HospitalInspections.org

Based on observations and interview, it was determined the facility staff failed to ensure that the medical record for one (1) patient, Patient #11, was kept confidential.

The findings include:

On 3/13/18 at approximately 11:04 A.M., during the facility tour of the third (3rd) floor with Staff Member #3, portions of Patient #11's medical record was observed lying on a medication cart. There was no staff present. Patient #11's name was clearly visible.

Staff Member #3 stated, "That should not be turned that way. I was hoping you hadn't seen it."

Based on document review and interview, it was determined the facility staff failed to follow physician's orders for bilateral mitten restraints, removal of the hand mittens every two hours for skin assessments and range of motion, and documented assessments for one (1) of one (1) patients surveyed for restrain use, Patient #8.

The findings include:

On 3/14/18 and 3/15/18 the medical record of Patient #8 was reviewed and the following items were noted:

Patient #8 was admitted on 2/1/18 with the diagnoses of Peripheral Arterial Disease, Thoracic Aortic Aneurysm, Status Post Thoracic surgery and Pressure Ulcers. Patient #8 was admitted with a Stage II (2) pressure ulcer of the upper back, Stage IV (4) pressure ulcer of the sacrum, Arterial wound of the first toe left foot and a surgical wound of the chest. Patient #8 was receiving nutrition via a tube feed and antibiotics via intravenous (IV).

The medical record nursing notes document Patient #8 attempting to pull out lines for feeding, Foley and IV fluids. The review of the medical record and Nursing Restraint Flow Sheets revealed orders for bilateral mittens, Range of Motion (ROM) and skin assessments every 2 hours. Deviations were noted for the following dates and times:

2/23/18 at 20:15 (8:15 P.M.) (date and time of order for bilateral mittens): no date/time as to when or if released from the mittens.

2/24/18 at 17:00 (5:00 P.M.) order obtained: No flowsheets to indicate when skin checks, (ROM) was performed or when mittens removed. Electronically signed by the nurse on 2/24/18 at 6:02 A.M.

2/25/18 at 17:45 (5:45 P.M.) order obtained: At 1:00, 3:00 and 5:00 A.M. there is no documentation of the need for the mittens, no documentation of skin checks or ROM at 4:00 and 6:00 A.M., and no documentation of the time mitten were removed. Electronically signed by the nurse on 3/02/18 at 4:10 A.M.

2/28/18 at 00:30 (12:30 A.M.) order obtained: No documentation from 12:30 A.M. to 7:00 A.M. regarding the skin assessments or ROM checked. No documentation of when the mittens were discontinued.

3/5/18 at 9:00 A.M. order obtained: No documentation as to when the mittens were discontinued.

3/6/18 at 14:00 (2:00 P.M.) order obtained: Nursing Restraint Flow Sheet documents order as 3/6/18 at 14:30 (2:30 P.M.). Flow Sheet documents Patient #8 was out of mitten restraints from 8:00 A.M. until 6 P.M. in the comment section but in the Additional Comment Section on the same form it is documented the mittens were reapplied. Flow Sheet has documentation of mittens on at 9:00 P.M. and at 2:00 A.M. with no documentation that would indicate mittens were removed, or that skin checks and ROM were performed.

3/8/18 at 16:30 (4:30 P.M.) order obtained: No no documentation as to why the restraints were applied, ROM performed and what time the restraints were removed. Electronically signed by the nurse on 3/09/18 at 14:52 (2:52 P.M.).

A second Nursing Restraint Flow Sheet with the same date and time (3/8/18 at 16:30 (4:30 P.M.) is all the blanks for Neurovascular Checks, Skin Integrity Checks and Safety Checks as well as Need for Restraint Re-Assessed and Comment was completed from 8:00 A.M. until 6:00 P.M. This time the documentation was electronically signed by the same nurse on 3/13/18 at 20:19 (8:19 P.M.).

None of the forms indicate a late entry or documentation change was performed.

The Nursing Restraint Flow Sheet documentation with a date of restraint order from 3/8/18 at 4:30 P.M. was continued at 8:00 P.M. until 6:00 A.M. There is no date other than when the order was obtained on 3/8/18. This flow sheet was Electronically signed by the nurse on 3/14/18 at 7:26 A.M.

3/9/18 at 16:30 (4:30 P.M.) order obtained: Flow Sheet says Right hand mitten with no documentation of Skin assessments and ROM checks from 4:30 P.M. until 7:00 P.M. This flow sheet was Electronically signed by the nurse on 3/13/18 at 23:14 (11:14 P.M.).

