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.

MERCY HOSPITAL SPRINGFIELD 1235 E CHEROKEE SPRINGFIELD, MO 65804 June 19, 2014
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review and policy review the facility failed to obtain physicians' orders for pressure sore (also known as pressure ulcer, wound created by skin breakdown from constant pressure to the skin) treatments for two current patients (#20 and #26) of three current patients reviewed with pressure sores. This had the potential to lead to worsening pressure sores and infections. There were 10 current patients with identified pressure sores. The facility also failed to return an unused and expired medication to the pharmacy for one discharged patient (#33) of one discharge patient medication stored in the behavioral health unit (BHU) refrigerator. This had the potential to affect all patients in the BHU unit. The BHU unit census was 14. The facility census was 484.

Findings included:

1. Record review of the facility's policy titled, "Pressure Ulcer Prevention," revised 05/13, showed that:
- The licensed nurse will notify the physician of skin breakdown and obtain physician's orders.
- All consults, dressings, wound treatments, and devices must have a physician's order documented in the electronic health record (EHR).
- Physician's orders, and implementation of the orders, will be the responsibility of the patient's primary nursing team.

2. Record review of current Patient #26's medical record showed:
- A wound culture dated 06/13/14 at 6:55 PM, indicated that it contained Staphylococcus aureus (bacteria), presumed to be Methicillin resistant Staph aureus (MRSA, highly contagious and difficult to treat infection, which can cause death) and [DIAGNOSES REDACTED] Eterococcus (VRE, highly contagious and difficult to treat infection, which can cause death).
- A History and Physical (H&P) dated 06/14/14 (admitted ), indicated the patient was admitted with fever and worsening pressure sores. The pressure sores were on the patient's buttocks and low back, were reddened, and with yellow drainage. The plan for the patient's pressure sores was local wound care and surgical consult.
- A physician's order dated 06/14/14 at 4:38 AM, for consult to the Skin Care Team.
- Physicians' orders for 06/14/14 did not include wound care for the pressure sores.
- A surgical consult dated 06/14/14 at 7:03 AM, indicated the patient had a pressure sore posterior (behind) to the rectum, but did not include wound care recommendations or orders.
- A Skin Care Team consult dated 06/14/14 at 11:38 AM, indicated the patient had pressure related skin breakdown, did not include wound care recommendations or orders.
- Physicians' orders on 06/15/14 did not include wound care for the pressure sores.
- A surgical report dated 06/15/14 at 10:55 AM, indicated that the patient underwent decubitus ulcer (pressure sore) debridement (removal of dead, damaged, or infected tissue).
- Wound care documentation on 06/15/14 at 4:55 PM, indicated that the patient's pressure sore/wound measured 4 centimeters (cm, unit of measure) long, by 8 cm wide, by approximately 3 cm deep.
- A physician's order for wound care was not received until 06/16/14 at 8:03 AM, greater than 48 hours after the patient was admitted with worsening wounds.

3. During an interview on 06/18/14 at 11:17 AM, Staff YY, Wound Care Nurse (WCN), stated that:
- Per the facility's policy, all wound care (includes pressure sores) should be directed by a physician's order.
- The physician's order should direct wound care as soon as a wound has been recognized.
- The Skin Care Team was available seven days a week from 7:00 AM until 3:30 PM or 4:30 PM.
- The Skin Care Team nurse, after evaluation of a patient's wounds, would contact the patient's physician for orders. If a physician did not respond to the Skin Care Team nurse, the wound care orders would be obtained by the patient's primary nurse.
- There were no wound care orders for Patient #26 until 06/16/14 at 9:00 AM, greater than 48 hours after the patient was admitted for worsening pressure ulcers.

4. Record review of current Patient #20's H & P, dated 06/10/14, showed he was admitted to the medical intensive care unit on that date with eight pressure sores.

Record review of a Pressure Ulcer (sore) Prevention Nurse Note, dated 06/12/14, showed he had the following:
- A Stage II (Partial thickness skin loss. Is usually superficial and presents clinically as an abrasion, blister or shallow crater) pressure sore on the left upper buttock that measured 0.3 centimeters (cm) by 0.5 cm;
- A Stage II pressure sore on the coccyx (tailbone) that measured 0.7 cm by 1.0 cm;
- A stage II pressure sore on the left buttock that measured 0.6 cm by 0.6 cm;
- A stage II pressure sore on the left lower buttock that measured 0.9 cm by 0.6 cm;
- A stage II pressure sore on the right buttock that measured 1.2 cm by 1.5 cm;
- A stage II pressure sore on the right lower buttock that measured 1.2 cm by 1.6 cm;
- A stage II pressure sore on the right hip that measured 1.4 cm by 2.1 cm; and
- A stage II pressure sore on the right shoulder that measured 0.5 cm by 0.4 cm.
- For the coccyx area, the WCN recommended to cleanse with soap and water, pat dry, apply a sacral border dressing such as Mepilex, and change every five days or as necessary.
- For the right hip area, the WCN recommended to cleanse with soap and water, pat dry, and apply a 4-inch by 4-inch Mepilex dressing, and change every five days or as necessary.
- For additional wounds the WCN recommended to use a silicone border dressing.

