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Based on review of patient records, observation, and interviews with treating staff, it was determined that the patient right to actively participate in the development and implementation of their plan of care was not maintained and encouraged.


Findings were:


In review of the individualized treatment plan of patient #25 on 11/10/15, it was found that this 45-year old male was diagnosed with schizophrenia and also had noted intellectual and development delays. He was admitted to the facility on 10/30/2015. Review of his group attendance revealed that he had attended a group on "elder abuse" when he was neither elderly nor was there any mention that he had been the victim of abuse in his record. When the social worker was asked about his inclusion in this particular group, the social worker replied, "Well, he shouldn't have been in there." Further discussion regarding the patient's involvement in insight-oriented groups rather than activity sessions ensued.


In review of the medical record of patient #26, this 75-year old female patient was admitted into the facility for dementia, first displayed on her discharge from another hospital where she had undergone a procedure. Assessments had been completed on this lady and her initial treatment plan had been completed. However, on questioning, the nursing staff reported that they had not received not requested any of the records from the other hospital that may have contributed to the patient's current status, so that the total patient assessment was incomplete as would, therefore, be her individualized treatment plan.


In review of the medical record of patient #29, it was found that this 26-year old male was diagnosed with Major Depressive Disorder, and also was diagnosed with PCP Use Disorder, THC Use Disorder, and ETOH Use Disorder. One of the patient's own expressed goals was assistance with his chemical use issues, and this had been incorporated into his treatment planning. On questioning the staff on the unit, they were asked what specific programming was available for the patient for his expressed treatment goals, and writer was informed that he attended the groups available on the unit. Sometimes these groups may address chemical dependency issues, but this patient attends whatever group is available at the time, making the implementation of his individualized treatment plan not responsive to his expressed needs and desires for treatment.

Based on observation, record review, and interview, the facility failed to ensure and provide nursing care to a patient as ordered for one (1) of four (4) patient reviewed for STAT (A common medical abbreviation for urgent or rush) EKG ( Electrocardiogram), a test that checks for problems with the electrical activity of your heart. (Patient #1)

Findings included:

An observation on 11/9/15, at 3:40 p.m., in the facility emergency room (ER), revealed a large monitor with the patient's room numbers; the monitor revealed four flashing blue heart icons. Further observation at 3:45 p.m. revealed Patient #1's cardiac monitor with a Pre-Mature Ventricular Contraction, an abnormal heart rhythm.

Review of Patient #1's medical record reflected a 52-year old male admitted to the ER with Altered Mental Status. Patient #1 had been found in a parking lot with a crack cocaine pipe in his pocket. Patient #1 was transported to the ER via ambulance service. Patient #1 was lethargic at the time of arrival.

Review of Patient#1's Physician's Orders dated 11/9/15, reflected an EKG was ordered at 1:43 p.m.

During an interview on 11/9/15, at 3:40 p.m., in the emergency room, Staff #1 stated that the blue heart icon represents either an EKG order or a Respiratory treatment order. When asked if the EKG for Patient #1 had been completed, Staff #1 stated the EKG had not been completed but the patient was not admitted for a Cardiac event. Staff #1 stated the Cardiac EKGs are completed within 10 minutes. When asked if there is a policy for the non-cardiac EKGs she stated, no. Staff #1 stated the primary nurse is ultimately responsible for the completion of the EKG.

Review of Patient #1's EKG was completed on 11/9/15, at 3:53 p.m.

During an interview on 11/9/15, at 4:20 p.m., in the ER, Staff #23, RN, the primary nurse for Patient #1 stated, I placed him on the cardiac monitor. When asked who completes the EKGs, Staff #23 stated the ER technicians or the Respiratory staffs usually complete the EKGs. Staff #23 stated she did not complete the EKG because she had other things to do.

During an interview on 11/10/15, in the conference room at 11:30 a.m., Staff #12, MD Quality Director stated, "Non-immediate EKGs must be completed within 60 minutes."

During an interview on the 11/9/15, at 4:45 p.m., in the ER, Staff #23 and Staff #1confirmed the findings.

Based on observation, record review, and interview, the facility failed to ensure and provide nursing care to a patient as ordered for one (1) of four (4) patient reviewed for STAT (A common medical abbreviation for urgent or rush) EKG ( Electrocardiogram), a test that checks for problems with the electrical activity of your heart. (Patient #1)

Findings included:

An observation on 11/9/15, at 3:40 p.m., in the facility emergency room (ER), revealed a large monitor with the patient's room numbers; the monitor revealed four flashing blue heart icons. Further observation at 3:45 p.m. revealed Patient #1's cardiac monitor with a Pre-Mature Ventricular Contraction, an abnormal heart rhythm.

