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.

AVALA 67252 INDUSTRY LANE COVINGTON, LA 70433 Feb. 28, 2013
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based upon observations, record review, review of hospital policy/procedures, and Administrative interviews, the hospital failed to ensure that a system was in place to provide the patients/family members with the address and telephone number for lodging a complaint/grievance with the State Agency. Findings:

Review of the hospital policy titled, "Patient/Visitor - Complaint/Grievance Process" revised date of 04/26/12, provided as current by S2 Director of Quality, revealed in part the following: "....At the time of admission to the facility, the patient or his/her representative, will be provided with information related to patient rights and responsibilities...."

On 02/16/13 at 5:50 p.m. an observation was made in the reception area/entrance and waiting room. There was no evidence of the Patient Rights and Responsibilities posted in the areas.

Review of the Patient Rights and Responsibilities revealed the following: You have the right to "....Be advised of the hospital's process for initiation, review, and resolution of patient complaints, should he or she wish to communicate a concern regarding the quality of the care he or she receives or if he or she feels the determined discharge date is premature."

In a face-to-face interview on 02/27/13 at 12:00 p.m., S1Chief Nursing Officer (CNO) provided a framed copy of "Privacy Notice" and stated normally this was hung on the wall next to the reception desk, adjacent to the hospital entrance. S1CNO stated it was removed from the wall two days ago (the day DHH surveyors entered the hospital) because a staff member noticed some of the information was incorrect. A copy of the framed document was provided for review and revealed on page 4 the following: "VII. Complaints: If you have a complaint or grievance, you may file a written complaint with the Hospital. A grievance form may be obtained from the business office. Please forward completed form to: [hospital address and telephone number]." The form included a complaint could also be filed with the Louisiana Department of Health & Hospitals (DHH), but an incorrect address and telephone number were listed. The form also included a statement that complaints could be filed with The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and listed their contact information. S1CNO also reviewed the "Privacy Notice" and verified the DHH information was incorrect and stated the hospital was accredited by another accrediting organization and not JCAHO. S1CNO further stated the "Privacy Notice" information was "offered" to patients upon admission, and verified the above Patient Rights and Responsibilities were included in the patient's admission packet.
VIOLATION: PATIENT RIGHTS: ACCESS TO MEDICAL RECORD Tag No: A0148
Based on records review, policy and procedure review, and staff interviews, the hospital failed to ensure that a system was in place to provide patients or patient's representative access to their clinical record as evidenced by failing to log all requests for medical records according to hospital policy. Findings:

Review of the hospital policy titled, "Access or Amendment to Records", review date of 04/26/12 provided as current by S2 Director of Quality, revealed in part the following: "....Upon request, [hospital] will allow a patient to inspect and/or copy his or her own medical records, billing records, or other records used by [hospital] to make decisions....
[Hospital] will act on all requests for access or inspection within thirty days by either sending a denial letter or providing the requested access....Procedure: 1. Employees should inform patients that all requests for access or amendments should be in writing to the attention of the Privacy Officer and either mailed or hand-delivered to the facility. The request should be signed and dated by the patient or the patient representative. If requests are hand-delivered to the office, all employees are responsible to making sure that the request is dated and signed and is given to the Privacy Officer. 2. The Privacy Officer, either personally or by delegation, will be responsible for keeping a log of all requests and the deadline for the requested information and/or amendment...."

In a face-to-face interview on 02/25/13 at 4:20 p.m., S12 Medical Records Clerk verified she was responsible for medical records and providing patients with access to requested records. S12 Medical Records Clerk provided a log of medical records mailed from 01/09/12 to 02/15/13. Review of the log revealed no documented evidence of the date the medical record was requested. The log included the following: patient's name, date of stay, requested by name, reason for request, information requested, charge amount, date mailed, and date paid. Further review of the log revealed only 1 request was from a patient (Patient #R1). All other requests were made by attorneys, insurance companies, or subpoena. S12 Medical Records Clerk stated she did not keep a log of patient requests for medical records. She verified Patient #R1 was the only patient request on the log and stated she included that patient on the log because the whole (entire) chart was requested. When asked what the hospital's process was for providing access to records, S12 Medical Records Clerk stated when she received a request, she pulled the record and has the Administration look at it and they give her the ok. She stated she contacted the person making the request for the record and informs them of the cost. S12 Medical Records Clerk stated Administration was to review any request from an attorney or any request for the whole record. S12 Medical Records Clerk stated they have no system for logging or tracking receipt of patient/family records requests. Further review of the log revealed no documented evidence of a medical records request from the family of Patient #3.

In a face-to-face interview on 02/26/13 at 3:00 p.m., S1CNO stated that she had heard that the family of Patient #3 had called for the medical records, and stated S12 Medical Records Clerk was handling that.

In a face-to-face interview on 02/27/13 at 4:30 p.m., S1CNO and S12 Medical Records Clerk both reviewed the policy and procedure for Access or Amendment to Records policy. S12 Medical Records Clerk stated the log was created to keep up with money. S1CNO verified she had heard the family of Patient #3 wanted the medical record. S12 Medical Records Clerk stated she did not know anything about that. S1CNO and S12 Medical Records Clerk verified the hospital's policy was not followed and they did not have a current system of tracking the receipt of patient requests for medical records access.
VIOLATION: MEDICAL STAFF Tag No: A0338
Based on records review and interviews, the hospital failed to meet the Condition of Participation for Medical Staff as evidenced by:

The hospital failed to ensure the medical staff was accountable to the governing body for the quality of the medical care provided to patients as evidence by:

1) failing to delineate the criteria for the hospital's intensive care unit (ICU) level of care, including the type and acuity level of patients appropriate for the hospital's capability, support services available, and transfer criteria;

2) failing to act upon patient care concerns brought to the MEC regarding appropriateness of patients, patient selection, nursing competence in ICU setting, lack of equipment, and staffing of respiratory services per hospital policy. (see findings at A-0347).
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on clinical records review, policy & procedure review, Medical Executive Committee (MEC) committee minutes review, observation, and interviews, the hospital failed to ensure the medical staff was accountable to the governing body for the quality of the medical care provided to patients as evidence by:

1) failing to delineate the criteria for the hospital's intensive care unit (ICU) level of care, including the type and acuity level of patients appropriate for the hospital's capability, support services available, and transfer criteria;

2) failing to act upon patient care concerns brought to the MEC regarding appropriateness of patients, patient selection, nursing competence in ICU setting, lack of equipment, and staffing of respiratory services per hospital policy.

Findings:

1) Failing to delineate the criteria for the hospital's intensive care unit (ICU) level of care, including the type and acuity level of patients appropriate for the hospital's capability, support services available, and transfer criteria:

Review of the hospital policy titled, "Scope of Services", revised date of 05/04/12, provided by S2 Director of Quality as current, revealed in part the following:

Patient Population: [hospital] provides 24 hour care to patients requiring surgical procedures, diagnostic gastrointestinal procedures, and outpatient diagnostic testing....

Scope and Complexity of Patient Care Needs: ....Procedures performed at the facility include general, ENT (Ear, Nose, Throat), ophthalmic, oral, urological, orthopedic, pain management, gynecological, plastic, bariatric, and gastrointestinal procedures. ....Once on the inpatient unit, the responsibility for the needs of the patient is with the attending physician and with the Anesthesiologist. The hospital accepts for care, treatment, and services only those patients whose identified care, treatment, and service needs can be met....

Staffing:....The inpatient unit will be staffed with two hospital employees one (1) of whom shall be a RN if one or more patients are on inpatient unit. The maximum nurse ratio for the inpatient unit will be 1 nurse to 8 patients.

There was no documented evidence in the policy that intensive care or critical care services were provided by the hospital. There was no documented evidence that staffing for critical/intensive care patients was addressed in the policy.

On 02/25/13 at 10:15 a.m., an observation was made of the inpatient unit with S3 Director of Inpatient Services. The inpatient unit had 12 private rooms with one nurse's station. S3 Director of Inpatient Services stated room "a" and room "b" were designated to be used for critical care and verified the hospital did not have a designated ICU. Observation of room "b" revealed an electric Blood Pressure machine, oxygen, and suction. There was no cardiac monitor noted in the room. S3 Director of Inpatient Services stated if the patient was an ICU patient, they would move the armoire out and move a portable monitor in. She stated room "a" was occupied with a patient who had surgery and was on the ventilator for 24 hours (Patient #5). Further observation of room "a" and "b" revealed the rooms were located across the hall from the nurse's station and only the foot of the bed was visible from the nurse's station, if the door to the room was open. S3 Director of Inpatient services stated usually their ICU patients were patients that were not able to be weaned from ventilator in PACU. She stated they typically were admitted to the inpatient unit and were weaned off the ventilator within 24 hours. S3 Director of Inpatient Services stated they had transferred 3 patients out in the recent past, one with an intracranial bleed, one needing dialysis, and one with chest pain.

Review of the clinical record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] for a laparoscopic gastric bypass redo. The patient's medical history included morbid obesity, congestive heart failure, mitral valve replacement, gastric bypass in 1977, intestinal bypass and reversal in 1974, stomach stapling, hypertension, reactive airway disease, diabetes mellitus, degenerative joint disease, and anemia. The record revealed the patient's surgical procedure was a laparoscopic Roux-en-Y gastric bypass, laparoscopic hiatal hernia repair, partial gastrectomy, and lysis of adhesions. After the surgery and PACU (Post Anesthesia Care Unit), the patient was admitted to the inpatient unit on a ventilator (no documentation of ICU status) with a propofol infusion. The patient was weaned off the ventilator on 07/18/12. The record revealed the patient had made a slow recovery and a transfer to a skilled nursing facility was ordered on [DATE]. On 07/23/12, the patient's status declined and she was placed on the ventilator for impending respiratory failure, along with propofol and dopamine infusions (no documentation of ICU status). The patient was diagnosed with [DIAGNOSES REDACTED][DIAGNOSES REDACTED], and respiratory and urine infections. The record revealed the patient was diagnosed with [DIAGNOSES REDACTED]

In a face-to-face interview on 02/26/13 at 11:25 a.m., S1 Chief Nursing Officer (CNO) was asked for the hospital's criteria for ICU status. S1CNO stated ICU status was for any patient that needed one-to-one care, hourly vital signs, a ventilator, or any kind of drips (Intravenous infusions requiring monitoring/titration). S1CNO stated ICU status was, "more of a staffing assignment than a classification." She stated they use a different form with the flow sheet for the ICU patients. S1CNO stated Respiratory Therapy was on call on the weekends unless there was a patient on a ventilator or the patient had respiratory issues, then Respiratory would have to be in house.

