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.
| CHRISTUS MOTHER FRANCES HOSPITAL | 800 EAST DAWSON TYLER, TX 75701 | June 16, 2021 |
| VIOLATION: PATIENT RIGHTS: INFORMED CONSENT | Tag No: A0131 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the rights of 2 patients (#22 and #23) of 24 patients (#1 through #24) whose consent to treat was either, not completed or completed incorrectly from September of 2019 through January 2020. This deficient practice had the likelihood to effect all patients of the hospital. Findings included. On June 14, 15,and 16 of 2021, medical record review and interview of hospital staff revealed the following findings. A. On 7/14/2021, the medical record (MR) for patient (Pt/pt) 22 was reviewed with the assistance of staff RN #41. The MR indicated pt #22 was brought to the Emergency Department (ED) by a friend in a private vehicle. Pt #22 was [AGE] years old (Four (4) days before her 18th birthday. She was a student at a local institution of higher education. Her complaint was lower quadrant pain and a low grade fever. The registration staff, nursing, and physician staff permitted pt #22 to be registered and be treated without notification of pt #22's parent, her mother. During the review of the MR it was identified that registration staff had identified and documented that pt #22 had signed her consent in error (registration staff realized pt #22 was a minor) and that one (1) attempt to contact her legal guardian was made. The documentation identified from the registration department failed to record the guardian's name or phone number used in the failed attempt. A telephone interview with pt. #22's mother confirmed she was at home and no phone call from the hospital was received. Interview with staff #5 confirmed if the staff attempted to call pt. #22's mother (guardian) the guardian's name, telephone number, and time of the attempted call, should also have been entered into the medical record as proof the call had failed to reach the pt's guardian. The staff failed to contact the minor pt's parent for consent. A review of the facilities Risk Management policy, reference number 8617-0012, "Consent for treatment-Minors", stated, "1. Consent for treatment should be obtained from one of the parents. 2. Should the parent(s) not be located and medical treatment if indicated, the following order of consent should be pursued: 2.1 Grandparent 2.2 An adult brother or sister 2.3 An adult aunt or uncle 2.4 An educational institution in which the minor is enrolled that has received written authorization to consent for the minor's parent or guardian. 2.5 An adult who has actual care, control and possession of the minor and had actual written authorization to consent from a person have the right to consent..." In bold letters the policy read, "Under no circumstances shall a minor be turned away from receiving emergent or urgent care due to an adult in one of the above categories being unavailable. When this situation arises, the clinical director of the area or the administrator on call shall be notified." The facility failed to follow its established policy and initiate the call down order to gain parental/guardian consent. The facility failed to document that a hospital staff member with knowledge of the failed attempt to contact the guardian had notified the unit director or on-call administrator. Further the hospital, auto populated insurance data identified in the hospital's electronic medical records system for pt #22 and billed ED visit to the mothers insurance without the knowledge of the mother. B. On 7/17/2021 with the assistance of staff RN #41, the MR for patient #23 was reviewed. Pt #23 was transferred from an acute care hospital for a higher level of care. Pt #23 had sustained a fall while at long term care facility that resulted in a subdural hematoma. She was not capable of consenting to care and the transferring hospital provided the names two (2) children that were listed as emergency contacts. During the stay at hospital of higher care pt #23's consents to treat and HIPPA (Health Information Protection and Portability Act) for the sharing of vital information remained unsigned. The person identified as the daughter arrived at the facility and the person identified as the son were not in agreement as to the care of pt #23. The daughter stated multiple times she was the Medical Power of Attorney (MPOA). The legal document to identify and secure the position of MPOA was never obtained by the hospital social workers. MR documentation indicated the son had been locally monitoring the care of his mother, while the daughter lived 2 hours or more away in a larger city. Documentation reflected the son was surprised the daughter was involved with pt #23 at this point because she had never been interested in the past. While visiting the daughter demanded the staff interact with a family friend by phone, who's connection to patient #23 was never established. Demands were made by the daughter for HIPPA guarded information to be shared with the friend. The hospital declined. At no time did the hospital document that a request had been made of the daughter to provide a copy of the MPOA. Care was determined and provided for pt #23 by the hospital staff, without any family member signing consent to treat or share HIPPA information. Interviews with staff #3, a risk management representative, indicated she never requested a copy of the MPOA. She indicated she was not involved in that part of the pt's stay and only learned of the questionable MPOA after the fact. She did confirm the Social worker (SW), at the time, should have requested and followed up on the proof of MPOA. That SW was no longer an employee of the facility and was unable to be interviewed. A review of the job description for a SW indicated, the SW, "Interviews patients and relatives to obtain social history relevant to medical problems and planning. Assist patients with environmental difficulties that interfere with obtaining maximum benefits from medical care, Serves as liaison between medical and nursing staffs, patients, relatives and appropriate outside agencies. Interprets and assists in resolving social problems that relate to medical and/or hospitalization ." The hospital's admission staff, nursing staff, SW staff failed to obtain evidence of authority for legal MPOA consent for treatment of pt #23. The facility failed to obtain any consent from the patient's children for treatment of pt #23, with or with out evidence of MPOA. |
