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.

ABBOTT NORTHWESTERN HOSPITAL 800 EAST 28TH STREET MINNEAPOLIS, MN 55407 Sept. 22, 2016
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, interview and document review, the hospital failed to maintain personal privacy for 2 of 2 patients (P37, OP3) observed before and after electroconvulsive therapy (ECT) treatments.

Findings include:

On 9/21/16, an electroconvulsive therapy (ECT) procedure (a procedure done under anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure) was observed. P37, an inpatient, was scheduled for an ECT at 9:00 a.m. P37 was in the prep area at 9:15 a.m. where an intranevnous (IV) therapy was started by two registered nurses (RN)s, RN-I and RN-J. P37 was the only patient in the preparation (prep)/recovery room with RN-I and RN-J. P37 was wheeled into the procedure room at 9:20 a.m. on a gurney by the two RNs.

After the ECT procedure, P37 was taken back to the prep/recovery room on a gurney at 9:52 a.m. P37 was sedated from the anesthesia medication she had been given in the procedure room. The two RNs put P37 in the 3rd bay, hooked up a heart monitor and took P37's vital signs. There was a male outpatient (OP3), on a gurney next to the wall who was observing P37 and the two RNs. P37 was asleep. Neither of the RNs pulled the privacy curtain to provide privacy for P37 after her ECT procedure. OP3 kept watching the two RNs administering care to P37.

OP3 was taken to the procedure room at 10:05 a.m. on a gurney.

RN-I and RN-J were interviewed at 10:06 a.m. and confirmed they should have pulled the privacy curtains so OP3 could not observe them taking care of P37, and also have provided privacy for OP3 as well.

The hospital's pamphlet on Patient Rights, dated 5/13, indicated the standard for privacy and safety was "the patient had the right to personal privacy."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and document review, the hospital failed to ensure orders and recommendations for pressure ulcer care were implemented for 2 of 3 patients (P48, P12) reviewed for nursing services and who admitted with current pressure ulcers. In addition, the hospital failed to ensure adequate monitoring was provided to 1 of 1 patient (P12) reviewed for skin tears and falls and for 1 of 1 patient (P46) reviewed for postpartum (following childbirth) nursing care.

Findings include:

Pressure ulcers:
P48's admission History & Physical (H&P) dated 9/10/16, identified P48 had been admitted to the hospital after presenting to the emergency department (ED) with confusion. The H&P indicated P48 had a "left heel ulcer" and listed a plan which included, "Wound nurse consult."

P48's signed wound/ostomy progress note dated 9/11/16, indicated P48 had a "Stage 3 Pressure Ulcer [wound extending into the tissue below the skin forming a crater]" on his left heel and listed a plan for, "Iodoflex [iodine soaked pad used to help prevent infection] and change dressing daily per wound team." Further, the note identified follow up would be completed the following day on 9/12/16.

No further wound/ostomy notes were identified in P48's medical record.

P48's Physician Orders dated 9/13/16, in a space labeled, "Wound Ostomy Orders," listed an order which read, "Wound Care Management Complex One Time, Routine." Further, the order had, "Complete. Discontinue" written with no further wound care orders being identified on the Physician Orders for P48.

During observation of wound care on 9/21/16, at 10:06 a.m. registered nurse (RN)-A entered the room. RN-A had already prepared a bedside table with supplies which included gauze, wound cleanser, Kerlix and ACE wraps (elastic bandages). P48 was lying in bed on his right side, and had a visible ACE wrap in place on his left heel. RN-A applied clean gloves and removed the ACE wrap exposing a pad saturated with an orange and brown colored fluid. The saturated pad fell on to the bed exposing a visible pressure ulcer to P48's heel. RN-A stated the ulcer had no visible wound bed as the wound had, "Slough [tissue consisting of pus and fibrin] in there," adding the ulcer appeared, "About the same," since RN-A had seen it yesterday. RN-A cleaned the surrounding skin of the ulcer, then sprayed clean 4 x (by) 4 (inch) gauze with Microcyn wound cleanser (to clean, assist with debriding and moisten a wide spectrum of acute and chronic wounds without harming healthy tissue) and pressed it onto the pressure ulcer on P48's heel. RN-A then wrapped the heel with Kerlix and three tan colored ACE wraps. RN-A did not measure the ulcer during the dressing change.

