HospitalInspections.org

Based on observation and interview, the facility failed to implement a process for ensuring expired medications were removed from use in the emergency department. This deficient practice had the potential to affect all patients requiring medication in an emergency. Findings include:

During an observation on 4/8/24 at 1:15 p.m., the emergency treatment room was observed to have the following expired medications:

Narcan Nasal Spray 4mg; expiration February 2024, 2 applicators, and November 2023, one applicator
Heparin 5000u; expiration 3/1/24, 6 vials
Enalaprilat 1.25mg: 3/2024, 5 vials

During an interview on 4/8/24 at 2:10 p.m., staff member B said nursing staff were responsible for checking all medication for outdates and the central supply staff were responsible for checking all supplies for outdates. Staff member B said outdates were checked once a month and replaced.

During an interview on 4/9/24 at 10:12 a.m., staff member A said there was an expectation that medication be checked by staff and replaced prior to the expiration date.

Based on interview and record review, the facility failed to account for acquisition and disposition of controlled medications. This deficient practice had the potential for controlled medication diversion. Findings include:

During an interview on 4/8/24 at 2:00 p.m., NF1 stated she had been meeting with staff member A on a weekly basis, working on a process for accounting for wasted and expired controlled medications.

During an interview on 4/9/24 at 8:50 a.m., staff member A stated there is not a process for accounting for wasted controlled medications and that he had been meeting with NF1 to come up with a process. Staff member Abstated that he did not know who comes and empties the wasted controlled medications lock box at the facility.

A review of a facility policy, with a revision date of 8/22/2022, titled, "Medication Storage, Labeling and Disposal," showed:
"DISPOSAL
[Facility Name] is responsible for the disposal of medications in its possession. ...
All controlled substances will be counted and signed by two licensed nurses listed and taken and dispensed into disposal bin that is provided by the pharmacy. All substances will be documented by amount. ... the facility will maintain a list of all Narcotics and non-narcotic med disposal. ..."

Based on interview and record review, the facility failed to provide a nutritional assessment for an acute swing bed admission, following surgical repair of a fractured femur, for 1 (#4) of 20 sampled patients. This deficient practice has the potential to affect patients to obtain their highest level for healing. Findings include:

During and interview on 4/9/24 at 7:32 a.m., patient #4 said he had been transferred to the facility for physical therapy, following a surgery to repair his femur fracture. Patient #4 said he did not remember talking to anyone about his nutritional needs for healing, following his surgery. Patient #4 said he spoke with a staff member about his food preferences shortly after arriving at the facility.

During a telephone interview on 4/10/24 at 10:12 a.m., staff member R said he visits the facility once monthly and provides dietary evaluations to one third of the patients. Staff member R stated he would evaluate any new patients and provide quarterly evaluations on patients residing in the facility long-term. Staff member R said the dietary manager would approach any new patients and ask about preferences, allergies, and any special dietary requests. Staff member R said the dietary manager would then notify him of the preferences, and they would have a conversation on the patients needs and his recommendations. Staff member R said he would then see the patient and provide an evaluation if the patient was still admitted to the facility. Staff member R said he did not routinely make a note in the EMR of any discussion with the dietary manager regarding the patients. Staff member R said there was not a way to track patients needing to have evaluations in the current EMR. Staff member R stated he has his own system of tracking patients for their quarterly evaluations. Staff member R said he would document his assessments in the facility EMR and would note the date they had been evaluated in his records. Staff member R stated his documentation was not in the EMR; he did not have a way to recover the information, and he does not have a separate note for his evaluations. Staff member R said he did not have a record of seeing patient #4 and was not aware he was admitted following a surgical repair of his femur.

Record review of patient #4's electronic medical record, with an admission date of 3/28/24, did not contain a nutritional assessment.

Record review of a facility policy, "Initial Patient Nutritional Screening," with a revision date of 12/8/2018, showed:

" ...4. The Registered Dietitian will evaluate each new Patient in the facility and complete an assessment. ..."

Based on the manner and degree of the deficient practice, the facility failed to meet the Conditions of Participation for Clinical Records.

