The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PROVIDENCE HOLY CROSS MEDICAL CENTER 15031 RINALDI ST MISSION HILLS, CA 91346 Oct. 29, 2012
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on observation, record review and interview, the facility failed to ensure that the use of physical restraint was in accordance with the patient's plan of care for 1 of 30 sampled patients (22).

Findings:

a. On October 23, 2012, at 10 a.m., Patient 22 was observed lying in bed and there was soft tie restraint tied around her left wrist. According to the Restraint Orders dated October 19, 2012, an order was to apply left wrist restraint to prevent pulling at tubes.

A review of the patient's electronic record was conducted with Registered Nurse (RN) 4. The electronic record contained a Plan of Care that included the patient's Problems, Outcomes and Interventions. However, the use of physical restraint was not addressed under the Problems, Outcomes and/or Interventions. In an interview on October 24, 2012, at 1:15 p.m., RN 4, she stated that there should be a care plan for the use of restraint and it should be addressed under the problem, Risk for Injury related to restraint use.

b. A review of Patient 23's Restraint Orders forms for October 18, 21 and 23, 2012 indicated the physician had signed the orders but not dated and timed as indicated on the order forms. According to RN 4 on October 24, 2012 at 1:40 p.m., there should be a date and time when the physician signed the restraint orders.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview and observation, the facility failed to inform each patient or patient's representative of their rights for 6 of 30 sampled patients (Patient 3, 8, 13, 22, 26 and 27). The medical record did not contain documentation that the patients were informed of their rights.

Findings:

a. During a review of the clinical record for Patient 3, the face sheet indicated the patient was admitted to the facility on on [DATE], with diagnosis of total hysterectomy.

During an interview with Patient 3 on October 23, 2012 at 10:30 a.m., she stated she thought someone talked to her about patient rights, but it was vague and she did not sign anything.

Further review of the clinical record for Patient 3 indicated the Condition of Admissions form did not contain in the clinical record (two days after admission).

During an interview and clinical record review with the charge nurse (RN 1) on October 24, 2012 at 10:45 a.m., she stated and confirmed the Condition of Admission (COA) form was not found in Patient 3's clinical record. RN 1 stated the COA should have been completed so the patient was aware of her rights and information regarding Advance Directives.

b. During a review of the closed clinical record for Patient 8, the face sheet indicated the patient was admitted to the facility on on [DATE] with diagnoses which included lung metastasis and was discharged on [DATE].

During a review of the clinical record for Patient 8, the Condition of Admissions form did not contain in the clinical record. This indicated the patient was not informed of his rights as a patient.

The facility policy and procedure titled "Patient Rights and Responsibilities" dated October 2011 indicated it was the policy of the facility to respect and uphold the rights and responsibilities of all individuals to whom care and services were rendered. The facility policy also indicated at the time of admission, each patient would receive a copy of the Patient Rights and Responsibility statement and the patient or representative would acknowledge receipt of patient's rights on the Condition of Admissions form.





c. On October 23,2012 at 10:30 a.m., in the Intensive Care Unit, Patient 13 was observed in bed, connected to a cardiac monitor and with a visitor at the bedside.

During a concurrent interview, Patient 13 stated she went to the emergency department because of abdominal pain. Patient 13 stated she did not recall if someone talked to her regarding patient rights.

On October 25, 2012 at 9:20 a.m., the clinical record for Patient 13 was reviewed with RN 16. The face sheet indicated the patient was admitted to the facility on on [DATE], with diagnoses which included jaundice and atrial fibrillation.

Further review of the clinical record for Patient 13 indicated the Condition of Admissions form was in the clinical record, however, the form was not signed by either the patient or the patient's representative. There was also no initial in the box to indicate the patient received information regarding patient rights and responsibilities.

During an interview on October 25,2012 at 3:50 p.m., Employee 1 stated the Emergency Department (ED) registration staff go to the bedside to attempt to get the signature for Condition of Admission and in-patient financial counselor assigned to the floor go to the bedside or call the family.

A review of the Collection Notes provided by the facility indicated on 10/21/12 indicated the following: At 11: 10 "Patient unable to sign due to medical condition presented in the ER. No family present only care giver." At 11 :35 the notes indicated, "Medicare A and B eligibility." There was no further documentation to indicate if there was another attempt to inform the patient regarding patient rights.





d. On October 24, 2012, a review of Patient 22's medical record revealed the patient was admitted to the facility on on [DATE] and was transferred to the facility's Telemetry/Neuro Unit on October 17, 2012 with diagnosis of altered level of consciousness. The medical record did not contain "Condition of Admission" form that indicated the patient's representative acknowledged the Patient Rights information.

