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.

PROVIDENCE HOSPITAL 1150 VARNUM ST NE WASHINGTON, DC 20017 May 9, 2018
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0146
Based on observation, policy and medical record review, and staff interviews, the registration staff failed to ensure the confidentiality of patients' sensitive information, whose health information or electronic medical records (EMRs) were left open and unattended, in five of 10 observations (Patients #26, 27, 29, 33, and 34). This is a repeat finding from the annual licensure survey conducted on 06/14/17.

Findings included ...

Record review of the hospital's policy titled, "Patient Rights and Responsibilities", revised 05/13, shows that all patients have the right to privacy.

Record review of the hospital's policy titled, "Clinical Documentation", revised 03/16, showed that staff are to keep clinical data confidential and secure at all times.

A. During a tour in the Emergency Care Center (ECC) on 05/04/18, at approximately 10:30 AM, the surveyor observed the computer, located in the nursing station, unattended and displaying Patient #26's personal identifiers, to include the patient's name, age, date of birth, height and weight, and allergies. Employee #27, Registered Nurse, was logged into the computer.

The practice failed to follow the hospital's policy to ensure the privacy and confidentiality of patients' medical/health information.

During a face to face interview on 05/04/18, at approximately 10:35 AM, with Employee #27, she explained she is aware of the policy and acknowledged the findings.

B. During a tour in the ECC on 05/04/18, at approximately 10:40 AM, the surveyor observed a laptop computer, located in the nursing station, unattended and displaying Patient #27's personal identifiers, to include the patient's name, age, date of birth, height and weight, and allergies. Employee #28, Medical Scribe, was logged into the computer.

The practice failed to follow the hospital's policy to ensure the privacy and confidentiality of patients' medical/health information.

During a face to face interview on 05/04/18, at approximately 10:45 AM, with Employee #28, she explained that she usually closes her computer, when not in use. She acknowledged the findings.

C. During a tour of the Cardiac Catheterization Room on 05/08/18 at approximately 2:30 PM, the surveyor observed the computer, open, unattended and displaying Patient #29's personal identifiers, to include the patient's name, age, date of birth, height and weight, and allergies. Employee #37, Registered Nurse, was logged into the computer.

The practice failed to follow the hospital's policy to ensure the privacy and confidentiality of patients' medical/health information.

During a face to face interview on 05/08/18, at approximately 2:30 PM, with Employee #37, she acknowledged the findings and closed the screen.

D. During a tour in the Infusion Center on 05/07/18, at approximately 11:16 AM, the surveyor observed the computer, located in nursing station, unattended and displaying Patient #33's personal identifiers, to include the patient's name, age, date of birth and allergies. Employee #41, Registered Nurse, was logged into the computer.

The practice failed to follow the hospital's policy to ensure the privacy and confidentiality of patients' medical/health information.

During a face to face interview on 05/07/18, at approximately 11:25 AM, with Employee #41, she acknowledged the findings.

E. During a tour in the Infusion Center on 05/07/18, at approximately 11:17 AM, the surveyor observed the computer, located in nursing station, unattended and displaying Patient #34's personal identifiers, to include the patient's name, age, date of birth and allergies. Employee #42, Registered Nurse, was logged into the computer.

The practice failed to follow the hospital's policy to ensure the privacy and confidentiality of patients' medical/health information.

During a face to face interview on 05/07/18, at approximately 11:20 AM, with Employee #42, she acknowledged the findings.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff confirmation, it was determined that the medical staff failed to ensure that the discharge summary was completed, within 30 days after discharge, in two of nine discharge records (Patients #7and 1).

The findings include:

A. Review of Patient #7's medical record showed the patient diagnoses included [DIAGNOSES REDACTED]

The surveyor reviewed the medical record on 05/08/18 at approximately 11:30 AM, in the presence of Employee #123. The record revealed the patient left AMA (Against Medical Advice) on 04/03/18; however, the medical record lacked evidence that a discharge summary and AMA form was completed, within 30 days after discharge.

The medical record lacked documented evidence that medical staff ensured the discharge summary and "Against Medical Advice" form was completed.

Employee's #123 acknowledged the findings.


B. Review of Patient #1's medical record showed the patient had a right thyroid lobe nodule.

The surveyor reviewed the medical record on 05/08/18 at approximately 12:00 PM, in the presence of Employee #123. The record revealed the patient had an ultrasound-guided fine-needle biopsy of the right thyroid lobe nodule on 04/16/18.

The medical record lacked documented evidence that medical staff ensured a discharge summary was completed.

Employee #12 acknowledged the findings.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and staff interview, the hospital failed to maintain supplies and equipment, in a manner that the safety and well-being of patients are assured, in two (2) of nine observations.

Findings included ...

A. During a tour of the Intensive Care Unit (ICU) conducted on 05/04/18 at 10:05 AM, the surveyor observed an unlocked cart, located in the hallway between patient rooms. The cart contained a Percutaneous Sheath Introducer Kit, with a scalpel. The observation was made in the presence of Employee #49, Program Coordinator.

The practice lacked evidence that staff maintained a safe environment to prevent the risk of sharps injury.

Employee #49 acknowledged the findings.

B. During a tour of the ICU conducted on 05/07/18 at 9:45 AM, the surveyor observed an unlocked rapid response cart, containing multiple intravenous needles. The observation was made in the presence of Employee #49, Program Coordinator. She stated that the cart is usually kept locked.

The practice lacked evidence that staff maintained a safe environment to prevent the risk of sharps injury.

Employee #49 acknowledged the findings.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on observations, reviews of records and staff interviews, the Governing Body failed to develop effective mechanisms to ensure the Chief Executive Officer managed the hospital to ensure: provisions for tracheostomy care and obstetric services, and that expired supplies were not available for patient use.

Findings included ...

1. Review of the Patient #16's medical record showed the patient had a chronic tracheostomy.

On 05/07/18 at approximately 11:00 AM, the surveyor conducted a tracheostomy care observation, performed by Employee #120, Registered Nurse. During the observation, the surveyor observed dried greenish, brown substance, inside the inner cannula and to the left of the stoma when Employee #120 removed the inner cannula to clean it.

Review of nursing and respiratory documentation lacked documented evidence of the performance of tracheostomy care from 05/04/18 to 05/07/18. Further record review lacked evidence that the Chief Executive Officer established an effective mechanism to ensure policies and procedures for tracheostomy care.

During a face-to-face interview on 05/07/18 at 11:30 AM PM with Employee #7, Nurse Manager, she revealed there was no documented evidence for the performance of tracheostomy care provided since 05/02/18. Employee #120, Registered Nurse requested that Employee #47, Respiratory Therapist perform an assessment of the patient's stoma site. Employee #47 reported the substance to the left of the stoma was "dried mucus."

There was no evidence that the Chief Executive Officer established a mechanism to ensure policies and procedures were developed for the management of patients with a tracheostomy.

Employees #7, 47 and 120 acknowledged the findings at the time of the observation.

2. Record review on 05/04/18 at approximately 10:00 AM revealed the state agency received a letter dated, 08/16/17 from the hospital, regarding changes to obstetric services. The letter detailed the hospital would not accept new obstetric patients, with delivery dates after 10/12/17 and would exit pregnancy related services, effective 10/17/17.

During a face-to-face interview on 05/04/18 at approximately 11:00 AM, with Employee #4, Director of Emergency Medicine, he explained that obstetric services were discontinued in 10/17; and explained the process for addressing patients who present less than and more than 20 weeks pregnant. He communicated that the medical staff received training related to their process and "challenging deliveries and preemies," and they have an arrangement with the Obstetric Department at a local hospital to transfer patients more than 20 weeks pregnant, requiring inpatient obstetric services. Employee #4 added he was unaware of a written agreement or arrangement, and explained that though it is not in writing, the medical team had the Obstetrician numbers and typically discussed the transfer situations case by case, telephonically. He also shared the nursing staff underwent training, as well.

However, record review of training did not support the hospital specific provisions for treatment for pregnancy services. Additionally, there was no documented evidence that the hospital staff developed a transfer agreement with local acute hospital (s), regarding obstetric services.

The practice lacked documented evidence that the Chief Executive Officer established a mechanism to ensure policies and procedures were developed for the management of pregnancy services, in the absence of obstetric services

During a subsequent face-to-face interview on 05/07/18 at approximately 11:00 AM, with Employee #2, Director of Quality, she could provide no hospital specific training for pregnancy services, or Memorandum of Understanding/transfer agreement for continuity of care, for patients requiring in-patient obstetric services. She acknowledged the findings.

3. Based on observation and staff interviews, the Governing Body failed to establish a mechanism that ensured expired supplies were not stored and available for patient use to maintain patient safety, in 12 of 15 observations. This is a repeat finding from the survey conducted on 06/14/17.

