), emergency room nurses used stated weights unless weight based medications were ordered. Lovenox was ordered as a weight based medication. Patient #16's actual weight once on the critical care unit was 62.5 kilograms the following morning, which would require a dose of 60 milligrams according to the facility's dose rounding table for weight based Lovenox. The facility's nurses continued to administer 70 milligrams daily through 6/11/11. The daily weights were all under 65 kilograms, requiring 60 milligrams of Lovenox, not 70 milligrams.

Between 6/12/11 and 6/13/11, the facility transferred Patient #16 to a medical surgical room. Patient #16 weight was 59.9 kilograms on 6/12/11. The pharmacy changed the Lovenox to 60 milligrams daily on 6/12/11, and Patient #16 received 60 milligrams of Lovenox daily through 6/23/11. The medical surgical floor nurses did not weigh Patient #16 again. The clinical manager indicated patients were not weighed daily on medical surgical floors unless they were receiving weight based medications. Patient #16 received Lovenox as a weight based medication.

On 6/20/11, the facility transferred Patient #16 back to the critical care area where nurses weighed patients daily. Patient #16's weight exceeded 65 kilograms on 6/22-23/11. Patient #16's Lovenox dose did not increase to 70 milligrams for either day.

On 6/23/11 at 11:25 AM, Employee #20 indicated the pharmacy used the weights recorded on the patients' medication administration records to determine weight based dosing. Employee #20 indicated nurses manually entered these weights in a computer. The weight on the medication administration record did not match the weight documented in Patient #16's file for determining the Lovenox dose on the morning of 6/23/11. Employee #20 indicated the Lovenox table was not facility policy yet and was in the final approval stage. Employee #20 did say the medical surgical floor should weigh a patient daily if a patient received a weight based medication.

The stated purpose of the facility's weights-nursing policy, last reviewed in 1/2011, was "to determine the appropriate weight of a patient in order to accurately calculate weight based medication dosages, fluid status, and nutritional monitoring."

Under part E of the procedure section of the policy, the procedure stated "...pharmacy will review the clinical profile weight and determine if a medication dosage change is indicated."

Summary for Patient #16 and the Administration of Lovenox:

The facility's emergency room nurse failed to follow policy regarding not using a stated weight for a patient receiving a weight based medication.

The facility's nurses failed to consistently document Patient #16's daily weights in accordance with the patient receiving a weight based medication.

The facility's nurses failed to update Patient #16's daily weight in the computer, so the pharmacy could properly determine the appropriate Lovenox dose.

The pharmacy failed to have a working policy covering dosing tables in place at the time of the Lovenox administration in order to ensure patients received dosages consistent with physician ordered weight based medications.

According to the facility's 01/03/11 dated plan of correction (POC) response to the 12/22/10 complaint validation survey (impetus for this survey) concerning the same issue of administrating Lovenox without properly evaluating the dose relative to the patient's weight, Employee #1 stated, "...the Chief Nursing Officer and Director of Clinical Operations reviewed the facility policies on patient weights, and revised and standardized them for the facility to include clearly the requirements for weight to be documented in Opus (the hospital's electronic medical record), for the pharmacy to be involved with weight-based medications, and for the required unit of measure to be kilograms."


4. Patient #17

On 6/16/11, the facility admitted Patient #17 with diagnoses of acute right middle cerebral artery infarct, hypertension history, hyperlipidemia, prostate history, and bibasilar atelectasis.

On 6/23/11 at 1:36 PM, the charges and credits report for Patient #17 showed nurses signed out 22 10 milligram/100 milliliter vials of Propofol. from 6:46 AM on 6/17/11 to 10:39 AM on 6/23/11.

Patient #17's medication administration record showed documentation of 10 vials administered.

On 6/23/11 in the afternoon, Employee #20 indicated medications administered should be documented on the medication administration record.

According to the facility's "Medication: Distribution/Administration" policy, dated 7/2010, nurses were supposed to initial the administration of intravenous medications (such as Propofol) on the medication administration record.

On 6/24/11 in the afternoon, Employee #2 indicated medications administered should be documented on the medication administration record.


5. Patient #18

a) On 6/10/11, the facility admitted Patient #18 with diagnoses of altered mental status, respiratory failure, atrial fibrillation, seizures, sinusitis, and leukocytosis.

On 6/10/11, a physician ordered Morphine Sulfate 1-5 milligrams every hour as needed intravenously.

Patient #18's medication administration record showed nurses failed to document the amount of Morphine Sulfate administered at 8:15 AM on 6/19/11, 6:45 PM on 6/20/11, and 8:35 AM and 1:25 PM on 6/21/11.

On 6/10/11, a physician ordered Lorazepam 0.5-5 milligrams every hour as needed intravenously.

Patient #18's medication administration record showed nurses failed to document the amount of Lorazepam administered at 7:45 AM, 2:20 PM, and 6:45 PM on 6/19/11; 5:45 PM and 7:45 PM on 6/20/11.

On 6/23/11 in the afternoon, Employee #20 indicated medications administered should be documented on the medication administration record.

According to the facility's "Medication: Distribution/Administration" policy, dated 7/2010, nurses were supposed to initial the administration of intravenous medications (such as Morphine Sulfate and Lorazepam) on the medication administration record.

On 6/24/11 in the afternoon, Employee #2 indicated medications administered should be documented on the medication administration record.

b) On 6/19/11 at 3:53 AM, Employee #72 signed out 5 milligrams of intravenous Morphine Sulfate from the Pyxis dispenser.

On 6/19/11 at 4:00 AM, Employee #72 initialed the administration of 3 milligrams of intravenous Morphine Sulfate on Patient #18's medication administration record.

On 6/23/11 at 1:36 PM, the charges and credits report for the Pyxis dispenser lacked documentation of 2 milligrams of wasted intravenous Morphine Sulfate.

Patient #18's file lacked documentation of 2 milligrams of wasted intravenous Morphine Sulfate.

Employee #72 did not appear on the facility's current employee roster dated 6/21/11.

A male charge nurse indicated Employee #72 was an agency nurse, not a facility employee.

The facility policy titled, "Medication: Distribution/Administration," dated 7/2010, documented:
- "Wasting Medications:
-1. Medications that are unusable (i.e., removed from their protective seal, broken vial, dropped on floor) or a partial dose of a controlled substance must be wasted.
- 2. To waste a medication:
- ...e. Have a witness enter ID and password for controlled substance ... "


6. Patient #26

On 6/20/11, the facility admitted Patient #26 with diagnoses of chronic back pain, status post L5-S1 posterior lumbar interbody fusion, and revision of L5-S1 microdiscectomy for lumber radiculopathy.

On 6/20/11, a physician ordered patient controlled Hydromorphone 0.2 milligrams intravenously on demand.

On 6/22/11 at 12:59 AM, Employee #79 signed out a Hydromorphone cartridge from the Pyxis dispenser.

Patient #26's medication administration record showed Employee #79 failed to document the administration of the Hydromorphone cartridge.

On 6/20/11, a physician ordered Hydromorphone 1-2 milligrams every three hours as needed intravenously.

On 6/22/11 at 5:08 PM, Employee #80 signed out a 2 milligram/1 milliliter vial of intravenous Hydromorphone.

Patient #26's medication administration record showed Employee #80 failed to document the amount of Hydromorphone administered.

On 6/23/11 in the afternoon, Employee #20 indicated medications administered should be documented on the medication administration record.

According to the facility's "Medication: Distribution/Administration" policy, dated 7/2010, nurses were supposed to initial the administration of intravenous medications (such as Hydromorphone) on the medication administration record.

On 6/24/11 in the afternoon, Employee #2 indicated medications administered should be documented on the medication administration record.


7. Patient #27

On 6/19/11, the facility admitted Patient #27 with diagnoses of sepsis, acute cholecystitis status post gallbladder drain placement, metabolic acidosis, acute renal failure/hydration, chronic atrial fibrillation, decompensated congestive heart failure, severe pulmonary hypertension, and severe debility.

On 6/19/11, a physician ordered Morphine Sulfate 1-5 milligrams every four hours as needed intravenously.

On 6/20/11 at 1:34 AM, a nurse signed out a 5 milligram vial of Morphine Sulfate and wasted 3 milligrams.

Patient #27's medication administration record showed the nurse failed to document the amount administered and that any Morphine was administered.

On 6/20/11 at 4:14 AM, a nurse signed out a 5 milligram vial of Morphine Sulfate and did not document a wasted amount.

On 6/24/11 at 10:00 AM, Employee #20 indicated the nurse signed out the 4:14 AM dose too soon for what the physician ordered (every four hours).

Patient #27's medication administration record showed the nurse failed to document the amount administered and that any Morphine was administered.