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| VIOLATION: NURSING SERVICES | Tag No: A0385 | |
| Based on interview and record review, the facility failed to ensure nursing services were organized in a manner to ensure medications were administered as ordered by the physician. The facility failed to: 1.) ensure insulin and vasopressor (vasoconstrictor) drips were titrated as ordered by the physician, failed to ensure the correct medication was administered and failed to ensure titration orders were complete in 4 of 9 patients sampled for titratable drips (Patient#'s 6, 10, 15 and 17). 2.) ensure patients received their routine medications on admission in 1 of 28 sampled patients (Patient #24). Refer to tag A0405 for additional information. |
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| VIOLATION: NURSING SERVICES | Tag No: A0385 | |
| Based on interview and record review, the facility failed to ensure nursing services were organized in a manner to ensure medications were administered as ordered by the physician. The facility failed to: 1.) ensure insulin, vasopressor (vasoconstrictor) and sedative (propofol) drips were titrated as ordered by the physician, failed to ensure the correct medication was administered and failed to ensure titration orders were complete in 4 of 9 patients sampled for titratable drips (Patient#'s 6, 10, 15 and 17). 2.) ensure patients received their routine medications on admission in 1 of 28 sampled patients (Patient #24). Refer to tag A0405 for additional information. 3) ensure for 1 patient (Patient #26) of 3 patient charts reviewed that Registered Nurses (RNs) assessed and documented the following: a) date and time the patient left the unit b) assessment of patient condition at the time of the patient departing the facility c) who transported the patient from the unit to the hospital exit and how the patient was transported (wheelchair, walked on own, by stretcher, etc.) d) who did patient depart the hospital with (family, friend, etc.) e) where the patient was being discharged to at the time of patient departure f) the method of transportation to the discharge location (private auto, ambulance, public transportation, etc.) Failure of the nurse to supervise the care of patients at time of discharge when unlicensed personnel were used to transport patients off of the unit and failure to assess the patient prior to leaving the unit for changes in condition, appropriate discharge transportation methods and location, and discharge to an appropriate individual designated to care for the patient could result in patient harm. Refer to tag A0395 |
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| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interview, the facility failed to ensure for 1 patient (Patient #26) of 3 patient charts reviewed that Registered Nurses (RNs) assessed and documented the following: a) date and time the patient left the unit b) assessment of patient condition at the time of the patient departing the facility c) who transported the patient from the unit to the hospital exit and how the patient was transported (wheelchair, walked on own, by stretcher, etc.) d) who did patient depart the hospital with (family, friend, etc.) e) where the patient was being discharged to at the time of patient departure f) the method of transportation to the discharge location (private auto, ambulance, public transportation, etc.) Failure of the nurse to supervise the care of patients at time of discharge when unlicensed personnel were used to transport patients off of the unit and failure to assess the patient prior to leaving the unit for changes in condition, appropriate discharge transportation methods and location, and discharge to an appropriate individual designated to care for the patient could result in patient harm. Findings included: Patient #26's chart was reviewed on the afternoon of 6-15-2021. The chart indicated that the patient was admitted on [DATE] and discharged on [DATE] at 3:23 PM. Review of the Physical Therapist's (PT) assessment from 4-28-2021 at 9:00 AM showed the PT had documented that the "patient reports her mother is coming to assist at home when she is discharged ". Review of the Case Management Assessment conducted at 9:31 AM on 4-28-2021 showed that the patient was anticipated to be discharged home by private vehicle. The plan did not indicate who would be transporting her by private vehicle to home. The physician saw Patient #26 on 4-28-2021at 12:35 PM and ordered the patient discharge. Review of vital signs showed that Patient #26's last set of vital signs were taken by a Unit Technician (UT) at 12:58 PM on 4-28-2021 and were within normal limits at that time. Review of the Discharge Instructions showed that the RN provided discharge instructions as "No stooping, bending, twisting, or heavy lifting. Avoid NSAIDs (non-steroidal anti-inflammatory drugs). The RN reviewed the nursing care plan and documented that patient was ready for discharge. No further assessment of when the patient actually left the unit, how the patient left the unit, with whom the patient left unit, or assessment of patient condition just prior to leaving the unit to ensure no change in condition was found. Review of the Daily Cares/Safety Rounding showed that the last documentation of rounding by the RN had taken place at 1:02 PM. The last documentation of rounding by the UT had taken place at 2:29 PM. On the afternoon of 6-15-2021, Staff #56 was asked to help locate the missing information in the electronic chart. The discharge date and time of 4/28/2021 at 3:23 PM had been found on the Patient Demographic sheet but had not been found in any of the nurse charting. During the interview, Staff #56 reported that she had called the office that manages unlicensed staff used to transport patient throughout the hospital. Staff #56 reported the date and time of discharge was entered by this office