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Based on policy review, record review, and interview, the facility failed to:
- ensure ongoing nursing assessment, supervision and oversight to meet the patient care and services and prevent complications;
- notify the primary care physician of an incident of potential harm;
- follow a patient turning schedule;
- develop, and update comprehensive care plans;
- administer medications in accordance with the approved medical staff policies and procedures;
- have a second nurse verify high risk medications prior to administration.

The facility census was 59.

The severity and cumulative effect of this systemic practice resulted in the facility's non-compliance with 42 CFR (Code of Federal Regulations) 482.23 Condition of Participation: Nursing Services.

Based on policy review, record review, and interview, the facility failed to:
- accurately document the consumption of tube feeding;
- consistently document the consumption of special nutritional supplements taken by mouth;
- accurately document patient hygiene;
- complete and authenticate History and Physicals;
- ensure order entries were accurately dated, timed, and authenticated; and
- ensure telephone and verbal orders were signed by a physician within 48 hours.

The facility census was 59.

The severity and cumulative effect of this systemic practice resulted in the facility's non-compliance with 42 CFR (Code of Federal Regulations) 482.24 Condition of Participation: Medical Record Services.

Based on facility policy review, record review, and interview, the facility failed to ensure the "Important Message from Medicare" notice was delivered correctly after admission for one (Patient L6) of seven medical records reviewed for the "Important Message," and failed to complete code status (i.e., if a patient would or would not be resuscitated it the patient went into either respiratory or cardiac arrest) orders for nine (Patients L6, L2, L12, L13, L15, L33, L34, SA1 and SA3) of nine medical records reviewed for code status.

The facility census was 59.

Findings included:

1. Review of the facility's policy titled "Patient Admissions, Discharges and Transfers 2.0," found it states the following (in part):
- "Inpatients - An Important Message from Medicare/Champus - This form shall be given to the patient within 2 calendar days of admission and be signed by the patient/representative. A follow-up copy of the form signed at admission shall be given to the patient within 2 calendar days of discharge."
- "Ensure that all fields are completed on admission documents and that the documents are signed by the patient/representative on admission."

Review of the facility policy titled "Code Status Classification", revised 01/07, gave direction, in part, to include the following:
"Purpose...To describe the Hospital's classification for patient resuscitation in the event of a cardiac, respiratory or cardiopulmonary arrest and the procedure for communicating code/status during the hospital stay...The physician enters the admitting Code Status as an order at admission or as soon after admission as possible."

2. Review of the medical record on 06/14/10 at 2:40 P.M. for current Patient L6 showed the following (in part):
- An "Important Message from Medicare" letter was signed by Patient L6's Power of Attorney, but was not dated. Therefore, there is no evidence that the "Important Message" was delivered in a timely manner after Patient L6's admission to the facility.

- A form titled "Code Status/Comfort Measures Orders" was marked as "Category 1 - Full code." A section at the bottom of the form stated "Please check one of the following: 'These categories have been discussed with and agreed upon with the patient.' OR 'These categories have been discussed with the family and agreed upon, based on the known wishes of the patient.'" There is a line for the patient or family to sign. The line for this signature was blank. The physician signed the form and dated it. There was no time indicated, and neither box had been checked.

3. Subsequent reviews of medical records for current Patients L2, L12, L13, L15, L33 and L34 failed to show patient signatures on any of the "Code Status/Comfort Measures Orders" forms. In an interview on 06/16/10 at 12:50 P.M., Director of Quality Management Staff LM said, "There is no policy that specifically tells staff how to complete the code sheet. We are doing a house sweep to ask patients Power of Attorneys, families, etc. to sign the forms."


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4. Review of current Patient SA1's medical record on 06/15/10 showed the patient was admitted on 05/27/10. The facility's form titled, "Code Status/Comfort Measures Orders", was not signed by a physician until 06/06/10.

5. Review of current Patient SA3's medical record on 06/15/10 showed the patient was admitted on 05/25/10. The facility's form titled, "Code Status/Comfort Measures Orders", was signed by a physician but not dated/timed.

Based on observation and interview, the facility failed to protect patient's right to privacy by placing patient names in public view in one unit at the Lindell campus and one hall at the St Anthony's campus. The facility census was 59.

Findings included:

1. Review of the facility's policy titled, "Patient Rights and Responsibilities", revised 05/09, gave direction, in part, to include the following:
"The rights and responsibilities referred to in this policy shall be protected and exercised for each patient...The list of Patient Rights and Responsibilities is provided to each patient at admission."

Review of the facility's document titled, "Patient Rights and Responsibilities", gave direction, in part, to include the following:
"The patient has the right to personal privacy...The patient has the right to the confidentiality of his/her clinical records...."

2. Observation on 06/14/10 at 1:45 P.M. in the observation unit at the Lindell campus showed patient charts in a rack at the nurses' station. Patients' first initial and last names were taped to the charts' binders and were legible to the public when entering the observation unit. This affected all five patients in the observation unit.

3. Observation on 06/15/10 at 10:25 A.M. on hall B at the St Anthony's campus showed patient charts in a rack. Patients' first initial and last names were taped to the charts' binders and were legible from the public hallway. This affected all 18 patients on hall A.

4. Review of the document titled, "Medical Executive Meeting, April 26, 2010", the facility's "recommendations/actions" from survey conducted on 04/09/10 include, "Will use first initial and last name".

Based on observation, interview and record review the facility failed to have adequate number of nursing staff to ensure ongoing nursing assessments, supervision of nursing care, and oversight to meet medical needs and prevent complications for two (L15 and L6) of seven patients surveyed. The facility census was 59.

Findings included:

The Lindell campus consisted of two floors (2nd and 3rd), plus a 5 bed Observation/Special Care Unit (SCU) located at the end of the 2nd floor nursing unit. The SCU consisted of a four-bed bay on one side of the unit and an isolation room enclosed by walls and a door on the opposite side. In between these two areas was the nurses' desk where the cardiac monitors were located. Patients on the 2nd and 3rd floor nursing units who were on telemetry (continuous monitoring of a patient's heart rate and rhythm which takes place at a remote location) were also monitored in the SCU by a C.N.A. (certified nurse assistant) who was assigned to observe the monitors and was not assigned to perform patient care. Assistance with patient care was provided by C.N.A.s who also provided coverage to the 2nd or 3rd floor.

According to the Kindred Healthcare website, "Kindred long-term acute care (LTAC) hospitals provide aggressive, specialized interdisciplinary care to medically complex patients who require extended recovery time. These patients are ill and have few care options left; they come to us because they require the aggressive, specialized care and prolonged recovery time that conventional short-term acute care hospitals may not be equipped to provide."

1. The facility was found to be out of compliance with the Condition of Participation (CoP) of Nursing Services during a survey concluded 02/02/10, and was found to continue to be out of compliance at two additional surveys. As of June 15, 2010, 15 complaints were received and investigated by the state agency for calendar year 2010. Six have been substantiated with issues related to nurse staffing and/or supervision.
- 02/02/10 - Complaint MO00059424 includes concerns about hygiene, failure to evaluate and treat two skin conditions, and failure to appropriately limit use of affected arm following a mastectomy. Substantiated with citation for wound care.
- 02/02/10 - Complaint MO00059828 includes concerns about restraints and unnecessary medications. Substantiated with deficiencies in nursing service and infection control.
- 04/09/10 - Complaint MO00060215 includes concerns about failure to respond to call lights in a timely manner, lack of bathing, unprofessional staff behavior, pest control, and failure to monitor bowel movements. Substantiated with citations for patient hygiene, and failure to address/treat lack of bowel movements.
- 04/09/10 - Complaint MO00060346 includes concerns about nurse aide yelling at patient. Substantiated with citation for failure to follow facility procedure for investigating allegations of abuse and neglect.
- 06/17/10 - MO00065281 includes concerns about falsifying patient records, inadequately trained nursing staff, failure to verify high-risk medications, and failure to use personal protective equipment. Substantiated for failure to follow facility policy in regard to verifying high-risk medications, and failure to follow facility policy regarding personal protective equipment.
- 06/17/10 - MO00062678 includes concerns about falsifying patient records, inadequate numbers of nursing staff, inadequately trained nursing staff, and failure to appropriately plan nursing care for patients. Substantiated for inadequate staffing, inadequate care planning, and inadequate documentation by nursing staff.

2. Review of the facility policy titled, "Staffing Plan," dated 12/2009, showed the following, (in part):
- The purpose of the policy is "To ensure the nursing department is staffed with sufficient numbers and skill mix of appropriately qualified direct care nursing staff in each unit to meet the unit population and individualized care needs of the patient."

3. Review of a document titled, "Appendix A," dated 01/20/10 states: "Nursing staffing ratios are based on census and acuity. Nurses care for 5-6 patients. Support to the nursing staff includes C.N.A.'s, Unit secretaries and the shift supervisor."

4. During an interview on 06/14/10, an anonymous R.N. staff member, asked about orientation and follow up training, stated, "Nursing orientation should be longer. Currently, new employees receive six days of orientation. Care for these acutely ill patients is different than a general care hospital." The anonymous R.N. staff member further stated that the facility receives patients with multiple sclerosis, quadriplegics, patients with contractures, etc. Many are on ventilators and require periodic suctioning, are in the process of being weaned from the ventilator, have tube feedings for nutrition, have pressure ulcers, etc. The majority of patients require isolation, triggering the need for staff to gown and glove before entering a room. The anonymous R.N. staff member further stated that administration agreed to allow new staff three additional days of orientation, but that still hasn't helped. The anonymous R.N. Staff said that new staff are overwhelmed and resign, and that employees receive periodic training for special equipment such as wound vacuums, but for some staff it's not enough. The anonymous R.N. staff member said, "Even the agency nurses are 'drowning' with the patient assignments."

5. During an interview on 06/14/10, an anonymous R.N. staff member, asked about timeframes for administering medication, stated that hospital policy dictates that when a patient is given an oral medication through a G-tube (a gastrostomy tube inserted through the skin of the abdomen directly into the stomach for feeding and medication purposes), each pill must be crushed, mixed with water, and injected into the stomach; then the tubing must be flushed with water prior to administering subsequent medications. The anonymous R.N. staff member stated this is a time consuming process. The anonymous R.N. staff member further stated, "We're not able to give meds on time. We try, but these patients are on a lot of medications. When you have six patients, plus all the little things that come up that pull your attention away, they don't get given on time. They're trying to order more meds in liquid form so that meds per G-tube goes faster, but there still isn't enough staff to get meds out on time. We just chart them at whatever time they are given."

6. During an interview on 06/14/10, an anonymous R.N. staff member, asked about facility procedures after a patient Codes (has a cardiopulmonary arrest), and whether special training is required to work in the Special Care Unit, stated that after a patient codes, " They are normally shipped to another facility. The Doctors evaluate and decide whether they can adequately be cared for here. They may be placed in SCU and a dopamine (used to increase heart rate and blood pressure) drip hung, or they may be sent to a different hospital after stabilized. There is usually an R.N. in the Observation Unit (SCU). If we can't staff it with an R.N., we'll staff it with an L.P.N. who is familiar with special drips. You don't have to have special training to work in Observation. It can be very hectic in there because these are very labor intensive patients."

