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Based on interviews and review of clinical records it was determined hospital staff failed to complete a written modification to the patient's plan of care after implementing the use of restraints for two (2) of five (5) patients included in the sample who had been restrained. (Patients #3 and #5)

The findings include:

1. Clinical records were reviewed with the assistance of a navigator provided by the hospital. Review of the clinical record for Patient #3 provided evidence of the application of soft bilateral upper extremity restraints on 5/31/18. Restraints were discontinued on 6/2/18. The plan of care for Patient #3 did not contain any reference to restraint use or any modification to the care plan. Patient #3 was interviewed on 6/5/18 and was not restrained at the time of the interview and stated that he/she did not remember being placed in restraints.

2. Review of the clinical record for Patient #5 provided evidence of the application of soft all extremity restraints on 5/27/18. Restraints were discontinued on 6/1/18. The plan of care for Patient #5 did not contain any reference to restraint use or any modification to the care plan.

Hospital Policy "Seclusion, Restraints and Restraint Alternatives" reads in part as follows: "10. Care of the Patient/Plan of Care: a. The plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications. 12. Documentation Requirements: The medical record contains documentation of: l. Modifications to the plan of care."

The above findings were discussed with the management team at the time of discovery and again prior to exit on 6/13/18. No further evidence was provided to the survey team.

Based on interviews and review of documents it was determined hospital staff failed to administer medications in accordance with the orders of the practitioner for 3 of 14 sampled patients. (Patient #2, Patient #3, and Patient #6)

The findings include:

1. Review of clinical records identified the failure of nursing staff to follow the CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised) protocol as written by the physician. The following information related to the implementation of the "CIWA Protocol" was provided to the survey team by Staff Member (SM) #3: Complete the CIWA-Ar now and then follow protocol. For scores less than 8 a CIWA assessment should be done every 4 hours. For a score of 8-15 a CIWA assessment should be done every 2 hours. For CIWA scores greater than 15 an assessment should be done every hour. If the CIWA-Ar scores are less than 8 for 3 consecutive readings, change to every 8 hours assessments then, if CIWA-Ar scores are less than 8 for 3 consecutive readings, change to every 12 hour assessments, if CIWA-Ar scores are less than 8 for 2 consecutive readings, notify the physician for discontinuation.
The CIWA-Ar score is used to determine the initiation of symptom triggered dosing ordered by the physician. For Patient #3 and Patient #6 the physician had ordered lorazepam (a benzodiazepine sometimes used for the treatment of acute alcohol withdrawal) 2mg every two (2) hours as needed for a CIWA-Ar score of 8-15, and lorazepam 4mg every two (2) hours as needed for a CIWA-Ar score greater than or equal to 15.

a. Patient #3 was admitted to the hospital on 5/23/18 for assistance with alcohol detoxification. Patient #3's electronic health record (EHR) was reviewed with the assistance of a navigator provided by the hospital.

An order was placed on 5/23/18 for CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised) protocol. Review of Patient #3's clinical record and staff adherence to CIWA-Ar protocol from 5/23/2018 to 6/5/2018 revealed the failure of nursing staff to follow the CIWA-AR protocol as written by the physician including but not limited to failure to complete CIWA-Ar assessments, failure to administer medication as ordered based on the assessment and administration of the wrong dose of medication based on the CIWA-Ar assessment.

b. Patient #6 was admitted to the hospital on 6/04/18 for alcohol withdrawal and dependence. Patient #6's electronic health record (EHR) was reviewed with the assistance of a navigator provided by the hospital. An order was placed on 6/4/2018 for CIWA-Ar protocol. Review of Patient #6's clinical record and staff adherence to CIWA-Ar protocol from 6/04/2018 to 6/07/2018 revealed the failure of nursing staff to follow the CIWA-Ar protocol as written by the physician including but not limited to failure to complete CIWA-Ar assessments, failure to administer medication as ordered based on the assessment and administration of the wrong dose of medication based on the CIWA-Ar assessment.

