HospitalInspections.org

Based on observations, record review, and interviews, the hospital failed to meet the Condition of Participation for Governing Body as evidenced by:

1) The hospital failed to ensure that the contracted services were provided in a safe and effective manner. There no documentation that the Governing Body had evaluated the contracted services within the last twelve months. There was no documented evidence that the contracted services had been involved in the hospital-wide quality assurance/performance improvement program. This resulted in inaccurate monthly facility checks performed by a contracted pharmacist for expired medications, unidentified medication variances, undocumented wastage of narcotics, and chart audits not being performed and nutritional assessments not being performed in a timely manner (see findings in tag A0084).

2) The hospital failed to meet the Condition of Participation for Quality Assurance/Performance Improvement (see findings in tag A0263).

3) The hospital failed to meet the Condition of Participation for Medical Staff (see findings in tag A0338).

4) The hospital failed to meet the Condition of Participation for Nursing services (see findings in tag A0385).

5) The hospital failed to meet the Condition of Participation for Medical Record Services (see findings in tag A0431).

6) The hospital failed to meet the Condition of Participation for Pharmaceutical Services ( see findings in tag A0490).

Based on record review and interview the hospital failed to meet the requirements for the Condition of Participation for Quality Assurance/Performance Improvement as evidenced by:

1) Failure to focus performance improvement activities on high-risk, high-volume or problem prone areas as evidenced by failing to include patients receiving intravenous (IV) titrate drips of cardiogenic and vasoactive medications and IV sedation in the adult ventilated patient resulting in failure to follow the policy and procedure for parameters for weaning of patients on cardiogenic and vasoactive medications for 2 of 2 patient with orders for dopamine out of a total of 20 sampled patients and monitoring and documentation of cardiac rhythm via telemetry by the RN and an anesthetic agent being titrate and monitored by an RN outside of a critical care setting for 1 of 1 patients with orders for Propofol (Diprivan) out of a total of 20 sampled patients and failing to accurately monitor blood administration to ensure blood was administered at the ordered rate of infusion resulting in blood being administered at the discretion of the nursing staff with at rates of > 1 hour to > 4 hours for 5 of 6 patients with orders for blood administration (#3, #4, #14, #15, #16) from a total of 20 sampled patients. (See finding at Tag A0285 and A0409);

2) Failure to develop an effective system for identification of errors in medication administration as evidenced by relying on self-reporting of errors by the nursing staff as the primary means of identification resulting in forty (106) unidentified medication variances identified through review of 20 sampled medical records (See findings at Tag A0266);

3) Failure to implement corrective action for the identified problem of narcotics shift counts failing to be performed according to policy and procedure. This resulted in undocumented wastage and therefore unaccounted Oxycodone for Patient #6 during record review. (See findings at Tag A0289);

Based on record review and interviews, the hospital failed to meet the Condition of Participation for Medical Staff as evidenced by:

1) The medical staff failed to ensure La. R.S. 9:111 relating to pronouncement of death was followed by physicians. The physicians delegated the assessment of irreversible cessation of spontaneous respiratory and circulatory functions to the nurse and determined and and pronounced the patients' death via the telephone for 2 of 3 patients who expired while admitted to the hospital (#9, #15) out of a total sample of 20 medical records (see findings in tag A0347).

Hospital Administrator S1 was notified on 04/27/12 at 11:25am of an Immediate Jeopardy situation. The Immediate Jeopardy situation was a result of the hospital failing to ensure the physician performed an onsite physical assessment of a patient to determine death prior to pronouncement of death as required by La. Revised Statute 9:111. This was evidenced by registered nurses assessing 2 of 3 patients (#9, #15) for lack of blood pressure, pulse, and respirations, notifying the physician by phone, and documenting a determination of death (which is not in their scope of practice). The time of death was then documented in the chart by the registered nurse. This has the potential to affect 10 of 28 admitted patients with diagnoses/conditions considered critical which could result in death.

A plan of removal developed by Administrator S1 was presented to the survey team on 04/27/12 at 4:00pm. Review of the plan of removal revealed the following:
(1) Medical Executive Committee meeting was held 04/27/12 at 2:15pm. Effective today the policy I-A.1.27 titled Patient Death has been revised; step #2 was removed from the procedure. Step #1 was revised to state "a physician or coroner" must pronounce a patient. No nurse will be allowed to pronounce death.
(2) The facility will not allow the nurses to practice outside their scope of practice by pronouncing death. The hospital will ensure the physician performs an onsite assessment of a patient to determine death as required by La. Revised Statute 9:111.
(3) All clinical staff will be notified of policy changes via a mandatory in-service. In-services will be scheduled to cover all rotations and shifts. In-service will be held before staff begins assignment. All staff will be inserviced by 04/30/12 at 6:00pm.
(4) All medical staff with admitting privileges will be notified via written communication with return receipt by 04/30/12 at 5:00pm.
(5) Monitoring: sign in roster will be generated for signature; a check-off sheet will be created to make sure all staff have been educated on the policy changes; admitting physician roster will be generated; all admitting physicians must sign if notified in person; once return receipt is received from written communication, it will be marked to indicate notified; mortality review tool will be updated to monitor if appropriate steps were taken.

On 04/27/12 at 4:30pm, Administrator S1 was notified that the Immediate Jeopardy was lifted. Condition level non-compliance remained for the Condition of Participation for Medical Staff.

2) The medical staff failed to enforce its bylaws to carry out its responsibilities.
a) The medical staff failed to complete patient medical records within 25 days of discharge as required by the bylaws which resulted in the hospital having a 71% (per cent) delinquency rate for the first quarter of 2012. Discharge summaries were not completed and authenticated by the physician within 25 days of discharge as required by the medical staff rules and regulations for 4 of 9 discharged patient records reviewed from a total of 20 sampled patients (#12, #13, #15, #16) and 19 random patients (R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21).
b) The medical staff failed to implement its bylaws for suspension of physicians with incomplete patient records 25 days after discharge (see findings in tag A0353).

3) The medical staff failed to ensure an updated examination of the patient that included any changes in the patient's condition was completed, documented, and placed in the patient's medical record within 24 hours after admission when the medical history and physical examination (H&P) was completed within 30 days before admission for 7 of 20 sampled patients (#6, #8, #10, #11, #12, #13, #19) (see findings in tag A0359).

4) The medical staff failed to ensure a medical history and physical examination (H&P) was completed and documented no more than 30 days before or 24 hours after admission and placed in the medical record within 24 hours after admission for 2 of 20 sampled patients (#7, #16) (see findings in tag A0358).

Based on record review and interviews, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

1) The hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient.
a) The RNs failed to practice within their scope of practice by assessing patients and pronouncing the death of 2 of 3 patients who expired (#9, #15) from a total of 20 sampled patients and administering and titrating an anesthetic agent (Propofol) to a patient (#15) while venitlated outside of a critical care setting for 1 of 1 patients on a Propofol drip out of a total of 20 sampled patients.

Hospital Administrator S1 was notified on 04/27/12 at 11:25am of an Immediate Jeopardy situation. The Immediate Jeopardy situation was a result of the hospital failing to ensure that the nursing staff provided care within their scope of practice by:
(1) Allowing registered nurses to pronounce the death of a patient. This was evidenced by registered nurses assessing 2 of 3 patients (#9, #15) for lack of blood pressure, pulse, and respirations, notifying the physician by phone, and documenting a determination of death. The time of death was then documented in the chart by the registered nurse. La. Revised Statute 9:111 requires the pronouncement of death be performed by a physician or coroner. This has the potential to affect 10 of 28 admitted patients with diagnoses/conditions considered critical which could result in death.
(2) Allowing the registered nurse to administer an anesthetic agent via intravenous drip outside of an intensive care unit and without appropriately documented critical care competency, experience, and/or training as required by La. Revised Statute 97:935. This resulted in registered nurses administering Propofol (Diprivan) via intravenous drip to 1 of 3 ventilated patients (#15) in a facility with no designated intensive care unit. This has the potential to affect 1 patient currently on a ventilator.

A plan of removal developed by Administrator S1 was presented to the survey team on 04/27/12 at 4:00pm. Review of the plan of removal revealed the following:
(1) Medical Executive Committee meeting was held 04/27/12 at 2:15pm. Effective today the policy I-A.1.27 titled Patient Death has been revised; step #2 was removed from the procedure. Step #1 was revised to state "a physician or coroner" must pronounce a patient. No nurse will be allowed to pronounce death. Effective today the policy II-C.3.59 titled IV Sedation in the Adult Ventilated Patient will be removed immediately.
(2) The facility will not allow the nurses to practice outside their scope of practice by pronouncing death. The hospital will ensure the physician performs an onsite assessment of a patient to determine death as required by La. Revised Statute 9:111.
(3) The contracted pharmacy/pharmacist was notified via phone and e-mail of the removal of the IV Sedation in the Adult Ventilated Patient policy. Pharmacy will be requested to contact the Medical Directors and Facility Administrator if any orders are received for anesthetics via intravenous drips. The ordering physician will be contacted by the Medical Director. The order will not be filled by pharmacy. A log of occurrences will be kept by the Administrator.
(4) Registered Nurses will not be allowed to administer anesthetic agents via IV in the facility.
(5) All clinical staff will be notified of policy changes via a mandatory in-service. In-services will be scheduled to cover all rotations and shifts. In-service will be held before staff begins assignment. All staff will be inserviced by 04/30/12 at 6:00pm.
(6) All medical staff with admitting privileges will be notified via written communication with return receipt by 04/30/12 at 5:00pm.
(7) Monitoring: sign in roster will be generated for signature; a check-off sheet will be created to make sure all staff have been educated on the policy changes; admitting physician roster will be generated; all admitting physicians must sign if notified in person; once return receipt is received from written communication, it will be marked to indicate notified; mortality review tool will be updated to monitor if appropriate steps were taken.

On 04/27/12 at 4:30pm, Administrator S1 was notified that the Immediate Jeopardy was lifted. Condition level non-compliance remained for the Condition of Participation for Nursing Services.

1b) The RNs failed to assess the cardiac rhythm of telemetry patients, verify telemetry settings and verify telemetry alarm in the "ON" position every shift according to physician order and hospital policy for 10 of 11 patient with orders for telemetry (#1, #2, #4, #7, #8, #12, #13, #15, #16, #17) from a total 20 sampled patients (see findings in tag A0395).

2) The hospital failed to ensure all drugs and biologicals were administered according to physician orders and acceptable standards of practice for 9 of 20 sampled patients (#1, #4, #6, #7, #8, #12, #15, #17, #20). This resulted in 106 medication errors noted during chart reviews that were not identified by the hospital for the nine patients (see findings in tag A0405).

Based on record review and interviews, the hospital failed to meet the Condition of Participation for Medical Record Services as evidenced by:

1) The hospital failed to ensure each patient's medical record was promptly completed no later than 30 days after discharge by having a 71% (per cent) delinquency rate for the first quarter of 2012. The hospital failed to ensure all discharge summaries were completed and authenticated by the physician within 25 days of discharge as required by the medical staff rules and regulations for 4 of 9 discharged patient records reviewed from a total of 20 sampled patients (#12, #13, #15, #16) and 19 random patients (R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21) (see findings in tag A0438).

2) The hospital failed to ensure all physician orders were dated and timed for 10 of 20 sampled medical records (#3, #4, #6, #7, #10, #11, #12, #13, #16, #19) (see findings in tag A0454).

3) The hospital failed to ensure all verbal orders were dated, timed, and authenticated when signed by the physician according to Medical Staff By-Laws for 12 of 20 sampled medical records (#3, #6, #7, #9, #10, #11, #12, #13, #14, #15, #16, #19) (see findings in tag A0457).

4) The hospital failed to ensure an updated examination of the patient that included any changes in the patient's condition was completed, documented, and placed in the patient's medical record within 24 hours after admission when the medical history and physical examination (H&P) was completed within 30 days before admission for 7 of 20 sampled patients (#6, #8, #10, #11, #12, #13, #19) (see findings in tag A0461).

Based on record review and interview the hospital failed to ensure that the contracted services were provided in a safe and effective manner as evidenced by: 1) no documentation that the Governing Body had evaluated the contracted services within the last twelve months;
2) no documentation the contracted service had been involved in the hospital-wide quality assurance/performance improvement program. This resulted in inaccurate monthly facility checks performed by a contracted pharmacist for: expired medications, unidentified medication variances, undocumented wastage of narcotics, chart audits not being performed and nutritional assessments not performed in a timely manner. Findings:

Review of the Annual Governing Board Meeting dated 01/31/12 revealed.... "1. Annual Evaluations: a. Contract Service Evaluation 2011 - annual evaluations reviewed and all recommendations have been reviewed. Discussion was held and evaluations have been accepted by medical staff. The evaluations have been approved by the GB (Governing Board)".

The hospital could not submit any documented evidence that evaluations of the contracted services had been performed.

In a face to face interview on 04/24/12 at 2:00pm S1 Interim Administrator indicated all service contracts were reviewed and approved at the January 2012 Governing Board Meeting. Further S1 indicated to her knowledge there was no written documentation of the evaluations and could not provide to the survey team the criteria used to evaluate the contracted services.

See additional findings concerning pharmacy services at Tag A0490 and A0621.

Based on record review and interview the hospital failed to follow their policy and procedure for informed consents as evidenced by: 1) failing to ensure the ordering physician signed a blood consent form for 4 of 6 patients who received blood/blood components (#4, #13, #15, #16) from a total of 20 sampled medical records and 2) having a patient and/or his/her representative sign a blank release of information form for 6 of 20 sampled medical records (#1, #2, #3, #4, #8, #9). Findings:

1) Failing to ensure the ordering physician signed a blood consent form:
Patient #4
Review of the medical record for Patient #4 revealed an 86 year old female admitted to the hospital for Myelodysplasia, UTI (Urinary Tract Infection), Venous Stasis Ulcers and Malnutrition. Additional diagnoses included anemia, electrolyte imbalance, and sacral decubitus ulcers. Review of the Physicians Orders dated/timed 04/04/12 at 0225 (2:25am) revealed an order to " T (transfuse)+M (match) 2 units packed cells " and 04/16/12 (no time documented) " Type and Cross 2 u PRBC (packed red blood cells)+ transfuse " .

In a face to face interview on 04/26/12 at 2:25pm RN S2 Director of Nursing indicated this information should be checked by the nurse administering the blood.

Review of the "Consent for Transfusion of Blood and Blood Components" for Patient #4
revealed no documented evidence the consent was signed by the physician.

Patient #13
Review of Patient #13's medical record revealed she was an 82 year old female admitted on 01/06/12 with the primary diagnosis of osteomyelitis right foot with stage IV ulcer. Further review revealed secondary diagnoses were MRSA (methicillin resistant staph aureus) and Proteus Mirabilis urinary tract infection, atrial fibrillation, iron deficiency anemia, hypertension, history of cerebrovascular accident with aphasia and dysphagia with a PEG (percutaneous esophageal gastrostomy) tube, and multiple decubitus ulcers.

Review of Patient #13's "Physician Orders" dated 01/10/12 at 7:38pm revealed an order to type and match for 2 units of packed red blood cells and transfuse each unit over 4 hours.

Review of Patient #13's "Consent For Transfusion Of Blood And Blood Components" revealed no documented evidence that the patient's condition for which the blood was being administered had been completed, and there was no documented evidence of that the consent was signed by the physician.

Patient #15
Review of the medical record for Patient #15 revealed a 75 year old male admitted to the hospital on 03/23/12 for continued care of acute respiratory failure, aspiration pneumonia, sepsis and malnutrition. Review of the Physicians Order dated/timed 03/30/12 at 1332 (1:32pm) revealed an order to "Type, match, transfuse 2u PRBC".

Review of the "Consent for Transfusion of Blood and Blood Components" for Patient #15 dated 03/30/12 at 1332 (1:32pm) revealed no documented evidence the physician timed when he signed the consent.

Patient #16
Review of the History and Physical (H&P) Patient #16 revealed a 67 year old female admitted to the hospital on 01/18/12 for continued treatment of Klebsiella pneumonia, urinary tract infection and Candida glabrata cystitis. Review of the Physicians Orders dated 01/27/12 at 0745 (7:45am) revealed a verbal order to "T+CM for 2 units & transfuse with dialysis".

Review of the "Consent for Transfusion of Blood and Blood Components" for Patient #16 dated 01/27/12 (no time documented) revealed no documented evidence the physician signed the consent.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations...D. Informed Consents It shall be the responsibility of the attending physician to obtain informed consent for any treatment or procedure he/she may perform. Consents for either a treatment or a procedure shall be obtained in writing on forms provided by the hospital whenever possible. ...Consents are obtained for all invasive procedures with risk involved including but not limited to the following: ...Blood Transfusions...".

2) Having a patient and/or his/her representative sign a blank release of information form:
Patient #1
Review of the release of information form for Patient #1, revealed a verbal consent was obtained from someone other than the patient; however the relationship to the patient was not documented. It was signed on the day of admit 04/18/12. Further review of the form revealed no documentation of the information requested.

Patient #2
Review of the release of information form for Patient #2, revealed a verbal consent was obtained from the patient's wife on the day of admit (04/19/12). Further review of the form revealed no documentation of the information requested.

Patient #3
Review of the release of information form for Patient #3, revealed her son had signed a blank form on 04/09/12 the day before her admit on 04/09/12. Further review of the form revealed no documentation of the information requested.

Patient #4
Review of the release of information form for Patient #4, revealed a verbal consent was obtained from the patient's niece on the day before admit (03/26/12). Further review of the form revealed no documentation of the information requested.

Patient #8
Review of Patient #8's medical record revealed he was an 85 year old male admitted on 04/20/12 with diagnoses of septicemia, end-stage renal disease with hemodialysis, hypotension, anemia, syncope, and congestive heart failure. Further review revealed secondary diagnoses included dementia, pacemaker, bilateral below the knee amputation, diabetes mellitus, neurogenic bladder, and chronic obstructive pulmonary disease.

Review of Patient #8's "Authorization For Release Of Protected Health Information (PHI)" revealed the patient's name, address, date of birth, and social security number were completed with a date of "4/20/12" and a hand-written note of "Pt (patient) verbal left message (with) wife)" with no documented evidence of the author of the note. Further review revealed no documented evidence of the description of the medical records to be released.

Patient #9
Review of the release of information form for Patient #9, revealed his son had signed a blank form at the time of admit on 03/19/12. Further review of the form revealed no documentation of the information requested.

In a face to face interview on 04/27/12 at 11:30am RN S2 Director of Nursing indicated the Case Managers are responsible for obtaining signatures for the release of information upon admit. S2 agreed consents which are not completed should not be signed by the patient or his/her family representative.

Review of the hospital policy titled "Release of Information", policy number III-A.1.13, revised 01/10, and contained in the policy manual presented by Administrator S1 as current, revealed, in part, "...Comprehensive and Centralized System All release of information shall be established under the jurisdiction and direct supervision of the HIM (health information management) Department. ...HIPAA (health insurance portability and accountability act) Compliant Authorization Before releasing information from a medical record, it is a requirement that the authorization contain the following: 1. A description of the information to be used or disclosed that identifies the information in a specific and meaningful fshion; ...7. Signature of the individual and date; ... 10. A description of the purpose of the requested use or disclosure...". Review of the entire policy revealed no documented evidence that having a patient or caregiver sign a blank release of information had been addressed.


25065

Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting by having sharps containers filled past the marked fill line in 2 of 24 patient rooms and in the first floor medication room and the lab. Findings:

Observation of the lab on 04/23/12 at 9:45am revealed the sharps container was filled beyond the marked fill line indicating that it needed to be replaced.

In a face-to-face interview on 04/23/12 at 9:45am, Respiratory Manager S3 confirmed the above observation.

Observation of the first floor medication room on 04/23/12 at 10:30am revealed the sharps box was filled beyond the marked fill line indicating that it needed to be replaced.

In a face-to-face interview on 04/23/12 at 10:30am, Director of Nursing (DON) S2 confirmed the above observation.

Observation of patient room "b" on 04/23/12 at 11:25am revealed the sharps container was filled beyond the marked fill line indicating that it needed to be replaced.

In a face-to-face observation on 04/23/12 at 10:30am, DON S2 confirmed the above observation.

Observation on 04/23/12 at 12:00pm of patient room "c" revealed the sharps container was filled beyond the marked fill line indicating that it needed to be replaced.

In a face-to-face interview on 04/23/12 at 12:00pm, DON S2 confirmed the above observation.

Based on record review and interview the hospital failed to update the plan of care for patients placed in restraints for 1 of 3 patients with orders for restraints (#16) from a total sample of 20 medical records. Findings:

Patient #16
Review of the History and Physical (H&P) Patient #16 revealed a 67 year old female admitted to the hospital on 01/18/12 for continued treatment of Klebsiella pneumonia, urinary tract infection and Candida glabrata cystitis.

Review of the Restraint Order Sheet dated 01/28/12 revealed Patient #16 was confused and attempted to climb over the siderails and bilateral wrist restraints were implemented at 2300 (11:00pm).

Review of the Interdisciplinary Plan of Care for Patient #16 which was initiated on 01/18/12 revealed no documented evidence it was updated to include application of restraints.

In a face to face interview on 04/26/12 at 11:30am RN S2 Director of Nursing indicated the plan of care should have been modified when the patient was placed in restraints.

Review of policy # II-C.3.20 titled "Restraints" last revised 12/09 and submitted as the one currently in use revealed.... "Procedure: Initiation of Restraints 13. Once the patients has been placed in a restraint there must be modification in the patient's plan of care which documents care of the patient while in restraints".

Based on record review and interview the hospital failed to ensure restraints were not ordered prn (as necessary) for 2 of 2 patients with orders for restraints (#10, #16) out of a total of 20 sampled medical records. Findings:

Patient #10
Review of the medical record for Patient #10 revealed a 95 tear old female admitted to the hospital on 01/10/12 for sepsis, infected left hip wound, malnutrition, and a history of dementia.

Review of the Restraint Order Sheet dated 01/12/12 revealed Patient #10 was confused, combative and uncooperative. Further Patient #10 was receiving intravenous fluids.

Review of the Physicians Orders dated 01/11/12 at 1940 (7:40pm) revealed a telephone order to "Bilateral wrist restraints as needed".

Patient #16
Review of the History and Physical (H&P) Patient #16 revealed a 67 year old female admitted to the hospital on 01/18/12 for continued treatment of Klebsiella pneumonia, urinary tract infection and Candida glabrata cystitis.

Review of the Restraint Order Sheet dated 01/18/12 revealed Patient #16 was confused and attempted to climb over the siderails. Further Patient #16 was receiving oxygen and intravenous fluids.

Review of the Physicians Orders dated 01/28/12 at 2345 (11:45pm) revealed a telephone order to "Place wrist restraints as needed".

In a face to face interview on 04/26/12 at 11:30am RN S2 Director of Nursing indicated both the medical staff and the nursing staff know prn orders are not acceptable. Further S2 indicated restraint logs were kept and restraints were monitored to make sure the policy and procedures are followed.

Review of policy # II-C.3.20 titled "Restraints" last revised 12/09 and submitted as the one currently in use revealed..... "Procedure: Initiation of Restraints 2. .... "PRN restraint orders are not acceptable and cannot be transcribed or carried out. The chain of command is to be followed for problems in obtaining a correct order. Each order must: a. Specify a time limitation (medical reason - 24 hours; behavioral reason - 4 hour limit for ages 18 and over; specify the type of restraint to be utilized; and be written for a specific episode; and the ordering MD or covering MD must sign the telephone or verbal order within 24 hours of obtaining the order".

Based on record review and interview the hospital failed to ensure La. R.S. 9:111 relating to pronouncement of death was followed by physicians as evidenced by delegating the assessment of irreversible cessation of spontaneous respiratory and circulatory functions to the nurse and determining and pronouncement of the patients' death via the telephone for 2 of 3 patients who expired while admitted to the hospital (#9, #15) out of a total sample of 20 medical records. Findings:

Patient #9
Review of the medical record for Patient #9 revealed an 83 year old male admitted to the hospital on 03/19/12 for treatment of aspiration pneumonia, acute renal failure, anemia and sepsis. Additional diagnoses included UTI (urinary tract infection), Septicemia, Severe malnutrition with failure to thrive, Coumadin Toxicity, Multiple Decubitus Ulcers, Dysphagia, CVA (Cerebrovascular accident) and Contractures. Patient #9 was a Full Code.

Review of the Rapid Response/Code Team Record for Patient #9 dated 03/21/12 revealed at 1910 (7:10pm) the code team was called to the room due to the patient experiencing labored breathing, increased rhonchi and decreased alertness. MD S34 notified. Nebulizer treatment in progress. 1913 (7:13pm) respirations at a rate of 3 per minute, Respiratory therapist in to assist with ambu bag. Heart rate decreased to 40's on telemetry monitor with no palpable pulse. CPR (Cardiopulmonary Resuscitation) initiated. 1915 (7:15pm) MD S34 on phone and at 1918 (7:18pm) ACLS protocol of Epinephrine, Atropine, Epinephrine administered. According to documentation Patient #9 failed to regain a pulse or respirations and at 1945 (7:45pm) MD S34 called the code via the telephone.

In a face to face interview on 04/26/12 at 4:55pm RN S4 Charge Nurse on duty the night of the code for Patient #9 indicated physicians were not always at the hospital when patient died. S4 indicated that when a physician is not at the hospital at the time the patient expires, the nurses follow the "Patent Death Step Policy" which allows two nurses to assess the patient for abscess of vital signs, call the MD and then he pronounces the patient dead by calling the time of death.

Patient #15
Review of the medical record for Patient #15 revealed a 75 year old male admitted to the hospital on 03/23/12 for continued care of acute respiratory failure, aspiration pneumonia, sepsis and malnutrition. Review of the Physicians Orders dated 04/11/12 (no time documented) revealed an order for DNR (Do Not Resuscitate).

Review of the Nurses Notes for Patient #15 revealed the following: 04/13/12 at 0010 (12:10am) HR (Heart Rate) 30. Respirations remain labored. Extremities cold to touch. 75ml notes to GU bag. Family awaken at bedside. 0015 (12:15am) No respirations, No Heart Rate. MD notified.
2 RNs at bedside. No vitals notes. No respirations, no heart rate, no pulse. MD notified. Time of death called per Dr. Henry.