In a face-to-face interview on 02/27/13 at 3:50 p.m., S1CNO verified the hospital had no written criteria for ICU status and no written criteria for the acuity level or types of patients the hospital was capable of providing intensive care services for. She verified there was no transfer criteria identified for critically ill patients and stated they transferred patients, "when the doctor ordered it." S1CNO stated they had no policy/procedure that defined when Respiratory Services were required to be in house or on-call. S1CNO stated the only policy the hospital had regarding staffing was the "Scope of Services" policy, and she verified the policy did not include ICU status.


2) failing to act upon patient care concerns brought to the MEC regarding appropriateness of patients, patient selection, nursing competence in ICU setting, lack of equipment, and staffing of respiratory services per hospital policy.

Review of the Medical Staff Bylaws, current revision dated 05/23/12 revealed in part the following: Purpose: To discharge those duties and responsibilities delegated to the Medical Staff by the Board, to monitor medical care in [hospital], to assure one standard of care for all patients in [hospital], to provide a leadership role in hospital performance improvement activities to improve the quality of care, treatment and services, and patient safety....
10.3 Medical Executive Committee

General Duties:

(c) receiving and acting upon reports and recommendations from Medical Staff Departments, committees, and assigned activity groups;

(f) evaluating the medical care rendered to patients in the Hospital;

(p) receiving information regarding the quality and appropriateness of services provided by members/physicians....

Review of the MEC Meeting Minutes dated 09/26/12 revealed in part the following:

New Business:

Discussion: Pulmonology: Dr. (S18 Physician) was at the meeting to discuss concerns he and the members of his practice have. A lengthy discussion took place regarding the following issues: capabilities of [hospital], appropriateness of patients, patient selection, nursing competence with an ICU patient, equipment that is not capable of what they want to do, lack of equipment such as MRI (Magnetic Resonance Imaging), fluoroscopy, and nuclear Medicine, staffing (one respiratory therapist per shift and on call on weekends)....

Recommendation/Action: S27 Former Chief Executive Officer (CEO) suggested this issue be turned over to the inpatient advisory board with bariatric, pulmonary and anesthesia representation. All present agreed. Inpatient advisory board also tasked to consider having a dedicated ICU room or rooms on the 3rd floor to alleviate congestion at second floor nurses stations.

Review of the MEC Meeting Minutes dated 10/24/12 and 11/07/12 revealed Inpatient Advisory Board attempts to meet were unsuccessful. Review of the 01/23/13 MEC Meeting Minutes revealed no mention of the Inpatient Advisory Board Meeting or the concerns expressed by S18 Physician.

In a face-to-face interview on 02/17/13 at 12:00 p.m. S2 Director of Quality verified she attended the MEC Meetings and stated the goal of the Inpatient Advisory Board was define guideline for admission of patients and stated they have not been able to get the physicians to meet yet. S2 Director of Quality verified the concerns presented by S18 Physician to the MEC on 09/26/12 were regarding Patient #3 and stated this was not a normal case for the hospital. S2 Director of Quality stated some of the staff felt strongly that the patient should be in another ICU. She stated 1 nurse was nervous about the situation and was concerned the patient would be better at another facility, not that the staff was not competent. S2 Director of Quality stated S23 Advance Practice Registered Nurse (APRN) voiced concerns in front of the staff that the patient did not need to be in the hospital.

On 02/27/13 at 2:40 p.m., S18 Physician was interviewed by telephone and verified the concerns he expressed at the 09/26/12 MEC meeting were regarding Patient #3. He stated his Pulmonology group had been on staff a few months before he received a consult for Patient #3 and this consult was his first visit to the hospital. S18 Physician stated one of the first things he heard when he arrived at the hospital was, "we need to transfer her, we can't take care of her here." S18 Physician stated he had not observed competency concerns with the staff, but the nurse expressed that to him. S18 Physician stated he had not been informed of any follow up to his concerns. When asked if he still had concerns with the care at this hospital, he stated yes. S18 Physician then explained that a couple of months ago there was a patient who had surgery, developed an abscess, was discharged and came back with pus in the Jackson Pratt drains. He stated they did a CT (Computerized Tomography) scan and determined the patient had 3 abscesses. S18 Physician stated the surgeon scheduled surgery for 6 am. He stated they called him at 2:00 a.m. and the patient was "crashing". He stated he ordered blood gases, but Respiratory Therapy had to be called in to get the blood gases. S18 Physician stated they don't have x-ray in house. S18 Physician stated this was a surgical hospital, but there were more and more acute care cases.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on medical records review, review of the Medical Staff Rules & Regulations, and interview, the hospital failed to ensure that the medical staff followed the medical staff bylaws when transferring a patient from one level of care to another for 1 (#3) of __ sampled patients reviewed for ICU (Intensive Care Unit) services (#3) out of a total sample of 10. The physician failed to discontinue previous orders and write new orders when the patient was transferred to ICU level of care.

Findings:

Review of the Medical Staff Rules and Regulations provided as current by S2 Director of Quality revealed in part the following: ....IV. Treatment and Therapeutics

A. Physician's Orders....

3. All orders must be reviewed when a patient goes to the OR (Operating Room), changes level of care (ICU < > General Care Unit) or is transferred to another clinical service. All previous written orders must be discontinued and new orders written. It is not acceptable to write "continue/renew/repeat". Hand written orders require date, time and full signature.

Patient #3

Review of the clinical record for Patient #3 revealed that the patient was a [AGE] year old female admitted on [DATE] for a laparoscopic gastric bypass redo. The patient's medical history included morbid obesity, congestive heart failure, mitral valve replacement, gastric bypass in 1977, intestinal bypass and reversal in 1974, stomach stapling, hypertension, reactive airway disease, diabetes mellitus, degenerative joint disease, and anemia. The record revealed the patient's surgical procedure was a laparoscopic Roux-en-Y gastric bypass, laparoscopic hiatal hernia repair, partial gastrectomy, and lysis of adhesions. After the surgery and PACU (Post Anesthesia Care Unit), the patient was admitted to the inpatient unit on a ventilator (no documentation of ICU status) with a propofol infusion. The patient was weaned off the ventilator on 07/18/12. On 07/23/12, the patient's status declined and she was placed on the ventilator for impending respiratory failure, along with propofol and dopamine infusions (no documentation of ICU status). The patient was diagnosed with Sepsis Syndrome/Shock from a central line site. Further review of the record revealed the patient remained as ICU status until 08/02/12 when she was transferred to another hospital ICU for a neurosurgical evaluation of a catastrophic cerebral bleed.

Review of the physician's orders revealed there was no documented evidence of a Physician's order for ICU and there was no documented evidence the physician orders were discontinued and new orders written when the patient was placed on ICU status on 07/23/12.

In a face-to-face interview on 02/27/13 at 11:00 a.m. S5RN verified he was assigned to patient #3 on 07/23/12 for the 7 p.m. to 7 a.m. and he recalled the events of that shift. S5RN verified the patient was placed on ICU status that evening when she was intubated and placed on a ventilator at 10:00 p.m.

In a face-to-face interview on 02/28/13 at 10:40 a.m., S3 Director of Inpatient Services stated physicians don't always write orders for the change in level of care between ICU and Inpatient. She stated anesthesia will write continue monitoring and ICU level is assumed if the patient is on a ventilator. S3 Director of Inpatient Services stated she has seen the pulmonary physicians write an order for ICU. She stated whether the physician ordered ICU status or not the nurses would still function at the ICU level of care. S3 Director of Inpatient Services verified the physician orders were not discontinued and written when the patient's level of care changed from inpatient to ICU, or from ICU to inpatient.

In a face-to-face interview on 02/28/13 at 1:05 p.m., S1 Chief Nursing Officer (CNO) verified the Medical Staff Rules & Regulations requirement for new written orders when the patient's level of care changed. She stated the patient doesn't go anywhere, they stay in the same room. S1CNO verified the patients do change the level of care when they change from inpatient to ICU status.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on records reviews and interviews, the hospital failed to meet the requirements of the Condition for Participation for Nursing Services as evidenced by:

1) Failing to ensure that the Registered Nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:

a) The RN failed to assess a central line site according to hospital policy for 2 ( #1, #5) of 2 (#1, #5) sampled current patients reviewed for central line site care out of a total sample of 10;

b) The RN failed to document wound assessments/injury in accordance with hospital policy for 2 (#1, #5) of 7 sampled current patients reviewed for assessments out of a total sample of 10;

c) The RN failed to clarify physician's orders for Dopamine infusions to include the rate of titration for 1 of 1 (#5) sampled current patients reviewed for Dopamine infusions out of a total sample of 10;

d) The RN failed to clarify physician's orders for medications ordered with a range of dosages for 2 of 2 (#1, #5) sampled current patients reviewed with a range of dosages ordered for medications out of a total sample of 10 (see findings in A-0395), and;

2) The hospital failed to ensure that a registered nurse (RN) assigned the nursing care of each patient according to the patient's needs and the specialized qualifications and competence of the nursing staff. The RN assigned the care of Intensive Care Unit (ICU) status patients to staff who had not received training, orientation, and had not been assessed for competency for 5 of 5 (S4RN, S5RN, S10RN, S11RN, S25RN) personnel files reviewed for ICU competency out of a total of 12 ICU nurses currently employed per hospital policy (see findings in A-0397).
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observation, policy and procedure review, and staff interview, the hospital failed to
ensure that a system was in place to provide staffing for Intensive Care Unit (ICU) level of care to meet the needs of the patients as evidenced by failing to define levels of patient acuity and the staff to patient ratio. Findings:

Review of the hospital policy titled, "Scope of Services", revised date of 05/04/12, provided by S2 Director of Quality as current, revealed in part the following:

Patient Population: [hospital] provides 24 hour care to patients requiring surgical procedures, diagnostic gastrointestinal procedures, and outpatient diagnostic testing....

