HospitalInspections.org

Based on observation, interview, and record review the hospital failed to have an organized dietary service that was directed and staffed by adequate qualified personnel as evidenced by:

1.) not having a designated full-time employee S11 DM, (Dietary Manager) who served as the director of the food and dietetic services and was responsible for the daily management of the service. Also by not having someone responsible for implementing training programs for the dietary staff and assuring established policies and procedures were maintained. (cited at A-620),

2). not having a designated full-time employee that served as the Dietary Manager of the food and dietetic services to supervise the daily management of the dietary services at Campus B. (cited at A-0620); and,

3) failing to ensure that the dietary staff were competent in their assigned duties as evidenced by lack of knowledge and training to perform the required task specific to meeting the dietary needs of the patients. (cited at A-0622)

Based on interview and record review the hospital failed to ensure that 1 (S23LIP) of 2 (S23LIP, S28LIP) Advanced Practice Registered Nurses (APRN) reviewed for licensure and privileges practiced within her scope of authorized practice as evidenced by an APRN writing orders for scheduled medications when her prescriptive authority did not authorize her to do so.
Findings:

Review of the credentialing file for S23LIP (Licensed Independent Practitioner) revealed the following:

-An approval letter from the hospital dated 4/26/13 informing S23LIP that her request for privileges had been reviewed and approved effective 4/25/13 and would expire 4/25/15.

- a Licensure Verification Form dated 1/7/14 which documented a current license from the state's board of nursing for an Advanced Practice RN (Registered Nurse) with an original issue date of 2/5/13 and an expiration date of 1/31/15. Further review of the license verification form revealed Prescriptive Authority Information that included a prescriptive authority number with an original issue date of 2/28/13 and an expiration date of 1/31/15.

The Licensure Status was "Active" and scheduled drugs authorized to prescribe were "None".

-An Allied Privilege Request Form for S23LIP that designated those co-signatures for orders was not required.

A list of privileges requested documented, under the heading of "Orders", Initiate and transcribe orders: requested and approved were marked with a check. "Initiate and transcribe medication orders": requested and approved columns were checked. "Others": columns were blank. Further review of request for privileges revealed no documentation related to the restriction of medication orders to those that were not scheduled drugs.

-Review of a Collaborative Practice Agreement between S23LIP and physicians that included S21MedDirector and S22MD revealed in part, under "1" . Methods of Patient Care..."The parameters of this practice also include (please mark each box that is applicable)...3. Controlled substances, see Addendum A, pages 1 & 2"-(blank/unmarked). IF APRN [Advanced Practice Registered Nurse] is requesting any controlled substances, Addendum A page 1 must be completed and Addendum A page 2 must be signed by APRN and all physicians." Further review of the Collaborative Agreement revealed no Addendum A.

Patient #R1
Review of the medical record of Patient #R1 revealed she was admitted to the hospital on 1/2/14 for IV (intravenous) antibiotics and aggressive wound treatment to bilateral groin abscesses. Patient #R1 was a current patient during the survey. Further review of a physician's order sheet revealed, in part, an order for Norco 5mg (milligrams), 1 every 6 hours as needed for pain. The order was noted to be a verbal order taken from S23LIP by a nurse.

Patient #2
Review of the medical record for Patient #2 revealed, in part that the patient was admitted to the hospital 1/2/14 and remained a current patient during the survey. Further review of physician's orders revealed an order dated and timed 1/3/14 at 3:05 p.m. The order included, "Norco clarification: Norco 10/325 mg 1 po (by mouth) Q (every) 6 (hours) prn (as needed [for]) pain. The order was signed by S23LIP. An order dated 1/4/14 at 12:25 p.m. read, "(1) D/C (discontinue) Norco 10/325 mg po Q 6 hours prn. (2) Start Norco 7/5mg/325mg 1 po daily at 8:00 a.m., 12:00 noon, 4:00 p.m. and 8:00 p.m." The order was written by a nurse as a telephone order taken from S23LIP.

Patient #3
Review of the medical record for Patient #3 revealed he was admitted to the hospital 12/19/13 and remained an inpatient during the survey. Further review of physician's orders revealed, in part the following:
-An order on 12/23/13 at 6:40 p.m. that included Ativan 1mg IVP (Intravenous push) now. The order was signed by S23LIP.

Review of Nursing 2009 Drug Handbook (29th Edition, Lippincott, Williams, & Wilkins) revealed Norco, a pain medication, was a schedule III drug under the Title 21 United States Code Controlled Substances Act. Further review revealed Ativan was a controlled substance schedule IV medication.

In an interview 1/9/14 at 3:15 p.m. S3ACCO (Assistant Chief Clinical Officer) reviewed the medical records of Patients #R1, #2, and #3 and verified the above noted orders were documented as written or given by S23LIP. He reported that he was not aware that she did not have prescriptive authority to prescribe/order controlled scheduled drugs. He reported that S23LIP was not available for interview at that time.

In an interview 1/9/14 at 3:25 p.m. S22MD (Medical Doctor) verified S23LIP worked with him and had a Collaborative Agreement with her (S23LIP). When he was shown the orders for Patients #R1, #2, and #3, he reported that he thought she could order and prescribe scheduled drugs as long as one of the doctors co-signed with her. When S22MD was shown S23LIP's Prescriptive Authority License noting her authority to prescribe controlled drugs as "none", he replied "OK, We won't have her do that anymore."

Based on record review and interview the Governing Body failed to ensure that credentialed practitioners were held accountable for practicing only within the privileges granted by licensure, as evidenced by 1 (S23LIP) of 2(S23LIP, S28LIP) Advanced Practice Registered Nurses reviewed writing orders for scheduled drugs when she did not have prescriptive privileges that authorized to do so.
Findings:

Review of the Medical Staff Bylaws revealed, under Section 10, Allied Health Professionals, the following in part:
10.1.3 The AHP (Allied Health Professional) and the physician sponsor must present a detailed specific list of tasks/competencies that the professional may perform, under the supervision of the physician.
10.1.4 The tasks/competencies shall not require a license or certification that the professional does not possess if they are licensed and/or certified the tasks/competencies must not exceed the scope of practice defined under these competencies.
10.4.8 The professional shall comply with all hospital policy and procedures and shall abide by these bylaws.

Review of the credentialing file for S23LIP (Licensed Independent Practitioner) revealed the following:
-An approval letter from the hospital dated 4/26/13 informing S23LIP that her request for privileges had been reviewed and approved effective 4/25/13 and would expire 4/25/15.

-A Licensure Verification Form dated 1/7/14 which documented a current license from the state's board of nursing for an Advanced Practice RN (Registered Nurse) with an original issue date of 2/5/13 and an expiration date of 1/31/15. Further review of the license verification form revealed Prescriptive Authority Information that included a prescriptive authority number with an original issue date of 2/28/13 and an expiration date of 1/31/15.

The Licensure Status was "Active" and scheduled drugs authorized to Prescribe were "None".

-An Allied Privilege Request Form for S23LIP that designated those co-signatures for orders was not required.

-Documentation of a list of privileges requested , under the heading of "Orders", Initiate and transcribe orders: requested and approved were marked with a check. "Initiate and transcribe medication orders": requested and approved columns were checked. "Others": columns were blank. Further review of request for privileges revealed no documentation related to the restriction of medication orders to those that were not scheduled drugs.

-Review of a Collaborative Practice Agreement between S23LIP and physicians that included S21MedDirector and S22MD revealed in part, under "1 " . Methods of Patient Care..."The parameters of this practice also include (please mark each box that is applicable)...3. Controlled substances, see Addendum A, pages 1 & 2"-(blank/unmarked). IF APRN [Advanced Practice Registered Nurse] is requesting any controlled substances, Addendum A page 1 must be completed and Addendum A page 2 must be signed by APRN and all physicians." Further review of the Collaborative Agreement revealed no Addendum A.

Patient #R1
Review of the medical record of Patient #R1 revealed she was admitted to the hospital 1/2/14 and was a current patient during the survey. Further review of a physician's order sheet revealed, in part, an order for Norco 5mg (milligrams), 1 every 6 hours as needed for pain. The order was noted to be a verbal order taken from S23LIP by a nurse.

Patient #2
Review of the medical record for Patient #2 revealed, in part that the patient was admitted to the hospital on 1/2/14 and remained a current patient during the survey. Further review of physician's orders revealed an order dated and timed 1/3/14 at 3:05 p.m. The order included, "Norco clarification: Norco 10/325 mg 1 po (by mouth) Q (every) 6 (hours) prn (as needed [for]) pain." The order was signed by S23LIP. An order dated 1/4/14 at 12:25 p.m. read, "(1) D/C (discontinue) Norco 10/325 mg po Q 6 hours prn. (2) Start Norco 7/5mg/325mg 1 po daily at 8:00 a.m., 12:00 noon, 4:00 p.m. and 8:00 p.m." The order was written by a nurse as a telephone order taken from S23LIP.

Patient #3
Review of the medical record for Patient #3 revealed he was admitted to the hospital 12/19/13 and remained an inpatient during the survey. Further review of physician's orders revealed, in part the following:
-An order 12/23/13 at 6:40 p.m. that included Ativan 1mg IVP (Intravenous push) now. The order was signed by S23LIP.

Review of Nursing 2009 Drug Handbook (29th Edition, Lippincott, Williams, & Wilkins) revealed Norco, a pain medication, was a schedule III drug under the Title 21 United States Code Controlled Substances Act. Further review revealed Ativan was a controlled substance schedule IV medication.

In an interview 1/9/14 at 3:15 p.m. S3ACCO (Assistant Chief Clinical Officer) reviewed the medical records of Patients #R1, #2, and #3 and verified the above noted orders were documented as written or given by S23LIP. He reported that he was not aware that she did not have prescriptive authority to prescribe/order controlled scheduled drugs.

In an interview 1/9/14 at 3:25 p.m. S22MD (Medical Doctor) verified that S23LIP worked with him and he had a Collaborative Agreement with her (S23LIP). When he was shown the orders for Patients #R1, #2, and #3, he reported that he thought she could order and prescribe scheduled drugs as long as one of the doctors co-signed with her. When S22MD was shown S23LIP's Prescriptive Authority License noting her authority to prescribe controlled drugs as "none", he replied " OK, We won't have her do that anymore."

Based on record review and interview the hospital failed to ensure that the patient/patient's representative was given the information needed to make an "informed" decision regarding his or her care as evidenced by consent forms signed by patients documented to be confused (#3), Informed consents not filled out completely (#3, #6), and consents obtained verbally from a patient/patient representative without documentation of the reason the consent could not be signed and/or the relationship to the patient of the person giving consent for 3 of 3 current patients ( #3, #6, #21) reviewed for Consents in regards to Patient's Rights out of a total sample of 30.
Findings:


Review of Policy number II.K.11.29 titled Consent to Treat, effective date 12/11/12, provided by S3ACCO (Assistant Chief Clinical Officer) as current, revealed in part, that each patient or family member/significant other will sign a Consent to Treat upon admission. Further review revealed the procedure included, under 1,"Upon admit, the admitting nurse or Admission Coordinator will have the patient or family member sign a Consent Treatment..."

