HospitalInspections.org

Based on observation, interview and record review the Governing Body failed to:

A. ensure that staff followed the physician's orders for performing peritoneal dialysis treatment, which included documentation of the treatment and the results of the dialysis treatment. Citing 1 (#1) of 1 peritoneal dialysis patient.

B. to screen for hepatitis B surface antigen (HBsAg) and (HbAb) within 30 days prior to admission or at the time of admission or have a known HBsAg positive status prior to admission, citing 5 (#1, #2, #3, #17 and #30) of 5 (#1, #2, #3, #17 and #30) patients records.

C. ensure and provide evidence that the dialysis machines used by the patients (#1, #2, #3, #17, and # 30) which had an unknown (HBsAg) were given intermediate level disinfection prior to use by another patient or ensure that each patient with an unknown (HBsAg) had a dedicated dialysis machine. Citing 5 (#1, #2, #3, #17, and # 30) of 5 (#1, #2, #3, #17 and #30) hemodialysis patient records reviewed. A review of the records indicated 7 dialysis machine (#14, #15, #16, #17, #18, #19, and #20) had been used on patients with an unknown (HBsAg) status and had not been disinfected prior to the use on other patients in the dialysis unit.

D. ensure that all samples for chlorine/chloramines testing were drawn when the water treatment system had been operating for at least 15 minutes. These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to harmful chlorine and chloramines chemicals. Citing 4 (RO3, ROZ2, ROZ4, ROZ1) of 4 RO's (Reverse Osmosis Water System) reviewed.

E. offer and administer Hepatitis B vaccinations to susceptible staff whose antibodies were less than 10 mIU (Mill International Unit); or test the staff for antibodies to determine the need for immunizations. Also, a review of records indicated the Engerix vaccine was not given as recommended by the Engerix guidelines. The facility failed to follow the facility's own policy and the Center for Disease Control. Citing 3 (#5, #6, and #9) of 4 (#5, #6, #7 and #9) dialysis staff personnel records reviewed.

F. ensure that the dialysis machines had maintenance conducted according to manufacturer instructions. Citing 1 (#14) of 7 (#14, #15, #16, #17, #18, #19, and # 20) dialysis machines reviewed.

G. ensure the dialysis machines were disinfected weekly as required by manufacture recommendation. Citing 1 (#14) of 7 (#14, #15, #16, #17, #18, #19, and # 20) dialysis machines reviewed.

H. ensure the Medical Director was credentialed by the Governing Body. Citing 1 (#8) of 1 Medical Director's file.

I. ensure the serial numbers were documented on the culture and endotoxin reports for the dialysis machines and portable RO (water) systems, Citing 7 (#14, #15, #16, #17, # 18 # 19 and # 20) of 7 dialysis machines and 4 (RO3, ROZ2, ROZ4, ROZ1) of 4 portable RO's.

J. ensure the water room and bicarbonate mixing area was clean and there was space to separate clean bicarbonate mixing from the dialysis machines.


Refer to tag A0144 for additional information.


K. ensure timely appointments to the medical staff in 6 of 6 credentialing files reviewed (Staff #11, Staff #37, Staff # 38, Staff #39, Staff # 40 and Staff #42). The credentialing files contained lapses in privileges. The facility did not contain a complete list of physicians who were credentialed to provide services in the hospital.

Refer to tag A0046 for additional information.


L ensure contracted services were assessed in a manner to identify quality and performance problems in 5 of 5 services (Dialysis, Environmental, Pharmacy Education/Orientation, Infection control-Employee Health, Wound Care services).
Refer to tag A0083 for additional information.



M. ensure nursing staff followed plans to ensure complete nursing skin assessments on patient with pressure sores, turning and repositioning was provided as ordered, pain assessments were performed and x-rays were obtained as ordered by the physician. This deficient practice was found in 3 of 3 patients (Patient #s' 13, 21, and 23).

Refer to tag A0396 for additional information.


N. ensure nursing staff administered medications as ordered, failed to ensure there were physician orders for medications being administered and failed to ensure medications were administered timely. This deficient practice was found in 4 of 4 patients (Patient #s' 9, 14, 15, and 22).
Refer to tag A0405 for additional information.


O. ensure nursing staff used verbal orders infrequently. The facility failed to ensure verbal orders were timed, dated and signed timely. This deficient practice was found in 11 of 11 patients (Patient #s' 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 28).

Refer to tag A0407 for additional information.



P. ensure the Infection Control Preventionist created and implement policies and /or protocols to insure a sanitary environment to inhibit the potential for Hospital Acquired Infections (HAI). They failed to ensure the employee vaccination policy was accurate for the patient population they were servicing. They failed to ensure sanitary environment in medications rooms, patient rooms, and patient supply rooms.

Refer to tags A0748 and A0749 for additional information.

Q. ensure evidence of hospital wide participation the Infection Control Program for 12 of 12 months. They failed to ensure environmental rounds were conducted to assess the condition of the environment.

Refer to tags A0756 for additional information.


R. Review of the evaluation tools on the contracted services for Dialysis, Environmental, Pharmacy Education/Orientation, Infection control-Employee Health, Wound Care services revealed the last time services were evaluated was on 12/09/2015. Documentation revealed all of the services met expectation and no problems were found.
The evaluations were performed annually and there was documentation that administration found no problems with the dialysis contracted services. The evaluations had not identified any of the problems found during the survey from 01/26-29/2016.
Review of the quality meeting minutes from 2015 revealed there was two areas being consistently reported on for dialysis. The dialysis conductivity and medical director review of signing the dialysis reverse osmosis machine reports monthly. The quality minutes for 2015 revealed quality indicators listed on the forms for other hospital departments and services. There was no attached data to determine how the quality indicators were selected.
During an interview on 01/27/2016 after 1:30 p.m., Staff #1 (CNO/Director of Quality) and Staff #27 (CEO) confirmed not knowing about the deficient problems found on the dialysis unit.
During an interview on 01/28/2016 after 8:00 a.m., Staff #1 (CNO) confirmed these were the only two areas they were monitoring for dialysis. They had not been tracking anything else in dialysis. Staff #1 confirmed the department heads were coming up with the quality indicators to track for the other departments. Staff #1 reported there was no systematic way of identifying what they needed to track. There was no collection of data to back up all of the quality indicators they were currently using. Nor did they have a way of identifying other quality indicators in the facility outside of what was listed on the form.
During an interview on 01/28/2016 after 10:00 a.m., Staff # 27(CEO) reported he was responsible for evaluating contracted services. The evaluations were performed annually and he had not found any problems with the dialysis contracted services.


S. ensure operating policies were updated. They failed to ensure policies being used were for the specialty hospital.
Review of the Board of Director Minutes for 2015 revealed the following on 05/27/2015 revealed 20 policy and procedures were reviewed. Included in the list of policies were Pharmacy, Patient Care Services, Infection Control Plan, Staffing Effectiveness Plan with policy, and Patient Safety Program.
Policies provided during the survey from 01/26-29/2016 revealed some of the following examples:
*Restraint or Seclusion policy which was under the title of another hospital and had an effective date of 12/01/2016.
*A policy named "CODE SILVER:ACTIVE SHOOTER/WORK PLACE VIOLENCE" which was for the main hospital. It was not designated as a policy the staff at the specialty unit should be using.
*A policy named "Safe Patient Handling and Movement" with an effective date of 06/17/2015 and was for the main hospital. It was not designated as a policy the staff at the specialty unit should be using.
* A policy named "Hospital Staffing Nurse Staffing Policy" dated March 2014 revealed nurse staffing levels would be set. There was no documentation of an updated plan with nursing levels.
*A policy named "Patient Safety Program" revealed a command center call down list of staff to call in the event of a disaster. The plan included administrative staff from the specialty hospital and another hospital. The Patient Safety Program including a list of events/occurrences that required reporting which were addressed at services they did not provide. The incident form that was suppose to be completed by staff was addressed to another hospital.

Review of the Amended Bylaws of the Governing Body of (Hospital #1) dated April 24, 2013 revealed the following:

ARTICLE iii
BOARD OF DIRECTORS
A. Responsibility/Authority-The property, business and affairs of the corporation shall be managed by the Board of Directors. Complete authority policy making, and management of said hospital is vested in the Board of Directors. The responsibilities and authorities of the Board include, but are not limited to the following:
1. The Board of Director is charged with the duties and responsibilities of the operation and management of said Hospital.
2. The Board of Director shall also prescribe the duties and powers of the officers of the Corporation and the officers and employees of the Hospital and shall fix the terms of employment of all officers and employees of the Hospital.
3. All appointments to the Medical and Dental Staffs of said Hospital shall be made by the Board of Directors.
4. The Board of Directors shall strive to assure quality patient care by requiring and supporting the establishment and maintenance of an effective hospital wide quality assessment and improvement program which among other things, performs the following functions:
a. Reviews the quality of patient care rendered by individuals who are not subject to the medical staff privilege delineation process to insure they are competent to provide such services.
b. Assures that all individuals responsible for the assessment, treatment or care of patients are competent for the following, as appropriate to the ages of the patient served;
i. The ability to obtain information and interpret information in terms of the patients ' s needs;
ii. The knowledge of growth and development; and
iii. An understanding of the range of treatment needed by these patients.
c. Assures that all patients with the same health problem are receiving the same level of care in the Hospital.

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


A. ensure that staff followed the physician's orders for performing peritoneal dialysis treatment, which included documentation of the treatment and the results of the dialysis treatment. Citing 1 (#1) of 1 peritoneal dialysis patient.

B. to screen for hepatitis B surface antigen (HBsAg) and (HbAb) within 30 days prior to admission or at the time of admission or have a known HBsAg positive status prior to admission, citing 5 (#1, #2, #3, #17 and #30) of 5 (#1, #2, #3, #17 and #30) patients records.

C. ensure and provide evidence that the dialysis machines used by the patients (#1, #2, #3, #17, and # 30) which had an unknown (HBsAg) were given intermediate level disinfection prior to use by another patient or ensure that each patient with an unknown (HBsAg) had a dedicated dialysis machine. Citing 5 (#1, #2, #3, #17, and # 30) of 5 (#1, #2, #3, #17 and #30) hemodialysis patient records reviewed. A review of the records indicated 7 dialysis machine (#14, #15, #16, #17, #18, #19, and #20) had been used on patients with an unknown (HBsAg) status and had not been disinfected prior to the use on other patients in the dialysis unit.

D. ensure that all samples for chlorine/chloramines testing were drawn when the water treatment system had been operating for at least 15 minutes. These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to harmful chlorine and chloramines chemicals. Citing 4 (RO3, ROZ2, ROZ4, ROZ1) of 4 RO's (Reverse Osmosis Water System) reviewed.

E. offer and administer Hepatitis B vaccinations to susceptible staff whose antibodies were less than 10 mIU (Mill International Unit); or test the staff for antibodies to determine the need for immunizations. Also, a review of records indicated the Engerix vaccine was not given as recommended by the Engerix guidelines. The facility failed to follow the facility's own policy and the Center for Disease Control. Citing 3 (#5, #6, and #9) of 4 (#5, #6, #7 and #9) dialysis staff personnel records reviewed.

F. ensure that the dialysis machines had maintenance conducted according to manufacturer instructions. Citing 1 (#14) of 7 (#14, #15, #16, #17, #18, #19, and # 20) dialysis machines reviewed.

G. ensure the dialysis machines were disinfected weekly as required by manufacture recommendation. Citing 1 (#14) of 7 (#14, #15, #16, #17, #18, #19, and # 20) dialysis machines reviewed.

H. ensure the Medical Director was credentialed by the Governing Body. Citing 1 (#8) of 1 Medical Director's file.

I. ensure the serial numbers were documented on the culture and endotoxin reports for the dialysis machines and portable RO (water) systems, Citing 7 (#14, #15, #16, #17, # 18 #19 and #20) of 7 dialysis machines and 4 (RO3, ROZ2, ROZ4, ROZ1) of 4 portable RO's.


J. ensure the water room and bicarbonate mixing area was clean and there was space to separate clean bicarbonate mixing from the dialysis machines.

Refer to tag A 0144 for additional information.