5. During an interview, on 06/17/14 at 3:45 PM, Staff TT (responsible for Patient #20), Registered Nurse (RN), stated that, typically, the physician ordered a skin assessment by the wound care team, the wound care team communicated their recommendations to the physician and the physician then gave the appropriate orders for treatment. Staff TT confirmed there were no physician's orders for treatment for Patient #20.

6. During an interview on 06/18/14 at 10:30 AM, Staff GGG (responsible for Patient #20), RN, stated that an order for treatment for the patient's pressure sores was received earlier this morning.

7. Observation on 06/18/14 at 10:35 AM, showed the following:
- A Stage II pressure sore on the left upper buttock that measured 0.8 cm by 0.9 cm (indicating an increase in size since admission);
- A Stage II pressure sore on the coccyx (tailbone) that measured 4.7 cm by 4.0 cm (indicating an increase in size since admission);
- A stage II pressure sore on the left buttock that measured 0.6 cm by 0.6 cm;
- A stage II pressure sore on the left lower buttock that measured 1.0 cm by 0.8 cm(indicating an increase in size since admission);
- A stage II pressure sore on the right buttock that measured 1.2 cm by 1.5 cm;
- A stage II pressure sore on the left lower buttock that measured 0.7 cm by 1.5 cm;
- A stage II pressure sore on the right hip that measured 1.4 cm by 2.1 cm; and
- A stage II pressure sore on the right shoulder that measured 0.5 cm by 0.5 cm (indicating an increase in size since admission).

8. Record review of the patient's physician's orders from admission (06/10/14) through 06/18/14, showed facility staff failed to obtain physician's orders to treat the patient's pressure sores until 8:10 AM on 06/18/14, after surveyor inquiry. The physician ordered soap and water cleanse, Mepilex dressings, and change every three days and as necessary. The order failed to address if each area was to be treated the same.

9. Record review of the facility's Nursing policy titled, "Dismissal" (patient discharge), dated 01/10, showed direction for nurses to return unused medications to the Pharmacy.

Record review of the facility's Pharmacy policy titled, "Drug Expiration," dated 03/14, showed that it was the responsibility for all staff to check expiration dates when dispensed, when returned for credit, and on a monthly basis. The supervisor for each area was responsible for staff assignment and documentation of expiration date checks.

10. Observation on 06/18/14 at 10:15 AM showed one flu vaccine (an injectable medication used to prevent the flu virus) for discharged Patient #33, dated 05/29/14 with an expiration date of 05/30/14.

11. During an interview on 06/18/14 at 10:15 AM, Staff DDD, RN, stated that usually the nurse who discharged a patient was the one who returned the medication to the pharmacy and she agreed that it was not done when Patient #33 was discharged .

12. During an interview on 06/18/14 at 10:25 AM, Staff LLL, RN, Director for Behavioral Health stated that the nurse who discharged the patient should have placed the medication in the bin for pharmacy pick up. She also stated they had no mechanism to check for outdated medications in the refrigerator.

13. During an interview on 06/18/14 at 10:30 AM, Staff EEE, Pharmacist, stated that nursing staff was responsible to place unused and expired medications in the pharmacy bin for return.
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
Based on interview, record review, and policy review the facility failed to ensure that blood products were administered according to facility policy for two current patients (#7 and #27) and one discharged patient (#2) of five patients' records reviewed who had received blood. This had the potential to increase the risk of the patients experiencing a blood transfusion reaction, which can be extremely dangerous and potentially lead to death. The facility infuses an average of 1200 blood products per month. The facility census was 484.

Findings included:

1. Record review of the facility's policy titled, "Administration of Blood or Blood Components," revised 12/13, showed direction for facility staff to:
- Obtain a set of vital signs prior to obtaining blood or blood product.
- Use two qualified persons, two nurses or a nurse and another licensed independent practitioner, to identify (verify) the recipient at the bedside.
- Initiate documentation in the electronic health record (EHR).
- Document vital signs 15 minutes after the blood or blood components reach the patient, then check vital signs every 15 minutes for the first 30 minutes of the transfusion, then every 60 minutes until the transfusion is complete.
- Note the time the transfusion was completed in the EHR.

Record review of the facility's policy titled, "Transfusion Reaction," revised 12/13, showed the following could indicate a transfusion reaction:
- A fever (body temperature elevation greater than two degrees above 98.6 degrees Fahrenheit);
- Respiratory distress, including difficulty breathing, increase or decrease respiratory rate, or low oxygen levels; and
- Sudden increase or decrease in blood pressure levels.

