HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) failure of the RN or LPN to follow the orders of the licensed practitioner, failure to follow the hospital approved hypoglycemia protocol, and failure to assess a patient with a critically low CBG reading (CBG of 29), being treated with a continuous insulin infusion, who was assigned to a LPN and failure to notify the MD of the critically low CBG for 1 (#11) of 2 (#2, #11) patients reviewed for continuous medication infusions out of a total sample of 32 patients; (see findings tag A-395); and

2) failure of the charge RN to perform and document an assessment to determine stability prior to delegating, to a LPN, the care of a medically complex patient (#11), requiring continuous insulin infusions to maintain blood glucose levels, as set forth in the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII", Section "3703. Definition of Terms Applying to Nursing Practice Delegating Nursing Interventions and hospital policy for 1 (#2) of 1 current patients receiving continuous IV insulin infusions (see findings tag A-0397); and

3) failure of the hospital to ensure all nursing staff, including agency nurses, were required to have competency evaluations for the administration of continuous IV Insulin infusions and administration of continuous IV Levophed infusions prior to caring for patients receiving these medications (see findings tag A-0397).

Based on record review and interview, the governing body failed to ensure the hospital, which is located within a hospital, independently met the requirement for emergency services as evidenced by the hospital utilizing the host hospital's emergency room physicians during "Code" (cardio respiratory arrest) procedures.

Findings:

Review of the hospital policy titled Cardiac Code, Policy Number: 9-2.0.0, revealed in part:
Purpose: To provide a process for administering Advanced Cardiac Life Support (ACLS) to individuals who have experienced a cardiopulmonary arrest (cardiac code).
If a credentialed physician/LIP is not available within the hospital, an RN/LPN/RT will notify the host facility emergency department to appraise of the Code Blue emergency situation. The emergency department physician/LIP will respond to the cardiac code in accordance to prior arrangements with the co-located hospital and in accordance with their policies and procedures.

Ochsner Extended Care Hospital of Kenner is a hospital leasing space on the 5th floor of Hospital "A" (host hospital).

Review of Patient #21's Medical Record revealed he had cardiac arrest on 6/11/17 at 6:45 p.m. Further review revealed the Code Blue was attended at the hospital by S17MD who was covering the Emergency Department at Hospital "A".

In an interview on 7/26/17 at 10:11 a.m. with S2DON, she verified the hospital was located within Hospital "A" on the 5th floor. S2DON said an Emergency Department doctor from Hospital "A" attended code blues at the hospital. She verified S17MD was covering in the Emergency Department of the host hospital on 6/11/17 while attending Patient #21's code at their hospital.

Based on record review and staff interview, the Hospital failed to follow their policy and procedure for initiating a Do Not Resuscitate (DNR) Order as evidenced by the physician failing to document a DNR order for 1 (#21) of 2 (#17, #21) sampled patients reviewed for DNR.

Findings:

Review of the hospital policy titled, Do Not Resuscitate, revealed in part the following: There are two components of a properly written DNR order. There must be (A) documentation in the medical record that indicates that the patient/family understands DNR status and there must be (B) a written order.

Review of the medical record for Patient #21 revealed the patient was 69 year old admitted to the hospital on 05/23/17 with a diagnosis of Acute Respiratory Failure. The record revealed the patient expired on 05/30/17 at 12:50 p.m. without any resuscitation efforts. Review of the record revealed a DNR Status Acknowledgement Form (Family) signed by the patient's family and witnessed by 2 staff members.

Review of the progress notes revealed on 05/30/17 at 9:23 a.m., the physician discussed the DNR status of the patient with the patient's family (2 brothers and a sister) and the family wanted comfort measures started.

Further review of the record revealed no documentation of a physician's order for the DNR status.

In an interview on 07/25/17 at 3:45 p.m., S2DON reviewed the medical record for Patient #21 and confirmed there was no physician's order for the DNR. S2DON confirmed the DNR had been carried out without a physician's order and there were no resuscitation efforts provided by the staff.

Based on observation and interview, the hospital failed to ensure patients had a right to personal privacy. This deficient practice is evidenced by staff leaving documents containing patients' information facing upward on a desk located in a hallway used by patients, visitors and staff for 4 (#4, #13, #16, #28) of 24 current patients.

Findings:

In observations on 7/24/17 at 9:25 a.m. and 9:40 a.m. in a hallway outside of patients' rooms, there were documents on an unoccupied desk containing patients' private information. The documents contained information including the patient's name, date of birth, admission date, medical record number and account number for Patient #4, Patient #13, Patient #16 and Patient #28.

In an interview on 7/24/17 at 10:00 a.m. with S11Dietician, she verified the desk in the hallway with the patient information was used by her and she had left the papers with the patient information on the desk. S11Dietician verified she should not have left the patient information on the desk where it could be seen by anyone in the hallway.

Based on record review and interview, the hospital failed to report an allegation of neglect to Louisiana Department of Health within 24 hours of receipt of the allegation for 1 (#11) of 1 sampled patients reviewed for grievances.

Findings:

Review of the policy titled "Complaint/Grievance Process", presented as a current policy by S2DON, revealed that a patient grievance is a written or verbal complaint by a patient or the patient's representative regarding the patient's care, abuse, or neglect by the staff present. All complaints that cannot be resolved immediately at the time of the complaint by staff will be addressed as a grievance.

Review of the hospital's complaints and grievances revealed a grievance regarding Patient # 11, filed on 07/20/17, alleging neglect in the care of the patient by hospital staff members. Further review of the grievance documentation revealed the following, in part: Complainant stated he was told that last night ( night shift of 07/19/17) Patient #11's insulin drip was running despite his tube feeding bag being empty. He stated Patient #11's capillary blood sugar was 20. He also stated he was told the patient asked for pain medication and the nurse did not give him any.

Further review of the grievance documentation revealed the following findings documented by S2DON (who investigated the allegations): Review of IV Insulin Flowsheet shows MD orders not followed. Educated the nurse involved. Written counseling done. Nurse stated he did not think the patient was able to take another dose of pain medication.

In an interview on 07/27/17 at 1:15 p.m. with S2DON, she confirmed she had classified the above referenced grievance as an allegation of patient abuse/neglect. S2DON indicated she had counseled S7LPN regarding the incident and had taken disciplinary action in the form of a warning. S2DON further confirmed she had not reported the above referenced allegations of neglect to LDH-HSS (Louisiana Department of Health - Health Standards Section) within 24 hours of discovery.

Based on policy review, record review and interview, the hospital failed to ensure the use of restraint or seclusion was in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient for 1 of 1 (#32) sampled patients with restraints out of a total sample of 32 (#1-#32).
Findings:

Review of the hospital policy titled, Initiating and Monitoring Restraints revealed in part the following: The use of restraint will be in accordance with an order from a physician or licensed independent practitioner (LIP) who is responsible for the care of the patient....Orders for the management of non-violent or non-self-destructive behavior will be written to include: the type of restraint and the clinical justification for restraint....A physician or LIP's order for restraints for the management of non-violent or non-self-destructive behavior will remain in effect until the restraints are removed.

Patient #32
Review of the medical record for Patient #32 revealed the patient was a 64 year old admitted to the hospital on 06/01/17 with diagnoses of Type 2 Diabetes Mellitus and Osteomyelitis. Review of the record revealed the patient was discharged to a skilled nursing facility on 07/07/17.

Review of the record revealed an order for restraints dated 06/04/17. The order revealed a soft limb holder was ordered for the right and left lower extremities due to the patient's inabililty to respond to direct requests or follow specific instructions, and patient attempts to directly remove vital catheters, IV lines, tubes, trachs, and the patient uses mouth and pulls mittens off.

Review of the Daily Restraint Assessment and Observation Record dated 06/05/17 and 06/06/17 revealed the type of restraints was documented as soft limb holder to the right and left upper extremities. There was no documented evidence of a physician's order for the upper extremity restraints.

Review of the record revealed an order for restraints dated 06/07/17. The order revealed soft limb holder to the right and left upper extremities was ordered for same reasons indicated on the above restraint order.

Review of the Daily Restraint Assessment and Observation Records revealed the following:
06/09/17 - Side rails up X 4, soft limb holder to right and left upper extremities.
06/10/17 - Side rails up X 4, soft limb holder to right and left upper extremities.
06/14/17 - Side rails up X 4, soft limb holder to right and left upper extremities.
06/15/17 - Side rails up X 4, soft limb holder to right and left upper extremities.
06/17/17 - Side rails up X 4, soft limb holder to right and left upper extremities.
06/20/17 - Side rails up X 4, soft limb holder to right and left upper extremities.
06/21/17 - Soft limb holder to right and left lower extremities.
06/22/17 - Side rails up X 4, soft limb holder to right and left upper extremities.
06/26/17 - Side rails up X 4, soft limb holder to right and left upper extremities.
06/27/17 - Side rails up X 4, soft limb holder to right and left upper extremities.
06/28/17 - Side rails up X 4, soft limb holder to right and left upper extremities.
06/29/17 - Side rails up X 4, soft limb holder to right and left upper extremities.
06/30/17 - Side rails up X 4, Freedom Splint to right and left upper extremities, soft limb holder to right and left upper extremities.
There was no documented evidence of an order for side rails X 4, limb holders to the lower extremities, or Freedom Splints to the upper extremities.

