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.

UNIVERSITY OF KENTUCKY HOSPITAL 800 ROSE STREET LEXINGTON, KY 40536 Feb. 29, 2012
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, clinical record review, facility policy review "Patient Rights and Responsibilities", Policy Number A08-105, Review/Revision Date: 08/2011 and "The Joint Commission Connect, Organization Response to a Complaint", Incident Number 4, it was determined the facility failed to ensure involvement in care planning and treatment for one (1) of twenty-eight (28) patients (Patient #1). The facility failed to ensure Patient #1's spouse was effectively informed of his/her health status to allow the spouse to be involved in care planning and treatment.

The findings include:

Review of facility policy titled, "Patient Rights and Responsibilities", Policy Number A08-105, Review/Revision Date: 08/2011, Number 4, revealed all patients have the right to actively participate in decisions regarding their medical care and the right to an explanation of care, in understandable terms of a) the identity of the physician primarily responsible for their care; b) the identity of all individuals participating in their care; c) a description of the nature and purpose of treatment; d) possible benefits of treatment; e) known serious side effects, risks or drawbacks from treatment; f) problems related to recovery; g) likelihood of success of a particular treatment; h) alternative procedures or treatments; and i) cost of treatment.

Review of "The Joint Commission Connect, Organization Response to a Complaint", Incident Number 4, a response to a complaint from Patient #1's spouse, revealed in "Conclusions" that "communication by and between the multiple services and many physicians with the patient's family throughout the hospital stay which included two major holidays was uncoordinated and fragmented. The autopsy report was not immediately released or explained to" Patient #1's spouse.

Review of Patient #1's clinical record revealed the facility admitted the patient on 12/25/10 with Expressive Aphasia and Headache and a past medical history of [DIAGNOSES REDACTED]. Patient #1 had a complex clinical presentation and many diagnoses were considered, including Viral Encephalitis, Brain Abscess, [DIAGNOSES REDACTED] and Post Transplant Lymphoproliferative Disease. Continued review revealed Patient #1 expired on [DATE] with a final diagnosis of [DIAGNOSES REDACTED]

Interview with the spouse of Patient #1, on 02/28/12 at 2:20 PM via telephone, revealed he/she believed no one doctor was in charge of Patient #1's care, communication was severely lacking, and consequently, he/she did not know who to communicate with concerning Patient #1's overall care and treatment. He/she also revealed no one at the facility ever discussed Patient #1's autopsy report.

Interview with the Risk Manager, on 02/24/12 at 3:33 PM, revealed there was a communication problem with Patient #1's spouse. He/she also stated the process for communicating autopsy results to families had been changed since this case.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review, interview and review of the facility's policy, it was determined the facility failed to ensure a registered nurse evaluated the nursing care for each patient, which included assessing the patient's health status/condition, when appropriate on an ongoing basis in accordance with hospital policy for two (2) of twenty-eight (28) sampled patients (Patients #5 and #6).

The findings include:

Review of the facility's policy titled, "Patient Falls", dated 11/2011, stated if an adult patient has an inpatient fall, follow the instructions in the "Adult Inpatient Fall Guidelines". Review of those guidelines revealed staff should obtain an initial set of vital signs and neurological checks, repeat fifteen (15) minutes after the fall, then every hour times two (2).

1. Review of the medical record revealed the facility admitted Patient #5 on 01/06/12 with diagnoses which included Recurrent Hepatitis and jaundice following a Liver Transplant. Further review revealed the facility completed a Falls Risk Assessment on 01/10/12 and determined Patient #5 was at low risk for a fall. However, review of the "Rapid Response Team Record", dated 01/10/12 at 9:19 AM, revealed Patient #5 experienced a fall while transferring self from the bed to the beside commode.

Review of Patient #5's record revealed no documented evidence that vital signs and neurological checks were completed per the facility's policy at fifteen (15) minutes following the fall and then every hour time two (2).

Interview with Patient Care Manager #1, on 02/29/12 at 8:58 AM, revealed following the fall of an inpatient, vital signs and neurological checks should be completed immediately and repeated in an hour. Continued interview revealed she was unaware of the specific time intervals for vital signs and neurological checks listed in the "Adult Impatient Fall Guidelines".

2. Review of the medical record revealed the facility admitted Patient #6 on 12/26/11 with a diagnosis of Hyperglycemia (elevated blood pressure). continued review revealed the facility completed a Falls Risk Assessment on 12/27/11 at 5:00 AM and determined patient #6 was at high risk for falls.

