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Based on observations, patient and staff interviews and record review, the hospital failed to ensure that the nursing staff provided adequate care to 18 out 38 patients reviewed. (Patients 1, 2,3,4,5,6,7, 9, 10, 12, 13, 14, 15,16,17, 18,23,37 and 38)
Findings:
1. Nursing Service combined the duties and responsibilities of the telemetry monitoring technicians and unit clerks into one position over a year ago. The practice resulted in the additional tasks performed by the telemetry monitoring technicians that contributed to delayed cardiopulmonary resuscitation of Patient 1. The practice could have a potential negative outcome to other 18 active patients on telemetry (Patients 18, 23, 7, 4, and 2). Refer to 0395.
2. Nursing staff did not follow the hospital policy and procedure to individualize the cardiac monitoring parameters for any of the monitored patients on the second and third floors (Patients 5, 7, 9, 10, 12, 13, 14, 15, 16, 17, 38). Refer to 0395
3. Nursing staff failed to consistently and completely measure and interpret the cardiac monitoring strips for five out of 11 active patients on telemetry monitoring in the second floor (Patients 1, 2,4,7 and 18,). Refer to 0392.
4. Patient 4 did not receive the breakthrough pain medication when the patient controlled analgesic (PCA, a device that delivers pain medication usually through Intravenous line by pressing a button) was not effective. The patient also had an inhaler at the bedside after surgery without a valid physician's order. Refer to 0405
5. Nursing staff failed to follow the physician orders for Patient 37. Refer to 0395.
These cumulative failures resulted in the hospital's inability to deliver patient care in accordance with the Nursing Services Condition of Participation.