Review of the record revealed an order for restraints dated 07/01/17. Review of the order revealed side rails X 4 and soft limb holders for right and left upper extremities were ordered.

Review of the Daily Restraint Assessment and Observation Record dated 07/04/17, 07/05/17, and 07/06/17 revealed no documented evidence that the side rails were used as ordered.

In an interview on 07/27/17 at 1:45 p.m., S2DON reviewed the medical record for Patient #32 and confirmed the restraints were not used in accordance with the written order of the physician. S2DON stated she remembered the patient and he was never in lower extremity restraints. S2DON stated the physician's order was not checked correctly. S2DON stated she did not know what Freedom Splints were and stated the order was not correct. S2DON confirmed the above documentation and confirmed the restraint use was not in accordance with the physician's orders.

Based on record reviews and interviews, the hospital failed to ensure the quality assessment performance improvement (QAPI) program documented evidence of data collection for indicators to measure, analyze and track to determine opportunities for improvement.

Findings:

Review of the QAPI data provided by the facility, there was no documented evidence of surveillance or medical record review for medication errors, infection control, dialysis infection control, restraint usage, and nursing care plans.

In an interview on 7/27/17 at 11:00 a.m. with S2DON, she verified she was not documenting data on indicators for medication errors, hand hygiene, infection control, dialysis infection control, restraints, nursing care plans, personal protective equipment usage and adherence to isolation precautions. S2DON said she did not actually watch contracted dialysis services for their infection control activities but used data from Dialysis "B" that the contracted service collected. S2DON said she watched staff for infection control breeches while on the unit but would correct the staff on the spot if she saw a problem and did not document her observations. She also verified she relied on self-reporting and did not do chart audits to look for medication errors. S2DON also said she did not have documented evidence of reviewing medical records for proper restraint usage or updating nursing care plans.

The hospital failed to ensure the QAPI program had a system to accurately identify medical errors, analyze their causes, and implement preventative actions and mechanisms to reduce the errors. This deficient practice is evidenced by the hospital failing to identify 40 medical errors on 8 (#6, #7, #8, #9, #11, #12, #19, #20) of 20 current patients reviewed for medical errors.

Findings:

Review of QAPI data revealed 0 medical errors had been discovered at the hospital from January 2017 through March 2017 with 64,962 doses of medications having been dispensed.

Review beginning on 7/25/17 of 20 current patients' medical records for medical errors revealed 8 patients with 40 medical errors.

In an interview on 7/26/17 at 2:18 p.m. with S12Pharmacist, he said he was the director of Pharmacy for the hospital. He said if a medical error was discovered it was reported by the hospital to the pharmacy and investigated by a pharmacist. He said the method of medication error discovery was self-reporting. S12Pharmacist said he was not sure if the hospital was reviewing medical records for errors or not.

In an interview on 7/26/17 at 2:55 p.m. with S2DON, she said the hospital did not have a process in place to review patients' medical records for medication errors. S2DON said self-reporting was the main source of discovering medication errors. S2DON said she was not made aware of any medication errors for the hospital for the month of July 2017. S2DON verified that based on the errors discovered by the survey team, the hospital was not accurately identifying medical errors.

Based on record review and staff interview, the hospital failed to ensure radiologists providing interpretation of radiologic tests from the contracted hospital were credentialed and granted privileges to provide the services by the hospital's medical staff and governing body for 3 (#S14MD, #S15MD, #S16MD) of 3 (#S14MD, #S15MD, #S16MD) contracted radiologists reviewed providing services to current hospital patients.

Findings:

Review of the hospital's written agreement with the host hospital dated 05/01/09 revealed radiology services were provided by the host hospital. There was no documented evidence in the written agreement of a provision related to the credenitaling process of the radiologist.

Review of the hospital's Medical Staff Roster provided by S1Adm as the complete current medcial staff, revealed the only member of the medical staff that was a radiologist was S13MD Director of Radiology.

Review of Patient #3's medical record revealed she was a current patient. Review of Patient #3's Chest x ray dated 07/10/17 revealed it had been interpreted by S15MD. Review of Patient #3's abdominal x-ray dated 07/06/17 revealed it had been interpreted by S16MD. There was no documented evidence that S15MD or S16MD were members of the medical staff of the hospital or that the hospital had conducted an internal review of the physicians' credentials.

Review of the medical record for Patient #9 revealed the patient was a current hospital patient. The patient's record revealed a chest x-ray report dated 07/21/17 and signed by S14MD. The record also revealed another chest x-ray report dated 07/24/17 that was signed by S14MD.
There was no documented evidence that S14MD was a member of the medical staff of the hospital or that the hospital had conducted an internal review of the physician's credentials.

In an interview on 07/27/17 11:20 a.m., S1Adm confirmed none of the radiologists that read the x-ray results for the hospital's patients were credentialed members of the hospital's medical staff and confirmed there was no internal review of the radiologists' credentials. S1Adm confirmed the radiology services were provided by the host hospital under a written agreement.

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30984


Based on interview and record review, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) failure of the RN or LPN to follow the orders of the licensed practitioner, failure to follow the hospital approved hypoglycemia protocol, and failure to assess a patient with a critically low CBG reading (CBG of 29), being treated with a continuous insulin infusion, who was assigned to a LPN and failure to notify the MD of the critically low CBG for 1 (#11) of 2 (#2, #11) patients reviewed for continuous medication infusions out of a total sample of 32 patients; and
2) failure of the RN to clarify an incomplete physician's order for Levophed prior to initiation of the Levophed infusion for 1 (#2) of 1 current patients receiving a continuous Levophed infusion out of a total sample of 32 patients; and
3) failure of the RN to notify the physician of blood glucoses greater than 400 mg/dl as ordered for 2 (#28, #30) of 2 current patients reviewed with blood glucoses over 400 mg/dl; and
4) failure of the RN to ensure patient vital signs were assessed as ordered for 4 of 4 (#9, #12, #17, #19) sampled patients reviewed for vital sign assessments out of a total sample of 32 patients; and
5) failure of the RN to ensure patient weights were obtained as ordered for 2 of 2 (#4, #7) patients reviewed for weight assessment out of a total sample of 32 patients.

Findings:

1) Failure of the RN or LPN to follow the orders of the licensed practitioner, failure to follow the hospital approved hypoglycemia protocol, and failure to assess a patient with a critically low CBG reading (CBG of 29), being treated with a continuous insulin infusion, who was assigned to a LPN and failure to notify the MD of the critically low CBG;

Review of Patient #11's medical record revealed an admission date of 07/18/17 with admit diagnoses of uncontrolled Type II Diabetes Mellitus with Stage III Kidney Disease without long-term current use of insulin. Further review revealed the patient had a PEG tube with tube feedings utilized as the primary means of nutrition/hydration and a tracheostomy tube.

Review of an incident involving Patient #11, that occurred on 07/19/17 at 9:00 p.m., revealed the following, in part: Patient's glucose was 94. Orders were for insulin drip to be stopped at glucose less than 100 and CBG rechecked in 30 minutes. Neither was done. Tube feeding was also empty at the time. At 01:00 a.m. pt's glucose was 29. Insulin drip stopped at that time. Hypoglycemia protocol was not followed. S2DON had documented the above referenced review of the incident. Further reivew of Patient #11 medical record revealed no documented evidence that the patient had been assessed by the RN or the LPN during the critical hypoglycemic episode referenced above. Additional review revealed no documented evidence that the MD had been notified of the critical low (29) capillary blood glucose reading.

In an interview on 07/26/17 at 2:00 p.m. with S2DON, she confirmed Patient #11 had no documented assessment by the LPN or the RN during the incident referenced above. She also confirmed that there was no documentation to indicate that the orders had been followed or that the hypoglycemia protocol had been followed. She also confirmed the MD had not been notified of the critical CBG level of 29 (obtained via fingerstick, at point of care, with a glucose meter). S2DON further reported there had been no root cause analysis performed and no action plan had been implemented to address and correct the issues identified while investigating the above referenced grievance.


2) Failure of the RN to clarify an incomplete physician's order for a continuous IV Levophed infusion prior to initiation of the infusion.