Review of Policy number II.K.11.35, effective date 12/11/12, titled Witnessing Consents/Legal Documents, provided by S3ACCO as current, revealed in part that it was the policy of the hospital that the witnessing of any consent for any and/or all types of procedures must be done by a Registered Nurse (RN). The procedure must be explained by the performing physician and all risk factors explained. The RN only witnesses that the patient or designated family member or guardian signs the consent.

Patient #3
Review of the medical record for Patient #3 revealed he was admitted 12/19/14 at 10:51 p.m. from a local acute care hospital after presenting with fever, altered mental status, and pain to his left knee. Review of a History and Physical dated 12/20/13 documented his past medical history to include CKD IV (Chronic Kidney Disease, Stage 4), Diabetes Mellitus type 2, Complete blindness in his Left eye, legally blind in his Right eye, and Encephalopathy. Further review of the medical record revealed the following:

-Conditions of Admission and Consent for Medical Treatment:
page 2 of 3
Statement of Patient Acknowledgment " (Patients should initial beside the appropriate items) " . the following were marked with a check mark only:
1: I have received information concerning my right to develop and Advance Directive/Living Will, and/or to appoint a legal representative under a Durable Power of Attorney and/or Health Care Power of Attorney.
1 a: No, I have not executed an Advance Directive/Living Will.
1b: No, I have not appointed a representative under a Durable Power of Attorney and/or Health Care Power of Attorney.
2. I have received a copy of the Patient Rights and Responsibilities.
3. I have received a copy of the Important Message from Medicare.
4. I have received a copy of the notice of Privacy Practices.
5. Yes, the Hospital may list my name and other limited personal information in the hospital directory, as described in section 8 above.
6. I am hereby notified that a physician is not present in the hospital 24 hours per day, 7 days per week, and that in the event that a patient develops a medical emergency, he or she may be transferred to an acute care hospital emergency room for treatment.
page 3 of 3,
"I hereby certify that I have read (or have had it read to me) and that I fully understand the terms contained in this Conditions of Admission and Authorization for Medical Treatment, and that I accept and agree to the terms as stated herein. I have signed this form knowingly, freely, and voluntarily. I have had the opportunity to ask questions and have had them answered to my satisfaction. I further certify that I am the patient, or if the patient's legal representative, that I have the patient ' s authority to sign this document on the patient's behalf..." on the patient signature line was documentation that read, "verbal consent per [name of spouse] with a date of 12/19/13, no time. The relationship was designated as "wife, with the reason the patient could not sign as "confused". The Hospital Representative Signature line was signed by S14AC (Admissions Coordinator), dated 12/9/13 with no time documented.

-Patient Rights: a two (2) page document listing 26 patient rights had no designated area for acknowledgement of receipt or review of patient rights. Documented was " Verbal Consent" with the signature of S14AC and a date of 12/19/13.

-Consent for Transfusion of Blood and Blood Components with the patient's condition for which the blood or blood components were indicated was blank. Under material risks of treatment procedure, (b), "Additional risks (if any) particular to the patient because of a complicating medical condition are:" was blank. #5.:" Reasonable therapeutic alternatives and the risks associated with such alternatives are:" was blank. Under #6, No Guarantees, the name of the authorized physician or group was blank, as was 5 (f), " Physician Certification: I hereby certify that I have provided and explained the information set forth herein, including any attachments, and answered all questions of the patient, or the patient's representative, concerning the medial [medical] or surgical procedure, to the best of my knowledge." The signature of physician line and date/time were blank. The Consent for Transfusion of Blood and Blood Components was signed by Patient #3 , dated and timed 1/6/14 at 8:25 p.m. ( relationship documented as "self"), and witnessed by S29RN 1/6/14 at 8:25 p.m.
Review of a Psychiatry Consult 1/6/14 at 8:32 a.m. revealed, in part, "...labile mood and effect. Thought processes-paranoid, confused. Thought content + [positive] for delusions...Poor insight and judgment."
An order 1/6/14 at 5:15 p.m. included in part "Type and match 2 units PRBC's (Packed Red Blood Cells). transfuse both units each over four hours."

-Informed consent Special Procedure-PICC (Peripherally inserted Central Catheter)/Midline:
the space for the patient's physician was blank. A box was unchecked/blank by "Local analgesic medication for the relief and protection from localized pain during the planned and additional procedures" noted. Boxes under alternatives denoting no other alternative or refusal of the procedure and I am aware of the consequences of the alternatives were unchecked/blank. Further review revealed no patient/patient representative signature or telephone consent were on the consent. Witness to telephone consent was lined through and "VERBAL" written. The witness was signed by an LPN (Licensed Practical Nurse) and dated 12/23/13; no area was designated for time of signatures, nor was a time documented.
Review of the Physician's orders revealed an order 12/23/13 at 8:25 a.m. that included "reinsert PICC line" and signed by S23LIP (Licensed Independent Practitioner). Further review revealed a PICC Line Placement Order 12/23/13 at 9:15 a.m. as a telephone/readback order by S22MD. #3. of the order read, "1% Lidocaine SQ [subcutaneously] for PICC placement.

Further review of the medical record revealed 2 separate Authorization for the Use and Disclosure of Health Information (Form LL-ADM-019) with Patient #3's name only written on one, and nothing filled in on the other. A form to acknowledge the receipt of "An Important Message From Medicare About Your Rights" was documented with "verbal consent- (S14AC signature) 12/19/13. No reason why verbal consent was obtained or from whom it was obtained was noted.


Patient #6
Review of the medical record for Patient #6 revealed he was admitted 12/17/13 at 8:00 p.m. His diagnoses included, Pneumonia, Pulmonary Abscess, COPD (Chronic Obstructive Pulmonary Disease Stage 4, Severe protein-calorie malnutrition, Diabetes mellitus, Hyponatremia, and Anemia, Small cell Carcinoma (status post chemotherapy and radiation).
Further review revealed the following:
-Conditions of Admission and Consent for Medical Treatment:
page 2 of 3: Under Statement of Patient Acknowledgment (Patients should initial beside the appropriate items), items 1. (I have received information concerning my right to develop an Advance Directive/Living Will, and /or to appoint a legal representative under a Durable Power of Attorney and /or Health Care Power of Attorney)1a.Yes, I have an Advance Directive/Living Will...,1b. (No, I have not appointed a representative under a Durable Power of Attorney and/or Health Care Power of Attorney), 2. (I have received a copy of the Patient Rights and Responsibilities), 3. I have received a copy of the Important Message from Medicare), 4. (I have received a copy of the Notice of Privacy Practices.), 5.Hospital Directory- (Yes the hospital may list my name...), 6. ( I am hereby notified that a physician is not present in the hospital 24 hours per day, 7 days per week, and that in the event a patient develops a medical emergency, he or she may be transferred to an acute care hospital emergency room for treatment were all marked with a check.
page 3 of 3: Under signature of patient "Verbal Consent per (first name other than patient)" 12/17/13, relationship to patient: spouse and reason patient cannot sign: Contact Precaution were written. The hospital representative's signature was that of S14AC and dated 12/17/13
-Patient Rights: the second page of 26 listed patient rights had "verbal consent, S14AC, and 12/17/13 written. No signature of Patient #6 or a representative was found on the document. No documentation of from whom the verbal consent was obtained or why a verbal consent was obtained.
-Consent for Transfusion of Blood and Blood Components: the following areas were blank- patient's condition for which the therapy was indicated or recommended, additional risks, reasonable therapeutic alternatives and the risks associated with such alternatives, name of authorized physician or group, date and time the consent was signed by the physician. Under consent, Patient #6's signature was noted with 12/28/13, 10:30 a.m. documented.
-A second consent for Transfusion of Blood and Blood Components revealed the blank/incomplete areas as the transfusion consent noted above. Patient #6 signed this consent with a date of 12/25/13, and it was witnessed 12/25/13 at 11:50 a.m.
-Authorization for the Use and Disclosure of Health Information (two forms with the same title) were blank except for Patient #6's name and information on his medical chart label. No signatures were noted.
-An Important Message From Medicare About Your Rights had written in the signature area, "verbal consent- (signature of S14AC), date/time documented as "12/17/13.
-Balance Billing Disclosure Notice: documented verbal consent was obtained because of contact precautions.
-A copy of a Durable Power of Attorney (POA) dated 8/28/13 signed by Patient #6. The designated POA was not the same name as the patient's spouse on the Consent for Treatment.


Patient #21
Review of the medical record for Patient #21 revealed she was admitted to the hospital 1/2/14. Further review revealed, in part, the following:
-A patient rights document listing 26 patient rights on two pages. The second page had written, " verbal consent per Pt. (patient) (signature of S14AC) 1/2/14.
-A document titled "An Important Message From Medicare About Your Rights". The form had written on the patient or representative signature line, " verbal consent per (S14AC), 1/2/14/ 4:30"
-A Conditions of Admission and Consent for Medical Treatment form that on page 2 of 3, under the Statement of Patient Acknowledgement ( with a note that patients should initial beside the appropriate items), check marks to acknowledge receipt of information on Advance Directives/Living Will , and/or appointing a legal representative under a Durable Power of Attorney (POA). The checked lines were that the patient had not executed an Advance Directive/Living Will, and No, she had not appointed a representative under a Durable Power of Attorney and/or Health Care Power of Attorney. Other checks documented the patient had received a copy of the Patient Rights and Responsibilities, an Important Message from Medicare, and the Notice of Privacy Practices. Also checked were the hospital may list her name and other limited personal information in the hospital directory and that she was notified that there is not a physician present in the hospital 24 hours a day, 7 days a week. Page 3 of 3 of the Consent for Treatment revealed on the signature of patient line was handwritten " Verbal per Pt. (name of Patient #21) 1/2/14 4:30
On the "Other Authorized Signature (if patient cannot sign), line was written "verbal per (name of pt ' s aunt); date and time were blank... The relationship of authorized signature was documented as "aunt". The reason patient could not sign was "contact precaution" Under these signature lines was a "Hospital Use Only" section in which S14AC's signature was as the hospital representative signature, dated 1/2/14 at 4:30. Under the Hospital Representative Signature line was, "*If verbal consent, due to patient unable to sign and no family present-additional witness signature is required below. " No other signature was noted.

