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.

WOODLAND HEIGHTS MEDICAL CENTER 505 SOUTH JOHN REDDITT DRIVE LUFKIN, TX 75904 Dec. 7, 2017
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure 1 of 37 sampled patients received blood transfusions as ordered and they failed to ensure there were complete physician orders for blood transfusions (Patient #21). Patient #21 had lab results which revealed his congestive heart failure was severe.


This deficient practice had the likelihood to cause harm in all patients who received blood transfusions in the facility.

Findings include:


Review of the Emergency department (ED) record of Patient #21 revealed he was a [AGE] year old male who (MDS) dated [DATE] at 1:20 p.m., with complaints of chest pain and shortness of breath.

Review of lab reports on Patient #21 revealed on 11/28/2017 at 1:54 p.m., he had a low hemoglobin of 7.4 (reference ranges being 13.5-17.5) and a low hematocrit at 28.3 (reference ranges being 36.0-46). Patient #21 had an elevated BNP- B-Type Natriuretic Peptide of 4043 with reference ranges being 0-125 (The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable).

Patient #21 left the ED at 7:18 p.m. and was transferred to the Step-down unit.
According to physician orders into the Step-down unit Patient #21 was given diagnoses of congestive heart failure and hypoxemia.

Review of lab reports dated 11/28/2017 at 10:05 p.m., revealed Patient #21 had a critically low hemoglobin of 6.6 (reference ranges being 13.5-17.5) and the hematocrit had decreased further to 23.1 (reference ranges being 36.0-46).
Review of physician orders revealed on 11/28/2017 at 11:41 p.m., there were two orders written to "TRANSFUSE PACKED RBCS".."ASAP" and "ONCE". There was no documentation on how fast to infuse the blood. The physician's order was incomplete and did not include the rate.

Review of physician's orders dated 11/29/2017 at 12:07 midnight, revealed an order to administer the diuretic "FUROSEMIDE INJ 40 MG/4ML SOLN" ...Dose: "40 MG" Route: "INTRAVENOUS PUSH" and Frequency :"ONE TIME ORDER UNSCHEDULED." There were instructions on the physician's order to "Give after first unit of blood."

Review of blood administration records revealed the first unit of blood was started on 11/29/2017 at 1:00 a.m. and stopped at 4:15 a.m.

Review of blood administration records revealed the second unit of blood was started on 11/29/2017 at 4:15 a.m. and stopped at 7:30 a.m.

According to the blood administration record on the first unit of blood, Staff nurse #25 was documented as the nurse administering and monitoring Patient #21 during the first unit.

Review of the blood administration record on the second unit of blood revealed Staff nurse #25 documented and signed as the nurse who obtained the blood from the lab at 04:07 a.m. This would have been during the time Staff nurse #25 documented that the blood infusion was still going on Patient #21. There was no documentation of another nurse monitoring Patient #21 while Staff nurse #25 went to the lab to get the second unit of blood.

Review of the medication administration record revealed documentation that Staff nurse #25 administered the Furosemide on 11/29/2017 at 3:24 a.m. ... The medication was administered prior to completion of the first unit of blood. The physician's order was not followed.

Review of the facility's policy named "Blood and Blood Product Administration" dated 10/2017 revealed the following:

" ...A physician order is required for administration for all blood products."

During an interview on 12/05/2017 after 3:00 p.m., Staff 24 confirmed the incomplete physician's order, time the Furosemide was administered and not knowing who was monitoring Patient #21 while the nurse went to the lab for more blood.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of records and interview, the hospital failed to ensure restraints were only initiated upon receipt of a valid physician order in 3 patients (Patient #'s 24, 27, and 29) out of 4 patients reviewed. Physician orders were not found permitting nursing staff to initiate restraints.

Review of Patient #24's chart and restraint log revealed the following:

On 10-31-2017 at 3:25 pm, nursing staff received a telephone order to apply soft wrist restraints, soft ankle restraints, and place all 4 bed side rails in the up position. These were ordered to prevent patient from removing medical devices. No order for a vest restraint was found.

On 11-1-2017, nursing documentation states that the patient was in a vest restraint at 6:00 am and again at 8:00 am. The restraint log for 11-1-2017 was not completed and did not indicate the type of restraint used for the patient.

A telephone interview was conducted with Staff #31 on the afternoon of 12-6-2017. Staff #31 confirmed that a vest restraint was on the patient when she conducted her morning assessment. Staff #31 stated she removed the vest sometime after 9:00 am because it had become soiled. Staff #31 stated the vest was not needed so she did not replace it.


