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Based on record review and interview, the hospital failed to protect patients' rights by established policies and processes as evidenced by:

A. Failed to provide the contact information for the Oklahoma State Department of Health for family/patients to file a grievance (Refer to Tag A-118)
B. Failed to ensure informed consent was obtained from patient's representative for 1 (Patient # 10) of 21 patient records reviewed (Refer to Tag A-131)
C. Failed to provide care in a safe setting for 1 (Patient #4) of 21 records reviewed resulting in patient developing an unstageable pressure ulcer (Refer to Tag A-144)
D. Failed to ensure competent care was provided for patients to prevent neglect for 1 (Patient # 4) of 21 records reviewed that resulted in development of an unstageable pressure ulcer (Refer to Tag A-145)

Based on record review and interview, the facility failed to ensure the patients' rights as evidenced by the following:

A. The correct contact information was not provided for the Oklahoma State Department of Health and Medicare Beneficiary to file a grievance. (See Tag A-0118)

B. Obtain informed consent was obtained from patient's representative. (See Tag A-0131)

C. Ensure patient # 4 was reviewed by QAPI and standards were followed by Infection Control . (See Tag A-0144)

D. To prevent the development of an unstageable pressure ulcer for patient # 4. (See Tag A-0145)

Based on record review and interview, the hospital failed to ensure the program reflected the complexity of the organization by ensuring patients were not neglected and did not develop pressure ulcers while an inpatient as evidenced by:

1. Failure to analyze the cause of Patient #4's neglect that lead to the development of a pressure ulcer (Refer to Tag A-286)
2. Failure to set a priority of a high risk, high volume area to ensure patients were not neglected and did not develop pressure ulcers while an inpatient (Refer to Tag A-283)

Based on record review and interview, the facility failed to:

A. Ensure RN were assessing and co-signing LPN assessment (See Tag A-0395)

B. Ensure daily weights were completed per doctor's order (See Tag A-0395)

C. Ensure peripheral intravenous catheter were assessed and changed appropriately (See Tag A-0395)

D. Ensure wound care protocol and wound care policy were followed (See Tag A-0395)

E. Ensure nursing care plans were initiated and updated (See Tag A-0396)

F. Ensure that wounds were assessed by RN with wound care competencies (See Tag A-0397).

Based on record review and interview, the hospital failed to provide an active program to avoid sources of transmission of infections under a qualified infection control officer as evidenced by:

1. Failure to designate a trained Infection Control Preventionist (ICP) compromising Patient #4's safety and had the potential to cause harm to all patients by increased risk of developing infections and communicable diseases due to the ICP's lack of knowledge regarding the infection control program. (Refer to Tag A-748)

2. Failure to maintain a sanitary hospital environment by failing to routinely assess the hospital for the identifing and investigating of a sanitary environment and increasing the risk of infections (Refer to Tag A-749)

Based on record review and interview, the facility failed to:

A. Provide correct contact number for the Oklahoma State Department of Health for filing a complaint.

B. Provide correct contact information in order for medicare beneficiary to submit a complaint.

This failed practice had the potential to impede patients from having accurate complaint contact information to file any complaints for all patients admitted to the hospital.

Findings:

The policy titled "Complaint and Grievance Process" said Oklahoma Department of Health Services 1000 NE 10th, Room 509, Oklahoma City, OK 73117-1299, Tel: 405-271-5585. The correct number is (405) 271 - 6576.

The policy titled "Complaint and Grievance Process" said if a Medicare Beneficiary wishes to complain regarding quality of care or premature discharge, the patient/family may contact OFMQ Quality Improvement Organization.

On 09/11/17 at 4:45 pm, Staff C stated the corporate quality director would help with putting the policy together properly.

Based on record review and interview, the facility failed to ensure informed consent was obtained from patient's representative for 1 of 20 patient record reviewed (Patient # 10).

This failed practice had the potential to put all patients at risk for receiving unconsented services.

Findings:

The policy titled "Consent for Medical and Surgical Procedures" said for patients whose capacity to consent is uncertain, consent should be obtained from the patient and the next legally authorized representative....the oral or telephone authorization of the patient will require documentation by two (2) witnesses.