when the transporter had picked up the patient. There was no evidence found in the chart or provided by the facility to show that the transporter checked with the nurse and confirmed that the patient's condition had not changed and the patient was safe to transport off of the unit. Lack of RN supervision of the discharge process where unlicensed personnel remove a patient from the unit without communicating with the RN and failure to assess the patient immediately prior to leaving the unit for change of condition have the potential to create a situation where a patient who may have had a change in condition placed at risk of adverse outcome. The record indicated that the RN last documented interaction with the patient on 4-28-2021 at 1:08 PM. The patient did not leave the unit until 3:23 PM, over 2 hours later, with no documentation that the RN had seen the patient within that timeframe. Additionally, while a tentative discharge plan had been developed, the RN did not verify who was at the hospital to pick the patient up at the time of discharge or how and with whom the patient had left the unit. Failure to assess changes in discharge plans prior to the patient leaving the unit have the potential to create a situation where a patient's original discharge plan may have fallen through, the patient becomes tired of waiting for the designated person to come and get them, and/or the patient leaves the unit or hospital grounds in an unsafe manner. |
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| VIOLATION: ADMINISTRATION OF DRUGS | Tag No: A0405 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medications were administered as ordered by the physician. The facility failed to: 1.) ensure insulin, vasopressor (vasoconstrictor) and sedative (propofol) drips were titrated as ordered by the physician, failed to ensure the correct medication was administered and failed to ensure titration orders were complete in 4 of 9 patients sampled for titratable drips (Patient#'s 6, 10, 15 and 17). 2.) ensure patients received their routine medications on admission in 1 of 28 sampled patients (Patient #24). This deficient practice had the likelihood to affect all patients. Findings include: INSULIN DRIP Review of the chart of Patient #6 revealed she was a 71- year -old patient who was admitted into the hospital on [DATE]. Patient #6 had diagnoses which included left sided weakness, intracranial hemmorrage, acute respiratory failure and diabetes mellitus. Review of lab results on Patient #6 revealed that on 06/12/2021 at 12:41 p.m., she had an elevated blood glucose level of 519 (reference ranges being 70-110) Review of physician orders dated 06/12/2021 at 8:10 p.m., revealed the following drip was ordered: "Initiate Insulin Drip Protocol Target Blood glucose less than 150 mg/dL ..Order Comments:Goal is BS to drop approximately :-75 mgdL an hour if BS>275, and 50mg/dL an hour <275.." "Starting the insulin drip Weight of patient in kg x 0.025 _____units/hour. Round to the nearest tenth. (eg. 1.76 units becomes 1.8 units/hour, 1.54 units becomes 1.5 units/hour). 2. If patient's glucose is less than 160, then start drip at 1 unit/hour. Glucometer checks q hour and record If infusion rate stable for 4 hours and patient is not on vasopressors, change glucometer check to every 2 hours. Titrate Insulin per nomogram" Another physician's order read as follows: "insulin regular human (HumuLIN R) 100 Units in sodium chloride 0.9 % 100 mL infusion [ 8927] Ordered Dose: 0-12 Units/hr Route: Intravenous Frequency: Continuous @ 0-12 mL/hr Volume: 100 mL Scheduled Start Date/Time: 06/12/21 2100 ... ** Do not exceed 12 units per hour without calling critical care High-Alert Medication: May cause [DIAGNOSES REDACTED]; monitor blood sugar; Stored in medication refrigerator in med room Admin Instructions: Start at 1 unit per hour" Review of the "INSULIN INTRAVENOUS NOMOGRAM AND ORDER SET" read as follows: "..Starting the insulin drip Weight of patient in kg x 0.025 _____units/hour. Round to the nearest tenth. (eg. 1.76 units becomes 1.8 units/hour, 1.54 units becomes 1.5 units/hour). 2. If patient's glucose is less than 160, then start drip at 1 unit/hour." There were discrepancies in the physician orders and the insulin nomogram. There were physician orders to start the drip at 1 unit and there were orders to base the starting rate on the patient's weight. Review of the medication administration record and blood glucose readings on Patient #6 revealed the following: 06/12/2021 At 9:28 p.m., the blood glucose was 350, and at 9:42 p.m. the drip was started at 1 unit. At 11:23 p.m., (almost 2 hours later) the blood glucose was 283, and at 11:27 p.m. the drip was increased to 1.4. Patient #6 was supposed to be on hourly blood glucose readings. There was no way to increase the dose correctly without a current glucose. According to the insulin nomogram, if the dose was calculated on the prior blood glucose at 9:28 p.m. (350) it was to remain at 1 unit. At 1250 a.m., the drip was increased to 2.52 units. There was no current blood glucose listed to base that rate on. At 1:26 a.m., the blood glucose was 301 and at 2:00 a.m. the drip was increased to 3.04. There was no prior blood glucose listed to base that rate on. At 2:57 a.m., the blood glucose was 305 and at 2:58 a.m. the drip was increased to 4.2. At 3:00 a.m., the drip was increased to 9.64. There was no current blood sugar listed to base that rate on. At 4:00 a.m., the blood glucose was 275. There were no documented adjustments made or an explanation as to why not. At 5:22 a.m., the blood glucose was 273. There were no documented adjustments made or an explanation as to why not. At 5:32 a.m., the blood glucose was 263. There were no documented adjustments made or an explanation as to why not. At 6:00 a.m., the drip was increased to 12.6. There was no current blood sugar listed to base that rate on. The rate was over what the physician order called for in one set of physician orders. At 6:33 a.m.,the blood glucose was 266 and the drip was at 5.88. At 7:00 a.m., the drip was at 2.66. At 7:27 a.m. the blood glucose was 272 and the drip was increased at 7:42 a.m. to 8.2 At 8:00 a.m. the drip was at 6.59 and at 8:03 a.m. the