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Based on policy reviews, record reviews, observations and interviews the facility failed to:

- have one documented Director of Nursing Services for all nursing personnel
- obtain verification ensuring Licensed Practical Nursing staff employed by the facility are certified and allowed by their standard of practice to administer intravenous medication
- provide patient hygiene timely
- ensure staff performed an appropriate skin assessment on admission
- ensure staff followed physician's orders related to wound care
- ensure medications were administered as ordered by the physician
- follow hospital policy with regard to administering medication per gastric tube
- follow hospital policy with regard to insulin administration
- follow hospital policy with regard to administration technique of medications by subcutaneous injection
- have order protocols placed on the medical record and signed by the physician and
- follow their policy with regard to administration of blood products.

These failures have the potential to affect any patient admitted to the facility.

The hospital census was 61.

The severity and cumulative effect of these systemic practices resulted in the facility being out of compliance with 42 CFR (Code of Federal Regulations) 482.23 Condition of Participation: Nursing Services.

Based on record review, the facility failed to complete code status (i.e., if a patient would or would not be resuscitated it the patient went into either respiratory or cardiac arrest) orders for two patients (Patients SA1 and SA2) of seven medical records reviewed for code status. The facility census was 61.

Findings included:

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

2. Review of current Patient SA1's medical record on 04/06/10 at 10:15 A.M. showed he/she was admitted to the facility on 03/29/10. The document titled "Code Status/Comfort Measures Orders", was blank with no category checked, no patient/family signature, and no physician signature. Nurse Manager, Staff SAA, confirmed that a code status order form was not completed.

3. Review of current Patient SA2's medical record on 04/06/10 at 11:30 A.M. showed he/she was admitted to the facility on 04/05/10. On the document titled "Code Status/Comfort Measures Orders", the "Comfort Measures Only" was checked. At the end of this category, the statement "Date of progress note documenting discussion with patient and family:_____" was blank. There was no physician signature.

Based on staff interviews and record review, the facility failed to correctly inform patients of the process for calling the State survey agency to file a grievance. This affects all patients who receive hospital services. The facility census was 61.

Findings included:

1. Review of current Patient L 6's medical record on 04/05/10 at 2:05 P.M. showed a three-page document with the heading "Patient Rights and Responsibilities". This document did not contain the telephone number for the State of Missouri's Hotline telephone number or an address for the State survey agency.

During an interview on 4/08/10 at 2:10 P.M. Quality Manager staff LH confirmed that the name, address and phone number of the State survey agency or hotline telephone number are not currently listed on the Patient Rights and Responsibilities form.


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2. During an interview on 04/06/10 at approximately 3:00 P.M., Unit Secretary, Staff SA D, stated that the patient/family gets a copy of the Patient Rights and Responsibilities. Staff SA D stated that the State Hotline and address has never been on the paperwork and it isn't listed in any of the paperwork that the patient receives. Staff SA D stated that if a patient/family has a complaint, they are told to go through the chain of command at the hospital and then if they don't get the issue resolved, to go to an outside agency.

Based on policy review, record review, and interview, the facility failed to respond in writing to one complainant (family member of Patient L 25) and the facility failed to accurately inform the complainant of the results of the investigation for another (family member of Patient L 26) grievance of five grievance files reviewed. The facility census was 61.

Findings included:

1. Review of the facility policy H-PC 05-007, "Patient Complaint/Grievance Process", effective date 01/01 with a revised date of 12/08, shows the Hospital CEO (Chief Executive Officer)/Administrator or designee will send a written response to a complainant within seven days. The letter shall include the name of the hospital's contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, the dates of completion, and that it is signed by the CEO/Administrator. Further review of the policy shows if resolution is not possible within 7 days, the letter will indicate an anticipated resolution date. A follow-up letter will then be sent once the resolution has been achieved.

2. Review of the face sheet for discharged Patient L 25 shows he/she entered the facility on 02/04/10 for treatment of acute respiratory failure
Review of Grievance Report Form dated 02/07/10, shows the family member of Patient L 25 contacted the facility with a complaint that staff did not seem to care about Patient L 25, that family member of Patient L 25 did not like the attitude of staff, and did not want specific staff to take care of Patient L 25. Further review of the Grievance Report Form shows Staff LH, Quality Manager, spoke by phone interview with the family member of Patient L 25 regarding concerns. Family member of Patient L 25 added that staff had an attitude, that Patient L 25 was smelly, eyes were not cleaned, and was told or overheard he/she was dying. Further review of the Grievance Report Form shows the patient expired, and Staff LH, Quality Manager, felt it was inappropriate to send a follow-up letter as it referenced a comment about Patient L 25 dying.

During an interview on 04/09/10 at 11:15 A.M., Staff LH, Quality Manager, said that a follow-up letter was not sent to the family member of Patient L 25 because he/she felt it would be inappropriate since Patient L 25 had expired.

3. Review of the face sheet for discharged Patient L 26 shows he/she entered the facility on 02/06/10 for treatment of a non-healing surgical wound.

Review of Grievance Report Form dated 02/16/10, shows the family member of Patient L 26 contacted the facility with complaints that Patient L 26 was found with his/her wound dressing off, he/she was "wet", "in stool" (i.e., feces) with "stool in finger nails", no heel protectors on, and "attitudes from nurse". Further review of the grievance follow-up letter dated 02/18/10, addressed to Patient L 26 and family members, documented that as of 02/16/10, the following has occurred: "disciplinary action will be taken with the nurse involved".

However, review of employee file for Staff LYY, LPN showed no documentation of disciplinary action taken with the nurse involved.

During an interview on 04/09/10 at 11:15 A.M., Staff LH, Quality Manager, said there was no documentation of Staff LYY, LPN, discipline received from Staff LU, Registered Nurse, Nurse Manager.

During an interview on 04/09/10 at 12:55 P.M., Staff LRR, Human Resource Coordinator, states there are no documents of unfiled disciplinary actions for staff LYY's employee file.

Based on interview and observation, the facility failed to include the patient and/or family in participation of the treatment planning process for one patient (L 20) of three patients reviewed for care planning process. The facility census was 61.

Findings included:

Observation of a dressing change on 4/06/10 showed Patient L 20 on a ventilator.

During an interview on 4/06/10 at 2:30 P.M. the spouse of Patient L 20 said staff had not discussed the patient's plan of care with him/her or the patient. Patient L 20 shook his/her head no when asked if staff had discussed the plan of care with him/her.

During an interview on 4/07/10 at 3:00 P.M. the spouse of Patient L 20 said Patient L 20 was not having a good day because he/she was so tired from being taken off the ventilator the previous day for 18 hours. The spouse of Patient L 20 said he/she did not know how long Patient L 20 would be off the ventilator this day because no one had told him/her or the patient. The spouse of Patient L 20 said the physician did tell him/her they are trying to wean the patient from the ventilator and would not keep the patient off the ventilator for such an extended period on this day. The spouse of Patient L 20 said none of the facility staff had discussed with him/her or the patient what to expect with the ventilator weaning.

During an interview on 4/07/10 at 3:30 P.M. registered nurse staff A said it is the policy of the facility to discuss plans of care with families and patients.

Based on observation, the facility failed to protect patient's rights to privacy by placing patient names in public view on one floor at the Lindell campus and one hall at the St. Anthony's campus and failed to secure confidential patient information in the laboratory area. The facility census was 61.

Findings included:

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

Review of the facility's document titled, "Patient Rights and Responsibilities", revised 10/08, gave direction, in part, to include the following:
"The patient has the right to personal privacy...The patient has the right to the confidentiality of his/her clinical records...."

2. Observation on 04/05/10 at 2:50 P.M. on the second floor of the Lindell campus showed patient charts, lying on the desk at the nursing station. Patients' first and last names were taped to the charts and the names visible from the public hallway. This potentially affected all 11 patients on the second floor.

3. Observation on 04/06/10 at 9:30 P.M. on hall B of the St. Anthony's campus showed patient charts in a rack. Patients' first and last names were taped to the charts' binders and were legible from the public hallway. This affected all seven patients on hall B.


