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A. Based on document review and staff interview, it was determined in 1 of 10 (Pt #1) patient record reviewed, the Hospital failed to ensure nurses obtained a medication reconciliation per policy. This has the potential to affect all patients with medication orders served by the Hospital.

Findings include:

1. The policy titled "Medication Reconciliation" (revised 5/16) was reviewed on 10/20/16. The policy noted "Reconciliation is the process of comparing medications taken prior to admission to a new setting where medication will be provided.... Medication reconciliation is an interdisciplinary process between physician, pharmacy and nursing... 2. Patients being transferred from another facility should have a transfer form that indicates current medications... 2. ...scan the patient's current medication list... in the electronic medical record."

2. The clinical record of Pt #1 was reviewed on 10/18/16 at approximately 3:00 PM through 10/20/16. The record noted Pt #1 arrived to the ED (Emergency Department) as a direct admit from a local Skilled Nursing Facility (SNF) on 4/30/16 for treatment of a subdural hematoma. The SNF Emergency Room Transfer Packet (Pt #1's medical history information sent by the SNF to the Hospital with the patient) included a medication list/profile with active/current medications. A Hospital nurses note under the "Home Medications"section authored by E#6 (Registered Nurse) on 5/5/16 at 3:55 PM, lacked the reconciliation of 9 medications (medications used to treat heart rate, stool softener, iron supplement, diabetic medication, antiseizure, c-diff antibiotic treatment, gastric upset) listed as active medications on the Medication Profile from the SNF and 3 medications (Lipitor, Nitroglycerin and Flomax (medication used to treat high cholesterol, chest pain and urinary function) listed under the "Home Medications" section were not on the Medication Profile from the SNF. The record lacked documentation of any medication clarification or phone calls to the SNF or family to inquire about active medications and past medical history.

3. During an interview on 10/19/16 at approximately 1:00 PM, E#1 (Senior Vice President and Chief Nursing Officer) stated the medication reconciliation process is a multidisciplinary responsibility. E#1 stated "I don't know where the SNF packet went. Apparently they (nurses) didn't see it or they would have documented the active medications in the record." E#1 verbally agreed the Home Medications should have been reconciled prior to 5/5/16.

B. Based on document review and staff interview, it was determined for 1 of 10 (Pt #1) patient record reviewed, the Hospital failed to ensure nurses assessed patient care needs per policy. This has the potential to affect all patients served by the Hospital.

Findings include:

1. The policy titled "Contact Isolation" (revised 3/15) was reviewed on 10/19/16. The policy required patients suspected to be infected or colonized to have "Diarrheal Enteric infections...Clostridium difficile (c-diff) (Diarrhea is defined as 3 or more watery stools in 24 hours)" to use Contact/C Contact Precautions (Special precautionary measures to prevent transmission/contamination of significant organisms).

2. The clinical record of Pt #1 was reviewed on 10/18/16 at approximately 3:00 PM through 10/20/16. The record noted Pt #1 arrived to the ED (Emergency Department) as a direct admit from a local Skilled Nursing Facility (SNF) on 4/30/16 for treatment of a subdural hematoma. The record lacked documentation Pt #1 was suspected to be infected or colonized and placed into C Contact precautions (specific precautions related to c-diff) until 5/5/16 at 11:00 PM. The record lacked documentation a physician was notified. The following documentation demonstrated suspected infection or colonization which would have required Contact/C Contact Precautions:
a) The Emergency Room Transfer Packet (Pt #1's medical history information sent by the SNF to the Hospital with the patient) noted on page 1 "Isolation: Yes Type: c-diff" and listed "Flagyl" (antibiotic for c-diff treatment) as a current/active medication which started on 4/27/16 and was ordered for 6 days. b) The record noted Pt #1 was incontinent of 5 loose watery stools on 5/4/16 and 6 stools (no description of consistency) on 5/5/16, and multiple loose watery stool assessments on 5/6/16, 5/7/16 and 5/8/16.
c) A nurses note dated 5/5/16 at 11:00 PM noted Pt #1's family stated Pt #1 was "positive for c-diff a week ago."
d) A Clostrium Toxin A Screen (c-diff test) was ordered by the physician on 5/7/16 at 1:30 PM. The record noted a stool specimen was collected by the nurse on 5/8/16 at 2:38 PM (25 hours later) although multiple loose watery stool were documented on 5/7/16 and 5/8/16. A Clostrium Toxin A Screen resulted positive for c-diff on 5/8/16 and a Flagyl order was obtained.

3. During an interview on 10/19/16 at approximately 1:00 PM, E#1 (Senior Vice President and Chief Nursing Officer) verbally agreed to the following: nurses failed to identify pertinent medical history upon admission and reconcile an accurate medication list; Pt #1 was not placed into Contact Isolation until 5/5/16 and should have been; the stool specimen was collected 25 hours after the order and should have been collected as soon as possible; the ongoing frequent watery/loose stool should have been suspected as an infection and reported to the physician.

A. Based on document review and staff interview, it was determined for 2 of 2 (Pt #1, #3) patients with Peripheral Venous Access Devices (PVAD) initiated outside the hospital setting, the Hospital failed to ensure the PVAD's were maintained per policy. This has the potential to affect all patients with a PVAD initiated outside the hospital.

Findings include:

1. The policy titled "IV (Intravenous)- Peripheral Venous Access Device" (revised 2/16) was reviewed on 10/18/16. The policy required peripheral intravenous sites to be rotated within 24 hours of a start initiated outside the hospital setting.