On 08/11/17, Staff BB signed a consent form for Ultrasound of left upper extremity; and Staff BB wrote unable to sign on the line for signature of patient or legally responsible individual. Staff BB was the only signature on consent form.

On 09/06/17 at 10:40 am, Staff A stated the process should be to get verbal consent with two witnesses.

Based on record review and interview, the facility failed to:

A. Ensure Patient # 4 record was reviewed by QAPI for 1 of 21 patient records reviewed, (See Tag - 0286).

B. Ensure infection control program had a qualified infection control officer and monitoring compliance with procedures and protocols, (See Tag - 0748, 0749).

This failed practice has the potential to increase risk for infection and physical harm to all patients.

Based on record review and interview, the hospital failed to ensure quality care was provided for patients to prevent neglect for 1 (Patient # 4) of 21 patient records reviewed .

This failed practice allowed a patient to develop an unstageable pressure ulcer while inpatient.

Findings:

Policy titled "Patient Rights" said receive care in a safe setting, free from mental, physical , sexual or verbal abuse and neglect, exploitation or harassment.

Patient # 4

~ Admitted on 08/09/17; and on admission, patient had a Stage II pressure ulcer to Left buttocks.

~ On 08/09/17, Staff R ordered - JW Butt Paste BID and PRN Soilage, & Support Surface - Low Air Loss Overlay mattress.

~ From 08/09/17 - 08/27/17, there were six 7A - 7P and four 7P - 7A shifts where the daily nursing assessment showed inconsistent checking of box for the Specialty Air Mattress (i.e. daily nursing assessment showed patient had specialty mattress before mattress was put on bed; and showed no assessment of mattress):

~ From 08/09/17 - 08/28/17, there were twelve 7A - 7P and ten 7P - 7A shifts where the skin assessment chart on the daily nursing assessment was left blank or the nurse charting did not reflect the correct number of wounds.

~ From 08/09/17 - 08/24/17, there were ten 7A - 7P and eleven 7P - 7A shifts were the daily nursing assessment showed no skin chart assessment said to "see wound care team notes". The nurse's would refer to the weekly wound care team notes.

~ On 08/09/17, a low air loss mattress was ordered and not placed on bed until 08/14/17 (5 days later).

~ Per the daily nursing assessment: On 08/14/17 at 06:50 pm, Staff H charted changed to low air loss mattress.

~ Per the weekly wound care report: On 08/14/17, Staff R charted Stage II pressure ulcer to Left Buttock: Current Treatment - JW Butt Paste BID and PRN Soilage, Braden Score - 16, Support Surface - Low Air Loss Overlay mattress. There was not a seperate wound assessment for the right buttock.

~ Per the weekly wound care report: On 08/21/17, Staff R charted Left Buttock Stage II pressure ulcer and Right Buttocks Unstageable (12 days since wound to Right buttock had been assessed): Current Treatment - JW Butt Paste BID and PRN Soilage, Braden Score - 15, Support Surface - Low Air Loss Overlay mattress.

~ On 08/25/17, Staff R wrote a order for wound care to 1) bilateral buttock cleanse with NS, pat dry, apply Gentamicin/Santyl 1:1 daily and PRN soilage; 2) DC Medihoney. Documentation did not show initial order for Medihoney.

~ Per the weekly wound care report: On 08/28/17, Staff R charted Left Buttock Stage II pressure ulcer and Right Buttocks Unstageable: Current Treatment - Gentamicin/Santyl 1:1 daily and PRN Soilage, Braden Score - 15, Support Surface - Low Air Loss Overlay mattress.

On 08/31/17 at 1:21 pm, Staff H stated when patient #4 got here, his bottom was red with a sore; and he liked to be turned every 30 minutes to an hour but it hurt to turn due to his knee. Staff H stated patient # 4 was not on a low air loss mattress at admission.

On 08/31/17 at 1:21 pm, Staff R stated patient # 4 had a Stage II pressure ulcer to left buttock and we ordered a low air mattress on Wednesday (08/09/17) but it got overlooked; and when I came back on Monday (08/14/17) left buttock was worse and the right was unstageable. Staff R stated if Staff F is not here then no one does anything; and Staff FF said to have Staff F look at it; and Staff F see him initially on 08/24/17 for wound on buttock.