In an interview 1/7/14 at 1:35 p.m. S14AC reported that she was the admissions coordinator. She further reported that she obtained signatures from patients or their representatives on admission. S14AC stated sometimes a patient can't sign or the family wasn't with them, then she would contact the family by phone. When asked to give an example of when a verbal consent would be needed because they couldn't sign S14AC stated if they were confused, were too weak, or shook too much. She reported that she usually got the consents signed and gave patients a folder that included information, including Patient Rights. She further reported that sometimes the nurse would get the consents if the patient was admitted at night, after hours. S14AC reported that sometimes the admission liaison would get consents when he/she was doing the preadmission assessment. S14AC reviewed the medical records of patient #s 3, 6, and 21. She verified that the signatures were hers, and she obtained the patient or the representative's consent. During the review of the medical records, S14AC verified that it was documented 12/19/13 that Patient # 3 was confused on his treatment consent, and his wife gave a verbal consent. She explained that the wife's consent must have been over the phone. S14AC reported that she wrote "verbal consent" for both verbal (person present) and phone consents. When asked if more than one witness was required when a verbal and/or phone consent was obtained, she responded that might be a good idea, but that was not the hospital's current practice. When asked about the time's being blank, S14AC had no explanation, other than sometimes; she got the consent during business hours the next day when they were admitted during the night. S14AC verified that Patient #s 6 and 21, in some places of verbal consent, had documentation of the reason they couldn't sign was contact precautions. When asked why that would prevent the patient from signing, she said she just went by what the preadmission assessment said.

An interview was conducted 1/9/14 at 1:40 p.m. with S20RN. She reported that she has a patient sign a consent after the physician/practitioner talk with the patient. She said she filled in the patient's name but nothing else. She reported she did not know who was supposed to fill in the risks and alternatives to the procedure or treatment. She further reported that if a patient was going to receive blood, she might write "H & H" (Hematocrit and Hemoglobin), but then agreed the patient might not know what "h & h" meant. She reported that she did not make sure the consent was completely filled out before she had a patient sign it and she witnessed their signature.

In an interview 1/9/14 at 11:50 a.m. S2CCO reviewed the medical records of Patients #3, #6, and #21. She verified the above findings. She reported that often a patient can't sign or make an "x" due to a problem with their hand, or they might be too weak and not have family around. S2CCO agreed that documentation should include who gave the consent, and why the patient was unable to consent. S2CCO reported that she was aware that "verbal consent" was obtained, but she was not aware that consents were not being filled out completely. She reported that staff had been in-serviced in the past on filling out consents completely. When asked if contact precautions was an example of when or why a patient could not sign a consent form, she responded, "No, it shouldn't be " .

Based on record review and interview the facility failed to ensure hospital staff and practitioners complied with a patient's Do Not Resuscitate advance directive as evidenced by a patient being attempted to be resuscitated after a cardiac arrest for 1 out of 1 Patient's(Patient # 18) medical record reviewed for a do not resuscitate death. Findings:

Review of the hospital's Policy on Do Not Resuscitate, Policy 1.A.1.10 revealed in part, "...The hospital's philosophy is to provide the dignity in impending death by adhering to the wishes of its patients and by instituting only medically appropriate care. Definitions: A. DNR (Do Not Resuscitate) order: When a DNR order is issued, the patient will receive all medically appropriate therapeutic care, but only to the point of cardiac or respiratory arrest. At that point, cardiopulmonary resuscitation will not be initiated..."

Review of the medical record for Patient #18 revealed the patient was a 81 year old female who was admitted to the hospital at Campus B on 11/22/13 for surgical debridement of her Stage IV necrotic left heel, Chronic Kidney Disease, Severe Malnutrition, and Congestive Heart Failure.

Continued review of her medical chart revealed on 12/22/13 at 16:18 she requested to become a DNR and a physician's order was written and documented in the medical record. Review of the physician's progress noted dated 12/22/13 at 16:18 revealed the patient refused a pacemaker after having bradycardia (low heart rate) episodes, 30 beats/minute and wanted to be a DNR. The decision was discussed with the patient's daughter and also was documented by the physician in the medical record.

Review of Patient #18's Interdisciplinary Progress Notes revealed on 12/26/13 at 1330, "RT (respiratory therapist) called to room STAT. Entered room to find pt (patient) non-responsive, pulseless, not breathing. Sternal rub done no response noted. RT began bagging with 100% O2 (oxygen) via ambu bag and RN (registered nurse) started chest compressions. ER (Emergency Room) doctor, Dr .... paged.
1335 - Dr.... entered pt's room, intubated pt with 7.0 ETT (endotracheal tube) x (times) 2 attempts. Intubation was a success on second attempt. BBS (bilateral breath sounds) heard equally. Pt. still non-responsive, pulseless, no breathing. CPR (Cardiopulmonary Resuscitation) protocol being done via Dr..... and hospital staff.
1345- Pt remains non-responsive, pulseless, no breathing. RT continuing to bag pt with 100% O2 via ambu bag and RN performing compressions. CPR protocol continued. Dr..... gave orders to hold compressions and stop bagging. Pt remains asystole. Dr. ....... pronounced pt and CPR stopped."

Review of the Physician Progress Note dated 12/26/13 at 13:49 revealed," ED (Emergency Department) Note- Called to Code Blue in Room ...... pt found unresponsive by CNA (Certified Nursing Assistant). CPR/bagging in progress on arrival. Informed by RN in room pt was a full code. Intubated on 2 rd attempt with bagging in between. Balloon inflated (symbol of arrow up) BL (bilateral) breath sounds secured at 23 cm (centimeters) at gingiva (gums). Asystole on monitor throughout. 3 rounds of epi (epinephrine) with CPR, no change in rhythm, efforts stopped -asystole, no pulse, 13:45 pronounced dead. Found out pt is DNR when I began charting. Death 2 (secondary) natural causes."

An interview was conducted with A3ACCO (Assistant Chief Clinical Officer) on 1/8/14 at 3:15 p.m. He reported Patient #18 was a DNR, the physician's DNR orders were on the chart appropriately, and the nurses and staff at Campus B did code the patient. He confirmed the staff should not have attempted to resuscitate Patient #18.


30420

Based on observation, record review and interview the hospital failed to ensure patients received care in a safe setting as evidenced by patients being allowed to smoke outside of the facility unsupervised and without a physician's order for 2 out of 2 active patients (Patient #5 and Patient # 8) reviewed for smoking.

Finding:

Review of the hospital's Smoking Policy, Policy Number III.P.16.16 revealed in part, "...Smoking is prohibited in all rooms and throughout the hospital at all times. Patients with a doctor's order to smoke will be directed to the designated smoking area...Designated smoking area shall be away form the hospital entry and in such an area so that smoke will not flow in the hospital building..."

Patient #5

Review of Patient #5's medical record revealed the patient was a 52 year old male admitted on 12/21/13 with a Type II Diabetes, Multi-organ failure, Hypertensive Cardiorenal Disease, Chronic Kidney Disease Stage IV, Multiple infarcts with brain volume loss and early vascular dementia, and New onset dialysis.

Review of the Physician's Orders revealed no physician order to allow the patient to go outside and smoke.

Numerous observations were made from 1/6/14 until 1/9/14 of patients going outside to smoke on the patio. The patio was located around the corner from the nurse's station and was not visible to the Nurses' Station. Staff did not accompany the patients outside to smoke.

Review of the Nurses' Narrative Notes for Patient #5 revealed the following:
12/21/13- 2100- CBG (Capillary Blood Glucose) 351 15 units Novolog given per s/s (sliding scale).
2300- Pt (Patient) diaphoretic and lethargic. CBG 26. Glucagon given IM (intramuscular), IV accessed obtained, D50 (Dextrose 50%) given. Juice given. Pt supervised until CBG back in range.
0100- CBG 320.
12/24/13 1320 Ambulates outside and back to room.
1700- CBG critical high. 15 U (units) Novolog given. No s/s (sign/symptoms) of hyperglycemia. Rechecked with result of 362.
2015- per CNA (certified nursing assistant) CBG 35 rechecked 36. Charge nurse aware. D50 being pulled. Pt diaphoretic, labile.
2024-D50 admin. pushed by charge nurse via R (right) AC (antecubital) HL(heparin lock). Pt tol (tolerated) well.
2026- CBG rechecked 186. Pt more responsive, no diaphoresis noted "I feel much better."
12/25/13-0100- Pt outside on patio smoking.
12/29/13 0400-Called to patient's room per pt's request. States "feeling like my sugar is low"..."please check my sugar." CBG 37 orange juice and D50 admin. per CN (Charge Nurse). CBG rechecked, 251 mg/dl (milligrams/deciliters)
12/30/13 0130- CBG 480, Insulin admin. (administered) per SS (sliding scale)
On 1/4/14 revealed at 1100- pt (patient) outside smoking on patio will monitor.
At 1830- Pt outside smoking.
At 2300-Pt outside smoking.
1/5/14 at 0100- Pt outside smoking
at 0300-Pt outside smoking

An interview was conducted with S2CCO (Chief Clinical Officer) on 1/8/14 at 10:45 a.m. She confirmed there was no order from the physician to allow the patient to go outside to smoke, which is not in compliance with the hospital's smoking policy.

Patient #8

Review of the medical record for Patient #8 revealed he was admitted to the facility on 12/20/13 with Infected Right Knee Replacement, Chronic Obstructive Pulmonary Disease, Hypertension and Bipolar. Review of his History and Physical revealed he smoked 1 pack of cigarettes a day.

Review of the Nurses' Narrative Notes for 1/07/14 at 0300 revealed, " Outside on patio smoking in WC (wheelchair)."

Review of Patient #8's physician order revealed no physician's order for the patient to go outside and smoke.

An interview was conducted with S2CCO on 1/8/14 at 10:45 a.m. She confirmed there was not a physician's order on the chart that indicated the patient was able to go outside and smoke.


30420

Based on record review and interview the hospital failed to initiate and evaluate a plan of care for a patient in restraints for 1 out of 1 patients (Patient #20) reviewed for restraints out of a sample of 30. Findings.

Review of the hospital's policy on Restraints, Policy Number II.K.11.07, revealed in part, "....5. Care Plan: The patient's care plan will be modified to reflect the need for restraint....9. Documentation: The following will be documented in the medical record whenever medical restraint is applied: g. An updated restraint care plan..."

Review of the medical record for Patient #20 revealed he was admitted on 1/2/04 for Subdural Hematoma, Seizure Disorder, Dysphagia, and COPD (Chronic Obstructive Pulmonary Disorder).

Review of the Restraint Order Sheet revealed Patient # 20 had verbal orders for a left mitt for his left hand on 1/3/14, 1/4/14, and 1/5/14. The restraint order was not signed on 1/6/14, 1/7/14, 1/8/14, and 1/9/14.

Review of Patient #20's LTAC (Long Term Acute Care) Interdisciplinary Plan of Care revealed the use of a left hand mitt on the patient was not included in the patient's plan of care.

An interview was conducted with S2CCO (Chief Clinical Officer) on 1/9/14 at 11 a.m. She confirmed the left hand mitt restraint was not included in the patient's care plan and she reported the restraint should have been in the care plan.

