HospitalInspections.org

Based on observations, interview, review of hospital staffing sheets and review of hospital policy and procedure, the hospital staff failed to obtain an intravenous order for 6 of 6 open patient charts (Patient 1, 2, 3, 4, 5 and 10), failed to obtain a physician order for a Foley catheter insertion for 1 of 6 open charts reviewed (Patient 4), and failed to ensure adequate staffing for supervision for 2 east and the emergency department for night shifts.

The findings are:

On 05/20/15 from 11:05 a.m.- 11:35 a.m., review of Patient 1's chart revealed the patient was admitted to the hospital on 05/18/15 for Chronic Obstructive Pulmonary Disease. Review of physician orders dated 05/18/15, stated, "Methylpredisolone Inj (injection) 125 mg (milligram) q (every) h (hour) IVP (intravenous push)". Review of the patient's chart revealed a 20 gauge intravenous catheter placement to the left forearm on 05/18/15. Further review of the patient's chart revealed there was no order for an intravenous catheter placement. On 05/22/15 at 10:15 a.m., the Chief Nursing Officer (CNO) revealed, "If a patient has medications ordered intravenously (IV), then its understood that they need an IV".

On 05/21/15 from 11:30 a.m.- 1:00 p.m., review of Patient 2's chart revealed the patient was admitted to the hospital on 05/17/15 for Dehydration, Hyperkalemia, and wound care. Physician orders dated 05/17/15, stated, "0.9 % (percent) Sodium Chloride 1000 ml (milliliters) 125 ml/hr (hour) IV (intravenous) and calcium CL (chloride) 10% injection 10 ml x 1 IVP (intravenous push)". Review of the patient's chart revealed a 20 gauge intravenous catheter placement to the right forearm on 05/17/15. Further review of the patient's chart revealed there was no physician order for an intravenous catheter placement. On 05/22/15 at 10:30 a.m., the findings were verified by the Chief Nursing Officer.

On 05/21/15 from 1:10 p.m.- 2:15 p.m., review of Patient 4's chart revealed the patient was admitted to the hospital on 05/18/15 for a Transient Ischemic Attack, Atrial Fibrillation, Seizure activity, and Diabetes Mellitus. Physicians orders dated 05/18/15, stated, "Fosphenytoin vial 50 mg/ml 1000 mg IVP and Lorazepam inj 2 mg (milligram)/ml IVPB (intravenous piggyback). Review of the patient's chart revealed a 20 gauge intravenous catheter placement to the right antecubital on 05/18/15. Further review of the patient's chart revealed there was no physician order for an intravenous catheter placement. On 05/22/15 at 10:45 a.m., the findings were verified by the chief nursing officer.

On 05/22/15 at 11:10 a.m.-11:40 a.m., review of Patient 10's chart revealed the patient was admitted to the hospital on 05/20/15 for Diabetic Ketoacidosis. Physician orders dated 05/21/15 stated, "0.45 % sodium chloride 1000 ml at 150 ml/hr continuous IV , regular insulin drip 100 units/ 100 ml titrate continuous IV, Demerol 25 mg/ml IV push q 4 H (hours) and morphine inj 2 mg/ ml prn (as needed) Q 2 H". Review of the patient's chart revealed a 20 gauge intravenous catheter placement to the left antecubital on 05/20/15. Further review of the patient's chart revealed there were no physician orders for an intravenous catheter placement. On 05/22/15 at 11:50 a.m., the findings were verified by the Chief Nursing Officer.

On 05/19/15 at 3:15 p.m., review of Patient 3's chart revealed Patient 3 presented to the emergency department on 05/18/15 at 7:09 p.m. and was admitted on 05/19/15 at 1:20 a.m. Physician orders were documented on 05/18/15 at 21:25 for "0.9% Sodium Chloride 1000 (ml) milliliter (Intravenous) IV bolus"; 05/18/15 at 21:25 for "Hydromorphone amp (ampule) 2 (milligram) mg/ml, 1 mg, IVP; 05/18/15 at 21:25 for "Ondansteron vial 4 mg/ml, 4 mg, IVP (intravenous push)"; 05/18/15 at 22:19 for "Gentamicin/NS IVPB 80 mg/100 ml, 100.0 ml IVPB (intravenous piggyback)" for Patient 3. Patient 3 had a physician order dated 05/20/15 at 16:06 that reads, "D/C IV access prior to dismissal". There was no physician order to initiate an intravenous (IV) catheter access.