K. ensure patients were not provided the correct information for contacting the Quality Improvement Organization (QIO), Kepro, and hospital representative upon admission and prior to discharge.

Refer to tag A 0117 for additional information.


It was determined that these deficient practices posed an Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequently death.

Based on interview and record review the facility failed to:
A. ensure all hospital departments and services under contact or arrangement were evaluated in a manner to identify quality deficient problems.
B. ensure other aspects of performance that assessed process of care/services were measured analyzed and tracked.
C. ensure a quality program which identified performance improvement activities which affected patient safety.

This deficient practice had the likelihood to cause harm to all patients.
Findings include:

A. Review of the evaluation tools on the contracted services for Dialysis, Environmental, Pharmacy Education/Orientation, Infection control-Employee Health, Wound Care services revealed the last time services were evaluated was on 12/09/2015. Documentation revealed all of the services met expectation and no problems were found.
The evaluations were performed annually and the administrator had not found any problems with the dialysis contracted services. The evaluations had not identified any of the problems found during the survey from 01/26-29/2016.
Review of the quality meeting minutes from 2015 revealed there was two areas being consistently reported on for dialysis. The dialysis conductivity and medical director review of signing the dialysis reverse osmosis machine reports monthly. The quality minutes for 2015 revealed quality indicators listed on the forms for other hospital departments and services. There was no attached data to determine how the quality indicators were selected.
During an interview on 01/27/2016 after 1:30 p.m., Staff #1 (CNO/Director of Quality) and Staff #27 (CEO) confirmed not knowing about the deficient problems found on the dialysis unit.
During an interview on 01/28/2016 after 8:00 a.m., Staff #1 (CNO) confirmed these were the only two areas they were monitoring for dialysis. They had not been tracking anything else in dialysis. Staff #1 confirmed the department heads were coming up with the quality indicators to track for the other departments. Staff #1 reported there was no systematic way of identifying what they needed to track. There was no collection of data to back up all of the quality indicators they were currently using. Nor did they have a way of identifying other quality indicators in the facility outside of what was listed on the form.
During an interview on 01/28/2016 after 10:00 a.m., Staff # 27(CEO) reported he was responsible for evaluating contracted services. The evaluations were performed annually and he had not found any problems with the dialysis contracted services.


B. Review of complaint and grievances for 2015 revealed no documentation of patient complaints being captured.
Review of patient grievance/incident reports for 2015 revealed no documentation of root cause analysis being performed.
During an interview on 01/27/2016 after 10:25 a.m., with Staff #1 and 14 revealed they were not documenting patient complaints. They were not performing root cause analysis on grievances.
Review of quality minutes for 2015 revealed no ongoing program for addressing patient safety which would have been captured from the complaint and incident process.


C. Review of the quality minutes for 2015 revealed no tracking of Emergency service for the specialty hospital.
During an interview on 01/26/2016 after 3:00 p.m., Staff #1 confirmed Emergency services was not being tracked in quality.

D. Review of the quality minutes for 2015 revealed no tracking or analysis of nursing medication errors.
During an interview on 01/27/2016 after 10:25 a.m., Staff #1 confirmed they did not have a system of monitoring nursing errors. Staff #1 reported nursing would be attending their first Pharmacy and Therapeutic meeting on today to address the problems.


28659

E. On 1/27/2016 in the morning, an interview with the director of the dietary department,staff #15, confirmed he did not submit his quality assessment or process improvement data to the specialty hospital for inclusion in their Quality Assessment Process Improvement (QAPI) program. He also confirmed he did not participate in department meetings with the specialty hospital. He simply provided dietary services as he would for any other area of, or department of the hospital.


F. On 1/27/2016 in the morning, an interview with the director of the radiology and nuclear medicine department, staff #18, revealed his department did not share any QAPI data with the specialty hospital. His department did not participate in department meetings. He provided after hours, weekend and holiday coverage for radiology or nuclear medicine services.

G. On 1/27/2016 in the office of the laboratory director, an interview with staff #46, the director, indicated his department did not share QAPI data with the specialty hospital. He also indicated he did not participate in department head meetings with the specialty hospital. There was little or no communication between the two. As far as his knew he turned his QAPI data into his quality program and it was shared as needed with the specialty hospital.


Review of the policy named "Performance Improvement Plan" dated 05/27/2015 revealed the following:
IV. GOALS
A. Clinical and administrative staff monitor and evaluate the quality of care, appropriateness of care, and the clinical performance on an ongoing basis in accordance with the Performance Improvement Plan. Evaluation will include measurement, analysis, and tracking of quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital services, and operations.
B. Performance improvement activities and outcomes are analyzed for trends, practice patterns, or potential problems in order to develop and implement a plan of correction.
C. The status of identified problems and corrective actions are monitored and reported to ensure measurable improvement in indicators that have evidence of improvement to health outcomes, including identification and reduction of medical errors.
D. The necessary information is communicated among services when problems or opportunities to improve patient care involve more than one service.

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

A. ensure nursing staff followed plans to ensure complete nursing skin assessments on patient with pressure sores, turning and repositioning was provided as ordered, pain assessments were performed and x-rays were obtained as ordered by the physician. This deficient practice was found in 3 of 3 patients (Patient #s' 13, 21, and 23).
Refer to tag A0396 for additional information.

B. ensure nursing staff administered medications as ordered, failed to ensure there were physician orders for medications being administered and failed to ensure medications were administered timely. This deficient practice was found in 4 of 4 patients (Patient #s' 9, 14, 15, and 22).
Refer to tag A0405 for additional information.


C ensure nursing staff used verbal orders infrequently. The facility failed to ensure verbal orders were timed, dated and signed timely. This deficient practice was found in 11 of 11 patients (Patient #s' 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 28).

Refer to tag A0407 for additional information.

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

A. ensure patient records were stored separately from other hospital and were easily accessible.
Refer to tag A 0438 for additional information.


B. ensure physician orders were complete, timed, dated and signed timely. This deficient practice was found in 12 of 12 patients (Patient #s' 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 28).
Refer to tag A 0454 for additional information.


C. ensure standing orders were complete, timed, dated, and signed timely in 4 of 4 patients (Patient #s' 21, 22, 24, and 25)
Refer to tag A 0457 for additional information.

D. ensure consents were properly completed and executed for 5 of 29 (#6, #7, #8, #10, and #17) patients.

Refer to tag A 0466 for additional information.

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


A. ensure the Infection Control Preventionist created and implement policies and /or protocols to insure a sanitary environment to inhibit the potential for Hospital Acquired Infections (HAI).

B. ensure the employee vaccination policy was accurate for the patient population they were servicing.

C. ensure a sanitary environment in medications rooms, patient rooms, and patient supply rooms.

Refer to tags A0748 and A0749 for additional information.

D. ensure evidence of hospital wide participation the Infection Control Program for 12 of 12 months. They failed to ensure environmental rounds were conducted to assess the condition of the environment.

Refer to tags A0756 for additional information.

Based on interview and records review, the Governing Body failed to make appropriate and timely appointments in 6 of 6 medical staff. (Staff #s' 11, Staff #37, Staff #38, Staff #39, Staff #40 and Staff #42).

A. The facility failed to ensure credentialing files did not contain lapses in privileges.
B. The facility failed to keep a list of credentialed staff available.
C. The facility failed to ensure hospital staff were able to verify that physicians were credentialed for the facility or verify the procedures the physician had been credentialed for to perform in the facility.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:


A. On the afternoon of 1-26-16, administration was not able to provide a list that identified the Medical Staff credentialed at the hospital. Staff #28 provided a list of physicians by specialty. The list that was provided was titled " Memorial Health Systems of East Texas Current Practitioner Appointments As of 02/26/16 ". The bottom of the page listed the selection criteria as, "Select records where Status is one of (Active, Adjunct/Consulting) and Hosp Mship (sic) equals" (the specialty hospital name).

An interview with Staff #28 was conducted on the afternoon of 1-26-2016 in the 6th floor conference room. Staff #28 stated this was the current list of credentialed physicians for the specialty hospital, but agreed that not all the physicians on the list, such as pediatricians, were credentialed at the hospital. Staff #28 reported that this appeared to be a list of the physicians credentialed at the hospital system that was contracted to provide administrative services.

Two more computer generated lists were provided, but contained names of physicians who were not credentialed at the specialty hospital. Staff #1 highlighted the names of physicians who were credentialed at the specialty hospital since they could not provide a list that did not contain non-credentialed physicians.

Two Medical Staff Members (Staff #11 and Staff #40) out of the 11 Medical Staff members reviewed (Staff #11, Staff #33, Staff #34, Staff #35, Staff #36, Staff #37, Staff #38, Staff #39, Staff #40, Staff #41, Staff #42) were not on the first two computer generated lists that were initially provided as a complete list.

B. An interview with Staff #12, Staff #13 and Staff #32 was conducted on 1-26-16 at 3:55 p.m. in the 6th floor nursing station. Staff were asked how they would check to verify a physician was credentialed to provide care in the specialty hospital and how they would verify the procedures the Medical Staff member was credentialed to perform.

Staff #12 reported that he did not know and that he would have to ask a manager.

Staff #13 reported the physicians would have ID badges. Staff # 13 also reported that previously there was a list of hospitalists in the breakroom, but it had been taken down.

Staff #32 reported that there was list of credentialed physicians on the computer, but was not able to access the list. He texted his supervisor who told him that he would need to ask a Nurse Manger if there was a question about credentialing.

Nursing and Contract Staff were not able to verify if Medical Staff were credentialed and the procedures they were credentialed to perform.

C. A review of Medical Staff Credentialing files revealed Medical Staff privileges were allowed to lapse.

Staff #37's privileges expired 8-31-15. Staff #37 was approved by the Credentials Committee, Medical Executive Committee, and the Administrator on 8-19-15. Final approval from the Governing Body was obtained on 10-28-15. This resulted in a 58 day lapse in credentialing.

Staff #38's privileges expired 12-31-15. Staff # 38 was approved by the Credentials Committee, Medical Executive Committee, and the Administrator on 12-16-15. Final approval from the Governing Body was obtained on 1-27-15. This resulted in a 27 day lapse in credentialing.

Staff #39' s privileges expired 9-30-15. Staff # 39 was approved by the Credentials Committee, Medical Executive Committee, and the Administrator on 10-21-15. Final approval from the Governing Body was obtained on 10-28-15. This resulted in a 28 day lapse in credentialing.

Staff #42' s privileges expired 9-30-15. Staff # 42 was approved by the Credentials Committee, Medical Executive Committee, and the Administrator on 8-19-15. Final approval from the Governing Body was obtained on 10-28-15. This resulted in a 28 day lapse in credentialing.

Staff #11' s privileges expired 12-31-15. Staff #11 did not submit an application for reinstatement of privileges. On 12-16-15 the Medical Executive Committee approved unanimously to provide Staff #11 with "Interim Reappointment".

A review of Medical Staff Bylaws identified the following (Article V, 5.1 Categories) "The Medical Staff shall include the following categories: Active, Provisional, Adjunct, Consulting, Honorary and Emergency. A Member ' s Staff category shall be determined at each time of reappointment." Types of Temporary Privileges (Article VI, 6.5 Temporary Clinical Privileges) include Specific Patient, Locum Tenens, and Pending Application. The instructions for the Pending Application category state "Upon receipt of a completed application for Medical Staff membership ... " Staff #11 had not submitted an application.

Further review of Medical Staff Bylaws identified the following (Article IV, 4.6 -1 Information form for Reappointment) "Failure without cause to timely file a completed form for reappointment shall result in automatic termination of membership and the automatic suspension of the Member' s privileges and prerogatives at the expiration of the Member' s current term. And the Member shall be deemed to have resigned from membership in the Medical Staff effective as of the end of the current Staff appointment. "

Staff # 40' s credential file had a letter of appointment for Provisional status effective from 1-27-10 to 12-31-10. The physician ' s application for appointment was signed on 1-29-10, two days after the appointment letter had been issued. The next appointment letter in the credential file was dated 10-22-14 for Active status effective from 10-22-14 to 9-30-16. There was not a new application on file and no reference checks or background check.