Based on interview and record review, the facility failed to observe the rights of three (1, 3, 37) of 37 sampled patients by:.
1. Failure to make an attempt to notify the family of Patient 1 who was admitted on 1/ 2 /16 for low blood sugar levels that caused altered level of consciouness.Patient 1 stayed in the hospital for three days. On 1/5/2016 at 7:24 a.m., after an unsuccessful cardiopulmonary resuscitation, Patient 1 was pronounced dead. Four hours after the death, the hospital's Medical Director notified the brother that Patient 1 was in the hospital and died. The hospital had taken Patient 1's remains to the morgue before the family arrived. The family had questions about Patient 1's hospital stay, care and cause of death. As of 3/23/2016, Patient 1's brother said there has been no resolution to the questions raised by Patient 1's brother concerning the failure to notify the family about the hospitalization, plan of care and factors surrounding Patient 1's death.
2. Failure to provide Patient 3, who was deaf/mute (unable to hear and unable to speak) a qualified sign language interpreter from the early phase of the hospitalization. Patient was in the emergency room and admitted as an inpatient on 3/19/2016 diagnosed with an inflammation of the respiratory tubes (bronchial tubes that carry air to and from the lungs) and a new onset of high blood sugar at 335 mg (normal: 70-100 mg/dL). Patient 3 communicated with the staff by writing. While in the hospital, Patient 3 received Lantus by injection as scheduled twice a day and Lispro by sliding scale four times a day. These two drugs were new to Patient 3, given to manage his blood sugar. On 3/22/2106, the physician wrote a discharge order. Patient 3 requested to have an interpreter with the doctor before his release from the hospital.
On 3/22/2016, the hospital discharged Patient 3 without seeing an interpreter. The hospital failed to anticipate and provide the sign language interpreter during the early phase of hospitalization.
3. Failure to provide Patient 37 visual privacy during patient care. The hospital also failed to provide Patient 37 the requested complaint form to file a complaint in writing about the care she received from the emergency room staff.
Findings:
1. The SA (state agency) received a complaint on 3/9/2016 that the hospital failed to notify Patient 1's family about his admission to the hospital on 1/2/2016 and died on 1/5/2016. Review of the emergency records on 3/21/2016 confirmed the hospital admitted Patient 1 on 1/ 2 /16 due to low blood sugar levels that caused altered level of consciouness.Patient 1 stayed in the hospital for three days. On 1/5/2016 at 7:24 a.m., after an unsuccessful cardiopulmonary resusucitation, Patient 1 was pronounced dead. At 11:00 a.m., approximately four hours after Patient 1's death, the hospital's Medical Director notified the brother that Patient 1 was in the hospital and died. The hospital had taken Patient 1's remains to the morgue before the family arrived. The family had questions about Patient 1's hospital stay, care and cause of death.
The admission sheet dated 1/2/2016 did not have any information on the next of kin. The medical record did not show any attempt by the hospital staff to contact the board and care facility where Patient 1 lived or the family until 1/5/2016 when the patient died.
During a telephone interview on 1/27/2016 at 2:33 p.m., Family A said, Patient 1 had at least 11 previous admissions to the same hospital from 4/29/2014 to 7/242015; Family A visited the patient at least three times during the past admissions except for the most recent admission on 1/2/2016.
In an email correspondence received on 2/1/2016 at 2:03 p.m.,the Nurse Administrator indicated that Patient 1 had only one admission to the hospital. On 2/10/2016 at 8:00 a.m., the Nurse Administrator reported to the surveyor that Patient 1 had at least 11 admissions to the same hospital. There was an error with Patient 1's birthdate that triggered the creation of a new medical record number. The computer system failed to capture all of Patient 1's information from the previous admissions including the contact person in the creation of a new medical record number.
During an interview on 3/23/2016 at 1:00 p.m., Family A said, he could have been a resource for the hospital to obtain information about Patient 1 health information and medical history. Family A said the hospital had misinformed him about Patient 1's length of stay in the hospital; that Patient 1 died the next day after being admitted to the hospital. The medical records showed the hospital admitted Patient 1 on 1/2/2016 and died on 1/5/2016 at 7:42 a.m.
2. Review of the Emergency Physician's Dictated Report dated 3/20/16 showed Patient 3 was deaf and mute who complained of productive cough. Patient 1's girlfriend brought the patient to the emergency room on 3/19/2016 and provided information to the emergency room staff. Patient 3 communicated by writing with the staff. The admission chest x-ray showed clear lungs. The admission blood sugar was high at 335 mg/dL (normal range: 70-100 mg/dL) without any history of diabetes or history of diabetes in the family. The physician decided to admit Patient 3 because the high blood sugar could be a stress induced new onset diabetes.
The Physician's Orders and the Medication Administration Records dated 3/20/2016 to 3/22/2016 showed Patient 3 was on scheduled injectable insulin (Lantus) twice a day and on sliding scale insulin (Lispro) four times a day (dosing of insulin according to the results of fingerstick blood sugar). The Progress Notes dated 3/21/2016 at 8:27 a.m. showed the new onset diabetes was still not controlled. The physician increased the dose of Lantus.
During a patient interview at the bedside on 3/22/2016 at 1:30 p.m., Patient 3 showed his hand written request dated 3/22/2016 for an interpreter before his release from the hospital. The sheet of paper where Patient 3 wrote his request showed a note at 1:45 p.m. for the nurse to check, "however the doctor has been communicating is how he should communicate." At 2 p,m, the note indicated the doctor ordered to get an interpreter. The note indicated the staff was not sure what the staff would do because they have the line on language barrier but not for the deaf and mute. In the morning of 3/23/2016, the nursing staff told the surveyor Patient 3 was discharged on 3/22/2016, a Tuesday. Patient 3 did not see an interpreter before discharge.
Review of the hospital's clinical policy and procedure on Patient Rights titled, "Auxiliary Aids and Services for Persons with Disabilities," updated on 10/2013 showed Agency A ( a contracted agency to provide interpretive services in the hospital) was the primary means of communication and its business hours are from 8:00 a.m. to 5:00 p.m. Monday through Friday. The written policy provided the telephone number and extension of Agency A. The policy listed other names, services and secondary sources for interpretive services after hours.
3. During an interview on 3/24/2016 at 1:25 p.m., Patient 37 said the emergency room staff left an intravenous line (IV) on her arm when she was discharged on 2/13/2016. She returned to the emergency room the same day to have the IV line removed. Patient 37 said the emergency room staff removed the IV line in the lobby, by the reception desk. Patient 37 said she addressed her concerns about the care to Manager 1 and requested a complaint form. Patient 27 said, the Nurse Manager did not provide a complaint form. She contacted the Administrator A's office, but "No one got back to me."
During an interview on 3/24/2016 at approximately 2 p.m., Manager 1 said she has been employed in the hospital for about eight weeks and only knew about the complaint form after Patient 37's complaint. Manager 1 said she received an email from the administrative assistant of Administrator A about Patient 37's request for a complaint form on 2/16/2016. She also received a call on 2/19/2016 about Patient 37's request for a complaint form. Nurse Manager said she mailed the form on 2/22/2016, the following Monday.
On 3/24/2016 at 4:20 p.m., the Nurse Director said the hospital sent the complaint form by certified mail and had communicated with Patient 37 about the complaint form through an email. The surveyor provided the Nurse Director the opportunity and time to retrieve any record or receipt of the certified mail and email sent to Patient 37. The hospital did not find and provide any record or receipt that Patient 37 received the complaint form as of 3/24/2016, the exit date of the survey.



