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Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:


A. Failing to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) The hospital failed to ensure the initial nursing assessment was conducted by a RN for 2 (#5, #23) of 2 current patients and 1 (#19) of 1 discharged patient out of 9 (#1 - #5, #12, #13, #19, #23) patient medical records reviewed for initial nursing assessments out of 30 sampled patient medical records;

2) The hospital failed to ensure that a RN documented a nursing assessment on each patient every 24 hours as evidenced by no documentation of a RN assessment in the patient's medical record for 3 (#3, #4, #15) of 3 current patients out of 8 (#1 - #5, #12, #13, #15) patients reviewed for RN documented assessments every 24 hours out of a total sample of 30 patient medical records;

3) The RN failed to reassess a patient's weight after a 25 pound discrepancy was documented from one day to the next day as evidenced for 1 (#3) out of 9 (#1- #5, #12, #13, #15, #29) current patient records and 2 (#20, #25) of 2 discharged patients records out of a total of 11 medical records reviewed for assessment of weights from a total sample of 30 patient medical records;

4) The RN failed to assess the patient's weight as ordered by the physician for 2 (#15, #29) of 2 current patients and 2 (#20, #25) of 2 discharged patients out of 11 (#1-5, #12, #13, #15, #20, #25, #29) sampled patient records reviewed for assessment of weights from a total sample of 30 patient records;

5) The RN failed to assess the patient's condition and cardiac rhythm after incidents with the remote telemetry monitoring were identified for 3 of 3 (#21, #24, #25) discharged sampled patients reviewed for incidents with remote telemetry monitoring out of a total sample of 30 patient medical records;

6) The RN failed to ensure telemetry monitor recordings were obtained and validated in accordance with hospital policy and the written agreement with the remote telemetry monitoring provider for 2 of 2 (#26, #29) current patients and 2 of 2 (#24, #25) discharged sampled patients reviewed for telemetry monitoring out of a total sample of 30 patient medical records.

7) The RN failed to ensure an initial wound assessment was conducted by the RN as required by hospital policy for 2 (#4, #14) of 3 (#4, #12, #14) current patient records reviewed for wound assessments out of a total sample of 30 patient medical records.

8) The RN failed to ensure that "Time Outs" were documented in the patient's medical record prior to a patient's procedure according to hospital policy for 3 (#1, #2, #14) of 5 (#1, #2, #4, #12, #14) current patient medical records reviewed for "Time Outs" out of a total sample of 30 patient medical records; (See Tag A-0395)


B. Failing to ensure the RNs assigned to the nursing care of High Observation patients had received education/training and had been evaluated for competency in the administration of a continuous infusion of an anesthetic agent (Propofol) for 2 (S40RN, S41RN) of 2 RNs assigned to the High Observation Unit. ( See A-0397)


C. Failing to ensure that non-employee licensed nurses were appropriately oriented prior to providing care to the hospital's patients and the hospital failed to ensure that non-employee licensed nurses were evaluated through a hospital-based competency skills checklist prior to providing care to the hospital's patients as evidenced by no documentation of a hospital orientation program or a competency skills checklist prior to providing care to the hospital's patients for 2 (S16RNDialysis, S24LPN) of 2 contract licensed nursing staff currently working with hospital patients. (See A-0398)

Based on record reviews, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Medical Record Services as evidenced by:

1) Failing to ensure medical records for each patient were promptly completed within 30 days of discharge as evidenced by:
a. a medical record delinquency rate greater than 65% for the past 10 months and 111 delinquent medical records as of 08/31/16, and;
b. failing to ensure medical records were complete and included the discharge summary for 4 of 4 (#8, #20, #21, #22) discharged patients reviewed for complete medical records out of a sample of 30 (see findings at A-0438).

2) Failing to ensure each patient's medical record entries were dated, timed, and authenticated by the person responsible for providing the service as evidenced by physicians not authenticating medical records entries in accordance with Medical Staff Bylaws for 4 of 4 (#2, #4, #14, #15) current patient medical records reviewed for authentication of medical record entries from a total sample of 30 (see findings at A-0450).

3) Failing to ensure all verbal orders had been authenticated (signed, dated and timed) within 10 days as required by hospital policy for 3 ( #1,#2, #5) of 5 (#1, #2, #3, #4, #5) current sampled patients reviewed for authentication of verbal orders and 1 of 1 (#24) closed sampled patient medical records reviewed for authentication of verbal orders out of a total sample of 30 (see findings at A-0454).

4) Failing to ensure medical history and physical examinations (H&P's) were completed and documented for each patient no more than 30 days before or 24 hours after admission or registration for 2 (#26, #29) of 2 current patients and 2 (#19, #20) of 2 discharged patients out of 7 (#19, #20, #24, #26, #27, #28, #29) patients reviewed for completed H&P's from a sample of 30 patients (see findings at A-0458).

5) Failing to ensure medical records included a properly executed informed consent for procedures and treatments. This deficient practice was evidenced by informed consents that were not completed as per hospital policy when information required was omitted in the informed consent, required information areas were left blank, and/or informed consents were not obtained for procedures/treatments performed for 3 of 3 (#1, #2, #14) current patient records reviewed for properly executed informed consents from a total sample of 30 (see findings at A-0466).

6) Failing to ensure all patient records included documentation of outcomes of hospitalization, disposition of care and provisions for follow-up care as evidenced by the failing to ensure the treating licensed practitioner completed a discharge summary for 3 of 3 (#20, #21 #22) discharged patient records reviewed for discharge summaries out of a total sample of 30 (see findings at A-0468).

Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation for Radiological Services as evidenced by:

1) failure of the Governing Body to appoint a Medical Director of the hospital's Radiological Services, and failure to ensure all interpreting radiologists were members of the hospital's Medical Staff as per their policy and procedure (see findings tag A-0546).

2) failure to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures (see findings in tag A-0536).

Based on record reviews and interview, the Governing Body failed to ensure the members of the Medical Staff were accountable to the Governing Body for quality of care provided to patients as evidenced by medical staff members not assessing and pronouncing death for 1 (#11) of 6 (#9, #10, #11, #16, #17, #18) sampled patients reviewed for pronouncement of death from a total sample of 30.
Findings:

A review of the Medical Staff ByLaws, Rules & Regulations, approved by the Governing Body and provided by S1CEO, revealed in part: A. Admission and Discharge of Patients: 1. A patient may be admitted to the Hospital only by a practitioner approved by the Medical Staff in accordance with the Medical Staff ByLaws. 2. The practitioner shall be responsible for the medical care and treatment of each patient in the Hospital, for the prompt completeness and accuracy of the medical record. 5. In the event of a Hospital death, the deceased shall be pronounced dead by the responsible practitioner or their designee within a reasonable period of time.

A review of the Nursing Notes on 05/31/16 at 4:10 a.m. for Patient #11 revealed: S44MD, the patient's attending practitioner, was texted by nursing staff to pronounce the patient. An entry at 4:20 a.m. revealed the patient pronounced deceased by S45MD.

A review of the Medical Staff credentialing roster, approved by the Governing Body and provided by S1CEO, revealed that S44MD was a credentialed member of the Medical Staff. A further review revealed no evidence that S45MD was a credentialed member of the Medical Staff.

In an interview on 09/06/16 at 1:15 p.m. with S1CEO he indicated that S45MD was not a credentialed member of the Medical Staff, as approved by the Governing Body. He indicated that the patient's practitioner was S44MD and that S45MD was the coroner who pronounced the patient when S44MD was unable to be reached by staff. S1CEO indicated that he thought that the practitioner's designee (for death pronouncement) could be a non-credentialed member of the Medical Staff if he was the coroner.

Based on record reviews, observation, and interview the hospital failed to ensure the use of restraints were in accordance with a written modification to the patient's plan of care for 1 (#3) of 4 (#1, #3, #5, #12) patients reviewed for restraint care plans out of a sample of 30.

Findings:

Review of the hospital policy, "Restraints, Forms #CL44 #1 and #2", revealed in part, D. Documentation : Document the results of the comprehensive assessment in the medical record. Review options that could be used as an alternative to restraints.
1. Modify the plan of care to include:
a. The safety issue that resulted in the need for restraints.
b. Desired measurable outcome-oriented goals.
c. Interventions to minimize restraint use, including attempts to use alternatives to restraints and to end-use at the earliest possible time.
d. Patient/family-education regarding the need for restraint, alternatives attempted and plan for safe removal.


Review of the medical record for Patient #3 revealed he was admitted to the hospital on 8/23/16 for long term antibiotics for VRE. His other diagnoses included: Hypertension, Coronary Artery Disease, Diabetes and Dementia. Review of his Physician's Orders dated 8/26/16 revealed on order to place the patient in an enclosure bed. Further review of his medical records revealed Restraints Orders for the enclosure bed for 8/26/16 until 8/30/16. With review of the patient's care plan revealed the enclosure bed/restraint was not included on his plan of care.

An observation was conducted on 8/30/16 at 2:00 p.m. of Patient #3 in his hospital room in an enclosure bed.

An interview was conducted with S2DON/IC on 8/30/16 at 2:45 p.m. She confirmed with review of Patient #3's care plan, the patient's restraint/enclosure bed was not included on his plan of care and should have been included in his plan of care.

Based on record reviews and interviews, the hospital failed to ensure its quality assessment and performance improvement (QAPI) program included activities to re-evaluate and implement corrective actions to address the delinquent medical records rate of greater than 65% for the past 10 months.
Findings:

Review of the Quality Management/Performance Improvement Plan 2016 revealed in part the following: 5. The Medical Staff executive committee and/or the medical director in conjunction with hospital or clinic leadership has the authority and responsibility for performance improvement activities throughout the hospital and ensure the following: B. Monitoring and evaluation activities are performed systematically, appropriately, effectively, with actions and follow up taken....

Review of the Monthly Reporting Statistics provided by S13DirMR as the medical records delinquency rates since October 2015 revealed the following medical record delinquency rates:
October 2015 - 368%
November 2015 - 255%
December 2015 - 243%
January 2016 - 303%
February 2016 - 344%
March 2016 - 130%
April 2016 - 160%
May 2016 - 116%
June 2016 - 75%
July 2016 - 65%

Review of the Chart Deficiencies Summary Report by physician provided by S13DirMR as a list of delinquent medical records by physician revealed a total of 111 delinquent records as of 08/31/16. The report revealed 25 physicians had delinquent records.

Review of the 2016 Quality Scorecard revealed the same percentages as indicated above.

Review of the Quality Improvement Committee Meeting Minutes dated 03/01/16 (Reporting January 2016), 03/29/16 (February 2016 data), 05/17/16 (March & April 2016 data), and 06/29/16 (May 2016 data) revealed the above chart delinquencies were reported and discussed. "Will continue to monitor and report" was documented under "Recommendations/Actions." There was no documented evidence of any new corrective actions to address the continuing problem of delinquent medical records.

Review of the MEC Committee meeting minutes dated 10/22/15, 02/18/16, and 05/05/16 revealed the medical records delinquency rates were reported and discussed, but there was no documented evidence of any corrective action plan to address the identified delinquent medical records problem.

In an interview on 08/31/16 at 9:00 a.m., S13DirMR stated she was the RHIA over this hospital and at the company's hospital in another city approximately 2 hours away. She stated she was hired at this hospital in October of 2015. She confirmed the above medical record delinquency rates. She stated she has focused on the delinquency rate and it has improved. S13DirMR stated the physicians have been an obstacle. She stated their goal for compliance was 50%. S13DirMR stated the Medical Staff bylaws include provisions for suspension of physicians with delinquent records but no physicians have been suspended to date. S13DirMR stated she was given the ok 2 weeks ago to suspend physicians. S13DirMR confirmed she had made multiple presentations to the MEC, but the delinquent records had not been addressed by the MEC. S13DirMR stated when she was employed by this hospital in October 2015, she developed a corrective action plan to address the high percentages of delinquent records. S13DirMR provided her corrective action plan dated 11/05/15 which revealed the following actions: Notifications of delinquencies will be sent out weekly to physician via fax, phone, or verbal notification. Ensure that all deficient charts are available for MD access. HIM will begin to concurrently flag charts along with unit secretary on a daily basis to decrease the overall deficiencies post discharge. Report status monthly to DQM and MEC and alert of any variances/issues. Will begin using Joint Commission Statistics form to track monthly, quarterly, annual rates. Will begin putting notifications on open records reminding physicians to sign as well as also date and time when signing orders and progress notes. There was no documented evidence of any new interventions since the plan was started on 11/05/15. S13DirMR confirmed there were no new interventions identified or implemented since she started the corrective action plan in November 2015.

In an interview on 09/06/16 at 2:00 p.m., S3DQM stated they had made progress with the delinquent medical records, but confirmed there was still a problem with large numbers of delinquent medical records. S3DQM confirmed there were no new interventions identified or implemented since S13DirMR developed a corrective action plan in November 2015.