During interview on 9/21/16, at 10:56 a.m. RN-A stated she changed P48's pressure ulcer dressing with just gauze and wound cleanser because she did not get any of the Iodoflex (a dressing with dual action for desloughing and antimicrobial actions) from supplies. RN-A stated she did not have time to obtain the Iodoflex, however, added she should have ordered. RN-A reviewed P48's medical record with the surveyor and stated she was unable to locate any current orders for P48's wound care, only being able to identify the treatment recommended on 9/11/16, by the Wound Ostomy (WOC) Progress Note. Further, RN-A stated the floor nurses had not been measuring the ulcer with each dressing change, because the WOC team was responsible for it.

P48's skin flowsheet was reviewed in the medical record. The only recorded measurements of the "Pressure Injury/Ulcer left heel," were completed on 9/10/16. At that time, the ulcer was identified to have a width of 2 cm (centimeters) and a depth of 0.2 cm.

During interview on 9/21/16, at 11:14 a.m. the patient care manger (PCM)-A stated she had reviewed P48's medical record and spoken to the hospital WOC team about the pressure ulcer. PCM-A said P48's last treatment recommendation had been on 9/11/16, as identified in the WOC Progress Note, and the WOC team should have continued to follow the pressure ulcer but had not. PCM-A stated the orders for the dressing change should have been carried over to the physician orders so nursing could have consistently implemented it, however, that had also not been done. PCM-A stated she was unable to determine whether the ulcer was worse or improved due to the lack of documentation in the record and stated, "Obviously that's concerning." PCM-A stated nursing should have completed the dressing change as recommended by the WOC team on 9/10/16.

When interviewed on 9/22/16, at 10:33 a.m. WOC registered nurse/RN-B stated she had just completed a dressing change to P48's left heel pressure ulcer the night prior (9/21/16). RN-B removed the dressing which consisted of dried white gauze and no Iodoflex. RN-B stated P48's pressure ulcer was now, "sixty percent slough at top of the wound," and the rest of the wound bed was, "necrotic tissue." RN-B described P48's pressure ulcer as, "worse" than it was when he had been admitted to the hospital as it was now considered unstageable due to increased slough with no visible wound bed. RN-B indicated the wound was Stage III but now unstagable due to slough.

P48's WOC Wound assessment dated [DATE], completed by RN-B at 5:38 p.m. documented P48's pressure ulcer to be, "Length 4.3 cm and Width 2.3 cm" in size with, "60% slough and 40% necrotic tissue."


P12's H&P dated 9/17/16, identified chief complaint of generalized weakness with diagnoses of [DIAGNOSES REDACTED]"Sacral ulcer mostly superficial, no obvious drainage, with surrounding [DIAGNOSES REDACTED]. To the left gluteal region is a superficial coin-sized ulcer. Both arms are wrapped with probably superficial ulcers. Multiple superficial ulcers bilateral lower extremities."

A nursing progress note on 9/18/16, identified P12 had a "Stage 2 Ulcer [Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater] lower buttocks, healed decubitus on coccyx." There was no measurements or description of the pressure ulcer (PU).

P12's WOC Wound Assessment sheet dated 9/18/16, identified P12 had a community acquired stage 2 PU on his sacrum. The depth was identified as partial thickness, and the patient was provided with a low air loss mattress and treatment orders. There was no description or measurement of the PU and if there was one or two PUs.

During interview on 9/20/16, at 2:28 p.m. WOC care manager RN-D, stated RN-H completed the note. She stated she spoke with RN-H about the note and indicated the PU had diffused pockets of shearing and felt it could not be measured, even though that was a stage 2 PU. RN-D stated the WOC nurses would reassess and follow up with P12's PU weekly, which was standard protocol. She also stated since it was only a stage 2, the nurses on the floor would follow that patient instead of the WOC nurses.

Review of the hospital's EPIC (a brand of electronic health record (EMR) ) flow sheets identified R12 had a skin problem pressure injury/ulcer on "bilateral butt cheek." Review of the flow sheet notation identified areas to be documented for PU were appearance, length, width, depth, visible percent of pink/red tissue, surrounding skin, drainage, dressing, interventions and PU stage. There were notations completed on 9/19/16, at 8:16 p.m., identifying surrounding skin and dressing intact. On 9/20/16, at 8:00 a.m., the PU appearance was, "blister ruptured with purple/maroon skin," intact surrounding skin and dressing. There was no additional documentation of P12's PU.

