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Based on interview, observation, policy and procedure review, medical record and personnel file review, the hospital does not meet the needs of patients in accordance with acceptable standards of practice in the provision of nursing services, as evidenced in the deficiencies noted under this Condition.

Findings include:

The facility does not ensure that policies and procedures are reviewed and updated as needed.
Cross-refer to Tag #A0386.

The facility does not ensure that registered nurses appropriately monitor telemetry in the intensive care unit and PCU II unit.
Cross-refer to Tag #A0395.

The intensive care unit does not have an acuity specific assignment protocol for staff to ensure the personnel are properly qualified and are competent to meet patient needs in the ICU.
Cross-refer to Tag #A0397.

Based on policy and procedure review, interview and medical record review, the hospital does not meet the needs of patients in accordance with acceptable standards of practice in the provision of respiratory care services, as evidenced in the deficiencies noted under this Condition.

Findings include:

The facility does not ensure that Respiratory Services policies and procedures are reviewed and updated as needed.
The facility does not ensure that respiratory medication is delivered in a timely manner
Cross-refer to Tag #A1160.

Based on policy and procedure review and medical record review, the facility does not ensure that patient restraints are ordered appropriately for 1 of 1 patients for whom restraints were used. (Patient #1)

Findings include:

Review on 10/19/11 of the Medical Surgical/ or Behavioral Restraints/Patient Safety Devices Policy and Procedure (dated 9/09) revealed the physician's order should be written on the physician's order sheet, specify the facts and circumstances for restraint needed, the time of initiation and the expiration of the order. Include the specific type of restraint to be used. The Physician must examine the patient within 24 hours and co-sign the restraint order and reorder every 24 hours. Restraints are re-evaluated and reordered by the physician each calendar day. The need for continued restraint use is based on the assessment. Less restrictive methods of restraint should be attempted and then documented in the patient's record.

Medical record review on 10/19/11 for Patient #1 revealed wrist restraints were in use on 10/17/11 despite no evidence of a current physician order in accordance with facility policy.

Based on interview, and policy and procedure review, the facility does not ensure that policy and procedures are reviewed and updated as needed.

Findings include:

Interview on 10/19/11 at 5:30am with Staff #7 revealed that she refers to the policy manuals located in administration for reference. She stated she is unable to access the computer for policies.

Review on 10/19/11 of the Nursing Administration policies and procedures manual signature page revealed policies were last reviewed 9/2007. Review of the ICU policies and procedures manual signature page on 10/19/11 revealed policies were last reviewed 8/2001.

Review on 10/19/11 of the policy and procedure for ECG monitoring "Monitoring Principles and Equipment" revealed it was last reviewed 5/06, and did not meet clinical needs. Cross-refer to Tag #A0397.

Review on 10/18/11 of the policy and procedure "Nurse Practice Guidelines For ICU" revealed it was last reviewed 5/06, and did not meet clinical needs. Cross-refer to Tag #A0397.

These findings were verified with Staff #1 on 10/19/11 and 10/20/11.

Based on policy and procedure review, interview, observation and medical record review, the facility does not ensure that registered nurses appropriately monitor telemetry in the intensive care unit (ICU) and PCU II unit. (Patients #2-5)

Findings include:

Review on 10/19/11 of the Policy and Procedure "Monitoring Principles and Equipment" (last reviewed 5/06) revealed in the ICU, the most important type of monitoring is continuous observation of the electrocardiograms. The policy distribution was for ER, ICU, Nursing Administration and Medical Staff. The procedure describes positioning of the electrodes and trouble shooting. The policy states that ECG strips are to be documented at least once every 8 hours and whenever major changes in rhythm occurs. The physician will be notified when major changes in rhythm occurs. This policy did not address remote monitoring.

Interviews on 10/18/11 and 10/19/11 with ICU nursing staff revealed they are responsible for monitoring the 8 second floor (PCU II) telemetry monitors and their 6 ICU telemetry monitors, as the PCU II staff are not telemetry certified. The ICU staff stated if they are tied up in a patient room, no one is monitoring telemetry. The interviews revealed that ICU staff may repeatedly call PCU II multiple times for the same patient in order to ensure critical cardiac rhythms are being addressed. In addition, at times the ICU nurse will physically go up to the second floor when phone notifications remain unaddressed, thereby causing other ICU staff to unexpectedly cover their patient assessment.

During interview on 10/19/11 at 5:30pm, Staff #7 acknowledged that ICU staff have occasionally gone up to PCU II due to issues related to telemetry monitoring.

Observation of the ICU on 10/18/11 from 2:45pm-3:33pm revealed 3 calls were made to PCU II over 40 minutes in order to ensure that staff were addressing a flatline or asystole rhythm for Patient #2. During this time period, the ICU staff were unaware of what interventions PCU II staff had taken in addressing the flatline. Interview with PCU II Staff #4 on 10/18/11 at 3:35pm revealed staff had attempted to change the battery and then replace the unit itself.

Interview with PCU nursing staff on 10/18/11 at 3:35pm revealed the nursing staff on PCU II are not telemetry certified and do not pay attention to the telemetry monitors located in the PCU II nursing station. The staff completely rely on ICU to notify the nursing staff when major changes in rhythm occurs.

Medical record review on 10/19/11 at 9:50am revealed no telemetry strips were noted in the following medical records despite the patients having been on telemetry for at least one shift:
- Patient #2: Review of the Admit orders dated 10/17/11 at 7:20pm revealed telemetry was ordered.
- Patient #3: Review of the Cardiac Standing Orders dated 10/17/11 at 3:30pm revealed telemetry was ordered.
- Patient #4: Review of the Doctor's Orders dated 10/19/11 at 1:45am revealed telemetry was ordered.
- Patient #5: Review of the Admit orders dated 10/16/11 revealed telemetry was ordered.

