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Based on observations and interviews, the CAH failed to ensure the facility was maintained to assure the safety of patients as evidenced by:
1) Having the plumbing for the toilets with an approximate 3 inch space between the bottom of the base of the structure that contained the plumbing fixture and the toilet that had a metal disc around which cloth or rope could be tied that presented a ligature risk for behavioral health patients in Rooms t, u, v, w, x, y, z, cc, and ee.
2) Having door hinges with spaces between the hinges that presented a ligature risk in Rooms aa (entrance door and the bathroom door within the room), cc, dd, and ee on the behavioral health unit.
3) Having bedside cabinets with an approximate 5 inch metal extension from the base of the cabinet that had wheels attached in Rooms t, y, w, x, y, and z. These cabinets presented a ligature risk if they were turned upside down by patients on the behavioral health unit.
4) Having 3 shower faucets in Room dd that extended approximately 4 inches from the shower wall that presented a ligature risk on the behavioral health unit.
5) Having a patient bathroom door in the Radiology Department with a hole in the exterior panel of the door which prevents proper cleaning and potential injury to patients.
Findings:

1) Having the plumbing for the toilets with an approximate 3 inch space between the bottom of the base of the structure that contained the plumbing fixture and the toilet that had a metal disc around which cloth or rope could be tied that presented a ligature risk for behavioral health patients:
Observation on the behavioral health unit on 12/17/18 at 10:40 a.m. revealed the plumbing for the toilets had an approximate 3 inch space between the bottom of the base of the structure that contained the plumbing fixture and the toilet that had a metal disc around which cloth or rope could be tied that presented a ligature risk for behavioral health patients in Rooms t, u, v, w, x, y, z, cc, and ee.

In an interview on 12/17/18 at 10:40 a.m., S22RN confirmed the above observations. She indicated she wasn't aware of the plumbing issue and confirmed it presented a ligature risk for behavioral health patients.

2) Having door hinges with spaces between the hinges that presented a ligature risk in Rooms aa (the entrance door and the bathroom door within the room), cc, dd, and ee on the behavioral health unit:
Observation on the behavioral health unit on 12/17/18 at 10:40 a.m. revealed the doors in Rooms aa (the entrance door and the bathroom door within the room), cc, dd, and ee had door hinges with spaces between the hinges that presented a ligature risk.

In an interview on 12/17/18 at 10:40 a.m., S22RN confirmed the door hinges with spaces between each hinge presented a ligature risk for behavioral health patients.

3) Having bedside cabinets with an approximate 5 inch metal extension from the base of the cabinet that had wheels attached in Rooms t, y, w, x, y, and z:
Observation on the behavioral health unit on 12/17/18 at 10:40 a.m. revealed Rooms t, y, w, x, y, and z had a bedside cabinet for each bed in the room that had an approximate 5 inch metal extension from the base of the cabinet that had wheels attached. Further observation revealed if the cabinets (which were not secured and able to be turned upside down) were turned upside down, the extended legs of the cabinet would present a ligature risk.

In an interview on 12/17/18 at 10:40 a.m., S22RN confirmed the above findings. She indicated she had not identified the bedside cabinets as a potential ligature risk.

4) Having 3 shower faucets in Room dd that extended approximately 4 inches from the shower wall that presented a ligature risk:
Observation on the behavioral health unit on 12/17/18 at 10:40 a.m. revealed Room dd had 3 shower faucets that extended approximately 4 inches from the shower wall that presented a ligature risk.

In an interview on 12/17/18 at 10:40 a.m., S22RN confirmed the above findings. She indicated behavioral health patients were allowed in the shower unattended by staff if they were not on a one-to-one observation level.

5) Having a patient bathroom door in the Radiology Department with a hole in the exterior panel of the door which prevents proper cleaning and potential injury to patients:
On 12/17/18 at 12:00 p.m. an observation of the Radiology Department revealed a hole in the exterior panel of the patient bathroom door located between the X-ray and Nuclear Medicine Rooms. The hole prevented the door from being properly cleaned and could cause injury to a patient from the splintering.

In an interview on 12/17/18 at 12:00 p.m., S35RM verified the above findings.


38777

Based on observation and interview, the CAH failed to ensure all patient care equipment was maintained in safe operating condition as evidenced by failing to ensure the functionality of the nurse call button located on the handrails of the beds in Rooms a, b, c, d, e, f, g, h, i, j, k, l, m, n, o, p, q, r, s.
Findings:

Observation of the CAH patient ward on 12/17/18 at 10:40 a.m., accompanied by S2DON, revealed the call button on the beds for Rooms a, b, c, d, e, f, g, h, i, j, k, l, m, n, o, p, q, r, and s had a button labeled "Nurse" and a picture of a nurse on the handrail of the beds. Further observation revealed the button was noted to be non-functional as it failed to activate any type of nurse call system.

In an interview on 12/17/18 at 11:10 a.m., S2DON confirmed that the nurse call button on the side rails of the beds did not activate the nurse call system.

