HospitalInspections.org

Based on document review and interview, it was determined for 1 of 2 (Pt. #2) records reviewed of patients with an order for suicide precautions and placed on 1:1 observation, the Hospital failed to ensure the patient was monitored as required.

Findings include:

1. The Hospital policy titled, "Precaution" (revised 3/7/11), reviewed on 5/12/14 at approximately 1:00 PM, required, "Suicide ideation ... Patients who have been assessed and evaluated... placed on suicide precautions 1:1 observation...Patients on 1:1 suicide precautions are under constant visual observation within arms reach at all times, during all activities. Never Leave the Patient Alone. ..."

2. The clinical record of Pt. #2 was reviewed on 5/12/14 at approximately 11:00 AM. Pt. #2 was a 57 year old female admitted on 5/6/14 with a diagnosis of abnormal laboratories due to missed dialysis. The nursing admission inquiry included the patient arrived to the 2 East nursing unit on 5/7/14 at 12:02 AM. A physician's order dated 5/6/14 at 11:55 PM included, "suicide precautions." The precaution and rounding sheet indicated that Pt. #2 was placed on 1:1 precautions on 5/7/14 at 7:00 AM (7 hours after the order was written).

3. During an interview on 5/12/14 at 11:15 AM, the Vice President of Quality and Compliance (E#5) stated, "I am unable to find any observation documentation prior to 7:00 AM."

Based on document review and interview, it was determined for 3 of 5 (Pt. #1, #2, #4) clinical records reviewed for care plans, the hospital failed to ensure the nursing care plan was individualized for each patient.

Findings include:

1. The hospital policy titled, "Clinical Care Station Multidisciplinary Care Plan (revised Feb. 2009)" reviewed on 5/13/14 required, "The admission problem and problems requiring obvious nursing intervention or patient/family education are to be included in the patient's care plan."

2. The clinical record of Pt. #1 was reviewed on 5/12/14. Pt. #1 was a 47 year old female admitted on 5/7/14 for chemotherapy. The clinical record included a physician's order dated 5/8/14 at 2:36 PM for "Neutropenic Precaution". The care plan initiated on admission lacked inclusion of neutropenic precautions (patient with a low white blood cell count and prone to infection). On survey date 5/12/14 at approximately 9:00 AM, Pt. #1's family was observed in the room not following precautions. The family stated was not aware of the precautions.

3. The clinical record of Pt. #2 was reviewed on 5/12/14. Pt. #2 was a 57 year old female admitted on 5/6/14 with the diagnosis of abnormal laboratories due to missed dialysis. The clinical record included a physician's order dated 5/6/14 at 11:55 PM for "Suicide Precautions". As of survey date of 5/12/14 the care plan initiated on admission lacked inclusion of these precautions.


30195


4. The clinical record for Pt #4 was reviewed on 5/12/14 and included Pt #4 was a 60 year old male admitted to the medical surgical unit on 5/8/14 with diagnosis of clotted arteriovenous fistula. Pt #4 had a history of end stage renal disease with hemodialysis and underwent surgery to de-clot his fistula on 5/9/14. However, Pt #4's plan of care did not include problems or patient education related to surgery or renal disease.

5. The above findings were discussed with the Vice President of Patient Care (E#5) on 5/12/14 at approximately 11:00 am. The vice president of patient care stated the care plans should have included the above findings.

Based on document review and interview, it was determined that in 1 of 4 (Pt #9) clinical records of patients that required restraint usage, the Hospital failed to ensure accurate nursing documentation.

Findings include:

1. Hospital policy entitled,"Precaution," (revised March 2011) required, "Procedures: 2. The RN will: 5. The registered nurse assigned to the patients and the charge nurse is responsible and accountable for ensuring that the observation technician is monitoring the patients according to the ordered / required precautions."

2. The clinical record of Pt #9 was reviewed on 5/13/14 at approximately 2:00 PM. Pt #9 was a 29 year old male admitted on 5/2/14 with a diagnosis of paranoid schizophrenia. Pt #9's clinical record contained a physician's order dated 5/3/14 at 3:00 PM that required Pt #9 be placed in full leather restraints for "aggressive behavior that threatens safety of others." Documentation included that Pt #9 was assessed every 15 minutes from 3:00 PM until 5:00 PM as required. Pt #9's precaution and rounding sheet dated 5/3/14 included that between 3:00 PM and 4:30 PM Pt #9 was in the dayroom calm not in restraints. At 4:45 PM the every fifteen minute rounding sheet indicated that Pt #9 was in bed calm and at 5:00 PM Pt #9 was documented as being in the dayroom not in restraints.