During an interview on October 24, 2012 at 11:25 a.m. Registered Nurse (RN 4) confirmed there was no "Condition of Admission" form in the patient's record.

e. On October 25, 2012, a review of Patient 27's medical record revealed the patient was admitted to the Step Down Unit on October 20, 2012 with diagnoses that included pneumonia and pulmonary embolism. A review of "Condition of Admission" form for Patient 27 revealed that it was not signed and dated by the patient's representative to indicate the patient's representative acknowledged the Patient Rights information. During an interview on October 25, 2012 at 11:35 a.m., RN 7 confirmed that the form was not signed and dated by the patient's representative.

f. On October 25, 2012, a review of Patient 26's medical record revealed the patient was admitted to the facility on on [DATE] and was transferred to the facility's Step Down Unit on October 22, 2012 with diagnosis of acute small bowel obstruction. A review of the "Condition of Admission" form revealed that it was not signed and dated by the patient's representative to indicate the patient's representative acknowledged the Patient Rights information. During an interview on October 25, 2012 at 12:05 p.m. RN 7 confirmed that the form was not signed and dated by the patient's representative.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to ensure the patient had the right to formulate an advance directive for 2 of 30 sampled patients (16 and 24).

Findings:

a. On October 24, 202, a review of Patient 24's open medical record revealed the patient was admitted to the facility's acute rehabilitation unit on October 19, 2012 with diagnosis of polyneuropathy.

A review of the patient's electronic medical record was conducted with Registered Nurse (RN) 5. The Mandatory Admission Assessment disclosed there was no documentation of the patient's advance directive information to determine if she wants to prepare a directive or has a directive and would bring it in. In an interview with RN 5 on October 24, 2012 at 2:20 p.m., he confirmed there was no advance directive information in the electronic record.

According to the facility's policy and procedure on Advance Directives, the nursing staff would review and update the patient's advance directive information during the initial assessment and document in the electronic medical record. If the patient has a completed Advance Directive, and it has not yet provided, the staff would request a copy be brought into the hospital and placed in the patient's medical record.

On October 25, 2012, at 2:35 p.m., RN 11 stated the patient was asked about her Advance Directive and the patient would bring it to the hospital.





b. On October 24,2012 at 3 p.m., the medical record for Patient 16 was reviewed with RN 12. The face sheet indicated the patient was admitted to the facility on on [DATE]. The patient was [AGE] years old with cancer of the bladder. The section for advance directive indicated "N."

A review of the PCS Flowsheet on October 17, 2012 at 11 :07 a.m., indicated the patient had advance directive, and "needs to bring in." At 8:27 p.m., PCS Flowheet indicated the patient had no advance directive, information given to patient. There was no further documentation of a follow up or verification.

Further review of the record revealed no copy of advance directive in the patient's medical record.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation and interview, the facility failed to provide personal privacy during provision of care and treatment to 1 of 30 sampled patient (Patient 30).

Findings:

On October 25,2012 at 9:55 a.m., two staff members (RN 14 and laboratory technician) were observed at Patient 30's bedside. RN 14 was performing blood withdrawal from the patient's central line. The procedure was in view from the hallway.

RN 14 was interviewed at 10:15 a.m., after she completed the blood draw. She stated the blood draw was for CBC, CMP and PTT and the laboratory technician was scanning the patient's identification (ID) band. When asked if she should provide patient privacy during procedure, RN 14 stated she forgot to close the curtain.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the facility failed to ensure 2 of 30 sampled patients (Patient 28 and Patient 29) had the right to be free from all forms of abuse and harassment from certified nursing assistant 1 (CNA 1).

Patient 28 and Patient 29 reported to the facility's staff of their unwelcome sexual contact by CNA 1. The facility failed to implement its policy and procedure on "Patient Abuse Claims and Reporting" as follows:

Findings:

On October 24 and 25, 2012, during a complaint validation survey, two entity reported incidents regarding alleged incidents of unwelcome sexual contact by Certified Nursing Assistant 1 to Patient 28 and Patient 29 was investigated.

A review of the facility's letter to the Department dated September 17, 2012, indicated that on September 12, 2012, Patient 28 reported an alleged unwelcome contact from facility employee that took place during the night shift and on September 17, 2012, Patient 29 reported unwelcome sexual contact by CNA 1.

a. A review of the medical record revealed Patient 28 was admitted to the facility on on [DATE], for generalized weakness.