On 6/21/11 at 10:12 AM, a nurse signed out a 5 milligram vial of Morphine Sulfate and did not document a wasted amount.

Patient #27's medication administration record showed the nurse failed to document the amount administered and that any Morphine was administered.

On 6/21/11 at 7:42 PM, a nurse signed out a 5 milligram vial of Morphine Sulfate and wasted 2 milligrams.

Patient #27's medication administration record showed the nurse failed to document the amount administered and that any Morphine was administered.

On 6/22/11 at 3:09 AM, a nurse signed out a 5 milligram vial of Morphine Sulfate and wasted 3 milligrams.

Patient #27's medication administration record showed the nurse failed to document the amount administered and that any Morphine was administered.

On 6/22/11 at 3:37 PM, a nurse signed out a 5 milligram vial of Morphine Sulfate and did not document a wasted amount.

Patient #27's medication administration record showed the nurse failed to document the amount administered.

On 6/23/11 at 10:33 PM, Employee #81 signed out a 5 milligram vial of Morphine Sulfate and did not document a wasted amount.

Patient #27's medication administration record showed the nurse documented 2 milligrams administered.

On 6/23/11 in the afternoon, Employee #20 indicated medications administered should be documented on the medication administration record.

According to the facility's "Medication: Distribution/Administration" policy, dated 7/2010, nurses were supposed to initial the administration of intravenous medications (such as Morphine Sulfate) on the medication administration record.

On 6/24/11 in the afternoon, Employee #2 indicated medications administered should be documented on the medication administration record.

The facility policy titled, "Medication: Distribution/Administration," dated 7/2010, documented:
- "Wasting Medications:
-1. Medications that are unusable (i.e., removed from their protective seal, broken vial, dropped on floor) or a partial dose of a controlled substance must be wasted.
- 2. To waste a medication:
- ...e. Have a witness enter ID and password for controlled substance ... "

On 6/24/11, Employee #20 indicated the pharmacy lacked a mechanism to audit/correlate Pyxis dispensed medications/times with the medication administration records of patients. The pharmacy only kept track of dispensed amounts.

Based on interview, record review, and document review, the facility failed to ensure physicians' orders were documented, dated, and signed by the practitioner for 8 of 34 sampled patients (Patient #10, #16, #17, #18, #21, #25, #33, and #34).

Findings include:

According to the facility's policy, "Diet Orders" (last reviewed on 6/3/11), "...all diet orders will be prescribed or ordered by the patient's physician or approved LIP (Licensed Independent Practitioner)...Verbal and telephone orders are not taken by the diet office..."


1. Patient #21

Patient #21 was admitted 6/16/11 with diagnoses including pancreatitis, hypertension, coronary artery disease, and history of stroke.

The following Physician's Orders were not signed by the physician:

-Physician's Orders 6/17/11: Discontinue Heparin.
-Physician's Orders 6/17/11: Benadryl 25 mg (milligrams) IV (Intravenous) x 1 Now
-Physician's Orders 6/17/11: Dilaudid 1 mg IV x 1 Now

On 6/23/11 in the afternoon, the 300 Hall Med Surg Unit Charge Nurse verified the Physician's Orders for the Heparin, Benadryl, and Dilaudid were not signed by the physician.


2. Patient #25

Patient #25 was admitted 5/31/11, with diagnoses/assessment including fever, nausea, vomiting, rule out ventriculoperitoneal shunt failure, history of seizures, and history of hydrocephalus.

The following Physician's Orders were not signed by the physician:

-The Admission Medication Reconciliation and Physician Order Form indicated the medications brought in at admission included Tegretol, 200 mg po (by mouth) bid (twice daily) ("Continue: Yes"), and Diazepam ?? mg po as needed for breakthrough sx (symptoms) ("Continue: No").

-Physician's Orders 6/4/11: Order Clarification: MRI r (right) shoulder.
-Physician's Orders 6/8/11: Order Clarification: Skull X-Ray to show shunt valve.
-Physician's Orders 6/9/11: Order Clarification: Abdominal X-Ray flat/upright.
-Physician's Orders 6/10/11: Colace mg po bid.
-Physician's Orders 6/10/11: Ok to have MRI of brain.
-Physician's Orders 6/10/11: X-Ray skull.
-Physician's Orders 6/14/11: May give pt (patient) another another Tegretol because pt vomited 1st (first) dose.
-Physician's Orders 6/17/11: Augmentin 875 mg po bid, Doxcylcine 100 mg bid, d/c (discontinue) Zyvox.
-Physician's Orders 6/17/11: Make sure all cultures are completed; blood, urine, sputum. D/C Augmentin and Doxycycline po, start Vancomycin 1 gm (gram); Pharmacy to dose. Zosin 3.375 gm IV q (every) 6 (hours).
-Physician's Orders 6/17/11: Continue Diflucan po.
-Physician's Orders 6/17/11: Urine C&S.

The facility's policy and procedure regarding "Physician's Telephone/Verbal Orders," dated 11/16/10, indicated as follows:

"Section E.3. All telephone/verbal orders for medications require a verification "read back" of the complete order by the person giving the order. All verbal orders shall be authenticated, dated, and timed within forty-eight (48) hours after they have been given by the order physician/practitioner."


26251



3. Patient #16

According to the facility's policy, "Diet Orders" (last reviewed on 6/3/11), "...all diet orders will be prescribed or ordered by the patient's physician or approved LIP (Licensed Independent Practitioner)...Verbal and telephone orders are not taken by the diet office..."

On 6/7/11, the facility admitted Patient #16 with diagnoses of hypoxia, chronic obstructive pulmonary disease history, pulmonary embolism, urinary tract infection, dementia history, hypertension, dyslipidemia, osteoporosis history, congestive heart failure history, and atrial fibrillation.

Observation during the initial tour showed a bottle of tube feeding administered by pump into Patient #16.

On 6/14/11 at 2:44 PM, Employee #73 completed a nutritional assessment of Patient #16.

Employee #73 recommended Jevity 1.2 at an eventual goal rate of 55 milliliters per hour.

On 6/15/11 at 12:00 AM, a registered nurse documented the tube feeding. Nurses continued to document the tube feeding periodically through 9:56 AM on 6/21/11.

On 6/17/11 at 11:54 AM, Employee #73 completed a nutritional assessment of Patient #16.

Employee #73 recommended Jevity 1.2 at an eventual goal rate of 55 milliliters per hour.

On 6/20/11 at 2:30 PM, Employee #74 completed a nutritional assessment of Patient #16.

Employee #74 recommended Peptamen at 55 milliliters per hour.

Patient #16's file lacked a documented physician's order for the Jevity and the Peptamen tube feeding solutions.

On 6/21/11 at 2:45 PM, Employees #73, #75, and #76 were interviewed.

Employee #73 indicated dietitians did not write orders (verbal or telephone). Dietitians wrote recommendations within progress notes, often utilizing a yellow sticker. The phrase "Physician order is required for any of the above." appeared at the bottom of the yellow sticker.

Employee #75 indicated a physician wrote tube feeding orders, and dietitians did not write orders.

Employees #75 and #76 indicated Patient #16's file lacked a physician's order for Patient #16's Jevity tube feeding.

On 6/21/11 at 3:34 PM, a physician's order was entered into the facility's computer system for Jevity 1.2 continuous at 55 milliliters per hour.


4. Patient #17

According to the facility's policy, "Diet Orders" (last reviewed on 6/3/11), "...all diet orders will be prescribed or ordered by the patient's physician or approved LIP (Licensed Independent Practitioner)...Verbal and telephone orders are not taken by the diet office..."

On 6/16/11, the facility admitted Patient #17 with diagnoses of acute right middle cerebral artery infarct, hypertension history, hyperlipidemia, prostate history, and bibasilar atelectasis.

Observation during the initial tour showed a bottle of tube feeding administered by pump into Patient #17.

On 6/17/11 at 11:53 AM, Employee #74 completed a nutritional assessment of Patient #17.

Employee #74 recommended Jevity 1.2 at an eventual goal rate of 65 milliliters per hour.

On 6/19/11 at 7:00 PM, a registered nurse documented the tube feeding. Nurses continued to document the tube feeding periodically through 7:40 PM on 6/21/11.

On 6/20/11 at 1:14 PM, Employee #74 completed a nutritional assessment of Patient #17.

Employee #74 recommended Jevity 1.2 at an eventual goal rate of 65 milliliters per hour.

From 6/18/11 through 6/21/11, nurses documented Jevity 1.2 on Patient #17's adult critical care flow sheet.

On 6/20/11 at 1:52 PM, a physician's order was entered into the facility's computer system for Jevity 1.2 continuous at 50 milliliters per hour.

