HospitalInspections.org

Based on staff interview and facility document review, it was determined facility staff failed to ensure that performance improvement activities were adequately monitored to guarantee that all staff completed training and education to ensure implementation and sustainability of the facility's plan of correction.

Findings included:

The facility's plan of correction (POC) included education for all staff on updated policies, procedures, protocols, and changes in the facility's electronic health records (EHR), utilizing monitoring and analysis of data collected though medical record audits.

The POC evidenced that a new "Restraint Initiate" template was initiated on 7/10/19; however, staff training and education for the new template "would be completed by 8/311/19". The surveyor asked SM #1 to contact SM #16, IT Cerner expert, in order to determine the date that the restraint template was implemented.

On 9/24/19 at 1:00 p.m. SM #1, Nurse Manager stated "It's hard to educate everybody on three (3) shifts-we wanted to make sure everybody was trained (SM #13's name) did over 27 trainings. We talked to IT on 7/10/19. We sent emails, we don't get that many restraint patients. I was very present and reminded staff of the new template, training was ongoing".

SM #16, IT Cerner expert, was contacted by SM #1, Nurse Manager, to determine date that new restraint templates were implemented in the EHR for staff use. SM #16 responded vial email, and at 1:05 p.m. on 9/25/19, SM #1 advised the surveyor that "The restraint template was implemented on Cerner 7/10/19. SM #1 added "I might have sent an email to nurses so they wouldn't be surprised when they saw it...".

On 9/24/19 at 1:25 p.m. Staff Member (SM) #1, Nurse Manager told the surveyors that "An email went to all nurses regarding the new restraint template on 7/11/19; because we know all nurses don't open and read the email, we also had the trainings. What's why we made the trainings mandatory, but there's no sign in sheet. The trainings didn't start until August".

A discussion regarding ongoing monitoring and audits of restraint documentation was held with SM #2, Quality Director, on 9/25/19 at 2:55 p.m. SM #2 stated "We audit the same records as (SM #1's name) for restraints. I presented the information to the medical executive committee".

SM #1 added "I looked at restraint orders, and they looked okay. I looked that nurses completed the template, and checked to make sure they had behaviors marked. I don't do the physician part. I'm only one of me. When the nurse calls the physician, I felt like the nurse and doctor were in agreement".

SM #2 stated "At the initial meeting, when we discussed how we were going to do the audits, SM #15, the Director of Physician Services, said (he/she) would do the physician restraint audits, then said (he/she) didn't know how.
(SM #4's name) was having weekly call meeting updates with SM #15 to go over everything, and discuss progress. I tracked and asked everyone for the information, I did my best".

When I realized that nobody was looking at the physician restraint documentation, I started doing it on 9/1/19. I didn't say what date we were going to start. When we realized that physicians weren't documenting rational/reason/behaviors for restraints, we asked SM #19, to be the physician champion for IT. I went to the physician meeting and told them they need to document the reason for restraints, I had to talk to them again and re-educate, but I didn't document that".

On 9/25/19 at 3:10 p.m. a discussion was held with SM #4, the Chief Operating Officer (COO), who stated "I met with the doctors (The CMO's (Chief Medical Officers), my peers) before a meeting, by phone (Tuesday July 22), and prepped them for the physician's meeting. I told them what they needed to train on, and went through about nine (9) items. (SM #2's name) had a demonstration to provide, a slide deck, which was to prompt discussion".

On 9/24/19 at 11:30 a.m. SM #1, Nurse Manager, was interviewed related to education and training of secretarial staff related to collecting information regarding advanced directives and patient representative's information. SM #1 stated "They did receive training, I guess I failed to record it, but they were trained. I told them to look for information that liaisons asked for-I talked to them and sent emails. The secretaries are the biggest link between the liaisons and nurses, so I was very specific with the secretaries. I have another audit with secretaries that (SM #2's name) doesn't have. I've been working hard, I thought I did everything I needed".

The POC evidenced that Staff Member (SM) #17, the Chief Nursing Officer (CNO), SM #1 Nurse Manager (NM), and SM #13, Nurse Coordinator and Staff Development would review the fall safety protocol, and educate staff . The facility failed to provide evidence that all staff reviewed the updated policies and procedures (P&P).