During a telephone interview on October 1, 2012, at 7:30 a.m., RN 17 stated she was the charge nurse/assistant nurse manager on September 12-13, 2012 during the 7 p.m. - 7 a.m. shift at 2 E (2 East).

According to RN 17, Patient 28 talked to her on September 12, 2012, at approximately 9 p.m. The patient was apologetic and said "I'm not sure what happened." The patient said "I received morphine after a long time, it could be a morphine induced dream." Patient 28 told RN 17 that the night before (September 11, 2012), the male certified nursing assistant (CNA 1) came to talk to her and asked her out. The patient told RN 17 that the CNA cleaned her lower part, then massaged her abdomen because she had abdominal pain. While doing that the CNA's hand touched her breast. The patient told RN 17 she did not want to cause trouble and that the CNA was very professional. The patient felt she had to report it. RN 17 reassured her that the incident would be investigated. The patient told RN 17 that she did not want to know the results of the investigation.

RN 17 also stated that on September 13, 2012, she verbally report with a brief report on paper the alleged incident to RN 18 (the day shift assistant nurse manager). RN 17 further stated that RN 18 told her not to complete an unusual occurrence report because she was going to investigate this incident.

RN 17 stated she should have informed the night supervisor and the unusual occurrence report should have been completed immediately.

According to the the patient's record, Patient 28 was discharged to a skilled nursing facility on September 12, 2012, and this alleged incident of unwelcome contact was brought to the attention of human resources on September 17, 2012, when there was another report incident of alleged unwelcome sexual contact by CNA 1.

RN 18 was suspended for 2 weeks then terminated on October 2, 2012.

During an interview on October 25, 2012, at 2:30 p.m., the human resources manager (Employee 4) stated RN 17 could have informed the night nurse supervisor.

The facility policy titled, "Patient Abuse Claims and Reporting" dated October 1, 2010, indicated the following:

"If a patient complains of being verbally, physically, or sexually abused by a medical center employee, physician, volunteer, student, or board member while a patient at the medical center;

1. the complaint will be reported to the appropriate department manager or House Supervisor.

2. the department manager or House Supervisor will then contact: the Employee Relations Manager in Human Resources, the appropriate Director

3. after business hours, on weekends or holidays, the House Supervisor will be contacted who will then call the Administrator On Call (AOC). The AOC will notify the appropriate Director accountable for the department /employee accused of the allegations. The AOC will also notify Human Resources and leave a message.

4. for physical or sexual allegations of abuse, Risk Management or their designee will contact the local police department to file a report.

b. A review of the medical record revealed Patient 29 was admitted to the facility on on [DATE] with diagnoses that included [DIAGNOSES REDACTED]

During a telephone interview on October 9, 2012, at 7:30 a.m., RN 19 stated she was the nurse assigned to the patient during the 7 p.m.-7 a.m., shift on September 16-17, 2012. RN 19 stated she went to Patient 29's room at around 10:30 p.m., and at midnight to administer medications. RN 19 stated she went back to the patient's room before 3 a.m., because the patient had a telephone call from a gentleman who said he was the patient's husband. The patient was asleep at the time. At approximately 3:30 a.m., RN 19 went to the patient's room and saw the patient awake and talking on the phone. The patient's sister was asleep. At approximately 4:15-4:30 a.m., she went to the patient's room to respond to the call light. The patient asked who was the "Filipino guy" that came to her room. The patient told RN 19 that the "guy" touched my "boobs" and my vagina. The patient told RN 19 that the "guy" took her pajama and put it in the linen bin outside the patient's room. RN 19 checked the bin and saw the pajama. RN 19 stated the patient was wearing a shirt and a white panty. The patient was almost crying while talking to RN 19. The patient stated she was scared because the "guy" was touching her IV and face and told her "it's okay."

During a telephone interview on October 9, 2012, at 7:53 a.m., the Resource Nurse (RN 20) stated that on September 17, 2012 at approximately 4 a.m., she got a call from RN 19 who told her that Patient 29 reported that the CNA assigned to her touched her inappropriately. RN 20 stated she talked to the patient at around 4:30 a.m. Patient 29 told her the CNA touched her breast, removed her pants and touched her private part. The patient was very upset and about to cry during the interview.

The house supervisor, RN 21 was notified of the alleged incident who made the decision to reassign CNA 1 (the alleged perpetrator ). The CNA was assigned to be a sitter to a male patient in room 2270 (a room across the hall 8 feet way from room 2269).

A review of the daily staffing record dated September 16, 2012, indicated CNA 1 was assigned to 2 East at 11 p.m., on September 16, 2012. The record also indicated CNA 1 was a sitter in room 2269.

