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Based on record review and interview the facility failed to ensure patient rights are protected by ensuring all restraint orders and renewed orders are authenticated by and under the direction of a physician or practitioner in 2 of 2 restraint records reviewed (#23 and 24); the facility failed to ensure there is a documented face to face assessment of the patient and ongoing assessments to ensure the well-being of the patient in restraints are documented in 2 of 2 restraint records reviewed (#23 and 24); the facility failed to ensure restraint training materials include all required content including how to determine the patient's behavior warrants removal of the restraint, how to assessment the physical and psychological distress and status of the patient in restraints, in 1 of 1 training document reviewed (Safety Storm: Gamma 2017); and the facility failed to ensure the Visitation Policy includes information allowing the patient to choose or deny visitors, and who will not be discriminated from visiting in 1 of 1 Visitation Policy reviewed. Total of 30 records reviewed.

Findings include:

The facility failed to ensure all restraint orders are under the direction of a physician or practitioner, in 1 of 2 restrain records reviewed, (#23). See Tag 168.

The facility failed to ensure restraint orders are obtained every 24 hours, in 2 of 2 medical records with restraints reviewed (#23 and #24). See Tag 173.

The facility failed to ensure there is a face to face assessment of a patient placed in restraints within 30 minutes of application of a restraint per facility policy, in 1 of 2 restraint records reviewed (#23). See Tag 184.

The facility failed to ensure the Restraint Management Flowsheets are completed facility policy, in 1 of 2 restraint records reviewed (#24). See Tag 188.

The facility failed to ensure the restraint training materials included how to determine physical and/or psychological distress, in 1 of 1 Restraint Training document (Safety Storm: Gamma 2017). See Tag 202.

The facility failed to ensure the restraint training materials included how to determine the patient's behavior warrants removal of the restraint, in 1 of 1 Restraint Training document (Safety Storm: Gamma 2017). See Tag 204.

The facility failed to ensure the restraint training materials included how to monitor the patient's physical and psychological status while in restraints, in 1 of 1 Restraint Training document (Safety Storm: Gamma 2017). See Tag 205.

The facility failed to ensure the visitation policy includes the patient's right to choose their visitors, in 1 of 1 record reviewed (Visitation Policy). See Tag 216.

The facility failed to ensure the visitation policy includes the following visitors will not be discriminated against based on gender identity, national origin or disability, in 1 of 1 policy reviewed (Visitation Policy). The cumulative affects of these system failures prevents the hospital from maintaining their patient rights program and ensuring patient rights are protected. See Tag 217.

Based on observation, interview and record review the facility failed to provide a safe environment, properly constructed and maintained to protect the health and safety of patients based on the following.

Findings include

K222 - one stairwell exit in the means of egress did not open;
K343 - two overnight rooms not provided with fire alarm notification devices;
K353 - sprinkler heads not maintained clean;
K363 - double corridor doors in one location did not have a latching hardware; and
K908 - dew point of medical air not maintained less than or equal to 35 deg. F and med gas alarms not activated when the high limit of 35 deg. F was exceeded.

Based on observation, record review and interview, the hospital's infection control program failed to have an active program for the prevention and control of infections and communicable diseases in 6 of 18 areas reviewed (Isolation Practices, Hand Hygiene, Medication Administration, Peripherally Inserted Central Catheter, Equipment Storage, Food Handling and Storage).

Findings include:

The hospital's infection control employee health program failed to ensure physicians and allied health staff receive N-95 respirator fit testing to ensure personal protective equipment protects staff from exposure to Tuberculosis (TB). See tag 0749

The hospital's infection control patient services program failed to ensure that hospital staff followed hospital infection control policies in the areas of isolation precautions, hand hygiene, aseptic medication preparation, food handling and storage, equipment storage, and Peripherally Inserted Central Catheter. See tag 0749

The cumulative effect of the hospital's failures to prevent and control the spread of communicable disease (TB) in staff and patients resulted in a high potential for harm to the health and safety of patients.

Immediate Jeopardy (IJ) was determined on 8/29/17 at 3:15 p.m. under 42 CFR Part 482.42- Condition of Participation: Infection Control, with regard to the hospital's failure to develop an infection control and prevention program which ensures N-95 respiratory fit testing for staff having contact with patients affected with active Tuberculosis. The facility's Chief Executive Officer B, Chief Nursing Officer A, Division President C, Chief Clinical Officer Y, and Director of Quality AA were notified of the IJ on 8/29/17 at 3:15 p.m. The IJ was removed on 8/30/17 at 10:30 a.m. after the facility presented a plan of correction detailing the immediate N-95 respiratory fit testing for Physician LL and all physicians and allied health staff prior to seeing patients in the hospital to ensure staff and patient protection from exposure to TB (Mycobacterium Tuberculosis). The deficient practice remains at the Condition-level.

Based on record review and interview, the facility failed to ensure Careplans are updated to include the use of restraints on a patient, in 1 of 2 restraint records reviewed (#23) out of a total 30 records reviewed.

Findings include:

Review of facility policy titled Restraints, dated September 2013 reveals, "Modify Plan of Care to include: a. The safety issue that resulted in the need for restraints. b. Desired measurable outcome-oriented goals. c. Interventions to minimize restraint sue, including attempts to use alternatives to restraints and to end-use at the earliest possible time. d. Patient/family education regarding the need for the restraint, alternatives attempted and the plan for safe removal."

Patient #23's medical record review, on 8/29/17 at 3:30 PM, revealed Patient #23 was placed in Mitt restraints on 7/27/17 at 5:45 PM. Per review of the Interdisciplinary Plan of Care, initiated on 7/27/17, there was no care plan addressing the restraints. This is confirmed in interview with Charge Nurse D on 8/29/17 at 3:50 PM.

Based on record review and interview the facility failed to ensure all restraint orders are under the direction of a physician or practitioner, in 1 of 2 restraint records reviewed, (#23).

Findings include:

Review of facility policy titled Restraints, dated September 2013 revealed for Medical Staff and Qualified AHPs (allied health professionals): 2. "Telephone orders may only be used for the first episode of restraint based on nursing assessment. 3. The need for restraints must be reevaluated and orders to renew the use of restraints must be entered at least once each calendar day."