Based on record review and interview, the CAH failed to ensure it had regular inspection and approval by the State fire control agency as evidenced by failure to have documented evidence of an annual inspection by the OSFM from 01/18/17 to 12/18/18 (23 months).
Findings:

Review of the most recent OSFM inspection prior to the OSFM inspection conducted during the survey, presented by S33FM, revealed it was conducted on 01/18/17. No documented evidence of an OSFM inspection that was conducted from that time until the inspection that was conducted during the survey was presented for review.

In an interview on 12/19/18 at 11:07 a.m., S33FM confirmed she had no OSFM inspection done between 01/18/17 and the one that was done on 12/18/18. She confirmed there had been no OSFM inspection for 23 months.

Based on observation, record review, and interview, the CAH failed to ensure drugs and biologicals were secured and not accessible to unauthorized personnel in accordance with hospital policy as evidenced by having an unlocked anesthesia cart that contained anesthesia drugs and supplies in Room ff that was not attended by anesthesia personnel.
Findings:

Observation on 12/19/18 at 8:40 a.m. in Room ff revealed the anesthesia cart was unlocked and contained medications and supplies. Further observation revealed no staff was present in Room ff when the surveyor and OR personnel entered the room.

Review of the policy titled "Medication Administration", presented as a current policy by an OR staff member, revealed storage areas must be secure, and fixtures and equipment used to store drugs should be constructed so that drugs were accessible only to designated and authorized personnel. Portable medication carts must be locked at all times when unattended.

In an interview on 12/19/18 at 8:50 a.m., S29CRNA indicated he locks the cart at the end of each day and when he leaves the department. He confirmed the cart remains unlocked during the day when he's in the department but may not be in the room. He confirmed the cart was unlocked with no appropriate staff present when the surveyor and OR personnel entered Room ff.

Based on observation, record review, and interview, the CAH failed to ensure its system for controlling infections and communicable diseases of patients and personnel was implemented as evidenced by failure to maintain safe work practices to prevent healthcare worker exposure to bloodborne pathogens. This deficient practice was observed during a tour of the lab on 12/17/18 at 10:30 a.m. when 3 sharps containers were observed to be filled above the designated fill line.
Findings:

Observation on 12//17/18 at 10:30 a.m. in the lab, while accompanied by S1ADM, revealed a sharps container in the phlebotomy section was filled above the fill line. Further observation revealed a sharps container in the blood bank area and in the coagulation area were filled above the fill line.

Review of the policy titled "Sharps, Handling Of", presented as a current policy by S7DRA, revealed sharps containers should not be overfilled. The containers should be replaced when they are 3/4 full.

In an interview on 12/17/18 at 10:30 a.m., S8Lab confirmed the sharps container in the phlebotomy area was over-filled.

In an interview on 12/17/18 at 10:30 a.m., S9LAB confirmed the sharps containers in the blood bank and coagulation areas were over-filled.

Based on record reviews and interviews, the CAH failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by failing to ensure a clarification order was obtained from the physician when the rate at which blood was to be transfused was not included in the original order given by the physician, the rate of transfusion at the start of the transfusion was implemented in accordance with hospital policy, the patient's condition was assessed and documented during the course of the transfusion, fluctuations in VS during or after blood administration were reported to the physician, and physician orders were followed for administering Lasix between blood transfusions (Patient #5) for 5 (#1 - #5) of 5 patient records reviewed for blood administration from a sample of 20 patients.
Findings:

Review of the policy titled "Administration Of Blood Products & Suspected Transfusion Reaction", presented as a current policy by S10CRM, revealed all patients will be carefully monitored during blood and blood product transfusions for transfusion reactions. Further review revealed the patient's VS were to be taken prior to the start of the transfusion, 15 minutes after the start of the transfusion, and at the completion of the transfusion. Unless otherwise indicated by the patient's clinical condition, the transfusion rate should be no > 5 ml/min for the first 15 minutes. The rate of transfusion should then be adjusted for the transfusion to be completed within 2 to 4 hours. No blood product should hang longer than 4 hours. Further review revealed the patient should be observed after the transfusion for any delayed reactions. There was no documented evidence the policy addressed the length of time the patient should be observed for delayed reactions and which VS (such as BP, pulse, respirations, O2 saturation) were to be assessed. Further review revealed the documentation should include the following: the time the transfusion started and completed; VS at the start of the transfusion, 15 minutes after the start, and at completion of the transfusion; amount and type of blood administered; signs and symptoms of any reaction; condition of the patient pre-transfusion, during transfusion, and post-transfusion. There was no documented evidence the policy addressed the time intervals that the patient's condition should be assessed during the transfusion.

