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Based on observation, interview and record review, the facility failed to prevent one pressure sore from deteriorating (Patient #11) , failed to ensure Registered Dietitian's recommendations were noted and/or followed-up on (Patient #11), failed to document pressure sore or wound treatments as completed per orders (Patients #4 # 6, #10, #11, and #13), failed to perform a laboratory test called a pre-albumin as ordered by the physician (Patient #10), failed to perform a dressing change/treatment on the appropriate area (Patient #10), and failed to stage and/or document what type of wound a pressure sore was (Patient #4 # 13), and failed to obtain physicians orders for wound care for four of six patients reviewed with pressure sores or wounds (Patients #6, #11, #10, #13). The facility census was 22.
Findings Included:
1. Review of a facility policy entitled, "Skin Care Assessment and Maintenance of," revised 07/16/08 showed only pressure sores can be staged. Reassessment weekly with documentation of location, staging, wound size, tunneling, drainage, odor, color, and surrounding skin.
During an interview on 12/08/10 at 3:50 PM, Registered Nurse Staff B stated nurses should document all treatments on the Nursing Wound Documentation sheet, if twice daily, it should appear as twice daily on the sheet.
Review of Patient #11's History and Physical (H & P) dated 11/03/10, showed the patient was admitted on 11/02/10 with diagnoses of respiratory failure, and decubitus (pressure sore) prevention. The patient was a paraplegic related to head trauma.
Review of a Nursing Wound Progress Note dated 11/02/10 showed the patient was admitted with a Stage I (persistent redness in the skin -that blanches) pressure sore to the sacrum/coccyx (tailbone), measuring 3.2 centimeters (cm) by 2.2 cm.
Review of Physician's Progress Notes dated 11/09/10 showed the patient suffered from malnutrition, and a note dated 11/30/10 showed the patient was a high risk for skin breakdown. A note dated 12/06/10 showed the patient suffered from malnutrition and was a high risk for skin breakdown.
Review of the patient's Braden scores (a tool used to assess risk for skin breakdown) dated 11/02/10 and 11/30/10 showed the patient was a high risk for skin breakdown with scores of "11" and "13," respectively.
Review of a nutritional assessment dated 11/03/10 showed no height, ideal body weight or usual body weight for the patient (blank). The patient received a tube feeding. There was no Albumin or Pre-albumin (protein levels in the blood which can be indicative of wound healing ability) levels included on the assessment (blank).
Review of a nutritional assessment dated 11/22/10 showed the Registered Dietitian (RD), Staff N, recommended re-checking an Albumin and Pre-albumin level.
Review of another nutritional assessment dated 11/29/10 showed another recommendation to re-check the Albumin and Pre-albumin levels.
Review of another nutritional assessment dated 12/06/10 showed another recommendation to, "Please check Albumin/Pre-albumin."
Review of laboratory results for Patient #11 revealed no Albumin or Pre-albumin levels drawn.
During an interview on 12/09/10 at 8:58 AM, Staff N stated he/she could not write physician's orders so when a recommendation was made, the physician should read the notes and/or a nurse should call the physician for an order regarding the recommendation. There was no written procedure for this process. Staff N stated he/she did call the physician, but was unaware of the follow-up after his/her call. Staff N failed to document this phone call with the physician. Staff N felt the Albumin and Pre-albumin still needed to be drawn and evaluated.
During an interview on 12/09/10 at 9:58 AM, the CNO stated that the RD should have made a nurse aware of his/her recommendations so the nurse could get an order from the physician. The CNO confirmed there was no policy or procedure for this process.
Review of a Nursing Wound Progress Note dated 12/08/10 showed the patient's sacrum/coccyx pressure sore had deteriorated to a Stage II (partial thickness skin loss), measuring 3.0 cm by 2.0 cm by 0.2 cm deep. The staging of the pressure sore did not appear on the Nursing Wound Progress Note, or any other place in the patient's record, until surveyor inquiry on 12/09/10.
Observation on 12/08/10 at 2:40 PM, showed the patient had a 4.0 cm by 2.5 cm (not consistent with the above measurements) irregularly shaped Stage II pressure sore on the coccyx. The pressure sore was draining moderate serosanguinous fluids. The patient was extremely thin and fragile.
Review of Nursing Wound Documentation sheets from 11/01-12/08/10 showed the following:
-A treatment ordered (11/01/10) for the sacrum/coccyx of Zinc oxide, ointment twice daily and as necessary.
-The treatment changed to Alginate (an absorptive type dressing) on 12/08/10 twice daily.
-Staff failed to document the above treatments as completed twice daily on 11/12, 11/14, 11/15, 11/16, 11/17, 11/20, 11/23, 11/24, 11/25, 11/26, 11/28, 12/01, 12/02, 12/05, 12/06, and 12/07/10.
-Staff failed to document the above treatments as completed at all on 12/03 and 12/04/10 (Friday and Saturday).
-Staff failed to document the size, stage and descriptive notes (surrounding skin, drainage, etc.) regarding the pressure sore per facility policy. The only measurements documented were on 11/02, 11/09, and then on 12/08/10, almost one month later.
2. Review of Patient #10's H & P dated 11/19/10 showed the patient had undergone a flap closure surgical procedure on a massive sacral/coccyx pressure sore on the left ischium (area between the buttocks and thigh-crease). This patient was admitted on 11/18/10. The patient also suffered from multiple sclerosis and paraplegia.
Review of physician's orders dated 11/19/10 showed an order to check the Pre-albumin level.
Review of the laboratory results for this patient, dated 12/09/10, showed staff failed to draw this Pre-albumin level. Staff confirmed there were no Pre-albumin levels to review. An Albumin level drawn on 11/19/10 was low at 2.3 MG/dL (normal = 3.5-4.8 MG/dL).
Observation on 12/09/10 at 10:20 AM, showed a dressing dated 12/08/10 (old dressing) placed at the coccyx area (not the correct site). There were no skin problems under the dressing at the coccyx. There was no dressing over the surgical site. RN, Staff M stated previous staff had placed the dressing over the wrong area.
Review of Nursing Wound Documentation from 11/19-12/08/10 showed the following:
-A Xeroform dressing (a gauze dressing impregnated with petrolatum-antibacterial, and nonadherent) had been ordered (11/19/10) daily.
-Staff failed to complete the above treatment on 11/24, and 12/01/10.
3. Review of Patient #13's H & P dated 11/10/10 showed the pateint was admitted on 11/10/10, with a diagnosis of severe peripheral vascular disease (poor circulation-creating a high risk for development of wounds/pressure sores) resulting in the need for wound care on his/her left thigh (a graft site for vascular access related to renal disease-not a pressure sore). The patient did not have pressure sores when admitted.
Review of the Nursing Admission Database dated 11/10/10 showed the patient had impaired bed mobility and bathing ability.
Review of the patient's Braden scores showed he/she was a moderate risk for development of pressure sores.
Review of a Physician's telephone order dated 11/19/10 showed an order to treat excoriated gluteal (buttocks) areas three times daily with zinc oxide. A low air loss mattress was ordered on 11/22/10, after the development of pressure sores, rather than prior to.
Review of Nursing Wound Documentation from 11/19-11/22/10 showed the following:
-Staff failed to apply the Zinc oxide to the patient's gluteal area three times daily on 11/19, 11/20, and 11/21.
Review of documentation regarding repositioning of the patient showed the staff failed to document his/her repositioning on 11/14/10 at 4:00 and 6:00 PM (every two hours).
Review of a Physician' Progress Note dated 11/22/10 showed the patient had developed gluteal pressure sores with large areas of eschar (dead tissue). The patient also suffered from severe protein/calorie malnutrition.
Review of pressure sore/wound documentation dated 11/20/10 showed the gluteal pressure sore measured 7.0 cm by 2.4 cm by 0.2 cm deep. The type and stage of the wound was left blank. This was the only measurement/description documented in the patient record. The patient was discharged on 11/22/10.




