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Based on interview and record review, the hospital failed to ensure physician's documentation showed the patient or the patient's representative was informed of the risks and benefits of a procedure prior to performing the procedure for two of 44 sampled patients (Patients 20 and 28). This failure had the potential for the patients not to receive information needed to make an informed decision regarding their care.

Findings:

The hospital's P&P, Consent, Informed and Authorization of Consent to Surgery or Special Diagnostic or Therapeutic Procedures, Including Blood Transfusion, approved 1/12, read in part, "In every case where informed consent is required, the physician must document in the medical record prior to the consented procedure that: A discussion with the patient/surrogate has taken place; Information on the risks, benefits, alternatives and any potential conflicting interests has been provided," and "The patient/surrogate has agreed to the procedure."

1. During a review of Patient 20's medical record in the ICU on 10/22/12, the record contained a consent form for a central IV line; however, there was no documentation found to show the physician discussed the risks and benefits of the procedure with the consenting party. The area on the consent form for the physician's signature attesting the patient was informed was left blank.

In an interview with RN A on 10/22/12 at 0900 hours, the RN was asked to review the medical record for Patient 20. The RN stated the central IV line was placed yesterday. The RN stated the doctor should sign the form to show the risks and benefits were discussed with the consenting party prior to the procedure.

2. The hospital's P&P, Blood/Blood Product Identification, Administration and Transfusion Reaction, approved 1/12, read in part, "The physician will document the patient/surrogate's understanding of the risks, benefits and alternatives, and their receipt of the State brochure in the medical record."

The medical record for Patient 28 was reviewed on 10/22/12. Two blood transfusion consent forms were reviewed. No documentation by the physician was found to show the risk of receiving blood products was discussed with the patient prior to the transfusions. The areas on the consent forms for the physician to sign attesting the patient was informed of the risks and benefits regarding blood transfusion were left blank.

In an interview with RN N on 10/22/12 at 1000 hours, the RN stated the physician should sign the form to indicate the risks of blood transfusion were discussed and information was provided to the patient about risks and benefits.

In an interview with RN O on 10/22/12 at 1005 hours, the RN stated Patient 28 had received blood transfusions on 10/18, 10/19, and 10/20/12. The RN stated the doctor was expected to discuss the risks and benefits of blood transfusion with the consenting party and sign the form within 24 hours after writing or giving a telephone order for blood products.

Based on observation, one of 44 sampled patients (Patient 42 ) was not provided respect and dignity during an assisted ambulation in the patient's room.

Findings:

On 10/22/12 at 1030 hours, while passing Patient 42's room, the patient was observed ambulating with a walker under the guidance of a PTA. The door to the patient's room was open and the patient was visible to anyone in the hallway. The patient was observed wearing a hospital gown tied only at the neck. The gown was hanging open at the back exposing the patient's entire backside.

Based on observation, interview and record review, the hospital failed to ensure patient care areas in the ED were thoroughly cleaned after each patient and infection control policies were implemented consistently for isolation patients to prevent the possible spread of infection to patients, staff and visitors.

Findings:

1. On 10/23/12 at 1600 hours, in the ED, an overflowing trashcan, with trash including paper products stained with red fluid, was observed in a patient care bay. At 1610 hours, a new patient was observed wheeled into the patient care bay. The trashcan had not yet been emptied.

During an interview with RN N on 10/23/12 at 1610 hours, the RN confirmed the new patient was placed in a patient care bay with a trashcan overflowing with contaminated material from the previous patient. When asked who cleaned the patient care areas, the RN stated the housekeepers cleaned the patient areas when asked; otherwise, "everybody" cleaned the patient care areas. The RN stated he also, on occasion, cleaned the patient care bays between patients. When questioned regarding the proper use of cleaning products to sanitize the patient care bay, the RN was unable to state the appropriate techniques to effectively use the sanitizing agents.

During an interview with the Infection Control Nurse on 10/24/12 at 1124 hours, he stated staff should clean the patient care bays after each patient, including emptying the trashcan. When asked if the ED nursing personnel were trained in the proper use of sanitizing products, the Infection Control Nurse answered he was "not sure."


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2. Review of the hospital's P&P, Isolation Precautions-Guidelines, revised 7/11, showed gowns, gloves and masks should be removed and hands washed prior to staff leaving an isolation room. Contact isolation precautions are for patients with known or suspected infections with microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient-care items in the patient's room.

The P&P also showed the patient's room door is to be closed for patients in airborne precautions. An N95 respirator mask must be worn when entering the room of a patient with known or suspected infectious pulmonary tuberculosis (N95 or NIOSH masks are different from surgical masks as they provide better protection).

a. On 10/22/11 at 1025 hours, PTA 1 was observed in Patient 43's contact isolation room wearing only gloves and no gown. The PTA was observed standing next to the bed arranging the sheets back over the patient's legs.

b. Patient 41 was observed on 10/22/12 at 1520 hours, in a contact isolation room. A sign outside the door instructed staff and visitors to wear a cover gown, mask and gloves when inside the room. A visiting family member wearing the required PPE walked out of the patient's room into the hallway and then re-entered the patient's room several times. The cart containing clean PPE was located outside the room door in the hall. Each time the family member came out of the room he passed next to the cart with his potentially contaminated gown brushing against the cart. Staff members did not approach the family member to caution him not to leave the room while wearing the PPE.

c. On 10/22/12 at 1540 hours, a family member was observed in Patient 44's contact isolation room. The visitor was wearing a gown and gloves. Prior to leaving the patient's room, the visitor removed the gown and gloves, but did not perform hand hygiene before or after leaving the patient's room.

d. On 10/23/12 at 1205 and 1210 hours, LVN F was observed leaving Patient 40's airborne isolation room wearing an N95 mask. Each time, LVN F removed the mask after leaving the room, and carried the possibly contaminated mask in her hand into the nurses' station. The masks were deposited in the trash container inside the nurses' station. The nurse washed her hands at the nurses' station. No container for the masks and no hand washing supplies were observed located outside the patient's room.

On 10/23/12 at 1155 hours, the surveyor's observations were discussed with the Infection Control Nurse. At 1510 hours, the Infection Control Nurse provided the surveyor with a copy of the hospital's infection control policy and a copy of a sign "Where to Remove PPE." It showed to remove gown and gloves at the doorway, before leaving the patient room or in anteroom. Remove respirator mask outside room, after door has been closed. Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rubs.

e. On 10/24/12 at 1330 hours, during an interview with LVN D, she stated she had just received a new patient who was admitted to rule out a possible tuberculosis infection. She was on her way to the room to get the patient settled. An airborne isolation sign was observed posted on the patient's door. The airborne contact isolation sign showed staff must wear an N95 mask when entering the room. During the interview, RN K opened the room door to exit the room. RN K was providing care to the patient and opened the door to gather more supplies from the cart outside the room. RN K was wearing a surgical mask not the required N95 mask.

Based on interview and record review, the hospital failed to:

1. Measure, track and analyze data regarding the timeliness and completeness of pressure ulcer prevention and treatment when data such as the size/stage of the pressure ulcers and the number of patients with pressure ulcers in the hospital was not tracked.