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4. During an observation on 04/08/10 at 11:05 A.M. a binder is found in the laboratory on a bookshelf containing labels of all the patients in the facility. The labels have full patient names and account numbers.

5. During an observation on 04/08/10 at 11:05 A.M. a binder is found in the laboratory on a bookshelf containing record of all sent out labs for all the patients in the facility. The reports have full patient names, dates of birth, and account numbers.

6. During an interview on 04/08/10 Laboratory Technician Staff L XX said that housekeeping staff does have access to the lab area for cleaning purposes after laboratory staff have left for the day and would be able to access the information in the binders.

Based on policy review, facility investigation review and interviews, the facility failed to promptly investigate an abuse allegation related to one patient (L 14) of five abuse allegation investigations reviewed. The facility census was 61.

Findings included:

1. Review of facility policy PC 02-014 "Abuse of Patient, Elder, Child by Staff Identification - Response and Reporting" shows the purpose of the policy is to communicate Hospital Division policy prohibiting abuse and to describe the procedures for preventing and responding to allegations of abuse, neglect or mistreatment of a patient.

Section titled "Suspected Abuse: First Responder/Supervisor Responsibilities" documents in part:
1. The employee who first becomes aware of a patient who is said to be abused, neglected, mistreated and/or exploited must take all appropriate steps necessary to protect the patient, including but not limited to, reassignment of staff, removal of staff from patient care and restriction of visitors.
2. If the report allegation is conveyed by a family member, legal representative or visitor, assure the individual that the Hospitals [sic] treats any allegation seriously. Thank the individual for conveying their concerns and explain that the supervisor will be notified promptly.
3. Notify the Chief Nursing Officer (CNO), Nursing Supervisor or clinical area manager immediately in any instance of reported, observed or suspected patient abuse, neglect, mistreatment and/or exploitation. The Chief Nursing Offer [sic], Nursing Supervisor or clinical area Manager shall immediately notify the Administrator on call.
4. Notify the patient's attending physician.
5. Document the allegations on a complaint form and enter as an event report. Forward immediately to the DQM or ADC for investigation.
6. Contact the Regional Office Representative (RDCO) 24 hours/day, 7 days a week.


2. Review of the facility investigation showed on the evening of 2/25/10 two staff members heard certified nurse aide (CNA) staff L BBB yelling at Patient L 14. CNA L BBB slammed the door to the patient's room and staff could hear the staff member yelling at the patient.

Further review of the facility investigation showed interviews with staff members who reported the alleged abuse were conducted by hospital staff on 2/26/10, the day following the allegation.

The investigation showed, in part, an interview with unit secretary staff L P that staff L BBB was screaming and yelling at Patient L 14 at 6:30 P.M. on 2/25/10. The door slammed and yelling was heard to continue with the door closed. The House Supervisor was notified.

However, the facility investigation does not document who was the House Supervisor on duty, when the House Supervisor was notified, or any actions taken by the House Supervisor.

During an interview on 4/08/10 at 12:45 P.M. unit secretary staff L P said that on 2/25/10 CNA L BBB was screaming and hollering at Patient L 14. Staff L P first said the incident occurred after 7:00 P.M., but later in the interview said the incident occurred earlier at the change of shift. Unit Secretary staff L P initially said he/she reported the incident to the evening supervisor and then went home and wrote the incident up. Staff L P said he/she was off for two or three days following the incident. Later in the interview staff L P said that she informed the day supervisor, staff L Q, of the incident and told the day supervisor he/she was going to write the incident up. Later in the interview Staff L P said he/she gave the day supervisor a copy of what he/she wrote up regarding the incident.

Review of the facility daily assignment sheet for Thursday 2/25/10 for the 2nd floor where Patient L 14 received treatment showed unit secretary staff L P was not on duty the day following the incident (2/26/10).

Review of the facility investigation showed during an interview on 2/26/10 at 5:35 P.M. nursing supervisor staff L Q said he/she did not hear anything at all. He/she only knew about the incident because he/she was notified on 2/26/10. The facility investigation does not document who notified staff L Q.

During an interview on 4/07/10 at 11:05 A.M. nursing supervisor staff L Q said he/she did not know who the nursing supervisor on duty was on 2/25/10. Staff L Q said he/she did not remember if he/she was the supervisor that day, but said he/she was standing at the nurses' station around the change of shift on 2/25/10 when the unit secretary staff L P told him/her of the incident and said he/she would write it up. Nursing supervisor staff L Q told the unit secretary, "Good, you should write it up." Nursing supervisor staff L Q said the unit secretary gave him/her a copy of what he/she wrote up regarding the incident. Nursing supervisor staff L Q said he/she thought he/she asked the evening supervisor to report the incident and said, "I guess it was my responsibility since it happened on my shift. It was time for me to go home. My shift was over." Later in the interview nursing supervisor L Q said she went and looked at the patient, but did not interview the patient. Nursing supervisor L Q said he/she did no investigation of the incident, did not interview the patient or the staff member who allegedly yelled at the patient, and did not report the incident either to administration or to the patient's physician.

Review of the facility daily assignment sheet for Thursday 2/25/10 showed staff L Q listed as the supervisor for the 7:00 A.M. to 7:00 P.M. shift.

Review of the facility investigation showed an interview with CNA staff L T on 2/26/10 at 3:50 P.M. The facility documented staff L T was in the room at the time of this incident and CNA (staff L BBB) was yelling loudly at the patient and the tone (of voice) was rough, but during an interview on 4/07/10 at 10:50 A.M. CNA staff L T said he/she was in another room at the time of the incident and heard CNA staff L BBB yell at the patient. CNA staff L T said he/she pulled the other CNA aside and told him/her that is not acceptable. CNA staff L T said it was mid-afternoon when the incident occurred and he/she reported it to the supervisor right away. Staff L T said she thought the supervisor was staff L Q, but it could have been a different nurse.

During an interview on 4/07/10 at 2:20 P.M. chief clinical officer (CCO) staff L V said he/she thought until today (4/07/10) the incident had occurred on 2/26/10 because that was when it was reported to him/her. The CCO said that today, after an interview with this surveyor, nursing supervisor staff L Q informed him/her that he/she was aware of the incident on the day it occurred, which is contradictory of the interview in the facility investigation.

Review of facility staffing sheets showed the facility suspended CNA staff L BBB on 2/26/10 pending the outcome of their investigation and terminated the employee on 3/01/10.

The facility investigation showed they terminated CNA staff L BBB as of 3/01/10.

Based on record review and interview, the facility failed to have one documented Director of Nursing Services for all nursing personnel. The facility census was 61.

Findings included:

The hospital is composed of two campuses approximately seventeen miles apart, both with nursing staff and patient care units.

Review of the job descriptions for Chief Clinical Officers at both campuses showed the following statement in the Summary in part: Directs and coordinates functions and activities of nursing department for multiple facilities. Consults with and advises Executive Director/Chief Executive Officer on the general operation of the hospitals. Develops nursing and clinical departments' goals, objectives, standards of performance, and policies and procedures. Organizes nursing and clinical departments according to administrative and nursing service guidelines; ensures compliance with legal, organizational, and medical staff standards. Has authority and responsibility for establishing, directing, and implementing the Standards of Nursing Practice and the clinical operations and financial matters related to al nursing and clinical care areas and functions.

Review of the Organizational Chart for the hospital showed Interim Chief Nursing Officer, Staff L RR, reports directly to the Chief Executive Officer. Further review of the Organizational Chart for the hospital showed Chief Nursing Officer Staff SA E reports first to the Interim Administrator and then finally to the Chief Executive Officer. The Organization chart does not show one Chief Nursing Officer to which all nursing personnel ultimately report.

During an interview on 04/09/10 at 1:40 P.M. Interim Chief Nursing Officer, Staff L RR, reviewed job descriptions for Chief Clinical Officers at both campuses and agreed that both job descriptions are the same and have the same responsibilities.