Because the CIWA-Ar score (determined by assessment of the patient) determines the amount of medication to be administered and the timing of the next assessment, when an assessment is not completed per protocol it is impossible to determine exactly how many assessments and resulting medication administrations may have been missed.

The failure of nursing staff to follow CIWA-Ar protocol as ordered by the physician was supported by an observation on 6/07/2018 at 2:24 p.m.. The surveyor had the opportunity to observe medication being administered to Patient #6. Patient #6 was given 2mg of lorazepam orally by Staff Member (SM) #12. The surveyor asked SM #12 if the medication was part of the CIWA protocol and if so what the assessment score was. SM # 12 stated that he/she had not entered the assessment in the record yet but that it was a nine. When asked what the previous assessment was, SM #12 stated that it was also a nine, but that he/she had not given the patient medication because the patient was "doing so good". SM #12 was asked if he/she had obtained a physicians order to deviate from the protocol and he/she replied "no" but that he/she had used nursing judgement to make that decision. SM #12 was asked if there was a nursing note to document the basis for that decision and he/she replied "no".

On 6/07/2018 an interview was conducted with SM #4 (the director of the unit where the observation took place) at 3:00 p.m.. SM #4 was asked what he/she would expect of nursing staff related to the implementation of the CIWA-Ar protocol. SM #4 stated the expectation would be for the staff to follow orders as written unless an order had been obtained from the physician to do otherwise.

Hospital policy "Adult Alcohol Withdrawal Policy and Procedure" last revised 12/2015 reads in part as follows: "Procedure: C. Frequency of vital signs and CIWA-Ar assessments will be determined by the nurse using the CIWA-Ar score based on the attached Alcohol Withdrawal Protocol Order Sheet (Appendix A) and CIWA-Ar Score Sheet (Appendix B) D: Doses will be administered by the nurse based on the calculated CIWA-Ar score by utilizing the attached Alcohol Withdrawal Protocol Order Sheet (Appendix A) and CIWA-Ar Score Sheet (Appendix B) " (Appendix A and B have been incorporated into the electronic health record order sets and are no longer hard copy).

The hospital staff's failure to monitor and record CIWA-Ar assessments and/or provide medications based on the CIWA-Ra assessment was discussed with the management team when discovered, at end of day meetings and prior to exit on 6/13/2018. No further information was provided to the survey team.


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2. Patient #2 was not provided as needed pain medications, as ordered.

Patient #2's medication orders included an order for oxycodone 5 mg tablet every four hours as needed for pain rated as a 1 - 5. This order's start date and time was 2/9/18 at 9:37 a.m.; this order's stop date and time was 2/16/18 at 9:38 a.m.

Review of clinical information provided to the surveyor by Staff Member (SM) #1 (the Quality Manager) and SM #3 (the VP of Quality/Compliance) indicted:
- On 2/12/18 at 9:54 a.m., Patient #2's pain was assessed as a '3'; no medication was documented as being provided. At 11:16 a.m., on the same day, Patient #2's pain was assessed as a '5' and oxycodone 5 mg was provided. At 11:45 a.m., Patient #2's pain was reassessed and was documented as still being a '5'; no addition pain interventions were documented.
- On 2/13/18 at 8:00 a.m., Patient #2's pain was assessed as a '4'; no medication was documented as being provided. At 9:32 a.m., on the same day, Patient #2's pain was assessed as a '5' and oxycodone 5 mg was provided. At 10:00 a.m., Patient #2's pain was reassessed and was documented as being a '4'; no additional pain interventions were documented.

The following statement was found in a facility policy and procedure entitled "Pain Management" (last revised - 4/16):
- "All patients experiencing pain will have an individualized pain management plan."
- "Reassessment - All patients will have their pain reassessed after any pharmacologic and/or non-pharmacologic intervention and at regular intervals in accordance with the Assessment/Reassessment Policy. Reassessment of pain will include: ... C. Additional interventions as indicated ..."

Patient #2's clinical record included specific medications ordered to address pain but no "individualized pain management plan" was found by or provided to the survey team. The aforementioned reassessments of the patient's pain failed to identify if additional interventions were desired by the patient.