Review of the "Nursing Practice & Skill Blood Transfusion: Administering - an Overview", presented as the resource used by the hospital for developing its blood administration policy by S7DRA, revealed the following information: verify that the physician's order contains the flow rate or any orders specific to the infusion time; assess the patient's VS and general health status, including pain level using a facility-approved pain assessment tool; premedicated the patient as prescribed; the rate of flow during the first 15 minutes should be approximately 2 ml/min , according to American Association of Blood Banks; after 15 minutes, reassess patient VS, auscultate the patient's lungs, check for jugular venous distention, and note the condition of the patient's skin to assess for transfusion reaction; RBC transfusions average 2 hours unless the patient is unable to tolerate rapid expansion of the intravascular volume; platelets and plasma transfusions average 10 ml/min (approximately 30 minutes) or as rapidly as the patient can tolerate; document the flow rate and the patient's VS, lung sounds, and appearance of the skin for urticaria, jugular venous distention, and other signs of circulatory overload or transfusion reaction at intervals required by hospital protocols and the patient's status; many facility protocols require assessment of VS during the first 15 minutes of the infusion, 30 minutes thereafter, at the completion of the transfusion, and several hours following completion of the transfusion.

Patient #1
Review of Patient #1's medical record revealed he was admitted on 12/12/18 with diagnoses of Acute Pancreatitis, Transaminitis, Diabetes mellitus, and Hypokalemia. Review of his physician orders revealed the following orders:
12/15/18 at 8:51 a.m. by S12MD - 2 units Platelets stat;
12/15/18 at 5:41 p.m. by S12MD - 2 units FFP stat;
12/16/18 at 6:48 a.m. by S12MD - 2 units Packed RBC 2, give now.
There was no documented evidence of the rate or time interval at which the blood was to be transfused included in S12MD's order, and there was no clarification order obtained by the RN.

Review of the Transfusion Form documented by S13RN on 12/15/18 at 11:10 a.m. and 12/15/18 at 2:10 p.m. and by S14RN on 12/16/18 at 12:50 a.m. revealed no documented evidence of the rate at which the blood, platelets, and plasma were administered to determine that the rate was no > 5 ml/min for the first 15 minutes in accordance with hospital policy. Further review revealed the following start and completion time for each transfusion:
12/15/18 Platelets started at 11:25 a.m. and completed at 2:00 p.m.;
12/15/18 Platelets started at 2:11 p.m. and completed at 3:05 p.m.;
12/16/18 FFP started at 1:13 a.m. and completed at 2:23 a.m.;
12/16/18 FFP started at 4:07 a.m. and completed at 5:20 a.m.;
12/16/18 RBCs started at 8:15 a.m. and completed at 11:25 a.m.;
12/16/18 RBCs started at 12:00 p.m. and completed at 3:00 p.m.

Review of the nurses' notes included in the EMR revealed no documented evidence of an assessment and documentation of Patient #1's condition from 11:25 a.m. until 12:00 p.m. and between 12:00 p.m. and 2:00 p.m. during administration of the first unit of Platelets. Further review revealed no documented evidence of an assessment and documentation of Patient #1's condition from 2:02 p.m. to 2:50 p.m. on 12/15/18 until 2:50 p.m. when documentation revealed he left in stable condition to be taken to the OR for surgery. Review of the surgery and anesthesia documentation revealed no documented evidence of the completion of the blood administration and whether he had a transfusion reaction from the second unit of Platelets. Further review revealed no documented evidence of Patient #1's condition at 2:23 a.m. when the first unit of FFP was completed and until 4:45 a.m. further review of the EMR revealed no documented evidence Patient #1's condition was assessed and documented at 4:07 a.m. when the second unit of FFP was started. Patient #1's condition was assessed at 4:45 a.m., was not assessed and documented at the completion of the second unit of FFP at 5:20 a.m. and until 8:00 a.m. (2 hours 40 minutes after the completion of blood products). Review of documentation in the EMR for the first unit of RBCs on 12/16/18 revealed no documented evidence of an assessment and documentation of Patient #1's condition until 10:00 a.m. (1 hour 45 minutes after the transfusion began at 8:15 a.m.) and at the time the transfusion was completed at 11:25 a.m. Further review revealed no documented evidence of Patient #1's condition at the time his second unit of RBCs was completed at 3:00 p.m. on 12/16/18.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 07/03/18 with a diagnosis of GI Bleed. Review of her physician orders revealed the following orders:
07/04/18 at 6:48 p.m. by S16MD - give 2 units RBCs now;
07/05/18 at 7:18 a.m. by telephone order from S16MD - give 1 unit RBCs.
There was no documented evidence of the rate or time interval at which the blood was to be transfused included in S16MD's order, and there was no clarification order obtained by the RN.

Review of the Transfusion Form documented by S17RN on 07/04/18 at 4:47 p.m., by S18RN on 07/04/18 at 8:48 p.m., and by S13RN on 07/05/18 at 9:25 a.m. revealed no documented evidence of the rate at which the blood was administered to determine that the rate was no > 5 ml/min for the first 15 minutes in accordance with hospital policy. Further review revealed the following start and completion time for each transfusion:
07/04/18 RBCs started at 5:06 p.m. and completed at 8:00 p.m.;
07/04/18 RBCs started at 8:52 p.m. and completed at 11:45 p.m.;
07/05/18 RBCs started at 9:30 a.m. and completed at 1:15 p.m.