2. Validate the data collected regarding patients with pressure ulcers and confirm nursing staff were conducting pain assessments for patients per the hospital's P&P.

These failures created the risk of poor wound care and incomplete pain assessments for patients.

Findings:

1. The hospital's P&P, Performance Improvement Plan, approved 6/12, read in part, "Data collection should focus on areas of prevalence and the severity of identified problems, giving consideration to patient safety and quality of care. Measurements are used to help ensure the data collected are appropriate for monitoring performance."

A review of the six medical records of hospitalized patients with wounds was conducted to determine if wound prevention/care was complete, timely, and correct according to the hospital's P&P. Three of the six records (Patients 1, 31, and 40) showed multiple failures and omissions in the care provided. This resulted in outcomes of persistent wounds for Patients 31 and 40, and two new or recurrent pressure ulcers for Patient 1. The failures included special mattresses not provided promptly when the patient was assessed as high risk for skin breakdown, failure to use the correct absorbent pads, failure to position the patients with pressure off the wounds, failure to ensure physician's documentation about a high risk skin condition or wound, and failure to provide timely assessment of wounds. Cross Reference to A392 #1.

In interviews with the Wound Care Nurse on 10/24/12 at 0900 and 1100 hours, she stated chart auditing was performed for patients with wounds, and the tabulated data was submitted to the Performance Improvement Department.

The performance improvement wound care data for the 4th quarter of 2011, and for the 1st, 2nd and 3rd quarters of 2012, were reviewed. For the 16 quality issues measured, the data showed an overall compliance of 97% - 98%. For 12 of the 16 measures, hospital compliance was over 95% during each of the four quarters reviewed. However, a review of the performance improvement measures showed they did not include parameters regarding the time frame in which actions were carried out, and did not confirm whether care plans were appropriate or fully implemented (just "treatment plan is initiated" and "care plan completed").

2. The hospital's P&P, Performance Improvement Plan (approved 6/12), read in part, "Data has a defined source, frequency, and intensity appropriate to the activity or process being studied. Examples of data sources include valid and reproducible databases."

a. In interviews with the Wound Care Nurse on 10/24/12 at 0900 and 1100 hours, the nurse stated the medical records of patients with wounds were audited and the tabulated data was submitted to the Performance Improvement Department. However, the Wound Care Nurse stated she did not keep the wound care audit sheets. In addition, when asked, the Wound Care Nurse stated she was not aware if her chart audits had ever been validated by anyone in the Performance Improvement Department.

b. During a review of the medical records for ED Patients 19, 26 and 34, on 10/23/12, documentation did not show pain assessments were performed during the patient's ED stay as per the hospital's P&P. Cross Reference A392 #2.

The Director of the Emergency Department reviewed the medical records for Patients 19, 26, and 34 on 10/23/12 at 1415 hours, during an interview. The Director confirmed there was no evidence to show pain assessments were performed for these patients at one or more of the required times. The Director stated per hospital P&P, the staff should quantify the patient's pain and document the corresponding number in the patient's medical record.

During a second interview with the Director of the Emergency Department on 10/24/12 at 1030 hours, the Director confirmed she was not aware pain assessments were currently not consistently performed for ED patients by nursing staff. The Director confirmed this had been a concern during a previous hospital survey completed on 9/7/12. The Director stated the ED staff was resistant to change. When asked what she was doing to quantify the problem, the Director stated the education of the staff was ongoing.

Based on interview and record review, the hospital's performance improvement program failed to perform quality surveillance of high risk and problem prone issues in the ED including the assessment of pain and the effectiveness of a new scribe program (by having scribes document patient information into the EHR for ED physicians). This resulted in pain assessments not completed per hospital's P&P for three patients (Patients 19, 26 and 34) and omissions from the records of six patients (Patients 18, 19, 25, 26, 29, and 35) when scribes were used by the ED physician to document patient information.

Findings:

The hospital's Performance Improvement Plan dated 6/12, read in part, "Data collection should focus on areas of prevalence and the severity of identified problems, giving consideration to patient safety and quality of care ...These measures will: Identify the events it was intended to identify ..." and "Data are collected in a systematic manner to: Establish a performance baseline; describe process performance or stability ..."

1. During a review of the medical records for ED Patients 19, 26 and 34 on 10/23/12, documentation did not show pain assessments were performed during the patient's ED stay as per the hospital's P&P. Cross Reference to A392 #2.

The Director of the Emergency Department reviewed the medical records for Patients 19, 26, and 34 on 10/23/12 at 1415 hours, during an interview. The Director confirmed there was no evidence to show pain assessments were performed for the patients at one or more of the required times. The Director stated per the hospital's P&P, the staff should quantify the patient's pain and document the corresponding number in the patient's medical record.

During a second interview with the Director of the Emergency Department on 10/24/12 at 1030 hours, the Director confirmed she was not aware pain assessments were currently not consistently performed for ED patients by nursing staff. The Director confirmed this had been a concern during a previous hospital survey completed on 9/7/12. The Director stated the ED staff was resistant to change. When asked what she was doing to quantify the problem, the Director stated the education of the staff was ongoing.

2. During a review of the medical records of Patients 18, 19, 25, 26, 29 and 35 on 10/23/12, there was incomplete or no documentation regarding the patient's medications found on the ED Physician Documentation. Cross Reference to A1104.

The ED Physician Documentation contained headers such as "History of Present Illness" and sub headers such as "chief complaint;" however, there was no header for "medications." No information regarding patient medications was found anywhere else on the physician's documentation.

In an interview with the ED Medical Director on 10/23/12 at 1535 hours, the Director stated the omission was possibly an oversight attributable to the new scribe program implemented earlier in the year in the ED. The Director stated the ED physicians in the hospital used scribes from 1000 hours until midnight. The Director stated the scribes may not have added in the medications when entering documentation on the computer.

During an interview with the Administrator/CNO on 10/24/12 at 1030 hours, the CNO stated the hospital was responsible for the quality of the medical record produced by the scribes. The CNO was asked about quality assurance conducted for the scribe program, specifically whether samples of the documents produced by the scribe service had been reviewed.

The CNO stated specific measures of the medical record were assessed. The CNO provided a list of these measures. When reviewed, the measures assessed did not include a review of the overall completeness or accuracy of the medical records produced by the scribe service. The CNO stated the scribe program was a new contracted service and the service had not been reviewed as yet. The CNO stated she was not sure if the contractor performed its own quality assurance activities and did not know if any quality assurance data had been submitted for review.

Based on interview and record review, the hospital's PI committee failed to evaluate an adverse patient event for one of the three adverse patient events reviewed (Patient 22). The lack of an evaluation of the quality of patient care preceding an adverse patient event, and implementation of corrective action if required, increased the risk of a similar adverse event for hospital patients.

Findings:

The hospital's P&P, Performance Improvement Plan, approved 6/12, read in part, "PI Core Team ...member's duties and responsibilities: Conduct the initial investigation and analysis of any significant event, sentinel event or near miss ..."