Medical record review on 06/16/10 12:50 P.M. for Patient L15 showed that on 05/10/10 at 9:45 P.M., the Observation unit contacted the 3rd nursing floor and reported Patient L15's heart rate was 38 beats per minute. [The typical resting heart rate in adults is 60-100 beats per minute. According to the Mayo Clinic, "If bradycardia is significant enough to cause symptoms, possible complications of the slow heart rate may include: frequent fainting spells, inability of the heart to pump enough blood (heart failure), and sudden cardiac arrest or sudden death. ()] When staff checked, the patient was pale, diaphoretic (sweating profusely), unresponsive, and breathing was labored. The patient was resuscitated (cardiopulmonary resuscitation: a procedure designed to restore normal breathing after cardiac arrest that includes the clearance of air passages to the lungs, mouth-to-mouth method of artificial respiration, and heart massage by the exertion of pressure on the chest), but was not moved to a higher level of care for closer observation. During an interview on 06/17/10 at 9:00 A.M. with Director of Quality Management Staff LM said that Patient L15 was not moved to the Observation Unit (SCU) because he/she did not "code." Per Staff LM, the patient's inner tracheostomy (a direct airway into the lungs via the windpipe) cannula (a slender tube inserted into the windpipe) was kinked, which led to the period of bradycardia and unresponsiveness. Nurse Manager Staff LV said, "Observation Unit (SCU) nurses are trained like the other nurses. The plan is to increase the knowledge base. If there was a true code, the patient would move to the Observation Unit (SCU) even though staff there don't have extra training except ACLS (Advanced Cardiac Life Support)."

7. During an interview on 06/14/10, an anonymous R.N. staff member, asked about when care plans are initiated and updated, said that when nursing supervisors are assigned to take care of patients, they're unable to perform other duties, e.g., assisting with care on both floors, relieving staff for meals, reviewing medical records to confirm that orders have been taken off, adding problems to care plans, etc.

During an interview on 06/14/10 at 4:20 P.M., Shift Supervisor LN said that when a patient is admitted, nurses are told to put at least two problems on the nursing care plan. The supervisor on night shift then checks all the paperwork and adds additional items to the care plan. If they have been assigned patients, they can't do that. Staff LN said, "If a PICC (peripherally inserted central catheter - used for long term access for intravenous fluids and medications) line is inserted during your shift, you are supposed to enter that on the care plan. Otherwise, updating the care plan is the supervisor's job. The staff nurse doesn't have time. They add items for the new patients only."

During an interview on 07/07/10 at 12:50 P.M., Chief Clinical Officer Staff LB said that Charge Supervisors provide general oversight of hospital operations, act as a reference for other nurses, make patient assignments, and provide patient care. When the Supervisor takes patients, they "only get involved as much as necessary. They primarily provide oversight." On night shift, the Supervisor will usually take patients based on acuity. Chief Clinical Officer Staff L stated that R.N.s assigned to patient care are responsible for making sure that all orders are taken off, and are also responsible for building and updating the patient care plan. This includes adding patient care issues such as turning every two hours, documenting wound care, follow-up appointments after surgery, suture removal, etc.

During an interview on 07/07/10 at 2:25 P.M., Director of Quality Management Staff LM said that Care Plans are checked monthly for accuracy and completeness.

Medical record review on 06/15/10 at 11:20 A.M. for Patient L13 showed that a pacemaker was inserted on 04/16/10 for chronic atrial flutter (an abnormal heart rhythm that sometimes causes a rapid and irregular heart beat). A follow-up appointment was set for 04/23/10 at 9:00 A.M. There were no physician orders for wound care or pacemaker aftercare. The admission nursing documentation on 04/17/10 failed to record evidence of an immobilizing device being used to prevent displacement of the pacemaker lead after insertion, but the Occupational Therapist documented that the left upper extremity was in a shoulder immobilizer. A nursing observation dated 04/25/10 at 2:54 P.M. noted the presence of steri-strips at the pacemaker site and also that the patient was wearing an arm sling. Shortly after the pacemaker was inserted, Patient L13 was pulled up in bed by the arm closest to the pacemaker. Review of the incident report showed that a student nurse was responsible. Despite this incident, there was no documentation on the Care Plan of the aftercare for Patient L13, including use of a sling or restricting movement of his/her left arm. During an interview on 06/15/10 at 2:45 P.M., Director of Quality Management LM said that the medical record showed no evidence that the follow up appointment scheduled 04/23/10 was kept, nor was there evidence that the physician was notified of possible dislodgement of the pacemaker after Patient L13 was lifted inappropriately.

8. During an interview on 06/14/10, an anonymous R.N. staff member, asked about patient assignments, workload, and ability to provide adequate care, said "Having one C.N.A. for 12 patients is unrealistic. They can't turn every patient every two hours, much less bathe patients, do perineal care (cleansing after toileting), feed patients, answer call lights, etc. And then just when you think staffing is 'right,' administration comes and says 'We're over budget and someone will have to go home.' We can't do without any of the staff. Maybe the secretary, if there aren't any planned admissions, but that's it. Nurses are being held more accountable and there have been some terminations, so we're down a bunch of nurses. We're trying to fill in with agency nurses. The goal is to have 5 patients to one nurse, but that's tough to do. It's often 6:1 or more. I think the majority of nurses here want to do a good job, but the load is too heavy and they can't do the nursing care they know is best."

During an interview on 06/17/10 at 1:10 P.M. Chief Clinical Officer Staff LB said that one nurse aide "absolutely and without fail" was expected to handle a patient assignment of eleven patients, including bathing, feeding, turning every two hours, answering call lights, etc. "They have nursing staff to call on for assistance, as well as supervisory staff."

During an interview on 06/14/10 at 2:10 P.M., Patient L6 said that it sometimes takes 30 minutes for a call light to be answered. "Sometimes I have accidents (inability to hold the contents of the bowel or bladder) because they don't get here fast enough." When asked whether staff explained the reason for the delay in answering the call light, the patient said, "They can't keep staff. Nurses keep leaving. C.N.A.s keep leaving. I had to wait 2-3 hours for my pain medicine once. They said they were busy with other patients."

During an interview on 06/17/10 at 10:00 A.M., Patient L15 said the call light often falls onto the floor and he/she can't reach it. Patient L15 reported using the tissue box to bang on the bedside table or bed railings, but that it often takes a long time for staff to respond. On at least one occasion, Patient L15 alleges that staff entered the room, turned off the call light, and left the room without ever addressing the patient. When asked what the name of the staff member who did this, Patient L15 shrugged and said the staff person turned their name badge over so the name could not be read.

During an interview on 06/14/10 at 2:10 P.M., Patient L6's hair did not appear to be clean. Patient L6 said he/she was bathed approximately once per week, if requested. Patient L6 also said he/she had a shampoo approximately once per month, if requested. The patient's mother, who was visiting, nodded her head in agreement with this allegation. Review of the internal document "Hygiene Audit" for May, 2010 on 06/15/10 at 8:30 A.M. showed a "B" for the dates of 05/05/10 and 05/07/10 through 05/30/10 for Patient L6. The date of 05/06/10 showed an "X." Review of the internal document "Hygiene Audit" for June, 2010 on 06/15/10 at 2:00 P.M. showed a "B" for the dates of 06/01/10 through 06/14/10 for Patient L6. There was no documentation to distinguish between days on which patients received hair care versus those on which they did not. During an interview on 06/14/10 at 3:30 p.m., Shift Supervisor Staff LN said the policy was changed as of 06/01/10, and patients are now bathed twice per week unless requested more often. Shampoos are done with a shower cap type product that contains shampoo, and when showers are needed, they are done by Occupational Therapy. Regarding charting what the patient received, B= bath and P= partial bath. During an interview on 06/16/10 at 1:30 P.M., Nurse Manager Staff LV confirmed that the "B" on the "Hygiene Audit" document meant a bath was performed. When asked why the audit would indicate a bath was done nearly daily but the patient (and mother) reported something different, Nurse Manager Staff LV said he/she would to talk to his/her staff before answering, but said, "Shampoos are done at the same time as baths."

During an interview on 06/16/10 at 10:00 A.M., Patient L15's hair did not appear to be clean. Patient L15 stated he/she received a bath every day, and received a shampoo two days earlier. Review of the internal document "Hygiene Audit" for June, 2010 on 06/15/10 at 2:00 P.M. showed a "B" for the dates of 06/01/10 through 06/14/10. There was no documentation to distinguish between days on which patients received hair care versus those on which they did not.

Observation from 06/14/10 to 06/17/10 on the 3rd floor showed ventilator (a machine to assist with breathing) alarms and call lights alarming almost non-stop. Ventilators alarm for a variety of reasons, including coughing, water in the machine tubing that needs to be cleared, secretions in the airway that need to be removed, rapid breathing, and no breathing at all. Staff were observed to respond to the ventilator alarms if they did not stop after 30 seconds or more. On at least three occasions, the surveyor heard supervisory staff at the nursing station ask staff sitting in a break room behind the nursing station to check a particular patient to determine what was causing the alarm.

9. According to the American Nurses Association, "identifying and maintaining the appropriate number and mix of nursing staff is critical to the delivery of quality patient care. Numerous studies reveal an association between higher levels of experienced R.N. staffing and lower rates of adverse patient outcomes. Research shows it is a problem for patients: Insufficient nurse staffing is linked with poorer patient outcomes, lengthened hospital stays and increased chance of patient death." ()

The facility utilizes two levels of nursing staff: R.N.s and L.P.N.'s (Licensed Practical Nurses). Job duties are similar for both positions, but only the R.N. can administer blood transfusions, start intravenous lines or give intravenous medications. R.N.s also provide direction and supervision to licensed practical nurses and nursing aides regarding patient care.

Typically, an R.N. is responsible for admitting or discharging patients. Admitting a patient is a lengthy process which includes completing a full history, physical and safety assessments, medication reconciliation, and all necessary forms, including advance directives. They also call physicians for orders, if necessary, and they review patients' admission histories. R.N.s then establish a care plan or contribute to an existing plan.

Similarly, discharging a patient is a lengthy process. Patients often have complex needs at discharge that require coordinating services with other agencies, obtaining medications and supplies, or arranging for professional/clinical services. Patients also need substantial instructions for continuing care. Attending to these needs increases the time registered nurses must spend on discharge duties, making discharge much more time consuming.

The facility contracts with a local agency to perform hemodialysis (a machine used to filter waste products from the blood) of patients needing this treatment. The procedure typically occurs three days per week on the second floor of the facility. Patients who receive hemodialysis often have a greater number of co-morbid conditions and are at higher risk for infection due to the direct link into the circulatory system. They require close monitoring of vital signs and fluid intake and output.

Patients who are on ventilators or who are in the process of being weaned from a ventilator require a higher level of nursing care related to oxygenation and assessing the patient's tolerance to weaning processes. Ventilator patients are at higher risk for infection due to the direct link into the respiratory system. They often require frequent suctioning to clear secretions from the trachea. This facility places a great deal of responsibility on the respiratory therapy staff in regard to monitoring these patients during the weaning process, however, nursing staff frequently assist with suctioning, and are responsible for additional care such as regularly turning the patient to prevent accumulation of secretions, preventing aspiration of food or fluids, reassurance of the anxious patient and/or his/her family, patient education, etc.

10. Review of facility census sheets and staffing grids revealed the following:
- The staffing grid dated Thursday, 05/20/10 showed the facility census was 21 patients on day shift with two admissions, and 23 patients on night shift with one admission. There was an R.N. assigned as "Charge Supervisor" on each shift. A Unit Secretary was available for 12 hours. A Wound Care Nurse provided care for 12 hours. The census included six hemodialysis patients, 13 patients on ventilators (a machine that helps a patient breathe), three patients with tracheostomies (a direct airway into the windpipe through an incision in the neck), seven patients in the process of being weaned from the ventilator, and two patients in restraints.
- The SCU had a census of four patients. One R.N. was assigned to care for all of these patients on each shift. One C.N.A. was assigned as monitor tech on each shift. A C.N.A. from the 3rd floor assisted with patient care on the day shift. On the night shift, a C.N.A. from the 3rd floor assisted with patient care for part of the shift. During an interview on 07/07/10 at 12:50 P.M., Chief Clinical Officer Staff LB said that nurses in the SCU do "primary care" when there aren't enough C.N.A.s.
- The 2nd floor census was 11 patients. On the day shift, one L.P.N. had six patients, one L.P.N. had five patients, and one C.N.A. had all 11 patients. On the night shift, one R.N. had five patients, one L.P.N. had six patients, and one C.N.A. had all 11 patients. A second C.N.A. was assigned 9 patients in other areas of the facility, but left work early. During an interview on 07/07/10 at 12:50 P.M., Chief Clinical Officer Staff LB said the other two C.N.A.s would have been expected to assume care for the remainder of the patients after that C.N.A. left.
- The 3rd floor census was six patients on the day shift and eight patients on the night shift. On the day shift, one R.N. had all six patients. One C.N.A. had 10 patients - six on the 3rd floor and four in the SCU. On the night shift, one R.N. had four patients, one L.P.N. had four patients, and one C.N.A. had all eight patients.