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4. Review of Policy #S02-N titled "Skin Care, Assessment of Maintenance of" dated 12/01/98, revised 07/16/08, showed in part the following: that standardized wound protocols are available in the wound care management manual and that a physician order is required to implement wound protocols (page 1 of 8).
Observation on 12/08/10 at 10:35 AM, showed Patient #6 with a gauze dressing on his/her left outer thigh. The dressing was dated 12/06/10 with the initials SS written on the dressing.
During an interview on 12/08/10 at 10:35 AM, Staff H, Licensed Practical Nurse (LPN) stated he/she did not have a physician order for patient #6's wound care. Staff I, LPN, stated the physician was aware of the wound, but did not write an order for a dressing for patient #6's wound.
Record review of current Patient #6's medical record on 12/08/10 at approximately 11:00 AM, showed no physician orders for wound care for his/her thigh wound.
Record review of current Patient #6's medical record on 12/08/10 at 2:30 PM, showed nursing documentation of the wound, with photographs, both dated 12/07/10.
During an interview on 12/08/10 at 2:30 PM, Staff O, Wound Care Nurse, when asked how patient #6's wound photo and documentation were dated 12/07/10, but his/her wound dressing dated 12/06/10 remained on his/her wound until 12/08/10. Staff O stated he/she dated the wound picture and documentation incorrectly.
During an observation on 12/08/10 at 2:30 pm, showed Staff O changed patient #6's wound photograph and documentation dates from 12/07/10 to 12/06/10.
During an interview on 12/08/10 at 2:40 PM, Staff Q, Physician, stated he ordered Zeroform gauze to the wound on Monday, 12/06/10.
During an observation on 12/08/10 at 2:47 PM, Staff I and Staff Q removed the gauze dressing from patient #6's wound. There was no Zeroform gauze beneath the dressing covering the wound. The wound appeared to be approximately golf ball sized, white in color, the skin covering the wound was loose but intact, similar to a large popped blister.
5. Record review of Patient #6's current medical record on 12/08/10 at 2:30 PM, showed nursing documentation for the patient's gluteal wound care, which was ordered two times a day on 12/06/10 (per physician) and as needed, but was only documented once a day for the following dates:
-12/05/10 at 9:00 PM;
-12/06/10 at unknown time (no time documented);
-12/07/10 at unknown time (no time documented);
-12/08/10 contained no documentation.