Scope and Complexity of Patient Care Needs: ....Procedures performed at the facility include general, ENT (Ear, Nose, Throat), ophthalmic, oral, urological, orthopedic, pain management, gynecological, plastic, bariatric, and gastrointestinal procedures. ....Once on the inpatient unit, the responsibility for the needs of the patient is with the attending physician and with the Anesthesiologist. The hospital accepts for care, treatment, and services only those patients whose identified care, treatment, and service needs can be met....
Staffing:....The inpatient unit will be staffed with two hospital employees on (1) of whom shall be a RN if one or more patients are on inpatient unit. The maximum nurse ratio for the inpatient unit will be 1 nurse to 8 patients.

There was no documented evidence that staffing for critical/intensive care patients was addressed in the policy.

On 02/25/13 at 10:15 a.m. an observation was made of the inpatient unit with S3 Director of Inpatient Services. The inpatient unit had 12 private rooms with one nurse's station. S3 Director of Inpatient Services stated room "a" and room "b" were designated to be used for critical care and verified the hospital did not have a designated ICU. Observation of room "b" revealed an electric Blood Pressure machine, oxygen, and suction. There was no cardiac monitor noted in the room. S3 Director of Inpatient Services stated if the patient was an ICU patient, they would move the armoire out and move a portable monitor in. She stated room "a" was occupied with a patient who had surgery and was on the ventilator for 24 hours (Patient #5). Further observation of room "a" and "b" revealed the rooms were located across the hall from the nurse's station and only the foot of the bed was visible from the nurse's station, if the door to the room was open. S3 Director of Inpatient services stated usually their ICU patients were patients that were not able to be weaned from ventilator in PACU. She stated they (ICU level patients) typically were admitted to the inpatient unit and were weaned off the ventilator within 24 hours. S3 Director of Inpatient Services stated staffing for the ICU level patient was 1 on 1 (RN) with respiratory therapy if the patient was on a ventilator. When asked what ICU level was, she stated patients with hourly vital signs, or on a ventilator would be ICU level.

In a face-to-face interview on 02/27/13 at 11:00 a.m. S5RN verified he had been assigned to the 7:00 p.m. to 7:00 a.m. S5RN stated staffing was an issue when there were only 1-2 patients and only 1 RN and 1 Respiratory Therapist. S5RN stated sometimes they don't have Respiratory Therapy at night and the nurses have to do the respiratory treatments. S5RN stated the RN is supposed to be 1 to 1 (1 nurse to 1 patient) if the patient is ICU status. S5RN stated on 07/23/12 he was assigned to Patient #3 when she was put on a ventilator and he had 1 other patient. S5RN stated when a patient is 1 to 1 the nurse had to stay in the room with the patient, because the patient was not visible from the nurse's station. S5RN stated they are required to keep the patient's door open, but the patient was still not visible from the nurse's station. S5RN stated he had voiced concerns to S3 Director of Inpatient Services that staffing was not adequate with ICU level patients. S5RN stated he had not received a response from S3 Director of Inpatient Services.

In a face-to-face interview on 02/27/13 at 11:35 a.m., S6RN stated she had been employed at the hospital since 2009. S6RN stated she has worked with ICU patients here where she had 1 ICU patient and 2 other medical/surgical patients. S6RN stated when there was an ICU patient on a ventilator, they have respiratory therapy. S6RN stated sometimes they have patients and don't have respiratory in the hospital, but on-call.

In a face-to-face interview on 02/27/13 at 3:50 p.m., S1CNO stated the only policy the hospital had regarding staffing was the "Scope of Services" policy, and she verified the policy did not include ICU status. S1CNO verified they had nothing to define acuity levels related to staffing for ICU level patients.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on Policy and Procedure review, clinical record review, and staff interviews, the hospital failed to ensure the Registered Nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:
1) failing to assess a patient for a change in respiratory and mental status for 1 (#3) of 10 sampled patients reviewed for assessments;
2) failing to assess a central line site according to hospital policy for 3 (#3, #1, #5) of 5 (#1, #3, #5, #7, #10) sampled patients reviewed for central line site care out of a total sample of 10;
3) failing to assess the patient's level of sedation (Ramsey Sedation Level) in titration of Propofol (Anesthetic medication) infusions in accordance with hospital policy for 1 (#3) of 3 (#3, #5, #10) sampled patients reviewed for Propofol infusions out of a total sample of 10;
4) failing to document wound assessments/injury in accordance with hospital policy for 3 (#3, #1, #5) of 10 sampled patients;
5) failing to clarify physician's orders for Dopamine infusions to include the rate of titration for 2 of 2 (#3, #5) sampled patients reviewed for Dopamine infusions out of a total sample of 10;
6) failing to clarify physician's orders for medications ordered with a range of dosages for 3 of 3 (#1, #5, #10) sampled patients reviewed with a range of dosages ordered for medications out of a total sample of 10, and;
7) failing to assess cardiac monitoring rhythms according to hospital policy for 2 (#3, #7) of 2 sampled patients reviewed for cardiac monitoring out of a total sample of 10.

Findings:

1) failing to assess a patient for a change in status:

Review of the hospital's policy titled, Scope of Services, revised 05/04/12, and provided as current policy by S2 Director of Quality, revealed in part the following: ....Patients will be reassessed regularly throughout their course of treatment to determine their response to treatment. When a significant change occurs in the patient's condition/diagnosis, the surgeon/physician/anesthesiologist will be notified and documentation will be made.....

Patient #3
Review of the clinical record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] for a laparoscopic gastric bypass redo. The patient's medical history included morbid obesity, congestive heart failure, mitral valve replacement, gastric bypass in 1977, intestinal bypass and reversal in 1974, stomach stapling, hypertension, reactive airway disease, diabetes mellitus, degenerative joint disease, and anemia. The record revealed the patient's surgical procedure was a laparoscopic Roux-en-Y gastric bypass, laparoscopic hiatal hernia repair, partial gastrectomy, and lysis of adhesions. After the surgery and PACU (Post Anesthesia Care Unit), the patient was admitted to the inpatient unit on a ventilator. The patient was weaned off the ventilator on 07/18/12. The record revealed the patient had made a slow recovery and a transfer to a skilled nursing facility was ordered on [DATE].

Review of the nurse's notes dated 07/23/12 revealed the following entries by S4RN:
1710 - On phone with S23APRN (Nurse Practitioner), obtaining order for ABGs (Arterial Blood Gases-assessment of respiratory function) after update given on RR (Respiratory Rate) via info (information) obtained from RT (Respiratory Therapist).
1740 - ABGs drawn per RT.
1800 - On phone with S21 Physician giving results of ABGs, multiple orders received.
1805 - Called S19 Physician (Patient's Surgeon) to give update and ABG results and to speak with daughter who is now at BS (bedside).
1810 - S19 Physician on phone with son now, who has just arrived, full update given on patient's status and all questions answered, new orders received via S19 Physician.
1845 - S22 Physician (Surgeon on call for S19 Physician) here and at bedside with family. Full report being given to oncoming night shift nurse per kardex.
There was no documented evidence of an assessment of the patient by the RN when the patient's condition changed. Review of the Nursing Daily Assessment form dated 07/23/12 revealed the only assessments documented by the RN were at 0745 and 1500.

In a face-to-face interview on 02/26/13 at 12:15 p.m. S4RN verified she was the RN assigned to Patient #3 on 07/23/12. When asked why she requested an order for ABGs, S4RN stated she thought the patient's daughter called and she was concerned. After reviewing the patient's record, S4RN verified she had called the nurse practitioner based on a report from the respiratory therapist. S4RN verified there was no documentation of a patient assessment and was unable to explain why there was no patient assessment when the patient's condition changed.

In a face-to-face interview on 02/27/13 at 9:25 a.m., S8RT (Respiratory Therapist) stated she remembered the patient had anxiety on 07/23/12. S8RT stated she went back to check on the patient at 1555 and gave her another breathing treatment. S8RT stated, "She just didn't look....there was a change." S8RT stated she communicated her concerns to the RN and she (S8RT) called S23APRN and got an order to do the ABGs.

2) failing to assess a central line site according to hospital policy:

Review of the hospital policy titled, ICU-Central Vascular Catheter (CVC) Insertion and Maintenance revised 08/12/11 and reviewed 05/02/12, provided as current by S2 Director of Quality, revealed in part the following: ....B. Maintenance: 1. Dressing Care: a. Inspect and document dressing condition daily for sings of infiltration, phlebitis or infection; including pain, redness, swelling, induration disruption of flow or lack of blood return....3. Assess the continued need for the CVC with the clinical team daily. Responsibilities:....B. Bedside Nurse: 2. Inspects the CVC dressing site daily and documents this assessment.....Documentation: D. Assessments of dressing site and CVC necessity will be documented every shift.

Patient #3
Review of the clinical record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] and had a laparoscopic Roux-en-Y gastric bypass, laparoscopic hiatal hernia repair, partial gastrectomy, and lysis of adhesions. Review of the operating room record revealed a left IJ (Internal Jugular) central line was placed by the anesthesiologist prior to the procedure. After the surgery and PACU (Post Anesthesia Care Unit), the patient was admitted to the inpatient unit.

Review of the patient's clinical record revealed the patient was diagnosed with [DIAGNOSES REDACTED].

