HospitalInspections.org

Based on interview and policy review the hospital's governing body failed to assure that the medical staff had written policies and procedures which addressed individuals' emergency care needs 24 hours a day, 7 days a week as evidenced by failing to establish policies and procedures for medical emergencies which included appraisal of emergencies, initial treatment and referral ( when appropriate).
Findings:.

Review of the hospital's policy and procedure manuals revealed no documented evidence of policies and procedures for medical emergencies which included appraisal of emergencies, initial treatment and referral, when appropriate.

In an interview on 7/24/14 at 10:30 a.m. with S1Administrator, he confirmed the hospital did not have an emergency room/emergency services. He also confirmed the hospital had no written policies and procedures addressing emergency care needs. S1Administrator said they usually called 9-1-1 to handle emergency care needs.

Based on interviews and record reviews the hospital failed to ensure that patient Advance Directives were properly documented in the patients' medical records upon admission. This failed practice was evidenced by inaccurate Advance Directive documentation in 4 (#15, #17, #20, #21) of 8 (#4, #6, #7, #8, #15, #17, #20, #21) patient medical records reviewed for Advance Directives out of a total sample of 31.

Findings:
A review of the hospital policy titled, "Advanced Directives in a Hospital", provided by administration as the most current, revealed in part: The hospital would inquire of each patient upon admission as to whether or not the patient had an Advance Directive and would document the answer in the patient's medical record. The charge nurse would review the document, would place the document in the patient's medical record, and would then place a sticker on the front of the patient's medical record denoting an Advance Directive. The charge nurse would notify the attending physician of the existence of a Advance Directive to include the date and the time of the notification.

A review of Patient #15's medical record revealed the patient was admitted on 7/16/14 for rehabilitation therapy following a cervical fusion surgery. A review of Patient #15's Admission Assessment on 7/16/15, performed by S15LPN and S12RN, revealed in the Advance Directive section that the patient had an Advance Directive. The patient's medical record further revealed that the attending physician was not notified, a copy of Patient #15's Advance Directive was not noted to be present on the patient's medical record, and a sticker was not noted on the patient's medical record that Patient #15 had an Advance Directive.

A review of Patient #17's medical record revealed the patient was admitted on 6/26/14 for rehabilitation therapy following a cervical laminectomy surgery. A review of Patient #17's Admission Assessment on 6/26/14 performed by S18RN revealed, in the Advance Directive section, the patient had an Advance Directive. The patient's medical record revealed a notation that an Advanced Directive was initiated at the hospital where Patient #17 had her surgery. The patient's medical record further revealed that the attending physician was not notified, a copy of Patient #17's Advance Directive was not noted to be present in the patient's medical record, and a sticker was not noted on the patient's medical record that Patient #17 had an Advance Directive

A review of Patient #20's medical record revealed the patient was admitted on 7/18/14 for rehabilitation therapy following an SAH (subarachnoid hemorrhage). A review of Patient #20's Admission Assessment on 7/18/14, performed by S19LPN and S22RN, revealed in the Advance Directive section that the patient did not have an Advance Directive. A further review of the patient's medical record revealed a copy of Patient #20's Advance Directive (dated 2/14/07) under the Advance Directive section of the patient's medical record.

A review of Patient #21's medical record revealed the patient was admitted on 7/19/14 for rehabilitation therapy following a decompression lumbar laminectomy surgery. A review of Patient #21's Admission Assessment on 7/19/14, performed by S19LPN and S18RN, revealed that the Advance Directive section was not completed.

In an interview on 7/22/14 at 11:45 a.m. with S12RN, he indicated that he had been employed by the hospital for 9 years and was the charge nurse 3 days a week. S12RN further indicated that he was responsible for reviewing and verifying patient admission assessments on his shift when the assessments were initiated by an LPN. S12RN indicated that he was not aware of any patients at present who had Advance Directives. S12RN indicated that if a patient had an Advance Directive, he would place a copy in the patient's medical record and notify the attending physician. Patient #15's Admission Assessment dated 7/16/14 was reviewed with S12RN. S12RN indicated that he had reviewed and verified the admission assessment information that was initiated by S15LPN. S12RN was asked about the Advance Directive section which indicated that Patient #15 had an Advance Directive. S12RN indicated he did not know why the attending physician was not notified and why a copy of the patient's Advance Directive was not present in the patient's medical record.

