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.

GLENWOOD REGIONAL MEDICAL CENTER 503 MCMILLAN ROAD WEST MONROE, LA 71291 March 26, 2015
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:

a) Failure to ensure patients were assessed by the RN and determined to meet the criteria for delegation of nursing care to the LPN (licensed practical nurse) according to the LSBN's (La. State Board of Nursing) "Administrative Rules Defining RN Practice LAC46:XLVII 3703. Definition of Terms Applying to Nursing Practice" for 5 current Emergency Department (ED) patient records (#12, #13, #14, #17, #18) and 4 closed ED patient records (#3, #5, #9, #10) reviewed for RN assessments from a total of 11 ED patient records reviewed (#3, #4, #5, #9, #10, #11, #12, #13, #14, #17, #18) from a total sample of 23 patients;

b) Failure to ensure the ED nurses included their title when they authenticated their electronic signature in order to determine what discipline had provided the nursing care as evidenced by having no documented evidence whether the documentation was made by an RN or an LPN for 5 (#12, #13, #14, #17, #18) of 5 active ED patient records and 6 (#3, #4, #5, #9, #10, #11) of 6 closed ED patient records reviewed for authentication of documentation from a total of 11 ED patient records reviewed from a total sample of 23 patients;

c) Failure to ensure physician's orders were followed for titration of critical medication drips for 1 active inpatient (#20) and 2 closed (#1, #23) medical records from a total of 4 (#1, #6, #20, #23) patient records reviewed for titration of critical medication drips from a total sample of 23 patients; and

d) Failure to ensure the RN assured accurate documentation of the time patients were transferred or left the ED as evidenced by having documentation that a patient was transferred at one time and documentation that the patient left the ED at a later time for 2 (#13, #14) active ED patient records and 3 (#4, #5, #11) closed ED patient records reviewed from a total of 11 ED patient records reviewed (#3, #4, #5, #9, #10, #11, #12, #13, #14, #17, #18) from a total sample of 23 patients.
(See findings in tag A0395).


2) Failing to ensure the RN assigned the nursing care of each patient to nursing personnel in accordance with the patient's needs and the qualifications and competence of the available nursing staff as evidenced by having the competency of the ED nursing staff evaluated by S4ED Director who had not been evaluated for competency in caring for patients in the ED for 4 (S4, S14, S18, S29) of 4 RNs' personnel files reviewed for competency from a total of 26 full-time and PRN (as needed) RNs in the ED (See findings in tag A0397).


3) Failing to ensure that the DON (Director of Nursing) provided for the evaluation of the clinical activities of non-employee nursing personnel which occur within the responsibility of the nursing services. The hospital had an active list of 39 registered nurses (RNs) and LPNs contracted through 3 nurse staffing agencies who were not evaluated for competency by a hospital-employed RN (See findings in tag A0398).
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and observations, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:

1) Failing to ensure patients were assessed by the RN and determined to meet the criteria for delegation of nursing care to the LPN (licensed practical nurse) according to the LSBN's (La. State Board of Nursing) "Administrative Rules Defining RN Practice LAC46:XLVII 3703. Definition of Terms Applying to Nursing Practice" for 5 current Emergency Department (ED) patient records (#12, #13, #14, #17, #18) and 4 closed ED patient records (#3, #5, #9, #10) reviewed for RN assessments from a total of 11 ED patient records reviewed (#3, #4, #5, #9, #10, #11, #12, #13, #14, #17, #18) from a total sample of 23 patients;

2) Failing to ensure the RN reassessed an ED patient with a change in condition for 1 (#4) of 3 (#3, #4, #11) patients reviewed with a change in condition from a total of 11 ED patient records reviewed (#3, #4, #5, #9, #10, #11, #12, #13, #14, #17, #18) from a total sample of 23 patients;

3) Failing to ensure the RN assured accurate documentation of the time patients were transferred or left the ED as evidenced by having documentation that a patient was transferred at one time and documentation that the patient left the ED at a later time for 2 (#13, #14) active ED patient records and 3 (#4, #5, #11) closed ED patient records reviewed from a total of 11 ED patient records reviewed (#3, #4, #5, #9, #10, #11, #12, #13, #14, #17, #18) from a total sample of 23 patients;

4) Failing to ensure the RN assured a patient ordered to be admitted to ICU (Intensive care Unit) was transferred to ICU rather than being transferred to an inpatient unit other than ICU for 1 (#5) of 1 ED patient record reviewed with physician orders to admit to ICU from a total of 11 ED patient records reviewed (#3, #4, #5, #9, #10, #11, #12, #13, #14, #17, #18) from a total sample of 23 patients;

5) Failing to ensure the ED nurses included their title when they authenticated their electronic signature in order to determine what discipline had provided the nursing care as evidenced by having no documented evidence whether the documentation was made by an RN or an LPN for 5 (#12, #13, #14, #17, #18) of 5 active ED patient records and 6 (#3, #4, #5, #9, #10, #11) of 6 closed ED patient records reviewed for authentication of documentation from a total of 11 ED patient records reviewed from a total sample of 23 patients;

6) Failing to ensure physician's orders were followed for titration of critical medication drips for 1 active inpatient (#20) and 2 closed (#1, #23) medical records from a total of 4 (#1, #6, #20, #23) patient records reviewed for titration of critical medication drips from a total sample of 23 patients;

7) Failing to reassess patients after a decline in status for 2 (#8, #19) of 23 (#1 - #23) patients sampled; and

8) Failing to follow physician's orders for notification of elevated blood pressures for 1 (#6) of 23 (#1 - #23) sampled patients.


Findings:

1) Failing to ensure patients were assessed by the RN and determined to meet the criteria for delegation of nursing care to the LPN according to the LSBN's "Administrative Rules Defining RN Practice LAC46:XLVII 3703. Definition of Terms Applying to Nursing Practice":

Review of the LSBN's "Administrative Rules Defining RN Practice LAC46:XLVII 3703. Definition of Terms Applying to Nursing Practice" revealed that the RN retains the accountability for the total nursing care of the individual and is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the RN or by the RN in conjunction with other licensed or unlicensed assistive personnel. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care
problems. This assessment shall be utilized to assist in determining which tasks may be
delegated and the amount of supervision which will be required. Any situation where tasks are delegated should meet the following criteria:

a) the person has been adequately trained for the task;
b) the person has demonstrated that the task has been learned;
c) the person can perform the task safely in the given nursing situation;
d) the patient's status is safe for the person to carry out the task;
e) appropriate supervision is available during the task implementation;
f) the task is in an established policy of the nursing practice setting and the policy
is written, recorded and available to all.

Further review revealed the RN may delegate to LPNs the major part of the
nursing care needed by individuals in stable nursing situations, i.e., when the following
three conditions prevail at the same time in a given situation:

a) nursing care ordered and directed by the RN or physician requires abilities based on a
relatively fixed and limited body of scientific fact and can be performed by following a
defined nursing procedure with minimal alteration, and responses of the individual to the
nursing care are predictable; and
b) change in the patient's clinical conditions is predictable; and
c) medical and nursing orders are not subject to continuous change or complex
modification.

Review of the hospital policy titled "Assignments of Nursing Care for Patients", approved 03/14/13 and presented as a current policy by S3DON (Director of Nursing), revealed that assignment of nursing care will be made by the Department Supervisor, Nursing Director, or Charge RN. Patient care assignments are based upon the patient's status (acuity), the environment in which the nursing care is provided, the competence of the nursing staff member who is to provide the care, and the degree of supervision required by and available to this person.