Based on record review and interview, the facility failed to obtain verification ensuring two of forty-one Licensed Practical Nursing staff (Staff SA C & L QQ) employed by the facility were certified to administer intravenous medication to patients. The facility census was 61.

Findings included:

1. Review of the facility policy titled "Licensure Verification", dated as revised 01/2007, states in part the following: It is the policy of Kindred hospitals to verify the licensure, certification or registration of all health care professionals as required by law prior to starting employment and at appropriate renewal periods.

The Procedure states in part the following: Department Manager (e.g., Nursing, Respiratory Therapy) or designee will conduct a primary source verification of the potential professional employee's license, certification, or registration in accordance with applicable State and Regulatory agency requirements during the pre-employment process.

2. Review of the personnel file for Licensed Practical Nurses Staff SA C showed a hire date of 09/24/04 and Staff L QQ personnel file showed a hire date of 03/02/09.

Review of the Missouri Professional Registration website (where nursing licenses may be checked and verified) showed Staff SA C and Staff L QQ had up-to-date licenses as Licensed Practical Nurses. However, neither is certified in the State of Missouri to start intravenous access lines (small plastic tube placed in a vein to provide fluids and/ or medications) or administer medication through an intravenous access line.

During an interview on 04/08/10 at 4:30 P.M., Chief Nursing Officer, Staff SA E, stated that Staff SA C is not IV certified. Staff SA E stated that Human Resource is responsible for checking this and it just wasn't caught. Staff SA E stated that Staff SA C has been giving IV medications and has been practicing outside of the scope of his/her license.

During a phone interview on 04/09/10 at 12:00 P.M. L.P.N. Staff L QQ said that he/she is a fourteen-month employee at the hospital. He/she said that their responsibilities include administering medication, like antibiotics, intravenously. He/she said that I.V. training was received at the Illinois Junior College where he/she graduated.

During an interview on 04/09/10 at 11:30 A.M. Human Resource Coordinator, Staff L RR said that the former Chief Executive Officer (no longer with the corporation) told her the certification Licensed Practical Nurse ( L.P.N.), Staff SA C, provided from a local Para-medic training course was okay to accept. Staff L RR said that he/she remembers L.P.N. Staff L QQ was on a temporary Missouri license about a year ago when hired, but did not notice the Missouri license did not include I.V. certification. Staff L RR said that both Licensed Practical Nurses Staff SA C and Staff L QQ are full time employees and have work as such in the past month.

During an interview on 04/09/10 at 1:30 P.M. interim Chief Clinical Officer, Registered Nurse Staff L V said that L.P.N.'s work under the direction of the Registered Nursing staff at the facility hanging intravenous fluids, intravenous medication piggy backs, and hanging fluids and medications to PICC lines (a peripherally inserted central catheter. It is long, slender, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access. It is similar to other central lines as it terminates into a large vessel near the heart. However, unlike other central lines, its point of entry is from the periphery of the body the extremities, and typically the upper arm is the area of choice.)




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Based on policy review, observation, record review and interview, the facility failed to provide hygiene (bath and shampoo) to two current and two discharged patients (Patient L1, SA1, SA9, and SA10) of four current and two discharged patients' records reviewed for hygiene, and the facility failed to ensure staff performed an appropriate skin assessment on admission for one patient (Patient L 20) of three admission skin assessments reviewed. The facility census was 61.

Findings included:

1. Review of the facility policy "Initial Wound Treatment", H-WC 03-002, revision date 11/2009, states in part the following:
Remove all dressings from wound(s), cleanse with normal saline, photograph and measure per photographing wound(s) guidelines.
Notify Wound Care Coordinator of all new admissions and newly discovered wounds".

2. Observation on 04/05/10 at 1:00 P.M. showed current Patient L1 with large, white flakes over his/her face, scalp and skin. Patient SA1's hair appeared dirty.

Review of Patient SA1's medical record on 04/05/10 at 2:40 P.M. showed he/she did not receive a bath on any of the last four days. There was no documentation that his/her hair had been shampooed in the last four days.

During an interview on 04/05/10 at 2:40 P.M., Infection Control Nurse, Staff LA, stated that patients get at least a partial bath every day. Staff LA stated that there was no set schedule for washing a patient's hair and stated that they could do much better.

3. Review of current Patient SA1's medical record on 04/06/10 at 10:15 A.M. showed no documentation of him/her receiving a bath or shampoo on 04/02/10, 04/03/10 or 04/04/10 (three of the last four days).

During an interview on 04/06/10 at 10:15 A.M., Nurse Manager, Staff SAA, stated that Patient SA1 often refused assistance with bathing but confirmed there was no documentation that Patient SA1 had even been offered assistance. Staff SAA stated that patients should be offered a bath and shampoo daily but that nursing should document if the patient refused.

4. Review of discharged Patient SA9's medical record on 04/07/10 at 10:40 A.M. showed that he/she was admitted on 02/08/10 and expired on 02/12/10. There was no documentation that he/she received a bath on 04/10/10 or 04/11/10. This was confirmed by Staff SAA.

5. Review of discharged Patient SA10's medical record on 04/08/10 at 2:05 P.M. showed that he/she was admitted on 01/25/10 and discharged on 02/18/10. There was no documentation that he/she received a bath on 13 of those 24 days. There was no documentation that he/she received a shampoo on 20 of those 24 days. This was confirmed by Staff SAA.

6. During an interview on 04/07/10 at 1:55 P.M., Quality Assurance nurse, Staff LC, stated that the facility did not have a policy on providing general hygiene procedures for patients.



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7. Observation of staff Q changing a PICC line dressing (peripherally inserted central catheter, a form of vein access that can be used for a prolonged period of time) on 4/05/10 at 2:10 P.M. showed a dressing on Patient L 20's right wrist with a date of 3/26/10.

Record review showed Patient L 20 entered the facility 4/02/10 for ventilator weaning. Review of the skin assessment completed on admission showed integumentary (skin, hair and nails) assessment as skin being pink, warm, dry, smooth, well hydrated and intact. No documentation is found in the record of a wound or dressing to the right wrist.

During an interview on 4/05/10 at 2:25 P.M. nursing supervisor, staff Q said the facility standard is to change wound dressings each Tuesday. Staff Q acknowledged Patient L 20 had an intact dressing on his/her right wrist, dated prior to admission.

Based on observation, facility policy review, record review, and interviews, the facility:

- failed to ensure staff followed physician's orders related to wound care for one current patient (L 3) of five observed and sampled;
- failed to ensure medications were administered as ordered by the physician for one (Patient SA 4) of five patients observed during medication administration;
- failed to follow hospital policy with regard to administering medication per gastric tube (G-Tube, also referred to as PEG tube), a percutaneous endoscopic gastrostomy tube surgically placed into a patient's stomach via the abdomen, used for feeding and administration of fluids and medications) for one (Patient SA 4) of three patients reviewed receiving medications via G-tube;
- failed to follow hospital policy with regard to insulin administration for two patients (SA 4 and L 6) of three patients observed receiving insulin; and
- failed to follow hospital policy with regard to administration technique for one (Patient SA 4) of two patients who reviewed receiving medications by subcutaneous injection. The facility census was 61.

Findings included:

1. Review of the facility policy titled "Medication Management (Administering)," revised 11/09 showed (in part):
- Cited from page 5, "Procedure...Medications will be administered within 30 minutes before or after the scheduled time."
- Cited from page 7, "Medications via Feeding Tube...Check placement and patency of feeding tube. Follow MD and/or facility guidelines specific to residuals."
- Cited from page 10, "Subcutaneous Injection...Select appropriate injection site. Rotate sites according to a schedule for patients who require repeated injections...With non-dominant hand, grasp the skin around the injection site firmly to elevate the subcutaneous tissue...Holding the syringe with the dominant hand, insert the needle at a 45- or 90- degree angle to skin surface. Angle depends on needle length and the amount of subcutaneous tissue at the site. Heparin should always be injected at a 90-degree angle. Release the patient's skin."

