HospitalInspections.org

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 a patient death pronounced over the telephone by a physician from another hospital for 1 (#12) of 2 (#12, #20) sampled patients reviewed for pronouncement of death from a total sample of 30.
Findings:

Review of the hospital policy titled, Code Blue Event/Cardiopulmonary Arrest, Policy number 1718 revealed in part the following:
Establish unresponsiveness and obtain emergency assistance via activating the Emergency Call Button and call for help....Once the Emergency Button is activated, the unit secretary will announce "Code Blue, location" over loudspeaker.
First available nurse/employee arriving after BLS has been initiated should assure that the Emergency Button has been activated and should bring crash cart to patient side....[Hospital] staff who have been credentialed in ACLS can initiate the ACLS protocol. The physician or LIP will assume responsibility for running the code upon their arrival. The code team members should remain at the bedside. Full cardiopulmonary resuscitation is administered until successful (patient responds) or discontinued by the physician....

Patient #12
Review of the medical record for Patient #12 revealed the patient was a 74 year old admitted to the off-site campus on 11/21/16 with diagnoses of Enterococcal Bacteremia, Chronic Systolic Heart Failure, and Atherosclerotic Vascular Disease. Review of the record revealed the patient was found unresponsive on 11/24/16 at 3:05 p.m.
Review of the Cardiopulmonary Resuscitation Record dated 11/24/16 revealed paramedics were on the unit and the patient was pronounced dead by S20MD at 3:38 p.m.
Review of the Record of Death revealed the patient was pronounced dead by S20MD (ED physician from Hospital "A") on 11/24/16 at 3:38 p.m.
Review of the Death Note documented by S19MD on 11/24/16 at 4:21 p.m. revealed the following: "Patient was resuscitated for about 35 minutes....Patient was pronounced dead at 3:38 p.m. by S20MD (Hospital "A" ED physician). Further review of the record revealed no documentation of a progress note or death note by S20MD.

In an interview on 03/15/17 at 9:32 a.m., S28RT stated he remember Patient #12 and stated the patient was coded on Thanksgiving Day. He stated EMS responded and participated in the resuscitation. S28RT stated EMS was speaking with someone over the phone who determined to stop CPR and all resuscitation efforts were stopped at that point.

In an interview on 03/15/17 at 11:35 a.m., S2CCO confirmed the patient was pronounced by an ED physician at Hospital "A" over the telephone through the paramedic. S2CCO stated the staff did not follow the hospital's policy and 911 should not have been called. S2CCO confirmed S29MD was not a member of the hospital's medical staff.

In a telephone interview on 03/15/17 at 1:00 p.m., S17RN confirmed she was present for the resuscitation of Patient #12. S17RN stated 911 was called and EMS responded. S17RN stated the patient was pronounced by the paramedic who called his physician. She stated she did not remember the physician's name. S17RN confirmed the physician contacted by the paramedic, pronounced the patient over the telephone through the paramedic. S17RN confirmed S19MD was on call that day, but she was not present for the resuscitation of the patient.

Based on record reviews and interviews the hospital failed to ensure each patient, or when appropriate, the patient's representative, was informed of the patient's rights in advance of furnishing or discontinuing patient care whenever possible. This failed practice was evidenced in 1 of 1 (#23) patient medical record of a patient not being provided patient rights information out of 30 sampled medical records reviewed for Patient Rights Notification.

Findings:
A review of hospital policy titled "Patient Rights and Responsibilities", as provided by the hospital as the most current, revealed in part: Upon admission, the patient will be provided a copy of the Patient Handbook which will be reviewed with the patient/support person by the Social Worker/Case Manager and will inform each patient of his or her rights and responsibilities. Topics reviewed in the Patient Handbook include but are not limited to: Patient Orientation, Advanced Directives, Grievance Process, Medicare Rights, and Patient Rights and Responsibilities. Documentation of the patient having received a review and a copy of the Patient Rights and Responsibilities is recorded on the Patient Rights and Responsibilities form and is signed by the patient and becomes a permanent part of the medical record.
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A review of Patient #23's medical record with S8RN and S14UnitSec on 03/14/17 revealed the patient was admitted on 02/19/17 and the medical record review revealed no documented evidence that Patient #23 had signed the Patient Rights and Responsibilities form indicating that the Patient Handbook had been reviewed and a copy was given to the patient.

In an interview on 03/14/17 at 3:00 p.m. with Patient #23 he indicated that he did not receive a Patient Handbook. The patient was shown the Patient Handbook and the accompanying form that he should have signed. Patient #23 indicated that he did not remember receiving a copy of the Patient Handbook and that he did not sign a form indicating that the Patient Rights and Responsibilities were reviewed with him.

In an interview on 03/14/17 at 3:15 p.m. with S8RN and S14UnitSec, they indicated that the patient had no documented evidenced in his medical record that the Patient Rights and Responsibilities were reviewed with him and further indicated that there was no documented evidence in the patient's medical record that the patient had signed the appropriate form indicating that he had received a review and/or a copy of the Patient Handbook with the Patient Rights and Responsibilities information.
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Based on record review and interview the hospital failed to ensure that the QAPI program had Quality Indicators for all hospital-wide services to include Radiological Services that included data collection, tracking, trending, and analysis as evidenced by no Quality Indicators established for Radiological Services.

Findings:
A review of the QAPI information with S4QADirector revealed no documented evidence of Quality Indicators for Radiological Services.

In an interview on 03/16/17 at 10:45 a.m. with S4QADirector she indicated that the QAPI program had not been collecting data on Radiological Services with tracking, trending, and analysis activities.

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

1) failing to ensure each patient was evaluated by an RN at least every 24 hours, before assigning care to an LPN for 2 (#9, #23) of 2 (#9, #23) sampled patients and failing to ensure that a RN performed the Initial Nursing Assessments for 1 of 1 (#23) sampled patient reviewed for RN assessments out of a total sample of 30;
2) failing to ensure hemodialysis vascular access sites were assessed for 1(#2) of 2 (#2, #3) hemodialysis patients sampled;
3) failing to ensure inpatients with orders for telemetry monitoring were continuously monitored only by staff trained and competent in telemetry monitoring;
4) failing to follow hospital procedure for Code Blue situations for 1 (#12) of 2 (#12, #20) patients reviewed for Code Blue procedures out of a total sample of 30;
5) failing to assess and document blood pressure and pulse prior to administering medications for 4 of 4 (#9, #12, #17, #23) sampled patients reviewed for monitoring of medications out of a total sample of 30.
Findings:

1) failing to ensure each patient was evaluated by an RN at least every 24 hours, before assigning care to an LPN:

Review of the hospital policy titled, Assessment/Re-assessment, Interdisciplinary Scope of Services, revealed in part the following: Each patient will be reassessed by a R.N., at a minimum, once every twenty-four hours.

Patient #9
Review of the medical record for Patient #9 revealed the current patient was a 67 year old admitted to the hospital on 02/18/17 with diagnoses of Osteomyelitis of Ankle and Foot, Atrial Fibrillation, Type 2 Diabetes Mellitus, uncontrolled, and Chronic Kidney Disease.

Review of the 24 hour Care Record dated 03/13/17 revealed no documented evidence of an RN assessment of the patient. The record revealed only LPNs had assessed the patient.
Review of the 24 hour Care Record dated 03/01/17 revealed no documented evidence of an RN assessment of the patient. The record revealed only LPNs had assessed the patient.
Review of the 24 hour Care Record dated 02/28/17 revealed no documented evidence of an RN assessment of the patient. The record revealed only LPNs had assessed the patient.

