HospitalInspections.org

38777


Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the care of each patient as evidenced by:

1) failing to ensure nursing staff were properly trained on the current facility policies and procedures to determine the code status of a patient in order to immediately respond to a patient found to be unresponsive, without respirations and pulse for 1 (#1) of 5 (#1, #2, #3, #4, #5) patients sampled for code status and interview with 3 on duty nurses (S1RN, S22LPN, and S23LPN); and

2) failing to ensure staff are properly trained on current professional guidelines regarding the initiation of CPR when a patient is exhibiting obvious signs of death for 1 (#2) of 2 (#2, #3) patient's records reviewed for death; and

3) failing to provide training, competencies, or orientation to agency nurses on facility policies and procedures prior to being assigned to work in the facility; and

4) failing to ensure all wound care orders are followed and documented in the medical record.


Findings:

1) Failing to ensure nursing staff were properly trained on the current facility policies and procedures to determine the code status of a patient in order to immediately respond to a patient found to be unresponsive, without respirations and pulse.

Review of the hospital's policy titled "Code Blue" revealed in part:
The code blue will be activated by pressing the "Code Blue Button" to trigger overhead page. The first person discovering or witnessing the arrest,
a. Calls for help verbally
b. Activates the "Code Blue" button or
c. Dials the operator (from the bedside) to announce "Code Blue" including site, room number and level.
d. Commences one person CPR.

Review of the Do Not Resuscitate (DNR) policy revealed in part:
Purpose:
A. To establish a mechanism for reaching decisions about withholding resuscitation services from individuals.
H. Once the DNR decision has been made, the order will be written by the attending physician. This order will be accompanied by documentation by the attending physician as to the patient's medical condition, the patient's concurrence if obtained and all other facts and considerations relevant to this decision.
I. A purple armband jewel will be applied to all patients who have who have a written DNR order as per the Patient Alert Wristband Policy.

Review of Patient #1's medical record revealed he had been admitted to the hospital on 10/13/2020 with diagnoses including impaired function and activities of daily living secondary to acute respiratory failure with hypoxia. Further review revealed no physician's order to be a full code or a DNR.

Review of Patient #1's signed "Declaration" dated 10/20/1994 in a document titled "Durable Power of Attorney" revealed the following:
If at any time I should have an incurable injury, disease or illness, or be in a continual profound comatose state with no reasonable chance of recovery, certified to be a terminal and irreversible condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care.

In an interview on 10/27/2020 at 10:00 a.m. with S21RN charge nurse, he was asked if there were any current DNR patients on the rehabilitation unit. He said the only DNR was one of his patients, Patient #1. When asked how DNR's are communicated between the staff members, he said it is passed on in report and there are stickers placed on the chart on the top and front by the patient's name. When asked to observe the patient's medical record, he verified there were no stickers on the record indicating the patient was a DNR. When asked to see the order for DNR, S21RN could not locate one. S21RN looked at Patient #1's Power of Attorney and said he signed to not be coded. S21RN said he would more than likely not code the patient. S12RN read the power of attorney again and said he might code Patient #1 unless the family was in the room. When asked if the patient was in their right mind and could make decisions for themselves, he said, "yes." When asked who signed his wishes for resuscitation in the medical record, he said, "the patient." When asked to read it again, he said it did not say the patient did not want to be resuscitated, but he did not want to be on life support if he would never come off of it. He said it would also be the decision of two doctors. He said after rereading the power of attorney again he would probably code the patient. When asked if he had gotten in report a few hours earlier that the patient was a DNR he said he could not remember. He said he thought Patient #1 was a do not intubate but could never locate the order.

In an interview on 10/28/2020 at 9:07 a.m. with S20NP, she said Patient #1 was not ready for Hospice and he wanted to keep fighting. She said Patient #1 had said he wanted everything done for him. She said if there is no order either way in the medical record then a patient is a full code. She reviewed Patient #1's physician's orders and there was no order for code status so he would be considered a full code.

In an interview on 10/27/2020 at 9:40 a.m. with S22LPN, she said the process for knowing if a patient was a DNR was to get it in report. She said she had never seen stickers placed on the patient's medical record. When asked if another nurse's patient was found on the floor when that nurse was at lunch how would she know if the patient was a DNR, she said she would call for help and someone would have to look at the patient's medical record to see if they were a DNR. She said she would not start resuscitation until they told her yes or no. S22LPN agreed this would cause a delay in treatment. She said she had never seen a notification on a patient's armband that they were a DNR.