2. The clinical record of Pt #1 was reviewed on 10/18/16 at approximately 3:00 PM. Pt #1 was admitted on 4/30/16 with a diagnosis of subdural hematoma. The record noted a peripheral IV was placed by "External Staff ?: EMS (Emergency Medical Service)" on 4/30/16 and was removed on 5/3/16, 2 days after the 24 hour requirement.

3. The clinical record of Pt #3 was reviewed on 10/18/16 at approximately 2:00 PM. Pt #2 was admitted on 10/15/16 with a diagnosis acute cystitis. The record noted a peripheral IV was placed by "External Staff ?: EMS" on 10/15/16 and was removed on 10/18/16, 2 days after the 24 hour requirement.

4. During an interview on 10/18/16 at approximately 3:30 PM, E#5 (Registered Nurse) verbally agreed Pt #1 and Pt #3's PVAD site was not rotated with in 24 hours and should have been.


B. Based on document review and staff interview, it was determined for 1 of 1 (Pt #1) patient with an order for bladder training, the Hospital failed to ensure the bladder training program was conducted per policy. This has the potential to affect all patients with an order for bladder training.

Findings include:

1. The policy titled "Bladder Training with Foley Catheter and/or assisting the patient with neurogenic bladder" (revised 11/13) and Bladder Training without Foley Catheter and/or assisting the patient with neurogenic bladder" (revised 10/15) was reviewed on 10/20/16. The policies noted "After foley removal, if bladder distention is suspected, complete bladder scan.... Bladder scan performed for the first 3 attempts at voiding after catheter removal, and as needed, if patient is: unable to void within 4-8 hours... If post scan, volume shows 300 +cc's (cubic centimeters), again have patient attempt to void. If still unable to void, straight catheterize the patient... and record volume. If volumes are above 400 cc+, patient should be monitored every 4 hours. Notify physiatrist if volume above 400 cc."

2. The clinical record of Pt #1 was reviewed on 10/18/16 at approximately 3:00 PM. Pt #1 was admitted on 4/30/16 with a diagnosis of subdural hematoma. The record noted 10 occurrences within the 12 days after Pt #1's foley catheter was removed and bladder training was ordered that Pt #1's output was not monitored or a bladder scan conducted for 8.5 to 19 hours. The record noted on 5/14/16 at 2:38 PM the bladder scan volume was 0, then catheterized for 350 ml (Milliliter) of urine. The record noted on 5/15/16 at 2:00 PM, no bladder scan was conducted but was catheterized for 500 ml urine.

3. During an interview on 10/20/16 at approximately 2:00 PM, E#5 verbally agreed the bladder training protocol was not followed per policy and should have been.

C. Based on document review and interview, it was determined for 1 of 6 (Pt #1) discharged patient, the Hospital failed to ensure patient was discharged per policy. This has the potential to affect all patients discharged by the Hospital.

Findings include:

1. The policy titled "Discharge of Patients" (revised 2/16) was reviewed on 10/18/16. The policy required pertinent medical information to be copied and sent to the receiving facility and to document the care given prior to discharge, the instructions given and patient's/family's response, any equipment sent, accompanying personnel and family, time of discharge, mode of discharge and the status/assessment of the patient's condition.

2. The clinical record of Pt #1 was reviewed on 10/18/16 at approximately 3:00 PM. Pt #1 was admitted on 4/30/16 with a diagnosis of subdural hematoma. The record lacked documentation that pertinent medical information was sent to the receiving facility, that instructions were given to the patient/family and their response, if any equipment was sent, who the accompanying personnel and/or family was, the time of discharge, the mode of discharge and the status/assessment of the patient's condition.

3. During an interview on 10/20/16 at approximately 2:00 PM, E#5 verbally agreed the discharge documentation was not completed per policy and should have been.

D. Based on document review and interview, it was determined for 1 of 1 (Pt #1) patient who received care on the rehabilitation floor, the Hospital failed to ensure outputs were monitored. This has the potential to affect all patients receiving care on the rehabilitation floor.

Findings include:

1. The policy "Nursing Documentation Standards" (revised 6/16) was reviewed on 10/18/16. The policy noted "6. Reassessment... will include at a minimum the health systems previously identified as abnormal... clinical judgement, treatment protocol, physician order..." The policy noted nurses may chart by exception if the patient assessment is Within Designated (WDL). The WDL for the Genitourinary system is defined as "Adults continent of urine Voiding/wetting diapers without difficulty or discomfort No unusual odor Output is age and weight appropriate."

2. The clinical record of Pt #1 was reviewed on 10/18/16 at approximately 3:00 PM. Pt #1 was admitted on 4/30/16 with a diagnosis of subdural hematoma, severe congestive heart failure and urinary retention. On 5/6/16 the Physical Medicine and Rehabilitation Physician noted on the History and Physical "The patient will require 24 hour rehabilitation nursing care who will assess for bowel and bladder function.... Rehabilitation nursing will also be utilized to monitor... output..." The nurses note dated 5/21/16 noted Pt #1 had an indwelling catheter and urine was dark yellow and malodorous at 7:00 AM and amber colored and malodorous at 5:00 PM. The record lacked documentation of any interventions related to the indwelling catheter or an assessment of urine color, odor or amount of output from 5/22/16 at 7:30 AM until 5/24/16 at 4:13 AM, approximately 45 hours.

3. During an interview on 10/19/16 at approximately 3:30 PM, E#5 verbally agreed record lacked documentation of any interventions related to the indwelling catheter or an assessment of urine color, odor or amount of output from 5/22/16 at 7:30 AM until 5/24/16 at 4:13 AM and should have been. E#5 stated "I can't believe Pt #1's output wasn't monitored especially since they were diuresing (medication to increase urine secretion)..."