Patient #2
Review of the medical record for Patient #2 revealed the patient was admitted on 06/29/17 with diagnoses of Acute Respiratory Failure with hypoxia and cerebral edema. Additional review revealed the patient had a tracheostomy and was requiring mechanical ventilation.
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Review of Patient #2's physician's orders revealed an order dated 07/22/17 at 6:40 p.m., for a continuous IV Levophed (Norepinephrine) infusion. The order for Levophed was written as 5 mcg/min, titrate to keep SBP (systolic Blood Pressure) greater than 90. The order was signed off by S9RN. Further review of the medical record revealed no documented evidence of an order clarification, by the nursing staff, for specific time increments and specific dosage increments for the titration of the continuous IV Levophed infusion.

Further review of Patient #2's medical record revealed the Levophed infusion was started on 07/22/15 at 7:00 p.m. at 5 mcg/min (blood pressure was 75/38 at the time of initiation of the Levophed infusion). Additional review revealed the following Levophed rate changes:
07/22/17 7:05 p.m.: Blood pressure: 74/42, Levophed rate 10mcg/min;
07/22/17 7:10 p.m.: Blood pressure: 87/45, Levophed rate 15 mcg/min;
07/22/17 7:15 p.m.: Blood pressure: 98/48, Levophed rate 17 mcg/min. ;
07/22/17 9:00 p.m.: Blood pressure: 110/62, Levophed rate 15 mcg/min.;
07/23/17 7:30 a.m.: Blood pressure: 138/56, Levophed rate 8 mcg/min;
07/23/17 8:30 a.m.: Blood pressure: 105/65, Levophed rate 10 mcg/min;
07/23/17 9:00 a.m.: Blood pressure: 109/64, Levophed rate 12mcg/min;
07/23/17 10:00 a.m.: Blood pressure: 88/77, Levophed rate 15 mcg/min;
07/23/17 12:30 p.m.: Blood pressure: 112/57, Levophed rate 20 mcg/min;
07/23/17 1:00 p.m.: Blood pressure: 123/75, Levophed rate: 18mcg/min;
07/23/17 2:00 p.m.: Blood pressure: 112/58, Levophed rate: 16mcg/min;
07/23/17 3:30 p.m.: Blood pressure: 115/63, Levophed rate: 15mcg/min;
07/23/17 4:00 p.m.: Blood pressure: 106/59, Levophed rate: 14mcg/min.
Additional review of the record on 07/24/17 revealed the patient was currently receiving Levophed via continuous infusion at a rate of 10 mcg/min.

In an interview on 07/24/17 at 12:15 p.m. with S10RN (charge nurse), she confirmed Patient #2's Levophed order was an incomplete order because the titration orders lacked specific dosage increments and time frames for titrating the Levophed infusion. S10RN also confirmed S9RN (agency nurse) had signed off the order. S10RN indicated S9RN should have clarified the Levophed order by obtaining specific dosage increments and time frames for titrating the Levophed infusion prior to the initiation of the infusion. S10RN indicated the hospital had a vasoactive medication order sheet with specific dosage increments and time frames that should have been used by the ordering MD when Patient #2's Levophed infusion had been ordered. S10RN reported S9RN may not have known to initiate the hospital's vasoactive medication order sheet when the Levophed was ordered because she was an agency nurse. S10RN reviewed the above referenced continuous IV Levophed rate change documentation for Patient #2 and agreed there were no clear documented indicators for the dose increment changes and the time intervals when the doses were increased and decreased.

3) Failure of the RN to notify the physician of blood glucoses greater than 400 mg/dl as ordered.
Patient #28
Review of Patient #28's medical record revealed a physician's order dated 7/21/17 at 7:00 p.m. to administer 10 units of insulin (not specific to which type) and notify the MD if blood glucose greater than 400 mg/dl.

Review of Patient #28's medical record revealed the blood glucose on 7/24/17 at 4:00 p.m. was documented as 505 mg/dl. Further review revealed blood glucoses documented on 7/25/17 of 538 mg/dl at 7:00 a.m. and 417 mg/dl at 12:00 p.m. There was no documentation of physician notification as ordered.

Patient #30
Review of Patient #30's medical record revealed a physician's order dated 07/21/17 at 7:00 p.m. to administer 10 units of Apidra and notify the MD if blood glucose greater than 400 mg/dl.

Review of Patient #30's medical record revealed the blood glucose on 07/26/17 at 3:00 a.m. was documented as 415 mg/dl. There was no documentation of physician notification as ordered.

In an interview on 07/26/17 at 2:45 p.m., S2DON verified the physician should have been notified of the elevated blood glucoses greater than 400 mg/dl.


4) Failure of the RN to ensure patient vital signs were assessed as ordered.

Patient #9
Review of the medical record for Patient #9 revealed the patient was a 46 year old admitted to the hospital on 07/20/17 with diagnoses of Intra Cranial Hemorrhage, Hemicraniectomy, Seizures, and Tracheostomy/PEG placement.
Review of the physician admission orders dated 07/20/17 at 6:00 p.m. revealed an order for vital signs every 4 hours.

Review of the Graphic/I&O Sheet dated 07/21/17 revealed no documented evidence of any vital signs from 4:00 a.m. to 8:00 p.m. Review of the Nurses Daily Flow Sheets revealed no documented evidence of any vital signs on 07/21/17.

In an interview on 07/25/17 at 11:10 a.m., S2DON reviewed the medical record and confirmed there were no vitals signs documented for 07/21/17 on the day shift from 4:00 a.m. to 8:00 p.m.


Patient #12
Review of the medical record for Patient #12 revealed the patient was a 66 year admitted to the hospital on 07/17/17 with diagnoses of Sacral Osteomyelitis/Decubitus Ulcer, Unstageable with Infection, Calculus of Gallbladder and Bile Duct with Acute Cholecystitis, Atrial Fibrillation, and Depression with Anxiety.

Review of the physician admission orders dated 07/17/17 at 7:30 p.m. revealed an order for vital signs every 8 hours.
Review of the Graphic/I&O Sheets dated 07/20/17 and 07/23/17 revealed no vital signs were documented from 4:00 a.m. to 8:00 p.m.

In an interview on 07/25/17 at 3:40 p.m., S2DON reviewed the medical record and confirmed there were no vitals signs documented on 7/23/17 and 7/20/17 from 4:00 a.m. to 8:00 p.m.


Patient #14
Review of Patient #14's medical record revealed an admission date of 06/29/17 with admission diagnoses of
End Stage Renal Disease with dialysis, Chronic Obstructive Pulmonary Disease, Sepsis, Atrial fibrillation, NSTEMI (non-ST elevated Myocardial infarction), and Combined systolic and diastolic heart failure. Further review revealed an admission order for vital signs every 8 hours.

Review of Patient #14's graphical flowsheet revealed no vital sign assessments were recorded on the day shift for the following dates: 07/05/17, 07/08/17, 07/11/17, 07/15/17, and 07/16/17.


Patient #19
Patient #19's medical record revealed an admission date of 07/05/17with an admission diagnosis of Stage IV Adenocarcinoma. Further review revealed an admission order for vital signs assessments every 4 hours.

Review of Patient #19's graphical flowsheet revealed no vital sign assessments were recorded on day shift for the following dates: 07/13/17 and 07/24/17 and no vital sign assessments recorded for the night shift for the following dates: 07/12/17, 07/14/17 and 07/15/17.

In an interview on 07/26/17 at 1:32 p.m. with S10RN, she confirmed, at times, patient vital signs were not assessed and documented as ordered.

In an interview on 07/27/17 at 1:30 p.m.with S2DON, she confirmed vital signs had not been assessed and documented as ordered for the above referenced patients.


5) Failure of the RN to ensure patient weights were obtained as ordered.

Patient #4
Review of Patient #4's medical record revealed an admission date of 07/20/17 with admission diagnoses including status post small bowel obstruction with wound dehiscence with wound vacuum, ESRD, Hemodialysis, and Pulmonary Hypertension. Further review revealed an admission order for daily weights. Additional review revealed that as of 07/25/17 (date of record review) the only weight documented was on 07/20/17.


Patient #7
Review of Patient #7's medical record revealed an admission date of 06/30/17 with admission diagnoses including
Multiple decubitus ulcers with malodorous drainage located on buttocks, sacrum and left heel, hemodialysis, and Diabetes Mellitus Type II. Further review revealed an admission order for daily weights. Additional review revealed that as of 07/25/17 (date of record review) daily weights had not been documented on 07/1/17, 07/02/17, and 07/03/17.

In an interview on 07/27/17 at 1:30 p.m.with S2DON, she confirmed daily weights had not been assessed and documented as ordered for the above referenced patients.

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current an individualized, comprehensive nursing care plan for each patient for 5 (#1, #2, #4, #5, #7) of 7 current patients reviewed for care plans out of a total sample of 32 patient records reviewed.