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Based on observation, interview and record review the facility failed to ensure patient safery when the monitor techs should perform continuous monitoring of the heart rhythm the patients on telemetry and performing the tasks of a unit clerk.

This failure contributed to the delayed and unsuccessful cardiopulmonary resuscitation of one patient (Patient 1) and placed all patients on telemetry at risk for delayed detection and interventions for life threatening abnormal heart rhythm.

Findings:

1. During an investigation of an entity reported incident of Patient 1, the SA (state agency) determined that the designated telemetry monitoring technician on 1/5/2016 at 6:35 a.m. was away from watching the telemetry monitor when Patient 1's heart rhythm converted to a very slow heart rate and life threatening dysrhythmia(abnormal rhythm) .The telemetry technician left the telemetry monitoring unit to make copies of the assignment sheets of the incoming day shift.

As a result, there was a delay calling the cardiopulmonary resuscitation team. The cardiopulmonary resuscitation was unsuccessful and Patient 1 was pronounced dead on 1/5/2016 at 7:42 a.m.

2. During separate observations on 3/21/16 at 8:40 a.m. 3/23/16 at 10:20 a.m. and 3/24/16 at 10:15 a.m.. the second floor telemetry nursing unit there six patients on telemetry. MT3, a telemetry monitoring tech, did the following tasks while her eyes were looking away from telemetry monitor:

a). Responded to three phone calls every one to three minutes. One phone call required MT3 to get up away from the desk and went to a patient's room.

b). Checked a patient's record for physician's orders. MT3 walked away MT3 walked away from watching the telemonitor and sent faxes and placed copies of the physician's orders to the nurses' communication boxes. During an interview at the time of an observation, MT3 stated the nurses would know if there would be new physician's order for their assigned patients. The telemetry technicians also watched the patients' heart rates and reported important changes to the licensed nurses.
c). Typed and entered data into the computer with their eyes away from the telemetry screens.
d). Answered inquiries from the physicians, nurses and visitors .
3. In an interview with MT3 on 3/21/16 at 9:00 a.m. she stated that the above additional duties made it sometimes "difficult" to concentrate and focus on the patient's cardiac monitor.

4. Review of the job description titled, " SLH Unit Clerk/Monitor Tech," revised on 3/23/2015 showed that the monitor tech performs clerical tasks directly and indirectly related to patient care and unit functioning. The job requires to monitor the heart rhythm pattern for patients to detect, record and report normal and abnormal heart rhythm patterns, normal and abnormal ECG interval measurements and proper and improper pacemaker or implantable defibrillator function. The monitor tech measures and interprets patient's rhythm and pattern and posts monitoring strips per hospital policy.

The monitor tech would perform clerical tasks including answering phone calls, taking phone reports from different services, referring calls, communicating changes in patient information to Admitting Department and Charge RN/Department Leader, responds to call lights, prepares admission and discharge patient records, reviews patient face sheets for errors and other numerous tasks of a unit clerk.

According to the staff, the duties and responsibilities of the unit clerks and the monitor techs were combined in one position about over a year ago when the hospital became a member of the health system in the district area.

5. Review of the hospital's policy titled, "Cardiac Telemetry Monitoring," revised on 1013 showed that at a minimum, a six-second telemetry strip will be run on admission or when the telemetry is initiated, at least every shift and mount the strip in the medical record. The strip should also be run any time a defective or abnormal heart rhythm occur. The rhythm strip's heart rate, PR interval, QRS duration and QT interval must be measured and interpreted. The monitor tech was expected by the hospital's policy to perform the task of cardiac telemetry monitoring.