Based on record review and interview, the hospital failed to set a priority of a high risk, high volume area to ensure patients were not neglected and did not develop pressure ulcers while an inpatient. (Refer to Tag A-286)

This failed practice had the potential to affect the safety and health of all patients receiving care due to the hospital's failure to identify and implement action plans for the risk of neglect resulting in the development of a pressure ulcer, and to improve patient outcomes.

Based on record review and interview, the hospital failed to analyze the cause of Patient #4's neglect that lead to the development of a pressure ulcer.


This failed practice had the potential to affect the safety and health of all patients receiving care due to the hospital's failure to assess, identify and implement action plans for the risk of development of pressure ulcers and to improve patient outcomes.

Findings:

The following committees' meeting minutes from 12/2016 to the most current 2017 minutes were reviewed:
1. Governing Body (which included credentialing, pharmacy and therapeutic, infection, utilization review, quality and other special committees)
2. Medical Executive Committee
3. Quality Committee

The Governing Body minutes contained data and discussed information from the Quality Committee, and Medical Executive Committee. There were no quality measurements or identification of trends regarding the risk of neglect resulting in the development of pressure ulcers discussed in the minutes. There was no data to assist the Governing Body with the decision-making necessary to provide quality hospital services.

The Quality Committee minutes documented data for set agenda topics; there was no data available after May 25, 2017 minutes. There was no identification of indicators and/or projects related to the risk of neglect resulting in the development of pressure ulcers, no establishment of goals and action plans, and no directive in the method of gathering data. Data was not analyzed or action plans developed to move issues towards sustained improvement. The risk of neglect resulting in the development of pressure ulcers was not discussed, trended, or analyzed within this committee or other committees.

On 9/06/17 at 9:03 am, Staff E, the Quality Manager, and Staff B, the CEO, stated Staff E started in her position in August, 2017 with no background in quality and had not started training; Staff E was unable to address the data collection, analyzing and trending of quality data.

Based on record review and interview, the facility failed to ensure the hospital nursing staff followed established policy and procedure for assessment and reassessment of patients.

This failed practice had the potential to increase the risk for inadequate assessment, lengthened hospital stay and decreased quality of care.

Findings:


A policy titled "Patient Assessment, Reassessment and High Risk Screens" said the patient's physical assessment is performed by an RN within 24 hours of admission.....the patient's medical history and subjective information may be recorded by an LVN/LPN and validated with the RN's signature after review.

A document titled "Oklahoma Board of Nursing; Patient Assessment Guidelines" said the registered nurse conducts comprehensive data collection.....recognizes alterations in the client's condition.......analyzes and synthesizes biological, psychological and social scientific data to determine rationale for nursing care needs of the client.

A document titled "Oklahoma Board of Nursing; Patient Assessment Guidelines" said the licensed practical nurse contributes to assessment of the patient by conducting focused assessment of the client through collecting data.....and determining when, to whom and where to report the data collected.

9 of 21 records reviewed (Patient # 1, 2, 3, 4, 5, 7, 9, 10 & 17) the LPN assessment information was not evaluated by the supervising RN.

On 09/06/17 at 10:40 am, Staff A stated the registered nurse's should sign behind licensed practical nurses.


Surveyor asked Staff A for weight policy. No policy was provided.

8 of 21 record reviews (Patient # 10, 11, 13, 14, 17, 19, 20 and 21) showed the daily weights were not completed and documented per doctor's order.

On 09/06/17 at 10:40 am, Staff A stated daily weights should be completed as ordered; and we do not have a policy.



A document titled "Guidelines for the Prevention of Intravascular Catheter-Related Infections" by the Centers for Disease and Control said short peripheral catheter sites commonly are rotated at 72-96 hour intervals to reduce both the risk for infection and patient discomfort associated with phlebitis.

2 of 21 records reviewed (Patient # 7 and 12) showed the same location for the peripheral intravenous catheter was charted on for 5 consecutive days (120 hours) .

On 09/06/17 at 10:40 am, Staff A stated we leave peripheral IV's in for 96 hours; and we do not have a policy.




A policy titled "Wound Assessment by Admitting Nurse and Wound Care Team" said all wounds will be assessed on admission, weekly and as needed for changes.

A standing order titled "Wound Care Orders" said wound care coodinator to complete photographic documentation for each wound upon admission and weekly thereafter and place on chart.

