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Based on observation, interview, and record review, the facility failed to ensure barriers protecting hazardous areas were free of penetrations, to comply with 14.6.2.4 of NFPA 72, 2010 edition, to comply with 5.1.1.2, 13.2.7, and 14.2.1 of NFPA 25, 2011 edition, to ensure smoke barriers were free of penetrations, to conduct fire drills in accordance with NFPA 101, 2012 edition, 19.7.1.4 and 19.7.16, to comply with 5.1.14.2.3of NFPA 99, 2012 edition, and to comply with 6.4.1.1.17 and 6.4.1.1.17.5 of NFPA 99, 2012 edition. (A709) The cumulative effect of this systemic practice result in the facility's inability to ensure a physical environment safe from fire. The facility census was 49 patients.

Based on medical record review, policy review and interview, the facility failed to ensure orders were obtained every 24 hours for one patient (Patient #30) in restraints of 32 medical records reviewed. The facility's active census was 49 patients.

Findings include:

The medical record for Patient #30 contained orders for an enclosed bed on 07/13/17 at 3:27 PM and 07/15/17 5:21 PM. A physician's Progress Note from 07/14/17 at 5:04 PM, stated Patient #30 was using an enclosure bed. A Restraint Log for Non-Violent/Non-Self-Destructive Restraints from 07/14/17 revealed Patient #30 was in an enclosed bed from 11:00 AM through 07/15/17 at 9:00 AM.

The facility's Restraint Policy was reviewed. The policy stated to obtain orders every 24 hours for Net beds. The policy stated the patient's plan of care must be modified to include safety/need for restraint.

The findings were shared with Staff A on 03/21/18 at 10:15 AM, and confirmed.

Based on medical record review, policy review and interview, the facility failed to provide evidence of nursing staff conducting observations in accordance with the care plan ordered frequencies for 22 active patients (Patient #1, #2, #3, #6, #7, #8, #9, #10, #11, #12, #13, #16, #17, #18, #20, #21, #23, #24, #25, #26, #27, and #28) who were at High Risk for falls of 27 active medical records reviewed. The facility census was 49 patients.

Findings include:

Review of Fall Risk Assessments revealed the facility utilized the Morse Scale. A score greater than 44 identified the patient was "High Risk" for falls. Corresponding interventions for a patient at high risk for falling included visual observation of the patient every 30 minutes; visual observation at all times when the patient was in the bathroom or shower; bed alarm on at all times while the patient is in bed; personal alarm applied while patient is in chair; must wear gait belt at all times when ambulating.

A score of 25-44 identified the patient was a "Moderate Risk" for falls. Corresponding interventions for a patient at moderate risk for falling included visual observation of the patient every hour while on the nursing unit and bed alarm on at all times while the patient is in bed.

1. Patient #1 was identified as "High Risk" for fall based on Morse Fall Risk Assessments completed on 03/16/18 (score of 65), 03/17/18 (score of 90), 03/18/18 (score of 75), and 03/19/18 (score of 65).

Review of Patient #1's Care Plan revealed "Safety-Falls" identified as a problem. Review of Patient #1's electronic medical record and Hourly Rounding sheets revealed no documented evidence visual observations of the patient were conducted every 30 minutes.

2. Patient #9 was identified as "High Risk" for fall based on Morse Fall Risk Assessments completed on 03/13/18 (score of 85), 03/14/18 (score of 85), 03/15/18 (score of 85), 03/16/18 (score of 85), 03/17/18 (score of 85), 03/18/18 (score of 85) and 03/19/18 (score of 60).

Review of Patient #9's Care Plan revealed "Safety-Falls" identified as a problem. It included an intervention to check frequently, every 15 to 30 minutes. Review of Patient #9's electronic medical record and Hourly Rounding sheets revealed no documented evidence visual observations of the patient were conducted every 15 or 30 minutes.

3. Patient #10 was identified as "Moderate Risk" for fall based on Morse Fall Risk Assessments completed on 03/07/18 (score of 40) and 03/12/18 (score of 80). Patient #10 was identified as "High Risk" based on assessments completed on 03/08/18 (score of 40), 03/09/18 (score of 40) and 03/13/18 (score of 60).

Review of Patient #10's Care Plan revealed "Safety-Falls" identified as a problem. It included an intervention to check frequently, every 15 to 30 minutes. Review of Patient #10's electronic medical record and Hourly Rounding sheets revealed no documented evidence visual observations of the patient were conducted every 15 or 30 minutes.