Review of the hospital policy titled "Patient Triage: Basic Nursing Assessment", approved 12/29/07 and presented as a current policy by S3DON, revealed that each patient presenting to the ED will be assessed by a RN in accordance with established guidelines for basic assessment. Each patient will be assessed by a RN on admission to the ED. Further review revealed patients should be reassessed on an ongoing basis with frequency of assessments based on patient's changing condition. There was no documented evidence that the policy addressed whether the reassessment was to be performed by a RN and how frequent the reassessment had to be done if there was no change in the patient's condition (such as a patient being held in the ED while waiting for an inpatient bed to be available).


Patient #12
Review of Patient #12's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 7:34 a.m. She presented from home by ambulance reporting that she was staggering and felt weak and dizzy right after waking up. She reported that her blood pressure which she took was 71/34 with a heart rate of 61.

Patient was diagnosed with Hypotension and Urinary Tract Infection. She was triaged by the RN at 7:59 a.m. who also documented a neurological assessment at 8:00 a.m., and her care was delegated to S9Agency LPN. S9Agency LPN conducted Patient #12's screening for abuse, nutrition, suicide risk, pneumonia and tuberculosis, and fall risk and performed an assessment at 8:06 a.m. and performed Patient #12's discharge assessment at 11:49 a.m. There was no documented evidence that the RN determined that Patient #12 met the criteria to have her care delegated to the LPN.


Patient #13
Review of Patient #13's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 9:47 a.m. with complaints of left abdominal pain, bloody stools, nausea, and weakness for over 3 days. Further review revealed her diagnoses were Colitis and Lower GI (Gastrointestinal) Bleeding.

Patient #13 was triaged on 03/23/15 at 9:59 a.m. by S29RN. Patient #13's care was delegated to S9Agency LPN who conducted a screening for abuse, nutrition, suicide risk, pneumonia and tuberculosis, and fall risk and performed an assessment at 10:00 a.m. There was no documented evidence that S29RN determined that Patient #13 met the criteria to have her care delegated to the LPN. There was no documented evidence Patient 313 was assessment by an RN after her triage assessment for 9 hours 32 minutes.


Patient #14
Review of Patient #14's ED record revealed she was an [AGE] year old female who (MDS) dated [DATE] at 10:16 a.m. by ambulance from dialysis for evaluation for Altered Mental Status. She was triaged by S29RN on 03/23/15 at 10:41, and her care was delegated to S9Agency LPN. S9Agency LPN conducted a screening for abuse, nutrition, suicide risk, pneumonia and tuberculosis, and fall risk at 10:46 a.m. and performed an assessment at 10:45 a.m. There was no documented evidence that S29RN determined that Patient #14 met the criteria to have her care delegated to the LPN. Further review revealed Patient #14 was not assessed by an RN after her triage assessment for 6 hours 37 minutes while she was in the ED.


Patient #17
Review of Patient #17's ED record revealed she was an [AGE] year old female who (MDS) dated [DATE] at 12:08 p.m. with chief complaints of CVA (Cerebrovascular Accident), left-sided weakness, slurred speech, and facial drooping within one hour of onset. Her diagnosis was Brain Mass.

Patient #17 was triaged by S30Agency RN on 03/23/15 at 12:16 p.m. Further review revealed Patient #17's care was delegated to S9Agency LPN on 03/23/15 at 12:40 p.m. at which time S9Agency LPN documented an assessment. S9Agency LPN screened Patient #17 for abuse, nutrition, suicide risk, pneumonia and tuberculosis, and fall risk at 1:54 p.m. There was no documented evidence that S30Agency RN determined that Patient #17 met the criteria to have her care delegated to the LPN. Further review revealed Patient #17 was not assessed by an RN after her triage assessment for 9 hours 29 minutes while she was in the ED.


Patient #18
Review of Patient #18's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 1:33 p.m. for further evaluation of elevated Troponin, abdominal pain, and left shoulder pain. Her diagnosis was Myocardial Infarction - non ST elevation.

Review of Patient #18's ED record revealed she was triaged on 03/23/15 at 1:52 p.m. by S29RN, and her care was delegated to S9Agency LPN. S9Agency LPN conducted the screening for abuse, nutrition, suicide risk, pneumonia and tuberculosis, and fall risk at 2:00 p.m. and assessed Patient #18 at the same time. There was no documented evidence that S29RN determined that Patient #18 met the criteria to have her care delegated to the LPN. Further review revealed Patient #18 was not assessed by an RN after her triage assessment for 5 hours 43 minutes while she was in the ED.


Patient #3
Review of Patient #3's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 7:31 a.m. by ambulance with chief complaints of chest pain with onset at 10:00 p.m. the previous night, vomiting with onset about midnight, and active vomiting during the triage assessment. Her diagnoses were Myocardial Infarction - non ST elevation, Atrial Fibrillation, Chronic Kidney Disease, and Diabetes Mellitus.

Patient #3 was triaged by S18RN at 7:40 a.m., and her care was delegated to S9Agency LPN. S9Agency LPN conducted the screening for for abuse, nutrition, suicide risk, pneumonia and tuberculosis, and fall risk at 7:55 a.m. and performed a nursing assessment at 8:07 a.m. Documentation by S9Agency LPN revealed Patient #3 was in cardiac arrest at 9:45 a.m. and expired at 10:07 a.m. There was no documented evidence that S18RN determined that Patient #3 met the criteria to have her care delegated to the LPN.


Patient #5
Review of Patient #5's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 9:49 a.m. by ambulance as a CVA transfer from another hospital. Her diagnoses were Emphysema and Sepsis.

Review of Patient #5's ED record revealed her triage assessment was performed by a RN at 10:04 a.m., and her care was delegated to S9Agency LPN. Further review revealed S9Agency LPN assessed Patient #5 at 11:10 a.m., 1 hour 6 minutes after she had been triaged. There was no documented evidence that the RN determined that Patient #5 met the criteria to have her care delegated to the LPN. Further review revealed Patient #5 was not assessed by an RN after her triage assessment for 7 hours 59 minutes while she was in the ED.


Patient #9
Review of Patient #9's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 11:09 a.m. with chief complaints of "low Hemoglobin" and sent from the physician's office. Further review revealed she was triaged by a RN on 03/12/15 at 12:06 p.m. (57 minutes after her arrival), and her care was delegated to S9Agency LPN.

Review of Patient #9's ED record revealed S9Agency LPN performed an assessment at 6:33 p.m., 6 hours 27 minutes after she had been triaged. Further review revealed no documented evidence that the RN determined that Patient #9 met the criteria to have her care delegated to the LPN. Further review revealed Patient #9 was not assessed by an RN after her triage assessment for 7 hours 19 minutes while she was in the ED.


Patient #10
Review of Patient #10's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 7:52 a.m. with complaints of chest pain since 5:00 a.m. with developing shortness of breath. Her diagnoses were Myocardial Infarction - non ST elevation, Malignant Hypertension, and Hyperkalemia.

Review of Patient #10's ED record revealed she was triaged by S18RN at 8:02 a.m., and her care was delegated to S9Agency LPN. S9Agency LPN assessed Patient #10 at 10:23 a.m. (2 hours 21 minutes after she had been triaged) and admitted her to the inpatient unit at 12:46 p.m. Further review revealed no documented evidence that the RN determined that Patient #10 met the criteria to have her care delegated to the LPN. Further review revealed Patient #10 was not assessed by an RN after her triage assessment for 4 hours 44 minutes while she was in the ED.


In an interview on 03/23/15 at 1:45 p.m., S4ED Director, when asked if a patient's condition was determined to be stable and changes in condition predictable after having been triaged, he indicated it was "dependent on the charge nurse's judgment." When asked if he was familiar with the LSBN's delegation criteria, S4ED Director indicated "I can't say I've read it."


In an interview on 03/25/15 at 1:35 p.m., S9Agency LPN indicated she gets assigned to patients in ED rooms when the ED is short-staffed. She further indicated "whatever's in her room, whether stable or not, I take care of them." She confirmed that ED patients' changes in condition were not predictable.