Review of La. R.S. 9:111. Definition of death revealed..... "A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions......". Added by Acts 1976, No. 233, ?1; Acts 2001, No. 317, ?1; Acts 2010, No. 937, ?1, eff. July 1, 2010.

In a face to face interview on 04/26/12 at 9:20 MD S22 Assistant Chief of Staff indicated he comes to the hospital to pronounce his patients. Further S indicated he was not aware of any policy allowing the nurses to the assess the patient and then call the MD who then gives the time of death.

Review of the policy #PAH-ADM-019-A titled " Patient Death Steps" implemented January 2010 and submitted by the hospital as the one currently in use revealed... "Two RN's (Registered Nurses) must witness to verify absence of vital signs, run a flat line EKG strip, call the attending MD for concurrence on the time of death and document this in the patient's chart. You will have a completed order, a signed DNR (Do Not Resuscitate) form and recorded with this information documented. You are to tag this for the physician. A copy of the entire event (notes, release/removal of remains, LOPA, etc) given to DON. ADON). 1. Confirm absence of vital signs by two qualified staff members. 2. Call medical physician to report absence of vital signs and any other pertinent information, document. 3. Call the coroner...... 10. Pull and complete form GS-ADM-019-B, write the order to release the body to (wherever) on our physician order sheet..... 12. Release body to funeral home with required paperwork....".
Review of the Medical Executive Committee Meeting Minutes for 10/27/11 revealed educational and training programs presented to the staff included "Review of Death Steps Guidelines". Further review revealed MD S22 was in attendance.

Based on record review and interviews, the hospital failed to ensure the medical staff enforced its bylaws to carry out its responsibilities. 1) The medical staff failed to complete patient medical records within 25 days of discharge as required by the bylaws which resulted in the hospital having a 71% (per cent) delinquency rate for the first quarter of 2012. Discharge summaries were not completed and authenticated by the physician within 25 days of discharge as required by the medical staff rules and regulations for 4 of 9 discharged patient records reviewed from a total of 20 sampled patients (#12, #13, #15, #16) and 19 random patients (R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21). 2) The medical staff failed to implement its bylaws for suspension of physicians with incomplete patient records 25 days after discharge. 3) The medical staff failed to perform patient consults within 72 hours as required by hospital policy for 2 of 20 sampled patients (#1, #8). Findings:

1) The medical staff failed to complete patient medical records within 25 days of discharge as required by the bylaws which resulted in the hospital having a 71% (per cent) delinquency rate for the first quarter of 2012; discharge summaries were not completed and authenticated by the physician within 25 days of discharge:
Review of the "Delinquent Chart Report 2011" presented by Registered Health Information Technician (RHIT) S28 revealed the delinquency rate for October 2011 was 61%, November 2011 69%, and December 2011 65%. Review of the "Delinquency Chart Report 2012" presented by RHIT S28 revealed the delinquency rate for January 2012 was 63%, February 78%, and March 2012 72%, for a delinquency rate of 71% for the first quarter of 2012.

In a face-to-face interview on 04/26/12 at 10:50am, RHIT S28 confirmed the delinquency rate for the first quarter of 2012 was 71%.

Patient #12
Review of Patient #12's medical record revealed a 74 year old male admitted to the hospital on 12/30/11 for continued care and rehabilitation after a CVA (Cerebrovascular accident), respiratory failure and urosepsis. Review of the Discharge Summary revealed Patient #12 was discharged to an acute care facility on 01/31/12; however the discharge summary was not dictated until 03/18/12 (47 days after dictation)and typed on 03/19/12. The Discharge Summary still remains without the physician's signature 38 days after being typed and remains a delinquent record past 86 days of discharge.

Patient #16
Review of the medical record revealed a 67 year old female admitted to the hospital on 01/18/12 for continued care for Klebsiella pneumonia, urinary tract infection and Candida glabrata cystitis. Additional diagnoses included right renal cell carcinoma, diabetes mellitus, paroxysmal Atrial fibrillation and a previous left hemisphere stroke. Review of the Discharge Summary revealed Patient #16 was discharged on 02/13/12, the summary dictated by the physician on 02/12/12 and typed on 02/13/12. The Discharge Summary still remains without the physician's signature 70 days after being typed and remains a delinquent record.

Review of the "Chart Deficiency Delinquency Report Deficiency Date Range: 9/01/2011 to 4/26/2012" presented by RHIT S28 revealed the following patients with their respective discharge date whose discharge summaries have not been written or dictated as of 04/26/12 (more than 30 days since discharge):
Patient #13 - 02/09/12; Patient #15 - 11/15/11 (previous admit); Patient R3 - 03/16/12; Patient R4 - 02/20/12; Patient R5 - 12/07/11; Patient R6 - 03/16/12; Patient R7 - 02/15/12; Patient R8 - 01/09/12; Patient R9 - 02/14/12; Patient R10 - 02/24/12; Patient R11 - 03/02/12; Patient R12 - 03/07/12; Patient R13 - 03/06/12; Patient R14 - 03/06/12; Patient R15 - 03/16/12; Patient R16 - 03/20/12; Patient R17 - 03/20/12; Patient R18 - 03/20/12; Patient R19 - 09/26/11; Patient R20 - 01/23/12; Patient R21 - 01/02/12.

In a face-to-face interview on 04/26/12 at 9:25am, Vice Chief of Staff S22 indicated there was one or two physicians who had been suspended for delinquent records. He further indicated they have nurse practitioners trying to assist the physicians with completion of records. S22 indicated they have sent letters to physicians notifying them of their delinquent medical records. S22 could offer no explanation for not following their bylaws regarding suspension of physicians' admitting and consulting privileges when they have patient records incomplete 25 days after discharge.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations... E. Medical Records 1. Preparation and Completion a. The attending physician shall be responsible for the preparation of a complete medical record for each patient. ... c. A chart shall not be considered "delinquent until thirty (30) days following discharge. Chart completion requirements are as follows: All medical records shall be completed by the attending physician within 25 days of discharge. The administrator and responsible physician will be notified of deficiencies pending completion periodically throughout the 25 day completion process via the HIM (health information management) Coordinator. If the records are not completed, within 25 days, the HIM coordinator will notify the Administrator. The Administrator/Designee will notify the responsible physician that his/her admitting/consulting privileges have been suspended until such time as the records are complete... 4. Discharge Summary a. A discharge summary shall be recorded at the time of discharge unless awaiting test results. Any patient that dies in the hospital shall have a recorded death summary. ... Discharge summaries must be authenticated by physicians...".

2) The medical staff failed to implement its bylaws for suspension of physicians with incomplete patient records 25 days after discharge:
Review of the "Physician Suspension Log" for October 2011 revealed Physician S36 was suspended on 10/26/11 and reinstated on 12/23/11.

Review of letters sent to Physician S36 by Administrator S1 revealed the following:
10/26/11 - notification of suspension of admitting privileges and 30 days to complete delinquent medical records (20 discharge summaries to be written or dictated and and 2 history and physical examinations to be written or dictated);
12/05/11 - list of deficient charts enclosed (4 of the above listed 20 discharge summaries to be written or dictated);
12/23/11 - letter notifying of suspension lifted "per direction of Governing Board Vice Chief of Staff S34" (currently chief of staff).

Review of the "Chart Deficiency Delinquent Report" ranging from 09/01/11 to 04/26/11 presented by RHIT S28 revealed Patient R19's medical record, which was delinquent for the discharge summary when Physician S36's suspension was lifted, remained delinquent for the discharge summary as of 04/26/12.

In a face-to-face interview on 04/26/12 at 9:25am, Vice Chief of Staff S22 indicated there was one or two physicians who had been suspended for delinquent records. He further indicated they have nurse practitioners trying to assist the physicians with completion of records. S22 indicated they have sent letters to physicians notifying them of their delinquent medical records. S22 could offer no explanation for not following their bylaws regarding suspension of physicians' admitting and consulting privileges when they have patient records incomplete 25 days after discharge.

In a face-to-face interview on 04/26/12 at 10:50am, RHIT S28 indicated no physician was currently suspended for delinquent medical records. She further indicated in the past physicians were sent letters but never suspended. S28 indicated the former administrator would not allow her to suspend physicians for delinquent medical records.

In a face-to-face interview on 04/26/12 at 1:55pm, RHIT S28 indicated Physician S36 had one chart delinquent when he was reinstated 12/23/11 at the direction of Chief of Staff S34. She further indicated Physician S36's patient record (R19) from 09/26/11 remained delinquent plus an additional 2 patient records from 01/02/12 (R21) and 01/23/12 (R20) were also delinquent.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations... E. Medical Records 1. Preparation and Completion a. The attending physician shall be responsible for the preparation of a complete medical record for each patient. ... c. A chart shall not be considered "delinquent until thirty (30) days following discharge. Chart completion requirements are as follows: All medical records shall be completed by the attending physician within 25 days of discharge. The administrator and responsible physician will be notified of deficiencies pending completion periodically throughout the 25 day completion process via the HIM (health information management) Coordinator. If the records are not completed, within 25 days, the HIM coordinator will notify the Administrator. The Administrator/Designee will notify the responsible physician that his/her admitting/consulting privileges have been suspended until such time as the records are complete. It shall be the responsibility of the HIM coordinator to notify the Administrator when the medical records are complete. Upon notification, the physician will be notified that his/her admitting privileges have been reinstated...".

3) The medical staff failed to perform patient consults within 72 hours as required by hospital policy:
Patient #1
Review of the medical record for Patient #1 revealed a 91 year old female admitted to the hospital on 04/18/12 for Severe C-Diff Colitis, Severe Malnutrition, Dehydration, Renal Failure and Leukocytosis. Review of the Physicians ' Admit Orders dated/timed 04/18/12 at 1400 (2:00pm) revealed an order for a consult with MD S37.

Review of Patient #1's medical record revealed no documented evidence the consult by MD S37 was performed as of 04/23/12.

Patient #8
Review of Patient #8's medical record revealed he was an 85 year old male admitted on 04/20/12 with diagnoses of septicemia, end-stage renal disease with hemodialysis, hypotension, anemia, syncope, and congestive heart failure.

Review of Patient #8's "Physicians Admission Orders: dated 04/20/12 at 1330 (1:30pm) revealed an order to consult Physician S37. Review of the entire medical record on 04/24/12, four days after admit, revealed no documented evidence that a consult was performed by Physician S37.

In a face-to-face interview on 04/24/12 at 2:05pm, Director of Nursing S2 confirmed that Physician S37 had not seen Patient #8 since his admission to the hospital as of the time of this interview. S2 indicated the request for a consult was either called to or faxed to the physician by the hospital's secretary. She further indicated the secretary was supposed to check the consult log every shift and confirmed that this was not being done.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations... 6. Consultants a. All consultation reports are to be recorded fully enough to serve the purpose of the consultation...". Further review revealed no documented evidence that the rules and regulations included a time frame for completion of the consult.

Review of the hospital policy titled "Physician Consult", policy number II-C.4.14, revised 12/09, and contained in the manual presented by Administrator S12 as current, revealed, in part, "...1. Notify physician to be consulted either verbally or by phone call. ... Consult needs to be answered within 72 hours...".

Based on record review and interviews, the medical staff failed to ensure a medical history and physical examination (H&P) was completed and documented no more than 30 days before or 24 hours after admission and placed in the medical record within 24 hours after admission for 2 of 20 sampled patients (#7, #16). Findings:

Patient #7
Review of Patient #7's medical record revealed he was an 81 year old male admitted on 04/17/12 with the primary diagnoses of respiratory failure with ventilator support and a tracheostomy, pneumonia, and malnutrition.

Review of Patient #7's "Initial Nursing Assessment" revealed he was admitted by ambulance on 04/17/12 at 1935 (7:35pm). Review of the H&P revealed Chief of Staff S34 dictated Patient #7's H&P on 04/18/12 at 2135 (9:35pm), more than 24 hours after admission. Further review revealed the H&P was transcribed on 04/19/12 (no documented time), 2 days after admission, which prevented the H&P from being on Patient #7's medical record within 24 hours of admission.

Patient #16
Review of the History and Physical (H&P) Patient #16 revealed a 67 year old female admitted to the hospital on 01/18/12 for continued treatment of Klebsiella pneumonia, urinary tract infection and Candida glabrata cystitis and resolution of her renal failure. Further review of the H&P revealed the document was not transcribed until 01/20/12 and therefore not available on the patient ' s chart within 24 hours after admission to the healthcare team.

In a face-to-face interview on 04/26/12 at 9:25am, Vice Chief of Staff S22, when informed that chart reviews revealed that H&Ps were not on the patient's medical records within 24 hours of admission, asked if a short-stay H&P could be used in place of the H&P. He could offer no explanation for the delay in the transcription process that could prevent a timely dictated H&P from being in the record timely. S22 indicated if he saw a patient the day before admission while the patient was at the transferring hospital, he (S22) may not be at Physicians' Alliance Hospital within 24 hours of admission to perform the H&P.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations... 2. History and Physical a. A complete history and physical examination shall in all cases be recorded within twenty-four (24) hours of admission of the patient by a practitioner or an AHP (allied health professional) who has been granted privileges to do so...". Further review revealed no documented evidence that the bylaws required the recorded H&P to be in the patient's medical record within 24 hours of admission.

Based on record review and interviews, the medical staff failed to ensure an updated examination of the patient that included any changes in the patient's condition was completed, documented, and placed in the patient's medical record within 24 hours after admission when the medical history and physical examination (H&P) was completed within 30 days before admission for 7 of 20 sampled patients (#6, #8, #10, #11, #12, #13, #19). Findings:

Patient #6
Review of Patient #6's medical record revealed she had been admitted to the facility on 4/4/12 with diagnosis which included Spinal Osteomyelitis/Diskitis, MRSA, ESRD (End Stage Renal Disease) with hemodialysis, Sepsis and Hypertension. Further review revealed a history and physical had been completed prior to admit. The "History and Physical Addendum" had not been completed until 2 days after admission on 4/6/12. No other documentation of a history or physical exam of the patient dated 4/4/12 or 4/5/12 was located in the medical record. These findings were confirmed by Director of Nursing S2 on 4/24/12 at 9:30 a.m.

Patient #8
Review of Patient #8's medical record revealed he was an 85 year old male admitted on 04/20/12 with diagnoses of septicemia, end-stage renal disease with hemodialysis, hypotension, anemia, syncope, and congestive heart failure.

Review of Patient #8's medical record revealed a H&P was performed on 04/18/12. Review of the entire medical record revealed no documented evidence that an updated examination that included changes in Patient #8's condition since 04/18/12 was performed and documented in the medical record within 24 hours of admission.

Patient #10
Review of the medical record for Patient #10 revealed a 95 tear old female admitted to the hospital on 01/10/12 for sepsis, infected left hip wound, malnutrition, and a history of dementia.

Review of the History and Physical Addendum form for Patient #10 revealed no documented time the physician completed the assessment on 01/11/12.

Patient #11
Review of the medical record for Patient #11 revealed he was admitted to the facility on 1/19/12 at 2:00 p.m. with diagnosis which included Osteomyelitis and Cellulitis of the right foot. Further review revealed a history and physical had been completed prior to admission, but the " History and Physical Addendum " had not been completed until 1/25/12 at 4:20 p.m. No other documentation of a history or physical exam dated 1/19/12 through 1/25/12 was located in the medical record.

Patient #12
Review of the medical record revealed a 74 year old male admitted to the hospital on 12/30/11 for continued care and rehabilitation after a CVA (Cerebrovascular accident) intracranial bleed of the thalamus, respiratory failure and urosepsis.

Review of Patient #12's H&P revealed it was dictated on 12/11/12 at the hospital from which he was transferred. Review of the "History And Physical Addendum" revealed it was performed on 12/31/11 with no time documented when written and therefore could not be ensured it was available to the medical team within the 24 hour time period as required by regulation and the bylaws.

Patient #13
Review of Patient #13's medical record revealed she was an 82 year old female admitted on 01/06/12 with the primary diagnosis of osteomyelitis right foot with stage IV ulcer.

Review of Patient #13's H&P revealed it was dictated on 12/26/12 at the hospital from which she was transferred. Review of the "History And Physical Addendum" revealed it was performed on 01/10/12, 4 days after Patient #13's admission rather than within 24 hours as required by regulation and the bylaws.

Patient #19
Medical record review revealed Patient #19 was admitted to the facility on 4/3/12 at 1412 (2:12 p.m.) with diagnosis which included acute respiratory failure. Further review revealed a history and physical had been completed at a local hospital on 4/3/12. The "History and Physical Addendum" in Patient #19's medical record was dated 4/9/12. No other documentation of a history or physical exam was located in Patient #19's medical record dated 4/3/12 through 4/9/12.

In a face-to-face interview on 04/26/12 at 9:25am, Vice Chief of Staff S22 could offer no explanation for the H&P updates not being performed within 24 hours of admission. He indicated that the addendums were usually done within 24 hours of admission.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations... 2. History and Physical a. ... A durable, legible copy of an H&P, performed no more than 30 days prior to admission, may be used in the patient's record. If a copy meeting timeframe is used as above, an addendum/update denoting any changes in physical exam and diagnosis and treatment plan is to be written or dictated within 24 hours of admit by a practitioner with privileges to do so...". Further review revealed no documented evidence that the bylaws required the updated H&P, if dictated, to be in the patient's medical record within 24 hours admission

25065

Based on record review and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient. 1) The RNs failed to practice within their scope of practice by assessing patients and pronouncing the death of 2 of 3 patients who expired (#9, #15) from a total of 20 sampled patients and administering and titrating an anesthetic agent (Propofol) to a patient (#15) while venitlated outside of a critical care setting for 1 of 1 patients on a Propofol drip from a total of 20 sampled patients. 2) The RNs failed to assess patients' blood pressure or pulse prior to administering medications requiring assessment of blood pressure or pulse according to physician orders or acceptable standards of care for 2 of 20 sampled patients (#12, #17). 3) The RNs failed to assess the cardiac rhythm of telemetry patients, verify telemetry settings and verify telemetry alarm in the "ON" position every shift according to physician order and hospital policy for 10 of 11 patient with orders for telemetry (#1, #2, #4, #7, #8, #12, #13, #15, #16, #17) from a total 20 sampled patients. 4) The RN failed to assess patients' capillary blood glucose according to physician order for 2 of 6 patients' records reviewed with orders for accuchecks from a total of 20 sampled patients (#7, #8). 5) The RN failed to assess the residual of tube feedings as ordered by the physician for 1 of 8 patients' records reviewed for assessment of tube feeding residuals from a total of 20 sampled patients (#7). Findings:

1) The RNs failed to practice within their scope of practice by pronouncing the death of 2 of 3 patients who expired and administering and titrating and anesthetic agent (Propofol) to a ventilated patient

Patient #9
Review of the medical record for Patient #9 revealed an 83 year old male admitted to the hospital on 03/19/12 for aspiration pneumonia, acute renal failure, anemia, sepsis. Additional diagnoses revealed a UTI (urinary tract infection), septecemia, severe malnutrition with failure to thrive, contractures and multiple decubiti. According to the Physicians' Orders Patient #9 was a full code.

Review of the Rapid response/Code Team Record dated 03/21/12 for Patient #9 revealed the Rapid Response Team was called to his room at 1910 (7:10pm) when #9 began experiencing labored breathing, increased rhonchi and decreased alertness. Thick mucus was suctioned from his oral airway and a breathing treatment was in progress. MD S37 was notified. At 1913 (7:13pm) Patient #9's respirations decreased to 3 per minute and the respiratory therapist began to assist his breathing with an ambu bag. At this time Patient #9 had no palpable pulse and a heart rate of 40 on the telemetry monitor (no rhythm documented). 1918 (7:18pm) CPR was in progress and ACLS protocols implemented. 1945 (7:45pm) MD S37 aware of continuous status of patient and CPR discontinued. 2210 (10:10pm) Funeral home here to pick up body.

Review of the Physicians Orders for Patient #9 revealed a telephone order on 03/21/12 at 1945 (7:45pm) from MD S37 to stop CPR and another verbal order dated 03/21/12 (no time documented) to release the body to funeral home.

In a face to face interview on 04/26/12 at 4:55pm RN S4 indicated she was following the policy of the hospital when documenting the time of death the MD communicates via the phone. S4 verified 2 nurses assess the patient for the absence of vital signs, tell the MD and then he/she calls the time of death which is pronouncing the patient dead.

In a face to face interview on 04/27/12 at 11:00pm RN S2 Director of Nursing indicated the previous DON and Administrator developed the "Patient Death Steps" policy and that the Louisiana Nursing Board approved. S2 could not produce any documentation of the e-mails of letters from the State Board of Nursing.

Patient #15
Review of the medical record for Patient #15 revealed a 75 year old male admitted to the hospital on 03/23/12 for continued care of acute respiratory failure, aspiration pneumonia, sepsis and malnutrition. Review of the Physicians Orders dated 04/11/12 (no time doscumented) revealed an order for DNR (Do Not Resuscitate).

Review of the Nurses Notes for Patient #15 revealed the following: 04/13/12 at 0010 (12:10am) HR (Heart Rate) 30. Respirations remain labored. Extremities cold to touch. 75ml notes to GU bag. Family awaken at bedside. 0015 (12:15am) No respirations, No Heart Rate. MD notified.
2 RNs at bedside. No vitals notes. No respirations, no heart rate, no pulse. MD notified. Time of death called per MD S34. Review of the Physicians Orders for Patient #15 dated/timed 04/13/12 at 0246 (2:46am) revealed a verbal order from MD 34 to release the body from the nursing home. There was no documented evidence in the chart MD S34 had assessed Patient #15 or called the time of death other than the nurse's documentation.

Review of Louisiana Revised Statute R.S. 9:111. Definition of death revealed..... "A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions......". Added by Acts 1976, No. 233, ?1; Acts 2001, No. 317, ?1; Acts 2010, No. 937, ?1, eff. July 1, 2010.

Review of the policy #PAH-ADM-019-A titled " Patient Death Steps" implemented January 2010 and submitted by the hospital as the one currently in use revealed... "Two RN's (Registered Nurses) must witness to verify absence of vital signs, run a flat line EKG strip, call the attending MD for concurrence on the time of death and document this in the patient's chart. You will have a completed order, a signed DNR (Do Not Resuscitate) form and recorded with this information documented. You are to tag this for the physician. A copy of the entire event (notes, release/removal of remains, LOPA, etc) given to DON.ADON). 1. Confirm absence of vital signs by two qualified staff members. 2. Call medical physician to report abscence of vital signs and any other pertinent information, document. 3. Call the coroner...... 10. Pull and complete form GS-ADM-019-B, write the order to relase the body to (wherever) on our physician order sheet..... 12. Release body to funeral home with required paperwork....".

Patient #15
Review of the medical record for Patient #15 revealed a 75 year old male admitted to the hospital on 03/23/12 for continued care of acute respiratory failure, aspiration pneumonia, sepsis and malnutrition.

Review of the Physicians Orders for Patient #15 dated/timed 03/24/12 at 5:00pm revealed an order to intubate the patient and and Ativan drip at 2-4 mg per hr. Further review of the Physicians Orders revealed on 03/30/12 a verbal order was received from MD S34 for an OK to use Propofol when Ativan becomes unavailable.

Review of the "IV Sedation of Adult Ventilator Patient Flowsheet" for Patient #15 revealed Propofol was started on 03/31/12 at 1300 (1:00pm) and continued until 04/09/12 at 0700 (7:00am).

Review of Louisiana Revised Statute R.S.37:935. revealed.... "Notwithstanding any order provision in this chapter to the contrary, a registered nurse may administer, in accordance with an order of an authorized prescriber, anesthetic agents to intubated patients in critical care settings...".

In a face to face interview on 04/26/12 at 9:20 MD S22 Assistant Chief of Staff the patients on Propofol are monitored by the registered nurse. S22 agreed the LTAC was not a critical care setting.

In a face to face interview on 04/26/12 at 4:55pm RN S4 Charge Nurse for the PM Shift indicated she was familiar with the RN Scope of Practice and felt it was within the scope of practice to administer and monitor the anesthetic drug of Propofol.

Observation on 04/23/12 at 10:00am of the physical environment of the hospital revealed the patient rooms were not visible to the nurses at the nurses station. Further observation revealed continual visualization would not be possible unless the nurse was in the room with the patient. Continuous monitoring in the hospital consisted of a telemetry monitor only providing a cardiac rhythm and heart rate. Level of consciouness and blood pressure would have to be assessed by the nurse and would not be continuous unless the nurse was in the room with the patient.

In a face to face interview on 04/26/12 at 10:15am RN S2 Director of Nursing indicated
2) The RNs failed to assess patients' blood pressure or pulse prior to administering medications requiring assessment of blood pressure or pulse according to physician orders or acceptable standards of care:
Patient #12
Review of the medical record for Patient #12 revealed a 74 year old male admitted to the hospital on 12/30/11 for additional care and rehabilitation from a CVA (cerebrovascular accident) intracranial bleed to the right thalamus.

Review of the Physicians Orders for Patient #12 dated 12/30/11 revealed the following orders: Lisinopril/HCTZ (Hydrochlorothiazide) 20/12.5mg po (by mouth) BID (twice a day) 1 tab Hold if BP (Blood Pressure) <110; Metoprolol 25mg per PEG (percutaneous esophageal gastrostomy) BID Hold if BP < 90/50 or HR (heart rate) <60; 01/07/12 order change Metoprolol 5mg IV (intravenous) to 25mg BID Hold if BP <90/50 or HR <60.

Review of the MAR (Medication Administration Record) for Patient #12 revealed no documented evidence the blood pressure and heart rate was assessed prior to administration of Lisinopril and Metoprolol as ordered for the following dates and times: 12/30/11 at 2100 (9:00pm); 12/31/11 at 0300 (3:00am), 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 01/01/12 at 0300 (3:00am), 1500 (3:00pm), 2100 (9:00pm); 01/02/12 at 0300 (3:00am), 0900 (9:00am), 1500 (3:00pm); 01/03/12 at 0300 (3:00am), 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 01/04/12 at 0300 (3:00am); 01/05/12 at 0300 (3:00am), 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 01/06/12 at 0300 (3:00am); 01/15/12 through 01/26/12 at 0900 (9:00am), 2100 (9:00pm); 01/27/12 at 2100 (9:00pm); 01/28/12 at 0900 (9:00am), 2100 (9:00pm).

