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Based on record review and interview the hospital failed to ensure the registered nurse evaluated the nursing care for 1 of 22 patients by not assessing and evaluating the knowledge of patient #11's wife before allowing her to perform dressing changes for the patient. Finding:

Review of the medical record revealed patient #11 was a 47 year-old admitted on 6/08/2010 at 12:30 PM for wound care treatment from a gunshot wound. Review of nursing documentation dated 6/12/2010 revealed the patient's wife changed his dressing to the left shoulder wound. Review of the medical record failed to reveal documentation that the wife had been instructed on wound care and deemed competent before allowing her to perform the task. In an interview on 6/22/2010 at 1:05 PM the ADON (Assistant Director of Nursing Services) confirmed that there was no documented evidence that an RN ensured staff instructed the wife before allowing her to perform a dressing change.

Based on observation, review of the medical records for 3 of 22 sampled patients, and interviews, the hospital failed to ensure the nursing staff provided an ongoing assessment of the needs for each patient as evidenced by the failure of the nursing staff to follow physician orders. Findings:

Patient #1
Review of the medical record revealed this was a 76 year-old admitted on 6/08/2010 at 1:35 PM with a principal diagnosis of right BKA (below the knee amputation). Review of the 6/13/2010 nurses notes revealed at 4:30 AM patient #1 complained of leakage and pain at the indwelling Foley catheter site and no urine was noted in the tubing or in the catheter bag. Further review of the nurses notes revealed the nurse tried to irrigate the catheter but was unable to so she removed the catheter and inserted another one. Review of the medical record revealed no documented evidence that a practitioner gave an order to remove the catheter and insert another one. An interview with the ADON (assistant director of nursing services) on 6/13/2010 at 1:00 PM confirmed that there was no physician order to remove the patient's cathter neither was there an order to insert one until 6/16/2010.

Patient #7
Observation on 6/22/2010 at 10:25 AM revealed patient #7 was on an ambulance stretcher with 2 ambulance personnel in attendance. S1LPN reported that the patient was returning from a diagnostic scan performed outside the hospital. S1 stated the patient was receiving chemotherapy, he had a low white blood count and that he was in protective isolation (a sign on the door confirmed the isolation) It was noted that the patient nor the ambulance personnel wore a mask, When the patient arrived at the door to his room, S1LPN was observed entering the room without a mask, gloves, or cleansing her hands prior to entering.

Review of the medical record revealed patient #7 was admitted to the hospital 6/07/2010 for wound care for a lesion on the buttocks which cultured MRSA (methicillin resistant staph aureus) and to receive his last chemotherapy treatment which was administered at Hospital A. Review of physician orders dated 6/10/2010 at 9:10 AM revealed the attending oncologist ordered "Protective isolation with mask and good handwashing".

In an interview on 6/22/2010 at 11:20 AM S1LPN was questioned why she entered patient #7's room without a mask and she replied that the patient's white blood count was up so she thought the attending oncologist did not mind if they did not wear a mask in the patient's room. S1 did acknowledge that the physician had not discontinued the order for the isolation and that she failed to follow the order.

Patient #13.
Review of the medical records revealed a 68 year old admitted on 6/04/2010 at 12:20 PM with a principal diagnoses of deconditioning. Review of the medical records revealed a 6/2010 at 4:30 PM physician order for a wound care consult. Further review revealed no documented evidence that a wound care consult was done. In an interview on 6/23/2010 at 10:00 AM RNS4 stated that when the order was written the wound care nurse had gone home for the day but confirmed that the consult was never done

II. Based on review of the medical record for 10 of 22 sampled patients the hospital failed to ensure the nursing staff kept a current nursing care plan for each patient. Findings:

Patient #1. Review of the medical record revealed a 76 year-old who was admitted on 6/08/2010 at 1:35 PM with a principal diagnosis of a right BKA (below the knee amputation). Further review revealed patient #1 had a history of diabetes mellitus, and chronic obstructive pulmonary disease (COPD). According to the medical record patient #1 was diagnosed with a urinary tract infection UTI) but there fail to be nursing care plan approaches for diabetes mellitus, COPD or UTIs.

Patient #2. Review of the medical record revealed a 91 year-old admitted on 6/02/2010 at 10:45 AM with principal diagnoses of subdural hematoma and respiratory failure. Further review revealed patient #2 had a tracheostomy and a peg tube. Review of the pre-printed care plan revealed no care plan approaches for alteration in comfort, alteration in communication and alteration in respiration function.