4. Patient #12 was identified as "High Risk" for fall based on Morse Fall Risk Assessments completed on 03/14/18 (score of 55), 03/15/18 (score of 55), 03/16/18 (score of 55), 03/17/18 (score of 65), 03/18/18 (score of 65) and 03/19/18 (score of 80).

Review of Patient #12's Care Plan revealed "Safety-Falls" identified as a problem. It included an intervention to check frequently, every 15 to 30 minutes. Review of Patient #12's electronic medical record and Hourly Rounding sheets revealed no documented evidence visual observations of the patient were conducted every 15 or 30 minutes.

5. Patient #16 was identified as "High Risk" for fall based on Morse Fall Risk Assessments completed on 03/15/18 (score of 55) and 03/18/18 (score of 55).

Review of Patient #16's Care Plan revealed "Safety-Falls" identified as a problem. Review of Patient #16's electronic medical record and Hourly Rounding sheets revealed no documented evidence visual observations of the patient were conducted every 30 minutes.

6. Patient #24 was identified as "Moderate Risk" for fall based on Morse Fall Risk Assessment completed on 03/07/18 (score of 100) and "High Risk" on 03/06/18 (score of 65), 03/18/18 (score of 55) and 03/19/18 (score of 65).

Review of Patient #24's Care Plan revealed "Safety-Falls" identified as a problem. Review of Patient #24's electronic medical record and Hourly Rounding sheets revealed no documented evidence visual observations of the patient were conducted every 30 minutes.

7. Patient #25 was identified as "High Risk" for fall based on Morse Fall Risk Assessment completed on 03/18/18 (score of 50).
Review of Patient #25's Care Plan revealed "Safety-Falls" identified as a problem. It included an intervention to check frequently, every 15 to 30 minutes.

Review of Patient #25's electronic medical record and Hourly Rounding sheets revealed no documented evidence visual observations of the patient were conducted every 15 or 30 minutes.

8. Patient #26 was identified as "High Risk" for falls based on Morse Fall Risk Assessment completed on 03/10/18 (score of 100), 03/11/18 (score of 85), 03/13/18 (score of 65) and 03/18/18 (score of 65).

Review of Patient #26's Care Plan revealed "Safety-Falls" identified as a problem. Review of Patient #26's electronic medical record and Hourly Rounding sheets revealed no documented evidence visual observations of the patient were conducted every 30 minutes.

9. Patient #28 was identified as "High Risk" for fall based on Morse Fall Risk Assessment completed on 03/14/18 (score of 75), 03/15/18 (score of 65), 03/16/18 (score of 75), 03/17/18 (score of 75), 03/18/18 (score of 75) and 03/19/18 (score of 65).

Review of Patient #28's electronic medical record and Hourly Rounding sheets revealed no documented evidence visual observations of the patient were conducted every 15 or 30 minutes.


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10. The medical record for Patient #2 was reviewed. A Nursing Admission Assessment conducted on 03/07/18 and the Nursing Daily Assessments from 03/07/18 through 03/19/18 listed Patient #2 as high risk for falls. The assessments stated to visually observe every 30 minutes. The medical record did not contain documented evidence Patient #2 was observed every 30 minutes.

The facility's Hourly Rounding sheets revealed Patient #2 was observed hourly or less frequently than hourly from 03/07/18 to 03/19/18.

11. The medical record review for Patient #3 revealed "Safety-Falls" was added to the Care Plan on 02/14/18. Interventions on the care plan included to "check frequently, every 15 to 30 minutes". The medical record did not contain documented evidence Patient #3 was observed every 30 minutes.

The facility's Hourly Rounding sheets revealed Patient #3 was observed hourly or less frequently than hourly in a random sampling of 2/26/18, through 03/01/18 and 03/18/18.

The medical record further revealed documentation in the patient care notes by Staff F stating "Called to room by staff assist alarm. Patient seen on floor of shower, nurse tech was with patient. She states she walked around the corner to grab a pair of socks and when she came back he was on the floor. Patient states he did not try to stand and thinks he slid out of the chair".

Review of the Facility policy titled Fall Prevention, Reduction and Assessment Policy, effective January 2012 was completed. The policy stated those patients designated High Risk: "Staff maintains visual observation when the patient is in the bathroom or shower at all times".