Additional record review on 12/08/10 at 2:30 PM, for Patient #6 showed nursing documentation for the patient's gluteal wound care, which was ordered two times a day and as needed, was only documented once a day for the following dates:
-11/23/10 at 8:00 PM;
-11/24/10 at 8:40 PM;
-11/26/10 at 10:00 AM;
-11/27/10 at 10:00 AM.
There was no wound documentation found for 11/25/10.

Further record review on 12/08/10 at 2:30 PM, for Patient #6 showed nursing documentation for the patient's right gluteal wound care, which was ordered two times a day and as needed, was only documented once a day for the following dates:
-11/16/10 at unknown time (not timed);
-11/17/10 at unknown time (not time);
-11/20/10 at 11:00 AM.

During an interview on 12/08/10 at approximately 3:00 PM, Staff P, Registered Nurse (RN) stated there should be written documentation on the wound documentation sheet each time a staff member provides care to the wound, even if only applying medication to the wound.



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6. Record review of Patient #4's current medical record on 12/08/10 showed he/she was admitted on 11/23/10 with a coccyx ulcer and a wound vac. (wound dressing that is attached to low suction machine for wounds that have large amounts of drainage). The admission wound photographs are dated 12/01/10 for the coccyx wound and heel blister. No other wound documentation was found in patient #4's medical record.

7. Record review of Patient #4's current medical record on 12/08/10 showed the only documentation of the Braden Scale (scale for predicting pressure sore risk) failed to be completed every 12 hours.

8. Facility Policy review on 12/09/10 for "Skin Care, Assessment and Maintenance of", revised 07/16/08, stated the following information:
-Skin assessment shall be performed at least every 12 hours. Any impairment in skin integrity shall be documented in the Nursing Flowsheet and Wound Documentation Form.
-4. The effectiveness of all wound care treatment will be reassessed on a weekly basis. Rounds will include measurement weekly and photographic documentation every other week of all wounds.
-5. Documentation will become a permanent part of the patient medical record. The status of the wounds will be compared to wound status documentation from previous wound rounds.

Based on record review and staff interviews, the facility failed to provide training, education and orientation to 2 of 5 (Staff W & CC) non-employee licensed nurses who were working in the hospital. The hospital's census was 22 patients.
Findings Include:
Review of facility's policy #A09-A, issued 12/01/98 and revised 01/01/10, entitled, "Agency, External Staffing" showed, in part, the following:
...Evaluating the agency personnel's competence will be an ongoing process while the agency personnel work at the Hospital.

Hospital retains ultimate responsibility to evaluate the qualifications of staff giving patient care. Thus, evaluation will begin during initial orientation and will continue throughout assignment at the Hospital. The department managers and charge nurses are accountable for this process.

The policy stated the evaluation would begin during initial orientation, but failed to mention when and what type of orientation would be provided to agency staff.

Review of facility's policy #A05-G, issued 2/08, titled, "Agency Files: Standard and Requirements" showed, in part, the following:

Each employee will have a file assembled to include the following:
-The approved method of competency assessment (written tests, etc as established by the Agency)
-Evidence of orientation to Hospital (either attendance at no cost to the Hospital at Hospital orientation or Agency-contract orientation prior to first scheduled shift.
-Evidence of performance appraisal after first scheduled shift and once per year thereafter.