drip was at 8.2. At 8:42 a.m.,the blood glucose was 252. At 8:49 a.m., the drip was increased to 11.48. There was no current blood sugar listed to base that rate on. 10:00 a.m. the drip was at 11.5 10:58 a.m blood glucose of 202 Review of the ""INSULIN INTRAVENOUS NOMOGRAM AND ORDER SET" revealed the target blood glucose was less than 150 milligrams per deciliter. During the timeframe the drip was running incorrectly the blood glucose was not recorded less than 150. During an interview on 06/14/2021 after 1:00 p.m., Staff #'s 23 and 25 confirmed the incorrect calculations. Staff #23 said the facility was having issues with the physician orders and the way the nurses were titrating. LEVOPHED DRIPS Review of physician orders on Patient #6 revealed some of the following orders for a vasoconstrictor medication used to treat low blood pressure on 06/10/2021: "norepinephrine (LEVOPHED) 4mg in NS 250mL premixed infusion" ..Dose (Remaining/Total): 0.1-3 mcg/kg/min (-/-) Route: Intravenous Frequency: Continuous Rate/Duration: 21.5-650.5 mL/hr / - Admin Instructions: Initiate at lowest ordered dose (if range) and titrate every 10 minutes by 0.05 mcg/kg/min to a max of 3 mcg/kg/min to maintain MAP > 65 mmHg ... "norepinephrine (LEVOPHED) 16mg in NS 250mL premixed infusion" Ordered On: 06/10/21 at 1418 (2:18 p.m.) Starts/Ends: 06/10/21 1600 (4:00 p.m.)- 06/11/21 2359 (11:59 p.m.) "Dose (Remaining/Total): 0.1-3 mcg/kg/min (-/-) Route: Intravenous Frequency: Continuous Rate/Duration: 5.5-162.5 mL/hr / -.. Admin Instructions: Initiate at lowest ordered dose (if range) and titrate every 10 minutes by 0.05 mcg/kg/min to a max of 3 mcg/kg/min to maintain MAP > 65 mmHg ..." Review of the medication administration record and flow sheets revealed the following: 06/10/2021 at 2:16 p.m. the Levodopa 4 milligrams was running at 0.4 mcg. 06/10/2021 at 5:15 p.m. the Mean arterial pressure (MAP) was 80 and the blood pressure was 112/55. 06/10/2021 at 5:20 p.m. the Levodopa 4 milligrams was documented as being stopped. 06/10/21 at 5:22 p.m.(Levodopa 16mg )- New Bag/Started at 0.2 mcg/kg/min 11 mL/hr 06/10/21 at 7:00 p.m. - Rate/Dose Change at 0.3 mcg/kg/min 16.5 mL/h 06/10/21 at 7:10 p.m.- Rate/Dose Change at 0.4 mcg/kg/min 21.5 mL/hr M 06/10/21 at 7:15 p.m., the MAP had dropped to 55 and the blood pressure was at 76/39. This was below the level the physician wanted it to be kept. There was no documentation of staff attempting to titrate up every 10 minutes in over an 1.5 hour timeframe after starting the new bag at 5:22 p.m.. The physician orders read to initiate at the lowest order does and that was not done.The physician orders did not give clear parameters for the MAP on what level was too high. During an interview on 06/14/2021 after 1:00 p.m., Staff #'s 23 and 25 confirmed the incorrect calculations. Staff #23 said the facility was having issues with the physician orders and the way the nurses were titrating. Review of the record of Patient #10's chart revealed he was a 75 -year -old male who was transferred from another hospital on [DATE]. Patient #10 had diagnoses which included coronary artery disease, heart bypasses times two, chronic kidney disease, chronic obstructive pulmonary disease, pneumonia, respiratory disease and sepsis. Review of the record revealed Patient #10 had the following physician orders for the vasoconstrictor Levophed (used to treat low blood pressure): "norepinephrine (Levophed) 4mg in NS 250 ml premixed infusion" was ordered at 3:19 p.m. on 03/31/2019. "..Dose (Remaining/Total): 0.1-3 mcg/kg/min (-/-) Route: Intravenous Frequency: Continuous Rate/Duration: 35.5-1,058.5 mL/hr / - Admin Instructions: Initiate at lowest ordered dose (if range) and titrate every 5 minutes by 0.05 mcg/kg/min to a max of 3 mcg/kg/min to maintain MAP > 65 mmHg. High-Alert Medication. ** Concentration is 16 mcg/mL **" "norepinephrine (Levophed) 16 mg in dextrose 5 % 250 mL infusion" was ordered at 4:52 p.m. on 03/31/2019. "Dose (Remaining/Total): 0.1-3 mcg/kg/min (-/-) Route: Intravenous Frequency: Continuous Rate/Duration: 9-264.5 mL/hr / - Admin Instructions: Initiate at lowest ordered dose (if range) and titrate every 5 minutes by 0.05 mcg/kg/min to a max of 3 mcg/kg/min to maintain MAP > 65 mmHg.." The physician orders did not give clear parameters for the MAP on what level was too high. Review of the medication administration record revealed that on 03/31/2019 at 4:59 p.m. the Levophed 4mg was infusing at 0.7 mcg/kg/min (247 mL/hr) and at 5:00 p.m. it was stopped. At 5:28 p.m., Levophed 16 mg was running at 0.9 mcg/kg/min (79.5 mL/hr) The ending dose of the Levophed 4 mg at 4:59 p.m. did not match the starting dose of the new strength of Levophed 16mg which was started at 5:28 p.m. The new strength was not started at the correct dose. On 03/31/19 at 11:30 p.m. to 04/04/2019 at 2:54 a.m., the Levophed ran at the same rate although the MAP dropped to 62 at 1:30 a.m. This rate was below the physician ordered parameter. On 04/01/2019 at 9:02 a.m., the blood pressure was 111/58 and MAP 76. Review of the medication administration record revealed Staff #27 hung a new bag of Levophed at 9:03 a.m. on 04/01/2019. On 04/01/2019 from 9:30 a.m. up until 11:10 a.m., the MAP remained 61 and 62 below what the physician wanted it to be. On 04/01/2019 at 11:10 a.m., the MAP was documented as being 46 and there was documentation that the blood pressure was "48/39 orthostatic hypotension, patient sat up and the MD made aware." Review of the record revealed some of the following vital signs on 04/01/2019: 04/01/19 at 11:11 am., blood pressure of 76/56 and a MAP of 67 04/01/19 at 12:10 p.m., blood pressure of 76/58 and a MAP of 66 Review of lab results dated 04/01/2019 at 12:44 p.m. revealed an elevated phosphorus level at 8.2 with reference ranges being (2.5-4.5). Review of the record revealed some of the following vital signs on 04/01/2019: 04/01/19 at 12:52 p.m., blood pressure of 122/83 and a MAP of 87 04/01/19 at 12:55 p.m., the blood pressure was elevated to 196/140 and the MAP was 167. Review of the medication administration record revealed Staff #27 titrated the medication up until 1:00 p.m., when it was paused. The reason given for the pause was that Patient #10's