A. During a tour of the Emergency Care Center (ECC) on 05/04/18 at approximately 10:20 AM, the surveyor observed expired supplies, in the following areas:

ECC Room 20 - one culture and sensitivity vacutainer that expired 09/15 and one Swab specimen collection kit that expired 04/30/18

ECC Room 22 - one unisex collection swab that expired 01/31/18

ECC Room 23 - two aerobic blood culture vials that expired 03/31/18

Diagnostic Room in Provicare (fast track area) - two culture and sensitivity vacutainers that expired 11/15 and two that expired in 04/16

Laboratory Room in Provicare area- one bottle of Hydrogen Peroxide that expired 12/17

The practice lacked evidence that the Chief Executive Officer assured a safe environment that ensured expired supplies were not available for patient use.

The observation was made in the presence of Employee #22, Nurse Manager, who acknowledged the findings.

B. During a tour of the radiology department to include the interventional treatment area on 05/07/18 at approximately 11:00 AM, the surveyor observed the supply cart, with a general purpose probe that expired 05/16, and a stylet kit that expired 10/28/17, stored in the second drawer.

The practice lacked evidence that the Chief Executive Officer staff assured a safe environment that ensured expired supplies were not available for patient use.

The observation was made in the presence of Employee #36, Manager of Cardiology Laboratory. He acknowledged the findings.

C. During a tour of the Cardiac Catheterization Room on 05/07/18 at approximately 2:20 PM, the surveyor observed the station cart, with the following expired supplies: one Colorimeter C02 (carbon dioxide) detector that expired 11/14, four blue top blood tubes that expired 12/31/17 and one that expired 04/30/18, and one green top blood tube that expired 01/31/18.

The practice lacked evidence that the Chief Executive Officer assured a safe environment that ensured expired supplies were not available for patient use.

The observation was made in the presence of Employees #37, Registered Nurse, and #38 and #39, Cardiology Technicians. All employees acknowledged the findings.

D. During a tour of the Cardiac Catheterization Room on 05/07/18 at approximately 2:20 PM, the surveyor observed one set of adult electrodes, with an expiration of 06/17, stored on the code cart, available for patient use. The observation was in the presence of Employees #37, Registered Nurse, and #38, Cardiology Technician.

The practice lacked evidence that the Chief Executive Officer ensured the supplies, likely used in emergency situations, were up to date and ready for use.

During a face-to-face interview on 05/07/18 at approximately 2:30 PM, Employee #37 explained she was responsible for code cart maintenance. She acknowledged the findings.

E. During a tour of the Intensive Care Unit (ICU) medication room, conducted on 05/04/18 at 10:15 AM, the surveyor observed two Carpujets [syringe device used for injections] of Epinephrine one milligram (mg)/10 milliliters (ml), located in a cabinet with an expiration date of 04/18. The observation was made in the presence of Employees #48, Charge Nurse, #55, Informatics Nurse, and #49, Program Coordinator.

The Chief Executive Officer failed to establish a mechanism to ensure medications were not used beyond expiration dates.

All employees acknowledged the findings.

F. Record review of hospital policy titled, "Floor Stock," dated 04/16, showed that anyone opening a multi dose vial should write an expiration date for 28 days, after the date the vial is opened [written on the vial with an indelible pen].

During a tour of 8-South Medical Surgical Unit on 05/07/18, at approximately 10:00 AM, the surveyor observed an open, undated multi dose vial of insulin in the medication refrigerator, located in the nursing station. The observation occurred in the presence of Employees #61, Registered Nurse (RN) and # 31, Scribe from Quality.

The practice lacked evidence that the Chief Executive Officer established a hospital policy for opened multi dose medication vials.

A face to face interview conducted at that time, with Employee #61, who acknowledged the finding.

G. During a tour of Outpatient Clinic on 05/08/18, at approximately 2:30 PM, the surveyor observed an open, undated multi dose insulin vial in the medication refrigerator. The observation occurred with Employee's #65 RN and 66, Director of Behavioral Health.

The practice lacked evidence that the Chief Executive Officer established a mechanism to ensure open dose medication vials are dated.

A face to face interview, at that time, conducted with Employee #65, who acknowledged the finding.

H. During a tour medical supply room, on 8 South on 05/07/18, at approximately 9:25 AM, the surveyor observed one Central Venous Catheterization Kit that expired 04/30/18.

The observation was in the presence of Employees #61 Registered Nurse and #31, Quality Scribe.

The practice lacked evidence that the Chief Executive Officer established an mechanism to ensure expired supplies were not available for patient use.

The surveyor conducted a face-to-face interview, at the time of the observation, with Employee #61, She acknowledged the finding.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, policy review and staff interview, hospital staff failed to maintain the personal privacy of a patient, who was exposed to passersby, during care and treatment, in an isolated observation observations (Patient #30).

Findings included...

Record review of the hospital's policy titled, "Patient Rights and Responsibilities," last revised 05/13, shows ..."13. All patients have the right to privacy ..."

During a tour of the Cardiac Catheterization area on 05/07/18 at approximately 3:00 PM, the surveyor observed Employee #40, Registered Nurse, performing an assessment in the hallway outside of the room, on Patient #30. The patient's lower extremities were uncovered and in view of passersby.

The practice failed to follow the hospital's policy to provide the patient personal privacy.

During a face to face interview on 05/07/18, at approximately 3:10 PM, with Employee #40, he explained that he was preparing the patient for a scheduled procedure, and since there was another patient in the procedure room, he decided to assess the patient's pedal pulses, in the hallway to expedite the process. He acknowledged the findings.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on review of preventive maintenance and service history reports, service request logs, manufacturer's guidance, and staff confirmation, the hospital staff failed to ensure equipment was monitored and/or serviced to ensure proper functioning in three (3) of 12 observations.

Findings included ...

A. A review of the hospital's manufacturer documents for the "Nihon Kohden AS-940PA Transmitters" (telemetry devices) revealed that staff are to perform maintenance inspections of the telemetry devices at least every six months for the instruments and parts.

During record review on 05/07 /18 at 3:30 PM, of preventive maintenance and service history reports and service request logs; documentation revealed the Nihon Kohden Transmitter telemetry devices located in the ICU were inspected and serviced to verify functionality on occasions when the instrument malfunctioned.

There was no evidence of scheduled maintenance (e.g. preventive maintenance) inspections at least every six months as stipulated by the manufacturer.

B. During a tour of the 2 South unit on 05/04/18 at approximately 10:30 AM, in the presence of Employee #7, Unit Manager, the surveyor observed the "Life Pak 20e/Defibrillator/Monitor" with an inspection tag that read "due 03/18."

The practice lacked evidence that staff performed preventative maintenance [March 2018] to ensure functionality of the defibrillator.

Employees #7 and #74, Director of Biomedicine acknowledged the findings at the time of observation.

C. Review of the hospital's undated policy titled, "Nova-Stat Glucometers," showed that staff are to perform quality control, every 24 hours.

During a tour of the Infusion Center on 05/07/18, at approximately 11:30 AM, the surveyor reviewed the quality control monitoring from 04/26/18 to 05/04/18 on the Nova-Stat glucometer, in the presence of Employees #42, Registered Nurse and #112, Educator. The results revealed that quality controls were not performed from 05/01/18 to 05/04/18.

The practice failed to ensure that staff performed quality control testing to ensure proper functioning of the glucometer.

During a face-to-face interview on 05/07/18 at approximately 11:50 AM, Employee #42 explained that quality control testing should be performed every day. She acknowledged the findings.

During a subsequent face-to-face interview on 05/08/18 at approximately 12:30 PM, Employee #51, Laboratory Director, explained that quality controls are to be performed every 24 hours. He acknowledged the findings
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
1. Based on observation and staff interview and confirmation, the hospital staff failed to follow the hospital policy for the reprocessing of endoscopes, in five of eight observations.

Findings included ...

A. Review of the hospital's policy titled, "Perioperative Services Flexible Endoscopes," showed that staff are to allow endoscopes to air dry, before storing or placing in cabinets for reuse.

During an observation of the manual cleaning and high level disinfection process for endoscopes, on 05/07/18 at 10:00 AM, the surveyor observed Employee #20 using a towel from a cabinet in the Endoscopy Room, to dry the wet endoscope, after finishing the high level disinfection process, and before storing it for reuse. The observation was in the presence of Employee #21.

The practice lacked evidence that staff followed the policy to prevent contamination of the endoscope.

Employees #20 and 21 acknowledged the findings.




B. The Centers for Disease Control (CDC) recommends the following sequence to apply Personal Protective Equipment (PPE), "...1. Gown ...Mask or respirator ...Goggles or face shield ...Gloves ..." If worn, gowns should fully cover torso, from neck to knees, arms to end of wrists, wrap around the back and fasten in back of neck and waist.

https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf

The Centers for Disease Control (CDC) recommends that gown and gloves are worn for all interactions involving contact with patients or with the patients' environment, who is on contact isolation.

https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html

The Centers for Disease Control (CDC) recommends that hand hygiene be performed before direct contact with patient, after direct contact with the patient and inanimate objects, and after glove removal.

https://www.cdc.gov/handhygiene/providers/index.html

During a tour of the Intensive Care Unit (ICU) on 05/04/098 at 12:15 PM, the surveyor observed patient room #282 with a sign posted outside the room, indicating the patient was on contact isolation. Employee #124, Patient Care Technician, was seen inside the room, with a partially donned isolation gown, adjusting the blinds. The observation was made in the presence of Employee # 49, Program Coordinator.