6. Review of Patient 1's closed record and five open records showed that the telemetry strips mounted did not have the measurements of the intervals and interpretation of the heart rhythm.

a). Patient 1's mounted strips dated 1/13/16 at 0001, 0722 and 1607 for each shift did not have the measurements of the PR, QRS and QT intervals.

b). Four active patients's mounted strips from 3/16 /16 - 3/24/16 did not have the measurements of the heart rate, PR, QRS and/or QT intervals.

For example:

1a). Patient 2's strip dated 3/22/16 at 7:35 a.m. showed atrial fibrillation. The QT interval was not measured.

1b). Patient 18's telemetry strips dated 3/20/16 at 12:48 a.m., 4:13 p.m and 11:57 p.m. did not measurements and interpretation of the heart rate, PR, QRS and/or QT intervals. The telemetry strip dated 3/21/16 at 7:08 a.m. did not have the measurements of the QRS and QT intervals. On 3/22/16 at 1:12 a.m., the strip did not have the measurements of the QRS and QT intervals.

1c). Four of Patient 23's strips dated 3/21/16 - 3/23/16 did not have the measurements of the PR, QRS and/or QT intervals. The signed rhythm strips were interpreted by the nursing staff as sinus rhythm with a bundle branch block.

1d). 18 of Patient 7's strips dated 3/16/16 to 3/21/16 had incomplete measurements of the PR, QRS or QT intervals.

Based on observation, interview and record review facility failed to ensure that the registered nursing staff effectively supervised and evaluated the delivery of care of 11 out 38 patients in the sample.

Findings:

1. During patient care observation on 3/21/16 at 8:40 a.m. in the telemetry unit 2nd floor nurses station the telemetry monitors for six patients were set at higher limit of 120 beats per minute and low limit of 50 beats per minute.

During an interview on 3/21/16 at 1:40 pm, CN4 stated that the heart monitor high and low limits had already been pre-set for all patients by the company "manufacturer" and that no physicians orders are needed. The telemetry staff set the parameters for the alarms from 50-120 beats regardless of the indications why the patients were placed on telemetry.

Review of the submitted hospital's policy and procedure effective date 5/2015 entitled,
"Clinical Alarms (Response & Safety)", Guidelines for Establishing Common Bedside Physiological Alarm Parameters indicated:.." The MD ( physician) or the RN ( Registered Nurse) may change the alarm parameters based on a written MD orders defining the new alarm parameters.

a. Heart Rate Limit
ii. Alarm Limits: High and low heart rate alarm limits should be set at the parameters according to the patient condition with the following guidelines:
. At any medical order parameter for intervention/
treatment.
. If actively treating heart rate may use 20- 25 % below and above current heart rate until intervention complete.
iii. Documentation : Alarm limits must be checked at the beginning of the shift and should be documented on the EKG ( electro cardiogram) strip."

2. During an interview on 3/23/16 at 3:16 p.m., Patient 4 said she used the Patient Controlled Analgesia (PCA) for pain control after her surgery on 3/21/16 on her left leg she had surgery done on her left leg on 3/2/1/16 Patient 4 said on 3/22/16 after lunchtime at level 8/10. She pressed her call light because she had a lot of chest pain. She had a bucket of water at her bedside to clean herself. When no one answered the call light for a long time, she tried to get up to the bedside commode and clean herself up. She felt dizzy and felt like sinking down. Patient 4 said that another surveyor witnessed the incident.

Review of the medical record showed that Patient 4 was on PCA with Hydromorphone for pain control. Patient 4 had 16 injections of Hydromorphone 0.2 mg/ml from 7:30 a.m. to 3:40 p.m. on 3/22/16. During a telephone interview on 3/24/16 at 11:22 a.m., RN 2 said she was the day shift primary nurse of Patient 4 on 3/22/16. She gave Patient 4 Neurontin, a pain pill at 2 p.m and at 3 p.m., the pain went down to 3/10 level. RN 2 acknowledged she did not write the pain reassessment on the medical record.

