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Based on medical record review and staff interview, the facility failed to ensure that restraint or seclusion use was in accordance with a change to the plan of care for 2 of 3 sample patients (#12, #16) who utilized restraints or seclusion. The findings were:

1. Review of the medical record showed patient #12 was admitted to the seclusion room on 8/3/15 at 9:53 PM. Further review of the medical record showed the patient remained in seclusion until 8/4/15 at 7:20 AM. Review of the care plan on 8/6/15 at 8:50 AM with RN #1 revealed the use of seclusion was not incorporated into the care plan. RN #1 confirmed at that time the care plan was not modified to include the use of seclusion.

2. Review of the medical record showed patient #16 was admitted on 2/23/15 related to depression and suicidal ideation. On 2/24/15 at 10:52 AM a chemical restraint and seclusion were initiated to control/prevent self injurious behavior and potential harm to self and others. Review of the record showed appropriate assessments and orders related to the use of the restraints; however, the care plan failed to address the restraint use. Interview with the DON on 8/6/15 at 12:30 PM verified the care plan did not specify any information related to restraint or seclusion.




20971

Based on patient, family, and staff interview, medical record review, and review of hospital policies and procedures, it was determined the hospital failed to ensure effective pain management for patients with postoperative pain. The hospital failed to ensure nutritional education was provided for patients with changes in nutritional needs (A395). In addition, the hospital failed to develop and implement appropriate care plans (A396). The cumulative effect of these systemic failures resulted in a determination that the facility failed to meet the Nursing Services Condition of Participation.

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27095


Based on medical record review, family, patient and staff interview, the facility failed to ensure pain was assessed and/or treated effectively for 7 of 30 sample patients (#1, #3, #7, #10, #11, #17, #19). In addition, the facility failed to assess educational needs for 1 of 1 sample patients (#4) with new onset diagnoses of insulin-dependent diabetes. The findings were:

Regarding pain management:

1. Review of the Pain Management Policy, approved 7/22/15, revealed the following information was included in the sections for Knowledge Base and Procedures:
a. Appropriate pain management tools will be made available for the measurement of acute/chronic pain... These tools include, but are not limited to 0 -10 numeric descriptive pain scale: mild pain 1-3, moderate pain 4-6, and severe pain 7-10.
b. Prior to intervention or treatment, assess the patient's pain.
c. Document assessment and treatment in the patient's medical record.
d. Document reassessment in the patient's medical record.

2. Interview with patient #3 and their family member on 8/3/25 at 5 PM revealed the patient had uncontrolled abdominal pain on 8/1/15 and 8/3/15. The patient's family member further stated the patient did not like the way the patient control analgesic medication made him/her feel; but was comfortable on 8/2/15 when the pain pills were administered at frequent intervals. Interview with RN #2 on 8/3/15 at 6:15 PM revealed staff noted the pain medication was not administered on 8/2/15 as prescribed by the physician and measures had been taken to address the error. However, during the interview the nurse did not reveal plans to review the pain management interventions to determine changes that were needed to assist the patient in being as comfortable as s/he had been on 8/2/15.

On 8/6/15 at 8:20 AM the electronic medical record for patient #3 was reviewed with the nurse practitioner. This review revealed the patient was admitted on 7/30/15 after surgery for an illeostomy take down. Orders for pain medication included a Fentanyl patient controlled analgesic, programmed to allow administration of 15 micrograms every eight minutes, and one to two Loratab pain pills every four hours. Review of the 8/1/15 to 8/4/15 nursing pain assessment documentation revealed the reassessment after pain medication administration on 8/2/15 was consistently rated at zero throughout the day. This review further revealed reassessed pain levels after every 4 to 6 hour pain medication administration on 8/1/15, 8/3/15, and 8/4/15 fluctuated between 6, 4, 3, 2 and "acceptable" levels.

3. On 8/6/15 at 9:40 AM the electronic medical record for patient #7 was reviewed with nurse practitioner #1. This review revealed the patient was admitted on 7/31/15 after surgery for a fractured hip. Orders for pain medication included a Fentanyl patient controlled analgesic, programmed to allow self-administrated prescribed doses. Additional orders for pain medication included two Norco pills every fours hours as needed. Review of the admission nursing assessment showed the patient's acceptable pain level was 2. Review of the following 8/2/15 nursing documentation showed the patient's pain level remained 4 or above throughout the day from 9:06 AM until 4 PM (almost seven hours):
a. At 9:06 AM, the pain level was 8, after receiving 2 Norco pills the reassessed pain level was 6 at 9:48 AM.
b. At 10:48 AM the pain level was 6, at 11:11 AM it was 4, and at 1:41 PM when the patient received 2 Norco pills it was 5.
c. At 2:12 PM the pain level was 4 and decreased to zero at 4 PM.