During an interview on October 24, 2012, at 1:40 p.m., the manager (RN 22) stated on September 17 at 6:30 a.m., she got a call from the house supervisor (RN 21) who informed her that the CNA involved in the abuse allegation was transferred to be a sitter for a male patient.

During an interview on October 25, 2012 at 2:30 p.m., human resources manager (Employee 4) stated CNA 1 should have been taken away from patient care.

The facility's corrective action on September 17, 2012 was to suspense CNA 1 for his misconduct. He was arrested on September 17, 2012, and was discharged on [DATE] for unavailability.

A review of the facility's "Patient's Rights/Responsibilities" dated October 1, 2011, indicated "A patient's rights shall include but not be limited to receive care in a setting free from mental, physical, sexual or verbal abuse and neglect, exploitation or harassment."

The facility policy titled, "Patient Abuse Claims and Reporting" dated October 1, 2010, indicated, "When the patient knows the identity of the accused employee, that employee will be either reassigned or suspended immediately as appropriate to the circumstances of the complaint to provide protection for the patient (s) as well as protection for the possibly wrongly accused employee.

On October 25, 2012 at 5 p.m., the 2 East nurse manager (RN 24) was interviewed. RN 24 stated that RN 17 informed RN 18, the assistant nurse manager, of the first occurrence. RN 18 was to follow-up, she was going to speak to the CNA and the patient. RN 24 stated RN 18 did not follow up, did not inform me (RN 24) and did not follow the chain of command. RN 24 further stated that RN 17 relied on RN 18. She (RN 17) should have done the reporting, she was the assistant manager at night and she did not call me. When asked regarding CNA 1 was as a sitter, RN 24 stated CNA 1 should be removed from patient care. RN 24 further stated CNA 1 was from the float pool and the nurse manager (RN 22) was not aware of the incident.

RN 22 (float pool nurse manager) and Employee 4 (human resources manager) were interviewed on October 29, 2012 at 12:35 p.m. RN 22 stated the house supervisor reassigned the CNA as "Sitter." The house supervisor was concerned with staffing and protecting hospital and employee. RN 22 stated, the CNA need to be removed from patient care. Employee 4 stated RN 18 was "dismissed due to this incident, not trust to fulfill duties" and RN 17 received "discipline based on poor choice."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0173
Based on observation, interview, and record review, the facility failed to ensure the Restraint Order for 3 of 30 sampled patients (10, 14, and 23) were completed.

Findings:

a. On October 23, 2012 at 10 a.m., Patient 10 was observed having soft restraints on both wrists.

A review of the medical record at 10:50 a.m., the same day revealed a telephone order for Restraint Order form dated October 12,2012. The purpose of the restraints to indicate "Non-Violent/Non-Self Destructive Behavior or Violent or Self Destructive Behavior" was not checked off and there was no physician's signature, date and time.

A review of the form indicated to, "Select the type of behavior or demonstrated by the patient by checking appropriate box."

b. On October 23,2012 at 10:45 a.m., Patient 14 was observed having soft restraints on both wrists.

A review of the medical record at 10:55 a.m., the same day revealed a telephone order for Restraint Order form dated October 20, 2012. The purpose of the restraints to indicate "Non-Violent/Non-Self Destructive Behavior or Violent or Self Destructive Behavior" was not checked off.
A review of the form indicated to, "Select the type of behavior or demonstrated by the patient by checking appropriate box.




c. A review of Patient 23's Restraint Orders forms for October 18, 21 and 23, 2012 indicated the physician had signed the orders but not dated and timed as indicated on the order forms.

According an interview with RN 4 on October 24, 2012 at 1:40 p.m., there should be a date and time when the physician signed the restraint orders.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, record review and interview, the facility's registered nurses failed to supervise and evaluate the nursing care for 6 of 30 sampled patients (10, 14, 16, 19, 20, and 21).
For Patient 20 and 21, the patient were observed receiving oxygen by nasal cannula, but they did not have an order from the physician for the use of oxygen. Patient 19 was observed receiving tube feeding and the physician order did not indicate an order for the rate of the tube feeding. For Patient 10 and Patient 16, the staff did not follow the Intravenous (IV) Therapy policy and procedure. The staff also failed to complete the Blood transfusion slip for Patient 10 and Patient 14 in accordance with the Blood Transfusion and Transfusion Record policy and procedure.

Findings:

a. On October 23, 2012 at 9:50 a.m., in the Acute Vent Unit, Patient 20 was observed lying in bed receiving oxygen at 2 liters per minute by a nasal cannula. On the following day, October 24, 2012 at 9:50 a.m., the patient was again observed receiving oxygen by nasal cannula at 2 liters by nasal cannula.