On 6/22/11 at 8:30 AM, Employees #75 and #76 indicated Patient #17's file lacked a physician order for Patient #17's Jevity tube feeding.

Patient #17's file lacked a documented physician's order for the Jevity tube feeding solution until 11:10 AM on 6/22/11.


5. Patient #18

According to the facility's policy, "Diet Orders" (last reviewed on 6/3/11), "...all diet orders will be prescribed or ordered by the patient's physician or approved LIP (Licensed Independent Practitioner)...Verbal and telephone orders are not taken by the diet office..."

On 6/10/11, the facility admitted Patient #18 with diagnoses of altered mental status, respiratory failure, atrial fibrillation, seizures, sinusitis, and leukocytosis.

Observation during the initial survey tour showed a bottle of tube feeding administered by pump into Patient #18.

On 6/11/11 at 12:29 PM, Employee #73 completed a nutritional assessment of Patient #18.

Employee #73 recommended Pulmocare at an eventual goal rate of 45 milliliters per hour.

On 6/14/11 at 11:29 AM, Employee #74 completed a nutritional assessment of Patient #18.

Employee #74 recommended Pulmocare at an eventual goal rate of 45 milliliters per hour.

On 6/14/11 at 4:24 PM, a physician's order was entered into the facility's computer system for Jevity 1.2 continuous at 45 milliliters per hour.

On 6/15/11 at 8:15 AM, a registered nurse documented the tube feeding. Nurses continued to document the tube feeding periodically through 10:00 AM on 6/24/11.

On 6/17/11 at 12:16 PM, Employee #74 completed a nutritional assessment of Patient #18.

Employee #74 recommended Jevity at an eventual goal rate of 55 milliliters per hour.

On 6/17/11, nurses documented Osmolyte at 45 milliliters per hour on Patient #18's adult critical care flow sheet.

On 6/20/11, nurses documented Jevity 1.2 on Patient #18's adult critical care flow sheet.

Patient #18's file lacked a documented physician's order for the Jevity and the Osmolyte and for changing one tube feeding solution to another.


27469



6. Patient #10

Patient #10 was admitted to the facility on 6/5/11, for physical therapy rehabilitation after stent placement. On 6/15/11 at 3:15 PM, an order for K Phos (Potassium Phosphate) was written. There was no documented route identified in the order. On 6/16/11, K Phos was ordered. There was no documented evidence of the time of the order or the route of the medication. On 6/18/11, an order to increase Neutra phos was written. There was no documented evidence of the time of the order or the route of the medication.


7. Patient #33

Patient #33 was admitted to the facility on 6/23/11, for a primary cesarean section. The post-op (post-operative) cesarean section with duramorph orders documented the physician's initials. There was no documented evidence of a physician signature, date or time the order was written.


8. Patient #34

Patient #34 was admitted to the facility on 6/22/11, for a primary cesarean section. The routine orders for post-op (post-operative) epidural morphine sulfate did not document the time the order was written. The routine pre-op (pre-operative) cesarean section orders received as a telephone order on 6/21/11, at 7:30 PM, were not signed by the physician as of 6/24/11 at 11:20 AM.

On 6/21/11, at 10:05 AM, the Director of Pharmacy (DOP) was interviewed. The DOP explained all physician orders are reviewed to assure they are complete. If an element was missing from the physician order, the pharmacist sent a clarification order to the nursing unit for the physician to complete.

On 6/21/11 at 10:30 AM, Employee #37, a pharmacist, was interviewed. The employee explained incomplete physician orders requiring clarification are entered into the pharmacy computer. The order was scanned to the nursing floor printer. The pharmacist would then follow up with a phone call to the nurse.

On 6/24/11 at 8:40 AM, the Director of Pharmacy and Employee #51 (the clinical manager of pharmacy) were interviewed. The Director explained when a medication can be administered only one route; the pharmacist would add the route automatically. Both employees reviewed Patient #10's physician orders dated 6/15, 6/16 and 6/18 and acknowledged a clarification should have been sent to the physician. Both employees acknowledged the pharmacy department was not following the medication clarification procedure as described by the Director on 6/21/11.

On 6/24/11 at 10:55 AM, Employee #54, a RN on the post partum unit was interviewed. The employee reviewed Patient #31's physician orders for post-op cesarean section with duramorph. The employee explained the pharmacy should have sent a clarification request to the physician. The employee acknowledged there was no clarification request found in the patient's medical record.

Based on record review, interview, and document review, the facility failed to ensure blood transfusions were administered in accordance with approved medical staff policies for 5 of 34 patients (Patients #12, #17, #28, #29, and #30).

Findings include:

According to the facility's policy "Blood Ordering, Procurement and Administration" (last reviewed 12/08), under the section entitled "Transfusion of Blood/Blood Products," nurses and/or physicians were to verify information regarding the blood product to be infused and sign the transfusion record as verifying the information. "...record pre-transfusion vital signs on Product Chart Copy in the appropriate space. (This provides a baseline prior to transfusion)...Take the patient's vital signs 15 [minutes] after the transfusion has begun and post transfusion..."


1. Patient #12

Patient #12 was admitted through the Emergency Room (ER) on 6/20/11 at 22:50 (10:50 PM), with complaints of chest pain and gastrointestinal bleeding (GIB). Documentation in Patient 12's medical record revealed the patient had active GI bleeding while in the ER, and was intubated on 6/21/11 at 18:25 (6:25 PM). Patient #12 was admitted as ICU (Intensive Care Unit) level of care, but was held in the ER since there was no ICU bed available.

Patient #12's physician orders dated 6/23/11 at 10:22 AM, included: "Transfuse 1 Unit PRBC (Packed Red Blood Cells)."

Patient #12's Blood Transfusion record indicated the PRBC's were started on 6/23/11 at 13:45 (1:45 PM), and ended on 6/22/11 (sic) at 1600 (4:00 PM). The Blood Transfusion record documented the signature of the person verifying the blood transfusion. The Blood Transfusion record lacked the signature of the person starting the transfusion and verifying.


26251



2. Patient #17

On 6/16/11, the facility admitted Patient #17 with diagnoses of acute right middle cerebral artery infarct, hypertension history, hyperlipidemia, prostate history, and bibasilar atelectasis.

On 6/17/11 in the morning, Patient #17 received transfusions of blood products including two units of fresh frozen plasma, a cryo pool of five units, and a unit of single donor platelets.

According to the facility's aforementioned "Blood Ordering, Procurement and Administration" policy, nurses should document pre-transfusion, 15 minute, and post transfusion vital signs.

Patient #17's transfusion record only showed pre and post transfusion vital signs for the first unit of fresh frozen plasma. The record showed only pre-transfusion and 15 minute vital signs for the second unit of fresh frozen plasma. The record showed incomplete post transfusion vital signs for cryo pool of five units. And the record showed only pre-transfusion vital signs for the single donor platelets.

On 6/17/11 at 6:00 AM, a physician ordered 2 units of single donor platelets stat.

Patient #17's transfusion record showed one unit of single donor platelets was infused.

The blood bank's patient information card showed no more than one unit of single donor platelets was dispensed.

According to Employee #77, the blood bank's computer printout of the order showed one of the units was canceled, because the computer software interpreted the order as a duplicate due to the fact that someone entered the units as separate orders two minutes apart. The print out also showed Employee #26 might have contacted the physician regarding the platelet level and a criteria exception. Employee #77 could not explain the meaning of the note on the print out.

Patient #17's file lacked documentation by Employee #26 regarding a discussion with the physician about the patient's platelet level and a reason to not infuse the second unit of single donor platelets.

Patient #17's lab reports showed the following decreasing platelet level trend before increasing again on 6/20/11:

--223 at 2:50 PM on 6/16/11.
--209 at 3:11 AM on 6/17/11.
--201 at 4:20 PM on 6/17/11.
--179 at 1:05 AM on 6/18/11.
--158 at 2:50 AM on 6/19/11.
--168 at 3:55 AM on 6/20/11.

Patient #17's file lacked a physician's order to cancel the second unit of single donor platelets.

Patient #17's medication administration record showed two units of single donor platelets transfused.


3. Patient #28

On 6/22/11, the facility admitted Patient #28 with diagnoses of pancreatic head adenocarcinoma and status post CT-guided biopsy.

On 6/23/11 at 1:10 PM, Patient #28 received a unit of fresh frozen plasma.

The transfusion record showed pre and post transfusion vital signs, but not 15 minute vital signs.

On 6/23/11 at 12:45 PM, the blood bank issue log showed a unit of fresh frozen plasma was signed out.

According to the transfusion record, "...if blood transfusion is not started within 20 minutes of issue, return to blood bank." The difference in sign out time to start time was 25 minutes.