Patient #17
Review of the medical record for Patient #17 revealed he was a 57 year old male admitted on 4/4/12 for a Scrotal abscess, Obesity, Diabetes Mellitus, Congestive Heart Failure, and Carotid Artery Disease.

Review of the admitting physician orders dated 04/04/12 revealed the patient was on Toprol XL 25 mg (milligrams) po (by mouth) daily, Hydrochlorothiazide 25 mg po daily, Benazepril 40 mg (Lotensin) by mouth every day, and Norvasc 1 tab (10 mg) by mouth every day.

Review of the MAR (Medication Administration Record) revealed the patient's blood pressure was not documented every day prior to administration of his hypertensive medications. According to the MAR his blood pressure was not documented on 04/10/12, 04/11/12, 04/14/12, 04/18/12, and 04/19/12. Also the patient's pulse was not taken prior to administration of the Toprol XL.

An interview was conducted with S2 DON (director of nursing) on 04/26/12 at 11 a.m. She indicated the CNA (certified nursing assistants) take the vital signs throughout the day, and if there is a problem with the vital signs, the nurse retakes the patient's vital signs. She indicated she was aware the blood pressure and apical pulse were not documented on the MAR prior to administrations of certain medications as it should be.

Review of the drug reference book, Nursing 2010, presented as the hospital drug's reference guide, revealed under Nursing Considerations for Metoprolol succinate, Toprol XL, that a patient's apical pulse rate should always be checked prior to administering the medication. If the pulse is slower than 60 beats/minute, the drug should be withheld. Also included under nursing administration was to monitor blood pressure frequently; drug masks common signs and symptoms of shock.

Review of the drug reference book, Nursing 2010 Drug Handbook, presented as the hospital drug's reference guide, revealed under Nursing Considerations for benazepril hydrochloride, Lotensin, that it was important to monitor patients for hypotension. Excessive hypotension can occur when the drug is given with diuretics.

3) The RNs failed to assess the cardiac rhythm of telemetry patients according to physician order and hospital policy:
Review of the Telemetry Protocol Physician Orders used for all patients placed on telemetry included the following: Rhythm Strip documented every 4, 6, 8 hours (one has to be chosen) and as indicated to document arrhythmia; Maintain alarm settings on at all times and verify alarm settings every shift; and Notify physician of the following - new arrhythmia onset, heart rate 20% (per cent) above baseline, blood pressure less than 90 systolic, pacemaker loses sensing, pacing, or capturing and ICD firing.

Patient #1
Review of the medical record for Patient #1 revealed a 91 year old female admitted to the hospital on 04/18/12 for Severe C-Diff Colitis, Severe Malnutrition, Dehydration, Renal Failure and Leukocytosis.

Review of the Telemetry Protocol Physician Orders for Patient #1 dated 04/18/12 revealed an order for telemetry which included strips to be run and interpreted by the nurse every 4 hours, maintain alarm settings at all times and verify alarm settings every shift.

Review of the telemetry strips for the dates of 04/18/12 through 04/23/12 revealed no documented evidence alarm setting were verified as being on, the correct settings were maintained or that a nurse had interpreted the strip.

Patient #2
Review of the medical record revealed a 58 year old male admitted to the hospital on 04/19/12 for acute respiratory failure with ventilatory support and a tracheotomy with secondary diagnoses of acute bilateral CVA (Cerebrovascular accident), anoxic encephalopathy, pneumonia, Peg tube and hypertension.

Review of the Telemetry Protocol Physician Orders for Patient #2 dated 04/19/12 revealed an order for telemetry which included strips to be run and interpreted by the nurse every 4 hours, maintain alarm settings at all times and verify alarm settings every shift.

Review of the telemetry strips for the dates of 04/22/12 through 04/23/12 revealed no documented evidence alarm setting were verified as being on, the correct settings were maintained or that a nurse had interpreted the strip.

Patient #4
Review of the medical record for Patient #4 revealed an 86 year old female admitted to the hospital on 03/27/12 for Myelodysplagia, Pseudomonas UTI (urinary tract infection), Venous Stasis Ulcers and Malnutrition. Patient #4 had a past history of anemia, electrolyte imbalance, HTN (hypertension), IVC Filter and DVT (deep vein thrombosis).

Review of the Telemetry Protocol Physician Orders for Patient #4 dated 03/27/12 revealed an order for telemetry which included strips to be run and interpreted by the nurse every 4 hours, maintain alarm settings at all times and verify alarm settings every shift.

Review of the telemetry strips for the dates of 04/22/12 through 04/24/12 revealed no documented evidence alarm setting were verified as being on, the correct settings were maintained or that a nurse had interpreted the strip.

Patient #7
Review of Patient #7's medical record revealed he was an 81 year old male admitted on 04/17/12 with the primary diagnoses of respiratory failure with ventilator support and a tracheostomy, pneumonia, and malnutrition.

Review of Patient #7's "Telemetry Protocol Physician Orders" dated 04/17/12 at 10:00am revealed an order for the rhythm strip to be documented every 4 hours, notify the physician of new arrhythmia onset, heart rate 20% above baseline, blood pressure less than 90 systolic, and pacemaker loses sensing, pacing, or capturing, maintain alarm settings on at all times, and verify alarm settings every shift. Further review revealed no documented evidence that the physician's order included the parameters for the alarms specific for Patient #7, and there was no clarification order documented by the nurse.

Review of the "Telemetry Strip Form" from 04/19/12 at 12:00am through 04/23/12 at 4:00am revealed no documented evidence that each strip included that the alarm setting was verified as being on, the correct settings were maintained, relevant calculations were documented, and that a nurse had interpreted the strip.

Patient #8
Review of Patient #8's medical record revealed he was an 85 year old male admitted on 04/20/12 with diagnoses of septicemia, end-stage renal disease with hemodialysis, hypotension, anemia, syncope, and congestive heart failure.

Review of Patient #8's "Telemetry Protocol Physician Orders" dated 04/20/12 at 2:30pm revealed an order for the rhythm strip to be documented every 4 hours, notify the physician of new arrhythmia onset, heart rate 20% above baseline, blood pressure less than 90 systolic, and pacemaker loses sensing, pacing, or capturing, ICD firing, maintain alarm settings on at all times, and verify alarm settings every shift. Further review revealed no documented evidence that the physician's order included the parameters for the alarms specific for Patient #8, and there was no clarification order documented by the nurse.

Review of the "Telemetry Strip Form" from 04/21/12 at 12:00am through 04/24/12 at 3:42am revealed no documented evidence that each strip included that the alarm setting was verified as being on, the correct settings were maintained, relevant calculations were documented, and that a nurse had interpreted the strip.

Patient #9
Review of the medical record for Patient #9 revealed an 83 year old male admitted to the hospital on 03/19/12 for aspiration pneumonia, acute renal failure, anemia, sepsis. Additional diagnoses revealed a UTI (urinary tract infection), septecemia, severe malnutrition with failure to thrive, contractures and multiple decubiti.

Review of the Telemetry Protocol Physician Orders for Patient #9 dated 03/19/12 revealed an order for telemetry which included strips to be run and interpreted by the nurse every 4 hours, maintain alarm settings at all times and verify alarm settings every shift.

Review of the telemetry strips for the dates of03/19/12 through 03/21/12 revealed no documented evidence alarm setting were verified as being on, the correct settings were maintained or that a nurse had interpreted the strip.

Patient #12
Review of the medical record revealed a 74 year old male admitted to the hospital on 12/30/11 for continued care and rehabilitation after a CVA (Cerebrovascular accident) intracranial bleed of the thalmus, respiratory failure and urosepsis.

Review of the Telemetry Protocol Physician Orders for Patient #12 dated 12/30/11 revealed an order for telemetry which included strips to be run and interpreted by the nurse every 4 hours, maintain alarm settings at all times and verify alarm settings every shift.

Review of the telemetry strips for the dates of 01/17/12 through 01/19/12 revealed no documented evidence alarm setting were verified as being on, the correct settings were maintained or that a nurse had interpreted the strip.

Patient #13
Review of Patient #13's medical record revealed she was an 82 year old female admitted on 01/06/12 with the primary diagnosis of osteomyelitis right foot with stage IV ulcer. Further review revealed secondary diagnoses were MRSA (methicillin resistant staph aureus) and Proteus Mirabilis urinary tract infection, atrial fibrillation, iron deficiency anemia, hypertension, history of cerebrovascular accident with aphasia and dysphagia with a PEG (percutaneous esophageal gastrostomy) tube, and multiple decubitus ulcers.

Review of Patient #13's "Telemetry Protocol Physician Orders" dated 04/20/12 at 2:30pm revealed an order for the rhythm strip to be documented every 4 hours, notify the physician of new arrhythmia onset, heart rate 20% above baseline, blood pressure less than 90 systolic, and pacemaker loses sensing, pacing, or capturing, ICD firing, maintain alarm settings on at all times, and verify alarm settings every shift. Further review revealed no documented evidence that the physician's order included the parameters for the alarms specific for Patient #13, and there was no clarification order documented by the nurse.

Review of the "Telemetry Strip Form" from 01/06/12 at 8:00pm through 01/08/12 at 4:00am and from 02/08/12 at 8:00am through 02/09/12 at 4:00am revealed no documented evidence that each strip included that the alarm setting was verified as being on, the correct settings were maintained, relevant calculations were documented, and that a nurse had interpreted the strip.

Patient #15
Review of the medical record for Patient #15 revealed a 75 year old male admitted to the hospital on 03/23/12 for continued care of acute respiratory failure, hypoxia, aspiration pneuminia, sepsis, and malnutrition.

Review of the Telemetry Protocol Physician Orders for Patient #15 dated 03/23/12 revealed an order for telemetry which included strips to be run and interpreted by the nurse every 4 hours, maintain alarm settings at all times and verify alarm settings every shift.

Review of the telemetry strips for the dates of 04/10/12 through 04/12/12 revealed no documented evidence alarm setting were verified as being on, the correct settings were maintained or that a nurse had interpreted the strip.

Patient #16
Review of the medical record revealed a 67 year old female admitted to the hospital on 01/18/12 for continued care for Klebsiella pneumonia, urinary tract infection and candida glabrate cystitis. Additional diagnoses included right renal cell carcinoma, diabetes mellitus, paroxysmal atrial fibrillation and a previous left hemisphere stroke.

Review of the Telemetry Protocol Physician Orders for Patient #16 dated 01/18/12 revealed an order for telemetry which included strips to be run and interpreted by the nurse every 4 hours, maintain alarm settings at all times and verify alarm settings every shift.

Review of the telemetry strips for the dates of 01/18/12 through 02/13/12 revealed no documented evidence alarm setting were verified as being on, the correct settings were maintained or that a nurse had interpreted the strip.

Patient #17
Review of the medical record for Patient #17 revealed he was a 57 year old male admitted to the hospital on 04/04/12 for a Scrotal Abscess, Obesity, Diabetes Mellitus, Congestive Heart Failure, and Carotid Artery Disease.
Review of his Physicians Admission Order sheet dated 4/4/12 revealed an order for Telemetry monitoring: "See physician order protocol attached."

Review of Patient #17's telemetry strip forms revealed the following telemetry strips had no documentation of the cardiac alarms being checked as being on or the settings of the alarms limits being checked; 04/17/12 at 0800 (8 a.m.), 04/17/12 at 1200 (12 p.m.), 04/17/12 at 1600 (4 p.m.), 04/18/12 at 0800 (8:00 a.m.), 04/18/12 at 1200 (12 p.m.), 04/18/12 at 1600 (4:00 p.m.), 04/18/12 at 2004 (8:04 p.m.), 04/19/12 at 0027 (12:27 a.m.), 04/19/12 at 0436 (4:36 a.m.), 04/19/12 at 0800 (8:00 a.m.), 04/19/12 at 1200 (12 p.m.), and 04/19/12 at 1600 (4 p.m.)

In a face-to-face interview on 04/24/12 at 10:40am, RN S16 indicated the telemetry monitor tech wrote the name of the nurse caring for the patient on the telemetry strip. She further indicated the nurse wrote the interpretation in the blank labeled "interpretation". When asked how one would know who interpreted the rhythm strip when a nurse's signature with the date and time was not documented on the strips, S16 indicated only a nurse can interpret the strip. When the question was repeated, S16 indicated the nurse charts the patient's cardiac rhythm on the "Daily Nursing Assessment" for the shift, but he/she does not sign their interpretation on each telemetry rhythm strip every 4 hours or as ordered.

Review of policy # H-C.3.40 "Telemetry Monitoring" last revised 03/12 and submitted by the hospital as the one currently in use revealed..... "Procedure: B. Charting: b. Technicians will post six second rhythm telemetry strips on all monitored patients a minimum of every four hours and with each new or potential lethal arrhythmia. c. Telemetry strips will be posted to the patient's chart under the TELE/EKG section on the floor. d. The strips will be identified by the nurse: relevant calculations, rhythm interpretation, and signature of nurse interpreting the rhythm strip...".

4) The RN failed to assess patients' capillary blood glucose according to physician order:
Patient #7
Review of Patient #7's medical record revealed he was an 81 year old male admitted on 04/17/12 with the primary diagnoses of respiratory failure with ventilator support and a tracheostomy, pneumonia, and malnutrition. Further review revealed his secondary diagnoses were dysphagia with PEG (percutaneous esophageal gastrostomy), stage III sacral ulcer, electrolyte imbalances, elevated LFTs (liver function tests), cervical cellulitis, diabetes mellitus (DM), and history of Cerebrovascular accident with left hemiparesis.

Review of Patient #7's "Physicians Admission Orders" dated 04/17/12 at 10:00am revealed an order for finger stick blood sugar (BS) checks QID (4 times a day); for finger stick BS readings less than 90, hold insulin on patients scheduled am and pm insulin (contact physician if Type I DM); repeat finger stick BS check in 2 hours; administer D50W (dextrose 50% water) 1 ampoule IV (intravenous) for blood glucose less than 60.

Review of the MAR (medication administration record) for 04/18/12 revealed Patient #7's blood glucose was 80 at 3:00pm. Review of the MAR and the nurses' notes for 02/18/12 revealed no documented evidence the blood sugar was rechecked as ordered in 2 hours (next check was at 9:00pm, 6 hours later). Review of the physician's order revealed no documented evidence of a clarification order to determine if Patient #7's next scheduled pm insulin dose was to be held.

Review of the MAR for 02/22/12 revealed Patient #7's blood glucose was 81 at 3:00pm. Review of the MAR and the nurses' notes for 02/22/12 revealed no documented evidence the blood sugar was rechecked as ordered in 2 hours (next check was at 9:00pm, 6 hours later).

Patient #8
Review of Patient #8's medical record revealed he was an 85 year old male admitted on 04/20/12 with diagnoses of septicemia, end-stage renal disease with hemodialysis, hypotension, anemia, syncope, and congestive heart failure. Further review revealed secondary diagnoses included dementia, pacemaker, bilateral below the knee amputation, diabetes mellitus, neurogenic bladder, and chronic obstructive pulmonary disease.

Review of Patient #8's "Physicians Admission Orders" dated 04/20/12 at 1:30pm revealed an order for finger stick blood sugar checks before meals and at bedtime; for finger stick BS readings less than 90, hold insulin on patients scheduled am and pm insulin (contact physician if Type I DM); repeat finger stick BS check in 2 hours; administer D50W 1 ampoule for blood glucose less than 60; recheck finger stick blood sugar in 1 hour; notify physician if patient is symptomatic.

Review of Patient #8's MAR revealed his blood glucose was 84 on 04/22/12 at 4:30pm. Review of the MAR and the nurses' notes for 04/22/12 revealed no documented evidence the blood sugar was rechecked as ordered in 2 hours (next check was at 9:00pm, 4 1/2 hours later). Review of the physician's order revealed no documented evidence of a clarification order to determine if Patient #8's next scheduled pm insulin dose was to be held.

In a face-to-face interview on 04/23/12 at 3:03pm, RN S14 indicated her interpretation of the physician order for blood glucose accuchecks meant to hold the insulin if the blood sugar at 9:00am or 9:00pm were out of range.

In a face-to-face interview on 04/24/12 at 8:45am, DON S2 indicated the insulin sliding scale and accucheck order was not clear and needed clarification. She further indicated it's a pre-printed order that needed to be clarified.

5) The RN failed to assess the residual of tube feedings as ordered by the physician:
Patient #7
Review of Patient #7's medical record revealed he was an 81 year old male admitted on 04/17/12 with the primary diagnoses of respiratory failure with ventilator support and a tracheostomy, pneumonia, and malnutrition. Further review revealed his secondary diagnoses were dysphagia with PEG, stage III sacral ulcer, electrolyte imbalances, elevated LFTs (liver function tests), cervical cellulitis, diabetes mellitus (DM), and history of Cerebrovascular accident with left hemiparesis.

Review of Patient #7's "Physicians Admission Orders" dated 04/17/12 at 10:00am revealed an order for continuous Pulmocare at 60 cc (cubic centimeters) per hour per the PEG tube; check residual every 4 hours; if residual is greater than 100 ml (milliliters) or greater than 2 times the rate of infusion, stop the feeding for 2 hours; recheck the residual after 2 hours and resume tube feeding unless residual remains greater than 100 ml then notify the physician.

Review of Patient #7's MAR and nurses' notes for 04/18/12 revealed no documented evidence that his tube feeding residual was assessed by the nurse at 5:00am and 5:00pm.

In a face-to-face interview on 04/24/12 at 8:45am, DON S2 confirmed the assessments for residual from the tube feedings were not performed as ordered for Patients #7.



26351

Based on record review and interviews, the hospital failed to ensure the nursing staff implemented the physician's plan of care for each patient. 1) The nursing staff failed to maintain a patient on telemetry as ordered by the physician for 1 of 20 sampled patients (#17). 2) The nursing staff failed to perform calorie counts as ordered by the physician for 2 of 2 patients with orders for calorie counts from a total of 20 sampled patients (#3, #10). 3) The nursing staff failed to perform wound care as ordered by the physician for 3 of 13 patients' records reviewed who had wounds from a total of 20 sampled patients (#7, #8, #11). 4) The nursing staff failed to obtain wound care orders for wound care that was performed for 1 of 13 patients' records reviewed who had wounds from a total of 20 sampled patients (#13). Findings:

1) The nursing staff failed to maintain a patient on telemetry as ordered by the physician:
Review of the medical record for Patient #17 revealed he was a 57 year old male admitted on 4/4/12 for a Scrotal abscess, Obesity, Diabetes Mellitus, Congestive Heart Failure, and Carotid Artery Disease.
Review of his Physicians Admission Order dated 4/4/12 revealed an order for Telemetry monitoring: See physician order protocol attached.

Review of the Telemetry Protocol Physician Orders dated 4/4/12 revealed to place Patient #17 on telemetry upon arrival to unit, document a rhythm strip every 4 hours, notify physician of the following: new arrhythmia onset, heart rate 20% above baseline, blood pressure less than 90 systolic, pacemaker loses sensing, pacing, or capturing, and ICD (implantable cardioverter-defibrillator) firing. Also included in the protocol was to maintain alarm setting on at all times, verify alarm settings every shift, and must have physician order to remove patient from telemetry.

Review of the medical record for Patient #17 revealed the last documented rhythm strip documented was 4/19/12 at 1600 (4 p.m.).

An interview was conducted with S32 LPN on 4/25/12 at 2 p.m. She reported she was taking care of Patient #17 currently and he was not on telemetry monitoring and hasn't been since 4/19/12 (6 days prior).

Review of the physician's order for Patient #17 revealed no order to discontinue the telemetry monitoring. S32 LPN confirmed there was no physician's order to discontinued the
telemetry monitoring. She went on to report when she came back from being off for a few days, she was informed in report that the telemetry monitoring had been discontinued by the physician. She reported the patient should still be monitored since there was no written order and there must be a physician's order to discontinue telemetry monitoring.

2) The nursing staff failed to perform calorie counts as ordered by the physician:
Patient #3
Review of medical record for Patient #3 revealed a 72 year old female admitted to the hospital after surgery for a diversion of a colostomy with complications of a fistula. In addition, Patient #3 had a history of anemia, malnutrition, hyperglycemia and a large abdominal wound.

Review of the Physicians Orders dated/timed 04/18/12 at 9:00pm revealed an order for a calorie count. Review of the Dietary Notes dated 04/25/12 at 10:10 am revealed..... "Calorie Count noted on 04/18/12 but not implemented and RD (registered dietitian) not notified. TPN d/c (discontinued) on 04/14/12......Per NS (Nursing Supervisor) calorie count was started, but no records found to document completion...".

Patient #10
Review of the medical record for Patient #10 revealed a 95 tear old female admitted to the hospital on 01/10/12 for sepsis, infected left hip wound, malnutrition, and a history of dementia.

Review of the Physicians Orders for Patient #10 dated 01/11/12 (no time documented) revealed an order for a calorie count.

Review of the Internal Medicine Progress Note dated 01/18/12 at 1500 (3:00pm) revealed... "Calorie count not faxed to RD (Registered Dietitian) as requested on 01/14/12.

Review of the "72 Hour Calorie Count" form for Patient #10 revealed a handwritten note on the form by the RD instructing the nursing staff to fax the form to her on 01/14/12. Further review revealed no documented evidence the information was communicated to the dietitian as requested.

In a face to face interview on 04/25/12 at 2:30pm, Registered Dietitian S25 indicated she was having communication problems with the hospital in receiving information about consults.

3) The nursing staff failed to perform wound care as ordered by the physician:
Patient #7
Review of Patient #7's medical record revealed he was an 81 year old male admitted on 04/17/12 with the primary diagnoses of respiratory failure with ventilator support and a tracheostomy, pneumonia, and malnutrition.

Review of Patient #7's "Physician Orders" revealed an order dated 04/18/12 at 11:35am for wound care to the left neck and left flank as follows: clean all wounds with wound cleanser; apply Aq powder, cover left flank with ABD pads and left neck with Optifoam every day and as needed. Further review revealed the buttocks/peri area was to have Calazime barrier cream applied with each cleaning and as needed. Further review revealed an order dated 04/19/12 at 11:25am to pack the trach/neck wound with vaseline gauze with trach care.

Review of Patient #7's "Treatment Record" revealed no documented evidence that wound care was performed to the left neck and left flank on 04/21/12, 04/22/12, and 04/23/12 and to the buttocks/peri area on 04/21/12 and 04/23/12 as ordered.

Review of Patient #7's "Ventilator Flow Sheet" (used to document care provided by the respiratory therapists) revealed the vaseline gauze was being applied to the stoma during trach care and not packed into the wound as ordered.

In a face-to-face interview on 04/24/12 at 1:10pm, Wound Care RN (registered nurse) S17 indicated he documents on the treatment record when he performs wound care. He further indicated he performed the patient's wound assessment, but the floor nurse was responsible for the daily wound care treatment.

In a face-to-face interview on 04/24/12 at 1:35pm, Respiratory Manager S3 indicated he applied the vaseline gauze to the stoma, but he didn't pack the wound. He further indicated he didn't think respiratory therapists should be packing wounds.

Patient #8
Review of Patient #8's medical record revealed he was an 85 year old male admitted on 04/20/12 with diagnoses of septicemia, end-stage renal disease with hemodialysis, hypotension, anemia, syncope, and congestive heart failure. Further review revealed secondary diagnoses included dementia, pacemaker, bilateral below the knee amputation, diabetes mellitus, neurogenic bladder, and chronic obstructive pulmonary disease.

Review of Patient #8's "Physicians Admission Orders" dated 04/20/12 at 1:30pm revealed an order to consult the ET (enterostomy) nurse for full assessment and recommendations.

Review of the "Non-Pressure Skin Condition Report" revealed the assessment was performed on 04/24/12 with no documented evidence of the time the assessment was performed.

In a face-to-face interview on 04/24/12 at 1:10pm, Wound Care RN S17 indicated he was required to perform wound assessments within 72 hours of the order. He confirmed that Patient #8's wound assessment was performed 4 days after admission. S17 indicated that since the order was for an assessment and no wound care was ordered other than ostomy care, he felt that the floor nurses could do ostomy care. He further indicated he prioritized his patient wound assessments based on the patient's need. He had no explanation when asked about the physician's order requesting his (S17) recommendations for wound care, and his assessment not taking priority because there were no wound care orders.

Patient #11
Review of the medical record for Patient #11 revealed he was a 67 year old male admitted on 01/19/12 for Osteomyelitis and cellulitis of the right foot, which required surgical incision and drainage.

Review of the Physician Order for 01/20/12 revealed an order for Wound Care. R (right) great toe. Apply Silvasorb gel, cover with Xeroform gauze and wrap with Kerlix every day and prn (as needed for) drainage.

Review of the Treatment Record for January 2012 revealed wound care was not performed on 01/22/12 on the patient's right great toe.

Review of the Physician Orders for 01/24/12 revealed an order for Wound Care. R (right) great toe. d/c (discontinue) previous wound care, apply Santyl oint (ointment) with wet to dry saline gauze every day and prn ( as needed for) drainage.

Review of the Treatment Record for February 2012 revealed wound care on the right great toe was not done on 2/3/12.

An interview was conducted with S2 DON (Director of Nursing) on 04/26/12 at 2:55 p.m. She reported that no wound care was documented as performed on Patient #11 on 01/22/12 and 02/03/12.

4) The nursing staff failed to obtain wound care orders for wound care that was performed:
Review of Patient #13's medical record revealed she was an 82 year old female admitted on 01/06/12 with the primary diagnosis of osteomyelitis right foot with stage IV ulcer. Further review revealed secondary diagnoses were MRSA (methicillin resistant staph aureus) and Proteus Mirabilis urinary tract infection, atrial fibrillation, iron deficiency anemia, hypertension, history of cerebrovascular accident with aphasia and dysphagia with a PEG (percutaneous esophageal gastrostomy) tube, and multiple decubitus ulcers.

Review of Patient #13's "Physicians Admission Orders" dated 01/06/12 at 10:00am revealed an order to consult ET (enterostomy) nurse for decubitus ulcers bilateral feet and heels, sacrum, and right elbow with full evaluation with recommendations for wound care. Review of the entire medical record revealed no documented evidence that wound care orders were received for any of the wound care performed during Patient #13's hospital stay from admission on 01/06/12 through the time of transfer on 02/09/12.