In an interview on 03/25/15 at 2:50 p.m., S18RN indicated she is a charge RN in the ED. She further indicated that in this position she is responsible for patient assignments. S18RN indicated she tries to assign nurses to certain rooms and "tries her best to control what goes in those rooms." She further indicated she is not familiar with LSBN's criteria to be met for patients to be delegated by the RN to the LPN. When the criteria was read to S18RN, she indicated she didn't think ED patients met that criteria. She further indicated that caring for patients who are having a CVA, Myocardial Infarction, upper GI (gastrointestinal) bleed, and Altered Mental Status do not have a predictable change in condition. She further indicated that "under the table" she had discussed her concerns about LPNs caring for ED patients with S4ED Director. She indicated that S4ED Director told her that they were looking for RNs to fill those positions, but it presented staffing issues currently. S18RN indicated she thought the ED was short-staffed, and that was why LPNs were assigned (to fill empty RN positions). S18RN indicated she was concerned for safety in providing the care needed for all ED patients. She explained that often there are 3 or 4 patients held in the ED awaiting beds in ICU when she arrives. She indicated that she has had as many as 4 of her ED patients become ICU holds, which is a greater patient to nurse ratio that if the patients were actually in ICU, where the ratio is 2 patients to one nurse.


In an interview on 03/26/15 at 9:45 a.m., S4ED Director indicated ED patient assignments are made by the charge nurse who tries to divide the assignments according to patient needs. He further indicated if the patient was being held for ICU, an RN would be assigned. He further indicated that because of ED "holds" (patients held in ED awaiting an inpatient bed), LPNs may have "a couple more rooms not normally assigned to an LPN that the LPN has to take." After having the criteria for delegation by the RN to the LPN read to him, S4ED Director confirmed that ED patients' condition and changes in their condition were not predictable. S4ED Director indicated when he asks for help from staffing agencies, the agencies "don't have a plethora of RNs and they send LPNs, feel it's better to have someone rather than no one." S4ED Director indicated RNs do assess patients but don't document at the time the assessment is done. He further indicated this is something they need to work on.


2) Failing to ensure the RN reassessed an ED patient with a change in condition:
Review of the hospital policy titled "Patient Triage: Basic Nursing Assessment", approved 12/29/07 and presented as a current policy by S3DON, revealed that each patient presenting to the ED will be assessed by a RN in accordance with established guidelines for basic assessment. Each patient will be assessed by a RN on admission to the ED. Further review revealed patients should be reassessed on an ongoing basis with frequency of assessments based on patient's changing condition. There was no documented evidence that the policy addressed whether the reassessment was to be performed by a RN and how frequent the reassessment had to be done if there was no change in the patient's condition (such as a patient being held in the ED while waiting for an inpatient bed to be available).


Patient #4
Review of Patient #4's ED record revealed he was a [AGE] year old male who (MDS) dated [DATE] at 12:24 p.m. as a transfer from another hospital for further evaluation of a perforated appendix and pain to the right side.

Review of Patient #4's ED "Nurse's Notes" revealed S29RN documented the triage assessment at 12:28 p.m. Further review revealed the next assessment was documented by S29RN at 4:07 p.m. (3 hours 39 minutes without an assessment) who documented that Patient #4 was accompanied by a nurse to ICU at 4:10 p.m. However, review of Patient #4's medical record revealed he arrived in the OR (Operating Room) Holding Room at 3:10 p.m. (prior to S29RN's documentation of his assessment) and was assessed by S19RN and found to be non-responsive to stimuli with vitals of oxygen saturation of 67%, blood pressure 155/72, and blood glucose 110. Patient #4 had to be intubated, have a central line inserted, and was transferred to ICU from the OR Holding area.

Review of Patient #4's entire ED record revealed no documented evidence of an assessment by an RN indicating a decline in Patient #4's condition.


In an interview on 03/24/15 at 7:30 a.m., S10ED Physician indicated Patient #4 had no respiratory issues that he was aware of while in the ED. He further indicated Patient #4 may have declined after he (S10ED Physician) had seen him (Patient #4), but he (S10ED Physician) wasn ' t informed. He indicated he spoke with S16Surgeon and informed him that he wasn ' t able to see the CT scan that was done prior to Patient #4 ' s arrival at the hospital because he (S10ED Physician) was having uploading the scan on the computer.


In an interview on 03/25/15 at 12:30 p.m., S16Surgeon indicated he remembered Patient #4 who was " in frank respiratory distress " when he saw him. He further indicated Patient #4 was unresponsive when he arrived to the OR Holding area. He further indicated the Anesthesiologist, CRNA, and S13Pulmonologist were with Patient #4 and had started working on maintaining his airway. S16Surgeon indicated he had received report from S10ED Physician that Patient #4 had been sent to the ED from another hospital with a suspected ruptured appendix. He further indicated he told S10ED Physician to send Patient #4 to the OR Holding area, and he ' d evaluated him there. He further indicated it was a span of about 10 minutes from the time he spoke with S10ED Physician and was notified of Patient #4 ' s respiratory distress. After a moment of thinking, S16Surgeon indicated the time between the report from S10ED Physician and the call reporting Patient #4 ' s respiratory distress could have been 1 hour.


In a telephone interview on 03/25/15 at 3:45 p.m., S19RN indicated the OR orderly transported Patient #4 alone to the OR Holding area from the ED. She further indicated she didn ' t know if someone in ED released Patient #4 to the orderly. When the documentation was read to S19RN by the surveyor, S19RN confirmed the documentation was correct and accurate. She indicated that she received no report from anyone in the ED, but she doesn ' t normally receive a report from the ED. S19RN indicated that patients who are stable are usually transported to the OR from ED by the transported, unless she is informed that the patient is not stable. She indicated she completed incident reports regarding Patient #4 (incident reports were confirmed and viewed by surveyor). She further indicated she used the incident report to document the condition of the patient upon arrival to the OR Holding area, and addressed the inaccurate documentation by the ED that stated that Patient #4 had been transferred to ICU by the nurse and verbalized understanding.


3) Failing to ensure the RN assured accurate documentation of the time patients were transferred or left the ED:

Patient #13
Review of Patient #13's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 9:47 a.m. with complaints of left abdominal pain, bloody stools, nausea, and weakness for over 3 days. Further review revealed her diagnoses were Colitis and Lower GI Bleeding.

Review of Patient #13's ED "Nurse's Notes" revealed S9Agency LPN documented that Patient #13 was admitted to her inpatient room at 7:31 p.m. Further review revealed an RN documented "Patient left the ED" at 5:59 a.m. on 03/24/15.


Patient #14
Review of Patient #14's ED record revealed she was an [AGE] year old female who (MDS) dated [DATE] at 10:16 a.m. by ambulance from dialysis for evaluation for Altered Mental Status.

Review of Patient #14's ED "Nurse's Notes" revealed S30Agency RN documented that Patient #14 was admitted to her inpatient room at 5:18 p.m. Further review revealed S9Agency LPN documented "Patient left the ED" at 6:08 p.m.


Patient #4
Review of Patient #4's ED record revealed he was a [AGE] year old male who (MDS) dated [DATE] at 12:24 p.m. as a transfer from another hospital for further evaluation of a perforated appendix and pain to the right side.

Review of Patient #4's ED "Nurse's Notes" revealed S29RN documented that Patient #5 was admitted to ICU at 4:10 p.m. Further review revealed Patient #4 was taken to the OR (Operating Room) Holding Room by the OR orderly at 3:10 p.m. He was taken to ICU by OR staff at 6:35 p.m. There was no documented evidence in the ED record that Patient #4 was taken to OR.