Based on record review and interview the hospital failed to follow their hospital policy and have a physician's order every 24 hours for a nonviolent and non-self destructive patient in a restraint for 1 out of 1 current patients (Patient # 20) reviewed for restraints out of a sample of 30. Findings:

Review of the hospital's policy on Restraints, Policy Number: II.K.11.07, revealed in part, "...6. Continuation of Restraint Orders: The attending physician or other licensed independent practitioner who is responsible for the care of the patient and authorized to order restraints will perform in-person assessments of a restrained patient at least once every 24 hours,at which time the restraint will either be reordered or discontinued as indicated..."

Review of the medical record for Patient #20 revealed he was admitted on 1/2/04 for Subdural Hematoma, Seizure Disorder, Dysphagia, and COPD (Chronic Obstructive Pulmonary Disorder).

Review of the Restraint Order Sheet revealed Patient # 20 had verbal orders for a left mitt for his left hand on 1/3/14, 1/4/14, and 1/5/14. The restraint order was not signed on 1/6/14, 1/7/14, 1/8/14, and 1/9/14.

An interview was conducted on 1/9/14 at 11 a.m. with S2CCO (Chief Clinical Officer). S2CCO confirmed the restraint order for the left mitt was not signed on 1/6, 1/7, 1/8 and 1/9/14. She reported according to the hospital policy the restraint order should be reordered or discontinued every 24 hours.

Based on record review and interview the hospital failed to ensure the medical staff by-laws were followed by not having a patients' history and physical in the chart within 24 hours after admission to the hospital as evidenced by 5 (Patient # 4, #16, #18, #22, and #24) out of 8 charts (Patient # 4, #8, #16, #18, #20, #22, #23, and #24) reviewed for having a history and physical in the chart within the first 24 hours out of a sample of 30. Findings:

Review of the Medical Staff By-Laws revealed in part, "A complete history and physical examination shall in all cases be recorded within twenty-four (24) hours of admission of the patient by a practitioner or an allied health professional who has been granted privileges to do so."

Review of Patient #4's History and Physical revealed he was admitted on 12/19/13 for care after surgery for amputation of his 5th metatarsal. Continued review of the History and Physical revealed it was done on 12/30/13 by S23NP.

Review of Patient #16's History and Physical revealed she was admitted on 12/18/13 for Fluid Volume Overload. Continued review of the History and Physical revealed the History and Physical was done on 12/20/13 by S23NP.

Review of Patient #18's History and Physical revealed she was admitted on 11/22/13 for a necrotic left heel. Continued review of the History and Physical revealed it was done on 11/25/13 by S23NP.

Review of Patient # 22's History and Physical revealed she was admitted on 12/24/13 for Vancomycin-resistant Enterococcus in her stool. Continued review of the History and Physical revealed it was done on 12/27/13 by S23NP.

Review of Patient # 24's History and Physical revealed she was admitted on 12/16/13 for Bilateral lower extremity cellulitis. Continued review of the History and Physical revealed it was done on 12/20/13.

An interview was conducted with S16MR (Director of Medical Records) on 1/7/13 at 1:45 p.m. She reported the History and Physical not getting done in a timely fashion by S22MD and his Nurse Practitioner, S23NP, became a problem in November 2013, but she was not sure why.



30420

Based on record review and interview the hospital failed to ensure daily weights were done as ordered by a physican for 4 out of 4 (Patient #5, #16, #23, and #24) patient's medical charts reviewed for daily weights out of a sample of 30.
Findings:

Patient #5
Review of Patient #5's medical record revealed the patient was a 52 year old male admitted on 12/21/13 with the diagnoses of Type II Diabetes, Multi-organ failure, Hypertensive Cardiorenal Disease, Chronic Kidney Disease Stage IV, Multiple infarcts with brain volume loss and early vascular dementia, and New onset dialysis.

Review of his Admission Order dated 12//21/13 and time 1700 revealed the physicain ordered daily weights on the patient.

Review of the patient's Graphic Sheet revealed he did not have a weight obtained on 12/23/13, 12/24/13, 12/25/13, 12/26/13, 12/27/13, 12/31/13, and 1/6/14.

Patient #16
Review of Patient #16's medical record revealed she was an 85 year old female admitted for Volume Overload, Congestive Heart Failure, and Chronic Kidney Disease Stage III.

Review of her Admission Order dated 12/18/13 at 2130 revealed an order for daily weights by the physician.

Review of the patient's Graphic Sheet revealed she did not have a weight obtained on 12/18/13, 12/19/13, 12/20/13, 12/21/13, 12/23/13, 12/24/13/ 12/25/13, 12/26/13, 12/27/13, 12/28/13, 12/29/13, 12/31/13, 1/1/14, 1/3/14, 1/4/14, 1/5/14, 1/6/14 and 1/7/14.

Patient # 23
Patient #23 was admitted to the hospital on 12//27/13 with the diagnosis of Urinary Tract Infection with Sepsis, Type 2 Diabetes Mellitus and Metabolic Encephalopathy.

Review of his Admission Orders dated 12/27/13 and timed 1700 revealed a physician's order for daily weights.

Review of the Graphic Sheet revealed a weight was not obtained on the patient on 12/28/13, 12/29/13, 12/31/13, 1/1/14, 1/2/14, 1/3/14, 1/4/14, 1/6/14, and 1/7/14.


Patient #24
Patient #24 was admitted to the hospital on 12/16/13 for Severe fluid overload and infection to her bilateral lower extremities that was nonresponsive to oral medication.

Review of her Admission Orders dated 12/16/13 revealed an order for daily weights.

Review of her Graphic Sheet revealed a weight was not obtained on 12/17/13, 12/18/13, 12/22/13, 12/23/13, 12/25/13, and 1/1/14.

An interview was conducted on 1/7/14 at 11 a.m. with S30LPN. He stated the nurses and CNAs obtains the daily weights on the patients and the weights are documented on the Graphic Sheet. He reported the Graphic Sheet was the only place in the medical record the patients' weights were charted.

An interview was conducted with S3ACCN (Assistant Chief Clinical Officer) on 1/7/14 at 1:15 p.m. He reported the CNAs on the night shift are suppose to obtain the patient's weight and the charge nurse was suppose to check to make sure the weights were obtained and documented in the patients' charts. He further reported obtaining the patients' weights had been a problem. He confirmed on the above charts the weights were not obtained daily as the physican ordered.


30420

Based on record review and interview the hospital failed to:
1. Ensure a Registered Nurse assigned the monitoring of the central telemetry monitoring to a Unit Secretary had been evaluated to be competent for 3 out of 3 Unit Secretaries' ( S25US, S26US, and S27US) personnel files reviewed for competencies on telemetry monitoring.
2. Ensure competencies on nursing skills were conducted on the hospital's nursing staff.
Findings:

Review of the hospital's policy, Staff Competency, Policy Number: I.B.2.22, revealed in part "...III. A. Annual competency 1. Annually, the CCO (Chief Clinical Officer) or Department Director will determine competencies that must be successfully completed by the clinical staff. These competencies may be determined based on regulatory requirements, quality data results over the year, event reporting data, etc.
B. Documentation of Competence 1. Competence will be documented on the company approved form and once completed will be placed in the employee's HR (Human Resources) file. 2. Completed unit-specific competency checklist by the 3 month evaluation at that time if employee is found to be lacking in the knowlege or application of any skills listed the company will supply either education material or hands on instruction to increase employees' competence..."

Review of the hospital's Telemetry Monitoring Policy, Policy Number: II.K.11.06 revealed in part, "...D. All telemetry patients will be monitored through a central monitor located at the nurse's station by a competency verified RN, LPN/LVN (Licensed Practical Nurse/Licensed Vocational Nurse) or monitor tech. (technician)...1. Cardiac rhythms will be monitored by a qualified person at all times. It is the responsibility of the assigned monitor technician to assure that a qualified individual covers in his/her absence during meal or break times. At no time is the central monitor to be left unattended..."

1. An interview was conducted with S19RN Charge Nurse on 01/07/14 at 11:05 a.m. She reported she was the charge nurse on 1/7/14. She further reported the Unit Secretary, herself or whoever was at the nurses' station monitored the central telemetry monitor.

An interview was conducted with S27US on 1/9/14 at 9:55 a.m. She reported her job duties as the telemetry monitor techician was to sit at the desk and monitor the EKG (Electrocardiogram) rhythms and if the rhythm was a flat line or anything abnormal, she was to report it to a nurse. She further reported if she had to leave the front desk she would notify the charge nurse and the nurse would monitor the central EKG monitors.

An interview was conducted with S3ACCO (Assistant Chief Clinical Officer) on 1/9/14 at 3:30 p.m. He reported the Unit Secretaries are instructed to watch a film, a packet is given to them and then a test is administered to them. He further reported that was all that was done related to education and competencies on monitoring the central EKG monitors by the Unit Secretaries. There was no competencies done to see if the Unit Secretaries were competent on identifying abnormal EKGs. He reported the charge nurses are at the desk with the Unit Secretaries. When questioned if the charge nurses are assigned patients, he stated sometimes.

Review of the Personnel files for S25US, S26US and S27US revealed no competencies were evaluated for EKG monitoring. The only documentation in the unit secretaries' personnel files were documentation of the EKG test that was administered to them.

An interview was conducted with S15HR (Human Resources) on 1/9/14 at 4 p.m. She confirmed no competencies were done on the Unit Secretaries on monitoring the central EKG monitors.

2. An interview was conducted with S3ACCO on 1/9/14 at 4 p.m. He reported the CCO and himself did competencies during staff nursing meeting. He further reported he was unable to obtain the staff nursing meeting minutes at that time. When informed we needed them immediately, he reported the only competencies that were conducted in the last year for the nursing staff was on the PCA (Patient Controlled Analgesia) pumps.

An interview was conducted on 1/9/14 at 4 p.m. with S15HR. She reported the hospital used to do yearly skill check off days, where all the licensed staff would get checked off on their competencies on one day. She further reported the hospital stopped that practice in 2011 and started doing competencies in the nursing staff meetings.

Review of the personnel files for S18RN, S20RN, and S31RN revealed no yearly competencies documented.


30420

Based on record review and interview the hospital failed to ensure medications were administered by acceptable standards of practice as evidenced by nurses not assessing a patient's blood pressure or pulse prior to administrating antihypertensive drugs and Digoxin for 2 (Patient #4 and #14) of 6 patients (#2,#4, #9, #10,#11, and #14) records reviewed for reviewed for medications. Findings:

Review of the hospital's policy on Medication Administration, Policy Number: II.K.11.31, in part revealed, "...B. Clinical assessment necessary before administering a specific type or dose of medication must be documented on the MAR (Medication Administration Record) e.g. pulse before Digoxin, Blood Pressure before antihypertensives.

Review of the medical record for Patient #4 revealed the patient was admitted on 12/21/13 for Hypertensive Renal Disease, Multi-Organ Failure and New Onset Dialysis.