Review of the nurses' notes included in the EMR revealed no documented evidence of an assessment and documentation of Patient #2's condition at the start of the first transfusion at 5:06 p.m. and until the completion at 8:00 p.m. (2 hours 54 minutes without a documented assessment of the patient's condition during the transfusion). Further review revealed no documented evidence of an assessment and documentation of Patient #2's condition at the start and completion of the second transfusion and throughout the time the transfusion was in progress. Further review revealed no documented evidence of an assessment and documentation of Patient #2's condition throughout the time the third transfusion was in progress.

Review of Patient #2's Transfusion Form and nurse's note documented by S13RN revealed prior to starting the third unit of blood at 9:30 a.m., her BP was 121/56 with a pulse of 68. Further review revealed 20 minutes after the blood was initiated her BP had dropped to 94/48 with a pulse of 72. There was no documented evidence S13RN notified the physician of the decrease in BP and increase in heart rate.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 11/13/18 with a diagnosis of Weakness. Review of her physician orders revealed an order on 11/22/18 at 11:52 a.m. by S19MD to give 2 units RBCs now. There was no documented evidence of the rate or time interval at which the blood was to be transfused included in S19MD's order, and there was no clarification order obtained by the RN.

Review of the Transfusion Form documented by S14RN on 11/22/18 at 7:55 p.m. and by S13RN on 11/22/18 at 3:45 p.m. revealed no documented evidence of the rate at which the blood was administered to determine that the rate was no > 5 ml/min for the first 15 minutes in accordance with hospital policy. Further review revealed the following start and completion time for each transfusion:
11/22/18 RBCs started at 4:00 p.m. and completed at 7:10 p.m.;
11/22/18 RBCs started at 8:00 p.m. and completed at 10:30 p.m.

Review of the nurses' notes included in the EMR revealed no documented evidence of an assessment and documentation of Patient #3's condition at the time the first unit of blood was completed at 7:10 p.m. Further review revealed no documented evidence of an assessment and documentation of Patient #3's condition from 8:15 p.m. to 10:00 p.m. (1 hour 45 minutes) while the second unit of blood was in progress.

Review of the nurse's notes and Transfusion Form on 11/22/18 revealed Patient #3's BP was 97/54 pre-transfusion (first unit) and 128/67 with a respiratory rate of 18 at the completion of the transfusion. There was no documented evidence that S13RN notified the physician of the change in VS.

Patient #4
Review of Patient #4's medical record revealed she was admitted to the emergency department on 09/10/18 with a diagnosis of Anemia. Further review revealed an order by S20MD to give 2 units RBCs now. There was no documented evidence of the rate or time interval at which the blood was to be transfused included in S20MD's order, and there was no clarification order obtained by the RN.

Review of the Transfusion Forms documented by S21RN on 09/10/18 at 12:35 p.m. and 2:50 p.m. revealed no documented evidence of the rate at which the blood was administered to determine that the rate was no > 5 ml/min for the first 15 minutes in accordance with hospital policy. Further review revealed the following start and completion time for each transfusion:
09/10/18 RBCs started at 12:48 p.m. and completed at 2:41 p.m. (1 hour 43 minutes and not at least 2 hours as required by policy);
09/10/18 RBCs started at 2:55 p.m. and completed at 5:11 p.m.

Review of the nurses' notes included in the EMR revealed the VS documented as 15 minutes after the transfusion was started were actually documented at 1:15 p.m. which was 27 minutes after the transfusion had started. Further review revealed no documented evidence of an assessment and documentation of Patient #4's condition at 2:41 p.m. when the first unit of blood was completed. Further review revealed the VS documented as 15 minutes after the second transfusion was started were actually documented at 3:16 p.m. which was 21 minutes after the transfusion had started. Further review revealed no documented evidence of an assessment and documentation of Patient #4's condition at 5:11 p.m. when the second unit of blood was completed.

Patient #5
Review of patient #5's medical record revealed he was admitted on 05/20/18 with a diagnosis of Sepsis. Further review revealed an order by S16MD on 05/23/18 at 7:21 a.m. to give 2 units packed RBCs stat to transfuse each over 2 hours and to give Lasix 20 mg between each unit. There was no documented evidence of the route for the Lasix.

Review of the Transfusion Forms documented by S17RN on 05/23/18 at 9:41 a.m. and 3:00 p.m. revealed no documented evidence of the rate at which the blood was administered to determine that the rate was no > 5 ml/min for the first 15 minutes in accordance with hospital policy. Further review revealed the following start and completion time for each transfusion:
05/23/18 RBCs started at 9:52 a.m. and completed at 1:23 p.m.;
05/23/18 RBCs started at 3:09 p.m. and completed at 6:12 p.m. with no documented evidence whether there was a reaction or not.