Patient #5
Review of Patient #5's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 9:49 a.m. by ambulance as a CVA transfer from another hospital. Her diagnoses were Emphysema and Sepsis.

Review of Patient #5's ED "Nurse's Notes" revealed S9Agency LPN documented that she was admitted to the inpatient unit at 7:09 p.m. Further review revealed S14ED RN documented that Patient #5 left the ED at 5:43 a.m. on 02/10/15.


Patient #11
Review of Patient #11's ED record revealed he was a [AGE] year old male who (MDS) dated [DATE] at 7:22 p.m. as a transfer from another hospital with a right ankle and fibula fracture.

Review of Patient #11's "Nurse's Notes" revealed S31ED RN documented that he was admitted to ICU at 10:54 p.m. Further review revealed S21RN documented that he left ED at 4:00 a.m. on 02/26/15.


In an interview on 03/25/15 at 9:00 a.m., S14ED RN indicated a lot of times the nurse documents when a patient leaves the ED and is admitted to the inpatient unit, but the nurse may not have removed the patient's name from the wall board. She further indicated the nurse then documents when she removes the patient's name from the wall board which explains having two different times that the patient left the ED. She confirmed the documentation is confusing and not accurate. S14ED RN indicated she was shown last week how to change the time in the computer, but she didn't know she could do that (change the time in the computer to reflect the correct time something was done) before last week.


In an interview on 03/26/15 at 9:45 a.m., S4ED Director indicated he usually calls report to the inpatient unit and takes the patient to his/her room which may take 20 to 30 minutes. He further indicated he leaves the patient's name on the ED wall board until he returns to the ED. He further indicated at some point later that day, someone will remove the patient's name from the ED wall board. S4ED Director indicated the staff who removes the patient's name from the ED wall board should put the correct time in the computer when the patient left the ED and not the time his/her name is being removed from the board.


4) Failing to ensure the RN assured a patient ordered to be admitted to ICU was transferred to ICU rather than being transferred to an inpatient unit other than ICU:
Review of Patient #5's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 9:49 a.m. by ambulance as a CVA transfer from another hospital. Her diagnoses were Emphysema and Sepsis.

Review of Patient #5's ED "Nurse's Notes" revealed S9Agency LPN documented that Patient #5 was admitted to the Med/Surg (Medical/Surgical) Unit on 02/09/15 at 7:09 p.m.

Review of Patient #5's physician orders revealed an order on 02/09/15 at 4:00 p.m. by the nurse practitioner to admit Patient #5 to ICU.

Review of the inpatient flowsheet revealed S33LPN documented on 02/09/15 at 8:15 p.m. "ward clerk pointed out that pt (patient) was suppose to be ICU pt, supervisor notified." Further review revealed S33LPN documented at 9:40 p.m. "pt transferred to ICU #7..."


In an interview on 03/24/15 at 10:35 a.m., S11RN Mgr. confirmed Patient #5's medical record revealed that she was in Room 374, But she knew Patient #5 went to the 6th floor, because S33LPN is one of her nurses who works the 6th floor. She further indicated that S33LPN told her that she (S33LPN) got a phone report from the ED, and they didn't say Patient #5 was to be admitted to ICU. She further indicated after Patient #5 was transferred from ICU, she went to Room 374, and perhaps that's where the room number of 374 that's in the computer comes from.


In an interview on 03/25/15 at 1:10 p.m., S9Agency LPN indicated if a physician or nurse practitioner sees a patient and places the order sheet under other papers in the record, she may not see the order. She confirmed that the nurse practitioner does see patients in the ED. She further indicated if she's "running around" taking care of other patients and don't see the physician or nurse practitioner in the ED, she wouldn't know to look for orders that were hand-written.


In an interview on 03/26/15 at 9:45 a.m., S4ED Director indicated he remembered Patient #5. He further indicated the nurse practitioner had hand-written orders to admit Patient #5 to ICU, and the nurse did not see the orders.


5) Failing to ensure the ED nurses included their title when they authenticated their electronic signature:

Review of the ED medical records of Patients #3, #4, #5, #9, #10, #11, #12, #13, #14, #17, #18 revealed no documented evidence of the nurse's title (RN or LPN) when he/she authenticated the ED record.


In an interview on 03/23/15 at 1:45 p.m., S3DON confirmed the ED nurses' notes did not include the staff title, so "you can't tell what discipline is doing the assessment." She indicated it's a fault with the computer system.


In an interview on 03/26/15 at 9:45 a.m., S4ED Director confirmed the nurses' title was not included when he/she authenticated the ED record. He confirmed that without a title, one could not determine that the patient care was being administered by a nurse.


6) Failing to ensure physician's orders were followed for titration of critical medication drips:

Patient #1
Review of the medical record for Patient #1 revealed she had been admitted to telemetry at 2:28 a.m. on 1/24/15 with the diagnosis of Congestive Heart Failure Exacerbation. Patient #1's weight was documented as 141 kg (kilograms).

Review of the physician's orders for Patient #1 dated 1/24/15 at 6:48 a.m. revealed an order for a Propofol infusion at 5mcg/kg/min IV (microgram/kilogram/minute intravenous). Further review revealed instructions to increase by 5-10 mcg/kg/min every 5 minutes until RASS (Richmond Agitation-Sedation Scale) score of 0 to -1.

Review of the medical record for Patient #1 revealed Propofol was started at 10/mcg/kg/min on 1/24/15 at 7:00a.m. The dose was increased to 20 mcg/kg/min at 7:10 a.m. and to 40 mcg/kg/min at 7:15 a.m. The RASS score was documented as a 3 at 7:06 a.m. and not reassessed again until 9:00 a.m.

Review of a physician's order for Patient #1 dated 1/24/15 at 6:56 a.m. revealed an order for Levophed to be administered at 0.05 mcg/kg/min. No titration orders were written.

Review of the medical record for Patient #1 revealed the Levophed was started at 5 mcg/min at 7:10 a.m., increased to 10 mcg/min at 7:15 a.m., decreased to 5mcg/min at 7:20 and discontinued at 8:00 a.m.


In an interview on 3/23/15 at 4:23 p.m. with S3DON, she verified the titrations for Patient #1 on the Propofol and Levophed were not administered as ordered but should have been. S3DON also verified there were no hospital protocols for the titration of medication drips.


In an interview on 3/25/15 at 9:17 a.m. with S24RN, she said she had been working at the hospital for approximately 3 months and was a new nurse. S24RN said she and her preceptor took care of Patient #1 on 1/24/15 and administered and adjusted her Levophed and Propofol drips. She said the titration of drips was done by using a pharmacy "drip chart." When shown the drip chart, S24RN verified it contained the minimum and maximum doses of several drugs but did not contain specific instructions on the titration of medications by giving physician-approved intervals or specific amounts for medication adjustments.


In an interview on 3/25/15 at 9:20 a.m. with S25RN, he said he was the nurse preceptor for S24RN when she took care of Patient #1 on 1/24/15. S25RN said they went outside of the physician's order when they adjusted the Propofol for Patient #1. S25RN also said there was no order by the physician for titrating the Levophed for Patient #1.


Patient #20
Review of the medical record for Patient #20 revealed she was a [AGE] year old female currently admitted to the hospital since 3/21/15 after having cardiopulmonary arrest in the Emergency Department.
Review of the physician's order for Patient #20 revealed an order dated 3/24/15 at 11:25 a.m. to infuse Propofol at 5mcg/kg/min and increase by 5-10 mcg/kg/min every 5 minutes until the RASS score was 0 to -1.
Review of the RASS scores for Patient #20 revealed they were consistently documented as "0" from 3/22/15 at 7:00 a.m. until 3/25/15 at 11:02 a.m.
Review of the nursing flow sheet for Patient #20 revealed Propofol was started at 5 mcg/kg/min on 3/24/15 at 11:05 a.m. Further review revealed the dose was increased to 20mcg/kg/min at 2:26 p.m. with no documented explanation for the increase or fluctuation in the RASS score from 0.