Review of his Medication Administration Record (MAR) revealed the patient was on Carvedilol Tab 12.5 mg (milligrams) Give 2 tablets (25 mg) twice daily, Record BP (blood pressure) and Heart Rate at 0900 and 2100. With further review of the MAR revealed the following dates and times the pulse and blood pressure weren't monitored prior to Carvedilol (Coreg) being administered:
12/28/13 at 0900
1/6/14 at 0900

Review of the Patient's MAR revealed the patient was also on Hydralazine tab (tablet) 50 mg, give1 tablet by mouth twice daily. Record BP and Heart Rate at 0900 and 2100. With further review of the MAR revealed the following dates and times the pulse and blood pressure weren't monitored prior to Hydralazine being administered:
12/28/13 0900
1/6/14 0900

Review of Patient #4's MAR revealed the patient was on Amlodipine tab 10 mg, generic for Norvasc. Give 1 tablet by mouth once a daily. Record BP and Heart Rate at 0900 .With further review of the MAR revealed the following date and time the pulse and blood pressure weren't monitored prior to administration of Norvasc:

12/28/13 at 0900

An interview was conducted with the S3ACCO (Assistant Chief Clinical Officer) on 1/7/13 at 1:15 p.m. He reported the CNAs (Certified Nursing Assistants) take the patients' vital signs at 0600 and 2100 and the nurses take the results of those vital signs and use them for their 0900 medications that require blood pressure and pulse checks prior to administration of the medication.

Review of Patient #14's MARs revealed on 12/26/13 the 0900 doses of Imdur 30 mg and Lanoxin 0.25 mg by mouth were administered. There was no documented evidence that Patient #14's blood pressure or pulse was taken before administration of the medications as evidence by no blood pressure or pulse recorded on the MAR.

In a face-to face interview on 1/7/14 at 3:25 p.m.S8RN, indicated that the pulse and blood pressure were not taken before administration of the Imur and Lanoxin as it was not documented on the MAR and should have been.






30420









31206

Based on observation, record review and interview the hospital failed to ensure
1. The hospital policy was followed for physicians with delinquent medical records.
2. Medical records were properly stored to protect them from water damage if the sprinkler system was activated for approximately 350 medical records and 60 outpatient wound care records.
Findings:

1. Review of the hospital's policy, Policy Number: I.F.6.17, revealed in part, "...Good patient care and health outcomes are dependent on accurate, clear, legible, complete and timely documentation of a patient's diagnosis, problems, treatment, and progress in the health record. Quality physician documentation have been shown to improve patient care and outcomes...In an effort to enhance/improve quality and timely physician documentation, the following disciplinary action plan was developed for use when a Practitioner's documentation quality falls below the standard hospital threshold of 90% for an overall compliance of all documentation indicators including readability, H & P (History and Physical) timeliness, H & P Quality, Verbal/Telephone order timeliness, dating and timing of entries, and Do Not Use Abbreviations. The action plan may be followed for consecutive months of non-compliance.

Month 1: A letter from administration and/or Medical Director will be sent to the Practitioner.
Month 2: A one on one meeting with administration and/or the Medical Director will be scheduled with the Practitioner.
Month 3: The Practitioner will be required to submit a written explanation for non-compliance with a plan for improvement.
Month 4: The Practitioner will be required to attend the next scheduled MEC (Medical Executive Committee) for discussion of the problem.

An interview was conducted with S16MR (Director of Medical Records) on 1/7/14 at 9:10 a.m. She reported the hospital had 130 deficient medical records at Campus A. Twenty-eight (28) of the 130 deficient records were over 60 days delinquent. At Campus B there were 12 medical records over 60 days delinquent. S16MR reported she faxed reminders to the physician's offices weekly with a list of their delinquent charts. She further reported in the Medical Executive Committee Meeting the statistics of delinquent charts are reported, but there are no disciplinary actions or suspensions enforced againist the physicians.

Another interview was conducted with S16MR on 1/9/14 at 11 a. m. She reported up until the beginning of October 2013, S23NP, who worked for S22MD, was completing the discharge summaries, but in October she stopped doing the discharge summaries. She further reported that is why the hospital's medical record delinquent rate is so high. She also reported S22MD sees the majority of the patients, 85% at Campus A and 50 % at Campus B. S16MR stated she had told corporate about the problem, but it hasn't been addressed at Medical Executive Committee Meeting yet.

2. Review of the hospital's policy on Storage of Medical Records, Policy Number III.O.15.14, revealed in part, "...Storage space shall be selected and maintained to protect records for unauthorized access, loss, and destruction...e. freedom from hazards, such as flooding or damage from broken water pipes..."

An observation was made in Medical Records of 1 open shelf with approximately 30 medical record stored on the shelf.

An interview was conducted with S16MR on 1/6/14 at 11 a.m. She confirmed the medical records on the open shelf were not protected from water damage if the sprinkler system was activated.

An observation was made on 1/6/14 at 12:30 p.m. in the storage room behind the nurses' station in Hallway 2 of 34 boxes of medical records (approximately 10 charts in a box) and 6 boxes of patients' outpatient wound care records stored in the room.

Another interview was conducted with S16MR on 1/7/14 at 9 a.m. She reported the medical records in the storage room behind the nurses' station were waiting to be scanned. She confirmed they were not protected from water if the sprinkler system was activated.


30420

Based on record review and interview the hospital failed to ensure all verbal orders were authenticated with in 10 days for 3 out of 3 (Patient #1, #4, #6) patients' medical records reviewed for verbal orders authentication.
Findings:

Review of the Medical Staff Bylaws revealed in part, "...5.8.9 All verbal/telephone orders must be signed within 10 days..."

Review of the physician orders' revealed the following verbal orders had not been authenticated by the time of the survey on 1/6/14.

Patient #1
Patient #1 was admitted on 12/6/13 with the diagnoses of the following; Urinary Tract Infection, Uncontrolled Diabetes, and Malnutrition.

12/25/13 0645- Ok to use Clinimix 4.25/10 until Clinimix 4.25/10E is available.
R.B.T.O (Read Back Telephone Order) Not Authenticated.

12/25/13 0700- Add 100 ml (milliliters) 3% NaCL (Sodium Chloride) to Clinimix
R.B.T.O. Not Authenticated.

12/25/13 0740- CXR (Chest x-ray) to verify L (left) arm midline PICC (Peripheral Inserted Central Catheter) tip.
R.B.T.O. Not Authenticated

Patient #4
Patient #4 was admitted on 12/19/13 with the diagnoses of Transmetatarsal amputations, Chronic Kidney Disease and Hypertension.

Review of the physician orders' revealed the following verbal orders had not been authenticated by the time of the survey on 1/6/14.

12/20/13 at 0840- Novolog 70/30 50 Units SQ(subcutaneously) with breakfast
Novolog 70/30 60 Units SQ with dinner.
R.B.V.O. (Read back verbal order) Not authenticated.

12/20/13 at 1215-1. Continue Vancomycin 1500 mg (milligrams) IV (intravenous) Q (every) 12 hours at 0900 and 2100.
2. Draw Vancomycin trough on 12/24/13 at 0830 and fax results.
R.B.V.O. Not authenticated.

12/20/13 1525- Incentive Spirometry Q 2 hours while awake.
R.B.V.O. Not authenticated

Patient #6
Review of the medical record 1/7/14 for Patient #6 revealed he was admitted to the hospital 12/17/13 with diagnoses that included Pneumonia, Pulmonary Abscess, Chronic Obstructive Pulmonary Disease, Malnutrition, Diabetes Mellitus, and Hypertension. Review of Physician Admission Orders revealed the following "yes" box was marked with an "x" by the following orders:
-Inform Referring Physician of Patient's Location.
-Fall Risk Assessment and follow Fall Risk Protocol.
-Call MD (Medical Doctor) if BP (Blood Pressure) Sys (Systolic) greater than 180 or Diastolic greater than 100.
-Intake and Output every shift.
-Instruct patient in bed mobility and safety techniques.
-Weigh patient on admit and weekly (circled).
-Turn patient every 2 hours while in bed.
-Verify current medications and dosages.
-May use Routine Standing Orders.
-Mediport: *Flush Mediport before and after medications administered with 10 cc (cubic centimeters) of Normal Saline followed by 300 U (units) Heparinized flush.
*Dressing change every 7 days with anti-microbial disc, * Reassess every 7 days, * Flush unused Mediport every shift with 10 cc of Normal Saline followed by 300 U Heparinized flush.
-Routine Medication Orders. A. Tylenol 325 mg 2 tabs by mouth every 4 hours as needed not to exceed 6 doses in a 24 hour period for headache, elevated temperature, or pain. [Notify MD for dosage clarification if patient is on Lortab or Percocet]
-If on Insulin CBG's (capillary blood glucose) before meals/at bedtime to Insulin Sliding Scale Protocol. (Protocol written out).
-Urinanalysis (within 48 hours of admit) Clean Catch or Straight Cath- except on dialysis patients.
-EKG (Electrocardiogram) if indicated by cardiac status.
Telemetry if indicated by cardiac status for 48 hours.
-Culture Central lines and Dialysis catheters when drainage or redness noted.
-Culture all wound sites within 48 hours of admit.
-Consult Wound Care on admit, site: right knee.
-Consult Dr. (name of wound care specialist).
-Assess nutritional needs/advise and recommend.
Additional Orders:
1. Complete Blood Count, Comprehensive Metabolic Panel, Prealbumin level in a.m.
2. Oxygen at 3 liters per nasal cannula.
3. Chest X-Ray in a.m.
All three (3) pages were marked at a telephone order/read back from S22MD per S31RN. 12/17/13 at 8:00 p.m. None of the 3 pages of admission orders were authenticated.

12/17/13 (no time) Admit: Clinimix 4.25/10 at 60 ml/hr (milliliters an hour) IV (Intravenous) continuously. Solumedrol 60 mg IVP (Intravenous Push) now times 1 dose. RBTO (Readback Telephone order): S23LIP/S22MD/S31RN. No authentication noted.

12/18/13 at 1:15 p.m.: Hold Clinimix for now- NS (Normal Saline) at 100 ml/hr times 1 liter, then restart Clinimix 4.25/10 a 50 ml/hr times 2 hours then increase to 100 ml/hr. RBTO (S23LIP/S19RN.) No authenticated noted.

In an interview 1/9/14 at 1:10 p.m. S2CCO review the medical record of Patient #6 and verified the above noted orders were not authenticated by the provider.

An interview was conducted on 1/7/14 at 1:45 p.m. with S16MR (Director of Medical Records). She reported recently she started having problems getting physicians to sign their verbal orders within 10 days.


30420

Based on record review and interview the hospital failed to have a history and physical completed in the patients' medical records 24 hours after admission for 10 charts ( Patient # 4, #16, #18, #22, #24, #9, #10, #11, #14,and #30) out of 16 charts (Patient # 4, #8, #16, #18, #20, #22, #23,#24, #9, #10, #11,#12, #13, #14, #29, and #30) reviewed for history and physicals out of a sample of 30. Findings:

Review of Patient #4's History and Physical revealed he was admitted on 12/19/13 for care after surgery for amputation of his 5th metatarsal. Continued review of the History and Physical revealed it was done on 12/30/13 by S23NP.