In an interview on 10/27/2020 at 9:50 a.m. with S23LPN, she said the nurses get report between shifts as to whether or not a patient is a DNR. She said they do not mark the patient's medical record although they should. When asked if another nurse's patient was found on the floor when that nurse was at lunch how would she know if the patient was a DNR, she said she would not start CPR until someone looked at the patient's medical record. S23LPN said they have things that say DNR to attach to the patient's armband but she did not know where they were kept. When asked if there had been patients in the hospital that were DNR status since she had worked there and she said, "Yes." When asked if any of the patients had a notation on their armbands, she said she had never seen one on a patient.

In an interview on 10/27/2020 at 9:58 a.m. with S21RN, he said there were purple tags that are attached to a DNR patient's armband. When asked if he had ever seen one on a DNR patient, he said he had not.

In an interview on 10/27/2020 at 10:00 a.m. with S2CCO, she verified there was a system failure in the hospital for the DNR process.


2) Failing to ensure staff are properly trained on current professional guidelines regarding the initiation of CPR when a patient is exhibiting obvious signs of death.

Review of the American Heart Association Guidelines for CPR and Emergency Cardiovascular Care revealed the following:
The American Heart Association urges all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order is in place; obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or initiating CPR could cause injury or peril to the rescuer

Patient #2
Review of Patient #2's medical record revealed he had been admitted to the hospital on 09/22/2020 for impaired function and ADL's secondary to ALS and debility.

Review of Patient #2's discharge summary revealed the following entry: Patient was not seen today (09/28/2020). Notified prior to morning rounds that patient was found unresponsive at 6:20 a.m. at which time CPR was initiated and 911 was notified. Per nursing patient expired at 6:57 a.m.

Review of Patient #2's nursing note dated 09/28/2020 at 8:27 a.m. revealed in part:
Patient found not responsive during a.m. rounds. No O2 observed on patient. 6:20 a.m. CPR initiated and 911 called. Time of death pronounced at 6:57 a.m.

Review of an investigation by the hospital dated 09/30/2020 at 5:58 p.m. revealed an interview with S17LPN. In the interview, S17LPN stated she had gone into Patient #2's room at 6:00 a.m. and she noticed he did not have on his oxygen and his eyes were open. She said she called his name and shook him and he did not respond. She said she then went to the door and called for S19RN. She said he was cold. S17LPN then said S19RN went and made phone calls. When asked what she had done next, S17LPN said she had one more patient she had to give medications and do an in and out catheter on so she went to that patient's room. When asked what Patient #2's code status had been, she replied, "Full code." When asked when she left to go to the other patient's room did she relinquish the care to S19RN, she replied, "I don't want to say I relinquished his care. I just did not know the protocol of the facility."

In an interview on 10/27/2020 at 12:40 p.m. with S2CCO, she said they had done an in-depth review of Patient #2's medical record. She said the nurse assigned to Patient #2 was S17LPN from a nurse staffing agency. She said Patient #2 was noted on 09/28/2020 at 6:11 a.m. to be unresponsive. When S17LPN went to the room she found Patient #2's eyes open, O2 not in place and he was unresponsive. S2CCO said S17LPN called for help and the other nurses went in to assist. She said the staff did not start CPR because they thought Patient #2 had clear signs of death. S2CCO said when they called to notify her of Patient #2's death she instructed them to begin CPR. She said they started CPR after that at 6:20 a.m. S2CCO said S17LPN knew Patient #2 was not a DNR, but since they felt there was obvious signs of death, she did not know if she should have started CPR or not.


3) Failing to provide training, competencies, or orientation to agency nurses on facility policies and procedures prior to being assigned to work in the facility.

In an interview on 10/27/2020 at 12:40 p.m. with S2CCO, when asked to see S17LPN's personnel file, S2CCO said the hospital does not have personnel files for agency nurses. S2CCO verified the hospital does not do training, competencies or orientation for agency nurses. She said the agency nurses have an attestation from their agency that they are trained in medical/surgical nursing. She also verified the hospital still uses agency nurses.