In an interview on 3/26/15 at 2:30 p.m. with S8Clinical Nurse Mgr.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record reviews and interviews, the hospital failed to ensure a registered nurse (RN) assigned the nursing care of each patient to nursing personnel in accordance with the patient's needs and the qualifications and competence of the available nursing staff as evidenced by having the competency of the ED (Emergency Department) nursing staff evaluated by S4ED Director who had not been evaluated for competency in caring for patients in the ED for 4 (S4, S14, S18, S29) of 4 RNs' personnel files reviewed for competency from a total of 26 full-time and PRN (as needed) RNs in the ED.


Findings:

S4ED Director
Review of S4ED Director's personnel file revealed his hire date was 10/01/14. Further review revealed no documented evidence that he had been evaluated for competency in performing nursing duties in the ED.


S14ED RN
Review of S14ED RN's personnel file revealed she was hired on 02/19/12. Review of her "ER (emergency room ) Skills Fair Station Check-Off", with no documented evidence of the date the evaluation was conducted, revealed S4ED Director assessed S14ED RN's competency for ESI (Emergency Severity Index) Triage and Hypovolemia Protocol. S4ED Director had no documented evidence that he had been assessed as competent in performing these skills.


S18RN
Review of S18RN's personnel file revealed she was hired on 02/26/14. Review of her "ER Skills Fair Station Check-Off", with no documented evidence of the date the evaluation was conducted, revealed S4ED Director assessed S18ED RN's competency for ESI Triage and Medication Management. S4ED Director had no documented evidence that he had been assessed as competent in performing these skills.


S29RN
Review of S29RN's personnel file revealed he was hired on 06/04/12. Review of his "ER Skills Fair Station Check-Off", with no documented evidence of the date the evaluation was conducted, revealed no documented evidence that S29RN had been evaluated for competency in the Chest Tube Station, Medication Management, ESI Triage, and Hypothermic Protocol as evidenced by having no signature of the evaluator in the space provided.


In an interview on 03/26/15 at 9:45 a.m., S4ED Director confirmed that he had not been evaluated for competency in performing nursing duties in the ED. He confirmed that he does perform patient care in the ED when he's needed to cover staffing shortages. S4ED Director confirmed he did some of the competency evaluations during the ED skills fair, even though he had not been evaluated as competent.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, interviews, and record reviews, the hospital failed to meet the requirements of the Condition of Participation for Patient's Rights as evidenced by failing to ensure patients received care in a safe setting. This was evidenced by:

1) having one telemetry monitor technician responsible for monitoring up to 72 patients on 5 different floors of the hospital at one time;

2) failing to implement a system to ensure notification of the nursing staff that patients' telemetry monitoring was abnormal;

3) failing to develop and implement policies and procedures for the management of telemetry monitoring;

4) failing to ensure physician's orders were obtained for individualized parameter settings for notification for each patient with telemetry orders (see findings in tag A0144).


An Immediate Jeopardy situation was identified on 03/26/15 at 12:45 p.m. and reported to S1CEO (Chief Executive Officer). The immediate jeopardy was a result of:
a)observations on 03/23/15 at 10:10 a.m. of S6Telemetry Tech monitoring 58 telemetry patients and on 03/26/15 at 11:30 a.m. of S28Telemetry Tech monitoring 49 telemetry patients located on 5 different units/floors.
b)The hospital also failed to ensure physician's orders had been obtained for vital sign parameters for notification.
c) the hospital failed to develop policies and procedures that addressed, at a minimum, notification of the nursing staff of patients with abnormalities that fall outside of physician-ordered parameters, methods of effective communication between the telemetry technician and the nursing staff, frequency of Registered Nurses' assessments of rhythm strips, method of communication by the nursing staff to the telemetry technician when a patient is removed from telemetry monitoring, such as for transfer for procedures, radiology, etc., determination of monitor technician to telemetry patient ratios to ensure safe monitoring of patients, methods for telemetry monitor technicians' coverage during absences from the monitor when taking breaks, and required orientation and training of the monitor technicians in the interpretation of rhythm strips and in the use of the telemetry monitoring equipment.

As a result of the hospital's action plan, the Immediate Jeopardy situation was removed on 03/26/15 at 3:00 p.m. due to the hospital doing the following:
1) Immediately changing the current telemetry unit staffing model to include 2 nursing staff personnel with validated competencies to staff the central telemetry monitoring unit to provide 24 hours per day coverage for telemetry patients monitored via the central monitoring unit. Two staff members were observed monitoring the telemetry monitors on 03/26/15 at 3:05 p.m.
2) Hospitalists were assigned to assure all of the current patients on telemetry monitors had a physician's order indicating parameter settings for each patient.
3) Verified competency for telemetry monitoring capabilities for the central monitoring nursing personnel currently on duty 03/26/15. Copies provided. They provided competencies for all telemetry techs who will cover all shifts.
4) Policy and procedures formalized and approved by clinical and administrative leadership. The policies were reviewed and included default parameters, notification instructions, communication parameters, Registered Nurse assessment requirements, coverage for technicians during breaks, staffing ratios, and training of the monitoring staff.
5) S3DON (Director of Nursing) and S2CNO (Chief Nursing Officer) will ensure all nursing staff in the centralized telemetry unit are educated and understand all of the policies and procedures and requirements on the central monitoring unit, including the need for physician orders for parameters. The monitoring and evaluation will be completed by S3DON in collaboration with the director of the telemetry unit , who will ensure that telemetry monitoring staffing remains at stated number, two nursing personnel at all times, and policy and procedure is being followed. The monitoring will be completed through daily review of telemetry logs, review of the medical record to ensure that a physician order is present; strips printed and signed by the nurse caring for the patient every shift, as well as abnormal results being addressed and physician contacted. Results of the monitoring and evaluation will be documented and reported to the administrative staff daily and through the Performance Improvement committee and the Medical Executive Committee monthly.
6) All nursing staff currently on duty will be educated relative to the new P/P (policies/procedures), including the need for physician orders and notification relative to parameters for telemetry monitoring on 03/26/15 by 5:00 p.m. All oncoming staff will receive this education at the beginning of the shift until 100% of the staff has been educated. The unit directors will ensure that all staff have been educated. This will be accomplished through ongoing review of the staff roster against the sign in sheets. S1CNO and S2DON are the responsible individuals.
Non-compliance continues at the condition level.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations, interviews, and record reviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:

1) having one telemetry monitor technician responsible for monitoring up to 72 patients on 5 different floors of the hospital at one time;

2) failing to implement a system to ensure notification to the nursing staff that patients' telemetry monitoring was abnormal;

3) failing to develop and implement policies and procedures for the management of telemetry monitoring;

4) failing to ensure physician's orders were obtained for individualized parameter settings for notification for each patient with telemetry orders.

Findings:

1) One telemetry monitor technician responsible for monitoring up to 72 patients on 5 different floors of the hospital at one time.

In an observation on 03/23/15 at 10:10 a.m., S6Telemetry Tech was observing 58 patients' cardiac rhythms on telemetry monitors. Further observation revealed there were no other staff members assisting S6Telemetry Tech with telemetry monitoring.

In an observation on 03/24/15 at 1:40 p.m., S6Telemetry Tech was observing 48 patients' cardiac rhythms on telemetry monitors. Further observation revealed there were no other staff members assisting S6Telemetry Tech with telemetry monitoring.