An interview was conducted on the afternoon of 1-26-16 with Staff # 28 in the conference room on the 6th floor. Staff #28 reported that the hospital was aware that there was a lapse time of privileges between the Credentials Committee, Medical Executive Committee, and Administrator approval times and the Governing Body approval times. This is due to meeting scheduling. Staff #28 reported that physicians were allowed to continue to provide care to patients during the lapse time of privileges. Staff #28 reported this would most likely be found in all of the credentialing files.

When asked why Staff #11 had not been credentialed, Staff #28 reported that he had never filled out an application. Staff #28 reported that Staff #11 was continuing to provide care to patients.

Staff #28 reported that Staff #40 had not been providing services during the period between expiration on 12-31-10 and re-appointment on 10-22-14. Staff #28 confirmed that Staff #40 was granted Active status after a 3 year, 10 month break without having to fill out a new application, reference checks or background check.

Based on interview and record review the facility failed to ensure contracted services were assessed in a manner to identify quality and performance problems in 5 of 5 services (Dialysis, Environmental, Pharmacy Education/Orientation, Infection control-Employee Health, Wound Care services).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of the evaluation tools on the contracted services for Dialysis, Environmental, Pharmacy Education/Orientation, Infection control-Employee Health, Wound Care services revealed the last time services were evaluated was on 12/09/2015. Documentation revealed all of the services met expectation and no problems were found.
The evaluations were performed annually and there was documentation that administration found no problems with the dialysis contracted services. The evaluations had not identified any of the problems found during the survey from 01/26-29/2016.
During an interview on 01/27/2016 after 1:30 p.m., Staff #1 (CNO/Director of Quality) and Staff #27 (CEO) confirmed not knowing about the performance problems practices found on the dialysis unit. They confirmed not having assessment procedures in place to identify their problems.
During an interview on 01/28/2016 after 10:00 a.m., Staff # 27(CEO) reported he was responsible for evaluating contracted services. The evaluations were performed annually and he had not found any problems with the dialysis contracted services.

Based on interview and record review the facility failed to ensure patients were not provided the correct information for contacting the Quality Improvement Organization (QIO), Kepro, and hospital representative upon admission and prior to discharge.

This deficient practice had the likelihood to cause harm in patients exercising their patient rights.

Findings include:

Kepro assumed the responsibility as the QIO from TMF Health Quality on 8-1-2014. A review of Patient #13' s chart revealed that it contained "An Important Message From Medicare About Your Rights" (IMM) form. The IMM listed the name of the QIO as " TMF Health Quality" and the phone number as "1-800-725-8399". At the bottom of the first page of the IMM, in the statement "To speak with someone at the hospital about this notice, call _____" , no phone number had been listed for the patient to call.

An interview was conducted with Staff #14 and Staff #25 on the morning of 1-27-2016 in the 6th floor conference room. Staff #14 reported that all IMM forms contain the preprinted information for TMF Health Quality rather than Kepro and that all Medicare patients are receiving the incorrect information. Staff #14 reported that she was not aware that anything had changed.

Staff #25 reported she was not aware of the change as well. Staff #25 could not provide a process for or evidence of the second delivery of the IMM that is required prior to discharge.

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

A. ensure that staff followed the physician's orders for performing peritoneal dialysis treatment, which included documentation of the treatment and the results of the dialysis treatment. Citing 1 (#1) of 1 peritoneal dialysis patient.

B. to screen for hepatitis B surface antigen (HBsAg) and (HbAb) within 30 days prior to admission or at the time of admission or have a known HBsAg positive status prior to admission, citing 5 (#1, #2, #3, #17 and #30) of 5 (#1, #2, #3, #17 and #30) patients records.

C. ensure and provide evidence that the dialysis machines used by the patients (#1, #2, #3, #17, and # 30) which had an unknown (HBsAg) were given intermediate level disinfection prior to use by another patient or ensure that each patient with an unknown (HBsAg) had a dedicated dialysis machine. Citing 5 (#1, #2, #3, #17, and # 30) of 5 (#1, #2, #3, #17 and #30) hemodialysis patient records reviewed. A review of the records indicated 7 dialysis machine (#14, #15, #16, #17, #18, #19, and #20) had been used on patients with an unknown (HBsAg) status and had not been disinfected prior to the use on other patients in the dialysis unit.

D. ensure that all samples for chlorine/chloramines testing were drawn when the water treatment system had been operating for at least 15 minutes. These deficient practices had the likelihood to cause harm to all patients receiving care at the dialysis unit by exposing them to harmful chlorine and chloramines chemicals. Citing 4 (RO3, ROZ2, ROZ4, ROZ1) of 4 RO's (Reverse Osmosis Water System) reviewed.

E. offer and administer Hepatitis B vaccinations to susceptible staff whose antibodies were less than 10 mIU (Mill International Unit); or test the staff for antibodies to determine the need for immunizations. Also, a review of records indicated the Engerix vaccine was not given as recommended by the Engerix guidelines. The facility failed to follow the facility's own policy and the Center for Disease Control. Citing 3 (#5, #6, and #9) of 4 (#5, #6, #7 and #9) dialysis staff personnel records reviewed.

F. ensure that the dialysis machines had maintenance conducted according to manufacturer instructions. Citing 1 (#14) of 7 (#14, #15, #16, #17, #18, #19, and # 20) dialysis machines reviewed.

G. ensure the dialysis machines were disinfected weekly as required by manufacture recommendation. Citing 1 (#14) of 7 (#14, #15, #16, #17, #18, #19, and # 20) dialysis machines reviewed.

H. ensure the Medical Director was credentialed by the Governing Body. Citing 1 (#8) of 1 Medical Director's file.

I. ensure the serial numbers were documented on the culture and endotoxin reports for the dialysis machines and portable RO (water) systems, Citing 7 (#14, #15, #16, #17, # 18 # 19 and # 20) of 7 dialysis machines and 4 (RO3, ROZ2, ROZ4, ROZ1) of 4 portable RO's.


J. ensure the water room and bicarbonate mixing area was clean and there was space to separate clean bicarbonate mixing from the dialysis machines.

Findings:
A.
Review of Patient #1's medical record for the admission dates of 11/13/2015 through 11/19/2015 revealed the physician had ordered peritoneal dialysis by CCPD (a cycler machine) 2.5 liters x 3 bags/6 cycles with last 2.5 liters + drain at start of rest CCPD cycles (sic). This order was for each day until 11/20/2015 and then the physician had ordered Patient #1 to start hemodialysis. In Patient's #1 record there was no documented evidence that the daily CCPD treatments were administered and neither was the treatment results.
Review of Patient #1's medical record for admission date of 1/16/2016, the physician had ordered peritoneal dialysis by CCPD (a cycler machine) with 2.5% 2 liter bags x 3 dwell time 1:30 (1 hour 30 min) and last fill 2500 ml 2.5 %. (Sic) Also, Patient #1 was getting back up hemodialysis during this admission. In Patient's #1 record revealed there were no documented evidence that the daily CCPD treatments were administered. In addition the results of the treatment were not documented.
In an interview with Staff #3 on 01/27/2016 at 10:30 a.m. reported that there was no documented evidence that the CCPD treatments were administered.
In an interview with Staff # 7 on 01/27/2016 at 1:30 p.m. she reported administering the CCPD during the current admission as ordered on 01/21/2016. Staff #7 confirmed she did not document the start of the CCPD or the final results for the treatments.
B. and C.
Review of medical records for Patient #1 for admission on 1/13/2016 revealed there was no evidence that the facility had a Hepatitis B surface antigen level. Patient #1 had received hemodialysis treatment from 11/20/2015 through 11/24/2015 with an unknown Hepatitis B status. Further review of the record revealed Patient #1 hemodialysis treatment records for 11/20/2015 and 11/21/2015 revealed dialysis was completed using an unknown dialysis machine. The space for recording the dialysis machine was left blank. The treatment record for 11/23/2015 and 11/24/2015 indicated dialysis machine #15 was used.
Review of the Patient #1's current admission for 01/16/2016 revealed the facility did not know the Hepatitis B surface antigen at the start of hemodialysis on 01/26/2016. Review of the record revealed Patient#1 received hemodialysis treatment from 1/16/2016 through 1/26/2016 with an unknown Hepatitis B status. Review of Patient #1's hemodialysis treatment records for 1/16/2015 and 1/21/2016 revealed dialysis was completed using an unknown dialysis machine. The space for recording the dialysis machine was left blank. The treatment record for the dates of 1/17/2016, 01/19/2016, 01/25/2016, 01/26/2016, and 01/27/2016 machine #15 was used for dialysis. On 1/18/2016 machine #19 was used for dialysis. On 1/20/2016 machine #17 was used for dialysis. The staff did not use a dedicated machine for treatment of Patient #1 which had an unknown Hepatitis B status. Also, a review of the disinfection logs for these treatment days revealed the machine did not receive a terminal disinfection before being used on other patients.
Review of Patient #2's medical record revealed an admission date 01/14/2016. The record revealed the Hepatitis B surface antigen was unknown. The patient was dialyzed from 01/16/2016 through 1/27/2016 which was the last day of the dialysis survey. On 01/16/2016 and 01/21/2016 the hemodialysis treatment records revealed the dialysis was completed using an unknown dialysis machine. The space for recording the dialysis machine was left blank. On 01/19/2016, and 01/22/2016 the patient was dialyzed using machine #19. On 01/26/2016, Patient #2 was dialyzed using machine #18. The staff did not use a dedicated machine for treatment of Patient #1 which had an unknown Hepatitis B status. Also, a review of the disinfection logs for those treatment days revealed the machine did not receive a terminal disinfection before being used on other patients.

Review of the medical record for Patient #3 revealed the patient was new to dialysis and the Hepatitis B surface antigen was unknown. The record revealed Patient #3 was admitted on 12/07/2015. The treatment records revealed that Patient #3 received dialysis on 12/11/2015, 01/04/2016, 01/11/2016, 01/16/2016 and 01/20/2016 using an unknown machine. The space for recording the dialysis machine was left blank. On 12/21/2015 Patient #3 was dialyzed on machine #16. On 12/12/2015, 12/14/2015 and 12/18/2015 Patient #3 was dialyzed using machine #17. On 12/19/2015 Patient #3 was dialyzed on machine #19. On 12/23/2015, 12/26/2015, 12/28/2015, 01/01/2016, 01/06/2016, 01/08/2016, 01/14/2016, 01/22/2016 and 01/25/2016 Patient #3 was dialyzed on machine #20. Review of the treatment records from admission until 01/26/2016 at 16:19 there was no known Hepatitis B surface antigen results. The staff did not use a dedicated machine for the treatment of Patient #3 which had an unknown Hepatitis B status. Also, a review of the disinfection logs for these treatment days revealed the machine did not receive a terminal disinfection before being used on other patients.

Review of Patient #17's medical record revealed an admission date of 01/10/2016, the physician ordered dialysis on 01/18/2016. There was no treatment recorded until 01/20/2016. On 01/20/2016, 01/25/2016, and 01/27/2016 the patient was dialyzed on machine #19. On 01/22/2016 the patient was dialyzed machine #17. The staff did not use a dedicated machine for treatment of Patient #17 which had an unknown Hepatitis B status. Also, a review of the disinfection logs for these treatment days revealed the machine did not receive a terminal disinfection before being used on other patients.
In an interview with staff # 3 on 01/27/2016 at 4:00 p.m. confirmed the findings regarding the hepatitis B status and the disinfection of the machine for the unknown hepatitis B status.
These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death; by failure to administer peritoneal dialysis, screen patients for Hepatitis B surface antigen, use a dedicate machine and/or terminally clean each machine after use on the patients with an unknown Hepatitis B status. (A. B. and C.)