4. Patient #29

On 6/20/11, the facility admitted Patient #29 with diagnoses of abdominal pain, diabetes, hypertension, and cardiomyopathy.

On 6/23/11 at 7:33 PM, Patient #29 received a unit of blood.

The transfusion record lacked pre and post transfusion vital signs and 15 minute vital signs.

On 6/23/11 at 7:45 PM, the blood bank issue log showed a unit of blood was signed out.

The transfusion record lacked start and end times and vital signs.

On 6/23/11 at 8:39 PM, the blood bank issue log showed a unit of blood was signed out.

The transfusion record lacked start and end times and vital signs.

On 6/24/11 at 1:20 AM, Patient #29 received a unit of blood.

The transfusion record lacked a verification signature from a nurse or physician.

5. Patient #30

On 6/20/11, the facility admitted Patient #30 with diagnoses of postpartum hemorrhage, uterine artery embolization, and right femoral artery resection.

On 6/22/11 at 4:00 AM, a lab technician checked a unit of fresh frozen plasma for Patient #30. The transfusion record in Patient #30's file lacked verification signatures and start/end times for the transfusion. The blood bank lacked information the unit was returned.

On 6/22/11 at 5:00 AM, a lab technician checked a unit of single donor platelets for Patient #30. The transfusion record in Patient #30's file lacked verification signatures and start/end times for the transfusion. The blood bank lacked information the unit was returned.

Based on interview, record review, and document review, the facility failed to ensure discharge summaries were completed according to the facility's policy for 2 of 34 patients (Patients #33 and #34).

Findings include:

The SVHMC (Spring Valley Hospital Medical Center) Rules and Regulations, dated November 16, 2010, section VI. Discharge Summaries indicated:
"A. A concise and up-to-date Discharge Summary shall be written or dictated within 30 days of discharge on all medical records of patients hospitalized over forty-eight (48) hours, except for normal obstetrical deliveries and normal newborn infants. This includes patients hospitalized for observation care.
1. All patients admitted for a period that exceeds forty-eight (48) hours and/or undergo a C-section (Cesarean) delivery shall require a dictated discharge summary."

1. Patient #33

Patient #33 was admitted to the facility on 6/23/11, for a primary cesarean section. On 6/24/11, the Obstetric Discharge Summary was noted to be signed by the physician. The date documented on the form was 6/27/11 at 10:57 AM. The complications: Operative and Postpartum were documented as none.

On 6/24/11 at 11:20 AM, the nurse caring for the patient, Employee #54, explained there was no plan for discharge at the time of the survey.


2. Patient #34

Patient #34 was admitted to the facility on 6/22/11, for a primary cesarean section. On 6/24/11, the Obstetric Discharge Summary was noted to be signed by the physician. The date documented on the form was 6/25/11 at 10:57 AM. The complications: Operative and Postpartum were documented as none.

On 6/24/11 at 11:20 AM, the nurse caring for the patient, Employee #54, explained the patient may be discharged later in the day, but there was no discharge order written at the time of the survey.

Based on observation, interviews, record review and document review, the facility failed to ensure the pharmacy notified staff of potential concerns regarding the safe administration of medications for 7 of 34 patients (Patients #11, #12, #16, #17, #18, #26, and #27).

Findings include:

1. Patient #11

Patient #11 was brought to the Emergency Room (ER) on 6/19/11 at 12:15 PM, by ambulance after being found down in his apartment. Based on the ER physician's notes, the patient was able to respond yes and no to questions and there was no other verbal response. A workup was completed including a CT (Computerized Tomography) of the brain, which showed an acute subdural hematoma, and a CT of the chest which showed bilateral pulmonary emboli.

The patient was started on IV (Intravenous) fluids, medications to control his blood pressure, and connected to a cardiac monitor. The patient was intubated on 6/19/11 at 13:50 (1:50 PM), and placed on a ventilator. The patient was admitted as ICU (Intensive Care Unit) level of care, but was held in the ER since there was no ICU bed available.

Patient #11's medications included:
- Diprivan (Propofol) drip for sedation based on the weight of the patient.

On 6/21/11, Patient #11 was observed to have a Propofol drip in progress.

Documentation on the MAR did not include the time the Propofol was hung. Documentation on the ICU nurse's documentation revealed the specific rate at which the Propofol was infusing on an hourly basis. However, there was no time documented when the Propofol was hung.


2. Patient #12

Patient #12 was admitted through the Emergency Room on 6/20/11 at 22:50 (10:50 PM), with complaints of chest pain and gastrointestinal bleeding (GIB). Documentation in Patient #12's medical record revealed the patient had active GI bleeding while in the ER, and was intubated on 6/21/11 at 18:25 (6:25 PM). Patient #12 was admitted as ICU (Intensive Care Unit) level of care, but was held in the ER since there was no ICU bed available.

On 6/22/11 at 2:00 PM, Patient #12 was noted to have a Propofol drip infusing. The IV tubing connected to the Propofol drip indicated: Start 6/22/11 at 12:30, D/C (Discontinue) 6/26/11 at 12:30 PM.

On 6/22/11 at 10:20 AM, interviewed the Registered Nurse (RN) caring for Patient #11 and #12 regarding the administration of Propofol. The RN explained she had experience with administering Propofol and the timeframes for changing the tubing was different at different facilities. She indicated sometimes the timeframe was 12 hours, 24 hours or whenever the bottle was changed. When interviewed if she knew what the policy was for this facility, she indicated she did not.

The facility policy titled, "Intravenous Therapy," dated 8/2009, documented: "Replace tubing used for the administration of Propofol is to be in use no longer than 12 hours and should be changed per manufacturers recommendation (sic)."

The manufacturer's recommendations documented on the Propofol insert regarding the administration of Propofol indicated: "The tubing and any unused portions of Propofol injectable emulsion should be discarded after 12 hours because Propofol injectable emulsion contains no preservatives and is capable of supporting growth of microorganisms."

On 6/23/11 at 10:00 AM, the Director of Pharmacy (DOP) was interviewed regarding the timeframe for disposing of Propofol. The DOP reviewed the Propofol insert and confirmed both the tubing and medication should be changed every 12 hours. The DOP added, the RN does not receive the insert with the manufacture's recommendation. He continued, the pharmacy staff did not include any alerts regarding the appropriate disposal of Propofol to the nursing staff when the medication was dispensed from the pharmacy.


26251



3. Patient #16

On 6/7/11, the facility admitted Patient #16 with diagnoses of hypoxia, chronic obstructive pulmonary disease history, pulmonary embolism, urinary tract infection, dementia history, hypertension, dyslipidemia, osteoporosis history, congestive heart failure history, and atrial fibrillation.

On 6/23/11 at 9:30 AM, Employee #82 washed hands, gloved and prepared Patient #16's medications. Employee #82 brought the medications into Patient #16's room and set them on the bedside table. At one point, Employee #82 dropped supplies on the floor. Employee #82 picked up the supplies with gloved hands and proceeded to administer the medications without removing the gloves to wash hands. Employee #82 used an alcohol wipe to clean an intravenous port with the same gloved hands and administered Maxipine. At one point, Employee #82 emptied crushed medications, putting a gloved finger inside the plastic pouch used to house the crushed medications. The gloved finger was on the same hand used to pick supplies off the floor.

On 6/24/11 in the afternoon, Employee #2 indicated nurses should wash hands and change gloves after handling something off a floor.

On 6/23/11 at 9:30 AM, Employee #82 administered 60 milligrams of Lovenox. Employee #82 indicated the dosing was 1 milligram per kilogram, and the pharmacy adjusted the dose based on the patient's weight.

On 6/8/11, a physician ordered Lovenox (renal dosing) daily subcutaneously.

Patient #16's medication administration record showed a nurse administered the initial dose of 70 milligrams in the emergency room at about 12:18 AM on 6/8/11. Emergency room records showed a stated weight of 72 kilograms.

According to the facility's policy, weights-nursing (last reviewed on 1/2011), emergency room nurses used stated weights unless weight based medications were ordered. Lovenox was ordered as a weight based medication. Patient #16's actual weight once on the critical care unit was 62.5 kilograms the following morning, which would require a dose of 60 milligrams according to the facility's dose rounding table for weight based Lovenox. The facility's nurses continued to administer 70 milligrams daily through 6/11/11. The daily weights were all under 65 kilograms, requiring 60 milligrams of Lovenox, not 70 milligrams.

Between 6/12/11 and 6/13/11, the facility transferred Patient #16 to a medical surgical room. Patient #16 weight was 59.9 kilograms on 6/12/11. The pharmacy changed the Lovenox to 60 milligrams daily on 6/12/11, and Patient #16 received 60 milligrams of Lovenox daily through 6/23/11. The medical surgical floor nurses did not weigh Patient #16 again. The clinical manager indicated patients were not weighed daily on medical surgical floors unless they were receiving weight based medications. Patient #16 received Lovenox as a weight based medication.