blood pressure was high. Review of a facility's investigation revealed that Staff #27 made a report of a medication error on 04/01/2019 at 1:12 p.m. Sodium phosphate was hung instead of Levophed. According to the report the infusion of sodium phosphate was titrated up on the patient thinking it was Levophed. The bag infused for 3 or 4 hours before it was caught. The patient was started on Vasopressors and epi for correction and then restarted on the Levophed. During an interview on 06/15/2021 Staff #27 said that she had made a medication error on Patient #10 on 04/01/2019. She stated that pharmacy brought up a hand full of drips and she thought they were all for Patient #10. She took a bag of the medication and hung it on the intravenous pole behind the bag of Levophed which was already hanging. Staff #27 said she went to another patient's room and she asked one of her colleagues to hang the medication when the existing bag was complete. The other nurse spiked the bag for her. Staff #27 said she ended up scanning the old bag instead of what was actually running when documenting administration. Staff #27 said the bag of medication that was accidently hung was sodium phosphate. Staff #27 said Patient #10 got almost all of the bag of medication which belonged to another patient. Staff #27 said she discovered the error when the patient's blood pressure wasn't coming up. Staff #27 said she immediately informed the physician, charge nurse, and the unit director. She also filled out a Midas report (incident report). Review of facility committee meeting minutes dated 04/29/2021 of staff working on the drips revealed the following: "Titratable drips are being initiated outside of the ordered parameters without supporting documentation or assessment." During an interview on 06/14/2021 at 3:09 p.m., with the Staff #23 revealed they had identified there was an issue with the orders and the way the nurses were titrating drips. They had developed a protocol and it has to go to the approving body and they will roll it out to the floors. She was already teaching her residency classes the new protocol. During an interview with Administrative staff members #'s 31, 41, 44, 52 and 59 on 06/16/2021 after 11:00 a.m., they said that they had identified problems with the titration orders and policy. The nurses were titrating outside of the physician orders. They had put together a committee to address the problems. Administrative staff said that prior to the survey the nurses were assigned some charts to audit of the patients on titrations. They were auditing as needed. The nurses just started auditing charts at 100 percent on yesterday (06/15/2021 during the survey). Nursing staff had been told to keep titrating the way they had been doing until the new process came out. There was no formal training yet. The new policies and protocol needed to be sent to the approving body first. That would be done probably in about 2 weeks. Administrative staff stated that the incident involving the Levophed and sodium phosphate was addressed with just the one nurse. They looked at the error of mixing up the medications and did not review the drips. Review of a facility's policy named "Titrating Medication" dated 12/22/2015 revealed some of the following: "2.For titrated medications additional order dosing parameters required include: 2.1 A dose at which to start the medication must be specified 2.3 A frequency at which the dosage may be titrated must be specified. 2.4 A dosage increment by which the dose may be titrated up and down must be specified.. ..2.8 Dosing instructions with parameters must be clearly present on the Medication Administration Record. 2.9 Dosing parameters for titrated medications must be included on any preprinted orders, clinical practice guidelines or written protocols for titrated medications. 2.10 Clinical staff must assess the patient frequently when titrating medications to detect potential problems as early as possible.." LEVOPHED DRIPS Review of the record of Patient #17's chart revealed the he is [AGE] years old and was admitted on [DATE] after a syncopal episode following dialysis. He has a past medical history of [DIAGNOSES REDACTED] Review of physician orders on Patient #15 revealed some of the following orders for a vasoconstrictor medication used to treat low blood pressure on 06/12/2021 and 06/13/2021: "norepinephrine (LEVOPHED) 16 mg in NS 250mL premixed infusion" ..Dose (Remaining/Total): 0.1-3 mcg/kg/min (-/-) Route: Intravenous Frequency: Continuous Rate/Duration: 10.5-322.5mL/hr / - Admin Instructions: Initiate at lowest ordered dose (if range) and titrate every 10 minutes by 0.05 mcg/kg/min to a max of 3 mcg/kg/min to maintain MAP > 65 mmHg ... "norepinephrine (LEVOPHED) 16mg in NS 250mL premixed infusion" Ordered On: 06/6/11/21 at 1926 (7:26 p.m.) Starts/Ends: 06/11/21 2000 (8:00 p.m) "Dose (Remaining/Total): 0.1-3 mcg/kg/min (-/-) Route: Intravenous Frequency: Continuous Rate/Duration: 10.5-322.5 mL/hr / -.. Admin Instructions: Initiate at lowest ordered dose (if range) and titrate every 10 minutes by 0.05 mcg/kg/min to a max of 3 mcg/kg/min to maintain MAP > 65 mmHg ..." Review of the medication administration record and flow sheets revealed the following: 06/12/2021 at 5:54 p.m. the Levophed 16 milligrams was running at 0.05 mcg. 06/12/2021 at 7:00 p.m. the Levophed 16 milligrams was documented at 0.04 mcg. 06/12/2021 at 8:40 p.m. the Levophed 16 milligrams was running at 0.03 mcg. 06/12/2021 at 10:35 p.m. the Levophed 16 milligrams was running at 0.02 mcg. 06/12/2021 at 12:00 a.m. the Levophed 16 milligrams was running at 0.025 mcg. 06/12/2021 at 12:30 a.m. the Levophed 16 milligrams was running at 0.03 mcg. This was below the level the physician wanted it to be kept at. There was no documentation the staff obtained an order from the physician or notified the physician the Levophed was running below 0.1 mcg/kg/min as ordered. The physician orders did not give clear parameters for the MAP on what level was too high or at what level to titrate medication down. Also, there were no orders found on how to wean the patient off the Levophed drip. PROPOFOL DRIPS Review of the record of Patient #17's is a [AGE] years old admitted on [DATE] with pneumonia due to COVID-19 and a urinary tract infection. She has a past medical history of [DIAGNOSES REDACTED]. A review of the physician orders revealed an order for propofol on 06/14/2021. The order read as follows: "Ordered On: 06/14/21 0924 Start: 06/14/21 1000 Dose (Remaining/Total): 5-50 mcg/kg/min (-/-) Route: Intravenous Frequency: Continuous Rate/Duration: 3-30.5 mL/hr / - Admin Instructions: **Initiate at ordered starting dose. May titrate within ordered dosing limits by 5 mcg/kg/min every 5 min to maintain ordered sedation goal** Do not administer through the same I.V. catheter with blood or plasma. Tubing and any unused portions of propofol vials should be discarded after 12 hours .....What is the target sedation score (RASS or BIS)? RASS 0 to -2; What is the starting dose? 10 mcg/kg/min." Review of the medication administration record revealed that on 06/14/2021 and 06/15/2021 the following RASS (Richmond Agitation Sedation Scale) scores: 06-14-21 11:00 a.m. the RASS was -3 moderate sedation. 06-14-21 1:52 p.m. the RASS was -3 moderate sedation. 06-14-21 7:15 p.m. the RASS was -3 moderate sedation. 06-14-21 8:00 p.m. the RASS was -3 moderate sedation. 06-15-21 1:32 a.m. the RASS was -3 moderate sedation. 06-15-21 3:00 a.m. the RASS was -3 moderate sedation. 06-15-21 7:23 a.m. the RASS was -3 moderate sedation. An interview was conducted on 06-14-21 11:30 a.m. with Staff # 15. The staff member was asked how to titrate medications, specifically Levophed and Propofol. Staff # 15 stated they titrate to the physician's order for Levophed to maintain a map over 65. Staff # 15 stated that propofol was titrated to a RASS of 0 to -2. An interview was conducted on 06-14-21 3:00 p.m. with Staff # 19. The staff member was asked how to titrate medications, specifically Levophed and Propofol. Staff # 19 stated they titrate to the physician's order for Levophed to maintain a map over 65. Staff # 19 stated that propofol was titrated to a RASS of 0 to -2. An interview was conducted on 06-14-21 3:15 p.m. with Staff # 20. The staff member was asked how to titrate medications, specifically Levophed and Propofol. Staff # 20 stated they titrate to the physician's order for Levophed to maintain a map over 65. Staff # 20 stated that propofol was titrated to a RASS of 0 to -2. During an interview on 06/15/2021 after 10:00 a.m., Staff # 17 confirmed the above medications were not titrated to the physician's order. A review of the Richmond Agitation Sedation Scale (RASS) used by the facility revealed the following: RASS (0) - Alert and Calm RASS (-1) - Drowsy RASS (-2) - Light Sedation RASS (-3) - Moderate Sedation RASS (-4) - Deep Sedation RASS (-5) - Unarousable On 6/17/2021 in a small conference room the medical record (MR) for patient (Pt/pt) #24 was reviewed with the assistance of staff #41. The MR for pt. #24 indicated she had arrived to the inpatient department May 19, 2021, in the afternoon. A review of the medication administration record indicated none of pt #24's routine medication was administered upon admission or during the completion of the shift. Interview with staff Registered Pharmacist (RPH) #28 confirmed the medication was ordered upon admission by a medical provider and was not administered. She confirmed all of pt #24's medication should have been available through the PIXIS (medication storage and retrieval device). She could not explain why the medication was not given. A review of pt #24's medication reconciliation was found to be incomplete. The list of home medication was identified, however the frequency, time and route of medication use was not recorded. An interview with the RPH confirmed the hospital's policy for once a day medication adminsitration was once in the morning. An interview with staff #41, who was assisting the electronic review process confirmed it was likely the inpatient nurse assumed pt #24 had already taken her once dally medications at home. Staff #41 also confirmed there was no documentation identified, to clarify when pt #24 had last taken her medication. Pt #24 was administered a one time does of emergency blood pressure medication later in the shift when her blood pressure rose to 191/62. After the emergency dose of medication pt #24's blood pressure returned to within normal parameters. On 6/17/2021 in the conference room the medication error log for May of 2021 was not identified as containing the missed doses of medication, identified as medication ommition errors. |
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| VIOLATION: THERAPEUTIC DIETS | Tag No: A0629 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview the facility dieticians failed to insure that meal services provided hot meals for #1 patient (#24) on the day of admission 5/19/2021. This deficient practice had the likelihood to effect all patients of the facility. On 6/16/2021 the medical record (MR) for patient (Pt/pt) #24 was reviewed. It was determined that pt #24 was admitted on [DATE] at 1:47 in the afternoon. Her evening meal tray should have been processed and served on the inpatient unit in the evening. A complaint was received that pt #24's meal tray was 45 minutes late in being served and the family reminded the staff pt #24 had not received her food. Further the complainant included an allegation that the staff reheated pt #24's meal tray in the staff microwave to insure it was warm for the patient. On 6/16/2021 an interview with staff Registered Nurse (RN), #6 confirmed that during the COVID-19 pandemic pts who were in isolation would have trays brought to the inpatient unit in a hot box. Those trays would be removed from the hot box and set on the nurses station counter top to be served by nursing staff. However, staff #6 also stated the nursing staff were seldom made aware the patient meal tray was sitting at the desk. The trays would get cold because the nurse would not exit what ever pt room she had been in to find the tray still sitting at the nurse's desk. She further explained the tray would only be reheated in the microwave if it had not been taken into the pt room. She confirmed the microwave was used to reheat pt. meal trays. Staff #6 also confirmed she had communicated her concern to the dietary department. No changes had been made to her knowledge. ON 6/16/2021 an interview with Registered Dietician (RD), staff #2, explained the dietary services used a hot box delivery system, that insured the meal trays were maintained at a temperature of 160 degrees for 1 hour after the hot box left the dietary department. The box itself maintained a plate temperature of 160 degrees. The dietary staff were unable to locate a policy that instructed nursing staff, what to do, when a meal tray became to cool to serve. The RD felt it was common sense that meal trays that became cold, would be reordered from the kitchen. In interview with staff #40 confirmed the issues with maintaining meals trays at a safe serving temperature could be resolved by leaving trays in the hot box on the unit until trays could be served within the hour. Rather than removing the meal tray in order to return the hot box to the dietary department. |