- The staffing grid dated Friday, 05/21/10 showed the facility census was 23 patients on day shift with four admissions, and one discharge. The census on night shift was 29 patients with two admissions. There was an R.N. assigned as "Charge Supervisor" on each shift. A Unit Secretary was available for 12 hours. A Wound Care Nurse provided care for 12 hours. The census included seven hemodialysis patients, 13 patients on ventilators, three patients with tracheostomies, seven patients in the process of being weaned from the ventilator, and two patients in restraints.
- The SCU had a census of four patients. One R.N. was assigned to care for all of these patients on each shift. One C.N.A. was assigned as monitor tech on each shift. On both shifts, a C.N.A. from the 2rd floor assisted with patient care.
- The 2nd floor census was 11 patients. On the day shift, one L.P.N. had six patients, and one R.N. had five patients. One C.N.A. had three patients on 2nd floor, and four patients in SCU. A second C.N.A. had eight patients. On the night shift, one R.N. had five patients, one R.N. had six patients, and one C.N.A. had 10 patients. A second C.N.A. had two patients on 2nd floor, four patients in the SCU and three patients on the 3rd floor.
- The 3rd floor census was eight patients on the day shift and 13 patients on the night shift. On the day shift, two L.P.N.'s had four patients each. One C.N.A. had all eight patients. On the night shift, two L.P.N.'s had six patients each, and the night shift "Charge Supervisor" had one patient. One C.N.A. had 10 patients. The remaining patients were cared for by a C.N.A. from 2nd floor.

- The staffing grid dated Saturday, 05/22/10 showed the facility census was 29 patients on day shift with one discharge, and 27 patients on night shift with one discharge. There was an R.N. assigned as "Charge Supervisor" on each shift. A Unit Secretary was available for 10 hours. The census included seven hemodialysis patients, 13 patients on ventilators, two patients with tracheostomies, and eleven patients in the process of being weaned from the ventilator.
- The SCU had a census of four patients on day shift and three patients on night shift. One R.N. was assigned to care for these patients on both shifts, and one C.N.A. was assigned as monitor tech for both shifts. One C.N.A. from the 2rd floor assisted with patient care on day shift, and on the night shift, a C.N.A. from the 3rd floor assisted with patient care.
- The 2nd floor census was 12 patients on the day shift and 11 patients on the night shift. On the day shift, two L.P.N.'s had six patients each. One C.N.A. had 10 patients. One C.N.A. was assigned to care for four patients in the SCU, two patients on 2nd floor and three patients on 3rd floor. On the night shift, one R.N. had five patients, one L.P.N. had six patients, and one C.N.A. had nine patients. A second C.N.A. was assigned to care for three patients in the SCU, two patients on 2nd floor and three patients on 3rd floor.
- The 3rd floor census was 13 patients. On the day shift, one R.N. had six patients, one L.P.N. had six patients, and the "Charge Supervisor" had one patient. One C.N.A. had 10 patients. One C.N.A. was assigned to care for four patients in the SCU, two patients on 2nd floor and three patients on 3rd floor. On the night shift, one R.N. had six patients, one L.P.N. had six patients, and the "Charge Supervisor" had one patient. One C.N.A. had nine patients. One C.N.A. was assigned to care for three patients in the SCU, two patients on 2nd floor and three patients on 3rd floor.

- The staffing grid dated Sunday, 05/23/10 showed the facility census was 27 patients on both shifts with no admissions or discharges. There was an R.N. assigned as "Charge Supervisor" on each shift. A Unit Secretary was available for eight hours. The census included seven hemodialysis patients, 13 patients on ventilators, two patients with tracheostomies, 11 patients in the process of being weaned from the ventilator, and two patients in restraints (one on day shift, two on night shift).
- The SCU had a census of three patients. One R.N. was assigned to care for all of these patients on each shift. One C.N.A. was assigned as monitor tech on each shift. A C.N.A. from the 2nd floor assisted with patient care on the day shift. There wasn't a C.N.A. assigned on the night shift.
- The 2nd floor census was 11 patients. The staffing grid was illegible to this reader. During an interview on 07/07/10 at 12:50 P.M., Chief Clinical Officer Staff LB said that the staffing was as follows: On the day shift, one L.P.N. had six patients, one R.N. had five patients, and one C.N.A. had nine patients. A second C.N.A. was assigned to care for three patients in the SCU, two patients on the 2nd floor and 3 patients on the 3rd floor. On the night shift, one R.N. had six patients, one L.P.N. had six patients, and one C.N.A. had 10 patients. During an interview on 07/07/10 at 12:50 P.M., Chief Clinical Officer Staff LB said there wasn't evidence that a C.N.A. was assigned to the remaining two patients.
- The 3rd floor census was 13 patients. The staffing grid was illegible to this reader. During an interview on 07/07/10 at 12:50 P.M., Chief Clinical Officer Staff LB said that the staffing was as follows: On the day shift, one R.N. had six patients, one L.P.N. had six patients, and the "Charge Supervisor" had one patient. One C.N.A. had 10 patients. A second C.N.A. was assigned to care for three patients in the SCU, two patients on the 2nd floor and two patients on the 3rd floor. On the night shift, one R.N. had six patients, one L.P.N. had six patients, and one C.N.A. had 12 patients.

During an interview on 07/07/10 at 12:50 P.M., Chief Clinical Officer Staff LB was asked why the numbers didn't seem to add up correctly in regard to specific staffing assignments considering the census reported. Chief Clinical Officer Staff LB said he/she was not employed at the facility on 05/23/10, but that the fluctuation in numbers of patients reflected the admissions and discharges to the facility.

- The staffing grid dated Monday, 05/24/10 showed the facility census was 27 patients on day shift with one admission and two discharges, and 27 patients on night shift with one admission. There was an R.N. assigned as "Charge Supervisor" on each shift. A Unit Secretary was available for 12 hours. A Wound Care Nurse provided care for 12 hours. The census included five hemodialysis patients, 13 patients on ventilators, two patients with tracheostomies, and eleven patients in the process of being weaned from the ventilator.
- The SCU had a census of three patients on day shift and two patients on night shift. One R.N. was assigned to care for these patients on each shift. One C.N.A. was assigned as monitor tech on each shift. A C.N.A. from the 2nd floor assisted with patient care on both shifts.
- The 2nd floor census was 11 patients. On the day shift, one L.P.N. had six patients, one L.P.N. had five patients, and one C.N.A. had nine patients. A second C.N.A. was assigned to care for three patients in the SCU, two patients on the 2nd floor and two patients on the 3rd floor. On the night shift, one R.N. had five patients, one L.P.N. had six patients, and one C.N.A. had nine patients. A second C.N.A. was assigned to care for two patients in the SCU, two patients on the 2nd floor and five patients on the 3rd floor.
- The 3rd floor census was 13 patients. On the day shift, two L.P.N.'s had six patients each, and the "Charge Supervisor" cared for one patient. One C.N.A. had nine patients. A second C.N.A. was assigned to care for two patients in the SCU, two patients on the 2nd floor and five patients on the 3rd floor. On the night shift, one R.N. had six patients, one L.P.N. had six patients, and the "Charge Supervisor" cared for two patients. One C.N.A. had nine patients. A second C.N.A. was assigned to care for two patients in the SCU, two patients on the 2nd floor and five patients on the 3rd floor. One C.N.A. was in Orientation and wasn't assigned patients.

During an interview on 07/07/10 at 12:50 P.M., Chief Clinical Officer Staff LB was asked why the numbers didn't seem to add up correctly in regard to specific staffing assignments considering the reported census. Chief Clinical Officer Staff LB said he/she was not employed at the facility on 05/24/10, but that the fluctuation in numbers of patients reflected the admissions and discharges to the facility.

- The staffing grid dated Tuesday, 05/25/10 showed the facility census was 27 patients on day shift with two admissions and one discharge, and 27 patients on night shift with one discharge. There was an R.N. assigned as "Charge Supervisor" on each shift. A Unit Secretary was available for 12 hours. A Wound Care Nurse provided care for eight hours. The census included six hemodialysis patients, 12 patients on ventilator

Based on observation, record review and interview, the facility failed to ensure that patients received prescribed follow up evaluation following surgery for one (Patient L13) patient; failed to notify primary physician incident of potential harm for one (Patient L13); and failed to follow a turning schedule for one (L33) patient of seven patients evaluated for quality of care. The facility census was 59.

Findings included:

1. Medical record review on 06/15/10 at 11:20 A.M. for current Patient L13 showed that a pacemaker was inserted on 04/16/10 for chronic atrial flutter (an abnormal heart rhythm that sometimes causes a rapid and irregular heart beat). A follow-up appointment was set for 04/23/10 at 9:00 A.M. Shortly after the pacemaker was inserted, Patient L13 was pulled up in bed by the arm closest to the pacemaker. An incident report showed that a student nurse was responsible.

After pacemaker implantation, patients are often required to immobilize the affected arm with a sling to minimize the risk of lead displacement. Additionally, patients are often warned to "avoid lifting more than 10 pounds for the first 2 weeks after surgery", and "avoid lifting the affected arm higher than the shoulder level for the first few weeks after implantation. "

During an interview on 06/15/10 at 2:45 P.M., Director of Quality Management LM said the medical record showed no evidence that the follow up appointment scheduled 04/23/10 was kept, nor was there evidence that the physician was notified of possible dislodgement of the pacemaker after Patient L13 was lifted inappropriately.

2. Review of the medical record on 06/16/10 at 3:15 P.M. of current Patient L33 showed readmission to the hospital 06/13/10 following placement of a diverting colostomy (a surgical procedure to bring a portion of the large intestine through the abdominal wall to carry stool out of the body) and flap closure of a left gluteal pressure ulcer (a surgical procedure to use a portion of muscle and skin to close a pressure ulcer on the buttocks). Pressure ulcers were also documented on the sacrum (a triangular bone at the base of the spine), left trochanter (a bony knob at the end of the thigh bone near the pelvis) and left heel.

Review of the nationally recognized guidelines for clinicians titled, "Pressure Ulcer Treatment," provided through the Agency for Health Care Policy and Research (AHCPR) and the AHCPR "Preventing Pressure Ulcers: A Patient's Guide" showed the following (in part):
- "A pressure ulcer is an injury usually caused by unrelieved pressure that damages the skin and underlying tissue."
- "Unrelieved pressure on the skin squeezes tiny blood vessels, which supply the skin with nutrients and oxygen. When skin is starved of nutrients and oxygen for too long, the tissue dies and a pressure ulcer forms."
- "A pressure ulcer is defined as any lesion cause by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are usually located over bony prominences," such as the trochanter.
- "While in bed: Avoid positioning patients on a pressure ulcer."
- "Written repositioning schedules should be developed even when patients are using pressure-reducing support surfaces, because these surfaces are only adjuncts to strategies for positioning and careful monitoring of at-risk patients."
- "Postoperative care: Minimize pressure to the operative site."