On 6/20/11, the facility transferred Patient #16 back to the critical care area where nurses weighed patients daily. Patient #16's weight exceeded 65 kilograms on 6/22-23/11. Patient #16's Lovenox dose did not increase to 70 milligrams for either day.

On 6/23/11 at 11:25 AM, Employee #20 indicated the pharmacy used the weights recorded on the patients' medication administration records to determine weight based dosing. Employee #20 indicated nurses manually entered these weights in a computer. The weight on the medication administration record did not match the weight documented in Patient #16's file for determining the Lovenox dose on the morning of 6/23/11. Employee #20 indicated the Lovenox table was not facility policy yet and was in the final approval stage. Employee #20 did say the medical surgical floor should weigh a patient daily if a patient received a weight based medication.

The stated purpose of the facility's weights-nursing policy, last reviewed in 1/2011, was "to determine the appropriate weight of a patient in order to accurately calculate weight based medication dosages, fluid status, and nutritional monitoring."

Under part E of the procedure section of the policy, the procedure stated "...pharmacy will review the clinical profile weight and determine if a medication dosage change is indicated."

Summary for Patient #16 and the Administrating of Lovenox:

The facility's emergency room nurse failed to follow policy regarding not using a stated weight for a patient receiving a weight based medication.

The facility's nurses failed to consistently document Patient #16's daily weights in accordance with the patient receiving a weight based medication.

The facility's nurses failed to update Patient #16's daily weight in the computer, so the pharmacy could properly determine the appropriate Lovenox dose.

The pharmacy failed to have a working policy covering dosing tables in place at the time of the Lovenox administration in order to ensure patients received dosages consistent with physician ordered weight based medications.

According to the facility's 01/03/11 dated plan of correction (POC) response to the 12/22/10 complaint validation survey (impetus for this survey) concerning the same issue of administrating Lovenox without properly evaluating the dose relative to the patient's weight,, Employee #1 stated, "...the Chief Nursing Officer and Director of Clinical Operations reviewed the facility policies on patient weights, and revised and standardized them for the facility to include clearly the requirements for weight to be documented in Opus (the hospital's electronic medical record), for the pharmacy to be involved with weight-based medications, and for the required unit of measure to be kilograms."


4. Patient #17

On 6/16/11, the facility admitted Patient #17 with diagnoses of acute right middle cerebral artery infarct, hypertension history, hyperlipidemia, prostate history, and bibasilar atelectasis.

On 6/23/11 at 1:36 PM, the charges and credits report for Patient #17 showed nurses signed out 22 10 milligram/100 milliliter vials of Propofol. from 6:46 AM on 6/17/11 to 10:39 AM on 6/23/11.

Patient #17's medication administration record showed documentation of 10 vials administered.

On 6/23/11 in the afternoon, Employee #20 indicated medications administered should be documented on the medication administration record.

According to the facility's "Medication: Distribution/Administration" policy, dated 7/2010, nurses were supposed to initial the administration of intravenous medications (such as Propofol) on the medication administration record.

On 6/24/11 in the afternoon, Employee #2 indicated medications administered should be documented on the medication administration record.


5. Patient #18

On 6/10/11, the facility admitted Patient #18 with diagnoses of altered mental status, respiratory failure, atrial fibrillation, seizures, sinusitis, and leukocytosis.

a) On 6/10/11, a physician ordered Morphine Sulfate 1-5 milligrams every hour as needed intravenously.

Patient #18's medication administration record showed nurses failed to document the amount of Morphine Sulfate administered at 8:15 AM on 6/19/11, 6:45 PM on 6/20/11, and 8:35 AM and 1:25 PM on 6/21/11.

On 6/10/11, a physician ordered Lorazepam 0.5-5 milligrams every hour as needed intravenously.

Patient #18's medication administration record showed nurses failed to document the amount of Lorazepam administered at 7:45 AM, 2:20 PM, and 6:45 PM on 6/19/11; 5:45 PM and 7:45 PM on 6/20/11.

On 6/23/11 in the afternoon, Employee #20 indicated medications administered should be documented on the medication administration record.

According to the facility's "Medication: Distribution/Administration" policy, dated 7/2010, nurses were supposed to initial the administration of intravenous medications (such as Morphine Sulfate and Lorazepam) on the medication administration record.

On 6/24/11 in the afternoon, Employee #2 indicated medications administered should be documented on the medication administration record.

b) On 6/19/11 at 3:53 AM, Employee #72 signed out 5 milligrams of intravenous Morphine Sulfate from the Pyxis dispenser.

On 6/19/11 at 4:00 AM, Employee #72 initialed the administration of 3 milligrams of intravenous Morphine Sulfate on Patient #18's medication administration record.

On 6/23/11 at 1:36 PM, the charges and credits report for the Pyxis dispenser lacked documentation of 2 milligrams of wasted intravenous Morphine Sulfate.

Patient #18's file lacked documentation of 2 milligrams of wasted intravenous Morphine Sulfate.

Employee #72 did not appear on the facility's current employee roster dated 6/21/11.

A male charge nurse indicated Employee #72 was an agency nurse, not a facility employee.

The facility policy titled, "Medication: Distribution/Administration," dated 7/2010, documented:
- "Wasting Medications:
-1. Medications that are unusable (i.e., removed from their protective seal, broken vial, dropped on floor) or a partial dose of a controlled substance must be wasted.
- 2. To waste a medication:
- ...e. Have a witness enter ID and password for controlled substance ... "


6. Patient #26

On 6/20/11, the facility admitted Patient #26 with diagnoses of chronic back pain, status post L5-S1 posterior lumbar interbody fusion, and revision of L5-S1 microdiscectomy for lumber radiculopathy.

On 6/20/11, a physician ordered patient controlled Hydromorphone 0.2 milligrams intravenously on demand.

On 6/22/11 at 12:59 AM, Employee #79 signed out a Hydromorphone cartridge from the Pyxis dispenser.

Patient #26's medication administration record showed Employee #79 failed to document the administration of the Hydromorphone cartridge.

On 6/20/11, a physician ordered Hydromorphone 1-2 milligrams every three hours as needed intravenously.

On 6/22/11 at 5:08 PM, Employee #80 signed out a 2 milligram/1 milliliter vial of intravenous Hydromorphone.

Patient #26's medication administration record showed Employee #80 failed to document the amount of Hydromorphone administered.

On 6/23/11 in the afternoon, Employee #20 indicated medications administered should be documented on the medication administration record.

According to the facility's "Medication: Distribution/Administration" policy, dated 7/2010, nurses were supposed to initial the administration of intravenous medications (such as Hydromorphone) on the medication administration record.

On 6/24/11 in the afternoon, Employee #2 indicated medications administered should be documented on the medication administration record.


7. Patient #27

On 6/19/11, the facility admitted Patient #27 with diagnoses of sepsis, acute cholecystitis status post gallbladder drain placement, metabolic acidosis, acute renal failure/hydration, chronic atrial fibrillation, decompensated congestive heart failure, severe pulmonary hypertension, and severe debility.

On 6/19/11, a physician ordered Morphine Sulfate 1-5 milligrams every four hours as needed intravenously.

On 6/20/11 at 1:34 AM, a nurse signed out a 5 milligram vial of Morphine Sulfate and wasted 3 milligrams.

Patient #27's medication administration record showed the nurse failed to document the amount administered and that any Morphine was administered.

On 6/20/11 at 4:14 AM, a nurse signed out a 5 milligram vial of Morphine Sulfate and did not document a wasted amount.

On 6/24/11 at 10:00 AM, Employee #20 indicated the nurse signed out the 4:14 AM dose too soon for what the physician ordered (every four hours).

Patient #27's medication administration record showed the nurse failed to document the amount administered and that any Morphine was administered.

On 6/21/11 at 10:12 AM, a nurse signed out a 5 milligram vial of Morphine Sulfate and did not document a wasted amount.

Patient #27's medication administration record showed the nurse failed to document the amount administered and that any Morphine was administered.

On 6/21/11 at 7:42 PM, a nurse signed out a 5 milligram vial of Morphine Sulfate and wasted 2 milligrams.

Patient #27's medication administration record showed the nurse failed to document the amount administered and that any Morphine was administered.

On 6/22/11 at 3:09 AM, a nurse signed out a 5 milligram vial of Morphine Sulfate and wasted 3 milligrams.

Patient #27's medication administration record showed the nurse failed to document the amount administered and that any Morphine was administered.