In an interview on 7/22/14 at 4:00 p.m. with S16LPN she indicated that Patient #20's family provided her (S16LPN) with a copy of Patient #20's Advance Directive around 7:00 a.m. today (7/22/14). (Patient #20 was admitted on 7/18/14). S16LPN indicated that she placed the patient's Advance Directive in the patient's medical record the morning of 7/22/14. S16LPN further indicated that she did not notify the charge nurse on the unit and she did not notify the attending physician or update the patient's medical record regarding an Advance Directive.

In an interview on 7/23/14 at 9:00 a.m.. with S2DON she was made aware of the Advance Directive issues regarding Patient #15, Patient #17, Patient #20, and Patient #21. S2DON indicated that staff received annual in-services on the hospital's Advance Directive policy. S2DON indicated she was not aware that staff were not following the hospital's Advance Directive policy and that Advance Directive issues were not identified in the 24 hour chart checks.

Based on interview and record review, the hospital Quality Assurance and Performance Improvement (QAPI) program failed to provide documentation of the continued implementation of actions to prevent medication errors and the analyzing of the success of the implementations.
Findings:
Review of the monthly QAPI Committee Minutes dated 3/17/14 revealed the Findings/Conclusions for medication errors were listed as being slightly increased. The Recommendations/Actions were listed as to continue to monitor medication errors and omissions and to continue education with nursing staff. No documentation was included in the QAPI binder of the specific types of medication errors, the documentation of education to the staff or the monitoring that was being done by the hospital to capture medication errors.

Review of the 1st quarter QAPI Committee Minutes dated 4/21/14 revealed the Findings/Conclusions for medication error rates listed the error rates for January 2014 as 0.10, February as 0.12 and March as 0.19. The Recommendations/Actions were listed as, to continue monitoring and education enforcement on the "cone of silence". No documentation was included in the QAPI binder of the monitoring by the hospital to capture medication errors or the effectiveness of the "cone of silence".

Review of the monthly QAPI Committee Meeting Minutes dated 5/19/14 revealed the Findings/Conclusions listed medication errors as trending downward. The Recommendations/Actions were listed to continue monitoring medication administration and education. Further review revealed no documentation in the QAPI binder about the education of the staff or the monitoring of medication errors by the hospital.

Review of the QAPI meeting minutes dated 6/16/14 revealed the Recommendations/Actions for medication errors were to continue with chart checks and to make charge nurses aware of incidents in Action Cue (electronic reporting program) on a daily basis. Further review revealed no documentation as to the number of patients' charts reviewed or what types of errors were discovered.

In an interview on 7/24/14 at 9:07 a.m. with S5LPN, she said she was over QAPI. She said the QAPI team met monthly and quarterly. S5LPN said the hospital realized there were problems with medication errors. S5LPN said she had a list of how many medication errors there were per month in the hospital, but she could not provide a list of what types of errors they were. S5LPN also said to prevent errors, they had instituted staff education and the "cone of silence" (silence during medication administration times). S5LPN also said in February 2014, they instituted checking the medication carts and reviewing the cameras at the hospital to ensure the nurses were checking the medication carts. She said she could not provide documentation of the types of medication errors because it was on the computer. When asked to see the documentation located on the computer, she said she did not know how to access the information. She also said she had no documentation of the random cart checks, random chart audits, "cone of silence" monitoring or camera monitoring.

S1Administrator verified there was no documentation in QAPI data of the medication error prevention interventions being performed, analyzed or evaluated.

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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) failing to document a patient's pulse prior to administration of Digoxin for 1 (#9) of 25
(#1-#25) patients reviewed for medication errors;
2) failing to assess and document a patient's status prior to and after administration of respiratory treatments for 1 (#23) of 25 (#1-#25) patients reviewed for medication errors;
3) failing to notify the MD (Medical Doctor) that a patient was refusing medications/treatments for 2 (#3, #10) of 25 (#1-#25) patients reviewed for medication errors;
4) failing to ensure medication administration was documented/administered correctly for1(#10) of 25 (#1-#25) patients reviewed for medication errors;
5) failing to ensure that only RN's revised and updated patient care plans for 4 of 4 (#4, #7, #8, #15) patient care plans reviewed out of a total sample of 31.
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Findings:
Review of hospital policy #: N 11.00, titled: Medication Administration, last revised 12/09, revealed the following, in part:...
Q. Nurses Responsibilities:
f. When administering medications that require pulse/blood pressure check ( i.e.[example] pulse with Digoxin or blood pressure with a diuretic), chart the value next to time administered.
y. Document the effects of the medication in the nurses notes.
R. Withheld/Omitted/Missing Medications:
1. When medications are withheld/omitted for any reason, document in the following manner on the Medication Administration Record (MAR):
a. Write "omit" above the time dose was scheduled.
b. Circle time dose was due and initial
c. Sign full signature in appropriate section on MAR.
d. make notation of explanation in Nurses' Notes.
Document the following:
i. The date and time the drug was withheld
ii. The reason for withholding the drug
iii. The name of the doctor notified
iv. The doctor's response
v. If the physician changed a drug order, record and document the new order and the time it was carried out.
vi. Any action taken to safeguard the patient.
e. When medications are resumed, follow regular charting procedure, giving actual time of administration.