Based on interview, the governing body failed to ensure that the quality assessment performance improvement (QAPI) program reflected the complexity of the hospital's organization and services and involved all hospital departments and services, including those services furnished under contract or arrangement. The QAPI program did not include quality indicators for the contracted lab, radiology, linen service, nurse staffing services, and the remote telemetry monitoring service. The QAPI program did not include quality indicators for Physical Therapy, Speech Therapy, and Occupational Therapy.
Findings:

Review of the Quality Management/Performance Improvement Plan 2016 revealed in part the following: Program Scope: The Quality/Performance Improvement Plan identifies assessment and improvement activities for all patients receiving care within the PAM (Post Acute Medical) facility as well as with contracted services....

Review of the 2016 Quality Scorecard and the Quality Improvement Committee Meeting Minutes for 2016 revealed no documented evidence of any quality indicators for the hospital services of Physical Therapy, Speech Therapy, and Occupational Therapy. There was no documented evidence of any quality indicators for the contracted services of lab, radiology, linen service, nurse staffing services, and the remote telemetry monitoring service.

In an interview on 09/26/16 at 2:00 p.m., S3DQM confirmed quality indicators had not been developed for the contracted lab services, radiological services, linen service, nurse staffing services, and the remote telemetry monitoring service. S3DQM confirmed the QAPI program did not include quality indicators for Physical Therapy, Speech Therapy, and Occupational Therapy.

30172

Based on record reviews and interviews, the Medical Staff failed to enforce its Bylaws as evidenced by:
1) Failing of the responsible practitioner to pronounce a deceased patient for 1 (#11) of 6 (#9, #10, #11, #16, #17, #18) sampled patients reviewed for pronouncement of death from a total sample of 30;

2) Failing to enforce its By-laws to carry out its responsibilities related to suspension of physicians with delinquent medical records as evidenced by having physicians with incomplete medical records not within 30 days of discharge who were not suspended in accordance with the Medical Staff By-laws for 7 of 7 (S46MD, S50MD, S51MD, S52MedDir, S53MD, S54MD, S55MD) physicians with delinquent medical records at the time of review on 08/31/16; and

3) Failing to ensure medical records included a properly executed informed consent for procedures and treatments. This deficient practice was evidenced by informed consents that were not completed as per Medical Staff ByLaws when information required was omitted in the informed consent, required information areas were left blank, and/or informed consents were not obtained for procedures/treatments performed for 3 of 3 (#1, #2, #14) patient records reviewed for properly executed informed consents from a total sample of 30.

Findings:

1) Failing of the responsible practitioner to pronounce a deceased patient

A review of the Medical Staff ByLaws, Rules & Regulations, approved by the Governing Body and provided by S1CEO, revealed in part: A. Admission and Discharge of Patients: 1. A patient may be admitted to the Hospital only by a practitioner approved by the Medical Staff in accordance with the Medical Staff Bylaws. 2. The practitioner shall be responsible for the medical care and treatment of each patient in the Hospital, for the prompt completeness and accuracy of the medical record. 5. In the event of a Hospital death, the deceased shall be pronounced dead by the responsible practitioner or their designee within a reasonable period of time. 7. Patients may be treated by the practitioners who have submitted proper credentials and have been approved for membership on the Medical Staff in accordance with the ByLaws of the Medical Staff.

A review of the Nursing Notes on 05/31/16 at 4:10 a.m. for Patient #11 revealed: S44MD, the patient's attending practitioner, was texted by nursing staff to pronounce the patient. An entry at 4:20 a.m. revealed the patient was pronounced deceased per S45MD.

A review of the Medical Staff credentialing roster, as provided by S1CEO, revealed that S44MD was a credentialed member of the Medical Staff. A further review revealed no evidence that S45MD was a credentialed member of the Medical Staff.

In an interview on 09/06/16 at 1:15 p.m. with S1CEO he indicated that S45MD was not a credentialed member of the Medical Staff. He indicated that the patient's practitioner was S44MD and that S45MD was the coroner who pronounced the patient when S44MD was unable to be reached by staff. S1CEO indicated that he thought that the practitioner's designee (for death pronouncement) could be a non-credentialed member of the Medical Staff if he was the coroner.


2) Failing to enforce its By-laws to carry out its responsibilities related to suspension of physicians with delinquent medical records

Review of the Medical Staff Bylaws, presented as current Bylaws by S3DQM, revealed that practitioners are required to complete medical records timely and legibly in accordance with the requirements set forth in the Rules. Practitioners who are delinquent in completion of medical records will be given notice that they must complete the records in accordance with the timelines set forth in the Rules or be subject to automatic suspension of privileges. Such notice shall be sent by certified mail and by facsimile or e-mail to the practitioner's office. If the records are not completed in accordance with the Rules following such notice, the practitioner's admitting privileges will be automatically suspended and will remain automatically suspended until all of the delinquent records are completed.

Review of the hospital policy titled Inpatient Medical Record Review and Internal Audit, Publication: HIM 03 revealed in part the following: 3.3.6 Medical Staff deficiencies are addressed at MEC and appropriate action plans are developed for improvement and monitored until improvement is made.


Review of the Monthly Reporting Statistics provided by S13DirMR as the medical records delinquency rates since October 2015 revealed the following medical record delinquency rates:
October 2015 - 368%
November 2015 - 255%
December 2015 - 243%
January 2016 - 303%
February 2016 - 344%
March 2016 - 130%
April 2016 - 160%
May 2016 - 116%
June 2016 - 75%
July 2016 - 65%

Review of the Chart Deficiencies Summary Report by physician provided by S13DirMR as a list of delinquent medical records by physician revealed a total of 111 delinquent records. The report revealed 25 physicians had delinquent records. The report revealed the following:
S46MD - 8 delinquent records
S50MD - 5 delinquent records
S51MD - 13 delinquent records
S52MedDir - 9 delinquent records
S53MD - 5 delinquent records
S54MD - 6 delinquent records
S55MD - 15 delinquent records

Review of the credentialing files for S46MD, S50MD, S51MD, S52MedDir, S53MD, S54MD, and S55MD revealed no documented evidence of any suspensions for delinquent medical records. There was no documented evidence of written notice regarding delinquent or incomplete records in the credentialing files.

In an interview on 08/31/16 at 9:00 a.m., S13DirMR stated she was the RHIA over this hospital and at the company's hospital in another city approximately 2 hours away. She stated she was hired at this hospital in October of 2015. She confirmed the above medical record delinquency rates. She stated she has focused on the delinquency rate and it has improved. S13DirMR stated the physicians have been an obstacle. She stated their goal for compliance was 50%. S13DirMR stated the Medical Staff Bylaws include provisions for suspension of physicians with delinquent records but no physicians have been suspended to date. S13DirMR stated she was given the ok 2 weeks ago to suspend physicians. S13DirMR confirmed she had made multiple presentations to the MEC, but the delinquent records had not been addressed by the MEC. S13DirMR provided the corrective action plan for delinquent medical records dated 11/05/15. Review of the corrective action plan revealed the following: 03/08/16 - unable to suspend MDs for non-compliance per direction from Administration. Actively working with the Medical Director, CEO, and MEC to encourage non-compliant physicians to complete records.

In an interview on 09/01/16 at 4:50 p.m., S1CEO confirmed delinquent records had been an ongoing problem for the hospital and stated he was proud of 50% compliance. S1CEO confirmed no physician had been suspended as directed in the Medical Staff Bylaws. He stated going forward he would take a hard stand and suspend physicians with delinquent records. S1CEO confirmed the Medical Staff Bylaws had not been followed by the MEC.


3) Failing to ensure medical records included a properly executed informed consent for procedures and treatments

A review of the Medical Staff ByLaws, Rules & Regulations, approved by the Governing Body and provided by S1CEO, revealed in part: B. Medical Records: The medical record must also contain properly completed patient informed consents for tests/treatments/surgery. E. General Rules Regarding Operative and Invasive Procedures With or Without Anesthesia or Sedation. It is the responsibility of the physician performing the procedure to obtain a written, signed, surgical consent prior to the procedure. Informed consents includes documentation that the following have been considered and discussed with the patient and family: a. Risks of procedure, b. benefits of procedure, c. Potential complications associated with the procedure, d. Alternative options to the procedure, e. Need for risk of and alternatives to blood transfusion when blood or blood components may be needed, f. Options and risks of anesthesia/sedation.


Patient #1
Review of the medical record for Patient #1 revealed he was admitted to the hospital 07/05/16. One of Patient #1's diagnoses was that of Mental Retardation. Further review revealed his mother was his legal representative. Review of consent forms revealed a consent for Serial Conservative (Selective) Sharp Wound Debridements. Further review of this consent revealed it was signed by a Nurse Practitioner and Patient #1's mother. The consent form had blank areas in the following: 3. Patient's condition ( Patient's diagnosis, description of the nature of the condition or ailment for which the medical treatment, surgical procedure or other therapy described is indicated and recommended), 4(b) additional risks, if any, particular to the patient because of a complicating medical condition are: ). Review of a Consent for Transfusion and Blood Components revealed 4.(b) Additional risks, and 5. Reasonable therapeutic alternative and the risks associated with such alternatives were left blank. Further review revealed this consent was obtained over the telephone, and had no signature of the clinician that was to obtain informed consent.

In an interview 09/06/16 at 12:50 p.m. S2DON/IC, after reviewing the consent forms for Patient #1, she verified that not all blanks were filled in or lined out. S2DON/IC agreed that the consents should not have had blanks on them when a patient (or representative) signed them.


Patient #2
Review of the medical record for Patient #2 revealed the patient was a 36 year old admitted to the hospital on 01/11/16 with diagnoses of Chronic Respiratory Failure, Quadriplegia, and Ventilator Dependent. Review of the patient's medical record revealed a physician consult for S49MD for a triple lumen catheter placement by S49MD on 06/27/16. A review of the Critical Care Flowsheet dated 06/27/16 at 11:45 a.m. revealed: "S49MD at bedside. Time Out for procedure performed. TLC changed over wire without difficulty. Patient tolerated well." Further review of the patient's medical record revealed a "General Surgical Consent" form for the procedure on 06/27/16 that was not completed by S49MD. The "General Surgical Consent" form revealed the patient was unable to sign due to quadriplegia and was documented as witnessed by 2 RNs and was dated and timed on 06/27/16 at 9:30 a.m. The "Purpose" section was documented as, "Change TLC". All other aspects of the "General Surgical Consent" form (Medical Treatment/Procedure, Description, Patient Condition, Material Risks of Medical Treatment/Procedure, Reasonable Therapeutic Alternatives and Risks Associated therewith, Risks of no Treatment, and the Physician Signature with date and time) was left blank. A further review of the medical record revealed no documented evidence in the physician process notes of the procedure being discussed with the patient or the family.

In an interview on 09/01/16 at 3:30 p.m., S2DON/IC reviewed the medical record for Patient #2 and confirmed the consent for the triple lumen catheter insertion was not completed in accordance with hospital policy and the sections for Medical Treatment/Procedure, Description, Patient Condition, Material Risks of Medical Treatment/Procedure, Reasonable Therapeutic Alternatives and Risks Associated therewith, Risks of no Treatment, and the Physician Signature with date and time were all left blank.


Patient #14
The patient was a 87 year old female admitted to the hospital on 08/03/16 with an admit diagnosis of MRSA septicemia and wound abscess. A review of the patient's medical record revealed a physician consult for S49MD for a triple lumen catheter placement by S49MD. A review of S56RN nursing daily flowsheet on 08/16/16 at 2:20 p.m. revealed: "S49MD at bedside. Inserted triple lumen catheter. Time Out completed at bedside. Patient tolerated well". A further review of the patient's medical record revealed a blank "General Surgical Consent" form for the procedure on 08/16/16 that had not been completed by S49MD. The "General Surgical Consent" form revealed it was a telephone consent with the patient's son and was documented as witnessed by 2 RNs and was dated and timed on 08/16/16 at 11:35 a.m. All other aspects of the "General Surgical Consent" form (Medical Treatment/Procedure, Description and Purpose, Patient Condition, Material Risks of Medical Treatment/Procedure, Reasonable Therapeutic Alternatives and Risks Associated therewith Risks of no Treatment, Physician Signature with date and time, and the Reason Section as to why the consent was signed by someone other than the patient) was left blank. A further review of the medical record revealed no documented evidence in the physician process notes of the procedure being discussed with the patient or the family.