4. Review of physician's orders showed patient #19 had an order for Norco (for pain) 10 mg-325 mg every 4 hours as needed (PRN) for pain. Review of the MAR showed on 8/4/15 at 8:39 PM the resident received a PRN dose of Norco 10 mg- 325 mg. Further review of the MAR and the pain assessment flowsheet showed no documented post-administration assessment to determine the effectiveness of the pain medication. During an interview on 8/6/15 at 8:40 AM RN #1 confirmed there was no post-administration assessment. She stated it should have been done after about 30 minutes.

5. Review of the MAR showed on 8/5/15 at 6:16 AM patient #10 received a PRN (as needed) dose of Acetaminophen 650 mg for pain. Further review of the MAR and the pain assessment flowsheet showed no evidence of a post-administration assessment to determine the effectiveness of the pain medication. During an interview on 8/6/15 at 8:35 AM RN #1 confirmed the lack of a post-administration pain assessment, and stated it should have been done after about 30 minutes.

6. Review of the medical record showed patient #1 was admitted to the swing bed unit on 7/31/15 for rehabilitation after a hip surgery. Interview with the patient on 8/4/15 at 10:15 AM stated he had pain related to the hip, and repositioning and pain medication helped to provide relief. The patient was experiencing some pain during the interview; however, stated the nurse had just given him a pain pill, and it should begin working soon. Review of the MAR for 8/4/15 showed the patient received 1 tab of 5/325 mg Percocet at 9:46 AM. Review of the nursing assessments for this date failed to show any assessment prior to administration of the PRN medication, nor was there any documentation to show effectiveness of the treatment. Interview with RN #2 on 8/6/15 at 8:40 AM verified the pain assessment was lacking.

7. Medical record review showed patient #11 was admitted on 8/4/15 diagnoses which included chest pain. Review of physician orders showed the patient had an 8/4/15 order for acetaminophen/hydrocodone (opioid for pain relief) 325/5 mg 2 tablets by mouth every 4 hours as needed for pain. Further review showed the patient received the acetaminophen/hydrocodone for pain on 8/5/15 at 9:09 AM. The review showed the facility failed to document assessment of the response to the medication to determine effectiveness. Interview with RN #1 on 8/6/15 at 9:30 AM confirmed the facility failed to assess the patient's response to the medication.

8. Medical record review showed patient #17 was admitted on 7/31/15 with diagnoses which included chronic back pain, pancreatitis, and rib fractures. Review of physician orders showed the patient had a 7/31/15 order for acetaminophen/hydrocodone (opioid for pain relief) 325/10 mg 1 tablet by mouth every 4 hours as needed for pain. Further review showed the patient received the acetaminophen/hydrocodone for pain on 8/5/15 at 8:44 PM. The review showed the facility failed to document an assessment of the level of the patient's discomfort prior to administration of the medication. Interview with RN #1 on 8/6/15 at 9:30 AM confirmed the facility failed to assess the patient's level of discomfort prior to administration of the medication.

Regarding patient education:

Review of the operation report for patient #4 showed the patient had a laminectomy on 7/29/15 and was admitted as an inpatient. Review of the 7/29/15 to 8/3/15 nursing notes, and physicians orders showed orders for scheduled and sliding scale insulin, glucose testing, and a diabetic diet. Review of the 7/29/15 to 8/3/15 medication administration record showed the patient received daily insulin injections. Review of the history and physical showed no information about the patient receiving daily insulin prior to the 7/29/15 surgery. Review of the medical record with the nurse practitioner on 8/6/15 at 11:30 AM revealed the patient had not received education or instructions regarding nutrition related to insulin use, hypoglycemia, and hyperglycemia. Interview with the nurse practitioner at that time revealed the patient should have received the teaching and instructions because there was no documented information about the patient receiving insulin injections, glucose monitoring and a diabetic diet in the past, prior to admission.

16146

Based on medical record review, family, staff and patient interview, the facility failed to develop comprehensive nursing care plans for 8 of 30 sample patients (#1, #2, #3, #7, #11, #12, #19, #31). The findings were:

1. Review of the medical record showed patient #12 was admitted on a Title 25 (involuntary) hold for alcohol intoxication and suicidal ideation. Further review of the medical record showed the patient was having hypoglycemia (low blood sugar), was refusing meals and cares, and was in seclusion from 8/3/15 at 9:53 PM until 8/4/15 at 7:20 AM. However, review of the care plan showed only "knowledge deficit" was addressed on the care plan. During an interview on 8/6/15 at 8:50 AM RN #1 agreed the care plan was not sufficient for this patient. She stated the electronic medical record system had recommended some areas to be included in the care plan, but nursing staff had not activated any of the suggestions.