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| VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES | Tag No: A0749 | |
| Based on observation, document review, and interview the facility failed to provide a clean and sanitary environment to mitigate the risks of possible hospital acquired infections. The facility also failed to follow their own policy and ensure patient medical supplies and equipment was stored and properly disinfected to ensure patient safety on 3 (Neurology Intensive Care Unit, Neurology Unit and BTT3 Surgical Intensive care unit) of 3 Units observed. Findings include: An observation tour was conducted on 6/14/2021 at 1:30 PM with Staff #5 on the Neuro ICU (Neurology Intensive Care Unit) and Neuro Unit. These two units flow together on the same floor with separate clinical staffing. The following was observed. Clean Utility Room/O /Neuro ICU A room used to store supplies for patients on the Neuro ICU was noted to have a rolling cart, cabinets, ice maker, and a sink. The blue bins used for storage of patient supplies was covered with dirt, dust, and debris. On the bottom shelf of the rolling cart the solid surface was heavily covered with dirt and dust. Under the sink was an unlocked cabinet. Inside the cabinet a large brown colored stain, dirt, dust, and debris was noted. The countertop was noted to have trash on the surface. There are two drawers that are labeled as "socks." One of the drawers that was labeled "socks" was noted to have chipped wood from the front surface exposing the porous surface. Inside the other drawer that was labeled "socks" was four unopened suction toothbrushes for patient use, an open yellow disposable scalpel (a disposable blade) and the hardware for the below cabinet. The drawer was full of dirt, dust, and debris. Below this drawer, was a cabinet door that was missing the hardware that allowed you to open the cabinet. Staff #5 could not confirm nor deny if the scalpel had been used. Down the hall, a patient room sign labeled O4434 is observed. Outside the patient room, on the wall next to the room sign, there are 8 holes noted in the wall between the room sign and the hand sanitizer dispenser. Four of the holes exposed the sheetrock. The porous surface cannot be properly sanitized. Soiled Utility/O Down the hall was a room labeled Soiled Utility/O . The door frame was noted to have missing and chipped paint. Metal surfaces cannot be properly cleaned or sanitized to prevent the spread of hospital acquired infections. Soiled equipment and materials are taken to and from this room. This enhances the risk of contaminating the surface of the door frame with infectious diseases, therefore increasing the risk for the spread of infectious diseases among patients and staff. Nourishment/O /Neuro ICU Inside the room is a refrigerator used to store patient nourishments. Inside the freezer was very heavy dirt, dust, and debris. Inside the refrigerator on the bottom shelf, a large brown colored dried liquid is noted on the front and the rear of the shelf. The metal frame on the bottom of the refrigerator was observed and had rust colored stains with chipped and missing paint. Staff #5 could not confirm if this was a dried liquid or rust from corrosion. Next to the refrigerator was a sink. Behind and around the countertop of the sink, the caulking was noted to be of brown color in multiple areas and peeling away from the solid surface in several areas creating an open area for the possibility of an infestation of small insects. Beside the sink is a yellow plastic bin and a coffee pot. When the bin and the coffee pot were moved it was noted that the countertop was heavily soiled with dirt, dust, and a brown colored dried liquid. A yellow bin used to store paper cups for patient use was soiled with dirt, dust, and dried brown colored liquid. A blue bin used to store straws for patient use was noted to have dirt, dust, and debris inside the bin. This nourishment room was used for patients in the Neuro ICU and the Neuro Unit. An interview was conducted with Staff #5 on 6/14/2021 at 1:45 PM. Staff #5 was asked if there were any work orders placed for the cabinet hardware to be repaired in the Clean Utility Room or for the wall to be repaired outside Patient Room O4434. Staff #5 could neither confirm nor deny that work orders had been placed for the areas observed during the tour. No further documentation was perceived or provided by the facility. Neuro Unit A small area was observed that stores moveable equipment used on patients or in patients rooms by staff. In this area the wall is noted to have chipped paint exposing the porous surface beneath. The porous surface cannot be properly sanitized to mitigate the spread of infectious diseases among patients and staff. A portable blood pressure machine is noted to have dirt and dust on the base of the pole. There is no identifying mark/tag to determine if the equipment is clean or dirty. An interview was conducted with Staff #63 on 6/14/2021 at 2:00 PM. Staff #63 was asked if the blood pressure monitor was clean or dirty. Staff #63 replied, "We clean our vital sign machines in between each patient use." Staff #63 was asked how she knew if the equipment was cleaned. Staff #63 stated, "I don't usually work on this floor, so I don't know. There is no tag saying that it has been cleaned but I know I always clean mine between each patient, and I keep the same monitor all day." Staff #65 intervened and stated, "If the equipment is in this area it has been cleaned." Staff #65 confirmed the base of the blood pressure stand was visibly soiled with dirt and dust. A review of the facility policy titled, "Cleaning Reusable Patient Equipment" Reference Number: 8705-2007 with an effective date of 6/26/2018 was as follows: " ...POLICY: 1. All reusable patient equipment should be cleaned, disinfected or sterilized after use, using approved disinfectants or sterilization methods in accordance with manufacturer recommendations. 