In an interview on 09/01/16 at 11:35 a.m. with S56RN, in the presence of S2DON/IC, she indicated that she was one of the nurses caring for Patient #14 on 08/16/16 and indicated that she assisted S49MD with the Triple Lumen Catheter insertion procedure. S56RN indicated that S49MD did not obtain the consent for the procedure and it was obtained by 2 RNs as a telephone consent with the patient's son. S56RN indicated that the obtaining of a properly executed informed consent by the physician performing the procedure was an oversite.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) The hospital failed to ensure the initial nursing assessment was conducted by a RN for 2 (#5, #23) of 2 current patients and 1 (#19) of 1 discharged patient out of 9 (#1 - #5, #12, #13, #19, #23) patient medical records reviewed for initial nursing assessments out of 30 sampled patient medical records;

2) The hospital failed to ensure that a RN documented a nursing assessment on each patient every 24 hours as evidenced by no documentation of a RN assessment in the patient's medical record for 3 (#3, #4, #15) of 3 current patients out of 8 (#1 - #5, #12, #13, #15) patients reviewed for RN documented assessments every 24 hours out of a total sample of 30 patient medical records;

3) The RN failed to reassess a patient's weight after a 25 pound discrepancy was documented from one day to the next day as evidenced for 1 (#3) out of 9 (#1- #5, #12, #13, #15, #29) current patient records and 2 (#20, #25) of 2 discharged patients records out of a total of 11 medical records reviewed for assessment of weights from a total sample of 30 patient medical records;

4) The RN failed to assess the patient's weight as ordered by the physician for 2 (#15, #29) of 2 current patients and 2 (#20, #25) of 2 discharged patients out of 11 (#1-5, #12, #13, #15, #20, #25, #29) sampled patient records reviewed for assessment of weights from a total sample of 30 patient records;

5) The RN failed to assess the patient's condition and cardiac rhythm after incidents with the remote telemetry monitoring were identified for 3 of 3 (#21, #24, #25) discharged sampled patients reviewed for incidents with remote telemetry monitoring out of a total sample of 30 patient medical records;

6) The RN failed to ensure telemetry monitor recordings were obtained and validated in accordance with hospital policy and the written agreement with the remote telemetry monitoring provider for 2 of 2 (#26, #29) current patients and 2 of 2 (#24, #25) discharged sampled patients reviewed for telemetry monitoring out of a total sample of 30 patient medical records.

7) The RN failed to ensure an initial wound assessment was conducted by the RN as required by hospital policy for 2 (#4, #14) of 3 (#4, #12, #14) current patient records reviewed for wound assessments out of a total sample of 30 patient medical records.

8) The RN failed to ensure that "Time Outs" were documented in the patient's medical record prior to a patient's procedure according to hospital policy for 3 (#1, #2, #14) of 5 (#1, #2, #4, #12, #14) current patient medical records reviewed for "Time Outs" out of a total sample of 30 patient medical records;

Findings:

1) The hospital failed to ensure the initial nursing assessment was conducted by a RN

Review of the hospital's policy titled, "Nursing Department Organization", Publication: CL 53, revealed in part the following: RN's, who work under the direction of the Charge Nurse complete initial nursing assessments.

Patient #5
Review of the medical record for Patient #5 revealed the patient was admitted to the hospital on 08/12/16 at 7:00 p.m. with a diagnosis of Acute on Chronic Systolic Heart Failure. Review of the initial nursing assessment revealed the entire initial assessment was conducted and documented by an LPN. There was no documented evidence of an initial nursing assessment by the RN.

In an interview on 08/31/16 at 1:15 p.m., S2DON/IC reviewed the medical record for Patient #5 and confirmed the initial nursing assessment was done entirely by the LPN.

Patient #19
Review of the medical record for Patient #19 revealed he was admitted 03/11/16 at 4:00 p.m. Further review revealed his Initial Nursing Assessment was documented to have been completed by S56LPN. No documentation of an RN assessment was noted on the initial assessment or the nursing notes during the patient's admission.

Patient #23
Review of the medical record for Patient #23 revealed she was admitted 08/10/16 at 4:00 p.m. Further review revealed her Initial Nursing Assessment was completed by S39LPN. Further review revealed no documentation of an assessment by an RN for the remainder of the day shift.

In an interview 09/06/16 at 12:50 p.m. S2DON/IC, after review of the initial assessments and initial nursing notes for Patient's #19 and #23, verified that the Initial Nursing Assessment was done by an LPN, with no assessment documented by an RN.


2) The hospital failed to ensure that a RN documented a nursing assessment on each patient every 24 hours

A review of the hospital policy titled "Assessment/Reassessment Nursing" as provided by S2DON/IC as the most current policy, revealed in part: The RN reassesses the patient every 24 hours at a minimum. The assessments are recorded in the patient medical record.

Review of the hospital policy, Publication CL 29 revealed in part, A specific physician order will supersede the minimum frequencies noted below: Assessment: systematic physical assessment done and recorded. Every shift and as condition changes. RN must assess once every 24 hours...2. An RN reassessed the patient every 24 hours at a minimum. The assessment (s) are recorded in the patient medical record. Using the reassessment, the RN responsible for the patient updates the patient's needs/problems and plan of care.

Patient #3
Review of the medical record for Patient #3 revealed he was admitted to the hospital on 8/23/16 for long term antibiotics. With review of his nursing assessments on 8/26/16 revealed the following nurses assessed the patient: S17LPN and S21LPN. On 8/27/16 the following nurses assessed the patient: S25LPN and S21LPN. On 8/28/16 the following nurses assessed the patient: S25LPN and S21LPN. For 72 hours (3 days) an RN did not assess Patient #3.

An interview was conducted with S2DON/IC on 8/31/16 at 2:30 p.m. She confirmed the above findings that a RN did not assess Patient #3 on 8/26/16, 8/27/16 and 8/28/16.

Patient #4
The patient was a 52 year old female admitted to the hospital on 08/24/16 with an admit diagnosis of abscess of right arm positive for MRSA, nausea and vomiting with diarrhea. A review of the daily nursing flowsheets revealed the patient was documented as being cared for and assessed by LPN's on 08/26/16 (S17LPN and S22LPN); 08/28/16 (S21LPN and S23LPN); and 08/29/16 (S20LPN and S24LPN). There was no documented evidence on the daily nursing flowsheets and/or in the corresponding daily progress notes that the patient was documented as being assessed by a RN every 24 hours.

In an interview on 09/06/16 at 2:00 p.m. with S2DON/IC she indicated that nurses were scheduled on 12 hour shifts. S2DON/IC indicated that a RN was to assess each patient every 24 hours, according to hospital policy and document the assessments in the daily nursing flowsheets.

Patient #15
Review of the medical record for Patient #15 revealed the patient was a current patient admitted to the hospital on 08/23/16 with a diagnosis of Acute on Chronic Renal Failure. Review of the Nursing Daily Flowsheets dated 08/26/16, 08/27/16, and 08/28/16 revealed the assessments for each 24 hour period were documented by an LPN. There was no documented evidence of an RN assessment of the patient for 72 hours (3 days).

In an interview on 09/01/16 at 1:25 p.m., S2DON/IC reviewed the medical record for Patient #15 and confirmed there was no RN assessment at least every 24 hours as required and she confirmed there was no RN assessment of the patient for 3 days.



3) The RN failed to reassess a patient's weight after a 25 pound discrepancy was documented

Patient #3
Review of the medical record for Patient #3 revealed he was admitted to the hospital on 8/23/16 for long term antibiotics.

Review of the Vital Signs and Intake and Outputs Records revealed the following daily weights on Patient #3: 8/23/16-149.7#, 8/24/16-150.9#, 8/25/16-151.3#, 8/26/16- 155.0#, 8/27/16-125.5#, 8/28/16-125.4#, 8/29/16-125.5#. A further review of the patient's medical record revealed no documentation of reassessment of the 29.5 weight loss from 8/26/16 to 8/27/16.

An interview of conducted with S2DON/IC on 8/31/16 at 2:30 p.m. She reported she re-weighed Patient #3 and the patient's current weight was 154.9#. She reported she thinks the weights from 8/27/16 until 8/29/16 were incorrect, but was not sure why the patient's weight was incorrect. She further reported there was no evidence that the RN reassessed the patient's documented weight loss of 29.5# and she should have reassessed the patient's weight.

4) The RN failed to assess the patient's weight as ordered by the physician.

Patient #15
Review of the medical record for Patient #15 revealed the patient was a current patient admitted to the hospital on 08/23/16 with a diagnosis of Acute on Chronic Renal Failure. Review of the Physician Admit Orders dated/timed 08/23/16 at 8:45 p.m. revealed an order to weigh the patient daily.
Review of the Vital Signs and Intake & Output Records (Graphic Record) and the Nursing Daily Flowsheets from admission to present revealed no documented evidence of the patient's weight on 08/23/16, 08/24/16, 08/27/16, and 08/31/16.

In an interview on 09/01/16 at 1:25 p.m., S2DON/IC reviewed the medical record for Patient #15 and confirmed the physician had ordered daily weights on the patient and the weights were not done on the above dates. S2DON/IC stated daily weights have historically been a problem for the hospital. She stated the weights are done at night and sometimes the patient was not awakened to be weighed.


Patient #20
Review of the medical record for Patient #20 revealed the patient was admitted to the hospital on 05/27/16 with a diagnosis of Acute Cholecystitis
Review of the Physician Admit Orders dated/timed 05/27/16 at 2:40 p.m. revealed an order to weight the patient daily.
Review of the Vital Signs and Intake & Output Records (Graphic Record) and the Nursing Daily Flowsheets from admission to discharge on 06/18/16, revealed no documented evidence of the patient's weight on 06/04/16, 06/05/16, 06/06/16, 06/08/16, 06/12/16, and 06/17/16.

In an interview on 09/01/16 at 3:35 p.m., S2DON/IC reviewed the medical record for Patient #20 and confirmed the physician had ordered daily weights on the patient and the weights were not done on the above dates.

Patient #25
Review of the medical record for Patient #25 revealed he was admitted to the hospital 07/11/16 with diagnoses that included Acute ischemic right cerebrovascular accident, Ventilator-dependent respiratory failure, Aspiration pneumonia, HTN, and Acute kidney injury Further review revealed he was admitted to the High Observation Unit, with continuous cardiac monitoring. Further review of the medical record revealed from 07/11/16 through 08/11/16 , 8 days ( 07/11, 07/12, 07/13, 07/14, 07/20, 07/28, 08/01, 08/07, and 08/08) occurred with no weight documented.

Patient #29
Review of the medical record revealed he was admitted to the hospital 090/2/16 with diagnosis that included infection associated with a temporary femoral HD line, aspiration pneumonia, and was receiving dialysis. Review of Patient #29's admitting order included to weigh on admit and then daily. Further review revealed no documented weight on 09/04/16 and 09/05/16.

In an interview 09/06/16 at 12:50 p.m. S2DON/IC reviewed the medical records of Patients #25 and #29 and confirmed the physician's orders were to weigh the patient daily, and that the above noted days did not have a weight documented as ordered.



5) The RN failed to assess the patient's condition and cardiac rhythm after incidents with the remote telemetry monitoring were identified:

Review of the written agreement between the hospital and Company "B" revealed Company "B" would provide through qualified representatives, on a 24-hour per day, 365 day per year basis, for every telemetry patient in the hospital....immediate notice of any rhythm change and a rhythm strip analysis no less than every six (6) hours on each patient.

Review of the hospital policy titled, "Continuous Cardiac Monitoring, Publication: CL18", revealed in part the following: Qualified staff maintains visual surveillance 24 hours a day....
3. Cardiac rhythm will be recorded, interpreted, and documented on the initiation of telemetry monitoring, every six (6) hours thereafter, and more frequently as indicated by the patient's condition.
7. The nurse assigned to the patient must respond immediately if any of the following occurs:
b. Any observed change in the patient's rhythm (a strip is to be recorded, assessed and documented).


Patient #21
Review of the medical record for Patient #21 revealed the patient was admitted to the hospital on 06/08/16 with diagnoses of Septic Shock from Sacral Decubitus, Severe Malnutrition, and Systolic Congestive Heart Failure. The record revealed the patient was admitted to the High Observation Unit and was placed on continuous cardiac monitoring.

Review of the incident report for Patient #21 dated 06/22/16 revealed at 9:30 a.m. on 06/22/16 the patient's telemetry alarmed Ventricular Tachycardia with a ten beat run of Ventricular Tachycardia. The report revealed the staff was notified by the onsite monitor technician at the hospital, but Company "B" (Remote telemetry monitoring company) did not actually call and notify the hospital of the alarm until 10:28 a.m., one hour after the arrhythmia was identified. There was no documented evidence of any follow up to the incident.

Further review of the patient's record revealed a Telemetry Report dated 06/22/16 at 9:30 a.m. from Company "B" indicating 11 beats of Ventricular Tachycardia. The report indicated the hospital was called at 10:28 a.m. on 06/22/16. There was no documentation of a validation or review of the rhythm by the hospital staff. Further review of the Nursing Daily Flowsheet for 06/22/16 revealed no documented evidence of a patient assessment at the time of the arrhythmia. There was no documented evidence the physician was notified of the arrhythmia. Further review of the Telemetry Reports revealed on 06/16/16 at 5:20 p.m. the patient had a 30 second sustained Ventricular Bigeminy that was identified by the hospital's onsite monitor technician. The Telemetry Report revealed Company "B" did not notify the hospital of the arrhythmia until 6:18 p.m., 58 minutes after the arrhythmia was identified.

On 09/01/16 at 12:50 p.m. an observation was made of S43MT. She was observed to be sitting at the desk where the telemetry monitor screens were located, but was observed to be working on patient records, answering the call system and the telephone. There was no staff observed to continuously monitor the cardiac monitors. S43MT stated she had been told not to watch the monitors anymore. S43MT indicated a company offsite was now responsible for monitoring telemetry and recording and evaluating the monitor strips. S43MT further stated there had been incidents where arrhythmias should have been caught by Company "B".