Review of the nurses' notes included in the EMR revealed the first unit of RBCs transfused over 3 hours 3 minutes rather than 2 hours as ordered. Further review revealed no documented evidence of an assessment and documentation of Patient #5's condition at 1:23 p.m. when the blood was completed. Further review revealed no documented evidence of an assessment and documentation of Patient #5's condition from 3:09 p.m. when the second unit of blood was started until 5:17 p.m. (2 hours 8 minutes).

review of the medication administration record revealed Lasix 20 mg was administered by intravenous push at 1:16 p.m. while the first unit of blood was infusing and not between the administration of the two units of blood as ordered.

In an interview on 12/17/18 from 2:30 p.m. to 3:40 p.m. while navigating the EMR, S15RN confirmed the findings related to Patient #1.

In an interview on 12/17/18 from 1:05 p.m. to 1:45 p.m., S3RN confirmed the findings related to Patients #2, #3, #4, and #5.

In an interview on 12/17/18 at 3:55 p.m., S4RN (nurse manager) indicated blood usually is transfused over 4 hours, but "it's not set in stone." She indicated the length of the infusion is based on the doctor telling how long he wants it to infuse. She further indicated the length of the transfusion should be ordered by the physician. After reviewing the policy, she indicated the policy stated it should be infused over 2 to 4 hours, and when asked who determines which it should be, she indicated the physician gives the order. After reviewing the EMRs, S4RN confirmed the physician orders did not include a rate at which the nurse was to infuse the blood. When asked how one could tell that the blood was infused no > 5 ml/minute for the first 15 minutes, she indicated you would have to look at the volume infused and the time started and completed to calculate the time. She then confirmed that would tell the average time but not specifically the rate for the 1st 15 minutes.

In an interview on 12/17/18 at 4:20 p.m., S2DON indicated staff had informed her of the survey findings thus far related to blood administration. She further indicated she wasn't aware of the issues that had been identified during the surveyor's review of the medical records.

In an interview on 12/19/18 at 7:35 a.m., S14RN indicated she works the Med/Surg Unit. She indicated her process when administering blood was to check for a consent, check that the intravenous catheter was the correct size and the tube was primed with Normal Saline, check the blood with another nurse, and get a baseline set of VS (BP, temp., pulse, respirations, pulse oximetry). She further indicated she monitors the patient for at least 15 minutes, making sure the blood is going in and she doesn't see signs of a reaction. She indicated minimum rounds are every 2 hours, but she likes to go in more frequently. She indicated she couldn't say specifically how often she does assess the patient. She indicated when she does go to check the patient,she doesn't "necessarily" document the assessments. She indicated when she does make a round, she looks at the breathing pattern and looks for fluid overload but "not necessarily" auscultate breath sounds. She indicated she checks if the skin is warm and dry, "that sort of thing." She indicated she doesn't lift gown to check the patient's trunk for rashes, but she looks at the arms. S14RN indicated if the patient complained of itching, she would look at the trunk. She indicated typically they know blood can only run for 4 hours, so they run it between 2 - 4 hours. She starts it at between 75-100 ml and then sets it to run over 2-4 hours. S14RN indicated she wasn't aware of the policy requirement that the transfusion be started at 5 ml/minute for the first 15 minutes.

In an interview on 12/19/18 at 7:55 a.m., S13RN indicated she worked the Med/Surg Unit. She indicated there needs to be an order for the blood, a second witness needs to check the blood with her, she needed to do a pre-transfusion VS check (BP, pulse, temp., respirations, O2 sat), start the blood, and wait 15 minutes with the patient and get a second set of VS 15 minutes after the blood had begun. S13RN indicated she checks the patient periodically ("guess you should check at least every hour") for signs and symptoms of a blood reaction (chest/back pain, rash, shortness of breath, fever). She indicated she does check every hour but is deficient in documenting her assessment. She indicated they don't have an order for the rate, so they run it in 2-4 hours. If it's an elderly patient, S13RN indicated she starts the blood at 75-100 ml/hour, and if not elderly, at 110-120 ml/hr. She indicated she leaves the rate at 100 ml/hour for elderly patients and for other patients, she increases it to 120-125 ml per hour. She indicated she didn't think there was a rate at which the blood was to be transfused in the policy. She confirmed she didn't document the patient's condition at the completion of the blood for Patient #3.

25119

Based on record review and interview, the CAH failed to ensure nursing care plans were developed and kept current as evidenced by failing to ensure nursing care plans were developed for Diabetes Mellitus and/or blood administration for 7 (#1, #2, #3, #5, #12, #18, #19) of 9 (#1 - #5, 12, 18, 19, 20) patient records reviewed for nursing care plans from a sample of 20 patients.

Findings:

Review of the CAH policy titled "Nursing Process Care Plan", dated 08/23/17 revealed in part: Care Plans must be initiated by a Registered Nurse within 24 hours of admission. Assessment, 3, a. The patient's plan of care will be personalized to meet individual patient care needs. 4. Each patient's nursing care is based on identified nursing diagnosis and/or patient care needs and patient care standards and is consistent with the therapies of other disciplines.