12. The medical record for Patient #8 was reviewed. A Nursing Admission Assessment conducted on 03/04/18 and the Nursing Daily Assessments from 03/04/18 through 03/19/18 listed Patient #8 as being high risk for falls. The assessments stated to visually observe every 30 minutes. The medical record did not contain documented evidence Patient #8 was observed every 30 minutes.

The facility's Hourly Rounding sheets revealed Patient #8 was observed hourly or less frequently than hourly from 03/07/18 to 03/19/18.

13. The medical record for Patient #18 was reviewed. A Nursing Admission Assessment conducted on 03/0/2018 and the Nursing Daily Assessments from 03/01/18 through 03/06/18 listed Patient #18 as being a high risk for falls. The assessments stated to visually observe every 30 minutes. The medical record did not contain documented evidence Patient #18 was observed every 30 minutes.

The Nursing Daily Assessment dated 03/07/18 listed Patient #18 as being a low risk for fall. The Nursing Daily Assessments dated 03/07/18 through 03/20/18 listed Patient #18 to be a moderate risk. The nursing assessment states to visualize the patient at least every hour while on the nursing unit.

The facility's Hourly Rounding sheets revealed Patient #18 was observed hourly or less frequently than hourly from 03/07/18 to 03/19/18.

14. The medical record for Patient #20 was reviewed. A Nursing Admission Assessment conducted on 03/13/18 and the Nursing Daily Assessments from 03/13/18 through 03/16/18 listed Patient #20 as being a high risk for falls. The assessments stated to visually observe every 30 minutes. The medical record did not contain documented evidence Patient #20 was observed every 30 minutes.

The facility's Hourly Rounding sheets revealed Patient #20 was observed hourly or less frequently than hourly from 03/13/18 to 03/16/18.

Review of the Nursing Daily Assessment dated 03/17/18 and 03/18/18 listed Patient #20 as low risk.

15. The medical record review for Patient #23 revealed "Safety - Falls" was added to the Care Plan on 03/16/18. Interventions on the care plan included to "check frequently, every 15 to 30 minutes". The medical record did not contain documented evidence Patient #23 was observed every 15 to 30 minutes.

The facility's Hourly Rounding sheets revealed Patient #23 was observed hourly or less frequently than hourly from 03/16/18 through 03/21/18.

16. The medical record for Patient #11 was reviewed. A Nursing Admission Assessment conducted on 03/09/18 and the Nursing Daily Assessments from 03/09/18 through 03/19/18 listed Patient #11 as being high risk for falls. The assessments stated to visually observe every 30 minutes. The medical record did not contain documented evidence Patient #11 was observed every 30 minutes.

The facility's Hourly Rounding sheets revealed Patient #11 was observed hourly or less frequently than hourly from 03/09/18 to 03/21/18.

17. The medical record review for Patient #7 revealed "Safety-Falls" was added to the Care Plan on 03/15/18. Interventions on the care plan included to "check frequently, every 15 to 30 minutes". The medical record did not contain documented evidence Patient #7 was observed every 30 minutes.

The facility's Hourly Rounding sheets revealed Patient #7 was observed hourly or less frequently than hourly from 03/15/18 to 03/21/18.

18. The medical record review for Patient #13 revealed "Safety-Falls" was added to the Care Plan on 03/14/18. Interventions on the care plan included to "check frequently, every 15 to 30 minutes". The medical record did not contain documented evidence Patient #13 was observed every 30 minutes.

The facility's Hourly Rounding sheets revealed Patient #13 was observed hourly or less frequently than hourly from 03/15/18 to 03/21/18.

19. The medical record review for Patient #17 revealed "Safety-Falls" was added to the Care Plan on 03/12/18. Interventions on the care plan included to "check frequently, every 15 to 30 minutes". The medical record did not contain documented evidence Patient #17 was observed every 30 minutes.

The facility's Hourly Rounding sheets revealed Patient #17 was observed hourly or less frequently than hourly from 03/12/18 to 03/21/18.

20. The medical record for Patient #27 was reviewed. Nursing Daily Assessments from 03/18/18 through 03/20/18 listed Patient #27 as a high risk for fall. The assessments stated to visually observe every 30 minutes. The medical record did not contain evidence Patient #27 was observed every 30 minutes.