Review of the nursing assessments revealed the only documentation of an assessment of the IJ central line site was at 7:30 a.m. on 07/19/12, 07/20/12, and 07/22/12. Review of the Nursing Daily Assessment forms from 07/17/12 through 07/23/12, revealed "IV Site Check" was initialed by the nursing staff. Further review of the record revealed the patient had a transparent dressing to the left IJ central line site. Review of the nurse's documentation on 07/23/12 revealed no documented evidence of an assessment of the IJ central line site on the 7:00 a.m. to 7:00 p.m. shift.

Review of the nurse's notes dated 07/23/12 at 7:00 p.m. revealed in part the following: "Left IJ TLC (Triple Lumen Catheter) reddened and oozing purulent drainage....."

In a face-to-face interview on 02/26/13 at 12:15 p.m. S4RN verified she was the RN assigned to Patient #3 on 07/23/12 for the 7:00 a.m. to 7:00 p.m. shift. S4RN stated she did not remember what type of dressing the patient had on the IJ central line site. S4RN verified the only assessment she documented of the IV site was initialing, "IV Site Check" section on the flow sheet, "we chart by exception". S4RN stated she would document any problems in the narrative section of the nurse's notes, but verified she had not documented an assessment in the narrative either.

In a face-to-face interview on 02/27/13 at 9:25 a.m., S8RT (Respiratory Therapist) stated the patient had to be assisted to the floor by physical therapy and several staff members during an attempt to ambulate the patient on 07/23/12. S8RT stated the patient had a bowel movement at this time and, "feces were everywhere". S8RT stated she recalled some of the tape in the IJ site had come off, but she did not remember if the site was red.

In a face-to-face interview on 02/27/13 at 11:00 a.m., S5RN stated he was the RN assigned to the patient on the 7:00 p.m. to 7:00 a.m. shift on 07/23/12. S5RN stated he remembered the events of this night well, as it was his first night to have an ICU patient at this hospital. S5RN stated after he received report on the patient he went into the room and the patient's son and daughter were present. S5RN verified the patient's son had called his attention to the IJ site. S5RN stated the dressing over the site was rolled up in one area, but was not off. S5RN stated there was purulent drainage just at the site of insertion and the tegaderm (transparent dressing) was clear without any drainage. S5RN stated there was redness only at the insertion site. S5RN stated he applied a new dressing to the site and notified the patient's physician.

In a face-to-face interview on 02/28/13 at 9:45 a.m., S2 Director of Quality stated she had talked to the nurses about the central line care. S2 Director of Quality stated S4RN told her she (S4RN) had to change the central line dressing because the patient soiled it when she got feces on her (Patient #3) hands during the assisted fall on 07/23/12. S2 Director of Quality verified there was no documented evidence of this dressing change in the nurse's notes and confirmed the hospital's policy on documentation of central line sites.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a [AGE] year old female admitted to the hospital 2/21/13 and was currently an inpatient. The patient's diagnoses included [DIAGNOSES REDACTED]'s PICC insertion site/dressing.

Patient #5
Review of the medical record for Patient #5 revealed he was a [AGE] year old male admitted to the hospital 2/14/13 for treatment of acute [DIAGNOSES REDACTED], and was currently an inpatient. Due to the patient taking an anticoagulant until the day before his admission, the planned cholecystectomy (removal of the gallbladder) was to be postponed until 2/18/13 while he continued to receive antibiotics. Patient #5's diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED] (inflammation of the gallbladder), and Pyemia of the gallbladder (accumulation of pus in the gallbladder). The patient underwent surgery 2/19/13 related to postoperative hemorrhage with an intra-abdominal hematoma.

Review of the nurses' flowsheet and narrative notes revealed Patient #5 returned from surgery 2/19/13 with a PICC line to his right antecubital area and a right IJ (Internal Jugular) central line. Further review of the nursing flowsheet revealed no documented results of daily assessments of the PICC or right IJ central line site.


3) failing to assess the patient's level of sedation (Ramsey Score) in titration of Propofol (Anesthetic medication) infusions in accordance with hospital policy:

Review of the Analgesia-Sedation Orders for Mechanically Ventilated Adults, dated 08/19/11, and provided by S1CNO (Chief Nursing Officer) as current protocol for Propofol infusions, revealed in part the following: **This protocol is to be initiated on adult mechanically ventilated patients only**....Propofol (Diprivan) 5 mcg/kg/min (micrograms per kilograms per minute) IV infusion, titrate in increments of 5 mcg/kg/min every 5 minutes to a RSS (Ramsey Sedation Scale) sedation level of 3-4 or as ordered.... Ramsey Sedation Scale:
Level 1 - anxious, irritated, agitated, or restless
Level 2 - cooperative, accepting ventilation, oriented and tranquil
Level 3 - Asleep; responds to verbal commands
Level 4 - Responds to light touch: brisk response to gentle shaking or light glabellar tap (reflex elicited by repetitive tapping on the forehead), or loud auditory stimulus
Level 5 - Only responds to noxious stimulus: nailbed pressure or trapezius pinch.

Patient #3
Review of the clinical record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] and had a laparoscopic Roux-en-Y gastric bypass, laparoscopic hiatal hernia repair, partial gastrectomy, and lysis of adhesions. After the surgery and PACU (Post Anesthesia Care Unit), the patient was admitted to the inpatient unit.

Review of the patient's clinical record revealed the patient was diagnosed with [DIAGNOSES REDACTED].m. A Propofol infusion was started at that time under the hospital's Analgesia-Sedation Orders for Mechanically Ventilated Adults. Further review of the record revealed Patient #3 remained on a Propofol infusion from 10:00 p.m. on 07/23/12 to 9:00 a.m. on 07/27/12.

Review of the nurses' documentation from 07/23/12 to 07/27/12 revealed the only documented assessment of the Ramsey Sedation Scale was on 07/23/12 from 10:00 p.m. to 6:00 a.m.
Further review of the nurses' documentation revealed the the dose of the Propofol was titrated on 07/24/12 at 8:00 a.m., 5:00 p.m., 7:00 p.m., 2:00 a.m., and 4:00 a.m. with no documented evidence of a RSS level.
On 07/25/12, the Propofol was titrated at 8:00 a.m., 9:00 a.m., 10:00 a.m., 11:00 a.m., and 7:00 p.m. with no documented evidence of a RSS level.
On 07/26/12, the Propofol was titrated at 10:00 a.m., 11:15 a.m., and 12:00 p.m. to the patient's respiratory rate. There was no documented evidence of the RSS level.
On 07/27/12, the Propofol was titrated at 7:00 a.m., 8:00 a.m. and 9:00 a.m. with no documented evidence of a RSS level.

In a face-to-face interview on 02/26/13 at 12:15 p.m. S4RN verified she had been assigned to Patient #3 while she was on the Propofol infusion. After reviewing the patient's record, she verified she was assigned to the patient on the 7 a.m. to 7 p.m. shift on 07/24/12 and 07/26/12. S4RN verified she had not documented the RSS level on either 07/24/12 or 07/26/12, and confirmed the patient was on Propofol infusion and she had titrated the patient's dose.

In a face-to-face interview on 02/26/13 at 3:00 p.m., S3 Director of Inpatient Services was interviewed and stated she would have expected the RN to document the RSS level on the flow sheet. After reviewing the flow sheet she verified there was no space on the flow sheet for a RSS level, and stated the nurse could write it in. S3 Director of Inpatient Services verified the hospital did not do training on Propofol infusions, and did not have competency evaluations on the administration of Propofol infusions. S1CNO who was present for the interview stated the hospital only hired nurses with ICU experience.

4) failing to document wound assessments/injury in accordance with hospital policy

Review of the hospital policy titled, revised 05/04/12, and provided as current policy by S2 Director of Quality, revealed in part the following: ....Patients will be reassessed regularly throughout their course of treatment to determine their response to treatment.

Review of the hospital policy titled, ICU-Guidelines for Routine Care, revised date of 08/12/11 and reviewed date of 05/02/12, provided by S1CNO as current, revealed in part the following:.... VIII. Integument A. Assessment; A complete integument assessment will be performed and documented every 12 hours, with changes in any component of the integument system and with a change in care-giver....Assessment includes: 1. Braden Score, 2. Skin Condition, 3. Color, 4. Turgor and Elasticity.... D. Surgical Incisions: Document every 12 hours or prn (as needed) on flow sheet.

Patient #3
Review of the clinical record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] and had a laparoscopic Roux-en-Y gastric bypass, laparoscopic hiatal hernia repair, partial gastrectomy, and lysis of adhesions. After the surgery and PACU (Post Anesthesia Care Unit), the patient was admitted to the inpatient unit.

Review of the Nursing Daily Assessment forms revealed a section for wound assessments which included the following statement: Please document completely for each injury/wound assessment. Review of the Nursing Daily Assessment forms dated 07/19/12, 07/20/12, and 07/23/12 through 08/01/12 revealed the nurse on the 7:00 p.m. to 7:00 a.m. documented, "Agree with above assessment" in the wound assessment section.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a [AGE] year old female admitted to the hospital 2/21/13 for Gastric Bypass surgery, and was currently an inpatient. The patient's diagnoses also included GI (Gastrointestinal) Bleed, Hypertension, Diabetes Mellitus II, Sleep Apnea, Degenerative Joint Disease, Bipolar Disorder, and Morbid Obesity.

Review of the Nursing Daily Assessment forms dated 02/26/13 revealed the nurse on the 7:00 p.m. to 7:00 a.m. documented, "Agree with above assessment" in the wound assessment section.

Patient #5
Review of the medical record for Patient #5 revealed he was a [AGE] year old male admitted to the hospital 2/14/13 for treatment of acute [DIAGNOSES REDACTED], and was currently an inpatient. Due to the patient taking an anticoagulant until the day before his admission, the planned cholecystectomy (removal of the gallbladder) was to be postponed until 2/18/13 while he continued to receive antibiotics. Patient #5 ' s diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED] (inflammation of the gallbladder), and Pyemia of the gallbladder (accumulation of pus in the gallbladder). The patient underwent surgery 2/19/13 related to postoperative hemorrhage with an intra-abdominal hematoma.