During a face to face interview at the time of the observation, the surveyor asked Employee #124, about the proper procedure for donning Personal Protective Equipment (PPE), when entering the room of a patient on contact isolation. She stated that she should have put on a gown and gloves before entering the room.

Employees #124 and 49 acknowledged the findings.

C. During a tour of unit 6 South conducted on 05/07/18 at 11:17 AM, the surveyor observed Patient room #629, with a posted sign for enteric precautions, and workstation on wheels (WOW) located inside the room. The surveyor then observed Employee #44, Registered Nurse, enter the room without donning gown and gloves. She retrieved the WOW and exited the room. Employee #44 did not sanitize her hands before entering the room, did not wear gown and gloves, and did not clean the WOW after removing it from the room. The surveyor made the observation in the presence of Employee #55, Informatics Nurse, and Employee #45, Nursing Supervisor for 6 South.

There was no evidence that nursing staff practiced infection prevention precautions as to prevent the spread of infection.

During a face to face interview at the time of the observation with Employee #44, she stated that she wanted to demonstrate the process of administering medication to a patient on enteric isolation. She sanitized her hands, donned gown and gloves, and entered the room with the medication scanner and scanned the wristband of the patient. She placed the scanner on the WOW that located outside of the room, doffed her gown and gloves and exited the room. She did not sanitize the scanner, before placing it on the WOW, and did not sanitize the WOW.

Employees #44, 45 and 55 acknowledged the findings.





D. Review of Patient # 49's medical record on 05/07/18, at approximately 1:10 PM, showed that the patient had a diagnosis of methicillin-resistant staphylococcus aureus (MRSA) infection of the right knee wound.

On 05/07/18, at approximately 1:20 PM, the surveyor observed contact isolation precautions signage on Patient #49's door. The surveyor observed Employee #67, Maintenance Worker, walking into the patient's room, without wearing PPE. The surveyor asked Employee #67 if he was aware that the patient was on contact isolation, and that he is required to wear PPE when entering the room. Employee #67 stated that he is aware of the policy for PPE, and that he forgot to look at the door sign, while checking the privacy curtain in the patient's room.

The practice lacked evidence that hospital staff followed standards of care for contact isolation.

During an interview on 05/07/18, at approximately 1:25 PM, Employee # 67 acknowledged the finding.

E. At approximately 1:50 PM, the surveyor observed a dressing change for Patient #49. Employee #43, Wound Care Nurse, in the presence of Employees #61, Nursing Supervisor for 8 South, and #62, Quality Registered Nurse. The surveyor asked Employee #61 why the back of her PPE gown was untied and open in the room. Employee #61 stated that the gown had untied itself.

The practice lacked evidence that nursing staff followed standards of care for the appropriate use of PPE.

During an interview on 05/07/18, at approximately 1:55 PM, Employee # 61 acknowledged the finding.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on open and closed record reviews, personnel record review, and staff interviews, the hospital failed to ensure: integration of services to include adequate treatment for lice infestation to meet the emergency care needs of a patient presenting to the Emergency Care Center (ECC) (Patient #42), patient assessments, and appropriate discharge instructions; staff met personnel requirements; and ensure policies and procedures for the provision of obstetric services, specific to the hospital.

The cumulative effect of these systemic practices resulted in the hospital's failure to comply with Conditions of Participation for Emergency Services.

Findings included ...

Noncompliance as follows to:

42 CFR 482.55(a) (2) - A-1103 The hospital must assess and render appropriate care in the emergency department

42 CFR 482.55(a) (3) - A-1104 The hospital must have policies and procedures governing medical care in the emergency department

42 CFR 482.55(b) - A-1110 The hospital must ensure emergency services personnel requirements are met
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on open and closed record reviews, personnel record review, and staff interviews, the hospital failed to ensure the integration of emergency services to include patient assessment and/or rendering appropriate care and providing appropriate discharge instructions, in four of eight patient records reviewed for emergency services in four of ten medical records reviewed (Patients #42, 23, 24, and 25).

Findings included ...

A. Review of the Federal Drug Administration guidance for the administration of Permethrin (a topical cream used for the treatment of bed bugs/lice), showed that the hospital should provide the patient with the instruction that medication is to be left on the skin for eight to 14 hours, and then washed off by taking a shower or bath.

https://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm 5.pdf

Review of the Emergency Care Center (ECC) Triage note dated 01/19/18 at 1:17 PM, showed that Patient #42 was brought to the ECC by ambulance on 01/19/18 at 12:50 PM, with a complaint of general weakness and lice. The Ambulance Run sheet [document recorded by first responders with pertinent patient information] showed that the patient had a "lice infestation and possibly bed bugs in his hair and on clothes ..." The triage note revealed the patient had no treatment for lice, prior to arrival; and his history included Schizophrenia. Further review of the ECC record lacked evidence that nursing staff performed a skin assessment, relative to the findings.

Review of physician "Emergency Department" documentation dated 01/19/18 at 3:24 PM, revealed the history of present illness, "Patient #42 was a "[AGE] year old male brought to the [ECC] because of pruritic rash, and in the [ECC] was found to have body lice ...alert and oriented to person place and time and walks without assistance" Further review of the physician's physical examination showed that the patient had generalized body scratches with "lichenification" [thick leathery patches of skin as a result of excessive scratching] and lice. The physician documented that the patient "...was treated and discharged ."

Review of the medication orders revealed that the physician ordered Permethrin 5% Cream 60 grams (gm) for the patient at 1:42 PM. The nurse documented the administration on the electronic medication administration record (eMAR); however, the record lacked documented evidence of the location of cream application, additional infection control measures taken to delouse the patient, and discharge instructions provided to the patient, regarding care after Permethrin administration. Patient #42 was given a prescription for Benadryl and discharged from the ECC at 4:14 PM on 01/19/18, via wheelchair.

Successive review of the ECC Triage note dated 01/20/18 at 06:50 AM showed that Patient #42 was brought back to the ECC on 01/20/18 at 06:39 AM. " ...patient was found by police laying in the bus stop unresponsive ..." Triage vital signs revealed Temperature 88 degrees Fahrenheit, a heart rate (HR) of 53 beats per minute, respiratory rate (RR) of 12, and blood pressure of 63/37 millimeters of mercury (mmHg). Further review of ECC nursing documentation revealed emergency measures taken to address the patient's current status and documentation at 7:30 AM revealed the patient had lice.

Review of physician "Emergency Department" documentation dated 01/20/18 at 1:47 PM, showed Patient #42 had severe hypothermia, vasopressor-dependent shock, acute vent dependent respiratory failure, cardiopulmonary arrest, from severe metabolic acidosis, generalized seizures, and a "massive lice infestation." The patient was subsequently admitted to the intensive care unit.

Review of the nursing note recorded in the intensive care unit dated 01/20/18 at 9:00 PM, revealed "patient is noted with dreadlocks and abundant live head lice crawling from his head; dreadlocks were cut one by one and more nests of head lice noted pouring out of the patient's head ..."

The practice lacked evidence that during the patient's initial presentation to the emergency department on 1/19/18 at 1:42 PM, nursing staff failed to perform a skin assessment reflective of the patient's parasitic infestation. There was no evidence that staff rendered appropriate and adequate treatment to eradicate the diagnosed parasitic infestation prior to discharge on 1/19/18 at 4:14 PM as evidenced by the "massive lice infestation" that was assessed upon his reentry to the hospital [1/20/18 6:50 AM]. Additionally, there was no evidence that the patient was provided education and/or discharge instructions for the management and prevention of lice infestation.

During a telephone interview conducted on 05/23/18 at 11:30 AM, with Employee #4, Emergency Care Center Director, regarding the treatment of patients with lice infestation, he stated that the nurse takes the patient to a decontamination area, where the medication is applied. If the cream is to be washed off, then instruction is given to the patient to indicate such. He stated that he did not see documentation in the record that the patient received that instruction.

During a telephone interview conducted on 05/23/18 at 12:18 PM, with Employee #27, Registered Nurse, assigned to the patient, she was asked the process for assessing and delousing Patient #42. Employee #27 said that she performed a head to toe assessment, gave the patient a shower, applied the cream and washed it off, after 45 minutes (contrarily, the medication is to be left on the skin for eight to 14 hours, and then washed off by taking a shower or bath). When asked about the documentation of the head to toe assessment and treatment performed, Employee #27 said that she did not document that information. The surveyor then inquired how she ensured a safe discharge for Patient #42 to include discharge instructions about Permethrin; she could not specify the instructions provided to the patient.

Employees #4 and #27 acknowledged the findings.

B. Record review of the hospital's policy titled, "Clinical Documentation," revised 03/16, showed that nursing staff are to perform a systems review of each patient assessment, once every 24 hours minimum. Physical and skin assessments and interventions are performed and documented every 12 hours. Reassessments are performed to include new or changes in condition and pain management. Discharge documentation includes pain assessment. " ...Charting should reflect assessments, observations, interventions and patient responses to care treatment, education ...from admission to discharge ..."