Observation of Patient L33 on 06/16/10 showed that the patient was positioned on the left side at 1:00 P.M. The Patient was observed periodically throughout the afternoon and was continually positioned on the left side. Patient L33 was positioned on the left side when the surveyor left the floor at approximately 4:05 P.M.

During an interview on 06/17/10 at 10:40 A.M., Director of Quality Management Staff LM said the electronic medical record for Patient L33 showed documentation on 06/16/10 that the patient was positioned on the left side at 11:31 A.M. Two separate documentations in the nursing notes were timed as 4:04 P.M. - one stating Patient L33 was turned to left side, and one stating Patient L33 was turned to the right side. Per Staff LM, documentation at 6:01 P.M. showed that Patient L33 was turned to the right side.

Based on observation, documentation, and interview, the patient was positioned on the newly grafted left trochanter site from 11:31 A.M. until at least 4:04 P.M. Continuous pressure on the newly grafted skin graft places the patient at risk of having a non-healing skin graft wound due to poor oxygenation of tissue.

Based on record review and interview, the facility failed to identify, develop, and update a comprehensive care plan that included interventions and measurable goals for two patients (Patients L13 and L33) of three records reviewed for care plan. The facility census was 59.

Findings included:

1. Medical record review on 06/15/10 at 11:20 A.M. for current Patient L13 showed that a pacemaker was inserted on 04/16/10 for chronic atrial flutter (an abnormal heart rhythm that sometimes causes a rapid and irregular heart beat). A follow-up appointment was set for 04/23/10 at 9:00 A.M. There were no physician orders for wound care or pacemaker aftercare. The admission nursing documentation failed to record evidence of an immobilizing device being used to prevent displacement of the pacemaker lead after insertion, but the Occupational Therapist documented that the left upper extremity was in a shoulder immobilizer. A nursing note 04/25/10 at 2:54 P.M. noted the presence of steri-strips at the pacemaker site and also that the patient was wearing an arm sling. Shortly after the pacemaker was inserted, Patient L13 was pulled up in bed by the arm closest to the pacemaker, potentially dislodging the pacemaker electrode. Despite this incident, there was no documentation on the Care Plan of the aftercare for Patient L13, including use of a sling or restricting movement of his left arm.

After pacemaker implantation, patients are often required to immobilize the affected arm with a sling to minimize the risk of lead displacement. Additionally, patients are often warned to "avoid lifting more than 10 pounds for the first 2 weeks after surgery", and "avoid lifting the affected arm higher than the shoulder level for the first few weeks after implantation," (www.baylorhealth.edu/proceedings/22_1/22_1_adams_sling.pdf ).

2. Review of the medical record on 06/16/10 at 3:15 P.M. of current Patient L33 showed readmission to the hospital 06/13/10 following placement of a diverting colostomy (a surgical procedure to bring a portion of the large intestine through the abdominal wall to carry stool out of the body) and flap closure of a left gluteal pressure ulcer (a surgical procedure to use a portion of muscle and skin to close a pressure ulcer on the buttocks). Pressure ulcers were also documented on the sacrum (a triangular bone at the base of the spine), left trochanter (a bony knob at the end of the thigh bone near the pelvis) and left heel. The initial skin assessment dated 06/14/10 by the facility Wound Nurse showed 8 staples present on the abdomen, and 30 surgical staples in the left trochanter area. There was no indication in the Care Plan or Physician Orders regarding staple removal. Review of the nursing care plan revealed no problem, interventions or goals related the skin graft or prevention of new pressure ulcers.

3. During an interview on 06/14/10 at 4:20 P.M., Shift Supervisor LN said that when a patient is admitted, nurses are told to put at least two problems on the nursing care plan. The supervisor on night shift then checks all the paperwork and adds additional items to the care plan. If they have been assigned patients, they can't do that. Staff LN said, "If a PICC (peripherally inserted central catheter - used for long term access for intravenous fluids and medications) line is inserted during your shift, you are supposed to enter that on the care plan. Otherwise, updating the care plan is the supervisor's job. The staff nurse doesn't have time. They add items for the new patients only."

Based on facility policy review, observation, and interview, the facility failed to ensure medications were administered as ordered by the physician for two patients (Patients L3 and L17) of ten observed during medication administration; failed to ensure a second nurse verified high risk medications prior to administration for two (Patients L4 and SA 4) of two patients' records reviewed for high risk medication; and failed to follow hospital policy with regard to administration technique for one (Patient L33) of two patients observed receiving medications by subcutaneous injection. The facility census was 59.

Findings Included:

1. Review of the facility policy titled, "High-Risk Medications", revised 05/09, showed the following (in part):
"High-risk (or high-alert) drugs are those drugs involved in a high percentage of medication errors and/or sentinel events and medications that carry a higher risk for abuse, errors or other adverse outcomes."
The list of "High Risk Medication" included "Heparin" (medication used to help prevent blood clots) with the "Special Instructions - Before administering any of these agents use a second nurse to independently check the drug dose".
The list of "High Risk Medication" included "Insulin" (medication used to lower the blood sugar) with the "Special Instructions - Verify dose with second nurse prior to administration".
"Safety Strategies Implemented" included "Double check system in place whereby one nurse prepares the medication and one nurse verifies".

Review of the facility policy titled, "Medication Management (Administering)," revised 11/09 showed (in part):
- "Subcutaneous Injection:"
- "Recommended needle gauge/length: average adult requires a 25 G 5/8"; an elderly or thin patient, a 25G to 27G 1/2."

2. Observation on 06/15/10 at 10:00 A. M. Staff LH, LPN (Licensed Practical Nurse) administered medications to Patient L 3 through patient's NG (nasogastric tube, a tube inserted down the nose to the stomach). Staff LH, LPN gave Senna-Lax (medication for constipation) one tab crushed in a small amount of water through the NG (nasogastric tube) tube. Record review on 06/15/10 at 2:25 P. M. of Patient L 3 medical record MAR (medication administration record) showed Staff LH, LPN documented giving 10 ml (milliters) Senna-Lax (medication given for constipation) through the NG (nasogastric) tube. Patient L 3 was to have two tablets of Senna-Lax (medication for constipation) to equal the dosage of 10 ml. (mililiters) liquid form Senna-Lax (medication given for constipation).

3. Observation on 06/16/10 at 9:15 A. M. Staff LQ, RN (Registered Nurse) administered oral (by mouth) medications to Patient L 17. Record Review of Patient L 17 on 06/16/10 at 10:50 A. M. showed that Staff LQ, RN (registered nurse) documented the medications were given by NG (nasogastric tube, a tube inserted into the stomach through the nose). Staff failed to obtain order from physician to discontinue the NG tube, and to change the route of medication from NG to oral.


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4. Review of current Patient L4's medical record on 06/14/10 showed that he/she was admitted on 06/01/10. Between 06/01/10 and 06/14/10, the patient had received 26 Heparin (medication to prevent blood clots) injections. Of those 26 injections, 23 were not verified by a second nurse. Further review showed that of the last nine Insulin (medication to lower blood sugar) injections, five were not verified by a second nurse.

During an interview on 06/14/10 at approximately 3:15 P.M., Infection Control Nurse, Staff LA, stated that Heparin and Insulin doses are to be verified by a second nurse prior to administration and the name of that second nurse should be on the medication record.

5. Review of current Patient SA4's medical record on 06/15/10 showed that he/she was admitted on 05/29/10. Between 05/29/10 and 06/15/10, the patient had received 50 Heparin injections. Of those 50 injections, 48 were not verified by a second nurse.


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6. Observation on 06/16/10 at approximately 1:30 P.M. showed Registered Nurse (R.N.) Staff LW preparing to administer medications to Patient L33. Staff LW withdrew the Heparin into a syringe using a 1 inch needle. Without changing needles, Staff LW grasped a large fold of skin from this slender patient's abdominal area and administered the Heparin at a 90 degree angle, burying the needle to a depth of 1 inch in the subcutaneous tissue. According to facility policy, a shorter needle should have been used.

Based on record review and interview, the facility failed to ensure staff followed physician's orders related to wound care for one current patient (L13) of seven patients observed during wound care. The facility census was 59.

Findings included:

Medical record review for current Patient L13 on 06/15/10 at 11:00 A.M. showed the following (in part):
- Nursing notes noting the application of Baza (an antifungal cream) to the buttock on the following dates and times:
06/12/10 at 7:07 A.M.
06/13/10 at 5:08 A.M.
06/14/10 at 8:16 A.M.
06/15/10 at 8:31 A.M.
- Review of the Medication Administration Record showed that Baza was not included on the list.
- There was no evidence of a signed "Protocol for Initial Wound Treatment" in the medical record.
- A notation on the Physician Orders page dated 06/11/10 at 3:45 P.M. as follows: "Wound Care Recommendations: buttock. Baza Antifungal Cream to buttock daily. Please call (physician, Staff LAA) with above recommendations to receive wound care orders." The physician did not co-sign the recommendations and no other wound care orders were found. Therefore, nursing staff were treating the patient without a physician order to do so.

During an interview on 06/15/10 at 10:30 A.M., Director of Quality Management Staff LM said that the Wound Care nurse typically assesses the patient and makes recommendations. The physician then signs the order and the treatment begins. There was no explanation for why this order was initiated without being co-signed by the physician.

Based on facility policy review, record review, and interview, the facility failed to replace tube feeding (a commercial product fed through a tube directly into the patient's digestive system) bottle and tubing for one (Patient SA4) of six patients reviewed for tube feeding; failed to accurately document the consumption of tube feeding for six (Patients SA4, SA3, L13, L33, SA9, and SA7) of six patients reviewed; failed to consistently document the consumption of special nutritional supplements taken by mouth for one (Patient SA8) of one patient records reviewed; and failed to accurately document patient hygiene for two (Patients L6 and L15) of four patient records reviewed. The facility census was 59.

Findings included:

1. Materials given to this surveyor by Director of Quality Management Staff LM as the facility policy showed a copy of a procedure from a Lippincott Nursing Manual. The section "Administration of Enteral (Tube) Feedings" stated the following nursing action (in part):
"Rinse equipment with warm water, and dry. Replace every 24 hours or per facility policy."
"Document type and amount of feeding, amount of water given, and patient tolerance of procedure."

2. Observation of current Patient SA4 on 06/15/10 at 1:40 P.M. showed the patient was receiving tube feeding (nutrition delivered through a tube).

Review of Patient SA4's medical record on 06/15/10 at 2:10 P.M. showed tube feeding was started on 06/08/10. There was no documentation that the bag and tubing were changed on 06/10/10, 06/11/10, 06/12/10, 06/13/10, and 06/14/10.

During an interview on 06/15/10 at 2:10 P.M., Nurse Manager, Staff SAB, stated that tubing should be changed every 24 hours and the bottle changed with the tubing and as needed.

Further review of Patient SA4's medical record showed the tube feeding was to be administered at 50 ml (milliliters) / (per) hr (hour). The following totals were documented:
06/12/10 at 8:41 A.M., 400 ml
06/12/10 at 6:54 P.M., 600 ml
06/13/10 at 8:15 A.M., 500 ml
06/13/10 at 5:44 P.M., 600 ml
The total amounts listed would have been calculated by multiplying 50 (ml) times the number of hours since the total was last documented, rather than recording the accurate amount of tube feeding delivered by the infusion pump. Staff SAB confirmed that on 06/12/10 and 06/13/10, the pump was not cleared as it should have been.

3. Observation of current Patient SA3 on 06/15/10 at 1:30 P.M. showed the patient was receiving tube feeding.

Review of Patient SA3's medical record on 06/15/10 at 3:05 P.M. showed tube feeding was started on 05/28/10. Documentation showed that the bag and tubing was not changed on 05/30/10, 06/02/10, 06/03/10 (only bag changed), 06/04/10, 06/07/10, 06/10/10, 06/11/10, 06/13/10, and 06/14/10. Further review showed the tube feeding was to be administered at 50 ml/hr. The following totals were documented:
06/13/10 at 8:11 A.M., 600 ml
06/13/10 at 1:27 P.M., 250 ml
The total amounts listed would have been calculated by multiplying 50 (ml) times the number of hours since the total was last documented, rather than recording the accurate amount of tube feeding delivered by the infusion pump.