Patient #23's medical record review, on 8/29/17 at 3:30 PM, revealed Patient #23 was placed in Mitt restraints on 7/27/17 at 5:45 PM. The restraint orders initiated on 7/27/17 at 5:45 PM are not authenticated by a physician. Patient #23 was placed in restraints on 7/28/17 at 7:00 PM. There is no order for the 7/28/17 restraints started at 7:00 PM. A renewed restraint order written on 7/29/17 at 7:00 AM is not authenticated by the physician. Patient #23 remained in restraints until 9:00 AM on 7/30/17 with no order written for the 7:00 AM to 9:00 AM time period. This deficiency was confirmed in interview with Charge Nurse D on 8/29/17 at 3:50 PM, who agreed there should be physician signatures for all restraint orders.

Based on record review and interview the facility failed to ensure restraint orders are obtained every 24 hours, in 2 of 2 medical records with restraints reviewed (23 and 24) out of a total 30 records reviewed.

Findings include:

Review of facility policy titled Restraints, dated September 2013 reveals for Medical Staff and Qualified AHPs (allied health professionals): 2. "Telephone orders may only be used for the first episode of restraint based on nursing assessment. 3. The need for restraints must be reevaluated and orders to renew the use of restraints must be entered at least once each calendar day."

Patient #23's medical record review revealed Patient #23 was placed in Mitt restraints on 7/27/17 at 5:45 PM with the Restraint Management Flowsheet showing documentation of restraint checks from 7:00 PM through 7/28/17 at 5:00 AM. Patient #24 was placed in restraints on 7/28/17 at 7:00 PM, with the Restraint Management Flowsheet showing documentation of checks through 6:00 AM on 7/30/17.

Physician restraint orders reviewed revealed no new orders for the restraints on 7/28/17 at 7:00 PM or for the restraints in place on 7/29/17 at 7:00 AM through 7/30/17 at 6:00 AM. The Restraint Management Flowsheet with documentation from 7:00 AM to 9:00 AM has no date. This is confirmed in interview with Charge Nurse D, who agreed there should be a new order everyday restraints are placed.

Patient #24's medical record review revealed on 8/2/17 Patient #24 was in Mitt restraints from 7:00 AM to 6:00 PM with no physician order. This deficiency was confirmed in interview with Director of Quality J on 8/29/17 at 4:30 PM.

Based on record review and interview the facility failed to ensure there is a face to face assessment of a patient placed in restraints within 30 minutes of application of a restraint per facility policy, in 1 of 2 restraint records reviewed (23), out of a total 30 records reviewed.

Findings include:

Review of facility policy titled Restraints, dated September 2013 reveals, "30 Minute Post Initial Restraint Application: RN (Registered Nurse) Restraint Check."

Patient #23's medical record review revealed Patient #23 was placed in Mitt restraints on 7/27/17 at 5:45 PM, there is no documentation of a 30 minute assessment by a nurse or physician between 5:45 PM and 6:45 PM. This is confirmed in interview with Charge Nurse D, who agreed there should be nurse assessments done every 30 minutes.

Based on record review and interview the facility failed to ensure the Restraint Management Flowsheets are completed per facility policy, in 1 of 2 restraint records reviewed (#24) out of 30 records reviewed.

Findings include:

Review of facility policy titled "Restraints" dated September 2013 revealed, "Every two (2) hours: Restraint Status (released for comfort/safety, then reapplied), Ensure proper placement, ROM (Range of Motion)/Ambulation, Position, Fluid/Nourishment, toileting, Personal Hygiene, Response to the restraint, Behavior Observation, Level of consciousness/orientation, Continue/Discontinue decision"

Patient #24's record review revealed the Restraint Management Flowsheet dated 7/28/17 indicates Patient #24 was in Mitt restraints from 7:00 AM to 6:00 PM. There is no documentation of the restraints being released or repositioned; the patient's mental status; or patient's behavior between 8:00 AM and 6:00 PM. The Restraint Management Flowsheet dated 7/30/17 indicates Patient #24 was in MItt restraints from 7:00 AM to 2:00 PM then 7:00 PM to 6:00 AM on 7/31/17. There is no documentation of any assessments of Patient #24 between 3:00 PM and 7:00 PM, there are no new restraint orders indicating they had been removed at 3:00 PM and restarted at 7:00 PM. The Restraint Management Flowsheet dated 8/1/17 indicates Patient #24 was in MItt restraints from 7:00 AM to 11:00 AM then 7:00 PM to 6:00 AM on 8/2/17. There is no documentation of any assessments of Patient #24 between 11:00 AM and 7:00 PM, there are no new restraint orders indicating they had been removed at 11:00 AM and restarted at 7:00 PM. This is confirmed in interview with Director of Quality J on 8/29/17 at 4:30 PM, who agreed the flowsheets should be complete.

Based on record review and interview staff failed to ensure the restraint training materials included how to determine physical and/or psychological distress, in 1 of 1 Restraint Training document (Safety Storm: Gamma 2017).

Findings include:

Per review of the facility's Restraint Training included in the Syllabus #50011 titled Safety Storm: Gamma 2017, the training does not include recognizing physical and psychological distress in patients that are placed in restraints. This is confirmed via email on 8/30/17 at 12:10 PM with Chief Medical Officer Y.

Based on record review and interview, the facility failed to ensure the restraint training materials included how to determine the patient's behavior warrants removal of the restraint, in 1 of 1 Restraint Training document (Safety Storm: Gamma 2017).

Findings include:

Per review of the facility's Restraint Training included in the Syllabus #50011 titled Safety Storm: Gamma 2017, the training does not include recognizing changes in the patient's behavior that would warrant removal of the restraint. This is confirmed via email on 8/30/17 at 12:10 PM with Chief Medical Officer Y.

Based on record review and interview, the facility failed to ensure the restraint training materials included how to monitor the patient's physical and psychological status while in restraints, in 1 of 1 Restraint Training document (Safety Storm: Gamma 2017).

Findings include:

Per review of the facility's Restraint Training included in the Syllabus #50011 titled Safety Storm: Gamma 2017, the training does not include how to ensure the patient's well-being while in restraints. This is confirmed via email on 8/30/17 at 12:10 PM with Chief Medical Officer Y.

Based on record review and interview, the facility failed to ensure the visitation policy included the patient's right to choose their visitors, in 1 of 1 record reviewed (Visitation Policy).