Review of the Nursing Daily Assessment form dated 02/20/13 through 02/23/13 revealed the nurse on the 7:00 p.m. to 7:00 a.m. documented, "Agree with above assessment" in the wound assessment section.

In a face-to-face interview on 02/26/13 at 5:05 p.m., S3 Director of Inpatient Services stated it was ok for the nurse to write she agreed with the assessment of the previous nurse.

5) failing to clarify physician's orders for Dopamine infusions to include titration rate:

Review of the hospital policy titled, ICU-Cardiac Infusion Medication Protocol revised date of 03/02/12 provided by S1CNO as the protocol for Dopamine infusions, revealed no documented evidence of a protocol or standing orders for a Dopamine infusion.

Review of the hospital policy titled, Drug Prescribing/Ordering Orders: Drugs, Contrast Media and Protocols, number PCS-05-02, effective date August 2012 provided by S1CNO as current, revealed in part the following: ....Titrating and Taping (Tapering) orders: Pharmacy will work with appropriate medical and hospital staff to establish safe ordering practices for these orders. These orders should contain the required elements of an order.

Review of the hospital policy titled, Medication Administration revised date of 12/06/12, provided as current by S2 Director of Quality revealed in part the following: ....Medication orders preferably should contain one specific dosage (instead of a dosage range), with the exception of those orders using a sliding scale where the physician specifies the parameters....

Patient #3
Review of the clinical record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] and had a laparoscopic Roux-en-Y gastric bypass, laparoscopic hiatal hernia repair, partial gastrectomy, and lysis of adhesions. After the surgery and PACU (Post Anesthesia Care Unit), the patient was admitted to the inpatient unit.

Review of the patient's clinical record revealed the patient was diagnosed with [DIAGNOSES REDACTED].m. A Dopamine infusion was started at 1:10 a.m. at 25 cc per hour or 5 mcg. per minute. Further review of the record revealed the patient received the Dopamine infusion until 07/25/12 at 10:00 p.m.

Review of the physician orders revealed the Dopamine order was as follows: 07/24/12 12:05 a.m. Dopamine 5 mcg/kg/min (Micrograms per kilograms per minute) prn (as needed) titrate to keep systolic BP (Blood Pressure) > 90 (greater than 90). There was no documented evidence the RN clarified with the physician how often the rate should be increased and the amount to increase the rate.

Review of the physician orders dated/timed 07/27/12 at 9:00 p.m. revealed a verbal order for, "May restart Dopamine drip to keep MAP (Mean Arterial Pressure) 65." There was no documented evidence the RN clarified with the physician the rate at which to start the infusion, or the parameters for titration.

In a face-to-face interview on 02/27/13 at 11:00 a.m., S5RN verified he was the RN assigned to Patient #3 on the 7:00 p.m. to 7:00 a.m. shift on 07/23/12. S5RN verified he had initiated the Dopamine infusion for Patient #3. After reviewing the physician orders, S5RN verified the order did not include a specific titration dose, or how often to increase the dose. S5RN stated he was instructed in school to increase drips by 5 mcg. S5RN stated he had not received any training from the hospital on Dopamine infusions.

Patient #5
Review of the medical record for Patient #5 revealed he was a [AGE] year old male admitted to the hospital 2/14/13 for treatment of acute [DIAGNOSES REDACTED], and was currently an inpatient. Due to the patient taking an anticoagulant until the day before his admission, the planned Cholecystectomy (removal of the gallbladder) was to be postponed until 2/18/13 while he continued to receive antibiotics. Patient #5's diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED] (inflammation of the gallbladder), and Pyemia of the gallbladder (accumulation of pus in the gallbladder). The patient underwent surgery 2/19/13 related to postoperative hemorrhage with an intra-abdominal hematoma.

Review of physician's orders for Patient #5 revealed, in part: 2/19/13 at 12:07 p.m.- "Start Dopamine 3-5 mics (micrograms)" ... Further review revealed no specific dosage or parameters for the titration of the ordered Dopamine.

Review of the MAR for Patient #5 for 2/19/13 revealed a handwritten entry that read "Dopamine 400 mg/250 cc, 3-5 mcg/kg/min (micrograms per kilogram per minute). A time of 1:00 a.m. with initials was noted for the 2/19/13 at 7:01 a.m. to 2/20/13 at 7:00 a.m. section. On the 2/20/13 at 7:01 a.m. to 2/21/13 at 7:00 a.m. section "-OFF-" was noted.

In a face-to-face interview on 02/28/13 at 10:40 a.m., S3 Director of Inpatient Services, stated they had a drip chart for Dopamine infusions to guide the staff on titrating. She verified the RN failed to clarify the specific dose and the parameters for titrating the medication.

6) failing to clarify physician's orders for medications ordered with a range of dosages:

Review of the hospital policy titled, Drug Prescribing/Ordering Orders: Drugs, Contrast Media and Protocols, number PCS-05-02, effective date August 2012 provided by S1CNO as current, revealed in part the following: ....B. Range Orders: Range orders (drug-X-one or two tablets every 4 to 6 hours......) are not acceptable. If a physician writes such an order, it should be clarified, ie., give on tablet every 6 hours...if relief is not obtained, then the next dose should be 2 tablets....if 2 tablets every 6 hours does not provide relief, then the dosage schedule should be adjusted to 2 tablets every 4 hours....Pharmacy will work through appropriate Committee to identify the required elements of these orders....

Patient #1
Review of the medical record for Patient #1 revealed the patient was a [AGE] year old female admitted to the hospital 2/21/13 and was currently an inpatient. The patient's diagnoses included [DIAGNOSES REDACTED].m.

Review of physician's orders for Patient #1 revealed an order dated/timed 2/22/13 at 9:30 a.m. that read, in part: Ativan (anti-anxiety medication) 1-2 mg (milligrams) IVP (Intravenous Push) q(every)4 hours prn (as needed) and Demerol (pain medication) 25-50 mg IVP q 6 hours prn. A physician's order dated/timed 2/22/13 at 10:12 a.m. revealed an order for Demerol 25-50 mg IVP q 1 hour prn. Further review revealed no documentation of the indications or order clarifications for any of the above medications.

Review of the MARs (Medication Administration Records) for Patient #1 revealed a handwritten entry as "Ativan 1-2 mg PO (orally) q 4 hours PRN anxiety" with a 1 mg dose documented as given at 10:15 a.m. and another dose of 1 mg documented at 3:00 p.m. on 2/22/13. Further review revealed a MAR for the dates that included 2/24/13, 2/25/13, and 2/26/13 with typed entries for Lorazepam (Ativan) Injectable 1 mg po 0.5 ml (milliliters) prn ... and Lorazepam Injectable 2 mg --po 1 ml prn.... with a start date of 2/22/13 at 5:00 p.m. No doses were documented as given on 2/24/13, 2/25/13, or 2/26/13. A MAR for 2/27/13 and 2/28/13 revealed the same typed entry for Lorazepam Injectable 1 mg and Lorazepam Injectable 2 mg as seen on the previous typed MAR. Review of the MAR for 2/21/13-2/23/13 also revealed a hand written entry for "Demerol 25-50 mg IVP every 1 hour prn pain" with no parameters included.

In an interview on 2/28/13 at 11:25 a.m., after review of Patient #1's medical record, S3 Director of Inpatient Services verified the above findings. S3 Director of Inpatient Services stated that the nurse and the pharmacist should have contacted the physician to clarify the orders.

In an interview 2/28/13 at 12:15 p.m., S16 Director of Pharmacy, after reviewing the physician's orders and MARs for Patient #1, verified the above findings. She stated that the pharmacist who entered the orders from 2/22/13 into the medication system should have contacted the physician and written a clarification order.

Patient #5
Review of the medical record for Patient #5 revealed he was a [AGE] year old male admitted to the hospital 2/14/13 for treatment of acute [DIAGNOSES REDACTED], and was currently an inpatient. Due to the patient taking an anticoagulant until the day before his admission, the planned cholecystectomy (removal of the gallbladder) was postponed until 2/18/13, while he continued to receive antibiotics. Patient #5's diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED] (inflammation of the gallbladder), and Pyemia of the gallbladder (accumulation of pus in the gallbladder). The patient underwent surgery again 2/19/13 related to postoperative hemorrhage with an intra-abdominal hematoma.

Review of physician's orders for Patient #5 revealed, in part , an order dated 2/19/13 at 12:07 p.m. to "Start Dopamine 3-5 mic's" . Further review revealed no clarification of the order for Dopamine that gave the specific dose, concentration, or parameters for titration.

Review of Patient #5's MAR for 2/18/13 - 2/20/13 revealed a hand written entry that read "Dopamine 400 mg/250cc (cubic centimeters), 3-5 mcg/kg/min" . Further review revealed no documentation of parameters for the administration or titration of the medication.

In an interview 2/28/13 at 11:25 a.m., after review of Patient #1's medical record, S3 Director of Inpatient Services verified the above findings.


Patient #10
Review of the medical record for Patient #10 revealed the patient was a [AGE] year old female admitted to the hospital 8/17/12 with complaints of abdominal pain, severe nausea and vomiting, and dehydration after undergoing a cholecystectomy the week before. She was diagnosed with [DIAGNOSES REDACTED]

Review of physician's orders for the patient revealed an order dated/timed 8/22/12 at 11:50 p.m that read, "Morphine 2-5 mg IV (intravenous) q 2 hours PRN for pain, Ativan 1-2 mg IV every 4 hours PRN agitation" . The order was written as one taken by telephone by an RN. Further review revealed no documentation of clarification of the above orders.