Review of the medical record of Patients #1, #2, #3, and #4 revealed each had received blood transfusions. Review of each patient's nursing plan of care revealed no documented evidence that a nursing care plan had been developed for blood administration with specific interventions and goals developed.

In an interview 12/17/18 at 4:20 p.m., S15RN confirmed Patient #1's nursing care plan did not include specific interventions and goals related to blood administration.

In an interview on 12/17/18 at 1:05 p.m., S3RN conformed the fluid balance and overload care plan did not include specifics related to blood administration for Patients #2, #3, and #5.

Patient #12
Review of the medical record for Patient #12 revealed the patient was admitted to the hospital on 10/23/18 with a diagnosis of HTN, DM, and GERD. Further review revealed a physician order dated 10/23/18 for CBS to be done AC & HS with S/S insulin 2u-150-200, 4u- 201-250, 6u- 251-300, 8u- 301-350, 10u- 351-400, 12u- 401-450, 14u- >450. Initial nursing assessment completed on 10/23/18 did not include a care plan and/or address goals or interventions for DM diagnosis.

Patient #18
Review of the medical record for Patient #18 revealed the patient was admitted to the hospital on 12/03/18 with a diagnosis of Dehydration, DM, Hypokalemia, Malnutrition, and Ca Lung. Further review revealed a physician order dated 12/03/18 for CBS to be done AC & HS with S/S insulin 2u-150-200, 4u- 201-250, 6u- 251-300, 8u- 301-350, 10u- 351-400, 12u- 401-450, 14u- >450. Initial nursing assessment completed on 12/03/18 did not include a care plan and/or address goals or interventions for DM diagnosis.

Patient #19
Review of the medical record for Patient #19 revealed the patient was admitted to the hospital on 10/19/18 with a diagnosis of Alzheimer's, DM, Dyspnea, HTN, PAD. Further review revealed a physician order dated 10/19/18 for CBS to be done AC & HS with S/S insulin 2u-150-200, 4u- 201-250, 6u- 251-300, 8u- 301-350, 10u- 351-400, 12u- 401-450, 14u- >450. Initial nursing assessment completed on 10/19/18 did not include a care plan and/or address goals or interventions for DM diagnosis.

In an interview on 12/18/18 at 2:20 p.m., S3RN verified that care plans should have included all of the patients' diagnoses with interventions.

In an interview on 12/18/18 at 3:45 p.m., S2DON confirmed that she was aware there were issues with the care plans.

Based on observation, record review, and interview, the CAH failed to ensure that patient's medical records were stored in a manner that protected the medical records from water damage in the event the hospital's sprinkler system was activated. This failed practice was evidenced by patient medical records being stored in the Medical Records Department in cabinets that were closed but not waterproofed in the event the sprinkler system was activated.
Findings:

Observation on 12/17/18 at 3:15 p.m., in the presence of S5CS of the Medical Records Department, revealed approximately 6 units that were not water-proofed containing 5 shelves with each shelf being approximately 2 feet long with closed sliding doors that had gaps around the edges. There were 2 rows of metal cabinets containing 5 shelves approximately 2 feet long and double-sided that had metal doors with ½ inch gaps at the top and bottom of the doors that were not waterproof. Further observation revealed a locked closet containing a metal filing cabinet with 5 drawers containing records and a metal cabinet containing 5 shelves approximately 2 feet long and double-sided containing records with metal doors that had ½ inch gaps at the top and bottom of the doors that were not waterproof. the cabinets contained records from 2009 - 2015, but did not know how many records were stored. All of the records were waiting to be scanned into the electronic system.

A review of the hospital policy titled "Storage of Records", Document Number 25 dated May 18, 2015, revealed in part: All primary hardcopy medical records shall be housed in physically secure areas under the control of the Director of the Medical Records Department.

In an interview on 12/17/18 at 3:30 p.m., S5CS confirmed that if the sprinkler system was activated, water could enter the cabinets and damage the records. She indicated the cabinets contained records from 2009 - 2015, but she did not know how many records were stored. She further indicated all of the records were waiting to be scanned into the electronic medical record system.

Based on observations, record reviews, and interviews, the CAH failed to meet the requirements of Condition of Partipation for Surgical Services as evidenced by failing to ensure surgical procedures were performed in a safe manner in accordance with acceptable standards of practice established by hospital policy and the AORN's guidelines for surgical practice as evidenced by:

1) Having a dehumidifier that was operating at the time of the observation on 12/19/18 at 8:25 a.m. and having recorded temperatures and humidity for November and December 2018 outside the acceptable range in accordance with AORN guidelines.

2) Failing to have an OR register that contained all required components as evidenced by observation on 12/19/18 at 9:00 a.m. of S28ORS being unable to view an OR register that contained the names of the scrub and circulating personnel, the type of anesthesia used, the name of the person administering anesthesia, the pre and post diagnosis, and the age of the patient as required by the CAH federal regulations.