Review of hospital policy #: 11.07, titled Medication Administration Record, issued 10/07, revealed the following, in part...
Purpose:
To outline basic procedures on the printing, generation, and documentation on the MAR.
Policy:...
E. If a specific assessment parameter must be monitored during administration of a drug, document this requirement on the MAR. For example, when Digoxin is administered, the patient's pulse rate needs to be monitored and charted on the MAR.
Procedure:6. If a medication is held/omitted the time is circled and the nurse holding the medication will place his/her initials next to the time. The nurse must document the reason for holding the medication in the narrative notes and notify the charge nurse who will in turn notify the physician of the held dose. Note: the Charge Nurse may delegate this task to the primary nurse as needed.

1) Failing to document a patient's pulse prior to administration of Digoxin.

Review of Patient #9's medical record revealed she was an 89 year old female, admitted on 6/2/14 with the following diagnoses, in part: Acute Cerebrovascular Accident (CVA) with new onset left hemiparesis and Atrial Fibrillation. Further review revealed the following notation: Patient on Digoxin, monitor closely.

Patient #9
Review of Patient #9's physician's orders revealed the following:
6/2/14 7:30 p.m.: Digoxin 0.125 mg (milligrams) p.o. (by mouth) daily.

Review of Patient #9's Medication Administration Record (MAR) revealed the following: Digoxin 0.125mg 1 p.o. check and document patient's pulse before dose.

Further review of the MAR revealed the following entries which had no documented pulse prior to administration of the patient's 8:00 a.m. Digoxin dose:
6/8/14: 8am per S16LPN; 6/9/14: 8am per S20RN;6/11/14: 8am per S20RN

Review of Patient #9's 24 hour patient care flow sheet for 6/8/14, 6/9/14 and 6/11/14 (day shift) revealed no narrative nurses note documenting Patient #9's pulse prior to administration of the patient's 8:00 a.m. Digoxin dose.

In an interview on 7/22/14 at 1:38 p.m. with S3DirectorPharmacy, he confirmed Patient #9's heart rate should have been assessed and documented immediately prior to administering her Digoxin dose. He explained the comments on the MARs reflected built in parameters based upon best practice. He agreed using vital signs obtained 1-2 hours before administration of Digoxin was not an acceptable practice. He said change in patient status can happen quickly.

In an interview on 7/23/14 at 12:58 p.m. S2DON said the patient's heart rate should have been assessed immediately prior to administration of Digoxin. She confirmed the heart rate should have been documented on the MAR. She also said using the patient's morning vital signs would not be an acceptable alternative to assessing the patient's heart rate at the time of administration.

2) Failing to assess and document a patient's status prior to and after administration of respiratory treatments.

Patient # 23
Review of Patient #23's medical record revealed she was an 87 year old female, admitted on 7/2/14 with the following diagnoses, in part: Pain and Weakness- back pain with Compression Fractures of Lumbar discs #1, #2 , #4 and Chronic Obstructive Pulmonary Disease (COPD).

Review of Patient #23's MAR revealed the following respiratory treatment order: Albuterol Sulfate 0.083 % Solution-1 Albuterol Sulfate neb (nebulizer) q (every) 6 hours-Document pre/post breath sounds and pre/post heart rate.
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Further review of Patient #23's MAR revealed the following entries for Albuterol Respiratory Treatments with no documented pre/post treatment breath sounds or pre/post treatment heart rate on the MAR:
7/19/14 at 6:01 a.m through -7/20/14 at 06: 00 a.m.: 8:00 a.m., 2:00 p.m., 8:00 p.m., and 02:00 a.m.
7/20/14 at 6:01 a.m through-7/21/14 at 06: 00 a.m. : 8:00 a.m., 2:00 p.m., 8:00 p.m., and 02:00 a.m.