Review of Patient #1's medical record reflected a 52-year old male admitted to the ER with Altered Mental Status. Patient #1 had been found in a parking lot with a crack cocaine pipe in his pocket. Patient #1 was transported to the ER via ambulance service. Patient #1 was lethargic at the time of arrival.

Review of Patient#1's Physician's Orders dated 11/9/15, reflected an EKG was ordered at 1:43 p.m.

During an interview on 11/9/15, at 3:40 p.m., in the emergency room, Staff #1 stated the blue heart icon represents either an EKG order or a Respiratory treatment order. When asked if the EKG for Patient #1 had been completed, Staff #1 stated the EKG had not been completed but the patient was not admitted for a Cardiac event. Staff #1 stated the Cardiac EKGs are completed within 10 minutes. When asked if there is a policy for the non-cardiac EKGs she stated no. Staff #1 stated the primary nurse is ultimately responsible for the completion of the EKG.

Review of Patient #1's EKG was completed on 11/9/15 at 3:53 p.m.

During an interview on 11/9/15, at 4:20 p.m., in the ER, Staff #23, RN, the primary nurse for Patient #1 stated, I placed him on the cardiac monitor. When asked who completes the EKGs, Staff #23 stated the ER technicians or the Respiratory staffs usually completed the EKGs. Staff #23 stated she did not complete the EKG because she had other things to do.

During an interview on the 11/9/15 at 4:45 p.m., in the ER, Staff #23 and Staff #1confirmed the findings.

Based on observation, interview, and record review, the facility failed to ensure the area used for medication compounding was kept in a manner to prevent cross contamination.

This deficient practice had the likelihood to cause harm in all patients presenting to the Emergency department.

Findings include:

During an observation on 11/10/2015, after 9:00 a.m., the off-site ED medication room was found to have an area used for mixing /compounding medications. On one side of the mixing area was a splash guard to prevent splashes from the sink and on the other side was the ice machine. There was no barrier in place to prevent contaminants to the ice machine.

Staff #44 (Pharmacist) confirmed the nurses were mixing medications and the observation of the area not having another barrier in place.

Review of the facility policy named "Sterile Admixture Program" dated 04/2015, revealed the following:

"PROCCESS

Sterile Compounding Area Environment;

All surfaces, fixtures, and carts are to be constructed of smooth, impervious, non-shedding material that can be cleaned and disinfected."

Based on observation, interview, and record review, the facility failed to ensure all medications were kept in a secure place on 2 of 2 units (Main Emergency department and Intensive care unit).

This deficient practice had the likelihood to cause harm in all patients on these units.

Findings include:

During an observation in the Main Emergency department on 11/09/2015, after 2:00 p.m., an unlocked urology cart was stored just outside the orthopedic supply room. A bottle of the anesthetic agent Xylocaine was found in the top drawer of the cart.

Staff #s 1, 2, and 31 confirmed the observation.

During an observation of the Intensive care unit on 11/11/2015, after 9:00 a.m., 13 open plastic bins were stored at the nurse's station. Some of the bins contained patient medications which were not secured. The open bins were stored in a place which was easy accessible for anyone standing at the nurses station. Some of the medications found in the bins was Fondaparinux injectable (anti-coagulant agent), and bags of antibiotics Clindamycin, Cefepime, and Meropenem.

Staff #s' 31, 46, 47 confirmed the observation.

Review of a facility policy named "Medication Storage, Security and Handling" dated 10/2015, revealed the following:

"D. Medications will be stored and transported under secure conditions that limit access to authorized personnel only.

E. Medications will not be accessible to non-authorized personnel, patients, family members or visitors.

3) Security

b) Non-Pharmacy medication storage areas will be kept secured when not under the direct, visual supervision of authorized personnel."

Based on observation, interview, and record review, the facility failed to ensure an EKG (electrocardiogram) machine received preventative maintenance (PM) as required in 1 of 2 Emergency departments (off-site ED).

This deficient practice had the likelihood to cause harm to all patients presenting to the ED.

Findings include:

During an observation on 11/10/2015, after 9:00 a.m., an EKG machine was found stored in front of the nursing station. The label on the equipment revealed it was last serviced over 1 year and 5 months ago in 05/2014 and was due again to be serviced 05/2015. There was no documentation on the equipment to show it received the preventative maintenance in 05/2015.

Review of an e-mail dated 11/10/2015, at 12:05 p.m., revealed a service engineer was scheduled to arrive at 1:30 p.m. to complete the PM inspection.