3. The Senior Vice President of Patient Care Services stated during an interview on 5/13/14 at approximately 2:15 PM that the patient (Pt #9) should have been documented on the rounding sheet as being in restraints and not in the dayroom.

Based on document review and interview, it was determined that for 4 of 4 (Pts. #13, 14, 17 & 18) clinical records with emergency department order sets, were reviewed. The Hospital failed to ensure entries into the medical record were legible and dated.

Findings include:

1. The Hospital Rules and Regulation of the Medical Staff (approved 3/13) required, "35. Entries on charts must be made by members of the Medical Staff must have both date and time recorded. This is to include order sheet, consultation sheet, progress notes....The entries must be legible..."

2. The clinical record for Pt. #13 was reviewed on 5/13/14. Pt. #13 was a 48 year old male admitted on 5/11/14 with diagnoses of hypotension and hypoglycemia. The clinical record included an illegible and un-timed emergency department (ED) physician progress note and order sheet.

3. The clinical record for Pt. #14 was reviewed on 5/13/14. Pt. #14 was a 87 year old male admitted on 5/10/14 with a diagnosis of urethral bleeding. The clinical record included an illegible and un-timed ED physician progress note and order sheet.

4. The clinical record for Pt. #17 was reviewed on 5/13/14. Pt. #17 was a 57 year old female seen in the Emergency Department on 5/13/14 with diagnoses of hypertension and left leg pain. The clinical record included an illegible physician progress note and order sheet.

5. The clinical record for Pt. #18 was reviewed on 5/13/14. Pt. #18 was a 69 year old female seen in the Emergency Department on 5/13/14 with a diagnosis of renal failure. The clinical record included an illegible physician progress note and order sheet.

6. The above findings were discussed with the Vice President of Patient Services on 5/13/14 at approximately 3:00 PM, who stated that the progress notes and order sheets should be complete and legible.

Based on document review and staff interview, it was determined for one of one medical records departments, the hospital failed to ensure medical records were completed within 30 days after discharge.

Findings include:

1. The Bylaws of the Medical Staff (approved 3/2013) required, "...Patient charts are to be completed at time of discharge, but if not they must be complete within 30 days of discharge..."

2. On 5/13/14 at approximately 11:50 am, the vice president of quality and compliance presented the surveyor with a letter of attestation dated 5/13/14 and signed by the director of health information management systems which included, "The number of physician delinquent charts is 444."

3. On 5/13/14 at approximately 10:45 am, the director of health information management systems stated the medical records should be complete within 30 days of discharge.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey due to Complaint conducted on May 12 - 14, 2014 the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey due to Complaint conducted on May 12 - 14, 2014 the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567.

Based on observation, document review and interview, it was determined for 2 of 2 (E #1 & #2) staff observed opening sterile packs, the Hospital failed to ensure adherence to standards of practice for sterile pack opening.

Findings include:

1. During an observational tour of operating room #4 on 5/14/14, at approximately 950 AM the following was observed:

* E #1 opened sterile instruments directly over the sterile field.
* E #2 opened a prep pack extending his arm with the prep pack over the sterile field.

2. The Acting Operating Room Director and the Senior Vice President of Patient Care Services were interviewed on 5/14/14 at approximately 10:30 AM, indicated that the Hospitals Surgical services follow the AORN standards for sterile techniques.

3. The AORN standard required: "all items should be delivered to the sterile field in a manner that prevents nonsterile objects or personnel from extending over the sterile field."

3. The above findings were discussed with the Senior Vice President of Patient Services, on 5/14/14 at approximately 10:30, AM. who stated that staff should not open packs over the sterile field.

B. Based on document review, observational the interview, it was determined for 1 of 1 Surgeon (MD #1) that Hospital failed to ensure skin prep was performed according to manufacturer's guidelines for use.

Findings include:

1. The Hospital policy titled, "Skin Prep Surgical Patients..." (revised 2/2003) required, "The Surgical prep will be performed according to surgeons' preference following aseptic technique."

2. The skin prep (ChloraPrep) manufacturer's direction for use (DFU) required, " ...completely wet the treatment area with antiseptic...Dry surgical sites (e.g. abdomen or arms): use gentle repeated back-and-forth strokes for 30 seconds."

3. During an observational tour of operating room #4 on 5/14/14, at approximately 9:50 AM, MD #1 was observed performing the skin prep. Using a Chloraprep sponge, MD #1 wiped an area approximately 12 by 12 inches, using individual stokes in one direction, instead of repeated back-and forth strokes for 30 seconds as per the DFU.

4. The above findings were discussed with the Senior Vice President of Patient Services, on 5/14/14 at approximately 10:30 AM, who stated she noted the physician did not perform the prep according to manufacturers recommended use.