Review of Patient #23's 24- hour patient care flow sheets for 7/19/14-7/20/14 and 7/20/14-7/21/14 revealed no documented evidence of Patient #23's respiratory status (pre/post treatment breath sounds and heart rate) prior to or after the respiratory treatments (Albuterol nebs administered every 6 hours on 7/19/14-7/21/14) for the following treatments:
7/19/14 at 6:01 a.m through -7/20/14 at 06: 00 a.m.: 8:00 a.m., 2:00 p.m., 8:00 p.m., and 02:00 a.m.
7/20/14 at 6:01 a.m. through -7/21/14 at 06: 00 a.m.: 8:00 a.m., 2:00 p.m., and 8:00 p.m.

Further review of Patient #23's 24- hour patient care flow sheets for 7/20/14 6:00 a.m.-6:00 a.m. on 7/21/14 revealed no documentation of the patient's breath sounds before and after her 2:00 a.m. Albuterol neb treatment.


In an interview on 7/23/14 at 12:58 p.m. with S2DON, she said Patient #23 's breath sounds and heart rate should have been assessed and documented both prior to and after she received each of her Albuterol nebulizer treatments. S2DON explained the nurses should have been documenting patient status both before and after respiratory treatments on the MAR and/or in the nurses notes.


3) Failing to notify the MD that a patient was refusing medications/treatments.

Patient #3
Review of Patient #3's medical record revealed she was a 73 year old female admitted on 7/17/14 with the following diagnoses, in part: status post Total Hip Revision, Diabetes Mellitus and Asthma.

Review of Patient #3's physician orders, dated 7/17/14 12:30 p.m., revealed the following:
Regular Insulin-Sliding Scale AC (before meals) and HS (hour of sleep):
Less than 60: give orange juice and 1 packet of sugar
61-200 units = 0 units; 201-250 = 2 units; 251-300 = 4 units; 301-350 = 6 units; 351-400 = 8 units;Greater than 400 = 10 units.

Review of Patient #3's 24 hour patient care flow sheet for 7/19/14 revealed the following entries:
12:05 p.m.: BGFS ( blood glucose fingerstick) 230 . Refuses sliding scale insulin. Verbalizes needing home med ( medication) Starlix. Daughter to bring from home. Further review of the narrative notes revealed no notification of the MD or charge nurse of patient refusal of sliding scale insulin.
5:05 p.m.: BGFS 223. Again refuses sliding scale insulin. Charge nurse aware. Further review of the narrative notes revealed no notification of the MD of patient refusal of sliding scale insulin for the second time that day.

In an interview on 7/23/14 at 12:58 p.m. with S2DON, she confirmed Patient #3's physician should have been notified of the patient's refusal of sliding scale insulin.

Patient #10
Review of the admission orders for Patient #10 dated 7/18/14 at 5:10 p.m. revealed an order for Diovan 320 mg po daily.

Review of the MAR for Patient #10 dated 7/19/14 revealed the 8:00 a.m. dose of Diovan 320 mg was not charted as having been given. The 8:00 a.m. time was circled indicating the dose had not been given and " Pt (patient) refused " was written next to the time. No documentation in the medical record noted that the physician was notified of the missed dose.

A review was made of Patient #10 ' s MAR dated 7/19/14 by S3DirectorPharmacy. He said the Physician should have been notified of the Diovan dose that had not been given at 8:00 a.m.


4) Failing to ensure medication administration was documented/administered correctly.

Review of the physician's orders for Patient #10 dated 7/19/14 at 4:48 p.m. revealed an order for Zoloft 50 mg po at bedtime.

Review of the MAR for Patient #10 dated 7/19/14 revealed Zoloft 50 mg daily was written. The time 8:00 a.m. was circled and had a line drawn through the time. A note was handwritten stating, " Pt requested to take at night. " A time of 8:00 p.m. also had a line through the time indicating it had been given at 8:00 p.m., in addition to the circle.

In an interview on 7/23/14 at 1:30 p.m. with S2DON, she said a medication time was circled on the MAR when it was not going to be given at that time and a line was drawn through the time when a medication had been given. S2DON verified the 8:00 a.m. dose of Zoloft for Patient #10 on 7/19/14 had been circled and a line had been drawn through the time. S2DON also verified the 8:00 p.m. dose of Zoloft had a line drawn through the time on the MAR indicating it had been given. S2DON said it was unclear if the 50 mg of Zoloft had been given twice for Patient #10 on 9/16/14 when it had been ordered to be given once per day.

5) Failing to ensure that only RN's revised and updated patient care plans for 4 of 4 (#4, #7, #8, #15) patient care plans reviewed out of a total sample of 31.

A review of the hospital policy, titled "Nursing Care Plan", provided by administration as the most current, revealed in part: A nursing care plan would be initiated by the Registered Nurse (RN) to include nursing diagnosis, short term goals, interventions, start date, review date and date resolved. The care plan would be updated weekly by an RN.

