HospitalInspections.org

Based on policy and procedure review, patient medical record review, and staff interview, the medical staff failed to ensure blood cultures were drawn and picked up by contracted lab services without extended time delays for one patient; failed to ensure speech therapy/swallow studies were not delayed due to policy requirement for order confirmation by the medical director for two patients; and failed to identify in the medical record the delay in obtaining a urine specimen for one patient (pts. #1, #8 and #9).

Findings:
1. pt. #1 was admitted on 8/29/13 with an admitting diagnosis of "sepsis", per the "record of death" form completed on 8/30/13. Also per the "record of death" form, the cause of death was listed as "Acute CVA (cardiovascular accident), with no documentation in the medical record as to the date of the CVA. The patient had:
A. blood cultures ordered at 6:45 PM on 8/29/13
B. blood cultures drawn at 12:39 AM on 8/30/13
C. blood cultures picked up by the contracted lab courier at 2:41 PM on 8/30/13 (more than 5 hours after the patient had died at 9:02 AM) and reported at 9:21 AM on 8/31/13 with preliminary results of "gram positive cocci, suggestive of staphylococci"

2. pt. #9 was admitted on 9/3/13 with a diagnosis, per the pre-admission assessment, of right lobe pneumonia and per the history and physical with a past history of UTIs (urinary tract infections). The patient's death occurred on 9/8/13, and was listed on the "record of death" form with a cause of death of "Acute Heart failure". The pt. had:
A. an admission order written on 9/3/13 for a "speech eval" that was authenticated by the psychiatrist (no reason/diagnosis was listed for the order--on 9/4/13, nursing noted the patient was "Independent wit meal after set up. Good consumption." On 9/5/13 the practitioner noted the pt "...leans to the RT (right) side and was "confused")
B. an order written on 9/5/13 at 8 AM that reads; "ST eval approved"
C. a speech eval/swallow study done on 9/6/13 at 11:10 AM
D. a urinalysis report in the chart from an 8/16/13 (reported at the previous facility) a C & S (culture and sensitivity) that indicated the patient had E coli in the urine at that facility hospitalization (no report of antibiotics that were resistant or susceptible for that C & S was in the medical record)
E. admission orders on 9/3/13 that had the UA checked with a written note to do on 9/6/13
F. a 9/7/13 culture done (prior to the patient's death on 9/8/13), and not reported until 9/10/13, that indicated there was e-coli present and not susceptible to Cipro (it is unknown why the patient had no UA performed prior to the one done on 9/7/13)

3. pt. #8 was admitted on 10/22/13 with an admission diagnosis of "acute mental status changes", per the pre-admission assessment. Also per the pre-admission assessment, the patient was noted in the "evaluator's observations"area that the patient was high-functioning physically and could feed themselves. Per the practitioner notes on 10/23/13, the patient had "late effect CVA", possibly thus causing a need for a swallow study with the patient's decreased sensorium. The pt. had:
A. orders written by the NP (nurse practitioner) on 10/24/13 at 9:50 AM for a "ST (speech therapy) eval - dysphagia" (swallow study for pt's difficulty in swallowing)
B. a note written on 10/24/13 at 11:05 AM, where the speech therapist noted "Waited 15 minutes for authorization before being able to proceed with eval per facility policy but no response from txt (text) sent to Dr. (chief of staff). Unable to complete eval [secondary to] no authorization received, as facility policy requires."
C. another order was written on 10/25/13 at 9:45 AM by the NP for: "ST eval please--dysphagia"
D. no swallow study note found in the medical record after 10/25/13 until the dietician wrote an order (authenticated by the physician) that read: "Speech tx (therapy) recom (recommends) pureed and honey thick liquids and only feed when alert"

4. Review of the policy and procedure "Criteria for Admittance to Therapy Services", policy number II - E.86, Issued 12/2012, indicated:
a. under "Procedure", it reads: "1. therapy Services Director will review the patient medical record and note the following: a. Written physician order...2. Therapy Services Director will contact Medical Director for confirmation of order..."

5. at 11:30 AM on 11/15/13, interview with staff members #60, the administrator, and #63, the VP of Project Management, indicated:
a. per facility policy, chief of staff "authorization" is "required" for ST/swallow studies for patients
b. this may be an unsafe practice due to aspiration possibilities in debilitated patients

Based on review of the medical staff rules and regulations, patient medical record review, and staff interview, the medical staff failed to ensure the implementation of the requirements related to admission history and physical exams for 3 patients (pts. #11, #12, and #14).

Findings:
1. Review of the medical staff rules and regulations, last approved 12/2012, indicated:
a. on page 9, under section "I. Medical Records", it reads: "...a. History and Physical: A medical history and physical examination shall in all cases be written or dictated, placed on the medical record within 24 hours following admission of the patient..."