Patient # 4

~ On 08/09/17, Wound care note to Stage II to Left Buttocks: Current Treatment - JW Butt Paste BID and PRN Soilage.

~ On 08/14/17, Staff R charted Wound care report to Stage II to Left Buttocks: Current Treatment - JW Butt Paste BID and PRN Soilage, Braden Score - 16, Support Surface - Low Air Loss Overlay mattress. There was not a seperate wound assessment for the right buttock.

~ On 08/21/17, Staff R charted Wound Care report to Left Buttocks Stage II and Right Buttocks Unstageable (12 days since wound to Right buttock had been assessed): Current Treatment - JW Butt Paste BID and PRN Soilage.

On 08/31/17 at 1:21 pm, Staff R stated patient # 4 had a Stage II to left buttock and we ordered a low air mattress on Wednesday (08/09/17) but it got overlooked; and when I came back on Monday (08/14/17) left buttock was worse and the right was unstageable. Staff R stated if Staff F is not here then no one does anything; and Dr. Kolli said to have Staff F look at it; and Staff F see him initially on 08/24/17 for wound on buttock.

Based on record review and interview, the facility failed to follow established policy and procedure for initiating and updating the multidisciplinary plan of care and nursing care plans for 7 of 21 patient records reviewed (Patient # 5, 6, 11, 12, 13, 14 & 18).

This failed practice had the potential to increase the risk for inadequate assessment, lengthened hospital stay and decreased quality of care.

Findings:

A policy titled "Patient Assessment, Reassessment and High Risk Screens" said a RN will evaluate all information collected on admission and will initiate the Multidisciplinary plan of care.

7 of 21 patient records reviewed (Patient # 5, 6, 11, 12, 13, 14 & 18) showed the nursing care plan was not initiated or updated.

On 09/06/17 at 10:40 am, Staff A stated we update nursing care plans weekly.

On 09/06/17 at 10:40 am, Staff B stated I would say the patients problem (related to diagnosis) should be initiated on interdisciplinary plan of care.

Based on record review and interview, the facility failed to ensure nursing staff was educated and had completed competencies about wound care 6 of 21 patient records reviewed (Patient # 4, 5, 7, 10, 12 & 17).

This failed practice had the potential to the quality of care provided to all wound care patients admitted to the facility.

Findings:

A policy titled "Wound Assessment by Admitting Nurse and Wound Care Team" said all wounds will be assessed on admission, weekly and as needed for changes....pressure ulcer assessment will be conducted weekly by Wound Care Team and daily during Nursing Assessment......Wound Care Team (RN, LVN/LPN, or PT/OT). Policy failed to identify criteria for how often staff nurse's would be educated and when competencies would be completed for wound care.

3 of 4 nursing personal files reviewed (Staff # 3, 5 & 6) showed who provided wound care to patient # 4, did so without documented wound care training.

6 of 21 patient records reviewed (Patient # 4, 5, 7, 10, 12 & 17) did not show consistency in completing the skin assessment chart on the daily nursing assessment; the skin assessment chart was either blank, box was checked to see wound care team notes, only completed by one or both shifts or two wounds would be documented as one wound.

On 08/30/17 at 11:00 am, Staff R stated that he/she is a certified wound care nurse; and a registered nurse assists me.

On 08/31/17 at 2:00 pm, Staff R stated nurse's are supposed to do wound care assessments every 12 hours; and when nurse's come across wounds, they should notify the charge nurse and then charge nurse should notify me.

Based on record review and interview, the facility failed to ensure the physician signed orders according to the medical staff rules and regulations for 1 of 21 patient records reviewed (Patient # 15).

This failed practice had the potential for increased risk for patient # 15 who was admitted to the hospital to receive care for order not signed by MD.

Findings:

A policy titled "Cornerstone Hospital of Shawnee Restated Medical Staff Rules & Regulations" said all orders, including telephone 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 Hospital policy.

Patient # 15

On 09/06/17, a review of order titled "Infusion Therapy Device Physician Order" dated 09/02/17 (96 hours after order initiated) was not signed by physician.

On 09/06/17 at 2:45 pm, Staff B stated the order should be signed within 24 hours.

Based on record review and interview, the facility failed to ensure the physician completed the history and physical within 24 hours of admission for 1 of 21 patient records reviewed (Patient # 17 ) .