Review of Patient #27's chart revealed the following:

Per the Nursing restraint initiation documentation, restraints were initiated on 7-19-2017 at 2:30 pm to prevent the patient from interfering with medical care, devices, tubes, or drains. The record documents the type of restraint as a vest restraint.

No restraint orders were found.




Review of Patient #29's chart and restraint log revealed the following:

A physician order for a vest restraint was written and signed on 5-14-2017. The physician did not time the order. Nursing staff did not document with signature, date, and time that the order had been noted.

Per nursing notes, soft wrist restraints had been discontinued on 5-14-2017 at 10:00 am.

Patient Assessment Report, Nursing - Restraint Initiation indicated the soft wrist restraints were initiated again on 5-14-2017 at 5:38 pm. No order for the initiation of wrist restraints was found.

Patient Assessment Report, Nursing - Restraint Monitor, Non Violent, indicated the staff were monitoring a restraint vest that had been applied on 5-12-2017 at 11:00. No order for a vest restraint was found for that time.

The restraint log for 5-14-2017 showed the wrist restraints discontinued, but did not show them re-initiated. The log indicated the vest restraint had been initiated at 5:00 pm on 5-14-2017.

Review of the Restraint and Seclusion Policy, PolicyStat ID: 93, Last Revised: 11/2016, was as follows:

Page 10 of 18, Item E. iii. "Orders for restraints may never been written as standing orders or PRN orders. Each episode of restraint or seclusion must be initiated in accordance with an order by a physician or other LIP. If a patient was recently released from restraint or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order is required. Staff can not discontinue restraint or seclusion as a trial and then re-start it under the same order." (sic)
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on interview and record review, the facility failed to ensure sufficient numbers of nursing staff on 3 of 3 units (Step-down unit, Intensive care unit (ICU), and Telemetry/Medical-Surgical unit).

The facility failed to have sufficient numbers of Registered nurse to serve as charge nurse and provide patient care. The charge nurses were attempting to be charge nurse over Step down and the Intensive care unit. They would go back and forth between the units during their shift. The facility failed to designate allotted hours for a charge nurse for the Step down unit on their staffing matrix. The facility failed to have sufficient numbers of licensed nurses on the Telemetry/Medical-surgical unit. The nurses were spending long hours after their shifts were over catching up on charting.

The facility failed to have sufficient numbers of Registered nurses to recover patients after bedside procedures which required administration of anesthesia. Patient #21 had a bedside procedure and a nurse on the unit had to recover the patient. There was documentation in the nurses notes that respiratory staff had to be called after the procedure to assist with getting Patient #21's oxygen saturation up to a safe level. The staffing was not adjusted considering the condition of the patient.

The facility failed to have sufficient numbers of certified nurses aide to provide activities of daily living care.

This deficient practice had the likelihood to cause harm in all patients.


Findings include:


STEP DOWN UNIT


Review of the facility staffing matrix dated 10/24/2017 revealed no designated allotted hours listed for a charge nurse.

For a patient census of 10 and above the staffing matrix called for 4 RN's on the 7:00 a.m. -7:00 p.m. shift (day shift) and 4 RN's on the 7:00 p.m. -7:00 a.m. shift (night shift).


Review of nursing staffing numbers for the timeframe of 11/28-12/04/2017 revealed the following:

On 11/28/2017 the patient census was 11 and there was 4 RN's on days and 4 RN's on nights. There was no allowance for the charge nurse.

On 12/02/2017 the patient census was 10 and there was 4 RN's on days and 4 RN's on nights. There was no allowance for the charge nurse.

On 12/03/2017 the patient census was 10 and there was 4 RN's on days and 4 RN's on nights. There was no allowance for the charge nurse.

On 12/04/2017 the patient census was 10 and there was 4 RN's on days and 4 RN's on nights. There was no allowance for the charge nurse.



During an interview on 12/06/2017 after 9:30 a.m., Staff #37 confirmed having to work as the charge nurse between the Stepdown unit and ICU during the shift. Staff #37 reported their unit is busy, stressful and they have high acuity patients. Staff #37 reported they used to have 5 RN's now they have 4 RN's without any unit secretary. The charge nurse is the go to person for everything. Some of their duties include caring for the patients after bedside procedures, monitoring patients, educate staff, and monitor blood administration. Sometimes it is so busy they cannot do vital signs. People are staying after the end of their shift to do their charting up until 8:00 p.m.