Findings:

A review of the hospital policy titled, The Nursing Process - Care Planning revealed in part the following: All patients shall be assessed on admission, and a written plan of care developed and initiated within 24 hours of admission by an RN. The plan of care shall reflect those standards of care applicable to that individual. The plan of care reflects integration of information from various disciplines involved in the care of the patient, provides for identification of individualized patient needs, and serves as the basis for patient care decisions based on identified needs....The nursing plan of care shall be evident in the medical record, providing evidence of the patient's problems/needs with the interventions to meet these needs as well as their effectiveness documented.

Patient #1
Review of Patient #1's medical record revealed she was receiving dialysis three days per week for Chronic Kidney Disease. Further review revealed she was on contact precautions for Pseudomonas aeruginosa.

Review of Patient #1's care plan revealed no problems and interventions identified for dialysis or contact precautions. A problem identified as infection had "potential" selected instead of "actual".

Patient #2
Review of Patient #2's medical record revealed the patient was admitted on 6/29/17 with admission diagnoses including Acute Respiratory Failure with hypoxia and cerebral edema. Further review revealed the patient was started on a continuous IV Levophed infusion for blood pressure regulation on 7/22/17 at 6:40 p.m.

Review of Patient #2's plan of care revealed the care plan had not been updated to address the initiation of the continuous IV Levophed infusion for blood pressure regulation as an identified problem and no identified interventions related to Levophed infusions.

Patient #4
Review of Patient #4's medical record revealed the patient had diagnoses including Diabetes Mellitus, ESRD with hemodialysis, and was being treated for a wound infection with a wound vacuum.

Review of Patient #4's care plan revealed no problems and interventions identified for hemodialysis, Diabetes Mellitus, and wound treatment with a wound vac.

Patient #5
Review of Patient #5's medical record revealed the patient had diagnoses including Diabetes Mellitus, indwelling Foley catheter, and was receiving treatment with Xeralto (anticoagulant) for Deep Vein Thrombosis. Further reivew revealed the patient had a positive stool culture for C.diff.

Review of Patient #5's plan of care revealed Diabetes Mellitus, indwelling Foley catheter, bleeding precuations related to treatment iwth anticiaogulants and isolation precuations for an actual C.diff infection were not addressed as problems on the patient's care plan.

Patient #7
Review of Patient #7's medical record revealed the patient was being treated with Lovenox 30 mg injections, administered subcutanously daily and Aspirin 81 mg by mouth daily.

Review of Patient #7's plan of care revealed bleeding precuations were not identified as a problem on the patient's care plan and no identified interventions related to anticoagualnt therapy were included in the plan.

In an interview on 7/27/17 at 1:30 p.m. with S2DON, she confirmed patient care plans should have been inclusive of all identfied patient problems. S2DON also confirmed the care plans should have been updated as new problems were identified.











30984

Based on record reviews and interview, the hospital failed to ensure a RN assigned the nursing care of each patient to nursing personnel in accordance with the specialized qualifications and competence of the nursing staff and according to hospital policy. This deficient practice was evidenced by:
1) failure of the charge RN to perform and document an assessment to determine stability prior to delegating, to a LPN, the care of a medically complex patient (#11) requiring continuous insulin infusions to maintain blood glucose levels, as set forth in the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII", Section "3703. Definition of Terms Applying to Nursing Practice Delegating Nursing Interventions and hospital policy for 1 (#2) of 1 current patients receiving continuous IV insulin infusions; and
2) failure of the hospital to ensure all nursing staff, including agency nurses, were required to have competency evaluations for the administration of continuous IV Insulin infusions and administration of continuous IV Levophed infusions prior to caring for patients receiving these medications.

Findings:

1) Failure of the charge RN to perform and document an assessment to determine stability of a patient prior to delegating, to a LPN, the care of a medically complex patient (#11) requiring continuous insulin infusions to maintain blood glucose levels.

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice Delegating Nursing Interventions revealed the RN retains the accountability for the total nursing care of the individual. The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. Any situation where tasks are delegated should meet the following criteria: a) the person has been adequately trained for the task; b) the person has demonstrated that the task has been learned; c) the person can perform the task safely in the given nursing situation; d) the patient's status is safe for the person to carry out the task; e) appropriate supervision is available during the task implementation; f) the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. The RN may delegate to LPNs the major part of the nursing care needed by individuals in stable nursing situations, that is, when the following three conditions prevail at the same time in a given situation: a) nursing care ordered and directed by the RN or MD requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; b) change in the patient's clinical conditions is predictable; and c) medical and nursing orders are not subject to continuous change or complex modification.

Review of the hospital policy titled, "Insulin Administration", Policy #: 9-4.11.0, effective date: 3/1/14, revealed in part: C. Continuous Insulin IV (intravenous) infusion-Regular Insulin. 1. Only RNs are allowed to administer and monitor continuous insulin IV infusions. 4. The RN shall monitor the patient with a continuous insulin infusion at least every hour for: Signs and symptonms of hypo-hyperglycemia and to assure blood glucose monitoring is completed appropriately.

Review of Patient #11's medical record revealed an admission date of 07/18/17 with admit diagnoses of uncontrolled Type II Diabetes Mellitus with Stage III Kidney Disease without long-term current use of insulin. Further review revealed the patient had a PEG tube with tube feedings utilized as the primary means of nutrition/hydration, and a tracheostomy tube.

Review of Patient #11's MD orders, dated 07/18/17 at 6:00 p.m., revealed the following hypoglycemic protocol revealed in part: Insulin Regular (Humulin R) 100 units in 100 ml of 0.9% Normal Saline. Continuous Insulin drip at 2.4 units/hour low dose correction scale. Accuchecks every 4 hours. BG of less than 100 mg/dl discontinue Insulin infusion. Recheck in 30 minutes. If blood sugar less than 70 follow hypoglycemia protocol. If Blood sugar above 70, leave insulin drip off and follow previous monitoring schedule with correction scale. BG goal 140 - 180.

Review of Patient #11's Insulin Flowsheet on 07/19/17 at 9:00 p.m. revealed the patient's capillary blood glucose was 94. Further review revealed the insulin drip was not discontinued and the CBG was not rechecked in 30 minutes. Additional review revealed at 01:00 a.m. the patient's capillary blood glucose was 29. The Insulin drip stopped at that time, but the Hypoglycemia protocol was not followed.

Review of Patient #11's narrative nurses' notes for the night shift of 07/19/17 revealed no documented assessment of the patient, by S8RN (night shift RN charge nurse), prior to delegation of the patient's care to S7LPN. Further review of the patient's medical record revealed no documentation of the continuous insulin infusion and no documentation of any actions taken, by S7LPN (on the night shift of 7/19/17), to address the patient's CBG of 29.

In an interview on 07/26/17 at 11:13 a.m. with S7LPN, he confirmed he had not received any type of training regarding administration of continuous insulin infusions. S7LPN also confirmed he had never taken care of a patient on a continuous insulin infusion prior to his assignment to care for Patient #11 on 07/19/17. S7LPN indicated S8RN had been aware that Patient #11 had a continuous insulin infusion. S7LPN also reported he could not, as a LPN, administer D50W (50% Dextrose) via IV push when the patient's CBG was 29. S7LPN further reported S8RN was made aware of the 29 blood glucose by him but she had not administered D50W via IV push to Patient #11 so he had given 240 mls of Boost (liquid supplement) with 6 packets of sugar twice, per Patient #11's PEG tube, in an attempt to raise the patient's blood sugar level. S7LPN indicated he administered 240 mls of Boost with 6 packets of sugar per PEG tube without a physician's order. S7LPN indicated he had based his actions on his prior nursing knowledge of ways to increase blood sugar levels. S7LPN also reported at times he felt he was assigned patients that were not appropriate and not stable enough to be assigned to him as a LPN.

In an interview on 7/26/17 at 1:32 p.m. with S10RN (day shift charge nurse), she indicated the charge nurse on the prior shift makes assignments, based on the number of RNs and LPNs and acuity level of the patients. S10RN reported that she had not assigned Patient #11 to S7LPN for the night shift of 07/19/17. S10RN further reported S8RN night charge nurse had changed the patient assignments and had reassigned Patient #11 to S7LPN. S10RN indicated patients that are acute, such as patients on continuous infusions like insulin, should have been assigned to RNs. S10RN confirmed patients on continuous insulin infusions, like Patient #11, were not stable, not predictable, and could change fast dependent upon their intake. S10RN also confirmed Patient #11 should not have been assigned to S7LPN.

In an interview on 07/27/17 at 1:30 p.m. with S2DON, she confirmed the above referenced medication error involving Patient #11. S2DON verified there was no account of the above referenced incident in the patient's medical record.

An attempt was made to contact S8RN night charge nurse for an interview. A message was left for S8RN to call the hospital, by S2DON, on 07/26/17. S8RN had not returned S2DON's call as of the time of the survey team's exit on 07/27/17. S2DON had informed the survey team that S8RN was on vacation leave.



2) Failure of the hospital to ensure all nursing staff, including agency nurses, were required to have competency evaluations for the administration of continuous IV Insulin infusions and administration of continuous IV Levophed infusions.