Findings include:

Per review of the facility's policy titled Visitation Policy, revised 8/17, it does not include the patient's right to choose their visitors, or deny a visitor. This is confirmed in interview via email with Chief Clinical Officer H on 8/30/17 at 12:10 PM.

Based on record review and interview, the facility failed to ensure the visitation policy included the following visitors will not be discriminated against based on gender identity, national origin or disability, in 1 of 1 policy reviewed (Visitation Policy).

Findings include:

Per review of the facility's policy titled Visitation Policy, revised 8/17, it does not include there will be no discrimination of visitors based on gender identity, national origin or disability. This is confirmed in interview via email with Chief Clinical Officer H on 8/30/17 at 12:10 PM.

Based on record review and interview staff failed to analyze and evaluate quality indicators for effectiveness in 3 of 4 quality projects reviewed (critical lab values, falls, vent weaning).

Findings include:

Policy reviewed titled, "Quality Assurance and Performance Improvement (QAPI) Plan" last reviewed 7/5/2017 revealed, "The overall objectives of the QAPI Plan are to collect data to monitor the organizations performance; compile and analyze the data; and improve performance on an ongoing basis."

Review on 8/30/2017 at 9:20 AM of Quality indicators with Corporate Director of Quality AA and Director of Quality J revealed the following:

1. Review of "Critical lab results with Readback" performance improvement project initiated in January 2017 revealed a goal for staff to be 90% compliant with all criteria including, "Provider contacted: result to receipt time to initial contact" and " Provider Notified: result receipt time to provider notified."

Review of critical lab values quality data from January 2017 to June 2017 reveals percent compliance ranging from 50% to 72%, the goal of 90% compliance was not met from January 2017 to June 2017.

Review of Quality Meeting minutes reveals no evidence of "follow up" on performance improvement project in February, May, and June 2017. Quality Meeting minutes from January 2017 to June 2017 reveals no evidence of a root cause analysis to identify barriers to improvement.

Quality meeting minutes revealed no documented evidence of an ongoing evaluation of interventions for effectiveness and when interventions were not successful, implementing new interventions to meet goals.

2. Review of the facility "Quality Scorecard" for Falls revealed a "Fall Rate Target (goal)" of "3". Fall rate (#falls/pt days x 1000) category shows the falls rate goal was not met in January, February, March, April, and July 2017.

Staff was unable to provide Quality meeting minutes recognizing and addressing fall rates from January 2017 to July 2017.

No documented evidence from January 2017 to July 2017 of performing a root cause analysis to identify barriers to improvement or evidence of an ongoing evaluation of interventions for effectiveness and when interventions were not successful, implementing new interventions to meet goals.

Interview with Director of Quality J on 8/30/17 at 11:30 AM, revealed there was no recent documentation of ongoing monitoring, analyzing, and evaluating action plan for the reduction of Falls.

3. Review of the facility "Quality Scorecard" for Respiratory revealed tracking of "Ventilator Wean Rate". Wean Rate goal is documented as 80%. Review of Ventilator Wean Rate for January 2017 to July 2017 revealed a ventilator wean rates from 20% to 63%, goal of 80% was not met from January 2017 to July 2017.

Staff was unable to provide Quality meeting minutes recognizing and addressing Ventilator Wean rates from January 2017 to July 2017.

No documented evidence from January 2017 to July 2017 of performing a root cause analysis to identify barriers to improvement or evidence of an ongoing evaluation of interventions for effectiveness and when interventions were not successful, implementing new interventions to meet goals.

Interview with Director of Quality J on 8/30/17 at 11:30 AM, revealed there was no documentation of analyzing data, developing an action plan, and evaluating action plan for effectiveness for Ventilator Weaning.

Interview with Corporate Director of Quality AA on 8/30/17 at 11:45 AM, revealed if the quality indicator is not meeting goal/threshold for more then 2 months, a quality improvement project should be initiated and an action plan developed and monitored.

Based on record review and interview, the facility failed to document progress made toward goals, the outcome of the care plan, and interventions performed in 8 of 30 records reviewed (Pt 15, 17, 18, 25, 26, 27, 28, 30).

Findings include:

Review of facility policy titled, "Care Plan" dated April 2017 revealed "The care plan will include the identified patient problems, the goals to work toward and the interventions to be utilized. Care plan is reviewed and updated with any changes as needed by appropriate disciplines."

Per medical record review on 8/30/2017 at 10:05 AM, Patient #15 was admitted to the facility on 8/8/2017 for wound care and osteomylitis. Patient #15's care plan includes a problem of impaired skin integrity with interventions to "reposition every 2 hours and PRN [as needed]." Review of Patient #15's activity flowsheets revealed Patient #15 was not turned every 2 hours and there was no documentation of why Patient #15 was not repositioned every 2 hours. Review of Patient #15's wound care orders, written by Wound Practitioner FF, state "Pressure Ulcer Prevention Measures: Turn every 2 hours."

During an interview on 8/30/2017 at 10:30 AM, Wound Practitioner FF stated staff "should be" turning the patient based on the orders. These finding were confirmed at the time of the review with Director H. H revealed nursing staff are expected to perform interventions as identified in the care plan.

Per medical record review on 8/30/2017 at 11:10 AM, Patient #17 was admitted to the facility on 8/10/2017 for wound care and osteomylitis. Patient #17's care plan includes a problem of Altered Tissue Perfusion related to diabetes initiated on 8/20/2017. The goal was for neuro/vascular checks within normal limits. The only intervention selected to help meet the goal was "perform circulatory checks every 4 hours and PRN [as needed]." The medical record does not contain evidence that the intervention was performed every 4 hours.

During an interview on 8/30/2017 at 11:10 AM, Director H stated "the nurses are doing assessments every shift which is twice a day, not every 4 hours. I'm not sure why that's in there." When asked if an intervention selected in the care plan should be documented, Director H stated "yes."

Per medical record review on 8/30/2017 at 10:55 AM, Patient #18 was admitted to the facility on 8/8/2017 for wound care. Patient #18's care plan initated 8/20/17 reveals problem of Altered Tissue Perfusion related to diabetes. The goal was for neuro/vascular checks within normal limits. The intervention selected to help meet the goal was "perform circulatory checks every 4 hours and PRN [as needed]." The medical record does not contain evidence that the intervention was performed every 4 hours.