Agency personnel that have not worked at the Hospital for a period of 12 months or more will be expected to re-orient to Hospital (either attendance at no cost to Hospital at Hospital orientation or Agency-contract orientation prior to scheduled shift.
1. Record review showed the facility did not provide Staff W, Agency Staff Licensed Practical Nurse (LPN), with the hospital's initial orientation, training and education prior to him/her providing care to patients in the facility. A review of the facility's agency staff schedule indicated Staff W first worked for the facility on 11/29/10 and as of survey date on 12/09/10 at 11:25 AM, he/she did not have documented proof of receiving the facility's orientation.

During interview on 12/09/10 at 11:20 PM, Staff F, Human Resources Officer, stated he/she informed Staff G, Chief Nursing Officer, that the facility needed to start providing non-employee staff hospital training to all agency staff. Staff F stated Staff G indicated he/she did not know that he/she needed to provide hospital orientation, training and education to the agency staff, but he/she would start providing the orientation and training.



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2. Record review on 12/09/10 of Staff CC's, Agency Registered Nurse (RN), personnel file showed he/she has been performing patient care without completion of hospital orientation, and restraint competency.

Based on observation, interview and record review the facility failed to administer medications according to facility policy and in accordance with Federal and State laws and regulations for six Patients (#1, #4, #6, #9, #14, and #15) of seven patients reviewed. This had the potential to affect all patients by over or under dosing theraputic medications prescribed by a physician. The facility had a census of 22.

Findings Include:

1. Observation during medication pass on 12/07/10 at 1:36 PM, for Patient #4 by Staff D showed the following information:
- Insulin (drug given to decrease blood sugar level) four units given subcutaneously (in fatty layer of skin) in right lower abdomen scheduled to be given at 11:30 AM, was given at 1345 (1:45 PM). Two hours and 15 minutes late.

2. Observation during medication pass on 12/08/10 at 10:35 AM, for Patient #4, by Staff K showed the following information:
-Ascorbic Acid (Vitamin C) 500 mg po two times a day scheduled to be given at 0900 (9:00 AM) was given at 1015 (10:15 AM). One hour and 15 minutes late.
-Cefepime HCL (an antibiotic) 1 Gram IVPB (Intravenous Piggy Back) every 12 hours scheduled to be given at 1000 (10:00 AM) documented as being administered at Noon. Two hours late.
-Famotidine (drug given to prevent stomach problems) 20 mg po two times a day scheduled to be given at 0900 (9:00 AM) was given at 1015 (10:15 AM). One hour and 30 minutes late.
-Fondaparinux (blood thinner) 2.5 mg SQ daily, scheduled to be given at 0900 (9:00 AM) documented as given at 1015 (10:15 AM). One hour and 15 minutes late.
-Metronidazole (drug for fungus infections) in NACL (normal saline) 500 mg IVPB every 8 hours scheduled to be given at 0800 (8:00 AM) documented as given at 1015 (10:15 AM). Two hours and 15 minutes late.
-Multiple Vitamin w(with)/minerals 1 Tablet po daily scheduled to be given at 0900 (9:00 AM) given at 10:15 AM. One hour and 15 minutes late.
-Potassium Chloride CR 40 mEq (milliequivalent) po with breakfast; one dose equal two tablet's scheduled to be given at 0800 (8:00 AM) given at 10:15 AM, after patient's breakfast. Two hours and 15 minutes late.
-Zinc Sulfate 220 mg po daily scheduled to be given at 0900 (9:00 AM) given at 10:15 AM. One hour and 15 minutes late.



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4. Review of Policy #M01-N, titled "Medication Administration," dated 12/01/98, revised on 02/19/10 showed the following:
-Non Respiratory Therapy medications are given at the time ordered or within 30 minutes before or 30 minutes after the time designated (page 3, #25);
-When a medication dose is not administered due to the patient's condition or other unavoidable factor, the individual responsible for administering the medication will circle doses not given and note the reason on the MAR (page 5, Documentation C);
-Charting medications in advance of drug administration is expressly forbidden (page 5, Documentation F).

5. Observation on 12/07/10 at 1:35 PM showed Staff C, Registered Nurse (RN), preparing to administer medication for Patient #6 of Zosyn (an antibiotic) 3.375 milligrams (mg) intravenous (in the vein). Zosyn was scheduled to be given at 12:00 PM. Staff C marked through the 12:00 PM dose, indicating the dose had been given at that time. As this was observed, Staff C then wrote 1:50 PM, (the actual time the dose was administered), and marked through the time, indicating the dose had been given at 1:50 PM.
6. Record review on 12/07/10 at 2:35 PM, of Patient #1's medication administration record (MAR), showed three topical (on the skin) medications due at 9:00 AM. These medications were not marked through (indicating they had not been given). The medications were:
-Miconazole powder 2% (anti-fungal), one application topical, two times daily, to skin folds;
-Moisturizing Cream 454 grams, one application topical, daily, to bilateral heels, dry skin on lower extremities, and to gluteal (buttocks) region;
-Triamcinolone Acetonide 0.1% (steroid cream), one application topical, daily, applied with moisturizing creme to left heel and gluteal region.