3/10/18 at 17:30 (5:30 P.M.) order obtained (one hour late): Flow Sheets do not indicate what time restraints were removed. The flow sheets documented Patient #8 was still pulling at tubes and lines and at 5:30 P.M. it was documented that Patient #8 show signs of increased agitation. This flow sheet was Electronically signed by the nurse on 3/11/18 at 18:04 (6:04 P.M.).

3/11/18 at 16:30 (4:30 P.M.) order obtained: Flow sheet has no documentation from 4:30 P.M. until 7:00 P.M. that Patient #8 was in a mitten or, if removed, when they were removed. No documented skin assessments or ROM between 4:30 P.M and 7:00 P.M. This flow sheet which is electronically signed by the nurse on 3/13/18 at 18:41 (6:41 P.M.).


The policy titled Use of Restraint/Safety Device-Hospital with a review date of 3/17 was provided by Staff Member #2 and documents the following:
Under the Procedure Section E) Staff shall not discontinue a restraint order and then restart it again under the same order. I...a) Order must be time limited, and not to exceed 24 hours; b) Order must be renewed every 24 hours after reassessment and the continued need for restraint is documented; c) Re-evaluate and renew the order every 24 hours until the restraint is discontinued.

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Based on interview and medical record review, it was determined that the facility failed to administer medications as ordered by the physician for seven (7) of thirty one (31) patients (Patient # 2, # 8, # 9, # 12, # 13, # 14 and # 18).

The findings include:

1. During medical record reviews on March 14 and March 15, 2018 the following medical records revealed physician orders for medications that were not administered:

Patient # 12
"Certavite SR, via tube every day"; not administered on February 23 at 9:00 a.m.
"Loratiadine 10mg, via tube every day"; not administered on February 23, 2018 at 9:00 a.m.

Patient # 13
Carvedilol F/C 6.25 mg, via tube twice daily; not administered on February 23, 2018 at 9:00 a.m.
Diltiazem HCL 60 mg, via tube three time daily; not administered on February 17 at 6:00 a.m.
Furosemide 40mg, by mouth twice daily; not administered on February 23, 2018 at 9:00 a.m.
Hydralazine HCL 50 mg, via tube every eight (8) hours; not administered on February 17, 2018 at 6:00 a.m.
Potassium chloride 40 meq, via tube twice daily; not administered on February 14, 2018 at 9:00 a.m.

Patient # 14
Ascorbic Acid 500mg, via tube twice daily; not administered on January 11, 2018 at 9:00 a.m.

Patient # 18
Donepezil HCL 5mg, via peg tube at bedtime; not administered on March 6 at 9:00 p.m.

An interview with Staff Member # 3 on March 15, 2018 at approximately 1:00 p.m. revealed "if it was not documented then it was not done".

2. Patient #8's medical record, nursing notes, MAR (medication administration record) and physician's orders for February and March 2018 was reviewed on 3/15/18 and revealed the following:

Orders for
2/1/18: Acetaminophen 325 mg (milligrams) tabs 2 (650 mg) or 20 ml (milliliters (640 mg)) per tube (feeding tube) as needed for pain. Tramadol 50 mg 30 minutes prior to wound care.
2/14/18: Tramadol 50 mg for dressing change.

2/8/18 at 23:50 (11:50 P.M.) the nurses notes indicate Patient #8 was "medicated prior to dressing change" but no time as to when the medication was given or when the dressing change was performed.

2/9/18 at 24:00 (12:00 midnight) the nursing notes states: "Pt. (Patient) attempted to hit during care, dressing change to sacrum." No indication Patient #8 was medicated prior to dressing change and no time as to when the dressing change occurred.

2/10/18 at 22:00 (10:00 P.M.) the nursing notes states "dressing change to sacrum. Tramadol given prior to". No indication as to the time medication was given or dressing change occurred.

2/13/18 at 17:00 (5:00 P.M.) The MAR documents Tylenol was given for pain. The results document it was ineffective. There is no documentation as to what else was done or the physician being notified about Patient #8's pain.
2/18/18 Patient #8 was medicated for pain and was yelling out. The results document it was ineffective. There is no additional documentation as to what else was done or the physician being notified about Patient #8's pain.