Based on interview, medical record review and personnel file review, the intensive care unit (ICU) does not have an acuity specific assignment protocol for staff to ensure the personnel are properly qualified and are competent to meet patient needs in the ICU.

Findings include:

Interview on 10/19/11 at 7:50am with Staff #6 revealed that in her year of working at the facility as the Nurse Manager, she could not recall a patient in the ICU with an arterial line.

Medical record review on 10/19/11 of Patient #1's Operative Report dated 10/17/11 at 10:36am revealed Patient #1 was septic, ventilator dependent, with acidosis and hypotension, had a need for frequent blood gas monitoring and needed arterial pressure monitoring. Therefore, an arterial line was placed.

Interview on 10/19/11 with ICU staff revealed the use of arterial lines is infrequent (less than one per year) and staff expressed concerns regarding their lack of training and competency in caring for a patient with an arterial line.

Personnel file review on 10/19/11 for Staff #2 revealed no evidence of an ICU job-specific orientation checklist, which would indicate competency for cardiac monitoring, use of an arterial line, ability to use a ventilator and CVP monitoring.

During observation in the ICU on 10/18/11 at 3:20pm, the investigator was unable to locate the arterial line policy in the policy and procedures binder in ICU. Staff #1 stated it was on the computer and was able to locate the Policy and Procedure "Nurse Practice Guidelines For ICU" dated 5/06; however, this policy did not include instructions on how to zero the arterial line.

Based on policy and procedure review, medical record review and interview, the facility does not ensure that physician orders are authenticated, as evidenced for 3 of 11 patients. (Patients #1, 6 and 9)

Findings include:

Review on 10/20/11 of the facility policy and procedure "Physician Orders - Nursing Responsibility" (dated 10/10) revealed verbal or telephone orders from the responsible physician may only be received and written in the patient medical record by an RN. When a nurse transcribes verbal or telephone orders they are to X out the previous order sheet and write at top of the next sheet. The order is to be signed and co-signed by the responsible physician within 24 hours All orders should be dated and timed when received and when transcribed.

Medical record review on 10/20/11 at 12:15pm for Patient #6 revealed the following verbal/telephone orders were not authenticated by a provider:
- 10/15/11: telephone order for Home Medications ordered on the Medication Reconciliation form
- 10/17/11 10:30pm: hold Vancomycin tonight and follow up with the physician in the morning.
- 10/17/11 12:50pm: Lortab 7.5/500 po QID

These findings were verified with Staff #5 on 10/20/11 at 12:15pm.

Medical record review on 10/20/11 at 1:30pm for Patient #9 revealed the following verbal/telephone orders were not authenticated by a provider:
- 10/16/11 10:00pm: Admit orders
- verbal order for Home Medications ordered on the Medication Reconciliation form

These findings were verified with Staff #5 on 10/20/11 at 1:30pm.

Medical record review on 10/24/11 at 9:00am for Patient #1 revealed the following verbal/telephone orders were not authenticated by a provider:
- 10/16/11 7:15pm: okay to use TLC, call if any complication, ABG, CBC, APTT, set of lytes at 10:00pm
- 10/16/11 7:15pm: Nubain 5 mg IV every 6 hours for pain prn
- 10/16/11 (probably 10/17/11) 3:45am ABG STAT, Levophed drip, titrate to maintain systolic >90
- 10/18/11 5:30pm: Normal Saline with 2 amps Bicarb at 100 ml/hour, Bumex 2 mg IV times one, Amp of Bicarb now
- 10/18/11 6:55pm: Repeat CBC, BMP at 9:00pm - call MD on this date.
- 10/18/11 7:00pm: change vent to pressure support with TV of 600, draw ABG 1 hour after and call with results.
- 10/18/11 9:00pm: change vent TV from 600 to 650, redraw ABG 1 hour following and call with any critical changes.

As of 10/20/11, the physician orders had not been authenticated.

Based on policy and procedure review and interview, the facility does not ensure that Respiratory Services policies and procedures are reviewed and updated as needed.

Findings include:

Review on 10/20/11 of the Respiratory Policy and Procedure Manual revealed the respiratory policies and procedures had not been updated biennially for example:
- Respiratory Therapy Procedure for Arterial Puncture For Blood Gas Analysis, dated 6/09
- Postural Drainage Therapy, dated 8/01
- Job Descriptions/Expectations of Employees, dated 10/01
- Ordering Respiratory Therapy, dated 9/01
- Oxygen Therapy, dated 7/99

This finding was verified with Staff #3 on 10/20/11.


Based on medical record review and interview, the facility does not ensure that respiratory medication is delivered in a timely manner, as evidenced for 1 of 2 ICU patients. (Patient #11)

Findings include:

Medical record review on 10/20/11 for Patient #11 revealed:
- The multidisciplinary progress note dated 10/18/11 at 5:35am documented the patient was complaining of chest wall pain when she takes a deep breath and also started wheezing during the night. Lungs were noted to have wheezes bilaterally not present last night. The plan was to start Duonebs, Solumedrol and Azithromycin.
- The Doctor's Orders dated 10/18/11 at 5:35am revealed an order for Duoneb aerosols four times a day (QID). Documented next to the order was the notation "not in Pharmacy".
- Review of the Medications sheet dated 10/18/11 revealed Ipratropium and Albuterol Sulfate nebulizers were not administered until 11:41am, approximately 6 hours after having been ordered.

This finding was verified with Staff #5 on 10/20/11.