4. Record review for current Patient L13 on 06/15/10 at 3:10 P.M. showed that the patient was receiving TwoCal tube feeding (a nutritional supplement) at 50 cc (cubic centimeter, same as milliliter) per hour for a daily total of 1200 cc/24 hours. The documentation showed the following amounts consumed by the patient:
06/11/10 504 cc
06/12/10 1250 cc
06/13/10 650 cc
06/14/10 1423 cc

5. Record review for Patient L33 on 06/16/10 at 3:40 P.M. showed that the patient was receiving Jevity tube feeding (a nutritional supplement) at 70 cc/hr for a daily total of 1680 cc/24 hours. The documentation showed the following amounts consumed by the patient:
06/14/10 1324 cc
06/15/10 1735 cc

6. During an interview on 06/16/10 at 3:45 P.M., Director of Quality Management Staff LM reviewed the electronic documentation and stated that staff were instructed to document tube feedings three times a day, but there seemed to be some confusion about how to calculate the amount to document.

7. Review of Patient SA9 ' s medical record on 06/16/10 at 2:00 P.M. showed an admission date of 05/24/10 and physician orders as follows:
- 05/24/10 for Jevity (a nutritional supplement for a gastrostomy tube) 1.2 calories at 70 cc (cubic centimeter same as milliliters) per hour (this would =1680 cc per 24 hours)
- 05/25/10 rate was increased to 75 cc per hour (this would = to 1800cc per 24 hours)
- 06/07/10 increased to 80 cc per hour (this would = 1920 cc in 24 hours)

Review of the supplement documentation showed the staff failed to document tube feedings appropriately.
05/30/10 1490 cc
05/31/10 2295 cc
06/01/10 2580 cc
06/03/10 1312 cc
06/04/10 1616 cc
06/05/10 1259 cc
06/06/10 1835 cc
06/07/10 1556 cc
06/08/10 2057 cc
06/09/10 1328 cc
06/10/10 1763 cc
06/11/10 1931 cc
06/12/10 1930 cc
06/13/10 1440 cc
06/14/10 2580 cc
06/15/10 3189 cc
06/16/10 1268 cc

8. Review of Patient SA7's medical record on 06/16/10 at 3:00 P.M. showed physicians orders as follows:
- 06/04/10 Pulmacare (a supplement for dietary intake) 30 cc (this would = 720 cc per 24 hours)
- 06/06/10 rate increased to 65 cc per hour (this would = 1560 cc per 24 hours)
- 06/07/10 rate decreased to 50 cc per hour (this would = 1200 cc per 24 hours)
- 06/08/10 Pulmacare changed to Jevity 1.2 calorie at 70 cc per hour (this would = 1680 cc per 24 hours)
- 06/10/10 tube feeding at 40 cc per hour (this would = 960 cc per 24 hours)
- 06/12/10 tube feeding on hold with water flushes after medication only.

Review of the supplement documentation showed the staff failed to document tube feedings appropriately.
06/05/10 1382 cc pulmacare
06/06/10 1153 cc
06/07/10 1402 cc order dc (discontinued)
06/08/10 699 cc
06/08/10 560 cc Jevity 1 calorie
06/09/10 890 cc
06/10/10 500 cc dc (discontinued)
06/11/10 650 cc
06/12/10 960 cc
06/13/10 240 cc

9. During an interview on 06/16/10 at 3:55 P.M., Staff SAB, Nurse Manager, verified that intake and output documentation for tube feeding amounts were not all accurate.

10. Review of Patent SA8's medical record on 06/16/10 at 1:00 P.M. showed the following: A physician order for "Ensure Plus (a drinkable nutritional supplement) to start 05/11/10 5:00 P.M, BID (twice a day) (give at) 08 and 17 (8:00 A.M. and 5:00 P.M.), after 90 days, renewable." Review of the supplement documentation showed staff failed to document the Ensure Plus appropriately. Patient SA8 was admitted for treatment of a fistula (an abnormal passage) between the ileum (lower part of the small intestine) and the rectum (lowest part of the intestine before evacuating from the body), a urinary tract infection, depression, anxiety, and wound care. The physician planned to continue physical and occupational therapy.
05/18/10 at 8:00 A.M. no documentation
05/28/10 at 8:00 A.M. no documentation
06/03/10 at 8:00 A.M. no documentation
06/04/10 at 8:00 A.M. no documentation
06/08/10 at 5:00 P.M. no documentation
06/14/10 at 9:18 P.M. no documentation

11. Observation on 06/14/10 at 2:10 P.M. showed that Patient L6's hair did not appear to be clean. During an interview, Patient L6 said he/she was bathed approximately once per week, if requested. Patient L6 also said he/she had a shampoo approximately once per month, if requested. The patient's mother, who was visiting, nodded her head in agreement with this allegation.

Review of the internal document "Hygiene Audit" for May, 2010 on 06/15/10 at 8:30 A.M. showed a "B" for the dates of 05/05/10 and 05/07/10 through 05/30/10 for Patient L6. The date of 05/06/10 had an "X." Review of the internal document "Hygiene Audit" for June, 2010 on 06/15/10 at 2:00 P.M. showed a "B" for the dates of 06/01/10 through 06/14/10 for Patient L6. There was no documentation to distinguish between days on which patients received hair care versus those on which they did not.

During an interview on 06/14/10 at 3:30 p.m., Shift Supervisor Staff LN said the policy was recently changed, and patients are now bathed twice per week unless requested more often. Shampoos are done with a shower cap type product that contains shampoo, and when showers are needed, they are done by Occupational Therapy. Regarding charting what the patient received, B= bath and P= partial bath.

During an interview on 06/16/10 at 1:30 P.M., Nurse Manager Staff LV confirmed that the "B" on the "Hygiene Audit" document meant a bath was performed. When asked why the audit would indicate a bath was done nearly daily but the patient reported something different, Nurse Manager Staff LV said he/she would to talk to her staff before answering, but said, "Shampoos are done at the same time as baths."

12. Observation on 06/16/10 at 10:00 A.M. showed that Patient L15's hair did not appear to be clean. During an interview, Patient L15 said he/she received a bath every day, and received a shampoo two days earlier.

Review of the internal document "Hygiene Audit" for June, 2010 on 06/15/10 at 2:00 P.M. showed a "B" for the dates of 06/01/10 through 06/14/10. There was no documentation to distinguish between days on which patients received hair care versus those on which they did not.


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Based on record review, the medical staff failed to complete and authenticate History and Physicals for four patients (Patient L6, L13, L15, and SA1) of 33 patient's medical records reviewed. The facility census was 59.
Findings included:

1. Review of the facility policy titled, "General Documentation Guidelines", revised 12/08 gave direction, in part, to include the following:
- "All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated and their authors identified."

Review of the facility document titled, "Medical Staff Rules and Regulations", approved 10/27/08 gave direction, in part, to include the following:
- "The responsible practitioner shall be responsible for the preparation of a complete medical record for each patient."
- "All clinical entries in the patient's medical record shall be accurately dated and authenticated."

2. Review of the medical record for current Patient L6 on 06/14/10 at 2:30 P.M. showed the patient was admitted to the facility on 05/04/10 and the History and Physical was dictated on 05/05/10. Included in the History and Physical was a blank line where the transcriptionist was unable to complete the sentence.
- "____________ mostly in the chest and abdominal wall."

The physician signed the history and physical on 05/06/10 but did not fill in the missing information.

3. Review of the medical record for current Patient L13 on 06/15/10 at 10:30 A.M. showed the patient was admitted to the facility on 04/16/10 and the History and Physical was dictated on 04/17/10. Included in the History and Physical were the following eight blank lines where the transcriptionist was unable to complete the sentence:
- "He also found to have some lung masses __________."
- "Significant for respiratory related _____________, vent (ventilator)-associated pneumonia (an infection of one or both lungs), cardiac arrhythmia (abnormal heart beat), brady-tachy syndrome (alternating rhythms of abnormally slow and abnormally fast heart beats), status post pacemaker placement, COPD (chronic obstructive pulmonary disease - a progressive lung disease), pleural effusion (an accumulation of fluid in the layers of tissue between the chest wall and the lungs), status post pleurodesis (a surgical procedure that causes the membranes of the lung to stick together and prevent fluid accumulation) of right lung mass, ulcerative colitis (an inflammatory bowel disease) status post tracheostomy (a surgical procedure that creates an artificial opening from the neck into the windpipe), anemia (insufficient numbers of healthy red blood cells), cholelithiasis (gallstones), venous stasis skin excoriation (poor circulation that can cause skin to deteriorate and die)."
- "___________ 1.25 mg p.o. every 12 hours"
- "__________ 30 mg daily"
- "____________ 12 hours"
- "No chest pain, not short of breath, no nausea or vomiting, has diarrhea, on Foley catheter, not associated _________ CVA (cerebrovascular accident - stroke)."
- "HEENT (an accronym for Head, Eyes, Ears, Nose, and Throat): Positive pallor (pale skin color), no icterus (jaundice of the eyes). ____________. "
- "I will continue the patient on ___________."

The physician signed the history and physical on 04/18/10 but did not fill in the missing information.

4. Review of the medical record for current Patient L15 on 06/16/10 at 10:35 A.M. showed the patient was admitted to the facility on 05/05/10 and the History and Physical was dictated on 05/05/10. Included in the History and Physical were the following 13 blank lines where the transcriptionist was unable to complete the sentence:
- "GYN (Gynecologist) evaluated the patient for that, but they are thinking the patient is on anticoagulation, possibly ___________ bleeding and they want to do a workup when the patient is more stable. The patient developed a seizure disorder a few days back and neurology was consulted."
- "___________ brain and has edema, possibly related to current illness, and given the seizure activity, the patient was started on Keppra (used to treat seizures) and maintained on seizure precautions."
- "We discontinued the heparin drip and have given the patient a dose of Lovenox (an anticoagulant) and also discontinued her mittens and __________ the patient closely."
- "__________ 1 mg (milligram) IM (intramuscular) every 4 p.r.n. (as needed)"
- " ___________ every 12 hours"
- "Has diarrhea on ___________."
- "We will keep the patient on ___________ trach (tracheostomy) collar."
- "The patient is on amiodarone (used to prevent abnormal heart rhythms) 150 mg every 12 hours and metoprolol (used to treat high blood pressure) ___________ b.i.d.(twice daily)"
- "Continue the patient's Nepro (nutritional supplement) __________ cc an hour. We will involve the nephrologist ________ renal functions."
- "Will give the patient _________ daily and also Bactrim DS (antibiotic) 1 daily."
- "The patient was confused and agitated possibly _________metabolic condition. We will keep the patient out of the restraints at this point and see _________."

The physician signed the history and physical on 05/07/10 but did not fill in the missing information.


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5. Review of current Patient SA1's medical record on 06/15/10 showed the patient was admitted on 05/27/10. The history and physical was dictated and typed on 05/28/10. Included in the history and physical were the following four blank lines where the transcriptionist was unable to complete the sentence:
"The patient came to _________ Hospital and was found to have osteomyelitis also."
"Medications: ...Amitiza (medication to treat constipation) ______ mg (milligrams) nightly".
"Right now he is ___________."
"He is an ex-sailor __________."
The physician signed the history and physical on 06/06/10 but did not fill in the missing information.

Based on facility policy review and record review, the medical staff failed to ensure order entries were accurately dated, timed and authenticated for 11 (Patient L2, L6, L13, L23, L11, L8, L7, L9, L17, SA8, and SA7) of 33 patient records reviewed. The facility census was 59.