In an interview on 03/14/17 at 12:40 p.m., S8RN, Charge Nurse confirmed there was no documented evidence of an RN assessment of the patient at least every 24 hours. S8RN stated they try to schedule the RNs on alternating shifts with the LPNs.

Patient #23
The patient was an 80 year old male admitted to the hospital on 02/19/17 with an admit diagnosis of Puncture Wound Left Foot with Cellulitis with treatment to include intravenous antibiotics, wound care, and physical therapy. The patient's other diagnoses included in part: Coronary Artery Disease, Diabetes, Hypertension, and Renal Insufficiency. A review of the patient's Initial Nursing Assessment dated 02/19/17 revealed no documented evidence of an RN performing the patient's Initial Nursing Assessment. A further review revealed the Initial Nursing Assessment was performed by S10LPN (contract nurse). A review of the 24 hour Care Record dated 03/08/17 revealed no documented evidence of an RN assessment of the patient during that time period. The record revealed that S11LPN and S12LPN had assessed the patient during that 24 hour time period on 03/08/17.

In an interview on 03/14/17 at 2:30 p.m. with S8RN (charge nurse) she reviewed the patient's medical record and indicated that the patient's Initial Nursing Assessment was performed by S10LPN and on 03/08/17 the patient was not assessed by an RN and was assessed by LPNs during that 24 hour time period.

2) failing to ensure hemodialysis vascular access sites were assessed.

Patient #2:
Review of the medical record revealed the patient was admitted to the hospital on 03/08/17 and had the diagnosis of End Stage Renal Disease. The patient received hemodialysis treatment and had a right upper arm arteriovenous fistula access.

Review of the nurses' notes dated 03/11/17 and 03/12/17 revealed no documented evidence the patient's right upper arm fistula was assessed.

In an interview on 03/13/17 at 1:55 p.m., S8RN indicated the patient had a right upper arm fistula that was used for hemodialysis treatments. S8RN indicated there was no documented evidence the patient's right upper arm fistula was assessed on 03/11/17 and 03/12/17.

In an interview on 03/15/17 at 8:56 a.m., S5COO confirmed patients dialysis access sites should be assessed each shift by a nurse and the assessment should be documented in the medical record.

3) failing to ensure inpatients with orders for telemetry monitoring were continuously monitored only by staff trained and competent in telemetry monitoring.

Review of the hospital policy titled, "Cardiac Monitoring", revealed in part: "Scope: Registered Nurses and Licensed Practical Nurses who have prerequisite knowledge of dysrhythmia recognition...Policy: Patients admitted to Promise Hospital may be placed on a cardiac monitor in order to closely and consistently maintain awareness of cardiac or cardiopulmonary status..."

Review of the personnel record for S14UnitSec revealed a job description for Unit Secretary. Further review revealed no documentation of training or competency in telemetry /interpretation of EKGs.

Review of daily staff assignments for the main campus 03/13/17, 7:00 a.m.-7:00 p.m. shift revealed no documentation of staff to monitor telemetry.

In an interview on 03/13/17 at 8:05 a.m. S8RN indicated she was the charge nurse and could walk with the surveyor for a tour of the hospital. S8RN instructed S14UnitSec to have someone put a patient back on the telemetry monitor. S8RN started the tour, with S14UnitSec as the only staff member at the desk to watch the telemetry monitor (at the main campus). Upon return of S8RN and the surveyor to the nursing desk, observation revealed S14UnitSec at the nursing desk, by the telemetry monitor, with 2 tracings on the monitor. S8RN reported that when staff was not watching the monitor, S14UnitSec would notify a nurse if an alarm sounded. S8RN indicated that she did not think S14UnitSec had telemetry training. S8RN asked S14UnitSec if she had any telemetry training and S14UnitSec responded that she had not. S8RN indicated that the charge nurse usually monitored the telemetry monitor, and if she had to leave the desk, she (or he) would ask someone else to watch the monitor while they were away.

On 03/13/17 at 12:05 p.m., an observation was made at the nurse's desk at the Main Campus. S14UnitSec was observed in the nurse's station alone, seated at the desk where the cardiac monitor screen was located. S14UnitSec was observed to have her back turned and was working with a patient's medical record. The monitor was emitting a "dinging" sound.

In an interview 03/13/17 at 12:10 p.m. S14UnitSec indicated she watched the telemetry monitor when the nurse was not at the desk to watch it. She reported she had not had any training in EKG interpretation, but that she would notify the nurse if the alarms when off. The unit secretary verified that no one else was monitoring the telemetry monitor at that time, and there were 2 patients being monitored at that time.

On 03/14/17 at 9:28 a.m., an observation was made at the nurse's desk at the Main Campus. S14UnitSec was observed in the nurse's station alone, seated at the desk where the cardiac monitor screen was located. S14UnitSec was observed to have her back turned and was working with a patient's medical record.

On 03/14/17 at 9:41 a.m., an observation was made at the nurse's desk at the Main Campus. S14UnitSec was observed in the nurse's station alone, seated at the desk where the cardiac monitor screen was located. S14UnitSec was observed to have her back turned and was answering calls from patient rooms.

On 03/14/17 at 9:46 a.m., an observation was made at the nurse's desk at the Main Campus. S14UnitSec was observed in the nurse's station alone. S14UnitSec left the nurse's desk and returned approximately 1 minute later.

On 03/14/17 at 12:20 p.m., an observation was made at the nurse's desk at the Main Camppus. There was no staff observed at the nurse's desk and there was no staff observed monitoring the telemetry monitor. Two patients were observed on the telemetry monitor.

In an interview 03/16/17 at 9:20 a.m., S2CCO verified Unit Secretaries did not have education and competency verifications for telemetry monitoring. S2CCO indicated the nurses, with training and annual competency evaluations in EKG interpretation, should be monitoring the telemetry monitor.


4) failing to follow hospital procedure for Code Blue situations for 1 (#12) of 2 (#12, #20) patients reviewed for Code Blue procedures:

Review of the hospital policy titled, Code Blue Event/Cardiopulmonary Arrest, Policy number 1718 revealed in part the following:
Establish unresponsiveness and obtain emergency assistance via activating the Emergency Call Button and call for help....Once the Emergency Button is activated, the unit secretary will announce "Code Blue, location" over loudspeaker.
First available nurse/employee arriving after BLS has been initiated should assure that the Emergency Button has been activated and should bring crash cart to patient side....[Hospital] staff who have been credentialed in ACLS can initiate the ACLS protocol. The physician or LIP will assume responsibility for running the code upon their arrival. The code team members should remain at the bedside. Full cardiopulmonary resuscitation is administered until successful (patient responds) or discontinued by the physician....

Patient #12
Review of the medical record for Patient #12 revealed the patient was a 74 year old admitted to the off-site campus on 11/21/16 with diagnoses of Enterococcal Bacteremia, Chronic Systolic Heart Failure, and Atherosclerotic Vascular Disease. Review of the record revealed the patient was found unresponsive on 11/24/16 at 3:05 p.m.

Review of the Cardiopulmonary Resuscitation Record dated 11/24/16 revealed paramedics were on the unit and attempted to intubate the patient. The record revealed a King tube was placed by the EMT at 3:18 p.m. The record revealed the patient was pronounced dead by S20MD (ED physician at Hospital "A") at 3:38 p.m.

Review of the Death Note documented by S19MD on 11/24/16 at 4:21 p.m. revealed the following: "Patient was resuscitated for about 35 minutes....Patient was pronounced dead at 3:38 p.m. by S20MD (Hospital "A" ED physician). Further review of the record revealed no documentation of a progress note or death note by S20MD.