Review of Patient #13's "Treatment Record" for 01/07/12 through 01/09/12 revealed the following wound care was performed:
Sacrum - clean with normal saline, pat dry, apply stoma powder, thin layer of protective paste, leave open to air daily and as needed with soiling; there was no documented evidence this wound care was performed on 01/08/12;
Left medial foot, left medial heel, left lateral heel - twice a day clean with normal saline, pat dry, apply Santyl to wound base, cover with normal saline-moist gauze, cover, wrap lightly with Kerlix and secure; there was no documented evidence this wound care was performed on 01/08/12;
Right lateral foot - twice a day clean with normal saline, pat dry, pack with Silvadene- impregnated Nu-gauze, cover, wrap lightly with Kerlix and secure; there was no documented evidence this wound care was performed on 01/08/12;
Right medial foot - daily saturate with chloraprep, leave open to air; there was no documented evidence this wound care was performed on 01/08/12;
Right elbow - clean with normal saline, dry, apply duoderm, cover with transparent dressing, change every 5 days.
Review of the "Treatment Record" for 01/09/12 through 01/31/12 and February 2012 revealed the following wound care was performed:
buttocks - apply stoma powder mixed with Calazime barrier cream twice a day and as needed with cleaning; no documented evidence the wound care was performed on 01/11/12, 01/13/12, 01/14/12, 01/17/12, 01/18/12, 01/19/12, 01/20/12, 01/25/12, 01/27/12, 01/28/12, 01/29/12, 01/30/12, 01/31/12; 02/01/12, 02/06/12, 02/07/12, and 02/08/12. Further review revealed wound care was performed once a day rather twice a day as recommended on 01/10/12, 01/12/12, 01/15/12, 01/16/12, 01/21/12, 01/22/12, 01/23/12,01/24/12, 01/26/12, 02/02/12, 02/03/12, 02/04/12, and 02/05/12;
Bilateral feet - unna-flex gauze loosely and wrap with Kerlix, no compression, change 2 times a week and as needed.

In a face-to-face interview on 04/24/12 at 1:10pm, Wound Care RN (registered nurse) S17 indicated he documents on the treatment record when he performs wound care. He further indicated he performed the patient's wound assessment, but the floor nurse was responsible for the daily wound care treatment. S17 could offer no explanation for not having physician orders for wound care performed.




26351

25065


Based on record review and interviews, the hospital failed to ensure all drugs and biologicals were administered according to physician orders and acceptable standards of practice for 9 of 20 sampled patients (#1, #4, #6, #7, #8, #12, #15, #17, #20). This resulted in 106 medication errors noted during chart reviews that were not identified by the hospital for the nine patients. Findings:

Patient #1
Review of the medical record for Patient #1 revealed a 91 year old female admitted to the hospital on 04/18/12 for Severe C-Diff Colitis, Severe Malnutrition, Dehydration, Renal Failure and Leukocytosis. Review of the Physicians Verbal Order for Patient #1 dated/timed 04/20/12 at 0725 (7:25am) revealed an order for Atarax 10 mg po (by mouth) prn (as needed) Q 6 hours (every 6 hours).

Review of the MAR (Medication Administration Record) revealed Atarax was administered to Patient #1 on the following dates and times: 04/20/12 at 2100 (9:00pm); 04/21/12 at 0300 (3:00am), 0900 (9:00am) and 2100 (9:00pm). Further review revealed no documented evidence the indication for the use of Atarax was clarified before the administration of the drug to Patient #1.

Review of the Physicians Verbal Order for Patient #1 dated/timed 04/18/12 at 1400 (2:00pm) revealed an order for the following: Decadron 4mg IV twice daily, Diflucan 200 mg po (by mouth) twice daily and Metoprolol (Lopressor) 12.5 mg po twice daily.

Review of the MAR (Medication Administration Record) for Patient #1 revealed no documented evidence the following drugs were administered as ordered: 04/19/12 at 2100-Decadron 4mg IV, Diflucan 100mg po, and Metoprolol 12.5 mg by mouth. Further review of the medical record revealed no documentation of the reason the medications were not given.

Patient #4
Review of the medical record for Patient #4 revealed an 86 year old female admitted to the hospital for Myelodysplasia, UTI (Urinary Tract Infection), Venous Stasis Ulcers and Malnutrition. Additional diagnoses included anemia, electrolyte imbalance, and sacral decubitus ulcers.

Review of the Physicians Orders for Patient #4 dated/timed 04/17/12 at 8:30am revealed an order to wean Dopamine as tolerated.

An interview was conducted with S2 DON on 4/27/12 at 1:20 p.m. She reported the order for the Dopamine should have included parameters for the patient's blood pressure, and the order should have been clarified by the nurse.
Patient #6
Medical Record review of the Physician's Orders for Patient #6 revealed an order dated 04/5/12 at 1345 (1:45 p.m.) for Percocet (Narcotic pain medication) 7.5 milligrams (mg) Q (every) 6 hours PRN (as needed) for pain. Further review of the Medication Administration Record (MAR), Nurse's Notes, and the Omnicell (medication dispensing machine) transaction record provided by the pharmacy for Patient #6 revealed the following medication errors:
04/08/12 at 1:30 a.m.- Two 5 mg Oxycodone/APAP (Percocet) tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 mg was documented.
04/09/12 at 8:46 a.m.- One 5 mg Oxycodone/APAP tablet was removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given.
04/09/12 at 5:15 p.m.- One 5 mg Oxycodone/APAP tablet was removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given.
04/10/12 at 12:20 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 mg was documented.
04/11/12 at 8:41 p.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 was documented.
04/12/12 at 8:47 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 mg was documented.
04/12/12 at 6:39 p.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 mg was documented.
04/13/12 at 5:36 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. Two ? tablets (2.5 mg each) were charted as having been wasted. No dose was charted on the MAR as having been given.
04/13/12 at 8:01 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell by RN S31. No dose was charted as having been given and no waste was charted.
04/13/12 at 2:50 p.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. No dose was charted as having been given and no waste was charted. Two more 5 mg tablets were removed from the Omnicell by RN S31 1 hour and 56 minutes later and charted as having been given.
04/14/12 at 8:21 a.m.- One 5 mg Oxycodone/APAP tablet removed from the Omnicell. A 7.5 mg dose was charted as having been given on the MAR.
04/15/12 at 8:56 a.m.- One 5 mg Oxycodone/APAP tablet removed from the Omnicell. A 7.5 mg dose was charted as having been given.
04/15/12 at 3:03 p.m.- One 5 mg Oxycodone/APAP tablet removed from the Omnicell. A 7.5 mg dose was charted as having been given.
04/16/12 at 4:09 a.m.- One 5 mg Oxycodone/APAP removed from the Omnicell. No dose was recorded as having been given.
04/17/12 at 1:23 a.m.- Two 5 mg Oxycodone/APAP tablets removed from the Omnicell. ? tablet (2.5 mg) was charted as having been given. No waste was charted.
04/17/12 at 9:11 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 5 mg tablet was charted as having been given at 9:13 a.m. Another 5 mg tablet was charted as having been given 3 hours and 47 minutes later at 1300 (1:00 p.m.).

In a face to face interview on 04/24/12 at 9:45 a.m. Registered Nurse (RN) S16, verified Patient #6's ordered dose of Oxycodone/APAP was 7.5 mg every 6 hours as needed for pain. S16 also indicated she had given Patient #6 5 mg of Oxycodone/APAP instead of 7.5mg, and then gave another 5 mg dose 3 hours and 47 minutes later for a total of 10 mg. S16 indicated she had not realize she had made a medication error. S16 indicated she thought if she could have given a smaller dose than what was ordered without clarifying the order with the physician. S16 stated that she had not filled out a medication variance form for the error.

In a face to face interview on 04/25/12 at 8:10 a.m. Licensed Practical Nurse (LPN) S8, indicated she had removed two 5 mg Oxycodone/APAP tablets from the Omnicell on 4/17/12 at 1:23 a.m. S8 verified that she charted she had given 5 mg of the narcotic to Patient #6, but did not have any documentation of wasting the other 5 mg. S8 indictaed she could not remember that day specifically, but she should have wasted the remaining 2.5 mg of the Oxycodone/APAP with another nurse. S8 also said if she had wanted to give a different dose than the physician ordered, she should have notified the physician.

In an interview on 04/27/12 at 1:35 p.m. with RN S31, he stated on 04/13/12 at 4:45 p.m., he must have forgotten to chart the waste of 2.5 milligrams of Oxycodone/APAP after giving 7.5 mg to Patient #6. S31 said he must have forgotten to chart the other doses of Oxycodone for Patient #6 on 04/13/12.

In a face to face interview interview on 04/25/12 at 8:30 a.m. Director of Nursing S2, verified the Oxycodone/APAP discrepancies from Patient #6's chart. S2 said the nursing staff should have given 7.5 mg of Oxycodone/APAP as ordered or called the physician to clarify the order. She also stated if 10 mg of Oxycodone/APAP had been removed from the Omnicell, 2.5 mg should have been charted as being wasted. S2 also said if a medication variance occurred, it should have been reported to her to be investigated. S2 said she could clearly see where there was a big problem with narcotic administration by the nursing staff.

Patient #7
Review of Patient #7's medical record revealed he was an 81 year old male admitted on 04/17/12 with the primary diagnoses of respiratory failure with ventilator support and a tracheostomy, pneumonia, and malnutrition.

Review of Patient #7's "Physicians Admission Orders" dated 04/17/12 at 10:00am revealed orders for Celexa 20 mg (milligrams) per PEG (percutaneous espohageal gastrostomy) daily and Omeprazole 40 mg per PEG every 12 hours.

Review of Patient #7's MARs (medication administration record) and nurses' notes revealed no documented evidence that he received Celexa as ordered at 9:00am on 04/19/12. Further review revealed Omeprazole 20 mg (rather than 40 mg as ordered) was administered per the PEG at 9:00am and 9:00pm on 04/17/12, 04/18/12, 04/19/12, 04/20/12, 04/22/12, and at 9:00am on 04/23/12.

In a face-to-face interview on 04/23/12 at 3:03 pm, RN (registered nurse) S14 confirmed Patient #7's MAR that was generated by the contracted pharmacy had Omeprazole 20 mg rather than 40 mg, and Patient #7 had received 20 mg since his admission. She further indicated the nurse was supposed to check the MARs when patients were admitted, a new medication order was received, and when the new MAR was generated on Saturday.

Patient #8
Review of Patient #8's medical record revealed he was an 85 year old male admitted on 04/20/12 with diagnoses of septicemia, end-stage renal disease with hemodialysis, hypotension, anemia, syncope, and congestive heart failure.

Review of the medical record for Patient #8 revealed a physician's order dated 04/26/12 at 1005 (10:05 a.m.) to Wean Dopamine as tolerated. There was no documented evidence of the specific parameters for blood pressure that were to be used to decrease the dopamine.
An interview was conducted with S2 DON on 4/27/12 at 1:20 p.m. She reported the order for the Dopamine should have included parameters for the patient's blood pressure, and the order should have been clarified by the nurse.
Patient #12
Review of the medical record for Patient #12 revealed a 74 year old male admitted to the hospital on 12/30/11 for additional care and rehabilitation from a CVA (Cerebrovascular accident) intracranial bleed to the right thalamus.

Review of the Physicians Order dated/timed 01/31/12 at 10:00am revealed an order for Avelox 500mg IVPB Q 24 hours (intravenous piggyback every 24 hours) which was the therapeutic substitute for Levaquin.

Review of the MAR (Medication Administration Record) for Patient #12 revealed... 01/30/12 at 0900 (9:00am) Not Available gave at 11:45am (1 hour 45 minutes late). Further review of the MAR and the Nurses Notes revealed no documented evidence the physician was notified or a medication variance was completed.

Review of the Physicians Orders for Patient #12 dated 12/30/11 revealed the following orders: Lisinopril/HCTZ (Hydrochlorothiazide) 20/12.5mg po (by mouth) BID (twice a day) 1 tab Hold if BP (Blood Pressure) <110; Metoprolol 25mg per PEG (percutaneous esophageal gastrostomy) BID Hold if BP < 90/50 or HR (heart rate) <60; 01/07/12 order change Metoprolol 5mg IV (intravenous) to 25mg BID Hold if BP <90/50 or HR <60.

Review of the MAR (Medication Administration Record) for Patient #12 revealed no documented evidence the blood pressure and heart rate was assessed prior to administration of Lisinopril and Metoprolol as ordered for the following dates and times: 12/30/11 at 2100 (9:00pm); 12/31/11 at 0300 (3:00am), 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 01/01/12 at 0300 (3:00am), 1500 (3:00pm), 2100 (9:00pm); 01/02/12 at 0300 (3:00am), 0900 (9:00am), 1500 (3:00pm); 01/03/12 at 0300 (3:00am), 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 01/04/12 at 0300 (3:00am); 01/05/12 at 0300 (3:00am), 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 01/06/12 at 0300 (3:00am); 01/15/12 through 01/26/12 at 0900 (9:00am), 2100 (9:00pm); 01/27/12 at 2100 (9:00pm); 01/28/12 at 0900 (9:00am), 2100 (9:00pm).

Patient #15
Review of the medical record for Patient #15 revealed a 75 year old male admitted to the hospital on 03/23/12 for continued care of acute respiratory failure, hypoxia, aspiration pneumonia, sepsis, and malnutrition.

Review of the Physicians Orders for Patient #15 revealed an order for Neurontin 300mg per Peg tube every 12 hours. Review of the MAR (Medication Administration Record) dated/timed 04/12/12 0900 (9:00am) revealed a circle with the initials of the nurse indicating the medication was not given. Further review of the MAR and the Nurses' Notes and the Physicians' Orders revealed no documented reason the medication was not adminsitered.

Patient #17
Review of the medical record for Patient #17 revealed he was a 57 year old male admitted on 4/4/12 for a Scrotal abscess, Obesity, Diabetes Mellitus, Congestive Heart Failure, and Carotid Artery Disease.
Review of the Physician Orders dated 4/23/12 and noted off by the nurse on 4/23/12 at 2300 (11 p.m.) revealed an order to administer Flomax 0.4 mg (milligrams) po (by mouth) q (every) p.m.-start tonight.
Review of the MAR (Medication Administration Record dated 4/22/12 to 4/28/12 revealed an entry to administer Flomax at 2100 (9 p.m.). 2100 was circled and written on the back on the MAR was written the medication was not available. The entry was rewritten as a change in the medication schedule to Flomax 0.4 mg by mouth every day and schedule for 4/24/12 at 9 a.m. as the first dose. There was no documentation the physician was notified of the unavailability of the medication and the time schedule was changed.
An interview was conducted with S2 DON on 4/25/12 at 2:30 p.m. She reported Patient #17 should have gotten the Flomax on the night of 4/23/12, as ordered by the physician. S2 went on to report the medication should have been in the Omnicell (medication delivery system) and if there was none there, the nurse could have called the pharmacist,who was on call 24 hours a day 7 days a week, and they could have gotten the medication from Hospital "A".
Review of the admitting physician orders dated 04/04/12 revealed the patient was on Toprol XL 25 mg (milligrams) po (by mouth) daily, Hydrochlorothiazide 25 mg po daily, Benazepril 40 mg (Lotensin) by mouth every day, and Norvasc 1 tab (10 mg) by mouth every day.

Review of the MAR (Medication Administration Record) revealed the patient's blood pressure was not documented every day prior to administration of his hypertensive medications. According to the MAR his blood pressure was not documented on 04/10/12, 04/11/12, 04/14/12, 04/18/12, and 04/19/12. Also the patient's pulse was not taken prior to administration of the Toprol XL.

An interview was conducted with S2 DON (director of nursing) on 04/26/12 at 11 a.m. She indicated the CNA (certified nursing assistants) take the vital signs throughout the day, and if there is a problem with the vital signs, the nurse retakes the patient's vital signs. She indicated she was aware the blood pressure and apical pulse were not documented on the MAR prior to administrations of certain medications as it should be.

Review of the drug reference book, Nursing 2010, presented as the hospital drug's reference guide, revealed under Nursing Considerations for Metoprolol succinate, Toprol XL, that a patient's apical pulse rate should always be checked prior to administering the medication. If the pulse is slower than 60 beats/minute, the drug should be withheld. Also included under nursing administration was to monitor blood pressure frequently; drug masks common signs and symptoms of shock.

Review of the drug reference book, Nursing 2010 Drug Handbook, presented as the hospital drug's reference guide, revealed under Nursing Considerations for benazepril hydrochloride, Lotensin, that it was important to monitor patients for hypotension. Excessive hypotension can occur when the drug is given with diuretics.

Patient #20 Review of the medical record for Patient #20 revealed he was a 65 year old male admitted to the hospital on 3/14/12 with the diagnoses of ventilator dependence, history of closed head injury with (VP) ventriculoperitoneal shunt, trach, peg tube and hypertension. He was admitted to the hospital in an attempt to wean him from the ventilator and for management of his seizure medications.
Review of the Physicians Admission Orders dated 3/14/12 revealed an order for Zosyn 3.375 gm (grams) IVPB (intravenous piggy back) every 6 hours.
Review of the MAR (Medication Administration Record) dated 3/25/12 to 3/31/12 revealed the 2100 (9 p.m.) dose of Zosyn on 3/29/12 was initialed and circled. Review of the back of the MAR revealed an entry that stated the 2100 dose was not available from the pharmacy.
An interview was conducted with S2 DON on 4/26/12 at 2:30 p.m. She reported the Zosyn should have been given because it is always available in the Omnicell.
Review of the policy provided by Director of Nursing (DON) S2 numbered II-F.7.10, titled Record Keeping, stated in part:
...When a medication is not given for any reason, chart this in the Nurses Notes and circle the space on the medication sheet ... Wasted drugs are charted in Nurses Notes. The drug, dose, nurse's signature, reason wasted and time are included in the notes ... Reporting abuse and losses of controlled substances shall be reported to the individual responsible for the pharmaceutical services, to the chief executive officer, Louisiana Board of Pharmacy, and the Regional Drug Enforcement Administration (DEA) office, as appropriate ...".

Review of the policy provided by DON S2 numbered II-F.7.00, titled Medication Management, stated in part, "...Before administering a medication, the following should be performed :...Verifies the medication is being administered at the proper time, the prescribed dose, and the correct route ....Observe the five rights in giving medications: the Patient, the right time, the right medication, the right dose, and the right method of administration ...Report a variance in medication immediately to the nurse in charge. Medication variance report to be completed by DON...Each patient has an individual medication record and the dose of the drug administered is properly recorded after administration in that record by the person whom administered the drug...".



































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30364

Based on record reviews and interview the hospital failed to follow their policy and procedure for blood administration as evidenced by: 1) failing to clarify physician orders for blood administration to include the blood component to be transfused and the rate of transfusion for 5 of 6 patients with orders for blood administration from a total of 20 sampled patients (#3, #4, #14, #15, #16) and 2) failing to monitor vital signs according to policy and procedure for 1 of 6 patients with orders for blood administration from a total of 20 sampled patients (#13). Findings:

1) failing to clarify orders for blood to include the blood component to be transfused and the rate of transfusion:
Patient #3
Review of medical record for Patient #3 revealed a 72 year old female admitted to the hospital after surgery for a diversion of a colostomy with complications of a fistula. In addition, Patient #3 had a history of anemia, malnutrition, hyperglycemia and a large abdominal wound.

Review of the Physicians Orders dated/timed 04/16/12 at 0800 (8:00am) for Patient #3 revealed a telephone order to " Type and Cross and Transfuse 2 units PRBC (packed red blood cells) " . Further review of the Physicians Orders revealed no documented evidence the order was clarified to include the rate of infusion.

Review of the " Blood/Blood Component Administration Record " for Patient #3 revealed the first unit of PRBC was started at 1400 (2:00pm) and completed at 1645 (4:45pm) for an infusion time of 2 hours and 45 minutes with a rate of infusion ranging from 50 ml/hr to 75 ml/hr to 100 ml/hr to 125/ml/hr. The second unit of PRBC was started at 2240 (10:40pm) and completed at 0125 (1:25am) for an infusion time of 2 hours and 45 minutes with a rate of infusion documented as ranging from 75 ml to 100 ml per hour.

Patient #4
Review of the medical record for Patient #4 revealed an 86 year old female admitted to the hospital for Myelodysplasia, UTI (Urinary Tract Infection), Venous Stasis Ulcers and Malnutrition. Additional diagnoses included anemia, electrolyte imbalance, and sacral decubitus ulcers. Review of the Physician's Orders dated/timed 04/04/12 at 0225 (2:25am) revealed an order to " T+M 2 units packed cells " and 04/16/12 (no time documented) " Type and Cross 2 u PRBC + transfuse " . Further review of the Physicians Orders revealed no documented evidence the order was clarified to include the rate of infusion.

Review of the " Blood/Blood Component Administration Record " for Patient #4 dated 04/04/12 revealed the first unit of PRBC was started at 1415 (2:15pm) and completed at 1615 (4:15pm)for a transfusion time of 2 hours. The second unit of PRBC was started at 2153 (9:53pm) and completed at 0053 (12:53pm) for a transfusion time of 3 hours. The rate of infusion was documented from 25 ml/hr to 125 ml/hr.

Review of the " Blood/Blood Component Administration Record " for Patient #4 dated 04/19/12 revealed the first unit of PRBC was started at 1400 (2:00pm) and completed at 1630 (4:30pm)for a transfusion time of 2 hours and 30 minutes. The second unit of PRBC was started at 2215(9:15pm) and completed at 0010 (12:53pm) for a transfusion time of 1 hour and 55 minutes. The rate of infusion was documented from 60 ml/hr to 120 ml/hr.

Patient #14
Medical record review revealed patient #14 was admitted to the Hospital on 2/15/12 with diagnosis which included osteomyelitis, a stage IV pressure ulcer, and septicemia. Review of the Physician ' s Orders dated 3/26/12 at 11:00 a.m. revealed an order to transfuse 2 units PRBC (Packed Red Blood Cells) and type and cross. Further review revealed no documentation from the nursing staff where the rate of transfusion had been clarified with the physician.

Review of the "Blood Component Administration Record" revealed 250 milliliters (ml) of PRBC's were started on 3/26/12 at 1520 (3:20 p.m.) and completed at 1805 (6:05 p.m.). Further review revealed 222 ml were started on 3/26/12 at 2105 (9:05 p.m.) and completed on 3/27/12 at 0001 (12:01 a.m.).

Patient #15
Review of the medical record for Patient #15 revealed a 75 year old male admitted to the hospital on 03/23/12 for continued care of acute respiratory failure, aspiration pneumonia, sepsis and malnutrition. Review of the Physicians Order dated/timed 03/30/12 at 1332 (1:32pm) revealed an order to "Type, match, transfuse 2u PRBC".

Review of the "Blood/Blood Component Administration Record" for Patient #15 dated 03/30/12 revealed the first unit of PRBC was started at 1730(5:30pm) and completed at 1840 (6:40pm) for a transfusion time of 160 ml in 1 hour 10 minutes with a transfusion rate of 100 ml/hr. The second unit of PRBC was started on 03/31/12 at 0015 (12:15am) and completed at 0240 (2:40am) for a transfusion time of 258 ml in 2 hours 25 minutes. The transfusion rate was documented as 80 ml/hr to 100 ml/hr. Further documentation indicated the rate of infusion was documented as "wide".

Patient #16
Review of the History and Physical (H&P) Patient #16 revealed a 67 year old female admitted to the hospital on 01/18/12 for continued treatment of Klebsiella pneumonia, urinary tract infection and Candida glabrata cystitis. Review of the Physicians Orders dated 01/26/12 at 1123 (11:23am) for Patient #16 revealed a verbal order to "give 6 units platelets". Further review revealed no documentation that the order had been clarified by the nurse for the rate of transfusion.

Review of the "Blood/Blood Component Administration Record" for Patient #16 dated 01/26/12 revealed six units of FFP (Fresh Frozen Plasma) was started at 1429 (2:29pm) and completed at 1519 (3:19pm) for a transfusion time of 330 ml of 50 minutes. Further documentation indicated the rate of infusion was documented as "wide".

Review of the Physicians Orders dated 01/27/12 at 0745 (7:45am) for Patient #16 revealed a verbal order to "T+CM for 2 units & transfuse with dialysis". Further review revealed no documentation that the order had been clarified by the nurse for the blood component or the rate of transfusion.

Review of the "Blood/Blood Component Administration Record" for Patient #16 revealed the first unit of PRBC was started at 10:00am and completed at 11:00am for an infusion time of 1 hour at a rate of 188 ml per hour. The second unit of PRBC was started at 11:00am and completed at 12:00pm for an infusion time of 1 hour at a rate of 192 ml per hour. Both were given during the dialysis process.

In a face to face interview on 04/25/12 at 2:25pm, RN S2 Director of Nursing indicated Blood Utilization Review was performed by the nurses administering the blood. Further S2 indicated no problems were identified through the form used as the tool to gather the information. S2 verified no other audits were performed to ensure blood administration was performed according to physician's orders, established criteria or policy and procedure.

Review of policy # II-C.3.15 titled "Blood Transfusion" last revised 12/09 and submitted as the one currently in use revealed...... "Procedure: 1. Verify physician order for transfusion. 14. Adjust rate to infuse 10 to 15gtts/min for the first 15 minutes. 17. Adjust rate as prescribed, but do not exceed 4 hours....".

2) failing to monitor vital signs according to policy and procedure:
Review of the "Blood/Blood Component Administration Record" revealed the following directions for vital signs: "Transfusion: Vital signs every 15 minutes x 3 (times 3), then 30 minutes x 2, then every 60 minutes until infused...". Further review revealed these directions conflicted with the vital signs required by hospital policy which were to be taken every 15 minutes for the first hour and then every 30 minutes times 2 then every hour thereafter until unit is transfused.

Patient #13
Review of Patient #13's medical record revealed she was an 82 year old female admitted on 01/06/12 with the primary diagnosis of osteomyelitis right foot with stage IV ulcer. Further review revealed secondary diagnoses were MRSA (methicillin resistant staph aureus) and Proteus Mirabilis urinary tract infection, Atrial fibrillation, iron deficiency anemia, hypertension, history of Cerebrovascular accident with aphasia and Dysphagia with a PEG (percutaneous esophageal gastrostomy) tube, and multiple decubitus ulcers.