In a telephone interview on 10/29/2020 at 12:40 p.m. with S2CCO, she verified there were 4 agency nurses scheduled from 10/29/2020 until the end of the following week.


4) Failing to ensure all wound care orders are followed and documented inthe medical record.

A review of Patient #6's medical record failed to reveal documentation on October 16, 17, 21 and 22, 2020 for the following orders written by S8NP on 10/15/2020.
a) Order for Sacrum wound clean with normal saline. Apply Medihoney. Cover with alginate. Secure with paper tape. Change Daily;
b) Low air mattress, turn every 2 hours, off load heels; and
c) Scrotum, perineum- clean with normal saline, apply silver alginate, cover with ABD. Change daily.

On 10/27/2020 at 1:30 p.m. in an interview S11RN reviewed the entire medical record and verified the medical record failed to contain documentation that the orders were completed on dates noted above.

A review of Patient #7's medical record failed to reveal documentation on October 8 and 13th, 2020 for the following orders written by S8NP on 09/17/2020.
a) Left leg wound and medial heel clean with normal saline, apply silver alginate, cover with form border. Change daily.
b) Right foot 2nd toe and right lateral and medial heel, clean with normal saline. Apply silver alginate. Cover with ABD. Wrap with Kerlix. Change daily.

On 10/27/2020 at 1:40 p.m. in an interview S11RN reviewed the entire medical record and verified the medical record failed to contain documentation that the orders were completed on dates noted above.

Based on record review and interview the hospital failed to ensure that the nursing staff develops, and keeps current, a nursing care plan for 1 (#7) of 5 (#3, #4, #6-#8) patients that reflects the patient's goals and the nursing care to be provided to meet the patient's needs.

Findings:

A review of the hospital policy titled Nursing Patient Care Plan last approved 02/20/2020 reads in part:
A. Initiating/ Updating the Patient Care Plan
1) The Plan of Care will be initiated by an RN after completion of the Admission Assessment.
2) The Plan of Care will be reviewed each shift and updated with changes as necessary.

A review of hospital policy titled Fall Prevention last approved 06/2020 reveals in part:
2. At Risk: those patients identified as being "at risk" for falls by a score >= 51 will have additional interventions added to their plan in an effort to prevent falls:

a) Use of a "Fall Prevention" yellow magnet on the door-frame, yellow wrist clips.
b) Use of "call don't fall" sign posted in patient's room to remind patient to call for assistance.
c) Use of bed alarms/ chair alarms.
d) Use of "low bed" if available.
e) Consider moving patient closer to nurses Station.
f) Rehab evaluation and treatment as appropriate for conditioning/ strengthening options/ use of assistive devices.
g) Pharmacy review of medications for fall risk potential.
h) Selection of suitable chairs that have armrest.
I) Consideration of family staying with patient.
j) Notifying Attending Physician or LIP that the patient is a high risk for falls by:
i) Documenting in the patient's nursing assessment and or progress note.
ii) Discussing and initiating a plan of care (potential for self-injury related to risk for falls)

A review of Patient#7's Morse Fall Risk Assessment completed on 09/16/2020 to be 40.

A review of Patient#7's Morse Fall Risk Assessment completed on 09/20/2020 to be 60. Further review failed to reveal the box for High Risk Fall Precautions Implemented to be checked nor any written comments.

A review of Patient#7's Morse Fall Risk Assessment completed on 10/01/2020 to be 75. Further review revealed "Bed Alarm" written in comments and the box checked for High Risk Fall Precautions Implemented.

A review of Patient#7's Morse Fall Risk Assessment completed on 10/07/2020 to be 65. Further review revealed the box checked for High Risk Fall Precautions Implemented.

A review of Patient#7's Morse Fall Risk Assessment completed on 10/08/2020 to be 20. Further review failed to reveal the box for High Risk Fall Precautions Implemented to be checked nor any written comments.

A review of Patient #7's Care Plan for Falls revealed a date of 09/16/2020 with the following boxes checked: confusion, standard precautions, the high risk intervention- frequent reminders to call, patient will remain safe. The review failed to reveal the care plan was updated to include the yellow wrist band clip, fall risk magnet/ sign, chair arm, bed alarm, medication, review, low bed (if available) rehab evaluation, family member to remain with patient.