In an interview on 03/15/17 at 9:32 a.m., S28RT stated he remember Patient #12 and stated the patient was coded on Thanksgiving Day. He stated EMS responded and participated in the resuscitation. S28RT stated EMS was speaking with someone over the phone who determined to stop CPR and all resuscitation efforts were stopped at that point.

In an interview on 03/15/17 at 11:35 a.m., S2CCO confirmed the patient was pronounced by an ED physician at Hospital "A" over the telephone through the paramedic. S2CCO stated the staff did not follow the hospital's policy and 911 should not have been called. S2CCO provided a form titled [Hospital off-site campus] Code Blue Process, dated 04/26/16 that revealed the following:
1. Initiate code Blue, CPR, and call HMG (physician group) on-call's cell phone provided in call log. Notify nurse practitioner of code as well.
2. The physician is to give orders over the phone until arrival. The physician should be bedside within 30 minutes

In a telephone interview on 03/15/17 at 1:00 p.m., S17RN confirmed she was present for the resuscitation of Patient #12. S17RN stated 911 was called and EMS responded. S17RN stated the ward clerk called 911. S17RN stated she called S20MD, the patient's attending physician since she had seen that physician on the unit that morning. S17RN confirmed S19MD was on-call that day and she confirmed she had not called S19MD regarding the patient's Code Blue. S17RN confirmed S19MD was not present for the resuscitation of the patient, but arrived on the unit after the code was completed.


5) failing to assess and document blood pressure and pulse prior to administering medications:

Review of the hospital policy titled, Medication Administration, revealed no documented evidence of any provisions that addressed assessment/monitoring parameters for medication administration.

Patient #9
Review of the medical record for Patient #9 revealed the patient was a 67 year old admitted to the main campus on 02/18/17 with diagnoses of Osteomyelitis of Ankle and Foot, Hypertension, Type II Diabetes Mellitus, and Atrial Fibrillation.

Review of the physician orders revealed the following orders:
Losartan Potassium (Medication for High Blood Pressure) 100 mg daily.
Amlodipine (Medication for High Blood Pressure) 10 mg daily.
Metoprolol Succinate (Medication for High Blood Pressure) 25 mg. daily.

Review of the MARs dated 03/08/17 through 03/13/17 revealed the Losartan Potassium and the Amlodipine were administered daily without documentation of an assessment of the patient's blood pressure. Further review of the MAR revealed a notation under the Metoprolol Succinate to hold the medication if the patient's pulse was less than 65.
Review of the MARs revealed the Metoptolol Succinate was held on the following days:
03/09/17 (pulse documented as 59).
03/10/17 (pulse documented as 60).
03/11/17 (pulse documented as 61).
There was no documented evidence the patient's pulse was assessed when the Metoprolol Succinate was administered on 03/08/17, 03/12/17, and 03/13/17.

In an interview on 03/15/17 at 12:30 p.m., S2CCO confirmed the patient's pulse and blood pressure should have been assessed and documented prior to the administration of the above medications.


Patient #12
Review of the medical record for Patient #12 revealed the patient was a 74 year old admitted to the off-site campus on 11/21/16 with diagnoses of Enterococcal Bacteremia, Chronic Systolic Heart Failure, Atherosclerotic Vascular Disease, and Hypertension.

Review of the physician orders dated 11/21/16 revealed the following orders:
Hydralazine (Medication for High Blood Pressure) 50 mg three times a day.
Amlodipine (Medication for High Blood Pressure) 10 mg daily, start on 11/22/16.
Metoprolol Succinate (Medication for High Blood Pressure) 50 mg. daily, start on 11/22/16.

Review of the MAR dated 11/23/17 revealed the above medications were administered but there was no documented evidence that the patient's blood pressure or pulse was assessed and documented prior to the administration of the blood pressure medications.

Review of the 24 Hour Care Record dated 11/23/17 revealed the patient's blood pressure and pulse were assessed at 7:00 a.m. and 7:00 p.m. only.

In an interview on 03/14/17 at 3:50 p.m., S2CCO confirmed there was no documented evidence that the nurse assessed the patient's blood pressure and pulse prior to the administration of the above medications.

Patient #17
Review of the medical record for Patient #17 revealed the current patient was a 59 year old admitted to the hospital on 03/05/17 with diagnoses of Non-healing Wound of Left Calf, Peripheral Vascular Disease, Hypertension, and Severe Protein Calorie Malnutrition.

Review of the physician orders dated 03/05/17 revealed the following orders:
Lisinopril (Medication for High Blood Pressure) 2.5 mg once a day.
Toprol XL(Medication for High Blood Pressure) 50 mg once a day.

Review of the MARs dated 03/11/17, 03/12/17, 03/13/17, and 03/14/17 revealed the Lisinopril and the Toprol XL were administered at 9:00 a.m. There was no documented evidence that the patient's blood pressure or pulse was assessed prior to the administration of the medications.

Review of the 24 Hour Care Record for the above dates revealed the patient's blood pressure and pulse were assessed at 7:00 a.m. and 7:00 p.m. only.

In an interview on 03/15/17 at 12:00 p.m., S2CCO confirmed vital signs were done at 7:00 a.m. and 7:00 p.m. S2CCO confirmed the MARs did not include documentation of the patient's blood pressure or pulse prior to the administration of Lisinopril or Toprol XL. S2CCO confirmed her expectation was the nurse would assess and document the patient's blood pressure and pulse prior to the administration of these medications.

Patient #23
The patient was an 80 year old male admitted to the hospital on 02/19/17 with an admit diagnosis of Puncture Wound Left Foot with Cellulitis with treatment to include intravenous antibiotics, wound care, and physical therapy. The patient's other diagnoses included in part: Coronary Artery Disease, Diabetes, Hypertension, and Renal Insufficiency. A review of the patient's medical record revealed in part. A physician order dated 02/20/17 revealed an order for Verapamil daily and to hold the Verapamil for a heart rate of less than 65 and a systolic blood pressure of less than 110 prior to administration

A review of the MAR dated 03/07/17, 03/08/17 and 03/10/17 revealed the Verapamil was administered at 9:00 a.m. but there was no documented evidence that the patient's blood pressure or pulse was assessed and documented prior to the administration of the Verapamil medication on those days.

A review of the 24 Hour Care Record dated 03/07/17, 03/08/17 and 03/10/17 revealed the patient's blood pressure and pulse were assessed at 7:00 a.m. and 7:00 p.m. only.

In an interview on 03/14/17 at 2:30 p.m. with S8RN (charge nurse) she reviewed the patient's medical record and indicated that there was no documented evidence that the patient's blood pressure and pulse were assessed prior to the administration of the Verapamil at 9:00 a.m.


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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 all the patient's current medical diagnoses for which the patients were being treated for 5 of 5 (#11, #16, #17, #19, #23) sampled patient medical records reviewed for nursing care plans out of a total sample of 30.

Findings:
A review of the hospital policy titled "Interdisciplinary Care Plan", as provided by the hospital as the most current, revealed in part: the interdisciplinary team shall coordinate with the patient to develop an individualized care plan to meet the patient's needs and shall identify problems specific to the medical plan of care.

Patient #11
Review of the medical record for Patient #11 revealed the current patient was a 65 year old quadriplegic, admitted to the hospital on 03/09/17 with diagnoses of Stage 4 Pressure Ulcer of right buttock, Pressure Ulcer of left buttock, stage 3, Sepsis secondary to Clostridium difficile colitis, Dysphagia, UTI, Depression, Hypertension, IDDM, History of DVT and bilateral PE, Severe Protein calorie malnutrition, Peripheral neuropathy, and DNR status.