On 6/22/11 at 3:37 PM, a nurse signed out a 5 milligram vial of Morphine Sulfate and did not document a wasted amount.

Patient #27's medication administration record showed the nurse failed to document the amount administered.

On 6/23/11 at 10:33 PM, Employee #81 signed out a 5 milligram vial of Morphine Sulfate and did not document a wasted amount.

Patient #27's medication administration record showed the nurse documented 2 milligrams administered.

On 6/23/11 in the afternoon, Employee #20 indicated medications administered should be documented on the medication administration record.

According to the facility's "Medication: Distribution/Administration" policy, dated 7/2010, nurses were supposed to initial the administration of intravenous medications (such as Morphine Sulfate) on the medication administration record.

On 6/24/11 in the afternoon, Employee #2 indicated medications administered should be documented on the medication administration record.

The facility policy titled, "Medication: Distribution/Administration," dated 7/2010, documented:
- "Wasting Medications:
-1. Medications that are unusable (i.e., removed from their protective seal, broken vial, dropped on floor) or a partial dose of a controlled substance must be wasted.
- 2. To waste a medication:
- ...e. Have a witness enter ID and password for controlled substance ... "

On 6/24/11, Employee #20 indicated the pharmacy lacked a mechanism to audit/correlate Pyxis dispensed medications/times with the medication administration records of patients. The pharmacy only kept track of dispensed amounts.

Based on a review of the laboratory and facility Look-Back policies and an interview with Employee #57, the laboratory did not have a comprehensive Look-Back policy.

Findings include:

1. The laboratory did not specify a definition of potentially HIV infectious blood and blood components as stated in this regulation.

2. The laboratory did not specify a definition of potentially hepatitis C virus (HCV) infectious blood and blood components as stated in this regulation.

3. The laboratory did not state in writing how it would respond to notification from the blood collecting establishment regarding the results of required supplemental testing of quarantined blood and blood products.

4. The laboratory did not specify in writing the record-keeping practices of the facility in regard to records of blood and blood components.

5. The laboratory did not state the applicability of HCV notification requirements as set forth in 21 CFR 610.48.

Based on policy review, observation, interview and record review, the facility failed to ensure enteral feeding solutions were prescribed by the practitioners responsible for 3 of 34 patients (Patients #16, #17, and #18).

Findings include:

According to the facility's policy, "Diet Orders" (last reviewed on 6/3/11), "...all diet orders will be prescribed or ordered by the patient's physician or approved LIP (Licensed Independent Practitioner)...Verbal and telephone orders are not taken by the diet office..."


1. Patient #16

On 6/7/11, the facility admitted Patient #16 with diagnoses of hypoxia, chronic obstructive pulmonary disease history, pulmonary embolism, urinary tract infection, dementia history, hypertension, dyslipidemia, osteoporosis history, congestive heart failure history, and atrial fibrillation.

Observation during the initial tour showed a bottle of tube feeding administered by pump into Patient #16.

On 6/14/11 at 2:44 PM, Employee #73 completed a nutritional assessment of Patient #16.

Employee #73 recommended Jevity 1.2 at an eventual goal rate of 55 milliliters per hour.

On 6/15/11 at 12:00 AM, a registered nurse documented the tube feeding. Nurses continued to document the tube feeding periodically through 9:56 AM on 6/21/11.

On 6/17/11 at 11:54 AM, Employee #73 completed a nutritional assessment of Patient #16.

Employee #73 recommended Jevity 1.2 at an eventual goal rate of 55 milliliters per hour.

On 6/20/11 at 2:30 PM, Employee #74 completed a nutritional assessment of Patient #16.

Employee #74 recommended Peptamen at 55 milliliters per hour.

Patient #16's file lacked a documented physician's order for the Jevity and the Peptamen tube feeding solutions.

On 6/21/11 at 2:45 PM, Employees #73, #75, and #76 were interviewed.

Employee #73 indicated dietitians did not write orders (verbal or telephone). Dietitians wrote recommendations within progress notes, often utilizing a yellow sticker. The phrase "Physician order is required for any of the above." appeared at the bottom of the yellow sticker.

Employee #75 indicated a physician wrote tube feeding orders, and dietitians did not write orders.

Employees #75 and #76 indicated Patient #16's file lacked a physician's order for Patient #16's Jevity tube feeding.

On 6/21/11 at 3:34 PM, a physician's order was entered into the facility's computer system for Jevity 1.2 continuous at 55 milliliters per hour.


2. Patient #17

On 6/16/11, the facility admitted Patient #17 with diagnoses of acute right middle cerebral artery infarct, hypertension history, hyperlipidemia, prostate history, and bibasilar atelectasis.

Observation during the initial tour showed a bottle of tube feeding administered by pump into Patient #17.

On 6/17/11 at 11:53 AM, Employee #74 completed a nutritional assessment of Patient #17.

Employee #74 recommended Jevity 1.2 at an eventual goal rate of 65 milliliters per hour.

On 6/19/11 at 7:00 PM, a registered nurse documented the tube feeding. Nurses continued to document the tube feeding periodically through 7:40 PM on 6/21/11.

On 6/20/11 at 1:14 PM, Employee #74 completed a nutritional assessment of Patient #17.

Employee #74 recommended Jevity 1.2 at an eventual goal rate of 65 milliliters per hour.

From 6/18/11 through 6/21/11, nurses documented Jevity 1.2 on Patient #17's adult critical care flow sheet.

On 6/20/11 at 1:52 PM, a physician's order was entered into the facility's computer system for Jevity 1.2 continuous at 50 milliliters per hour.

On 6/22/11 at 8:30 AM, Employees #75 and #76 indicated Patient #17's file lacked a physician order for Patient #17's Jevity tube feeding.

Patient #17's file lacked a documented physician's order for the Jevity tube feeding solution until 11:10 AM on 6/22/11.


3. Patient #18

On 6/10/11, the facility admitted Patient #18 with diagnoses of altered mental status, respiratory failure, atrial fibrillation, seizures, sinusitis, and leukocytosis.

Observation during the initial survey tour showed a bottle of tube feeding administered by pump into Patient #18.

On 6/11/11 at 12:29 PM, Employee #73 completed a nutritional assessment of Patient #18.

Employee #73 recommended Pulmocare at an eventual goal rate of 45 milliliters per hour.

On 6/14/11 at 11:29 AM, Employee #74 completed a nutritional assessment of Patient #18.

Employee #74 recommended Pulmocare at an eventual goal rate of 45 milliliters per hour.

On 6/14/11 at 4:24 PM, a physician's order was entered into the facility's computer system for Jevity 1.2 continuous at 45 milliliters per hour.

On 6/15/11 at 8:15 AM, a registered nurse documented the tube feeding. Nurses continued to document the tube feeding periodically through 10:00 AM on 6/24/11.

On 6/17/11 at 12:16 PM, Employee #74 completed a nutritional assessment of Patient #18.

Employee #74 recommended Jevity at an eventual goal rate of 55 milliliters per hour.

On 6/17/11, nurses documented Osmolyte at 45 milliliters per hour on Patient #18's adult critical care flow sheet.

On 6/20/11, nurses documented Jevity 1.2 on Patient #18's adult critical care flow sheet.

Patient #18's file lacked a documented physician's order for the Jevity and the Osmolyte and for changing one tube feeding solution to another.

Based on observation and interview, the facility failed to maintain infection control practices in an operating room setting.

Findings include:

On 6/24/2011 in the afternoon, a procedure was observed in operating room (OR) #3. The Anesthesiologist was preparing his area when a sterile package fell into a red biohazard bin filled with contaminated bloody devices such as uncapped needles and syringes. The Anesthesiologist reached inside the container and retrieved the package setting it aside to use in the case.

After the procedure was completed, the Anesthesiologist placed an open used 5 (ml) milliliter vial of Flumazenil back into the anesthesia medication cart.

The Director of Clinical Operations confirmed that the vial should have been discarded after opening and the sterile package should not have been retrieved from the biohazard bin.