During a review of Patient 22's medical record, the Archived Notes dated 4/20/12 at 1640 hours, indicated the family member came to the nursing station and stated something was wrong with the patient. The Rapid Response team was called to the patient's bedside and a code blue was called (a team of nurses, respiratory therapists, and sometimes a physician who respond in a situation where a patient required resuscitation or otherwise was in need of immediate medical attention). Patient 22 was intubated (placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway), placed on mechanical ventilation to assist breathing, and was transferred to the ICU (Intensive Care Unit).

The Administrator/CNO was interviewed on 10/24/12 at 1030 hours. When asked if the PI committee reviewed unexpected code blues, the CNO stated, "Yes, a time line study is done." When asked if the hospital's PI committee had developed specific criteria by which deaths or adverse events were reviewed, the CNO stated "no." When asked, the CNO confirmed the PI committee had generated a written assessment of Patient 22's adverse event.

The report provided by the CNO showed only the appropriateness of the Rapid Response Team's performance was reviewed. There was no evidence the PI committee evaluated the events leading up to Patient 22's unexpected code blue for a root cause or implemented corrective actions to improve the quality of patient care.

Based on observation, interview and record review, the hospital failed to ensure the ongoing needs of patients when:

1. The hospital failed to ensure pressure ulcer/ prevention care was provided per the hospital's P&P for three of the six patients with wounds reviewed (Patients 1, 31, and 40).

For Patient 1, the hospital failed to initiate a care plan to develop interventions to address a previously healed sacral pressure ulcer observed on admission until the day after the patient's skin breakdown was observed; there was no documentation to show the patient was placed on a low air loss mattress at the time of admission and specialty underpads were used; there was no documented assessment of the sacral area to show measurements when the wound opened; two photographs of the open wound labeled the wound as "right" sacral when an evaluation by the Wound Care Nurse showed the site as "left" sacral/buttocks; and the patient was consistently positioned with pressure on the open wound. Patient 1 developed an additional area of breakdown on the opposite side of sacral/buttocks area prior to discharge.

For Patients 31 and 40, both of whom were admitted with sacral pressure ulcers, the hospital failed to provide the care needed to help the pressure ulcers heal. The patients were not consistently kept positioned off the pressure ulcer site. In addition, for Patient 40, the care plan developed to address the pressure ulcer was not specific and individualized to ensure the patient was kept positioned off the area. For Patient 31, there was no follow-up by the Wound Care Nurse for 19 days.

2. The hospital failed to show documentation that complaints of pain were addressed for three of 30 patients reviewed for the assessment of pain (Patients 19, 26 and 34). This created an increased risk of discomfort and a poor health outcome for those patients.

Findings:

1. In February 2007, the NPUAP (The National Pressure Ulcer Advisory Panel) defined a pressure ulcer as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

Review of the hospital's P&P, Pressure Ulcer Prevention and Treatment dated 1/12, showed the purpose of the policy was to provide guidelines for assessment of skin integrity, to determine risk of developing pressure ulcers, to develop a plan of care for prevention of pressure ulcers in those patients determined to be at risk, and to provide guidelines for treatment.

The RN/LVN will document their assessment of each wound by including the following in their documentation: location on body; size (length x width x depth in cm); wound/periwound skin color; drainage; undermining; presence of pain; and signs of infection.

Wounds will be photographed in the ED, upon admission, when transferred to another unit in the hospital and upon discharge from the hospital. Photography of wounds should be obtained upon discovery of new wounds, a change in condition of wounds and weekly. Place photo in physician's order section for signatures.

A Risk Prevention Protocol, "Save Our Skin" will be initiated as indicated according to the patient's Braden Scale score and/or physician's orders. Patient's will be identified at risk for pressure ulcer and the patient's care plan will reflect preventing injury by maintaining improving tissue tolerance to pressure in order to prevent injury and to protect against the adverse effects of mechanical forces. (Braden Scale, the most commonly used pressure ulcer assessment tool in the United States, consists of six subscales based on the primary etiologic factors of pressure ulcer development, and the lower the score, the higher the patient's risk for developing a pressure ulcer)

It is the responsibility of the nursing team to position the patient and ensure skin integrity is maintained in accordance with "Save our Skin" protocol and the patient care plan. The following steps should be considered, but not limited to:
*Positioning patient every 2-4 hours based on patient's condition and co-morbidities as patient condition permits.
*Avoid direct pressure over bony area or ulcer site.

It is not recommended to use diapers or adult briefs for non-ambulatory patients. One ultrasorb pad is to be used for incontinent patients. Nurses should consult manufacture guidelines for bedding needs.

a. The hospital's P&P, Skin Integrity, approved 1/12, read in part, "Upon identification of need, a low air loss mattress will be provided for patients requiring them...Pressure reduction support surface for patients with "moderate risk 13-14" or high risk 10-12" Braden scale scores."

The medical record for Patient 1 was reviewed beginning on 10/22/12. The patient was admitted to the hospital on 10/19/12, from a skilled nursing facility in order to treat an infection. The patient had a history of brain damage from a stroke and was in a chronic vegetative state.

Review of the Nursing Initial Physical Assessment dated 10/19/12 at 2030 hours, showed Patient 1 was completely immobile and was unable to speak or respond. Documentation showed an old pressure ulcer on the sacrum was identified as a "hypo pigmented area." The skin was intact. A photograph of the area was obtained.

Patient 1 was assessed to have a Braden Score of 12 (high risk). There was no evidence the patient was placed on a special mattress on 10/19/12, as per the hospital's policy.

Review of the plan of care for Patient 1 showed a care plan had been developed at the time of admission to address the patient's potential for impaired skin integrity; however, there was no documentation to show the sacrum was a targeted site.

On 10/20/12 at 1630 hours and 10/21/12 at 1430 hours, photographs were taken of an open sacral wound for Patient 1. The wound location was documented as "right" sacral area on both photographs. There was no documentation to show the size of the wound. The wound was described as red in color with no drainage. The areas on the photograph to show documentation the physician had reviewed the photographs and assessed the wound were left blank.

Review of the shift assessment for Patient 1 dated 10/20/12 at 2100 hours, showed the sacrum was an "open wound." However, there were no measurements of the wound or description of the wound documented.

Review of Patient 1's care plan did not show a plan was developed to address an open sacral wound until 10/21/12 at 0900 hours. The interventions were not specific and individualized to show how frequently to reposition the patient, the specific wound care to be given, or to show repositioning of the patient in the supine position should be avoided to keep pressure off the affected site.

Review of the shift assessments dated 10/21/12 at 0900 and 2100 hours, and 10/21/12 at 0900 hours, did not show measurements of the sacral open wound which was described as "pink."

On 10/22/12 at 1100 hours, Patient 1 was observed along with the Wound Care Nurse. The patient was on a low air loss mattress. The head of the bed was slightly elevated. Patient 1 was positioned slightly to the right side, with pillows placed behind the back to prevent rolling to the supine position. However, after removing the pillows from behind the patient, the Wound Care Nurse had to use the draw sheet to roll Patient 1 even further over on to her right side, remove the two to three blue chux pads (pads with an absorbent layer with a blue plastic backing) in place under the patient and reposition the patient even more on her right side in order to view the skin wound on her left buttock. The wound was covered with a gauze dressing.