In an interview on 09/01/16 at 3:25 p.m., S2DON/IC reviewed the medical record and the incident report dated 06/22/16 for Patient #21. S2DON/IC confirmed Company "B" did not notify the hospital timely on either episode of the patient's arrhythmias. She further stated these issues were being handled at the corporate level and the staff are documenting all issues on the incident reports. S2DON/IC confirmed the arrhythmia identified on 06/22/16 was not documented in the record and stated it should have been. S2DON/IC confirmed the nursing staff should have documented an assessment of the patient, notification of the physician, and the arrhythmia in the patient's record. S2DON/IC confirmed the delay in notification of an arrhythmia on 06/16/16 should have been documented on an incident report, but was not.

In an interview on 09/01/16 at 4:40 p.m., S1CEO confirmed Company "B" was contracted to provide remote telemetry monitoring for the hospital. He stated they had issues with reporting arrhythmia to the hospital and had started documenting those on incident reports. He stated the staffing module change had been put on hold and the onsite monitor technicians had been left in place. He stated the monitor technician responsibilities were to remain at the nurse's station in plain view of the monitors and report changes to the RN. S1CEO confirmed the monitor technicians were also responsible for answering the telephone and patient call system, and ordering labs. He stated Company "B" was responsible for analyzing and sending telemetry strips. S1CEO further indicated the issues with Company "B" were being addressed at the corporate level.

Patient #24
Review of the medical record for Patient #24 revealed the patient was admitted to the hospital on 06/28/16 with a diagnosis of Aspiration Pneumonia. The record revealed the patient was admitted to the High Observation Unit and was placed on continuous cardiac monitoring.

Review of the incident report for Patient #24 dated 07/02/16 revealed at 1:30 p.m. on 07/02/16 Company "B" failed to pick up on the patient's telemetry changes. The report indicated Company "B" did not notify the hospital of the changes. The report indicated the staff watched the progress and were taking care of the patient and also notified Company "B" of the changes. The report revealed a rapid response was called and the patient was sent to the Emergency Department. There was no documented evidence of any follow up to the incident.

Further review of the patient's record revealed Telemetry Reports dated 07/01/16, 07/02/16, 07/03/16, and 07/04/16 at 9:00 a.m. and 9:00 p.m. from Company "B" indicating the patient was in Sinus Rhythm or Sinus Tachycardia. There was no documented evidence of any telemetry records indicating changes in the patient's rhythm on 07/02/16 or any of the days before and after 07/02/16. There was no documented evidence the patient was transferred to the Emergency Department during her hospital stay. There was no documented evidence of a telemetry record for 07/02/16 at 1:30 p.m. Further review of the Nursing Daily Flowsheets for 07/01/16 to 07/04/16 revealed no documented evidence of any changes in the patient's cardiac rhythm or condition.

On 09/06/16 from 11:12 a.m. to 11:35 a.m. S43MT was observed sitting at the desk where the cardiac monitors were located. S43MT was observed to document in patient records, answer questions from staff, family members, physicians and paramedics, answer the telephone and patient call system. S43MT was not observed to monitor the telemetry monitors and at times was observed to have her back to the monitors. At 11:50 a.m. S42Sec was observed to relieve S43MT and be seated at the nurse's desk adjacent to the telemetry monitors. S42Sec was observed to leave the area at times and not provide observation of the cardiac monitors. S42Sec stated she does not watch the cardiac monitors and stated, "There is a company somewhere else that does that."

Review of the personnel record for S42Sec revealed no documented evidence of any training or competencies in cardiac monitoring.

In an interview on 09/06/16 at 1:00 p.m., S2DON/IC reviewed the medical record for Patient #24 and confirmed there was no follow up documented for the incident dated 07/02/16 regarding changes in the patient's telemetry that were not reported by Company "B". She confirmed the incident report was inaccurate as the patient was not transported to the Emergency Room. S2DON/IC stated she did not know why this was documented, she stated it may be the wrong date or the wrong chart. S2DON/IC confirmed there was no assessment of the patient's condition documented at the time of the telemetry changes. S2DON/IC stated she had told the hospital's monitor technicians they didn't have to watch the telemetry monitors as close.


Patient #25
Review of the medical record for Patient #25 revealed he was admitted to the hospital 07/11/16 with diagnoses that included Acute ischemic right cerebrovascular accident, Ventilator-dependent respiratory failure, Aspiration pneumonia, HTN, and Acute kidney injury. Further review revealed he was admitted to the High Observation Unit, with continuous cardiac monitoring.

Review of an incident report for Patient #25 dated 07/15/16 revealed at 12:30 a.m. on 07/15/16 the monitor on this particular patient was reading ventricular Tachycardia. Further review of the report's Brief Factual Description revealed, "The charge nurse and primary nurse were at the bedside assessing the patient, and he was NOT in v-tach (ventricular tachycardia). Heart rate was verified apically and radially in the 60s. However [Company B] never called to notify us of said v-tach..."

Further review of the patient's medical record for the 07/14/16-07/15/16 (6:00 a.m.) shift revealed no documentation of the event or of an assessment of the patient at 12:30 a.m. Review of the nursing notes for that shift had no entry at 10:30, with the next entry documented at 1:00 a.m. (07/15/16) which read, "sleeping, NAD, VSS." Review of Telemetry Reports for 07/14/16 revealed 2 tracings as follows: 9:00 a.m. and 9:00 p.m.. No other tracing was found for the time of the reported occurrence.

In an interview 09/06/16 at 3:00 p.m. S2DON/IC verified there was no documentation on Patient #25's medical record of a cardiac tracing indicating Ventricular Tachycardia, or of an assessment of the patient and those findings. She indicated that there was no documentation of a call to Company B regarding the tracing that indicated Ventricular Tachycardia, or regarding a notification from Company B of the arrhythmia.


6) The RN failed to ensure telemetry monitor recordings were obtained and validated in accordance with hospital policy and the written agreement with the remote telemetry monitoring provider.

Review of the hospital policy titled, "Continuous Cardiac Monitoring, Publication: CL18", revealed in part the following: Qualified staff maintains visual surveillance 24 hours a day....
3. Cardiac rhythm will be recorded, interpreted, and documented on the initiation of telemetry monitoring, every six (6) hours thereafter, and more frequently as indicated by the patient's condition.
6. A qualified staff member competent in rhythm interpretation will assess each strip and measure and record the rate, rhythm.... A qualified and competent RN will validate the rhythm strip.
7. The nurse assigned to the patient must respond immediately if any of the following occurs:
b. Any observed change in the patient's rhythm (a strip is to be recorded, assessed and documented).


Review of the written agreement between the hospital and Company "B" revealed Company "B" would provide through qualified representatives, on a 24-hour per day, 365 day per year basis, for every telemetry patient in the hospital....immediate notice of any rhythm change and a rhythm strip analysis no less than every six (6) hours on each patient.

Patient #24
Review of the medical record for Patient #24 revealed the patient was admitted to the hospital on 06/28/16 with a diagnosis of Aspiration Pneumonia. The record revealed the patient was admitted to the High Observation Unit and was placed on continuous cardiac monitoring.

Further review revealed Telemetry Reports, faxed from Company "B", with a tracing and interpretation at 9:00 a.m. and 9:00 p.m. Further review of theses tracings revealed no documentation of a nurse's review. The nursing signature line was blank on all pages.

In an interview on 09/06/16 at 1:00 p.m., S2DON/IC reviewed the medical record for Patient #24 and confirmed the hospital only received telemetry reports every 12 hours from Company "B"and the RNs did not validate the telemetry strips as directed in the hospital's policy.


Patient #25

Review of the medical record for Patient #25 revealed he was admitted to the hospital 07/11/16 with diagnoses that included Acute ischemic right cerebrovascular accident, Ventilator-dependent respiratory failure, Aspiration pneumonia, HTN, and Acute kidney injury. Further review revealed he was admitted to the High Observation Unit, with continuous cardiac monitoring. Further review revealed Telemetry Reports, faxed from Company "B", with a tracing and interpretation at 9:00 a.m. and 9:00 p.m. Further review of theses tracings revealed no documentation of a nurse's review. The nursing signature line was blank on all pages.


Patient #26
Review of the medical record for Patient #26 revealed the patient was admitted to the hospital on 09/02/16 with diagnoses of Guillian Barre Syndrome and Respiratory Failure with Ventilator Dependence. The record revealed the patient was admitted to the High Observation Unit with continuous cardiac monitoring ordered on admission.
Review of the Telemetry Reports on the patient's record revealed only 3 telemetry strips as follows: 09/04/16 at 9:00 p.m., 09/05/016 at 9:00 a.m., and 09/05/16 at 9:00 p.m. There was no documented evidence of any other Telemetry Reports on the record.

In an interview on 09/06/16 at 1:00 p.m., S2DON/IC reviewed the medical record for Patient #26 and confirmed there were only 3 telemetry reports on the patient's record. She stated there should be a strip sent by Company "B" every 12 hours or once a shift. After reviewing the hospital's policy and the written agreement with Company "B", she confirmed both documents included provisions for the recording of telemetry strips every six (6) hours. S2DON/IC stated Company "B" had verbally agreed to sending telemetry reports every six hours. She stated the RNs were not validating any telemetry strips as directed in the hospital's policy. S2DON/IC confirmed the hospital's policy for Cardiac Monitoring had not been updated since the hospital contracted the telemetry monitoring with Company "B".


Patient #29
Review of the medical record for Patient #29 on 09/06/16 at 10:05 a.m. revealed he was admitted to the hospital on 09/02/16 with diagnoses that included: Infection associated with Temporary Femoral HD line, Leaking AAA, and retroperitoneal hematoma, aspiration pneumonia, PAD with lower limb ischemia, and severe malnutrition. Review of his physician's admit orders included telemetry monitoring and weight on admit and then daily. Further review revealed Telemetry Report/ Tracings faxed from Company B on 09/03/16 at 3:50 a.m., 09/04/16 at 9:00 p.m., and another on 09/04/16 (each of these were interpreted by a different tech with tracings timed at 8:16 p.m. and 8:37 p.m.), and on 09/05/16 at 9:00 a.m. Review of these 4 tracings revealed no documentation of a nurse's review. No other tracings were found on the patient's medical record.

In an interview 09/06/16 at 10:05 a.m. S25LPN reported she was assigned to the care of Patient #29. She verified that only 4 telemetry tracings/reports were on the patient's medical record. She reported that the nurses did not review the tracings. The LPN reported that the telemetry reports were faxed to the hospital and reviewed by the monitor techs. She said she thought they received the telemetry reports every shift.

In an interview 09/06/16 at 12:50 p.m. S2DON/IC verified that the telemetry reports on Patient #29's medical records were only the four listed above, but should have included reports for each day the patient was admitted. She reported that the reports should be received and put on the chart every shift.


7) The RN failed to ensure an initial wound assessment was conducted by the RN as required by hospital policy

A review of the hospital policy titled "Initial Wound Assessment/Treatment" as provided by S2DON/IC as the most current policy, revealed in part: The policy provides direction for the nurse to initiate wound care on patients newly admitted. The Wound Care Nurse (Wound Care Consult) will evaluate the patient within 72 hours of admission and photographs will be taken. On newly admitted patients, remove all dressings from wounds and perform a head to toe assessment. Document location of wounds and record the measurements. Measure in centimeters the length, width and depth of the wound. Describe the wound appearance and record the color and amount of drainage.

Patient #4
The patient was a 52 year old female admitted to the hospital on 08/24/16 with an admit diagnosis of abscess of right arm positive for MRSA, nausea and vomiting with diarrhea. A review of the Initial Nursing Assessment dated 08/24/16 by S15RN under "Wound Description" revealed that no wound measurements were documented for the patient's wounds.
Patient #14
The patient was a 87 year old female admitted to the hospital on 08/03/16 with an admit diagnosis of MRSA septicemia and wound abscess. A review of the Initial Nursing Assessment dated 08/03/16 by the RN under "Wound Description" revealed that no wound measurements were documented for the patient's wounds.
In an interview on 08/31/16 at 9:15 a.m. with S2DON/IC she indicated she had in-serviced nurses several times on the importance of documenting all patients wounds upon initial nursing assessments to include wound measurements. S2DON/IC indicated that to help the nurses in compliance with wound assessments she had developed "wound stickers" for the medical records that included all the required documentation to help remind the nurses. S2DON/IC indicated that emails were sent to nursing staff on 04/01/16 indicating that "wound stickers" for new admits with wounds were available and were located at the nurse's desk. S2DON/IC further indicated that she thought that the nurse were utilizing the "wound stickers".