The facility's Hourly Rounding sheets revealed Patient #27 was observed hourly or less frequently than hourly from 03/18/18 to 03/21/18.

21. The medical record review for Patient #21 revealed "Safety-Falls" was added to the Care Plan on 02/02/18. Interventions on the care plan included to "check frequently, every 15 to 30 minutes". The medical record did not contain documented evidence Patient #21 was observed every 30 minutes.

The facility's Hourly Rounding sheets revealed Patient #21 was observed hourly or less frequently than hourly from 03/13/18 to 03/21/18.

22. The medical record for Patient #6 was reviewed. Nursing Daily Assessments from 03/15/18 through 03/19/18 listed Patient #6 as a high risk for fall. The assessments stated to visually observe every 30 minutes. The medical record did not contain documented evidence Patient #6 was observed every 30 minutes.

The facility's Hourly Rounding sheets revealed Patient #6 was observed hourly or less frequently than hourly from 03/15/18 to 03/19/18.

The findings were confirmed by Staff A on 03/21/18 at 10:15 AM. Staff A reported the Hourly Rounding forms do not allow staff to document 30 minute observations and stated one hour observations are not done overnight. Staff A reported there is not another place in the medical record to document the fall risk interventions.












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Based on medical record review, policy review and staff interview, the facility failed to ensure nursing staff administered high risk medications, in accordance with policy. This affected two of two current patients whose medical records were reviewed for insulin administration, Patients' #24 and #26. A total of 27 current medical records were reviewed. The facility census was 49 patients.

Findings include:

Medication Administration Policy (revised 11/13) was reviewed. Per policy, "Medications that require exact or precise timing of administration shall be administered at the scheduled time. Time-critical scheduled medications are those for which an early or late administration of greater than 30 minutes might cause harm or have significant, negative impact on the intended therapeutic or pharmacologic effect. Insulin."

The policy further specified "High Risk Medications: Administration of insulin requires a double check by another licensed staff member to assure patient safety." This double check was documented in the electronic Medication Administration Record as "Dual Signature."

Interview with Staff A on 03/20/18 at 2:53 PM was completed to clarify the "double check" process. Per Staff A, the second nurse (double check) was expected to view the insulin in its original container to verify the type of insulin and the expiration date. The second nurse was expected to observe the administering nurse draw the insulin from the vial and confirm the dosage. Staff A stated she expected the second nurse to chart this in the electronic medical record by the end of his/her shift.

1. Review of Patient #24's medical record revealed insulin was administered without documented evidence of the required "double check" on 03/09/18 at 12:44 PM four (4) units of Humalog, 03/14/18 at 7:59 AM five (5) units of Humalog and 03/14/18 at 8:00 AM 25 units of Lantus.

The following contained documented evidence the "double check" of administration of insulin occurred more than 24 hours later on 03/06/18 at 6:57 PM 12 units of Humalog, dual signature not until 03/10/18 at 6:42 AM and on 03/12/18 at 7:38 AM 25 units of Lantus, dual signature not until 03/13/18 at 2:52 PM

2. Review of Patient #26's medical record revealed insulin was administered without documented evidence of the required "double check" on 03/12/18 at 7:43 AM four (4) units of Humalog, 03/12/18 at 11:29 AM six (6) units of Humalog, 03/13/18 at 11:28 AM two (2) units of Humalog and 03/13/18 at 5:14 PM three (3) units of Humalog.

The following administrations of insulin contained documented evidence the "double check" occurred more than 24 hours later on 03/10/18 at 7:15 AM four (4) units of Humalog, dual signature not until 03/12/18 at 7:36 PM
and 03/16/18 at 5:24 PM three (3) units of Humalog, dual signature not until 03/19/18 at 11:16 AM.

Staff A confirmed the above findings on 03/20/18 at 2:53 PM.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients at the facility. The facility census was 49 patients.

Findings include:

Please refer to life safety code findings:

K321 Failed to ensure barriers protecting hazardous areas were free of penetrations.