Review of S7LPN's personnel file revealed he was a staff LPN. Further review revealed no documented evidence of an evaluation of competency in the administration of continuous insulin infusions. S7LPN had been assigned a patient (#11) on the night shift 07/19/17 who was receiving insulin via continuous infusion for treatment of insulin dependent Diabetes Mellitus.

Review of S9RN's personnel file revealed she was a contracted agency RN. Further review revealed no documented evidence of an evaluation of competency in administration of insulin or Levophed [Levophed is a potent alpha/beta agonist that causes vasoconstriction and an increase in blood pressure, that is used to treat severe hypotension, shock or bradycardia].

Review of S3RN's personnel file revealed he was a contracted agency RN. Further review revealed no documented evidence of an evaluation of competency in administration of insulin or Levophed

Review of S4LPN's personnel file revealed she was a staff nurse at the hospital. Further review revealed no documented evidence of an evaluation of competency in administration of insulin or Levophed

In an interview on 07/24/17 at 12:17 p.m. with S10RN (day shift charge nurse), she confirmed S9RN had taken care of a patient (#2) who was being treated with a continuous Levophed infusion for blood pressure stabilization. She also confirmed S9RN did not have skills competencies for Levophed infusions.

In an interview on 07/27/17 at 1:30 p.m. with S2DON, she confirmed that none of the nursing staff had skills competencies for the administration of insulin or Levophed although those medications were administered at the hospital. S2DON said it was not a requirement of the hospital to have competencies for insulin and Levophed infusions. S2DON said she had only been in her current role as DON for a few weeks.

Based on record review and interview, the hospital failed to ensure non-employee licensed nurses working in the hospital were adequately supervised by an appropriately qualified hospital-employed RN as evidenced by having S9RN, a contracted RN, working as the charge nurse with no other hospital-employed RN present.
Findings:

Review of Daily Assignment Sheet for 07/21/17 revealed S9RN a contracted nurse was the charge nurse on the 6:00 p.m. to 6:00 a.m. shift and the only other RN on the shift was also an agency nurse.

In an interview 07/27/17 at 3:00 p.m., S2DON confirmed S9RN was a contracted nurse and was the charge nurse on 07/21/17 on the 6:00 p.m. to 6:00 a.m. shift. S2DON confirmed there was no hospital-employed RN to supervise the nursing staff on that shift.

30364


Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with the orders of qualified practitioners responsible for the patient's care and in accordance with hospital policy. This deficient practice is evidenced by 40 medication errors that had not been identified by the hospital for 8 (#6, #7, #8, #9, #11, #12, #19, #20) of 20 patients reviewed for medication administration.

Findings:

Review of the hospital policy titled Medication Administration, Policy Number: 9-4.13.0, revealed in part:
Withholding Medications and/or treatments:
Any drug that is withheld shall be circled and initiated on the MAR; The nurse shall document shall document on the MAR or in the nurse's narrative notes, if necessary, the reason the drug was not given; The physician must be notified if a medication or treatment is held without a specific order to hold the medication or treatment.
Missed or Late Administration of Medications:
c) If the medication is not available, the pharmacist should notify nursing and recommend a substitution. Nursing will contact the physician and inform of the pharmacist's recommendation. This shall be documented as an order in the medical record.
Availability of Medications:
Medications printed on the MAR by the pharmacy should be readily available in the medication room or in the automated medication dispensing cabinet. If medications are not readily available for administration to patients, the following procedure will be followed:
a. The staff nurse will contact the contracted pharmacy.
b. The contracted pharmacy pharmacist will explore all options to secure the medication
including contacting a local pharmacy or contacting the host facility.

Patient #6
Review of Patient#6's medical record revealed a physician's order dated 07/19/17 at 6:13 p.m. for Cefazolin 2 grams every 8 hours.

Review of Patient #6's MAR dated 07/20/17 revealed the 9:00 a.m. dose of Cefazolin had been circled indicating the dose had not been given. Further review revealed no documentation as to why the dose had not been given as ordered or physician notification of the missed dose.

Patient #7
Review of Patient #7's medical record revealed a physician's order, dated 6/30/17, for Insulin Low Dose sliding scale with accuchecks before meals and at hour of sleep. Further review revealed no order for discontinuation of the sliding scale order.

Review Patient #7's Diabetic Flow Chart, utilized to document sliding scale insulin coverage, revealed the following, in part:
7/4/17 9 a.m.: CBG 156- no coverage administered, 2 units of Apidra Insulin should have been administered for an accucheck of 151 - 200 mg/dl.
7/8/17 9 p.m.: Accucheck : 199- no coverage administered, 2 units of Apidra Insulin should have been administered for an accucheck of 151 - 200 mg/dl.;
7/9/17 9a.m. CBG 202, no coverage administered, 4 units of Apidra Insulin should have been administered for an accucheck of 201 - 250 mg/dl.
7/10/17 9 p.m. CBG 158- no coverage administered, 2 units of Apidra Insulin should have been administered for an accucheck of 151 - 200 mg/dl..
7/17/17 9 a.m. CBG 152, no coverage administered, 2 units of Apidra Insulin should have been administered for an accucheck of 151 - 200 mg/dl.
7/18/17 9 p.m. CBG 176, no coverage administered, 2 units of Apidra Insulin should have been administered for an accucheck of 151 - 200 mg/dl.
7/21/17 9 p.m. CBG 177, no coverage administered, 2 units of Apidra Insulin should have been administered for an accucheck of 151 - 200 mg/dl.
7/22/17 9 pm CBG 218, no coverage administered, 4 units of Apidra Insulin should have been administered for an accucheck of 201 - 250 mg/dl..

In an interview on 7/25/17 at 10:30 a.m. with S2DON, she confirmed there was no order to discontinue the Low Dose Sliding Scale insulin. S2DON reported the only order that had been changed was to change the interval for obtaining accuchecks to BID.

Patient #8
Review of Patient #8's medical record revealed a physician's order dated 07/14/17 for Amantadine 100 mg every 8 hours, Coreg 25 mg twice per day, and Chlorhexidine gluconate 15 ml twice daily, Heparin Sodium 5,000 u/ml every 8 hours, Apresoline 25 mg every 8 hours, Diclofenac 2 gm twice per day, Normal Saline 10 ml flush each shift, and Heparin Sodium flush 200 units each shift.

Review of Patient #8's MAR dated 07/14/17 revealed the 9:00 p.m. doses of Amantadine, Coreg, Chlorhexidine, Heparin 5000 u/ml, Apresoline, Diclofenac, Heparin 250 units and Normal Saline were circled indicating they had not been administered as ordered. Next to each medication was written, "Med not available". Further review revealed no documentation of physician notification or an order to hold the medications.

Patient #9
Review of the medical record for Patient #9 revealed the patient was a 46 year old admitted to the hospital on 07/20/17 at 5:34 p.m. with diagnoses of Intra Cranial Hemorrhage, Hemicraniectomy, and Tracheostomy/PEG placement.

Review of the physician orders dated 07/20/17 at 6:00 p.m. revealed the following medications were ordered and scheduled for 9:00 p.m.:
Bacitracin ointment 500 Units/GM to left ear twice a day.
Bromocriptine Mesylate (Parlodel) 2.5 mg twice a day.
Clobazam (ONFI) 10 mg twice a day.
Famotidine (Pepcid) 20 mg twice a day.
Lacosamide (Vimpat) 200 mg twice daily.
Senna/Docusate Na (Senna-S) 50 mg-8.6 mg twice a day.

Further review of the physician orders dated 07/20/17 at 6:00 p.m. revealed the following medications were ordered on admission .
Piperacillin/Tazo 4.5 Gm/Normal Saline every 8 hours. Last dose 7/20/17 at 9:58 a.m.
Chlorhexidine gluconate (Peridex) four times daily (9 a.m., 1 p.m., 5 p.m., 9 p.m.).
Heparin Sodium 5000 units/ml every 8 hours.

Review of the MAR dated 07/20/17 revealed the following medications were not administered at 9:00 p.m.:
Bromocriptine Mesylate (Parlodel) 2.5 mg
Clobazam (ONFI) 10 mg
Famotidine (Pepcid) 20 mg
Lacosamide (Vimpat) 200 mg
Senna/Docusate 50 mg-8.6 mg
Peridex 12%
Bacitracin 500 Units/GM

Further review of the MAR dated 07/20/17 revealed the Heparin 5000 u SQ every 8 hours was not administered until 5:00 a.m. on 07/21/17. The MAR revealed the Piperacillin was not administered until 6:00 a.m. on 07/21/17. The MAR dated 07/20/17 revealed a print date/time of 07/21/17 at 3:00 a.m.