2. Review of the medical record showed patient #19 was admitted following a surgical procedure related to a gastrostomy tube site. Review of the MAR for 8/4/15 to 8/6/15 up until 2 PM showed the patient received 9 PRN (as needed) doses of Norco 10 mg-325 mg for pain. However, review of the care plan showed pain was not addressed. On 8/6/15 at 8:40 AM RN #1 confirmed that pain was not addressed on the care plan. She stated that nursing staff usually just picked "the top 3 or 4 areas" to put on the care plan, and did not necessarily address all needed areas.

3. Review of the medical record showed patient #1 was admitted to the swing bed unit on 7/31/15 for rehabilitation after hip surgery. Interview with the patient on 8/4/15 at 10:15 AM revealed s/he used oxygen, had pain, was a fall risk, and was receiving physical therapy. Review of the care plan with an initiation date of 8/1/15 showed the only area identified for this patient was falls. Interview with RN #2 on 8/6/15 at 8:40 AM verified there were no other care plan problems documented, and more areas may need to be addressed.

4. Review of the medical record showed patient #2 was admitted to the swing bed unit on 8/1/15. Review of the care plan showed impaired physical functioning was identified 8/1/15 as a problem, and there were no other identified problems until 8/5/15 when falls was added. Review of the falls risk assessment showed it was completed on 8/1/15 at 3:29 PM and the patient's score was an 80 which was "high risk." Interview with RN #2 on 8/6/15 at 8:40 AM verified the patient was at high risk for falls and stated the area should have been care planned upon admission.

5. Review of the medical record showed patient #31 was a 4 month old child who was admitted on 8/5/15 for intravenous antibiotic treatment for an infection. Review of the care plan showed as of 8/5/15 the only care plan area was related to knowledge deficit. Interview with RN #2 on 8/6/15 at 8:40 AM verified additional care plan areas should be added.

6. Medical record review showed patient #11 was admitted on 8/4/15 with diagnoses which included chest pain. Review of the physician orders showed the patient had an 8/4/15 order for acetaminophen/hydrocodone (opioid for pain relief) 325/5 mg 2 tablets by mouth every 4 hours as needed for pain. Review of the patient's care plan showed the facility failed to incorporate a plan to address the patient's pain. Interview with RN #1 on 8/6/15 at 9:30 AM confirmed the facility failed to address the patient's pain in the care plan.

7. Review of the operation report for patient #3 showed s/he had surgery for an illeostomy take down on 7/30/15. Interview with the patient and family member on 8/3/15 at 5 PM revealed post operatively his/her pain had been poorly managed by staff. Review of the 7/30/15 to 8/4/15 medication administration record showed pain medications were ordered and had been administered. Review of the care plan showed pain had not been identified as a problem area for this patient and non-pharmacological interventions had not been developed.

8. Review of the operation report for patient #7 showed s/he had hip surgery on 8/1/15 and was admitted with orders for Fentanyl patient controlled analgesic (PCA) and as needed, Norco, pain medication. Review of the 8/1/15 - 8/4/15 medication administration record showed the patient received as needed pain medication in addition to the PCA 3 to 4 times daily. Review of the care plan showed pain and non-pharmacological interventions for pain relief had not been included in the care plan.

9. Interview with nurse practitioner #1 on 8/6/15 at 11:30 AM verified pain had not been included in the care plan for patients #3 and #7, but should have been.




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27095

Based on observation, staff interview, facility floorplan review, and policy and procedure review, the facility failed to demonstrate compliance concerning the safeguarding of medical records against unauthorized use (A441). The effect of this system failure resulted in the determination that the facility failed to meet the Condition of Participation for Medical Record Services.