The hospital's policy required a special air flow pad to be placed under patients on a low air loss mattress to improve air circulation around the wound area to assist with healing. Observation of Patient 1 on 10/22/12 at 1100 hours, with the Wound Care Nurse, showed the patient had been placed on pads with an absorbent material on one side and a plastic material on the other side, not the special air flow pad. When asked about the air flow pad for Patient 1, the Wound Care Nurse stated she did not order the air flow pads for the patients, the floor nurses should get the pads to place under the patients. The Wound Care Nurse confirmed low air loss mattresses were to be provided to patients with Braden scores less than or equal to 12.

In an interview with RN P on 10/22/12 at 1000 hours, the RN stated an air mattress should be obtained for a patient with a Braden score of 12; however, when asked, RN P was unable to find documentation in Patient 1's record to show an air mattress was provided for the patient upon admission on 10/19/12. RN P was unable to find documentation to show when the air mattress was provided.

Review of the Wound Care Evaluation for Patient 1 dated 10/22/12 at 1145 hours, showed the Wound Care Nurse documented a "left coccyx/buttock partial thickness wound measuring 2.0 x 1.5 x 0.1 cm in size. Prior history of a pressure ulcer unknown in size. Wound bed is beefy red. Moderate amounts of serous drainage. Periwound intact with scar tissue visible. Recommend frequent turning." However, earlier documentation by nursing staff on the photograph dated 10/20/12 at 1630 hours, showed the open wound as "right sacral."

Review of the hourly rounding documentation for Patient 1 showed the position of the patient in the bed at each check. Although the patient's open wound was documented on the sacral area, the patient was shown to be in the supine (back lying) position on 10/20/12 at 0200 hours, 10/22/12 at 0200 and 0300 hours. 10/23/12 at 0500, 0600, 0900, 1000, 1600, and 2300 hours, and on 10/24/12 at 0400, 0500, and 1000 hours.

Review of nursing shift assessments for Patient 1 dated 10/22/12 at 2100 hours, 10/23/12 at 0900 and 2100 hours, and 10/24/12 at 0857 hours, did not show a change in the patient's sacral/buttock wound. Review of the care plan for the same dates did not show new information was added.

During a tour of the 7th floor nursing unit on 10/24/12 at 1345 hours, RN C reported Patient 1 was transferred back to the skilled nursing facility a few minutes ago.

During a medical record review for Patient 1 with RN C and LVN G, the discharge photograph of the sacral pressure ulcer was reviewed. Review of the photograph dated 10/24/12 at 1045 hours, showed an additional open area on the right sacral/buttocks, similar in size to the wound on the left side. There was no documentation to show the new wound was measured and there was no physician's review prior to the patient's discharge. RN C confirmed the right side was a new wound, which was not present when she cared for the patient the previous day.

The Transfer/Discharge Summary Report, a copy of which was sent with Patient 1 to the skilled nursing facility upon transfer as a communication tool for continued care, was reviewed with LVN G. The area for documentation of pressure ulcers and treatment was left blank. When asked, LVN G stated she "forgot to fill it out."


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b. Medical record review for Patient 40 showed the patient was admitted to the hospital on 10/19/12, with a Stage IV sacral pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Wound often has undermining and tunneling).

A Plan of Care for Patient 40 was initiated on 10/19/12 at 0230 hours. The interventions included a wound care consultation, repositioning of the patient, documentation of the skin condition and wound care. The interventions were not specific and individualized to show how frequent the patient was to be repositioned, what specific wound care was to be given, and the patient should not be positioned in the supine position in order to keep pressure off the affected site.

On 10/23/12 at 1145 hours, Patient 40 was observed in bed in a supine position.

Review of the hourly rounding documentation for Patient 40 showed the patient was placed in the supine position on 10/19/12 from 0500 to 0700 hours, from 1200 to 1300 hours, and from 1800 to 2000 hours, and on 10/20/12 from 0000 to 0300 hours, and at 0600 hours.


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c. The medical record for Patient 31 was reviewed on 10/23/12, with RN L. The patient was admitted on 10/2/12.

A Wound Assessment dated 10/2/12, showed a 4 cm x 3 cm sacral Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling).

The physician's orders for Patient 31 dated 10/3/12 at 1145 hours, read, "Turn and reposition every 2 hours and as needed." There was not an order to not position the patient supine (on back).

On 10/3/12, the Wound Care Nurse saw the patient and wrote recommendations. There was no documentation to show follow-up by the Wound Care Nurse until 10/22/12.

The nursing notes in the EHR showed the patient had been repositioned every two hours on his left and right side as well as supine. For example, the "hourly rounding" section of the EHR showed Patient 31 was positioned supine from 1200 to 1400 hours on 10/22/12, from 1200 to 0200 hours, and from 0400 to 0600 hours on 10/23/12. The 10/21/12 Wound Assessment showed a persistent sacral wound, 5 cm x 3 cm.

In an interview with RN L on 10/23/12 at 1120 hours, she stated it was okay to reposition a patient lying on an ulcer site as long as the patient was moved every 2 hours.

During an interview with the Wound Care Nurse on 10/24/12 at 0840 hours, when asked about positioning of patients with identified pressure ulcers, she stated these patients should not be positioned directly on a wound. After completing a consultation, the Wound Care Nurse stated she wrote directions for frequent turning but did not specify the patient should not be placed on the wound. The Wound Care Nurse stated the floor nurses knew not to place patients on the site of a wound.

The Wound Care Nurse stated she evaluated a patient when requested by the floor nurses. The Wound Care Nurse stated, after initially assessing a patient, she reassessed the patients with wounds one time per week, when the patient's condition changed, and at discharge. If patients were admitted on the weekend, the floor nurses initiated the plan of care and called the physician for treatment orders. The nurses could not stage the pressure ulcers, only the physician and the Wound Care Nurse could stage a pressure ulcer. The Wound Care Nurse stated she did not get involved with the daily care of the patient's with wounds unless there was a change in the patient's condition.

The Wound Care Nurse stated she was not sure if there was a policy that defined her role. The Wound Care Nurse stated she also worked in the wound care clinic around six hours per day and the balance of her shift was in the hospital, 1.5 to 2 hours daily. The Wound Care Nurse stated if she was away during a regular week there would not be a response to a request for wound care services as no one else stepped into her role during her vacations.

The Wound Care clinic schedule was reviewed, and showed the Wound Care Nurse was scheduled in the clinic some or all the days of each week in October, 2012, during Patient 31's hospitalization.

2. The hospital's P&P, Pain Assessment and Management, formulated 7/08, reviewed 8/11, indicated it was for use by all clinical staff, and read in part, "Staff will assess and monitor patients for presence of pain. They will encourage patient's self-reporting of pain by asking the patient about their pain and by remembering pain is what the patient says it is ... " "All patients will be screened for pain at the time of admission." "Pain will be monitored throughout patient's stay in the hospital with each set of vital signs ...and PRN (as needed)." "Response to pain relieving intervention will be documented based on the mode of pain medication delivery (i.e. IV-15 minutes, IM-30 minutes, PO-1 hour)," and "Pain assessment will be documented and be communicated at points of transition of care such as transfer, discharge or referral ..."