On October 24, 2012, the patient's Face Sheet indicated the patient was admitted to the facility on on [DATE] with diagnoses that included severe anemia and pneumonia. The Physician Orders revealed no order for oxygen use. In an interview on October 24, 2012 at 9:50 a.m., Registered Nurse (RN) 8 stated there should be a physician order for the use of oxygen.

A review of the electronic record was conducted with RN 8. Under Patient Care section, the View Assessment indicated the patient was receiving oxygen at 2 liters per minute by nasal cannula on October 23, 2012 at 8:25 p.m. and October 24, 2012 at 12:53 a.m. The patient's oxygen saturation was at 95 to 96 percent.

The facility's policy and procedure on Administration of Oxygen dated May 3, 2010 stipulated oxygen will be provided to the patient with the prescription/order of a physician. The procedure indicated the staff has to verify the order prior to administration of oxygen to the patient.

b. On October 23, 2012, at 10 a.m., in the Acute Vent Unit, Patient 21 was observed in his room receiving oxygen by a nasal cannula. On October 24, 2012, at 9:55 a.m.., the patient was observed sitting up in a chair and was receiving oxygen by a nasal cannula. According to RN 8 on October 24, 2012 at 9:55 a.m., the patient was receiving oxygen at 1 liter per minute.

On October 24, 2012, a review of the patient's Face Sheet indicated the patient was admitted to the facility's Acute Vent Unit on October 19, 2012 with diagnosis of acute appendicitis. A review of the Physician Orders revealed no order for the use of oxygen. A review of the electronic record was conducted with RN 8. The Vital Signs section indicated the patient was receiving oxygen at 2 liters per minute on October 20, 2012 at 10 p.m., and the patient's oxygen saturation was at 95-96 percent on October 20, 2012 between 7:37 a.m. and 10 p.m.

On October 25, 2012, at 12:25 p.m., during an interview, the nurse manager (RN 6) stated there was an order for the oxygen on October 19, 2012 and provided the Post Anesthesia Care Orders to the surveyor. A review of the Post Anesthesia Care Orders dated October 19, 2012 revealed an order that if the patient's oxygen saturation was below 94 percent, then continue current oxygen therapy and contact the primary care physician for further orders. There was no documentation in the Physician Orders between October 19 and 24, 2012, that the patient may continue the oxygen therapy and the oxygen flow rate.

c. On October 23, 2012 at 10:05 a.m., Patient 19 was observed lying in bed receiving nasogastric tube feeding continuously. The feeding pump machine showed the tube feeding rate at 40 milliters (ml) per hour. However, the feeding bag label indicated Glucerna, 60 ml per hour and there was no time when feeding was hang, the amount of formula and staff initial on the label. In an interview with Registered Nurse 9 at the time of observation, she stated the patient was receiving tube feeding at 40 ml per hour.

On October 25, 2012, a review of the medical record indicated the patient was transferred to the facility's Acute Vent Unit on October 22, 2012 with diagnoses that included pneumonia. The Physician Order sheet dated October 22, 2012 indicated an order, "TF glucerna goal 60." There was no physician order for the tube feeding rate per hour and length of time the tube feeding was to be infused per day.

A review of the electronic record was conducted with Registered Nurse 10. A review of the Feeding Tube Protocol dated October 23 and 24, 2012, completed by the licensed nurses, indicated the patient was receiving tube feeding at a rate of 40 ml per hour, the gastric residual amount was between 40 and 105 ml, and the patient was tolerating tube feeding. On October 24, 2012 at 8 p.m., the tube feeding was stopped due to gastric residual was 175 ml. According to the Progress Notes by the physician dated October 25, 2012 at 6:18 a.m., the patient was nothing by mouth for gastric tube placement.

During an interview of October 25, 2012 at 9:10 a.m., Registered Nurse 10 stated there should be an order for the rate of the tube feeding.

A review of the facility's policy and procedure on tube feeding dated October 29, 2012, indicated to verify the doctor's order, which should contain patient's identifier, the type of formula, delivery device, administration method and tube feeding rate prior to the implementation of administration of tube feeding.





d. 1. On October 23, 2012 at 10 a.m., in the Intensive Care Unit, Patient 10 was observed in bed, with an intravenous fluid (IVF) normal saline 1 liter bag. The label indicated the bag was hung on 10/20 at (0900) 9 a.m.

During an interview on October 24, 2012 at 9: 15 a.m., RN 16 reviewed the medical record and stated the staff did not follow the proper protocol.