Findings:

1) Having a dehumidifier that was operating at the time of the observation on 12/19/18 at 8:25 a.m. and having recorded temperatures and humidity for November and December 2018 outside the acceptable range in accordance with AORN guidelines:
Observation on 12/19/18 at 8:25 a.m., with S27QCA present, revealed a dehumidifier was operating in the hall in the OR suite.

Review of the policy titled "Environmental Controls", presented by S30ST as a current policy, revealed all patients will be provided with the safest environment in which to undergo surgical intervention. Further review revealed relative humidity is maintained at least at 55%, and temperature at 65-70 degrees to combat growth of organisms. There was no documented evidence the policy addressed the required temperature/humidity for the decontamination room and the sterile supply room.

Review of the "Surgery Department Check List (Daily Operational Days)", presented as a current policy by S30ST, revealed the list included sterile processing room, sterile supply room, decontamination room, OR 1, and OR 2. Further review revealed the temperature range was 68 - 73 degrees F, and the humidity was 30% - 60%.

Review of the "2018 Edition Guidelines For Perioperative Practice" revealed the OR humidity should be 20% to 60%, and the temperature should be between 68 - 75 degrees F. The decontamination room temperature should be between 60 - 73 degrees F, and sterile storage temperature should be a maximum of 75 degrees F with the humidity at a maximum of 60%. Further review revealed free-standing fans, portable HEPA filtering devices, humidifiers, air conditioners, and dehumidifiers should not be used in restricted areas or sterile processing areas.

Review of the temperature/humidity logs for November & December 2018 revealed the temperature in Room ff and Room gg was outside the acceptable range in accordance with AORN standards for 20 of 20 days documented in November 2018 and for 13 of 14 days documented in December 2018 with temperatures ranging from 52 degrees F to 67 degrees F. Further review revealed the humidity in Room ff was outside the acceptable range in accordance with AORN standards for 13 of 20 days documented in November 2018 with ranges between 61% and 75% and for 4 of 14 days documented in December 2018 with ranges between 62% and 75%. The humidity in Room gg was outside the acceptable range in accordance with AORN standards for 11 of 20 days documented in November 2018 with ranges between 62% and 75% and for 3 of 14 days documented in December 2018 with ranges between 68% and 73%. Further review revealed the temperature in the Room hh was outside the acceptable range in accordance with AORN standards for 12 of 20 days documented in November 2018 with ranges between 55 degrees F and 59 degrees F and for 6 of 14 days documented in December 2018 with ranges between 53 degrees F and 75 degrees F. Further review revealed the humidity in Room ii was outside the acceptable range in accordance with AORN standards for 9 of 20 days documented in November 2018 with ranges between 62% and 68% and for 2 of 14 days documented in December 2018 with 63% and 65%.

In an interview on 12/19/18 at 8:25 a.m., S27QCA indicated they were waiting on a project to be done to address the humidity issue. She further indicated they have difficulty maintaining the temperature and humidity even with the use of the dehumidifier. S27QCA confirmed the OR followed the AORN guidelines.

2) Failing to have an OR register that contained all required components:
Observation on 12/19/18 at 9:20 a.m. of S28ORS attempting to view the computerized OR register revealed the list she was able to view did not have the names of the scrub and circulating personnel, the type of anesthesia used, the name of the person administering anesthesia, the pre and post diagnosis, and the age of the patient.

Review of the OR register presented for review on 12/19/18 at 10:45 a.m. by S32RAC revealed no documented evidence it included the type of anesthesia used, the name of the person administering anesthesia, the pre and post diagnosis, and the age of the patient.

In an interview on 12/19/18 at 9:20 a.m., S28ORS confirmed she could not access the computerized OR register that contained the above-listed information.

In an interview on 12/19/18 at 10:45 a.m., S32RAC presented the OR register that included the names of the scrub and circulating personnel. She confirmed S28ORS did not have access to the register and should have.

Based on record review and interview, the CAH failed to ensure its annual evaluation included the utilization of CAH services, including at least the number of patients served and the volume of services as evidenced by failure to include the volume of services in its evaluation.
Findings:

Review of the annual evaluation for 2017 - 2018, presented as the last completed evaluation by S27QCA, revealed no documented evidence the volume of services was included for all areas.

In an interview on 12/19/18 at 10:05 a.m., S27QCA confirmed the volume of services was not included in the annual evaluation listed above.

Based on record review and interview, the CAH failed to ensure its annual evaluation included a representative sample of both active and closed clinical records as evidenced by failure to include a review of closed and active clinical records in the evaluation.
Findings:

Review of the annual evaluation for 2017 - 2018, presented as the last completed evaluation by S27QCA, revealed no documented evidence of closed and active clinical record reviews that included acute care, lab, pharmacy, radiology, rehab, respiratory, and surgical services. There was no documented evidence that a sample of active clinical records was included for the behavioral health and emergency departments.

In an interview on 12/19/18 at 10:05 a.m., S27QCA confirmed the above findings.