The policy further read, "Pain scores are documented as the actual score versus the total possible score. A score of 4 or greater indicates the need for pain relieving interventions" and describes "Severe pain: a pain level of 7, 8, 9 or 10 on the 0-10 scale. Moderate pain: a pain level of 3, 4, 5 or 6 on the 0-10 scale. No pain: a pain level stated at "0" on the 0-10 scale."

a. On 9/17/12 at 0508 hours, Patient 34 came to the ED with a chief complaint of ankle pain. The triage assessment did not include a pain assessment, although other vital signs were assessed.

The ED Manager was interviewed on 10/23/12 at 1345 hours, regarding Patient 34. She reviewed the medical record and stated the patient's pain level should have been assessed and documented during triage.

b. Patient 26 came to the ED on 9/16/12 at 0017 hours, with a chief complaint of a toothache. During triage, the patient's pain was rated at 10/10 (severe pain). The patient left the ED at 0126 hours. There was no numerical pain score documented during her time in the ED after the triage score.

In an interview with the ED Director on 10/23/12 at 1430 hours, the Director reviewed Patient 26's record. The Director concurred there was no reassessment of the patient's pain after pain medication was given, or prior to discharge. The Director stated the nurse should have addressed pain on the discharge assessment.

c. During a review of the medical record for Patient 19, the Emergency Department Visit Summary Report was reviewed. Vital signs taken on 9/20/12 at 1031, 1210 and 1525 hours, did not show evidence of a pain assessment despite the fact the patient presented to the facility with the chief complaint of abdominal pain.

During an interview with the ED Director on 10/23/12 at 1415 hours, the Director reviewed the medical record for Patient 19 and confirmed the medical record lacked evidence of a pain assessment for the times stated above. The Director stated, per hospital P&P, the staff should quantify the patient's pain and document the corresponding number in the patient's medical record.

Based on interview and medical record review, the hospital failed to implement the P&P for Assessment and Reassessment of Patients and to follow the standard of nursing practice for 14 of 20 patients reviewed who were assigned to the care of an LVN (Patients 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 25, 35, and 38). Nursing assessments, reassessments, and care plan reviews were documented by the LVN assigned to the patients. There was no documented evidence to show the RN directly conducted the assessments and reviewed the care plan for these patients prior to delegating the care of the patients to the LVN. This resulted in the potential for harm to patients as decisions are made and executed regarding delivery of care to patients on the basis of an assessment.

Findings:

The hospital's P&P, Assessment /Reassessment of Patients, approved 1/12, showed all patients who receive care are assessed by an RN to determine the patient's needs, changing needs and effectiveness of care/intervention. Assessments are performed by each discipline within their scope of practice, licensure laws, applicable regulations and certifications.

The P&P showed the RN is responsible for performing all assessment processes for the initial assessment. A complete reassessment is completed and documented on each shift by the RN.

Interviews were conducted with the following nursing staff beginning on 10/22/12:

RN I stated LVNs were assigned to an RN who was responsible to cover their patients. However, the RN stated she has had LVNs for whom she was not assigned to cover approach her and ask her to cosign their assessment documentation in a patient's EHR because the nurse assigned to them was too busy.

RN F stated she assessed and reviewed the care plan for the LVN's patients when assigned. However, the RN F stated, "sometimes if it is really busy, I have had the LVN document their assessment and I will sign if I agree."

RN C demonstrated how patient assessments were entered into the computer. RN C also showed where the patient assessment would be documented if they were done by an LVN and where the RN's co-signed the LVN's assessment. RN C added she preferred to do all her own assessments; however, if an LVN did assess a patient, she would go and check the patient before she signed off the LVN's assessment.

LVN D stated the RN assessed the patients and she did the updates on the patients. LVN D added if she did assess a patient, the RN needed to sign the assessment and look at the patient.

1. The medical record for Patient 7 was reviewed with RN H on 10/22/12 at 1145 hours. RN H stated LVN A was assigned to care for Patient 7 for that shift.

Review of the day shift assessment dated 10/22/12, showed the physical assessment of Patient 7 was documented in the EHR by LVN A and cosigned by RN H.

RN H stated she usually conducted her patient assessments along with the LVN; however, she allowed the LVN to document the findings. The RN stated she did not realize when the LVN documented the assessment it appeared as if the LVN had completed the assessment.

2. Review of the nursing assignment sheet dated 10/17/12, showed LVNs were assigned to care for Patients 8, 9, and 13 on the night shift.

The medical record for Patients 8, 9, and 13 were reviewed with the Interim Director of Maternal Child Health on 10/23/12 at 0900 hours.

a. Patient 8 was transferred to the MBU at 0100 hours on 10/17/12, following the delivery of her infant.

Review of the initial transfer assessment of Patient 8 showed the physical assessment, including an assessment of the patient's uterus, perineal laceration, breasts, lung sounds, and presence of bowel sounds was recorded and signed by the LVN and co-signed by the RN.

Review of the care plan for Patient 8 showed the plan was initiated on admission to the MBU by the LVN and co-signed by the RN.

b. Patient 9 delivered an infant early on 10/17/12, prior to arriving at the hospital.

Review of the nursing shift assessment dated 10/17/12 at 1930 hours showed the assessment was recorded and signed by the LVN and co-signed by the RN.

Review of the care plan in the EHR did not show a care plan had been initiated for Patient 9. There was no documentation to show the RN reviewed for the presence of a care plan.

c. Patient 13, the newborn infant of Patient 9, was born outside of the hospital on 10/17/12.

Review of the nursing shift infant assessment dated 10/17/12 at 1930 hours, showed the assessment was recorded and signed by the LVN and co-signed by the RN.

3. Review of the nursing assignment sheet dated 10/8/12, showed an LVN was assigned to care for Patient 14 on the day shift and Patients 12 and 15 on the night shift.

The medical record for Patients 12, 14, and 15 were reviewed on 10/23/12 at 0945 hours, with the Interim Director of Maternal Child Health.

a. Patient 14 was transferred to the MBU at 1330 hours on 10/8/12, following the delivery of her infant.

Review of the initial transfer assessment of Patient 14 showed the physical assessment, including assessment of the patient's uterus, perineal laceration, breasts, lung sounds, and presence of bowel sounds was recorded and signed by the LVN and co-signed by the RN.

Review of the care plan in the EHR did not show a care plan was initiated for Patient 14 until 0351 hours on 10/9/12. There was no documentation to show the RN reviewed for the presence of a care plan.

b. Patient 12 delivered her infant by Caesarian section (delivery of an infant through a surgical incision in the abdomen) on 10/7/12.

Review of the nursing shift assessment dated 10/8/12 at 0800 hours, showed the assessment was recorded and signed by the LVN and co-signed by the RN.

Review of the care plan for Patient 12, which included comfort measures with the use of a PCA pump (patient controlled analgesia- IV pain medication to the patient when the patient pushes a button), showed it was recorded by the LVN and co-signed by the RN.

c. Patient 15, the newborn infant of Patient 14, was born at 1330 hours on 10/8/12.

Review of the nursing shift infant assessment and the care plan dated 10/8/12 at 1930 hours, showed the assessment and the care plan was recorded and signed by the LVN and co-signed by the RN.

4. Review of the nursing assignment sheets dated 10/14 and 10/15/12, on the day shift showed LVNs were assigned to care for Patient 11 and on 10/15/12, LVNs were assigned to care for Patients 10, 16, and 17 on the day shift.