Review of Patient #10's MAR for 8/20/12 - 8/24/12 revealed, in part, the following entry: Morphine 4 mg IV x (times) 1, with a notation of 2:00 p.m.
Another MAR for 8/20/12 - 8/24/12 with "PRNs" written at the top of the page revealed, in part, the following: Ativan 1 mg IVP q 4 hours PRN agitation, and Ativan 2 mg IVP q 4 hours prn agitation.
Review of Patient #10's MAR for 8/25/12 - 8/29/12 revealed, in part, the following entries: Morphine 2 mg IVP q 2-4 hours PRN pain, Morphine 5 mg IVP q 2 hours PRN pain, Ativan 1 mg IVP q 4 hours PRN agitation, Ativan 2 mg IVP q 4 hours PRN agitation, and Morphine 0.5 mg IVP q 4 hours prn pain. Notations made in administration columns indicated that the patient received 5 mg Morphine IV on 8/25/12 at 10:30 p.m. and Ativan 2 mg IV at 9:00 p.m.

In an interview 2/28/13 at 11:25 a.m., after review of Patient #10's medical record, S3 Director of Inpatient Services verified the above findings.


7) failing to assess cardiac monitoring rhythms according to hospital policy:

Review of the hospital policy titled, Cardiac Monitoring, revised date of 03/02/12, provided by S1CNO as current, revealed in part the following: ....Documentation: Monitor strips are to be timed, dated and initialed with rhythm interpretation noted by RN in the patient's medical record at least once per shift or as warranted by change inpatient cardiac status. Monitor strips should be recorded every four hours with vital signs. Documentation should include rate, rhythm, PR interval, and QRS interval.

Patient #3
Review of the clinical record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] and had a laparoscopic Roux-en-Y gastric bypass, laparoscopic hiatal hernia repair, partial gastrectomy, and lysis of adhesions. After the surgery and PACU (Post Anesthesia Care Unit), the patient was admitted to the inpatient unit.

Review of the patient's record revealed cardiac monitoring was documented from 07/19/12 to 08/02/12. Review of the cardiac monitoring records revealed only 1 out of 49 cardiac monitor rhythm strips had all the required documentation (07/25/12 9:35 a.m.). 30 out of
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review and staff interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to have an individualized patient care plan that provided interventions to meet the needs of the patient, had measurable goals, and included all identified patient problems and needs for 5 of 10 sampled patients (#1, #2, #3, #5, #6). Findings:

Review of the hospital policy titled "Care Planning" revised date of 04/23/12, provided as current by S1 Chief Nursing Officer (CNO) revealed in part the following: Care, treatment, and services are planned to ensure that they are appropriate to the patient's needs. Therefore, it is the policy of [hospital] to provide an individualized, interdisciplinary plan of care for all patients that is appropriate to the patient's needs, strengths, limitations, and goals....The plan of care will be documented through the use of written care planning.....The plan of care shall be individualized, based on the diagnosis, patient assessment and personal goals of the patient and his/her family. The planning for care, treatment and services will include the following: 1. Care planning is based on data collected from patient assessment including pain assessment and interventions as appropriate with integration of assessment findings and the personal goals of the patient. 2. Developing a plan for care, treatment and services that includes patient care goals that are reasonable and measurable....

Patient #3
Review of the clinical record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] for a laparoscopic gastric bypass redo. After the surgery and PACU (Post Anesthesia Care Unit), the patient was admitted to the inpatient unit on a ventilator with a Propofol infusion. The patient was weaned off the ventilator on 07/18/12. The record revealed the patient had made a slow recovery and a transfer to a skilled nursing facility was ordered on [DATE]. On 07/23/12, the patient's status declined and she was placed on the ventilator for impending respiratory failure, along with Propofol and dopamine infusions. The patient was diagnosed with [DIAGNOSES REDACTED][DIAGNOSES REDACTED], and respiratory and urine infections. The record revealed the patient was diagnosed with [DIAGNOSES REDACTED]

Review of the patient's record revealed the nursing care plan was a section of the Nursing Daily Assessment form and included a section titled "Nursing Diagnosis Potential for", and a section titled "Goal". These sections listed 18 nursing diagnoses with a space to check beside each one, and 18 goals with space to initial by each one. There was no documented evidence of any interventions to address the identified goals, and there was no documented evidence of any resolution dates for the goals, and no evidence the goals were measurable.

Further review of the nursing care plan for Patient #3 revealed no documented evidence that the patient's potential for infection was identified (not included in list of 18 diagnoses) and there were no interventions identified to prevent infection. There was no documented evidence the nursing care plan was updated to include the respiratory failure requiring ventilator support, Propofol and dopamine infusions, sepsis with blood, urine, and respiratory infections. There was no documented evidence the nursing plan of care was individualized to meet the needs of the patient.

In a face-to-face interview on 02/26/13 at 12:15 p.m. S4RN verified she was the RN assigned to Patient #3 on 07/23/12. After reviewing the patient's record, she verified there were no interventions to address the identified problems, and verified the care plan was not individualized.


Patient #1
Review of the medical record for Patient #1 revealed the patient was a [AGE] year old female admitted to the hospital 2/21/13 (Currently in hospital) with diagnoses that included [DIAGNOSES REDACTED]#3. There was no documented evidence of any interventions to address the identified patient problems and there was no documented evidence of any measurable goals. There was no documented evidence of an individualized plan of care.


Patient #2
Review of the medical record for Patient #2 revealed the patient was admitted on [DATE] (Currently in hospital) and had a Left Total Knee Arthroplasty on 02/25/13.

Review of the nursing plan of care revealed the same 18 nursing diagnoses and goals as Patient #3. There was no documented evidence of any interventions to address the identified patient problems and there was no documented evidence of any measurable goals. There was no documented evidence of an individualized plan of care.


Patient #5
Review of the medical record for Patient #5 revealed he was a [AGE] year old male admitted to the hospital 2/14/13 (Currently in hospital) for treatment of acute [DIAGNOSES REDACTED]. Due to the patient taking an anticoagulant until the day before his admission, the planned Cholecystectomy (removal of the gallbladder) was to be postponed until 2/18/13 while he continued to receive antibiotics. Patient #5's diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED] (inflammation of the gallbladder), and Pyemia of the gallbladder (accumulation of pus in the gallbladder). The patient underwent surgery 2/19/13 related to postoperative hemorrhage with an intra-abdominal hematoma.

Review of the nursing plan of care revealed the same 18 nursing diagnoses and goals as Patient #3. There was no documented evidence of any interventions to address the identified patient problems and there was no documented evidence of any measurable goals. There was no documented evidence of an individualized plan of care.


Patient #6
Review of the patient's medical record revalued the patient was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of the nursing plan of care revealed the same 18 nursing diagnoses and goals as Patient #3. There was no documented evidence of any interventions to address the identified patient problems and there was no documented evidence of any measurable goals. There was no documented evidence of an individualized plan of care.

In a face-to-face interview on 02/28/13 at 10:40 a.m. S3 Director of Inpatient Services verified the nursing care plan was part of the Daily Nursing Assessment form and had a set of Nursing Diagnoses and Goals that were to be checked if applicable to the patient. She verified there were no interventions for the problems identified. S3 Director of Inpatient Services verified the potential for infection was not included in the nursing diagnoses. S3 Director of Inpatient Services verified the nursing care plans were not individualized and did not include measurable goals.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on personnel records review, policy and procedure review, and staff interviews, the hospital failed to ensure that a registered nurse (RN) assigned the nursing care of each patient according to the patient's needs and the specialized qualifications and competence of the nursing staff. The RN assigned the care of Intensive Care Unit (ICU) status patients to staff who had not received training, orientation, and had not been assessed for competency for 5 of 5 (S4RN, S5RN, S10RN, S11RN, S25RN) personnel files reviewed for ICU competency out of a total of 12 ICU nurses currently employed.

Findings:

Review of the hospital policy titled, "Orientation" reviewed date of 04/26/12, and provided by S1 Chief Nursing Officer (CNO) as current, revealed in part the following: All staff, whether clinical or supportive, including contract staff, students and volunteers shall receive an orientation to specific job duties and responsibilities and their work environment as required by Federal and State law and regulation and the organization. The orientation shall take place prior to the individual functioning independently in their job....Employees will begin their departmental orientation on the first day of work. The employee will be assigned a designee within the department for their initial 90 day introductory period. During this time they will receive orientation and training to their specific job duties and responsibilities and to their work environment. This orientation will take place prior to the employee working independently in their job and may be extended if necessary.

Review of the hospital policy titled, "Clinical Competencies Inventory", revised date of 05/02/12, provided by S1CNO as current, revealed in part the following: ....

Clinical performance/competencies will be completed during orientation and annually for each RN, RT (Respiratory Therapist), LVN/LPN (Licensed Vocational/Practical Nurse), and surgical technician by immediate supervisor. Information obtained will be assessed and evaluated by the department manager. The performance evaluation will reflect the clinical competency of the employee and corrective action will be provided to ensure compliance with and maintenance of current employee knowledge and skills.

Procedure: Human Resources assign the required annual competencies in Decision Critical (computer software used for employee training and competency evaluation). The department manager assigns the department specific competencies.....The department manager or a designee will sign off on competencies requiring observation as indicated....

S4RN
Review of the personnel record for S4RN revealed a date of hire of 11/20/06 as an RN in the inpatient department. There was no documented evidence of the date S4RN was designated as a ICU nurse, and there was no job description for an Inpatient Critical Care RN. There was no documented evidence of a competency assessment for Propofol infusions, Dopamine or other cardiovascular infusions, cardiac monitoring, and the Total Care Bariatric bed. There was no documented evidence of any orientation to the position of Inpatient Critical Care RN.

Review of the clinical record for Patient #3 revealed on 07/24/13, S4RN assisted the patient onto the Total Care Bariatric Bed at 9:30 a.m. Further review revealed the Total Care Bariatric Bed rotation was increased to 60 %, "per family request."

In a face-to-face interview on 02/26/13 at 12:15 p.m., S4RN stated the company that delivered the Total Care Bariatric Bed gave an inservice on the bed, but verified there was no documentation of that inservice.