Patient #4
A review of Patient #4's medical record revealed the patient was 77 years old and was admitted to the hospital on 7/15/14 for rehabilitation services for generalized weakness and a history of falls at home.

A review of Patient #4's Admission Assessment on 7/15/14 indicated the patient's care plan was initiated by S12RN. A further review of the patient's care plan revealed Patient #4's care plan was revised and updated on 7/22/14 by S13LPN.

Patient #7
A review of Patient #7's medical record revealed the patient was 84 years old and was admitted to the hospital on 7/19/14 for rehabilitation services following lumbar decompression surgery.

A review of Patient #7's Admission Assessment on 7/19/14 indicated the patient's care plan was initiated by S18RN. A further review of the patient's care plan revealed Patient #7's care plan was revised and updated on 7/22/14 by S13LPN.

Patient #8
A review of Patient #8's medical record revealed the patient was 84 years old and was admitted to the hospital on 7/14/14 for rehabilitation services for a Cerebrovascular Accident (CVA).

A review of Patient #8's Admission Assessment on 7/14/14 indicated the patient's care plan was initiated by S22RN. A further review of the patient's care plan revealed Patient #8's care plan was revised and updated on 7/21/14 by S13LPN.

Patient #15
A review of Patient #15's medical record revealed the patient was 63 years old and was admitted to the hospital on 7/16/14 for rehabilitation services following anterior cervical fusion surgery.

A review of Patient #15's Admission Assessment on 7/16/14 indicated the patient's care plan was initiated by S15LPN. A further review of the patient's care plan revealed Patient #15's care plan was revised and updated on 7/18/14 by S15LPN.

In an interview on 7/22/14 at 3:00 p.m. with S12RN, charge nurse, he indicated that RNs were required to do the patient's Admission Assessment and initiate the patient's care plan. S12RN further indicated that he did not know if only RN's were required to do patient care plan revisions and updates. S12RN indicated that LPNs did most of the care plan revisions and updates.

In an interview on 7/22/14 at 4:00 p.m. with S13LPN, S15LPN and S16LPN they indicated that the LPNs did most of the patient care plan revisions and updates. They indicated that RNs are supposed to do the initial patient care plans and that the LPNs were allowed to do the revisions and updates.

In an interview on 7/23/14 at 9:00 a.m. with S2DON she was made aware of the patient care plans being revised and updated by the LPNs. S2DON indicated that the patient care plans were supposed to be initiated and revised by the RNs.

Based on interviews and record reviews the hospital failed to ensure that the nursing staff developed a nursing care plan for each patient based on assessing all the patient's care needs and not solely those needs related to the admitting diagnosis to include individualized interventions and goal target dates for 4 of 4 (#4, #6, #7, #8) medical records reviewed for care plans out of a sample of 31.

Findings:
A review of the hospital policy, titled "Nursing Care Plan", provided by administration as the most current, revealed in part: A nursing care plan would be initiated by the Registered Nurse (RN) to include nursing diagnosis, short term goals, interventions, start date, review date and date resolved. The care plan would be updated weekly by an RN.

Patient #4
A review of Patient #4's medical record revealed the patient was 77 years old and was admitted to the hospital on 7/15/14 for rehabilitation services for generalized weakness and a history of falls at home. The patient's medical diagnoses included in part: recent CVA (cerebrovascular accident), new onset of A-fib (atrial fibrillation), COPD (chronic obstructive pulmonary disease), high blood pressure, UTI (urinary tract infection).

A review of Patient #4's initial and revised care plan indicated the patient was care planned for: fall risks, skin impairment, communication impairment and cognition impairment with no checks or write-ins noted on the intervention check list to designate an individualized care for that patient. A further review of the patient's care plan revealed no evidence of any other care plan needs identified and no evidence of any target goal dates for the care plan needs that were identified.

Patient #6
A review of Patient #6's medical record revealed the patient was 79 years old and was admitted to the hospital on 7/19/14 for rehabilitation services following a posterior lumbar fusion surgery. The patient's medical diagnoses included in part: prior CVA, A-fib, high blood pressure, diabetes, high cholesterol, alcohol abuse, CHF (congestive heart failure), PVD (peripheral vascular disease), depression, and CAD (coronary artery disease).

A review of Patient #6's initial and revised care plan indicated the patient was care planned for: self care deficit, impaired mobility, communication impairment and cognition impairment with no checks or write-ins noted on the intervention check list to designate an individualized care for that patient. A further review of the patient's care plan revealed no evidence of any other care plan needs identified and no evidence of any target goal dates for the care plan needs that were identified.