8) The RN failed to ensure that "Time Outs" were documented in the patient's medical record prior to a patient's procedure according to hospital policy:

A review of the hospital policy titled, "Universal Protocol" as provided by S2DON/IC as the most current, revealed in part: In support of the goal of preventing wrong site, wrong procedure, wrong person surgery/procedure, it is the policy of the hospital to comply with The Joint Commission's "Universal Protocol" to have an organization wide procedure for verifying the side, site, patient and procedure to ensure patient safety for invasive/surgical procedures that expose patients to more than minimal risk. Examples of such procedures are in part: chest tube insertion, central venous line catheterization, debridement of wounds and procedures that require informed consent. Verification of the items listed below should be documented: correct patient identity, correct site/side, agreement on the procedure to be done, correct patient position, and availability of correct special equipment/requirements.

Patient #1
Review of the medical record revealed Patient #1 was admitted to the hospital 07/05/16. During his admission he underwent a surgical excisional debridement of a wound to the left Knee. Further review revealed a Time Out Confirmation form, dated 7/21/16 signed by 2 LPNs. No documentation was noted as to who was present and in agreement with the time out information.

In an interview 09/06/16 at 12:50 p.m. S2DON/IC reviewed the procedural time out for Patient #1's wound debridement dated 07/21/16. S2DON/IC verified that the time out did not include the names of who were present for the time out to agree on the correct patient, site, and procedure. S2DON/IC verified the time out only had the signatures of 2 LPNs.

Patient #2
Review of the medical record for Patient #2 revealed the patient was a 36 year old admitted to the hospital on 01/11/16 with diagnoses of Chronic Respiratory Failure, Quadriplegia, and Ventilator Dependent.
Review of the patient's medical record revealed a physician consult for S49MD for a triple lumen catheter placement by S49MD on 06/27/16. A review of the Critical Care Flowsheet dated 06/27/16 at 11:45 a.m. revealed: "S49MD at bedside. Time Out for procedure performed. TLC changed over wire without difficulty. Patient tolerated well." There was no further documented evidence in the medical record that the hospital's Time Out protocol was documented and conducted according to policy that included documented verification of correct patient identity, correct site/side, agreement on the procedure to be done, correct patient position, and availability of correct special equipment/requirements.

In an interview on 09/01/16 at 3:30 p.m., S2DON/IC reviewed the medical record for Patient #2 and confirmed the "Time Out" for the triple lumen catheter insertion was not doc

30172

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a comprehensive nursing care plan for each patient that included target dates for the goals established in each patient's care plan as evidenced by failing to individualize patient's nursing care plans to include all the patient's medical diagnoses for which the patients were being treated and failing to set target dates for each patient's established goals for 3 (#1, #4, #5) of 7 (#1 - #5, #12, #13) patient medical records reviewed for nursing care plans from a sample of 30 patients. The hospital had a current census of 33 patients.

Findings:

Review of the hospital policy titled, " Plan of Care, Publication: CLI" revealed in part the following: The care plan will include the identified patient problems, the goals to work toward, and the interventions to be used....The plan of care will be reviewed and updated daily if needed by the RN.


Patient #1
Review of the medical record for Patient #1 revealed he was admitted 07/05/16. Further review of the medical record revealed care plans for Impaired Mobility, Decline in ADLs, Ineffective Airway Clearance, Altered Comfort/Pain, Impaired Communication, Altered Nutrition, Altered Urine Elimination, High Risk for Infection, High Risk for Injury related to Falls and Functional Limitations, Impaired Skin Integrity, Ineffective Coping related to Family Process and Altered Self Image, Knowledge Deficit related to Barriers of learning and Cultural/Spiritual beliefs, Cognitive Deficit, Potential for injury related to restraints, Potential for Injury related to Seizures, Risk for decreased cardiac output related to HTN, and Discharge Planning related to discharge plan. Further review revealed no target dates for any goal.

In an interview 09/06/16 at 12:50 p.m. S2DON/IC verified that the above noted care plan goals did not have a target date.


Patient #4
The patient was a 52 year old female admitted to the hospital on 08/24/16 with an admit diagnosis of abscess of right arm positive for MRSA, nausea and vomiting with diarrhea. Other diagnoses included in part: hypertension, depression, hypoglycemia, anemia, anxiety and alcohol dependency. A review of the medical record revealed care plans for impaired mobility, altered nutrition, altered bowel, fluid volume deficit, risk for infection, impaired skin integrity, falls, decline in ADL's, pain, and knowledge/cognition deficit, A further review of the nursing care plan revealed no documented care plans for decreased cardiac output relating to hypertension or ineffective coping relating to anxiety.
In an interview on 08/31/16 at 9:30 a.m. with S2DON/IC she indicated that the patient should have been care planned for all their medical diagnoses/conditions being treated at the hospital to include hypertension and anxiety. She further indicated that target dates should have been set for the goals established in each patient's care plan and indicated that the patient had no set target dates documented in the care plan.
Patient #5
Review of the medical record for Patient #5 revealed the patient was a 50 year old admitted to the hospital on 08/12/16 with diagnoses of Acute on Chronic Systolic Congestive Heart Failure and Acute Renal Failure. Further review of the patient's record revealed multiple episodes of patient behaviors of yelling, agitation, and psychosis. The record revealed the patient had received multiple doses of Haldol and Ativan to address the patient's behavior.
Review of the Interdisciplinary Plan of Care revealed goals and interventions identified for impaired mobility, decline in ADLs, ineffective airway clearance, ineffective breathing pattern, impaired gas exchange, fluid volume excess, high risk for impaired skin, and potential for injury related to restraints. Review of the plan of care revealed no documented evidence of any target dates for any of the identified goals. Further review of the plan of care revealed no documented evidence that the patient's behaviors of yelling, agitation and psychosis were included in the plan of care.
In an interview on 08/31/16 at 1:15 p.m., S2DON/IC reviewed the medical record for Patient #5 and confirmed the patient had demonstrated behaviors that required administration of Haldol and Ativan to relieve. She confirmed the patient's behaviors were not included in the plan of care and they should have been. S2DON/IC confirmed none of the identified goals documented in the plan of care had target dates.


30420

Based on record reviews and interviews, the hospital failed to ensure the RNs assigned to the nursing care of High Observation patients had received education/training and had been evaluated for competency in the administration of a continuous infusion of an anesthetic agent (Propofol) for 2 (S40RN, S41RN) of 2 RNs assigned to the High Observation Unit.

Findings:

A review of the hospital policy titled, "Administration of Propofol (Diprovan)", as provided by S2DON/IC as the most current, revealed in part: Propofol via continuous infusion is indicated to relieve anxiety and/or agitation in order to achieve a calm and quiet state in the intubated and mechanically ventilate patient. Propofol may only be administered to intubated and mechanically ventilated patients. Propofol may cause transient hypotension, especially during bolus injection. The hospital policy further indicated that RNs were prohibited from administering Propofol IV bolus unless specialized training in deep sedation was documented.

A review of the employee personnel files for S40RN and S41RN with S8DirHR, revealed both nurses had no documented evidence in their employee files of a competency for the administration of Propofol (Diprovan) infusions.

In an interview on 09/06/16 at 3:45 p.m. with S2DON/IC she indicated that the hospital accepts and cares for ventilated patients that frequently have orders for Propofol (Diprovan) infusions. She indicated that the patients are placed on the High Observation Unit. S2DON/IC further indicated that S40RN and/or S41RN are usually the RNs assigned to that unit to care for ventilated patients receiving Propofol (Diprovan) infusions on the High Observation Unit. S2DON/IC indicated that the hospital has access to a IV Conscious Sedation/Moderate Sedation course that included the administration of Propofol (Diprovan). S2DON/IC further indicated that S40RN and/or S41RN had not attended that course and had no documented evidence in their employee files of a competency for the administration of Propofol (Diprovan) infusions.

Based on record reviews and interviews the hospital failed to ensure that non-employee licensed nurses were appropriately oriented prior to providing care to the hospital's patients and the hospital failed to ensure that non-employee licensed nurses were evaluated through a hospital-based competency skills checklist prior to providing care to the hospital's patients as evidenced by no documentation of a hospital orientation program or a competency skills checklist prior to providing care to the hospital's patients for 2 (S16RNDialysis, S24LPN) of 2 contract licensed nursing staff currently working with hospital patients.

Findings:
A review of the contract employee file for S16RNDialysis, with S8HR and S2DON/IC, revealed no documented evidence of the following: a hospital-based job description, a hospital orientation, a hospital-based competency skills checklist, an annual performance evaluation, or annual hospital required CEUs. The contract employee file for S16RNDialysis only revealed a job description from the contract agency and a competency skills checklist performed by the contract agency.

A review of the contract employee file for S24LPN, with S8HR and S2DON/IC, revealed no documented evidence of the following: a hospital-based job description, a hospital orientation, a hospital-based competency skills checklist, an annual performance evaluation, or annual hospital required CEUs. The contract employee file for S24LPN only revealed a competency skills checklist performed by the contract agency and an expired CPR card (expired 08/2016).

In an interview on 09/06/16 at 3:15 p.m. with S8HR he indicated that he was only responsible for maintaining employee files for the hospital and that he was not responsible for maintaining the contract employee files for the hospital.

In an interview on 09/06/16 at 3:45 p.m. with S2DON/IC she indicated that S38AdmAsst was responsible for maintaining the contract employee files and in requesting any information from the contract agencies regarding the contract personnel. S2DON/IC indicated that the hospital accepted the information sent to them by the contract agencies and therefore did not provide a hospital-based job description to the contract personal, a hospital orientation, a hospital-based competency skills checklist, an annual performance evaluation, or annual hospital required CEUs for the contracted employees. S2DON/IC indicated that both S16RNDialysis and S24LPN are currently working with and caring for hospital patients. S2DON/IC further indicated that she assumed the information provided to them from the contracted agencies was sufficient.

Based on record reviews and interviews the hospital failed to ensure that verbal/telephone orders were used infrequently and was not a common practice according to hospital policy as evidenced by the frequent use of verbal/telephone orders by the admitting physicians for 4 (#4, #5, #12, #14) of 4 patient medical records reviewed for admitting orders out of a total sample of 30.

Findings:

A review of the hospital policy titled "Verbal and Telephone Orders", as provided by S3DQM as the most current, revealed in part: Verbal and telephone orders shall be minimized. Verbal orders should only be taken in emergency circumstances.

A review of Patient #4, admit date of 08/24/16; Patient #12, admit date of 07/29/16; and Patient #14, admit date on 08/03/16 revealed each patient had admit orders that were verbal telephone orders from physicians S53MD, S50MD, and S58MD respectively.

Review of the medical record for Patient #5 revealed the admission orders dated 08/13/16 had been received as telephone verbal orders from S46MD. Review of the orders revealed no documented evidence of authentication by S46MD.

In an interview on 09/06/16 at 2:30 p.m. with S11RN, she indicated that she was usually assigned as the charge nurse. S11RN indicated that the charge nurses obtained patients admitting orders from the admitting physician mostly as a verbal telephone order. She further indicated that this was the current practice of the hospital's admitting physicians.

In an interview on 09/06/16 at 3:00 p.m. with S2DON/IC, she indicated that the charge nurses usually obtained patients admitting orders from the admitting physician mostly as verbal telephone orders. She further indicated that this was the current practice of the hospital's admitting physicians.

26351

Based on record reviews and interviews, the hospital failed to ensure medical records for each patient were promptly completed within 30 days of discharge as evidenced by:

1) A medical record delinquency rate greater than 65% for the past 10 months and 111 delinquent medical records as of 08/31/16, and;

2) Failing to ensure medical records were complete and included the discharge summary for 4 (#8, #20, #21, #22) out of 4 discharged patients reviewed for complete medical records out of a sample of 30.

Findings:

1) A medical record delinquency rate greater than 65% for the past 10 months and 111 delinquent medical records as of 08/31/16:

Review of the hospital policy titled Medical Record Deficiency Analysis-Inpatient, Publication: HIM 04 revealed in part the following: HIM will make reasonable efforts to ensure that medical records are completed within the time frames designated in the medical staff bylaws and in adherence to time frames mandated by accrediting and regulatory entities, not to exceed 30 days post-discharge. The total of all medical record delinquencies will not exceed 50% of discharges, computed quarterly.

Review of the Monthly Reporting Statistics provided by S13DirMR as the medical records delinquency rates since October 2015 revealed the following medical record delinquency rates:
October 2015 - 368%
November 2015 - 255%
December 2015 - 243%
January 2016 - 303%
February 2016 - 344%
March 2016 - 130%
April 2016 - 160%
May 2016 - 116%
June 2016 - 75%
July 2016 - 65%

Review of the Chart Deficiencies Summary Report by physician provided by S13DirMR as a list of delinquent medical records by physician revealed a total of 111 delinquent records. The report revealed 25 physicians had delinquent records. The report revealed the following:
S46MD - 8 delinquent records
S49MD - 2 delinquent records
S50MD - 5 delinquent records
S51MD - 13 delinquent records
S52MedDir - 9 delinquent records
S53MD - 5 delinquent records
S54MD - 6 delinquent records
S55MD - 15 delinquent records
S60MD - 4 delinquent records


In an interview on 08/31/16 at 9:00 a.m., S13DirMR stated she was the RHIA over this hospital and at the company's hospital in another city approximately 2 hours away. She stated she was hired at this hospital in October of 2015. She confirmed the above medical record delinquency rates. She stated she has focused on the delinquency rate and it has improved. S13DirMR stated the physicians have been an obstacle. She stated their goal for compliance was 50%. S13DirMR stated the Medical Staff bylaws include provisions for suspension of physicians with delinquent records but no physicians have been suspended to date. S13DirMR stated she was given the ok 2 weeks ago to suspend physicians. S13DirMR confirmed she had made multiple presentations to the MEC, but the delinquent records had not been addressed by the MEC.