Based on interview, record review and document review, the facility failed to reassess the appropriateness of the patients discharge plan to address factors that affected the patients continuing care needs and safety. (Patient #1)

Findings include:

Patient #1

A Physician Discharge Summary, dated 04/27/11, documented the following: Patient #1 was a 57 year old male who was admitted to the facility with a massive intercranial bleed and was taken to the operating room twice for treatment of a subdural hematoma. The patient had a prolonged stay in the ICU (Intensive Care Unit). The patient was weaned off a ventilator and transferred to a nursing unit. "The patient was in a stage 1 waking coma. Eventually he started to wake up. At that time I noticed that the staff were ordering a guest tray for the wife and found out that the patient was actually more awake than we knew. He would wait until we left the room to communicate with his wife. He was actually eating. The wife refused to take him home, said that she could not take care of him because she had to bath him, clean him and keep him fed. She said they did not have any insurance, had no money and she was not going to take him home. We finally convinced her that we had started the disability process and we will try to get them as much help as possible to convince her to take him home. She went for one day and refused to do anything for him and was told by Home Health Agency to take him to an (Acute Care Hospital)."
"The patient was discharged home in stable condition from here. He was awake, he was responding verbally to questions. He was able to tolerate oral intake. He was actually on a regular diet on discharge. He did not require any medications."
"The patient does need physical therapy until he is strong enough to get out of bed on his own power and take care of his own personal needs. The patient no longer needed or met inpatient criteria. He was discharged into his wife's care. The patients discharge diagnoses included the following:

1. Status post subdural hematoma.
2. Stage 3 coma.
3. Decubitus ulcer, healing.
4. Cirrhosis of the liver.
5. Alcohol abuse.

A Physician Order, dated 04/18/11, included the following: "Case Manager to arrange discharge, home health care."

A Social Workers Note, dated 04/18/11, indicated the Social Worker and the patient's Physician spoke with the patient's wife regarding discharging the patient home with home health care services. The wife continued to decline to care for the patient at home and felt the patient needed to be placed in a rehabilitative hospital.

A Case Managers Note, dated 04/25/11, indicated the patient's wife (responsible party) was requesting a delay in the patient's discharge to 05/02/11, so she could finish a job and obtain funds to pay the rent and move furniture in her trailer to make room for a hospital bed for the patient. The case worker notified the patient's physician of the wife's request for a delay in the discharge order. The physician's plan was to discharge the patient home on 04/26/11, with durable medical equipment and home health care services.

A Speech Pathology Note, dated 04/25/11, indicated the patient was more alert and tolerating thick nectar with no signs or symptoms of aspiration. The patient was still choking with solid food. The recommendation was a one-to-one feeding with aspiration precautions.

Physician Discharge orders, dated 04/26/11, documented it was OK to discharge the patient home with home health care and speech therapy. The patient was on a one-to-one feeding with aspiration precautions and a puree/nectar thick liquid diet.

A Case Managers Note, dated 04/27/11, indicated the patient's wife informed the Case Manager that she did not have a telephone or cell phone that home health care services or social services could reach her. The patient's wife reported she would have to use a neighbor's phone who did not live close by to her and were not always home.

A review of the patients Exit Care Discharge Instruction form, dated 04/26/11, documented the patient was discharged home on 04/27/11, with home health care, speech therapy, puree/nectar thick liquids, 1-to-1 feeding and aspiration precautions. Discharge instruction sheets included information on influenza, hand washing, pneumococcal vaccine, seizures and smoking cessation. The patient's wife signed the discharge instructions. There were no physician discharge orders or instructions for care of the patient's PICC line (Peripherally Inserted Central Catheter), Foley catheter or stage II decubitus wound care.

On 06/21/11 at 2:00 PM, an interview was conducted with Employee #25 assigned to coordinate the patients discharge plan. Employee #25 reported the patient had no medical insurance and she handled all discharge planning for patients with no medical insurance at the hospital. Employee #25 reported working with the patient's wife to obtain financial aid through Clark County Social Services and also worked with the patient and the patient's wife to apply for Medicaid and Medicare. Several attempts were made to place the patient in a rehabilitative care facility, but no facility would accept the patient without insurance, Medicare or Medicaid. Employee #25 reported the patient's condition improved and arrangements were made to discharge the patient home with home health care, hospital bed, occupational therapy, and speech therapy. Employee #25 reported coordination with the patient's Case Manager who was responsible for handling clinical issues related to the patients discharge. Employee #25 acknowledged not being aware Patient #1 was discharged home with a PICC line, Foley catheter and no decubitus wound care orders. Employee #25 reported it was the Case Manager and nursing staffs' responsibility to handle clinical issues regarding the patients discharge.

On 06/21/11 at 3:00 PM, an interview was conducted with Employee #58. Employee #58 acknowledged responsibility for handling clinical issues regarding the patient's discharge and coordinating the patient's discharge needs with the patient's Social Worker. Employee #58 acknowledged not being aware the patient was discharged with a Foley catheter, PICC line and no decubitus wound care orders. Employee #58 reported it was the patient's nurse's responsibility to obtain an order to discontinue the patient's PICC line and Foley catheter if not needed. Employee #58 reported the patient's nurse should have called the patient's physician and obtained an order to discontinue the patient's PICC line and obtained orders for wound care and Foley catheter care prior to the patients discharge from the facility. Employee #58 acknowledged being aware the patients wife had no telephone at the residence and no cell phone to call 911 in case of an emergency prior to the patient's discharge. Employee #58 reported physicians typically write generic orders for home health care and the home health care agencies call the physician after assessing the patient to obtain or clarify discharge orders.

On 06/22/11 at 11:00 AM, an interview was conducted with Employee #32 who acknowledged the Charge Nurse, Case Manager and Social Worker were responsible for coordinating the patient's discharge to ensure a safe discharge, and if PICC line or Foley catheter were no longer needed that the patient's nurse should contact the physician and obtain an order to discontinue intravenous lines or Foley catheters prior to discharge. Employee #32 confirmed when the patient was discharged with a PICC line, Foley catheter and decubitus ulcer, the nursing staff were responsible for providing the patient or responsible party with exit care patient information pertaining to wound care, Foley catheter and wound care prior to discharge.

On 06/21/11 at 1:00 PM, an interview was conducted with the Director of Clinical Services for the Home Health Agency chosen to care for the patients following discharge from the hospital. The Director reported the patient had no insurance. The agency home health nurse responded to conduct an initial assessment of the patient following discharge from the hospital and found the patient could not eat or swallow food. The patient was an aspiration risk. The patient had a Foley catheter, PICC line and a stage II decubitus ulcer on the patient's hip. There were no physician discharge orders that addressed the care of the patient's PICC line and Foley catheter. There were no discharge wound care orders for care and treatment of the decubitus ulcer. The patient had limited mobility and was a fall risk. The home health nurse indicated the patient's level of care far exceeded the patient's wife's capabilities. The Director indicated the patient should have been discharged to a rehabilitative hospital or higher level of care. The home health agency assisted in making arrangements to transfer the patient to another acute care hospital for appropriate care.

Home Health Agency Nursing Notes, dated 04/29/11, documented the following: "Patient home from (Hospital) with wife. Patient has PICC line in left arm, Foley catheter, and coccyx pressure ulcer. Patient non verbal, maximum assistance for all activities and bed bound. Patient sent home without prescriptions for seizure medication. Per wife, patient does not have insurance and would be unable to get prescription. Discussed concerns with wife regarding no hot water, unable to pay electric bill. No phone in home. If wife had to contact 911 she would have to leave patient and go across the street. Contacted supervisor regarding home safety concern. Supervisor attempted to contact patient's physician who was out of town. Contacted patient's physician's office in order to speak with physician and get discharge orders. I was told by physician's office that physician was on vacation and unavailable till next week. I asked to have the phone number of the physician covering for the physician when absent and was told there was no covering physician and I would have to wait until the physician returned next week to discuss anything with the physician. The patient was sent to hospital as the home was unsafe and not appropriate for home care. Hospital discharge planner called and message left.

A review of the Admission History and Physical, dated 04/29/11, from Acute Care Hospital #2 indicated Patient #1 was admitted to the facility from home on 04/29/11, after being discharged from Acute Care Hospital #1 to home health care on 04/27/11. The patient's admitting diagnoses included history of traumatic brain injury, failure to thrive, dehydration and urinary tract infection. The patient had neurologic dysfunction and was unable to answer questions. The patient was admitted with a PICC line, Foley catheter and stage II to stage III coccyx decubitus ulcer. The patient's wife (responsible party) had no idea why the patient had a PICC line or Foley catheter. The wife reported she was unable to care for the patient in a home setting. The home health agency advised the patient wife that the patient required physical therapy, speech therapy and occupational therapy and was not appropriate for home health nursing care.

The facility's (Acute care Hospital #1) Discharge Planning Policy and Procedure, last reviewed 04/10, included the following:

Purpose: "To establish a mechanism that encourages a smooth transition for all patients being discharged from the hospital. To identify at an early stage those patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning and to aid in the appropriate transfer of relevant clinical information to the patient/family or accepting facility/service, at the time of discharge."

Policy:

1. Interdisciplinary discharge planning will begin for every patient as soon as possible after admission.
2. Discharge instructions are to be given to every patient discharged from the facility.