Patient #7
A review of Patient #7's medical record revealed the patient was 84 years old and was admitted to the hospital on 7/19/14 for rehabilitation services following lumbar decompression surgery. The patient's medical diagnoses included in part: COPD, high cholesterol, high blood pressure, glaucoma, renal cysts, and post operative anemia.

A review of Patient #7's initial and revised care plan indicated the patient was care planned for: impaired skin integrity, fall risks, and pain with no checks or write-ins noted on the intervention check list to designate an individualized care for that patient. A further review of the patient's care plan revealed no evidence of any other care plan needs identified and no evidence of any target goal dates for the care plan needs that were identified.

Patient #8
A review of Patient #8's medical record revealed the patient was 84 years old and was admitted to the hospital on 7/14/14 for rehabilitation services following a CVA. The patient's medical diagnoses included in part: A-fib, COPD, dementia, CHF, recurrent UTI's and prior hip fracture surgery.

A review of Patient #8's initial and revised care plan indicated the patient was care planned for: incontinence, impaired skin integrity, fall risks, communication impairment, cognition impairment, and impaired mobility with no checks or write-ins noted on the intervention check list to designate an individualized care for that patient. A further review of the patient's care plan revealed no evidence of any other care plan needs identified and no evidence of any target goal dates for the care plan needs that were identified.

In an interview on 7/22/14 at 11:10 a.m. with S12RN, charge nurse, he indicated that the patient care plans developed by the RNs were based upon the patient's admitting diagnosis and the nurses did not care plan for all the patient's medical problems.

In an interview on 7/23/14 at 9:00 a.m. with S2DON she was made aware of the patient care plans that were reviewed. S2DON indicated that the RNs did not care planning each patient based on assessing all the patient's care needs and mostly only care planned those needs related to the admitting diagnosis. S2DON further indicated that the care plans did not include goal target dates and that the interventions were not individualized.

Based on interview and record review the hospital failed to ensure medications were administered in accordance with the orders of a practitioner as evidenced by Coumadin being administered without a physician 's order for 1 (#1) of 1 (#1) patients reviewed for Coumadin administration.

Findings:
Review of the hospital policy and procedure titled Medication Administration, Policy Number: N 11.00, Revised December 09, revealed in part:
C. Medications shall be administered according to the approved standard dosing schedule by appropriately qualified individuals in accordance with the orders of the physician responsible for the patient's care and accepted standards of practice.

Review of the medical record for Patient #1 revealed a MAR (medication administration record) dated 5/31/14 with a hand written entry for Coumadin 5 mg (milligrams) po (by mouth) every day at 5:00 p.m. A dose was documented as having been given at 5:00 p.m. on 6/1/14. Further review revealed no order for 5 mg Coumadin daily or on 6/1/14 was located in the medical record.

On 6/23/14 at 1:20 p.m., a review was made of Patient #1's MAR, dated 6/1/14, with S2DON. S2DON verified there was no order for the 5 mg of Coumadin on 6/1/14 and it was a medication error.

Based on interview and record review, the hospital failed to ensure drugs and biologicals were controlled and distributed in accordance with acceptable standards of practice as evidenced by failing to ensure all medication orders (except in emergency situations) were reviewed by a pharmacist before the first dose was dispensed for therapeutic appropriateness, duplication of a medication regimen, appropriateness of the drug and route, appropriateness of the dose and frequency, possible medication interactions, patient allergies and sensitivities, variations in criteria for use, and other contraindications.
Findings:

In an interview on 7/21/14 at 12:30 p.m. with S4Pharmacist, she said a pharmacist was at the hospital Monday through Friday from 8:30 a.m. through 3:30 p.m. S4Pharmacist said there was not a pharmacist in the hospital on nights and on the weekends but there was a pharmacist on call. S4Pharmacist verified first dose review of new medications was not being done on orders that were written after working hours and on the weekends. S4Pharmacist said if a medication order had been written on a Friday night it may not be reviewed for appropriateness by a pharmacist until the following Monday. S4Pharmacist said she was aware all new medication orders should have been reviewed before the first dose was dispensed.

In an interview on 7/21/14 at 12:45 p.m. with S3PharmacyDirector, he said there was no first dose review of new medications done at night or on the weekends. S3PharmacyDirector said the hospital was negotiating a contract with a remote pharmacist, but they had not begun performing the first dose reviews. S3PharmacyDirector said he was not sure of the date when the remote pharmacy would start doing the first dose reviews at night and on the weekends.