A review of the facility Intravenous (IV) Therapy policy and procedure effective date December 1,2008, indicated, "All IV solutions must be changed every 24 hours.

d. 2. A review of the medical record for Patient 10 revealed two Transfusion Request form dated October 20, 2012 and October 22, 2012. Further review of the form revealed the Transfusion Record section indicating the date of transfusion, amount of IV normal saline and reaction noted with "Yes" or "No" box were blank.

During an interview on October 24, 2012 at 9:15 a.m., RN 16 stated the staff chart by exception, the transfusion form was for the laboratory and the normal saline would be documented in the intake and output.

A review of the facility policy titled, Blood Transfusion and Transfusion Record with effective date of October 12, 2009, indicated to, "Complete the Blood bank transfusion slip at the conclusion of the transfusion by taking vital signs and documenting in designated location, and documenting the amount of normal saline infused."

e. On October 23, 2012 at 2:13 p.m., in the Telemetry Unit, Patient 16 was observed in bed with a saline lock on the left forearm. The saline lock was covered with a clear tape and there was a small pink drainage around the insertion site. There was no date to indicate the date of insertion.

During a concurrent interview, Patient 16 stated the IV site had been there for a few days and it was for her antibiotics administration.

The medical record for Patient 16 was reviewed on October 24, 2012 with RN 12. The record revealed an IV catheter was inserted on the left forearm on October 17, 2012 and discontinued on October 24, 2012 prior to discharge. This indicated the patient's IV site was on the patient's left forearm for more than 96 hours.

During an interview at 3:15 p.m., the same day RN 12, reviewed the record and was unable to find documentation that the IV site was changed or for another IV site. RN 12 stated, "Per CDC (Communicable Disease Control), to change IV site every 72 -96 hours, no more than 96 hours."

A review of the facility policy titled, Intravenous (IV) Therapy effective date December 1, 2008, indicated, "Peripheral IV sites are assessed every shift and changed every 72-96 hours. If no other vein is available to change IV site and there are no signs/ symptoms of infection, document reason site not changed every shift and assessment of site."

f. A review of the medical record for Patient 14 revealed a Transfusion Request forms dated October 15, 2012. Further review of the form revealed the Transfusion Record section indicating the date of transfusion, amount of IV normal saline and reaction noted with "Yes" or "No" box were blank.

During an interview on October 24,2012 at 9:15 a.m., RN 16 stated the staff chart by exception, the transfusion form was for the laboratory and the normal saline would be documented in the intake and output.

A review of the facility policy titled, Blood Transfusion and Transfusion Record with effective date of October 12, 2009, indicated to, "Complete the Blood bank transfusion slip at the conclusion of the transfusion by taking vital signs and documenting in designated location, and documenting the amount of normal saline infused."
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review and interviews the facility's nursing staff failed to develop and maintain a nursing care plan for 7 of 30 sampled patients (Patients 5, 6, 7, 11, 17, 25 and 27).

Findings:

a. During an observation on October 23, 2012 at 11:10 a.m., in the oncology unit, Patient 5 was in his room sitting on the side of the bed.

During an interview with Patient 5 on the same day at 11:15 a.m., he stated he was supposed to go home this day, but the doctor wanted to keep him due to the pain in his left lower stomach. Patient 5 stated he was also scheduled for a test later that day.

During a review of the clinical record for Patient 5, the face sheet indicated the patient was admitted to the facility on on [DATE] with diagnosis of [DIAGNOSES REDACTED]

A review of the history and physical (H/P) dated October 19, 2012 indicated Patient 5 had some abdominal pain and discomfort for 1 - 2 days in the left abdomen and with the pain rated at 6 of 10 (10 being the worse pain possible). The assessment and plan from the H/P indicated Patient 5 with fever and abdominal pain, concerning for ileus versus obstruction, rule out intra-abdominal infection.

A review of the surgical consultation report dated October 20, 2012 indicated Patient 5 came to the hospital for blood transfusion, but was complaining of some left lower quadrant abdominal pain and was admitted for further evaluation.

A review of the physician order dated October 19, 2012 indicated Patient 5 received Morphine 2 mg intravenously every 4 hours as needed for severe pain and Norco for mild to moderate pain as needed. The physician order dated October 21, 2012, indicated Patient 5 received Toradol 30 mg intravenously as needed for pain. A review of the physician's order dated October 23, 2012 indicated Patient 5 received 2 units packed red blood cells and a CAT scan of abdomen with contrast.