During interview on 9/20/16, at 11:30 a.m. RN-E stated she completed the PU dressing change on P12 that morning and he had two PU, one on his coccyx with a pin head size open area, and one on his right buttock. She described the right buttock PU as a stage 2, pink, shallow, with no drainage. RN-E stated she did not do any measurements of the PUs, even though she had just completed his dressing change that morning.

The above documentation was reviewed with RN-C on 9/20/16, at 11:41 a.m. and stated there were inconsistencies with the documentation of P12's PUs in the record, making it difficult to determine if there was one or two PU. If there are two sites, then two separate notations of the dressing changes and PU measurements need to be completed, not just identifying the skin problem of bilateral butt cheek. RN-C stated the best time to complete these assessment are with dressing changes, which was not completed.

Although P12 had PUs, the PU assessments had inconsistent documentation to determine if there one or two PU. The PUs were not assessed to identify size, appearance, length, width, depth, visible percent of pink/red tissue, surrounding skin, and drainage even though P12's H&P on admitted d 9/17/16, identified the PUs were superficial but later developed into two stage 2 PU with a ruptured blister and purple, maroon skin color.
An undated Med Surg (medical surgical) Assessment Guidelines/Documentation policy indicated: "Skin inspection" should be documented, "On admission and at least daily."

An undated, Required Documentation Checklist RN Role policy, directed staff to document a patient's skin condition upon admission. Further, the policy identified steps to take if a patient developed a pressure ulcer during their hospitalization , however lacked any direction on how to ensure pressure ulcers present upon admission were appropriately addressed and managed.

A hospital policy on pressure ulcer care was requested, but none was provided.





Skin tears:
P12's H&P dated 9/17/16, also identified, "Both arms are wrapped with probably superficial ulcers."

During observation on 9/20/16, at 8:30 a.m. P12 was in bed, and had a gauze dressing unsecured that covered his left anticubital (inside of elbow) area. A Kerlix wrap was loose, bunched up and hanging down on P12 left forearm. P12 stated he had a skin tear when he bumped his arm at home. At 9:58 a.m. RN-E gathered her dressing supplies and proceed to remove P12 old gauze dressing and Kerlix from his left arm. Under the dressing on his left anticubital area was a long, wide open area. P12's had two medium size U shaped scabbed areas on the anterior aspects of his left wrist. RN-E was unaware of any measurements of P12 anticubital skin tear, and was directed by the surveyor to obtain measurements. RN-E measured the area and identified it was 7 cm by 1 cm. RN-E did not measure the two scabbed U shaped areas on the wrist. RN-E proceed to cover these three areas with Xeroform (petrolatum salve impregnated on a fine mesh gauze so the dressing did not adhere to the ulcer(s) dressing and Kerlix from his wrist to his elbow.

Review of the hospital nursing flow sheets dated 9/17 thru 9/20/16, only identified one notation of P12's skin tear on 9/20/16, at 10:00 a.m., which occurred during the survey with the surveyor. The notation read, skin tear-total flap loss, 7 cm by 1 cm. surrounding skin intact, yellow/gold drainage. Dressing changed with Xeroform and Kerlix. There was no consistent monitoring of P12's skin tear and scabbed areas, even though the hospital was doing dressing changes, and the admission history and physical on 9/17/16, identified, "Both arms are wrapped with probably superficial ulcers."

During interview on 9/20/16, at 10:45 a.m. RN-C indicated any open skin area needed to be consistently assessed and monitored by nursing so interventions can be changed it needed. RN-C confirmed there was only one notation on P12's skin tear, even though P12 has been in the hospital for four days.


FALLS
P12 was identified on the undated care plan, he was at risk for falls with the goal of free from fall injury. The staff were directed to assess patient frequently for physical needs, identify cognitive, physical and behaviors that affect risk of falls, institute fall precautions per Fall Risk Score assessment, education patient/family, instruct patient to call for assistance, modify environment and consider occupational and physical consultation.

Review of the EPIC nursing flow sheet identified the Hendrich Model, a scoring tool used to identify if a patient is at risk for falls. The flow sheet charting from 9/17/16 to 9/20/16, identified P12 ranged from a score of 10 to 5, with any score of a 5 or greater is a high risk for falls. The fall interventions indicated to follow hospital fall protocol of using visual identifiers with door signs, magnets and communicate fall risk during report.