This failed practice had the potential to cause harm or improper treatment for patient # 17 who was admitted to the hospital.

Findings:

A policy titled "Cornerstone Hospital of Shawnee Restated Medical Staff Rules & Regulations" said a physician shall be responsible for a complete admission history and physical examination, which shall be recorded within twenty-four (24) hours after admission.

1 of 21 patient records reviewed (Patient # 17 ) showed the patient was admitted on 08/04/17 and the history and physical was completed on 08/07/17.

On 09/06/17, Staff B stated the physicians should complete the history and physical within 24 hours of admission.

Based on observation and interview, the hospital failed to:

A. Ensure expired and no open dates insulin and medications were discarded

B. Ensure expired medications located in the medication preparation area were discarded.

This failed practice had the potential affect all patients receiving medications that are not in accordance with the manufacturer's instructions.

Findings:

A document titled "Frequently Asked Questions regarding Safe Practices for Medical Injections" by the Centers for Disease Control and Prevention said if a multi-dose has been opened or accessed, the vial should be dated and discarded within 28 days unless specifies a different date for that opened vial.

On 08/30/17 at 11:00 am, the surveyor observed the following in the black refridgerator located on the North side of the hall:

~ Novolin N: expired 07/21/17 - multi-dose vial
~ Novolin 70/30: expired 07/10/17 - multi-dose vial
~ Levemir: no open date - multi-dose vial
~ Novolog: no open date - multi-dose vial
~ Humalog: no open date - multi-dose vial
~ Cardizem: expired 07/2017 - single use medication

On 08/30/17 at 11:00 am, Staff CC stated the nurse's should be checking the insulin; I will do better.

On 08/30/17 at 11:45, Staff A discarded the expired Cardizem.


A document titled "Frequently Asked Questions regarding Safe Practices for Medical Injections" by the Centers for Disease Control and Prevention said if a single-dose or single use vial has not been opened or accessed, it should be discarded according to the manufacturer's expiration date.

On 08/30/17 at 3:30 pm, the triage room contained 11 saline flushes that expired on 06/01/17.

On 08/30/17 at 3:30 pm, Staff A stated the medications should not be in here; and I will throw them out.

Based on record review and interview, the hospital failed to designate the responsibility of the infection control program to a qualified (through ongoing education, training, experience or certification) individual to oversee the infection control program.

This failed practice of an untrained Infection Control Preventionist (ICP) had the potential to cause harm to all patients by causing an increased risk of developing infections and communicable diseases due to the ICP's lack of knowledge regarding the infection control program.

Findings:

A review of Staff D's (Infection Control Preventionist) employee file showed no training in the infection control field.

On 09/06/17 at 9:03 am, Staff D (the ICP) stated she had no education, training or experience in infection control or quality.

Based on observation and interview, the hospital failed to maintain a sanitary hospital environment increasing the risk of infections by failing to assess the hospital and ensure an active and investigative control of possible infectious exposures.

FINDINGS:

During tours of the hospital, the following observations were made:

1. Contaminated and clean equipment stored in the same room; unable to verify clean from contaminated. Some of the equipment had plastic covering indicating the equipment was clean; other equipment was not wrapped but staff indicated should be clean.
2. Ozarka water bottles were stored setting directly on the floor prohibiting the cleaning of the floor.
3. Single patient use items were being provided to multiple patients. Opened, partially used packages were observed in the clean storage area
4. Wallpaper throughout the kitchen and dining room was cracked and peeling prohibiting the cleaning of the walls.
5. Employee lockers were located within the patient food preparation area
6. Expired cleaning supplies were stored in the housekeeping/janitor closets
7. Observed a patient room marked that the patient was on droplet precautions. Two non-employees in the room and close to the patient had no personal protective equipment.
8. Observed a patient walking in hallway with gown and gloves on
9. Expired insulin vials were observed in the medication refrigerators
10. Multiple medications in the two medication refrigerators were opened and not marked with a Beyond Use Date
11. Expired saline flushes were observed in the emergency department medication carrier
12. Patient use equipment (not marked clean or dirty) was stored in the clean medication room

On 09/11/17 at 4:45 pm, Staff B and Staff A stated they were unaware of some of the situations and would continue to monitor.