D.
A review of the Portable RO (#ROZ2) form for 04/11/2015 through 06/26/2015 revealed when it was tagged as "out of service" there was no indication prior to collecting the chlorine after the first carbon tank that the RO was allowed to run for 15 minutes prior to performing the chlorine test.
A review of the Portable RO (#ROZ3) form for 11/18/2015 through 01/26/2016 revealed there was no indication prior to collecting the chlorine after the first carbon tank that the RO was allowed to run for 15 minutes prior to performing the chlorine test.
A review of the Portable RO (#ROZ1) form for 10/07/2015 through 01/25/2016 revealed there was no indication prior to collecting the chlorine after the first carbon tank that the RO was allowed to run for 15 minutes prior to performing the chlorine test.
A review of the manufacture guidelines revealed not allowing the water to circulate through the carbon tank for at least 15 minutes prior to collecting the chlorine could result in the test being inaccurate and the patients being dialyzed with chlorine in the water.
An interview with staff # 4 on 01/27/2016 confirmed they failed to show evidence the RO was running for at least 15 minutes prior to collecting the chlorine test.

E.
A review of Engerix vaccine insert recommends the dosing schedule should be initial dose, a does a month later and at six months. CDC recommends the same dosing schedule and that two complete series are administered prior to considering them a non-converter.
Review of Staff #5's record revealed the staff hepatitis antibodies were less than 10 mIU. The facility's staff started the immunization on 08/11/2015. There were no records to indicate the facility completed the Hepatitis B immunization per manufacture and CDC recommendations.
Review of Staff #6's record revealed the hepatitis antibodies were less than 3 mIU. The vaccine administration record in the file revealed the first dose were administered on 08/19/2011. The second dose administer was not until 10/26/2011 (two months after the first dose verse the required month after the 1st dose) the last dose was given on 02/20/2012. There were no records to indicate that Staff #6 received a second series prior to being considered a non-converter.
Review of Staff #9's record revealed the hepatitis antibodies were 0.00 mIU. There were no vaccine administration records in the file or evidence that Staff #6 A had received two series and was a non-converter.
In an interview with staff # 3 on 01/27/2016 at 3:30 p.m., she confirmed the hepatitis immunization status of the staff.
F.

A review of machine #14's maintenance records revealed the 6 month preventive maintenance check was completed on 01/16/2015 and the machine hours were listed to be 32,789. The annual preventive maintenance check was completed on 07/22/2015 and the hours were noted to be 26, 328. The maintenance records indicated the machine hours had rolled backwards. An interview with Staff # 4 on 01/27/2016 at 10:45 a.m. confirmed the above findings.

G.

Review of the dialysis machines disinfection logs for machine #14 revealed the facility staff failed to bleach the machine on 01/09/2016, 01/16/2016 and 01/23/2016 as required by the manufacture. An interview with staff #4 on 01/27/2015 at 11:30 a.m. confirmed the record did not reveal the machine was disinfected.

H.

A review of the Quality Minutes from the Medical Executive Staff meeting from January through December 2015 revealed no evidence the Medical Director of the Dialysis unit participated in the quality meetings. Also, there was no indication that the dialysis nursing staff and biomedical staff of the dialysis unit participated in the quality process. Further review of the Quality meetings revealed the facility failed to monitor or evaluate the logs for accuracy, machine maintenance records, disinfection logs, bicarbonate mixing logs and the patient care provided within the dialysis unit. In addition the facility was asked to provide the dialysis Medical Director Credential file. Staff #1 and #3 confirmed on 01/26/2016 at 9:30 a.m. that The Medical Director was not a member of the medical staff. There was no indication in the November and December Quality meetings the problems identified during the survey had been identified through the facilities quality process. There were no trending reports over time to evaluate the water cultures and other Quality Improvement information.

I.

Review of the culture and endotoxin repots for portable RO ' s (RO3, ROZ2, ROZ4, and ROZ1) and the dialysis machines (#14, #15, #16, #18, #19, and #20) revealed no evidence that the facility's staff included the serial number on the report. There was no evidence to be certain which report belonged to which piece of equipment. The report had numbers that the facility had given the machines which are not permanently attached to the machines and could be removed or moved from machine to another machine. Staff #3 confirmed the above findings on 01/26/2016 at 1:30 p.m.

J.

During a tour of the water room, observed bicarbonate being mixed. Staff had a dialysis machine broken down exposing internal parts of the machine for repair. The room was very small and there was not clear space for the separation of clean and dirty. The portable RO used for bicarbonate mixing was sitting in a white tray that was dirty. The booster pumps were rusted and sitting in dirty water. The room was cluttered with machine parts and supplies that should be kept out of the bicarbonate mixing area.

An interview with Staff #4 on 01/26/2016 at 11:00 a.m. confirmed the bicarbonate mixing area was small and also used for storage and maintenance of equipment.



36827


K. A tour of the Emergency Treatment Room and Patient Care Area on the 6th floor revealed that emergency equipment was not maintained and readily available.

A facility tour was conducted with Staff # 1 on the morning of 1-26-17 on the 6th floor.

The Emergency Treatment Room oxygen register (supplies supplemental oxygen at a controlled rate) was missing the adapter used to connect the oxygen supply line for the patient to the oxygen register. This could have caused a delay or prevented a patient from receiving supplemental oxygen during an emergency situation.

The Emergency Crash Cart located in the front of the Nurses Station had a defibrillator (machine to detect heart rhythm and provide electrical shock to the heart in emergency situations) on it. Staff #12 was asked to run a test of the machine. The paper strip that prints out during the test and during actual use, had the date and time of event on it and would have been used for record tracking. The date was correct but the time was off by 1 hour and 10 minutes. This could have created the potential for error in timing of emergency medications and confusion of timing of events during an analysis of events.

Based on observation, interview and record review the facility nursing staff failed to follow the care plans to complete nursing skin assessments on patient with pressure sores, turning and repositioning was provided as ordered, pain assessments were performed and x-rays were obtained as ordered by the physician. This deficient practice was found in 3 of 3 patients (Patient #s' 13, 21, and 23).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of the initial nursing assessment dated 01/21/2016 revealed Patient #21 was a 73 year female who was admitted with a diagnosis which included pulmonary hypertension.
Review of the nursing assessment revealed no documentation of the home medications upon admission.
Review of the initial nursing assessment revealed Patient #21 was at risk for skin breakdown and was also described as having a pressure ulcer to the sacral area that was a Stage II on 01/21/2016.
Review of "Daily Assessment Inquiry" dated 01/22-28/2016 revealed Patient #21 had a Stage II pressure ulcer, was at moderate risk, and there was no photographic documentation. There was no documentation of size and the appearance of the skin. There was no way to tell if the pressure sore got better or not.
Review of physician skin care orders revealed an order to turn every 2 hours at a time unless contraindicated. If incontinent, gently cleanse area with soap and water following each episode. After cleansing with soap and water apply a thin layer of Boudreaux Butt Paste. Notify the physician immediately of any signs and symptoms of skin breakdown.
Review of the record did not reveal every 2 hour turning during the time frame of 01/22-28/2016.

Review of the facility policy named "PRESSURE ULCER PREVENTION PROGRAM" date April 2013 revealed the following:

Stage II
Partial-thickness skin loss involves the dermis. The ulcer is superficial open ulcer with a red-pink wound bed. No slough or bruising (bruising indicates suspected deep tissue injury). The ulcer presents clinically as an abrasion, intact or open serum-filled blister or shallow crater.

It is the policy of (name of hospital) that all patients admitted to this hospital shall receive a complete head -to- toe assessment, at which time a thorough examination of the skin will be done


Review of the facility policy named "PREVENT OF ALTERATION OF SKIN INTEGRITY" date August 2012 revealed the following:
*F. Turn and reposition every 1-2 hours. On 30 degree angles, even with use of specialty beds. Encourage mobility when patient's condition allows. Review of the record on


Patient #23 revealed he was a 72 year old male with diagnoses including respiratory failure, sepsis and status post laporatomy.
Review of the initial nursing assessment report dated 12/23/2015 at 3:45 p.m., revealed Patient #23 had a pressure sore to the coccyx and on both heels. The pain category was left blank.
The first documented assessment of Patient #23' s pain level was at 7:44 p.m. (almost 4 hours later). There was documentation that Patient #23 denied having pain.
During an interview on 01/28/2016 after 10:00 a.m., Stafff #46 confirmed the assessment problems.




36827


Rerview of Patient #13' s chart revealed admission orders dated 12-23-15 and an order for a chest x-ray daily while the patient is on a ventilator (used to assist patient with breathing). Record review revealed staff failed to obtain a chest x-ray on 1-2-16, 1-5-16 and 1-24-16 as ordered by the physician.

During an interview on 01/28/2016 after 10:00 a.m., Staff #47 confirmed the x-rays were not obtained.

Based on observation, interview and record review the facility failed to ensure nursing staff administered medications as ordered, failed to ensure there were physician orders for medications being administered and failed to ensure medications were administered timely. This deficient practice was found in 4 of 4 patients (Patient #s' 9, 14, 15, and 22).
This deficient practice had the likelihood to cause harm in all patients.

Findings include:
Review of a Pre-Op History and Physical dated 01/26/2016 revealed Patient #9 was a 72 year old male with a diagnosis of respiratory failure.
During an observation on 01/26/2016 after 11:00 a.m., Staff #12 donned gloves and administered the intravenous anesthetic medication Propofol to Patient #9.
Staff #12 confirmed Patient #9 had been transferred to the specialty hospital from the main hospital. Staff #12 confirmed he was using the orders from the other hospital. He was waiting until the physician came in to see the patient to get orders.
Staff 29 printed off all of the orders they had on Patient #9 and there were no current physician orders for Propofol. The only orders on the chart were discharge orders from the main hospital.
During an interview on 01/27/2016 after 5:00 p.m., Staff #14 confirmed that nursing staff were not suppose to use the discharge orders. The admitting physician was supposed to be called first for orders before medication administration.


Review of the clinical record of Patient #22 revealed he was a 61 year old male who was admitted on 01/21/2016 with a diagnoses which included acute respiratory failure, cerebral vascular accident and right upper extremity deep venous thrombosis at 2:00 p.m.
Review of the record revealed a list of discharge orders was sent over with Patient #22 from the previous hospital. Nursing signed the discharge order from the other hospital as continuing with the medications. The medications included orders for antibiotics, anticoagulation therapy and insulin sliding scale.
The orders were not re-written on the facility's order sheets. The orders were signed off by the physician at 4:30 p.m. and noted by nursing at 7:20 p.m.
The following was written on the discharge order sheet:
Heparin 25,000 unit/500 ml IV per protocol (an anti-coagulant agent).
Review of the specialty hospital Heparin protocol dated 01/21/2016 at 7:30 p.m. revealed documentation that Patient #22 came with a Heparin drip at 44 ml /hr (2204 units). The physician did not sign the protocol off until 01/27/2016 (6 days later).
1. The instructions on the form were to check baseline Xa, PT/INR,CBC/platelet count( if not available within previous 24 hours).
(The heparin XA is designed to measure plasma Heparin level. Protime (PT) blood test which measure how long it takes blood to clot. The International normalized ratio also used to monitor patients on anti-coagulant therapy).
3. Repeat Xa 6 hours after initiation of therapy and 6 hours after ANY dose adjustment...
4. Adjust heparin infusion rate to maintain Xa 0.3 to 0.7 units/milliliter per protocol.
There was no PT/INR on the chart and the lab for a Heparin Xa was on 01/22/2016 at 2:55 a.m.
The first documentation of monitoring for Heparin administration was at 3:22 a.m. on 01/22/2016. This was started over 12 hours after being admitted with the Heparin infusion.

According to documentation on the Heparin tracking sheet revealed the first documentation at 3:22 a.m. Patient #22 had a Heparin XA of 0.22 (reference ranges being 0.30-0.70). When the Heparin XA was at that level the order called for a bolus of 40 units/kilogram and increase rate by 2 units /kilogram /hour. According to documentation on the tracking form the Heparin was increased up to 2400 units/hour (which would be 48 cc/hr). There was no documentation on the tracking form of what the Heparin dose was before the increase.
On 01/22/2016 at 10:30 a.m. the Heparin XA was 0.31 and the protocol called for no changes. This lab result was 7 hours later after the last dosage adjustment not 6 hours as the protocol called for.
On 01/22/2016 at 8:00 p.m., the Heparin XA was 0.25 and the protocol called for a bolus of 40 units /kilogram and an increase in the rate by 2 units. Documentation revealed the Heparin was increased by 1 unit/hr (2500 units). There was documentation on the form that the pump limit was at 2500 units per hour. There was no documentation of what was done to supplement the amount not administered. The lab results for the Heparin XA was actually at 6:40 p.m.
On 01/23/2016 at 3:00 a.m. the Heparin XA was 0.29 and the protocol called for a bolus of 40 units/kilogram and an increase in the rate by 2 units. Staff documented the bolus of 40 units/kilogram was given and the rate was still at 2500 units/hour. There was documentation on the form that the pump limit was at 2500 units per hour. There was no documentation of what was done to supplement the amount not administered.
Review of physician orders revealed no documentation of a change in the orders during this time frame.
During an interview on 01/28/2016 after 10:00 a.m. Staff # 46 confirmed the Heparin was administered incorrectly.