Review of Patient #25's medical record revealed Patient 25 received inpatient services from 7/11/2017 through 7/24/2017 for wound care and antibiotic therapy. Patient #25's care plan, reviewed on 8/29/2017 at 9:55 AM, includes 8 problem/focus areas with goals and interventions. There was no documentation that goals were met or that progress was made toward the goals during the inpatient stay.

Review of Patient #26's medical record revealed Patient #26 received inpatient services from 7/10/2017 through 7/22/2017 for wound care and antibiotic therapy. Patient #26's care plan, reviewed on 8/29/2017 at 10:50 AM, includes 12 problem/focus areas with goals and interventions that were identified during the hospitalization. There was no documentation that goals were met at the time of discharge.

Review of Patient #27's medical record revealed Patient #27 received inpatient services from 6/22/2017 through 7/25/2017 for wound care. Patient #27's care plan, reviewed on 8/29/2017 at 11:15 AM, includes a problem of Impaired Skin Integrity related to pressure ulcers. The goal revealed wounds will improve as evidenced by a decrease in slough base percentage and decrease in size. Review/progress towards goal attainment revealed "wounds remain." There was no documentation of progress toward goals or the status of wounds at discharge.

Review of Patient #28's medical record revealed Patient #28 received inpatient services from 6/16/2017 through 7/26/2017 for endocarditis and intravenous antibiotic therapy. Patient #28's care plan, reviewed on 8/29/2017 at 12:40 PM, includes 6 problem/focus areas with goals and interventions. There was no documentation of progress toward goals during the inpatient stay or the status of the problems at discharge.

Review of Patient #30's medical record revealed Patient 30 received inpatient services from 7/28/2017 through 8/11/2017 for sepsis and intravenous antibiotic therapy. Patient #30's care plan, reviewed on 8/29/2017 at 2:10 PM, includes 5 problem/focus areas with goals and interventions. There was no documentation of progress toward goals during the inpatient stay or the status of the problems at discharge.

The findings for Patients #25, #26, #27, #28 and #30 were confirmed with Chief Nursing Officer A on 8/29/2017 at 2:30 PM. A stated outcomes should be documented at discharge and that is "something we are working on."

Based on record review and interview staff failed to provide evidence of contracted dialysis staff receiving a hospital orientation in 12 of 12 contracted dialysis staff (II, QQ, RR, SS, TT, UU, VV, WW, XX, YY, ZZ, AAA).

Findings include:

Record review on 8/29/17 beginning at 11:00 AM of personnel files for Registered Nurse "II" revealed "II" was a contracted agency dialysis nurse. Review of personnel files showed no evidence of "II" receiving an orientation to the hospital including but not limited to,
- The hospital and the unit;
- Emergency procedures;
- Nursing services policies and procedures; and
- Safety policies and procedures.

Per interview with Nurse Scheduler "MM" on 8/29/17 at 1:30 PM, "MM" revealed there is no evidence of the 12 contracted dialysis nurses (II, QQ, RR, SS, TT, UU, VV, XX, YY, ZZ, AAA) completing an orientation prior to providing care to patients in the dialysis unit.

Based on record review and interview the facility failed to ensure all entries into the patient medical record are complete, timed, dated and authenticated, in 10 of 30 records reviewed (Pt 2, 4, 7, 9, 10, 11, 12, 20, 21, 22).

Findings include:

Review of Patient #7's medical record on 8/29/17 at 9:00 AM revealed physician orders for vital signs every 8 hours and intake and output to be monitored routinely. Identified the following issues in Patient 7's medical record:

-The form titled Nursing Daily Flowsheet indicated documentation from 7:00 AM on 7/28/17 through 7/29/17 at 6:00 AM revealed,
*Bath (bed/shower) and mouth care was left blank.
*Bowel and Bladder documentation was blank
*Graphics record dated 7/28/17 has no vital signs, or meal intake documentated.
-Nursing Daily Flowsheet indicated documentation from 7:00 AM on 7/29/17 through 7/30/17 at 6:00 AM revealed,
*Bath (bed/shower) was left blank.
*Bowel and Bladder documentation was blank
-Graphics record dated 7/30/17 did not have any meal or oral intake documented for dinner.
-Nursing Daily Flowsheet indicated documentation from 7:00 AM on 7/31/17 through 8/1/17 at 6:00 AM revealed, *Bath (bed/shower) and mouth care was left blank.
*Bowel and Bladder documentation was blank.
Graphics record dated 7/31/17 did not have any meal intake documented and did not document fluid intake for lunch or dinner.
-Nursing Daily Flowsheet indicated documentation from 7:00 AM on 8/1/17 through 8/2/17 at 6:00 AM revealed,
*Bath (bed/shower), mouth care, and peri-care was left blank.
*Bowel and Bladder documentation was blank.
-Graphics record dated 8/2/17 did not have dinner meal or fluid intake documented.
-Graphics record dated 8/3/17 did not have any meal intake documented.
-Graphics record dated 8/4/17 did not have dinner meal intake documented.
-Nursing Daily Flowsheet indicated documentation from 7:00 AM on 8/9/17 through 8/10/17 at 6:00 AM revealed, *Bath (bed/shower), mouth care, peri-care was blank.
*Bowel and Bladder documentation was left blank.
-Graphics record dated 8/11/17 did not have dinner meal or fluid intake documented.
-Nursing Daily Flowsheet indicated documentation from 7:00 AM on 8/12/17 through 8/13/17 at 6:00 AM revealed, *Bath (bed/shower) and mouth care was left blank.
-Nursing Daily Flowsheet indicated documentation from 7:00 AM on 8/14/17 through 8/15/17 at 6:00 AM revealed *Bath (bed/shower) and mouth care was left blank.

Per interview with Patient #7 on 8/28/17 at 12:00 PM, Patient #7 only "received a bath (bed/shower) every blue moon". Patient #7 stated the staff do not wash us up, I was told I had to ask."

Review of Patient #20's medical record review on 8/29/17 at 10:30 AM revealed Patient #20 died in the hospital on 7/27/19. The Progress Note dictated on 7/24/17 was not authenticated by the provider within 30 days of the record being closed. The Progress Note dictated on 7/26/17 was not authenticated by the provider within 30 days of the record being closed. The Consultation Report dictated on 7/26/17 was not authenticated by the provider within 30 days of the record being closed.