Staff #s 39, 40 and 41 confirmed the observation.

During an interview on 11/10/2015, after 1:00 p.m., Staff #42 reported the PM on the equipment had been missed.

Review of a facility policy named "Clinical Equipment management" dated 7/31/2012, revealed the following:

"1.Long Term Clinical Equipment (six months or longer on-site):

g. Clinical Equipment that will be on the PM schedule will receive a PM label. The month and year next due for PM will be recorded on the label.

h. Clinical Equipment that will not be on the PM schedule will receive an Initial inspection label that designates on the label that no additional inspection will be required.

2. Short Term Equipment (less than six months on-site)

clinical equipment that successfully passes the listed procedures will receive an Electrical Safety Inspection label and designate on the label the next inspection due date based on either the equipment removal date or the normal planned maintenance cycle for the device. "

Based an observation and interview, the facility failed to ensure expired supplies were discarded timely in 2 of 2 units (Main Emergency department and Pediatric).

This deficient practice had the likelihood to cause harm to all patients presenting to these units.

Findings include:

During an observation of the orthopedic supply room on 11/09/2015, after 2:00 p.m., the following expired casting supplies were found:

Three packets of 3 inch Scotch cast expired 09/2012;

Five packets of 4 inch Scotch cast expired 02/2014;

Three packets of 2 inch Scotch cast expired 03/2014;

Seven packets of 3 inch Scotch cast expired 04/2014;

Staff #s 1, 2, and 31 confirmed the observations.


During an observation on 11/11/2015, after 11:00 a.m., a bag of sterile inhalation fluid expired 06/2015 was found stored in the Pediatric treatment room.

Staff #43 confirmed observation.





33326

Based on record review and interview, the facility failed to provide a safe environment:

- (25) Metal sterilizing trays were coated with old adhesive tape residue and not cleanable.

-The surgical equipment washer's daily cleaning was not performed according to the manufacturer's recommendation.

Findings Included:

During an interview on 11/10/15, at 9:45 a.m., in the sterile processing area, Staff #13, the Sterile Processing Department Director stated, I am aware of the old tape and I was planning on replacing the old labels with labels that don't stick to the containers. Staff #13 stated, "I was waiting till I run out of the old ones."

During an interview on 11/10/15, at 10:15 a.m., in the sterile processing area, Staff #8, Instrument Technician, stated she drains and wipes down the washers daily and descales the washers weekly." Staff #8 was not aware of the manufacture's recommended daily cleaning instructions.


Review of the facility provided sterilization clean washer operator manual 6.2 Daily Cleaning reflected:

6. Remove manifold sliding inlet and inspected for debris.

7. Brush off and rinse under tap water, as necessary

8. Reinstall manifold sliding inlet.

Based on observation, interview, and record review, the facility failed to ensure patients received thorough and timely assessments and treatment in 4 of 4 patients (#s' 15, 18, 19 and 20).

This deficient practice had the likelihood to cause harm to all patients presenting to the Emergency department (ED).

Findings include:

Review of a nurses notes dated 11/09/2015, at 1:53 p.m., revealed Patient #15 was a 52-year old female who presented to the ED with diagnoses including head contusion, unspecified part of head, and concussion without LOC (loss of consciousness).

During an observation on 11/09/2015, at 1:53 p.m., Staff #45 was observed to take information about purpose for the visit and an oxygen saturation on Patient #15. Patient #15 was assigned an acuity level of Semi-urgent and was directed to the waiting room. Staff #45 reported patients classified as Emergent were taken straight back to a room and the others of lesser acuity to the waiting room. Those patients in the waiting room were checked every two hours by nursing.

Review of the nurse's notes dated 11/09/2015, at 3:00 p.m. (over an hour later), revealed documentation of Patient #15 being placed in an exam room and this was the first documentation of a neuro checks, full set of vital signs and a pain assessment by nursing. Patient #15 reported having a pain level of 10 out of 10 (0 being no pain and 10 being the worst pain). There was also documentation in the assessment that Patient #15 had a history of hypertension, transient ischemic attacks and high cholesterol.

Patient #15 was medically screened at 3:24 p.m..

At 4:26 p.m., there was documentation of Patient #15 having a pain level of 9. There was documentation of Patient #15 reporting complaints of a headache and was being discharged home with a prescription of the anti-inflammatory agent Anaprox.

At 4:27 p.m., Patient #15 left the ED.

Review of the clinical record of Patient #20 revealed she was a 66-year old female who presented to the ED on 11/09/2015, at 2:32 a.m. with a chief complaint of chest pain.