Review of the Patient Controlled Analgesia policy and procedure effective 9/1/2012 showed that the following will be monitored every hours: sedation level, pain score, respiratory rate and oximtery monitoring will be performed. Patient 4's Nursing Vital Sign Queries and PCA Flowsheet dated 3/23/16 were reviewed with RN 1 and NM. There was no documentation that Patient 4's vital signs and PCA monitoring parameters were done every four hours. RN 1 said she took the vital signs and PCA monitoring parameters but acknowledged they were not in the medical record. NM said that when nurses do not hit the "file" button the entered information could not go into the electronic medical record.

Patient 4's PCA Flowsheet from 3/21/16 at 11:30 p.m. to 3/22/16 at 11:29 p.m., showed a documentation gap of accounting the medication pump delivery. There was no documentation on the flowssheet that a new syringe of Hydromorphone 50 ml was loaded and started on the machine on 3/22/16 approximately after 5:24 p.m.. The PCA policy required the documentation of each medication syringe initiated.

3. Patient 37 went to the emergency room on 2/13/16 because of painful rash and itching all over the body. At 1930, the Emergency Department Order Sheet included an order for a chest x-ray signed by a registered nurse at 1000 (p.m.). Review of the Emergency Physician's Dictated Report showed that the chest x-ray was accidentally omitted and did not get put in properly.

The Emergency Department Nurse's Notes showed that an intravenous line was inserted on 2/13/16 at 1550 on the right arm by a registered nurse and administered drugs through the intravenous line. The patient was given discharge instructions at 20 15 and discharged at 2025 with a designated driver. There was no documentation that the registered nurse discontinued the IV line.

During an interview on 3/24/16 at 1:25 p.m., Patient 27 said, on 2/13/16 from the emergency room, she and her son went to get a sandwich, went to a drugstore for the prescriptions and then home. While she was removing her jacket, something was caught in the sleeve of her jacket, She found the IV line with blood in the short tubing on her arm and felt pain. She returned to the hospital and the emergency room staff removed the IV needle at the receptionist area in the emergency room lobby.

Based on observation, interview and record review the facility failed to develop a plan of care for two (Patients 2 and 3) sampled patients identified to have: anxiety and chest pain (Patient 2) and a newly identified high blood sugar problem on a deaf and mute individual (Patient 3).


Findings:

1. The Cardiology Consultation Report dated 3/22/2016 showed the hospital initially admitted Patient to the hospital on 3/8/16 due to a heart attack. The hospital transferred Patient 2 to another acute care hospital for interventions that included heart surgery.

The report said that a week prior to the current admission, Patient 2 was readmitted to the hospital, but was discharged home because of extreme anxiety and wanted to go home.

On 3/21/2016 the hospital readmitted Patient 2 with chest pain, back pain and exerted great effort to breath (hyperventilation). The Cardiology Consultation Report showed the chest pain was due to anxiety. The report identified anxiety a huge problem which confused the patient to chest discomfort or breathing problem. . The nursing admission care plan did not address Patient 2's anxiety. The Cardiology Consultation Report had a statement, "Again she is asking to go home now. Her daughter thinks it is all anxiety."

2. Review of the medical record showed the facility admitted Patient 3 on 3/20/16 with a diagnosis of new onset of diabetes. Patient 3 was deaf and mute (unable to hear and unable to speak). When requested, the facility did not arrange for interpreter services in a timely manner. Patient 3's significant other said they had requested interpreter services while in the emergency room on 3/19/16. On 3/22/16, Patient 3 requested in writing for the facility staff to arrange for an interpreter before he was discharged.
Review of the nursing admission assessment Part I dated 3/20/16 at 11:50 a.m. showed Patient 3 was assessed as without any factor or barrier to learning. The assessment showed the patient was ready and cooperative to learn and would learn best by demonstration. Patient 3 was assessed not to have need for diabetes teaching.
The hospital discharged Patient 3 without proper diabetic teachings especially on medications. On 3/22/16, the facility staff could not show a plan that a qualified sign language interpreter was contacted for diabetic teaching during the early phase of hospitalization.

Based on observation, patient interview, staff interview and record review, the facility failed to ensure that Patient 4 did not keep and use an inhaler at the bedside without a physician's order. This failure was not consistent with the federal and state requirements that drugs must be administered only with a physician's order.