3/4/18 7:00 P.M. The MAR documents patient received Tramadol and the dressing to the sacrum was performed at 18:00 (6:00 P.M.) (The MAR is written Tramadol 50 mg 1 tab via tube 30 minutes prior to wound care and has the hours of 7A - 7P and 7P - 7A.)
3/9/18: the 7A - 7P dose is circled. Under the comment section on the MAR the legend documents B. Circle initials when medication is refused.
3/10/18: the 7P - 7A dose is left blank.

The nurses' note dated 3/5/18 at 4:59 P.M. document "Medicated with Tylenol times 2 for pain, effective both times." The MAR only shows documentation for one dose of Tylenol at 04:00 A.M.


3/10/18 the following feedings, intravenous fluids and medications were not signed off as given:
1. Jevity 1.5 at 55 ml/hour; (per abbottnutrition.com JEVITY 1.5 CAL is a calorically dense formula with a unique fiber blend that provides Complete, Balanced Nutrition®. ... For supplemental or sole-source nutrition.)
2. H20 (water) flush 60 ml following tube feeding of Jevity.
3. Tramadol 50 mg as above.
4. NS (normal saline) IV at 75 ml/hour X 3 days; not signed off as given on 3/11/18 and 3/12/18.
5. Sulfamethoxazole/Trimethoprim DS (Bactrim DS) 1 tablet via peg (feeding) tube twice daily through 3/23/18; no initials indicating medication was given on 3/10/18 or 3/14/18 at 21:00 (9:00 P.M.).
6. Vancomycin oral 250 mg/5 ml solution give 2.5 ml (125 mg) via feeding tube 4 times a day through 4/1/18; no initials indicating the medication was given on 3/10/18.
7. Pro-Stat S/F wild Cherry 15G-100/30 liquid (Grams) 30 ml via feeding tube three times per day (per vitalitymedical.com, Pro-Stat, is a sugar free protein supplement that can be used for patients with pressure ulcers, malnutrition, involuntary weight loss, dialysis, low serum proteins and more.); No initials indicating the nutritional supplement was given on: 3/7/18 at 6:00 A.M., 3/10/18 at 22:00 (10:00 P.M.) and on 3/11/18 at 6:00 A.M. .
8. Atorvastatin 10 mg via tube at bedtime was not initialed as given on 3/10/18 at 21:00 (9:00 P.M.).
9. Digoxin 125 mcg tablet via tube every day was being given at 9:00 A.M. On 3/5, 3/9, 3/10 and 3/12/18 on the MAR there was no documented heart rate prior to administration.
10. First-Omeprazole Compounding 20 ml via tube twice daily. No initials indicating it was given on 3/10/18.
11. Prevalite 4 GM packet via tube three times daily. At 6:00 A.M. on 3/7 and 3/11/18 and on 3/10/18 at 22:00 (10:00 P.M.) there is no indication by initial the medication was administered.

On 3/15/18, Staff Member #3 was asked to explain the MAR's and stated, "We either missed administering some medications or did not document we gave them. Either way we did not do what we should have done."

Based on interview and medical record review, it was determined that the facility failed to ensure all information ordered by the physician was completed and added to the medical record for two (2) of thirty one (31) patients, Patients # 9 and # 14.

The findings include:

During medical record reviews on March 14 and March 15, 2018, the following medical records revealed physician orders for treatments were not documented as ordered:
Patient # 9-
Weekly skin assessment every Sunday 7P-7A; no skin assessment documented on February 18, 2018.

Patient # 14-
Trach tie change Mondays, Wednesdays and Fridays; no documented trach tie change on March 12, 2018.

An interview with Staff Member # 3 on March 15, 2018 at approximately 1:00 p.m. revealed "if it was not documented then it was not done".

Based on document review and interview, it was determined the facility staff failed to ensure they followed their Utilization Review (UR) Plan.

The findings include:

The UR plan, meeting minutes notebook and the sign in sheets for the past year were reviewed on 3/14/18 at various times with Staff Members #1 and #10. Staff Member #1 stated, "I am usually in the meeting but (Name of Staff Member #10) conducts the meeting." Staff Member #10 stated, "We have meetings every Wednesday which are our Patient Status Review meetings. We review all patients in two (2) groups; they are separated by Medicare private insurance, contracts and the second group is Medicaid. This information is reported to the Medical Staff monthly. There are no physician's in the UR meeting."

The UR Plan provided documents the following:
Page 2 Section V Part A documents: "§Conditions of Participation Standard:
Committee consists of three or more practitioners that carry out the UR function. At least two of these members of the committee must be doctors of medicine or osteopathy and one must be a staff member of the institution. The other members may be any of the other types of practitioners specified in the §482.12(c)(1)."