1.1 Equipment that remains on the unit should be cleaned by housekeeping and/or nursing personnel, i.e. monitors screens (ICU), computer keyboards/mouse for bedside electronic record documentation, beds, etc ..." A review of the facility policy titled, "Cleaning of Moveable Equipment" Reference Number:8460-300 with an effective date of 12/4/2020 was as follows: " ...PROCEDURE: 1. Moveable equipment entering the patient's room will be cleaned in the patient room before leaving the room according to manufacturer's guidelines focusing on tubing and all high touch areas. (tubing, touch screen, handle) 2. When moveable equipment is stored anywhere outside the patient room it will be designated as clean ..." Staff #5 confirmed the findings. During an observation on 06/14/2021 after 11:00 a.m., the following was found: BTT3 Surgical Intensive care unit Clean supply room 3061 Clean supply room 3061 had cardboard boxes on shelves which contained supplies and they were stored with open bins which had supplies. Plastic bins which had medical supplies stored in them had a build-up of dust and spills. The bins contained such supplies as infusion equipment, lab supplies, and syringes. The supply shelves had plastic protective covers that were underneath the plastic bins of supplies. The protective covers were soiled with spills and debris. A plastic bin which had lab vacutainer tubes stored in it had a scrub jacket and sheets laying on top of some of the tubes. A Christmas tree which still had ornaments on it was stored in the room. Two transport carts were in the middle of the room. One of the carts had open cardboard boxes stacked on it. The flooring underneath the shelves was soiled with debris and dust. There were clean supplies still in their packet which were on the floor and a container of sanitizing wipes was on the floor. Otoscopes were stored on a shelf in the room and were not bagged or had any identifying tag to show they had been cleaned. Clean supply room 3057 Respiratory supplies and a pre-packaged saline syringe were stored in a plastic bin that was soiled with spills and dust. Someone had also placed their personal unbagged faceshield in the bin. A battery to the hoyer lift was stored in a bin in the room. It was not bagged or had any identifying tag to show it had been cleaned. Med room 3041 Had an open shelf which contained dialysis supplies such as filters and containers of dialysate stored on plastic protective covers which were soiled with spills. Staff #25 confirmed the observations. Staff #25 said they cleaned the equipment that was on the shelves in the rooms themselves. They did not bag them or put anything on them to identify they had been cleaned. Review of a facility's policy named "Cleaning of Movable Equipment" dated 12/04/2020 revealed: "..When movable equipment is stored anywhere outside the patient room it will be designated as "clean.." Clean utility room BTT 4 IMU/ICU Observations made in the clean utility room on 06/14/2021 and 06/15/2021 revealed five (5) portable blood pressure machines and four (4) portable heating units in this room. There was no identifying mark/tag to determine if the equipment is clean or dirty. An interview was conducted with Staff # 16 on 6/14/2021 at 11:45 A.M. Staff #16 was asked if the blood pressure monitor was clean or dirty. Staff #16 replied, "It is clean." Staff #16 was asked how she knew if the equipment was cleaned. Staff #16 stated, "It is clean because it is in this room. Only clean items are in this room. Used equipment is placed in the soiled utility room and nursing staff clean it before putting it back in this room. Then once a week EVS takes the equipment down and do a deep clean and then bring it back up here." Staff # 16 was asked how someone would know that the machine had been cleaned by staff or EVS, Staff # 16 again stated "Because it is in the clean utility room." Staff # 17 intervened and stated, "If the equipment is in this room the expectation is that it has been cleaned, however we do not use any tags or anything that indicate that." A review of the facility policy titled, "Cleaning of Moveable Equipment" Reference Number:8460-300 with an effective date of 12/4/2020 was as follows: " ...PROCEDURE: 1. Moveable equipment entering the patient's room will be cleaned in the patient room before leaving the room according to manufacturer's guidelines focusing on tubing and all high touch areas. (tubing, touch screen, handle) 2. When moveable equipment is stored anywhere outside the patient room it will be designated as clean ..." Medication room 3 Dawson Medical Surgical Unit Observations made in the medication room on this unit on the afternoon of 06/15/2021 revealed the following: 1. One 33-ounce bottle of Vital HP Tube Feeding was found with an expiration dare of May 2021. This was available for patient use. 2. 34 laboratory blood tubes with expirations dates that ranged from 08/03/2020 to 06/09/2021 were found in a drawer and available for patient use. 3. Bottle of glucometer strips that the opened and expiration date was illegible and being used to test patient's blood sugars. An interview with Staff # 1 and Staff # 66 was held on 06/15/2021 at the time of observations. Staff # 1 was asked who is responsible for checking expirations dates on blood tubes, tube feedings and glucometer strips? Staff # 1 stated that the nurses assigned to the unit should be checking the expiration dates and removing any expired items from the room. |
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