Review of Patient #21's medical record review on 8/29/17 at 11:00 AM revealed Patient #21 died in the hospital on 7/2/17. The Expiration Summary dictated on 7/2/17 was authenticated on 8/28/17, more than 30 days after the record was closed.

Review of Patient #2's medical record on 8/29/17 at 12:05 PM revealed the "Nursing Daily Flowsheet" dated 8/26/17 from 7:00 PM to 7:00 AM and 8/27/17 had no documentation of "Bowel & Bladder" function. Per nursing documentation on 8/26/17 from 7:00 AM to 7:00 PM Patient 2 was documented as "Incontinent". "Graphic Record" for 8/24/17 has no documentation of bedtime blood sugar and gastroenteral feeding intake and output from 7:00 PM to 7:00 AM.

Review of Patient #9's medical record on 8/29/17 at 1:00 PM revealed physician orders for vital signs every 8 hours and intake and output to be monitored routinely. Identified the following issues in Patient 9's medical record:
-The form titled Nursing Daily Flowsheet indicated documentation from 7:00 AM on 7/20/17 through 7/21/17 at 6:00 AM. Patient #9 was admitted at 2:00 PM, Bath (bed/shower), mouth care was left blank. Bowel and Bladder documentation indicated patient #7 was incontinent at 9:00 AM, there was no documentation that patient voided, was continent or had a bowel movement.
-The form titled Nursing Daily Flowsheet indicated documentation from 7:00 AM on 7/27/17 through 7/28/17 at 6:00 AM. Bowel and Bladder documentation was left blank for void, continent and incontinent.
-Graphics record dated 8/4/17, 8/8/17, 8/14/17, and 8/16/17 did not have any meal intake documented for dinner.
-Medication administration sheet dated 8/20/17 states, Sterile dressing change IV site (Sunday night) Change PICC or midline dressing every Sunday night and prn, this was not initialed indicating the dressing change was completed.

Review of Patient #22's medical record review on 8/29/17 at 1:30 PM revealed Patient #22 died in the hospital on 7/26/17. The Progress Note dictated on 7/25/17 was not authenticated by the provider within 30 days of the record being closed.

Review of Patient #10's medical record on 8/29/17 at 2:00 PM revealed physician orders for vital signs every 8 hours. Graphic record dated 8/16/17 indicated vital signs were completed at 2:00 PM and 10:00 PM, not every 8 hours.

Review of Patient #11's medical record on 8/29/17 at 2:30 PM revealed physician orders for vital signs every 6 hours and blood sugars to be checked before every meal and at bedtime. Identified the following issues in Patient 11's medical record:
-Graphics record dated 8/23/17 indicated vital signs were completed at an undocumented time, 11:00 PM and 6:00 AM, not completed every 6 hours.
-Graphics record dated 8/25/17 does not have a blood sugar documented prior to breakfast.
-Graphics record dated 8/27/17 does not have a blood sugar documented prior to lunch or supper.
-Graphics record dated 8/28/17 does not have a blood sugar documented prior to bedtime.

Review of Patient #4's medical record on 8/29/17 at 2:45 PM revealed a physician order for vitals signs every 6 hours. Per Patient 4's "Graphic Record" dated 8/28/17, 8/23/17, and 8/17/17, vital signs are documented every 8 hours and not every 6 hours as per physician order. Patient 4 record has no documentation of gastroenteral feeding intake or output from 7:00 PM to 7:00 AM.

Review of Patient #12's medical record on 8/29/17 at 3:00 PM revealed Patient 12's "Nursing Daily Flowsheet" dated 8/27/17 revealed no documentation of urinary output or bowel movements for the last 24 hours.

Findings during medical record review was confirmed by Director of Quality J at time of record reviews, Director of Quality J confirmed that the above documentation was not completed.

Interview with Chief Nursing Officer A on 8/29/17 at 2:45 PM revealed "vital signs, blood sugar checks, and documentation on the Nursing Daily Flowsheet were not completed per physician order and expectations".

Interview with Director of Quality J on 8/29/17 at 2:00 PM revealed the records should be completed within 30 days of discharge.


29963

Based on record review and interview the staff failed to ensure verbal and telephone orders are authenticated by the physician within 24 hours in 7 of 30 medical records reviewed (Pt 7, 9, 10, 11, 16, 22, 31).

Findings include:

Review of policy titled "Verbal and Telephone Orders" last reviewed September 2014, revealed "All telephone or verbal orders for medications will be transcribed in the medical record and shall be countersigned by the practitioner within twenty-four (24) hours."


34337


Review of Patient #22's medical record review on 8/29/17 at 1:30 PM revealed Patient #22 died in the hospital on 7/26/17. The History and Physical examination dictated on 7/13/17 was not authenticated by the provider with a time. The Progress Note dictated on 7/24/17 was authenticated with an illegible date and time by the provider.

Review of Patient 31's medical on 8/29/2017 at 2:30 PM, revealed a telephone order dated 8/22/2017 was not signed or authenticated by the physician, more than 48 hours later.

Review of Patient 16's medical on 8/30/2017 at 9:35 AM, revealed admission orders written as telephone orders on 8/23/2017 at 9:00 PM are not signed or authenticated by the physician at the time of the review, more than 48 hours later.


29963


Review of Patient 7's medical record on 8/29/17 at 9:00 AM revealed the following:
Telephone orders written on 8/16/17 at 8:15 AM, 8/18/17 at 7:50 AM, and 8/28/17 at 7:25 AM not authenticated by the physician.

Review of Patient 9's medical record on 8/29/17 at 1:00 PM revealed the following:
Telephone orders written on 8/15/17, (not timed), 8/16/17 at 8:20 AM, 8/18/17 at 8:20 AM, 8/23/17 at 3:30 PM, 8/24/17 at 3:00 PM, and 8/25/17 at 9:15 AM not authenticated by the physician.

Review of Patient 10's medical record on 8/29/17 at 2:00 PM revealed the following:
Telephone orders written on 8/10/17 at 1:30 AM, 8/16/17 at 9:20 and 11:15 AM, and 8/25/17 at 9:15 AM not authenticated by the physician.