Review of the facility policy titled "Preparing and Dispensing Medications," revised 11/09, showed (in part):
- "Any clarification or verification of orders shall be done between the pharmacist/nurse/respiratory therapist and the ordering physician...All medication orders will be reviewed by a licensed pharmacist (OR nursing supervisor and the administering nurse if the pharmacy is closed) prior to dispensing and administering the medication: (including) Appropriateness of the drug, dose, frequency, and route of administration."

Review of the facility's policy titled "High-Risk Medications," revised 5/2009, showed direction (in part) "Insulin: Verify dose with second nurse prior to administration."

Findings Included:

2. During observation of wound care on 04/06/10 at 9:30 A.M., Wound Care Registered Nurse, Staff L ZZ, was observed to apply a new dressing to Patient L 3's left foot dressing after cleansing the wound. However, Staff L ZZ did not apply Silvasorb (SilvaSorb Gel, a topical medication, has been shown to be effective against MRSA and other antibiotic-resistant organisms) as ordered by the physician on 03/31/10.

Medical record review for Patient L 3, admitted on 02/24/10 with a diagnosis of Osteomyelitis of the left foot and leg, showed a physician's order on 03/31/10 at 1:53m P.M. for Wound care: left foot (dorsal). Cleanse wound with (and pat dry): wound cleanser (central supply), apply peri-wound skin barrier: barrier wipe, apply dressing with :Silvasorb, apply dressing with :gauze: 4x4, roll, Start 03/31/10 09:00, daily, stop after 30 days, not renewable.

During an interview on 04/06/10 at 2:00 P.M., Staff L ZZ said that Patient L 3's wound did not need the Silvasorb gel any longer, and it should have been discontinued after consultation by the physician.


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3. Observation of Staff SA C on 04/06/10 showed the following medications were administered to Patient #SA 4 at 9:45 A.M.:
- Finasteride (used to treat benign prostatic hypertrophy), 5 mg (milligrams);
- Senna/docusate (stool softener and laxative), 2 tabs;
- Polyethylene glycol powder (used to treat constipation), 17 gm (gram);
- Insulin glargine (a long acting hormone used to regulate energy and glucose metabolism), 8 units;
- Acyclovir (an antiviral medicine) 5% topical ointment;
- Aspirin (used to prevent heart attacks and strokes), 81 mg;
- Diltiazem (used to treat high blood pressure, chest pain, and heart disorders), 60 mg; and
- Trypsin/balsam peru/castor oil topical ointment (used as a wound agent to promote healing of tissues).

The following medications were administered to Patient #SA 4 at 9:46 A.M.:
- Heparin (anticoagulant, used to prevent blood clots) 5,000 units;
- Insulin (Regular) (a short acting hormone used to regulate energy and glucose metabolism), 3 units;
- Lisinopril (used to treat high blood pressure and heart failure), 10 mg; and
- Lansoprazole (prevents the stomach from producing acid), 30 mg.

Review of the MAR (Medication Administration Record) for Patient #SA 4 showed the above listed medications were scheduled to be given at 9:00 A.M.

During an interview on 04/06/10 at 10:00 A.M., Staff SA C said:
- Medications for Patient #L 4 are entered into the MAR when the entire "med pass" is complete.
- Medication administration for Patient #L 4 was delayed because the most recent policy is to crush each medication individually, mix with water, and administer individually - flushing the G-tube between medications.

4. Observation of Staff SA C on 04/06/10 at 9:30 A.M. showed Staff SA C checked for G-tube patency by injecting a bolus of air and listening to the patient's abdomen with a stethoscope. However, gastric contents were not aspirated to ensure proper placement. (Review of the training records for LPN Staff SA C showed receipt of training on 03/18/10 which included instruction to: Check placement and patency of feeding tube by auscultation and check residual before administering medications.)

The following medications were then administered to current Patient SA 4 per G-tube:
- Senna/docusate 2 tabs;
- Polyethylene glycol powder, 17 gm; and
- Lisinopril 10 mg.

However, review of the MAR (medication administration record) for current Patient SA 4 on 04/06/10 at 9:50 A.M. showed:
- The route of administration for senna/docusate was specified as PO (by mouth).
- The route of administration for polyethylene glycol was specified as PO.
- The route of administration for lisinopril was specified as PO.

During an interview on 04/05/10 at 1:00 P.M., Quality Manager Staff L C said physician orders are "taken off" by a Registered Nurse (RN), and put into the MAR. The orders are then double-checked by Pharmacy for accuracy.

During an interview on 04/05/10 at 2:00 P.M., Director of Pharmacy Staff L N said two Pharmacists review medical records each Wednesday to reconcile medication orders where medications are ordered PO but are given per G-tube. Staff L N said "lots of orders" were changed from PO to G-tube last week and noted that this is an ongoing process.

During an interview on 04/06/10 at 4:00 P.M., Staff SA C said that Patient L 4 is able to swallow his medications, but stated, "In the morning we usually crush all his meds because he doesn't like to swallow that many pills, and he doesn't like the grittiness of the Miralax (polyethylene glycol). In the evening, sometimes he will swallow his meds."

5. Observation of Staff SA C on 04/06/10 at 9:40 A.M. showed the following medications were administered to Patient SA 4 by injection into the abdominal area:
- Heparin, 5,000 units;
- Insulin glargine, 8 units; and
- Insulin (Regular), 3 units.

However, Staff SA C did not double check insulin doses with another staff member prior to administration, following hospital policy, and with each injection, Staff SA C was observed to angle the needle into the subcutaneous tissue rather than pinching the skin up as instructed per policy. Observation of Patient SA 4 showed a slender torso with minimal subcutaneous tissue. The abdomen showed bruises in multiple locations, and the patient winced with each injection.

During an interview with Chief Nursing Officer Staff SA E, a form titled "Insulin Injection Site Rotation Log" was produced. Staff SA E said the form was to be used to help staff appropriately document and rotate injection sites, but it wasn't used often.

Review of the medical record and MAR for Patient SA 4 showed the difficulty of determining where previous injections had been given. The "Insulin Injection Site Rotation Log" was not found in Patient SA 4's medical record, nor was there evidence that an injection site rotation schedule had been arranged for Patient SA 4.

6. Observation of medication administration for Patient L 6 on 4/06/10 at approximately
10:20 A. M. showed staff L VV Licensed Practical Nurse (LPN) failed to verify insulin
dose with second nurse prior to administration.

Review of an order dated 3/17/10 showed the following telephone order for Patient
L 6: discontinue scheduled regular insulin and start/give Insulin human regular
subcutaneous (under the skin) 4 units every 6 hours, and to start next dose on 3/18/10
at midnight. Therefore, insulin was ordered to be given at midnight, 6:00 A.M., 12 noon, and 6:00 P.M.

Based on observation, record review, and interview, the facility failed to have a physician ordered protocol placed on the medical record and signed by the physician for one patient (L 16) of one protocol record reviewed. The facility census was 61.

Findings included:

During observation of wound care on 04/07/10 at 10:30 A.M., Wound Care Registered Nurse, Staff L ZZ was observed to remove the old dressing from Patient L 16's coccyx and sacral area. Removal of the old dressing, dated as applied on 04/06/10, showed a large ABD (type of dressing), 4 x 4 gauze (type of dressing), and white fluffy material applied directly to the wound. Staff L ZZ identified the fluffy white material as calcium alginate (a type of material used to absorb excess drainage from wounds).

During an interview on 04/07/10 at 10:10 A.M. Patient L 16 said that he/she was admitted the evening before and facility staff changed his/her dressing one to two time during the evening of the admission yesterday, 04/06/10.

During an interview on 04/07/10 at 11:00 A.M., Staff L ZZ said that Patient L 16's wound would have been treated by the facility staff on admission using the skin care protocols as a guide for orders for treatment. Staff L ZZ said that the nurses changing the wound would have assessed Patient L 16's wound and referred to the protocol for treatment orders. Staff L ZZ said at the present time a copy of the skin care protocol is not placed in the patient's medical record for the ordering physician to review and sign.