Review of the plan of care dated 03/09/17 revealed the patient had a diagnosis of "Sepsis secondary to UTI". Further review of the plan of care revealed the patient had no care plan to address her depression, pressure ulcers/wounds, Diabetes, her infections (UTI, Clostridium difficile/ isolation precautions), potential for DVTs and PEs, hypertension, mobility, or self care. There were no specific interventions identified on the plan of care for her Dysphagia, Bladder/Bowel needs for incontinence, or safety. The Interventions were documented as "Refer to the following disciplines documentation for details, with the following checked: Physician, Nursing, Wound Care, Physical Medicine. Further review of the medical record revealed no other documents with details of interventions for the patient's care plan.


Patient #16
Review of the medical record for Patient #16 revealed she was admitted 03/08/17 with diagnoses that included Hypertension, Type II Diabetes, Hepatitis C, Cirrhosis, Portal Hypertension, history of hepatic encephalopathy, chronic pancreatitis, chronic Thrombocytopenia, s/p Ileal neuroendocrine tumor resection, chronic back pain, GERD, and the patient was noted to have a ileostomy. Further review revealed she had been admitted from a local acute care hospital after having surgery for an abdominal wall abscess, and having had hypovolemic Acute Kidney Injury.
Review of her care plan revealed no care plan for pain, care for her Diabetes, Hypertension, wound care, self-care, Thrombocytopenia, nausea/vomiting related to her chronic pancreatitis, or potential for DVTs/PEs. The Interventions were documented as "Refer to the following disciplines documentation for details, with the following checked: Physician, Nursing, Wound Care, Physical Medicine. No interventions and measurable goals related to her ileostomy, wound care, bed mobility, self-care, or safety were documented.

In an interview 3/15/17 at 10:50 a.m. S16RN, Charge Nurse indicated the nursing care plans were as provided above. She confirmed that the goals were not measurable, and that interventions were not documented. She confirmed the care plan indicated for interventions refer to the physician, nursing, and departmental care Plans. When asked where those would be found, she said that sheet WAS the care plan, and there were no other Physician, nursing or departmental care plans. She reviewed the care plans for Patient #16, confirmed it was not comprehensive, did not identify nursing diagnoses, and did not have intervention documented for all nursing needs.

In an interview on 03/15/17 at 12:00 p.m., S2CCO confirmed the plan of care did not include all of the patient's current problems, the goals were not measurable and there were no specific interventions.


Patient #17
Review of the medical record for Patient #17 revealed the current patient was a 59 year old admitted to the hospital on 03/05/17 with diagnoses of Non-healing Wound Left Calf, Peripheral Vascular Disease, Anemia, Hypertension, Diabetes Mellitus, and Severe Protein Calorie Malnutrition.

Review of the plan of care dated 03/05/17 revealed the patient had constant pain in the left lower extremity with a pain level of 8. There was no documented evidence of any goals or interventions related to the patient's pain. Further review of the plan of care revealed the patient had 5 different wounds identified and the only goal identified was, "Pressure ulcer prevention education". There were no specific interventions identified on the plan of care.
Review of the nutrition section of the care plan revealed no documented evidence of specific interventions to meet the identified goal of greater than 75% intake of meals.

In an interview on 03/15/17 at 12:00 p.m., S2CCO confirmed the plan of care did not include all of the patient's current problems, the goals were not measurable and there were no specific interventions.


Patient #19
Review of the medical record for Patient #19 revealed the current patient was a 49 year old admitted the hospital on 02/27/17 with diagnoses of End Stage Renal Disease, Non-healing Above the Knee Amputation, and Insulin Dependent Diabetes Mellitus. Review of the record revealed the patient was currently receiving hemodialysis on Monday, Wednesday, and Friday. The record revealed the patient was receiving sliding scale insulin.
Review of the plan of care dated 02/27/17 revealed hemodialysis on Monday, Wednesday, Friday and an access in the right groin were indicated on the plan of care. There was no documented evidence of any goals or interventions related to the patient's renal failure or hemodialysis.
Review of the Skin Integrity/Circulation section of the care plan revealed five (5) different wounds were identified and the only goal was, "Pressure Ulcer prevention education." There was no documented evidence of specific interventions for skin integrity.
Further review of the plan of care revealed there were no interventions identified for the following identified problems:
Safety, Bladder/Bowel, Nutrition, and Mobility. There was no documented evidence the patient's diabetes and insulin administration was included in the plan of care.

In an interview on 03/15/17 at 12:15 p.m., S2CCO confirmed the patient's plan of care did not include all of the patient's current problems and the goals were not measurable and there were not specific interventions.


Patient #23
The patient was an 80 year old male admitted to the hospital on 02/19/17 with an admit diagnosis of Puncture Wound Left Foot with Cellulitis with treatment to include intravenous antibiotics, wound care, and physical therapy. The patient's other diagnoses included in part: Coronary Artery Disease, Diabetes, Hypertension, and Renal Insufficiency. A review of the care plan for the patient revealed he was care planned for Cellulitis, Mobility/Falls, and Nutrition. A further review of the care plan revealed no care plan was initiated for Coronary Artery Disease, Diabetes, Hypertension, or Renal Insufficiency.

In an interview on 03/16/17 at 10:30 a.m. with S31RN, Director of Nursing, he indicated that the nurses mostly developed care plans for the patient's primary admit diagnoses and did not care plan for all the other diagnoses as they were considered secondary medical conditions.


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Based on record review and interview the hospital failed to ensure that contract 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-based competency skills checklist for 1 of 1 (S10LPN) contract nurse employee file reviewed for a hospital-based competency skills checklist prior to providing care to the hospital's patients.

Findings:
A review of the contract employee file for S10LPN with S2CCO revealed no documented evidence of a hospital-based competency skills checklist. The contract employee file for S10LPN only revealed a competency skills checklist performed by the contract agency.

In an interview on 03/16/17 at 12:15 p.m. with S2CCO she indicated that the hospital accepted the skills competency checklist provided to the hospital by the nurses' contract agency and did not perform a hospital-based competency skills checklist for the contracted employees. S2CCO indicated that S10LPN has currently worked and has cared for hospital patients. S2CCO further indicated that she assumed the information provided to them from the contracted agencies was sufficient.

Based on record review and interview the hospital failed to ensure drugs and biologicals were administered as ordered in accordance with the approved hospital policies and procedures. This deficient practice was evidenced when an ordered medication was omitted, without documentation of the reason the medication was omitted on the patient's medical record or notification of the omission to the provider for 1( #16) of 5( #1, #2, #3, #4, #16) medical records reviewed for medication errors, of a total sample of 30.
Findings:


Review of hospital Policy #1207, titled " Medication Administration and Documentation" (last reviewed 02/20/16) revealed , in part the following: "Medication Administration Recording: An entry of drugs administered (including drugs administered in error)...and omitted doses shall be properly documented in the patient's medical record as follows:...If the patient for any reason does not receive a dose of medication prescribed, the nurse must chart the reason for omitting the dose in the nurse's notes of the chart. The nurse shall also circle the dose omitted on the MAR and write a brief explanation next to the circled dose. Explain in the nurses's notes, the reason for each PRN, non-recurring or omitted dose (including refused doses)...

Review of hospital Policy # MM-6.20-01, titled "Medication Error Reporting", (last review date 12/06/15) revealed, in part "Drugs administered in error and doses omitted shall be reported and reviewed in accordance with this policy..."