Findings included:

1. Review of the facility policy titled, "General Documentation Guidelines", revised 12/08 gave direction, in part, to include the following:
- "All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated and their authors identified."
- "Verbal and telephone orders must be authenticated by the responsible practitioner within the time frame defined in the Medical Staff Rules and Regulations."

Review of the facility document titled, "Medical Staff Rules and Regulations", approved 10/27/08 gave direction, in part, to include the following:
- "All verbal orders shall be transcribed in the medical record and shall be countersigned by the practitioner in a time frame that complies with State regulations."
- "All clinical entries in the patient's medical record shall be accurately dated and authenticated."

Review of the facility policy titled, "Ordering of Medications", revised 11/09 gave direction, in part, to include the following:
-"All medication orders must be entered into the patients' medical record (computerized or manual) and must include: drug name, strength, form, route, dosage, frequency, date, time of order, and name of prescribing licensed practitioner."
- "Medication orders identified to be missing any of the required elements as outlined in this policy are considered incomplete. The ordering prescriber will be contacted for clarification prior to implementation of the medication order."

2. Review of the medical record for current Patient L2 on 06/15/10 at 4:20 P.M. showed the following:
- A sticker entry dated 06/11/10 stated (in part): "Please D/C (discontinue) Salmeterol (Serevent [used to treat wheezing, shortness of breath and breathing difficulties]). Change to Advair (Fluticasone/Salmeterol [used to prevent wheezing, shortness of breath and breathing difficulties]) 250/50 mcg (micrograms). To/Dr: (Staff LY)." The sticker was signed by a Pharmacist. There was a signature and date of 06/14/10 to the right of the sticker. The signature was timed with "13." The time and date on the order was verified by Director of Quality Management Staff LM.
- A physician order dated 06/11/10 which was signed, but not dated, for the following:
- "Advair (a steroid used to treat asthma and COPD)
- Coumadin (anticoagulant) 5 mg (milligrams) po (by mouth) daily
- PT (prothrombin time) with INR (international normalized ratio) in AM (a test used to determine the clotting tendency of blood)
- Consult Dr. (Staff LZ)
- ESR (erythrocyte sedimentation rate), CRP (C-reactive protein) in AM (tests used to measure inflammation in the body)
- Megace (used as an appetite enhancer) 800 mg po daily
- Increase Sertraline (antidepressant) to 100 mg po daily
- Dig (digoxin) level in AM (test used to monitor efficiency/toxicity of digitalis [used to strengthen heart contractions] in the blood)"

3. Review of the medical record for current Patient L6 on 06/14/10 at 2:45 P.M. showed the following:
- A sticker entry dated 05/05/10 stated (in part): "Acetaminophen (a pain reliever): moderate pain." To/Dr: (Staff LAA)." The sticker was signed by a Pharmacist. There was a signature and date of 05/05/10 to the right of the sticker, but not a time.
- A formulary substitution sticker entry dated 05/05/10 stated (in part): "Pharmacy has made a Formulary Substitution per approved Medical staff guidelines. Non-Formulary medication: Esomeprazole (used to treat gastroesophageal reflux) 40 mg PT (meaning of abbreviation unknown) daily. Hospital Formulary medication: Prevacid (used to prevent stomach and intestinal ulcers) 30mg PT daily." The sticker was signed by a Pharmacist. There was a signature and date of 05/05/10 to the right of the sticker, but not a time.

4. Review of the medical record for current Patient L13 on 06/15/10 at 10:00 A.M. showed the following:
- A physician order dated 04/17/10 for "Telemetry." The order was signed and dated 04/17/10, but not timed.
- A formulary substitution sticker entry dated 04/18/10 stated (in part): "Pharmacy has made a Formulary Substitution per approved Medical staff guidelines. Non-Formulary medication: Adsorbotears (artificial tears). Hospital Formulary medication: Akwa Tears Lubricant Eye Drops, 1 drop OU (both eyes) BID (twice daily)." The sticker was signed by a Pharmacist. There was a signature to the right of the sticker, but no date or time.
- A sticker entry dated 04/29/10 stating (in part): "Seroquel (used to treat schizophrenia) - for mild to moderate anxiety." To/Dr: (Staff LBB)." The sticker was signed by a Pharmacist. There was a signature to the right of the sticker, but no date or time.


09117

5. Review of the medical record for current Patient L 23 showed the following telephone orders:-Physician order of 06/09/10 at 10:45 P.M. for Morphine (a narcotic medication for severe pain) 1 milligram IVP (Intravenous push), x 1 (one dose only) for severe pain. The order was not signed by 06/17/10.
-Physician order of 06/09/10 at 11:45 P.M. for Morphine 1 milligram IVP x 1 dose for severe pain. The order was not signed by 06/17/10.


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6. Record review on 06/15/10 at approximately 1:30 P.M. of current Patient L 11 medical record showed the following:
-Physician order dated 06/01/10 stated, "DC (discontinue) (writing illegible), repeat blood cultures x2 sets can be done at HD (interpretion unknown)" was not timed by the physician.
-Physician order dated 06/02/10 stated, "No (writing illegible) resume on 06/03/10" was not timed by the physician.
-Physician order dated 06/08/10 that stated "1. Check ABG (arterial blood gases [blood obtained per needle stick directly into the artery]) 2. If OK trials 2 hours BID (two times per day)" was not timed by the physician.
-Physician order dated 06/08/10 that stated "Begin (writing illegible) 250mg (milligrams) IV (intravenous) Q (every)12 hrs. (hours), Blood Cultures x (times) 2 sets, CXR (chest x-ray) Portable-Pneumonia, Check UA (urine specimen)/urine culture" was not timed by the physician.
-Physician order dated 06/09/10 that stated "Blood Cultures x (times) 2 sets" was not timed by the physician.

7. Record review on 06/15/10 at 2:00 P.M. of current Patient L 8 medical record showed the following:
-Physician order dated 06/02/10 stated, "Check UA (urine specimen) with Micro (special urine test)" was not timed by the physician.
-Physician order dated 06/02/10 stated, "Change Dilaudid (medication given for pain) 2 mg (milligrams) po (orally) Q (every) 4 hours PRN (as needed)" was not timed by the physician.
- Physician order dated 06/08/10 stated, "Increase (writing illegible) to 200 mg (milligrams) (writing illegible) weekly" was not timed by the physician.

8. Record review on 06/15/10 at 2:25 P.M. of current Patient L 7 medical record showed the following:
-Physician order dated 06/01/10 stated, "PICC (peripherally inserted central catheter) peripheral (pertaining to the arms) line and remove Left (writing illegible) check tip for culture. If unable to set peripheral (writing illegible) PICC (peripherally inserted centeral catheter) line. Check CBC (complete blood count) with (writing illegible). Check Blood cultures x 2 sets at HD" was not timed by the physician.
-Physician order dated 06/03/10 stated, "Check CXR (chest x-ray) portable, pneumonia" was not timed by the physician.
- Physician order dated 06/08/10 stated, "D/C (disconitinue) (writing illegible) " was not timed by the physician.
-Physician order dated 06/09/10 stated, "Vancomycin (potent antibiotic) 1 Gram IV (intravenous) Q (every) HD day start today, Ceferine (antibiotic) 1 Gram IV (intravenous) Q (every) 24 hours" was not timed by the physician.

9. Record review on 06/15/10 at 3:00 P.M. of current Patient L 9 medical record showed the following:
-Physician order dated 06/15/10 stated, "Continue Fluconezole (a drug to treat fungus infections), Continue po (oral) Vanco (Vancomycin), Change Imipenem (antibiotic) to 500 mg (milligram) IV (intravenous)Q (every) 6 hours, Begin Vancomycin 1 G (Gram) IV (intravenous) Q (every) 12 hours, Check Vanco (Vancomycin) trough (blood test for amount of Vancomycin in patient's blood stream) level prior to 4th dose," was not timed by the physician.

10. Record review on 06/16/10 at 9:15 A.M. of current Patient L 17 medical record showed the following:
- Physician order dated 06/02/10 stated, "Check blood cultures x (times) 2 sets, PICC (peripherally inserted central catheter) peripherally (pertaining to the arms) line, remove PICC (perpherially inserted central line) and send tip for culture" was not timed by the physician.
-Physician order dated 06/08/10 stated, "DC (discontinue) Cefepime (antibiotic), check blood cultures x (times) 2 sets" was not timed by the physician.
-Physician order dated 06/10/10 stated, "Vancomycin 1 Gr (gram) IV (intravenous) Q (every) 12 hours first dose now, get Vanco (Vancomycin) trough (blood test to obtain amount of drug in patient's blood stream) prior to 4th dose" was not timed by the physician.
-Physician order dated 06/10/10 stated, "DC (discontinue) Vancomycin tomorrow, Continue Fluconazole" was not timed by the physician.


29117

11. Record review on 06/16/10 at 1:00 P.M. of current Patient SA8 ' s medical record showed an order written on 06/16/10 for "Vt Ds (unable to interpret Vt Ds) 2000 (unable to interpret word) PO (by mouth) daily, hold KCL (potassium), (unable to interpret word) 25 mg. (milligram) PO daily, OK to discharge to SNF (skilled nursing facility), PT (physical therapy) evaluation and treat at the NH (nursing home)-SNF." The order was not timed by the physician.

12. Record review on 06/16/10 at 3:00 P.M. of current Patient SA7's medical record showed the following:
- an order written on 06/07/10 at 2:00 P.M. by Staff SAJ, Nurse Practitioner (N.P.) for:
1) " DC (discontinue) IV (intravenous) fluids "
2) Unable to interpret this order
3) Unable to interpret part of this order. The last part reads per "GT (gastric tube) every day". The order was not dated or timed by the physician.
- an order written on 06/08/10 for "Inhaled Tobramycin (antibiotic) 160 mg every 8 hours." The order was not timed by the physician.
- an order written on 06/08/10 at 5:00 P.M. by Staff SAJ, N.P. for "Trach. (tracheotomy [a hole surgically placed in the trachea to breath from]) collar for 24 hours as tolerated. Check ABG's (lab test for blood gasses) every 24 hours. Change the MDL (a breathing treatment) to Duo Nebs (a breathing treatment) every four hours and up in a chair bid (twice a day)." The order was not dated or timed by the physician.
-an order written on 06/10/10 at 12:35 P.M. by Staff SAJ, N.P. for "CBC and BMP in am". The order was not dated or timed by the physician. .
-an order written on 06/10/10 at 12:55 P.M. by Staff SAJ, N.P. to
1) "Hold GT (gastric tube) feeding for one (unable to interpret this word." 2) "Change hold GT water flush."
3) "Change to Reglan (a medication for the stomach) 10 mg (milligrams) per IVP (intravenous push) every 8 hours. Start first dose at 4:00 P.M."
4) "Nystantin (an antifungal antibiotic) liquid, swish and swallow TID (3 times a day)." The order was not dated or timed by the physician.
-an order written on 06/10/10 at 3:10 P.M.by Staff SAJ, N.P. for "Simethicone (a medication to help relieve gas) 80 mg per GT (gastric tube) every 8 hours Start now." The order was not dated or timed by the physician.
- an order written on 06/11/10 at 9:15 A.M. by Staff SAJ, N.P. for
1) "CT (CAT scan - an x-ray test that shows tissues at any depth) of abdomen and pelvis in the (unable to read next few words) IV contrast (an intravenous dye) (abdominal pain and distention)."
2) "Keep NPO (nothing by mouth)"
3) "D5 NS (intravenous fluids of dextrose and salt water solution) 50 ml (milliliters)/hour x 1 liter."
The order was not dated or timed by the physician.
- an order written on 06/11/10 at 11:15 A.M. by Staff SAJ, N.P. for
1) "CBC (a blood test to check the number of red blood cell and white blood cells in the blood) and BMP( a blood test for electrolyte levels ) in A.M."
2) (Unable to interpret word.) BMP and CBC on (unable to interpret rest of order)
The order was not dated or timed by the physician.
-an order written on 06/11/10 at 2:55P.M. by Staff SAJ, N.P. for
1) "Miralax (a laxative) 17 gram x 1 per G Tube"
2) "Miralax 17 gram per GT (G-tube) every day hold for diarrhea"
The order was not dated or timed by the physician.
-an order written on 06/12/10 at 9:30 A.M. by Staff SAJ, N.P.
1) "Hold GT flushes with free H2O (water) use 30 ml. H2O flush for meds only."
2) "BMP and CBC in am"
3) (unable to interpret all words in order)
The order was not dated or timed by the physician.
-an order written on 06/13/10 at 8:40 AM by Staff SAJ, N.P. for
1) "CXR (chest x-ray) x 1 now"
2) "Obstructive series now"
The order was not dated or timed by the physician.
-an order written on 06/13/10 at 10:35 A.M. by Staff SAJ, N.P. for
1) "Digital (unable to interpret word)"
2) "Change to N. (normal) Saline to (unable to interpret word)"
3) "Hold GT (gastric tube) feeding for now"
4) "Labs in am" .
5) "Change to Raglan (a stomach medication) 10mg IV QID (four times a day) every 6 hours"
6) "Hold Miralax"
The order was not dated or timed by the physician.
- an order written on 06/14/10 at 12:30 P.M. by Staff SAJ, N.P. for a "CBC and BMP in am." The order was not dated or timed by the physician.
-an order written on 06/14/10 at 12:50 P.M. by Staff SAJ, N.P. that read "Please place rectal tube for decompression." The order was not dated or timed by the physician.