In an observation on 03/26/15 at 11:30 a.m., S28Telemetry Tech was observing 49 patients' cardiac rhythms on telemetry monitors. Further observation revealed there were no other staff members assisting S28Telemetry Tech with telemetry monitoring.

In an interview on 03/23/15 at 12:15 p.m. with S6Telemetry Tech, she said an average number of patients to watch on telemetry were 40 patients. She said they had the capability to watch 72 patients and she was monitoring 58 today. She said she was responsible to call the nurses with abnormal telemetry strips, call when the ECG (electrocardiogram) leads were off of the patients, print abnormal rhythm strips and send them to the floor, and answer the phones. S6Telemetry Tech said she thought watching 70 patients was dangerous because that was too much to do and peoples' lives were at stake. She said about a month ago they went from having 2 telemetry technicians every shift to only having 1 for budget reasons. She said she told her supervisor it was too busy, but she said they were understaffed.

In an interview on 03/24/15 at 2:15 p.m. with S11RN Mgr., she said the hospital had no policies for the number of patients one telemetry technician could safely monitor. She said she believed a trained monitor technician could safely monitor 72 telemetry patients at one time. She also said the unit was staffed with two telemetry monitor technicians until a couple of months ago when they traded the position for a floor nurse.

In an interview on 03/26/15 at 11:31 a.m. with S28Telemetry Tech, she said she was currently observing 49 patients on telemetry monitoring. She said they had the capability to monitor 72 patients on 5 different floors. She said she thought she could probably safely monitor 44 patients on telemetry.


2) Failing to implement a system to ensure effective notification to the nursing staff that patients' telemetry monitoring was abnormal.

Review of a sign above the telemetry monitoring station on the 5th floor titled Monitor Tech Rules revealed in part:

3. If the telemetry patient is off the monitor (no signal) the Monitor Tech will notify that patient's primary nurse. If after 5 minutes and the patient is not on the monitor, the Monitor Tech will re-notify that patient's primary nurse. If after another 5 minutes off the monitor, the Monitor Tech will notify the Unit/Department Charge Nurse. If after another 5 minutes off of the monitor, the Monitor Tech will notify that Unit/Department Manager/Director. If after hours, the Nursing Supervisor will be notified.

In an observation/interview on 03/23/15 at 12:45 p.m. at the telemetry monitoring station, S23Telemetry Tech called to inform a nurse that her patient's ECG leads were not connected. S23Telemetry Tech hung up the phone and said a physician told her that no nurses were at the nurses' station and for her to call back in a little while.

In an observation on 03/24/15 at 1:50 p.m. of the telemetry monitoring station, Patient R1, Patient R2, Patient R3, Patient R4 and Patient R5 had notifications on the telemetry screen that their ECG leads were disconnected so no reading was available. Review of the telemetry log book revealed staff had been notified by S6Telemetry Tech about the ECG leads being off of Patient R1 at 1:32 p.m. (5 hours and 42 minutes earlier), Patient R3 at 1:07 p.m. and 1:24 p.m. (43 minutes and 26 minutes earlier) and Patient R2 at 1:24 p.m. (26 minutes earlier).

In an interview on 03/24/15 at 1:50 p.m. with S6Telemetry Tech, she said Patients R1 through R5 had been on the telemetry monitors and their leads were off since the times she listed in the log as having notified staff. She said she did not try and recall the nurses every 5 minutes as the sign above the monitors indicated, because the nurses never answered the phones when she called. She said often the staff on the various floors would pick up the phones and hang the phone back up on her when they saw "telemetry" on the caller identification. S6Telemetry Tech said she would sometimes have to trick the nurses and have a ward clerk from her floor call to notify of an abnormal rhythm or the leads being off, so the staff would not see it was from her and they would answer the phone.

In an interview on 03/24/15 at 2:15 p.m. with S11RN Mgr., she said the hospital did not have a policy on when or how to notify staff of an abnormal rhythm on the telemetry strips. S11RN Mgr. also said she had been aware that the staff was picking up the phone and hanging it up on the telemetry technician when she called with a notification. She said she had talked to some of the staff but did not have documentation. S11RN Mgr. also said she was not aware the monitor technicians were not calling every 5 minutes if they did not get an answer or any interventions for ECG leads being off of the patients.

In an observation on 03/26/15 at 11:30 a.m. of the telemetry monitoring station, a yellow alarm was on the screen indicating a patient had PVC (premature ventricular contractions) lasting greater than 10 minutes.

In an interview on 03/26/15 at 11:31 a.m. with S28Telemetry Tech, she said she did not call the nurses about a yellow warning on the screen, only a red one. She verified she did not have a policy about when to call the nurses. S28 Telemetry Tech also said she did not call the nurses back every 5 minutes to remind them a patients' ECG leads were off if they were not put back on, because they do not answer the phones anyway.


3) Failing to develop and implement policies and procedures for the management of telemetry monitoring.

Review of the only telemetry policy presented by the hospital revealed it was a policy for remote telemetry monitoring on a Med-Surg floor (medical-surgical). The policy did not address when or how notification of the nursing staff would be done when an abnormal rate or rhythm was detected, methods of effective communication between the telemetry technician and the nurses, frequency of printing and interpreting strips by the Registered Nurse, parameters for notification, patient to staff ratios or responsibilities and training of the monitor technicians.

In an interview on 03/24/15 at 2:15 p.m. with S11RN Mgr., she verified she only had one policy for telemetry that addressed indications for a patient to be placed on remote telemetry while on a medical-surgical floor. She verified the policy did not address responsibilities and procedures to be performed by the monitor technician.


4) Failing to ensure physician's orders were obtained for parameter settings for notification for each patient with telemetry orders.

Review of the physician's orders for Patient R6 dated 03/21/15 at 9:13 p.m. revealed an order for Telemetry. Further review revealed no order for parameters for alarm or notification of the physician.

In an interview on 03/24/15 at 2:15 p.m. with S11RN Mgr., she said she had been manager of the telemetry unit for a year and had never seen a physician order parameters for the patients receiving telemetry. She said the alarm parameters were determined by the preset numbers in the telemetry monitor. S11RN Mgr. also said the parameters could be adjusted by the monitor technician without a physician's order if the baseline heart rate ran low. S11RN Mgr. said she did not have any policies or protocols for telemetry alarm parameters.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the hospital failed to ensure that the DON (Director of Nursing) provided for the evaluation of the clinical activities of non-employee nursing personnel which occur within the responsibility of the nursing services. The hospital had an active list of 39 registered nurses (RNs) and licensed practical nurses (LPNs) contracted through 3 nurse staffing agencies who were not evaluated for competency by a hospital-employed RN.


Findings:

Review of a list of "Active Agency Nurses" presented by S3DON revealed a total of 39 agency RNs and LPNs were providing patient care within the hospital.


Review of the personnel file of S9Agency LPN revealed, she began working at the hospital on [DATE]. Further review revealed no documented evidence that a hospital-employed RN had evaluated the competency of S9Agency LPN in providing nursing care. Review of the ED medical records of Patients #3, #5, #9, #10, #12, #13, #14, #17, and #18 revealed that S9Agency LPN had provided their nursing care.


Review of the personnel file of S17Agency LPN revealed, she had been working at the hospital since 12/11/13. Further review revealed no documented evidence that a hospital-employed RN had evaluated the competency of S17Agency LPN in providing nursing care. Review of the ED medical record of Patient #3 revealed that S17Agency LPN had provided nursing care.