Review of the "Rapid Response Team Record", dated 12/28/11, revealed the team was notified that patient #6 experienced a fall on 12/28/11 at 6:53 AM. Continued review of the medical record revealed no documented evidence that vital signs and neurological checks were completed per the facility's policy at fifteen (15) minutes after the fall and then every hour times two (2).

Interview, on 02/28/12 at 9:30 PM, with Registered Nurse (RN) #6, who was assigned to care for patient #6 on the day of the fall, revealed sh was unaware of a specific fall policy with guidelines detailing how frequent vital signs and neurological checks would be required after a fall.

Interview with Patient Care Manager #2, on 02/29/12 at 8:38 AM, revealed she thought orders for vital signs and neurological checks were Physician dependent. She further stated when the few fall policy was implemented on 11/2011, all staff received web-based training. However, continued interview revealed she ws not aware of the specific "Fall Policy" procedure requirements listed in the "Adult Inpatient Fall Guidelines".

Interview with the Chairman of the Acute Care Council, on 02/29/12 at 10:00 AM, revealed a required web-based training was developed to educate staff on procedures to follow regarding patient falls. Further interview revealed the web-based training did not include the actual link which would have allowed staff to visualize the instructions and procedures on the "Adult Inpatient Falls Guidelines" sheet.
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, clinical record review, review of the facility's policies, "Department of Pharmacy Policy, Medication Orders" Policy Number PH-04-01, Review Date: 08/2009 and "Department of Pharmacy Policy, The Role of the Pharmacist in the Electronic Medical Record", Policy Number: PH-02-17, Review Date: 12/2011 and review of "Lorazepam Injection, USP", package insert, Revised 09/2004, it was determined the facility failed to ensure a medication order was appropriately reviewed for safety of the dosage prescribed for one (1) of twenty-eight (28) patients (Patient #1).

The findings include:

Review of the facility policy titled, "Department of Pharmacy Policy, Medication Orders", Policy Number PH-04-01, Review Date: 08/2009, revealed a pharmacist is responsible for reviewing a copy of each order for medication prior to preparation and administration. Based on information in the patient's medication profile, the pharmacist may choose to contact the prescribing/ordering practitioner to suggest modification.

Review of the facility policy titled, "Department of Pharmacy Policy, The Role of the Pharmacist in the Electronic Medical Record", Policy Number PH-02-17, Review Date: 12/2011, revealed the pharmacist would be an integral team member in submitting and reviewing dose range checking rules.

Review of the package insert for "Lorazepam Injection, USP", Revised 09/2004, revealed in Precautions, General, "Extreme caution must be used when administering Lorazepam Injection to elderly patients, very ill patients, or to patients with limited pulmonary reserve because of the possibility that hypoventilation and/or hypoxic cardiac arrest may occur". In Dosage and Administration, Intravenous Injection, the insert stated "for the primary purpose of sedation and relief of anxiety, the usual recommended initial dose of lorazepam for intravenous (IV) injection is 2 milligrams (mg) total, or 0.044 mg/kilogram (kg), whichever is smaller. This dose will suffice for sedating most adult patients and ordinarily should not be exceeded in patients over 50 years of age".

Review of Patient #1's clinical record revealed the facility admitted the patient on 12/25/10 with Expressive Aphasia and Headache and a past medical history of [DIAGNOSES REDACTED]. He/she was under the care of multiple medical specialties, including neurology, infectious disease, pulmonary critical care, and neurosurgery. Patient #1 had a complex clinical presentation and many diagnoses were considered, including Viral Encephalitis, Brain Abscess, [DIAGNOSES REDACTED] and Post Transplant Lymphoproliferative Disease. Review of the record also revealed, on 12/30/10 at 3:37 PM, a Physician's Order was written for Lorazepam 5 mg IV once, give 30 minutes prior to MRI. Further review of the record revealed Patient #1 was placed on oxygen at 2 liters per nasal cannula on 12/31/10 at 12:00 AM for a decreased oxygen saturation level of 89% on room air. On 12/31/10 at 9:30 AM, Patient #1 was taken to radiology for an MRI, accompanied by Registered Nurse (RN) #1; at 9:45 AM, Patient #1 had an oxygen saturation level of 88% and was placed on 5 liters of oxygen per nasal cannula. RN #1 also charted that she gave Lorazepam 2 mg IV to Patient #1 at 9:45 AM for anxiety and agitation. At 10:15 AM, RN #1 noted a respiratory rate of 8-10 breaths per minute, cyanosis and oxygen saturations in the mid 70's and the oxygen flow rate was increased to 10 liters per nasal cannula. At 10:20 AM, Patient #1 experienced cardiac arrest and resuscitation efforts were begun. By 10:25 AM Patient #1 was intubated, had a stabilized blood pressure, and an oxygen saturation of 100%. Patient #1 was sent to Post Anesthesia Recovery Unit and then the Intensive Care Unit on mechanical ventilation. Further review of the record revealed Patient #1 expired on [DATE] with a final diagnosis of [DIAGNOSES REDACTED]