Record review of the hospital's policy titled, "Pain Management," revised 03/14/16, showed that nursing staff are to perform pain assessments to include quality, intensity, location, onset, duration, variation and patterns, aggravating/alleviating factors, impact on function and quality of life [characteristics of pain].

Review of Patient #23's medical record on 05/04/18 at approximately 11:30 AM, revealed the nurse triaged the patient in the Emergency Care Center (ECC) on 05/04/18 at 6:29 AM, who had a complaint of shortness of breath for five days. Nursing staff administered Prednisone, as ordered.

However, the record lacked evidence the nurse performed and documented a respiratory assessment. Additionally, the nursing staff failed to perform a complete pain assessment at 8:06 AM to include the following characteristics of pain, quality, onset, duration, variation and patterns, aggravating/alleviating factors, impact on function and quality of life.

The practice lacked evidence that nursing staff performed an assessment to justify care and treatment and responses to interventions.

During a face-to-face interview with Employee #32, Registered Nurse, on 05/04/18 at approximately 11:45 AM, she reviewed the record and acknowledged the findings.

C. During a face-to-face interview with Patient #24 on 05/04/18 at approximately 10:40 AM, she explained that she was seen on 05/02/18 in the ECC for cramping and bleeding, and shared that she was cramping since yesterday, and knows she had a miscarriage because she passed blood clots yesterday and is still slightly bleeding. She explained she was medicated for pain and is at an acceptable level. She had her blood drawn and was waiting for an ultrasound.

Review of Patient #24's medical record on 05/04/18 at approximately 12:10 PM, revealed the nurse triaged the patient in the ECC on 05/04/18 at 9:33 AM, for a repeat quantitative blood pregnancy test, and with a pain intensity of 4/10 [Numeric scale indicates 0 as no pain and 10 as the worse pain]. Medical staff documented on 05/04/18 at 10:26 AM that the patient presented for follow up visit for possible miscarriage, as the patient communicated she passed large clots on 05/03/18 and still had some bleeding. The patient was seen on 05/02/18 in the ECC.

Review of the nursing documentation lacked evidence that the nurse performed a genitourinary assessment. Additionally, the nurse failed to assess the patient for pain characteristics to include location, quality, onset, duration, variation and patterns, aggravating/alleviating factors, and impact on function and quality of life.

The practice lacked evidence that nursing staff performed assessments to justify care and treatment and responses to interventions.

During a face-to-face interview with Employee #33, Registered Nurse, on 05/04/18 at approximately 12:30 PM, she explained she did not assess the patient's genitourinary status and did not know that the patient had passed blood clots or if the patient was still bleeding. She acknowledged the findings.

D. Review of Patient #25's medical record on 05/04/18 at approximately 2:00 PM, revealed the nurse triaged the patient in the ECC on 05/04/18 at 10:13 AM. Patient #25's chief complaint was a burn to the right thigh, from "hot tea." The medical staff ordered Silver Sulfadiazine topically and Ibuprofen orally at 11:01 AM. Documentation, on the electronic medical record, revealed nursing staff administered the medications, at 11:31 AM. However, the record lacked evidence the nurse performed and documented a skin/wound assessment or assessed and documented pain characteristics to include quality, onset, duration, variation and patterns, aggravating/alleviating factors, impact on function and quality of life.

Additionally, an ECC nursing note recorded on 05/04/18 at 12:06 PM read as follows: "Patient was assessed, treated and discharged by the provider. No nurse assessment or intervention needed."

The practice lacked evidence that nursing staff performed an assessment to justify care and treatment and responses to interventions, and documented accurate and complete information.

During a face-to-face interview with Employee #33, Registered Nurse, on 05/04/18 at approximately 2:30 PM, she was asked to explain her documentation. She reviewed the record and acknowledged the absence of assessment and said the medications and treatments were interventions performed by the nurse. She acknowledged the findings.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interviews, the hospital staff failed to ensure policies and procedures were developed for the management of patients arriving by ambulance and/or seeking services in the emergency department; and pregnancy services, in the emergency department, in the absence of obstetric services.

Findings included ...

A. Review of an ambulance patient care record (PCR) dated 01/19/18 at 11:13 PM recorded by first responders revealed that Patient #42 was transported to the hospital emergency department. The PCR narrative included, "Pt [patient] first complained of left side pain and then stated there was no complaint, he wanted a meal from the hospital..." The PCR revealed Patient #42 was alert with vitals: 75 (pulse), 136/76 (blood pressure), 16 (respirations) pulse oximetry 96. Further review of the ambulance record showed that Employee #130, Registered Nurse at hospital Emergency Department, signed a section of the PCR form indicating the transfer of care to the hospital. Of note, Patient #42 was treated and released from the same hospital on [DATE] approximately 7 hours earlier at 4:00PM. (Cross reference - 482.55(a ); A-1103).

Review of hospital documentation for the evening of 1/19/18 [11:13 PM - 11:59 PM] including the Emergency Department central log, and patient registration information lacked evidence that Patient #42 was registered, triaged, or treated on or about the time of entry on 01/19/18 at11:13 PM.

Review of an Emergency Care Center physician's note dated 01/20/18 at 6:50 AM showed that Patient #42 re-entered the Emergency Department at approximately 6:50 AM. According to the physician note, the patient was brought in from "...bus stop just outside the ED ..." the police reported that the patient was " ...sitting at the bus stop. However, he did not get on the bus, and therefore they brought him back inside ..."

The surveyor conducted a telephone interview with Employee #130 regarding Patient #42. She stated that she did not specifically remember the patient. She noted that the process is that the nurse gets a report for the ambulance staff and the patient can be sent to the waiting room if the acuity is low.

The surveyor conducted a face-to-face interview with Employees #7, Nursing Director Emergency Department, #22 Nurse Manager Emergency Department, and #129 Director of Revenue Cycle, regarding registration and triage process. Employee #22 stated that when a patient is brought in by ambulance, the charge nurse assesses the patient and if the acuity is low the patient goes to the waiting room. When asked how that patient is registered, Employee #129 stated that those patients are registered like walk-in patients. The patient has to be registered in order to be called to triage. The surveyor asked for the policies and procedures specifying the process. Employee #7 stated that there were no policies specific to patients sent to the waiting room who arrive by ambulance, and no policy directing staff how to ensure all patients are registered.

The practice lacked documented evidence that hospital administration established policies and procedures to account for all patients presenting to the emergency department for treatment. Employees #2, 7, 22, and 129 acknowledged the above findings.

B. Record review on 05/04/18 at approximately 10:00 AM revealed the state agency received a letter dated, 08/16/17 from the hospital, regarding changes to obstetric services. The letter detailed the hospital would not accept new obstetric patients, with delivery dates after 10/12/17 and would exit pregnancy related services, effective 10/17/17.

During a face-to-face interview on 05/04/18 at approximately 11:00 AM, with Employee #4, Director of Emergency Medicine, he explained that obstetric services were discontinued in 10/17; and explained the process for addressing patients who present less than and more than 20 weeks pregnant. He communicated that the medical staff received training related to their process and "challenging deliveries and preemies," and they have an arrangement with the Obstetric Department at a local hospital to transfer patients more than 20 weeks pregnant, requiring inpatient obstetric services. Employee #4 added he was unaware of a written agreement or arrangement, and explained that though it is not in writing, the medical team had the Obstetrician numbers and typically discussed the transfer situations case by case, telephonically. He also shared the nursing staff underwent training, as well.

However, record review of training did not support the hospital specific provisions for treatment for pregnancy services. Additionally, there was no documented evidence that the hospital staff developed a transfer agreement with local acute hospital (s), regarding obstetric services.

The practice lacked documented evidence that the medical staff established policies and procedures to ensure continuity of care, for patients seeking pregnancy services at the hospital.

During a subsequent face-to-face interview on 05/07/18 at approximately 11:00 AM, with Employee #2, Director of Quality, she could provide no hospital specific training for pregnancy services, or Memorandum of Understanding/transfer agreement for continuity of care, for patients requiring in-patient obstetric services.

Employees #2 and 4 acknowledged the findings.
VIOLATION: EMERGENCY SERVICES PERSONNEL Tag No: A1110
Based on record review and staff confirmation, the hospital failed to ensure that emergency staff personnel requirements were met to include current cardiopulmonary resuscitation certification and/or advanced cardiac life support certification, health screening, Tuberculosis (TB) Screening and fit test, in accordance to hospital requirements, in six of seven emergency department personnel records reviewed (Employees #24, 27, 32, 33, 34, 95, and 106).

Findings included ...

Review of the hospital's job description for a registered nurse (RN), in the Emergency Care Center, showed that they are to possess current advanced cardiac life support certification.

Review of the hospital policy titled, "Pre-Employment and Health Examinations, Occupational Health Services" stipulates that all associates working in direct patient care, including contract workers, are required to have a pre-employment health examination, within 30 days prior to their start date and every two years thereafter.
Review of hospital policy titled, "Occupational Health Screening Policy," stipulates that TB screening is required of all staff and administration, annually.