S5RN
Review of the personnel record for S5RN revealed a date of hire of 03/07/12 as an RN in the PACU (Post Anesthesia Care Unit). There was no documented evidence of the date S5RN was designated as a ICU nurse, and there was no job description for an Inpatient Critical Care RN. Review of the training/competency transcript revealed the only current competency evaluations were competencies evaluated in PACU. There was no documented evidence of a competency assessment for Propofol infusions, Dopamine or other cardiovascular infusions, cardiac monitoring, and the Total Care Bariatric bed. There was no documented evidence of any orientation to the position of Inpatient Critical Care RN.

In a face-to-face interview on 02/27/13 at 11:00 a.m., S5RN stated he was hired as a PACU nurse and went to the inpatient unit in May or June of 2012. S5RN stated he was assigned to another nurse for 1 day in PACU. He stated the first 2 months he worked in the inpatient unit there were no ICU patients. S5RN stated his orientation to ICU was, "here's the patient". S5RN stated he was told to ask if he had any questions. S5RN stated the first ICU patient he had was Patient #3 on 07/23/12, when the patient was intubated, placed on a ventilator, and was administered Propofol and Dopamine infusions. S5RN stated he was not assigned to another nurse for orientation to critical care patients. S5RN stated he has not been provided training or received any competency evaluation for administration of Propofol infusions. S5RN verified the only competency evaluations he had were done in PACU.


S10RN
Review of the personnel record for S10RN revealed a date of hire of 09/26/12 as an Inpatient Critical Care RN. Review of the training/competency transcript revealed the only current competency evaluations were for laboratory procedures, nursing orientation day 2. There was no documented evidence of a competency assessment for Propofol infusions, Dopamine or other cardiovascular infusions, cardiac monitoring, arterial line, central venous pressure monitoring, advanced airway management, or the Total Care Bariatric bed. There was no documented evidence of any orientation to the position of Inpatient Critical Care RN.


S11RN
Review of the personnel record for S11RN revealed a date of hire of 04/29/10 as an Inpatient Critical Care RN. There was no documented evidence of a competency assessment for Propofol infusions, Dopamine or other cardiovascular infusions, cardiac monitoring, and the Total Care Bariatric bed. There was no documented evidence of any orientation to the position of Inpatient Critical Care RN.


S25RN
Review of the personnel record for S4RN revealed a date of hire of 05/24/06 as an RN surgical services department. There was no documented evidence of the date S4RN was designated as a Critical Care nurse, and there was no job description for an Inpatient Critical Care RN. There was no documented evidence of a competency assessment for Propofol infusions, Dopamine or other cardiovascular infusions, cardiac monitoring, and the Total Care Bariatric bed. There was no documented evidence of any orientation to the position of Inpatient Critical Care RN.

In a face-to face interview on 02/27/13 at 4:30 p.m., S13 Director of Human Resources (HR) verified she was unable to verify when S4RN, S5RN, and S25RN were moved to the position of Critical Care RN. S13 Director of HR stated human resources was responsible for new employee review of the job description, obtaining the employee's signature and placing a signed copy in the personnel file. S13 Director of HR stated when an employee changes positions, the new position job description was sent to the department manager for review. She stated the department manager was responsible for reviewing the job description with the employee, obtaining the employee's signature and returning a signed copy to human resources to be filed. S13 Director of HR stated all training and competency evaluations were done in Decision Critical. S13 Director of HR verified the only competency evaluations in the ICU profile were competencies for Arterial Lines and Central Venous Pressure Monitoring.

In a face-to-face interview on 02/26/13 at 11:25 a.m., S1CNO verified the hospital had no policy and procedure for the use of beds rented by the hospital, including the Total Care Bariatric Bed. S1CNO stated the beds come with a manual and the staff of the bed company will provide inservice's to the staff on the use of the bed. S1CNO verified they had no documentation of inservices on the Total Care Bariatric Bed.

In a face-to-face interview on 02/26/13 at 3:00 p.m., S1CNO stated they only hire nurses with ICU experience. S1CNO stated they cannot provide training for nurses for ICU because they have critical care patients infrequently. S3 Director of Inpatient Services, who was also present for the interview, verified she was unable to find any competency assessments for administration of Propofol, Dopamine, or any other cardiovascular infusions. S3 Director of Inpatient Services asked if it was required to verify all skills of PACU and ICU.

In a face-to-face interview on 02/28/13 at 10:40 a.m., S3 Director of Inpatient Services verified they did not do competency assessments for Propofol infusions, Dopamine or other cardiovascular infusions, cardiac monitoring, and any specialized beds the hospital rented. S3 Director of Inpatient Services stated nurses received training on ventilators and stated the name of the training was Advance Airway Management in Decision Critical, but verified there was no evaluation of competency. S3 Director of Inpatient Services stated they rely on the nurse's past experience in ICU as verification of ICU skills. She stated if nurses are hired with ICU experience they assume they have the skills. S3 Director of Inpatient Services stated if the nurse has ACLS (Advanced Cardiac Life Support) certification, they are competent to interpret cardiac rhythms. S3 Director of Inpatient Services verified the above findings in the personnel records of S4RN, S5RN, S10RN, S11RN, and S25RN. S3 Director of Inpatient Services stated when a new nurse was oriented to ICU, the new nurse was paired with a preceptor who reviews the protocols for taking care of patients. She stated the time spent with a preceptor depends on the nurse's comfort level. S3 Director of Inpatient Services stated they try to cover everything but it depends on the type of patient surgeries that occur in that time. S3 Director of Inpatient Services verified there was no documentation of orientation to ICU.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on records review and interview, the facility failed to ensure that medications were administered in accordance with the order of the physician and acceptable standards of care for 2 (#1, #3) of 10 sampled patients. This resulted in 5 medication errors noted during chart review that were not identified by the hospital for Patients #1 and #3.

Findings:

Review of the hospital policy titled, "Medication Administration", revised 12/06/12, and provided as current by S1Chief Nursing Officer (CNO), revealed in part the following: Medication will be administered only on the order of a physician, or podiatrist, who is a member of the medical staff....Errors in administration of medication will be reported immediately to the attending physician, and an occurrence report will be created and given to the Quality Director and/or the Pharmacist who will route to appropriate individuals....

Review of the hospital policy titled, "Prescribing and Ordering", revised 12/08/12 and provided as current by S1CNO, revealed in part the following: ...."Stat" means within 15 minutes, "Now" means within one (1) hour.....


Patient #1
Review of the medical record for Patient #1 revealed she was a [AGE] year old female with diagnoses that included, in part, GI (Gastrointestinal) Bleed, Gastric Bypass surgery, Hypertension, Diabetes Mellitus II, Sleep Apnea, Degenerative Joint Disease, Bipolar Disorder, and Morbid Obesity.

Review of physician's orders dated 02/22/12 at 9:30 a.m. revealed the following orders, in part: Ativan (anti-anxiety medication) 1-2 mg (milligrams) IVP (intravenous push) q (every) 4 hours prn (as needed). Further review of the physician's orders dated 2/22/12 at 9: 30 a.m. revealed no documented indication for the prn medication.

Review of MARs (Medication Administration Records) for Patient #1 revealed a handwritten entry as "Ativan 1-2 mg PO (orally) q 4 hours PRN anxiety" with a 1 mg dose documented as given at 10:15 a.m. and another dose of 1 mg documented at 3:00 p.m. on 2/22/13. Further review revealed a MAR for the dates that included 2/24/13, 2/25/13, and 2/26/13 with typed entries for Lorazepam (Ativan) Injectable 1 mg po 0.5 ml (milliliters) prn ... and Lorazepam Injectable 2 mg --po 1 ml prn.... with a start date of 2/22/13 at 5:00 p.m. No doses were documented as given on 2/24/13, 2/25/13, or 2/26/13. Review of the MAR for 2/27/13 and 2/28/13 revealed the same typed entry for Lorazepam Injectable 1 mg and Lorazepam Injectable 2 mg as seen on the previous typed MAR.

In an interview 2/28/13 at 11:25 a.m., after review of Patient #1's medical record, S3 Director of Inpatient Services verified the above findings. S3 Director of Inpatient Services stated that the nurse and the pharmacist should have contacted the physician to clarify the order. S3 Director of Inpatient Services confirmed that the MAR documented that Lorazepam (Ativan) was given orally instead of an injection, as ordered, 2 times.

In an interview 2/28/13 at 12:15 p.m., S16 Director of Pharmacy, after reviewing the physician's orders and MARs for Patient #1, verified the above findings. She stated that the pharmacist who entered the Ativan order from 8/22/12 into the medication system should have contacted the physician and written a clarification order. The Director of Pharmacy further stated that neither the transcription error nor the medication administration errors had been identified by the staff.




Patient #3
Review of the clinical record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] and had a laparoscopic Roux-en-Y gastric bypass, laparoscopic hiatal hernia repair, partial gastrectomy, and lysis of adhesions. After the surgery and PACU (Post Anesthesia Care Unit), the patient was admitted to the inpatient unit. Review of the patient's clinical record revealed the patient was diagnosed with Sepsis Syndrome/Shock (Systemic response to Infection) related to the central line on 07/23/12 at 10:30 p.m., and was intubated and placed on a ventilator.

Review of the physician's orders dated/timed 07/26/12 at 9:40 p.m. revealed an order to administer 20 meq.(milli-equivalents) of NaPhos (Sodium Phosphate) IVPB (Intravenous Piggy Back) now over 4 hours. Review of the MARs dated 07/26/12 revealed no documented evidence the NaPhos was administered to the patient.

Review of the physician's orders dated/timed 07/27/12 at 10:30 a.m. revealed an order to administer 20 meq. of NaPhos (Sodium Phosphate) IVPB now over 4 hours. Review of the MARs dated 07/27/12 revealed the NaPhos was administered at 9:30 p.m., 11 hours after the medication was ordered to be given "Now".