During observation on 9/20/16, at 9:49 a.m. P12 was in his bed, there was a bedside commode and Geri chair in his room. There was no visual identifiers on his door, any signs, magnets or any identification on the white board in P12's room that would have communicated to other staff P12 was a fall risk. The white communication board inside P12's room, had a stack of 2 inch by 2 inch plastic card that identified P12 moved independently.

During interview on 9/20/16, at 9:50 a.m. RN-E confirmed the missing visual cues were not implemented as part of the hospital fall intervention policy, and (P12) was not independent. The fall risk visual reminders are implemented so all staff in the hospital are aware of any patients at risk for falls.

During interview on 9/20/16, at 9:55 a.m. licensed practical nurse (LPN)-A stated (P12) needed assistance for one person to transfer and two assist to stand yesterday.

The Allina Fall Prevention Intervention Guidelines (undated) identified patients must have, red slippers/socks, visual identifier i.e. door sign, magnets, communicate fall risk during report and during all hand off communication and patient/family education.


Post Partum:
P46's OB (Obstetrics) Discharge Summary dated 6/21/16, verified P46 had delivered a baby on 6/19/16, at 6:24 p.m. adding P46's pregnancy had been, "complicated by [DIAGNOSES REDACTED]" Further, the summary identified P46's newborn baby had, "Abnormal" placenta pathology, and P46's, "Postpartum course was complicated by [DIAGNOSES REDACTED].

The hospital policy for Post Caesarean (C-section) Birth Providers Orders dated 4/5/16, directed staff to obtain the blood pressure (B/P), respirations, and pulse every 30 minutes x2, then every one hour x 2 then every 8 hours and as needed (PRN) after the first two initial hours after a C-section. The temperature was to be taken every four hours for 24 hours, then every shift. Staff were to call the physician if the temperature was greater than 100.4 degrees Fahrenheit. In addition, the staff were to perform a post-partum assessment which included fundal (generally defined as the distance from the pubic bone to the top of the uterus
measured in centimeters), lochia (a discharge from the uterus and vagina following delivery) and perineal monitoring. The post-partum assessment was to be conducted every 30 minutes x4, every hour x4, and if stable, every four hours x2, then every eight hours and as needed, after the initial two hours of birth.

P46's OB Shift Transfer Reports dated 6/19/16 through 6/21/16, identified spacing to record vital signs and monitoring for potential bleeding complications following delivery of a baby. P46 was transferred to the Post-Partum unit on 6/19/16, at 10:20 p.m. The vital signs were as follows:

B/P recorded on the report for 6/19/16, at 10:20 p.m. was recorded as being 120/65, the temperature was 98.8 orally and the respirations were documented as 16. These vitals signs were not monitored again until 6/20/16, at 9:55 a.m. when they were essentially unchanged: temp was 98.5 orally, respirations were 18, and the B/P was 115/62.

R46's medical record lacked evidence of the B/P and respirations being obtained in accordance with hospital protocols: every 30 minutes x2 and then every hour x2. In addition, the temperature log lacked evidence of the temperature recordings at the every four hour checks.

The EMR was reviewed on 9/20/16, at 2:00 p.m. for the post-partum assessments that were to be performed two hours after the initial assessment. At 3:00 p.m. nurse manager RN-C indicated P46 had a fundal check at 10:00 p.m. but was unable to locate any additional documentation of fundal, lochia and perineal monitoring after 10:00 p.m. on 6/19/16. R46 was not provided appropriate ongoing nursing care after the delivery of the baby according to the hospital policy.

When interviewed on 9/22/16, at 10:45 a.m. registered nurse manager (RN)-F stated after a Cesarean section was completed, patients are taken to the post anesthesia care unit (PACU) for two hours, then transferred to the post-partum floor. Review of P46's medical record indicated P46 had been transferred to the post-partum floor on 6/19/16, at 10:20 p.m. RN-F stated no vitals or monitoring of potential bleeding had been recorded from 6/19/16, at 10:20 p.m. through 6/20/16, at 9:55 a.m. by the nursing staff. RN-F stated staff were responsible to monitor a mom vital signs every thirty minutes for two occasions, then hourly for two occasions, then every shift. However, RN-F verified documentation was lacking to support that had occurred following P46's delivery as the area provided to record these items had been left blank. RN-F stated a patient was at risk for bleeding post-delivery and that at least a blood pressure and pulse should have been monitored in order to make sure she was hemodynamically stable.