Based on record review and interview, the CAH failed to ensure its annual evaluation included a review of the CAH's health care policies as evidenced by failure to include a review of of the health care policies in its annual evaluation.
Findings:

Review of the annual evaluation for 2017 - 2018, presented as the last completed evaluation by S27QCA, revealed no documented evidence that a review of the hospital's health care policies was included in the evaluation.

In an interview on 12/19/18 at 10:05 a.m., S27QCA confirmed the health care policies were not reviewed as part of the annual evaluation.

Based on record review and interview, the CAH failed to ensure its annual evaluation was conducted to determine whether the utilization of services was appropriate, the established policies were followed, and whether any changes were needed as evidenced by failing to include all required components in the evaluation that would allow the hospital to make such a determination.
Findings:

Review of the annual evaluation for 2017 - 2018, presented as the last completed evaluation by S27QCA, revealed no documented evidence that the evaluation included the volume of services, a sample of active and closed clinical records, and a review of the hospital's health care policies.

In an interview on 12/19/18 at 10:05 a.m., S27QCA confirmed that without the above-listed components, a determination couldn't be made as to whether the utilization of services was appropriate, the established policies were followed, and whether any changes were needed.

Based on record reviews and interview, the CAH failed to ensure its quality assurance program evaluated the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes as evidenced by failure to have all patient care services affected patient health and safety evaluated through its program. The CAH failed to have quality indicators developed and documented for the contracted services of blood bank, organ procurement, telecardiology, hospitalists, and emergency physicians. The CAH's quality assurance program failed to identify problems related to blood administration that were identified during the survey for 5 (#1 - #5) patient records reviewed for blood administration from a sample of 20 patients.
Findings:

Review of the quality dashboard for October 2017 to September 2018 and October 2018 to September 2019, presented as the current quality indicators developed for tracking and trending by S27QCA, revealed no documented evidence that quality indicators had been developed for the contracted services of blood bank, organ procurement, telecardiology, hospitalists, and emergency physicians.

Review of the medical records for Patients #1, #2, #3, #4, and #5 revealed the patients had blood administered during their hospital stay. Further review revealed problems identified by the surveyor during record review that had not been identified by the hospital included the following: a clarification order was not obtained from the physician when the rate at which blood was to be transfused was not included in the original order given by the physician, the rate of transfusion at the start of the transfusion was not implemented in accordance with hospital policy, the patient's condition was not assessed and documented during the course of the transfusion, fluctuations in VS during or after blood administration were not reported to the physician, and physician orders were not followed for administering Lasix between blood transfusions when applicable.

In an interview on 12/19/18 at 10:05 a.m., S27QCA confirmed all services provided by the hospital were not included, such as the contracted services listed above. She confirmed no quality indicator was developed that would have identified the issues found during the survey related to blood administration. S27QCA confirmed the hospital was not aware of the problems related to blood administration that were identified by the surveyor.

Based on chart reviews and interview, the CAH failed to ensure the psychiatric evaluation for each inpatient included an assessment of the estimated intellectual functioning and/or memory functioning as evidenced by failure to have documented evidence of an assessment of intellectual functioning and/or memory functioning documented in the psychiatric evaluation for 3 (#15, #16, #17) of 3 (#15, #16, #17) inpatient psychiatric records reviewed for inclusion of the intellectual and memory functioning assessment in the psychiatric evaluation from a sample of 20 patients.
Findings:

Patient #15
Review of Patient #15's psychiatric evaluation conducted on 12/14/18 by S24MD revealed no documented evidence of an assessment of intellectual and memory functioning.

Patient #16
Review of Patient #16's psychiatric evaluation conducted on 12/14/18 by S24MD revealed no documented evidence of an assessment of intellectual functioning.

Patient #17
Review of Patient #17's psychiatric evaluation conducted on 12/13/18 by S26NP revealed no documented evidence of an assessment of intellectual functioning.

In an interview on 12/18/18 at 4:30 p.m., S22RN confirmed the above findings. She indicated the paper copy that was to document the psychiatric evaluation prior to changing to an EMR had the place to document an assessment of intellectual and memory functioning, but this wasn't included on the electronic form. She confirmed that the psychiatrist and NP were able to add narrative documentation of the electronic form.

Based on chart reviews and interview, the CAH failed to ensure the psychiatric evaluation for each inpatient included an inventory of the inpatient's assets in descriptive, not interpretive fashion, as evidenced by failure to have documented evidence of the patient's assets in the psychiatric evaluation for 2 (#15, #17) of 3 (#15, #16, #17) inpatient psychiatric records reviewed for an inventory of assets in the psychiatric evaluation from a sample of 20 patients.
Findings:

Patient #15
Review of Patient #15's psychiatric evaluation conducted on 12/14/18 by S24MD revealed no documented evidence of an inventory of assets.

Patient #17
Review of Patient #17's psychiatric evaluation conducted on 12/13/18 by S26NP revealed no documented evidence of an inventory of assets.

In an interview on 12/18/18 at 4:30 p.m., S22RN confirmed the above findings.