During an interview on 06/16/10 at 3:30 P.M. Staff SAB, Nurse Manager verified these orders were not appropriately dated or timed by the physicians.

Based on the facility's Rules and Regulations and record review, the facility failed to ensure telephone and verbal orders were signed by a physician with 48 hours for 13 (Patient L2, L1, L25, SA6, L7, L10, L17, SA9, SA7, L4, SA1, SA4, and SA11) of 33 medical records reviewed. The facility census was 59.

Findings included:

1. Review of the facility policy titled, "General Documentation Guidelines", revised 12/08 gave direction, in part, to include the following:
- "All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated and their authors identified."
- "Verbal and telephone orders must be authenticated by the responsible practitioner within the time frame defined in the Medical Staff Rules and Regulations."

Review of the facility document titled, "Medical Staff Rules and Regulations", approved 10/27/08, gave direction, in part, to include the following:
"All verbal orders shall be transcribed in the medical record and shall be countersigned by the practitioner in a time frame that complies with State regulations."

2. Review of the medical record for current Patient L2 on 06/15/10 at 4:20 P.M. showed a telephone order dated 06/11/10 at 11:40 P.M. to "Give first dose of Coumadin (anticoagulant) now from previous Coumadin order." The order was not signed by the physician.

3. Review of the medical record for current Patient L1 on 06/14/10 at 3:00 P.M. showed a telephone order dated 06/04/10 at 3:30 P.M. to "DC Acetylaysteine (a drug used to dissolve mucus)." The order was not dated or timed by the physician.

4. Review of the medical record for current Patient L25 on 06/16/10 at 1:53 P.M. showed a telephone order dated 05/28/10 at 1:30 P.M. to "Change zyvox (antibiotic) to PO (by mouth). DC (discontinue) IV (intravenous) zyvox." The order was not dated or timed by the physician. A verbal order dated 05/30/10 at 2255 (10:55 P.M.) stated "OK to use (R) (right) arm PICC (peripherally inserted central catheter - used for long term access for intravenous fluids and medications)." The order was not timed.

5. Review of the medical record for current Patient SA6 on 06/15/10 at 10:35 P.M. showed a telephone order dated 06/08/10 at 9:50 A.M. to "DC Previous Combivent (used to prevent bronchial spasms) order BID (twice daily). Change to 4 puffs Combivent PRN (as needed) QID (four times daily)for SOB (shortness of breath) and to help clear congestion. Pt (patient) will let R.T. (Respiratory Therapy) know." The order was not signed.


29079

6. Record review on 06/15/10 at 2:25 P.M. of current Patient L7's medical record showed the following:
- A telephone order written on 06/09/10 at 8:00 A.M. for "modified barium swallow (x-ray of stomach and colon). This order was not signed by a physician.
- A telephone order written 06/09/10 at 8:45 A.M. for pureed diet, thin liquids, NCS. This order was not signed by a physician.

7. Record review on 06/15/10 at 2:45 P.M. of current Patient L10's medical record showed the following:
- A telephone order written 06/11/10 at 4:30 A.M. for "Give 5 mg (milligrams). Lopressor (drug for blood pressure). IVP (drug pushed directly into the vein) x (times) 1, check BP (blood pressure) in 10 min (minutes). If systolic BP greater than 105 repeat Lopressor." These orders were not signed by a physician.
- A telephone order written 06/11/10 at 5:00 A.M. for "Hold Lopressor (drug given for blood pressure)". This order was not signed by a physician.

8. Record review on 06/16/10 at 9:15 A.M. of current Patient L17's medical record showed the following:
- A telephone order dated 06/10/10 at 9:30 P.M. for "Hold scheduled 8 units of Regular insulin (medication to lower the blood sugar)". This order was not signed by a physician.
- An order dated 06/11/10 at 1:06 A.M. for "CBC (Complete Blood Count [a blood test]), CMP (Complete Metabolic Profile [a blood test])". These orders were not signed by a physician.


29117

9. Record Review on 06/16/10 at 2:00 P.M. of current Patient SA9's medical record showed the following:
- a telephone order written on 05/25/10 at 1:05 P.M.to "Consult (a physician's name)" The order was not signed by the physician.
-a verbal order written on 05/28/10 at 12:00 noon that it was "ok to D/C (discontinue) KC 1 wound vac (a vacuum assisted closure-a special dressing is put in the wound, covered with a transparent dressing and the vacuum is attached) - Xenaderm (an ointment used to promote wound healing) to hand wound site every 12 hours with a dry dressing to cover." The order was not signed by the physician.
-a verbal order written on 06/03/10 at 11:55 A.M. for "sacral dressing changes to every 12 hours. May place (unable to interpret word) topically to dry dressing for (unable to interpret word) needed (unable to interpret next few words) dry dressing." The order was not signed by the physician.
-a verbal order written on 06/05/10 at 7:00 P.M. for "Santyl (an ointment to promote wound healing) wet to dry dressing to left hand the (unable to interpret word) and 2ND digit and cover with dry gauze (unable to interpret word)." The order was not signed by the physician.
-a verbal order written on 06/10/10 at 2:00 P.M. for "Santyl dressing to sacrum to (unable to interpret word) to wound bed and cover with Exoderm (an ointment to promote wound healing) drainage dressing every 3 days." The order was not signed by the physician.
-During an interview on 06/16/10 at 2:40 P.M. Staff SAB, Nurse Manager, verified that all orders by physicians were not appropriately signed.

10. Record review on 06/16/10 at 3:00 P.M. of the current patient SA7's medical record showed the following:
-an order written on 06/04/10 at 3:30 P.M. by Staff SAJ, N.P. (nurse practitioner) for "1) Colace 100 mg(milligram) liquid per G-Tube (gastrostomy [a tube put into the stomach to put fluid and medication down]). 2) Cover (patch) left eye at night." The order was not signed by the physician.
-a verbal order written on 06/04/10 at 7:00 P.M. for "Xeroform (a special type of gauze dressing) with D/D (unknown meaning) to occipital incision line daily." The order was not signed by the physician.
-a telephone order written on 06/07/10 at 10:18 A.M. that said it was "okay to change the trach (tracheotomy [a hole surgically placed in the trachea to breath from]) to Bivnona #7." The order was not signed by the physician.
-a telephone order written on 06/07/10 at 8:20 A.M. to "reduce rate to 50 ml. (milliliters)/hour". The order was not dated or timed by the physician.
- a telephone order written on 06/10/10 at 8:30 A.M. to change tube feeding to 2 calorie HN (a type tube feeding) x 40 ml. (milliliter) per hour/qual (unable to interpret this word) rate". The order was not dated or timed by the physician.
- a telephone order written on 6/10/10 at 11:30 P.M. for "soap suds enema x 1" and "place patient on air mattress". The order was not dated or timed by the physician.
-a telephone order written on 06/12/10 at 11:45 P.M. for "Quiac (test for blood) emesis and sputum culture to be obtained." The order was not dated or timed by the physician.
-a telephone order written on 06/13/10 at 7:30 A.M. for "Nexium (a stomach medication) 40 mg (milligrams) IV every day and notify Dr. (unable to read word) in A.M. TF (unknown meaning) to remain off at this time." The order was not dated or timed by the physician.

-During an interview on 06/16/10 at 3:30 P.M. Staff SAB, Nurse Manager verified these orders were not appropriately signed by the physicians.



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11. Review of current Patient L4's medical record on 06/14/10 at 3:05 P.M. showed the following physician's telephone orders:
- An order dated 06/02/10 at 3:15 A.M. for "Bolus with 500 cc (cubic centermeters) NS (Normal Saline [solution administered through the vein]) X (times) 1 (one) for low B/P (blood pressure)". This order had not been signed by the physician.
- An order dated 06/05/10 at 9:50 A.M. for "Vancomycin (antibiotic) 1 gm (gram) has already been infused this A.M. Do not infuse another gm." This order had not been signed by the physician.
- An order dated 06/05/10 at 11:45 A.M. for "ABG (arterial blood gas [lab test to show how well the patient is breathing]) now. Combivent (medication to prevent spasms in the airway) 8 puffs QID (four times a day) and PRN (as needed) for SOB (shortness of breath). Continue Albuterol (medication to relax the airway muscles) MDI (metered-dose inhaler). Decrease oxygen to maintain sat (saturation [oxygen saturation]) above 92%." These orders had not been signed by the physician.
- An order dated 06/10/10 at 2:30 P.M. for "Flexiseal (device used to collect incontinent bowel movements) okay to place". This order had not been signed by the physician.
- An order dated 06/10/10 at 2:36 P.M. for "Increase rate to 15. ABG (arterial blood gas) at 0800 (8:00 A.M.) 06/11/10." These orders had not been signed by the physician.

12. Review of current Patient SA1's medical record on 06/15/10 at 10:30 A.M. showed the following physician's telephone orders:
- An order dated 05/27/10 at 4:45 P.M. for "Stage IV air mattress". This order had not been signed by the physician.
- Orders dated 05/27/10 at 5:10 P.M. on a form titled, "Admission Order Set", for the following:
"Central/PICC (Peripherally Inserted Central Catheter [intravenous line inserted into a larger vein]) line care per policy"
"Central/PICC line flushes per policy"
"Oral care per policy"
"Fall assessments per policy"
"Pain assessments per policy"
"Isolation Precautions" - "Standard Precautions".
This page of orders had not been signed by the physician. There was a sticky tab that stated, "Please sign" attached to the page.

During an interview on 06/15/10 at 10:30 A.M., Nurse Manager, Staff SAB, stated that the physician is expected to sign both pages of the admission order form.