Review of the admission orders dated 01/21/2016 revealed Patient #22 had tube feeding of Glucerna 1.5 infusing at 50 cc per hour and was NPO (taking nothing by mouth).
Review of the medication administration record (MAR) on Patient #22 revealed the following order:
Insulin Lispro (100 units/ml) solution Subcutaneous before meals and at bedtime.
Glucose level Dose( IN UNITS)
80-100 0 UNITS
101-120 2 UNITS
121-150 3 UNITS
151-200 5 UNITS
201-250 8 UNITS
251-300 10 UNITS
301- 350 12 UNITS
351-400 16 UNITS
>400 16 UNITS+CALL MD
Review of the blood sugar tracking sheet and the MAR revealed the following:
01/21/2016 at 9:05 p.m. the blood sugar was 152 and at 11:32 p.m. (over 2 hours later) 5 UNITS of insulin was administered.
On 01/22/2016 at 10:00 a.m. the blood sugar was 128 and at 11:29 a.m. (over 1 hour later) 3 UNITS of insulin was administered. At 4:00 p.m. there was no documentation of what the blood sugar was and what was given.
On 01/23/2016 at 4:00 a.m., the blood sugars were logged as being 140 and 154. The result of 140 called for 3 UNITS and 154 called for 5 UNITS. At 5:00 a.m. over an hour later 5 UNITS of insulin was administered.
During an interview on 01/28/2016 after 10:00 a.m., Staff #46 confirmed the insulin was administered incorrectly.

Review of the MAR on Patient #22 revealed an order for the anti-convulsant Dilantin 100 milligrams intravenous every 6 hours.
On 01/21/2016 at 11:41 p.m. there was documentation of a dose being administered and again at 4:24 a.m. (over an hour too early).
On 1/22/2016 at 10:41 a.m. a dose was administered and at 9:44 p.m., (11 hours later)..
Review of the facility policy named "Admission of a Patient" dated April 2013 revealed the following:
I. PROCEDURE:
b. Obtain physician orders, introduce self to the patient. Check two patient identifiers. If no physician orders, the nurse will call physician for orders.

Review of the facility policy named" Administration of Drugs: General" approved 05/20/2015 revealed medications ordered every 6 hours were scheduled for the times of 4:00 a.m., 10:00 a.m., 4:00 p.m. and 10:00 p.m. can be given 30 minutes prior to or after the scheduled time.




36827


Two charts were reviewed for timing of scheduled antibiotics administration (Patient #14 and Patient #15). Multiple doses of antibiotics were given at the wrong times. None of those were identified as a medication error or written up as medication errors on an incident report.

Review of Patient #14's chart revealed staff failed to administer medications as ordered. The antibiotics Ceftriaxone and Vancomycin were ordered to be given every 12 hours intravenously. The medications should have been administered by nursing staff between the hours of 9:30 - 10:30 a.m., and 9:30 - 10:30 p.m.

The Vancomycin was rescheduled on 1-24-16 to the times of 1134 a.m. and 1134 p.m. Vancomycin should have been administered between 11:04 a.m. and 12:04 p.m. for the morning dose and 11:04 p.m. and 12:04 a.m. for the evening dose after 1-24-16.

A review of the Medication Administration Record revealed the following:

The 9:30 - 10:30 a.m. dose of Ceftriaxone was given outside of the time frame on 1-18-16, 1-19-16, 1-23-16, 1-27-16, and 1-28-16 for a total of 5 out of 14 doses.

The 9:30 - 10:30 p.m. dose of Ceftriaxone was given outside of the time frame on 1-19-16, 1-20-16 and 1-26-16 for a total of 3 out of 14 doses.

The 9:30 - 10:30 a.m. dose of Vancomycin was given outside of the time frame on 1-18-16, 1-19-16 and 1-23-16 for a total of 3 out of 9 times.

The 01-18-16 dose of Vancomycin was given at 3:46 p.m., over 5 hours late. An interview with Staff #14 was conducted on the afternoon of 1-28-16 in the 6th floor conference room. Staff #14 reported she spoke with the nurse who administered this dose of Vancomycin. Staff #14 reported the nurse held the dose because the patient did not have a workable central venous line (a line that is placed in large veins to minimize the potential harm certain medications can have on smaller veins). The nurse later became concerned about the patient not receiving her antibiotic and started a peripheral venous line (a line that is usually placed in the hand/arm in a smaller vein and the vein has the potential to be damaged by certain medications such as Vancomycin). The nurse gave the dose without an order from the physician to hold the morning dose or to give it over 5 hours late without rescheduling it. The evening dose was given 7 hours later when the order was for the dose to be given every 12 hours. Staff #14 reported that the nurse had told her she spoke with the physician prior to giving the dose, however, there was no documentation available to support this.

The 9:30 - 10:30 p.m. dose of Vancomycin was given outside of the time frame on 1-20-16, 1-21-16 and 1-22-16 for a total of 3 out of 9 times.

The 11:04 a.m. - 12:04 p.m. dose of Vancomycin was given outside of the time frame on 1-25-16, and 1-28-16 for a total of 2 out of 5 times.

The 11:04 p.m. - 12:04 a.m. dose of Vancomycin was given outside of the time frame on 1-26-16 for a total of 1 out of 5 times.

Review of the facility policy named "Administration of Drugs: General" approved 05/20/2015 revealed medications ordered every 12 hours were scheduled for the times of 10:00 a.m. and 10 p.m. and can be given 30 minutes prior to or after the scheduled time.





Review of Patient #15's chart revealed staff failed to administer medications as ordered. The antibiotic Zosyn was ordered to be given every 8 hours intravenously. The medications should have been administered by nursing staff between the hours of 1:30 - 2:30 a.m., 9:30 - 10:30 a.m., and 5:30 - 6:30 p.m.

A review of the Medication Administration Record revealed the following:

The 1:30 - 2:30 a.m. dose of Zosyn was given outside of the time frame on 1-22-16, 1-23-16, 1-26-16, and 1-28-16 for a total of 4 out of 10 doses.

The 9:30 - 10:30 a.m. dose of Zosyn was given outside of the time frame on 1-20-16, 1-21-16, 1-22-16, 1-26-16, 1-27-16, 1-28-16 and 1-29-16 for a total of 7 out of 10 doses.

The 5:30 - 6:30 p.m. dose of Zosyn was given outside of the time frame on 1-28-16. On 1-25-16 the dose was not given at all without an explanation on the Medication Administration Record or Nursing Notes.

Review of the facility policy named "Administration of Drugs: General" approved 05/20/2015 revealed medications ordered every 8 hours were scheduled for the times of 2:00 a.m., 10:00 a.m., and 6:00 p.m. and can be given 30 minutes prior to or after the scheduled time.

Based on interview and record review the facility failed to ensure nursing staff used verbal orders infrequently. The facility failed to ensure verbal orders were timed, dated and signed timely. This deficient practice was found in 11 of 11 patients (Patient #s' 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 28).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

Review of an initial nursing assessment dated 01/21/2016 revealed Patient #21 was a 73 year female who was admitted with a diagnosis which included pulmonary hypertension.
The following was found concerning verbal orders:
01/21/2016 an order set for Venous Thromboembolism Prophylaxis revealed it was incomplete. Nursing obtained a verbal order for the screen and documented the following under the physician order category "on Lovenox 40 mg Q 24". There was no documentation as to what route to give the medication nor were the orders timed.
01/21/2016 two orders were received and the physician signed them, but did not date them.
01/22/2016 one order was received. It was signed off by the physician, but not dated.
01/24/2016 two orders were received and had not been signed off by the physician as of 01/29/2016.
01/27/2016 one order was received, signed off by the physician, but not dated.


Review of an initial nursing assessment dated 12/23/1015 revealed Patient #23 was confused, disoriented and unable to follow directions. Patient #23 was documented as having soft restraints to bilateral upper limbs.
Review of restraint orders on Patient #23 revealed nursing wrote an order on 12/23/2015. The physician signed the orders,but failed to date and time them.
On 01/07/2016 an order was written at 1:00 a.m. and signed off by the physician on 01/08/2016 at 5:00 p.m. (16 hours past the due date).
On 01/08/2016 01/09/2016, 01/10/2016, 01/11/2016, 01/12/2016, orders were written for bilateral wrist restraints and signed by the physician on 01/15/2016 (3 - 7 days later).
On 01/25/2016 orders were written for bilateral wrist restraints and the physician failed to sign the orders.

Skin care orders dated 12/23/2015 was signed by the physician, but was not dated or timed.
Operating room orders dated 12/24/2015 revealed a verbal order taken by nursing for Lidocaine 1% with epinephrine which was not signed off by the physician as of 01/29/2016 (over 1 month later). On 01/05/2016 and 01/14/2016 for normal saline to be started was not signed off by the physician as of 01/29/2016.

The following was received about verbal orders:
12/23/2015 one order written and had not been signed by the physician.
12/26/2015 one order was written and had not been signed by the physician.
12/28/2015 two order was written and had not been signed by the physician.
12/31/2015 one order was written and was not signed off by the physician.
01/02/2016 and 01/03/2016, 01/08/2016, 01/14/2016 one order was written.
1/25/2016 one verbal order was written and as of 01/29/2016 (4 days later) it had not been signed by the physician.

Review of the clinical record of Patient #22 revealed he was a 61 year old male who was admitted on 01/21/2016 with a diagnoses which included acute respiratory failure and right upper extremity deep venous thrombosis.
The following days there were verbal orders written by nursing that were not signed off by the physician as of 01/29/2016:
01/16/2016 one order;
01/24/2016 one order;
and 01/25/2016 two orders.



Review of the clinical record of Patient #28 revealed she was a 52 year old female who was admitted on 08/10/2015 with diagnoses including syncope and hypokalemia.
Review of admit orders dated 08/10/2015 revealed medications scratched out and there was no indication as to who scratched them out.
A verbal order was written for Total Parental Nutrition on 08/10/2015 and as of 01/29/2015 the orders were still not signed off by the physician.
Two verbal orders were written on 08/12/2015 and signed off by the physician on 09/05/2015.
Verbal order concerning increasing dosage of the TPN on 08/15/2015 and 08/17/2015 revealed the physician had signed it off as of 01/29/2016.
Two verbal orders dated 08/18/2015 were signed off by the physician on 09/05/2015.
During an interview on 01/28/2016 after 10:00 a.m., Staff #46 confirmed the condition of the orders.


36827

Review of Patient #13 orders show that, 1 telephone order was not properly written, 10 telephone orders were not signed by the physician, 2 telephone orders were signed by the physician outside of the 48 hour requirement, 2 physician orders were not dated and 8 physician orders were not timed. Pre-procedure endoscopy orders were on the chart and were not signed at all (no verbal, telephone, or physician order signature).

Review of Patient #15 orders show that, 1 telephone order was not signed by the physician, 2 telephone orders were signed by the physician but not dated, 2 telephone orders were signed by the physician but not timed, 1 physician order was not dated and 2 physician orders were not timed. The Checklist for RD 's (registered dietician) to Write Orders per Physician Direction was signed by the physician but not timed. There were no orders checked. There was no patient identifier on the order sheet.

Review of Patient #16 orders show that, 1 telephone order was not signed by the physician, 4 telephone orders were not dated and 4 telephone orders were not timed.

Review of Patient #17 orders show that, 7 telephone orders were not signed by the physician, 3 telephone orders were signed by the physician but not dated, 3 telephone orders were signed by the physician but not timed and 4 physician orders were not timed.