During an interview on 12/07/10 at 2:35 PM, RN Staff E stated he/she had not administered the 9:00 AM topical medications to Patient #1 because "I have not had the time yet."

7. Observation on 12/07/10 at 2:34 PM showed Staff E documented he/she administered the following medications to Patient #1:
-Digoxin 0.25 mg, po (slows the heart rate), which was scheduled to be administered at 1:00 PM;
-Diltiazem 60 mg, po (lowers blood pressure or treats heart rhythm disorders), which was scheduled to be administered at 12:00 PM;
-Warfarin 5 mg, po (blood thinner), which was scheduled to be administered at 1:00 PM.

Observation at 2:53 PM, showed Staff E administering the three above medications to Patient #1, 19 minutes late, Staff E documented giving these medications at 2:34 PM.

During an interview on 12/07/10 at 3:20 PM, Staff E stated when medications, such as Diltiazem, are given late, he/she usually tries to give them within the next dosage hour they are due. An example, given by Staff E, included the following:
- Patient #1's medication (Diltiazem 60 mg, po every six hours) scheduled to be given at 12:00 PM, according to the MAR;
-Staff E administered Diltiazem to Patient #1 at 2:34 PM, (two hours and 34 minutes after the dose was scheduled);
-the next scheduled dose of Diltiazem, according to the MAR, was to be given at 6:00 PM;
-Staff E stated he/she would administer Diltiazem closer to 7:00 PM (approximately four hours and 20 minutes after the last dose), "within the scheduled hour it is due."

8. Record review of Patient #15's MAR, as compared to the Patient Transaction report dated 12/09/10 at 9:08 AM, showed the following discrepancies for medications administered on 12/04/10:
-Insulin Aspart (Insulin) sliding scale SQ, due at 6:00 AM, pulled from the med station (electronic medication dispenser) at 7:01 AM, documented as administered at 6:00 AM;
-Priperacillin (antibiotic) 3.375 grams Intravenous (IV), due at 8:00 AM, pulled from the med station at 10:47 AM, documented as administered at 10:00 AM.

Record review of Patient #15's MAR, as compared to the Patient Transaction report dated 12/09/10 at 9:08 AM, showed the following discrepancies for medications administered on 12/05/10:
-Insulin Aspart sliding scale SQ, due at 12:00 AM, pulled from the med station at 1:11 AM, documented as administered at 12:00 AM;
-Piperacillin 3.375 grams IV, due at 8:00 AM, pulled from the med station at 9:39 AM, documented as administered at 8:00 AM;
-Clonidine 0.2 mg PO, due at 8:00 AM, pulled from the med station at 10:01 AM, documented as administered at 8:00 AM;
-Amlodipine Besylate (treatment for high blood pressure and chest pain) 10 mg PO, due at 9:00 AM, pulled from the med station at 10:01 AM, documented as administered at 9:00 AM;
-Ferrous Sulfate (Iron) 300 mg PO, due at 9:00 AM, pulled from the med station at 10:02 AM, documented as administered at 9:00 AM;
-Heparin Sodium 5000 units SQ, due at 9:00 AM, pulled from the med station at 10:02 AM, documented as administered at 9:00 AM;
-Lisinopril (treatment for high blood pressure) 10 mg PO, due at 9:00 AM, pulled from the med station at 10:02AM, documented as administered at 9:00 AM;
-Piperacillin 3.375 grams IV, due at 4:00 PM, pulled from the med station at 4:40 PM, documented as administered at 4:00 PM;
-Clonidine 0.2 mg PO, due at 4:00 PM, pulled from the med station at 6:06 PM, documented as administered at 4:00 PM.