Patient #3. Review of the medical record revealed a 50 year-old admitted on 5/14/2010 at 1:30 PM with principal diagnosis of wound vac. Further review revealed a history of borderline personality, anemia, mild COPD and MRSA of surgical wound. Review of the pre-printed care plan revealed no documented approaches for alteration in mood or behavior, alteration in nutrition, alteration in respiratory function or for infection control.

Patient #4. Review of the medical record revealed a 42 year-old admitted on 6/14/3020 at 12:50 PM with principal diagnoses of severe leg weakness, spinal stenosis, herniated disc and a history of depression, and delirium. Review of the pre-printed care plan failed to reveal care approaches for alteration in mood or behavior.

Patient #5. Review of the medical record revealed the patient had a principal diagnosis of sigmoid volvulus times 2 wound care. Further review revealed physician order for restraint. Review of the care plan revealed no nursing approaches for alteration in cognition or alteration in communication.

Patient #7. Review of the medical record revealed this was a 46 year-old with a malignant brain lesion and a wound on the buttocks. Review of physician orders revealed the patient received 8 units of packed red blood cells and platelets over a 3 day period. Review of the nursing care plan failed to reveal the plan was modified to address a potential for transfusion reaction.

Patient #11. Review of the medical record revealed a 47 year-old admitted on 6/08/2010 at 12:30 PM with principal diagnosis of rotator cuff repair to the left shoulder, asthma, decubitus ulcer and spinal cord injury. Review of the nursing care plan on 6/23/2010 failed to reveal documented evidence that the nursing approaches had been updated since 6/09/2010 (one day after admission).

Patient #12. Review of the medical record revealed a 73 year-old admitted on 6/04/2010 at 1:30 PM with diagnoses of recurrent pancreatitis, chronic abdominal pain and history of acute renal failure. Review of the nursing care plan revealed no care plan approaches for renal failure.

Patient #19. Review of the medical record revealed a 65 year-old admitted on 11/19/2009 at 1:50 PM with CVA and respiratory failure. Review of the pre-printed nursing care plan revealed no approaches for alteration in comfort, alteration in ADLs (activity of daily living), or respiratory function.

Patient #20. Review of the medical record revealed this patient was admitted on 2/16/2010 at 6:00 PM with principal diagnosis of acute subacute bacteria endocarditis. Review of the nursing care plan revealed only one approach and that was for safety.

Based on review of the Medical Records policy and procedure manual, interview with the administrator and S3 (CCA), the hospital failed to have a person administratively responsible for the Medical Records Department and to provide over site for S3 who is a Certified Coder Assistant (CCA, the only staff who works in the Medical Records Department). The hospital failed to provide documented evidence that an agreement was made with a RHIA (Registered Health Information Administrator) or RHIT (Registered Health Information Technician) to provide supervision for S3 as required under state licensing regulation 9387.B. Finding:

Review of the medical records policy and procedure manual revealed no documented evidence that the manual had been reviewed and signed by a RHIA or RHIT since 4/26/2004. An interview was held on 6/23/2010 at 1:30 PM with S3 who stated she could call the RHIT at the host hospital (Hospital A) or the RHIA at the "sister hospital" if she needs help but neither of the two provides over site or supervision for her. On 6/23/2010 at 2:00 PM the administrator stated that he had a contract with the RHIA at the sister hospital. The administrator failed to provide the survey team with an agreement or documented evidence that a RHIA was providing over site for the CCA. Review of state regulation 9387. B revealed the "Medical records shall be under the supervision of a medical records practitioner (i.e. registered record administrator or accredited record technician) on either a full-time, part-time or consulting basis".

Based on review of medical records, review of the policy "Titled: Notification Of Physicians Of Incomplete Or Delinquent", review of the Medical Staff Rules and Regulations (Effective 11/02), and interview with the certified coder assistant (S3) the hospital failed to ensure medical records of patients discharged after 30 days were promptly completed as evidenced by having 7 of 7 (patient #14, #15, #16, #17, #18, #19 and #20) incomplete medical records. Findings:

Patient #14. Review of the closed medical record revealed an admit date of 1/13/2010 and a discharge date of 3/09/2010. Further review revealed no documented evidence that a discharge summary was written or dictated by a practitioner. Review of the 1/13/2010 at 8:20 PM physician orders revealed an order for a CBC (complete blood count), CMP (complete metabolic panel) pre-albumin and Dilantin level. There failed to be documentation of results of these studies in the medical record. Further review of the medical record revealed a form signed by S3, the certified coder, indicating that there was no lab results for the month of January 2010.