Review of Patient #16's History and Physical revealed she was admitted on 12/18/13 for Fluid Volume Overload. Continued review of the History and Physical revealed the History and Physical was done on 12/20/13 by S23NP.

Review of Patient #18's History and Physical revealed she was admitted on 11/22/13 for a necrotic left heel. Continued review of the History and Physical revealed it was done on 11/25/13 by S23NP.

Review of Patient # 22's History and Physical revealed she was admitted on 12/24/13 for Vancomycin-resistant Enterococcus in her stool. Continued review of the History and Physical revealed it was done on 12/27/13 by S23NP.

Review of Patient # 24's History and Physical revealed she was admitted on 12/16/13 for Bilateral lower extremity cellulitis. Continued review of the History and Physical revealed it was done on 12/20/13.

An interview was conducted with S16MR (Director of Medical Records) on 1/7/13 at 1:45 p.m. She reported the History and Physical not getting done by S22MD and his Nurse Practitioner, S23NP, for their patients, became a problem in November 2013, but she was not sure why.

Review of Patient #9's medical record revealed a 57 year old male admitted to Campus B hospital on 12/31/13, admitting diagnoses were Multidrug-resistant UTI (Urinary Tract Infection), Stage IV decubitus ulcer infected, Severe protein-calorie malnutrition, and Chronic obstructive pulmonary disease. Further review of Patient #9's medical record revealed no documented evidence that a History and Physical was completed within 24 hours of admission as evidene by no History and Physical in Patient #9's medical record.

Review of Patient #10's medical record revealed a 78 year old male admitted to Campus B hospital on 12/24/13, admitting diagnoses were Chronic venous hypertension, chronic venous insufficiency with nonhealing venous stasis, and Diabetes Mellitus. Further review of Patient #10's medical record revealed the History and Physical was completed on 12/26/13.

Review of Patient #11's medical record revealed a 65 year old female admitted to Campus B hospital on 12/24/13, admitting diagnoses were Sepsis, Diabetes Mellitus Type 2, and Mild protein calorie malnutrition. Further review of Patient #11's medical record revealed the History and Physical was completed on 12/26/13.

Review of Patient #14's medical record revealed a 59 year old male admitted to Campus B hospital on 12/17/13 admitting diagnoses were COPD(Chronic Obstructive Pulmonary Disease), and Hypertension. Further review of Patient #14's medical record revealed the History and Physical was completed on 12/20/13.

In a face-to face interview on 1/7/14 at 12:15 p.m. S8RN indicated after review of the medical records for patients #9, #10, #11 and #14 that the History and Physicals were not completed within 24 hours of admission and should have been. S7RN presented a copy of a History and Physical at 12:25 p.m. for Patient #9 with a dictation date of 1/7/14.

Review of Patient #30's medical record revealed a 55 year old female admitted to Campus A hospital on 12/24/13, admitting diagnoses were Left foot wound, Venostasis ulcers, Bilateral lower extremity cellulitis and lymphedema, Sepsis, Diabetes Mellitus Type 2, and Mild protein calorie malnutrition. Further review of Patient #11's medical record revealed the History and Physical was completed on 12/26/13.

In a face-to-face interview on 1/9/14 at 1:30 p.m. with S16Director Medical Records, she indicated the History and Physical for Patient #30 was not completed within 24 hours of admission and should have been.















30420





31206

Based on medial records reviews, policies/procedures and interviews the hospital failed to ensure that medications were administered as ordered by the physician for 2 ( #11 and #14)of 6 patients (#2, #4, #9, #10,#11, and #14) records reviewed for medication administration out of a sample of 30 patients. This resulted in 5 medication administration errors that were identified during the survey that had not been identified by the hospital. Findings.

Review of the hospital policy titled "Administration of Medication" presented as being current, stated in part; A. The individual administering the medication(s) must document all medications immediately after administration in the patient's medication administration record (MAR).

Review of the hospital policy titled "Medication Variances", presented as being current, stated in part ; Definition - 4. Omission error: The failure to administer an ordered dose to a patient before the next scheduled dose, if any. Further review of the policy revealed that employees are required to report medications variance and potential errors via the online Event Report.

Review of Patient #11's medical record revealed a 65 year old female was admitted to Campus B hospital on 12/24/13, admitting diagnoses were Sepsis, Diabetes Mellitus Type 2, and Mild protein calorie malnutrition. Review of the physician order's revealed an order was written on 12/24/13 at 1900 for Vancomycin 1750 mg (milligrams) IVPB(Intravenous piggy back) every 12 hours. Review of the MARs (medication administration records) revealed no documented evidence that Vancomycin 1750 mg IVPB was administered on 12/31/13 at 2100 as evidenced by the time noted to be blank on the MAR.

Review of Patient #14's medical record revealed a 59 year old male was admitted to Campus B hospital on 12/17/13, admitting diagnoses were COPD(Chronic Obstructive Pulmonary Disease) and Hypertension. Review of the physician order's revealed that an order was written on 12/17/13 at 1900 for Lipitor 80 mg hs (at the hour of sleep) and Lovenox 40 mg sq.(subcutaneous) daily. Continued review of the physician order's revealed t an order was written on 12/27/13 (no documented time the order was written) for Prilosec 20 mg bid (twice a day). Review of the MARs revealed no documented evidence that Lovenox 40 mg subcutaneous was administered on 12/21/3 and 1/2/14 at 0900 as evidenced by the times noted to be blank on the MARs. Review of the MARs revealed no documented evidence that Prilosec 20 mg and Lipitor 80 mg were administered on 1/5/14 at 2100 as evidenced by the times noted to be blank on the MAR.

In a face-to-face interview on 1/7/14 at 3:20 p.m.S9LPN, indicated on 1/2/14 she administered medications to patient #14, and she was not able to recall if Lovenox was administered or not. S9LPN confirmed that the 0900 dose was blank on the MAR and it should have been initialed as given, as the other 0900 medications were initialed.. S9LPN confirmed that as evidenced by the Lovenox not being initialed it was not administered.

In a face-to face interview on 1/7/14 at 3:25 p.m.S8RN, indicated that all medications that are administered, are indicated with the nurse's initial who administered the medication. If a medication is not administered, that medication is circled, which would indicate it was not administered. Review of the MARs for Patient #11 and Patient #14, S8RN confirmed the omission of the medications, which were not identified by the hospital as medication errors and should have been.




30420

Based on observation and interview the hospital failed to ensure that outdated drugs and biologicals are not available for patient use. Findings.

An observation at Campus A on 1/19/14 at 11:00 a.m. of the medication refrigerator located in the medication room revealed 2 boxes of Racepinephrine Inhalation Solution USP 2.25% (used for patient with asthma). One box contained 27 (single dose) foiled wrapped unopened packets with an expiration date of 9/12. A second box contained 28 (single dose) foiled wrapped unopened packets with an expiration date of 9/13.

In a face-to-face interview on 1/9/14 at 11:00 a.m. S20RN indicated the medications were expired, and available for patient use. According to S20RN the medications should have been disposed of and were not.

Based on record review and interviews, the hospital failed to ensure the following:
1) The designated full-time employee, S11 DM (Dietary Manager), who served as the director of the food and dietetic services, was responsible for the daily management of the service, implementing training programs for dietary staff, and assuring established policies and procedures are maintained.
2) The hospital failed to ensure that a designated full-time employee served as the director of the food and dietetic services to supervise the daily management of the dietary services at Campus B as evidenced by not having a qualified DM. Findings:

1) Review of the personnel record for S11DM revealed a hired date of 4/26/13 as a full-timed DM for Campus A and Hospital "A". Further review of the record for S11DM revealed a job description for DM at Hospital "A" and form titled position description /performance was noted to be signed/dated on 8/20/13 by S11DM and Hospital "A" CEO. There was no documented evidence in S11DM's record of a job description for Campus A.

Review of the personnel record for S10DS revealed a hired date of 6/12/13, with a job description for dietary cook, signed/dated by S10DS on 6/11/13. Further review of the record for S10DS revealed a general orientation check list dated 6/12/13 and signed by S10DS and S11DM. There was no documented evidence of S10DS having an specific orientation/training to the dietary department or any other outside dietary training/certification in food service.

In a face-to-face interview on 1/6/14 at 11:25 a.m. S7RD indicated S11DM was the full-time DM for Campus A and Hospital "A" and there was no DM at Campus B. According to S7RD, S11DM made on-site visits to Campus A 2-3 hours per week with S10DS in charge of the dietary department.

In a face-to-face interview on 1/8/14 at 10:00 a.m. S10DS indicated S11DM was the full-time DM at Campus A and Hospital "A". According to S10DS, S11DM worked (office) out of Hospital "A" and visited Campus A 2-3 hours per week and was available by telephone if needed. S10DS reported she had no training for the DS position, only verbal information/instruction on the first day (unable to recall date 6/13) by S11DM. S10DS reported no supervisory training. S10DS reported of not having any knowledge of Infection Control in the dietary department or who was the Infection Control Nurse for Campus A .

In a face-to-face interview on 1/8/14 at 10:30 a.m. S2CCO indicated S11DM was a shared full-time employee for Campus A and Hospital "A" and was the Director of the dietary department at Campus A. According to S2CCO, S11DM was not on-site at Campus A 40 hours per week. S2CCO reported that S11DM spent 30 hours/week at Campus A and 10 hours a week at Hospital "A". S2CCO reported S11DM was a salaried employee and her time was divided up into 30 hours at Campus A and 10 hours at Hospital "A". S2CCO reported that S11DM was a salaried employee and there was no documented record of time spent at Campus A. S2CCO reported there is no DM at Campus B and there is not a staff member that serves as a DM because dietary is contracted out.

In a face-to-face interview on 1/8/14 at 1:10 p.m. S11DM indicated a hired dated of 4/26/13 as full-time DM for Campus A and Hospital "A". S11DM reported on-site visit to Campus A of 3-5 days a week arriving between the hours 1:00 p.m. to 1:30 p.m. for 3 hours. S11DM reported S10DS was in charge the rest of the time. S11DM reported Campus B had no DM, as the dietary services was contracted with the hospital in which it was located at.

2) In a face-to-face interview on 1/7/14 at 2:30 p.m. S8 RN indicated Campus B dietary services was contracted by the hospital in which it was located. S8RN reported the patients' trays are prepared by the hospital's dietary department and are transported up to the floor on a food cart. The diets are checked against the floor's diet list and the diet cards, which are on the tray, by the CNA and sometimes by the nurse. According to S8RN there is no DM or designated staff member that manage the daily services of dietary such as; making certain the patients diets are as ordered and meeting the nutritional needs of the patients.


30420

Based on record review and interview the hospital failed to ensure the dietary staff were competent in their assigned duties as evidenced by lack of knowledge and training to perform the required task specific to meeting the dietary needs of the patients. Findings.