In an interview on 03/26/15 at 9:45 a.m. with S4ED Director, S3DON, and S34Corporate CNO (Chief Nursing Officer) present, both S4ED Director and S3DON confirmed that no hospital-employed RN evaluates the competency of the nurses provided by the nurse staffing agencies. Both indicated they rely on the competency evaluations provided by a representative from each agency.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure drugs and biologicals were prepared and administered and their effectiveness assessed in accordance with the orders of the practitioner and policies and procedures for 2 active ED (Emergency Department) patients (#13, #17) and 4 closed ED patient records (#3, #5, #9, #10) reviewed for medication administration from a total of 11 ED patient records reviewed (#3, #4, #5, #9, #10, #11, #12, #13, #14, #17, #18) from a total sample of 23 patients.


Findings:

Review of the hospital policy titled "Medication Administration Policy", approved 02/25/15 and presented as the current policy by S3DON (Director of Nursing), revealed that the policy was a hospital-wide policy that pertains to all areas of the hospital that administer medications. Further review revealed that medications that were ordered by the physician as "one time" were to be immediately administered or administered at the time specified in the order.


Review of the hospital policy titled "Initial Patient Assessment and Reassessment", approved 03/14/13 and presented as a current policy by S3DON, revealed that reassessment is performed in order to evaluate the outcomes of the care provided. Further review revealed reassessment should take place 15 to 30 minutes after IV (intravenous) administration and 30 to 60 minutes after IM (intramuscular) administration of medication by assessing and documenting the level of sedation, pain level, and respiratory rate.


Patient #13
Review of Patient #13's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 9:47 a.m. with complaints of left abdominal pain, bloody stools, nausea, and weakness for over 3 days. Further review revealed her diagnoses were Colitis and Lower GI Bleeding.

Review of Patient #13's "Medication Orders Summary" revealed the following medications were ordered by S32Physician on 03/23/15:

Dilaudid 1 mg (milligram) IVP (intravenous push) once at 10:25 a.m.;
Zofran 4 mg IVP once over 2 minutes at 10:25 a.m.;
Dilaudid 1 mg IVP once at 1:35 p.m.;
Zofran 4 mg IVP once over 2 minutes at 1:35 p.m.

Review of Patient #13's ED "Nurse's Notes" revealed S29RN administered the first ordered dose of Dilaudid at 11:30 a.m., 1 hour 5 minutes after it was ordered. Further review revealed he administered the first ordered dose of Zofran at 11:31 a.m., 1 hour 6 minutes after it was ordered. S29RN administered the second ordered dose of Dilaudid and Zofran at 2:28 p.m., 53 minutes after they were ordered.

Review of Patient #13's ED "Nurse's Notes" revealed S9Agency LPN assessed the effectiveness of all drugs administered in the ED on 03/23/15 (Dilaudid and Zofran) at 7:24 p.m., more than 7 hours after the first dose was administered and more than 4 hours after the second dose was administered.


Patient #17
Review of Patient #17's ED record revealed she was an [AGE] year old female who (MDS) dated [DATE] at 12:08 p.m. with chief complaints of CVA (Cerebrovascular Accident), left-sided weakness, slurred speech, and facial drooping within one hour of onset. Her diagnosis was Brain Mass.

Review of Patient #17's physician orders revealed an order by S32Physician on 03/23/15 at 1:02 p.m. for Decadron 4 mg IM once and Keppra 1000 mg IV bolus once.

Review of Patient #17's ED "Nurse's Notes" revealed S9Agency LPN administered Decadron 4 mg IM at 1:37 p.m., 35 minutes after it was ordered, and Keppra 1000 mg IV bolus at 2:00 p.m., 58 minutes after it was ordered. Further review revealed S9Agency LPN evaluated the effectiveness of the medication at 7:49 p.m., 6 hours 12 minutes after Decadron was administered and 5 hours 49 minutes after Keppra was administered.


Patient #3
Review of Patient #3's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 7:31 a.m. by ambulance with chief complaints of chest pain with onset at 10:00 p.m. the previous night, vomiting with onset about midnight, and active vomiting during the triage assessment. Her diagnoses were Myocardial Infarction - non ST elevation, Atrial Fibrillation, Chronic Kidney Disease, and Diabetes Mellitus.

Review of Patient #3's physician orders revealed the following medications were ordered by S10ED Physician on 03/13/15:

Zofran 4 mg IVP once over 2 minutes at 7:46 a.m.;
Hydralazine 10 mg IV bolus once at 8:07 a.m.;
Nitro-Bid Ointment 2% (per cent), 1 inch transdermal once at 8:24 a.m.;
Morphine 4 mg IVP once at 8:24 a.m.;
Lovenox 70 mg Sub Q (subcutaneous) once at 8:36 a.m.;
Aspirin 325 mg by mouth once at 8:36 a.m.;
Lipitor 80 mg by mouth once at 8:47 a.m.;
Lopressor 50 mg by mouth once at 8:47 a.m.;
Plavix 300 mg by mouth once at 8:47 a.m.

Review of Patient #3's ED "Nurse's Notes" for 03/13/15 revealed Zofran 4 mg IVP, Hydralazine 10 mg IV bolus, and Morphine 4 mg IVP were administered at 9:15 a.m. by S4ED Director, 1 hour 29 minutes after Zofran was ordered, 1 hour 8 minutes after Hydralazine was ordered, and 51 minutes after Morphine was ordered. Further review revealed Nitro-Bid ointment was applied transdermally by S9Agency LPN at 9:27 a.m., 1 hour 3 minutes after it was ordered. Further review revealed Lovenox was administered Sub Q by S9Agency LPN at 9:29 a.m., 53 minutes after it was ordered. There was no documented evidence that Aspirin, Lipitor, Lopressor, and Plavix were administered as ordered.

Patient #3 was found unresponsive and was coded at 9:45 a.m. and expired at 10:07 a.m.


In an interview on 03/23/15 at 1:45 p.m., S4ED Director indicated the order for Aspirin should have been canceled, since Aspirin was administered prior to arrival at the hospital by the ambulance attendants.


In an interview on 03/23/15 at 2:20 p.m., S9Agency LPN indicated she didn't give Aspirin, Lipitor, Lopressor, and Plavix, because Patient #3 was vomiting the entire time she was being triaged. She further indicated she was supposed to "click" on medications that she didn't give, but "it was so crazy that day, I know I didn't give it." She further indicated the delay in administering medications was due to searching for an RN, and they (RNs) have their own patients to care for. She further indicated she didn't remember how many RNs were working that day, and she thinks S4ED Director was triaging patients.


Patient #5
Review of Patient #5's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 9:49 a.m. by ambulance as a CVA transfer from another hospital. Her diagnoses were Emphysema and Sepsis.

Review of Patient #5's physician orders revealed orders by S10ED Physician on 02/09/15 for the following medications:

Cerefolin NAC 1 tab-caps by mouth once at 11:39 a.m.;
Vancocin 1 gram IVPB (intravenous piggyback) once over 2 hours at 1:11 p.m.;
Zosyn 3.375 grams IVPB once at 1:11 p.m.

Review of Patient #5's ED "Nurse's Notes" for 02/09/15 revealed S9Agency LPN administered Cerefolin NAC 1 tab-caps by mouth at 12:38 p.m., 59 minutes after it was ordered. Further review revealed S9Agency LPN administered Zosyn 3.375 grams IVPB to the right forearm at 3:30 p.m., 2 hours 19 minutes after it was ordered. Further review revealed S9Agency LPN administered Vancocin 1 gram IVPB at 3:54 p.m., 2 hours 43 minutes after it was ordered.

S9Agency LPN assessed the effectiveness of Cerefolin at 7:11 p.m., more than 6 hours after it was administered.


Patient #9
Review of Patient #9's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 11:09 a.m. with chief complaints of "low Hemoglobin" and sent from the physician's office.

Review of Patient #9's physician orders revealed orders by S10ED Physician for the following medications at 12:18 p.m. on 03/12/15:

Pepcid 20 mg IVP once;
Protonix 80 mg IVP once;
Protonix 8 mg/hr (milligrams per hour) at calculated rate continuous.