On 6/12/18 at 4:00 p.m., the failure of facility staff members to administer Patient #2's as needed pain medications as ordered and the failure of facility staff to develop a pain management plan to include acceptable pain levels for Patient #2 was discussed during a survey team meeting with SM #1 and SM #3; no additional information related to this issue was provided to the survey team prior to exit.

This is a complaint deficiency.

Based on observations, interviews, and the review of documents, it was determined the facility staff failed to ensure operating rooms (ORs) were cleaned between patients/procedures according to the facility's written policy and procedure.

The findings include:

The facility staff failed to use a "hospital-approved germicide" when mopping an operating room (OR) floor between patients/procedures.

On 2/12/18, the surveyor observed facility staff members cleaning an operating room between patients/procedures; the facility's Quality Manager (Staff Member (SM) #1) was present for this observation. The surveyor was shown what cleaning agents were used during the cleaning observations. Two cleaning agents (Agent A and Agent B) where identified, by facility staff members, as being mixed together and used to mop the OR between patients/procedures. On the morning of 2/13/18, the surveyor and SM #1 confirmed with OR staff that the two cleaning agents identified on the previous day were the correct agents used when mopping the OR floors between patients/procedures. Neither of the two agents identified were labeled as 'germicidal'. The surveyor asked SM #1 for evidence of what "hospital-approved germicide" was to be used for mopping the floors between OR cases/procedures.

On 6/13/18 at 1:00 p.m., SM #1 provided the surveyor with product information for another cleaning agent (Agent C); this agent's information indicated it was a 'disinfectant cleaner and deodorant'. SM #1 stated that Agent C should have been used to mop the floor between patients. SM #1 reported Agent A and Agent B have been replaced with Agent C in the supply area for the OR cleaning supplies.

SM #1 provided the survey team with a policy entitled "Sanitation, Operating Room" (last revised - 1/15); SM #1 reported this policy addressed the cleaning of operating rooms between procedures (turnover cleaning). This policy included the following statement: "The floor will be mopped using a hospital-approved germicide."

On the afternoon of 6/13/18, the failure of the facility staff to clean the OR floors with the correct cleaning agent was discussed during a survey team meeting with the facility's Vice-President of Quality/Compliance and SM #1.

Based on interviews and the review of documents, it was determined the facility staff failed to ensure a post-procedure note detailing an operation/procedure was immediately included in the patient's clinical record for three (3) of six (6) patients reviewed for operations/procedures (Patient #1, Patient #2, Patient #10).

The findings include:

Patient #1's clinical documentation was reviewed on 6/5/18 at 10:40 a.m. with Staff Member (SM) #1 (the Quality Manager). No immediately documented post-surgical note was found in the clinical record. Evidence of an immediately dictated operative report was found.

Patient #2's clinical documentation was reviewed on 6/5/18 and 6/6/18 with SM #1. No immediately documented post-surgical note was found in the clinical record. Evidence of an immediately dictated operative report was found.

Patient #10's clinical documentation was reviewed on 6/7/18 at 9:15 a.m. with SM #1. No immediately documented post-surgical note was found in the clinical record. Evidence of an immediately dictated operative report was found.

The following information was found in the facility's "Rules and Regulations of the Medical Staff" (dated 4/19/17): "Operative reports and reports on other surgical procedures shall include a detailed account of the findings at surgery or at the time of the procedure as well as the details of the surgical technique or the procedure involved, the names of the surgeon and assistant, specimens removed, estimated blood loss, and post operative diagnosis. Operative and procedure reports shall be dictated immediately after surgery or other procedure. A written progress note is also to be entered which contains pertinent information. The reports are to be promptly signed by the surgeon or physician and made a part of the patient's current medical record."

On 6/12/18 at 4:00 p.m., the failure of facility staff members to ensure a post-surgical note was documented immediately after the aforementioned three (3) procedures was discussed during a survey team meeting with SM #1 and the facility's VP of Quality/Compliance (SM #3); SM #3 confirmed that the dictated operative report would not be immediately available in the patients' clinical records at the time of dictation.