2) Failing to ensure medical records were complete and included the discharge summary:

Review of the 2016 Medical Staff Bylaws, Rules, and Regulations, provided by S3DQM as current revealed in part the following: B. Medical Records: 9. A discharge summary shall be dictated on all medical records of patients hospitalized over 48 hours. All discharge summaries shall be authenticated by the responsible practitioner. 14. The patient's medical record shall be complete at the time of discharge.

Review of the hospital policy titled, "Medical Record Deficiency Analysis-Inpatient, Publication: HIM 04" revealed in part the following: HIM will make reasonable efforts to ensure that medical records are completed within the time frames designated in the medical staff bylaws and in adherence to time frames mandated by accrediting and regulatory entities, not to exceed 30 days post-discharge.

Patient #8
Review of Patient #8's medical record revealed he was admitted to the hospital on 06/02/16 for Acute Renal Failure and discharged on 06/20/16. Further review of the record revealed the discharge summary was dictated on 08/04/16 and transcripted on 08/05/16 approximately 46 days after discharge. This finding was confirmed by S26HIM.

Patient #20
Review of the medical record for Patient #20 revealed the patient was admitted to the hospital on 05/27/16 and was discharged to an acute care hospital on 06/18/16. Further review of the record revealed no documented evidence of a discharge summary.
In an interview on 09/01/16 at 4:40 p.m. S26HIM confirmed there was no discharge summary on the record for Patient #20 and stated the physician dictated it yesterday (08/31/16, over 2 months after the patient was discharged).

Patient #21
Review of the medical record for Patient #21 revealed the patient was admitted to the hospital on 06/08/16 and was discharged to a skilled nursing facility on 07/16/16. Review of the record revealed a progress note documented by S46MD with the following documentation: "D/C Summary. I got disconnected in the middle of the dictation (Do not know at what stage)." Review of the dictated discharge summary revealed the discharge summary ended with an incomplete review of systems with the following documented, "Dictation ends here."

In an interview on 09/01/16 at 5:00 p.m., S26HIM reviewed the medical record for Patient #21 and confirmed the Discharge Summary had not been completed by the physician and did not include all required summaries of the patient's hospital stay.

Patient #22
Review of the medical record for Patient #22 revealed the patient was admitted to the hospital on 07/14/16 and discharged on 07/29/16. Further review revealed no discharge summary. Review of a document on top of the medical record of Patient #22 revealed a list of unresolved chart deficiencies that included the dictation of a discharge summary.

In an interview 09/01/15 at 3:10 p.m. S26HIM confirmed the medical record for Patient #22 did not have a discharge summary. S26HIM verified the discharge summary was not completed within the required 30 days from the discharge of the patient. S26HIM confirmed the above patient records were delinquent.

30172

Based on record reviews and interviews, the hospital failed to ensure each patient's medical record entries were dated, timed, and authenticated by the person responsible for providing the service as evidenced by physicians not authenticating medical records entries in accordance with Medical Staff ByLaws for 4 of 4 (#2, #4, #14, #15) current patient medical records reviewed for authentication of medical record entries from a total sample of 30.

Findings:

A review of the Medical Staff ByLaws, Rules and Regulations, approved by the Governing Body and provided by S1CEO, revealed in part: B. Medical Records: 6. All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated. All entries must be legible.

Patient #2
Review of the medical record for Patient #2 revealed the History & Physical dictated by S50MD on 01/12/16 revealed no documented evidence of the date or the time the History & Physical was signed by S50MD. The patient was a current patient.

In an interview on 08/30/16 at 2:45 p.m., S2DON/IC reviewed the medical record for Patient #2 and confirmed the physician had failed to date and time his signature on the History & Physical.

Patient #4
A review of the current medical record for Patient #4 revealed the History & Physical dictated by S53MD on 08/25/16 revealed no documented evidence of the date or the time the History & Physical was signed by S53MD.

Patient #14
A review of the current medical record for Patient #14 revealed the History & Physical dictated by S62MD on 08/04/16 revealed no documented evidence of the time the History & Physical was signed and dated by S62MD.

In an interview on 09/06/16 at 1:15 p.m. with S1CEO he indicated that the hospital had issues with physicians not authenticating the patient's medical records with all three requirements of signature, date and time.


Patient #15
Review of the medical record for Patient #15 revealed the patient was a current patient admitted on 08/23/16. Review of the record revealed a History & Physical hand written by the physician on 08/24/16. There was no documented evidence of the time the History & Physical was conducted.

In an interview on 09/01/16 at 1:30 p.m., S26HIM reviewed the medical record for Patient #15 and confirmed the physician failed to time his signature on the History & Physical.

Based on record reviews and interviews, the hospital failed to ensure all verbal orders had been authenticated (signed, dated and timed) within 10 days as required by hospital policy for 3 ( #1,#2, #5) of 5 (#1, #2, #3, #4, #5) current sampled patients reviewed for authentication of verbal orders and 1 of 1 (#24) closed sampled patient medical records reviewed for authentication of verbal orders out of a total sample of 30.

Findings:

A review of the hospital policy titled, "Verbal and Telephone Orders, Publication: CL49" revealed in part the following: Verbal orders are only taken in emergency circumstances....All telephone or verbal orders for medications will be transcribed in the medical record and shall be countersigned by the practitioner within 10 days.

Review of the Medical Staff Rules and Regulations revealed in B. 6. (page 5) "All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated. All entries must be legible."

Patient #1
Review of the medical record for Patient #1 revealed he was admitted to the hospital 07/05/16. Review of the physician orders revealed the following verbal/telephone orders' authentication did not contain a date and time:
07/11/16 at 12:00 p.m.-KUB, diagnosis: abdominal pain... no authentication
07/11/16 at 1:00 p.m.-Agree with DNR per mother's request- no authentication
07/16/16 at 4:00 p.m.- Return to LTAC, diet pureed nectar, Pulmicort 1 mg per Respiratory inhaler, Lasix 20 mg IV daily, Calmoseptine ointment BID topical, Protonix 40 mg IV daily, Miralax 17 G po BID.... authentication signature without date and time.
07/19/16 at 12:30 a.m.-Zofran 4 mg IV q 6 hours prn N/V- no date and time on authentication signature.
07/20/16 at 10:00 a.m. - Fluorometholone 0.1 % ophthalmic suspension, 1 gtt OS QID. No date and time of authentication signature
07/22/16
07/21/16 at 9:00 p.m.- Resume the following: Klonopin 1 mg po tid, Diazepam 10 mg rectally PRN seizures, Prozac 20 mg po daily, Nuedexta 20-10 mg 1 po BID, Keppra 750 mg po daily, Seroquel 100 mg po tid- no date or time with authentication signature.
07/23/16 at 1:55 a.m. Late Entry for 2/22/16 at 10:00 p.m.: OK to hold Nuedexta until available from pharmacy- no date and time with authentication signature.
07/25/16 at 3:50 p.m.- KCL 20 meq per PEG daily, Mg (Magnesium) level- no date and time with authentication signature.
07/23/16 at 3:50 p.m. - Order clarification: KCL 20 meq suspension po daily- no date and time with authentication signature.
07/30/16 at 7:30 p.m. Geodon 10 mg IM q 8 hours prn agitation- no date and time with authentication signature.
08/01/16 at 4:58 p.m.- wound care orders- no date and time with authentication signature
08/03/16 at 10:30 a.m. - discontinue telemetry. Change respiratory treatments to q 6 hours.- no date and time with authentication signature.
08/14/16 at 3:55 p.m.- Haldol 4 mg IM time 1 and consult [psychiatric nurse practitioner]. no date and time with authentication signature.

In an interview 09/06/16 at 12:50 p.m. S2DON/IC reviewed the above noted orders and verified that the authentication signature of S14NP was not dated and timed. S2DON/IC indicated that all entries in the medical record should be authenticated with the time and date.


Patient #2
Review of the medical record for Patient #2 revealed the patient was admitted to the hospital on 01/11/16 with diagnoses of Respiratory Failure, Multiple Decubitus, and Quadriplegia.
Review of the physician orders revealed the following verbal orders had not been authenticated with signature, date, and time:
07/12/16 at 8:00 a.m. - Cancel 2-D Echo....verbal order.
07/12/16 at 4:10 p.m. - Consult PICC team for PICC or midline placement.
07/12/16 at 8:05 p.m. - Midline Placement Orders.
07/12/16 at 10:35 p.m. - Consult GI first ting in a.m.
07/13/16 at 12:14 p.m. - DC TLC. Culture tip.
07/13/16 at 6:00 p.m. - Schedule patient for PEG tube replacement.
07/15/16 at 3:00 p.m. - PEG tube placement....
07/17/16 at 11:00 a.m. - Type & Cross 1 unit PRBC
07/17/16 at 1:00 p.m. - Ok to renew Oxycodone IR 10 mg. every 8 hours.
07/17/16 at 6:00 p.m. - Transfuse 1 unit PRBC.
07/20/16 at 5:30 p.m. - Schedule TEE for Friday....
07/24/16 at 11:17 a.m. - Hold Lovenox....
07/24/16 at 3:26 p.m. - Random Vancomycin trough.
08/08/16 at 7:15 p.m. - Claritin 10 mg. 1 tablet daily by mouth at 6:00 p.m. for 3 days.
08/20/16 at 9:50 p.m. - Accuneb every 6 hours.

In an interview on 08/30/16 at 2:45 p.m., S2DON/IC reviewed the above physician verbal/telephone orders and confirmed the verbal/telephone orders had not been signed by the physician within 10 days of the date the order was given. S2DON/IC confirmed the hospital's policy was for the physician to authenticate verbal/telephone orders within 10 days.


Patient #5
Review of the medical record for Patient #5 revealed the patient was admitted to the hospital on 08/12/16 with a diagnosis of Acute on Chronic Systolic Congestive Heart Failure.
Review of the physician orders revealed the following verbal orders had not been authenticated with signature, date, and time:
Physician Admit Orders dated 08/12/16 at 12:30 a.m. (S46MD).
08/12/16 at 9:20 p.m. - Order clarification: Artificial tears, Tessalon Pearles, Breo Ellipta....
08/13/16 at 8:45 a.m. - Chest X-ray stat, ABG now, Blood Culture X2....
08/13/16 at 9:05 a.m. - Hold K (Potassium) by mouth, K level = 5.1....
08/13/16 at 6:45 p.m. - Increase Lasix to 15 mg. IV....
08/13/16 at 11:30 a.m. (Late entry) - Dobutamine 5 mcg/kg/min IV.
08/14/16 at 7:45 p.m. - Discontinue Lactulose.
08/15/16 at 11:37 a.m. - Wound care orders....
08/15/16 at 12:00 p.m. - Consult Wound Care Associates.
08/17/16 at 4:20 p.m. - PICC Line Placement Orders.
08/17/16 at 10:40 a.m. - Wound care orders.....
08/18/16 at 7:55 a.m. - Consult PICC for PICC placement.

In an interview on 08/31/16 at 1:15 p.m., S2DON/IC reviewed the above verbal/telephone orders and confirmed the verbal/telephone orders had not been signed by the physician within 10 days of the order.


Patient #24
Review of the medical record for Patient #24 revealed the patient was admitted to the hospital on 06/28/16 with a diagnosis of Aspiration Pneumonia. The record revealed the patient was discharged to a skilled nursing facility on 08/05/16.
Review of the physician orders revealed the following verbal orders had not been authenticated with signature, date, and time:
Physician Admit Orders dated 06/28/16 at 8:30 p.m.
06/29/16 at 1:30 a.m. - Increase Ativan to 2 mg. IV every 4 hours as needed for anxiety.
06/29/16 at 1:50 p.m. - Increase tube feeding to Jevity 1.2 at 50 ml....
06/29/16 at 5:00 p.m. - Consult Wound Care Associates.
07/02/16 at 12:45 p.m. - Draw Vancomycin trough today at 4:30 p.m.....
07/26/16 at 8:30 p.m. - Pull NG tube, hold tube feedings....
07/26/16 at 10:50 p.m. - Morphine 5 mg. IV every 8 hours as needed pain....

In an interview on 09/06/16 at 1:00 p.m., S2DON/IC reviewed the above verbal/telephone orders and confirmed the verbal/telephone orders had not been signed by the physician within 10 days of the order. S2DON/IC confirmed the above discharged record was delinquent.