Review of the hospital policy titled, "Occupational Health Screening Policy," stipulates that all staff members in contact with patients will be fit-tested on initial hire and annually thereafter.

Review of Human Resources record conducted on 05/09/18 at approximately 11:45 AM, revealed the following:

Employee #24, Registered Nurse in the ECC, lacked current documentation of Advanced Cardiac Life Support certification as required in her job description.

Employees #24 and 27 lacked current cardiopulmonary resuscitation certification documentation, as required in their job description.

Employees #24, 34, 33, 27, and 32 lacked documentation of a current health screening, as required in their job description.

Employees #24, 34, 33, 27, and 32 lacked documentation of a current TB screening, as required in their job description.

Employees #24, 37, and 106 lacked documentation of a current fit testing, as required in their job description.

During an interview conducted with Employee #101, Human Resources Advisor, on 05/09/18 at approximately 2:22 PM, she confirmed the findings.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on observation, medical record review, policy review, and staff interview, medical staff failed to accurately complete an order for restraints, in one of one observation (Patient #15).

Findings included ...

Review of the facility's policy titled, "Behavior Management for Violent/Self-Destructive Patients Requiring Physical Restraints/Seclusion", revised 05/3/16, shows " ... V. iii For the Non-Violent and Non-Self, the physician or other LIP [Licensed Independent Practitioner] who is responsible for the care of the patient must give and order for the restraint. The order must specify: (a) Type of restraint, (b) Reason for restraint ...(c) Duration of restraint use and (d) Specific time the patient was placed in restraints and discontinuation time ..."

Review of Patient #15's medical record revealed nursing documentation that indicated that bilateral soft wrist restraints were applied, for pulling out intravenous lines.

During the a unit tour on 2 South on 05/04/18 at approximately 10:00 AM, with Employees #7, Unit Manager and
#54, Educator, the surveyor observed Patient #16 lying supine in bed with bilateral soft wrist restraints.

Further review of the medical record on 05/04/18 at approximately 11:00 AM, revealed a "Physician's Order Sheet"/Patient Safety Order" for the use of restraints. The sections of the "Physician's Order Sheet, "titled, "Indication (Check 1 Box ONLY) and "Time Period of Restraint (Check ALL that apply), "dated 05/03/18, revealed blank spaces.

Employees #7 and #54 acknowledged the findings.

The medical staff failed to ensure that the pre-printed order forms for restraints were accurately completed to constitute a complete order that includes type of restraint and time period of restraint.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
1. Based on record review and staff interview, the nursing staff failed assess one patient's care needs and clarify a physician order for the administration of antihypertensive medication, in one (1) of five medical records reviewed (Patient #41).

Findings included ...

Review of the History and Physical (H&P) dated 05/04/18 showed that Patient #41, had a Subdural Hematoma with an evacuation. After the removal, he was admitted to the Intensive Care Unit (ICU).

Review of a physician order dated 05/03/18 at 6:30 PM, directed that Hydralazine 5 mg (milligrams) be administered every six hours as needed for blood pressure greater than 150/90 millimeters of mercury (mmHg).

The surveyor conducted a review of the vital signs, from 05/04/18 to 05/07/18, which revealed the following: on 05/04/18 at 11:00 PM, Patient #41's blood pressure (BP) was 160/68 mmHg; 05/06/18 at 4:00 AM his blood pressure was 165/77; 05/06/18 at 7:00 AM BP - 160/71 mmHg; 05/06/18 at 9:00 AM- BP 183/84 mmHg; 05/06/18 at 10:00 AM- blood pressure- 166/67 mmHg; 05/07/18 at 7:00 AM -blood pressure-166/64 mmHg.

The medical record lacked documented evidence of the administration of Hydralazine for these values or physician notification for clarification of the order.

The surveyor conducted a face-to-face interview on 05/09/18 at 2:52 PM with Employee #48, Intensive Care Unit Nurse, in the presence of Employee #7, Nursing Director. When asked why Hydralazine was not administered as indicated during her shift with the patient, she stated that when the patient's blood pressure increased to 183/84 mmHg, the physician instructed her not to administer the Hydralazine. However, there was no physician documentation or physician order in the medical record indicating the medication should be held.

2. Based on record review, policy review, and staff interview, nursing staff failed to provide an intervention for a report of pain in one of one medical record reviewed (Patient #41).

Findings included ...

The Providence Hospital policy entitled, "Pain Management," effective March 2016, showed that all the patients undergo assessment for ongoing pain and relief at regular intervals.

Review of the History and Physical (H&P), dated 05/04/18, showed that Patient #41 had a Subdural Hematoma with an evacuation. After the evacuation, he was admitted to the Intensive Care Unit (ICU).

Review of a physician order dated 05/04/18 at 5:30 PM directed 50 micrograms (mcg) of Fentanyl to be administered as needed for moderate pain (described as four to six on the pain scale).

Review of pain assessments showed that on 05/04/18 at 8:00 PM, 05/05/18 at 12:02 AM, and 05/05/18 at 4:00 AM, Patient #41 reported a pain score of 10, on the numeric pain scale. The intervention listed was "medication." However, review of the electronic Medication Administration Record (eMAR) for those dates and times showed no pain medication was administered.

The surveyor conducted a face-to-face interview on 05/07/18 at 10:15 AM with Employee #49, Intensive Care Unit Program Coordinator and Employee #55, Informatics Nurse. Both acknowledged the findings.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

1. Based on medical record review, policy review, and staff interview, the nursing staff failed to develop an individualized nursing care plan, based on the patient's identified needs to include the date initiated and goals of treatment, in one (1) of six records reviewed (Patient #16).

Findings included...

Record review of the hospital's policy titled, "Clinical Documentation," revised 03/16, shows that individualized care plans are developed on admission, based on the admitting diagnosis and/or data gathered from the initial assessment.

Review of the nursing assessment dated [DATE] showed Patient #16 had a tracheostomy.

A review of the medical record lacked evidence of a nursing care plan to address Patient #16's tracheostomy care.

Employees #6, Director of Ambulatory Medicine and #7, Nurse Manager acknowledged the finding on 05/07/18 at approximately 11:00 AM.

2. Based on observation, medical record review, policy review and staff interview, the nursing staff failed to follow hospital policy and procedure for a PICC (Peripheral Inserted Central Catheter) dressing, for one (1) of six patients (Patient #16).

Findings included ...

Record review of the hospital's policy titled, "Management of a Patient With a Long-Term Central Venous Access Device," dated 06/17, showed that nursing staff are to change central line dressings every Wednesday, document it in the patient's electronic medical record; and record the IV (intravenous) intervention, the date, time, person performing dressing change or device access, and any problems noted and actions taken."

Observation on 05/07/18 at approximately 12:00 PM, showed Patient #16 lying supine in bed with a right upper basilica PICC line in place, covered with a transparent dressing. There was no date, time, and initials of the person who performed the dressing change.

The practice failed to ensure that staff followed the hospital policy for central venous access device management.

Employee #73, Clinical Manager, acknowledged the findings at the time of the observation.




3. Based on medical record review and staff interview, the nursing staff failed to follow physician's orders for glucose management, in accordance with the plan of care, for one of three patients (Patient #22).

Findings included...

Record review of Patient #22's medical record on 05/04/18 at 3:40 PM, revealed a physician's order dated, 05/04/18 at 8:30 AM that directed staff to administer one (1) unit of correctional insulin, for blood glucose 151mg/dl (milligrams/deciliter) -199mg/dl.

The patient's blood glucose at 8:47 AM read 175 mg/dl; however, the record lacked documented evidence that staff administered the correctional insulin, as ordered.

The practice failed to ensure that staff followed physician orders to ensure adequate glucose management.

During a face-to-face interview on 05/04/18 at approximately 4:20 PM, with Employee #24, Registered Nurse, she reviewed the record and acknowledged the findings.

(Cross-reference A-0405)

4. Based on medical record review, policy review, and staff interviews, the staff failed to ensure accurate, complete, and consistent patient assessments, in accordance with the patient's plan of care, in five (5) of nine records reviewed (Patients #23, 24, 25, 21 and 48).

Findings included...

Record review of the hospital's policy titled, "Clinical Documentation," revised 03/16, showed that nursing staff are to perform a systems review of each patient assessment, once every 24 hours minimum. Physical and skin assessments and interventions are performed and documented every 12 hours. Reassessments are performed to include new or changes in condition and pain management. Discharge documentation includes pain assessment. " ...Charting should reflect assessments, observations, interventions and patient responses to care treatment, education ...from admission to discharge ..."

Record review of the hospital's policy titled, "Pain Management," revised 03/14/16, shows that nursing staff are to perform pain assessments to include quality, intensity, location, onset, duration, variation and patterns, aggravating/alleviating factors, impact on function and quality of life [characteristics of pain].