Review of Patient 11's medical record on 8/29/17 at 2:30 PM revealed the following:
Telephone order written on 8/16/17 at 11:10 AM was not authenticated by the physician.

Per interview with Director of Quality J during record reviews on 8/29/17 all telephone orders should be authenticated by the physician within 24 hours.

Based on record review and interview, staff failed to ensure medical records include a completed discharge summary per policy in 2 of 6 discharged patients reviewed (Pt 26, 28) in a total sample of 30 records.

Findings include:

Review of policy titled, "Medical Record -- General" (undated) revealed "Discharge summary: The discharge summary should be completed before or shortly after the time of inpatient discharge from the facility and should follow the following approved format: ...admission/discharge date; ...information provided to the family (i.e., diet, medication, activity and follow up, other discharge instructions)."

Review of policy titled, "Medical Record Documentation" last revised September 2013 revealed, "Medical Records will be complete within 30 days of the patient's discharge."

Per medical record review on 8/29/2017 at 10:50 AM, Patient #26 was discharged from the facility on 7/22/2017. Patient #26's medical record did not contain a discharge summary. This finding was confirmed with Coder L on 8/28/2017 at 1:45 PM. L stated during an interview on 8/28/2017 at 1:45 PM that the physician "thought s/he had dictated it [discharge summary]. We just noticed today that we didn't have it."

Per medical record review on 8/29/2017 at 12:40 PM, Patient #28 was discharged from the facility on 7/26/2017. Patient #28's discharge summary, dictated on 8/7/2017, failed to include Patient #28's admission and discharge date. This finding was confirmed at the time of the review with Director H. Director H stated on 8/29/2017 at 12:40 PM that the summary should include admission and discharge dates.

Based on record review, observation, and interview, the facility failed to ensure that drugs/biologicals are kept in secure area and locked when appropriate in 1 of 5 medication administration observations (Pt 18) and 1 of 1 patient rooms observed (medication cupboard).

Findings include:

Review of facility policy titled "DRUG PROCUREMENT/INVENTORY CONTROL" #3201 revealed, "Medications are stored in a secure manner."

On 8/28/17 at 11:30 AM observed room cleaning of a patient that had been discharged. Upon entering the room "Medication Cupboard" standing open with a bottle of artificial tears and Humalog (insulin) in cupboard unsecured. An interview was conducted with Staff H (Case Management) at the time of finding who stated "The pharmacy comes and removed the medications from the cupboard after a patient is discharged but the cupboard should remain locked until they come."

An interview was conducted with Staff U (pharmacist) on 8/29/17 at 9:20 AM who stated "we used to keep medications in the locked cupboard of each patient room. We don't do that anymore. All patient medications should be in the locked medication room out by the nurses station. There should not have been any medications in the room."


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During an observation of medication preparation and administration on 8/28/2017 at 11:25 AM, Registered Nurse T entered the common medication room to prepare an insulin injection for Patient #18. Registered Nurse T looked in Patient #18 medication bin, then left the room and returned with a vial of insulin. Registered Nurse T stated "I don't know why" the insulin vial was in Patient #18's room and not in the medication room. Per Nurse T, all medications are to be stored in the medication room, not in patient rooms.

Based on observation, interview and record review the facility failed to provide a safe environment, properly constructed and maintained to protect the health and safety of patients based on the following.

Findings include

K222 - one stairwell exit in the means of egress did not open;
K343 - two overnight rooms not provided with fire alarm notification devices;
K353 - sprinkler heads not maintained clean;
K363 - double corridor doors in one location did not have a latching hardware; and
K908 - dew point of medical air not maintained less than or equal to 35 deg. F and med gas alarms not activated when the high limit of 35 deg. F was exceeded.

Based on observation and staff interview, the facility failed to provide proper ventilation in 2 of 6 storage areas (soiled utility room, clean storage room).


Findings include:

1. On 8/28/17 at 4:30 pm, observation revealed that the Soiled Utility room across the 3rd Floor Nurse Station was not maintained under negative pressure to cause airflow in the right direction from clean to dirty spaces in accordance with the CDC Guidelines, and AIA Guidelines for Design and Construction of Health Care Facilities.

2. On 8/29/17 at 9:55 am, observation revealed that the clean storage Med Supply Room 223 across the 2nd Floor Nurse Station was not maintained under positive pressure.

The above two deficiencies were confirmed by the concurrent observation and interview with Staff R (director of plant operations) and Staff S (corporate director of plant operations), and at the time of exit conference with Staff B (hospital president), Staff C (divisional president) and Staff Y (chief clinical officer) on 8/29/17 at 2:20 pm.

Based on observations, record reviews, and interviews, the hospital failed to ensure a system for controlling potential transmission of infections and communicable diseases, in 6 of 18 areas reviewed (Isolation Practices, Hand Hygiene, Medication Administration, Peripherally Inserted Central Catheter, Equipment Storage, Food Handling and Storage). This has the potential to affect the total census of 34 patients.

Findings include:

1. Isolation Practices

Review of policy titled, "Tuberculosis Control Plan" last revised 4/2017 revealed personal respiratory protective equipment will be used in situations in which the risk of infection with TB may be high. Specific measures to reduce the risk for transmission include Respiratory fit testing program. Per policy, all personnel should don respirator (N-95/NIOSH mask) and conduct fit checks for potential air leakage prior to entering room.

Review of personnel files on 8/29/2017 beginning at 11:00 AM revealed Physician Assistant CC, Physician DD, Physician EE, and Nurse Practitioner FF had no documented evidence of N-95 respirator fit testing done to prevent potential exposure to Tuberculosis (TB).

Per interview with Administrative Assistant KK on 8/29/17 at 11:00 AM, KK revealed the hospital does not have records of N-95 respirator fit testing for Physicians and Allied Health staff (Nurse Practitioners, Physician Assistants). Review of the Provider list including physicians, Nurse practitioners, physician assistants, revealed there are 94 staff members potentially providing care to patients at this hospital.

Interview with Physician LL on 8/29/17 at 1:43 PM revealed LL is currently the physician for Patient 13. Review of Patient 13's "History and Physical" dated 8/25/17 at 6:01 PM, revealed Patient 13 was admitted on 8/24/17 to receive treatment for Tuberculosis. Patient 13 was placed in Airborne precautions in a negative pressure room.