Review of Patient #18 orders show that, 2 telephone orders were not signed by the physician, 1 physician order is not dated and 3 physician orders are not timed. One pre-printed VTE (venous thromboembolism /blood clot in the vein) Screen order set was signed by the physician. It was not dated or timed. The screen portion was not completed and the order section check boxes were left blank.

Review of Patient #19 orders show that, 20 telephone orders were not signed by the physician, 3 telephone orders were signed by the physician but not dated, 4 telephone orders were signed by the physician but not timed, 2 physician orders were not timed.

Review of Patient #20 orders show that, 1 telephone order written by the nurse did not include the time the nurse received the order, 12 telephone orders were not signed by the physician, 5 telephone orders were signed by the physician but not dated, 5 telephone orders were signed by the physician but not timed.

A review of Medical Staff Rules & Regulations of Memorial Specialty Hospital, Section III General Conduct of Care, 3.2 Treatment Orders, 3.2-1 " All orders for treatment shall be in writing and signed by the attending practitioner. A verbal order shall be considered to be in writing if dictated to a duly authorized person functioning within his or her sphere of competence and signed by the responsible practitioner. All orders dictated over the telephone shall be dictated by the physician and shall be signed by the appropriate authorized person to whom dictated with the name of the practitioner per his or her own name. The responsible practitioner shall authenticate such orders at the next visit, or within 48 hours."

Based on observation and interview the facility failed to ensure patient records were stored separately from other hospital records and were easily accessible.
Findings include:

During an observation on 01/27/2016 after 10:00 a.m., medical records from the specialty hospital were stored in with records from the main hospital. They were not separated.
Staff #30 and 31 confirmed the observation. Staff #30 and 31 reported there were more records in storage belonging to the specialty hospital that were not separated from the main hospital.

Based on interview and record review the facility failed to physician orders were complete, timed, dated, and signed timely. This deficient practice was found in 12 of 12 patients (Patient #s' 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 28).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of an initial nursing assessment dated 01/21/2016 revealed Patient #21 was a 73 year female who was admitted with a diagnosis which included pulmonary hypertension.
The following was found concerning verbal orders:
01/21/2016 an order set for Venous Thromboembolism Prophylaxis revealed it was incomplete. Nursing obtained a verbal order for the screen and documented the following under the physician order category "on Lovenox 40 mg Q 24". There was no documentation as to what route to give the medication nor were the orders timed.
01/21/2016 two orders were received and the physician signed them, but did not date them.
01/22/2016 one order was received. It was signed off by the physician, but not dated.
01/24/2016 two orders were received and had not been signed off by the physician as of 01/29/2016.
01/27/2016 one order was received, signed off by the physician, but not dated.

Review of an initial nursing assessment dated 12/23/1015 revealed Patient #23 was confused, disoriented and unable to follow directions. Patient #23 was documented as having soft restraints to bilateral upper limbs.
Review of restraint orders on Patient #23 revealed nursing wrote an order on 12/23/2015. The physician signed the orders, but failed to date and time them.
On 01/07/2016 an order was written at 1:00 a.m. and signed off by the physician on 01/08/2016 at 5:00 p.m. (16 hours past the due date).
On 01/08/2016, 01/09/2016, 01/10/2016, 01/11/2016, 01/12/2016, orders were written for bilateral wrist restraints and signed by the physician on 01/15/2016 (3 - 7 days later).
On 01/25/2016 orders were written for bilateral wrist restraints and the physician failed to sign the orders.

The following was received about verbal orders:
12/23/2015 one order written and had not been signed by the physician.
12/26/2015 one order was written and had not been signed by the physician.
12/28/2015 two order were written and had not been signed by the physician.
12/31/2015 one order was written and was not signed off by the physician.
01/02/2016 and 01/03/2016, 01/08/2016, 01/14/2016 one order was written
1/25/2016 one verbal order was written and as of 01/29/2016 (4 days later) it had not been signed by the physician.

Review of the clinical record of Patient #22 revealed he was a 61 year old male who was admitted on 01/21/2016 with a diagnoses which included acute respiratory failure and right upper extremity deep venous thrombosis.
The following had verbal orders written by nursing that were not signed off by the physician as of 01/29/2016:
01/16/2016 one order;
01/24/2016 one order;
and 01/25/2016 two orders.


Review of the clinical record of Patient #24 revealed he was a 56 year old male with diagnoses which included respiratory failure and cerebral vascular accident.
An order dated 06/23/2015 revealed an insulin sliding scale protocol that was not signed by the physician until over 2 months later on 09/02/2015.
Verbal orders from 06/24/2015 were signed off by the physician on 09/15/2015.
On 06/25/2015 there was one order that was not signed off at all by the physician.
06/26/2015 one order that was signed off by the physician on 09/07/2015;
06/27/2015 one order that was signed off by the physician on 09/01/2015.


Review of the clinical record of Patient #28 revealed he was a 52 year old female who was admitted on 08/10/2015 with diagnoses including syncope and hypokalemia.
Review of admit orders dated 08/10/2015 revealed medications were scratched out and there was no indication as to who scratched them out.
A verbal order was written for Total Parental Nutrition on 08/10/2015 and as of 01/29/2015 the orders were still not signed off by the physician.
Two verbal orders were written on 08/12/2015 and signed off by the physician on 009/05/2015.
A verbal order concerning increasing dosage of the TPN on 08/15/2015 and 08/17/2015 revealed the physician had signed it off as of 01/29/2016.
Two verbal orders dated 08/18/2015 were signed off by the physician on 09/05/2015.


Review of the clinical record of Patient #28 revealed she as a 52 year old female admitted on 08/10/2015 with diagnoses which included syncope, hypokalemia and ETOH abuse (ethyl alcohol).
Review of physician orders revealed the following :
On 08/14/2015 and 08/15/2015 orders were written for wrist restraints and signed off by the physician. The physician failed to date and time the orders.
On 08/21/2015 a restraint order was written by nursing at 12:05 midnight and signed off by the physician 2 days later on 08/23/2015 at 9:10 p.m. There was no documentation on the order as to what type of restraint that was being ordered.
During an interview on 01/28/2016 after 10:00 a.m., Staff #46 confirmed the condition of the orders.


36827


Review of Patient #13 orders show that, 1 telephone order was not properly written, 10 telephone orders were not signed by the physician, 2 telephone orders were signed by the physician outside of the 48 hour requirement, 2 physician orders were not dated and 8 physician orders were not timed. Pre-procedure endoscopy orders were on the chart and were not signed at all (no verbal, telephone, or physician order signature).

Review of Patient #15 orders show that, 1 telephone order was not signed by the physician, 2 telephone orders were signed by the physician but not dated, 2 telephone orders were signed by the physician but not timed, 1 physician order was not dated and 2 physician orders were not timed. The Checklist for RD's (registered dietician) to Write Orders per Physician Direction was signed by the physician but not timed. There were no orders checked. There was no patient identifier on the order sheet.

Review of Patient #16 orders show that, 1 telephone order was not signed by the physician, 4 telephone orders were not dated and 4 telephone orders were not timed.

Review of Patient #17 orders show that, 7 telephone orders were not signed by the physician, 3 telephone orders were signed by the physician but not dated, 3 telephone orders were signed by the physician but not timed and 4 physician orders were not timed.

Review of Patient #18 orders show that, 2 telephone orders were not signed by the physician, 1 physician order is not dated and 3 physician orders are not timed. One pre-printed VTE (venous thromboembolism / blood clot in the vein) Screen order set was signed by the physician. It was not dated or timed. The screen portion was not completed and the order section check boxes were left blank.

Review of Patient #19 orders show that, 20 telephone orders were not signed by the physician, 3 telephone orders were signed by the physician but not dated, 4 telephone orders were signed by the physician but not timed, 2 physician orders were not timed.

Review of Patient #20 orders show that, 1 telephone order written by the nurse did not include the time the nurse received the order, 12 telephone orders were not signed by the physician, 5 telephone orders were signed by the physician but not dated, 5 telephone orders were signed by the physician but not timed.


A review of Medical Staff Rules & Regulations of Memorial Specialty Hospital, Section III General Conduct of Care, 3.2 Treatment Orders, 3.2-1 " All orders for treatment shall be in writing and signed by the attending practitioner. A verbal order shall be considered to be in writing if dictated to a duly authorized person functioning within his or her sphere of competence and signed by the responsible practitioner. All orders dictated over the telephone shall be dictated by the physician and shall be signed by the appropriate authorized person to whom dictated with the name of the practitioner per his or her own name. The responsible practitioner shall authenticate such orders at the next visit, or within 48 hours. "

Based on interview and record review the facility failed to ensure standing orders were complete, timed, dated and signed timely in 4 of 4 patients (Patient #s' 21, 22, 24, and 25).
This deficient practice had the likelihood to cause harm in all patients.
Findings include:
Review of the clinical record of Patient #22 revealed he was a 61 year old male who was admitted on 01/21/2016 with a diagnoses which included acute respiratory failure, cerebral vascular accident and right upper extremity deep venous thrombosis at 2:00 p.m.
Review of record revealed a list of discharge orders was sent over with Patient #22 from the previous hospital. Nursing signed the discharge order from the other hospital as continuing with the medications. The medications included orders for antibiotics, anticoagulation therapy and insulin sliding scale.
The orders were not re-written on the facility's order sheets. The orders were signed off by the physician at 4:30 p.m. and noted by nursing at 7:20 p.m.
The following was written on the order sheet:
Heparin 25,000 unit/500 ml IV per protocol (an anti-coagulant agent).
Review of the specialty hospital Heparin protocol dated 01/21/2016 at 7:30 p.m. revealed documentation that Patient #22 came with a Heparin drip at 44 ml /hr (2204 units). The physician did not sign the protocol off until 01/27/2016 (6 days later).
During an interview on 01/28/2016 after 10:00 a.m. Staff # 46 confirmed the condition of the orders.

Review of the initial nursing assessment dated 01/21/2016 revealed Patient #21 was a 73 year female who was admitted with a diagnosis which included pulmonary hypertension.
Review of physician orders revealed the following:
An order set named "Checklist for RD's to Write Orders Per Physician's Discretion" was pre-signed by the physician and dated 01/22/2016. There were categories for enteral nutrition, parenteral nutrition, oral diets, nutritional supplements,laboratory monitoring and consults. None of the selects were made yet. At the bottom of the orders there was a statement that read "The Clinical Dietitians have my permission to order the above items when nutritional evaluation shows these changes are needed".

Review of the clinical record on Patient #23 revealed an admission dated of 12/23/2015.
A Skin care order set dated 12/23/2015 was signed by the physician, but was not dated or timed.
An Operating room order set dated 12/24/2015 revealed a verbal order taken by nursing for Lidocaine 1% with epinephrine which was not signed off by the physician as of 01/29/2016 (over 1 month later). On 01/05/2016 and 01/14/2016 for normal saline to be started was not signed off by the physician as of 01/29/2016.

Review of the clinical record of Patient #24 revealed he was a 56 year old male with diagnoses which included respiratory failure and cerebral vascular accident.
An order dated 06/23/2015 revelaled an insulin sliding scale protocol that was not signed by the physician until over 2 months later on 09/02/2015.

Review of the clinical record of Patient #25 revealed he was a 72 year old male who was admitted on 08/12/2015 with a diagnosis of pneumonia.
Review of physician orders revealed a skin care standing order that was presigned and dated by the physician on 08/13/2015. The physician failed to make selections for which orders he wanted the nursing staff to follow.

Based on record and interview the facility failed to maintain properly executed consents for 5 of 29 (#6, #7, #8, #10, and #17) patients.

This deficient practice had the likelihood to cause harm in all patients.

Findings include:


On 1/29/2016 in the conference room the medical records for patients #6, #7, #8, #10, and #17 were reviewed and identified the following incomplete consents:

Patient #6:
The consent for a bedside bronchoscopy 1/15/2016, was not signed dated or timed by the physician who conducted the procedure.
The consent for blood administration 1/13/2016, was not signed dated or timed by the physician who ordered the packed red blood cells to be given.