Patient #16Review of the medical record 03/15/17 for Patient #16 revealed she was admitted to the hospital 03/08/17, was a current patient at the time of the survey, and had diagnoses that included, in part, hypertension, Type II Diabetes,Cirrhosis, Portal hypertension, History of hepatic encephalopathy, Chronic pancreatitis, Ileal neuroendocrine tumor , and was s/p right hemicolectomy and diverting ileostomy. Review of admission orders revealed medication included, in part, Coreg twice a day , Lasix daily, Lisinopril daily, and Aldactone daily. Review of the patient's MAR for 03/14/17 revealed her daily dose of Lisinopril (blood pressure medication), scheduled for 9:00 a.m. was documented as not given. No documentation on the MAR, as to the reason Lisinopril was not given, was found. Review of the nursing notes for 03/14/17 revealed no documentation of the omitted dose of Lisinopril or a notification to the provider.

In an interview 3/15/17 at 10:45 S27RN reported he took care of Patient #16 on 03/14/16 and did hold her Lisinopril. He said he thought it was probably because she was on other medications that could affect her blood pressure which runs low, and her output is high. S27RN explained that medication administration was entered into an eMAR on the computer, then the night shift staff printed the eMAR for that previous day and placed it in the patient's medical record before the next (day) shift assumed duty. He reviewed the eMar on the computer and showed the surveyor that the reason documented on a drop-down box on the computer screen was "medical considerations". He agreed that did not explain what medical considerations were that required the medication be held, but that this was the most appropriate option under reasons the medicine was not given. He indicated he notified the physician, but could not remember the time. After a review of the nurses' notes and the physician's progress notes, he reported that he could not provide any documentation that the physician had been notified, or the specific medical indication for which the medication was held. He said he was not sure how to print the eMAR, as that was done on the night shift by the staff. He indicated he was holding Patient #16's Lisinopril medication again this morning because of the patient's blood pressure being low. He had not yet notified the physician or provider. S16RN, Charge Nurse, present for the interview, indicated there might be a note in the progress notes. After review of the medical record she reported she could not find any documentation of the notification or reason the medication was held in the progress notes or elsewhere. She reported that the eMAR is the only electronic part of the medical record. She indicated the medical record department did not have access to the eMar, so that they could not print a copy, only the nursing staff could, and that was usually done on the night shift. She indicated she would provide a printed copy of the eMAR. Review of the copy of the reprinted eMAR , provided by S16RN revealed it did not document the documentation choices chosen by S27RN 03/14/16, in the drop down boxes, in the eMAR. S16RN verified not all of the nursing documentation from the eMAR was included in the patient's medical record.

In an interview 3/15/17 S2CCO indicated the expectation was that nurses would document if a medication was not given or held, as well as the reason for the medication being withheld. It was also her expectation that the physician would be notified and the notification would be documented in the patient's record. S2CCO indicated she did not know the process for getting the information from the eMAR onto the medical record.

Based on record review and interview the hospital failed to ensure a medical record for each patient was accurately completed and authenticated as per hospital policy and procedure and Medical Staff bylaws. This deficient practice was evidenced by an eMAR used by staff at the offsite campus that was not integrated in whole, into the medical records to complete the records, as evidenced in 1 of 1 (#16) medical records reviewed for incomplete eMAR documentation on the medical record.
Findings:


Review of Medical Staff Rules, Rule #9, Medical Records, revealed (9.1-1) all entries in the medical record shall be accurately timed, dated, and authenticated by the person responsible for the entry. The persons allowed to make entries in the medical record include, Members of the medical staff, Registered and licensed nurses, Physician's Assistants, Nurse Practitioners, Dietitians, Therapists ( Physical, Occupational, Speech, and Recreational), Social Workers, and Pharmacists.

Review of hospital Policy #1207, titled " Medication Administration and Documentation"(last reviewed 02/20/16) revealed , in part the following: "Medication Administration Recording: An entry of drugs administered (including drugs administered in error)...and omitted doses shall be properly documented in the patient's medical record as follows:...If the patient for any reason does not receive a dose of medication prescribed, the nurse must chart the reason for omitting the dose in the nurse's notes of the chart. The nurse shall also circle the dose omitted on the MAR and write a brief explanation next to the circled dose. Explain in the nurses's notes, the reason for each PRN, non-recurring or omitted dose (including refused doses)...

Review of hospital Policy # MM-6.20-01, titled "Medication Error Reporting", (last review date 12/06/15) revealed, in part "Drugs administered in error and doses omitted shall be reported and reviewed in accordance with this policy..."

Patient #16
Review of the medical record 03/15/17 at 10:15 a.m., for Patient #16 revealed she was admitted to the hospital 03/08/17. Review of admission orders revealed medication included, in part, Coreg twice a day , Lasix daily, Lisinopril daily, and Aldactone daily. Review of the patient's MAR for 03/14/17 revealed her daily dose of Lisinopril (blood pressure medication), scheduled for 9:00 a.m., was documented as not given. No documentation on the MAR, as to the reason Lisinopril was not given, was found. Review of the nursing notes for 03/14/17 revealed no documentation of the omitted dose of Lisinopril or the notification of the provider.

In an interview 3/15/17 at 10:45 S27RN reported he took care of Patient #16 03/14/16 and did hold her Lisinopril. S27RN explained that medication administration was entered into an eMAR on the computer, then the night shift staff printed the eMAR for that previous day and placed it in the patient's medical record during the night shift. S27RN reviewed Patient #16's eMar on the computer and showed a drop-down box (on the computer screen) which documented "medical considerations" under reason medication was not given. He agreed that did not explain what medical considerations necessitated the medication be held. He also verified that "medical considerations", the reason the dose of Lisinopril was held, was not documented on the printed MAR in Patient #16's medical record. S27RN indicated he notified the physician, but could not remember the time. After a review of the nurses' notes and the physician's progress notes, he reported that he could not provide any documentation that the physician had been notified, or the specific medical indication for which the medication was held. S16RN, Charge Nurse, present for the interview,after review of the medical record, reported she could not find any documentation of the notification or reason the medication was held in the progress notes or elsewhere. She reported that the eMAR is the only electronic part of the medical record, and it has to be printed by the night shift because it does not interface with any other part of the medical record. She indicated the medical record department did not have access to the eMar, so that they could not print a copy , only the nursing staff, and that was done on the night shift. She indicated she would provide a printed copy of the eMAR. Review of the copy of the reprinted eMAR , provided by S16RN revealed it did not document the reason for omitting the medication, from the documentation choices available, chosen by the nurse, in the drop down boxes, in the eMAR. S16RN verified not all of the nursing documentation from the eMAR was included on the printed MAR on the patient's medical record.

In an interview 3/15/17 S2CCO indicated the expectation was that nurses would document if a medication was not given or held, as well as the reason for the medication being withheld. It was also her expectation that the physician would be notified and the notification would be documented in the patient's record. S2CCO indicated she did not know the process for getting the information from the eMAR onto the medical record. After a review of Patient #16's medical record, S2CCO confirmed the documentation on the printed MAR did not include all required information regarding the care and status of Patient #16.

Based on record reviews and staff 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 for 4 of 4 (#2, #3, #9, #15) patient medical records reviewed for authentication of medical record entries from a total sample of 30.

Findings:

Review of the Medical Staff Rules & Regulations revealed in part the following:
Medical Records:
9.1-1 All entries in the medical record shall be accurately timed, dated and authenticated by the person responsible for the entry.
9.3 History and Physical:
9.3.1.2 The attending physician, or his designee, must validate and sign this report.