Review of the physician's orders dated/timed 07/28/12 at 1:30 p.m. revealed an order to administer Lactulose 300 cc (cubic centimeters) diluted to 1 L (liter) with 700 cc NS (Normal Saline) or water for 30-60 minutes every 6 hours X (for) 2 doses. Review of the MARs dated 07/28/12 revealed the Lactulose was administered at 9:00 p.m. and 3:00 a.m., over 7 hours after the medication was ordered.

In a face-to-face interview on 02/26/13 at 5:05 p.m. S3 Director of Inpatient Services reviewed the physician orders and MARs for Patient #3. S3 Director of Inpatient Services verified there was no documented evidence the NaPhos prescribed on 07/26/12 was administered to the patient. She verified the NaPhos was again ordered on [DATE] to be given "Now" and verified the medication was not administered until 11 hours after the medication was ordered. S3 Director of Inpatient Services verified "Now" medication orders were to be administered within 1 hour. S3 Director of Inpatient Services verified the Lactulose ordered on [DATE] at 1:30 p.m., was not administered until 9:00 p.m. She stated her expectation would have been for the Lactulose to be administered sooner. S3 Director of Inpatient Services verified all 3 incidents were medication errors and verified they had not been identified by the hospital as medication errors.
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
Based on interviews and records reviews, the hospital failed to ensure that the pharmacy distributed medications in accordance with applicable standards of practice and consistent with Federal and State laws when it failed to ensure that all first doses of medications were not administered to patients before being reviewed by a pharmacist for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes for all patients admitted after or before pharmacy working hours. This practice had the potential to affect 6 of 6 patients in the hospital. Findings:
Review of the "Louisiana Administrative Code Title 46 - Professional and Occupational Standards Part III: Pharmacists Chapter 15. Hospital Pharmacy", revealed, in part, "...1511. Prescription Drug Orders A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency...". Further review of definitions listed revealed, in part, "...(13) "Drug regimen review" means and includes, but is not limited to, the following activities: (a) Review of the prescription drug order and patient record for [i] known allergies, [ii] therapy contraindications, [iii] dose and route of administration, and [iv] directions for use, (b) Review of the prescription drug order and patient record for duplication of therapy, (C) Review of the prescription drug order and patient record for interactions, and (d) Review of the prescription drug order and patient record for proper utilization including over-or under-utilization, and optimum therapeutic outcomes...".

Review of the hospital policies and procedures revealed no policies for a first dose review by a pharmacist before a non-emergent medication could be administered.
Review of the hospital's contract with the pharmacy (S30) dated 06/04/12, revealed in part the following: S30 agrees to meet the requirements of hospital and its patients at a minimum of twenty (20) hours per week, Monday through Friday....A pharmacist will be on call for the hospital with a minimum call back times if they return to the facility of two hours....
In a face-to-face interview on 02/26/13 at 2:45 p.m., S17 Pharmacist verified the pharmacy hours were 12:00 p.m. to 5:00 p.m., or whenever they were through with entering orders. When asked how a first dose review of the patient's medication profile was done before new medications were dispensed, S17 Pharmacist stated the pharmacist reviewed and verified new orders when they (Pharmacist) arrived at noon. S17 Pharmacist stated medications ordered after hours (After 5:00 p.m. and before 12:00 p.m. the next day) were reviewed the next day. S17 Pharmacist verified new medications could be administered before the pharmacist review by over-riding the Pyxis system. S17 Pharmacist stated the pharmacist was on-call if needed for a second or third source to review the new orders. S17 Pharmacist stated the nurses on the floor reviewed the new medications.
In a face-to-face interview on 02/28/13 at 12:15 p.m. S16 Director of Pharmacy verified there was no system in place for a first dose medication review prior to dispensing medications for medications ordered after hours.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based upon review of personnel files, policy and procedure review, and staff interview, the hospital failed to ensure the designated infection control officer S2 Director of Quality was qualified through education, training, experience or certification. Findings:

Review of the hospital policy titled, "Infection Prevention and Control Overview", revised date of 04/30/12 and provided by S2 Director of Quality as current policy, revealed in part the following: The scope of [hospital]'s Infection Prevention and Control Program includes all departments, committees, and organizational elements. The infection prevention and control process is managed by the Infection Prevention and Control Officer. This person has the qualifications to govern the policies for controlling infections and communicable diseases. This practitioner shall complete a course in basic surveillance by a recognized body and show evidence of continuing education related to infection prevention and control minimally every 2 years.

In a face-to-face interview on 02/27/13 at 12:00 p.m., S2 Director of Quality stated she was the designated infection control officer for the hospital.

Review of the personnel file for S2 Director of Quality revealed there was no documented evidence of any past experience with infection control, nor was there evidence the employee had obtained any education, training or certification in infection control. Review of the job description dated 05/15/12 for S2 Director of Quality revealed in part the following:
Duties and Responsibilities: Infection Control Practitioner: Demonstrates comprehensive knowledge of complete infection control process in the health care setting. Attends continuing education programs and maintains current knowledge of all aspects of infection control....

In a face-to-face interview on 02/27/13 at 4:00 p.m. S2 Director of Quality verified she had been the Infection Control Officer since May 2012. S2 Director of Quality confirmed she had had no prior experience, had not obtained any type of certification, and had not received any training or ongoing education in infection control. S2 Director of Quality stated she was a member of APIC (Association for Professionals in Infection Control and Epidemiology) and she consulted with infection control practitioners at area hospitals. S2 Director of Quality verified there was no contract with any of the infection control practitioners she consulted with.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on records review, and interviews, the infection control officer failed to investigate, and control infections and communicable diseases as evidenced by failing to investigate hospital acquired infections including central-line sepsis, catheter-associated urinary tract infection, and respiratory infection identified by the Infection Control department in July 2012. Findings:

Review of the hospital policy titled "Infection Prevention and Control Overview", revised date of 04/30/12 and provided by S2 Director of Quality as current policy, revealed in part the following: ....Each department will be responsible and accountable for its role in the Infection Prevention and Control Program. In addition to reporting suspected isolation cases, suspected infections, positive cultures, and providing required follow-up information, each department will be responsible for full and timely cooperation with the Infection Control Committee and practitioners to develop and implement remedial/corrective action....

Review of the Infection Control Log for 2012 revealed Patient #3 was identified with the following:

07/23/12 at 9:35 p.m.: Culture of Central Line site in left IJ (Internal Jugular) - Staph (Staphylococcus) Aureus heavy, few positive cocci.

07/23/12 at 9:35 p.m.: Blood from PICC (Peripherally Inserted Central Catheter) - Staph Aureus, gram positive cocci in clusters.

07/23/12 at 9:35 p.m.: Urine Culture - Enterococcus faecalis, staph aureus.

07/23/12 at 11:00 p.m.: Tip of Central line catheter - Staph Aureus, moderate.

07/27/12 at 1:15 a.m.: Blood Culture - Gram positive cocci in clusters, Staph coag (Coagulase) negative isolated from one culture only.

07/27/12 at 10:00 p.m.: Sputum: Klebsiella moderate, no normal flora isolated.

07/27/12 at 10:00 p.m.: Catheterized Urine - Staph aureus.

07/31/12 at 5:15 a.m.: Blood from venous line - Gram positive cocci in clusters, Staph coag negative isolated from one culture.

There was no documentation on the log that the above infections were hospital acquired.

There was no documented evidence of any investigation of the above infections.

Review of the clinical record for Patient #3 revealed the patient was a [AGE] year old female admitted on [DATE] for a laparoscopic gastric bypass redo. The patient's medical history included morbid obesity, congestive heart failure, mitral valve replacement, gastric bypass in 1977, intestinal bypass and reversal in 1974, stomach stapling, hypertension, reactive airway disease, diabetes mellitus, degenerative joint disease, and anemia. The record revealed the patient's surgical procedure was a laparoscopic Roux-en-Y gastric bypass, laparoscopic hiatal hernia repair, partial gastrectomy, and lysis of adhesions. After the surgery and PACU (Post Anesthesia Care Unit), the patient was admitted to the inpatient unit on a ventilator and was weaned off the ventilator on 07/18/12. The record revealed the patient had made a slow recovery and a transfer to a skilled nursing facility was ordered on [DATE]. On 07/23/12, the patient's status declined and she was placed on the ventilator for impending respiratory failure. The patient was diagnosed with Sepsis Syndrome/Shock from a central line site. Further review of the record revealed the further deterioration in the patient's condition on 07/28/12 with encephalopathy, and respiratory and urine infections. The record revealed the patient was diagnosed with a catastrophic cerebral bleed on 08/02/12 and was transferred to another hospital ICU for neurosurgical evaluation.

In a face-to-face interview on 02/27/13 at 12:00 p.m., S2 Director of Quality verified the above infections for Patient #3 and verified the infections were hospital acquired. When asked if an investigation of the hospital acquired infections identified in Patient #3, she stated a Root Cause Analysis (RCA) was done. S2 Director of Quality stated she looked at the patient's record for insertion documentation for compliance with the CDC (Centers for Disease Control) Bundle for catheter related infections. S2 Director of Quality stated she did not interview staff, or observe staff in the insertion or care of central lines.

Review of the RCA (no date documented) provided by S2 Director of Quality, revealed the RCA was done by S29 Medical Director, S1 Chief Nursing Officer (CNO), S3 Director of Inpatient Services, and S2 Director of Quality. Review of the RCA revealed details of Patient #3's hospital stay, but there was no mention of the patient's central line related sepsis, or any other infections identified. There was no documented evidence of any investigation of the infections identified in Patient #3.

In a face-to-face interview on 02/28/13 at 9:45 a.m., S2 Director of Quality verified the RCA did not identify or include an investigation of Patient #3's central line sepsis, catheter related sepsis, or respiratory infection. She verified she had not done any surveillance of central line care/insertion or urinary catheter care/insertion. S2 Director of Quality verified there was no corrective action plan developed to prevent these infections in the future. When asked if the Central Line Sepsis was a reportable infection, S2 Director of Quality stated the hospital was not required to report central line infections to NHSN (National Hospital Surveillance Network) since they had no designated ICU (Intensive Care Unit) beds.