Patient #15. Review of the closed medical record revealed an admit date of 4/10/2010. Further review revealed no documented evidence that a history and physical or discharge summary were documented for this patient. Review of documentation by S3 revealed the results of the CBCs ordered by the physician on 3/3, 3/24, and 3/29/2010 were not in the chart. Also, this form indicated that the lab results for the 3/25/2010 urinalysis and x-ray report for the abdominal, kidneys, ureter, and bladder, ordered by the physician on 3/20/2010, were not in the chart. Further review of the medical record confirmed that the physician ordered these studies.

Patient #16. Review of the closed medical record revealed the patient was admitted on 12/21/2009 and discharged on 1/09/2010. Further review revealed the lab reports for a CBC and renal function ordered on 12/29/2009 and 1/06/2010 were not in the medical record. Also, the chest x-ray report was not in the record that was ordered on 1/18/2010.

Patient #17. Review of the closed medical record revealed the patient was admitted on 2/04/2010 and discharged on 3/07/2010. Documentation in the medical record revealed the history and physical was not signed and the practitioner did not document the discharge summary in the medical record.

Patient #18. Review of the closed medical record revealed the patient was admitted on 3/11/2010 and discharged on 3/29/2010. Further review revealed there was no discharge summary or history and physical in the chart.

Patient #19. Review of the closed medical record revealed an admit date of 11/19/2010 and discharge date of 12/31/2010. Further review failed to reveal a discharge summary.

Patient #20. Review of the medical record revealed the patient was admitted on 11/19/2010 and discharged on 12/21/2010. Further review revealed no discharge summary.

Review of the Medical Staff Rules and Regulations, adopted 6/2009, revealed that "a discharge summary (clinical resume) shall be written or dictated on all medical records within thirty (30) days of discharge of patients hospitalized". Further review revealed "a complete admission history and physical examination shall be recorded by the attending physician or his designee within twenty-four (24) hours of admission to the hospital".

Review of the policy for "Notification of Physicians of Incomplete or Delinquent" records revealed "after the third week the suspension letters will be mailed certified mail, return receipt requested. Phone calls will also be made at this time. The suspension list will be distributed to: Admitting Office(,) Administration(,) Nursing Administration(,) Chief of Staff(,) Medical Executive committee(,) Utilization Review/Medical Records Committee". An interview with S3 on 6/23/2010 at 1:30 PM confirmed that the above medical records were over 30 days incomplete and that the physicians had not been suspended. S3 further stated that the hospital does not suspend practitioners for delinquent records.

Based on record reviews and interviews the hospital failed to ensure all entries in the medical record were signed, dated and timed for 8 of 22 sampled patients (patients #1, #2, #3, #5, #6, #8, #17 and #19). Findings:

Patient #1. Review of the 6/08/2010 at 12:35 PM admit orders revealed a physician order to see the "reconciliation" form for patient's medications. Further review revealed the nurse (RNS5) who transcribed the orders did not date and time her signature.

Patient #2. Review of the 6/03/, 6/10 and 6/18/2010 physician orders revealed the orders were not timed.

Patient #3. Review of physician orders for 5/14/2010, 5/15, 5/17 and 5/18/2010 revealed the practitioner did not time the orders.

Patient #5. Review of the 5/29/2010, 6/03-6/09/10, 6/11/2010, 6/14-6/22/2010 physician orders revealed the practitioners' signatures were not dated and timed.

Patient #6. Review of the 5/21/2010 physician orders revealed a verbal order that was not dated or timed. Further review revealed a 6/06/2010 phone order that was not dated and timed.

Patient #8. Review of the admission orders revealed the practitioner's signature was not dated and timed.

Patient #17. Review of the closed medical record revealed the practitioner did not sign, date and time the history and physical.

Patient #19. Review of the 11/24/2009, 12/05, 12/18, and 12/29/09 physician orders failed to reveal signatures of a practitioners.

Based on record review, and interview with S3, the hospital failed to ensure a medical history and physical (H & P) was completed and documented within 24 hours of admission for 5 of 22 (patient #5, #10, #13, #16, #17) sampled patients. Findings:

Patient #5. Review of the medical record revealed an admission date of 5/25/2010 and the H&P was not documented until 5/28/2010 (3 days after admission to the hospital).

Patient #10. Review of the medical record revealed an admission date of 6/18/2010 and as of 6/23/2010 (survey dates 6/22/2010 through 6/24/2010) there was no documented H&P.

Patient #13. Review of the medical record revealed the patient was admitted to the hospital on 6/04/2010. Further review revealed the physician did not document a H&P until 6/06/2010 (2 days after admission to the hospital).

Patient #16. Review of the closed medical record revealed the patient was admitted to the hospital on 12/21/2009 and the H&P was documented on 1/08/2010 (18 days after admission to the hospital).

