HospitalInspections.org

A. Based on review of the medical record of one patient, review of hospital policies and procedures, a tour of the hospital, and interviews with administrative staff, it was determined that a patient documented to have been full code status was not provided CPR (Cardiopulmonary resuscitation).

Findings include:

Reference #1: Policy and procedure titled, "CORE: Code Status Classification" states: " .....
POLICY
1. This policy of Kindred Hospital outlines the process and steps needed to determine and document the code status of patients.
a. Patients are asked about code status and their preferences regarding life-sustaining treatment at admission.
b. There shall be two categories of Code Status in Kindred Hospitals for patient resuscitation (Yes and No).
c. Patients are provided resuscitation services unless precluded by a legal advance directive and physician's order.
d. Any patient without a Code Status designation will receive a CPR (cardiopulmonary resuscitation) Full Code Status.
e. The primary reference point for Code Status classification is the electronic medical record. Paper documents are used only in the event that the electronic record is unavailable, in a hospital with a paper only record, or to document new orders, which should be transmitted to the electronic record.
CATEGORY YES Full Code. The patient will receive CPR in the event of a cardiac and/or respiratory arrest. Category Yes, is used on any patient without a Code Status designation.
CATEGORY NO No CPR. In the event of a cardiac or pulmonary arrest, DO NOT resuscitate by manual (CPR), chemical, and/or electrical means (defibrillation), and DO NOT intubate.
.....
PROCEDURE
1. At admission
a. Inquire from patients and legal representatives about the existence of advance directives/Physician Orders for Life Sustaining Treatment (POLST) or other documentation around patient's wishes at admission.
b. The patient or representative is asked about preferences for life sustaining treatment and it is documented in the medical record.
.....
c. The physician is expected to review the patient's written advance directive and the patient's documented preferences about life-sustaining treatment (if available) at admission and when new information becomes available related to the patient's wishes about CPR and end of life care.
2. Advance directives (if available) are considered prior to the Code Status being entered as the physician's order and that the physician considers the patient and family member/responsible party wishes.
3. End of life care is a continuing discussion during the hospital stay. When new information becomes available or patient circumstances change, this information (changes in wishes, code status, etc.) should be incorporated into the patient's plan of care.
.....
7. Code status classification and the patient's preferences for life-sustaining treatment are documented in ProTouch (preferred) or on the Code Status Classification form (only if the electronic record is unavailable or in hospitals with a paper-only record).
....."

Reference #2: "COVID-19 CPR/ACLS (Advanced Cardiac Life Support) Algorithm" states:
" .....
Code Team Positioned in the Room in full PPE
First Responder: first person to discover patient unresponsive
* Initiate Code
* Place towel over patient's face
* Begin Chest [sic] compressions
* Place back board [sic] under patient when 2nd responder arrives with back board [sic]
* Rotate as needed with alternate compressor
Cart/Medication Nurse #1: positioned at bedside (ACLS certified nurse)
* Brings defibrillator, cables and backboard
* Attaches all pads/electrodes to patient
* Operates Monitor/Defibrillator
* Verifies patency or initiates IV (Intravenous) access
* Administers medications (retrieved from cart nurse or pharmacist outside of the room)
Respiratory Therapist (ACLS Certified)
Patients on Ventilator: DO NOT DISCONNECT (avoids break in clodes [sic] circuit)
Change settings to: volume control mode (S-CMV, Assist Control, Volume A/C) [sic]
TV 500, RR 10, Increase Peak Pressure Limit to Max
.....
Team Leader/Physician
* Assign roles to team members
Maintains control of the code
....."

1. Review of the medical record of Patient #7 revealed:

a. An EMERGENCY CONTACTS sheet including the names and phone numbers of two nephews of the patient.

b. A CODE STATUS ORDER sheet indicating that the patient did not have an Advance Directive and a check mark in the "YES" box indicating: "CPR: (Resuscitate using ACLS protocol, including chest compressions, intubation [sic] medications and/or electrical stimulation of the patient's heart)." The form was documented to have been signed and dated by a physician and nurse on 3/19/20.

c. A HISTORY AND PHYSICAL, documented as having been dictated and electronically signed at 7:03pm on 3/19/20, stated: ".....
ASSESSMENT AND PLAN
.....
MEDS REVIEWED WITH NURSING DISCUSSED WITH NEPHEW PATIENT IS FULL CODE."

d. A CODE BLUE FLOWSHEET dated 3/26/20 stated:
"Time Code Called: 05:45 Time Ended: 06:20
Code Called By: (First and surname of RN)
.....
Time of Precipitating Event: 05:42
.....
Initial Signs of Arrest: ..... Other: (tick mark in box) Change in heart rhythm
Initial Rhythm: ..... (tick mark in box) Asystole
.....
Code Status: Full Code
....."
The abbreviation, "N/A" (Not Applicable) was entered on "CPR" column of the flowsheet.
The flowsheet indicated that "1" "Epi" was administered.
The entry, "Pending Covid 19 results, per hospitalist and Dr. ______ no CPR" was written in the "Comments/Procedures" section of the flowsheet.