During interview on 9/22/16, at 9:16 a.m. the director of quality (DOQ) confirmed documentation was lacking to ensure P46 had been monitored according to hospital policy, "We don't have them [vitals]."
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on interview and document review, the hospital failed to develop a comprehensive nursing care plan for 3 of 30 patients (P35, P2, P12) reviewed for their nursing care. In addition, the hopsital did not implement the nursing care plan for 1 of 1 patient (P46) reviewed for post partum checks after the delivery of a child.

Findings include:

P35's History & Physical (H&P) dated 9/19/16, identified P35 had been admitted to the hospital for, "Alcohol intoxication," with, "Acute gastroenteritis." P35 had consumed mouth wash and had complaints of, "Being slightly shaky." Further, the H&P identified had been to treatment nine times for alcohol consumption and, "She would like to stop drinking."

P35's hospital care plan dated 9/21/16, identified problems for P35 which included the cardiovascular, urinary and gastrointestinal systems, with a goal of, "Patient's electrolyte balance stabilizing." However, the care plan lacked any direction for P35's alcohol use, monitoring for potential side effects of post alcohol use, or any developed plans for address P35's psychosocial needs after being admitted for ongoing alcohol consumption with an identified desire to stop as identified in the H&P.

During interview on 9/21/16, at 10:40 a.m. patient care manager (PCM)-A stated P35's care plan lacked those areas and no other documentation could be found to identify they had been addressed on the care plan.




P2's Critical Care Service History and Physical dated 9/3/16, identified P2 was admitted to the hospital with acute encelphalopathy (disorder or disease of the brain, malfunction); polysubstance abuse (multiple addictions to drugs); sepsis (presence of a harmful bacteria), and hypoxia (lack of oxygen to the brain).
The Patient Story dated 9/14/16, identified P2 was a homeless male with a history of asthma, coronary artery disease, intentional drug overdose, substance induced mood disorder and poly substances abuse.
P2's care plan last undated on 9/19/16, identified problems of cardiovascular, gastrointestinal, integumentary, musculoskeleltal, neurological, and respiratory problems. There was no mention of his attempted suicide, or any psychosocial concerns identified even though P2 was homeless and had a history of polysubstance abuse.
During interview on 9/21/16, at 11:52 a.m. registered nurse manager (RNM)-A indicated that patient's care plan should have been updated that identified (P2) being a potential suicide risk and to address psychosocial concerns of being homeless with a diagnosis of polysubstance abuse.


P12's History and Physical dated 9/17/16, identified chief complaint of generalized weakness with diagnoses of chronic sacral ulcer, begin prostatic hypertrophy with suprapublic catheter, urinary tract infection and high blood pressure.

P12's WOC (wound ostomy continence) Wound Assessment sheet dated 9/18/16, identified P12 had a community acquired stage 2 pressure ulcer (Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) on his sacrum. The depth was identified as partial thickness, and the patient was provided with a low air loss mattress and treatment orders.

The hospital's nurses overview report last updated 9/20/16, identified P12's had a Braden scale (tool used to determine pressure ulcer risk) with a score of 17, identifying P12 was at risk for pressure ulcer development, and at risk for pressure/shear skin injury. The report identified P12's care plan problems and goals. It identified P12 had problems with pain with a goal of verbalizing/display adequate comfort level; discharge planning, to discharge home or other facility when appropriate resources; safety-falls, free from fall injury; infection prevention, absence of infection during hospitalization and interdisciplinary care rounds to occur where patient need is identified. There was no mention of P12's pressure ulcer, even though P12 had a pressure ulcers on his sacrum, and was identified at risk.

During interview on 9/20/16, RN-C stated pressure ulcer should be part of (P12's) care plan and confirmed that was missing and not addressed.


P46's OB (Obstetrics) Discharge Summary dated 6/21/16, verified P46 had delivered a baby on 6/19/16, at 6:24 p.m. adding P46's pregnancy had been, "Complicated by Prior cesarean, anemia, and strong desire for an attempt at VBAC [vaginal birth after cesarean]." Further, the summary identified P46's newborn baby had, "Abnormal" placenta pathology, and P46's, "Postpartum course was complicated by chronic asymptomatic anemia." P46's had undergone a Cesarean section. P46's plan of care was not implemented for monitroing and assessing post-partum and post-operative care.