Further review of the clinical record indicated there was no care plan for the pain and no care plan for the blood transfusion for Patient 5. When RN 2 was asked if there was a care plan developed regarding pain and blood transfusion, he stated and confirmed there was no care plan to address Patient 5's pain and no care plan for the blood transfusion. RN 2 also stated they were not aware of the cause of Patient 5's pain which was why the CAT scan was ordered.

During an interview with the nurse manager (RN 3) on October 24, 2012 at 10:30 a.m., she stated Patient 5's pain was not a primary focus because it was intermittent pain and not something the patient came into the hospital with. However, the history and physical and clinical record indicated otherwise.

A review of the admission assessment of Patient 5 dated October 19, 2012 at 10 a.m., indicated Patient 5 had pain present that was recurrent, intermitten, radiating and sharp, aggravated by exercise or activity.

A review of the patient care notes dated October 20, 2012 at 1:50 p.m., indicated medication was given to Patient 5 for pain which was rated at a 10 and the pain was located in the abdomen. The same occurred at 3:36 p.m., 7:25 p.m., and 11:50 p.m. The patient care notes dated October 21, 2012 at 11:24 a.m., 9 p.m., October 23, at 5:10 a.m., 11:01 a.m., 3:31 p.m., 8:51 p.m. and October 24, 2012 at 3:52 a.m., and 7:50 a.m., indicated Patient 5 received medication for pain, and the pain was rated at an 8, located in the abdomen.

The facility's policy and procedure titled "Pain Management" dated June 2007 indicated the purpose was to identify patients with pain and ensure patients with unrelieved pain have continued additional comprehensive pain assessment and intervention. The policy indicated the elderly were more likely to under report their pain and that pain was a major health care priority and pain was the number one reason people seek medical attention.

The facility's policy and procedure titled Documentation of Care dated January 2011 indicated the purpose was to promote consistency of in-patient care and communication between nurses and other health team members. The policy indicated the plan of care was an individual plan for the patient care needs done every shift and the nurse selects the patient's problems that required focused attention for the shift per patient need.

b. During an observation on October 23, 2012 at 11:20 a.m., in the oncology unit, Patient 6 was noted in his room sitting in the chair.

During a review of the clinical record for Patient 6, the face sheet indicated the patient was admitted to the facility on on [DATE] with diagnoses which included dehydration, diarrhea and hyperglycemia (excessive amounts of sugar circulating in the blood).

A review of the emergency department report - admitted d October 20, 2012, indicated Patient 6 presented to the emergency department unable to care for himself, hyperglycemic with a blood sugar result of 441 mg/dl (normal range 60 - 120 mg/dl) and with multiple episodes of diarrhea. The emergency department report indicated the treatment for Patient 6 was regular insulin, 8 units intravenously for the hyperglycemia and one liter of normal saline for the dehydration.

A review of the admission assessment dated [DATE], indicated Patient 6's sensory perception and mobility was slightly limited, activity was chairfast and the Braden scale score was 18, which placed the patient at risk for skin breakdown, requiring a specialty bed.

A review of the physician's order dated October 21, 2012, indicated Patient 6 received Lantus (type of insulin used for diabetes where the body can not control amount of sugar in the blood) 30 units subcutaneously every night.

A review of the laboratory of blood sugar results dated October 22, 2012 indicated Patient 6 had a result of 254 mg/dl and October 23rd result was 334 mg/dl (both abnormally high).

Further review of the medical record indicated there was no care plan for Altered Glucose Metabolism to address Patient 6's hyperglycemia.

During an interview with the Clinical Educator (RN 12) on October 25, 2012 at 3:35 p.m., she stated Patient 6's glucose levels were out of control and the patient required a more appropriate care plan such as altered glucose metabolism. The Clinical Educator stated the care plan was important so the nursing staff could address the risk for infection, healing process and dehydration. Further review of the care plan indicated no intervention of the social worker regarding education of medication and programs available for assistance in housing and medication costs.

c. During an observation on October 23, 2012 at 2:15 p.m., in the telemetry/medical/surgical unit, Patient 7 was noted in her room lying in bed.

During a review of the clinical record for Patient 7, the face sheet indicated the patient was admitted to the facility on on [DATE] with diagnoses which included [DIAGNOSES REDACTED](irregular heart beat) and rapid ventricular response.

A review of the history and physical dated October 23, 2012, indicated Patient 7 had initial pulse of 120 beat/minute and heart rate was as high as 140 (normal range 60 - 100). The assessment and plan for Patient 7 was [DIAGNOSES REDACTED]with rapid ventricular response, continue amiodarone drip, resume labetalol and to obtain cardiology consult.

