HospitalInspections.org

Based on review of documents and interview, the hospital failed to have a Registered Nurse:
A. document the head to toe physical assessment every 24 hours.
B. ensure vital signs were completed as ordered.
C. utilize the "Patient Controlled Analgesia (PCA)" worksheet to monitor the patient.
D. ensure licensed nursing staff performed re-evaluation of pain after pharmacological intervention.
E. report critical lab values to the ordering physician.

Findings include:

A policy titled "Assessment and Reassessment" showed an RN will perform a head to toe assessment every 24 hours.

A review of medical records showed nine (Patients #1, 2, 8, 9, 10, 11, 12, 19 and 20) of 20 medical records did not document the head to toe physical assessment by the RN every 24 hours.

During an interview on 03/07/17 at 4:30 p.m., the CCO stated the RN is required to assess patients and document the assessment every 24 hours.

A policy titled "Vital Sign Policy" showed vital signs to be taken as ordered by the provider or more frequently as determined by inuring assessment.

A review of medical records show five (Patients #1, 5, 8, 9 and 10) of 20 medical records showed vital signs were ordered every four hours by the licensed independent practitioner. Nursing staff did not document vital signs for the patients every four hours.

A policy titled "Patient Controlled Analgesia" showed the PCA Flowsheet was to be utilized for documentation of PCA therapy. Respiration rate, level of consciousness (LOC) and pain assessment were to be recorded on the PCA record prior to initiating the PCA. Upon initiating therapy, the RN would assess blood pressure, pulse, respiratory rate, pain score and sedation level.

A review of medical records show one (Patient #6) of 20 medical records with no evidence of RN initial assessment prior to initiation of therapy, no blood pressure, pulse, respiratory rate, pain score or sedation level. The medical record documents the order for PCA initiated on "12/23/16 at 2340". There was no evidence the RN documented the assessment of respiration rate, level of consciousness and pain utilizing the PCA Flowsheet.

A policy titled "Pain Assessment and Management" showed patients to be reassessed after pharmacological intervention for pain according to the following intervals: oral medication within one hour, IV medication within 30 minutes and document effectiveness.

A review of medical records showed five (Patients #1, 5, 8, 9 and 11) of 20 medical records showed no evidence of reassessment of the patients' pain within the identified time intervals.

A policy titled "Critical Value Test Results" showed results of critical labs will be called/reported to the ordering licensed independent practitioner or designee within 15 minutes.

A review of one (Patient #11) of 20 medical records showed no documentation of a critical value result of hemoglobin reported to the ordering licensed independent practitioner with 15 minutes.

During an interview on 03/08/17 at 2:00 p.m., the CCO stated there was no evidence of reporting the critical value to the licensed independent practitioner within 15 minutes.

Based on review of documents and interview, the hospital failed to ensure licensed healthcare providers timely documented the administration of scheduled medications.

Findings include:

A review of medical records showed four (Patients #1, 2, 3 and 4) of 20 records had no evidence on the Medication Administration Record (MAR) of medications being administered by licensed nursing staff.

A review of medical records showed two (Patients #5 and 9) of 20 records had evidence in the nursing flowsheet of pain medication being administered to the patient by documenting "M" as medication for relief. There was no corresponding documentation in the MAR of the actual medication and dosage given to the patient.

During an interview on 03/08/17 at 2:00 p.m., the CCO stated entries in the medical record were incomplete.

Based on review of documents and interview, the hospital failed to ensure healthcare providers completed, dated and timed written medical record entries.

Findings include:

A review of medical records showed three (Patients #1, 5 and 7) of 20 records had no evidence of date and/or time for medical record entries including physical therapy notes, wound care notes and admission orders.

During an interview on 03/08/17 at 2:00 p.m., the CCO stated all entries into the medical record shall have a date and time noted.

Based on review of documents and interview, the hospital failed to ensure licensed healthcare providers dated, timed and authenticated verbal orders.

Findings include:

A policy titled "Orders: Verbal" showed verbal orders to be received by authorized professionals and immediately reduced to writing and read back to the prescriber to confirm and/or clarify. The policy also showed information required for the verbal order "shall include the date and time of entry, prescribing practitioner's name and signature and title of person who accepted the order".

A review of medical records showed four (Patients #1, 2, 3 and 5) of 20 records had no evidence of date and time the telephone orders were received by the licensed nuring staff.

Additionally, the medical records showed four (Patients #4, 6, 9 and 10) of 20 records had no evidence of read-back for verbal orders received by respiratory therapists.

During an interview on 03/08/17 at 2:00 p.m., the CCO stated all entries, including orders, should have a date and time on the entry. Orders received verbally or by telephone should have a read-back noted in the patient's medical record.

Based on observations, document review and interview, the infection control preventionists failed to:
A. evaluate processes to mitigate the risk of infections and communicable diseases in the area of hand hygiene
B. ensure patient environment was clean.

A policy titled "Infection Control Plan" showed the infection control program operates under the standards set by Center for Disease Control and Prevention (CDC), Occupational Safety and Health Administration (OSHA), and The Joint Commission (TJC).

During a tour of the facility on 03/03/17 at 3:50 p.m., surveyors observed a staff member coming out of a patient room without performing hand hygiene.

On 03/08/17 at 9:40 a.m., surveyors observed staff member coming out of a patient room with gloves on, obtained linens from the linen cabinet, and returned to the patient room without removing gloves or performing hand hygiene.

On 03/08/17 at 9:41 a.m., surveyors observed staff member answering call light to room 2816. Staff member pulled on gloves without performing hand hygiene.

During an interview on 03/08/17 at 3:00 p.m., the CEO, Infection Control and Infection Control assistant stated the hospital had ongoing issues with hand hygiene.

Surveyors also observed corrugated boxes stacked outside the door to the supply room; corrugated boxes stacked in the medication room; uncovered, unused equipment in a hallway and used, concovered food trays in a hallway.

During an interview on 03/08/17 at 2:00 p.m., the CCO stated:
A. Corrugated boxes were inappropriately placed in hallway
B. Equipment was inappropriately stored in the hallway and
C. Uncovered food trays were left in the hallway.

Based on a document review and interview, the hospital failed to obtain an "Against Medical Advice (AMA)" release prior to the discharge of a patient.

Findings include:

A policy titled "Patient Discharge/AMA" showed an AMA release form was to be signed by the patient or responsible relative and two witnesses prior to the patient leaving the facility.

A review of medical records showed one (Patient #4) of 20 records had no evidence of an AMA release form signed by the patient and witnessed prior to the patient being discharged from the hospital.

During an interview on 03/08/17 at 2:05 p.m., the CCO stated an AMA release form should have been obtained prior to the patient leaving the hospital against medical advice.