The medical records for Patient 10, 11, 16, and 17 was reviewed on 10/23/12 at 1010 hours, with the Interim Director of Maternal Child Health.

a. Both the assessment and the care plan for Patient 10 were recorded and signed by the LVN on 10/15/12. The RN co-signed the LVN's documentation for the assessment and the care plan. In addition, review of the Discharge Criteria completed at the time of discharge for Patient 10 was recorded and signed by the LVN and co-signed by the RN.

b. The shift assessments and the care plans for Patient 11 dated 10/14 and 10/15/12, were recorded by the LVN. The RN co-signed the LVN's documentation for the assessments and the care plan.

c. The nursing shift assessment and the care plan for Patient 16 dated 10/15/12, were recorded at 1440 hours, by the LVN. The RN co-signed the LVN's documentation for the assessment and the care plan.

d. Review of the nursing shift infant assessment dated 10/15/12 at 0817 hours, for Patient 17 showed the assessment was recorded and signed by the LVN and co-signed by the RN.


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5. The medical record of Patient 25 was reviewed on 10/23/12 and 10/24/12. The patient came to the ED on 10/22/12, with suicidal ideation.

The LVN documented a physical assessment of Patient 25 was performed on 10/22/12 at 1950 hours, which included a suicide risk assessment. The RN Assessment Note documented at 0540 hours on 10/23/12 (approximately 10 hours after the LVN's assessment), read, "Agree w/LVN documentation." There was no documented evidence an assessment was performed on the patient by the RN. Vital signs were taken several times subsequently, but there were no further assessments documented prior to the patient's discharge on 10/24/12 at 1140 hours.

In an interview with CNA A on 10/23/12 at 1540 hours, the CNA stated she had been present in the ED all day as a sitter for Patient 25. CNA A stated LVN E was the nurse for the patient. The CNA stated the LVN checked the patient and listened to the patient's heart and lungs. The CNA stated there was no other nurse checking on the patient, except for the charge nurse, who came in and asked her if everything was all right. However, the CNA stated the charge nurse did not talk to the patient or assess the patient; the patient was asleep at the time.

In an interview with RN P on 10/23/12 at 1530 hours, he stated an LVN or an RN saw and assessed each patient. RN P stated an RN must review and co-sign the LVN's documentation of an assessment, but the RN did not reassess the patient in order to do so.

6. During a review of the medical record of Patient 35 on 10/23/12, the record showed that a "gastrointestinal assessment" and a "physical assessment" were documented as completed by the LVN on 9/19/12 at 0150 hours. At 0235 hours, the LVN's note read in part, "Pt (patient) ambulated out of the ER." An RN note was written about Patient 35 at 0608 hours, indicating the assessment occurred and was recorded at 0608 hours. However, the RN also documented Patient 35 departed the ED at 0317 hours. There was no documentation to show an RN assessed the patient prior to the patient ambulating out of the ED at 0235 hours.

In an interview with the Director of the ED on 10/23/12 at 1420 hours, she confirmed there was a discrepancy in the time of discharge for Patient 35 in the medical record. The Director stated it did not make sense the nursing assessment documentation was timed after the patient ambulated out of the ED.


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7. Patient 38 was admitted to the hospital on 10/23/12, through the ED. The patient was placed in an isolation room to rule out pulmonary tuberculosis. Review of the ED Visit Summary Report for Patient 38 showed the patient's physical assessment was recorded by an LVN on 10/23/12 at 1210 hours. An RN assessment note recorded on 10/23/12 at 1426 hours, showed "agree with LVN documentation." The patient's discharge from the ED was recorded on 10/23/12 at 1648 hours, by the LVN.

Based on observation, interview and medical record review, the hospital failed to ensure an individualized plan of care was developed, updated and implemented for 6 of 44 sampled patients (Patients 1, 2, 9, 20, 39 and 40). A lack of comprehensive care plan development may result in interventions not initiated which can further compromise the patient's medical status.

Findings:

The hospital's P&P to address the Plan of Care and Treatment, approved 1/12, showed it was the policy of the hospital to establish an individualized appropriate plan of care and treatment for all patients admitted to the hospital. The process was begun on admission and based on assessment findings, interdisciplinary collaboration will prioritize the patient problems and needs and incorporate then into the care plan.

For each problem identified of the care plan the following will be included:
-The date identified.
-Specific nature and cause of the problem.
-Patient specifics, measurable treatment goals of statement of projected outlines.
-Identification of the discipline identifying the issues and accepting primary responsibly for resolution.
-Patient specific interventions designed to achieve the goals.

The hospital's P&P, Pressure Ulcer Prevention and Treatment dated 1/12, showed the purpose of the policy was to provide guidelines for assessment of skin integrity, to detemine risk of developing pressure ulcers, to develop a plan of care for prevention of pressure ulcers in those patients determined to be at risk, and to provide guidelines for treatment.

1. The medical record for Patient 1 was reviewed beginning on 10/22/12. The patient was admitted to the hospital on 10/19/12, from a skilled nursing facility to treat an infection. The patient had a history of brain damage from a stroke and was in a chronic vegetative state.

Review of the Nursing Initial Physical Assessment dated 10/19/12 at 2030 hours, showed the patient was completely immobile and was unable to speak or respond. Documentation showed an old pressure ulcer on the sacrum was observed. The skin was intact with discoloration from a previously healed pressure ulcer. A photograph was obtained of the area.

Review of the plan of care for Patient 1 showed a care plan had been developed at the time of admission to address the potential for impaired skin integrity; however, there was no documentation to show the sacrum was a targeted site as high risk for breakdown.

A care plan for actual skin impaired skin integrity was initiated for Patient 1 on 10/21/12 at 0804 hours. However, the areas listed were the upper leg and thigh as well as the sacrum. Interventions showed to obtain a wound care consultation, assess and document the skin condition, reposition the patient and give skin care. There was no documentation to show an individualized plan was developed to show the frequency of repositioning or the need to keep the patient positioned to keep pressure off the affected sacral area.

Evaluation by the Wound Care Nurse, dated 10/22/12 at 1145 hours, showed partial thickness skin breakdown on the left coccyx/buttock area measuring 2.0 cm by 1.5 cm by 1 cm in size with moderate amount of clear drainage.

During an interview with RN C on 10/24/12 at 1345 hours, the RN stated Patient 1 was discharged to return to the skilled nursing facility a few minutes ago. The discharge photograph of Patient 1's sacral pressure ulcer was requested for review. The photograph showed breakdown of the right sacral buttock in addition to the left sided breakdown as documented by the wound consult on 10/22/12.

Review of the care plan for impaired skin integrity last reviewed 10/24/12 at 0749 hours, did not show documentation of the increase in the area of skin breakdown for Patient 1.

2. Patient 40 was admitted to the hospital on 10/19/12, with a Stage IV sacral pressure ulcer. A Plan of Care for Patient 40 was initiated on 10/19/12 at 0230 hours. The interventions listed included a wound care consultation, repositioning of the patient, documentation of the skin condition, and wound care. The interventions were not specific and individualized to show how frequent the patient was to be repositioned, what specific wound care was to be given, and the patient should not be positioned in the supine position to keep pressure off the affected site.