Review of the personnel records for S10DS revealed a job description for the dietary cook, signed/dated 6/11/13. Continued review of the personnel record for S10DS revealed an annual general orientation checklist dated/signed on 6/12/13 by S10DS and S11DM as the supervisor. There was no documented evidence of documented training specific to the dietary department, no supervisor training, and no job description for Dietary Supervisor.

A stack of clipped papers were presented to the Surveyors as the personnel file for S12DW by S15HR on 1/9/14 at 5:00 p.m. after a 3rd request was made for the personnel file for S12DW.

Review of the personnel papers (paper clipped together) presented by S15HR as being the personnel papers for S12DW revealed a job description/performance evaluation for dietary cook with prepared by, date, approved by, and date were all blank was noted. A review of the job description/performance revealed that it was signed by S12DW on 7/22/13. Further review of the personnel papers presented revealed no documented evidence that the job description and performance evaluation were discussed with S12DW as evidence by the top portion of the form left blank. Continued review of the personnel papers presented for S12DW revealed no documented evidence that a general orientation checklist was completed as evidence by none presented by S15HR. There was no documented evidence of documented training specific to the dietary department in the personnel papers presented to the surveyor, no supervisor training, and no job description for Dietary Supervisor.

In a face-to-face interview on 1/8/14 at 10:00 a.m. S10DS, indicated the training for a new dietary workers included following another worker around on the day shift for 1-2 days, and after that time the employee will follow S10DS for the remainder of the week. S10DS stated the new dietary worker will be trained on the evening shift on week 2, again following another dietary worker around. S10DS indicated no formal training are offered to new dietary employees, which focus on the dietary department. According to S10DS she was never given a job description of what her duties or responsibilities are as a Dietary Supervisor. S10DS indicated she made requested (not certain of dates) and voiced concerned to S11DM and S2CCO about the duties and responsibilities in dietary. According to S10DS, as of this date, there have been no job description and/or specific training presented to her by S11DM or any other staff member from Campus A or B.

In a face-to-face interview on 1/8/14 at 1:10 p.m. S11DM, indicated that all new dietary employees attend an orientation with S15HR and there is no formal orientation job specific to dietary. According to S11DM new dietary employees are trained by S10DS. S11DM indicated that S10DS had no formal food service training or attended any approved food service training. According to S11DM, S10DS training and orientation to the dietary department was provided by S11DM.

Based on observations and interviews the hospital failed to ensure that all patient supplies were maintained at an acceptable level of safety and quality as evidenced by:
1. Not having a system in place to ensure periodic maintenance and testing were done on medical equipment;
2. Having expired patient's medical supplies in central supply, the supply closet and in the procedure room;
3. Having a broken bed in a patient's room, which was deemed ready to accept a new admission, having broken equipment in the clean equipment storage room ready for patient use and having a central telemetry system, which was not functioning,
4. Having bed linen with multiply holes on three beds, which were deemed ready for a patient admission, out of three beds observed.(Patient room cc,dd,and ee).

Findings:

1. Review of the hospital's policy on Medical Equipment Plan, Policy Number III.P.16.74, revealed in part, "...F. Inspection, Testing, Maintenance i. The designated maintenance individual has overall reasonability of the strategy and inspection, testing and maintenance of the equipment in the medical equipment program. The equipment inspection, testing and maintenance schedule is assessed to minimize risks. Recommendations of the designated maintenance individual are based on manufacturer's criteria, risk levels and current organizational experiences... All medical equipment included in the program is inspected before initial use and is inspected, tested and maintained according to the approved strategy.
ii. Outside contractors are used for most inspection, testing maintenance of medical equipment.

Review of the hospital's policy on Bio Medical Equipment Inspection, Policy Number: III.P.16.75 revealed in part, "...All biomedical equipment shall be inspected yearly and tagged with an appropriate label... The Director of Plant Operations/Designee shall keep a list of the biomedical equipment. The list shall include:
A. Equipment name
B. Equipment identification number/serial number
C. Date of initial inspection
D. Date of yearly service inspection
3. All documentation from the certified inspector shall be maintained in the EOC Manual.
6. All biomedical/electrical equipment shall be safety checked by the facilities department before being placed in service. This includes rental, personal, patient, and hospital owned equipment..."

1. An observation was made on 1/8/14 at 1 p.m. in the clean supply closet of a suction machine with a sticker for date of service due of 12/12, 5 nebulizers in boxes with no inspection stickers, EKG (Electrocardiogram) machine with a date of service sticker of 12/12, and a defibrillator on the hospital's crash cart with a date of service due sticker of 7/13. All observations were verified by S1CEO (Chief Executive Officer).

Review of the contract company's service history for medical equipment, presented to the surveyor by S5PO (Director of Plant Operations and Security), revealed 59 pieces of medical equipment past due for service out of a total of 96 pieces of medical equipment.

An interview was conducted with S1CEO on 1/8/14 at 1:55 p.m. He reported the information provided by the contract company's service history was incorrect. He further reported the contract company places the service history on their website, but their website is not up-to-date. When questioned if a system was in place to track when the medical equipment was due for inspection and service, he stated there was currently not a system in place, but the hospital was trying to get all the equipment inspected in January 2014.

2. An observation was made in central supply on 1/6/14 at 10:45 a.m. of approximately 20 biopsy punches that expired in 1/11 and 20 more that expired in 2/11. Two (2) boxes of suction connection tubing were expired, one in 8/2008 and the second box in 10/2006. Also there were approximately 25 stylets used for ETT (Endotracheal tubes) intubation that expired in 10/13 and 3/13. These observations were confirmed by S24CEO.

An observation was made on 1/6/14 at 11:15 a.m. in the procedure room of 4 bottles of packing strip that expired in 10/09, 1 bottle that expired in 11/09, and another bottle that expired in 3/10. Also in the procedure room there was an expired 3.5 oz (ounce) bottle of Gebauer Ethyl Chloride. The expiration date was listed as 10/12. These observations were confirmed by S2CCO.

An observation was made on 1/6/14 at 11:30 a.m. in the supply closet of 15 Xerform gauze that expired in 10/12, 1 1000 ml (milliliter) bottle of Acetic Acid that expired in 1/12, and 11 urinary bags that expired in either 9/13 or 10/13. These observations were confirmed by S24CEO (CEO in training).

3. An observation was made on 1/6/14 at 11:30 a.m. in room cc, which was a room deemed ready of an admission, of a hospital bed with a left broken side rail. The observation was confirmed by S24CEO (CEO in training).

An observation was made on 1/8/14 at 1 p.m. in the clean supply closet of a suction machine with a broken ground plug. The observation was verified by S1CEO.

An observation was made on 1/8/14 at 10:00 a.m. of the hospital's central telemetry monitor in the nurses' station not functioning.

An interview was conducted with S32LPN on 1/8/14 at 10 a.m. She reported the central EKG monitor had been broken for 3 weeks.

A phone interview was conducted with S31RN on 1/9/14 at 1:30 p.m. She reported the central EKG monitor had been broken for a few weeks.

An interview was conducted with S2CCO (Chief Clinical Officer) on 1/8/13 at 10:45 a.m. She reported the central telemetry monitor has only been broken for a few days. When documentation of a work order was requested on the monitor, none could be provided.

4. An observation was made on 1/6/14 at 11:30 a.m. of 3 patients' rooms, which were deemed ready for an admission: room cc, room dd, and room ee. Room cc's bed was made with linen, the bottom sheet had 8 holes in the sheet. Room dd's bed was made with linen, the bottom sheet had 3 holes in the sheet. Room ee's bed was made with linen, the bottom sheet had a hole in the sheet. The observations were confirmed with S24CCO.

An interview was conducted with S2CCO on 1/6/14 at 1 p.m. She reported the hospital has been having trouble with their contracted linen service sending the hospital linens with holes in the sheets.










30420

Based on observations and interviews the hospital failed to ensure the infection control officer implemented measures to prevent and control infections and communicable diseases as evidence by failure to maintain a sanitary hospital environment. Findings:

Review of the hospital's policy for Cleaning Central Supply, Policy Number, III.Q.17.03, revealed in part, "...The ES (Environmental Science) personnel will clean the Central Service Department on a daily basis...2. Damp dust counter, furniture, telephones and receivers, with a hospital approved germicidal solution...Vacuum all carpeted floors according to procedure..."

Review of the hospital's policy for Cleaning Doors and Door Jams, Policy Number: III.Q.17.05, revealed in part, "...To ensure proper cleaning of doors and door jams...5. Wet a cleaning cloth in the cleaning/germicidal solution and wring it out. Wipe all surfaces of the door including the door jamb, starting at the top and working down to the floor..."

Review of the hospital's policy for Cleaning Occupied Rooms, Policy Number III.Q.17.12, revealed in part, "...Dust all fixtures, ledges and surfaces in the room..."

An observation was made on 1/6/14 at 10:30 a.m. of room aa's and bb's room doors and bathroom doors having approximately 20 areas with old tape residue on the doors. The tape residue had a dark substance stuck to the residue. The observation was confirmed by S24CEO (Chief Executive Officer in training).

An observation was made on 1/6/14 at 10:45 a.m. in central supply of dust on the shelving where the supplies were located, debris on the floor, 2 phone outlets crusted with a dark brown substance, and a sink with a whitish colored substance around it. Stored in the cabinet under the sink were 5 containers of Force Full Wipes and 7 containers of MicroKill. In the hallway in front of central supply was a grate on the floor with numerous piles of dust under the grate. These observations were confirmed by S24CEO.

The following rooms, Room cc, dd, and ee were deemed ready for an admission by S1CEO and S24CEO.

An observation was made on 1/6/14 at 11 a.m. in room cc, which was deemed ready for a patient admission, of the room's bathroom vent caked with a dark substance. Also on the floor in the room was an orange substance in approximately 5 places that were able to be removed with a wet paper towel by the surveyor. These observations were confirmed by S24CEO.

An observation was made on 1/6/14 at 11:05 a.m. in room dd of tape residue on the bathroom door, and a pile of dust on the trash can lid. These observations were confirmed by S24CEO.

An observation was made on 1/6/14 at 11:10 a.m. in room ee of a blue substance splattered on the ceiling above the bed, old tape residue on the bed, and the baseboard behind the toilet was missing. These observations were confirmed by S24CEO.

An observation was made on 1/7/14 at 1 p.m. of three of the hospital's medicine carts with adhesive glue stuck to all the drawers and a dark brown substance stuck to the adhesive. The observation was confirmed by S1CEO.

An observation was made on 1/8/14 at 1:35 p.m. of the crash cart with dust on top of the cart and the defibrillator with a dried substance on the screen. The observation was confirmed by S1CEO.

An observation was made on 1/6/14 at 12 p.m. in the dialysis room of dried droplets of a substance on the lid of the trash can, a dried substance around the sink and on the countertop and dust on the shelving with the dialysis supplies. The observation was confirmed by S24CEO.