Patient #7:
The consent for a "tunnel dialysis catheter" was signed and dated by the physician on 12/27/2015, the day of the procedure but failed to time the consent. The patient signed the consent on 12/26/2015.
The consent for hemodialysis for 12/26/2015, was not signed, dated, or timed by the physician who ordered the procedure.
The consent for blood transfusion dated 12/18/2015 by the patient was not signed, dated, or timed buy the physician who ordered the packed red blood cells to be given.
The consent for both colonoscopy and esophagogastroduodenoscopy (EGD), was not signed, dated, or timed by the physician who conducted both of the procedures.

Patient #8:
Consents for blood transfusion dated 12/22/2015 at 1:30 p.m. and 12/22/2015 at 5:15 p.m. respectively, were not signed, dated or timed by the physician who ordered the packed red blood cells be given.

Patient #10:
The consent for Blood administration on 1/17/2016, was not signed, dated or timed by the physician who ordered the packed red blood cells to be given.
The consent for the Below the knee amputation scheduled 1/28/2016 was signed by the physician on 1/28/2016, but not dated or timed. The patient signed the consent on 1/27/2016.

Patient #17:
A consent for blood transfusion 1/20/2016, was not signed, dated or timed by the physician who ordered the packed red blood cells to be given.
A surgical debridement 1/28/2016, was done at the bed side. The physician who conducted the procedure failed to sign, date or time the consent.

On 1/19/2016 in the conference room, staff #14 confirmed the consents were not properly completed.



36827

Records for review of six (Patient #6, Patient #13, Patient # 17, Patient #31, Patient #32, Patient #33) bedside procedures were requested and provided.

Two (Patient #13, Patient #17) were missing Physician Signatures in the informed consent section of the Pre-Procedure Moderate Sedation Physician Assessment & Plan. One (Patient #32 was missing the entire Pre-Procedure Moderate Sedation Physician Assessment & Plan form.

Two (Patient #31, Patient #33) of the Disclosure of Risk for Medical and Surgical Procedures forms were electronically signed by the physician over three weeks after each of the procedures. One (Patient #32) Disclosure of Risk for Medical and Surgical Procedures form contained the Physician signature and date, but was not timed. It was dated the same day of procedure.

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

A. ensure medications were labeled as their policy required. They failed to ensure medications were labeled with all identifying information prior to medication administration. They failed to ensure respiratory medications were kept in their protective packages.

Refer to tag A 0500 for additional information.

B. ensure a system for identifying and reporting wrong time medication errors in the Quality Assurance Process Improvement program or to the meeting of the whole (medical staff and Governing Body) for 12 of 12 months.

Refer to tag A 0508 for additional information.


C. ensure current reference information to the professional staff related to drug interactions and information op drug therapy, side effects toxicology, dosage, indications for use, and routes of administration in one of two nursing medication rooms (6th floor).

Refer to tag A 0510 for additional information.

Based on observation, document review and interview the facility failed to follow its policies regarding medication labeling for 12 of 12 months.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:

On 1/26/2026 at 9:30 a.m. during a tour of the nurses medication administration room the following was observed: Patient (Pt/pt) medications were being stored in individual bin. Each patient bin was labeled with each patients name, however, medications stored within the bins were not labeled. The medication was identified by manufacture packaging. Staff #1, who gave the tour, confirmed that patient medications, identified within the bins did not have a labels affixed to them.

On 1/28/2016 in the conference room the facility pharmacy policies and procedures were reviewed. Found in the "Job description/Performance Evaluation Director of Pharmacy Services" was the following: "Principal Responsibilities":
#16. Ensures that pharmacists review patient profiles, medication orders, and provide quality pharmaceutical care.
#17. Effectively performs drug utilization reviews and adverse drug reaction reviews and implements recommendations.
#18. Monitors medication errors and implements changes to decrease errors.
#19. Monitors drug distribution system, IV additive system, and other drug distribution systems to ensure accuracy, compliance with policies and optimum safety and efficiency.

Review of the Pharmacy policies titled:

"Policy: All drugs stocked in the pharmacy, supplied to floor stock, or dispensed to patients shall be clearly, accurately, appropriately, and safely labeled using a standardized method".

"Consistency: Drug labeling must be consistent among all preparation areas throughout the facility".

"Labeling so that recalls can be effected: Drugs shall be labeled so that recalls can be effected as necessary and proper controls established. Labels must contain lot numbers when applicable:.

"Mislabeled Drugs: Drugs that are mislabeled (labels are illegible, incomplete, incorrect, etc) shall not be available for use".

"Typed or computer printed labels: Labels prepared by the pharmacy should be typed or printed by a computer".

"Label Content, All labels shall include at least:
Patient name, location,account number, and other patient identifiers.
Generic and brand name(if appropriate) of the drug.
Drugs strength\Dosage form
Lot number of pharmacy control numbers
Manufacturer (if not evident from a proprietary name or from pharmacy prepackaging records)
Expiration date when applicable.
Quantity of drug
Appropriate accessory and cautionary statements or supplemental labels that address storage requirements, administration procedures, safety precautions, etc.

On 1/26/2016 in the medication room an interview with he Director of Nurses confirmed she did not realize the patient medications were not being labeled.

On 1/26/2016 in the afternoon staff #1 reported she had spoken with the pharmacy tech who delivered patient medications to the nurse's medication room. The tech had delivered medications for a long time and thought she was doing it correctly. Staff #1 reported the pharmacy tech didn't realize individual labels were required for each patient drug.

On 1/27/2016 in the pharmacy an interview with the pharmacist confirmed he didn't realize the tech was not labeling the patient medications prior to delivery to the medication room.




10135

During an observation on 01/26/2016 after 10:25 a.m., two blood pressure pills (Metoprolol) were found inside an open unlocked compartment on a computer stand. The pills were not labeled as to whom they belonged to. The computer stand was located outside a patient room in the hallway. The pills were accessible to anyone passing by in the hallway.
Staff # 1 confirmed the observations.
The medications were not labeled as to whom they belonged to and were not locked in a secure place.

During an observation on 01/26/2016 after 10:30 a.m. the following was found:
Inside the medication room was an open bin of respiratory medications that were not in the foil covering. According to the labels on the medication they were to be used in 1 week after removing from the packet.

Based on observation, document review and interview the facility failed to follow its policies regarding medication labeling for 12 of 12 months.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:

On 1/26/2026 at 9:30 a.m. during a tour of the nurses medication administration room the following was observed: Patient (Pt/pt) medications were being stored in individual bin. Each patient bin was labeled with each patients name, however, medications stored within the bins were not labeled. The medication was identified by manufacture packaging. Staff #1, who gave the tour, confirmed that patient medications, identified within the bins did not have a labels affixed to them.

On 1/28/2016 in the conference room the facility pharmacy policies and procedures were reviewed. Found in the "Job description/Performance Evaluation Director of Pharmacy Services" was the following: "Principal Responsibilities":
#16. Ensures that pharmacists review patient profiles, medication orders, and provide quality pharmaceutical care.
#17. Effectively performs drug utilization reviews and adverse drug reaction reviews and implements recommendations.
#18. Monitors medication errors and implements changes to decrease errors.
#19. Monitors drug distribution system, IV additive system, and other drug distribution systems to ensure accuracy, compliance with policies and optimum safety and efficiency.

Review of the Pharmacy policies titled:

"Policy: All drugs stocked in the pharmacy, supplied to floor stock, or dispensed to patients shall be clearly, accurately, appropriately, and safely labeled using a standardized method".

"Consistency: Drug labeling must be consistent among all preparation areas throughout the facility".

"Labeling so that recalls can be effected: Drugs shall be labeled so that recalls can be effected as necessary and proper controls established. Labels must contain lot numbers when applicable:.

"Mislabeled Drugs: Drugs that are mislabeled (labels are illegible, incomplete, incorrect, etc) shall not be available for use".

"Typed or computer printed labels: Labels prepared by the pharmacy should be typed or printed by a computer".

"Label Content, All labels shall include at least:
Patient name, location,account number, and other patient identifiers.
Generic and brand name(if appropriate) of the drug.
Drugs strength\Dosage form
Lot number of pharmacy control numbers
Manufacturer (if not evident from a proprietary name or from pharmacy prepackaging records)
Expiration date when applicable.
Quantity of drug
Appropriate accessory and cautionary statements or supplemental labels that address storage requirements, administration procedures, safety precautions, etc.

On 1/26/2016 in the medication room an interview with he Director of Nurses confirmed she did not realize the patient medications were not being labeled.

On 1/26/2016 in the afternoon staff #1 reported she had spoken with the pharmacy tech who delivered patient medications to the nurse's medication room. The tech had delivered medications for a long time and thought she was doing it correctly. Staff #1 reported the pharmacy tech didn't realize individual labels were required for each patient drug.

On 1/27/2016 in the pharmacy an interview with the pharmacist confirmed he didn't realize the tech was not labeling the patient medications prior to delivery to the medication room.

Based on observation and interview the facility failed to provide current reference information to the professional staff related to drug interactions and information op drug therapy, side effects toxicology, dosage, indications for use, and routes of administration in one of two nursing medication rooms.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:

On 1/26/2016 during the initial tour of the 6th flour of the specialty hospital the nurses medication administration room was toured and found the following expired drug reference manuals:
Mosby 2006 and 2008
PDR (Physician's Desk Reference) 2004 and 2007

There was no current drug reference manual found in the medication room for the nursing or medical staff use. This was confirmed by staff #1.

Based on observation, interview and document review the facility failed to:


A. ensure the Infection Control Preventionist created and implemented policies and /or protocols to insure a sanitary environment to inhibit the potential for Hospital Acquired Infections (HAI).


On 1/26/2016 at 10:00 a.m. during the initial tour of the 6th floor of the specialty hospital the following observation were made:

The small refrigerator at the entrance to the unit was found to have a dried white liquid, possibly milk and what appeared to be dried juice with small particulate matter stuck to the bottom shelf of the refrigerator. One carton of expired milk, dated 1/24/2016, was found in the refrigerator.

In the room designated for Emergency Room use, no gloves were found in the room. The wall bracket was empty of small, medium, and large gloves. Two (2) carts (emergency use cart and general supply cart) were observed with a dusty film on them.
An opened 2 x 2 gauze (possibly used) was found on the top of the general supply cart.

In the supply storage area at the end of the hallway, one shipping box of isolation gowns was stored on the floor beneath the supply storage bins. Two (2) bio-patch's (anti-biotic impregnated patch often placed over centrally inserted intravenous (IV) lines for protection) were found to be expired, 12/14 and 4/15 respectively.

In the Medication room, two (2) pill crushers were observed, both heavily coated with residue from repeated crushing of pills for patient medication administration.
One (1) large bottle of "Benefiber" opened without "Open date" identified on the bottle.
One Large bottle of "Promod" liquid protein/collagen supplement was found opened, without the "Date Opened" written on the bottle. The bottle label indicated dispose of within three months of opening. The bottom of the shelf itself, was coated with a sticky residue as was the bottle of Promod.

Fifty (50) cc bag of IV solution of normal saline was found resting on an empty shelf. The solution was not in its factory issued protective plastic cover and did not appear to contain the entire content when compared to 50 cc's of Normal saline still in its protective covering.

White powder was noticed on three different shelves where patient medication was being stored.

There was no visible thermometer in the medication room. The room was noted to be very warm. Staff nurse #12 asked the surveyor if it seemed hot in the room.

Four (4) Brown bins were observed to be heavily soiled with white powder, a liquid that had dried on the inside of the containers, and small particles of an unknown substance.
Three (3) large plastic storage containers were observed to be very dirty near the rims and hands. A heavy sticky residue with small particulate matter was stuck to the storage containers. One storage container held 30 cc (centimeter) syringes, the other held 10 cc syringes and the third held 5 cc syringes.

The medication room was the storage area for a medication cart on wheels. The cart was observed to have a trash bag tied to the middle frame. The bag held trash from an earlier medication pass. The contents were opened unit dose medication containers, empty syringes, paper and IV medication tubing.

On 1/26/2016 at 1:00 p.m. in the office of the Infection Control Preventionist (ICP) the following interview revealed environmental rounds were not being made on a regular basis. "They had made their first environmental round last week". Review of notes taken from the environmental rounds made last week did not include the medication room and the notes did not indicate when the rounds had actually been completed.