Review of Patient #13's "Physician Orders" dated 01/10/12 at 7:38pm revealed an order to type and match for 2 units of packed red blood cells and transfuse each unit over 4 hours.

Review of Patient #13's "Blood/Blood Component Administration Record" revealed the first unit of blood was started on 01/11/12 at 2100 (9:00pm). There was no documented evidence of the time the pre-transfusion vital signs were taken. Further review revealed vital signs were taken at the start of the infusion at 2100 and at 2115 (9:15pm), 2130 (9:30pm), 2200 (10:00pm), 2230 (10:30PM), 2330 (11:30pm), and 2430 (12:30am on 01/12/12). There was no documented evidence vital signs were taken at 9:45pm (the last of the every 15 minutes vital signs ordered every 15 minutes for the first hour per policy), at 11:00pm (the second of the every 30 minute vital signs) and at 12:00am (vital signs every hour) as required by hospital policy.

Review of Patient #13's "Blood/Blood Component Administration Record" revealed the second unit of blood was initiated on 01/12/12 at 1:30am. There was no documented evidence of the time the pre-transfusion vital signs were taken. Further review revealed vital signs were taken at the start of the infusion at 1:30am, 1:45am, 2:00am, 2:30am, 3:00am, 4:00am, and 4:35am when the transfusion was completed. There was no documented evidence vital signs were taken at 2:15am and 3:30am as required by hospital policy. Further review revealed the blood was administered in 3 hours 5 minutes rather than over 4 hours as ordered by the physician.

In a face to face interview on 04/25/12 at 2:25pm, RN S2 Director of Nursing indicated Blood Utilization Review was performed by the nurses administering the blood. Further S2 indicated no problems were identified through the form used as the tool to gather the information. S2 verified no other audits were performed to ensure blood administration was performed according to physician's orders, established criteria or policy and procedure.

Review of policy # II-C.3.15 titled "Blood Transfusion" last revised 12/09 and submitted as the one currently in use revealed...... "Procedure: 1. Verify physician order for transfusion. 14. Adjust rate to infuse 10 to 15gtts/min for the first 15 minutes. 15. Stay with the patient and monitor for signs of reaction for the first 15 minutes. 16. Monitor vital signs every 15 minutes for the first hour and then every 30 minutes times 2 then every hour thereafter until unit is transfused. 17. Adjust rate as prescribed, but do not exceed 4 hours....".



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25065

Based on observation, record review, and interviews, the hospital failed to ensure: 1) each patient's medical record was promptly completed no later than 30 days after discharge by having a 71% (per cent) delinquency rate for the first quarter of 2012; 2) all discharge summaries were completed and authenticated by the physician within 25 days of discharge as required by the medical staff rules and regulations for 4 of 9 discharged patient records reviewed from a total of 20 sampled patients (#12, #13, #15, #16) and 19 random patients (R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21); 3) medical records were properly stored to protect them from water damage. Findings:

1) Each patient's medical record was promptly completed no later than 30 days after discharge as required by the medical staff rules and regulations:
Review of the "Delinquent Chart Report 2011" presented by Registered Health Information Technician (RHIT) S28 revealed the delinquency rate for October 2011 was 61%, November 2011 69%, and December 2011 65%. Review of the "Delinquency Chart Report 2012" presented by RHIT S28 revealed the delinquency rate for January 2012 was 63%, February 78%, and March 2012 72%, for a delinquency rate of 71% for the first quarter of 2012.

Review of the "Physician Suspension Log" for October 2011 revealed Physician S36 was suspended on 10/26/11 and reinstated on 12/23/11.

Review of letters sent to Physician S36 by Administrator S1 revealed the following:
10/26/11 - notification of suspension of admitting privileges and 30 days to complete delinquent medical records (20 discharge summaries to be written or dictated and and 2 history and physical examinations to be written or dictated);
12/05/11 - list of deficient charts enclosed (4 of the above listed 20 discharge summaries to be written or dictated);
12/23/11 - letter notifying of suspension lifted "per direction of Governing Board Vice Chief of Staff S34" (currently chief of staff).

Review of the "Chart Deficiency Delinquent Report" ranging from 09/01/11 to 04/26/11 presented by RHIT S28 revealed Patient R19's medical record, which was delinquent for the discharge summary when Physician S36's suspension was lifted, remained delinquent for the discharge summary as of 04/26/12.

In a face-to-face interview on 04/26/12 at 9:25am, Vice Chief of Staff S22 indicated there was one or two physicians who had been suspended for delinquent records. He further indicated they have nurse practitioners trying to assist the physicians with completion of records. S22 indicated they have sent letters to physicians notifying them of their delinquent medical records. S22 could offer no explanation for not following their bylaws regarding suspension of physicians' admitting and consulting privileges when they have patient records incomplete 25 days after discharge.

In a face-to-face interview on 04/26/12 at 10:50am, RHIT S28 indicated no physician was currently suspended for delinquent medical records. She further indicated in the past physicians were sent letters but never suspended. S28 indicated the former administrator would not allow her to suspend physicians for delinquent medical records.

In a face-to-face interview on 04/26/12 at 1:55pm, RHIT S28 indicated Physician S36 had one chart delinquent when he was reinstated 12/23/11 at the direction of Chief of Staff S34. She further indicated Physician S36's patient record (R19) from 09/26/11 remained delinquent plus an additional 2 patient records from 01/02/12 (R21) and 01/23/12 (R20) were also delinquent.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations... E. Medical Records 1. Preparation and Completion a. The attending physician shall be responsible for the preparation of a complete medical record for each patient. ... c. A chart shall not be considered "delinquent until thirty (30) days following discharge. Chart completion requirements are as follows: All medical records shall be completed by the attending physician within 25 days of discharge. The administrator and responsible physician will be notified of deficiencies pending completion periodically throughout the 25 day completion process via the HIM (health information management) Coordinator. If the records are not completed, within 25 days, the HIM coordinator will notify the Administrator. The Administrator/Designee will notify the responsible physician that his/her admitting/consulting privileges have been suspended until such time as the records are complete. It shall be the responsibility of the HIM coordinator to notify the Administrator when the medical records are complete. Upon notification, the physician will be notified that his/her admitting privileges have been reinstated...".

2) Discharge summaries were not completed and authenticated by the physician within 25 days of discharge as required by the medical staff rules and regulations:
Patient #12
Review of Patient #12's medical record revealed a 74 year old male admitted to the hospital on 12/30/11 for continued care and rehabilitation after a CVA (Cerebrovascular accident), respiratory failure and urosepsis. Review of the Discharge Summary revealed Patient #12 was discharged to an acute care facility on 01/31/12; however the discharge summary was not dictated until 03/18/12 (47 days after dictation)and typed on 03/19/12. The Discharge Summary still remains without the physician's signature 38 days after being typed and remains a delinquent record past 86 days of discharge.

Patient #16
Review of the medical record revealed a 67 year old female admitted to the hospital on 01/18/12 for continued care for Klebsiella pneumonia, urinary tract infection and candida glabrate cystitis. Additional diagnoses included right renal cell carcinoma, diabetes mellitus, paraxysmal atrial fibrillation and a previous left hemisphere stroke. Review of the Discharge Summary revealed Patient #16 was discharged on 02/13/12, the summary dictated by the physician on 02/12/12 and typed on 02/13/12. The Discharge Summary still remains without the physician's signature 70 days after being typed and remains a delinquent record.

Review of the "Chart Deficiency Delinquency Report Deficiency Date Range: 9/01/2011 to 4/26/2012" presented by RHIT S28 revealed the following patients with their respective discharge date whose discharge summaries have not been written or dictated as 04/26/12 (more than 30 days since discharge):
Patient #13 - 02/09/12; Patient #15 - 11/15/11 (previous admit); Patient R3 - 03/16/12; Patient R4 - 02/20/12; Patient R5 - 12/07/11; Patient R6 - 03/16/12; Patient R7 - 02/15/12; Patient R8 - 01/09/12; Patient R9 - 02/14/12; Patient R10 - 02/24/12; Patient R11 - 03/02/12; Patient R12 - 03/07/12; Patient R13 - 03/06/12; Patient R14 - 03/06/12; Patient R15 - 03/16/12; Patient R16 - 03/20/12; Patient R17 - 03/20/12; Patient R18 - 03/20/12; Patient R19 - 09/26/11; Patient R20 - 01/23/12; Patient R21 - 01/02/12.

In a face-to-face interview on 04/26/12 at 9:25am, Vice Chief of Staff S22 indicated there was one or two physicians who had been suspended for delinquent records. He further indicated they have nurse practitioners trying to assist the physicians with completion of records. S22 indicated they have sent letters to physicians notifying them of their delinquent medical records. S22 could offer no explanation for not following their bylaws regarding suspension of physicians' admitting and consulting privileges when they have patient records incomplete 25 days after discharge.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations... 4. Discharge Summary a. A discharge summary shall be recorded at the time of discharge unless awaiting test results. Any patient that dies in the hospital shall have a recorded death summary. ... Discharge summaries must be authenticated by physicians...".

3) Medical records were properly stored to protect them from water damage:
Observation of the medical record storage room on 04/26/12 at 4:00pm revealed medical records were stored on mounted rolling storage shelves. Further observation revealed no means of protecting the fronts of two sections of shelving from water damage in the event that the sprinkler system would activate.

In a face-to-face interview on 04/26/12 at 4:00pm, RHIT S28 confirmed that the patients' medical records had no protection from water damage.

Based on record review and interview the hospital failed to ensure all entries into the medical record were signed, dated and timed for 3 of 20 sampled patient records (#5, #6, #13). Findings:

Patient #5
Review of the medical record for Patient #5 revealed she was a 35 year old female admitted on 04/13/12 for bacterial endocarditis, sepsis, pneumonia, and hemodialysis.

Review of the progress notes revealed the following progress notes were not timed: 04/14/12, 04/16/12, 04/17/12, 04/18/12, 04/19/12, 04/20/12, 04/21/12, 04/22/12, and 04/23/12.

Patient #6
Review of the medical record for Patient #6 revealed she was a 66 year old female admitted on 04/04/12 for spinal abscess and osteomyelitis of her vertebra.

Review of the progress notes revealed the following progress notes were not timed: 04/05/12, 04/06/12, 04/07/12, 04/10/12, 04/11/12, 04/13/12, 04/15/12, 04/16/12, 04/17/12, 04/19/12, 04/20/12, and 04/22/12.

Patient #13
Review of Patient #13's medical record revealed she was an 82 year old female admitted on 01/06/12 with the primary diagnosis of osteomyelitis right foot with stage IV ulcer.

Review of Patient 313's "Physician Progress Notes" dated 01/07/12, 01/08/12, 01/10/12, 01/21/12, 01/22/12/02/04/12, and 02/05/12 revealed no documented evidence of the time the progress notes were written by the physician.

In a face-to-face interview on 04/24/12 at 10:08am, Director of Nursing S2 indicated physicians not timing their progress notes was an ongoing issue at the hospital.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations... E. Medical Records 1. Preparation and Completion ... All medical record entries must be legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided consistent with hospital policy and procedure..."









25065





26351

Based on record review and interview the hospital failed to ensure all physician orders were dated and timed for 10 of 20 sampled medical records (#3, #4, #6, #7, #10, #11, #12, #13, #16, #19). Findings:

Patient #3
Review of medical record for Patient #3 revealed a 72 year old female admitted to the hospital after surgery for a diversion of a colostomy with complications of a fistula. In addition, Patient #3 had a history of anemia, malnutrition, hyperglycemia and a large abdominal wound. Review of the Physicians Orders revealed the following orders were not timed when ordered by the physician: 04/16/12 to stop Morphine and start Loratab 7.5mg po (by mouth) for prn (as needed) for pain; 04/21/12 Iv fluids at 50ml/hr and CBC, CMP Mg on Monday; and 04/22/12 stop IV fluids, assist with all meals, and a pre-albumin on Monday.

Patient #4
Review of the medical record for Patient #4 revealed an 86 year old female admitted to the hospital on 03/27/12 for Myelodysplagia, Pseudomonas UTI (urinary tract infection), Venous Stasis Ulcers and Malnutrition. Review of the Physicians Orders revealed the following orders were not timed when ordered by the physician: 03/27/12 Admission Orders; 04/02/12 Fentanyl and a CBC; 04/06/12 CBC, BMP; 04/10/12 Daily CBC this week; 04/16/12 Type, Cross 2 u (units) PRBC (packed red blood cells) and transfuse; and 04/20/12 ensure tid.

Patient #6
Review of the medical record revealed Patient #6 was admitted to the facility on 04/04/12 with diagnosis which included Spinal Osteomyelitis/Diskitis, MRSA, ESRD with hemodialysis, Sepsis and Hypertension. Further review revealed the following physician's orders had not been timed or dated: 04/04/12 Admission Orders ; 04/09/12 at 10:00 a.m. Epogen 10,000 units subcutaneous every dialysis treatment Tuesday, Thursday, Saturday; 04/05/12 at 10:00 a.m. Hemodialysis orders; 04/20/12 at 10:10 a.m. ESR and CRP Monday.

Patient #7
Review of Patient #7's medical record revealed he was an 81 year old male admitted on 04/17/12 with the primary diagnoses of respiratory failure with ventilator support and a tracheostomy, pneumonia, and malnutrition.

Review of Patient #7's "Physician Orders" revealed an order written by Chief of Staff S34 on 04/22/12 for CPAP (continuous positive airway pressure) and labs with no documented evidence of the time the order was written.

Patient #10
Review of the medical record for Patient #10 revealed a 95 tear old female admitted to the hospital on 01/10/12 for sepsis, infected left hip wound, malnutrition, and a history of dementia.
Review of the Physicians Orders revealed the following were not dated when written: 01/11/12 for TPN and a calorie count; 01/13/12 DNR (Do Not Resuscitate); 01/18/12 KCL 60 meq TPN with lytes; and 01/18/12 NG tube and dietary consult.
Review of the Restraint Orders for Patient #10 revealed no documented evidence the orders were signed by a physician on the following dates: 01/30/12, 02/03/12, 02/04/12 and 02/05/12.

Patient #11
Review of the medical record revealed Patient #11 was admitted to the facility on 01/19/12 with diagnosis which included Osteomyelitis and Cellulitis of the right foot. Further review revealed the following physician's orders had not been timed or dated by the physician: 01/19/12 at 1400 (2:00 p.m.) Physician's Admission Orders; 01/23/12 at 1:00 p.m. Increase Lantus 15 unit SQ (subcutaneous) qd (every day); 01/26/12 8:00 a.m. increase Lantus 20 units sq daily; 01/30/12 8:00 a.m. Give 5 mg (milligram) Coumadin po (by mouth) today; 01/31/12 at 4:45 p.m. Give total 5 mg po Coumadin today; 02/03/12 at 12:40 p.m. Zoloft 25 mg po qd (every day).

Patient #12
Review of the medical record for Patient #12 revealed a 74 year old male admitted to the hospital on 12/30/11 for additional care and rehabilitation from a CVA (Cerebrovascular accident) intracranial bleed to the right thalamus. Review of the Physicians Orders dated 01/29/12 for an abdominal x-ray revealed no documented time the order was written by the physician.

Patient #13
Review of Patient #13's medical record revealed she was an 82 year old female admitted on 01/06/12 with the primary diagnosis of osteomyelitis right foot with stage IV ulcer.

Review of Patient #13's "Physician Orders" revealed the following physician orders were not timed when written by the physician: -1/22/12 - order for Coumadin; 02/02/12 - medication and infusion orders.

Patient #16
Review of medical record for Patient #16 revealed a 67 year old female admitted to the hospital on 01/18/12 for continued treatment of acute tubular necrosis. Review of the Physician's Orders revealed the following orders were not timed when ordered by the physician: 01/18/12 Admission Orders; 01/21/12 BMP, Phosphate, CBC PT/INR tomorrow; 01/31/12 Carafate Suspension 10ml po now and tid (three times a day) prn for heartburn, Labs; 02/02/12 Seroquel 50mg po (by mouth) hs (hour of sleep), Stop Risperadol, extra diligence to prevent falls, CBC, CMP, PT/INR in AM; and 02/04/12 CMP, CBC, GGT in AM; 02/06/12 Wednesday CBC,BMP, AST, PT/INR, Albumin, AST.

Review of the Telemetry Protocol Physician Orders dated/timed 01/18/12 at 10:00am revealed no documented evidence the physician signed the orders.

Patient #19
Medical record review revealed Patient #19 was admitted to the facility on 4/3/12 with diagnosis which included acute respiratory failure. Further review revealed the following physician's orders had not been timed or dated by the physician: 04/03/12 at 3:00 p.m. Admission Orders; 04/05/12 at 9:30 a.m. Decrease IV (intravenous) fluids to 50 ml/hr (milliliters per hour), Megace 10 ml PO (by mouth) BID (twice per day), Cancel consult for Dr. M----; 04/09/12 at 9:10 a.m. KCl (potassium chloride) 40 meq (milliequivalents) x 1 dose now. KCl 20 meq IVPB (intravenous piggy back) x 1 dose now; 04/09/12 (no time noted) CMP (complete metabolic panel) in a.m.; 04/10/12 (no time noted) Repeat urine C&C. Geodon 20 meq PO BID; 04/16/12 (no time noted) KCl 20 meq PO x 1 dose.

In a face-to-face interview on 04/24/12 at 10:00am, Director of Nursing S2 indicated physician orders not being timed, dated, and signed timely was an ongoing problem.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations... Orders... 2. All orders for treatment shall be in writing. ...".

Review of the hospital policy titled "Authentication", policy number III-A.1.06, revised 01/10, and contained in the manual presented by Administrator S1 as current, revealed, in part, "...C. Every Medical record entry must be legible, complete, dated, timed, author identified, and when required authenticated...".














25065




30364

Based on record review and interview the hospital failed to ensure all verbal orders were dated, timed, and authenticated when signed by the physician according to Medical Staff By-Laws for 12 of 20 sampled medical records (#3, #6, #7, #9, #10, #11, #12, #13, #14, #15, #16, #19). Findings:

Patient #3
Review of medical record for Patient #3 revealed a 72 year old female admitted to the hospital after surgery for a diversion of a colostomy with complications of a fistula. In addition, Patient #3 had a history of anemia, malnutrition, hyperglycemia and a large abdominal wound.
Review of the Physicians Orders revealed the following verbal orders were not timed when signed: 04/11/12 at 11:55am for KCL 40meq IVPB (intravenous piggyback) X1 over 2 hours; 04/11/12 at 12:15pm orders for Physical Therapy; 04/13/12 at 11:25am Diflucan 300mg po (by mouth) daily X 7 days; 04/16/12 at 8:00am Type, Cross and transfuse 2 units PRBC (packed red blood cells); and 04/16/12 at 0255 (2:55am) orders for OT (Occupational Therapy).

Patient #6
Review of the medical record revealed Patient #6 was admitted to the facility on 04/04/12 with diagnosis which included Spinal Osteomyelitis/Diskitis, MRSA, ESRD with hemodialysis, Sepsis and Hypertension. Further review revealed the following verbal order had not been signed, dated or timed by the physician: 04/12/12 8:45 a.m. Hemodialysis orders.

Patient #7
Review of Patient #7's medical record on 04/23/12 revealed he was an 81 year old male admitted on 04/17/12 with the primary diagnoses of respiratory failure with ventilator support and a tracheostomy, pneumonia, and malnutrition.

Review of Patient #7's "Physicians Admission Orders" received by telephone on 04/17/12 at 10:00am revealed no documented evidence of the time the physician signed the verbal order. Review of the "Telemetry Protocol Physician Orders" received by telephone on 04/17/12 at 10:00am revealed no documented evidence the physician timed his signature when he signed the verbal order. Further review revealed no documented evidence the physician dated and timed when he signed the following verbal orders: received 04/17/12 at 1530 (3:30pm) for Primaxin 500 mg IVPB every 6 hours; received 04/18/12 at 10:30am for physical therapy plan; received 04/18/12 at 11:10am to decrease the vent setting and obtain ABGs (arterial blood gases) in the morning; received 04/18/12 at 11:35am for wound care; received 04/18/12 at 1600 (4:00pm) for blood cultures, urine culture and sensitivity, and medications; received 04/19/12 at 11:15am for antibiotic orders; and 04/19/12 at 11:25am for wound care.

Patient #9
Review of the medical record for Patient #9 revealed an 83 year old male admitted to the hospital on 03/19/12 for aspiration pneumonia, acute renal failure, anemia, sepsis. Additional diagnoses revealed a UTI (urinary tract infection), septicemia, severe malnutrition with failure to thrive, contractures and multiple decubitus.

Review of the Physicians' Verbal Orders revealed the following orders were not dated and/or timed when signed: 03/19/12 at 1400 (2:00pm) Admission Orders; 03/20/12 6:50am Occupational Therapy evaluation; 03/20/12 9:15am Physical Therapy evaluation; 03/20/12 11:20am Wound Care orders; 03/20/12 2100 (9:00pm) order not to change Foley; 03/21/12 9:00am abdominal x-ray; 03/21/12 1945 (7:45pm) order to stop CPR; 03/21/12 (no time documented) to release body to funeral home; and 03/21/12 1910 (7:10pm) Late entry transfer to emergency room.

Patient #10
Review of the medical record for Patient #10 revealed a 95 tear old female admitted to the hospital on 01/10/12 for sepsis, infected left hip wound, malnutrition, and a history of dementia.
Review of the Physicians Orders for Patient #10 revealed the following verbal order were not dated or time when signed by the physician: 01/10/12 1400 (2:00pm) Admission Orders; 01/11/12 at 9:30am Physical Therapy orders; 01/11/12 1800 (6:00pm) clarification of Clinimix order; 01/11/12 1940 (7:40pm) PICC placement, IV fluids, bilateral wrist restraints; 01/11/12 2215 (10:15pm) hold TPN and IV fluids until PICC line placement; 01/11/12 2330 (11:30pm) clarification of the PICC line and restraints; 01/12/12 1630 (4:30pm) discontinue TPN and Clinimix; 01/12/12 2100 (9:00pm) consult for central line; 01/16/12 0800 (8:00am) 40meq K (Potassium) rider; 01/17/12 1730 (5:30pm) may use PICC line; 01/17/12 1910 (7:10pm) change Heparin 5000 units to daily; 01/18/12 1730 (5:30pm) discontinue NG insertion, clarification of KCL order; 01/19/12 1830 (6:30pm) place mittens on after PICC line placement; 01/20/12 1300 (1:00pm) Chest x-ray to check PICC line placement; 01/21/12 10:14am Zyprexa 2.5mg po daily; 01/21/12 10:20am OK to use right arm PICC; 01/23/12 1710 (5:10pm) order clarification for fluids; 01/23/12 18445 (6:45pm) clarification of TPN; 01/26/12 1735 (5:35pm) contact family concerning Peg tube placement, Megace 400mg BID; discontinue TPN after this bag; 01/27/12 1650 (4:50pm) order clarification for Clinimix; and 02/04/12 0005 (12:05am) OK to use Clinimix E.

Patient #11
Review of the medical record revealed Patient #11 was admitted to the facility on 01/19/12 with diagnosis which included Osteomyelitis and Cellulitis of the right foot. Further review revealed the following verbal order had not been signed, dated, or timed by the physician: 02/03/12 0800 Valium 5 mg (milligrams) by mouth x 1 now.

Patient #12
Review of the medical record for Patient #12 revealed a 74 year old male admitted to the hospital on 12/30/11 for additional care and rehabilitation from a CVA (Cerebrovascular accident) intracranial bleed to the right thalamus. Review of the Physicians Orders revealed the following verbal orders were not timed when signed: 12/30/11 Admit Orders; 01/03/13 Orders for Occupational Therapy; 01/03/12 Hold Metoprolol for BP lower than 90/60 and HR lower than 50; 01/05/12 Ativan 2mg IVP i dose now and Geodon 20mg per PEG daily; 01/07/12 dc Lopressor IV Lopressor 25mg po BID Hold if BP <90/60 or HR < 60; 01/10/12 Orders for Physical Therapy; 01/12/12 change times of accuchecks to 0900 and 2100; 01/16/12 change Geodon to hs; and 01/19/12 d/c (discontinue) telemetry, keep Foley in, Ambien 5mg per PEG prn QHS for insomnia, change Respiratory Treatments to every 8 hours.
Further review of the Physician orders revealed no documented evidence the physician signed the verbal orders for the following verbal orders: 01/22/12 Zyprexa 2.5mg per PEG at HS; 01/25/12 Consult Rehab; 01/26/12 Consult rehab; 01/26/12 at 1738 (5:38pm) Chest x-ray, PPD; and 01/20/12 Resume TF and meds via PEG.

Patient #13
Review of Patient #13's medical record revealed she was an 82 year old female admitted on 01/06/12 with the primary diagnosis of osteomyelitis right foot with stage IV ulcer.

Review of Patient #13's "Physicians Admission Orders" received by telephone on 01/06/12 at 10:00am revealed no documented evidence the physician had dated, timed, and authenticated the order (108 days since it was written). Review of the "Telemetry Protocol Physician Orders" received by telephone on 01/06/12 at 10:00am revealed no documented evidence the physician had dated, timed, and authenticated the order (108 days since it was written). Review of the "Physician Orders" revealed no documented evidence the physician dated and timed when signing the verbal order received 01/06/11 at 10:30am for clarification of an order for Glucerna, Vancomycin, and Vancomycin level. Further review revealed no documented evidence that the physician timed when he signed the following verbal orders: received 01/06/11 at 1400 (2:00pm) to cancel the urine culture and sensitivity, discontinue Protonix, begin Omeprazole; received 01/09/12 at 7:00am for an occupational therapy evaluation; received 01/09/12 at 1:00pm for a physical therapy evaluation; and received 01/11/12 at 7:30pm for approval to use the PICC (percutaneously inserted central catheter) line. Further review revealed no documented evidence that the physician dated, timed, and authenticated the following verbal orders: received 01/07/11 at 11:00am for changes to Vancomycin; received 01/09/12 at 7:30pm for clarification of an order for Flagyl; received 01/23/12 at 6:25pm to discontinue accuchecks; received 01/30/12 at 2:35pm for a complete blood count in the morning; received 02/06/12 at 10:30pm for Lasix; and received 02/09/12 at 10:00pm to transfer the patient.