30172




30420

30420

Based on record reviews and staff interviews, the hospital failed to ensure medical history and physical examinations (H&P's) were completed and documented for each patient no more than 30 days before or 24 hours after admission or registration for 2 (#26, #29) of 2 current patients and 2 (#19, #20) of 2 discharged patients out of 7 (#19, #20, #24, #26, #27, #28, #29) patients reviewed for completed H&P's from a sample of 30 patients.
Findings:

Review of the Medical Staff Bylaws and Rules and Regulations, provided by S3DQM as current, revealed (B.2) "A complete medical history and physical examination shall, in all cases, be dictated or entered into the record by the responsible practitioner and available on the chart no more than 24 hours after admission of the patient."

Patient #19
Review of the medical record for Patient #19 revealed he was admitted to the hospital on 03/11/16 at 4:00 p.m. Further review revealed an H&P with a dictation date and time of 03/13/16 at 1:47 p.m., and a transcription date of 03/13/16 at 4:14 p.m.

In an interview 09/06/16 at 12:50 p.m. S2DON/IC verified the H&P on the medical record of Patient #19 was dictated and transcribed later than the hospital's 24 hour requirement.


Patient #20
Review of the medical record for Patient #20 revealed the patient was admitted to the hospital on 05/27/16 at 2:40 p.m. Review of the H&P revealed the transcription date was 05/28/16 at 10:27 p.m., over 24 hours after admission.

In an interview on 09/01/16 at 4:20 p.m., S26HIM reviewed the H&P and confirmed it was not on the patient's record within 24 hours of admission.


Patient #26
Review of the medical record for Patient #26 revealed the patient was a current patient admitted to the hospital on 09/02/16 at 7:20 p.m. with diagnoses of Guillian Barre, Respiratory Failure, Ventilator Dependent. Further review of the record revealed no documented evidence of a H&P.

In an interview on 09/06/16 at 1:00 p.m., S2DON/IC reviewed the medical record for Patient #26 and confirmed the patient was admitted on 09/02/16 (Friday) and the H&P was not on the patient's record as of today (09/06/16), over 3 days after admission.


Patient #29
Review of the medical record for Patient #29 revealed he was a current patient and was admitted on 09/03/16 at 1:10 a.m. per Initial Nursing Assessment and Admission Physician's orders that were noted 09/03/16. Further review revealed that as of 09/06/16 at 10:05 a.m. no H&P was noted on Patient #29's medical record.

In an interview 09/06/16 at 10:05 a.m. S25LPN verified there was no H&P on Patient #29's medical record.

30172

Based on record reviews and interviews, the hospital failed to ensure medical records included a properly executed informed consent for procedures and treatments. This deficient practice was evidenced by informed consents that were not completed as per hospital policy when information required was omitted in the informed consent, required information areas were left blank, and/or informed consents were not obtained for procedures/treatments performed for 3 of 3 (#1, #2, #14) current patient records reviewed for properly executed informed consents from a total sample of 30.

Findings:

A review of the hospital policy titled "Consent", as provided by S3DQM as the most current, revealed in part: To establish guidelines, consistent with state and federal law to be followed when confirming the patient's consent to medical treatment or medical procedures.... based on reasonable medical judgement for the patient to understand the consequences of the treatment, including the significant benefits, risks, complications, and reasonable alternatives to any proposed treatment. Medical Treatment- A health care treatment, service, or procedure designed to maintain or treat a patient's physical condition, as well as preventive care. The duty to obtain the consent of the patient for medical procedures rests with the physician. Staff may deliver the form to the patient for signature , but staff IS NOT authorized to explain the procedure in lieu of the physician.


Patient #1
Review of the medical record for Patient #1 revealed he was admitted to the hospital 07/05/16. One of Patient #1's diagnoses was that of Mental Retardation. Further review revealed his mother was his legal representative. Review of consent forms revealed a consent for Serial Conservative (Selective) Sharp Wound Debridements. Further review of this consent revealed it was signed by a Nurse Practitioner and Patient #1's mother. The consent form had blank areas in the following: 3. Patient's condition ( Patient's diagnosis, description of the nature of the condition or ailment for which the medical treatment, surgical procedure or other therapy described is indicated and recommended), 4(b) additional risks, if any, particular to the patient because of a complicating medical condition are: ). Review of a Consent for Transfusion and Blood Components revealed 4.(b) Additional risks, and 5. Reasonable therapeutic alternative and the risks associated with such alternatives were left blank. Further review revealed this consent was obtained over the telephone, and had no signature of the clinician that was to obtain informed consent.

In an interview 09/06/16 at 12:50 p.m. S2DON/IC, after reviewing the consent forms for Patient #1 verified that not all blanks were filled in or lined out. S2DON/IC agreed that the consents should not have had blanks on them when a patient (or representative) signed them.


Patient #2
Review of the medical record for Patient #2 revealed the patient was a 36 year old admitted to the hospital on 01/11/16 with diagnoses of Chronic Respiratory Failure, Quadriplegia, and Ventilator Dependent. Review of the patient's medical record revealed a physician consult for S49MD for a triple lumen catheter placement by S49MD on 06/27/16. A review of the Critical Care Flowsheet dated 06/27/16 at 11:45 a.m. revealed: "S49MD at bedside. Time Out for procedure performed. TLC changed over wire without difficulty. Patient tolerated well." Further review of the patient's medical record revealed a "General Surgical Consent" form for the procedure on 06/27/16 that was not completed by S49MD. The "General Surgical Consent" form revealed the patient was unable to sign due to quadriplegia and was documented as witnessed by 2 RNs and was dated and timed on 06/27/16 at 9:30 a.m. The "Purpose" section was documented as, "Change TLC". All other aspects of the "General Surgical Consent" form (Medical Treatment/Procedure, Description, Patient Condition, Material Risks of Medical Treatment/Procedure, Reasonable Therapeutic Alternatives and Risks Associated therewith, Risks of no Treatment, and the Physician Signature with date and time) was left blank. A further review of the medical record revealed no documented evidence in the physician process notes of the procedure being discussed with the patient or the family.

In an interview on 09/01/16 at 3:30 p.m., S2DON/IC reviewed the medical record for Patient #2 and confirmed the consent for the triple lumen catheter insertion was not completed in accordance with hospital policy and the sections for Medical Treatment/Procedure, Description, Patient Condition, Material Risks of Medical Treatment/Procedure, Reasonable Therapeutic Alternatives and Risks Associated therewith, Risks of no Treatment, and the Physician Signature with date and time were all left blank.


Patient #14
The patient was a 87 year old female admitted to the hospital on 08/03/16 with an admit diagnosis of MRSA septicemia and wound abscess. A review of the patient's medical record revealed a physician consult for S49MD for a triple lumen catheter placement by S49MD. A review of S56RN nursing daily flowsheet on 08/16/16 at 2:20 p.m. revealed: "S49MD at bedside. Inserted triple lumen catheter. Time Out completed at bedside. Patient tolerated well". A further review of the patient's medical record revealed a blank "General Surgical Consent" form for the procedure on 08/16/16 that was not completed by S49MD. The "General Surgical Consent" form revealed it was a telephone consent with the patient's son and was documented as witnessed by 2 RNs and was dated and timed on 08/16/16 at 11:35 a.m. All other aspects of the "General Surgical Consent" form (Medical Treatment/Procedure, Description and Purpose, Patient Condition, Material Risks of Medical Treatment/Procedure, Reasonable Therapeutic Alternatives and Risks Associated therewith Risks of no Treatment, Physician Signature with date and time, and the Reason Section as to why the consent was signed by someone other than the patient) was left blank. A further review of the medical record revealed no documented evidence in the physician process notes of the procedure being discussed with the patient or the family.

In an interview on 09/01/16 at 11:35 a.m. with S56RN, in the presence of S2DON/IC, she indicated that she was one of the nurses caring for Patient #14 on 08/16/16 and indicated that she assisted S49MD with the Triple Lumen Catheter insertion procedure. S56RN indicated that S49MD did not obtain the consent for the procedure and it was obtained by 2 RNs as a telephone consent with the patient's son. S56RN indicated that the obtaining of a properly executed informed consent by the physician performing the procedure was an oversite.





30420

Based on record reviews and interviews, the Hospital failed to ensure all patient records included documentation of outcomes of hospitalization, disposition of care and provisions for follow-up care as evidenced by the failing to ensure the treating licensed practitioner completed a discharge summary for 3 of 3 (#20, #21 #22) discharged patient records reviewed for discharge summaries out of a total sample of 30 patient medical records reviewed.

Findings:

Review of the 2016 Medical Staff Bylaws, Rules, and Regulations, provided by S3DQM as current revealed in part the following: B. Medical Records: 9. A discharge summary shall be dictated on all medical records of patients hospitalized over 48 hours. All discharge summaries shall be authenticated by the responsible practitioner. 14. The patient's medical record shall be complete at the time of discharge.


Patient #20
Review of the medical record for Patient #20 revealed the patient was admitted to the hospital on 05/27/16 and discharged on 06/18/16 to a higher level of care. Further review of the medical record revealed no documented evidence of a discharge summary.

In an interview on 09/01/16 at 4:40 p.m., S26HIM reviewed the medical record for Patient #20 and confirmed the discharge summary was not on the patient's record and stated the physician dictated the discharge summary yesterday (08/31/16), over 2 months after the discharge of the patient.


Patient #21
Review of the medical record for Patient #21 revealed the patient was admitted to the hospital on 06/08/16 and was discharged to a skilled nursing facility on 07/16/16. Review of the record revealed a progress note documented by S46MD with the following documentation: "D/C Summary. I got disconnected in the middle of the dictation (Do not know at what stage)." Review of the dictated discharge summary revealed the discharge summary ended with an incomplete review of systems with the following documented, "Dictation ends here."

In an interview on 09/01/16 at 5:00 p.m., S26HIM reviewed the medical record for Patient #21 and confirmed the Discharge Summary had not been completed by the physician and did not include all required summaries of the patient's hospital stay.


Patient #22
Review of the medical record for Patient #22 revealed the patient was admitted to the hospital on 07/14/16 and discharged on 07/29/16. Further review revealed no discharge summary. Review of a document on top of the medical record of Patient #22 revealed a list of unresolved chart deficiencies that included the dictation of a discharge summary.

In an interview 09/01/15 at 3:10 p.m. S26HIM confirmed the medical record for Patient #22 did not have a discharge summary. S26HIM verified the discharge summary was not completed within the required 30 days from the discharge of the patient.


30420

Based on observation and interviews, the hospital failed to ensure the medication automated distribution units were stored in a secure area to prevent unauthorized unmonitored access. This was evidenced by 2 medication automated distribution units (Med Select) being located next to patients' rooms located in common hallways.
Findings:

An observation was conducted on 8/29/16 at 2:00 p.m. of the two medication automated distribution units being located on Hallway "a" and "b". On Hallway "a" the medication automated distribution unit was located between rooms "a" and "b". On Hallway "b" the medication automated distribution unit was located between rooms "c" and "d". Numerous observations were conducted from 8/29/16 to 8/31/16 of patients, visitors and staff passing the nurses in the common hallways while they are removing medications from the medication automated distribution units.
An interview was conducted with S7DirRPh on 8/31/16 at 2:30 p.m. She reported there was no room in the locked medication room located between Hallway "a" and "b" to relocate the automated distribution units to secure them behind a locked door. She reported the nurses had to have an access code to gain access to the narcotics and medications in the automated distribution units in the hallways.

Based on record review, observations and interview, the hospital failed to ensure narcotics were kept locked within a secure area. This was evidenced by narcotics being stored in the Medication Automated Distribution Unit (Med Select), which was located in a common area in two (2) hallways directly next to patient rooms.
Findings:

Review of the hospital policy, "Management and Administration of Controlled Substance, Publication: PH 16", revealed in part, Establish the conditions, procedures, and guidelines under which controlled substances are made available to Post Acute Medical patients and to ensure compliance with applicable state and federal laws/regulations for controlled substances...Each nursing unit that has controlled substances will maintain a permanent record of each drug administered and wastage for each drug.

An observation was conducted on 8/29/16 at 2:00 p.m. of the two medication automated distribution units being located on Hallway "a" and "b". On Hallway "a" the medication automated distribution unit was located between rooms "a" and "b". On Hallway "b" the medication automated distribution unit was located between rooms "c" and "d". Numerous observations were conducted from 8/29/16 to 8/31/16 of patients, visitors and staff passing the nurses in the common hallways while they are removing medications (including narcotics) from the medication automated distribution units.
An interview was conducted with S7DirRPh on 8/31/16 at 2:30 p.m. She reported there was no room in the locked medication room located between Hallway "a" and "b" to relocate the automated distribution units to secure them behind a locked door. She reported the nurses had to have an access code to gain access to the narcotics in the automated distribution units, but she confirmed the automated distribution units were not in a secured locked room.

An observation was conducted on 8/30/16 at 12:20 p.m. in the locked medication room of Diazepam 10 mg gel being in an unsecured open patient bin for Patient #1.

An interview was conducted with S27RPh on 8/30/16 at 12:20 p.m. She reported the Diazepam should have been brought back to the pharmacy and not left in an open patient bin in the medication room since it is a narcotic.