Patient #17. Review of the closed medical record revealed an admit date of 3/25/2010. Further review failed to reveal a H&P for the patient.

In an interview on 6/24/2010 S3 confirmed that the H&Ps for patients #5, #13 and #16 were not documented within 24 hours of admission and also confirmed that patients #10 and #17 did not have a H&P in the closed medical record.

Based on review of the radiology contract and interview with administrator, the hospital failed to have a written contract with the provider (Hospital A) for radiology services which meet the needs of the patients as evidenced by the contract not specifying a time frame for performing and reporting the results of radiology studies ordered immediately, or those done on a routine basis. Findings:

Review of the hospital's 6/24/2002 radiology contract (renewed automatically every 3 years) with Hospital A failed to reveal time frames for performing and reporting immediate radiology studies as well as those done on a routine basis. An interview with the hospital administrator on 6/24/2010 at 1:30 PM confirmed the findings.

Based on review of the laboratory services contract and interview the administrator, the hospital failed to have a written contract with the provider (Hospital A) for laboratory services which meet the needs of the patients as evidenced by the contract not specifying a time frame for performing and reporting results of laboratory studies ordered immediately, or those done on a routine basis. Findings:

Review of the hospital's 6/24/2002 laboratory services contract (renewed automatically every 3 years) with Hospital A failed to time frames for performing and reporting immediate laboratory results as well as those done on a routine basis. An interview with the hospital administrator on 6/24/2010 at 1:30 PM confirmed the findings.

Based on observation and interview the hospital failed to ensure a current therapeutic diet manual approved by the dietitian and medical staff was available to the nursing staff. Findings:

Observation of the written dietary information provided to nursing staff revealed the only dietary manual available to staff was printed in 1992. Additionally, the manual did not contain documentation that the dietitian or the medical staff had approved the information. In an interview on 6/24/2010 at 10:10 AM the DON confirmed the dietary manual was out of date and did not provide current dietary guidance for staff.

Based on observation, review of the medical record for 3 of 19 sampled patients with wounds in a total sample of 22, policy titled "Infection Control" (reference #17.008 and dated 11/02), and interviews, the infection control officer failed to ensure consistent infection control practices were followed by all staff as evidenced by: 1) failure to adhere to isolation policies and procedures to prevent the spread of infections (#7 and #22), and 2) failure to provide safe and effective wound care for patients #10 and #22 . Findings:

Patient #7
Observation on 6/22/2010 at 10:25 AM revealed patient #7 was on a stretcher with 2 ambulance personnel in attendance. S1LPN reported at that time that the patient was returning from a diagnostic scan performed outside the hospital. S1 stated the patient was receiving chemotherapy, had a low white blood cell count, and was in protective isolation (a sign on the door indicated the patient was in protective isolation). It was noted that the patient nor the ambulance personnel wore a mask. When patient #7 arrived at the door to his room, S1LPN was observed entering the room without a mask, gloves, or cleansing her hands prior to entering.

Review of the medical record revealed patient #7 was admitted on 6/07/2010 for wound care of a decubitus on the buttocks which cultured MRSA (methicillin resistant staph aureus), and to receive his last chemotherapy treatments which were administered at Hospital A. Review of physician orders dated 6/10/2010 at 9:10 AM revealed the attending oncologist ordered "Protective isolation with mask and good handwashing".

In an interview on 6/22/2010 S1LPN was questioned why she entered patient #7's room without a mask and she replied that the patient's white blood count was up, so she thought the attending oncologist did not mind if staff did not wear a mask while in the patient's room. S1 did acknowledge that the physician had not discontinued the order for isolation.

Patient #22
On 6/23/2010 at 8:45 AM Housekeeper #1 was observed wearing gloves and entering patient #22's room. There was a sign on the door indicating the patient was in contact isolation. The sign instructed visitors to report to the nurses' station prior to entering the room, and to wear gloves upon entering. Housekeeper #1 allowed the door to the patient's room to remain open while she cleaned the room with supplies from her cart in the hallway. She pulled her gloves off, retrieved the wand for cleaning window blinds from her cart, dampened the wand in the mop water and proceeded to clean the blinds while the patient was in bed and dust filled the air. Afterwards, Housekeeper #1 mopped the floor of the patient's room, placed the mop in the bucket of water on her cart and started to move the cart when the infection control officer stopped her.

In an interview on 6/23/2010 at 9:05 AM, Housekeeper #1 stated she had worked 24 years for Hospital A who contracts housekeeping services for Riverside Hospital. She stated she received oral and video instructions for cleaning isolation rooms and that she would have emptied her mop water before she went to another room. Housekeeper #1 further stated that she "got confused" and did not wear gloves the entire time she was in patient #22's room.