Per interview, LL stated "its been about 3 or 4 years" since LL completed N-95 respirator fit testing. When asked how LL knows what size respirator mask to don before entering Patient 13's room, LL revealed when fit tested 3 or 4 years ago LL fit a size small mask so LL continues to don a size small when entering Patient 13's room.

Per interview with Chief Medical Officer NN on 8/29/17 beginning at 3:40 PM, NN revealed that physicians and allied health staff do not require fit testing. Per NN, disposable N-95 respirator masks "do not require fit testing"; staff was unable to provide documented evidence of manufactures guidelines revealing N-95 respirator masks did not require fit testing. When asked do nursing staff require N-95 respirator fit testing, NN responded "Yes" because they are in the patients room more than the physician.

Per interview with Medical Director Z on 8/30/17 at 3:00 PM, Z revealed there was "no need" for fit testing because it had been a while since there was an active Tuberculosis patient in the facility. Per Z, physicians and allied staff should have N-95 respirator fit testing done. Z revealed staff do not keep track of who has been fit tested or not.

Per interview with Chief Nursing Officer A on 8/29/17 at 2:00 PM, A revealed all staff having contact with patients should receive fit testing annually.

2. Hand Hygiene

Review of policy titled, "Standard Precautions" last revised 9/2014 revealed, "Remove gloves promptly after use and wash or disinfect hands immediately before touching non-contaminated items and environmental surfaces...", "Change gloves and wash or disinfect hands between tasks and procedures on the same patient after contact with materials that may contain blood or other body fluids.

Review of policy titled, "Hand Hygiene" effective date 7/2013 revealed, hand hygiene is to be performed at a minimum before applying gloves and after removing gloves, before performing clean/aseptic procedure, after touching patient surroundings.

On 8/29/17 at 11:00 AM observation of patient cares in room 200 revealed patient #10 is on contact isolation precautions. Physician N entered patient 10's room and did not perform hand hygiene prior to putting on gown and gloves, to complete an assessment on patient #10.

On 8/29/17 at 11:15 AM Registered Nurse O was observed going up to Dialysis Machine in station 2, Registered Nurse O took a glove and wrapped it around the tip of her finger to adjust the settings on the dialysis machine. Registered Nurse O was also observed placing gloves on without performing hand hygiene prior to going into station #1 by patient #7. Findings were confirmed with Lab Director I on 8/28/17 at 1:20 PM. Lab Director I stated hand hygiene should be completed prior to putting on gloves.

During observation of insulin administration on 8/28/2017 at 11:25 AM, Registered Nurse T donned gloves to draw insulin from a vial into a syringe in the common medication room. Wearing the same pair of gloves, Registered Nurse T left the medication room with the syringe, walked down the hallway to Patient #18's room. Nurse T proceeded to disinfect Patient #18's skin and inject the medication without changing gloves or performing hand hygiene.

3. Medication Administration

On 8/29/17 at 11:10 AM observed Registered Nurse W drawing up an intravenous medication for patient #8. Registered Nurse W did not perform hand hygiene prior to preparing medications for patient #8. Registered Nurse W removed the cap from the vial and proceeded to insert needle and draw up medication into the syringe. Registered Nurse W did not clean the rubber septum of the medication vial prior to inserting needle.

Per interview with Chief Nursing Officer "A" on 8/29/17 beginning at 4:00 PM, Chief Nursing Officer A revealed staff should be cleaning the rubber septum of medication vial with alcohol wipe before inserting needle. Chief Nursing Officer A confirmed there is no facility policy and procedure that includes this cleaning process.


4. Peripherally Inserted Central Catheter (PICC) dressing change

Per interview with Director of Quality J on 8/29/17 at 1:00 PM the facility uses Lippincott Nursing Procedures Seventh Edition for PICC care procedures. Per the Lippincott Nursing Procedures page 603 for Performing PICC dressing change it states after removing the old dressing "...remove and discard your glove, perform hand hygiene, put on sterile gloves..."

Per observation on 8/29/17 between 8:37 AM and 9:23 AM, Registered Nurse Q performed a PICC dressing change. At 9:15 AM, after removing the old dressing, Nurse Q left the room to obtain more supplies, leaving the PICC site open to air and unprotected from potential contaminates. Upon return, Nurse Q proceeded to leave the site uncovered while removing the line's cap, removed gloves and donned sterile gloves without performing hand hygiene. Per interview with Nurse Q on 8/29/17 at 4:00 PM, Nurse Q confirmed s/he should not have left the patient room with the PICC site uncovered.

Per interview with Director of Quality J on 8/29/17 at 1:00 PM the facility uses Lippincott Nursing Procedures Seventh Edition for PICC care procedures. Per review of Lippincott Nursing Procedures page 603, after removing the old dressing "...remove and discard your glove, perform hand hygiene, put on sterile gloves..."

5. Clean Equipment Storage

Per tour of area where high level disinfecting of Endoscopes was completed on 8/28/17 at 1:40 PM with Respiratory Therapist M, noted the scope was stored in a vented closet with a retractable cover, it was observed that the cover had a 2 inch tear in the plastic. Interview with Respiratory Therapist M at the time of the observation revealed the "rip was fixed with a piece of tape at one time but appears to be ripped again".

Per review of policy titled High Level Disinfection, #RT 6, dated 3/22/17. The purpose of policy was to ensure uniform cleaning and high level disinfecting of bronchoscope ... utilizing an EPA registered product solution. To ensure proper use and processing of endoscopes between patients. Place scope in a appropriate storage area.

6. Food Handling and Storage

The following was observed on 8/29/17 between 7:45 AM and 7:35 AM:

At 7:45 AM, Dietary Manager K did not have a beard net covering all facial hair.

At 7:50 AM, Cook OO took the temperature of the scrambled eggs, verbalized it was 168 degrees, and documented it as 165 degrees on the Holding Temps on Steam Table sheet dated August 29, 2017. Cook OO verbalized the temperature of the sausage as 152 degrees and documented it as 165 degrees on the Holding Temps sheet. The Holding Temp sheet had a minimum temperature for "Entrees" (sausage) as 165 degrees. Cook OO verbalized and documented the sausage and gravy temperature as 140 degrees, the Holding Temps sheets has a minimum temperature of 155.