A. Review of Patient #23's medical record on 05/04/18 at approximately 11:30 AM, revealed the nurse triaged the patient in the Emergency Care Center (ECC) on 05/04/18 at 6:29 AM, with shortness of breath for five days, for which nursing staff administered Prednisone, as ordered. However, the record lacked evidence the nurse performed and documented a respiratory assessment. Additionally, the nursing staff failed to perform a complete pain assessment at 8:06 AM to include the following characteristics of pain, quality, onset, duration, variation and patterns, aggravating/alleviating factors, impact on function and quality of life.

The practice lacked evidence that nursing staff performed an assessment to justify care and treatment and responses to interventions.

During a face-to-face interview with Employee #32, Registered Nurse, on 05/04/18 at approximately 11:45 AM, she reviewed the record and acknowledged the findings.

B. During a face-to-face interview with Patient #24 on 05/04/18 at approximately 10:40 AM, she explained that she was seen on 05/02/18 in the ECC for cramping and bleeding, and shared that she was cramping since yesterday, and knows she had a miscarriage because she passed blood clots yesterday and is still slightly bleeding. She explained she was medicated for pain and is at an acceptable level. She had her blood drawn and was waiting for an ultrasound.

Review of Patient #24's medical record on 05/04/18 at approximately 12:10 PM, revealed the nurse triaged the patient in the ECC on 05/04/18 at 9:33 AM, for a repeat quantitative blood pregnancy test, and with a pain intensity of 4/10 [Numeric scale indicates 0 as no pain and 10 as the worse pain]. Medical staff documented on 05/04/18 at 10:26 AM that the patient presented for follow up visit for possible miscarriage, as the patient communicated she passed large clots on 05/03/18 and still had some bleeding. The patient was seen on 05/02/18 in the ECC.

Review of the nursing documentation lacked evidence that the nurse performed a genitourinary assessment. Additionally, the nurse failed to assess the patient for pain characteristics to include location, quality, onset, duration, variation and patterns, aggravating/alleviating factors, and impact on function and quality of life.

The practice lacked evidence that nursing staff performed assessments to justify care and treatment and responses to interventions.

During a face-to-face interview with Employee #33, Registered Nurse, on 05/04/18 at approximately 12:30 PM, she explained she did not assess the patient's genitourinary status and did not know that the patient had passed blood clots or if the patient was still bleeding. She acknowledged the findings.

C. Review of Patient #25's medical record on 05/04/18 at approximately 2:00 PM, revealed the nurse triaged the patient in the ECC on 05/04/18 at 10:13 AM, with a burn to the right thigh, from "hot tea," for which medical staff ordered Silver Sulfadiazine topically and Ibuprofen orally at 11:01 AM. Documentation, on the electronic medical record, revealed nursing staff administered the medications, at 11:31 AM.

However, the record lacked evidence the nurse performed and documented a skin/wound assessment or assessed and documented pain characteristics to include quality, onset, duration, variation and patterns, aggravating/alleviating factors, impact on function and quality of life. Additionally, nursing staff documented on 05/04/18 at 12:06 PM, "Patient was assessed, treated and discharged by the provider. No nurse assessment or intervention needed."

The practice lacked evidence that nursing staff performed an assessment to justify care and treatment and responses to interventions, and documented accurate and complete information.

During a face-to-face interview with Employee #33, Registered Nurse, on 05/04/18 at approximately 2:30 PM, she was asked to explain her documentation. She reviewed the record and acknowledged the absence of assessment and said the medications and treatments were interventions performed by the nurse. She acknowledged the findings.




D. Review of a History and Physical (H&P) dated 04/27/18 at 2:47 PM, showed that Patient #21 was brought to the hospital after being "found down" by Emergency Medical Services (EMS). The physician assessment showed that Patient #21 was responsive to pain and did not follow commands.

Review of a physician order dated 04/27/18 at 2:21 PM, directed neurological assessments be performed every hour. The medical record showed that Patient #21 was transferred to the Intensive Care Unit (ICU) on 05/03/18, after an episode of unresponsiveness and bradycardia on a medical-surgical floor.

Review of the nursing assessments from 05/03/18, once the patient was in the ICU, showed that neurological evaluations were being performed every four hours.

The practice lacked evidence that nursing staff followed the physician's order for every hour neurological assessment.

The surveyor conducted a face to face interview on 05/04/18 at 3:15 PM with Employee #49, ICU Program Coordinator, who stated that perhaps the order had been changed. She then spoke to Employee #120, Resident Physician, who said that there was no change to the order, and Patient #21 should have a neurological check performed every hour.

Employee #49 acknowledged the above findings.

E. Review of the medical record on 05/07/18 at 9:20 AM, showed that the Patient #48 was admitted to the hospital for observation and dialysis. The patient received dialysis on 05/05/18, via a left upper arm arteriovenous (AV) fistula, and was transferred to a medical surgical (med-surg) unit. Review of the record lacked documented evidence that nursing staff assessed the patient's AV fistula on 05/05/18 and 05/06/18.

The practice lacked evidence that the nursing staff on the med-surg assessed the patient's AV fistula from 05/05/18 thru 05/06/18.

During a face-to-face interview conducted at that time, Employee #61, Registered Nurse, acknowledged the findings, in the presence of Employee #31, Quality Nurse.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record review and staff interview, the nursing and respiratory staff failed to administer medication in accordance with a physician order, in two of two patient records reviewed (Patients #22 and 41).

Findings included...

A.Nursing staff failed to administer correctional dose insulin in accordance with a physician order. (Cross-reference - A-0396)

B.Respiratory staff administered a nebulizer treatment, which was ordered for wheezing and shortness, without documented evidence of those symptoms. (Cross-reference - A-1160)
VIOLATION: CONTENT OF RECORD Tag No: A0458
Based on medical record review and staff confirmation, it was determined that the medical staff failed to ensure that a history and physical was completed, within 30 days after discharge, in one of nine discharge records (Patient #1).

Findings included:

Review of Patient #1 medical record showed the patient had a right thyroid lobe nodule.

The surveyor reviewed the medical record on 05/08/18 at approximately 12:00 PM, in the presence of Employee #123. The record revealed the patient had an ultrasound-guided fine-needle biopsy of the right thyroid lobe nodule on 04/16/18.

The medical record lacked documented evidence that medical staff ensured the a history and physical summary was completed.

Employee #12 acknowledged the findings.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on medical record review, policy review and staff interview, the medical staff failed to ensure physician's orders were legible to ensure appropriate interventions and treatment, in one of three patients (Patient #31).

Findings included...

Review of the hospital's policy titled, "Clinical Documentation," revised 03/16, showed that staff are to ensure legible handwriting on paper documentation.

A. Review of Patient #31's medical record on 05/08/18 at 10:00 AM, revealed a physician order dated, 05/01/18 at 4:10 PM that directed staff to administer intravenous fluids at 100 milliliters/hour (ml/hr). The type of fluid written was illegible.

The record lacked documented evidence that medical staff ensured all entries in the medical record are legible.

During a face-to-face interview on 05/08/18 at approximately 10:15 AM, with Employee #37, Registered Nurse, she explained that she could not read the illegible handwriting. She acknowledged the findings.
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
Based on a review of facility documents to include Pyxis [Automated Dispensing Machine (ADM)] - Schedule II, III, IV, and V Controlled Substances Transactions by patient report, physicians' orders, and the Medication Administration Record [MAR], in the presence of Employee #77, it was determined that the hospital staff did not properly document the administration, wasting, or handling of eight (8) controlled substances.

Findings included...

On May 04, 2018, the automated dispensing machine, for controlled substances schedule II-V., generated a seventy-two (72) hour and all stations event reports the seventy-two (72) hour report was printed for Units: 5 South, 6 East, 6 South, 8 South, and ICU. All patients were randomly selected for this audit. The survey of records was started on May 4, 2018, at approximately 10:00 AM and was completed on May 10, 2018, at approximately 11:00 AM.

In the presence of Employees #76, 77, and 78, the physician order, ADM records, and the Electronic Medication Administration Record (eMAR) were reviewed for accuracy. Withdrawal from the automatic dispensing machine were compared with the dose administered, the administration times and the dispositioning of the controlled substance. The following were observed:

A. On May 2, 2018, at 12:03 PM, Patient #49, on 8 South, was ordered Morphine 4mg (milligram) intravenously every four hours as needed for pain. The prescribe doses were removed from the ADM at 15:58 (3:58 PM) and 20:01 (8:01 PM). There is no record of Morphine administration.


B. On May 4, 2018, at 05:52 AM, Patient #67 on 6 East, was ordered Morphine 2mg, inject intravenously every six hours. On May 6, 2018, at 23:50 (11:50 PM), ADM shows that 2mg was wasted. This leaves 6mg of Morphine unaccounted for.


C. On May 2, 2018, at 10:17 AM, Patient #81, on 8 South, was ordered Oxycodone/Acetaminophen 5/325mg; give 2 tablets by mouth every 4 hours as needed for pain. On May 5, 2018, at 01:48 AM, two tablets were removed from the ADM, but there is no record of administration.