Findings:

The hospital admitted Patient 4 for a surgical procedure on the left leg with gangrene (decaying wound) on 3/21/16.. During an interview and observation on 3/22/16 at 2:22 p.m., Patient 4 took random puffs from an inhaler kept at the bedside. According to Patient 4, the surgical staff "downstairs" gave her the inhaler because she has asthma and had difficulty breathing while in the surgery department. Patient 4 said she had the inhaler when the surgical staff brought her back to her room in the nursing unit.

During an interview on 3/23/16 at 1:15 p.m. RN 1,( the nurse who accepted Patient 4 back from surgery on 3/21/2016 at 1:30 p.m) said, she reviewed Patient 4's chart and found a written physician's order dated 3/21/16 at 9 a.m., for Duoneb, an inhaler without a specific dosage while Patient 4 was in surgery. RN 1 said there was no order to continue Duoneb when Patient 4 returned to the nursing unit.

On 3/23/16 at 2:55 p.m. RN 1 said that when she received Patient 4 back from surgery department on 3/21/16 at 1:30 p.m., she did not find an inhaler with Patient 4. In staff interview on 3/23/16 at 3:27 p.m., NM said that patients were not supposed to have medication at bedside.

In a phone interview on 3/24/16 at 11:22 a.m., RN 2 identified herself as Patient 4's primary nurse on 3/22/16 during the day shift. RN 2 said there was an inhaler at Patient 4's bedside and endorsed the inhaler to the incoming shift. RN 2 told the incoming shift to call the physician if the inhaler should be continued..

Based on observation, interview and record review the hospital did not provide an adequate and safe discharge plan for one ( Patient 3) of 38 sampled patients. Patient 3, deaf and mute was found to have a new onset of diabetes on admission and required insulin at home. The hospital discharged the patient without the assistance of a sign language interpreter and did not receive discharge instructions on home medications, including insulin.

Failure to accommodate and appropriately plan for a safe and follow up discharge had the potential to cause harm and life threatening complications for Patient 3.

Findings:

Review of the emergency room clinical records on 3/23/16 at 12 noon showed the hospital admitted Patient 3 on 3/20/16 with diagnoses that included neww onset diabetes with an "elevated" blood sugar of 335 mg/dL( normal range: 70-100 mg/dL)
On 3/22/16 , Patient 3 requested in writing to have an "interpreter with the doctor" , prior to discharge. The request was not followed up and interpreter was not provided. The hospital discharged Patient 3 on 3/22/2016 without seeing an interpreter. The staff instructed the patient to return to the hospital the following day, 3/23/2016 to receive discharge instructions.

On 3/23/16 at 11:30 a.m. the discharge instructions for Patient 3's take home medications included:
a. Lantus (medication for diabetes) 10 units s.q. (subcutaneous-injected underneath the skin) once a day.
b. Metformin (tablet to control blood sugar) 1gm (gram) po (take by mouth) bid (twice a day).
There was no documented instructions for Patient 3 on how to inject himself with insulin, instructions on signs and symptoms of high and low blood sugar levels and what to do when symptoms appears.

During an interview on 3/23/16 at 12 noon, NM said she was unable to show that detailed discharge instructions was done for Patient 3 who was a newly diagnosed diabetic. NM added that Patient 3 did not get his prescription drugs for diabetes for reason that Patient 3 did not have insurance to cover his prescription drugs.

On an interview on 3/23/16 at 12:30 p.m., Dr 4 stated he admitted Patient 3 due to his respiratory problem , and a newly diagnosed diabetes with "social and communication issue."
On 3/23/16 at same time between 12:30 p.m. and 12:45 p.m. with Agency A (a contracted sign language interpreter, Patient 3 stated that the discharge instructions done day before (on 3/22/16) was "very fast" and "very confusing", reason why he requested for an interpreter. Patient 3 did not have detailed instructions about diabetes management prior to discharge such as :
a. blood testing machine was not provided for use at home.
b. Insulin injection instructions .
c. Detailed diabetic dietary instructions .
Patient 3 stated that "only now" that he is receiving all the instructions.

During interview on 3/21/16 at 11:15 a.m. RN, CM and SW 1 said that discharge planning for the patients starst as early as during admission. One of the roles and responsibility of RN CM is to check patient's insurance and coverage. The hospital's social services oversees social and family issues of the patient and SW is responsible for referrals to outside agencies.