In an interview on 07/25/17 at 11:10 a.m., S2DON reviewed the medication orders on admit (07/20/17) and the MAR (07/20/17) and confirmed the above medications due at 9:00 p.m. on 07/20/17 were not administered. After reviewing the MAR she stated the MAR was not received by the hospital from pharmacy until 3:00 a.m. She stated the staff can give medications if the patient needs them before they receive the printed MAR from the pharmacy. She confirmed the patient did not receive the Piperacillin at 10:00 p.m. as scheduled and stated she wished the staff would have administered that. She confirmed none of the 9:00 p.m. meds were administered as ordered. She was unable to explain why the MAR was not received until 3:00 a.m. when the patient was admitted at 8:00 p.m. She confirmed the pharmacy would have been faxed the orders once the patient arrived around 8:00 p.m.

In an interview on 07/26/17 at 2:20 p.m., S12Pharmacist stated once the orders are received by pharmacy the MAR is ready within 15-20 minutes, if there are no clarifications needed. S12Pharmacist stated the nurse can hand write a MAR if medications are needed to be administered before the printed MAR is available. S12Pharmacist indicated he had not received any feedback from the hospital regarding medications not being available when needed.

Patient #11
Patient #11 was admitted on 07/18/17 with admit diagnoses of uncontrolled Type II Diabetes Mellitus with Stage III Kidney Disease without long-term current use of insulin.

Review of Patient #11's physician's orders dated 7/18/17 revealed an order for Zyrtec 5 mg every morning.

Review of Patient #11's MAR dated 7/19/17 revealed the 9:00 a.m. dose of Zyrtec 10 mg had been circled to indicate it had not been given. Next to the dose was written, "unavailable". Further review revealed no documentation of physician notification or an order to hold the medication.

Review of Patient #11's physician's orders revealed an order for hypoglycemic protocol, dated 07/18/17 at 6:00 p.m., for Insulin Regular (Humulin R) 100 units in 100 ml of 0.9% Normal Saline. Continuous Insulin drip at 2.4 units/hour low dose correction scale. Accuchecks every 4 hours. BG of less than 100 mg/dl discontinue Insulin infusion. Recheck in 30 minutes. If blood sugar less than 70 follow hypoglycemia protocol. If Blood sugar above 70, leave insulin drip off and follow previous monitoring schedule with correction scale. BG goal 140 - 180.

Review of the Capillary Blood glucose sliding scale orders, dated 07/18/17 at 6:00 p.m. revealed in part: For CBG less than 60 mg/dl give 12.5 grams (½ amp) of D50 W or 1 mg of Glucagon SQ if no IV access, recheck CBG and notify MD.

Review of Patient #11's Insulin Flowsheet on 07/19/17 at 9:00 p.m. revealed the patient's capillary blood glucose was 94. Further review revealed the insulin drip was not discontinued and the CBG was not rechecked in 30 minutes. Additional review revealed at 01:00 a.m. the patent's capillary blood glucose was 29. The Insulin drip stopped at that time, but the Hypoglycemia protocol was not followed.

In an interview on 07/27/17 at 1:30 p.m. with S2DON, she confirmed the physician's orders had not been followed.

Patient #12
Review of the medical record for Patient #12 revealed the patient was a 66 year old admitted to the hospital on 07/17/17 at 7:30 p.m. with diagnoses of Sacral Osteomyelitis/Decubitus Ulcer, Unstageable with Infection, Calculus of Gallbladder and Bile Duct with Acute Cholecystitis, Atrial Fibrillation, and Depression with Anxiety.

Review of the physician orders dated 07/17/17 at 7:30 p.m. revealed the following medications were ordered twice a day and were scheduled to be administered at 9:00 p.m.:
Lipitor 10 mg
Ascorbic Acid 500 mg

Review of the MAR dated 07/17/17 revealed the Lipitor and Ascorbic Acid were not administered on 07/17/17 at 9:00 p.m.

Further review of the physician orders dated 07/18/17 at 12:41 a.m. revealed CBG checks with sliding scale insulin administration was ordered for 9:00 a.m., 3:00 p.m., 9:00 p.m., and 3:00 a.m. Review of the sliding scale revealed 2 units were ordered for a blood sugar range of 151-200.

Review of the MAR dated 07/19/17 revealed the patient's CBG blood sugar was 189 at 9:00 a.m. Review of the MAR and the Diabetic Flow Chart revealed no documented evidence that the ordered dose of insulin was administered for the blood sugar of 189 (2 units).

Review of the MAR dated 07/20/17 revealed the patient's CBG blood sugar was 156 at 9:00 a.m. Review of the MAR and the Diabetic Flow Chart revealed no documented evidence that the ordered dose of insulin was administered for the blood sugar of 156 (2 units).

In an interview on 07/25/17 at 3:40 p.m., S2DON reviewed the medical record for Patient #12 and confirmed the Lipitor and Ascorbic Acid were not administered as ordered at 9:00 p.m. on the day of admit (07/17/17). S2DON confirmed the sliding scale insulin was not administered as ordered on 07/19/17 and 07/20/17 at 9:00 a.m..


Patient #19
Review of Patient #19's medical record revealed a physician's order for 30 ml of Bicitra (120 ml concentration) to be administered every 4 hours orally

Review of Patient #19's MAR dated 7/24/17 7:00 a.m. -7/25/17: 6:59 a.m. revealed all of the scheduled doses
(timed every 4 hours at 9 a.m.-1 p.m.- 5 p.m.- 9 p.m.-1 a.m.- 5 a.m. ) were circled and a handwritten note indicated the medication was unavailable. Further review revealed no documented evidence of actions being taken to obtain the medications.

In an interview on 7/26/17 at 1:32 p.m. with S10RN, she reported there are ways to get medications that are unavailable. She indicated the charge nurse should have been be notified if a medication was unavailable and steps could have been taken to ensure the medication was obtained. She said they could borrow the medication from the host hospital or they could have gotten the medication from a local pharmacy. S10RN confirmed all doses for an entire day of a medication should not be circled and documented as medical unavailable. S10RN said documenting medication unavailable was no excuse for a patient missing 6 doses of a medication.














Patient #20
Review of Patient #20's physician's orders dated 07/06/17 revealed an order for Apidra per low dose sliding scale before meals and at bedtime. The dose for 151mg/dl -200 mg/dl was 2 units.

Review of Patient #20's Diabetic Flow Chart dated 07/09/17 revealed the 7:00 a.m. blood glucose was documented as 180 mg/dl. Review of Patient #20's medical record revealed no documentation of insulin administration.


In an interview on 07/25/17 at 10:35 a.m. with S2DON, she verified the above mentioned doses of medications had not been given as ordered. S2DON also said most of the medications circled and marked "unavailable" were available in the automated dispensing system and should have been given.





30984

30364


Based on record reviews and interview, the hospital failed to ensure all patient medical record entries were authenticated in written or electronic form by the person responsible for providing the service. This deficient practice is evidenced by failure to have nurses' signatures on entries for 4 (#11, #18, #28, #32) of 32 medical records reviewed for authenticating entries.

Findings:

Patient #11
Review of Patient #11's nursing daily flowsheet narrative entries dated 7/18/17 revealed the entries at 10:00 p.m., 11:00 p.m., and 2400 had not been authenticated.

Review of Patient #11's nursing daily flowsheet narrative entries dated 7/19/17 revealed the entries at 1:00 a.m., 3:00 a.m., 4:00 a.m., 6:00 a.m. and 6:15 a.m. had not authenticated.

Review of Patient #11's nursing daily flowsheet narrative entry dated 7/20/17 revealed the entry at 6:30 p.m. had not authenticated.

Review of Patient #11's nursing daily flowsheet narrative entry dated 7/20/17 revealed the entry at 7:00 a.m. had not authenticated.


Patient #18
Review of Patient 18's nursing daily flowsheet narrative entries dated 7/20/17 revealed the entry at 12:30 a.m. had not been authenticated by the writer.

Review of Patient 18's nursing daily flowsheet narrative entries dated 7/21/17 revealed the entry at 6:00 a.m. had not been authenticated by the writer.

Patient #28
Review of Patient #28's nursing daily flowsheet narrative entries dated 7/23/17 revealed the entries at 6:00 a.m., 7:00 a.m., 9:00 a.m. and 12:00 p.m. had not been authenticated.

In an interview on 7/17/17 at 10:00 a.m. with S2DON, she verified all entries in the medical record should have been authenticated by the writer.


Patient #32
Review of the medical record for Patient #32 revealed the patient was admitted to the hospital on 06/01/17 and discharged on 07/07/17 to a skilled nursing facility.
Review of the Daily Restraint Assessment and Observation Form dated 07/06/17 revealed the entries (Every 2 hours) from 7:00 p.m. to 4:00 a.m. had not been authenticated.
Review of the Daily Restraint Assessment and Observation Form dated 06/15/17 revealed the entries from 6:00 p.m. to 5:00 a.m. had not been authenticated.