Review of the contract between the hospital and Remote Pharmacy A for verification of medication orders after pharmacy working hours revealed the contract had been signed by S1Administrator but had not been signed by Remote Pharmacy A.

Based on interview and record review, the hospital failed to ensure medication administration errors were documented in patients' medical records for 3 (#18, #19, #31) of 3 patients reviewed for medication errors discovered by the hospital.
Findings:

Review of the hospital policy titled Reporting Medication Errors, Policy Number: N 11.05, revealed in part:
A copy of the medication variance report will not be placed in the patient's medical record; however, medication errors will be documented (recorded) in the patient's medical record.

Review of a hospital listing of medication errors revealed the following:
On 6/10/14 at 8:00 p.m. Patient #18 received 75 mg of Lyrica instead of the 150 mg ordered.
On 6/4/14 at 9:00 p.m. Patient #19 received 20 mg of Lipitor instead of the 40 mg ordered.
On 6/9/14 at 6:00 a.m. Patient #31 received 1 gram of Ampicillin instead of the 2 grams ordered.

Review of the medical records for Patients # 18, #19, #31 revealed no documentation in the medical records of the above mentioned medication errors.

In an interview on 7/21/14 at 3:00 p.m. with S1Administrator, he verified the above mentioned medication errors had not been documented in the patients' medical records. S1Administrator said the medication errors were documented on a computer program but was not printed and placed with the chart while the patient was an inpatient or after they were discharged.

Based on interview and policy/procedure review the hospital failed to assure proper safety precautions were maintained against radiation hazards as evidenced by failing to develop and establish policies and procedures addressing safety standards for adequate shielding of patients and personnel.
Findings:

Review of the hospital's radiological services policies/procedures revealed no documented evidence of policies and procedures addressing safety standards for adequate shielding of patients and personnel.

In an interview on 7/21/14 at 4:05 p.m., with S1Administrator, he confirmed the hospital had no policies and procedures addressing safety standards for adequate shielding of patients and personnel.

Based on review of physician credential files and interview the hospital failed to ensure contracted Radiologic services were supervised by a qualified Radiologist on either a full-time, part-time or consulting basis as evidenced by failing to appoint a qualified Radiologist to supervise the hospital's Radiologic Services.
Findings:

Review of physician credentialing files revealed no documented evidence that a credentialed Radiologist had been appointed by the Governing Body to supervise Radiology Services.

In an interview on 7/21/14 at 4:05 p.m., with S1Adminstrator, he confirmed the Governing Body had not appointed a credentialed Radiologist to supervise the hospital's contracted Radiology Services.

Based on observation and interview, the facility failed to ensure all equipment was maintained to ensure an acceptable level of safety and quality as evidenced by 26 of the 27 patient beds at the hospital having an emergency call button on the side rails that was not functional.

Findings:

In an observation on 7/21/14 at 9:50 a.m., 26 of the 27 beds at the facility had red crosses on the side rails indicating they could be pushed in an emergency to call staff. Further review revealed the buttons did not work when pushed.

In an interview on 7/21/14 at 10:15 a.m. with S1Administrator, he verified the red crosses on the side rails of the beds were call buttons but they did not work. S1Administrator stated the hospital had a call button on a cord from the wall that could be used but agreed a confused patient or a family member may mistake the call bell on the side rail for a functioning emergency call device.

Based on observations, interviews and record reviews the hospital 1) failed to ensure that the infection control department identified the infection control breaches in the rehabilitation therapy department in regards to laundry services and disinfecting of equipment used for patients and, 2) failed to ensure the infection control officer implemented measures to prevent and control infections by maintaining a sanitary hospital environment as evidenced by: a) failing to separate the storage of clean and dirty equipment and, b) failing to store clean equipment in a clean area.

Findings:
1) failing to ensure that the infection control department identified the infection control breaches in the rehabilitation therapy department in regards to laundry services and disinfecting of equipment used for patients

A review of the hospital policy titled,"Routine Cleaning of Gym", as provided by administration as the most current, revealed in part: Routine cleaning of the Therapy Department is to be performed daily by the therapy technicians.

A review of the hospital policy titled,"Use of Mats", as provided by administration as the most current, revealed in part: The mat will be cleaned after patient use with a disinfectant solution.

Observations on 7/21/14:
1) Loose unfitted sheets were used on the therapy mats when therapists were working with the patients. The sheets were noted getting "bunched up" under patients during their treatment.
2) The chairs used in the therapy department were noted to be placed on the top of the occupational therapy tables at the end of the day.