An observation was made 1/6/14 at 12:20 p.m. of a clean equipment storage room that included a Bladder (Ultrasound) Scanner with a soiled display face and dark and dusty substance noted around the control buttons. An electrocardiogram machine was noted to have old, darkened adhesive on the handle and a clear dried substance in a drip pattern on top of the machine. In an interview at the same time, S1CEO confirmed the above findings and verified that both machines were currently used on patients.

Review of the policy titled Sanitation and Infection Control presented by S3ACCO as being current read in part; Procedure: 1. The Dietary director, clinical dietitian and lead cook are responsible for supervising sanitation, housekeeping procedures.......... maintain an environment that is safe for the storage, preparation and serving of food.....

Review of the policy titled Equipment and Cleaning Procedures presented by S3ACCO as being current read in part; 1. A weekly cleaning schedule is developed for the equipment.

Observation at Campus A on 1/6/14 at 11:30 a.m. revealed S12DW, preparing the lunch meal picking up a pork chop with her gloved hand, placed the meat on a plastic styrofoam lid container on a food scale, removed the meat with the glove hand, place 2 scoop of rice on the plate, used her hands to place the rice in a foam ball on the plate, reached over the gravy on the steam table (with her arms over the gravy) to place beans on the rice, touching the inside of the plate with her thumb. S12DW touched the counter top, the food cart, the serving utensil, and then removed a plate from the warmer without changing her gloves. S7RD was present during the observation and was not aware of the break in infection practice by S12DW while preparing the food tray.

Observation at Campus A on 16/14 at 11:35 a.m. revealed posted menus suspended from the ceiling over the stainless steel table next to the steam line and was noted to have layers of thick dark brown particles on it. The plastic menu covers were noted to have green, yellow, and brown dried substances on them. A large gray uncovered trash can with trash was noted in front of the cooler. There were 18 opened containers of spices not dated with dried food particles on the outside of 14 of the containers. A can opener was noted to have dried food particles on the blade. Three pitchers on a stainless steel table was noted to have a powdery white substance in each. The pitchers were removed by S13DW, washed, with the substance easily removed.

In a face-to-face interview on 1/6/14 at 11:35 a.m. S7RD, confirmed that the trays were prepared by S12DW without maintaining Infection Control Practice. According to S7RD, S10RS was off and S11DM was at Campus A and there was no one to supervise the dietary workers at this time. S7RD indicated she was the clinical dietitian and S11DM was the supervisor of the Dietary Department. S7RD confirmed the above findings.

Observation on 1/6/14 at 11:40 a.m. revealed, S13DW loaded the dishwasher and did not log the temperature. S13DW visually looked at the gauge of the dishwasher. Further observation in the area revealed no documented temperature for the dishwasher or the sanitizer. S7RD confirmed that there was no posted log for the dishwasher or the sanitizer.

In a face-to-face interview on 1/6/14 at 12:30 p.m. S13DW, indicated that the temperature was not documented. According to S13DW the temperature is checked by looking at the gauge.

In a face-to-face interview on 1/8/14 at 1:10 p.m. S11DM, indicated that there was no documented logs of the temperature for the dishwasher or sanitizer. S11DM indicated the food temperature were not recorded nor was the cleaning of the equipment .

Observation at Campus B on 1/7/14 at 10:40 a.m. revealed a storage room with 4 SCD(compression stocking) pumps, 1 back up mechanical ventilator covered with a plastic cover, 2 feeding pumps, 2 IV (intravenous) pumps, bumper pads, wheel chair, leg lift, and a foot board stored in a divided section located near the door. In a section located in the back of the room there was 2 bags of biohazard waste and 5 bags of soiled linens.

In a face-to-face interview on 1/7/14 at 10:40 a.m. S8RN, indicated the equipment was cleaned and ready for patient use and was stored in a dirty area. According to S8RN the hospital was aware that clean equipment was stored in a dirty area. S8RN indicated that the issue with the storage was being addressed by the QA (Quality Improvement) committee.

Review of the policy presented by S8RN as being current titled Cleaning of non-critical, reusable patient care equipment stated in part; M. 5. Glucometers must be cleaned between each patient or before going into storage.

Observation on 1/7/14 at 1:30 pm. of glucometer #1 revealed a red substance noted on the front portion of the machine. The substance was noted to be easily wiped off by S8RN. Observation of glucometer #2 revealed a red stain in the replacement case. The red substance was noted to wipe off easy by S8RN.

In a face-to-face interview on 1/7/14 at 1:35 p.m. S8RN, indicated that the glucometer does not touch the patient; therefore it does not have to be cleaned between patients. S8RN reported that she does not clean the glucometer between patient use.

Observation of the medication room at Campus A on 1/9/14 at 10:55 a.m. revealed a thick gray layer of dust noted on top of the medication storage refrigerator A large thick layer of lint with strains of dark hair noted in the bottom area of inside door. Dust was noted on the shelves of the doors. The following was noted in the refrigerator on the shelves: 5 vials of flu vaccines (1) opened, tuberculosis solution (1) vial opened, Humulin-N (1) vial not opened, liquid Vancomycin (1) opened bottle, Normal Saline irrigation solution (1) 1000 ml. (milliliter), Keppra (1) vial, Thrombin (2) vials, and 2 boxes of Racepinepherine. The dust and particles were easily removable as evidence by S20RN passing a damp paper towel on the bottom shelf of the refrigerator. Observation of 5 large blue totes on the counter top in the medication room with Clinimix (Parenteral) were noted to have white powdery substance on the top and brown, black, white matter in the inside of the totes. The container space was caked with a white and brown substance under the bottom of the last two totes.

Observation of the lab refrigerator at Campus A located in the laundry room on 1/9/14 at 11:10 a.m. revealed, a large amount of ice on the freezer door (not able to open) and a large amount of dust noted on the shelves of the refrigerator. The top shelf was noted to have a large, dried, yellow stain and a red stain on the bottom shelf

In a face-to-face interview on 1/9/14 at 11:15 a.m. S20RN, confirmed all of the above findings and that the Infection Control practices were not maintained. According to S20RN she is not sure who is responsible for keeping these areas clean.

In a face-to-face interview on 1/9/14 at 11:30 a.m. S3ACCO, indicated that he was the Infection Control Officer and it is the responsibility of all employees to follow Infection Control Practice at all times. According to S3ACCO the nursing staff are responsible for cleaning the medication and laboratory refrigerators. S3ACCO reported that all areas are monitored quarterly for cleanliness and safety.




30420





31206

Based on record review and interview the hospital failed to have a respiratory therapist and/or have competent nursing staff to perform respiratory related physician's orders at Campus A.
Findings:

An interview was conducted with S1CEO (Chief Executive Officer) on 1/9/14 at 10:10 a.m. He reported at Campus A the nurses do the respiratory nebulizers, oxygen therapy, BIPAP(Bilateral Positive Airway Pressure), and incentive spirometry for the patients. He further reported there was no respiratory therapist assigned to Campus A.

An interview was conducted with S3ACCO (Assistant Chief Clinical Officer) on 1/9/14 at 3:30 p.m. He reported no competencies have been conducted with the nursing staff for respiratory related physician's orders since the previous respiratory therapist left the staff in 2012.

Review of the personnel files for S18RN, S20RN, and S31RN revealed no yearly competencies documented for respiratory related skills.



30420

Based on observation and interview the hospital failed to ensure that changes made to the current posted menu was approved as evidence by changes made to the lunch meal on 1/6/14 without approval of S7RD or S11DM. Findings.

Observation on 1/6/14 at 11:30 a.m. revealed the lunch served from the steam table was suppose to be the lunch on the posted lunch menu. The food on the steam table was as follows; red beans, sausage, rice, turnip greens, yellow cake with whip topping, and a roll. Review of the posted lunch menu revealed chocolate chip cookies and cornbread were to be served to the patients on a regular diet and 2 Gm (gram) Sodium diet. Pineapple mousse and a roll were to be served to the patients on therapeutic diets.

In a face-to-face interview on 1/6/14 at 11:30 a.m. S7RD, confirmed there were substitution/changes made to the lunch menu. According to S7RD the menus are approved by her, and changes or substitution to the menu are to be approved by S11DM or S10DS. A policy was requested for substitution or changes made to posted menu.

In a face-to-face interview on 1/6/14 at 12:00 p.m. S12DW, indicated that the reasons the substitution were made was because there was not enough cornbread mix for the lunch meal and there was no chocolate chip cookie mix available. S12DW indicated that, S11DM(Hospital A) and S10DS(day off) were both not available at the time and the patients had to eat. S12DW indicated that she cooked what was available. S12DW reported she had never been informed by S11DM or S10DS to get approval or to notify S7RD when they were not present. S12DW indicated that S11DM only visits 2-3 hours weekly and she was not such on how to contact S11DM at Hospital "A" if needed, because S10DS handles everything at Campus A.

In a face-to-face interview on 1/8/14 at 10:00 a.m. S10DS, indicated all changes made to the menu are to be approved before preparing the meal by S11DM or S10DS. S10DS reported the substitution to the menu was not needed as there was enough cornbread mix and chocolate chip cookie mix for the scheduled meal when checked upon S10DS's return to work on 1/7/14. S10DS reported that S12DW is not always aware of what is on hand and available or what to do. According to S10DS, a disciplinary action form was filled out and completed on 1/7/14 for the substitution to the diet without approval. A second request was made for a policy on substitution or changes made to posted menu.

In a face-to-face interview on 1/8/14 at 1:10 p.m. S11DM, indicated that the menus are reviewed and approved by S7RD. S11DM stated that all substitution and or changes made to the posted menu must be approved by S11DM or S10DS. According to S11DM all substitution have to logged in on the food substitution log, which is located in the kitchen with the menus. S11DM indicated on 1/6/14, S10DS was off for the day; however S11DM was at Hosptial "A" and could be reached by telephone. S11DM indicated that S12DW should have contacted S11DM and did not.

Review of the policy titled "Nutritional Adequacy of Patient Menus" presented by S11DM on 1/8/14 at 2:15 p.m. as being current policy used at Campus A, read in part; 4. Menus will be reviewed, updated and approved by the Registered Dietitian.

Review of the food substitution log presented by S11DM on 1/8/14 at 2:15 p.m. revealed a column for supervisor/designee approval and a column for dietitian approval. The log revealed a total of 11 substitutions made between 7/19/13-11/10/13. Further review of the log revealed the columns for approval by the supervisor/designee and dietitian were blank on all 11 requests. There was no documented evidence that a substitution was made to the menu on 1/6/14 as evidence by no request for approval on the food substitution log.

In a second face-to face interview on 1/8/14 at 2:30 p.m. S11DM, indicated that the approval column should have been signed by S10DS or S11DM. S11DM offered no explanation or if S7RD approval was needed as stated in the policy titled Nutritional Adequacy of Patient Menus.




30420