Based on record review and interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.
Findings:
Review of hospital policies and procedures, provided by S26HIM as current, revealed no policy and procedure for the provision of safety of staff, and patients during radiological services.
In an interview on 08/31/16 at 9:05 a.m., S1CEO reviewed the radiology policies and procedures provided for surveyor review. S1CEO verified X-rays were taken in the hospital by an imaging contractor. S1CEO confirmed the policies and procedures did not address the safety of hospital staff, patients, or visitors.

Based on record review and interview, the hospital failed to:
1) ensure radiological services were under the direction of a radiologist on the medical staff, as evidenced by failure of the Governing Body to appoint a Medical Director of the hospital's Radiological Services, and;
2) ensure all radiological interpretations were made by radiologists who were credentialed members of the Medical Staff, as per hospital policy and procedure, as evidenced by no radiologists on their Medical Staff. Hospital radiological exams were interpreted by 9 radiologists from Company B, that were not privileged (credentialed) or members of the hospital's Medical Staff.
Findings:
1) Ensure radiological services were under the direction of a radiologist on the medical staff, as evidenced by failure of the Governing Body to appoint a Medical Director of the hospital's Radiological Services:

Review of hospital policy titled "Radiology scope of services" (reviewed/revised date 1/22/15), provided by S26HIM as current, revealed a "board certified Radiologist who is an active member of the Medical Staff serves as the director of Radiology."
Review of the hospital's organizational chart revealed no documented evidence of an appointed Medical Director of Radiological Services.
Review of the hospital's medical staff roster revealed no documented evidence of an appointed Medical Director of Radiological Services, or any member with a specialty of radiology.
A review of the Governing Body meeting minutes revealed no documented evidence that the Governing Body had appointed a Medical Director of Radiological Services.

In an interview 8/31/16 at 9:05 a.m. S1CEO confirmed the hospital did not have a physician (radiologist) appointed as Director of Radiological Services for the hospital, or any radiologists on the Medical Staff. S1CEO confirmed diagnostic radiological tests were performed in the hospital.

2) Ensure all radiological interpretations were made by radiologists who were a credentialed member of the Medical Staff, as per hospital policy and procedure, as evidenced by no radiologists on their Medical Staff. Hospital radiological exams were interpreted by 9 radiologists from Company B, that were not members of the hospital's Medical Staff.

Review of hospital policy #RA17, titled "Interpretive Services" (reviewed/revised date of 01/22/15), provided by S26HIM as current, revealed, "1. Provider: Interpretations will be provided by a Radiologist who is a credentialed member of the Medical Staff and certified by the American Board of Radiology."

A review of the Medical Staff Roster revealed no physicians with a specialty of Radiology.

In an interview 08/31/16 at 2:25 p.m., S3DQM provided a list of radiologists (S29MD, S30MD, S31MD, S32MD, S33MD, S34MD, S35MD, S36MD, and S37MD) employed by Company B (in contract with the hospital), that read or interpreted radiology exams and imaging exams performed at the hospital. S3DQM confirmed that none of the radiologists were members of the hospital's Medical Staff.

26351

Based on record reviews, observations and interviews, the hospital failed to ensure the infection control officer developed a system for investigating and controlling infections and communicable diseases of patients and personnel as evidenced by:

1) failing to ensure that the hospital staff followed acceptable infection control standards of practice regarding patients requiring contact precautions for 1 (#2) of 1 patients on isolation precautions;

2) failing to ensure that staff adhered to acceptable infection control practices regarding the cleaning/disinfecting of patient multi-use equipment and failing to ensure that staff adhered to acceptable infection control practices during patient care procedures;

3) failing to maintain a sanitary environment, and;

4) failing to ensure all hospital staff was free of TB in a communicable state as evidenced by failing to ensure all medical staff were screened for TB per state regulation and hospital policy for 5 (S46MD, S47MD, S48MD, S49MD, S50MD) of 13 (S14NP, S46MD, S47MD, S48MD, S49MD, S50MD, S51MD, S52MedDir, S53MD, S54MD, S59MD, S60MD, S61NP) credentialing records reviewed.



1) failing to ensure that the hospital staff followed acceptable infection control standards of practice regarding patients requiring contact precautions:

An observation on 08/30/16 at 12:50 p.m. of Patient #2's room revealed signage on the door indicating that Patient #2 was on contact precautions. An isolation caddy was also noted hanging on the patient's door with PPE items in it. S19CM/Hospice was observed donning PPE (disposable gown and gloves) and entering the patient's room with a large shoulder bag over her PPE gown. S19CM/Hospice was later observed exiting the patient's room and removing her PPE attire and was not observed sanitizing or washing her hands after removing her PPE. S19CM/Hospice was observed proceeding immediately to the case manager's office in the next hallway.

In an interview on 08/30/16 at 1:00 p.m. with S19CM/Hospice she indicated that she was not an employee of the hospital and was a case manager from a hospice agency. She indicated that she was told by an employee, who was a new employee, that S19CM/Hospice had to gown and glove before entering Patient #2's room and the employee did not inform her that she had to sanitize or wash her hands or that she should not bring her large shoulder bag into the patient's room. She further indicated that she was not familiar with contact precaution protocols and that she did not read the signage on the patient's door that indicated the hand sanitizing protocol.

In an interview on 08/30/16 at 1:10 p.m. with S2DON/IC, Infection Control Officer, she indicated that contract staff should have been aware of the hospital's infection control protocols for isolation precautions.


2) failing to ensure that staff adhered to acceptable infection control practices regarding the cleaning/disinfecting of patient multi-use equipment and failing to ensure that staff adhered to acceptable infection control practices during patient care procedures:

A review of the MFU on the EPA disinfectant used by the hospital for multiple use patient equipment revealed in part: The contact time is 2 minutes and allow to air dry.

In an observation on 09/01/16 at 10:45 a.m. of an accu-check procedure on Patient #R1 with S56RN, S56RN was observed not sanitizing her hands after removing her soiled gloves and was observed placing the glucometer, after she had disinfected it with the EPA wipe, under her arm and she did not observe the 2 minute contact time or allow the glucometer to air dry.

In an observation on 09/01/16 at 11:10 a.m. of a wound care procedure on Patient #14 with S12LPN, S12LPN was observed picking up the patient's clean wound care supplies with her soiled gloves and returning the supplies back into the patient's closet area without removing her soiled gloves.

In an observation on 09/01/16 at 11:30 a.m. of an IV placement on Patient #23 with S11RN, S11RN was observed removing her soiled gloves on 2 different occasions and not sanitizing or washing her hands prior to re-donning clean gloves.

In an interview on 09/01/16 at 1:30 p.m. with S2DON/IC she indicated that she was the designated Infection Control Officer for the hospital. S2DON/IC was made aware of the above observations of infection control breaches. S2DON/IC indicated that staff did not follow hospital infection control policy or acceptable infection control protocols.


3) failing to maintain a sanitary environment:

a. the hospital failed to ensure patient care items were stored off the floor in the central supply storage by storing patient care items on floor in Central Supply

An observation was conducted on 8/30/16 at 1:00 p.m. of a box of Kerlix and a box of Chest tube trays being stored on the floor in Central Supply.

The above finding was confirmed by S28MMgr at 8/30/16 at 1:00 p.m.

b. the hospital failed to ensure all patient care/staff work areas had smooth wipe able surfaces for disinfection as evidenced by multiple areas of missing Formica with exposed rough surfaces on the walls and desks of staff work areas.

An observation of the hospital was conducted on 08/30/16 from 12:10 p.m. to 1:10 p.m. with S2DON/IC. At 12:15 an observation of the Front Nurse's station revealed an 8 inch by 4 inch area of missing Formica, exposing a rough, unfinished surface on the front wall of the nurse's station. Three (3) other smaller areas of missing Formica were observed on the wall. The edge of the nurse's desk was observed to have missing Formica for 6-7 feet, exposing a rough, unfinished surface. The side of the nurse's desk was observed to have a 3 foot area of missing Formica. S2DON/IC confirmed the missing Formica at the time of the observation and confirmed the areas of missing Formica could not be properly disinfected.

At 12:35 p.m. an observation was made of the Respiratory Supply area located on Hall "b". A 6 inch strip of Formica was missing from the edge of the cabinet top exposing a rough, unfinished surface. S2DON/IC confirmed the area of missing Formica at the time of the observation.

At 12:45 p.m. an observation of the Back Nurse's station revealed an area approximately 10 inches by 4 inches of missing Formica located in front of the printer. Another area of missing Formica approximately 4 feet long on the edge of the desk to the left of the printer was also noted. The middle of the nurse's desk was observed to have a 12 inch area of missing Formica and another 3 foot long area of missing Formica was observed on the edge of the desk near the telemetry monitors. A 6 inch area of missing Formica was observed on the desk area in front of the telemetry monitors. The surfaces left exposed by the missing Formica were observed to be rough and unfinished. S2DON/IC confirmed the findings at the time of the observations.

c. the hospital failed to ensure soiled linen was stored in designated containers as evidenced by soiled linen stored on the floor in a patient bathroom.

An observation was made of Room "e" with S2DON/IC on 08/30/16 at 12:10 p.m. A blue colored plastic bag of soiled linen was observed on the floor in the bathroom of this patient room. S2DON/IC confirmed the soiled linen was improperly stored on the floor and should have been placed in the designated soiled linen container.

d. the hospital failed to ensure patient care equipment was clean and ready for patient use as evidenced by an accumulation of dust on the "Crash Cart", suction equipment, defibrillator, and tape residue on the surface of the "Crash Cart."

An observation was made of the "Crash Cart" on Hall "b" with S3DQM on 08/30/16 at 12:30 p.m. An accumulation of dust was observed on the top of the "Crash Cart", on the suction machine, and on the defibrillator. Also observed on the "Crash Cart" were multiple areas of tape and tape residue. S3DQM confirmed the findings at the time of the observation.


4) failing to ensure all hospital staff was free of TB in a communicable state:

Review of the Louisiana Public Health Sanitary Code, Title 51, Part II. The Control of Diseases - Health Examinations for Employees, Volunteers and Patients at Certain Medical Facilities, Section 503, Mandatory Tuberculosis Testing, revealed in part: All persons prior to or at the time of employment, involved in providing direct patient care, shall be free of tuberculosis in a communicable state as evidenced by either 1. A negative purified protein derivative skin test for TB, 2. A normal chest x-ray, if the skin or a blood assay for TB is positive, or 3. A statement from a licensed physician certifying that the individual is non-infectious if the x-ray is other than normal....C. Any employee or volunteer at any medical or 24-hour residential facility requiring licensing by the Department of Health and Hospitals....in order to remain employed or continue work as a volunteer shall be rescreened annually.

Review of the hospital policy titled, "Tuberculosis Control Plan, Policy # IC 20" revealed in part the following: To utilize a hospital wide exposure control plan designed to reduce the risk of patient, employee, physician/licensed independent practitioners (LIP) and visitor exposure to Mycobacterium tuberculosis (MTB) in accordance with regulatory guidelines....New employees who can document a negative TST within the 3 months will not be required to receive a TST. All other employees will receive a one-step TST....TST annual screening for all employees should be based on the Annual TB Risk Assessment and State regulations.

S46MD
Review of the credentialing file for S46MD revealed the current appointment to the medical staff was from 02/12/16 to 02/12/18. Review of the file revealed no documented evidence of a TB screening.


S47MD
Review of the credentialing file for S47MD revealed the current appointment to the medical staff was from 08/26/15 to 08/26/17. Review of the file revealed no documented evidence of an annual TB screening.


S48MD
Review of the credentialing file for S48MD revealed the current appointment to the medical staff was from 05/22/15 to 05/22/17. Review of the file revealed no documented evidence of a TB screening since 02/09/15.


S49MD
Review of the credentialing file for S49MD revealed the current appointment to the medical staff was from 10/15/15 to 10/15/16. Review of the file revealed no documented evidence of a TB screening since 06/12/15.


S50MD
Review of the credentialing file for S50MD revealed the current appointment to the medical staff was from 09/23/15 to 09/23/17. Review of the file revealed no documented evidence of a TB screening since 03/24/15.


In an interview on 09/01/16 at 11:20 a.m. S38AdmAsst reviewed the above credentialing files and confirmed there was no documented evidence of a current TB screening on the records. She stated she sends a letter and reaches out to the physician offices to get current TB tests, but they don't always respond.



30172

Based on record reviews and interview, the hospital failed to ensure a physician was appointed as the director of the hospital's respiratory care services. This deficient practice was evidenced by failure of the hospital's governing body to appoint a physician to serve as director of the hospital's respiratory care services.
Findings:

Review of the Hospital's organizational chart revealed no documented evidence of an appointed physician to serve as the medical director of the hospital's respiratory care services.

Review of the hospital's Governing Body meeting minutes for 2015-2016 revealed no documented evidence that a member of the Medical Staff had been appointed to serve as the medical director of the hospital's respiratory care services.

In an interview on 9/01/16 at 10:45 a.m., S3DQM confirmed there was no documentation of the appointment of any Medical Staff member as the Director of Respiratory Services.