On 9/24/19 at 11:00 a.m., SM #1, Nurse Manager told the surveyor that "Staff meetings are not mandatory, a lot of people don't come. Staff meetings are done three (3) times during the day at 7:30 a.m., 2:30 p.m., and at 3:30 p.m. Those that can't attend are emailed "FYI" information. Information is covered in many other ways-emails, one-on-one training; we have educated people in multiple ways".

The surveyor was provided with a sign in sheet for the August 2019 Nursing Staff Meeting which included nineteen (19) signatures, all dated 8/28/19.

Staff Member (SM) #13, Staff Development Coordinator, was interviewed on 9/26/19 at 1:00 p.m. related to how education was provided to staff. SM #13 stated "The power-point was provided to staff". The surveyor noted that documentation at the beginning of the power point was for Staff to read policies and procedures. The surveyor asked SM #13 how the facility ensured staff read the updated policies; he/she stated "Policies are on the intranet, in a policy book in the report room that is kept current, and there is a bulletin board with updated policies, in the report room. Staff signed off that policies were reviewed". SM #1, Nurse Manager, added "Policies are put on the bulletin board for one month after the policy has been updated, and there is a signature page on the bulletin board. (SM #18's name) is in charge of the policy book, it is not always up to date (he/she) has been off".

On 9/26/19 at approximately 1:15 p.m., the surveyor asked the chart navigator go to the policies on the facility's intranet, and noted that the Infection Control Risk Assessment Policy #401, was dated 1/2019, which was not current. Based on the written documentation provided to the surveyor, the infection control risk assessment was revised 7/9/19. At 1:20 p.m. on 9/26/19, SM #2, Quality Director, stated "Yes, the policy should have been updated on the computer when the risk assessment was revised because the risk assessment is included as an attachment to the policy".

After reviewing the policies on the intranet, the surveyor asked to go to the report room to review the copy of the policy and procedure manual and the bulletin board. An audit of the manual revealed that it was not up to date with the most current policies and procedures.

The policy update bulletin board included a sign off sheet titled "CMS Survey June/July Policy Updates 2019; Monthly Policy and Procedure Review Signature Log: Nursing Policies Reviewed: 115 Blood and Blood Component Administration; 148 Sage Warmer, cleaning and maintenance; 180 Hazardous, Cytotoxic, and Reproductive Risk Drug Handling; 227 Orders: Wound Care Treatments; Written/Verbal/Telephone/Medication; 215 Jet Aerosol/Jet Nebulizer. There were eight (8) signatures on the page with dates ranging from 8/13/19 to 9/21/19.

Another page titled June/July's Policy Updates 2019 Monthly Policy and Procedure Review Signature Log Nursing Policies Reviewed: 110 Oral Care Deficit Protocol; 145 patient Warming K-Pad/TPump; 163 Urinary Catheter; 216 Passy Muir Valve; 224 Halo vest: Care of Patient; 229 Negative Pressure Wound Therapy; 400 Agency Personnel Assignments; 401 Assigning Care of the Patient. There were seven (7) signatures on the page with dates ranging from 8/13/19 to 9/12/19.

On 10/1/19 the surveyor was given two documents: 1. July/August Policy Updates 2019 Monthly Policy and Procedure Review Signature Log Nursing Policies Reviewed: 227 Wound Care Treatments; 130 Dialysis Apheresis Catheter; 154 Percutanelusly inserted Tube Dislodgement; 215 Jet aerosol/jet nebulizer; 147 Specialty Beds, Procurement & Selection; 104 Documentation. This page included signatures of 59 Staff Members with dates ranging from 9/26/19 to 9/30/19, after the AOC date of 9/20/19.

The surveyor was also provided with a document titled "July Policy Updates 2019 Policy and Procedure Review Signature Log Administrative Policy Reviewed: 524 Patient Fall Program for Inpatient; 521 Suicide Alert. There were fifty-nine (59) Staff Member signatures with dates ranging from 9/26/19 to 9/30/19, after the AOC date of 9/20/19.

The facility failed to provide evidence to support that the plan of correction had been fully implemented by the allegation of correction date (AOC) of 9/20/19.

Concerns were discussed with SM's #1, 2, 4, and 17 multiple times throughout the course of the validation re-visit survey related to lack of documented credible evidence which supported that the POC was fully implemented by the AOC date of 9/20/19. Those concerns were addressed again with SM's 1, 2, 4, and 17 again on 9/26/19 at
4:00 p.m.