9. Record review of Patient #6's MAR, as compared to the Patient Transaction report dated 12/08/10 at 3:55 PM, showed the following discrepancies for medications administered on 12/05/10:
-Omeprazole 20 mg PO, due at 6:00 AM, pulled from the med station at 6:34 AM, documented as administered at 6:00 AM;
-Amantadine (used to treat Parkinson's disease or conditions similar) 100 mg PO, due at 9:00 AM, pulled from the med station at 7:48 AM, documented as administered at 9:00 AM;
-Ascorbic Acid (Vitamin C) 500 mg PO, due at 9:00 AM, pulled from the med station at 7:48 AM, documented as administered at 9:00 AM;
-Calcium Carbonate-Vitamin D (for bone health) 500 mg PO, due at 9:00 AM, pulled from the med station at 7:48 AM, documented as administered at 9:00 AM;
-Citalopram Hydrobromide (treatment for depression) 20 mg PO, due at 9:00 AM, pulled from the med station at 7:48 AM, documented as administered at 9:00 AM;
-Fondaparinux (prevents blood clots) 2.5 mg PO, due at 9:00 AM, pulled from the med station at 7:48 AM, documented as administered at 9:00 AM;
-Iron 150 mg PO, due at 9:00 AM, pulled from the med station at 7:48 AM, documented as administered at 9:00 AM;
-Loratidine (treatment for allergies) 10 mg PO, due at 9:00 AM, pulled from the med station at 7:48 AM, documented as administered at 9:00 AM;
-Meclizine (treatment for dizziness) 12.5 mg PO, due at 9:00 AM, pulled from the med station at 7:48 AM, documented as administered at 9:00 AM;
-Multiple Vitamins with minerals PO, due at 9:00 AM, pulled from the med station at 7:48 AM, documented as administered at 9:00 AM;
-Oxybutynin (treatment of urinary incontinence) 5 mg PO, due at 9:00 AM, pulled from the med station at 7:48 AM, documented as administered at 9:00 AM.

Record review of Patient #6's MAR, as compared to the Patient Transaction report dated 12/08/10 at 3:55 PM, showed the following discrepancies for medications administered on 12/06/10:
-Potassium 10 mEq PO, due at 8:00 AM, pulled from the med station at 9:02 AM, documented as administered at 8:00 AM;
-Sucralfate (treatment of stomach ulcers) 1 gram PO, due at 8:00 AM, pulled from the med station at 9:02 AM, documented as administered at 8:00 AM;

Record review of Patient #6's MAR, as compared to the Patient Transaction report dated 12/08/10 at 3:55 PM, showed the following discrepancies for medications administered on 12/07/10:
-Potassium 10 mEq PO, due at 8:00 AM, pulled from the med station at 9:07 AM, documented as administered at 8:00 AM;
-Omeprazole 20 mg PO, due at 5:00 PM, pulled from the med station at 5:49 PM, documented as administered at 5:00 PM.

10. Observation during medication pass for Patient #4 on 12/09/10 at 11:15 AM, performed by Staff R, RN showed the following:
-Amlodipine 10 mg PO, due at 9:00 AM;
-Artificial tears to both eyes, due at 9:00 AM;
-Chlorhexidine Gluconate (mouthwash antiseptic) 10 milliliters swish and spit, which was due at 9:00 AM;
-Collagenase ointment (protects against bacteria) to groin area, due at 9:00 AM.
Staff R gave Patient #4 these four medications two hours and 15 minutes late.

11. During an interview on 12/09/10 at 11:45 AM, Staff G, Chief Nursing Officer(CNO), stated that medications administered within 30 minutes before or after the medication is scheduled, does not require the administration times to be changed. Staff G stated he/she had practiced this way for "20 plus" years.

During an interview on 12/09/10 at 12:20 PM, Staff G stated (while providing a medication policy) that medications administered within 30 minutes before or after the medication is scheduled should have the administration time changed to reflect the actual time the medication was administered. Staff G stated that what he/she had said in the previous interview was incorrect.

Based on observation, interview, and record review, the facility's Quality Assurance staff failed to identify, develop and maintain facility driven quality improvement study priorities focused on high risk, problem prone patient care issues such as patients identified with aspiration precautions. Facility staff provided care without suction equipment in the room (Patient #8) and patients (#7 and #12) were administered Total Parenteral Nutrition (TPN) without consistently documented blood glucose monitoring. The facility census was 22 patients, (6 identified as aspiration precautions and 2 receiving TPN).

Findings included:

1. Review of the facility policy titled "Proactive Risk Assessment Policy" (FMEA) revised 08/24/09 and provided by the Director of Quality Management (DQM), directed, in part, the following:
-The {facility}conducted proactive risk assessment to manage and reduce potential risks to patients.
-The {facility}used Proactive Risk Assessment, also known as Failure Mode and Effects Analysis (FMES), as a tool to improve patient outcomes related to high-risk processes at least annually.
-The procedures directed staff to select a high-risk process, form a team, assess the process to find the "undesirable variations" or "failure mode," identify the possible effects to the patient and how serious the effect, assign a numeric value, frequency, severity and discoverability all effect the assigned numeric value.
-For the most critical effects, {mathematical calculation of criticality score} the policy directed a root cause analysis be conducted.
-The policy directed for the highest criticality scores a redesign be completed.
-Testing and implementation of redesign processes should be completed.
-Measurement of the redesign should be completed.
-Monitor overtime to "maintain the gain."