On 10/23/12 at 1145 hours, Patient 40 was observed in bed in a supine position.

Review of the hourly rounding documentation for Patient 40 showed the patient was placed in the supine position on 10/19/12 from 0500 to 0700 hours, from 1200 to 1300 hours, and from 1800 to 2000 hours, and on 10/20/12 from 0000 to 0300 hours, and at 0600 hours.

During an interview with the Wound Care Nurse on 10/24/12 at 0840 hours, when asked about positioning of patients with identified pressure ulcers, she stated these patients should not be positioned directly on a wound. After completing a consultation, the Wound Care Nurse stated she wrote directions for frequent turning but did not specify the patient should not be positioned on the wound site. The Wound Care Nurse stated the floor nurses knew not to place patients on the site of a wound.

3. The medical record for Patient 2 was reviewed with RN E on 10/22/12 at 0930 hours. Patient 2 was admitted to the Labor and Delivery Unit on 10/12/12, due to pre term labor at 35 weeks and gestational diabetes (diabetes during pregnancy). The patient was on a calorie restricted diet and her blood sugar was measured fasting in the morning and 30 minutes after each meal. RN E stated although the patient was no longer having contractions, she remained in the hospital as her blood sugars were not yet in control.

Review of the physician's orders for Patient 2 showed the patient was begun on a long acting insulin once a day and the family was no longer allowed to bring food in from home.

Review of the plan of care for Patient 2 did not show a care plan was developed to address the primary reasons for the hospitalization, pre-term labor and gestational diabetes.

RN E confirmed the plan of care was not individualized for Patient 2.

4. The closed medical record for Patient 9 was reviewed on 10/23/12 at 0915 hours, with the Interim Director of Maternal Child Health. Patient 9 delivered an infant early on 10/17/12, prior to arriving at the hospital. Documentation in the nurses' notes showed the patient's family was unaware of the pregnancy.

Review of the care plan in the EHR did not show a care plan had been initiated for Patient 9. There was no documentation to show the RN reviewed for the presence of a care plan for Patient 9.


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5. Patient 20 was admitted to the hospital on 10/21/12, with diagnoses that included brain damage. The patient was mechanically ventilated and had a feeding tube. Review of the treatment plan assessments did not show the plan consistently reflected the patient's status in order to develop a plan of care specific to the patient's needs. For example:

The Treatment Plan Assessment dated 10/22/12 at 0052 hours, showed:
* The patient will verbalize understanding of precautions "yes."
* Will understand why seizure precautions were placed "yes."
* Will call for assistance "yes."

The Treatment Plan Assessment dated 10/22/12 at 0841 hours, showed the patient was mechanically ventilated and was therefore unable to speak and staff was also unable to teach the patient due to mental status.

The Treatment Plan Assessment dated 10/22/12 at 2100 hours, and 10/23/12 at 0808 hours, showed:
* Will verbalize understanding of precautions "yes."
* Will understand why seizure precautions are placed "yes."
* Will call for assistance "yes."
* Verbalizes relief of discomfort after intervention "yes."
* Will verbalize/demonstrate elimination management "yes" (the patient was incontinent of bowel and had a urinary drainage catheter).
* Verbalizes understanding of teaching (Education Record) "yes".

The Treatment Plan Assessment dated 10/22/12 at 2352 hours, again showed the patient was unable to comprehend and was unable to communicate.

6. Patient 39 was admitted to the hospital on 10/9/12. Review of the patient's medical record showed on 10/18/12, the patient was identified with bruising on the right lateral side of her body. A review of the photographs showed the bruising was from the right shoulder to the right hip. The Treatment Plan Assessment interventions dated 10/18/12 at 0900 hours, showed the patient was to be taught pressure relief; the skin condition was to be assessed; and the patient was to be repositioned. The interventions were not specific and did not address how frequent the patient was to be repositioned and if positioning on the bruised right side was to be avoided.

Based on document review, the hospital failed to implement the P&P to address "Preceptor Standards" during the orientation of LVN B, a new graduate. The preceptor, LVN C, was also a new graduate, hired only 10 months prior to LVN B. This resulted in the potential for new staff to be trained and assessed as competent to care for patients by inexperienced staff.

Findings:

Review of the P&P, Preceptor Standards dated 11/01, showed a preceptor was to function as the new employee's "trainer" and role model. Preceptors may be assigned to a new staff member to assure competency in skills.

A preceptor was defined as an experienced and competent professional who serves as a clinical role model and resource person to newly employed staff.

Eligibility of a LVN preceptor showed the requirement of a "Meets Standard" on evaluation and at least six months experience at the hospital.

The personnel records of LVN B and LVN C were reviewed on 10/22/12 at 1610 hours, with the Manager of Human Resources.

LVN B, a new graduate, began orientation to the hospital on 4/20/11. LVN C was assigned to precept LVN B. Review of LVN B's competency checklist showed LVN C signed off competencies for LVN B during the month of May, 2011.

Review of the personnel record for LVN C showed he was also a new graduate when hired by the hospital on 7/12/10. The LVN did not receive his one year evaluation showing he met the "standard" caring for patients until 9/23/11, four months after precepting LVN B.

Based on observation and staff interview, the hospital failed to ensure their system for computer logoff time was maintained at a level to ensure confidentiality of patient records.

Findings:

During a medical record review with RN Q on 10/23/12 at 0830 hours, the length of time that it took for a computer to log off if a staff person walked away without logging off was discussed. RN Q was informed of a finding in the ED where an RN's assessment information showed it had been entered by an EMT. The hospital felt the EMT had failed to log out of the computer and the RN had entered the assessment under the EMT's sign in. RN Q stated the computer logged the user off two to three minutes after no use if staff did not log out.

A test of the log off time was performed with RN Q. After 5 minutes of non-use the computer was still active.

When contacted, the hospital's IT Department confirmed the computer would not log off a user for 900 seconds (15 minutes) after it was idle. The IT representative stated a recent system update may have changed the computer's log out time. RN Q confirmed the delayed computer log out had the potential for possible unauthorized access to confidential patient information.

Based on interview and record review, the hospital failed to ensure the Rules and Regulations for the Medical Staff were implemented for one of 44 sampled patients (Patient 2) when multiple telephone orders from the physician for the patient's care and treatment were not reviewed and signed by the physician as correct within the required 48 hours. When verbal or telephone orders are not reviewed and signed by a physician as correct in a timely manner there is the potential for transcription error and risk for patient safety.

Findings:

The General Medical Staff Rules and Regulations, last revised 2/11, showed verbal or telephone orders must be signed within 48 hours after the order was given.

Medical record review for Patient 2 was conducted with RN E on 10/22/12 at 0930 hours. Patient 2 was admitted to the Labor and Delivery Unit on 10/12/12, due to pre-term labor at 35 weeks and gestational diabetes.

Review of the physician's orders showed admission orders for Patient 2 dated 10/12/12 at 0930 and 1200 hours, had not been signed by the physician. The orders included activity, laboratory tests, frequency of blood sugar testing, IV antibiotics, and IV pain medication orders. Two additional orders for fetal diagnostic tests dated 10/15/12, had also not been signed by the physician.