On 10/28/2020 at 12:15 p.m. in a telephone interview S2CCO verified Patient #7's care plan should have been revised to reflect the high risk interventions. She further stated once a patient is on high risk interventions the level of interventions does not go back down to standard precautions even if the patients Morse Fall Risk Assessment goes down.

Based on record review and interview, the hospital failed to ensure all patient medical record entries were accurate and complete. This deficient practice was evidenced by:

1) failure to document who pronounced a patient deceased for 1 (#3) of 2 (#2, #3) sampled patients reviewed for having had ACLS performed and expired from a total patient sample of 7 (#1-#7).
2) failure to document wound descriptions for 2 (#6, #7) of 5 (#3, #4, #6-#8) sampled patient records reviewed for wounds from a total sample of 8 (#1-#8).

Findings:

1) Failure to document who pronounced a patient deceased.

Review of Patient #3's medical record revealed an admission date of 07/07/2020. Further review revealed the patient expired on 07/16/2020. Patient #3's code status was documented as being Full Code.

Review of Patient #3's Daily nurses' notes revealed the following entry:
07/16/2020 05:19 a.m.: Patient found pulseless, breathless, EMS called, S13Dr called, ACLS protocol initiated, EMS at 05:26 a.m.

Review of the hospitals' Code Blue documentation sheet revealed the following note:
05:19 a.m.: Patient found breathless, pulseless, ACLS protocol initiated, 05:20 a.m. notified EMS, S13Dr. Code called at 06:08 a.m.

Review of Patient #3's discharge summary, dictated by the attending S13Dr on 07/16/2020, revealed the following, in part: I was notified at 5:24 a.m. this morning by nursing staff at Cura LTAC that the patient had unexpectedly expired at some point in the night. The nurse taking care of the patient stated that she went in to do a routine assessment and found the patient to be nonresponsive and without a pulse. EMS was contacted at that point. As per nursing reports, ACLS protocol was employed at the time of arrival by EMS, but was unsuccessful and the patient was pronounced deceased.

Further review of the above referenced entries in the patient's nursing notes, code documentation and physician's discharge summary revealed no documented evidence of the name of the physician who pronounced the patient.

In an interview on 10/28/2020 at 9:49 a.m. with S2COO, she reported almost every EMS code call has an MD with them on their calls. She further reported it is her understanding EMS assumed care of patient and their MD pronounced. She confirmed there was no documentation in Patient #3's medical record indicating the name of the physician who had pronounced the patient.

2) Failure to document wound descriptions for 2 (#6, #7) of 5 (#3, #4, #6-#8) sampled patient records reviewed for wounds from a total sample of 8 (#1-#8).

A review of Patient #6's medical record failed to reveal nursing documentation describing Patient #6's wounds on October 16, 17, 21 and 22, 2020. Further review revealed for the skin/ dressing assessment section Skin Intact: the nursing staff checked the box "No describe" and documented see WC but failed to describe the wounds. Further review of the record failed to reveal the wound documentation.

A review of Patient #7's medical record failed to reveal nursing documentation describing Patient #7's wounds on October 7- 10 and 13, 2020. Further review revealed for the skin/ dressing assessment section Skin Intact: the nursing staff checked the box "No describe" and documented see WC but failed to describe the wounds. Further review of the record failed to reveal the wound documentation.

On 10/27/2020 at 1:30 p.m. in an interview S11RN reviewed the entire medical record for Patient #6 and Patient #7 and verified the medical records failed to contain documentation describing the wounds on the dates noted above.




38777

Based on observations, record review and the hospital failed ensure a system for controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:
1) failure to ensure all staff and or visitors were screened for COVID-19 symptoms during a national pandemic of COVID-19;
2) failure to ensure staff performed proper hand hygiene;
3)failure to ensure staff properly wore PPE;
4) failure to ensure all opened medications, which were available for patient use ,were properly labeled and dated and/or not expired; and
5) failure to ensure all medication and patient nourishment refrigerator temperatures were documented.

Findings:

A review of the hospital policy titled Visitation COVID-19 approved 03/2020 revealed the following, in part:
Screening of visitors
Hospital staff shall man all designated points of entry. Each visitor should be actively assessed for the following:
- Presence of fever (i.e. temperature above 99.4) and/ or respiratory symptoms (cough).
- Known or suspected history of COVID-19.
- Known or suspected contact with an individual diagnosed with COVID-19.
- The ability to understand and comply with precautions.