Patient #14
Review of the medical record for Patient #6 revealed he was admitted to the facility on 02/15/12 for diagnosis which included osteomyelitis of the right hip/left shoulder and multiple stage IV decubitus ulcers. Further review revealed the following physician's verbal orders had no signature, time or date: 02/27/12 2130 (9:30 p.m.) stool for occult blood x 2; 03/13/12 7:23 a.m. CXR (chest x ray), UA (urinalysis) with C&S (culture and sensitivity); 03/22/12 1350 (1:50 p.m.) Wound care: Right ischial ulcer, Decrease dressing change frequency to 2 x week and prn (as needed) soiling; 03/26/12 at 11:00 a.m. Transfuse 2 units PRBC (packed red blood cells) and type and cross, Lasix 20 mg (milligram) IVP (intravenous piggy back) between PRBC, get a CBC (complete blood count) 6 hours after last transfusion.

Patient #15
Review of the medical record for Patient #15 revealed a 75 year old male admitted to the hospital on 03/23/12 for continued care of acute respiratory failure, hypoxia, aspiration pneumonia, sepsis, and malnutrition.

Review of the Physicians Orders for Patient #10 revealed the following verbal order were not dated or time when signed by the physician as follows: 03/23/12 decrease fluids to 50ml/hr; 03/26/12 7:17am Occupational Therapy Orders; 03/26/12 1330 (1:30pm) Physical Therapy Orders; 03/26/12 1430 (2:30pm); 03/26/12 1710 (7:10pm) Speech Therapy Orders; 03/27/12 0230 (2:30am) type, match, transfuse 2 units fresh frozen plasma, Vitamin K 10mg per peg tube now; 03/27/12 0615 (6:15am) discontinue Coumadin; 03/27/12 1500 (3:00pm) Lasix 40mg IVP X1 dose; 03/28/12 0730 (7:30am) Lasix 40mg IVP now and 30 meq of KCL down Ped tube now; 03/29/12 1430 (2:30pm) Lasix 40mg IVP now and ABGs in 1 hour; 03/31/12 1730 (5:30pm) Change Vancomycin to 1 gram every 8 hour; 04/02/12 0945 (9:45am) clarification of Propofol order; 04/02/12 1730 (5:30pm) Sliding scale order; 04/02/12 1930 (7:30pm) Late entry: begin C-PAP trials; 04/03/12 1800 (6:00pm) give 20 Units regular insulin for 357 accucheck; 04/03/12 2130 (9:30pm) Stop daily PT/INR; 04/04/12 0919 (9:10am) continue CPAP, T-aerosol trials; 04/08/12 0640 (6:40am) decrease FiO2 to 35%; 04/09/12 0900 (9:00am) leave off Diprivan drip, discontinue Lasix and Zaroxolyn, CBC, BMP tomorrow, CPAP every 3 hours times 6 hours; 04/10/12 9:05am Extubate; 04/11/12 0300 (3:00am) ABGs now; 04/11/12 1420 (4:20pm) Increase FiO2 to 60%; 04/12/12 7:40am Hold Seroquel, 40 meq KCL rider over 2 hours IVPB; 04/12/12 1545 (3:45pm) Robinul 1mg per peg tube; and 04/12/12 2216 (10:16pm) discontinue long acting insulin.

Patient #16
Review of medical record for Patient #16 revealed a 67 year old female admitted to the hospital on 01/18/12 for continued treatment of acute tubular necrosis. Review of the Physicians Orders revealed the following verbal orders were not signed by the physician:
01/26/12 Cath urine; 01/26/12 Discontinue Plavix and aspirin, hold Coumadin, give six units of platelets; 01/27/12 Type and Crossmatch 2 units and Transfuse with dialysis; 0127/12 Orders for Hemodialysis; 01/27/12 BMP; and 01/27/12 Ativan 0.5mg IVP X 1 now.
Review of the Physicians Orders revealed the following verbal orders were not dated or timed when signed by the physician: 01/18/12 Flora Q capsules i po daily; 01/19/12 Clarification of order for Plavix 75mg po daily and Synthroid 125mcg po daily; 1/19/12 Occupational Therapy orders for treatment; 01/19/12 Physical Therapy orders for treatment; 01/20/12 Hemodialysis orders; 01/20/12 BMP, Albumin, H&H, Phosphate; 01/22/12 Lotrisone Cream; 01/23/12 BMP; 01/23/12 Heparin 5000 units X 2 every Dialysis treatment for catheter flush; 01/23/12 Risperadol 0.5mg po bid; 01/25/12 Consult with surgeon; 01/25/12 Hemodialysis orders; 01/25/12 Phoslo i each meal; 01/25/12 Tylenol 650mg po every 6hrs prn (as needed) for pain;

Patient #19
Review of the medical record for Patient #19 revealed he was admitted to the facility on 04/03/12 with diagnosis which included acute respiratory failure. Further review revealed the following verbal order had not been signed, dated or timed by the physician: 04/04/12 1815 (6:15 p.m.) Clarification: Zosyn 3.375 gm (gram) IV (intravenous) every 6 hours.

In a face-to-face interview on 04/24/12 at 10:00am, Director of Nursing S2 indicated physician orders not being timed, dated, and signed timely was an ongoing problem.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations... Orders... 2. All orders for treatment shall be in writing. ...4. Verbal orders or telephone orders received for care or treatment of patients shall be written by the caregiver... Read back verification will be documented... All verbal orders must be dated, timed and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and authorized to write orders by this facility. All verbal/telephone orders must be signed within 10 days...".



25065

Based on record review and interviews, the hospital failed to ensure a medical history and physical examination (H&P) was completed and documented no more than 30 days before or 24 hours after admission and placed in the medical record within 24 hours after admission for 2 of 20 sampled patients (#7, #16). Findings:

Patient #7
Review of Patient #7's medical record revealed he was an 81 year old male admitted on 04/17/12 with the primary diagnoses of respiratory failure with ventilator support and a tracheostomy, pneumonia, and malnutrition.

Review of Patient #7's "Initial Nursing Assessment" revealed he was admitted by ambulance on 04/17/12 at 1935 (7:35pm). Review of the H&P revealed Chief of Staff S34 dictated Patient #7's H&P on 04/18/12 at 2135 (9:35pm), more than 24 hours after admission. Further review revealed the H&P was transcribed on 04/19/12 (no documented time), 2 days after admission, which prevented the H&P from being on Patient #7's medical record within 24 hours of admission.

Patient #16
Review of the History and Physical (H&P) Patient #16 revealed a 67 year old female admitted to the hospital on 01/18/12 for continued treatment of Klebsiella pneumonia, urinary tract infection and Candida glabrata cystitis and resolution of her renal failure. Further review of the H&P revealed the document was not transcribed until 01/20/12 and therefore not available on the patient ' s chart within 24 hours after admission to the healthcare team.

In a face-to-face interview on 04/26/12 at 9:25am, Vice Chief of Staff S22, when informed that chart reviews revealed that H&Ps were not on the patient's medical records within 24 hours of admission, asked if a short-stay H&P could be used in place of the H&P. He could offer no explanation for the delay in the transcription process that could prevent a timely dictated H&P from being in the record timely. S22 indicated if he saw a patient the day before admission while the patient was at the transferring hospital, he (S22) may not be at Physicians' Alliance Hospital within 24 hours of admission to perform the H&P.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations... 2. History and Physical a. A complete history and physical examination shall in all cases be recorded within twenty-four (24) hours of admission of the patient by a practitioner or an AHP (allied health professional) who has been granted privileges to do so...". Further review revealed no documented evidence that the bylaws required the recorded H&P to be in the patient's medical record within 24 hours of admission.

25065

Based on record review and interviews, the hospital failed to ensure an updated examination of the patient that included any changes in the patient's condition was completed, documented, and placed in the patient's medical record within 24 hours after admission when the medical history and physical examination (H&P) was completed within 30 days before admission for 7 of 20 sampled patients (#6, #8, #10, #11, #12, #13, #19). Findings:

Patient #6
Review of Patient #6's medical record revealed she had been admitted to the facility on 4/4/12 with diagnosis which included Spinal Osteomyelitis/Diskitis, MRSA, ESRD (End Stage Renal Disease) with hemodialysis, Sepsis and Hypertension. Further review revealed a history and physical had been completed prior to admit. The "History and Physical Addendum" had not been completed until 2 days after admission on 4/6/12. No other documentation of a history or physical exam of the patient dated 4/4/12 or 4/5/12 was located in the medical record. These findings were confirmed by Director of Nursing S2 on 4/24/12 at 9:30 a.m.

Patient #8
Review of Patient #8's medical record revealed he was an 85 year old male admitted on 04/20/12 with diagnoses of septicemia, end-stage renal disease with hemodialysis, hypotension, anemia, syncope, and congestive heart failure.

Review of Patient #8's medical record revealed a H&P was performed on 04/18/12. Review of the entire medical record revealed no documented evidence that an updated examination that included changes in Patient #8's condition since 04/18/12 was performed and documented in the medical record within 24 hours of admission.

Patient #10
Review of the medical record for Patient #10 revealed a 95 tear old female admitted to the hospital on 01/10/12 for sepsis, infected left hip wound, malnutrition, and a history of dementia.

Review of the History and Physical Addendum form for Patient #10 revealed no documented time the physician completed the assessment on 01/11/12.

Patient #11
Review of the medical record for Patient #11 revealed he was admitted to the facility on 1/19/12 at 2:00 p.m. with diagnosis which included Osteomyelitis and Cellulitis of the right foot. Further review revealed a history and physical had been completed prior to admission, but the " History and Physical Addendum " had not been completed until 1/25/12 at 4:20 p.m. No other documentation of a history or physical exam dated 1/19/12 through 1/25/12 was located in the medical record.

Patient #12
Review of the medical record revealed a 74 year old male admitted to the hospital on 12/30/11 for continued care and rehabilitation after a CVA (Cerebrovascular accident) intracranial bleed of the thalamus, respiratory failure and urosepsis.

Review of Patient #12's H&P revealed it was dictated on 12/11/12 at the hospital from which he was transferred. Review of the "History And Physical Addendum" revealed it was performed on 12/31/11 with no time documented when written and therefore could not be ensured it was available to the medical team within the 24 hour time period as required by regulation and the bylaws.

Patient #13
Review of Patient #13's medical record revealed she was an 82 year old female admitted on 01/06/12 with the primary diagnosis of osteomyelitis right foot with stage IV ulcer.

Review of Patient #13's H&P revealed it was dictated on 12/26/12 at the hospital from which she was transferred. Review of the "History And Physical Addendum" revealed it was performed on 01/10/12, 4 days after Patient #13's admission rather than within 24 hours as required by regulation and the bylaws.

Patient #19
Medical record review revealed Patient #19 was admitted to the facility on 4/3/12 at 1412 (2:12 p.m.) with diagnosis which included acute respiratory failure. Further review revealed a history and physical had been completed at a local hospital on 4/3/12. The "History and Physical Addendum" in Patient #19's medical record was dated 4/9/12. No other documentation of a history or physical exam was located in Patient #19 ' s medical record dated 4/3/12 through 4/9/12.

In a face-to-face interview on 04/26/12 at 9:25am, Vice Chief of Staff S22 could offer no explanation for the H&P updates not being performed within 24 hours of admission. He indicated that the addendums were usually done within 24 hours of admission.

Review of the "Medical Staff Bylaws, Rules And Regulations", reviewed and approved January 2012 and presented by Administrator S1 as current, revealed, in part, "...Article XIV Rules And Regulations... 2. History and Physical a. ... A durable, legible copy of an H&P, performed no more than 30 days prior to admission, may be used in the patient's record. If a copy meeting timeframe is used as above, an addendum/update denoting any changes in physical exam and diagnosis and treatment plan is to be written or dictated within 24 hours of admit by a practitioner with privileges to do so...". Further review revealed no documented evidence that the bylaws required the updated H&P, if dictated, to be in the patient's medical record within 24 hours admission








30364

Based on observations, record reviews, and interviews, the hospital failed to meet the Condition of Participation for Pharmaceutical Services as evidenced by:

1) The hospital failed to ensure the pharmacy was administered according to accepted professional principles. The hospital failed to ensure the pharmacist reviewed all medication orders prior to dispensing the first dose of medication and reviewed the physician's medication order and patient record for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes (see findings in tag A0491).

2) The hospital failed to ensure the contracted pharmacist accurately monitored the receipt and disposition of all scheduled drugs. This resulted in 18 unidentified (by the hospital) drug discrepancies with the administration of Oxycodone to Patient #6 over a 10 day period that could not be resolved by the nursing staff and the pharmacist during the survey (see findings in tag A0494).

3) The hospital failed to ensure the contracted pharmacist supervised and coordinated all the activities of the pharmacy services ( see findings in tags A0492, A0491, A0494).

4) The hospital failed to ensure drug administration errors were immediately reported to the attending physician and the hospital-wide quality assurance program. There were 106 medication errors noted during chart reviews that were not identified by the hospital for 9 of 20 sampled patients (#1, #4, #6, #7, #8, #12, #15, #17, #20) (see findings in tag A0508).

Based on observation, record review, and interviews, the hospital failed to ensure the pharmacy was administered according to accepted professional principles. The hospital failed to ensure the pharmacist reviewed all medication orders prior to dispensing the first dose of medication and reviewed the physician's medication order and patient record for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes. Findings:

Review of the "Pharmacy Services Agreement" between the hospital and Company C effective 10/01/06 revealed no documented evidence that a review of all medications ordered prior to dispensing the first dose for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes was included in the responsibilities of the pharmacy.

In a face-to-face interview on 04/26/12 at 8:15am, Contract Pharmacist S30 with Company C indicated a pharmacist reviewed medications that were ordered by the physician during the pharmacy's hours of operation. She further indicated the hours of operation were 8:00am to 9:00pm Monday through Friday and 8:00am to 1:00pm on Saturday with an on-call pharmacist available on Sunday. S30 indicated medications ordered outside of these hours, such as for patients admitted after pharmacy hours or new medications ordered, a pharmacist review was not done prior to administration of the first dose. She further indicated that in this instance the nurse would override the Micelle (drug dispensing unit) to get the medication.

Review of the "Louisiana Administrative Code Title 46 - Professional and Occupational Standards Part III: Pharmacists Chapter 15. Hospital Pharmacy", revealed, in part, "...1511. Prescription Drug Orders A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency...". Further review of definitions listed revealed, in part, "...(13) "Drug regimen review" means and includes, but is not limited to, the following activities: (a) Review of the prescription drug order and patient record for [i] known allergies, [ii] therapy contraindications, [iii] dose and route of administration, and [iv] directions for use, (b) Review of the prescription drug order and patient record for duplication of therapy, (C) Review of the prescription drug order and patient record for interactions, and (d) Review of the prescription drug order and patient record for proper utilization including over- or under-utilization, and optimum therapeutic outcomes...".

Review of the hospital policy titled "Ordering Medications From Pharmacy", policy number II-F.7.01, revised 01/10, and contained in the policy manual presented by Administrator S1 as current, revealed, in part, "...2. In the event that a first dose medication is taken out of stock after standard pharmacy hours and prior to the pharmacy review of the 1st dose, 2 nurses will verify that the correct medication is procured. The pharmacy will assess that 1st dose medication administration the next morning".

Based on observations, record review, and interviews, the hospital failed to ensure the contracted pharmacist supervised and coordinated all the activities of the pharmacy services. 1) The contracted pharmacist failed to ensure all medication orders were reviewed by a pharmacist prior to dispensing the first dose of medication and reviewed the physician's medication order and patient record for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes. 2) The contracted pharmacist failed to accurately monitor the receipt and disposition of all scheduled drugs. This resulted in 18 unidentified (by the hospital) drug discrepancies with the administration of Oxycodone to Patient #6 over a 10 day period that could not be resolved by the nursing staff and the pharmacist during the survey. 3) The hospital failed to ensure drug administration errors were immediately reported to the attending physician and the hospital-wide quality assurance program. There were 106 medication errors noted during chart reviews that were not identified by the hospital for for 9 of 20 sampled patients (#1, #4, #6, #7, #8, #12, #15, #17, #20). Findings:

1) The contracted pharmacist failed to ensure all medication orders were reviewed by a pharmacist prior to dispensing the first dose of medication and reviewed the physician's medication order and patient record for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes.
See findings in tag A0491.

2) The contracted pharmacist failed to accurately monitor the receipt and disposition of all scheduled drugs. This resulted in 18 unidentified (by the hospital) drug discrepancies with the administration of Oxycodone to Patient #6 over a 10 day period that could not be resolved by the nursing staff and the pharmacist during the survey.
See findings in tag A0494.

3) The hospital failed to ensure drug administration errors were immediately reported to the attending physician and the hospital-wide quality assurance program. There were 106 medication errors noted during chart reviews that were not identified by the hospital for for 9 of 20 sampled patients (#1, #4, #6, #7, #8, #12, #15, #17, #20).
See findings in tag A0508.

Review of the "Pharmacy Services Agreement" effective 10/01/06 between the hospital and Company C, provided by Administrator S1, revealed, in part, "...Render all services in accordance with any applicable requirements of local, state and federal laws and regulations, community standards of practice, and pharmacy's policies and procedures manual...".

Based on interviews and record review, the facility failed to ensure the contracted pharmacist accurately monitored the receipt and disposition of all scheduled drugs. This resulted in 18 unidentified (by the hospital) drug discrepancies with the administration of Oxycodone to Patient #6 over a 10 day period that could not be resolved by the nursing staff and the pharmacist during the survey. Findings:

Review of the monthly Pharmacy reports for the facility dated 01/12-03/12 revealed that the only indicator for narcotic discrepancies was a "Controlled Substance Wastage Report" which listed the amount of narcotic wastage for each nurse.

Medical Record review of the Physician's Orders for Patient #6 revealed an order dated 04/5/12 at 1345 (1:45 p.m.) for Percocet (Narcotic pain medication) 7.5 milligrams (mg) Q (every) 6 hours PRN (as needed) for pain. Further review of the Medication Administration Record (MAR), Nurse's Notes, and the Omnicell (medication dispensing machine) transaction record provided by the pharmacy for Patient #6 revealed the following medication errors:
04/08/12 at 1:30 a.m.- Two 5 mg Oxycodone/APAP (Percocet) tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 mg was documented.
04/09/12 at 8:46 a.m.- One 5 mg Oxycodone/APAP tablet was removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given.
04/09/12 at 5:15 p.m.- One 5 mg Oxycodone/APAP tablet was removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given.
04/10/12 at 12:20 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 mg was documented.
04/11/12 at 8:41 p.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 was documented.
04/12/12 at 8:47 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 mg was documented.
04/12/12 at 6:39 p.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 mg was documented.
04/13/12 at 5:36 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. Two ? tablets (2.5 mg each) were charted as having been wasted. No dose was charted on the MAR as having been given.
04/13/12 at 8:01 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell by RN S31. No dose was charted as having been given and no waste was charted.
04/13/12 at 2:50 p.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. No dose was charted as having been given and no waste was charted. Two more 5 mg tablets were removed from the Omnicell by RN S31 1 hour and 56 minutes later and charted as having been given.
04/14/12 at 8:21 a.m.- One 5 mg Oxycodone/APAP tablet removed from the Omnicell. A 7.5 mg dose was charted as having been given on the MAR.
04/15/12 at 8:56 a.m.- One 5 mg Oxycodone/APAP tablet removed from the Omnicell. A 7.5 mg dose was charted as having been given.
04/15/12 at 3:03 p.m.- One 5 mg Oxycodone/APAP tablet removed from the Omnicell. A 7.5 mg dose was charted as having been given.
04/16/12 at 4:09 a.m.- One 5 mg Oxycodone/APAP removed from the Omnicell. No dose was recorded as having been given.
04/17/12 at 1:23 a.m.- Two 5 mg Oxycodone/APAP tablets removed from the Omnicell. ? tablet (2.5 mg) was charted as having been given. No waste was charted.
04/17/12 at 9:11 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 5 mg tablet was charted as having been given at 9:13 a.m. Another 5 mg tablet was charted as having been given 3 hours and 47 minutes later at 1300 (1:00 p.m.).

In a face to face interview on 04/24/12 at 9:45 a.m. Registered Nurse (RN) S16, verified Patient #6's ordered dose of Oxycodone/APAP was 7.5 mg every 6 hours as needed for pain. S16 also indicated she had given Patient #6 5 mg of Oxycodone/APAP instead of 7.5mg, and then gave another 5 mg dose 3 hours and 47 minutes later for a total of 10 mg. S16 indicated she had not realize she had made a medication error. S16 indicated she thought if she could have given a smaller dose than what was ordered without clarifying the order with the physician. S16 stated that she had not filled out a medication variance form for the error.

In a face to face interview on 04/25/12 at 8:10 a.m. Licensed Practical Nurse (LPN) S8, indicated she had removed two 5 mg Oxycodone/APAP tablets from the Omnicell on 4/17/12 at 1:23 a.m. S8 verified that she charted she had given 5 mg of the narcotic to Patient #6, but did not have any documentation of wasting the other 5 mg. S8 indictaed she could not remember that day specifically, but she should have wasted the remaining 2.5 mg of the Oxycodone/APAP with another nurse. S8 also said if she had wanted to give a different dose than the physician ordered, she should have notified the physician.

In an interview on 04/27/12 at 1:35 p.m. with RN S31, he stated on 04/13/12 at 4:45 p.m., he must have forgotten to chart the waste of 2.5 milligrams of Oxycodone/APAP after giving 7.5 mg to Patient #6. S31 said he must have forgotten to chart the other doses of Oxycodone for Patient #6 on 04/13/12.

In a face to face interview interview on 04/25/12 at 8:30 a.m. Director of Nursing S2, verified the Oxycodone/APAP discrepancies from Patient #6's chart. S2 said the nursing staff should have given 7.5 mg of Oxycodone/APAP as ordered or called the physician to clarify the order. She also stated if 10 mg of Oxycodone/APAP had been removed from the Omnicell, 2.5 mg should have been charted as being wasted. S2 also said if a medication variance occurred, it should have been reported to her to be investigated. S2 said she could clearly see where there was a big problem with narcotic administration by the nursing staff.

In a telephone interview on 04/25/12 at 3:15 p.m., Contract Pharmacist S26 indicated Contract Pharmacist S30 was responsible for going to the facility twice per month. He further indicated S30 would inventory the crash carts and medication rooms monthly for excess medications, open vials that had not been discarded, and the timing and dating of multi-dose medications. He further indicated S30 would perform random chart audits to review medication orders and medication administration. S26 indicated S30 was responsible for writing a monthly report on controlled substance wastage. S26 indicated there was currently no system in place for the Omnicell (medication dispensing system) to alert the contracted pharmacist if a patient had a discrepancy in the dosage or wastage of a narcotic.

In a telephone interview on 04/25/12 at 3:30 p.m. with Contract Pharmacist S27, he indicated that no one had been designated to be the Pharmacy Director at the facility, but he was in charge of the pharmacy that was contracted to provide medications to the facility. S27 indicated S30 would write a report on controlled substance wastage monthly. S27 further indicated if S30 found any problems at the facility, she would report the problems to him. S27 indicated S30 provided no other reports about narcotic disposition and had not reported any medication variances from the facility. S27 further indicated S30 did not participate in any performance activity programs at the facility. S27 indicated "S30 has a breakdown in what her responsibilities are when she reviews the facility".

In an interview on 04/25/12 at 3:45 p.m. with Director of Nursing S2, she indicated Contract Pharmacist S30 came to the facility once or twice per month and looked in the Omnicell and looked at a few charts. S2 indicated S30 did not participate in performance improvement meetings.

In an interview on 04/26/12 at 8:15 a.m. with Contract Pharmacist S30, she indicated the pharmacy that provided medications for the facility contracted her to review the facility twice per month. She indicated that her responsibilities included removing expired medications from the Omnicell, checking the refrigerators for expired medications, and removing discharged patients' medications. She indicated she would also review 10 charts monthly for correct medication ordering and administration. S30 further indicated that the only indicator she looked at for narcotic discrepancies was a monthly audit of the narcotic wastage by each nurse in the Omnicell. S30 indicated that she was not monitoring medication discrepancies and was not aware that she had to review medication variances. She indicated that when she did find a medication variance, she did not complete a medication variance form at the facility. S30 further indicated she was not aware of the CMS regulations for hospitals.

In an interview on 04/26/12 at 11:15 a.m., S30 indicated the Omnicell machine did not automatically send a notice to the pharmacy when a patient had a narcotic discrepancy with dosing, wastage, or timing. S30 further indicated no pharmacy staff was manually checking for narcotic discrepancies. S30 indicated "there was a breakdown in the system with monitoring narcotic usage".

Based on interviews and observation, the facility failed to keep narcotic waste in a secured area that prevents unmonitored access by unauthorized staff members. Findings:

In an interview on 04/26/12 at 12:00 p.m. with Registered Nurse (RN) S14, she indicated narcotics, including pills, were wasted in the sharps container. S14 further indicated when full, the sharps containers were taken to the biohazard waste room by the charge nurse. She indicated that the charge nurses, Dietary Manager, and Maintenance staff had a key to the Biohazard room.

An observation on 04/26/12 at 12:00 p.m. of the Biohazard room revealed a cardboard box containing sharps containers that had been placed in red bags.

In an interview on 04/26/12 at 11:15 a.m., Contract Pharmacist S30 indicated narcotics, including pills and vials, were wasted in the sharps containers. She indicated the sharps containers were locked while in the medication rooms, but they were not disposed of by a pharmacist. S30 indicated she was not sure how intravenous solution bags with narcotics were wasted by the nurses. She indicated that she had seen a half-full vial of a narcotic in a sharps container earlier in the day.

In an interview on 04/26/12 at 1:45 p.m. with Director of Nursing S2, she indicated when the sharps containers were full, the charge nurses would bring the containers to the Biohazard room. S2 further indicated the charge nurses, maintenance, and the Dietary Manager had keys to the Biohazard room. She indicated the room was locked, but not continuously monitored. S2 further indicated the Omnicell (medication dispensing machine) had a locked place to secure wasted narcotics, but it was not used by the facility. S2 indicated the Pharmacist did not dispose of narcotic waste, and there was a breakdown in the system to monitor narcotics.