The hospital policy for Post Caesarean (C-section) Birth Providers Orders dated 4/5/16, directed staff to obtain the blood pressure (B/P), respirations, and pulse every 30 minutes x2, then every one hour x 2 then every 8 hours and as needed (PRN) after the first two initial hours after a C-section. The temperature was to be taken every four hours for 24 hours, then every shift. Staff were to call the physician if the temperature was greater than 100.4 degrees Fahrenheit. In addition, the staff were to perform a post-partum assessment which included fundal (generally defined as the distance from the pubic bone to the top of the uterus
measured in centimeters), lochia (a discharge from the uterus and vagina following delivery) and perineal monitoring. The post-partum assessment was to be conducted every 30 minutes x4, every hour x4, and if stable, every four hours x2, then every eight hours and as needed, after the initial two hours of birth.

P46's OB Shift Transfer Report dated 6/19/16 through 6/21/16, identified spacing to record vital signs and monitoring for potential bleeding complications following delivery of a baby. P46 was transferred to the Post-Partum unit on 6/19/16, at 10:20 p.m. The vital signs were as follows:

B/P recorded on the report on 6/19/16, at 10:20 p.m. as being 120/65. The temperature was 98.8 orally and the respirations were 16. These vitals signs were not monitored again until 6/20/16, at 9:55 a.m. in which the vital signs were within normal limits.

R46's medical record lacked evidence of the B/P and respirations being obtained at the every 30 minutes x2 and then every hour x2. In addition, the temperature log lacked evidence of the temperature recordings at the every four hour checks.

R46's medical record lacked evidence of the B/P and respirations being obtained at the every 30 minutes x2 and then every hour x2. In addition, the temperature log lacked evidence of the temperature recordings at the every four hour checks.

The EMR was reviewed on 9/20/16, at 2:00 p.m. for the post-partum assessments that were to be performed two hours after the initial assessment. At 3:00 p.m. nurse manager RN-C indicated P46 had a fundal check at 10:00 p.m. but was unable to locate any additional documentation of fundal, lochia and perineal monitoring after 10:00 p.m. on 6/19/16. R46's nursing plan of care was not implemented for the mother after the delivery of the child by c-section.

When interviewed on 9/22/16, at 10:45 a.m. registered nurse manager (RN)-F stated after a Cesarean section was completed, patients are taken to the post anesthesia care unit (PACU) for two hours, then transferred to the post-partum floor. Review of P46's medical record indicated P46 had been transferred to the post-partum floor on 9/19/16, at 10:20 p.m. RN-F stated no vitals or monitoring of potential bleeding had been recorded from 6/19/16, at 10:20 p.m. through 6/20/16, at 9:55 a.m. by the nursing staff. RN-F stated staff were responsible to monitor a mom vital signs every thirty minutes for two occasions, then hourly for two occasions, then every shift. However, RN-F verified documentation was lacking to support that had occurred following P46's delivery as the area provided to record these items had been left blank. RN-F stated a patient was at risk for bleeding post-delivery and that at least a blood pressure and pulse should have been monitored in order to make sure she was hemodynamically stable.

During interview on 9/22/16, at 9:16 a.m. the director of quality (DOQ) confirmed documentation was lacking to ensure P46 had been monitored according to hospital policy, "We don't have them [vitals]."
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on observation, interview, and document review, the hospital failed to ensure staff wore personal protective equipment (PPE) appropriately to protect against blood spray during termination of patient dialysis treatment for 1 of 1 dialysis patient (DP1) observed with arteriovenous fistulas (AVF).

Findings include:

On 9/20/16, at 12:20 p.m. registered nurse (RN)-Z was observed during the termination of DP1's dialysis treatment. RN-Z had donned gloves and a semi-permeable gown and wore prescription eye glasses, but had not donned a face shield that was designed to cover the face from forehead to chin. RN-Z removed DP1's dialysis needles and applied the clamps to DP1's AV fistula. At 12:22 p.m. RN-Z took down P1's tubing and dialyzer from the dialysis machine, and had not donned a semi-permeable gown or a face shield which exposed RN-Z's body, eyes, nose and mouth to possible blood spray.