In an interview on 7/21/14 at 4:30 p.m with S9Therapy Tech he indicated that he was a therapy technician and that the therapy technicians were responsible for the routine cleaning of the equipment used by the patients in therapy. S9Therapy Tech indicated that the "hot pack covers" and the wheelchair covers used by the patients in therapy were washed on the 4th floor of the building by the therapy technician. The "hot pack covers" and the wheelchair covers were then brought back to the therapy department and hung on the grab bars in the patient bathroom to dry. S9Therapy Tech indicated that unfitted sheets were used on the therapy mats under the patients during treatment and that the mats were cleaned twice a day, before lunch and at the end of the day. S9Therapy Tech further indicated that the chairs used in the therapy department were placed on the top of the occupational therapy tables at the end of the day so housekeeping could mop the floors each night. S9Therapy Tech further indicated that the occupational therapy tables were cleaned twice a day, before lunch and at the end of the day before placing the chairs on the top of the tables. S9Therapy Tech further indicated that he removed the chairs from the occupational therapy tables each morning so the occupational therapists could give treatments to their patients. S9Therapy Tech indicated that he did not again clean the tables in the morning after the chairs were removed.

In an interview on 7/22/14 at 1:45 p.m with S6Director Therapy she indicated that the above cleaning was the routine performed by the therapy technicians each day and as needed. S6Director Therapy indicated that the hospital had a laundry contract but that the therapy department used the washers on the 4th floor of the building. S6Director Therapy further indicated that the 4th floor was not part of the hospital and that she had no laundry contract with the provider on the 4th floor. S6Director Therapy indicated that she did not have a policy in place for the cleaning of the "hot pack covers" and the wheelchair covers

In an interview on 7/22/14 at 2:10 p.m. with S5LPN, Infection Control Nurse, she was made aware of the infection control practices in the therapy department. S5LPN, Infection Control Nurse, indicated that she was not aware of the therapy department practices. S5LPN, Infection Control Nurse, further indicated that these practices were infection control breaches.


2) failing to ensure the infection control officer implemented measures to prevent and control infections by maintaining a sanitary hospital environment as evidenced by:
a) failing to separate the storage of clean and dirty equipment and,
b) failing to store clean equipment in a clean area.

a) Failing to separate the storage of clean and dirty equipment:

On 7/21/14 at 9:55 a.m., during the initial hospital tour, an observation was made of the clean storage room on the patient care floor. A box fan, covered in dust, and red biohazard garbage cans (uncovered) were noted in the clean storage room. S21LPN confirmed the dusty box fan should have been stored in the housekeeping room and not in the clean storage room. S21LPN agreed the biohazard garbage cans should not be stored in the clean storage room.

In an interview on 7/21/14 at 10:10 a.m. with S1Administrator, he confirmed the dusty box fan should not be stored in the clean storage room. He also confirmed the red biohazard garbage cans should not be stored in the clean storage room.

In an interview on 7/21/14 at 2:08 p.m. with S5LPN/Infection Control Nurse she said the box fans should have been cleaned and stored in the housekeeping room. She also explained the red biohazard garbage cans should have been disinfected with Dispatch cleaning solution and bagged after cleaning. She agreed the biohazard garbage cans should not be stored in the clean storage room.

b) Failing to store clean equipment in a clean area.
In an observation on 7/21/14 at 10:00 a.m. of the dining room, there were 16 wheel chairs in a corner near the dining tables.

In an interview on 7/21/14 at 10:01 a.m. with S14CaseManager, she said the wheel chairs in the dining room were clean equipment that had been moved from storage.

In an interview on 7/21/14 at 10:20 a.m. with S1Administrator, he verified the wheel chairs should not be stored in the dining room. He said there was a shortage of storage space for the hospital.
Interview and record review on 7/24/14 at 9:07 a.m. with S5LPN, she said she was over infection control at the hospital. S5LPN said the hospital knew there was a problem with where to store the wheelchairs. S5LPN said the wheelchairs were typically stored in a patient room that was not being used until a patient needed the room. S5LPN said when the patient rooms were all being used the wheelchairs were moved to wherever they could find space for them.




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Based on interview and record review the hospital failed to ensure there was an appointed Medical Director of Respiratory Care Services.
Findings:

Review of physician credentialing files revealed no documented evidence that a physician had been appointed, by the Governing Body, as Medical Director of Respiratory Services.

In an interview on 7/21/14 at 12:18 p.m. with S1Administrator, he confirmed the Governing Body had not appointed a Medical Director of Respiratory Services.