In an interview on 07/27/17 at 1:45 p.m., S2DON reviewed the medical record for Patient #32 and confirmed the above entries had not been authenticated by the nurse.












30984

Based on record review and interview, the hospital failed to ensure medical records included a properly executed informed consent for procedures and treatments. This deficient practice was evidenced by informed consents that were not completed as per hospital policy, when information required was omitted in the informed consent and required information areas were left blank for 2 of 2 (#9, #12) current patients reviewed for properly executed informed consents out of a total sample of 32 (#1-#32). Findings:

Review of the hospital policy titled Informed Consent, revealed in part a properly executed informed consent contains at least the following: Alternative procedures and treatments....Date and time consent obtained....


Patient #9
Review of the medical record for Patient #9 revealed the patient was admitted to the hospital on 07/20/17 with diagnoses of Intra Cranial Hemorrhage, Hemicraniectomy, and Tracheostomy/PEG placement.
Review of the record revealed a consent for PICC line placement dated 07/21/17 (no time). Review of the consent revealed the possible alternatives were typed in as "No other alternative available or Refusal of the procedure and I am aware of the consequences of the alternatives." Neither alternative was checked.

In an interview on 07/25/17 at 11:10 a.m., S2DON reviewed the medical record for Patient #9 and confirmed the consent form for the PICC line insertion dated 07/21/17 did not include alternatives or the time of the signature.


Patient #12
Review of the medical record for Patient #12 revealed the patient was admitted to the hospital on 07/17/17 with diagnoses of Sacral Osteomyelitis/Decubitus Ulcer, Unstageable with Infection, Calculus of Gallbladder and Bile Duct, Atrial Fibrillation, and Depression with Anxiety.
Review of the record revealed a consent for PICC line placement dated 07/21/17 (no time). Review of the consent revealed the possible alternatives were typed in as "No other alternative available or Refusal of the procedure and I am aware of the consequences of the alternatives." Neither alternative was checked.

In an interview on 07/25/17 at 3:40 p.m., S2DON reviewed the record and confirmed the PICC consent form did not include alternatives to the procedure or the time of the signature.

Based on record review and interview, the hospital failed to ensure drug administration errors were documented in the patient's medical record for 1 (#11) of 1 patient records reviewed for identified medication errors out of a total patient sample of 32.

Findings:

Patient #11 was admitted on 07/18/17 with admit diagnoses of uncontrolled Type II Diabetes Mellitus with Stage III Kidney Disease without long-term current use of insulin.

Review of Patient #11's physician's orders revealed an order for hypoglycemic protocol, dated 07/18/17 at 6:00 p.m., for Insulin Regular (Humulin R) 100 units in 100 ml of 0.9% Normal Saline. Continuous Insulin drip at 2.4 units/hour low dose correction scale. Accuchecks every 4 hours. BG of less than 100 mg/dl discontinue Insulin infusion. Recheck in 30 minutes. If blood sugar less than 70 follow hypoglycemia protocol. If Blood sugar above 70, leave insulin drip off and follow previous monitoring schedule with correction scale. BG goal 140 - 180.

Review of the Capillary Blood glucose sliding scale orders, dated 07/18/17 at 6:00 p.m. revealed in part: For CBG less than 60 mg/dl give 12.5 grams (½ amp) of D50 W or 1 mg of Glucagon SQ if no IV access, recheck CBG and notify MD.

Review of Patient #11's Insulin Flowsheet on 07/19/17 at 9:00 p.m. revealed the patient's capillary blood glucose was 94. Further review revealed the insulin drip was not discontinued and the CBG was not rechecked in 30 minutes. Additional review revealed at 01:00 a.m. the patient's capillary blood glucose was 29. The Insulin drip stopped at that time, but the Hypoglycemia protocol was not followed.

In an interview on 07/27/17 at 1:30 p.m. with S2DON, she confirmed the above referenced medication error involving Patient #11. S2DON verified there was no account of the above referenced incident in the patient's medical record.

Based on record review and interview, the hospital failed to ensure the UR (Utilization Review) committee consisted of 2 or more physicians who were not professionally involved in the care of the patients whose cases were being reviewed by the UR committee.

Findings:

Review of the hospital policy titled, Utilization Management Plan revealed the following: Physicians or individuals may not participate in the review of the any cases in which he/she has been or anticipates being professionally involved. Physicians or individuals having a direct or indirect financial interest in the case(s) being reviewed may not participate in the utilization management activities pertaining thereto.

Review of the Utilization Management Committee meeting minutes dated 01/19/17 and 04/20/17 revealed S18MedDir, S19MD, and S20MD were the physician members of the UR committee.

In an interview on 07/26/17 at 4:00 p.m., S2DON confirmed she was responsible for UR. S2DON confirmed S18MedDir was the hospital's medical director and was the attending physician for many of the hospital patients. S2DON stated all 3 physicians on the UR committee review cases depending on the issue on the record. S2DON stated they do UR together as part of the morning meeting. S2DON confirmed S18MedDir reviewed her own patients' records. S2DON stated S19MD reviews patient records if there is a nephrology issue, but he does not have patients in this hospital. S2DON stated S20MD may be reviewing his records or it may be another pulmonary physician's record. S2DON confirmed the hospital did not have 2 physicians on the UR committee that were not involved in the care of the patient.

In an interview on 07/27/17 at 9:30 a.m., S1Adm confirmed the current UR committee consisted of physician's that were involved in the patient's care. He stated if there was a physician review need for S18MedDir's patient they would ask another physician to review. S1Adm confirmed the current UR process did not include 2 physicians that were not involved in the patient's care.

Based on observations, record reviews, and interviews, the hospital failed to ensure the infection control officers developed an effective system that included identification, reporting, investigation, and controlling of infections and communicable diseases of patients and personnel as evidenced by:
1) failing to ensure contracted dialysis staff adhered to standard infection control practices while dialyzing patients in the hospital for 1 (#1) of 1 patient observed receiving dialysis services; and
2) failure to place a patient (#5) with positive stool cultures for C. diff (Clostridium difficile) in enhanced contact isolation precautions for 3 days after receipt of report of positive cultures for 1 (#5) of 1 current patients reviewed with a diagnosis of C. diff out of a total sample of 11 current patients reviewed on contact precautions; and
3) failure to ensure that staff adhered to the hospital policy when cleaning/disinfecting patient multiple-use equipment as evidenced by failing to clean a glucometer with a hospital approved disinfectant after patient use; and
4 ) failure to ensure that staff adhered to acceptable hand hygiene practices during patient care procedures as evidenced by staff failing to perform hand hygeine after glove removal; and
5) failure to store cleaned patient care equipment according acceptable standards of practice as evidenced by storage of patient bedside commodes in the restroom used by staff; and
6) failure to ensure clean linens were stored in a manner to protect them from potential contamination with dust, dirt and particulate matter.
7) failure to ensure staff adhered to contact isolation precautions while performing radiology procedures in patient rooms.

Findings:

1) Failing to ensure contracted dialysis staff adhered to standard infection control practices while dialyzing patients in the hospital.

Review of the policy for contracted company Dialysis "B" titled Infection Control in the Hospital Dialysis Setting revealed in part:
8. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces.
10. Gloves should be changed when: Going from a "dirty" area or task to a "clean" area or task; Moving from a contaminated body site to a clean body site of the same patient.

In an observation on 7/24/17 from 2:30 p.m. until 3:00 p.m., contracted dialysis nurse S21DialysisRN entered Patient #1's room that was on contact precautions. S21DialysisRN exited and entered Patient #1's room 2 more times after touching multiple items at the bedside and the bed without ever disinfecting her hands, donning gloves or wearing a gown. She had touched the dialysis machine which is considered "dirty" during dialysis several times without wearing gloves. S21DialysisRN then donned a gown and gloves, without tying the back of the gown, and began touching supplies, the patient's bedside and the patient's dialysis machine. S21DialysisRN then reached into her pocket and pulled out a cell phone with her gloves. After talking on the phone she returned the phone to her pocket. She then put a clean field beneath Patient #1's central line catheter with the contaminated gloves, removed the two caps of the catheters, connected syringes, flushed the catheters and then aspirated blood from the catheters. Patient #1's daughter was at the bedside and not required to don a mask during the catheter care. S21DialysisRN then removed the protective cover from a vial of 25% Albumin and spiked it with a tubing set and connected it to the dialysis machine to infuse into the patient. While puncturing the vial using her contaminated gloves, she ran her finger across the septum before spiking the vial. She did not wipe the septum with alcohol before puncturing it with the tubing set. She then put her hand into a bag of supplies with the contaminated glove and obtained a stethoscope. S21DialysisRN never changed her gloves or sanitized her hands throughout the entire observation.