When asked, RN E confirmed telephone orders were to be signed by the physician within 48 hours.

Based on observation, interview and record review, the hospital failed to ensure patient care areas in the ED were thoroughly cleaned after each patient and infection control policies were implemented consistently for isolation patients to prevent the possible spread of infection to patients, staff and visitors.

Findings:

1. On 10/23/12 at 1600 hours, in the ED, an overflowing trashcan, with trash including paper products stained with red fluid, was observed in a patient care bay. At 1610 hours, a new patient was observed wheeled into the patient care bay. The trashcan had not yet been emptied.

During an interview with RN N on 10/23/12 at 1610 hours, the RN confirmed the new patient was placed in a patient care bay with a trashcan overflowing with contaminated material from the previous patient. When asked who cleaned the patient care areas, the RN stated the housekeepers cleaned the patient areas when asked; otherwise, "everybody" cleaned the patient care areas. The RN stated he also, on occasion, cleaned the patient care bays between patients. When questioned regarding the proper use of cleaning products to sanitize the patient care bay, the RN was unable to state the appropriate techniques to effectively use the sanitizing agents.

During an interview with the Infection Control Nurse on 10/24/12 at 1124 hours, he stated staff should clean the patient care bays after each patient, including emptying the trashcan. When asked if the ED nursing personnel were trained in the proper use of sanitizing products, the Infection Control Nurse answered he was "not sure."


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2. Review of the hospital's P&P Isolation Precautions-Guidelines, revised 7/11, showed gowns, gloves and masks should be removed and hands washed prior to staff leaving an isolation room. Contact precautions are for patients with known or suspected infections with microorganisms that can be transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient-care items in the patient's room.

The P&P also showed the patient's room door is to be closed for patients in airborne precautions. An N95 respirator mask must be worn when entering the room of a patient with known or suspected infectious pulmonary tuberculosis (N95 or NIOSH masks are different from surgical masks as they provide better protection).

a. On 10/22/11 at 1025 hours, PTA 1 was observed in Patient 43's contact isolation room wearing only gloves and no gown. The PTA was observed standing next to the bed arranging the sheets back over the patient's legs.

b. Patient 41 was observed on 10/22/12 at 1520 hours, in a contact isolation room. A sign outside the door instructed staff and visitors to wear a cover gown, mask and gloves when inside the room. A visiting family member wearing the required PPE walked out of the patient's room into the hallway and then re-entered the patient's room several times. The cart containing clean PPE was located outside the room door in the hall. Each time the family member came out of the room he passed next to the cart with his possibly contaminated gown brushing against the cart. Staff members did not approach the family member to caution him not to leave the room while wearing the PPE.

c. On 10/22/12 at 1540 hours, a family member was observed in Patient 44's contact isolation room. The visitor was wearing a gown and gloves. Prior to leaving the patient's room, the visitor removed the gown and gloves, but did not perform hand hygiene before or after leaving the patient's room.

d. On 10/23/12 at 1205 and 1210 hours, LVN F was observed leaving Patient 40's airborne isolation room wearing an N95 mask. Each time, LVN F removed the mask after leaving the room, and carried the possibly contaminated mask in her hand into the nurses' station. The masks were deposited in the trash container inside the nurses' station. The nurse washed her hands at the nurses' station. No container for the masks and no hand washing supplies were observed located outside the patient's room.

On 10/23/12 at 1155 hours, the surveyor's observations were discussed with the Infection Control Nurse. At 1510 hours, the Infection Control Nurse provided the surveyor with a copy of the hospital's infection control policy and a copy of a sign "Where to Remove PPE (personal protective equipment). It showed to remove gown and gloves at the doorway, before leaving the patient room or in anteroom. Remove respirator mask outside room, after door has been closed. Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rubs.

e. On 10/24/12 at 1330 hours, during an interview with LVN D, she stated she had just received a new patient who was admitted to rule out a possible tuberculosis infection. The LVN was on her way to the room to get the patient settled. An airborne isolation sign was observed posted on the patient's door. The airborne contact isolation sign showed staff must wear an N95 mask when entering the room. During the interview, RN K opened the room door to exit the room. RN K was providing care to the patient and opened the door to gather more supplies from the cart outside the room. RN K was wearing a surgical mask not the required N95 mask.

On 10/24/12 at 1515 hours, RN K was interviewed. The RN stated she had just completed a skills day which included infection control teaching. The RN confirmed the teaching covered all different types of isolation, including airborne isolation. RN K confirmed she had been fit tested for the N95 masks used in airborne isolation rooms.

Based on interview and record review, the hospital failed to ensure the ED medical records for six of 12 ED patients reviewed (Patients 18, 19, 25, 26, 29 and 35) were accurate and complete when the physician's documentation did not include the patients' medication history, creating the risk of a poor health outcome for those patients.

Findings:

The General Medical Staff Rules and Regulations (undated), page 12, read in part, "The complete H & P (history and physical) shall include pertinent findings resulting from an assessment of the systems of the body including chief complaint, history of present illness, past medical/surgical history, current medications ... "

During a review of the medical records of Patients 18, 19, 25, 26, 29 and 35, on 10/23/12, there was no documentation regarding the patient's medications on the ED Physician Documentation in the EHR. The documentation contained headers, such as "History of Present Illness", and sub-headers, such as, "chief complaint;" however, there was no header for "medications." Medication information was not found located anywhere else on the physician's documentation of the patients' history as follows:

During a review of the medical record for ED Patient 18, the ED Physician Documentation of the History and Physical dated 9/19/12 at 1900 hours, indicated no documented evidence of whether or not the patient took any medications. Further review of other documents in the chart revealed that this patient did not take any medications.

During a similar review of the medical record for ED Patient 19, the ED Physician Documentation of the History and Physical dated 9/20/12 at 0815 hours, indicated no documented evidence of whether or not the patient took any medications. Further review of other documents in the chart revealed that this patient took three medications routinely.

The ED Physician Documentation history and physical dated 10/22/12, for Patient 25 contained a narrative that noted the patient was, "currently off psych meds," but no note regarding what those meds had been, or if she was taking other medications.

The ED Physician Documentation of history and physicals for Patients 26, 29 and 35, dated 9/16, 9/21 and 9/19/12, respectively, had no notation about medications.

In an interview with the Director of the ED on 10/23/12 at 1420 hours, the Director stated the history and physical completed by the physician should include a review of the patient's medications. The physician should note they reviewed the medication reconciliation form. The Director reviewed the medical records for Patients 18, 19, 26 and 35. The Director stated she was unable to find documentation of the patient's medication list on the ED Physician Documentation History and Physical form.

In an interview with the ED Medical Director on 10/23/12 at 1535 hours, he stated when he entered a patient's information into the computer, he entered their medication list into the History and Physical. The Medical Director demonstrated the EHR program which had a section to type the medication. He reviewed a physician's history and physical exam in the computer and confirmed no medications were listed for the patient. The Medical Director stated he thought the omission was probably an oversight by the scribe service. The Medical Director stated the ED physicians in the hospital used scribes from 1000 hours until midnight, and the scribes may not add in the medications when documentation was entered in the computer.