Review of Patient #9's ED "Nurse's Notes" revealed S18RN administered Pepcid 20 mg IVP at 1:29 p.m., 1 hour 11 minutes after it was ordered. Further review revealed she administered Protonix 80 mg IVP and started the IV of Protonix at 1:30 p.m., 1 hour 12 minutes after they were ordered. There was no documented evidence of an assessment for effectiveness of the medications administered.


Patient #10
Review of Patient #10's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 7:52 a.m. with complaints of chest pain since 5:00 a.m. with developing shortness of breath. Her diagnoses were Myocardial Infarction - non ST elevation, Malignant Hypertension, and Hyperkalemia.

Review of Patient #10's physician orders revealed orders by S10ED Physician on 03/12/15 for the following medications:

Aspirin (81 mg times 4) 324 mg by mouth once at 8:04 a.m.;
Nitro-Bid Ointment 2% 1 inch transdermal once at 8:04 a.m.;
Ativan 1 mg IVP once at 8:04 a.m.;
Trandate 20 mg IVP once over 2 minutes at 8:04 a.m.;
Heparin 7000 units IVP once at 9:17 a.m.;
Kayexalate Suspension 30 grams by mouth once at 9:37 a.m.;
Plavix 300 mg by mouth once at 9:56 a.m.;
Lipitor 80 mg by mouth once at 9:56 a.m.;
Lopressor 50 mg by mouth once at 9:56 a.m.;
Lovenox 60 mg Sub Q once at 9:56 a.m.

Review of Patient #10's ED "Nurse's Notes for 03/12/15 revealed S4ED Director administered Ativan 1 mg IVP and Trandate 20 mg IVP at 10:00 a.m., 1 hour 56 minutes after they were ordered. Further review revealed S9Agency LPN administered Aspirin 324 mg orally at 10:19 a.m., 2 hours 15 minutes after it was ordered, applied Nitro-Bid Ointment 2% transdermally at 10:19 a.m., 2 hours 15 minutes after it was ordered, and administered Kayexalate Suspension 30 grams orally at 10:20 a.m., 43 minutes after it was ordered. Further review revealed S9Agency LPN administered Plavix, Lipitor, and Lopressor orally and Lovenox Sub Q at 10:21 a.m., 25 minutes after they were ordered. There was no documented evidence that Heparin 7000 units IVP was administered as ordered.

Review of Patient #10's ED "Nurse's Notes for 03/12/15 revealed S9Agency LPN assessed the effectiveness of Ativan, Trandate, Aspirin, Nitro-Bid Ointment, and Kayexalate Suspension at 12:48 p.m., 2 hours 48 minutes after Ativan and Trandate were administered, 2 hours 29 minutes after Aspirin was given and Nitro-Bid Ointment was applied, and 2 hours 28 minutes after Plavix, Lipitor, Lopressor, and Lovenox were administered.


In an interview on 03/25/15 at 1:10 p.m., S9Agency LPN indicated not all medications are kept in the Pyxis (medication delivery system) in ED, and the nursing staff has to call pharmacy to send the medications. She further indicated a "lot of times it takes a while to get the medications and have to call several times." She further indicated she couldn't explain the reason for the delay in medications for Patient #10. She indicated that medications should be given as soon as they're ordered in the ED. She further indicated that sometimes a delay occurs, because she has to wait for an RN to be available to push IV medications. S9Agency LPN indicated the documentation of the assessment of effectiveness of medications was incorrect, because the time wasn't changed to reflect the actual time the assessment was done.


In an interview on 03/26/15 at 9:45 a.m., S4ED Director confirmed that the delay in medication administration in the ED could be related to the LPN having to wait for an RN to be available to push IV medications.
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure blood transfusions were administered in accordance with approved medical staff policies and procedures as evidenced by failure to have the physician order the rate at which the blood was to be transfused and having a 5 hour 12 minute delay in starting the transfusion once the cross match was completed for 1 (#9) of 1 ED patient record reviewed who had a blood transfusion from a total of 11 ED patient records reviewed (#3, #4, #5, #9, #10, #11, #12, #13, #14, #17, #18) from a total sample of 23 patients.


Findings:

Review of the hospital policy titled "Blood Transfusions - Administration", approved 02/12/15 and presented as a current policy by S3DON (Director of Nursing), revealed that a written order by the physician for blood components must be present on the patient's chart. Special instructions regarding the transfusion should be indicated on the chart, such as the type of product, whether the patient was to be premedicated, the process including flow rates, rate of infusion, and use of a blood warmer or electrical device, and the need for emergency release. Further review revealed the transfusion should be started at a rate of approximately 2 milliliters per minute (exceptions are made for urgent situations), and the transfusionist should remain with the patient for at least the first 15 minutes of the transfusion. After the first 15 minutes, vital signs should be recorded, and the rate of infusion can be increased to that specified in the physician's order.


Review of Patient #9's ED record revealed she was a [AGE] year old female who (MDS) dated [DATE] at 11:09 a.m. with chief complaints of "low Hemoglobin" and sent from the physician's office. Her diagnoses were GI (gastrointestinal) Bleeding and Anemia.

Review of Patient #9's physician orders revealed S10ED Physician ordered an antibody screen and blood type and match on 03/12/15 at 12:12 p.m. Further review revealed he ordered Patient #9 to be transfused with 2 units of packed red blood cells on 03/12/15 at 1:00 p.m. with no documented evidence of the flow rate or rate of transfusions. There was no documented evidence of clarification order received by the nurse with this information regarding the transfusion flow rate and rate of each transfusion. Further review revealed the request for the blood to be released was on 03/12/15 at 5:51 p.m.

Review of documentation regarding the time the blood was ready to be released by the lab, presented by S8Clinical Nurse Mgr. (Manager), revealed the blood typing and cross matching was completed and the blood was ready on 03/12/15 at 1:48 p.m.

Review of Patient #9's ED "Nurse's Notes" for 03/12/15 revealed no documented evidence that the blood transfusion had been started while in the ED.

Review of the transfusion record, presented by S8Clinical Nurse Mgr., revealed that the first unit of blood was begun on 03/12/15 at 7:00 p.m., 5 hours 12 minutes after the blood was ready to be released. Further review revealed the nurses who signed the blood slip were S18RN (Registered Nurse), S9Agency LPN (Licensed Practical Nurse), and S35RN. Further review revealed pre-transfusion vital signs were documented at 6:55 p.m., first 5 - 15 minutes vital signs were documented at 7:05 p.m., during transfusion vital signs were documented at 7:50 p.m. and post-transfusion (less than or equal to 1 hour) vital signs were documented at 9:20 p.m. Documentation revealed that the first unit of blood was completed on 03/12/15 at 9:05 p.m. (infused in 2 hours 5 minutes). There was no documented evidence to determine whether the blood transfusion began at a rate of 2 milliliters per minute, if the transfusionist remained with Patient #9 at least the first 15 minutes of the transfusion, and if the rate of transfusion was increased to the ordered rate after the first 15 minutes (no physician orders were obtained for the rate), all required by hospital policy.



In an interview on 03/25/15 at 1:35 p.m., S9Agency LPN indicated she doesn't enter the request for the blood to be released from the lab until she has an available RN to start the transfusion.


In an interview on 03/26/15 at 9:45 a.m., S4ED Director, when informed that record review revealed Patient #9 (diagnosed as a GI Bleed) didn't have her blood transfusion for more than 5 hours after the blood was ready to be released by the lab, indicated blood should be hung as soon as it;s ready. He further indicated that during this interview was the first time he heard about the delay in blood transfusion. He further indicated that most doctors write the rate that blood was to be transfused, but the ED doctors may not.