13. Review of current Patient SA4's medical record on 06/15/10 at 2:10 P.M. showed the following physician's telephone orders:
- Orders dated 05/29/10 at 3:00 P.M. on a form titled, "Admission Order Set", for the following:
"Diagnosis: Respiratory Failure"
"Pulse Oximetry (test done at bedside to monitor oxygen saturation) - continuous q (every) 4 for SIMV (synchronized intermittent mandatory ventilation [mode of ventilation where the patient is given a specified number of breaths in addition to their own breathing]) 4 or less"
"Trach tube change q 30 days @ (at) 10 A.M."
"Respiratory culture and gram stain (lab test to show if the sputum contains bacteria) on admission"
"Tracheostomy (airway opening in the neck) care q (every) 12 hours"
"High humidity trach (tracheostomy) collar % (percent) FIO2 (fraction of inspired oxygen [percentage of oxygen concentration]) 40%".
These orders had not been signed by the physician.
- An order dated 05/29/10 at 6:00 P.M. for the following:
"Albuterol (medication to relax the airway muscles) 2.5 mg (milligrams), Atrovent (medication to prevent airway spasms)0.5 mg (illegible) nebs (nebulizer [aerosol treatment]) q (every) 6 hours"
"ABG (arterial blood gas [lab test to show oxygenation of the patient])"
"Wean oxygen to lowest FIO2 (fraction of inspired oxygen) to maint (maintain) Sp02 (oxygen saturation) = (greater than or equal to) 92%"
"CXR (chest x-ray)"
"Up in chair bid (twice a day)"
These orders were written by a nurse practitioner but had not been signed by the physician.

14. Review of current Patient SA11's medical record on 06/16/10 at 12:25 P.M. showed the following physician's telephone orders:
- An order dated 06/07/10 at 1:50 A.M. for the following:
"TPN (total parenteral nutrition [liquid nutrition given through a vein]) labs for 6/8: BMP (basic metabolic panel [lab test]), Mg (magnesium [lab test]), Phosphorus (lab test)"
This order had not been signed by the physician.

Based on observation and interview the facility failed to maintain all areas in a clean and orderly manner. This deficit practice affects all patients and staff at both campus buildings. The facility census was 59.

Findings include:

Observation during a tour of the Lindell campus building, conducted on the afternoon of 04/14/10, revealed the following:

Observation at 1:42 P.M. revealed the wooden door to patient room 316 was cracked and splintered leaving a jagged edge.

Observation at 1:50 P.M. revealed the wooden door to patient room 213 was cracked and splintered leaving a jagged edge.

Observation at 1:51 P.M. revealed the wooden door to patient room 209 was cracked and splintered leaving a jagged edge.

Observation at 1:52 P.M. revealed the wooden door to patient room 204 was cracked and splintered leaving a jagged edge.

Staff LT Director of Plant Operations confirmed each of the observations made requiring repair at that time.

Observations during a tour of the St. Anthony's campus building, conducted on the afternoon of 04/15/10, revealed the following:

Observation at 1:13 P.M. revealed the wooden door to patient room 321 was cracked and splintered leaving a jagged edge.

Observation at 1:15 P.M. revealed a hole in a wall, approximately 1 inch by 5 inches, of the soiled utility room adjacent to patient room 333.

Staff SAF Administrator confirmed each of the observations made requiring repair at that time.

Based on facility policy review, record review, observation, and interviews, the facility failed to enforce infection control policies and procedures to prevent the risk of transmission of infections for five (Patient L11, SA1, SA9, SA3, and L33) patients; failed to enforce infection control policies in regard to visitors at the Lindell campus; and failed to enforce infection control policies in regard to Housekeeping Services. The facility census was 59.

Findings included:

1. Review of the facility policy titled, "Contact Precautions", revised 11/09, gave the following direction (in part):
- "Don gloves and gown prior to entering a Contact Precautions room."
- "If use of common equipment is unavoidable, then adequate cleaning and disinfecting is necessary upon removal from the room, before use with other patients."
- "Visitors: Educational information on Contact Precautions is available and will be included in Patient/Family teaching. Evidence of consistent non-compliance should be documented in the patient's chart along with any follow-up activity."

Review of the facility policy titled, "Donning and Removing Personal Protective Equipment (PPE)", revised 01/07, gave the following direction (in part):
"Position gown top around your neck. Fasten the neckline ties."

Review of the facility policy and procedure titled, "Hand Hygiene," last revised 01/07, showed the following (in part):
"Hand hygiene will be performed:
- Before beginning a work shift
- After finishing a work shift
- Before performing invasive procedures
- Before and after patient contact
- Between patients
- After situations during which microbial contamination of the hands is likely to occur (i.e. contact with potentially contaminated environmental surfaces)
- Before and after eating
- After covering a cough or a sneeze
- After removal of gloves."

2. Observation on 06/15/10 at 9:40 A.M. showed Staff LG was finishing medication administration for Patient L 11 through his/her PEG (feeding tube surgically inserted directly into the stomach through the stomach wall) when Staff LG dropped the irrigation syringe plunger on the floor and asked the CNA (certified nurse assistant) Staff LF to pick it up. Staff LF picked the plunger up off the floor and placed it on Patient L 11 bedside table. Staff LG then placed the plunger back into the irrigation syringe and placed the syringe into the irrigation bottle, then left the room. Patient L 11 was not in isolation.


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3. During an observation on 06/15/10 at 2:02 P.M. Staff RN, SAK put on gloves and flushed Patient SA1 ' s PICC (peripherally inserted central catheter-a central line for insertion of fluids) line. Staff RN, SAK removed gloves and did not wash hands or use disinfectant hand sanitizer. The patient was on isolation precautions.
4. Review of the facility's document tltled, "Infection Control Log", showed that Patient SA1 had VRE (Vancomycin Resistant Enterococci [infection resistant to antibiotics]).
5. During an observation on 06/15/10 at 3:00 P.M. Staff RN, SAD had gloves on to clean area in Patient SA9's room after wound care was completed. The gloves were removed and Staff RN, SAD did not wash hands or use disinfectant hand sanitizer. The patient was on isolation precautions.
6. Review of the facility's document titled, "Infection Control Log", showed that Patient SA9 had VRE, MRSA (Methicillin Resistant Staphylococcus Aureus [infection resistant to antibiotic]), and ACINO (Acinetobacter [a bacteria]).
7. During the same observation period on 06/15/10 at 3:00 P.M in Patient SA9's room Staff RN, SAD had gloves on to sanitize bedside table and scissors. Staff RN, SAD removed gloves and did not wash hands or use disinfectant hand sanitizer.



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6. Observation on 06/15/10 at 11:03 A.M. showed physician, Staff SAH, enter Patient SA1's room wearing an isolation gown pulled only onto his/her forearms, not securing the gown around the neck or waste and leaving the upper arms and chest area exposed. The Wound Care Nurse, staff SAD was inside the room at the patient's bedside. A sign outside SA1's room stated that the patient was on contact isolation precautions and instructed all persons entering to wear an isolation gown and gloves.

Review of the facility's infection control log showed that Patient SA1 had VRE (Vancomycin-resistant Enterococci [infection resistant to antibiotics]).

During an interview on 06/16/10 at 4:10 P.M., Wound Care Nurse, staff SAD, stated that physician, Staff SAH doesn't want to wear PPE (personal protective equipment [garments worn around patients in isolation]) correctly and that when he entered Patient SA1's room on 06/15/10, he/she had said to the physician, "Let me help you tie that". Staff SAD stated that the physician got upset because it has to be his/her idea.

7. Observation on 06/15/10 at 1:30 P.M. showed Infection Disease physician, Staff SAI, enter Patient SA3's room wearing an isolation gown pulled onto his/her forearms, not securing the gown around the neck or waste and leaving the upper arms and chest area exposed. A sign outside SA3's room stated that the patient was on contact isolation precautions and instructed all persons entering to wear an isolation gown and gloves.

Review of the facility's infection control log showed that Patient SA3 had VRE (Vancomycin-resistant Enterococci [infection resistant to antibiotics]).


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8. Observation on 06/16/10 at approximately 1:30 P.M. showed Registered Nurse (R.N.) Staff LW preparing to administer medications to Patient L33. Patient L33 was on contact isolation. Staff LW gowned and gloved for isolation, entered the patient room and opened the locked medication cabinet in the room. After retrieving Heparin (anticoagulant), Staff LW discovered there were no needles to administer the medication with. Staff LW requested another staff member bring a supply of needles to the room. While waiting, staff LW asked this surveyor whether it would be acceptable to retrieve medication labels from his/her pocket while gloved? Staff LW eventually requested that a staff member outside the room retrieve the label, and proceeded to fill it out. When the needles were brought to the room, staff LW withdrew the Heparin into the syringe using a 1 inch needle. Without recapping the syringe, Staff LW walked across the room and had a staff member outside the room double check the dose. Staff LW then affixed the medication label, went to the patient bedside, and laid the uncapped syringe on the bedside table. There was no barrier on the bedside table. Staff LW raised the patient's gown, repositioned the arms, and cleaned the potential injection site. As Staff LW turned to pick up the syringe from the bedside table, the patient's arms moved across the prepared site. Staff LW then used the same hand the uncapped syringe was in to re-cleanse the site. While rubbing the alcohol pad with a back and forth motion, the tip of the syringe in Staff LW's hand brushed against the patient's linens, potentially contaminating the tip. Without changing the needle, Staff LW injected the medication.

9. Observation on 06/16/10 at approximately 1:50 P.M. showed RN Staff LW retrieve and withdraw 2 mg (milligrams) of Morphine (a narcotic analgesic) into a syringe. Staff LW then removed the needle, leaving the end of the syringe open. Staff LW went to the nursing station, juggled the syringe from hand to hand while preparing and applying a medication label, then proceeded to the room of Patient L33 and reapplied isolation gown and gloves. Staff LW laid the uncapped syringe on the ledge over the patient's sink while tying the back of the isolation gown. Proceeding into the room, Staff LW opened the medication cabinet, and laid the syringe on the fold down desk area of the work station. There was no protective barrier on the desk. Staff LW accessed the electronic medical record, verified the correct dose, and laid the uncapped syringe on the bedside table. There was no protective barrier on the table. Staff LW then wiped the IV (intravenous) port and laid it back against the patient's linens. Without changing gloves, Staff LW walked across the room and retrieved a pre-filled syringe from the medication cabinet. After removing the pre-filled syringe from its packaging, Staff LW proceeded to the bedside and without changing gloves or re-cleaning the hub, accessed the patient's IV port, attached the prefilled syringe, and injected half the solution. Staff LW then laid the uncapped prefilled syringe on the patient's bedside table, retrieved the uncapped syringe from the bedside table and injected it over the course of approximately 15 seconds. Staff LW then retrieved the prefilled syringe from the bedside table and injected the remaining solution into the IV port.

10. During an observation on 06/15/10 at 2:45 P.M., a visitor was observed leaving a patient room. The door was marked with a "Contact Precautions" sign instructing those who entered to wear gown and gloves. The visitor was not wearing a gown or gloves as the contact isolation signage instructed. Director of Quality Management Staff LM spoke to the visitor about wearing gown and gloves. The visitor replied that they had never been told to do this before.

11. During an observation on 06/16/10 at approximately 4:00 P.M., a visitor was observed wearing gown and gloves while talking on a cell phone near the elevator. Director of Quality Management Staff LM spoke to the visitor, reminding the visitor to remove gown and gloves before exiting a patient room.

12. Observation on 06/17/10 at 2:45 p.m. showed a Housekeeper walking down the hallway, using a short broom to push down trash in the wastebaskets just inside patient rooms. Most of the patients in this hall are on Contact Isolation for a variety of organisms. Infection Control Nurse Staff LA spoke to the Housekeeper, and the Housekeeper stopped this activity. Infection Control Nurse Staff LA said, "Whoever is in the room should empty the trash if it is too full."

13. Observation on 06/17/10 at 2:30 p.m. showed Physical Therapist Staff LX in the room of Patient L15. Staff LX wore gloves while working with the patient, who was not in isolation. When Staff LX removed the gloves, it was noted that hand splint(s) were being worn. Staff LX did not remove the hand splint(s) while performing hand hygiene.