On 1/27/2016 at in the conference room a review of the Infection Control plan and the Infection Control policies and procedures revealed the following:

"Infection Preventionist Responsibilities". The designated Infection Control Preventionist is responsible for implementing, monitoring, and evaluating the infection control program. The designated Infection Preventionist will remain current with federal, state, and local regulations. The designated Infection Preventionist will communicate with outside facilities within the extent of the law, appropriate information in order to monitor and manage active and dormant infections. The Infection Preventionist will maintain a log of all reportable diseases and infections, including healthcare associated infections, designated as epidemiologically significant."

"Surveillance". "Surveillance data is used for planning control efforts, directing in-service education in infection control, and identifying individual patient problems for intervention, Data is gathered from the medical record, current reporting and historical information".

No where within the Infection Control Plan was environmental surveillance mentioned. All surveillance data mentioned was for patients who were being treated for active infections. No consideration was given for potential infection caused from an unsanitary environment. There was nothing found in the Infection Control Plan that addressed sources of infections or potential infections. Review of the Infection Control Policies and Procedures, identified none which addressed establishing and maintaining a sanitary environment for the patient or staff.

A review of employee's education files (#2, #3, #4, #5, #6, #7, #9, #12, #13, and #14) revealed no inservice education for establishing and maintaining a sanitary work environment.





36827

B. ensure the Infection Control Preventionist developed and implemented effective measures to monitor staff for communicable diseases. The deficient practices had the likelihood to cause harm to all patients. The Infection Control Preventionist also failed to ensure the employee vaccination policy was accurate for the patient population they were servicing

An Interview was conducted in the 6th floor conference room with Staff #44 and Staff #45. Staff #44 reported that staff are screened for Tuberculosis annually. Staff #45 reported that even though the hospital was in a low risk area, they determined it was going to be their policy to require it annually.

Staff #44 reported that if a staff member is unable to receive the Tuberculosis skin test, the staff member must have an initial chest x-ray that shows the staff member is clear of the disease. After that, the staff member is screened annually by questionnaire. If a positive symptom is reported on the questionnaire by the staff member, the employee health nurse will interview the staff member and make a determination if another chest x-ray is required. If it is determined another chest x-ray is not required, the employee health nurse would make a note on the Employee Health Nurse's Note and place it the staff member's employee health file.

Review of health file for Staff #43 revealed Staff #43 reported a positive symptom on the questionnaire dated 7-9-2015. There was not a follow-up chest x-ray. There was not an Employee Health Nurse's Note in the file. Staff #44 verified that a follow-up chest x-ray was not available, nor was there a note.

Employee #44 and #45 were asked, "If a vaccination were recalled, how would you determine which staff members had received it?" Staff #45 reported that the employee health files would have to be reviewed on all employees. Staff #44 reported that they would look at the lot numbers on the vaccination form signed at the time of administration of the vaccine. Staff #44 verified this could not be done for the Tuberculosis skin test since the information to include manufacturer, lot number, and expiration date is not included on the vaccination form.

A policy was provided, titled "Employee Vaccination Program", that was in use. The policy was not specific to the hospital. Staff #45 confirmed this was the policy being used. This policy did not detail the procedures described by Staff #44 and Staff # 45.


Review of policy titled "Employee Vaccination Program". The policy was not specific to the hospital. The policy contained guidance for departments of the host hospital that provides that provides the Infection Control Preventionist through contracted Infection Control services. The policy requires all staff identified as a Risk Category 1 (all nursing personnel) to have proof of Tetanus, Diphtheria, and Pertussis (Tdap) vaccination. If the nursing personnel decline the Tdap, they have to follow alternate practices. The alternate practice for declining Tdap is that staff may not care for anyone 1 year or younger. The hospital does not provide care to a patient population in that age range. Staff #45 confirmed this was the policy being used.

Based on observation, interview, and record review the facility failed to provide a system for identifying environmental risk factors for infections which had the potential to effect all patients and staff.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:


On 1/26/2016 at 10:00 a.m. a tour of the 6th floor of the specialty hospital was provided by staff #1. The following findings were observed by the surveyors and confirmed by staff #1.

The small refrigerator at the entrance to the unit was found to have a dried white substance, possibly milk, and what appeared to be dried juice with small particulate matter stuck to the bottom shelf of the refrigerator. One carton of expired milk was found in the refrigerator dated 1/24/2016.

In a room used for Respiratory therapy, an unpackaged humidifier bottle was found in the stock supplies along with humidifiers still packaged from the manufacturer. One (1) 1000 cc volume container of respiratory "S1 Rinse" was expired as of 11/15.

In the area designated as the Emergency Room, no gloves were found in the room. The wall bracket designed to hold small, medium, and large gloves was observed to be empty. No other gloves were identified in the room. Two (2) carts, an emergency use "crash car" and a general supply cart, was observed with a dusty film on each cart. An non packaged 2 x 2 gauze (possibly used) was found on the top of the supply cart.

The supply storage area at the end of the hallway, had one unopened shipping box of isolation gowns placed on the floor beneath the supply storage bins. Two (2) bio-patch's (anti-biotic impregnated circular disc placed over centrally inserted intravenous (IV) lines at the point of entry into the skin for protection) were found in a storage bin expired as of 12/14 and 4/15 respectively.

In the Medication room: Two (2) pill crushers were observed. Both were heavily coated with residue from repeated crushing of pills for patient medication administration. One (1) large bottle of "Benefiber" was observed to be opened without an "Open date" identified on the bottle. One Large bottle of "Promod" liquid protein/collagen supplement was found opened, without the date opened written on the bottle. The bottle label indicated dispose of within three months of opening. The sanitation and expiration of the medications can not be insured. The bottom of the shelf itself, was coated with a sticky residue, as was the Promod bottle itself.

Fifty (50) cc's IV solution of normal saline was found resting on an empty shelf. The solution was not in its factory issued protective covering and did not appear to contain the entire content when compared to a 50 cc's of Normal saline still in its protective covering. Staff #1, who was giving the tour, could not explain why the bag was left on the shelf or why its appearance indicated it had been open for use.

White powder was noticed on three different shelves where patient medication was being stored.

There was no visible thermometer in the medication room. The room was noted to be very warm.

Four (4) Brown bins were observed to be heavily soiled with white powder, a liquid that had dried on the inside of the containers, and small particles of an unknown substance.
Three (3) large plastic storage containers were observed to be very dirty near the rims and hands. A heavy sticky residue with small particulate matter was stuck to the storage containers. One storage container held 30 cc (centimeter) syringes, the other held 10 cc syringes and the thirds held 5 cc syringed.

The medication room was the storage area for a medication cart on wheels. The cart was observed to have a trash bag tied to the middle frame. The bag held trash from an earlier medication pass. The contents were opened unit dose medications containers, empty syringes, paper and medication tubing.

On 1/26/2016 at 1:00 p.m. in the office of the Infection Control Preventionist (ICP) the following interview revealed that Environmental rounds were not being made on a regular basis. "They had made their first environmental round last week". Review of typed notes taken from the environmental rounds made last week did not include the medication room and the notes did not indicate the date the rounds had actually been completed.

On 1/27/2016 at in the conference room a review of the Infection Control plan and the Infection Control policies and procedures revealed the following:

"Infection Preventionist Responsibilities". The designated Infection Control Preventionist is responsible for implementing, monitoring, and evaluating the infection control program. The designated Infection Preventionist will remain current with federal, state, and local regulations. The designated Infection Preventionist will communicate with outside facilities within the extent of the law, appropriate information in order to monitor and manage active and dormant infections. The Infection Preventionist will maintain a log of all reportable diseases and infections, including healthcare associated infections, designated as epidemiologically significant."

"Surveillance". "Surveillance data is used for planning control efforts, directing in-service education in infection control, and identifying individual patient problems for intervention, Data is gathered from the medical record, current reporting and historical information".

Nowhere within the Infection Control Plan was environmental surveillance mentioned. All surveillance data mentioned was for patient's with infections. No consideration was given for potential infection caused from an unsanitary environment.








10135

During an observation on 01/26/2016 after 10:20 a.m., of the 6th floor the following was found:
The bed frame for the patient bed in the Emergency Treatment room was found to be rusted. There was no way the bed could be sanitized.
There was an intravenous caddy which had clean supplies in it. A soiled 2 x 2 dressing was laying on top of the supplies.
The trash can in Patient Room #601 was overflowing with trash and soiled gloves were noted on the floor.
The clean sterile supply area had 20 plus plastic bins which contained patient use supplies. The bins were soiled with a build-up of dust and were not covered to protect them from being soiled from hallway.
Inside the medication room was an open bin of respiratory medications that were not in the foil covering. According to the labels on the medication they were to be used in 1 week after removing from the packet.
The computers inside the medication room that were being used by nursing staff were soiled with a build-up of spills, dust and debris
The floor on the side of the Pyxis medication machine had a build up of dust. One of the front panels on the Pyxis was missing and bottom of the equipment had a buildup of dirt and dust. The plastic medication bins on the inside were soiled with spills, dust and debris.
The biohazard container was sitting inside a metal holder which was soiled with dirt. There was a used medication vial and a needle on the outside of bin. Staff failed to discard the items on the inside of the container.
Plastic medication bins were soiled with brown stains and had a build-up of tape from stickers being removed. The medication bins could not be properly sanitized with the build-up of tape.
Six needles that expired in 2013 were stored in the room.
A baseboard had separated from the wall. There was a build-up of dirt, dust, debris and a pill at the baseboard.
During an observation on 01/26/2016 after 11:00 a.m., Staff #12 was observed to donn gloves and administer intravenous medications to Patient #9. With the same soiled gloves on Staff #12 went into his uniform pocket, took out a pen and identified the line. The pen was placed back into his pocket and then the soiled gloves were removed.
Two tubes of urine were on an overbed table in Patient #9' s room. The urine was not identified as to when it was collected and it was not on a protective barrier.
Staff #12 confirmed the observation and reported not knowing when the urine specimens were collected.
During an observation of the 5th floor on 01/27/2016 after 4:00 p.m., a patient clean/sterile supply room was found behind the nurses station. Inside the patient supply room was a staff bathroom which had no sink in it. Staff had to walk approximately 25 feet, through the clean/sterile supply storage area, through the nutritional area to reach the handwashing sink.



36827

Based on document review and interview the facility failed to show evidence of hospital wide participation in the Infection Control Program for 12 of 12 months.

This deficient practice had the likelihood to cause harm to all patients.

Findings include:

On 1/26/2016 at 1:00 p.m. in the office of the Infection Control Preventionist (ICP) an interview with the ICP confirmed environmental rounding was not part of the Infection Control Plan and had only been initiated one (1) week prior. The ICP also confirmed all departments did not participate in the IC plan. The primary focus was on patient infections once admitted to the facility.

On 1/27/2016 at 9:00 a.m., in the conference room, a review of the Infection Control (IC) plan and the Infection Control policies and procedures revealed thatthe IC plan addressed, "Infection Preventionist Responsibilities: "The designated Infection Control Preventionist is responsible for implementing, monitoring, and evaluating the infection control program. The designated Infection Preventionist will remain current with federal, state, and local regulations. The designated Infection Preventionist will communicate with outside facilities within the extent of the law, appropriate information in order to monitor and manage active and dormant infections. The Infection Preventionist will maintain a log of all reportable diseases and infections, including healthcare associated infections, designated as epidemiologically significant."

"Surveillance". "Surveillance data is used for planning control efforts, directing in-service education in infection control, and identifying individual patient problems for intervention, Data is gathered from the medical record, current reporting and historical information". The IC plan did not address participation by departments that impacted the patient quality of care and directly affected the Infection Control program.

On 1/28/2016 during the course of the day the managers of the dietary, respiratory, radiology/nuclear medicine, laboratory, housekeeping and laundry department were interviewed. All department managers indicated they maintained infection control data for their individual departments but none shared the data with the specialty hospital, which they provided contracted services. None of the department managers submitted information for the ICP or the Quality Assessment Processes Improvement program for the hospital.