Patient #2:
Review of the medical record for current Patient #2 revealed a History & Physical with a date of service 03/08/17 by S26PA. Further review revealed no documented evidence the History & Physical was signed and timed by S26PA.

Review of the medical record revealed Progress Notes dated 03/13/17 and 03/14/17 by S26PA. Further review revealed no documented evidence the Progress Notes were signed and timed by S26PA.


Patient #3:
Review of the medical record for current Patient #3 revealed a History & Physical with a date of service 02/21/17 by S26PA. Further review revealed no documented evidence the History & Physical was signed and timed by S26PA.

Review of the medical record revealed Progress Notes dated 03/13/17 by S26PA. Further review revealed no documented evidence the Progress Notes were signed and timed by S26PA.


Patient #9
Review of the medical record for current Patient #9 revealed a History & Physical with a date of service of 02/19/17 by S26PA. There was no documented evidence that the H&P had been signed by S26PA and there was no time documented on the record. Further review of the record revealed a Progress Note with a date of service of 03/13/17 documented by S26PA. There was no documented evidence that the Progress Note was signed by S26PA and there was no time documented on the form.


Patient #15
Review of the medical record for Patient #15 revealed the patient was admitted to the hospital on 10/18/16 and discharged on 11/08/16.
Review of the record revealed an H&P documented by S26PA with an "Admit Date" of 10/18/16. There was no documented evidence of a date/time/signature on the H&P. The H&P had, "Printed by S26PA at 10/20/16 11:1..." documented across the top of the page.
Review of the Progress Notes dated 10/28/16, 10/29/16, 10/30/16, 10/31/16, 11/01/16, 11/02/16, 11/03/16, 11/04/16, 11/05/16, and 11/06/16 revealed no documented evidence of a signature or time of signature on the documents.
Review of the Discharge Summary documented by S26PA with a Discharge Date of 11/08/16 revealed no documented evidence of a signature or the date and time the document was signed. Further review of the document revealed, "Printed by S26PA at 11/18/16 1:15..."

In an interview on 03/14/17 at 10:25 a.m., S21RHIA and S25HIM stated the physicians and PA at the main campus document their H&Ps, Progress Notes, and Discharge Summaries in the electronic medical record of the host hospital. S25HIM stated S26PA prints the H&P and the Progress Notes from a printer located in the facility and the PA puts the document on the patient's record. S25HIM stated the process recently changed. S21RHIA stated they need to find out what the current process is to ensure the H&P, Progress Notes, and Discharge Summaries are dated, timed and signed. S25HIM confirmed her chart review process only looked for an H&P and Discharge Summary on the record and she does not review the documents for a signature or date and time. After reviewing the above patient records, S21RHIA and S25HIM confirmed the H&P, Progress Notes, and Discharge Summary did not include the signature of the person or the time of the entry.







17091




30420

Based on record review and staff interview, the Hospital failed to ensure verbal orders were dated, timed, and authenticated promptly by the ordering physician in accordance with state law and medical staff bylaws, rules, and regulations for 4 of 4 (#9, #12, #13, #15) sampled records reviewed for authentication of verbal orders out of a total sample of 30. Findings:

Review the Louisiana Hospital Licensing Standards, LAC 48:I.Chapter 93, revealed the following:
Subchapter H. Medical Records Services
9387. Organization and Staffing.
E. Written orders signed by a member of the medical staff shall be required for all medications and treatments administered to patients.... The bylaws may grant the medical staff up to ten days following the date an order is transmitted verbally or electronically to provide the signature or countersignature for such order.

Review of the Medical Staff Rules & Regulations revealed in part the following:
9.5.2 Verbal orders shall be considered to be in writing if dictated to a registered nurse, pharmacist, respiratory therapist, occupational therapist, physical therapist, licensed practical nurse, or social worker.
9.5.2.2 The physician who gave the verbal order, or his designee, shall time, date and countersign such orders within ten (10) days.

Patient #9
Review of the medical record for Patient #9 revealed the current patient was a 67 year old admitted to the hospital on 02/18/17 with diagnoses of Osteomyelitis of Ankle and Foot, Aortic Valve Replacement, and Type II Diabetes Mellitus uncontrolled.

Review of the physician orders revealed the Hypoglycemia Protocol orders were taken as a verbal order from the nurse practitioner on 02/18/17 at 8:48 p.m. Review of the orders revealed the physician signed the order, but did not date or time his signature.
Further review of the physician orders revealed verbal orders were taken by the pharmacist on 03/01/17 and 03/09/17 for changes in the Vancomycin dosages. Review of the orders revealed the physician signed and dated both orders, but failed to document the time of his authentication.

In an interview on 03/14/17 at 1:30 p.m., S25HIM confirmed the above verbal orders had not been timed, and/or dated and timed when signed by the physician.


Patient #12
Review of the medical record for Patient #12 revealed the patient was a 74 year old male admitted to the hospital on 11/21/16 with diagnoses of Enterococcal Bacteremia, Chronic Systolic Heart Failure, and Hypertension. Review of the record revealed the patient expired at the hospital on 11/24/16.

Review of the physician's orders revealed the following verbal orders had been signed by S20MD but were not dated or timed when signed by the physician:
Physician Admission Orders dated 11/21/16.
Admit/Discharge Medication Reconciliation and Order Sheet dated 11/21/16.
General Wound Care Protocol orders dated 11/21/16.
Hypoglycemia Protocol orders dated 11/21/16.
Admission medication orders dated 11/21/16.
Hold insulin orders for tonight dated 11/22/16.
Lasix and Duo nebs orders dated 11/22/16
Vancomycin orders dated 11/24/16.

In an interview on 03/14/17 at 3:50 p.m., S2CCO confirmed the above verbal orders had not been dated or timed by S20MD when the orders were signed.


Patient #13
Review of the medical record for current Patient #13 revealed the patient was a 72 year old admitted to the hospital on 03/07/17 with diagnoses of Sacral Decubitus, Left Lateral Hip Wound, Paraplegia, Hypertension and Anemia.

Review of the physician's orders revealed the following verbal orders had been signed by the nurse practitioner but were not dated or timed when signed by the LIP:
Physician Admission Orders dated 03/07/16.
Admit/Discharge Medication Reconciliation and Order Sheet dated 11/21/16.
Medication orders dated 03/07/17.
Orders for Juven supplement and Vitamins dated 03/08/17.

In an interview on 03/14/17 at 12:00 p.m., S2CCO confirmed the above verbal orders had not been dated or timed when signed by the nurse practitioner.



Patient #15
Review of the medical record for Patient #15 revealed the patient was a 72 year old admitted to the hospital on 10/18/16 with diagnoses of Thoracic Osteomyelitis and Chronic Back Pain.

Review of the physician orders revealed the following verbal orders were not authenticated by the physician within 10 days of the order:
10/24/16 verbal order for Vancomycin documented by the pharmacist as received from S32MD.
10/24/16 verbal order to change Xanax documented by the RN as received from S26PA/S32MD.
10/26/16 verbal order for Boost Glucose Control documented by the RD as received from S26PA.
11/04/16 verbal order for Vancomycin documented by the pharmacist as received from S32MD.

In an interview on 03/15/17 at 2:20 p.m., S25HIM confirmed the above verbal orders were not signed by the physician or PA.