Based on interview and record review, the facility:

- failed to have a process in place to verify the completeness of medical records;

- failed to ensure all patient records contained a properly executed informed consent for care; and

- failed to ensure a medical doctor co-signed and assumed full responsibility for the history and physical when a patient was admitted to the facility by a mid-level provider.

Based on interview and record review, the facility failed to have a process in place to verify the completeness of medical records for 13 (#s 2, 3, 4, 6, 7, 8, 9, 10, 11, 13, 17, 18, and 20 ) of 20 sampled residents. This deficient practice had the potential to affect all medical records for patients receiving care at the facility. Findings include:

A review of patient #2's EMR, with an admission date of 3/14/23, failed to contain a social services evaluation, or a history and physical.

A review of patient #3's EMR, with an admission date of 4/2/24, failed to contain a signed copy of the patient rights, and include notification of visitation rights.

A review of patient #4's EMR, with an admission date of 3/28/24, failed to contain a signed copy of the patient rights, grievance information, informed consent to treat, notification of advanced directives, notification of visitation rights, a care plan, and a nutritional assessment.

A review of patient #6's EMR, with an admission date of 1/19/21, failed to contain an informed consent to treat, grievance information, and notification of advance directives.

A review of patient #7's EMR, with an admission date of 3/1/24, failed to contain a signed copy of the patient rights, and include notification of visitation rights.

A review of patient #8's EMR, with an admission date of 1/30/24, failed to contain a signed copy of the patient rights, notification of visitation rights, and an informed consent to treat.

A review of patient #9's EMR, with an admission date of 8/4/23, failed to contain a signed copy of the patient rights, notification of visitation rights, and a care plan.

A review of patient #10's EMR, with an admission date of 5/12/20, failed to contain a signed copy of the patient rights, notification of visitation rights, grievance information, and a nutritional assessment.


44769


A review of patient #11's EMR, with an admission date of 4/24/23, failed to contain a signed copy of grievance information.

A review of patient #13's EMR, with an admission date of 6/23/23, failed to contain a signed copy of patient rights and grievance information.

A review of patient #17's EMR, with an admission date of 10/19/23, failed to contain a signed copy of patient rights, grievance information, notification of visitation rights, and notification of advance directives.

A review of patient #18's EMR, with an admission date of 10/19/23, failed to contain a signed copy of patient rights, grievance information, notification of visitation rights, and notification of advance directives.

A review of patient #20' s EMR, with an admission date of 4/2/24, failed to contain a signed AMA form.

During an interview on 4/9/24 at 3:11 p.m., staff member O said the facility had a breakdown in their electronic medical records and scanning of patient records into the system, and the documents disappear when the patient is discharged. Staff member O said the patients had to be discharged because the system would "bog" down and then the patient would need to be re-admitted. Staff member O siad some of the information from the previous admit would not be accessible, only the date the documentation was created showed in the system. Staff member O stated care plans had to be copied from one admission to the next; if it was not copied, it would not show in the system. Staff member O said chart reviews were completed by staff, but she was not aware of anyone checking the chart to make sure all items were contained within the EMR.

During an interview on 4/10/24 at 10:07 a.m., staff member O stated patients are given rights and grievance forms, but the forms were not always signed by the patient.

Record review of a facility policy, "Medical Record Content," with a revision date of 10/31/2017, showed:

" ...1. The patient medical records for acute and swing bed patients are required to contain at least the following:

... c. Physical examination
... e. Evidence of appropriate informed consent
f. Clinical observations, including clinical notes, consultation reports, nursing notes, and entries by specified personnel
...n. Social Services assessment
o. Patient's Rights
...q. Advanced Directives
... w. Admission Care Plan ..."

Based on interview and record review, the facility failed to ensure all patient records contained a properly executed informed consent for care for 3 (#s 4, 6, and 8) of 20 sampled patients. This deficient practice had the potential to affect all patient choices when consenting for care in the facility. Findings include:

A review of patient #4's EMR, with an admission date of 3/28/24, failed to contain a signed informed consent to treat.

A review of patient #6's EMR, with an admission date of 1/19/21, failed to contain a signed informed consent to treat.

