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Based on record review and interview the hospital failed to appraise the qualifications and quality of care provided by medical staff at least every 24 months. This deficiency is evidenced by failure of hospital to perform evaluations of the quality of specific work, patient outcomes, and adherence to medical staff rules for 6 (S9MD, S10MD, S11MD, S12MD, S13MD and S14MD) of 6 reviewed medical staff files.
Findings:

Review of the Medical staff Bylaws revealed, in part, " the information and factors to be considered in evaluating a Member for reappointment and renewal of privileges or granting of additional privileges shall include, but not be limited to, the following 4.4.3.11- relevant specific information from hospital performance improvement activities , which is reviewed and compared to aggregate data where appropriate for comparison and evaluation of professional performance , judgment and skills" and "Periodic re-determination of privileges, including either the increase or curtailment of privileges, shall be based on direct observation of care provided; review of the records of patients treated in this and/or other hospitals; Medical Staff evaluation of the member's participation in the delivery of medical care; results of performance improvement measurements and monitoring; and utilization review or other factors that may affect the ability to provide safe, quality care."

Review of the credentialing files for S9MD, S10MD, S11MD, S12MD, S13MD and S14MD failed to reveal periodic appraisals of the quality of care and adherence to medical staff policies and procedures for each of the licensed providers.

In interview on 12/07/2022 at 9:00 a.m., S2RN verified the hospital did not appraise the performance and quality of patient care provided by the medical staff.

Based on record review and interview the hospital failed to ensure nursing staff followed the policies and procedures of the hospital. This deficiency is evidenced by failure of the nursing staff to perform a thorough skin assessment on each 12 hour shift in 1 (#12) of 30 (#1-#30) medical records reviewed.
Findings:

Review of hospital policy CSM-114, "Assessment Reassessment," effective 12/2012 and last revised 11/2022, revealed in part, "B. Nursing Re-assessment- a. Re-assessments are performed at a minimum of every twelve (12) hours (each shift) and prn according to patient's change in condition."

Review of the electronic medical record for Patient #12 navigated by S8RN revealed the patient was admitted on a Friday, 12/02/2022 at 6:56 p.m. with a diagnosis of disruption of surgical wound. The initial nursing assessment revealed the skin was "intact" and "WNL" and noted an abdominal wound which was not described further. Skin assessments were performed by the same nurse and one other nurse each 12 hour shift throughout the weekend and the skin assessment remained WNL with no associated erythema.

Further review of the medical record revealed Patient #12 was evaluated by the wound care nurse on 12/05/2022, the Monday following admission. The patient was noted to have a Stage 2 sacral decubitus and an open left heel lesion measuring 3.5 X 2 cm and described as "deep tissue injury." The patient was also noted have the open abdominal incision on admission.

In interview on 12/06/2022 at 10:55 a.m., S8RN verified the skin lesions were probably missed by the nurses providing care over the weekend. S8RN verified the nursing staff is responsible for assessing the skin each shift and providing wound care on weekends.

Based on record review and interview the hospital failed to ensure nursing staff administered drugs and biologicals according to hospital policy and accepted standards of practice. This deficiency is evidenced by 1) failure to perform an assessment for effectiveness after the administration of prn medication in 3 (#1, # 2, #5) of 5 (#1-#5) medical records reviewed for re-assessment; 2) failure to document the daily volume intake in 1 (#9) of 30 (#1-#30) total records reviewed; and 3) failure to document administered antibiotics in the medication administration record (MAR) in 1(#13) of 30 (#1-#30) total records reviewed.
Findings:

1) Failure to perform an assessment for effectiveness after the administration of prn medication.

Review of the hospital policy CSM-102, "Pain Management," effective 01/2018 and last revised 11/2022, revealed in part, "Pharmacological treatment of pain as ordered by the physician will be administered in dosage and timeframe specified. The caregiver will assess the effectiveness of the medication (within 30 minutes for IV medication, 60 minutes for IM, PO, and PR medications.) If the patient is not relieved or does not indicate verbally or non-verbally that pain is at a tolerable level, the physician may be notified."

Review of hospital policy CSM 245, "Medication Administration Record," effective 01/2018, revised 11/2022, revealed in part, "Indicate PRN and non-reoccurring doses in the appropriate space. Explain (in the nurse's notes) the reason for each PRN, non-recurring or omitted dose (including refused doses). Note the patient's response to PRN medications."

Patient #1
Review of the electronic orders for Patient #1 navigated by S8RN revealed on 11/29/2022 an order was placed for "Oxycodone HCL/ Acetaminophen (Percocet) 10 mg/ 325 mg. Give one tablet by mouth every 6 hours PRN. High Alert Medication. Look alike/ sound alike. Indication: pain."

Review of the medication administration record revealed the medication was administered on 12/30/2022 at 10:26 p.m. and the nurse failed to enter a re-assessment within the next hour.

Patient #2
Review of the electronic orders for Patient #2 navigated by S8RN revealed on 12/03/2022 an order was placed for "Morphine Sulfate (Duramorph) 2 mg/mL Inject 1 mg (0.5 ml) IV push every 6 hours PRN. High Alert pain Medication. Look alike/ sound alike. Indication: pain."

Review of the medication administration record revealed the medication was administered on 12/03/2022 at 8:14 p.m. and assessment for effectiveness was performed on 12/04/2022 at 4:55 a.m.