D. On May 3, 2018, at 12:10 PM, Patient #82 on 5 South, was ordered Oxycodone/Acetaminophen 5/325mg, give 2 tablets by mouth every 4 hours as needed for pain. On May 5, 2018, eMAR indicates that 2 tablets were administered at 01:50 AM. There was no record of removal of two tablets from the ADM.


E. On April 25, 2018, at 23:00 (11:00 PM), Patient #88 on 6 South, was ordered Tramadol 50mg by mouth three times a day. On May 4, 2018, at 09:01 Ultram 50mg was removed from ADM at 09:01 AM and administered at 10:10 AM (late administration- over one hour). On May 4, 2018, Tramadol 50mg was removed from ADM at 21:28 (9:28 PM) and administered at 22:39 (10:39 PM). (Late administration- over one hour).


F. On May 5, 2018, at 20:01 (8:01 PM), Patient #90 on 6 South, was ordered Morphine 2mg intravenously once. At 20:04 (8:04 PM), Morphine was removed from the ADM. There is no record of administration of this dose on the eMAR.

Employee #77 acknowledged the findings.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation and staff interview, the staff failed to ensure that biologicals were labeled according to hospital policy and not stored and available for use in the absence a 'use by' date, in two (2) of four observations.

Findings included ...

A. Record review of hospital policy titled, "Floor Stock," dated 04/16, showed that anyone opening a multi dose vial should write an expiration date for 28 days, after the date the vial is opened [written on the vial with an indelible pen].

During a tour of 8 South Medical Surgical Unit on 05/07/18, at approximately 10:00 AM, the surveyor observed an open, undated multi dose vial of insulin in the medication refrigerator, located in the nursing station. The observation occurred in the presence of Employees #61, Registered Nurse and #31, Scribe from Quality.

The practice lacked evidence that the hospital staff followed hospital policy for opened multi dose medication vials.

A face to face interview conducted at that time, with Employee #61, who acknowledged the finding.

B. During a tour of the hospital's outpatient clinic on 05/08/18, at approximately 2:30 PM, the surveyor observed an open, undated multi dose insulin vial in the medication refrigerator. The observation occurred with Employee's #65, Registered Nurse and 66, Director of Behavioral Health.

The practice lacked evidence that the hospital staff followed hospital policy for opened multi dose medication vials.

A face to face interview, at that time, conducted with Employee #65, who acknowledged the finding.
VIOLATION: ORGANIZATION Tag No: A0619
Based on observations and staff confirmation, the Dietary Services were not adequate to ensure that foods are served and prepared, in a safe and sanitary manner. The observations were in the presence of Employees #14, Director of Dietary Services and #15, Assistant Director of Dietary Services, between 10:00 AM and 3:30 PM on 05/04/18.

Findings included ...

1. Ceiling surfaces were soiled, near the refrigerator compressor, the cover was soiled with dust; and floor surfaces were soiled and damaged, in Refrigerator #6.

2. Splatters were observed on ceiling tiles, in Refrigerator #4, in one of one observation.

3. Condensate water was observed dripping from a drain pipe joint, near the compressor onto floor surfaces, in one of one observation.

4. Mildew and mold growth was observed on the surfaces of Sweet Source Strawberries, in two of 19 boxes, in Refrigerator #3.

5. Dishwasher air curtains were soiled with food debris and calcium deposits on the clean and soiled sided curtains of the dish machine, in two of two observations.

6. The following cold foods in the Grill Area were served above 40 degrees Fahrenheit, in the Cafeteria during the lunch meal: cheese -50 degrees; mushrooms- 56 degrees; provolone cheese-46 degrees; and five packages of hot dogs were stored in the refrigerator beyond the expiration date of 05/03/18.

7. The following cold foods in the Deli Area were served above 40 degrees Fahrenheit: cheese- 56 degrees; Picodo Gyro -73 degrees; Guacamole on the tray line- 45 degrees; and Mozzarella Cheese- 48 degrees.

8. The following cold foods on the cafeteria Salad Bar were above 40 degrees Fahrenheit: Chick Peas -45 degrees; Cheese-46 degrees; shredded cheese- 46 degrees, and cucumbers- 42 degrees.

9. The interior panels, gas supply and electrical lines of deep fryers, in the Main Kitchen, were soiled with grease, in three of three observations.

10. The following renal test tray cold food temperatures were served above 40 degrees Fahrenheit: applesauce 60-degrees; and cranberry juice 64 degrees. Regular test tray cold food temperatures were as follows: fruit cup -71 degrees and apple juice-63 degrees.

11. Boxes of Ensure were stored on shelves in the storage room beyond the expiration date of 04/18/18, in one of four observations; and 24 boxes of Oxepa Therapeutic, for modulating inflammation, were stored on the shelf, in the Storage Room, beyond the expiration date of 04/18/18.

12. Sprinkler heads and shaft surfaces, located under cooking hoods, were soiled with dust, in the Main Kitchen, in seven of seven observations.

13. Cutting boards, used in the cook's preparation area, were observed with deep grooves, and boards were stained in the following instances: four green; two yellow; three red; one white, and one tan, in 11 of 15 observations.

14. Scoops and ladles, stored in large bins, in the Pot and Pan Washer Area, were soiled with left over food particles and hard water stains, in 19 of 34 observations.

15. The interior and bottom surfaces of hotel pans were soiled with leftover food particles and had stains on the interior and bottom surfaces, as follows: 24 X 12 X 4 inch pans in five of seven observations; 12 X 10 X 2 inch pans in three of seven observations, and 24 X 6 X 4 inch, in three of five observations.

16. The top and bottom surfaces of chinaware plates were soiled with food particles and residual food stains were observed after washing, in the dishwasher, in 10 of 23 observations.

17. Drain pipes, under the sink, in the Food Preparation Area were soiled and stained; the proper air gap was not maintained between the drain and pipe; the garbage grinder failed to operate when tested ; chinaware plates were stored on a counter, in the Food Preparation Area; wall surfaces were marred and damaged, in Food Preparation Areas # 1 and 2, near the Main Kitchen; and Chinaware plates, stored on a counter were not covered in 10 of 23 observations of plates. Residual stains and leftover foods were on plates, stored after washing in the plate warmer, in 11 of 25 observations.

18. Floor surfaces in the Cooks Preparation, Tray Serving Line, Steam Kettle Areas, and Dishwasher and Pot and Pan Wash Areas, were soiled and damaged; and paint was separated from floors, in the Main Kitchen, in five of five observations.

Employees #14 and Employee #15 acknowledged the findings.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations and staff confirmation, the housekeeping and maintenance services staff failed to maintain the environment in a safe and sanitary manner. The observations were in the presence of Employees #16, Director of Engineering and #17, Director of Facilities.

1. The following findings were observed, during a tour of the Morgue, between 10:00 AM and 10:30 AM on 05/04/18.

A. The top surfaces of exam lamps were soiled with dust, and the interior and exterior surfaces of exhaust vents were soiled, in two of two observations in the Autopsy Area.

B. Wall surfaces, doors, door jambs, and cabinets were marred near the bathroom in three of three observations.

C. Floors and baseboards were worn and cleaning supplies were improperly stored on the floor surfaces in the bathroom. Hot water temperatures in the bathroom measured at 74 degrees Fahrenheit, which is below the minimum 105 degree temperature requirement, in four of four observations.

D. The antiskid strips in front of morgue refrigerators were worn and torn.

E. Wall surfaces were marred and damaged in the hallways outside of the Morgue.

2. The following findings were observed, during a tour of Sterile Processing Department, between 11:25 AM and 11:50 AM on 05/07/18.

A. Floor surfaces, in front of the autoclaves were worn and stained and exhaust vents, under the Autoclave were soiled with dust, in two of two observations.

B. Walls, ceilings and insulation around pipes were damaged; and floor surfaces, in the rear of autoclaves were unfinished and damaged, in three of three observations.

C. Walls near the Sonic Washer were marred and damaged; floor surfaces were stained and damaged; ceiling tiles were stained; exhaust vent louvers were soiled with dust; the frontal surfaces of the washer had hard water stains; and hard water stains were noted on the floors; walls, and equipment, in the area near rear, in five of five observations.

D. Exhaust vents were soiled and ceiling tiles were missing in the Cart Washer Area.

E. Floor surfaces in the staff bathroom were damaged and the threshold was missing at the entrance.

F. Floor surfaces, in the Environmental Services Hallway, near the Sterile Processing Department were soiled.

3. The following findings were observed, during a tour of the Medical Intensive Care Unit, at 12:15 PM on 05/07/18.

A. The top surfaces of lamps, the horizontal surfaces of the bed frame, and the top surfaces of monitors were soiled with dust; the faucet failed to cut off the water supply when turned on; the sink drained slowly; and biohazard receptacle lids were discolored and stained, in Room 282.

B. Bedside table drawer door handles were broken; Venetian blind slats, the entrance door handle, and wall surfaces were damaged in the corner; and the top surfaces of the over bed lamp were soiled with dust, in four of four observations, in Room 285.