During an interview on 12/05/2017 after 11:45 a.m., Staff #21 reported the patient to nurse ratio was 3:1 and the nurses provided total patient care. Staff #21 reported that the charge nurse had to do everything. They were charge nurse for the Step-down unit and also the 15 bed Intensive care unit (ICU).They had to go back and forth between the units during their shift. Staff #21 reported that on 12/01/2017 they had 2 patients who were on 1:1 care and no changes had been made in the staffing. The nurses kept the same number of patients. The nurses had to recover a patient who had a bedside procedure (EGD/colonoscopy) and a heart cath patient.

Review of the staffing sheet for 12/01/2017 revealed the patient census was 8 and there was 4 RN's on day and 3 RN's on nights. There was no documentation of change in staffing to accommodate the 1:1 patients. There was no allotted time for the charge
nurse.


Review of a chart of one of the 1:1 patients from 12/01/2017 revealed the following:


Review of nurses notes on Patient #21 revealed on 12/01/17 the endoscopy team and the physician were in the patient's room to do an EGD and Colonoscopy.

According to the operative notes the following was done:

The type of anesthesia listed was general and it was started at 11:14 a.m.. An esophagogastroduodenoscopy (EGD) was started at 11:17 a.m. and it was over at 11:22 a.m.. A colonoscopy with polypectomy was started at 11:25 a.m. and over at 11:47 a.m.. At 11:54 a.m. the anesthesia was stopped. There was documentation that the nurse circulator (on the Endo team) gave report to the (floor) nurse. Patient #21 remained on the Step down unit.

According to nurses notes at 12:30 p.m., the physician was talking to the family about the scope finding. At 1:27 p.m., the patient was desaturating to 72 % while on oxygen at 2 liters via nasal cannula. Patient #21 was placed on oxygen at 6 liters via facemask. Still desaturating at 84 %. Respiratory was called to put the patient back on Bipap. Placed on Bipap at 60 %. Saturation picked up to 94%.. The next documentation from nursing was at 3:00 p.m. and then at 5:33 p.m. when the saturation level was at 98 % on Bipap.

During an interview on 12/05/2017 after 11:45 a.m., Staff #21 confirmed that they have to recover patients after bedside procedures. Staff #21 reported they had to recover patients who had received sedation.


Review of the facility's policy named "Moderate Sedation" dated 07/2016 revealed the following:
" ...In addition to the Licensed Independent Practitioner (LIP) performing the procedure, there are sufficient numbers of qualified staff present during the procedure to provide the sedation, monitor and recover the patient, and assist the LIP ...."

Review of the 2014 Edition of the Perioperative Standards and Recommended Practices, For Inpatient and Ambulatory Settings, pages 607 and 608 revealed the following:

"Postoperative
Phase 1 level of care ...

Class 1:1 -One nurse to one patient
*At the time of admission until the critical elements**are met.
*Unstable airway.***
*Any unconscious patient 8 years of age and under.
*A second nurse must be available to assist as necessary."

"**Critical elements can be defined as:
-Report has been received from the anesthesia care provider, questions answered, and the transfer of care has taken place.
-Patient has a secure airway.
-Initial assessment is complete.
-Patient is hemodynamically stable."



ICU UNIT


Review of nursing staffing numbers for the timeframe of 11/26-12/04/2017 revealed the following:

On 11/26/2017 the day shift was short 1RN's and the night shift was short 3 RN's.

On 11/27/2017 the day shift was short 2 RN's and the night shift was short 3 RN's.

On 11/28/2017 the day shift was short 2 RN's and the night shift was short 2 RN's.

On 11/29/2017 the day shift was short 1RN's and the night shift was short 2 RN's.

On 11/30/2017 the day shift was short 1RN. There was also a 1:1 patient which would have affected the staffing numbers.

On 12/01/2017 the night shift was short 1 RN. There was also a 1:1 patient which would have affected the staffing numbers.

On 12/02/2017 the night shift was short 2 RN's.

On 12/03/2017 the day shift was short 1RN and night shift was short 2 RN's.

On 12/04/2017 the night shift was short 1 RN. There was also a 1:1 patient which would have affected the staffing numbers.

On 12/05/2017 the day shift was short 2RN's.


Review of the facility staffing matrix dated 10/24/2017 revealed 12 designated hours listed for a charge nurses for 6:00 a.m.-6:00 p.m. day shift and 6:00 p.m. -6:00 a.m. night shift.