Record review of the facility Quality Assessment and Performance Improvement Plan (QAPI) approved 02/23/10, provided by DQM, directed, in part, the following:
-All QAPI activities were interdisciplinary placing emphasis on process improvement.
-The scope and organization of the plan encompassed three categories, one of which was patient focused functions.
-Directed the DQM to ensure an ongoing systematic process for monitoring, measuring, assessing and improving care delivery processes, clinical outcomes and appropriateness of care provided.
-At a minimum, performance indicators shall be designed to measure high risk, high volume, high cost, and problem prone processes.

2. Record review of current patient #8's admission history and physical (H & P), showed he/she was admitted on 12/02/10 with the following diagnoses: gastrointestinal bleeding, anemia, leukocytosis (high level of white blood cells) possibly related to leukemia (a blood cancer), malnutrition, lethargy, heart disease and high blood pressure.

Observation on 12/08/10 at 10:25 AM, showed patient #8, in room 308 A, with a sign posted above the head of the bed indicating he/she was on swallowing precautions, was to sit-up at 90 degrees when eating, was to be fed small bites, and staff were to check his/her mouth for residual food. Located on the wall by the head of the bed was a suction regulator (controls the amount of suction, continuous or intermittent), with no canister attached to the regulator. If patient #8 began to choke or aspirate (process by which food, fluid, or vomitus is inhaled into the lungs) facility staff would not be able to suction him/her without the canister.
During an interview on 12/08/10 at 3:30 PM, Staff L, Quality Director stated suction canisters were not necessary for patients on swallowing precautions, but only necessary for patients on aspiration precautions. Staff L stated patients on aspiration precautions are patients who had experienced an episode of aspiration, and he/she could not give a reason for patients on swallowing precautions to need suction in their room.
During a telephone interview on 12/08/10 at 3:52 PM, Speech Therapist, Staff Y stated patient #8 was on swallowing precautions. Staff Y stated that swallowing precautions and aspiration precautions are "kind of the same". Staff Y stated the difference with patients on swallowing precautions is that they might aspirate when eating or being fed, and patients on aspiration precautions, are usually NPO (nothing by mouth). Staff Y stated canisters are not necessary in patient rooms with swallowing precautions, but if the patient began to aspirate, staff could put one in the room immediately.
During an interview on 12/08/10 at 4:00 PM, Registered Nurse, (RN), Staff P stated there was not a policy regarding the standard of care for patients on swallowing precautions.

3. Record review of current patient #7's H & P showed he/she was admitted on 11/30/10 with the following diagnoses: acute respiratory failure (inability to breath in oxygen and exhale carbon dioxide), undergoing ventilator weaning with tracheotomy (surgically placed airway into the trachea) in place, small bowel obstruction (blockage in the small intestine) due to multiple ventral hernias (intestine protrudes through the abdominal wall) with small bowel perforation (hole in the intestine), two recent bowel surgeries with resultant peritonitis (inflammation of abdominal lining) and sepsis (whole body inflammatory response) and severe malnutrition receiving total parenteral nutrition (TPN, intravenous nutrition bypassing the gastrointestinal system).

Record review of the patient's physician's orders dated 12/02/10 directed staff to administer an intravenous solution, (TPN, containing protein, carbohydrate as sugars, fats, vitamins and minerals) over twenty four hours, start the infusion at 8:00 PM, and check the patient's blood sugars (due to the sugars administered) every six hours for the first week on TPN.

During an interview on 12/09/10 at 8:38 AM, RD, Staff N stated the following:
-The patient was one of two current patients provided TPN.
-Blood sugars should be checked every six hours for the first week while the patient was on TPN.
-The blood sugars should be recorded in the patient's medical record.
-He/she always looked at a form in the medical record titled Twenty-four Hour Patient Record and Plan of Care.

During an interview on 12/09/10 at 10:35 AM, the Director of Pharmacy, Staff X stated nursing staff were directed to obtain blood glucose monitoring at the same times as the standard medication administration times (four times a day would correspond to 6:00 AM, noon, 6:00 PM and midnight daily).