Review of the medical record for Patient L 16, admitted on 04/06/10 with Stage IV decubitus (Stage IV is the pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints) to Left Buttock, Osteomyelitis, paraplegia, and left above-the-knee amputation showed no order for dressing changes using the calcium alginate or a copy of the skin care protocol(s) in place on the medical record for the physician to sign.

Therefore, nursing staff were treating the patient without a physician order to do so.

Based on policy review, record review and interview, the facility failed to follow their policy with regard to administration of blood products for two (Patients L 6 and L 2) of three records reviewed for blood administration when the physician did not sign the consent form. The facility census was 61.

Findings included:

1. Review of facility policy H-PC-08-072, "Transfusion Policy", revised 3/10, showed consent is required for administration of blood products. The policy directs staff to obtain a signed consent form.

Review of the facility policy H-PC-04-004, "Informed Consent", showed the following (in part):
- "Informed consent is required prior to the initial transfusion of blood or any blood product."
- "Initial informed consent must be obtained by the attending physician or a designee as outlined in Section A2."

2. Review of current Patient L6's history and physical showed the patient entered the facility on 03/01/10 for ventilator weaning and acute respiratory failure.

Review of the physician's orders showed an order dated 3/12/10 at 1:40 P.M. to transfuse 2 (two) units of PRBC (packed red blood cells).

However, review of the patient informed consent dated 3/13/10 at 8:00 P.M. showed no physician signature or date indicating the physician had informed Patient L 6 of the risk, consequences and alternatives of the procedure.

Review of the blood bank transfusion form showed Patient L6 received blood on 3/14/10 at 1:12 A.M. and 3/14/10 at 12:40 P.M.

During an interview on 4/05/10 at 2:45 P.M., Unit Secretary staff P said the consent was not signed by the physician.





28722

3. Review of the medical record for current Patient L2 revealed a document titled "Patient Informed Consent," dated 03/24/10, indicates consent for "Blood Transfusion: Whole Blood or Packed Red Blood Cells." At the bottom of the consent it states, "I have explained the matters indicated above relating to the procedure and the risk, consequences and alternatives. The patient and/or the relative indicated understanding and consented to the procedure as described above." There was a place beside that statement for the physician to sign. However, there was no physician signature, date or time.

Based upon observation and interview, the facility failed to have timely retrieval of a medical record from long term storage. This applied to one (L 27) of one patient reviewed for medical record retrieval. The facility census was 61 and the total sample was 43.

Findings included:

Request for the medical record of Patient #L 27, discharged from the facility on 04/6/2006 revealed the retrieval process to take a day for delivery. The request was made on 4/5/10 at 2:15 P.M. and the record was received on 04/6/10 at 12:00 Noon.

During interview at the time of request on 04/5/10 at 2:15 P.M., the Director of Quality Management, Employee L C, stated, "It will be tomorrow."

Timeliness of retrieval is important for physician care.

Based upon record review, interview and review of facility policy, the facility failed to consistently document the consumption of tube feeding (a commercial product fed through tube directly into the patient's digestive system) for four (Patients # SA 7, L 28, L 11, L 10) of four patients, and the consumption of special nutritional supplements taken by mouth for two (Patient # SA 8 and #SA 4) of 43 patient records reviewed. The facility census was 61.

Finding included:

1. Review of the facility policy and procedure failed to show expectation of the documentation for tube feeding and nutritional supplements amount consumed.

2. Record review for Patient # SA 7, admitted since 03/25/10, receiving tube feeding as Optimintal at 90 cc (cubic centimeter, same as milliliter) per hour for a daily total of 2160 cc/24 hours.

The documentation showed the following amounts consumed by the patient:
03/25/10 no documentation
03/26/10 no documentation
03/27/10 1620 cc
03/28/10 1983 cc
03/29/10 1710 cc
03/30/10 2091 cc
03/31/10 1906 cc
03/31/10 2101 cc
04/01/10 2101 cc
04/02/10 1915 cc
04/03/10 1980 cc
04/04/10 2239 cc
04/05/10 2110 cc
04/06/10 623 cc / day: Patient was out of the building for procedure at another facility.
04/07/10 1504 cc

3. Record review for Patient # L 28, admitted since 03/29/10, and receiving Nepro (a specialized product for limited kidney function) at 40 cc/hr for a daily total of 960 cc / 24 hours. The documentation included:
04/02/10 720 cc
04/03/10 720 cc
04/04/10 1350 cc
04/05/10 705 cc
04/04/10 466 cc

4. Record review of Patient # L 11, admitted since 01/10/10, and receiving Nepro at 60 cc/hour, for a total of 1440 cc/ 24 hours showed the tube feeding documentation included the following:
04/01/10 1419 cc
04/02/10 720 cc
04/03/10 1140 cc
04/04/10 1293 cc
04/05/10 923 cc
04/16/10 1440 cc

5. Record review of Patient # L 10, admitted since 03/17/10, and receiving Jevity 1.2 (a specialized product, high in protein and fiber) at 50 cc/ hour, for a daily total of 1200 cc/ 24 hours included the following:
04/01/10 1070 cc
04/02/10 1125 cc
04/03/10 485 cc
04/04/10 840 cc
04/05/10 667 cc
04/06/10 960 cc

6. During interview on 4/6/10 at 2:00 P.M., the nurse on 3rd Floor, Employee L J, reviewed the computer documentation and stated that the night shift had failed to document on the days where the totals were significantly less than the goal amount.

For nutritional supplements taken by mouth:
7. Record review of Patient # SA 8, admitted since 02/25/10, and receiving Nepro as an oral (drinkable) supplement twice per day, the documentation included:
03/27/10 no documentation
03/28/10 480 cc
03/29/10 no documentation for one serving; one serving refused
03/30/10 120 cc
03/31/10 240 cc
04/01/10 480 cc
04/02/10 no documentation
04/03/10 no documentation
04/04/10 no documentation
04/05/10 120 cc
04/06/10 600 cc (servings increased to three times per day, for a daily total of 720 cc.
04/07/10 240 cc

Nutritional consumption below ideal levels will hamper the patient's ability to progress medically. Without complete and accurate documentation, the Registered, Licensed Dietitian and the Medical Physician are unable to assess the patient's ongoing nutritional status and medical needs.


28722

8. Review of the medical record on 04/06/10 at 10:45 A.M. for current Patient #SA 4, showed a physician order dated 03/30/10 for Ensure Plus, twice daily.

Review of the MAR (Medication Administration Record) for Patient #SA 4 showed the supplement was charted as "done," twice daily.

Observation during medication administration on 04/06/10 at 9:45 A.M. for current Patient #SA 4 revealed two cans of Ensure Plus on the patient's bedside table. Patient #SA 4 was able to indicate which can had been brought to the room that morning. Staff SA C was observed to chart on the MAR that the Ensure Plus was present on the bedside table, but did not provide the Ensure Plus to the patient to drink and did not document the volume of supplement either issued or consumed.

9. During an interview on 04/07/10 at 11:45 A.M., Dietitian Staff SA H said that supplements are sometimes documented with meal intake in the "other" category by the nursing staff, but that charting was inconsistent. Staff SA H stated that there wasn't a policy dictating how supplements should be recorded.

Based on facility policy review and record review, facility staff failed to document the date and time of signatures for one (Patient #L 2) of 43 patient records reviewed. The facility census was 61.

Findings included:

Review of the facility policy titled, ""General Documentation Guidelines," revised 12/08 showed the following instruction (in part): "All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated and their authors identified."

1. Review of the medical record for one (current Patient #L 2) showed the following:
- A document titled, "Patient Informed Consent," dated 03/24/10 indicates consent for "Blood Transfusion: Whole Blood or Packed Red Blood Cells." Verbal consent was given by the patient's daughter, and was witnessed by two Licensed Practical Nurses (LPNs). The signatures of the two nurses are not dated or timed.
- A document titled, "Patient Informed Consent," not dated or timed, indicates consent for hemodialysis (a method of removing waste products from the human body when the kidneys do not work properly) treatments . The patient's husband signed the consent form, and his signature was witnessed by a staff Registered Nurse (RN). The RN signature is not dated or timed.
- A document titled, "Blood Bank Transfusion Medicine Services" indicates the patient received a transfusion on 03/25/10. There is no indication of the time the transfusion was started. The first set of vital signs is documented as 1:45 P.M.