On 9/20/16, at 12:22 p.m. RN-Z was interviewed regarding use of a semi-permeable gown and face shield. RN-Z confirmed she should have used both a semi-permeable gown and face shield during dialysis termination and machine take down.

On 9/22/16, at 9:30 a.m. RN-Y who was the director of acute inpatient dialysis (a contracted service provided by Fresenius Medical Care) was interviewed and confirmed RN-Z should have worn a semi-permeable gown and face shield during termination of dialysis and dialysis tubing take down procedures.

Review of Fresenius Medical Care (FMS) Clinical Services policy, Personal Protective Equipment (PPE), revised 3/20/13, directed staff to wear a full face shield or mask, and protective eyewear with full side shield, fluid resistant gowns, and gloves to protect and prevent employees from blood or other potentially infectious materials to pass through to or reach the employee's skin, eyes, mouth, other mucous membranes when terminating treatment and stripping the dialysis machines.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the hospital failed to provide Important Message (IM) from Medicare notice in a timely manner for 2 of 27 patients (P8, P37) reviewed with Medicare coverage.

Findings include:

P8's physician orders dated 9/14/16, identified P8 was admitted to the hospital with inpatient status, "Admit to inpatient."

P8's Important Message From Medicare About Your Rights (CMS-R-193) was signed as being received on 9/19/16.

When interviewed on 9/20/16, at 2:32 p.m. licensed social worker (LSW)-A stated P8 was admitted as an inpatient on 9/14/16, with a payer source of Medicare. LSW-A stated the hospital admission office provided the CMS-R-193, five days after P8 was admitted to the hospital.

During interview on 9/20/16, at 2:42 p.m. the registration supervisor (RS)-A stated P8 should have been provided a CMS-R-193, "Within 48 hours of admission." RS-A stated her staff attempted to provide the notice on 9/16/16, however, P8 was asleep. RS-A stated registration staff were expected to, "try the next day" if a patient was sleeping and unable to be provided the notice. Further, RS-A stated P8's medical record lacked any documentation why P8 was not re-approached the following day.






P37's physician's orders dated 8/31/16, identified P37 was admitted on [DATE], as an inpatient with a payer source of Medicare.

P37's medical record lacked documentation that P37 had been given the IM from Medicare. The lack of documentation was confirmed by registered nurse (RN-G). In addition, there was no documentation that the staff had attempted to offer P37 the IM.

P37's IM from Medicare About Your Rights (CMS-R-193) was signed as being received on 9/21/16. An interview on 9/21/16, at 3:45 p.m. with RN-G confirmed that P37's IM from Medicare was given to her on 9/21/16, after her chart had been reviewed by the surveyor.

RN-G confirmed P37 should have received the IM from Medicate within 48 hours of admission to the hospital.
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
Based on observation and interview, the hospital failed to ensure an intravenous line (IV) was patent for 1 of 1 patient (P37) who was observed during an electroconvulsive therapy (ECT) procedure.

Findings include:

On 9/21/16, P37 was observed in the prep area at 9:15 a.m. where her IV was started by two registered nurses (RN)s, RN-I and RN-J. The IV was started in the right lower arm after some difficulty of threading the IV cannula into the vein. The IV fluid was a 1000 milliliter (ml) bag of normal saline (NS) going in at a keep vein open (KVO) rate. P37 was wheeled into the procedure room for ECT (a procedure done under anesthesia in which small electric currents were passed through the brain, intentionally triggering a brief seizure) at 9:20 a.m. on a gurney by the two RNs.