A review of patient #8's EMR, with an admission date of 1/30/24, failed to contain a signed informed consent to treat.

During an interview on 4/9/24 at 3:11 p.m., staff member O said a consent for treatment should be signed with each admission. Staff member O stated if a patient was moving from inpatient status to swing bed within the facility, it might be missed.

Based on interview and record review, the facility failed to ensure a medical doctor co-signed and assumed full responsibility for the history and physical, when a patient was admitted to the facility by a mid-level provider for 17 (#1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18) of 20 sampled residents. This deficient practice had the potential to affect all patients admitted to the facility by a mid-level provider. Findings include:

A review of patient #1's medical record showed an admission date of 8/20/21. A history and physical was performed by staff member K, but was not co-signed by staff member J.

A review of patient #3's medical record showed an admission date of 4/2/24. A history and physical was performed by staff member M, but was not co-signed by staff member J.

A review of patient #4's medical record showed an admission date of 3/28/24. A history and physical was performed by staff member K, but was not co-signed by staff member J.

A review of patient #5's medical record showed an admission date of 1/31/24. A history and physical was performed by staff member K, but was not co-signed by staff member J.

A review of patient #6's medical record showed an admission date of 1/19/21. A history and physical was performed by staff member K, but was not co-signed by staff member J.

A review of patient #7's medical record showed an admission date of 3/21/24. A history and physical was performed by staff member L, but was not co-signed by staff member J.

A review of patient #8's medical record showed an admission date of 1/30/24. A history and physical was performed by staff member M, but was not co-signed by staff member J.

A review of patient #9's medical record showed an admission date of 8/4/23. A history and physical was performed by staff member K, but was not co-signed by staff member J.

A review of patient #10's medical record showed an admission date of 5/12/20. A history and physical was performed by staff member M, but was not co-signed by staff member J.


44769

A review of patient #11's medical record showed an admission date of 4/24/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J.

A review of patient #12's medical record showed an admission date of 12/15/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J.

A review of patient #13's medical record showed an admission date of 6/23/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J.

A review of patient #14's medical record showed an admission date of 3/3/24. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J.

A review of patient #15's medical record showed an admission date of 11/2/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J.

A review of patient #16's medical record showed an admission date of 12/31/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J.

A review of patient #17's medical record showed an admission date of 10/19/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J.

A review of patient #18's medical record showed an admission date of 12/10/23. A history and physical was performed by a mid level practioneer and had not been co-signed by staff member J.

During an interview on 4/9/24 at 2:06 p.m., staff member J stated he had not co-signed history and physicals performed by mid level practioneers at the facility.

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship Program.

Based on interview and record review the facility failed to communicate antibiotic stewardship to facility staff (See C 1242); the facility failed to develop and implement an antibiotic stewardship program (See C 1244); and the facility failed to document antibiotic stewardship activities (See C 1246).

Based on interview and record review, the facility failed to effectively communicate antibiotic stewardship to facility staff. This deficient practice had the potential to harm patients from unnecessary antibiotic use. Findings include:

During an interview on 4/10/24 at 4:00 p.m., staff member P stated she had not presented any antibiotic stewardship training to facility staff.

A review of a facility policy, titled, "Antimicrobial Stewardship Program," with a revision date of 2/26/24, showed:

"POLICY:

The Antimicrobial Stewardship Program (ASP) will monitor compliance with evidence-based guidelines or best practices regarding antimicrobial prescribing which may include but is not limited to the following activities:
... 2. Educational Activities
Education to prescribers and other relevant staff regarding evidence-based guidelines or best practices including antimicrobial management should occur upon hire and at minimum annually thereafter. ..."

A request for antibiotic stewardship training documentation was submitted to staff member N on 4/9/24 at 5:25 p.m. No documentation was provided prior to the end of the survey.

Based on interview and record review, the facility failed to develop and implement an antibiotic stewardship program. This deficient practice had the potential for emergence of antimicrobial-resistant bacteria to be introduced into the facility. Findings include:

During an interview on 4/10/24 at 4:00 p.m., staff member P stated she had not been, "real educated" on an antibiotic control program.