Review of the physician documentation sheet revealed Patient #20 was medically screened at 2:58 a.m. The sheet contained documentation of history information that was obtained by nursing. There was no documentation of the screening by the physician which included an assessment of all the systems on Patient #20.

During an interview on 11/10/2015, after 10:00 a.m., Staff #39 confirmed the missing assessment.

Review of the clinical record of Patient #19 revealed she was a 93-year old female who presented to the ED on 11/09/2015, at 9:30 a.m. with diagnoses of sepsis and hypertension. Patient #19 was classified as being Urgent.

Review of the notes revealed documentation that Patient #19 was medically screened at 9:48 a.m.

Review of vital signs on Patient #19 revealed the first documented assessment of a temperature by nursing was taken at 11:32 a.m., over 2 hours after presenting to the ED.

Review of ED notes revealed documentation of the physician assessment being timed 12:59 p.m. The first treatment for an antibiotic was timed at 1:00 p.m. over 3 ½ hours after presenting to the ED.

During an interview on 11/10/2015, after 10:00 a.m., Staff #39 confirmed the missing assessment and time of treatment provided.

Review of records on Patient #s 18, 19, and 20 revealed they presented to the ED on either 11/07/2015, or 11/09/2015, an EKG were ran on the patients. Review of the EKG results revealed no documentation of the physician signing or timing when they received and reviewed the results.

During an interview on 11/10/2015, after 10:00 a.m., Staff #39 confirmed there was no documentation of the physician signing they reviewed the EKG results. Staff #39 reported this was their procedure for keeping up when the physicians were receiving the EKG results.

During an interview on 11/10/2015, after 1:30 p.m., Staff #11 (ED medical director) reported the doctors were supposed to sign and date the results when they received the EKG strips from the technician and that they were reviewed.

Review of the facility policy named "TRIAGE ASSESSMENT AND PATIENT CLASSIFICATION" dated 09/2014 revealed the following:

PROCEDURE
1. A Registered Nurse will perform the triage assessment and assign the appropriate ESI level.
2. Assess each patient' s chief complaint and vital signs. This information will be documented on the Emergency Services Record.
3. Patients will be assigned the appropriate triage level:
Category 1- Imminent
Category 2- Emergency
Category 3- Urgent
Category 4- Semi Urgent
Category 5- Non urgent
4. When appropriate, the Triage nurse should initiate approved ED protocol order sets.
5. Patients in the waiting area should be reassessed periodically to determine if the triage level has changed.
"EMERGENCY DEPARTMENT ASSESSMENTS AND DOCUMENTATION"
The Emergency Department record is a legal document of the patient care performed and must be accurate and legible.
The ED physician and ED nurse discharging the patient are both responsible for making sure that the ED record is complete.

Based an observation and interview, the facility failed to ensure expired supplies were discarded timely in 2 of 2 units (Main Emergency department and Pediatric).

This deficient practice had the likelihood to cause harm to all patients presenting to these units.

Findings include:

During an observation of the orthopedic supply room on 11/09/2015, after 2:00 p.m., the following expired casting supplies were found:

Three packets of 3 inch Scotch cast expired 09/2012;

Five packets of 4 inch Scotch cast expired 02/2014;

Three packets of 2 inch Scotch cast expired 03/2014;

Seven packets of 3 inch Scotch cast expired 04/2014;

Staff #s 1, 2, and 31 confirmed the observations.


During an observation on 11/11/2015, after 11:00 a.m., a bag of sterile inhalation fluid expired 06/2015 was found stored in the Pediatric treatment room.

Staff #43 confirmed observation.





33326

Based on record review and interview, the facility failed to provide a safe environment:

- (25) Metal sterilizing trays were coated with old adhesive tape residue and not cleanable.

-The surgical equipment washer's daily cleaning was not performed according to the manufacturer's recommendation.

Findings Included:

During an interview on 11/10/15, at 9:45 a.m., in the sterile processing area, Staff #13, the Sterile Processing Department Director stated, I am aware of the old tape and I was planning on replacing the old labels with labels that don't stick to the containers. Staff #13 stated, "I was waiting till I run out of the old ones."

During an interview on 11/10/15, at 10:15 a.m., in the sterile processing area, Staff #8, Instrument Technician, stated she drains and wipes down the washers daily and descales the washers weekly." Staff #8 was not aware of the manufacture's recommended daily cleaning instructions.


Review of the facility provided sterilization clean washer operator manual 6.2 Daily Cleaning reflected:

6. Remove manifold sliding inlet and inspected for debris.

7. Brush off and rinse under tap water, as necessary

8. Reinstall manifold sliding inlet.