RN-K was attending P37 in the procedure room for an ECT and failed to monitor the IV for patency. RN-K was at P37's right side of the bed as the anesthesiologist did a pre-anesthesia exam, then connected the patient to the cardiac monitor and maintained the airway for R37. RN-K had not checked R37's IV for patency. The attending psychiatrist (MD)-A hooked P37 to the electrodes on P37's forehead. The anesthesiologist was about to inject Etomidate 80 mg into the IV to sedate the patient (Etomidate is a short acting IV anesthetic agent used for induction of general anesthesia) when this writer told the team to stop and check the IV insertion site at 9:25 a.m. The IV site and the arm area above the IV site had a very large bubble area under the skin that was approximately 6 inches long and 3 inches wide that was increasing in size. The anesthesiologist then stated that they would stop what they were doing to check the IV. MD-A then took over and maintained the airway on P37. The anesthesiologist confirmed that P37's IV had infiltrated and had to be discontinued and he would start a new IV in the patient's left arm. RN-K then discontinued the IV on the right arm and put a dressing over the site and applied pressure. The anesthesiologist indicated that if he would have administered the sedation medication that it would have caused irritation in the arm at the site of the infiltration. The anesthesiologist started an IV on the left antecubital area. The anesthesiologist proceeded to medicate R37 (following the time out procedure) with sedation medication through the IV line. After P37 was sedated MD-A was able to complete the ECT without incident. The procedure was completed at 9:50 a.m.

On 9/21/16, at 9:55 a.m. RN-G and the director of mental health were interviewed and confirmed that RN-K should have observed the IV site for patency after R37 was bought into the ECT procedure room.

The hospital's policy, IV Peripheral Catheters: Insertion and Care by RN Staff, revised 5/20/15, indicated that IV sites "should be changed when there is evidence of infection, phlebitis, pain or infiltration."
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Bases on observation, interview and document review, the hospital failed to maintain sanitation for food preparation equipment in the kitchen, around the solid waste compacting area and for 2 of 2 dumpsters where food debris was located.

Findings include:

KITCHEN:
A kitchen tour was conducted on 9/19/16 at 1:30 p.m., with the food service director, production manager (PM) and patient services manager (PSM). A blender base and a food processor base were observed on a production table. Both items had dried on food splatters on all sides of the equipment. A manual can opener had thick dried on debris along the blade and cutting mechanism. Bits of flaked metal was observed between the gear teeth. The PM verified the hospital did not dismantle the cutting blade unit for regular cleaning. The PM verified the blender and food processor bases required a more thorough and consistent cleaning.

The PM and PSM explained each position had cleaning duties assigned. Review of the "CPR" positions indicated to thoroughly clean and sanitize mixers and can opener daily.

COMPACTING AREA:
During a facility tour on 9/21/16, at 9:00 a.m. with the director of facility management (DFM), the solid waste disposal and compacting area was observed. The hospital operated one solid waste compactor. One of two waste dumpsters was situated with one end in the compacting area and the other end outside. The compacting area had access to the outside at the bottom edges and around the dumpster. Spilled waste debris of used gloves, paper, cups and other items was noted around the ground of the compactor on all sides. There was also liquid spillage in the area. The DFM verified the observation and acknowledged the level of debris did not meet expected standards. The DFM stated that the dumpsters were not sealed and could allow fluids to seep out.

FOOD WASTE BINS:
A blue plastic bin full of food waste was observed outside near the dumpster. The bin was not covered. The DFM stated the bin was from the kitchen. There were several similar blue bins in the area. The bins were in various degrees of disrepair with cracks and heavy soiling inside and out. The bins were not covered. Bin covers were observed on the ground and or in the bins. The covers were also soiled and in disrepair.

On 9/23/16, at 12:45 p.m. the food waste bins were observed in the kitchen with executive chef (EC)-A . EC-A explained two bins were utilized in the kitchen to collect food waste for pig feed and would be taken to the outside area by the dumpsters when full. One bin was in a production area and the other bin was located in the dirty side of the pot and pan room. Both bins had debris of spillage down the outside. The bin in the pot and pan area had a broken cover with dark coloration of soiling. EC-A was not aware of procedure for sanitizing the bins and stated the kitchen did not have a cart wash area.

At 1:00 p.m., the DFM and food service production manager (PM) were interviewed. The PM and DFM verified there was not a process for ensuring the cleanliness of the food waste bins prior to returning them to the kitchen after being outside in the dumpster area. The DFM explained he would not want any receptacles in the outside area that could collect rain water and they should be covered with well fitting lids. The PM explained the bins were the property of the pig farmer and were picked up on a daily basis.

The DFM stated the dumpster area had been cleaned and a new policy was now in draft form. He stated the issue of the food bins would be reviewed with a new policy and procedure developed to ensure proper sanitation.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0710
Based on observation, interview, and documentation review, the hospital was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code (LSC) deficiencies cited at:

K-027, K-038, K-046, K-052, K-064, K-072, K-075 for additional information.