Based on facility policy review and record review, the medical staff failed to ensure order entries included the time for three (Patient L 1, L 2, and SA 3) of twenty open patient records reviewed. The facility census was 61.

Findings included:

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

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

Review of the "Medical Staff Rules and Regulations" showed the following (in part): "All clinical entries in the patient's medical record shall be accurately dated and authenticated."


2. Review of current Patient L1's medical record on 04/05/10 at 2:05 P.M. showed the following physician orders written on 04/05/10 but did not include the time:
"- Sputum C&S (culture and sensitivity [lab tests])
- Neck/trach (tracheotomy [airway opening in the neck]) site - check wound, get C&S.
- Ask wound care to check neck wound and advise.
- Scopolamine patch (medication to prevent nausea and vomiting) apply q (every) 72 h (hours)."


28722

3. Review of the medical record on 04/05/10 at 2:00 P.M. for current Patient L 2 showed the following:
- A physician order dated 04/02/10 to "Leave on AC (unknown meaning) mode. ABG (arterial blood gases) on 04/04/10 at 8:00 A.M." The order was signed and dated, but not timed.
- A physician order dated 04/02/10 to "D/C (discontinue) Micafungin (antifungal)." The order was signed and dated, but not timed.
- A physician order dated 04/02/10 for "BMP (basic metabolic panel) in AM." The order was signed and dated, but not timed.
- A physician order dated 04/03/10 to "Stop IV (intravenous) Reglan (used to treat gastroesophageal reflux). Make Lactulose (laxative) PRN (as needed) (for) no BMs. (Dose) 30 ml (milliliters). Increase NPH (insulin) (to) 12 (units) every 12 (hours)." The order was signed and dated, but not timed.
- A physician order dated 04/04/10 to "Wean off dopamine (used to increase blood pressure and cardiac output) gtt (drip) as tolerated to keep MAP (unknown meaning) greater than 60." The physician signed and dated the order, but did not time it.

4. Review of the medical record on 04/06/10 at 10:15 A.M. for current Patient SA 3 showed the following:
- A physician order dated 03/29/10 to "Stop Tygacil (an antibiotic that is used intravenously for the treatment of infections of the skin and abdominal organs) and start Fluconazole (an antifungal medicine used to treat certain kinds of fungal or yeast infections) 400mg (milligrams) PO (by mouth) every 12 hours." The order is signed and dated, but not timed.
- A physician order dated 04/05/10 to "Stop Fluconazole after dose tomorrow." The order is signed and dated, but not timed.
- A physician order dated 04/05/10 for "Pressure map wheelchair ROHO (a device that conforms to each user's individual body shape and continuously self-adjusts with every movement, enhancing blood flow and supporting posture) cushion." The order is signed and dated, but not timed.










29079

Based on facility policy review and record review, the facility failed to ensure telephone and verbal orders were signed by a physician with 48 hours for five (Patient L 1, SA 5, SA 10, SA 3 and SA 4) of 43 medical records reviewed. The facility census was 61.

Findings included:

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

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

2. Review of current Patient L1's medical record on 04/05/10 at 2:15 P.M. showed the following:
- On 02/22/10, the following telephone order was not signed by a physician: "Type and cross match 2 units of PRBC (packed red blood cells) and transfuse."

3. Review of current Patient SA5's medical record on 04/06/10 at 2:45 P.M. showed the following:
- On 03/31/10, the following telephone order was not signed by a physician: "Pureed diet, thin liquids."

4. Review of discharged Patient SA10's medical record on 04/08/10 at 1:15 P.M. showed the following:
- On 01/26/10, the following order was not signed by a physician: "Change TF (tube feeding) to Jevity (dietary supplement) 1.2 55 ml/hr (milliliters per hour)."
- On 01/26/10, the following telephone order was written. The physician signed but did not date/time his/her signature: "D/C (discontinue) 4 hour HHTC (high humidity tracheotomy collar) trials. Start on CPAP (continuous positive air pressure [oxygen delivered with continuous pressure]) 12/5 and titrate PSV (pressure support ventilation) to keep VT (tidal volume [the amount of air in the lungs during respiration]) > (greater than) 325 (surveyor unable to interpret). RR (respiratory rate) < (less than) 34 and sats (oxygen saturation) > 90%, 2-4 hrs (hours) each as tolerated."
- On 01/26/10, the following telephone orders were checked on a pre-printed sheet titled, "MNT (Medical Nutrition Therapy) Order Form". The physician signed but did not date/time his/her signature: "Write a diet order that is consistent with the transferring facility. Adjust food texture and liquid consistency to speech therapist recommendations.
Determine appropriate calorie and protein levels for diabetic, renal and hepatic diets. Modify or liberalize therapeutic diet restrictions. Modify diets to avoid food and drug interactions. Order, change or discontinue oral supplements and/or modular supplements.
Adjust enteral (diet supplements administered into the intestines) formulas, rate, volume or infusion time. Add modular protein supplementation. Modify infusion period to avoid food and drug interactions. Provide water flushes to meet fluid requirements.
Change, add or modify dextrose, amino acid and lipid content of parenteral (nutritional supplement administered through a vein) nutrition.
Write and adjust micronutrients and electrolytes in TPN (total parenteral nutrition [nutritional formula administered through a vein]).
Order TPN relevant lab data including Complete Metabolic Profile, Basic Metabolic Profile, Magnesium, Phosphorus, Pre Albumin, Triglyceride and Liver Enzymes.
Order a multivitamin supplement when enteral nutrition or oral intake does not meet 100% of the Recommended Dietary Allowance.
Order or discontinue vitamin oral supplements related to wound healing."
- On 02/06/10, the following telephone orders were written. The physician signed but did not date/time his/her signature: "OK to leave on TC (tracheotomy [airway opening in the neck] collar) up to 12 hours as tolerated. D/C Combivent (medication dilates airway) and start Albuterol (medication relaxes the airway)/Atrovent (medication dilates airway) nebs (nebulizer) q (every) 4 hours with 2 ml (milliliters) of 20% mucomyst (medication thins secretions in the airway)."


28722

5. Review of the medical record for current Patient SA 3 on 04/06/10 at 10:15 A.M. showed the following physician telephone/verbal orders were not signed/dated/timed:
- A physician telephone order dated 03/24/10 at 11:45 P.M. for Benadryl (an antihistamine used multiple ways, including use as a nighttime sleep aid) 50 mg (milligram) IVP (intravenously) times one now for insomnia.
- A physician telephone order dated 03/25/10 at 8:50 A.M. "May hold copper supplement. Provide daily vitamin."
- A physician telephone order dated 03/29/10 at 9:00 A.M. for 10,000 IU (international units) Vitamin A BID (twice daily). The order was signed by the physician, but not timed or dated.
- A physician telephone order dated 04/04/10 at 11:30 A.M. for Neurontin (used to control partial seizures in adults with epilepsy and also used to treat certain types of nerve pain) 100 mg TID (three times daily) PO (by mouth).

6. Review of the medical record for current Patient SA 4 on 04/06/10 at 10:45 A.M. showed the following physician telephone/verbal orders were not signed/dated/timed:
- A physician telephone order dated 03/29/10 at 6:50 A.M. to implement Medical Nutrition Therapy Orders. The order is signed by the physician, but not dated or timed.
- A physician telephone order dated 03/30/10 at 4:20 P.M. for "continuous telemetry tachycardia."