Procedure: Discharge Planning:

1. "Through a collaborative effort of the patient (or individuals acting on behalf of the patient), the attending physician, Case Management Department, Ancillary staff and Nursing staff, development of a discharge plan will be initiated on all patients at the time of admission. Coordination of a discharge plan will occur among various disciplines responsible for the patients care. Reassessment will occur on an ongoing basis throughout the admission when changes in the patients condition and need occurs."
2. Discharge Planning will include the following:
a. The need and availability of post discharge services.
b. The ability, willingness and capacity for self-care.
c. Determining the possibility of returning the patient to a pre-hospital care setting or making arrangements for appropriate alternative placement of the patient after discharge.
d. Completed Discharge Instruction Forms: Information on medications, treatments, anticipated outcomes and potential complications related to diagnosis should be included in the discharge instructions.

Complaint # 28318

Based on observation and interview, the facility failed to ensure a patient who was held in the Emergency Room (ER) was monitored by a physician daily to ensure continuity of care (Patient #15).

Findings include:

Patient # 15

Patient #15 was brought to the Emergency Room (ER) on 6/19/11, with symptoms of bizarre and manic behavior. The patient was placed on a legal hold (Legal 2000 is the State of Nevada's involuntary civil commitment process). She was medically cleared and had an assessment by the Southern Nevada Adult Mental Health (SNAMH) crisis team on 6/20/11, for evaluation of an inpatient psychiatric admission. The recommendation by the SNAMH crisis team was Patient #15 was appropriate for in-patient psychiatric admission.

Since there was no inpatient psychiatric bed available, Patient #15 was being held in the psychiatric holding area of the ER.

Review of the medical record on 6/21/11, revealed there was no documented evidence Patient #15 was seen by a physician on 6/20/11.

On 6/21/11 in the morning, the ER Medical Director (ERMD) indicated all patients in the Psychiatric holding area were to be seen daily. The ERMD confirmed there was no physician progress notes documented for 6/20/11. The ER MD contacted the person who was supposed to round (evaluate) on this patient and was informed she was not aware there was a patient in the psychiatric holding area that needed to be seen.

The facility policy titled, "Legal Holds in the Emergency Department (E.D.)," dated 5/11/2005, documented:
- "...3. The psychiatric patient will remain under the care of the E.D. physician with a consult to a psychiatrist or psychiatric crisis team or behavioral health consultant. 4. An E.D. physician must round daily on psychiatric hold patients. "

Based on interviews and document review, the facility failed to ensure emergency room staff were adequately trained in monitoring patients in labor, and intensive care procedures to meet the emergency needs of patients presenting to the facility.

Findings include:

1) On 6/22/11 in the morning, the Director of Emergency Room Services (DERS) revealed when a pregnant patient presented to the Emergency Room (ER) with symptoms of active labor, an initial screening was performed. This included obtaining information regarding the gestational age, if the patient had received prenatal care, name of the physician and current symptoms.

If the patient's pregnancy had been confirmed and the patient was greater than 20 weeks pregnant, the patient would be referred to the Labor and Delivery (L&D) area of the hospital to be monitored. If the patient's pregnancy had not been confirmed, or the gestational age was less than 20 weeks, the patient would be monitored in the ER. The DERS added, although the current cutoff for gestational age was 20 weeks, the facility was changing this to 24 weeks gestational age.

The DERS verbalized the Triage Nurse would call the L&D area to check if the area had capacity to accept the patient. If the L&D did not have a bed available, or did not have enough staff available to monitor the patient, the patient would be held in the ER to be monitored, regardless of the gestational age of the fetus.

The ER staff would continue to hold and monitor the patient, and would call the L&D area every 30 minutes until a bed was available. If a bed became available, the patient would be transferred to the L&D area.

When the patient was held in the ER, the patient would be monitored, which included monitoring the patient's vital signs, performing an ultrasound of the abdomen to check the viability of the fetus and checking the fetal heart by using a Doppler. There was no fetal monitor available in the ER to continuously monitor the fetus, no TOCO (Tocodynamometer) to monitor the patient's contractions. The DERS added there were no nursing staff working in the ER who were trained in monitoring labor and delivery patients.

The DERS indicated the L&D staff would be available to come to the ER to assist with monitoring the patient and could bring a fetal monitor to the ER. When the DERS was asked if the L&D area did not have enough staff to accept a pregnant patient how would L&D be able to send a staff member to the ER, the DERS was not able to answer that scenario.

The DERS also revealed when a delivery was imminent the staff would call a "Code Stork" overhead so the L&D staff would be alerted and could respond to provide assistance.

On 6/24/11 at 9:15 AM, the Assistant Director of Nurses (ADON) verbalized when the ER calls the L&D area for a patient and there were no beds available, the L&D staff try to move patients to accommodate the ER patient. After a half hour, the nursing supervisor would be called to assist with moving patients. The ADON added the clinical supervisor makes every effort to send a nurse from L&D to the ER to evaluate a patient.

On 6/24/11 in the morning, the ER physician verbalized a pregnant patient with a viable fetus should not be monitored in the ER. The nursing staff are not trained to monitor the patient and fetus and there are no fetal monitors available in the ER. The ER physician added, the ER physicians are not available at all times since they have to cover emergencies and codes throughout the facility.

During the survey, interviews with several Registered Nurses (RN's) assigned to the ER were conducted. All staff who were interviewed, confirmed they did not have specialized training in L&D. One RN, was not aware of the "Code Stork" code.

Review of the facility's "Clinical Competency Checklist for Triage/Medical Screening Competency Labor and Delivery RN," dated 4/06, included:
- " ...Obtains FHT (Fetal Heart Tones) (applies External Fetal Monitor - U/S (Ultrasound) and Toco...)
- " Obtain contracture status:
- 1. Present/Absent
- 2. Date/Time began
- 3. Regular/Irregular
- 4. Frequency/Duration status
- 5. Intensity: Mild, Moderate, Strong, uterus relaxed between contractions "
- " Maintains current NRP (Neonatal Resuscitation Program) "

Review of the facility's "Clinical Competency Checklist for Labor and Delivery R.N. Orientation/Competency Checklist," undated, included: "...Monitor contractions via palpation. Operate electronic fetal monitoring equipment..."

Review of the facility's "Clinical Competency Checklist for ED (Emergency Department) - RN," dated 9/2007, did not include the competency measures which were specific to monitoring pregnant patients in labor including monitoring fetal heart tones, monitoring contractions, and NRP.

2) During the survey from 6/21/11 through 6/24/11, observed Emergency Room (ER) Registered Nurses (RN's) caring for patients who were being held in the ER, but were on ICU (Intensive Care Unit) level of care.

Two of the patients were noted to be on ventilators and were on Propofol (Diprivan) drips for sedation.

Several nurses were interviewed to determine if they knew the protocol for the correct administration of Propofol. The R.N.'s provided varying responses indicating the tubing should be changed after 12 hours, 24 hours, or whenever a new Propofol bottle was hung. None of the nurses interviewed knew the timeframes for changing the bottle of Propofol.

The facility policy titled, "Intravenous Therapy," dated 8/2009, documented: "Replace tubing used for the administration of Propofol is to be in use no longer than 12 hours and should be changed per manufacturers recommendation (sic)."

The manufacturer's recommendations documented on the Propofol insert regarding the administration of Propofol indicated: "The tubing and any unused portions of Propofol injectable emulsion should be discarded after 12 hours because Propofol injectable emulsion contains no preservatives and is capable of supporting growth of microorganisms. "

Based on a review of Respiratory Services job descriptions, a review of employee files and interviews with employee #49, employee #55 and employee #56, two of eight personnel whose personnel files were verified did not meet the qualifications for experience upon hire as stated in the Respiratory Therapist II job description.

Findings include:

1. The work experience of one Respiratory Therapist II whose personnel file was reviewed could not be verified by the Human Resources Department prior to hire, as stated in the employee file and confirmed by employee #56.

2. A Respiratory Therapist II who was hired upon completion of student training did not meet the requirement of one year of experience prior to hire, in accordance with the Respiratory Services job description for the position.

Based on a review of respiratory department policies and interviews with employee #49 and employee #55, the amount of supervision required for respiratory department personnel to perform their duties was not specified in writing.

Findings include:

Employees #49 and #55 confirmed that the amount of supervision required for the performance of duties by respiratory department personnel was not specified in documents reviewed during survey or in other facility documents.

Based on a review of respiratory department staffing schedules, an employee timecard, the iSeries Timekeeper Punch Care Detail for the facility, and an interview with employee #49, the facility was not staffed with General Supervisors for the collection and testing of blood gases during all routine hours of operation.

Findings include:

Blood Gas Technologist General Supervisors were not working in the facility from 6:00 p.m. through 6:00 a.m. on 4/24/11 and 6/19/11, based on documentation and confirmation provided by employee #49.