C. The upper and lower wall surfaces near the Nursing Station were marred and damaged.

D. Paint was observed on the shaft, head surfaces of sprinkler heads; the lamp cover was soiled with dust, and wall surfaces were marred, in two of two observations, in Room 281.

E. The hot water faucet failed to shut off the water supply, after the supply had been turned off; wall surfaces were damaged; venetian blinds, near the hallway and the metal that supports the suction container and the horizontal surfaces of the bedframe were soiled with dust; headboard surfaces were marred, and floor surfaces were soiled and damaged, in six of six observations, in Room 288.

4. The following findings were observed, during a tour of the Emergency Department between 2:30 PM and 4:10 PM on 05/07/18.

A. Floor surfaces were damaged near the entrance door in Room 32.

B. The horizontal surfaces of the bed, intravenous poles, and the top surfaces of monitors, and ophthalmoscopes were soiled; the lower panel on the bed was marred and soiled; sprinkler head surfaces and exhaust vents were dusty; wall surfaces outside of the restroom were marred; penetrations were observed in wall surfaces; and the hot water temperature was measured at 67 degrees Fahrenheit, which is below the required minimum temperature of 105 degrees Fahrenheit, in four of four observations, in Room 2.

C. The top surfaces of monitors and the ophthalmoscope and the computer stand were dusty; computer keyboards surfaces were soiled; the bed frame and the bottom plastic cover were soiled and marred; and wall surfaces near the door were marred and damaged, in Treatment Room 4.

D. Privacy curtain mesh surfaces were damaged and hooks were detached and failed to provide complete privacy; the lower wall surfaces were marred; the base surfaces of the intravenous pole were soiled; and bed frame surfaces were soiled.

E. The ice machine condensate drain pipe, made contact with the open drain, and lacked the proper air gap to prevent bacteria from migrating back into the ice chest, in one of one observation, in Treatment Room 16.

F. The top surfaces of monitors were dusty; privacy curtain mesh surfaces were torn and hooks were detached; walls were marred and small penetrations were observed; the base surfaces of intravenous poles were soiled, from spillages, and wall surfaces were marred in the hallway, outside of Room 17, in four of four observations.

G. The mesh surfaces of privacy curtains were torn and curtain hooks were detached and failed to provide complete privacy; the base surfaces of the stretcher and horizontal surfaces were soiled with dust; the top surfaces of the suction container was soiled; paint was separating from the base surfaces of the intravenous pole; the interior and exterior louver surfaces of exhaust vents were soiled with dust, in the room and bathroom; and wall surfaces were marred, in seven of seven observations, in Room 25.

H. Floor surfaces were soiled and stained in Treatment Room 31.

I. Concrete floor surfaces, outside of the Emergency Waiting Area, were soiled and stained.

J. The asphalt covered areas of the loading dock were worn and damaged, and areas around the dumpsters were soiled.

5. The following findings were observed, during a tour of the Surgical Suite between 11:05 AM and 2:35 PM on 05/08/18.

A. Wall surfaces were marred and scarred, near the lower exhaust vent; and the top surfaces of the lamp were dusty, in Operating Room 2, in two of two observations.

B. Wall surfaces in the hallway near Operating Room 4 were marred.

C. The top surfaces of the cystoscopy instrument were soiled with dust and door surfaces were marred, in two of two observations.

D. The top surfaces of the anesthesia machine were dusty, and two of two large vents were soiled with dust, in Operating Room 5.

E. Door edge surfaces were damaged and the top surfaces of the anesthesia machine were soiled with dust, in Operating Room 6.

F. Exhaust vents were soiled with dust, sprinkler head covers were not fully secured; and ceiling tiles were damaged, in the Soiled Utility Room.

G. The exterior surfaces of the open drain cover were soiled with debris; floor surfaces were soiled with a rusty film; and the threshold was missing at the entrance to the Soiled Utility Room.

6. The following findings were observed, during a tour of the Post Anesthesia Care Unit at approximately 11:45 AM on 05/08/18.

A. Hot water temperatures measured at 99 degrees Fahrenheit, which is below the required minimum temperature of 105 degrees Fahrenheit; venetian blind slats were damaged; the entrance door surfaces were marred; and the top surfaces of the biohazard receptacle cover was discolored, in three of three observations, in the Computer Room.

B. The interior and exterior surfaces of exhaust vents were soiled, in Room 23.

C. The receptacle plate cover was not secured and the screws had sharp edges, in Bay 19.

D. The headboard and window sill surfaces were marred and soiled, in Bay 15.

E. Walls and head board surfaces were marred, curtain hooks were detached; and the sink and side splash guards were damaged, in Bay 10.

F. Wall surfaces were damaged and exhaust vents were soiled with dust, in Bay 6.

G. A small opening was detected around the ductwork, in surfaces in the Pathology Lab.

7. The following findings were observed, during a tour in the Pre Operation Area at 12:35 PM on 05/08/18.

A. Wall surfaces were marred and exhaust vents were soiled, in Bay 2.

B. Wall surfaces were marred, bed frame surfaces were soiled, privacy curtain hooks were detached, and the backsplash areas of the sink were damaged, in Bay 1.

C. The interior surfaces of exhaust vents were soiled with dust, and ceiling tiles were damaged, in the anesthesia lunch room.

8. The following findings were observed, during a tour of the Endoscopy Area at 2:40 PM on 05/08/18.

Ceiling tiles surfaces were soiled and stained; and wall surfaces were marred in Procedure Room 1 and the Endoscopy Wash Room.

9. The following findings were observed, during a tour in the Operating Waiting Room at 3:30 PM on 05/08/18.

A. Windows and window sill surfaces were soiled and dusty, carpet surfaces were soiled and stained, the finish was worn on the chair armrest; deceased insects were on the interior of lamps; the hand sink faucets were turned off and failed to operate, in the rear area of the Waiting Room.

B. The women's bathroom door was marred on both sides and the top surfaces lamps were soiled, in the Waiting Room.

C. Wall surfaces were damaged near the sink, and the door handle was not secured, in the men's restroom.

10. The following findings were observed, during a tour in the Radiology Department at 3:45 PM on 05/08/18.

A. The interior and exterior surfaces of exhaust and supply vents covers were soiled with dust, in Computerized Tomography Rooms 1 and 2, in two of two observations.

B. Hot water temperatures measured at 89 degrees Fahrenheit, which is below the required minimum temperature of 105 degrees Fahrenheit.

C. Wall surfaces in Computerized Tomography Room 2 and the Ultrasound Room 302 were marred.

D. Hot Water temperatures measured at 78 degrees Fahrenheit, which is below the required minimum temperature of 105 degrees Fahrenheit, in Room 308C.

11. The following findings were observed, during a tour of the Dialysis Unit at 11:00 AM on 05/09/18.

A. The horizontal surfaces of the bed frame were soiled with dust, in Bay 1.

B. Penetrations approximately 1.5 to 2 inches were observed around pipes extending through wall surfaces, in Bay 6.

C. Penetrations were observed in wall surfaces around two reverse osmosis supply lines; the suction cup holder was soiled with debris; hot water temperatures measured at the sink, were 89 degrees Fahrenheit, which is below the required minimum temperature of 105 degrees Fahrenheit; wall surfaces were marred and damaged; and floor surfaces were cracked and damaged; in Isolation Room 1.

D. Wallpaper was separated from the lower walls and walls were marred and damaged; baseboards were marred and soiled, and the interior areas in the cabinet, under the sink were soiled, in Isolation Room 2.

Employees #16 and 17 acknowledged the findings.
VIOLATION: RESPIRATORY CARE SERVICES POLICIES Tag No: A1160
Based on record review and staff interview, the respiratory staff failed to administer respiratory treatment as ordered by the physician in one of five medical records reviewed (Patient #41).

Findings included ...

Review of the History and Physical (H&P) dated 05/04/18 showed that Patient #41 had a Subdural Hematoma with an evacuation. After the removal, he was admitted to the Intensive Care Unit (ICU).

Review of a physician order dated 05/03/18 at 7:00 PM, directed Albuterol Sulfate 0.083% nebulizer be administered every six hours, as needed for shortness of breath and wheezing.

Review of the Electronic Medication Administration Record (eMAR) showed that the nurse administered the medication on the following dates, at the following times: 05/05/18 at 8:47AM and 1:55 PM; 05/06/18 at 2:15 AM, 8:45 AM, and 8:59 PM; 05/07/18 at 1:34 AM and 7:48 AM. Review of the pre-treatment assessments for the listed administration times, showed that Patient #41's breath sounds were "diminished." There was no documented evidence that Patient #41 experienced wheezing or shortness of breath before administration of nebulizer treatments.

The practice lacked evidence that respiratory staff followed the physician order to administer the medication for shortness of breath and wheezing.

The surveyor conducted a face to face interview on 05/07/18 at 11:05 AM, with Employee #119, Respiratory Therapist, in the presence of Employee #49, Program Coordinator, regarding the administration of nebulizer treatments for Patient #41. She stated that she administers the medication to help improve his lungs, even when he is not wheezing.

Employee #49 acknowledged the findings.

(Cross-reference A-0405)