These deficiencies were confirmed in interview with Dietary Manager K and Cook OO at the time of the observations. Cook OO stated "I was nervous and wrote the wrong numbers down."

At 7:08 AM Dietary Aide PP changed out his/her gloves and did not perform hand hygiene.

At 7:09 AM Cook OO removed gloves used hand sanitizer without first using soap and water, donned new gloves. Per Serve Safe 6th Edition, it states under Chapter 4, Section 4 "Hand antiseptics must only be used after handwashing and not in place of it."

At 7:15 AM Cook OO removed gloves and did not perform hand hygiene, after finishing preparing the tray line.

At 7:35 AM a test tray, prepared at 7:14 AM, was followed to the third floor and the following temperatures were recorded: Eggs -126 degrees, sausage-124.6 degrees, another type of eggs- 107 degrees, oatmeal- 134 degrees, coffee-151 degrees, milk-57 degrees and apple juice-56.8 degrees. These temperatures were confirmed at time of testing, 7:35 AM with Dietary Manager K who agreed the temperatures should be sustained longer after leaving the kitchen. Manager K revealed there is no record of test tray temperature checks.

At 7:45 AM during observations kitchen storage areas, with Manager K, the refrigerator contained food items outside of their original packaging without identifying labels. These items included sliced yellow cheese, blocks of ground meat, meatballs. There was a pitcher that Manager K stated was "diet lemonade", with no label. The Freezer included unidentified vegetables outside of their original container.

At 7:50 AM the handwashing and beard net deficiency was confirmed in interview with Manager K who stated a beard net should always be worn and handwashing should be after gloves are removed.

At 7:55 AM, there a spray bottle of Peroxide Multi-surface Cleaner, the label that does not state it was safe for food surfaces. Per interview with Manager K at 7:55 AM, s/he was told this product was for kitchen surfaces. On 8/29/17 at 1:30 PM Manager K revealed s/he contacted the distributor and learned the cleaner is for machines that can be rinsed and not for food preparation surfaces.

Per review of The Holding Temperature on Steam Table Sheets from July 31, 2017 through August 29, 2017, there are no temperatures recorded for hot beverages, cold beverages, salads or desserts. This deficiency was confirmed in interview with Director of Quality J, on 8/29/17 at 1:00 PM, who agreed the temperatures should be recorded, and confirmed there was no policy on doing food temps.

The following was observed on 8/29/17 between 1:10 PM and 1:46 PM:

At 1:18 PM, Manager K's beard net did not cover all facial hair.

At 1:25 PM the dishwasher rinse cycle reached 180 degrees for less than 1 second, the second rinse cycle reached 181 degrees for less than 1 second, the third rinse cycle reached 182 degrees for 1 second, and the fifth rinse cycle reached 178 maximum temperature.

At 1:35 PM one tray of dished was observed to go through the wash/rinse cycle 5 times with the following maximum temperature in the rinse cycles: 169, 172, 174, 176 and 177.

Per interview with Dietary Manager K on 8/29/17 at 2:30 PM, Manager K confirmed the low rinse temperatures and provided the Cleaning and Sanitizing section of the 2005 Food Code from the Federal Drug Administration, that states under II. Sanitizing Methods, Heat. "...If high-temperature warewashing machines used to sanitize cleaned dishes, the final sanitizing rinse must be at least 180 degrees Fahrenheit. Cleaned items must be exposed to theses temperatures for at least 30 seconds."


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Based on record review and interview, the facility failed to provide discharge instructions to 3 of 5 patients discharged to home (Patient #25, Patient #28, Patient #31) out of a total of 30 records reviewed.

Findings include:

Review of facility policy "Discharge/Transition Planning" dated November 2016 revealed, "If discharge plan is home, provide patient and/or family/responsible caregiver with discharge instructions (prescribed treatment, medications, nutritional plan, activity level, follow up appointments) that are written in laymen's terms... The nurse and the patient and/or family /responsible caregiver should date, time and sign the form. A copy should be given to patient, and/or family/responsible caregiver."

Per medical record review on 8/29/2017 at 9:55 AM, Patient #25 received inpatient services from 7/11/2017 through 7/24/2017. Patient #25 was discharged home on 7/25/2017. There were no documented discharge instructions in Patient #25's record. Patient #25's medication reconciliation list, dated 7/21/2017, does not include medications ordered as inpatient from 7/22/2017 through 7/24/2017.

During an interview on 8/29/2017 at 1:35 PM, Director H revealed the medication reconciliation list was sent home with patients at discharge. The list includes all medications received at the hospital with the physician indicating whether the patient was to continue the medication at discharge by circling either a "yes" or "no" next to each medication. H revealed Patient #25 was scheduled to be discharged on 7/22/2017 but the discharge got delayed and the medication list "should be updated" to include all medications prescribed as an inpatient. When asked about Patient #25's discharge instructions, Director H stated "I don't know, that [discharge instructions form] should have been filled out."

Per medical record review on 8/29/2017 at 12:40 PM, Patient #28 was discharged from the facility to home on 7/26/2017. There were no discharge instructions included in Patient #28's record. During an interview on 8/29/2017 at 1:35 PM, Director H stated "the nurses are supposed to fill out the discharge instruction forms for the patients. That is something we are working on."

Per medical record review on 8/30/2017 at 2:30 PM, Patient #31 was discharged from the facility to home on 8/22/2017. Patient #31's discharge summary revealed, "Follow up: The patient should have a CBC and basic chem [laboratory tests] in 1 week." Review of Patient #31's discharge instructions do not include any instructions to follow up for testing. This finding was confirmed during an interview with Direcotor H at the time of the review.

Based on interview, the facility failed to evaluate the discharge planning program in 1 of 1 department reviewed (Case Management).

Findings include:

During an interview on 8/29/2017 at 8:55 AM, Case Management Director H was unable to produce evidence that the facility was reviewing their discharge planning program on a regular basis. When asked how the facility was able to evaluate that discharge plans are meeting patient needs, H stated "we are working on follow up phone calls for discharged patients, but we are not doing them consistently." Director H revealed readmissions are being tracked by Division President C, but not something that was looked at within the Case Management department.

During an interview with Division President C on 8/29/2017 at 4:00 PM, C was unable to provide documented evidence that readmissions are being tracked as a way to evaluate the effectiveness of the discharge planning program.