In an interview on 7/25/17 at 12:40 p.m. with S22AdminDialysis, he said he was the administrator of Contracted Dialysis "B". He verified S21DialysisRN should have changed her gloves and performed hand hygiene after touching the dialysis machine, between clean and dirty activities, and before and after catheter care. S22AdminDialysis also verified the septum of the Albumin should have been disinfected before puncturing the Albuterol vial. He also said S21DialysisRN should have never touched the dialysis machine without wearing gloves.

2) Failure to place a patient (#5) with positive stool cultures for C. diff in enhanced contact isolation precautions for 4 days after receipt of report of positive cultures.

Review of the hospital policy titled," Isolation Precautions", Policy #: 8-2.0.0 revealed in part: Contact precuations are designed to reduce the risk of transmission of epidemioloically important microorganisms by direct or indirect contact. Direct contact involves skin-to-skin contact and physical transfer of microorganisms to a susceptible host from a colonized person, such as occurs when personnel turn patients, bathe patients, or perform other patient care activities that require physical contact. Contact precuations apply to specified patients known or suspected to be infected or colonized (presence of microorganism in or on patient but without clinical signs and symptoms of infection) with epidemiologically important microorganisms that can be transmitted by direct or indirect contact (touching) with environmental surfaces or patient-care items in the patient's environment). Contact precautions require standard precautions, gloves, and gowns if contact with the patient environment is expected. Further review revealed C.diff requires contact isolation precautions for the duration of the illness.

Review of the hospital policy titled,"Hand Hygiene", Policy #: 8-5.0.0, revealed in part: Note: When providing care to patients with C. diff associated diarrhea, health care personnel will perform hand washing technique prior to and after direct patient care activities or interaction with any potentially contaminated environmental surfaces or items. Gloves will be worn during any patient care activities or interaction with any potentially contaminated environmental surfaces or items.The physical activity of washing and rinsing hands under such circumstances is recommended because alscohols, chlorhexidine, iodophors, and other antispetic agents have prro activity against spores.


Review of Patient #5's medical record revealed an admission date of 7/13/17 with admission diagnoses including unstageable sacral decubitus ulcer, sepsis, and purulent ulcers of lower extremities.

Review of the culture result reports for Patient #5 revealed a stool culture was obtained to rule out C. diff on 7/12/17 at 11:07 p.m. Further review revealed the the test was resulted as positive on 7/15/17.

Review of Patient #5's nurses daily flowsheet revealed the following entries:
7/13/17: patient incontinent of stool on admit;
7/14/17: rectal tube in place related to chronic diarrhea resulting from antibiotics.
7/18/17: Contact isolation for C.diff. This nurses daily flowsheet was the first documented evidence in the patient's medical record indicating the patient had been placed on enhanced contact precautions for positive stool cultures for C.diff.

In an interview on 7/26/17 at 1:30 p.m. with S2DON, she confirmed Patient #5 had a culture for C. diff pending on admission on 7/13/17. S2DON indicated the hospital was notified of the positive C.diff culture result on 7/14/17. She reviewed the patient's medical record and verified C.diff precautions were not documented on the nurses daily flowsheet until 7/18/17. S2DON indicated she was not sure why the patient had not been documented as having enhanced contact isolation precautions for C.diff until 7/18/17. She confirmed nurses could place patients on enhanced contact precautions for C.diff upon reciept of notification of positive cultures and could obtain a physician's order for contact precautions at a later time. S2DON also reported positive cultures for C.diff required the enhanced contact isolation precautions of performance of handwashing for hand hygiene and prohibited the use of antibacterial hand gel.



3) Failure to ensure that staff adhered to the hospital policy when cleaning/disinfecting patient multiple-use equipment as evidenced by failing to clean a glucometer with a hospital approved disinfectant after patient use.

Review of the hospital policy titled," Accu-check Inform Glucose Meter", Policy#: 9-6.0.0 revealed in part: The meter will be cleaned with a disinfectant laden cloth before and after use on each patient.

On 7/24/17 at 9:00 a.m. an observation was made of S6LPN performing a capillary blood glucose on Patient #3. Patient #3 was on contact isolation precautions for positive respiratory cultures for Pseudomonas Aeruginosa and she had a tracheostomy. S6LPN was observed performing a fingerstick and obtaining a sample for a capillary blood glucose. S6LPN performed the capillary blood glucose test and placed the glucose meter on the patient's bed. She then placed the meter on the patient's bedside table. S6LPN removed the glucose meter from the bedside table and placed it in the glucose meter carrying case. S6LPN was never observed cleaning the glucose meter for the entire duration of the observation. S6LPN also failed to disinfect the bedside table surface after placing the meter on the table.

In an interview on 7/27/17 at 1:30 p.m. with S2DON, she confirmed the glucose meter should have been disinfected with a disinfectant cloth after patient use, and prior to returning the device to the caddy.

4 ) Failure to ensure that staff adhered to acceptable hand hygiene practices during patient care procedures as evidenced by staff failing to perform hand hygeine before and after glove removal and failing to change gloves between tasks.

Review of the hospital policy titled,"Hand Hygiene", Policy #: 8-5.0.0, revealed in part: Indications for Handwashing and Hand Antisepsis: When hands are visibly dirty or contaminated with proteinacious material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water. If hands are not visibly soiled, use an alcohol based hand rub for routinely decontaminating hands.Decontaminate hands after removing gloves. Other aspects of hand hygiene include wearing of gloves when contact with blood or other potentially infectious materials, mucous membranes and non-intact skin could occur. Wear gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient. Change gloves during patient care if moving from a contaminated body site to a clean body site.


On 7/24/17 at 9:00 a.m. an observation was made of S6LPN performing a capillary blood glucose on Patient #3. Patient #3 was on contact isolation precautions for positive respiratory cultures for Pseudomonas Aeruginosa and she had a tracheostomy. S6LPN was observed donning gloves (no hand hygiene performed prior to donning gloves). S6LPN cleansed Patient #3's right neck and chest area with a cloth. S6LPN then removed the glucose meter from the carrying case, placed the meter on the bed. S6LPN cleansed the patient's finger with an alcohol wipe and performed a fingerstick to obtain a sample of blood for the capillary blood glucose test. S6LPN performed the capillary blood glucose test and placed th glucose meter on the patient's bed, then on the bedside table, prior to placing it back into the caddy. . S6LPN removed her gloves and did not perform hand hygiene. S6LPN performed all of the above referenced tasks with the same pair of gloves, moving from soiled to clean areas.

In an interview on 7/27/17 at 1:30 p.m. with S2DON, she confirmed S6LPN should have performed hand hygiene before and after donning gloves and should have changed gloves between tasks.

5) Failure to store cleaned patient care equipment according acceptable standards of practice as evidenced by storage of clean patient bedside commodes in a restroom used by staff.

On 7/24/17 at 9:30 a.m. an observation was made of 4 patient bedside commodes, covered in plastic, stacked on top of each other in a bathroom which contained a sink, a toilet, and shower. The trash can in the bathroom was noted to contain crumpled, used, brown paper towels. S1Adm confirmed, during the observation, that the cleaned patient bedside commodes were routinely stored in the bathroom. He reported the shower room was no longer used for patient showering.


6) Failure to ensure clean linens were stored in a manner to protect them from potential contamination with dust, dirt and particulate matter.

On 7/24/17 at 9:25 a.m. an observation was made of the hospital's linen carts in the hospital's conference room. The carts were uncovered and noted to have folded sheets in them. Further observation of the hospital linen storage room revealed patient gowns, sheets and blankets were stored stacked on top of each other, uncovered, in the linen room.

In an interview on 7/24/17 at 9:30 a.m. S2DON confirmed the above referenced findings. S2DON also confirmed the linens, blankets, and patient gowns should have been covered and the carts should not be stored in the hospital conference room.


7) Failure to ensure staff adhered to contact isolation precautions while performing radiology procedures in patient rooms.

Review of the hospital policy titled, Isolation Precautions revealed in part the following: Gowns and protective apparel are worn to provide barrier protection and reduce opportunities for transmission of microorganisms in hospitals....Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms, to reduce the opportunity for transmission of pathogens from patients or items in their environment to other patients or environments.

On 7/25/17 at 3:00 p.m. an observation was made of S5RadTech performing a radiology procedure on Patient #10. Patient #10 was observed to be on Contact Precautions. S5RadTech was observed to take a portable x-ray of Patient #10. S5RadTech was observed to have gloves on but no gown as he entered the patient's room and removed the x-ray film from under the patient. After removing the film from under the patient, S5RadTech removed the plastic bag covering from the film, discarded it into trash can in the patient's room, and placed the film in the portable machine. S5RadTech removed the gloves after completing the procedure.

In an interview on 07/25/17 at 3:04 p.m., S2DON confirmed she had observed S5RadTech enter the room of Patient #10 without a gown on, and confirmed S5RadTech should have put a gown on before entering the patient's room. S2DON confirmed Patient #10 was on contact precautions and a gown was required for all staff entering the room.