2. Review of patient medical records indicated:
a. pt. #11 was admitted on 8/14/13 and had a H & P (History and Physical) dictated on 8/16/13
b. pt. #12 was admitted on 8/18/13 and the H & P wasn't dictated until 10/22/13
c. pt. #14 was admitted on 10/31/13 and the H & P was dictated on 11/2/13

3. Interview with staff members #60, the administrator, and #62, the chief nursing officer, at 11:30 AM on 11/14/13 and 1:00 PM and 1:30 PM on 11/15/13, indicated:
a. the H & Ps listed in 2. above are not per the medical staff rules and regulations requirements

Based on policy and procedure review, facility document review, and staff interview, the nursing executive failed to ensure that nursing staff implemented the policy and procedure related to the completion of an incident report for one patient (N9); and failed to ensure the timely administration of an antibiotic ordered for two patients (pt. #1 and #6).

Findings:
1. review of the policy and procedure "Incident Reports", policy number III-B.11, with an issued date of 12/2012, indicated:
a. under "Procedure", it reads: "An Incident Report should be completed immediately when an incident occurs..."

2. Review of facility incident reports indicated that pt. #9 had a fall at 12:15 PM on 9/4/13 that lacked completion of page two in the areas of: "Intervention"; "Outcome"; "How could this incident have been prevented?"; Supervisor's Comments"; Signature of person preparing report"; "Signature of person reviewing report"' "Risk Management Review/Follow-Up"; and a date and time at the bottom of the page

3. at 11:30 AM on 11/15/13, interview with staff members #60, the administrator, and #63, the VP of Project Management, indicated page two was not completed by nursing staff as expected after an incident occurs

4. pt. #1 was admitted on 8/29/13 with an admitting diagnosis of "sepsis", per the "record of death" form completed on 8/30/13. Also per the "record of death" form, the cause of death was listed as "Acute CVA (cardiovascular accident), with no documentation in the medical record as to the date of the CVA. The patient had Vancomycin 1 gm ordered IV as a "now" order at 5:00 PM on 8/29/13 and not started until 11:00 PM

5. pt. #6 was admitted on 8/28/13 at 7:50 PM. Per the History and Physical, in the section "History of Present Illness" section, it reads: "...has been having escalating agitation and behaviors, verbally abusive with staff, refusing care...also has visual hallucinations, seeing things in [their] food and so...is admitted to [fac. A] for an interdisciplinary team workup and approach." The patient's death was noted at 8:30 PM on 9/3/13 with physician progress notes of 9/3/13 reading: "Death was due to pneumonia related causes.".
A. on 9/3/13, at 12:00 PM, nursing wrote: "Staff check on pt d/t (due to) heard pt having difficulty breathing. Pt using abd (abdominal) muscles and staff could hear wet moist crackles. Writer called NP [named]."
B. at 2:35 PM on 9/3/13, the NP ordered "IV Cipro 400 mg BID (two times/day)- pharmacy to dose..." (pharmacy did not see the patient prior to death and no Cipro was given--interview with staff indicated pharmacy staff are on site 8 AM to 5 PM Monday through Friday--9/3/13 was a Tuesday so it is unknown why there was a delay in the administration of Cipro or in evaluation by Pharmacy staff)

Based on policy and procedure review and medical record review the nursing executive failed to ensure that nursing staff completely developed nursing care plans for 2 patients. (pts. #2 and #13)

Findings:
1. Review of the policy and procedure "Individual Plan of Care", policy number II - C.28, issued 12/2012, indicated:
a. under "Policy", it reads: "All patients will have an individualized plan of care that is individually tailored, integrated and coordinated."
b. under "Purpose", it reads: "To establish a comprehensive,individualized plan for each patient served."

2. Review of patient medical records indicated:
a. pt.#2 was admitted on 9/16/13 and had no care plan documented until 9/22/13
b. pt. #13 was admitted on 10/31/13 and was care planned for:
A. "Patient requires assistance with ADLs (activities of daily living) and mobility r/t (related to) decreased mobility..."
B. "Potential for falls R/T poor safety awareness..."
C. lacked any documentation of "Nursing Interventions" for the problems the patient was care planned for

Based on document review, and interview, the facility failed to develop a method of assessment of its discharge plans that would ensure responsiveness to discharge needs.

Findings:
1. Review of the facility Quality Improvement Plan titled "Organizational Performance Improvement Plan", policy number I - E.1, issued 12/2012, indicated:
a. on page two under "Review Processes", it reads: "...E. Discharge Planning: will report to the Quality Council on discharge quality measures..."

2. review of Quality Council meeting minutes indicated:
a. the 10/22/13 meeting listed "Total admissions: 226 Total discharges: 225"
b. the 7/22/13 meeting listed "Total admissions 219 Total discharges: 218"
c. the 4/29/13 meeting listed "Total admissions: 166 Total discharges: 156"

3. phone interview with staff member #64, the chief clinical officer, quality assurance director, and compliance officer, at 8:25 AM and 1:30 PM on 11/20/13, indicated:
a. this staff member logs all transfers and deaths and discusses them with the chief of staff before reporting at the Quality Council meetings
b. the report given at Quality Council meetings is an aggregate of discharges with no determination of indicators or quality standards to be met, and whether they are, or are not, met
c. the only quality measure currently reviewed and reported is whether the "notice of non coverage" has been signed by patients' significant party/poa (power of attorney)