On 6/23/2010 at 9:40 AM an interview was held with the ADON who confirmed staff should wear gloves upon entering the room of a patient in contact isolation. The ADON further stated staff must wear a gown when in substantial contact with the patient or any environmental surface. Review of Infection Control Policy 17.008 revealed staff should wear clean, nonsterile gloves upon entering the room of a patient in contact isolation and a nonsterile gown if the patient is incontinent, has diarrhea, an ileostomy, colostomy, or wound.

Patient #10
According to the medical record, patient #10 was a diabetic who fell at home and was on the floor for 2 days before someone found her. As a result of the accident, patient #10 sustained gangrene of her left 2nd-5th toes which required amputation. The patient also sustained a pressure wound on the right hip.

Review of 6/22/2010 physician orders revealed the attending physician ordered for staff to cleanse the suture line on the foot with Wound Cleanser (lifts bacteria) twice daily and to leave the suture line open. There was a 6/18/2010 order to cleanse the hip wound twice daily with Wound Cleaner and redress.

On 6/24/2010 at 10:42 AM S1LPN was observed preparing to provide wound care for patient #10. S1 washed her hands, put on nonsterile gloves and turned the patient's overbed light on and positioned the patient on the left side. S1 removed the lightly soiled absorbant dressing from the patient's right hip and changed her gloves. After applying clean gloves, S1 cleansed the hip wound with the Wound Cleanser. The wound was approximately 3inches in length, 1/2inch deep and had a yellow center. S1 applied a sterile nonabsorbent pad and positioned the patient supine.

S1LPN changed her gloves and positioned the patient's left foot for wound care. She sprayed the suture line with the Wound Cleaner and used 4x4 gauze. She allowed the gauze to absorb the cleaner and then brought the gauze from underneath the suture line up over the suture line (dirty to clean area). S1 did not provide a thorough cleansing of the suture line. In an interview on 6/24/2010 at 11:30 AM the survey team questioned S1LPN why she started with the hip wound and not the surgical site and she replied, "I don't know, I just did".

Patient #22
On 6/24/2010 at 8:15 AM the daughter of patient #22 reported that on the evening of 6/23/2010 LPN S7 changed the decubitus dressing on her mother's right buttocks which was infected with MRSA. The daughter stated that the patient was incontinent of a large amount of feces and that LPNS7 turned the patient to the left side cleansed the stool and rolled the incontinent brief which contained the stool under the patient while the patient was still on the left side. The daughter stated S7 removed the decubitus dressing from the patient's buttocks without changing her gloves after cleaning the stool, and then applied a new dressing to the wound, still without changing her gloves.

An interview on 6/24/2010 at 9:05 AM with LPNS7 confirmed she did provide wound care for patient #22 on the evening of 6/23/2010 and that she did not change her gloves after cleaning the stool from the patient and prior to providing wound care. S7 stated she changed her gloves several times during incontinent care, but not prior to wound care. S7 further stated the hospital's wound care nurse was on leave and "I guess she has spoiled me".

Based on observation and interview, the hospital failed to measure, analyze and track quality indicators for all contracted services. This was evidenced by the staff identifying a problem with housekeeping services contracted by Hospital A and not monitoring and evaluating the problem to ensure quality standards were met. Findings:

Observation of patient rooms a and b (empty rooms which staff unlocked and reported were terminally clean and prepared for a patient) on 6/22/2010 at 10:15 AM and at 10:45 AM, revealed there was dust and debris in all the corners of the rooms and behind the sofas. The bathroom vents were thick with dust.

On 6/23/2010 at 8:45 AM patient #22's daughter reported to the survey team that her mother was admitted on 6/22/2010 and that on admission, her mother's room (a) was dirty. The daughter stated there was debris and dust balls on the floor of the room and in the bathroom. The daughter also stated that electrical wires were exposed around the loose outlet cover beside the sink in the patient's room.

In an interview on 6/23/2010 at 2:55 PM the ADON reported the hospital had a contract with Hospital A to provide housekeeping services, but in 12/09 he identified that patient rooms were not cleaned adequately. The ADON further stated he spoke with the manager of housekeeping services from Hospital A about the problem and that the manager stated to him that he would monitor the situation and ensure improvement of services. The ADON stated environmental cleaning had not improved since 12/09, but that he had not tracked the problem through QA/PI in order to formulate a corrective action to ensure the contract for housekeeping met the quality needed for patients, and expected by the hospital.
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