In an interview on 04/27/12 at 4:35 p.m. with Contract Pharmacist S26, he indicated the pharmacy needed to change the system for monitoring controlled substances. S26 further indicated he did not have a system in place for monitoring and removing narcotic waste from the facility.

An interview was held on 04/26/12 at 4:30 p.m. with Housekeeping Supervisor S38. S38 indicated if she or any of her housekeeping staff needed access to the biohazard room, Dietary Manager S9 would give her the keys to unlock the Biohazard room.

Based on observations, record review, and interviews, the hospital failed to ensure outdated, mislabeled, and unusable drugs and biologicals were not available for patient use. Findings:

Observation of the central venous catheter cart located in the hall on first floor on 04/23/12 at 10:15 a.m. revealed the following expired drugs and biologicals:
1) Two 5 ml (milliliters) Lidocaine HCL (hydrochloride) 1% (per cent) 10 mg/ml (milligrams per milliliter) expired 11/01/11;
2) 250 ml 0.9% Sodium Chloride injection expired 01/12.
3) A bottle of Isopropyl Alcohol expired 8/09.
These observations were confirmed by DON S2.

Observation of the x-ray department on 4/23/12 at 10:00 a.m. revealed the following expired drugs and biologicals:
1) Five bottles of 30 milliliter Gastrografin expired 2/12.
These observations were confirmed by DON S2.

Observation of the first floor medication room on 04/23/12 at 10:30am revealed the following:
1) Novolin R U-100 regular insulin 10 ml vial opened on "4/19 at 2100" (9:00pm) with no documented evidence of the year it was opened;
2) Tuberculin Purified Protein 1 ml vial opened 02/12/12 (greater than 28 days as allowed by policy);
3) 5 opened bottles of Nystatin (5 ml) 100mu/ml oral suspension labeled for Patient R2 who was no longer an inpatient;
4) Two vials of Aranesp 100 mcg (micrograms) for Patient R1 who was no longer an inpatient.
5) Acetic Acid 1000 milliliters expired 1/12.
6) Dyna-Hex (anti-microbial skin cleaner) expired 2/12.
7) An 8 ounce bottle of Povidone Iodine 10% expired 2/12.
8) An 8 ounce bottle of Hydrogen Peroxide expired 6/11.
These observations were confirmed by DON S2.

Observation of the crash cart on the second floor on 4/23/12 at 11:00 a.m. revealed the following:
1) A bag of 400 milligram Dopamine expired 3/12.
2) A bag of 5% Dextrose expired 3/12.
3) A bag of 2 gram Lidocaine expired 3/1/12.
These observations were confirmed by DON S2.

Observation of the second floor supply room on 04/23/12 at 11:10am revealed the following:
1) Nine 500 ml bags of 5% Dextrose injection expired 03/12;
2) Three 1000 ml bags of 5% Dextrose and 0.9% Sodium Chloride with an expiration date of 09/13 with the plastic protective covering removed;
3) One 1000 ml bag of 0.15% Potassium Chloride in 5% Dextrose and 0.45% Sodium Chloride injection with an expiration date of 05/12 with the plastic protective covering removed;
4) One 1000 ml bag of 0.15% Potassium Chloride in 5% Dextrose and 0.45% Sodium Chloride injection with an expiration date of 03/12. These observations were confirmed by DON S2.

Observation of the second floor medication room on 04/23/12 at 12:10 p.m. revealed the following:
1) Hydrogen Peroxide 16 fluid ounces expired 02/12;
2) "Novolog Insulin Aspart" injection 10 ml, 100 u/ml (units per milliliter), opened "2/9" with no documented evidence of the year (opened greater than 28 days).
3) 30 tubes of Saline expired 7/10.
4) 250 milliliters sterile water expired 9/10.
5) 250 milliliters normal saline expired 1/12.
6) A bottle Isopropyl Alcohol expired 8/11.
7) A 16 ounce bottle of Hydrogen Peroxide, a bottle of Isopropyl Alcohol, and a bottle of Povidone Iodine were opened but not labeled with the opening date or time.
These observations were confirmed by DON S2.

Observation of the crash cart on the first floor on 4/24/12 at 1:00 p.m. revealed the following:
1) Bag of 2 gram Lidocaine expired 3/1/12.
2) Bag of 400 milligram Dopamine expired 3/12.
These observations were confirmed by DON S2.

Review of monthly Pharmacy Reports from 1/12-3/12 generated by Contract Pharmacist S30 indicated the medications in the crash carts and the Omnicell medication dispensing machine had been checked for expiration dates monthly. Further review revealed open multi-dose vials were indicated as having been initialed and within date. No other areas of the hospital were listed on the reports as having been checked for expiration dates.

In a face-to-face interview on 04/23/12 at 11:10am, DON S2 indicated she could not be certain that an IV bag of fluids that was not contained in the protective plastic wrap had not been tampered with. She further indicated the IV solutions not contained in plastic wrap should be discarded if not used by the person who removed the wrap.

In an interview on 4/24/12 at 3:30 p.m., DON S2 indicated there was no system in place to accurately check for expiration dates.

In a face-to-face interview on 04/26/12 at 8:15am, Contract Registered Pharmacist (R. PH.) S30 indicated she came to the hospital for the past 4 months every 2 weeks. She further indicated she checked the medication rooms and "cleaned out" expired drugs, pulled discontinued medications for inpatients, and inspected areas for medications that remained for patients who were discharged. S30 indicated she checked the medication refrigerators for proper temperature, labeling of and expiration dates for insulin and TB (tuberculin purified protein). She further indicated she inspected the crash carts for expiration dates. S30 indicated she did not check IV solutions, because they were not supplied by the contracted pharmacy. She further indicated she didn't "look at peroxide because that's wound care". S30 indicated she was not knowledgeable of the federal certification and state licensing regulations for hospitals.

Review of the hospital policy titled "Crash Cart", policy number II-C.3.02, revised 12/09, and contained in the manual presented by Administrator S1 as current policies revealed, in part, "...Crash carts are located in the hospital near the Nurse Stations. Drugs are checked monthly by the responsible contracted pharmacist and if any outdated drugs are found, they are replaced with in-date stock. During this monthly check, drugs nearing their expiration date will be rotated with other pharmacy stock bearing longer expiration dates up to at least a year..."

Review of the hospital policy titled "Disposal of Discontinued or Unused Medications", policy number II-F.7.11, revised 01/10, and contained in the manual presented by Administrator S1 as current policies, revealed, in part, "...Drugs For Patients Who Are Deceased Or Discharged From The Facility ... 2. When a Patient is discharged from the facility, the drugs will not be sent with the Patient. ...Patient's Individual Form... 2. A record of the discontinued and unused drugs shall be maintained in the Medicine Destruction book. The record shall include: Patient's name, name of drug, strength and amount of medication, date destroyed and method of destruction, and two witnesses for actual destruction must be included in the documentation".







30364

Based on record review and interview, the hospital failed to ensure drug administration errors were immediately reported to the attending physician and the hospital-wide quality assurance program. There were 106 medication errors noted during chart reviews that were not identified by the hospital for for 9 of 20 sampled patients (#1, #4, #6, #7, #8, #12, #15, #17, #20). Findings:

Review of the medical records of Patients #1, #4, #6, #7, #8, #12, #15, #17,and #20 revealed a total of 106 medication errors that had not been identified by the hospital, not reported to the physician, and not included in the quality assurance program.

See findings in tag A405.

In a face-to-face interview on 04/26/12 at 9:25am, Vice Chief of Staff S22 could offer no explanation when informed of the numerous medication errors identified during chart reviews.

In a face-to-face interview on 04/25/12 at 3:55pm, Director of Nursing confirmed that the medication errors identified during chart reviews performed by surveyors had not been identified by her, the nursing staff, or the contracted pharmacist.

Review of the hospital policy titled "Medication Administration Error", policy number II-F.7.08, revised 01/10, and contained in the policy manual provided by Administrator S1 as current, revealed, in part, "...Procedure: When medication is administered improperly or a drug reaction occurs, the following procedure is used: 1. Notify Director of Nursing... 2. Notify physician immediately. ... 4. Complete "Medication Variance" forms... 7. Consultant Pharmacist will be notified on next visit on all drug reactions".


26351

Based on record review and interviews, the hospital failed to ensure radiation badge reports were checked monthly and reviewed monthly by the Radiation Safety Officer as required by hospital policy. Findings:

Review of the "Radiation Dosimetry Report" presented by Administrator S1 revealed no documented evidence of a report for February 2012 and April, June, August, October, and November 2011. Further review revealed the "Radiation Dosimetry Report" for January and March 2012 were reviewed by Radiology Tech S29. There was no documented evidence that the Radiation Safety Officer had reviewed the reports as required by hospital policy.

In a face-to-face interview on 04/24/12 at 11:25am, Administrator S1 indicated the hospital did not have a radiation safety committee or officer. She could offer no explanation for the policy requiring the radiation dosimetry badge reports to be reviewed by the radiation safety officer when the hospital did not have such a position.

In a face-to-face interview on 04/27/12 at 10:10am, Radiology Tech S29 confirmed that she reviewed the radiation dosimetry reports, and they were not reviewed by a radiologist or radiation safety officer.

Review of the hospital policy titled "Radiation Protection & (and) Safety", policy number III-E.5.01, revised 01/10, and contained in the manual presented by Administrator S1 as current, revealed, in part, "...Physicians' Alliance Hospital of Houma is committed to keeping exposures As Low As Reasonably Achievable (ALARA). The Radiation Safety committee (RSC) will perform an annual review of the radiation safety program. ...The RSC will delegate authority to the RSO (radiation safety officer) enforcement of the ALARA concept...".

Review of the hospital policy titled "Personnel Dosimetry", policy number III-E.5.05, revised 01/10, and contained in the manual presented by Administrator S1 as current, revealed, in part, "...The Radiation Safety Officer shall inspect the badge reports monthly and maintain records of occupational exposure to ionizing radiation. In addition, each monthly report shall be posted and signed by the Radiation Safety Officer...".

Based on record review and interview, the hospital failed to ensure a radiologist was privileged to supervise the ionizing radiology services provided at the hospital. Findings:

Review of the list of services provided at the hospital, presented by Administrator S1, revealed Radiology Services were provided by contract.

Review of the "Medical Staff Roster" presented by Administrator S1 revealed the hospital had 3 radiologists credentialed as consulting physicians.

Review of the "Agreement To Provide On-Call Radiology Services" between the hospital and Company A revealed the agreement was made on 11/21/06 and signed by the hospital representative. There was no documented evidence of a signature of Company A's representative. Further review of the agreement revealed the hospital would "arrange for the provision of remote consultation and interpretation services" by Company A that was located in Santa Monica, California. Further review revealed no documented evidence that supervision of the ionizing radiology services provided at the hospital was a responsibility of Company A.

Review of Radiologist S24's credentialing file revealed his privileges and appointment was approved by the Governing Board on 01/31/12. Review of S24's "Delineation Of Privileges Radiology" revealed the only privilege approved was "interpretation of plain films". There was no documented evidence that S24 was privileged to supervise the radiology services provided at the hospital.

In a face-to-face interview on 04/24/12 at 10:55am, Administrator S1 indicated the hospital did not have a radiologist who responsible to supervise the radiology services provided at the hospital.

Based on observation, record review, and interviews, the hospital failed to ensure lab supplies provided by the contracted provider were not expired. Findings:

Observation of the lab on 04/23/12 at 9:45am revealed 21 containers of "BacT/Alert SA" (used for cultures) had expired on 02/01/12. Further observation revealed 69 Seracult test for fecal occult blood had expired on 04/09. These observations were confirmed by Respiratory Manager S3.

Observation of the central venous catheter cart located in the hall on the first floor on 04/23/12 at 10:05am revealed 2 pediatric gold top blood tubes had expired 09/11 and 2 purple top blood tubes had expired 05/10. Further observation revealed a "Quick A.B.G. (arterial blood gas) Sampler" had expired 03/11. This observation was confirmed by Director of Nursing (DON) S2.

Observation of the second floor crash cart on 04/23/12 at 10:55am revealed 2 BacT/Alert PF yellow top (used for pediatric blood cultures) expired 01/27/12. Further observation revealed 1 Bac T/Alert SN blood culture red top expired 03/10/12. Further observation revealed 2 "BD Vacutainers" blue top expired 02/12. These observations were confirmed by DON S2.

An observation was made on 04/23/12 at 12:10 p.m. of the Medication room on the second floor. The following items were found to be expired: 11 Anaerobic culture bottles expired 01/27/12, 2 Aerobic culture bottles expired 08/11, a 4 milliliter lavender top blood collection tube expired 11/11, and a blue top blood collection tube expired 09/09. These observations were confirmed by DON S2.

In a face-to-face interview on 04/26/12 at 9:25am, Vice Chief of Staff S22 could offer no explanation for having expired lab supplies that were provided by the contracted lab provider.

Review of the "Services Agreement" signed by the hospital's representative on 11/16/06 and the Chief Executive Officer of Hospital A on 11/20/06 revealed, in part, "...1. Hospital request Provider outpatient services for its residents including the processing of laboratory specimens, diagnostic testing ... as needed. ... 3. Provider will provide necessary specimen collection supplies for all tests submitted by Provider...".


30364

Based on record review and interview, the hospital failed to ensure the policy for the action to be taken in the event the hospital was notified that blood or blood products received were at risk of transmitting HIV (human immunodeficiency virus) or HCV (Hepatitis C virus) included all the components of patient notification required by CMS (Centers for Medicare and Medicaid Services). Findings:

Review of the hospital's policy titled "Contaminated Blood/Blood Products", policy number II-C.3.16, revised 12/09, and contained in the manual presented by Administrator S1 as current policies, revealed the policy only addressed blood at risk of transmitting HIV. There was no documented evidence that the risk of transmitting the Hepatitis C virus and patient notification was addressed in the policy. Further review revealed no documented evidence that the policy addressed the following:
1) The blood collecting establishment must notify the hospital within 3 calendar days if the blood collection establishment supplied blood or blood components collected from a donor who tested negative at the time of donation but tests reactive for evidence of HIV or HCV on a later donation; within 45 days of the test, of the results of the supplemental test for HIV or HCV or other follow-up testing required by FDA (Food and Drug Administration); within 3 calendar days after the establishment supplied blood or blood products collected from an infectious donor, whenever records are available;
2) The hospital must make reasonable attempts to give notification to the patient over a period of 12 weeks (policy revealed it would make attempts for a period of 8 weeks);
3) Content of notification must include a basic explanation of the need for HCV testing and counseling (policy only addressed HIV); enough oral or written information so than an informed decision can be made about whether to obtain HCV testing and counseling; a list of programs or places where the person can obtain HCV testing and counseling.

In a face-to-face interview on 04/26/12 at 2:20pm, Director of Nursing S2 confirmed the hospital policy for notification of patients when potentially infectious blood or blood components was administered did not address HCV and did not contain the timeframes required by CMS regulations.

Based on observation, record review, and interviews, the hospital failed to ensure dietary supplements and patient nourishments that were available for patient use were not expired and that food items were dated and timed when opened. Findings:

Observation of the first floor nourishment room on 04/23/12 at 9:30am revealed 5 bottles of "Nepro with Carb Steady", 8 fluid ounces, had expired 03/01/12. Further observation revealed 2 cans of "Benefiber Soluble Dietary Fiber", 7.2 ounces, with an expiration date of 05/27/11 and three packs with an expiration date of 01/21/12. Further observation revealed 16 (0.85 ounces) packs of "Juven Therapeutic Nutrition Drink" with an expiration date of 04/01/12. Further observation revealed 15 packs of individually-wrapped graham crackers in a plastic zip-loc bag with no documented evidence of the date the crackers were placed in the drawer. Further observation revealed 9 single-serving containers of sugar-free breakfast syrup in a plastic zip-loc with no documented evidence of the date the containers of syrup were placed in the drawer. These observations were confirmed by Director of Nursing (DON) S2.

An observation on 04/23/12 at 9:30 a.m. of the first floor Nourishment Room refrigerator revealed an 8 ounce bottle of Glucerna which had expired on 03/01/12 and an 8 ounce bottle of Glucerna which had expired on 04/01/12. Further observation revealed an open container of Apple Sauce, a fat free carton of milk, and a 15 ounce container of butter all of which were not dated or timed after opening. Director of Nursing S2 confirmed the expired items and the opened items that had been undated and untimed.
In a face-to-face interview on 04/23/12 at 9:30am, DON S2 indicated the kitchen staff restocked the patient refrigerator twice per week and should have been checking the refrigerator items for expiration dates.
Observation of the first floor medication room on 04/23/12 at 10:30am revealed 1 can of "Benefiber Soluble Dietary Fiber", 7.2 ounces, with an expiration date of 11/01/10. This observation was confirmed by DON S2.

Observation of the second floor nourishment room on 04/23/12 at 11:45am revealed one unopened can of "Benefiber Soluble Dietary Fiber", 7.2 ounces, with an expiration date of 05/27/11, 13 (0.85 ounces) packs of "Juven Therapeutic Nutrition Drink" with an expiration date of 04/01/12, and 6 cans of Ensure, 8 fluid ounces, with an expiration date of 07/01/11. Further observation revealed 16 packs of individually-wrapped graham crackers in a plastic zip-loc bag with no documented evidence of the date the crackers were placed in the drawer. Further observation revealed 4 packs of individually-wrapped "Zesta Unsalted Tops Saltines" loose in the drawer with no documented evidence of the date the crackers were placed in the drawer. This observation was confirmed by DON S2.

Observation of the second floor storage room revealed 8 bottles (8 fluid ounces each) of Nepro with an expiration date of 03/01/12. This observation was confirmed by DON S2.

Observation of the second floor medication room on 04/23/12 at 12:10pm revealed a can of "Active Food Thickener" that was opened on 08/09/11 with an expiration date of 03/11 (the product was expired when it was opened for patient use). Further observation revealed an unopened can of "Active Food Thickener" with an expiration date of 03/11. Further observation revealed a can of "Benefiber Soluble Dietary Fiber", 7.2 ounces, that was opened 11/10/11 with an expiration date of 01/21/12.

In a face-to-face interview on 04/23/12 at 9:30am, DON S2 indicated the supply personnel restocked the dietary rooms more than once a week and was supposed to check items for expiration at that time.

An observation was made on 04/24/12 at 7:50 a.m. of the walk-in refrigerator and freezer in the kitchen. In the freezer, a package of hamburger buns, a package of hamburger steaks, and a package of ground meat were observed to have not been labeled with the time or date when opened. Further observation in the refrigerator revealed an opened package of chicken tenders and a ziplock bag with blueberry muffins not dated or timed after opening.
In an interview on 04/24/12 at 8:00 a.m. with Dietary Manager S9, S9 indicated all items in the refrigerators and freezers should have been dated and timed when it arrived to the facility and after they were opened. S9 further indicated expired foods and nutritional supplements should have been discarded.
Review of the hospital policy provided by Director of Nursing S2 titled "Storage of Opened Food Items", policy number FS3,4, revised 04/10 revealed, in part, "...Established guidelines for perishable items: 1. All opened items will be labeled with a date item was opened, content and date of disposal...Established guidelines for non-perishable items: 1. All opened items will be labeled with a date item was opened, content and date of disposal. 2. ...no food shall be stored past its expiration date...".

Review of the hospital policy titled "Stock Rotation", policy number II-C.4.62, revised 12/09, and contained in the manuals presented by Administrator S1 as current policies, revealed, in part, "...All stock items will be stored using the rotation system and the oldest products will be issued first. This prevents stock deterioration and/or expiration of sterile products. ... The Stockroom Clerk will check dated items to ensure that the "oldest" items are issued first. ... Any items noted to have an expiration date will be pulled from stock before the expiration date and discarded...".



30364

The hospital failed to ensure the registered dietitian performed and documented nutritional assessments within 72 hours according to hospital policy for 6 of 20 sampled patients (#1, #2, #7, #8, #13, #15). Findings:

Review of the "Information For RD (registered dietitian) Telephone/Fax/Email Consult) revealed the top portion of the form included the patient's name, admit date, reason for admit, pertinent medical history, height, weight, food allergies, diet order/supplement, whether the patient had chewing or swallowing difficulties, whether feeding assistance was required, whether aspiration precautions were ordered, the most recent lab values (glucose, potassium, sodium, hemoglobin, hematocrit, albumin, blood urea nitrogen, creatinine), presence of pressure ulcers or wounds, whether an attached medication list was included, and a space for the dietary manager's signature. The bottom portion of the form was labeled "RD Assessment".

Patient #1
Review of the medical record for Patient #1 revealed a 91 year old female admitted to the hospital on 04/18/12 for Severe C-Diff Colitis, Severe Malnutrition, Dehydration, renal failure and leukocytosis.

Review of the Physicians Admit Orders for Patient #1 dated/timed 04/12/12 at 1400 (2:00pm) revealed an order for a dietary assessment.

Review of the form titled "Information for RD (registered dietitian) Telephone/Fax/E-Mail Consult" for Patient #1 revealed the form was faxed on 04/19/12 and returned to the hospital on 04/20/12 (no time documented) with the RD's recommendations to continue the current nutrition plan of care and the RD would follow-up on 04/25/12.

Review of the medical record for Patient #1 revealed a "Nutrition Follow-up" request was sent via fax by the Dietary Manager to the RD on 04/20/12 at 8:30 informing the RD Patient #1 was refusing food.

Patient #2
Review of the medical record for Patient #2 revealed a 58 year old male admitted to the hospital on 04/19/12 for acute respiratory failure with ventilatory support and a tracheotomy with secondary diagnoses of acute bilateral CVA (Cerebrovascular accident), anoxic encephalopathy, pneumonia, Peg tube and hypertension.

Review of the Physicians Admit Orders for Patient #2 dated/timed 04/19/12 at 0900 (9:00am) revealed an order for a dietary assessment.

Review of the form titled "Information for RD (registered dietitian) Telephone/Fax/E-Mail Consult" for Patient #2 revealed the form was faxed on 04/20/12 at 7:39am to the RD. Further review of the form revealed no documented evidence the assessment was completed as of 04/23/12.

Patient #7
Review of Patient #7's medical record revealed he was an 81 year old male admitted on 04/17/12 with the primary diagnoses of respiratory failure with ventilator support and a tracheostomy, pneumonia, and malnutrition. Further review revealed his secondary diagnoses were dysphagia with PEG (percutaneous esophageal gastrostomy), stage III sacral ulcer, electrolyte imbalances, elevated LFTs (liver function tests), cervical cellulitis, diabetes mellitus (DM), and history of Cerebrovascular accident with left hemiparesis.

Review of Patient #7's "Physicians Admission Orders" dated 04/17/12 at 10:00am revealed an order for a dietary assessment.

Review of Patient #7's "Information For RD Telephone/Fax/Email Consult" revealed the top portion was completed by Dietary Manager S9 on 04/18/12 at 9:51am and faxed to RD S25 on 04/18/12 at 8:43am. Further review revealed the consult with the RD assessment by RD S25 was faxed to the hospital on 04/20/12 at 6:14pm. Review revealed RD S25's recommendation was to continue the current nutrition plan of care, continue tube feedings at 60 ml (milliliters) per hour, and she would follow up on 04/25/12.

Patient #8
Review of Patient #8's medical record revealed he was an 85 year old male admitted on 04/20/12 with diagnoses of septicemia, end-stage renal disease with hemodialysis, hypotension, anemia, syncope, and congestive heart failure.

Review of Patient #8's "Physicians Admission Orders" dated 04/20/12 at 1:30pm revealed an order for "Dietary Assessment: Sepsis, Albumin 2.4, ESRD With HD (end-stage renal disease with hemodialysis).

Review of Patient #8's "Information For RD Telephone/Fax/Email Consult" revealed the top portion was completed by Dietary Manager S9 on 04/21/12 with no documented evidence of the time the form was documented. Further review of the fax "Transmission Verification Report" revealed S9 faxed the consult to RD S25 on 04/21/12 at 9:04am. Further review revealed the consult with the RD assessment by RD S25 was faxed to the hospital on 04/23/12 at 6:19pm. Review revealed RD S25 recommended to continue the current nutrition plan of care, obtain and honor food preferences, and she would follow up on 04/25/12.

Patient #13
Review of Patient #13's medical record revealed she was an 82 year old female admitted on 01/06/12 with the primary diagnosis of osteomyelitis right foot with stage IV ulcer. Further review revealed secondary diagnoses were MRSA (methicillin resistant staph aureus) and Proteus Mirabilis urinary tract infection, atrial fibrillation, iron deficiency anemia, hypertension, history of cerebrovascular accident with aphasia and dysphagia with a PEG (percutaneous esophageal gastrostomy) tube, and multiple decubitus ulcers.

Review of Patient #13's "Physicians Admission Orders" dated 01/06/12 at 10:00am revealed an order for a dietary assessment.

Review of Patient #13's "Information For RD Telephone/Fax/Email Consult" revealed the top portion was completed and signed by Dietary Manager S9 with no documented evidence of the date it was documented. Further review revealed the "RD Assessment" was completed and signed by RD S25 on 01/09/12 and faxed to the hospital on 01/09/12 at 6:49pm. Further review revealed RD S25 recommended to continue the current nutrition plan of care, obtain and honor food preferences, and she would follow up on 01/11/12.

Patient #15
Review of the medical record for Patient #15 revealed a 75 year old male admitted to the hospital on 03/23/12 for continued care of acute respiratory failure, hypoxia, aspiration pneumonia, sepsis, and malnutrition.

Review of the Physicians Admit Orders dated 03/23/12 at 10:00am revealed an order for a dietary assessment.

Review of Patient #15's "Information For RD Telephone/Fax/Email Consult" revealed the top portion was completed and signed by Dietary Manager S9 on 03/26/12. The form revealed a fax date and time to RD S25 of 01/09/12 at 6:49pm. Further review revealed the "RD Assessment" was completed and signed by RD S25 on 01/26/12. There was no documented evidence when the assessment was received by the hospital.

Review of policy # FS5.2 titled "Nutrition Assessment" last revised 04/10 and submitted as the one currently in use revealed.... "Procedure: 1. An assessment is performed by the Registered Dietitian and is documented on the Nutritional Assessment form and may include, but is not limited to, diagnosis, height/weight; usual body weight; diet order; lab values; medications and interactions; diet history, comprehension, compliance, recommendations and plan. 2. A nutrition treatment plan will be documented. This includes related measurable goals and actions to achieve them".