1) Failure to ensure all staff and or visitors were screened for COVID-19.

On 10/27/2020 at 8:15 a.m. this surveyor entered the hospital off site campus located in Slidell, met with S7RN and toured the hospital without staff screening this surveyor for COVID-19.

On 10/27/2020 at 11:40 a.m. a review of the visitor and staff screening log failed to reveal S12RNDia was logged in and screened for COVID-19.

On 10/27/2020 at 11:45 a.m. S7RN confirmed S12RNDial was not listed as a visitor or staff for COVID-19 screening.

2) Failure to ensure staff performed proper hand hygiene.

On 10/27/2020 at 8:50 a.m. an observation of S10HKeep revealed she was cleaning Patient #R2's room, who was on contact isolation, and she exited the room not wearing a gown while carrying a trash bag out of the patient's room. S10HKeep then proceeded to open a door to the outside with her dirty glove and placed the trash bag outside. Upon re-entering the hospital, she touched her cleaning cart in multiple places, obtained a new trash bag from a roll then re-entered the patient's room.

On 10/27/2020 at 8:50 a.m. S14RT confirmed S10HKeep failed to wear a gown, change her gloves and perform hand hygiene.

3) Failure to ensure staff properly wore PPE.

On 10/26/2020 at 1:20 p.m. an observation of S15LPN, S16CNA and S3RN revealed they were wearing their mask below their nose while on the patient care unit.

On 10/26/2020 at 1:20 p.m. S2CCO verified the staff members referenced above were inappropriately wearing their masks.

On 10/26/2020 at 1:40 p.m. S2CCO stated all staff and visitors are to wear a mask or face covering over their nose and mouth.

On 10/27/2020 at 8:15 a.m. an observation of S7RN revealed she was wearing her mask below her nose.

On 10/27/2020 at 8:15 a.m. S7RN verified all staff and visitors are to wear a mask or face covering while in the hospital.

On 10/27/2020 at 11:25 a.m. an observation of S12RNDia while in Patient #R1's room providing dialysis revealed he was not wearing a mask or face shield.

On 10/27/2020 at 11:27 a.m. S7RN verified S12RNDia was at Patient#R1's bedside providing dialysis and not wearing a mask or face shield.


4) Failure to ensure all opened medications which were available for patient use were properly labeled and dated and/or not expired.

A review of the hospital's Storage of Medications policy last approved 04/2019 revealed the following, in part:
17. When a patient is discharged, medications will be removed from the individual patient storage area on the patient care unit (medication cassette/storage box) and returned to the medication room, until pharmacy retrieves them or they are returned to pharmacy.

On 10/27/2020 an observation of the hospital wound care cart revealed the following opened, not dated medications for patients who had been discharged.
a) 4 tubes of Santyl Ointment 250 units open and not dated with the labels partially removed;
b) Mupirocin 2% cream open and not dated;
c)2 bottles of Iodoform Packing Strips open and not dated.

On 10/27/2020 at 9:10 a.m. S7RN verified the labels were partially removed, the patients were no longer admitted to the hospital and the medications were not dated as to when they were opened.

5) Failure to ensure all medication and patient nourishment refrigerator temperatures were documented.

A review of the hospitals policy titled Storage of medications last approved 04/2019 reads in part:
Medications will be stored at appropriate temperatures.
Temperature monitoring
a. Pharmacy will oversee the continuous monitoring and maintenance of all drug storage refrigerators.
c. Refrigerator temperature logs will be maintained and audited by the Pharmacy and/or nursing Departments, and discrepancies will be tracked and reported to the Director of Pharmacy.

On 10/27/2020 an observation of the patient nourishment refrigerator failed to reveal documented temperatures on the following dates: 2020: July 16-18, 24, and 30th; August 5, 6, 13, 22, and 27th; September 8; October 6, 14, and 15th.

On 10/27/2020 at 9:00 a.m. S7RN verified the missing temperatures.

On 10/27/2020 an observation of the patient medication refrigerator revealed missing documented temperatures on the following dates for October 2020: 3rd- day shift, 16th - night shift, 20th -night shift, 21st and 22nd - day shift, 23rd and 24th- night shift.

On 10/27/2020 at 9:05 a.m. S7RN verified the missing patient medication refrigerator temperatures.