e. A PHYSICIAN ORDER sheet included the order dated 3/26/20 at 5:47am: "Follow hospitalist recommendation for no CPR. T.O. (Telephone Order) Dr. ______ (surname) ....."

f. An INTERDISCIPLINARY PROGRESS NOTES entry dated 3/26/20 at 6:16am stated:
"On call Hospitalist Code + Death Note
Code blue called on patient.
Hx (History) : Dementia, Afib (Atrial fibrillation), septic shock on multiple pressors (vasopressors), respiratory failure 'on vent (mechanical ventilator)', suspected COVID with pending test. Asystole on exam and despite epinephrine injection, patient remained in asystole throughout [sic] limited staff in room during code due to suspected COVID with exposure risk in a COVID pandemic. Prolonged (resusciitory ?) effort deemed futile by me and patient therefore pronounced dead at 6:03am. pupils [sic] fixed and dilated, absent breath sounds, remained asystolic. I informed / notified patient's nephew: _______ _______(First name and surname) of patient's expiration by phone."

B. Based on review of the medical record of one patient, review of hospital policies and procedures, a tour of the hospital, and interviews with administrative staff, it was determined that facility failed to ensure that supplies are properly maintained.

Findings include:

Reference: Policy and procedure titled, "CORE: Nova StatStrip Point of Care Blood Glucose Testing" states: " .....
PROCEDURE:
Only personnel who have documented training and competency may perform this procedure
.....
2. Equipment and Supplies
.....
d. Storage Requirements (Test Strips)
.....
ii. When opening a new vial of StatStrip Glucose Test Strips, label the vial with the opened date and discard date prior to use. There are spaces on the vial to record this necessary information.
iii. Test strips may be used for 180 days after opening or until the expiration date listed on the original vial, whichever comes first.
.....
3. Quality Control
a. To assure accurate and precise patient results and to assure proper functioning of the entire system, a high and low control must be run every 24 hours.
..... NOTE: When opening a new vial of quality control, immediately label the vial with the discard date prior to use.
....."

1. A tour of the Main Nurse's Station on the morning of June 1, 2020, accompanied by Administrator #2, revealed that the glucometer kit had two vials of opened test strips, an opened vial of Control 1, and an unopened vial of Control. None of the four (4) opened vials were dated.

2. Administrator #2 agreed with the findings.

Based on a tour of the hospital, review of hospital policies and procedures, and interview with administrative staff, it was determined that the facility failed to destroy documents with confidential patient information that were not components of the medical record.

Findings include:

Reference #1: Policy and procedure titled, "Safeguards: Paper Documents Containing Protected Health Information" states:
"PURPOSE
To reasonably safeguard protected health information from unintentional or incidental uses or disclosures.
POLICY
Paper documents containing PHI (Protected Health Information) are at risk for theft or loss because of their portability. All paper documents containing PHI are maintained in a manner that maintains privacy. All reasonable safeguards are taken to reduce the potential for unauthorized acquisitions, access, use or disclosure of PHI.
.....
Other Papers Containing Protected Health Information
Workforce members and other persons take all reasonable precautions to prevent paper documents containing PHI from being viewed by unauthorized individuals.
At the end of each shift, workforce members destroy notes created during the shift that are not included in the medical record.
....."

Reference #2: Policy and procedure titled, "Safeguards: Destruction of Protected Health Information" states:
"PURPOSE
To destroy protected health information in a manner that maintains the privacy and confidentiality of such information.
.....
PROCEDURE
Paper Records
Shredding is the only appropriate means of destroying paper records.
Paper documentation containing PHI that is not part of the medical record and will not become part of the medical record will be destroyed promptly when no longer needed. Paper records will be shredded immediately or placed in a secure recycling or shredding bin until it is destroyed.
....."

1. A tour of the nurse's stations on the morning of June 1, 2020, accompanied by Administrator #2, revealed the following:

Main Nurses Station:

a. An unlocked cabinet contained NURSING SHIFT REPORTs strewn about with other papers including the following random examples:

(i) A NURSING SHIFT REPORT with the name, date of birth, age, diagnoses, medical record number, code status, wound documentation, diet, mentation, urinary output, and other PHI for Patient #13. The discharge date for the patient was 6/10/19 per Administrator #3.