In a face-to-face interview on 04/23/12 at 3:30pm, Director of Nursing S2 indicated RD S25 was supposed to assess patients in person and not by fax.

In a face-to-face interview on 04/25/12 at 2:30pm, RD S25 indicated she was employed by the hospital part-time. She further indicated she works one week on Wednesday, Thursday, and Friday and works the next week on Wednesday and Thursday. S25 indicated she completes the top portion of the nutritional assessment if she's at the hospital, otherwise the dietary manager completes it and she reviews it. S25 confirmed that her nutritional assessment is done by fax on the days that she's not at the hospital, and she would see the patient on her next scheduled day to work at the hospital. When asked how she can assess a patient by phone or fax, S25 indicated she looked at the patient's weight, height, lab results, and finds out if they're eating. S25 indicated there have been problems with obtaining accurate weights of patients, which she has communicated verbally to the Director of Nursing but did not put any concerns in writing. S25 indicated she had no monitors for dietary in place and was not involved with the quality assessment performance improvement program of the hospital. S25 indicated she worked at another facility and performed her assessments in person, because "I work there".

Review of the hospital policy titled "Nutritional Screening", policy number II-A.1.03, revised 12/09, and contained in the policy manual presented by Administrator S1 as current, revealed, in part, "...The admitting nurse conducts an initial screening of each patient's nutrition status at the time of the initial assessment upon admission. ... 3. When the need to consult the Registered Dietitian arises, she will be contacted by faxing the nutrition assessment section of the Admit Nursing Assessment along with the physician's admission orders or any new written nutrition/dietary order or consults ... The dietitian will perform an assessment within 72 hours or as the patient's need warrants".

Review of RD S25's job description signed on 02/03/11, presented by Human Resource Coordinator S40, revealed, in part, "...Essential Functions Statement(s) ... Interview patients to obtain information regarding their dietary history, as well as food habits and preferences for guidance in planning the patient's diet. ... Reviews the medical record and charts appropriately in the patient's medical record after each patient contact...".


25065

Based on observation, record review, and interviews, the hospital failed to ensure supplies and equipment were maintained to ensure an acceptable level of safety and quality. 1) There were boxes and equipment stacked on the floor in the equipment storage room #1, the patient storage room on the second floor, equipment storage room #2, the second floor storage room, the central storage room on the second floor, and the medical records storage room on the first floor. 2) There were 13 portable fans available for use by patients that had not been safety checked and had dust and hair adhered to the screen. 3) There were expired infusion and injection supplies, expired respiratory supplies, and equipment with expired biomedical inspection available for patient use in the lab and crash carts. Findings:

1) Boxes stacked on the floor in the equipment storage room #1, the patient storage room on the second floor, equipment storage room #2, the second floor storage room, and the medical records storage room on the first floor:
Observation of the equipment storage room #1 on 04/23/12 at 9:20am revealed 11 boxes of tracheostomy supplies stacked on the floor. Further observation revealed a large box containing opened, empty boxes stacked on the floor. Further observation revealed 3 IV (intravenous) pumps on the floor. These observations were confirmed by Director of Nursing (DON) S2.

Observation of the patient storage room on the second floor on 04/23/12 at 10:45am revealed shelves with bags of patients' belongings that were left by the patient at the time of discharge. Further observation revealed a box and a plastic bag containing a patient's belongings were on the floor. These observations were confirmed by DON S2.

Observation of the second floor storage room on 04/23/12 at 10:50am revealed 3 boxes of toilet tissue and 1 box of Plaza Plus sealer finish on the floor. This observation was confirmed by DON S2.

Observation of the equipment storage room #2 on 04/23/12 at 11:25am revealed 23 boxes stacked on the floor containing various products such as syringes, vacutainers, specimen containers, blood infusion sets, and primary infusion sets. This observation was confirmed by DON S2.

Observation of the central storage room on the second floor on 04/23/12 at 11:50am revealed 69 boxes stacked on the floor. This observation was confirmed by DON S2.

2) 13 portable fans available for use by patients that had not been safety checked and had dust and hair adhered to the screen:
Observation of Room "a" on 04/23/12 at 10:52am revealed a portable fan was situated on top of the overbed table. Further observation revealed no evidence of a safety or biomedical inspection sticker.

Observation of the medical equipment room of the second floor on 04/23/12 at 11:55am revealed 12 portable fans with no evidence of a safety or biomedical inspection sticker.
Further observation revealed several of the fans had an accumulation of dust and hair on the screens covering the front and back of the fan.

In a face-to-face interview on 04/23/12 at 10:55am, DON S2 indicated the portable fans should be inspected, and there should be a sticker as evidence that it was inspected.

Review of the hospital policy titled "Inventory and Inspection of New Equipment", policy number III-B.2.64, revised 01/10, and contained in the manuals presented by Administrator S1 as current policies, revealed, in part, "...2. After receipt of any new equipment, but before its installation, it must be inspected; electrical and mechanical tests performed and determined by the Bi-medical Department that it meets all appropriate safety standards. After passing inspection, the new equipment is assigned an identification number and is placed on a maintenance schedule. 3. When equipment is assigned an identification number, the technician performing the inspection will document the inspection and the date the inspection was performed in the comment section of the equipment form. ... 5. It shall be the responsibility of the Hospital's Administration to schedule and insure that routine inspection all pertinent hospital equipment to determine its safe operation...".

3) Expired infusion and injection supplies, expired respiratory supplies, and equipment with expired biomedical inspection available for patient use in the lab and crash carts:
Observation of the lab on 04/23/12 at 9:50am revealed one cuffless tracheostomy tube that expired 10/11 and another one with an expiration date of 07/11. Further observation revealed two disposable cannula low pressure cuffed tracheostomy tubes that expired 04/10. Further observation revealed a nebulizer compressor in the drawer with a biomedical inspection sticker dated 11/09.

In a face-to-face interview on 04/23/12 at 9:50am, Respiratory Manager S3 indicated the nebulizer compressor was broken and was not being used. S3 confirmed that the compressor should be labeled as broken and not available for use with patients. He further indicated that equipment and supplies should be checked once a month.

Observation of the central venous catheter cart located in the hall on first floor on 04/23/12 at 10:05am revealed the following expired infusion and injection supplies:
1) "Introcan Safety-W IV (intravenous) Catheter" 18 gauge - 1 expired 04/09; 1 expired 12/09; 2 expired 10/10; 4 expired 08/11; 2 expired 03/12;
2) Two "Monoject Safety Needles" 20 gauge by 1 inch expired 03/10;
3) One "BD Leuer Lock Cannula" expired 09/11;
4) Three debridement kits expired 03/11;
5) 22 gauge 1 inch Protect intravenous (IV) catheter expired 07/10;
6) 18 gauge 1 ? inch Protect IV catheter expired 09/10;
7) 2 Port access infusion sets expired 09/09.
These observations were all confirmed by Director of Nursing (DON) S2.

Observation of the isolation cart in the hall on the second floor on 04/23/12 at 11:05am revealed a disposable cannula low pressure cuffed tracheostomy tube with an expiration date of 09/11. This observation was confirmed by DON S2.

Observation of the second floor supply room on 04/23/12 at 11:10am revealed ten port access infusion sets that expired 07/11. This observation was confirmed by DON S2.

In an interview on 04/23/12 at 10:30 a.m., DON S2 indicated the expired supplies should not have been in the supply carts and storage room.

Review of the hospital policy titled "Stock Rotation", policy number II-C.4.62, revised 12/09, and contained in the manuals presented by Administrator S1 as current policies, revealed, in part, "...All stock items will be stored using the rotation system and the oldest products will be issued first. This prevents stock deterioration and/or expiration of sterile products. ... The Stockroom Clerk will check dated items to ensure that the "oldest" items are issued first. ... Any items noted to have an expiration date will be pulled from stock before the expiration date and discarded...".








30364

Based on observations and interviews, the hospital failed to maintain a sanitary environment as evidenced by having dust collected on carts and patient care equipment, having clean equipment used for patient care stored in a closet with discharged patients' personal belongings left at the hospital when the patient was discharged, and having an overflowing trash bag without a cover on the central venous catheter cart. Findings:

Observation of the crash cart located on the first floor hall next to room "d" on 04/23/12 at 9:00am revealed the suction machine, canister, and defibrillator on the top of the crash cart had an accumulation of dust.

In a face-to-face interview on 04/23/12 at 9:00am, Director of Nursing (DON) S2 confirmed the above findings.

Observation of the central venous catheter cart located in the hall next to room "e" on 04/23/12 at 10:05am revealed an uncovered trash compartment attached to the cart with garbage overflowing out of it.

In a face-to-face interview on 04/23/12 at 10:05am, DON S2 indicated the trash was supposed to have been emptied on 04/20/12. She further indicated the trash compartment should have been covered.

Observation of the patient storage closet on the second floor on 04/23/12 at 10:45am revealed shelving that contained personal belongings of patients that were left at the hospital when they were discharged. Further observation revealed the hoyer lift scale used to weigh patients was stored in the closet with unclean items.

In a face-to-face interview on 04/23/12 at 10:45am, DON S2 indicated the clean item used for patient care should not be stored with unclean items.

Observation of the medical equipment room on the second floor on 04/23/12 at 11:55am revealed 12 fans used for patients was stored in the room. Further observation revealed several of the fans had dust and hair collected on the screen.

In a face-to-face interview on 04/23/12 at 11:55am, DON S2 indicated the fans were ready for use by patients. She confirmed the presence of dust and hair on some of the fans.

Based on record review and interviews, the hospital failed to ensure an individual with the necessary knowledge, experience, and capabilities had been appointed as Director of Rehab Services with the responsibility of supervising and administering the rehab services provided to patients in the hospital. Findings:

Review of the list of employees with job titles presented by Administrator S1 revealed the hospital employed one physical therapist, one PRN (as needed) occupational therapist, one PRN speech therapist, and two physical therapy assistants. Further review revealed no documented evidence of a Director of Rehab Services.

Review of the job description of Physical Therapist S35, the only employee designated as full-time or part-time, revealed her "position summary" included "plans and administers medically prescribed physical therapy treatment for patients suffering from injuries, or muscle, nerve, joint and bone diseases, to restore function, relieve pain, and prevent disability...". Further review revealed no documented evidence that S35 was assigned or appointed the title and duties of Director of Rehab Services.

In a face-to-face interview on 04/26/12 at 10:45am, Administrator S1 indicated the hospital did not have a physician or qualified employee responsible for rehab services.

In a face-to-face interview on 04/27/12 at 9:55am, Physical Therapist S35 indicated to her knowledge, no one was designated as Director of Rehab Services.

Based on record review and interview, the hospital failed to ensure rehab services were performed according to hospital policy for 2 of 20 sampled patients (#7, #17). Findings:

Patient #7
Review of Patient #7's medical record revealed he was an 81 year old male admitted on 04/17/12 with the primary diagnoses of respiratory failure with ventilator support and a tracheostomy, pneumonia, and malnutrition.

Review of Patient #7's "Physicians Admission Orders" dated 04/17/12 at 10:00am revealed an order for a speech therapy consult. Review of the entire medical record revealed no documented evidence that a speech therapy evaluation had been performed as of 04/23/12, 6 days since the order was received.

In a face-to-face interview on 04/24/12 at 2:05pm, Director of Nursing indicated the secretary had not completed a speech therapy consult request for Patient #7 and confirmed the evaluation had not been performed. She further indicated the secretary was supposed to check the consult log every shift, and that was not being done.

Patient #17
Review of the medical record for Patient #17 revealed he was a 57 year old male admitted on 04/04/12 for a scrotal abscess, Obesity, Diabetes Mellitus, Congestive Heart Failure, and Carotid Artery Disease.
Review of the Physicians Admission Orders revealed a Physical Therapy consult was ordered on 04/04/12 at 15:30 (3:30 p.m.).
Review of the Physical Therapy evaluation for Patient #17 revealed the date listed on the physical therapy evaluation as the evaluation being ordered by the physician was 04/09/12. Review of the Physical Therapy evaluation revealed it was done on 04/09/12 at 10 a.m., five (5) days after the physician ordered the physical therapy evaluation.
An interview was conducted with S35 Physical Therapist on 04/27/12 at 9:50 a.m. S35 Physical Therapist said she was off on 04/04/12 and was unable to do the physical therapy evaluation until 04/09/12 for Patient #17. When questioned if anyone covered for her while she was out, she stated, "No".
Review of the hospital's policy for Rehabilitation Therapy Services for Receiving Orders (Policy # II-E.6.00) revealed in part, " ...5) Evaluations are to be completed within 72 hours of doctor's orders ...".







25065

Based on record review and interview, the hospital failed to ensure a physician with the knowledge, experience, and capabilities had been privileged as Director of Respiratory Services to supervise and administer the service properly. Findings:

Review of the "Medical Staff Roster" presented by Administrator S1 as the current list of credentialed physicians revealed no documented evidence that a credentialed physician served as Director of Respiratory Services.

In a face-to-face interview on 04/24/12 at 9:35am, Administrator S1 indicated the hospital did not have a physician privileged and responsible for Respiratory Services provided to patients in the hospital.

Based on record review and interview the hospital failed to ensure respiratory services were provided as ordered by the physician for 1 of 20 sampled patients (#17). Findings:
Review of the medical record for Patient #17 revealed he was a 57 year old male admitted on 04/04/12 for a Scrotal Abscess, Obesity, Diabetes Mellitus, Congestive Heart Failure, and Carotid Artery Disease.
Review of the Respiratory Therapy Flow sheet dated 04/22/12 at 0000 (12:00 a.m.), 04/23/12 at 0020 (12:20 a.m.), and 04/24/12 at 0100 (1:00 a.m.) revealed "Home CPAP in use, nurse aware".
Review of the Respiratory Assessment dated 04/04/12 revealed under the section labeled treatment plan only HHN (hand held nebulizer) was indicated as included on the treatment plan. BiPAP/CPAP (Positive Airway Pressure/Continuous Positive Airway Pressure) was not marked as included in the treatment plan.
An interview was conducted on 04/25/12 at 2 p.m. with S32 LPN (licensed practical nurse). She indicated that she was the nurse taking care of Patient #17 currently. She also reported that Patient #17 was using his home CPAP (Continuous Positive Airway Pressure) machine at night while he was in the hospital. S32LPN reviewed the patient's physician's orders and was unable to find a physician's order for use of the patient's home CPAP machine while he was hospitalized.
Review of Patient #17's physician's orders revealed no order for use of the patient's home CPAP machine.
An interview was conducted with S3 Respiratory Manager on 04/25/12 at 2:15 p.m. S3 reviewed the patient's chart and was unable to find an order for use of the patient's home CPAP machine.
An interview was conducted with S2 DON (director of nursing) on 04/25/12 at 2:30 p.m. She was unable to find a physician's order for use of the patient's home CPAP machine. She indicated there should have been an order if the patient was using his CPAP machine.

Based on record review and interview the hospital failed to develop an effective system for identification of errors in medication administration as evidenced by relying on self-reporting of errors by the nursing staff as the primary means of identification resulting in forty (106) unidentified medication variances identified through review of 20 sampled medical records. Findings: (See additional findings at Tag A0405).

In a face to face interview on 04/26/12 at 8:15am, Contract Pharmacist S30 with Company C indicated she does not perform chart audit. Further S30 indicated the hospital faxes the medication errors to the pharmacy; however the pharmacist is not directly involved in the process for corrective action. S30 indicated her role is to review the errors. S30 added to her knowledge the hospital had no problems with medication administration variances.

In a face to face interview on 04/26/12 at 8:45am RN S2 Director of Nursing indicated the nurses fill out the medication variances and the forms are reviewed by her and then a copy is sent to the pharmacist. S2 indicated medication errors are not a problem.

Review of the Pharmacy and Therapeutics Reports presented by S2 to the Professional Practice Committee revealed 19 total medication variances were reported for October-November-December 2011. Further review of the variances revealed the following breakdown: (1) ordering; (3) transcribing; (0) dispensing; and (15) administration.

Based on record review and interview the hospital failed to focus performance improvement activities on high-risk, high-volume or problem prone areas as evidenced by: 1) failing to include patients receiving intravenous (IV) titrated drips of cardiogenic and vasoactive medications and IV sedation in the adult ventilated patient resulting in failure to follow the policy and procedure for parameters for weaning of patients on cardiogenic and vasoactive medications for 2 of 2 patient with orders for dopamine out of a total of 20 sampled patients and monitoring and documentation of cardiac rhythm via telemetry by the RN, and anesthetic agent being titrated and monitored by an RN outside of a critical care setting for 1 of 1 patients with orders for Propofol (Diprivan) out of a total of 20 sampled patients and 20 and 2) failing to accurately monitor blood administration to ensure blood was administered at the ordered rate of infusion resulting in blood being administered at the discretion of the nursing staff with at rates of > 1 hour to > 4 hours for 5 of 6 patients with orders for blood administration (#3, #4, #14, #15, #16) from a total of 20 sampled patients. Findings:

1) failing to include patients receiving intravenous (IV) titrated drips of cardiogenic and vasoactive medications and IV sedation in the adult ventilated patient
Patient #4
Review of the medical record for Patient #4 revealed an 86 year old female admitted to the hospital for Myelodysplasia, UTI (Urinary Tract Infection), Venous Stasis Ulcers and Malnutrition. Additional diagnoses included anemia, electrolyte imbalance, and sacral decubitus ulcers. Review of the Physicians Orders for Patient #4 dated/timed 04/17/12 at 8:30am revealed an order to wean Dopamine as tolerated. There was no documented evidence of the specific parameters for blood pressure that were to be used to decrease the dopamine.

Patient #8
Review of Patient #8's medical record revealed he was an 85 year old male admitted on 04/20/12 with diagnoses of septicemia, end-stage renal disease with hemodialysis, hypotension, anemia, syncope, and congestive heart failure.

Review of the medical record for Patient #8 revealed a physician's order dated 04/26/12 at 1005 (10:05 a.m.) to Wean Dopamine as tolerated. There was no documented evidence of the specific parameters for blood pressure that were to be used to decrease the dopamine.
An interview was conducted with S2 DON on 4/27/12 at 1:20 p.m. She reported the order for the Dopamine should have included parameters for the patient's blood pressure, and the order should have been clarified by the nurse.
Patient #15
Review of the medical record for Patient #15 revealed a 75 year old male admitted to the hospital on 03/23/12 for continued care of acute respiratory failure, aspiration pneumonia, sepsis and malnutrition.

Review of the Physicians Orders for Patient #15 dated/timed 03/24/12 at 5:00pm revealed an order to intubate the patient and and Ativan drip at 2-4 mg per hr. Further review of the Physicians Orders revealed on 03/30/12 a verbal order was received from MD S34 for an OK to use Propofol when Ativan becomes unavailable.

Review of the "IV Sedation of Adult Ventilator Patient Flowsheet" for Patient #15 revealed Propofol was started on 03/31/12 at 1300 (1:00pm) and continued until 04/09/12 at 0700 (7:00am).

Review of R.S.37:935. revealed.... "Notwithstanding any order provision in this chapter to the contrary, a registered nurse may administer, in accordance with an order of an authorized prescriber, anesthetic agents to intubated patients in critical care settings...".

In a face to face interview on 04/26/12 at 9:20 MD S22 Assistant Chief of Staff the patients on Propofol are monitored by the registered nurse. S22 agreed the LTAC was not a critical care setting.


2) failing to accurately monitor blood administration to ensure blood was administered at the ordered rate of infusion resulting in blood being administered at the discretion of the nursing staff with at rates of > 1 hour to > 4 hours (See findings at Tag A0409)

Based on record review and interview the hospital failed to implement corrective action for the identified problem of narcotics shift counts failing to be performed according to policy and procedure. This resulted in undocumented wastage and therefore unaccounted Oxycodone for Patient #6 during record review. Findings:


Patient #6
Medical Record review of the Physician's Orders for Patient #6 revealed an order dated 04/5/12 at 1345 (1:45 p.m.) for Percocet (Narcotic pain medication) 7.5 milligrams (mg) Q (every) 6 hours PRN (as needed) for pain. Further review of the Medication Administration Record (MAR), Nurse's Notes, and the Omnicell (medication dispensing machine) transaction record provided by the pharmacy for Patient #6 revealed the following medication errors:
04/08/12 at 1:30 a.m.- Two 5 mg Oxycodone/APAP (Percocet) tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 mg was documented.
04/09/12 at 8:46 a.m.- One 5 mg Oxycodone/APAP tablet was removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given.
04/09/12 at 5:15 p.m.- One 5 mg Oxycodone/APAP tablet was removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given.
04/10/12 at 12:20 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 mg was documented.
04/11/12 at 8:41 p.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 was documented.
04/12/12 at 8:47 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 mg was documented.
04/12/12 at 6:39 p.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 7.5 mg dose was charted on the MAR as having been given. No waste of 2.5 mg was documented.
04/13/12 at 5:36 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. Two ? tablets (2.5 mg each) were charted as having been wasted. No dose was charted on the MAR as having been given.
04/13/12 at 8:01 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell by RN S31. No dose was charted as having been given and no waste was charted.
04/13/12 at 2:50 p.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. No dose was charted as having been given and no waste was charted. Two more 5 mg tablets were removed from the Omnicell by RN S31 1 hour and 56 minutes later and charted as having been given.
04/14/12 at 8:21 a.m.- One 5 mg Oxycodone/APAP tablet removed from the Omnicell. A 7.5 mg dose was charted as having been given on the MAR.
04/15/12 at 8:56 a.m.- One 5 mg Oxycodone/APAP tablet removed from the Omnicell. A 7.5 mg dose was charted as having been given.
04/15/12 at 3:03 p.m.- One 5 mg Oxycodone/APAP tablet removed from the Omnicell. A 7.5 mg dose was charted as having been given.
04/16/12 at 4:09 a.m.- One 5 mg Oxycodone/APAP removed from the Omnicell. No dose was recorded as having been given.
04/17/12 at 1:23 a.m.- Two 5 mg Oxycodone/APAP tablets removed from the Omnicell. ? tablet (2.5 mg) was charted as having been given. No waste was charted.
04/17/12 at 9:11 a.m.- Two 5 mg Oxycodone/APAP tablets were removed from the Omnicell. A 5 mg tablet was charted as having been given at 9:13 a.m. Another 5 mg tablet was charted as having been given 3 hours and 47 minutes later at 1300 (1:00 p.m.).

In a face to face interview on 04/24/12 at 9:45 a.m. Registered Nurse (RN) S16, verified Patient #6's ordered dose of Oxycodone/APAP was 7.5 mg every 6 hours as needed for pain. S16 also indicated she had given Patient #6 5 mg of Oxycodone/APAP instead of 7.5mg, and then gave another 5 mg dose 3 hours and 47 minutes later for a total of 10 mg. S16 indicated she had not realize she had made a medication error. S16 indicated she thought if she could have given a smaller dose than what was ordered without clarifying the order with the physician. S16 stated that she had not filled out a medication variance form for the error.

In a face to face interview on 04/25/12 at 8:10 a.m. Licensed Practical Nurse (LPN) S8, indicated she had removed two 5 mg Oxycodone/APAP tablets from the Omnicell on 4/17/12 at 1:23 a.m. S8 verified that she charted she had given 5 mg of the narcotic to Patient #6, but did not have any documentation of wasting the other 5 mg. S8 indictaed she could not remember that day specifically, but she should have wasted the remaining 2.5 mg of the Oxycodone/APAP with another nurse. S8 also said if she had wanted to give a different dose than the physician ordered, she should have notified the physician.

In an interview on 04/27/12 at 1:35 p.m. with RN S31, he stated on 04/13/12 at 4:45 p.m., he must have forgotten to chart the waste of 2.5 milligrams of Oxycodone/APAP after giving 7.5 mg to Patient #6. S31 said he must have forgotten to chart the other doses of Oxycodone for Patient #6 on 04/13/12.

In a face to face interview interview on 04/25/12 at 8:30 a.m. Director of Nursing S2, verified the Oxycodone/APAP discrepancies from Patient #6's chart. S2 said the nursing staff should have given 7.5 mg of Oxycodone/APAP as ordered or called the physician to clarify the order. She also stated if 10 mg of Oxycodone/APAP had been removed from the Omnicell, 2.5 mg should have been charted as being wasted. S2 also said if a medication variance occurred, it should have been reported to her to be investigated. S2 said she could clearly see where there was a big problem with narcotic administration by the nursing staff.

Review of the "Omnicell Checklist for January 2012 and February 2012 performed by the on-coming and off-going charge nurses for narcotic reconciliations for the 1st floor revealed the following: January 2012 - 01/03/12 PM, 01/10/12AM, 01/15/12, 01/16/12, 01/18/12PM, 01/19/12AM and PM, 01/20/12 AM, 01/22/12PM, 01/23/12 PM, 01/24/12 AM and PM, 01/25/12 AM, 01/20/12 PM, and 01/31/AM had only one nurse signature. 2nd floor 01/03 12 6PM, 01/13/12PM, 01/14/12AM, 01/16/12 (not documented as done), 01/17/12AM, 01/18/21 PM, 01/19/12AM and PM, 01/20/12AM, 01/25/12AM, and 01/31/12AM. February 2012 1st floor: 02/01/12PM, 02/02/12PM, 02/03/12AM, 02/22/12AM, 02/24/12AM andPM, 02/24/12 AM and PM, 02/26/12 aM and PM, AND 02/29/12 AM and PM. 2nd floor: 02/01/12PM, 02/10/12AM, 02/12/12PM,02/15/12PM, 02/22/12AM, 02/26/12AM andPM, 02/27/12 AM and PM.

Review of the Quality Assurance/Performance Improvement data submitted for March 2012 revealed no documented evidence correctove action was implemented for the inaccurate narcotics reconciliation forms for January and February 2012.

Based on record review and interview the hospital's Governing Body failed to ensure the safety of its patients as evidenced implementation of an in-effective system for identification of errors in medication administration which relyed on self-reporting of errors by the nursing staff as the primary means of identification resulting in forty (106) unidentified medication variances identified through review of 20 sampled medical records. (See findings at Tag A0405).