K345 Failed to comply with 14.6.2.4 of NFPA 72, 2010 edition

K353 Failed to comply with 5.1.1.2, 13.2.7, and 14.2.1 of NFPA 25, 2011 edition

K372 Failed to ensure smoke barriers were free of penetrations

K712 Failed to conduct fire drills in accordance with NFPA 101, 2012 edition, 19.7.1.4 and 19.7.16

K908 Failed to comply with 5.1.14.2.3of NFPA 99, 2012 edition

K916 Failed to comply with 6.4.1.1.17 and 6.4.1.1.17.5 of NFPA 99, 2012 edition

Based on review of facility policies, manufacturer recommendation for product use, observations and staff interviews the facility failed to ensure staff followed infection control practices when providing care to three patients (Patients #8, #14 and #32). This had the potential to affect all patients receiving services from the facility. The census was 49 patients.

Findings include:

Review of the manufacturer's Usage Guide for BD Heparin Lock Flush Syringe was completed. The Guide directs to attach the syringe to the injection site and flush per institution policy. After use, discard syringe, including unused solution. Do not reuse.

On 03/20/18 at 9:10 AM Staff D was observed obtaining two prefilled 10 ml normal saline and one 5 ml heparin syringes from the medication room. Staff D verified the order for flushing the PICC (peripherally inserted central catheter) for Patient #8. Upon entering the room Staff D verified the patient's identify by asking his name and date of birth, reverified the order, performed hand hygiene and applied gloves. Patient #8's PICC had two lumens. Staff D cleansed off the port of one lumen with an alcohol wipe, flushed with 10 ml of normal saline, then flushed with 2.5 ml of the heparin. Staff D then cleansed off the second port with an alcohol wipe, flushed with the second syringe of 10 ml normal saline followed by the remainder 2.5 ml of heparin. Upon completion, Staff D removed her gloves and washed her hands. After leaving the patient's room, Staff D confirmed he/she used the same syringe of heparin to flush both ports.

Interview at 9:25 AM with Staff B confirmed a second syringe of heparin should have been used for flushing the second lumen.

Review of the Facility's policy titled Tracheostomy Care with the Disposable Inner Cannula, (January, 2012) was completed. The policy stated to "apply sterile gloves" prior to inserting the new sterile inner cannula and locking it in place.

2. On 03/20/18 at 9:45 AM Staff E was observed performing tracheostomy care on Patient #14 with a disposable inner cannula. Staff E washed her hands, obtained a disposable trach care kit, and opened it. Staff E applied gloves, poured hydrogen peroxide into the tray of the kit. Staff E removed the soiled drain sponges around the trach and disposed of them. Staff E then reached into the tray and took sterile gauze, moistened it with the peroxide and wiped around the trach insertion site. Staff E instructed the patient she would be removing his inner cannula so he would not be able to speak for a while. Staff E removed the inner cannula and placed it in the tray. Staff E then took the new sterile cannula and inserted it into Patient #14's tracheostomy stoma. After leaving the patient's room, Staff E confirmed she had not changed her gloves and performed hand hygiene after removing the soiled drain sponges, cleansing around the site or after removing the old cannula. Neither did she perform hand hygiene or don sterile gloves before inserting the new cannula.

Interview at 10:00 AM with Staff B confirmed the above findings.

Review of the Facility policy titled BGT Point of Care Testing (POCT) (January 2012) was completed. The policy stated after obtaining sample: remove test strip from monitor, perform post patient care and discard lancet, test strip and other equipment in appropriate biohazard containers, clean meter with approved disinfecting cleaning wipe and remove gloves and wash hands thoroughly with soap and water and/or hand sanitizer.

3. On 3/20/18 at approximately 11:25 AM, Staff C was observed performing Point of Care Blood Glucose Testing on Patient #32. After scanning the patient's wrist band, Staff C performed Point of Care blood glucose testing. When completed Staff C discarded the test strip and other supplies. Staff C wiped off the glucometer, test strip vials, and carrying case with disinfectant wipes. Staff C then removed his gloves. Staff C verified the insulin dose the patient was to receive on the computer in the room. Staff C proceeded to the nurse station, again verified the insulin dose the patient was to receive. Staff C obtained a multi dose bottle of Humalog insulin from the Pyxis system and drew up three units which he/she verified with a second registered nurse. Staff C returned to Patient #32's room, again verified the patient's identification and scanned the wrist band. Staff C donned gloves and administered the insulin subcutaneously in the patient's abdomen. Staff C discarded the syringe in the sharps container, removed his gloves and washed his hands.

After leaving the room, Staff C confirmed he had not washed his hands at all between the blood glucose testing and the drawing up and administering the insulin.

On 03/20/2018 at approximately 11:50 AM, Staff B confirmed these findings.