Based on record reviews and staff interviews, the hospital failed to follow their policy on properly completing informed consents for patients having procedures. This failed practice was evidenced in 4 (#4, #11, #23, #25) of 4 (#4, #11, #23, #25) patient informed consents reviewed out of a total sample of 30.
Findings:

Review of a hospital policy titled, "Informed Consent" (no number, last reviewed 02/16) revealed in part, the person performing the procedure must disclose to the patient the following information prior to obtaining consent: Potential benefits and drawbacks, potential problems related to recuperation, the likelihood of success, possible results of non-treatment, and any significant alternatives. Further review revealed the consent must be specific to the procedure being done, and should not be completed with abbreviations. "Procedure: A. Element of Informed Consent...information should include all of the following: 1) The nature of the patient's condition; 2) the proposed treatment, possible treatment alternatives, including no treatment...4) the consequences of no treatment.... E. Informed consent shall be generally obtained before each new procedure..."

Patient #4
Review of the medical record for Patient #4 revealed he was admitted to the hospital 02/03/17 with diagnoses that included, in part, Sepsis, Osteomyelitis, and Decubitus Ulcers to his Right hip (stage 4), Sacrum (Stage 4), and severe malnutrition. Further review revealed one single consent for wound debridement with checked boxes for "sharp debridement", "ultrasonic debridement", and printed on the consent and checked, "serial debridement". Further review of the consent for wound debridement revealed no condition specific to the patient for which the procedure was recommended by the practitioner, no alternative treatments, or the risk(s) of not having the wound debridement done. The consent documented wounds for debridement of his inferior back, right tochanter, left (arrow pointed down) (not completed). The consent was not signed by the patient, and had a note in place of the signature that the patient was unable to sign due to contractures, and noted a verbal consent with 2 witnesses and dated 02/06/17. Further review of the medical record revealed wound orders, Procedure record, and time outs for 2/9/17. The notes revealed Patient #4 underwent both sharp and ultrasonic debridement to his inferior back and right Tochanter wound, as well as a bone culture, and tissue cultures. These cultures were not noted in the informed consent.

Patient #11
Review of the medical record for Patient #11 revealed he was admitted to the hospital 03/09/17 with diagnoses that included, in part, Type II Diabetes, peripheral neuropathy, Pressure Ulcers to her left buttock (stage 3) and right buttock (stage 4), and unstagable pressure ulcer of her sacrum. Review of a wound care consent signed 3/10/17 by Patient #11. The consent had checked marks by "sharp debridement", "ultrasonic debridement", and hand written in "serial debridements". The consent did not document a specific condition for which the procedure was recommended by the practitioner, alternative treatments, with the risks and benefits of those treatments, or the risk of not having the procedure performed (debridement). Cultures (invasive) were not documented as addressed on the form. The wounds listed for consent of debridement included right heel, left heel, left lateral ankle, right lateral ankle, left great/second toe, right buttock, left buttock, and sacrum. "sacrum" was written over printed words, and "left" and "right" were abbreviated.


Patient #23
The patient was an 80 year old male admitted to the hospital on 02/19/17 with an admit diagnosis of Puncture Wound Left Foot with Cellulitis with treatment to include intravenous antibiotics, wound care, and physical therapy. A review of the patient's consent for Wound Debridements revealed a single consent which was checked for "sharp debridement", "ultrasonic debridement", and hand written next to"sharp debridement" and "ultrasonic debridement" was a checked box for "serial debridements". The consent did not document the specific condition or the specific procedure to be performed by the practitioner and the consent did not include alternative treatments, with the risks and benefits of those treatments, and/or the risk of not having the procedure performed (debridement). A further review of the patient's medical record revealed the patient had debridements on 02/22/17, 02/28/17, and 03/06/17 with only one documented consent on the medical record.

In an interview on 03/14/17 at 3:05 p.m. with S6RN, wound care nurse, she indicated that since patients sometimes receive several debridements while they are in the hospital that the physician gets a single consent that included all types of debridements and specified on the single consent that the consent would be for "serial debridements" (multiple debridements). She indicated that it was not the practice of the physicians to obtain a new consent for each debridement procedure performed.


Patient #25:

Review of the medical record revealed the patient was admitted to the hospital on 02/18/17. The patient had the diagnoses of Osteomyelitis of the left foot, diabetes mellitus, and cerebral vascular accident.

Review of the Consent for Wound Debridement form dated 02/20/17 revealed the boxes for sharp debridement, ultrasonic debridement, and serial debridement were checked. Further review of this consent revealed no documented evidence alternatives to the procedures were discussed with the patient.


In an interview 3/15/17 at 11:35 a.m. S2CCO, after a review of the medical records for Patient #4 and Patient #11 verified the consents did not include alternative treatments, with the risks and benefits of each, including not having the treatment, or the reason the wound debridement was recommended in the patients' specific cases. She agreed that a separate consent should be obtained for each new procedure, and that "serial debridement" should not have been written in.


14442




17091




30172

Based on observation, record review, and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of the beds for 28 of 28 beds currently in use at the off-site campus of the hospital. Findings:

On 03/14/17 at 2:05 p.m., with S16RN (Charge Nurse) and S2CCO, an observation was made of the nurse call button in Room "a" at the off-site campus. On the siderails of the patient's bed was a square button with picture of a nurse with the word "Nurse" under the picture. The button was noted to be non-functional as it failed to activate any type of nurse call system. S16RN confirmed the nurse call button was not functional. S16RN stated they had tried to use the nurse call buttons in the side rails of the bed, but no one wanted to use them. S16RN stated they decided to use the nurse call system that includes a cord with a button and reported that patients are instructed to use this call system. S16RN confirmed only one call system could be used, either the cord or the call button in the side rails, but not both. S16RN confirmed all of the beds at the off-site campus were the same and none of the nurse call buttons in the side rails were functional. S16RN and S2CCO confirmed it would be possible for a patient who may be sedated and/or confused to press the nurse call button on the handrail of the bed thinking they are calling for assistance without the nursing staff's knowledge due to the call button not working. Further observations of unoccupied beds at the off-site campus revealed Rooms "b", "c" and "d" had patient beds with non-functional nurse call buttons in the side rails of the bed.

Based on record reviews and interview, the hospital failed to ensure that the designated Infection Control Officer was qualified through experience, ongoing education and/or training to be responsible for the development and implementation of the hospital's Infection Control Program.

Findings:
A review of the Infection Control Officer's employee file, S3ICOfficer, revealed that he was the designated Infection Control Officer. A review of his employee file revealed in part: infection control training to include: Central Line Infection webinar, Introduction to Device Assist webinar, Pneumonia Events webinar, Reducing Sepsis with Best Practices webinar, and Multiple Drug Resistant Organism workshop. A review of his resume and qualifications included in part: Weekend Supervisor at a Nursing Home, RN at a Mental Health Hospital, RN in a Rehab Unit, and Home Health. A further review of S3ICOfficer's employee file revealed no other documented evidence of any infection control training/experience in the development and implementation of a hospital Infection Control Program.

In an interview on 03/15/17 at 12:30 p.m. with S3ICOfficer he indicated that he was the designated Infection Control Officer for the hospital and had been in that position since December 2016. S3ICOfficer indicated that he had no further documented evidence of infection control training/experience to present in the development and implementation of a hospital Infection Control Program.

Based on record reviews, observations and interviews, the hospital failed to ensure the infection control officer developed a system for investigating and monitoring infection control practices and breaches as evidenced by:
1) failing to ensure that staff adhered to the EPA disinfectant's MFU when cleaning/disinfecting of patient multiple-use equipment and failing to disinfect multiple-use patient equipment,
2) failing to ensure that staff adhered to acceptable hand hygiene practices during patient care procedures,
3) failing to store sterile instruments used for patient's procedures according acceptable professional guidelines, and
4) failing to maintain a sanitary environment.