Patient #5
Review of the electronic orders for Patient #5 navigated by S8RN revealed on 11/08/2022 an order was placed for "Acetaminophen 650 mg/ 20.3 mL by mouth every 6 hours PRN. Do not exceed 4 GMS in 24 hours from all sources. Indication: fever."

Review of the medication administration record revealed the medication was given 11/22/2022 at 2:03 p.m. and 11/26/2022 at 2:58 p.m., with no documentation of assessment for fever after both administrations.

During the review of the electronic medical records performed on 12/05/2022 between 1:15 p.m. and 3:45 p.m., S8RN verified nursing staff failed to re-assess the patient after the administration of prn medication. S8RN verified all patients who receive prn medication are to be assessed for effectiveness even if the medication is not for pain.


2) Failure to document the daily volume intake

Review of the electronic medical record for Patient #9 navigated by S8RN revealed the patient was admitted on 09/29/2022 with a diagnosis of acute respiratory failure, urinary tract infection, and Stage 3 sacral decubitus.
Review of the physician's orders revealed Patient #9 had an order placed 09/30/2022 for "Tube Feeding Continuously, Request Type: Routine, Tube feeds: Nepro, Route: PEG Tube, bolus/ continuous: CONTINUOUS, Rate (mL/hr): 50."

Review of the intake/ output record for Patient #9 revealed no recorded intake on 12/02/2022, 12/03/2022, and 12/05/2022.

In interview on 12/06/2022 at 9:25 a.m., S8RN verified the tube feedings should have been documented on the intake/ output record.

3) Failure to document administered antibiotics in the medication administration record.
Review of hospital policy CSM 245, "Medication Administration Record," effective 01/2018, revised 11/2022, revealed in part, "Persons who administer medications shall record the administration in the medication administration record (MAR)."

Review of the electronic medical record for Patient #13 navigated by S8RN revealed the patient was admitted on 11/15/2022 with a diagnosis of osteomyelitis.

Review of the orders for Patient #13 revealed an order placed on 11/16/2022 for "Nafcillin Sodium IVPB (UNIPEN,) Infuse 2 grams over 1 hour intravenously every four hours, infuse at 100mL/hr; stop 12/21/2022. Indication: Staphylococcus aureus osteomyelitis."

Review of the medication administration record revealed no documentation the medication was administered on 11/17/2022 four hours after the 1:36 p.m. dose.

Review of the nurse's notes revealed a note from 11/17/2022 at 6:49 p.m. "IV abx in progress."

In interview on 12/06/2022 at 11:20 a.m., S8RN verified administered medication should be documented in the medication administration record.

Based on record review and interview the hospital failed to ensure each patient's medical record contained documentation of all care provided while admitted to the hospital. This deficiency is evidenced by 1) failure to document procedures performed as outpatient at another hospital in the medical record for 1 (#8) of 1 reviewed medical record with an outpatient procedure; and 2) failure to retain previously revised versions of each patient's care plan.
Findings:

1) Failure to document procedures performed as outpatient at another hospital in the medical record.

Review of the electronic medical record for Patient #8 navigated by S8RN revealed the patient was admitted on 01/16/2022 with diagnoses of acute respiratory failure, hypoxia, and pulmonary edema. Patient #8 was still an inpatient at the time of review on 12/05/2022.

Review of the physician's orders for Patient #8 revealed orders placed on 11/17/2022, 11/18/2022, and 11/21/2022, for a thoracentesis to be performed as an outpatient at Hospital "B" while the patient was admitted to the surveyed hospital, Hospital "A".

Further review of the medical record failed to reveal the reports from the procedures that had been performed more than 2 weeks prior to the medical record review.

In interview on 12/06/2022 at 8:20 a.m., S15HIM verified the reports for the procedures were not in the medical record for Patient #8. S15HIM also verified the reports had to be retrieved from the electronic medical record at Hospital "B." S15HIM indicated the documents are usually printed from the medical record of Hospital "B" after discharge from hospital "A" and then uploaded into the medical record at Hospital "A" before the record is closed.

2) Failure to retain previously revised versions of each patient's care plan.

Medical record review for the selected patients revealed the current electronic medical record system only allowed the user to view the current multidisciplinary plan of care, the dates it was modified and the name of the person who modified the plan of care.

In interview on 12/06/2022 at 2:00 p.m., S2RN verified the original care plan could not be viewed and if a specific date of modification was chosen, the user could not view the modifications specific to that date.

47397

Based on record reviews and interview, the hospital failed to ensure respiratory services were administered in accordance with hospital policy as evidenced by failure to document tracheostomy care for Patient #21.
Findings:

A review of the facility's Tracheostomy Care Policy on 12/05/2022 at 1:40 p.m. revealed, in part:
Purpose: To provide guidelines for performing tracheostomy care.
Policy, in part: All patients with a tracheostomy tube will receive trach care every shift and as needed using the following guidelines unless otherwise ordered by physician.
20. Tracheostomy care will be performed every shift.

A review of Patient #21's medical record on 12/06/2022 at 10:34 a.m. revealed documentation of tracheostomy care performed during the day shift, 12/03/2022 at 8:00 a.m. and during the day shift, 12/04/2022 at 7:44 a.m.
Further review revealed no documented evidence of tracheostomy care during the night shift between 8:00 a.m., 12/03/2022, and 7:44 a.m., 12/04/2022.

In an interview on 12/06/2022 at 10:39 a.m., S4RN verified that there is no documented evidence that tracheostomy care was performed during the night shift between 8:00 a.m., 12/03/2022, and 7:44 a.m., 12/04/2022.