A review of the minutes and sign in sheets for the meetings for at least 12 months did not demonstrate a physician was involved in any of the meetings.

Based on observations and interviews, it was determined the facility staff failed to ensure equipment in two (2) areas of the facility were repaired or replaced to ensure the safety of patients and staff.

The findings include:

During the tour of the rehabilitation area, Staff Member #6 stated, "Our rehabilitation area is used by both hospital and long term care patients." The following items were noted:

The parallel bars had a wooden pathway that was broken, splintered and uneven making it a fall or trip hazard for all who used it.

The seat on the Electric Stander was torn. Staff Member #6 stated, "I didn't realize that was torn."

The floor of the rehabilitation area (in front of the doorway) was cracked and had uneven areas where patients would ambulate creating a fall or trip hazard. Staff Member #6 stated, "We have had to have the floor repaired before (pointed out at least one place where the floor had been torn open to repair issue). I think this is the same type of problem."

During the tour of the pediatric unit, the room identified on the pediatric ward as the CT room (Century Tub) was observed with Staff Member #3 and #5. Staff Member #5 stated, "The CT room is used by all the children when they are able to get in the tub." The floor of the room was observed with cracked, broken and separating tiles that could be a fall or trip hazard.

Based on observations and interviews, it was determined the facility staff failed to ensure the equipment in two (2) areas of the facility was maintained in a manner that would prevent the spread of infections.

The findings include:

During the tour of the rehabilitation area, Staff Member #6 stated, "Our rehabilitation area is used by both hospital and long term care patients." The following items were noted:

Five (5) chairs were observed that were used by patients (2 patients were observed sitting in the chairs) with black tape around at least one arm of the chair. The tape prevents the chairs from being cleaned and disinfected between use.

The covers for the hydroculator packs were observed stacked on top of each other while still damp. Staff Member #6 stated, "We have the covers laundered each week and at the end of each day we place them over the parallel bars to dry. We do not have a drying rack for the covers." The warm, damp stacked covers promote the growth of mold and mildew.

Nine (9) wedges, used to support patients, were observed lying on the mat tables and various other places. The wedges had portions of the protective vinyl covering missing. The missing protective covering left exposed foam which is porous and can not be disinfected.

During the tour of the pediatric unit, the room identified on the pediatric ward as the CT room (Century Tub) was observed with Staff Members #3 and #5. Staff Member #5 stated, "The CT room is used by all the children when they are able to get in the tub." The floor of the room was observed with cracked, broken and separating tiles that could not be properly cleaned and disinfected.

Based on documentation review and interview, the facility failed to ensure their Emergency Preparedness Plan (EPP) was evaluated and updated annually.

The findings include:

On 3/13/18 at approximately 1:30 P.M., the EPP was reviewed and discussed with the outgoing EPP Coordinator. The plan was not signed and dated as to when it was updated. When this was pointed out and a copy provided by Staff Member #9, the plan was signed and dated on 3/14/18.

Based on documentation review and interview, it was determined the facility failed to ensure an all hazards approach assessment and drills were conducted each year.

The findings include:

On 3/13/18 at approximately 1:30 P.M., review of the EPP revealed that the plan lacked contingencies for emergencies other than tornado.

Staff Member #8 was interviewed on 3/13/18 at approximately 1:30 P.M. and stated, "Each year at least since 2009 we have participated in the statewide tornado drill. The only other drills, which was an actual event, we have done is for inclement weather in January 2017. There was a discussion between me and the Vice President to ensure we had things in place. There were no other staff involved in the planning or evaluation of the process."

Based on documentation review and interview, it was determined the facility failed to ensure there was a secondary plan in place to notify staff members should there be no switchboard operator.

The findings include:

On 3/13/18 at approximately 1:30 P.M., the Emergency Preparedness Plan (EPP) was reviewed with Staff Member #8. The EPP documents the following under Authority and Direction of the Plan:
"In the event of a disaster, the President/CEO or his designate will activate the plan by calling the hospital switchboard. The switchboard operator will notify all personnel that the plan has been activated and will announce the appropriate verbiage overhead and through the phone's speakerphone system. Messengers will be used in case the public address system is out of order...."

There is no alternative plan should a switchboard operator not be available.

Staff Member #8 stated, "I see there are some areas were we can improve."