During an interview on 4/10/24 at 4:00 p.m., when asked if the facility's antibiotic stewardship program was based on nationally recognized guidelines, staff member P stated, "I have not done anything like that."

A review of a facility policy, titled, "Antimicrobial Stewardship Program," with a revision date of 2/26/24, showed:

"POLICY

The Antimicrobial Stewardship Program (ASP) will monitor compliance with evidence-based guidelines or best practices regarding antimicrobial prescribing which may include but is not limited to the following activities:

1. Streamlining or de-escalation therapy
2. Educational activities
3. Antimicrobial management protocols and guidelines
4. Surveillance monitoring
5. Formulary restrictions

PURPOSE:

To comply with evidence-based guidelines or best practices regarding antimicrobial prescribing and promote rational and appropriate antimicrobial therapy while improving clinical outcomes while minimizing unintentional side-effects of antimicrobial use, including toxicity and emergence of resistant organisms.

... 3. Antimicrobial Management Protocols and Guidelines

ASP shall develop/update implement evidence-based practice protocols and guidelines that incorporate local microbiology and resistance patterns. Recommendations shall be presented to the Infection Control Committee and/or P&T Committee for approval as needed. ..."

Based on interview and record review, the facility failed to document antibiotic stewardship activities. This deficient practice had the potential for the development of antimicrobial-resistant bacteria. Findings include:

During an interview on 4/10/24 at 4:00 p.m., staff member P stated she had no documentation for the monitoring or use of antibiotics in the facility.

A review of a facility policy, titled, "Antimicrobial Stewardship Program," with a revision date of 2/26/24, showed:

"... PROCEDURE:

The program assessment and strategic plan is based on the [Organization Name] guidelines for Antimicrobial Stewardship. The outcomes and impact of the program shall be tracked and reported to the Medical Staff at a quarterly minimum to include improved utilization of antimicrobials and cost effectiveness. The following activities are to be carried out by the ASP team. ..."

Based on interview and record review, the facility failed to provide a written explanation of the patient's rights prior to a swing bed admission for 6 (#s 3, 4, 7, 8, 9, and 10) of 20 sampled residents. This deficient practice had the potential to affect the patient's ability to exercise their rights. Findings include:

A review of patient #3's EMR, with an admission date of 4/2/24, failed to contain a signed copy of the patient rights.

A review of patient #4's EMR, with an admission date of 3/28/24, failed to contain a signed copy of the patient rights.

A review of patient #7's EMR, with an admission date of 3/1/24, failed to contain a signed copy of the patient rights.

A review of patient #8's EMR, with an admission date of 1/30/24, failed to contain a signed copy of the patient rights.

A review of patient #9's EMR, with an admission date of 8/4/23, failed to contain a signed copy of the patient rights.

A review of patient #10's EMR, with an admission date of 5/12/20, failed to contain a signed copy of the patient rights.

During an interview on 4/9/24 at 2:28 p.m., staff member O said she would not expect to see patient rights forms signed for each admission. Staff member O stated, "If they transfer from swing bed to inpatient and then back to their previous status as swing bed, they would have the same rights and I would not expect to have the patient sign a new patient rights document each time."

Based on interview and record review, the facility failed to inform all patients whom to contact to file a grievance for 3 (#s 4, 6, and 10) of 20 sampled residents. This deficient practice had the potential to limit a patient's rights to submit a grievance to the facility. Findings include:

During an interview on 4/9/24 at 7:32 a.m., patient #4 said he did not remember receiving any information on filing a grievance. Patient #4 said he had no need to file a grievance, but it was good information to provide.

A review of resident #4's EMR, with an admission date of 3/28/24, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review or resident #6's EMR, with an admission date of 1/19/21, showed no information was provided to the patient or the patient's representative about filing a grievance.

A review or resident #10's EMR, with an admission date of 5/12/20, showed no information was provided to the patient or the patient's representative about filing a grievance.

During an interview on 4/9/24 at 3:11 p.m., staff member O said all patients should have been provided information on filing a grievance. STaff member O stated the information and attestation documentation was supposed to be provided in the patient's admission packet.