Interview with the Clinical Staff Pharmacist, who processed the order for Lorazepam 5 mg IV once, give 30 minutes prior to MRI, on 02/28/12 at 9:15 AM, revealed 5 mg was above the usual dosage parameters for IV Lorazepam. He stated he failed to notice this at the time due to a high volume of orders to review. He also stated the process would be for the pharmacist to notify the physician for clarification if an order was questionable.

Interview with RN #1, on 02/28/12 at 10:05 AM, revealed she only gave 2 mg of Lorazepam IV to Patient #1 at 9:45 AM on 12/31/10 because 5 mg would have been too much to give at one time.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure staff who had never had a tuberculosis skin test of ten (10) or more millimeters induration was skin tested annually on or before the anniversary of their last skin test for five (5) of twenty-one (21) sampled employees, (Employee #3, #9, #17, #18 and #20).

The findings include:

Review of the facility's policy titled, "UK Healthcare Employee Healthy Program Policy", #A03-005, dated 7/2011, stated, "All UK HealthCare HCW's [Health Care Workers] shall have a test for tuberculosis...at least annually on or before the anniversary of the date of their last test". It further stated, "starting in the fiscal year 2012, testing shall be performed annually during the birth month of the employee regardless of the date of their previous test for tuberculosis".

1. Review of the employee file for Employee #3, revealed a hire date of 07/01/07. Continued review revealed the last tuberculosis skin test was completed on 01/14/11. There was no documented evidence the facility had performed the skin test annually per the facility's policy.

2. Review of the employee file for Employee #9, revealed a hire date of 07/01/07. Continued review revealed the last tuberculosis skin test was completed on 01/03/11. There was no documented evidence the facility had performed the skin test annually per the facility's policy.

3. Review of the employee file for Employee #17, revealed a hire date of 08/16/10. Continued review revealed the last tuberculosis skin test was completed on 01/31/11. There was no documented evidence the facility had performed the skin test annually per the facility's policy.

4. Review of the employee file for Employee #18, revealed a hire date of 10/25/07. Continued review revealed the last tuberculosis skin test was completed on 01/27/11. There was no documented evidence the facility had performed the skin test annually per the facility's policy.

5. Review of the employee file for Employee #20, revealed a hire date of 07/01/07. Continued review revealed the last tuberculosis skin test was completed on 01/30/11. There was no documented evidence the facility had performed the skin test annually per the facility's policy.

Interview with Registered Nurse (RN) #2, Employee Health Services, on 2/23/12 at 12:05 PM, revealed historically annual skin tests were performed on all employees in January. The policy was changed in July 2011 [fiscal year 2012] to have employees tested annually during their birth month. However, this change in policy did not account for employees with birth months in February, March, April, May or June who had received their previous tuberculosis skin test in January 2011. These select employees would be out of compliance during the transition to the new policy by waiting until their birth month to receive their annual tuberculosis skin testing follow-up. He further stated the facility did not have a system in place to ensure compliance for those identified employees.

Interview with the Senior Nurse Administrator, on 2/23/12 at 1:15 PM, revealed the facility failed to have an adequate system to track annual tuberculosis skin testing compliance during the implementation of the new policy change. Patient Care Managers informed staff of the policy changes but did not follow-up to ensure all employees with birth months in February, March, April, May or June were in compliance with the regulations which require annual screening and follow-up testing on or before the anniversary date of their last test.

Interview with the Team Leader of UK HealthCare Employee Health Program, on 2/28/12 at 4:10 PM, revealed supervisors were made aware of the changes in the policy effective July 2011 related to the dates employees would received their annual tuberculosis screening and follow-up testing and supervisors would be responsible for ensuring their employees were tested in their birth month. He further stated there was a failure in the system to ensure all employees remained compliant during the months of transition.