29079



Based on observation, interview, and record review the facility failed to ensure telephone and verbal orders were signed by a physician within 48 hours for three patients (Patient L 7, Patient L 10, and Patient L 17) of 21 open records reviewed.
Census was 59

Findings include:

7. Observation, interview and record review on 06/15/10 at 2:25 p.m. of Patient L 7 medical record showed on 06/09/10 at 0845 telephone order for pureed diet, thin liquids, NCS was not signed by a physician.
8. Observation, interview and record review on 06/15/10 at 2:25 p.m. of Patient L 7 medical record showed telephone order on 06/09/10 at 800 stating "modified barium swallow" was not signed by a physician.
9. Observation, interview and record review on 06/15/10 at 2:45 p.m. of Patient L 10 medical record showed telephone order dated 06/11/10 at 0500 "Hold Lopressor" was not signed by a physician.
10. Observation, interview and record review on 06/15/10 at 2:45 p.m. of Patient 10 medical record showed telephone order dated 06/11/10 at 0430 "give 5mg Lopressor IVP x1, check BP in 10 min. If systolic BP greater than 105 repeat Lopressor" was not signed by a physician.
11. Observation, interview and record review on 06/16/10 at 9:15 a.m. of Patient L 17 medical record showed order dated 06/11/10 at 106 "CBC, CMP," was not signed by a physician.
12. Observation, interview and record review on 06/16/10 at 9:15 a.m. of Patient L 17 medical record showed telephone order dated 06/10/10 at 2130 "Hold scheduled 8 units Regular insulin." Was not signed by a physician.

Based upon record review and interview, the facility physicians failed to complete medical records when they failed to sign the discharge summary within the required thirty days after discharge. This applied to seven patients (Patients # SA 9, SA 11, SA 13, SA 12, SA 14, SA 15, and SA 10). The facility census was 61 and the total sample was 43.

Finding included:

1. Review of the facility's document titled "Medical Staff Rules and Regulations", approved 10/27/08, gave direction, in part, to include the following:
"The responsible practitioner shall be responsible for the preparation of a complete medical record for each patient...All discharge summaries shall be authenticated by the responsible practitioner...Delinquent records are those that are incomplete, including signatures/authentication, after thirty (30) days following discharge of the patient."

Review of the facility's policy titled "General Documentation Guidelines", revised 12/08, gave direction, in part, to include the following:
"A discharge summary must be written or dictated and authenticated by the responsible physician on the medical record of hospitalized inpatients for stays over 48 hours...The time period for completion of the medical record is specified in the Medical Staff Rules and Regulations and cannot exceed 30 days after discharge."
2. Record review for Patient # SA 9, admitted 02/08-10/10, showed the death summary to have been dictated on 02/19/10 and transcribed on 2/20/10. The physician signature is dated only 04/7 at 14:00 P.M. No year is specified for the signature. As a signature of 2010, and the day of the survey, it is beyond the thirty day requirement for timeliness of physician signature for complete records. The discharge summary was not signed by the physician.

3. Record review for Patient # SA 11, discharged 01/28-02/9/10, showed the discharge summary to have been dictated and transcribed on 01/29/10, more than a week before the discharge of the patient. The physician signature is dated only 04/7 at 14:00 P.M. No year is specified for the signature. As a signature of 2010, and the day of the survey, it is beyond the thirty day requirement for timeliness of physician signature for complete records.

4. Record review for Patient # SA 12, admitted 02/13-26/10, showed the discharge summary to have been dictated on 02/27/10 and transcribed on 02/28/10. The document was signed by the physician, but failed to include the date and time of the signature.

5. Record review for Patient # SA 13, admitted 02/23-24/10, showed the death/discharge summary to have been dictated on 02/26/10 and transcribed on 02/27/10. The document failed to have physician signature.

6. Record review for Patient # SA, admitted 01/28/10-02/15/10, showed the death/discharge summary to have been dictated on 02/16/10 and transcribed on 02/17/10. The document failed to have physician signature.

7. During interview on 04/5/10 at 12:30 P.M., the Medical Records Clerk, Employee L G stated that the charts were audited for content of discharge summaries, but not for timeliness of signature.



27724

9. Review of discharged Patient SA10's medical record on 04/08/10 showed he/she was admitted 01/25/10 to 02/18/10. The discharge summary was not signed by the physician at the time of the survey.

Based on observation and interview, the facility failed to ensure medications are kept in a secure and, if needed, locked area in one patient room to prevent access by unauthorized persons. Five patient rooms were observed for secured medications. The facility census was 61.

Findings included:

During an interview on 4/05/10 at 2:30 P.M., the Director of Lab, Respiratory and Radiology staff F said the respiratory medications are kept in each patient's room in a locked box. The director said that the boxes are checked twice a day by his/her department staff to ensure the medications are locked and secured.

However, observation of patient room 205 at the Lindell location on 4/06/10 at 8:50 A.M. showed three boxes with locks for securing medications. One of the boxes, the box for respiratory therapy medications, was not locked. Medications in the unlocked box were Combivent, used to prevent bronchospasm, and Chlorhexidine, a chemical antiseptic.

During an interview on 4/06/10 at 8:55 A.M. Licensed Practical Nurse staff VV said the medications are to be locked at all times.

Based on observation and interview, the facility failed to maintain all areas in a clean and orderly manner. The facility census was 61.

Findings included:

Observations during a tour of the Hyland building, conducted on the afternoon of 4/06/10, revealed the following:

- Observation at 1:54 P.M. revealed a hole in a wall, approximately 1 inch by 5 inches, in the soiled utility room adjacent to patient room 333.
- Observation at 2:12 P.M. revealed the wooden door to patient room 321 was cracked and splintered leaving a jagged edge.
- Observation at 2:21 P.M. revealed the wooden door to patient room 307 was cracked and splintered leaving a jagged edge.
- Observations during a tour of the St. Louis building, conducted on the afternoon of 4/07/10, revealed the following:
- Observation at 1:55 P.M. revealed the wooden door to patient room 304 was cracked and splintered leaving a jagged edge.
- Observation at 2:01 P.M. revealed the wooden door to patient room 310 was cracked and splintered leaving a jagged edge.
- Observation at 2:04 P.M. revealed the wooden door to patient room 316 was cracked and splintered leaving a jagged edge.
- Observation at 2:07 P.M. revealed the wooden door to patient room 213 was cracked and splintered leaving a jagged edge.
- Observation at 2:11 P.M. revealed the wooden door to patient room 209 was cracked and splintered leaving a jagged edge.
- Observation at 2:15 P.M. revealed the wooden door to patient room 204 was cracked and splintered leaving a jagged edge.

At the time of each observation, Staff W Director of Plant Operation confirmed the need for required repair.

Based on policy review, observation and interview, the facility:
- failed to ensure staff followed their policy for two (Patient L 1 and Patient L 15) of five patients observed during medication administration;
- failed to ensure staff perform hand hygiene during medication preparation;
- failed to ensure staff followed follow facility isolation precautions related to application of Personal Protective Equipment [PPE];
- failed to ensure dialysis equipment was cleaned and disinfected for four (Patient L 10, L 11, L 28, and SA 7) of four patients reviewed for dialysis needs;
- failed to ensure staff followed their policy for dressing changes for one (Patient L 20) of one patient with a peripherally inserted central catheter line (PICC). The facility census was 61.

Findings included:

1. Review of the facility's policy titled "Hand Hygiene", revised 01/07, found it gave direction, in part, to include the following:
"HAND HYGIENE WILL BE PERFORMED AS FOLLOWS...After situations during which microbial contamination of hands is likely to occur."

Review of the facility's policy titled "Standard Precautions", revised 08/07, found it gave direction, in part, to include the following:
"All clinical and non-clinical personnel will practice standard Precautions...Remove gloves promptly after use and wash or disinfect hands immediately before touching non-contaminated items and environmental surfaces...Change gloves and wash or disinfect hands between tasks and procedures on the same patient after contact with materials that may contain blood and or other body fluids. Failure to change gloves between patients is an infection control hazard."