2. Record review of current Patient #7's medical record showed the following:
- The transfusion record indicated that blood transfusions were initiated on 05/29/14 at 6:00 AM (first transfusion) and 7:39 AM (second transfusion), and on 06/01/14 at 2:14 PM (third transfusion). The third transfusion was not verified by a second qualified person.
- The patient's vital sign log should have contained the patient's temperatures on 05/29/14 at approximately 6:15 AM and 6:30 AM for the first transfusion, at approximately 8:00 AM, 8:15 AM, and 8:45 AM for the second transfusion, and on 06/01/14 at approximately 2:30 PM and 2:45 PM for the third transfusion, but the patient's temperatures were not documented at those times.
- The patient's vital sign log should have contained the patient's blood pressure on 05/29/14 at approximately 6:15 AM for the first transfusion, and on 06/01/14 at approximately on 2:30 PM and 2:45 PM for the third transfusion, but the patient's blood pressure was not documented at those times.
- The patient's vital sign log indicated that the patient's blood pressure (normal is 90/60 to 140/90) elevated from 136/95 at 2:00 PM, to 153/100 at 3:00 PM and 196/127 at 4:00 PM, during the third blood transfusion.
- The patient's vital sign log indicated that the patient's respiratory rate (normal 12-20 breaths per minute) elevated from 18 breaths per minute at 2:00 PM to 49 breaths per minute at 4:00 PM, during the third blood transfusion.
- The patient's vital sign log indicated that the patient's oxygen level (normal is 90 to 99 percent) decreased from 99 percent at 2:00 PM to 86 percent at 3:00 PM, during the third transfusion, and the patient required supplemental oxygen by mask.
These changes in the patient's vital signs could have indicated that the patient was having a blood transfusion reaction during the third transfusion. Staff failure to assess or document the patient's vital signs according to policy could cause a blood reaction to go unidentified and or untreated.

During an interview on 06/16/14 at 2:35 PM, Staff E, Co-Manager of 3A Surgical Department, stated the following during Patient #7's medical record review:
- The third blood administration should have included a second nurse verification;
- A complete set of vital signs, including the patient's temperature, pulse, respiratory rate, blood pressure and oxygen saturation (oxygen level in the blood) should be taken before the blood administration was started, when the blood reached the patient (infused into the patient's vein), 15 minutes after the blood reached the patient, in another 15 minutes, in 30 minutes, and then hourly.
- The patient's missing vital signs should have been documented during the blood administration.

3. Record review of current Patient #27's medical record showed the following:
- The transfusion record indicated that a platelet (blood cells that stop bleeding) transfusion was initiated on 06/13/14 at 7:49 PM, but was not verified by a second qualified person.
- The patient's vital sign log should have contained the patient's temperature at approximately 8:15 PM and approximately 8:45 PM, but the patient's temperature was not documented at those times.
- The patient's vital sign log should have contained the patient's blood pressure at approximately 8:00 PM, but the patient's blood pressure was not documented at that time.
- The transfusion record did not indicate the time the transfusion was completed.

During an interview on 06/17/14 at 1:43 PM and again at 2:17 PM, Staff AAA, Nurse Manager of 3 East Intensive Care Unit (ICU), stated:
- She did not know why staff did not document the patient's vital signs as required.
- She was not aware of the missing vital sign documentation until the survey.
- She was unable to determine if the patient had experienced a transfusion reaction because the patient's temperature was not recorded as per the facility policy.
- She did not review blood administration records for completeness of vital sign and verifiers as part of the quality assurance program.

4. During an interview on 06/18/14 at 9:50 AM, Staff H, Chief Nursing Officer (CNO), stated (related to blood transfusions) that she knew the facility was not doing what they should. "We have an opportunity for improvement."

5. Record review of Blood transfusion Quality Assurance showed no indicators related to vital sign completion or the presence of a second blood product verifier documentation in the medical record.

6. Record review of discharged Patient #2's History and Physical, dated 05/10/14, showed he was admitted on that date with severe dehydration (lack of fluids in the body), and anemia (a below normal level of hemoglobin, or the protein found in blood that transports the oxygen).

Record review of the patient's hemoglobin levels showed the patient had a 7.0 g/dl (grams per deciliter) level (normal = 14.0 g/dl-18.0 g/dl) on 05/19/14, and 7.7 g/dl on 05/21/14.

Record review of Transfusion Records showed:
- That blood transfusions were initiated on 05/19/14 at 7:37 AM and on 05/21/14 at 8:21 AM. The second transfusion was not verified by a second qualified person.
- The patient's vital sign log, dated 05/19/14, showed staff failed to document the patient's blood pressure throughout the transfusion.
- The patient's vital sign log, dated 05/21/14, showed staff failed to document the patient's temperature throughout the transfusion.

During an interview on 06/18/14 at approximately 3:30 PM, Staff JJ, Executive Director of Nursing, stated that there was no evidence in the patient's record that the vital signs were taken and/or documented per policy.