During an interview on 12/06/2017 after 6:11 p.m., Staff #22 confirmed the staffing numbers. Staff #22 reported not having a criteria for what ICU patients met the 1:1 status. The charge nurse was being shared with the Step down unit. Staff #22 reported they may spend a total of 6 hours on each unit.



MEDICAL/SURGICAL UNIT


Review of nursing staffing numbers for the timeframe of 11/26-12/04/2017 revealed the following:

On 11/26/2017 the night shift (7p-7a) was short by two Certified nurses aides (CNA) and short 10 hours for a unit secretary.

On 11/27/2017 the day shift (7a-7p) was short by two nurses and one CNA. The night shift (7p-7a) was short by two nurses and short two CNAs.

On 11/28/2017 the day shift (7a-7p) was short by one nurse and one CNA. The night shift (7p-7a) was short by one nurse and short two CNAs.

On 11/29/2017 the day shift (7a-7p) was short by two nurses and one CNA. The night shift (7p-7a) was short by two nurses and short three CNAs.

On 11/30/2017 the day shift (7a-7p) was short by one nurse.

On 12/01/2017 the day shift (7a-7p) was short by one nurse.

On 12/02/2017 they were short a unit secretary by two hours on the 3p-11p shift.

On 12/03/2017 they were short a unit secretary by two hours on the 3p-11p shift.

On 12/04/2017 the day shift (7a-7p) was short by one nurse.The night shift (7p-7a) was short by one nurse and short one and a half CNAs.

On 12/05/2017 the day shift (7a-7p) was short by one CNA. The night shift (7p-7a) was short by one nurse and short three CNAs.

During an interview on 12/06/2017 after 4:00 p.m., Staff #5 confirmed the staffing numbers.

During confidential interview with staff on the unit the following was reported about staffing:

One staff member reported that staffing is rough. Four to five patients per nurse would be ideal, but that's not what always occurring. The staff member reported one nurse having up to 7 patients and that meant going home in tears. Sometimes the charge nurse had to take patients when they were short staffed. The charge was over the entire floor which was over 30 beds. The staff member reported working a weekend recently and having to take 6 patients. The CNAs who worked that weekend had 15 patients a piece and they are only supposed to have 10 patients a piece. Some of the nurses are getting exhausted.


One staff member reported sometimes the three CNAs have to take care of 40 patients. They each have 13 -14 patients. The family members get upset because they cannot make it to the patient's rooms timely. The CNAs are responsible for vital signs, activities of daily living, transfers and feeding patients. Sometimes if baths cannot be given on their shift they have to be passed to the night shift. If night shift cannot get the baths done they are pushed to the next day. It is hard for staff to get their charting done.


One staff member reported that here lately the staffing has been bad. The nurses are averaging 5-6 patients each, but the ideal number would be 1 nurse to 5 patients. The day shift CNAs are taking 15-16 patients sometimes and night shift CNAs are taking 15-16 patients always. The charge nurse also had to take patients when the unit was understaffed. A couple of days the charge nurse took 5-6 patients and took care of the charge nurse duties also. Day shift nurses normally get off at 6:00 p.m., but they are staying over sometimes until 10:00 p.m. charting.


During an interview on 12/07/2017 after 8:30 a.m., Staff #1 (CNO) reported corporate was getting onto her about the nursing staff overtime hours. Staff #1 reported not knowing the reason the nurses were getting so much overtime.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on interview and record review, the facility failed to ensure one nurse who was currently assigned to patient care had current competencies in 1 of 2 personnel files reviewed for the step down unit (staff #25).

Staff #25 started his competencies 4/14/ 2017 and as of 12/6/2017 (over 7 months) had not completed it.

This deficient practice had the likelihood to cause harm to all patients in ICU and Step down unit.

Findings include:


Review of the "ICU & SDU RN/LVN Orientation Competency" sheet on Staff #25 revealed his 2017 competencies were started 04/14/2017. Review of the form revealed the following areas had not been completed as of 12/06/2017 (over 7 months):

Intravenous lines and medications
Pulmonary system care
Weaning from ventilators
Assisting with extubations
Assisting with insertion of chest tubes
Assisting with removal of chest tubes
Auto transfusions
Insertion of NG (nasogastric) or feeding tube orally and nasally
Insertion of Dobhoff tube
Genitourinary System Care
Cardiovascular System Care
Integumentary System Care
Neuro System Care

During an interview on 12/06/2017 after 11:01 a.m., Staff #5 confirmed Staff #25 had not completed the competencies. Staff #5 reported it should have been completed by mid August 2017.