2. Observation on 04/05/10 at 1:00 P.M. showed Licensed Practical Nurse, (LPN), Staff L B, administer medications to Patient L 1. Patient L 1 was on contact precautions (isolation requiring wearing gown and gloves) for MRSA (Methicillin-Resistant Staphylococcus Aureas - bacterial infection resistant to antibiotics), Acinetobacter (bacterial infection resistant to many antibiotics), and C-diff (Clostridium difficile - bacterial infection causing diarrhea]).

Before entering the patient's room, Staff L B retrieved a bottle of medicine from the refrigerator in the unit's medication room and then took this bottle of medicine into Patient L 1's room. Upon entering the room, Staff L B suctioned the patient and then went directly to the medicine bottle and measured the dose for the patient. During the process of administering medications, Staff L B suctioned the patient several times but did not exchange gloves and perform hand hygiene afterwards. When administering a pain medication through the patient's G-tube (a tube inserted into the stomach directly through the stomach wall), Staff L B withdrew stomach contents into the syringe and then attempted to push the contents back into the G-tube. When Staff L B attempted to push the contents back into the G-tube, the syringe disconnected from the G-tube, spraying the gastric contents on the surrounding area, including Staff L B's gloves. Also during medication administration, Staff L B's lanyard, worn around his/her neck, with an identification badge and pens attached, was hanging outside of the isolation gown and got tangled in the patient's G-tube. Staff L B used his/her soiled glove to put the lanyard inside his/her isolation gown, potentially contaminating the lanyard and attachments. After completing tasks in Patient L 1's room, staff LB returned the medication bottle to the unit's medication refrigerator without disinfecting the bottle.

During an interview on 04/09/10 at approximately 11:05 A.M., Infection Prevention Nurse, Staff L A, stated that Staff L B should have changed gloves and performed hand hygiene when giving medications and going from a dirty process to a clean process. Staff L A stated that the medication bottle should have been disinfected before returning to the medication refrigerator or the medication could have been measured in the medication room, which would have prevented the bottle from going into an isolation room. Staff L A stated that he/she observed the contaminated medication bottle being returned and was aware that it had not been disinfected and spoke to Staff L B.

3. During observation of medication being administered to patients on 4/06/10 at 8:50 A.M., licensed practical nurse (LPN) staff L VV donned gloves then potentially contaminated them by using the touch screen computer in the patient's room, then prepared medications and touched furniture. Without changing gloves Staff L VV then instilled one eye drop into each eye of Patient #L 15.
4. Observation on 04/08/10 at 10:40 A.M. showed Pharmacy Technician, Staff SA N, drawing up syringes of multivitamin from a measuring cup. Staff SA N stopped during this process to clean a water spill off the floor, potentially contaminating his/her gloved hands, then returned to drawing up multivitamin in syringes without changing gloves and performing hand hygiene.

5. Observation on 4/07/10 showed an isolation sign outside the door to room 212. The isolation sign instructed staff and visitors to wear gowns and gloves while in the room. During observation of patient care in room 212 on 4/07/10 at 10:05 A.M. physician L AAA entered the room and did not wash his/her hands. The physician donned a gown, tied the gown at the neck, but not around the waist and examined the patient. Observation showed during the examination of the patient the physician's pants and shirt came in contact with the patient and the bed linens, potentially contaminating them.
6. For Dialysis Treatments:
- Review of the policy "Acute Services Policy & Procedure Manual, #1, DaVita, Inc., Policy 07-03-01, Hospital Dialysis Setting Hygiene" showed the policy to direct, in part,
"28. Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, tape, etc.) taken to the patient's station should be used only for that patient and should not be returned to a common clean area or used on other patients...31. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials. Use and appropriate disinfectant such as 1:100 bleach solution for environmental surfaces. For gross blood spills, a 1:10 bleach solution must be utilized. After all visible blood is cleaned with the 1:10 bleach solution, teammates are to use a new disposable towel soaked with 1:10 bleach solution and clean area a second time...34. The outside surfaces of all equipment will be wiped with a bleach solution prior to removal from treatment area."
However:
- Observation during the dialysis tour for the St. Anthony's Campus on 4/08/10 at 10:15 A.M. showed the RO (Reverse Osmosis, an equipment cart for the process of water purification) cart to have visible dust and dirt on the base and to include as noted for:
-- Cart #2N: a faucet adapter for hook up to a sink, a small terry cloth bath towel, a chloroprep package (packaged item used to clean the access for the dialysis treatment) and alcohol wipes.
-- Cart #6: a syringe, a small terry cloth bath towel, and a metal clip.
- Observation for the dialysis tour for the Lindell Campus on 04/09/10 at 2:00 P.M. showed the RO cart to have visible dust and dirt on the base and to include as noted for:
-- Cart: a ball point pen
-- Cart: a used glove
During interview on 04/08/10 at 10:15 A.M., and when the dirty carts were pointed out, the dialysis charge nurse, Employee SA L observed the carts and stated, "I agree."


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7. Review of facility policy H-PC 04-006 "Dressing Change-Central Line/PICC Line" showed the purpose of the policy is to provide nursing personnel with guidelines to be used when changing dressings on central venous lines. The policy documents the procedure for central line dressing changes will be performed under strict aseptic technique (aseptic technique refers to a procedure that is performed under sterile conditions). Femoral line dressing will be changed every three (3) days according to procedure. All other central line dressings and catheter caps will be changed every seven (7) days. If the dressing requires change earlier than seven (7) days, the catheter caps will follow the dressing change. Further review of the policy instructs staff to clean injection cap site, remove old caps and replace with new sterile caps.

However, record review showed Patient L 20 entered the facility 4/02/10 for ventilator weaning. Observation of staff Q changing a PICC line dressing (peripherally inserted central catheter, a form of vein access that can be used for a prolonged period of time) on 4/05/10 at 2:10 P.M. showed a PICC line dressing on Patient L 20's right upper arm with a date of 3/26/10 (nine days ago).

When cleaning the end of the receiving catheter hub with a back and forth motion, the flush syringe with the sterile cap on the end rubbed against the patients' gown, potentially contaminating the tip. Staff Q then placed the contaminated cap on the PICC.

During an interview on 4/05/10 at 2:25 P.M. nursing supervisor, staff Q, said the facility standard is to change the PICC line dressings each Tuesday. Staff Q acknowledged Patient L 20 entered the facility 4/02/10 and had an intact dressing on his/her right upper arm with a date of dressing change 3/26/10, nine days prior to this dressing change.


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Based upon record review, policy review and interview, the facility staff failed to follow hospital procedure and document when the Organ Procurement Organization was contacted for two (Patient # L 8, L 12) of seven cases reviewed for organ procurement. The facility census was 61 and the total sample was 43.

Findings included:

Review of facility policy "Organ and Tissue Donation, H-PC 02-016" found it stated, in part, "Referral of the death should be made within one hour of the time of death...F. All referrals will be recorded in the patient's medical record."

However:
- Record review of Patient # L 8, admitted 02/4-14/10, showed the record to have organ donation declined by the patient's daughter, but the call by facility staff to the Organ Procurement Organization (OPO) was not documented in the patient's medical record.
- Record review of Patient #L 12, admitted 03/09-10/10, showed the patient expired on 03/10/10, but facility staff failed to document a call to the OPO. During interview on 4/6/10 at 10:10 A.M., the Director of Quality Management for the Lindell Campus, Employee L H, confirmed with the OPO agency that the call had been made in timely fashion, but agreed that the documentation of the call was lacking.

Based upon interview and review of the facility records, the Rehabilitation Department failed to have physician oversight for the review of policies and quality assurance, as required by the 19CSR 30-20.134 (1), Missouri Regulations for Hospital Licensure. This applied to all patients, including one (Patient L 5) of one patient reviewed for Rehabilitation Services. The facility census was 61 and the total sample was 43.
Findings included:
Review of the facility Rehabilitation Department, a contracted service, revealed the Policy and Procedure book to be unsigned by any physician or hospital management staff. The Policy book is dated July 2009.
During interview on 04/9/10 at 11:45 A.M., the Physical Therapist, Employee L M, verified this information and also stated that the physician advisor does not review the department Quality Assurance projects and reports.