A review of the consultation report dated October 23, 2012 indicated Patient 7's intake and output was balanced since admission, the recommendation was to increase maintenance of amiodarone daily and that anticoagulation was clearly indicated.

A review of the physician's orders dated October 23, 2012, indicated Patient 7 received Coumadin per pharmacy and Lovenox 1 mg subcutaneously every 12 hours.

According to Nurse's Drug Guide 2009, Coumadin and Lovenox were anticoagulants used to treat [DIAGNOSES REDACTED]and myocardial infarction. The drug guide indicated it was important to monitor and report immediately any signs or symptoms of [DIAGNOSES REDACTED]

However, further review of the medical record indicated Patient 7's risk for decreased cardiac tissue perfusion care plan's intervention was to monitor and evaluate intake and output. This indicated the care plan interventions did not include monitoring Patient 7 for unexplained or increased bleeding, (a common and life threatening adverse effect of both medications).

During an interview with the nurse clinician (RN 13) on October 24, 2012 at 2:30 p.m., she stated there should be a care plan for the use of Lovenox because it was a blood thinner and there would be risk for bruising and bleeding to the patient.

The facility's policy and procedure titled Documentation of Care dated January 2011 indicated the care plan was an interdisciplinary plan that defined how care was given to the patient. The policy indicated the patient needs were reflective of the medical condition, activities of daily living and psychosocial needs.





d. On October 23, 2012 at 10:15 a.m., in the Intensive Care Unit, Patient 11 was observed in bed, orally intubated and on a ventilator.

On October 24, 2012, the patient's medical record was reviewed with RN 12. Patient 11 was admitted to the facility on on [DATE] with diagnoses that included [DIAGNOSES REDACTED]

During an interview at 10:35 a.m., the same day, RN 12 stated a score of 10 is considered high risk.

Further review of the medical record revealed no plan of care to address the risk for skin integrity impairment.

During an interview on October 24, 2012 at 10:30 a.m., RN 15 stated when there is a trigger, and score of 18 and below is a trigger, skin integrity would appear on the screen, the nurse has to click skin integrity and save and acknowledge.

e. The closed medical record for Patient 17 was reviewed on October 25, 2012. According to the face sheet, Patient 17 presented to ED on August 31, 2012 at 8:07 a.m., status post cardiac arrest, respiratory failure, chronic renal failure and was discharged to another acute hospital on September 1, 2012 at 6:56 p.m.

The ED record indicated the patient fell at home, head hit the floor, was unresponsive and apneic (not breathing).

The electronic record indicated the patient was transferred to the Intensive Care Unit at 10:32 a.m., on August 31, 2012. The patient was intubated, on a ventilator, on vasopressor drip and had a pacemaker. The record also indicated the patient had a right 3rd toe amputated.

Review of the Patient Care Notes dated August 31, 2012, indicated the following: 10:45 received pt (patient) from ER, on a vent. (ventilator), sedated, levophed infusing at 8 mcgs (micrograms)...11:45 pt's sbp (systolic blood pressure) ranges from 120 - 130 mmHg (milliliter mercury), levophed titrated to off at this time.

Further review of the electronic record disclosed a problem titled risk for infection. There was no other care plan documented.

During an interview at 3:50 p.m., on October 25, 2012, when asked for the care plan, RN 13 stated that, instead of adding under the umbrella care plan, the nurse selected a single problem, "Risk for Infection."





f. On October 25, 2012, a review of Patient 27's medical record revealed the patient was transferred to the Step Down Unit on October 20, 2012 with a stage I pressure sore on the right heel and excoriation on the buttocks. A review of the electronic record was conducted with Registered Nurse 7. The Shift assessment dated [DATE] indicated the right heel and buttocks were assessed as stage I pressure sore and the patient was assessed to be at moderate risk for skin breakdown. The electronic record contained a Plan of Care that addressed the patient's care concerns in the following areas: Problems, Outcomes and Interventions. However, Patient 27's impairment of skin integrity was not addressed in the Problems, Outcomes and/or Interventions. In an interview on October 25, 2012 at 12 p.m., RN 7 stated that the care plan is developed automatically based on the shift assessment. RN 7 stated that a nursing care plan for impairment of skin integrity should have been developed and stated it would be added manually.

g. A review of the closed record of Patient 25 revealed the patient was transferred to the Step Down Unit on October 21, 2012 with diagnosis status post fall, rib fracture. A review of the Plan of Care revealed a care plan for risk of injury was developed, however, there was no interventions designed to prevent future falls and injuries. In an interview on October 25, 2012 at 2:30 p.m., RN 12 stated there was no interventions for the risk of fall in the electronic record.