Based on observation, staff interview, facility floorplan review, and policy and procedure review, the facility failed to safeguard medical records against unauthorized use in 2 of 2 storage areas (the medical records office and cage room in the basement). The findings were:

Observation on 8/5/15 at 2:30 PM showed the facility stored physical medical records in the "cage room" located in the basement and the medical records office. Review of the floorplan for the medical records office showed physical records were stored on 8 foot high shelves in an area that measured 930.5 square feet. Review of the floorplan for the "cage room" in the basement of the facility showed past years of physical medical records were stored on 8 foot high shelves in 3 areas. The first area measured 678.63 square feet. The second area measured 703.41 square feet. The third area measured 517.27 square feet. Each of these areas had open shelves lined with individual files of medical records. There amount of records was great and only allowed for narrow passage between the shelves. The following concerns were identified:
a. Interview with the health information manager on 8/5/15 at 2:30 PM revealed the maintenance staff had access to the stored physical records in both locations. She acknowledged the maintenance staff do not have a need to know information contained in the medical records, and maintenance staff had access for maintenance work and fire safety.
b. Interview with the maintenance director on 8/6/15 at 9 AM confirmed that he and the other 8 maintenance staff had access to the stored medical records in the medical records office and "cage room" located in the basement.
c. Review of the facility policy and procedure titled, "Safeguards" last reviewed/revised on 11/4/11 contained the following information, "B. [The facility] personnel must reasonably safeguard PHI [personal health information] to limit incidental uses or disclosures made pursuant to an otherwise permitted or required use or disclosure. C. [The facility] may not disclose PHI without patient authorization or as permitted by law...G. Physical Safeguards. 1. Paper Records. Paper records and medical charts must be stored or filed in such a way as to avoid access by unauthorized persons. Some type of physical barrier must be used to protect paper records from unauthorized access...Paper records shall be secured when the office/administrative area is unattended by persons authorized to have access to paper records."

Based on observation, staff interview and review of policy and procedures, the director of food and dietetic services failed to ensure required policies and procedures were developed related to kitchen sanitation, and safe food handling practices. In addition, the facility failed to ensure a variety of stored food was labeled with use by dates. The findings were:

Observation on 8/4/15 at 9:35 AM showed several stored food items labeled with past dates. These included:
a. In a reach-in freezer there was a container of diced yellow/orange food with a labeled date of "6/8/15" the label did not indicate what the item was. Interview with dietary staff #1 on 8/4/15 at 9:40 AM verified the item in the container was diced mangos. The staff member stated she wasn't sure what the date meant. She thought that it may have been the date it was put into the container, and she wasn't sure how long it could be kept.
b. In the walk-in-refrigerator there were plates of sausage and biscuits and a container of cooked turkey breast with dates of "8/3/15."
c. In the "meat refrigerator" there were bags containing cooked chicken breast dated "7/24/15" and two deep pans one containing sliced beef and one with sliced ham, both were dated "8/2/15."
d. Interview with the dietary manager and the Registered Dietitian on 8/4/15 at 9:25 AM verified they were unable to locate policy and procedures that addressed safe food handling practices and kitchen sanitation. Further, the dietary manager stated her expectation was for foods to be labeled with use by dates. She stated date labeling was something they needed to work on.

According to Food Code 2013, U.S. Public Health Service: 3-501.17 "(A)...refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days."

Based on observation and staff interviews, the hospital failed to ensure appropriate safe injection practices were implemented for 2 of 3 patients (OP #8, OP #9) observed receiving intravenous medication administration. The findings were:

1. On 8/4/15 from 10 AM to 10:40 AM before and during the procedure for OP #8, RN #3 was observed administering intravenous medications to the patient. The observation revealed the RN did not disinfect the septum prior to piercing the vial of Midazolam (medication used to produce sleepiness or drowsiness and to relieve anxiety before procedures). After administering the medication intravenously, she used the same needle and syringe to pierce another vial of Midazolam and again did not disinfect the septum prior to piercing the vial. Continued observation revealed RN #1 administered the second dose of Midazolam to the patient. Interview on 8/4/15 at 10:25 AM revealed this was the RN's usual practice, and she was not aware of the safety concerns associated with this practice.

2. Observation on 8/4/15 from 12:10 PM to 12:20 PM revealed anesthesiologist #1 administered intravenous medications to OP #9 four times without disinfecting the intravenous port. Interview on 8/6/15 at 7:45 AM revealed this was the anesthesiologist's usual practice.

3. The Association for Professional in Infection Control and Epidemiology (APIC) standards for safe injection practices, published in the American Journal of Infection Control, April 2010, recommends intravenous ports, vial stoppers, and access diaphragms be disinfected prior to each use.

4. According to the Centers for Disease Control and Prevention (CDC) recommendations for Safe Injection Practices, updated 2011, the septum on the medication vial and intravenous ports should be disinfected before piercing. In addition, review of the CDC 2011 publication, "A Patient Safety Threat - Syringe Reuse" revealed, "Healthcare providers (doctors, nurses, and anyone providing injections) should never reuse a needle or syringe either from one patient to another or to withdraw medicine from a vial. Both needle and syringe must be discarded once they have been used."