Findings:
1) failing to ensure that staff adhered to the EPA disinfectant's MFU when cleaning/disinfecting of patient multiple-use equipment and failing to disinfect multiple-use patient equipment,
A review of the MFU on the EPA disinfectant used by the hospital for disinfecting multiple-use patient equipment revealed in part: The contact time is 2 minutes and the item(s) to be disinfected is to remain visibly wet for 2 minutes.

An observation (main campus) on 03/14/17 at 11:20 a.m. of S9TherapyTech, as he was disinfecting a soiled patient wheelchair with the EPA disinfectant, was not observed allowing the EPA disinfectant to remain visibly wet for 2 minutes.

In an interview on 03/14/17 at 11:30 a.m. with S9TherapyTech he indicated that the 2 minute contact time was the time required before reusing the patient care equipment for another patient and that the EPA disinfectant solution did not have to remain visibly wet for 2 minutes.

An observation on 03/13/17 at 11:50 a.m. revealed S30RN perform a capillary blood glucose test on Patient #23. When the test was complete, the RN replaced the glucometer and closed the case. S30RN then took the glucometer case to the medication room and left it there without disinfecting the glucometer and any contents she had contact with while wearing her used gloves. S30RN verified the observation. S30 RN confirmed she should have taken only the glucometer and supplies needed into the patient room and disinfected the glucometer after patient use, before returning it to the case.

2) failing to ensure that staff adhered to acceptable hand hygiene practices during patient care procedures
An observation (main campus) on 03/14/17 of S6RN performing Patient #1's wound dressing change and S6RN not sanitize her hands each time (6 times) after she removed her gloves and donned fresh gloves.

An observation on 03/13/17 at 11:50 a.m. revealed S30RN perform a capillary blood glucose test on Patient #23. S30RN took the carrying case containing the glucometer and supplies (individual lancets, alcohol wipes, gauze 1x1s, and canister of test strips) into the patient room and placed it on the counter. S30RN prepared the patient's finger with an alcohol wipe removed from the carrying case, obtained a lancet, and obtained blood from the finger stick, placed it on the test strip, then reached into the carrying case to get a 1x1 piece of gauze to place on the patient's finger. The RN did this without removing the gloves she wore to prep and obtain blood from the patient.


3) failing to store sterile instruments for patient's procedures according to acceptable professional guidelines,
A review of AORN, 2015 edition - Guideline for Sterilized Surgical Items revealed in part: Sterilized items should be labeled and stored in a manner to ensure sterility. Paper-plastic pouch packages should be used only for small, lightweight, low-profile items and should not be stored in a manner to cause undue compression to the integrity of the sterile paper-plastic pouch packages. Sterilized items should be considered sterile until an event occurs to compromise the sterility of the sterile item such as, moisture penetration or unacceptable storage conditions, compromised package integrity, compression, and exposure to airborne and other environmental contaminants. The sterility of sterile items is event related and not time related.

An observation (main campus) on 03/14/17 of the instrument storage area where the sterile instruments were stored revealed the following: Multiple sterile paper-plastic peel packages (over 50) that were stored in a clean patient plastic wash basin where the items were layered on top of one another and causing compression to the sterile packages and where many items in the paper-plastic peel packages were too heavy for the packages and were noted to be causing stress to the sealed package's seams.

In an interview on 03/14/17 at 10:30 a.m. with S6RN, wound care nurse, she indicated that the hospital had a contract with another hospital to process and sterilize their debridement instruments for patient's sterile procedures. She indicated that the hospital did not have a policy in place for proper storage of sterile instruments.

4) failing to maintain a sanitary environment.
An observation (main campus) of the Wound Care Cart on 03/14/17 revealed the following expired items: a sterile Punch Biopsy that expired in February 2016, 4 packs of Xerofoam Petroleum dressing that expired in December 2015, and a patient's opened bottle of Acetic Acid irrigation solution where the label indicated to discard any unused portion.

A tour of the main hospital campus 03/13/17 from 8:05 a.m. to 8:30 a.m., accompanied by S8RN revealed the following infection control concerns:
A portable O2 concentrator located in the therapy gym was noted to have dust and a dark colored hair on it near the handle. The filter located on the side was noted to be covered in light colored dust. S29OT, present for the observation, indicated the O2 concentrator was for any therapy patient on O2 while in therapy. S29OT verified the observation that it was not clean.
The Biohazard room was noted to have dark brown dried liquid splatters on the wall. The sink had hair in it, and a small covered white garbage can, with a foot control to lift the lid, was noted to have a lid covered with light grayish brown soiled areas. S8RN verified the room was soiled and needed to be cleaned.

An observation of the offsite campus 03/14/17 from 2:00 p.m. to 2:30 p.m., accompanied by S16RN, Charge Nurse, revealed the following infection control concerns:
An observation of Room "a" revealed a thick rubber bumper around the headboard of the bed, partially torn away from the bedframe, leaving open holes, which could not be properly cleaned and disinfected. Multiple small areas of rusted spots on the bed frame along the siderails, where a patient might touch, leaving the area rough, and unable to be cleaned and properly disinfected. The rubber covering of the top of the siderails had gouges and uneven nicks in the surface. S16RN and S2CCO, present for the observation confirmed the findings, and agreed there was no way to determine if the bed had been disinfected completely with the holes and rough surfaces.

An observation of Room "b" revealed a bedside table with the laminate covering on the side(upper edge) of the tabletop torn on 2 sides, leaving the absorbent, particleboard type of surface exposed. The patient bed was noted to have a thick rubber bumper around the headboard of the bed, partially torn away from the bedframe, leaving open holes, which could not be properly cleaned and disinfected. The rubber covered tops of the bed handrails had gouges in the rubber, creating a very uneven surface. The wallpaper in Room "b" was noted to have seams that were open, not approximated, and not sealed approximately a foot in length horizontally and another approximately 7 inches vertically. The floor tiles wrapped from the floor up onto the wall were noted to have cracks in them intermittently along 2 walls, where they curved from the floor surface to the wall surface. These cracks left a space in which soiling materials could be spilled and/or collect. A corner tile at the bottom of the wall, next to the floor tile was noted to be missing near the bathroom door, leaving uneven grout exposed. A plastic shower curtain, hanging in the patient bathroom, was noted to have 3 dried reddish/brown splash- patterned spots.

An observation of Room "c" revealed the vinyl covering on the rim/edge of the bedside table was missing, leaving a particle board type of surface exposed. The tile baseboard next to the bathroom door was observed to be loose with a section of the tile missing.

An observation of Room "d" revealed handrails on the patient bed that had small rusted areas in the patient touch areas that were rough. A shelf near the bottom of the patient belongings closet was noted to be broken with exposed particleboard. A 2 foot long crack in the floor was observed at the juncture of the baseboard, allowing potential soiling materials to collect.

In an interview 03/14/17, during the above referenced tour S16RN and S2CCO both present for the tour, verified the findings and confirmed the findings were such that cleaning and disinfection of the environment and patient furnishing could not be guaranteed.

In an interview on 03/15/17 at 1:30 p.m. with S3ICOfficer, he was made aware of the infection control breaches at the main campus. He indicated that acceptable infection control practices were not followed by staff and that the identified infection control breaches had not been identified by his infection control surveillance monitoring.


30420

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 2016- present ( March 15, 2017) 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 3/15/17 at 9:25 a.m.,S28RT reported there was no Medical Director of Respiratory Services, to his knowledge.

In an interview 3/15/17 at 5:10 p.m. S23CEO confirmed there was no qualified Medical Staff member appointed as the Director of Respiratory Services.