Record review of the patient's Twenty-four Hour Patient Record and Plan of Care forms showed blood sugar measurements including the following:
-Entries dated 12/04/10 at midnight performed at 11:00 PM
-Entries dated 12/05/10 at noon was illegible and no entry for 06:00 PM
-Entries dated 12/06/10 no entry for 6:00 PM
-Entries dated 12/07/10 no entry for 6:00 PM

Record review of the patient's MAR (Medication Administration Record, a record of when medications were provided) showed the following:
-A section for staff to record blood glucose readings without times.
-A second section of the form for staff to record a blood glucose reading with a corresponding time of day.
-Only three blood glucose measurements documented dated 12/07/10.
-Only three blood glucose measurements documented dated 12/08/10 including two which were difficult to read.

4. Record review of current patient #12's H & P showed he/she was admitted on 11/18/10 with the following diagnoses: two enterocutaneous fistulas (fistula is an abnormal passageway between two organs or vessels that normally does not connect), chronic respiratory failure (ongoing inability of the lungs to function normally), wound care, a requirement for tube feeding (liquid feeding through a tube into the stomach) and nutrition support.

Record review of the patient's physician's orders dated 11/26/10 directed staff to administer intravenous TPN, start the infusing at 8:00 p.m., and monitor the patient's blood glucose (sugar) every six hours for the first week then daily.

Record review of the patient's Twenty-four Hour Patient Record and Plan of Care forms and the patient's MAR showed staff failed to measure blood sugar (glucose) on 12/03/10 at 6:00 PM.

5. During an interview on 12/07/10 at 2:07 PM, Staff N stated the following:
-He/she participated in two quality assurance studies.
-One study was to test tray temperatures.
-The second was accuracy of tray service (correct foods and condiments).
-Did not currently have any clinical nutrition quality assurance studies.
-Prior to three weeks ago, was looking at patient body weights and dysphagia (problems swallowing) diets.
-Performed a quality assurance study on body weights because of the last State survey results.
-The Quality Assurance Manager sets up the studies.
-I just collect the data.

During an interview on 12/07/10 at 2:40 PM, Staff P stated he/she was not involved with Quality Assurance studies.

During an interview on 12/07/10 at 2:40 PM, RN, Staff Z stated the following:
-He/she was not involved most of the quality assurance studies.
-Most studies were done by the Director of Quality Management
-The last study discussed at a recent monthly department head meeting was an anti-coagulation/Heparin study.

6. During an interview on 12/08/10 from 9:20 AM, through 10:35 AM, the Director of Quality Management (DQM), Staff L stated the following:
-The facility quality assurance program was multi-tiered.
-Quality assurance/Performance Improvement (QA/PI) projects were discussed at a monthly meeting.
-Staff at the monthly meeting included all department heads and ad hoc staff members.
-The QA/PI committee members were the Safety Officer who was also the Lead Respiratory Therapist, the Director of Quality Management who had been in position since 01/10, the Chief Nursing Officer who had been in position since 07/10, the Chief Executive Officer who had been in position since 07/10, the Director of Health Information Management (HIM, medical records), the Case Manager, the Director of Pharmacy.
-The facility also maintained an informal work group (facility staff who meet for specific problems on an informal basis) who met monthly without meeting minutes.
-The facility maintained a formal committee, the Organizational Improvement Committee (OIC) who met monthly, maintained minutes and was composed of the department heads plus the Medical Director.
-The medication errors were monitored by the Director of Pharmacy, the Wound Care was monitored by the Wound Care Nurse, use of personal protective equipment (PPE) and Infection Control (IC) procedures followed for isolated patients was audited by leadership staff (like the Director of HIM and/or CEO).

During an interview on 12/08/10 from 2:49 PM, through 3:55 PM, the DQM, Staff L stated the following:
-The facility had different types of QA/PI projects including wound care, falls, infection control, medication errors, patient satisfaction, employee satisfaction, hand hygiene and use of personal protective equipment.
-He/she did not maintain a list of current projects.
-Patients identified as aspiration precautions or swallowing precautions were not a quality assurance/patient safety issue.
-Respiratory Therapy staff was responsible for patients with swallowing precautions or aspiration precautions, not nursing staff.
-Patients identified with swallowing precautions were not a high risk patient.
-If the patient with swallowing precautions had an adverse event that event would trigger an investigation and could be added or developed into a quality assurance project.
-Facility quality assurance projects were data driven.
-Bedside nursing staff or any staff could suggest a quality assurance study project by putting (the written suggestion) in the suggestion box (located on the wall in the staff break room).
-Some problems identified by staff were referred to the Chief Nursing Officer (CNO) for immediate response.
-The DQM stated staff identified problems referred to the CNO were not quality assurance issues.








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