(ii) A NURSING SHIFT REPORT with the name, date of birth, age, diagnoses, allergy, bladder function, code status, diet, mentation, urinary output, trachea documentation, wound documentation, and other PHI for Patient #14. The discharge date for the patient was 7/15/19 per Administrator #3.

(iii) A NURSING SHIFT REPORT with the name, date of birth, age, diagnoses, allergies, Foley catheter documentation, lab results, code status, diet, mentation, urinary output, wound documentation, and other PHI for Patient #15. The discharge date for the patient was 7/9/19 per Administrator #3.

(iv) A NURSING SHIFT REPORT with the name, date of birth, age, diagnoses, medical history, medical record number, code status, wound documentation, diet, mentation, urinary function, lab results, and other PHI for Patient #16. The discharge date for the patient was 7/5/19 per Administrator #3.

(v) A NURSING SHIFT REPORT with the name, date of birth, age, diagnoses, medical history, medical record number, code status, wound documentation, diet, mentation, Foley catheter documentation, lab results, and other PHI for Patient #17. The discharge date for the patient was 7/1/19 per Administrator #3.

b. The top drawer of a cabinet contained 7 (seven) NURSING SHIFT REPORTs including information as documented above.

c. The bottom drawer of a cabinet contained approximately 40 (forty) NURSING SHIFT REPORTs strewn about including information as documented above.

d. Administrator #2 agreed that the NURSING SHIFT REPORTS should have been destroyed per policy and procedure.

A. Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that medical equipment is cleaned between patients, in accordance with manufacturer's instructions for use (IFUs).

Findings include:

Reference #1: Facility policy, "Nova StatStrip Point of Care Blood Glucose Testing" states, "... 11. Cleaning and Maintenance... When performing testing on patients, follow the cleaning and disinfection times of the germicidal wipe for the meter. ... ."

Reference #2: Manufacturer's Instructions for Use, StatStrip Glucose Hospital Meter System, states, "... 6.3 Cleaning and Disinfecting the Meter... Nova Biomedical recommends the use of Clorox Healthcare Bleach Germicidal Wipes, EPA Registration #67619-12, or any disinfectant product with EPA Registration #67619-12 may be used. ... Clean and disinfect after each patient use by following this protocol to help ensure effective cleaning and disinfection. ..."

1. During a facility tour on 6/1/20, the following was observed:

a. At 11:33 AM, Staff #9 was observed exiting Room #351 holding a glucometer. He/she then entered Room #352 with the glucometer and used it to check the patient's blood glucose. The patient in Room #351 was on contact isolation precautions.

b. Upon interview at 11:38 AM, Staff #9 stated that prior to exiting Room #351, he/she cleaned the glucometer with alcohol. Alcohol is not an approved disinfectant for glucometer cleaning.

2. Staff #1 and Staff #3 confirmed the above findings.

B. Based on review of six (6) of six (6) personnel health files (#25, #26, #27, #28, #29, #30), staff interviews, and review of facility documents, it was determined that the facility failed to ensure that infection control methods used to minimize the transmission of infections are implemented by adhering to employee health requirements.

Findings include:

Reference: Facility policy, "Employee Health Program" states, "... 2. Prospective and current employees will undergo periodic health evaluations as required by local and State licensure regulations. These may include, but are not limited to some or all of the following... a. Pre-placement history or physical (this may be by a personal physician, facility Medical Director or facility's preferred provider). b. On Hire-2-step TST [tuberculin skin test], an interferon gamma release assay (IGRA) such as Quantiferon gold testing or T-SPOT testing according to current guidelines and regulations. ... d. Documentation of immunity to specific childhood diseases (Rubella, Rubeola, Mumps and Varicella) as required by State and Federal rules. ... f. Documentation of immunity to specific infectious diseases (Hepatitis B). ... ."

1. Review of six (6) of six (6) medical staff personnel files on 6/3/20 revealed the following:

a. The health files of Staff #25 lacked evidence of a history and physical.

b. The health files of Staff #26 lacked evidence of a history and physical, 2-step TST or an acceptable equivalent, or documentation of immunity to rubella, rubeola, or hepatitis B.

c. The health files of Staff #27 lacked evidence of a history and physical, 2-step TST or acceptable equivalent, or documentation of immunity to rubella, rubeola, varicella, or hepatitis B.

d. The health files of Staff #28 lacked evidence of a 2-step TST or acceptable equivalent, or documentation of immunity to rubella, rubeola, varicella, or hepatitis B.

e. The health files of Staff #29 lacked evidence of a history and physical, 2-step TST or acceptable equivalent, or documentation of immunity to rubella, rubeola, varicella, or hepatitis B.

f. The health files of Staff #30 lacked evidence of a history and physical or documentation of immunity to rubella, rubeola, varicella, or hepatitis B.

2. Staff #1 and Staff #2 confirmed the above findings.