On 05/21/15 at 11:50 a.m., review of Patient 5's chart revealed Patient 5 was admitted on 01/21/15. Physician orders were documented on 01/27/15 at 07:47 a.m. for "Furosemide (Lasix) vial 40 mg/ml, 40 mg IVP; 01/27/15 at 10:17 a.m. for "Hydromorphone amp 2 mg/ml, 1 mg, IVP"; and on 01/28/15 at 19:38 for "Dextrose 50% INJ abbj (abbuject) syr (syringe), 1 ea (each), IVP for Patient 5. There was no physician order to initiate an IV catheter.

On 05/21/15 from 1:10 p.m.- 2:15 p.m., review of Patient 4's chart revealed the patient was admitted to the hospital on 05/18/15 for a Transient Ischemic Attack, Atrial Fibrillation, Seizure activity and Diabetes Mellitus. Review of the patient's chart revealed there was no physician order for insertion of a Foley catheter on the day of admission or during the survey. Review of the progress notes dated 05/18/15 at 6:24 p.m. revealed, "output 2300 ml catheter urine". On 05/22/15 at 10:45 a.m., the findings were verified by the Chief Nursing Officer.

On 05/21/15 at 10:20 a.m., Registered Nurse (RN) 2 revealed, "as the "HS" (house supervisor), the responsibilities include patient complaints, bed placement, staffing issues if I'm not working in the ER (Emergency Room), I'm working on the floor. As the House Supervisor, I usually have a patient assignment". On 05/21/15 at 10:25 a.m., RN 1 revealed that "we always have two (2) nurses in the emergency room (ER) regardless on each 12 hour shift".

On 05/20/14 at 5:00 p.m. review of the "daily Staff Assignment" sheet revealed the following:
02/01/15-PM, 1 nurse documented as scheduled for ED
02/02/15-PM, 1 nurse documented as scheduled for ED
02/07/15-PM, 1 nurse documented as scheduled for ED
02/08/15-PM, 1 nurse documented as scheduled for ED
02/20/15-PM, 1 nurse documented as scheduled for ED
02/24/25-PM, 1 nurse documented as scheduled for ED
02/25/15-PM, 1 nurse documented as scheduled for ED
02/26/15-PM, 1 nurse documented as scheduled for ED
03/02/15-PM, 1 nurse documented as scheduled for ED
03/08/15-PM, 1 nurse documented as scheduled for ED
03/09/15-PM, 1 nurse documented as scheduled for ED
03/11/15-PM, 1 nurse documented as scheduled for ED
03/13/15-PM, 1 nurse documented as scheduled for ED
03/17/15-PM, 1 nurse documented as scheduled for ED

On 05/20/15 at 5:10 p.m., review of daily staff assignment sheets revealed the following staff assignments with no house supervisor designated on the staff assignment sheets:
04/02/15 - No house supervisor for PM shift
04/03/15 - No house supervisor for PM shift
04/04/15 - No house supervisor for PM shift
04/05/15- No house supervisor for PM shift
04/06/15 - No house supervisor for PM shift
04/07/15 - No house supervisor for PM shift
04/09/15 - No house supervisor for PM shift
04/13/15 - No house supervisor for PM shift
04/17/15 - No house supervisor for PM shift
04/18/15 - No house supervisor for PM shift
04/20/15 - No house supervisor for PM shift
04/21/15 - No house supervisor for PM shift
04/22/15 - No house supervisor for PM shift
04/24/15 - No house supervisor for PM shift
04/25/15 - No house supervisor for PM shift
04/26/15 - No house supervisor for PM shift
04/27/15 - No house supervisor for PM shift
04/29/15 - No house supervisor for PM shift
04/30/15 - No house supervisor for PM shift
05/02/15 - No house supervisor for PM shift after 11 PM
05/03/15 - No house supervisor for PM shift
05/04/15 - No house supervisor for PM shift
05/05/15 - No house supervisor for PM shift
05/06/15 - No house supervisor for PM shift
05/07/15 - No house supervisor for PM shift
05/08/15 - No house supervisor for PM shift
05/09/15 -No house supervisor for PM shift
05/10/15 - No house supervisor for PM shift
05/11/15 - No house supervisor for PM shift
05/13/15 - No house supervisor for PM shift
05/14/15 - No house supervisor for PM shift
05/15/15 - No house supervisor for PM shift
05/16/15 - No house supervisor for PM shift
05/17/15 - No house supervisor for PM shift
05/18/15 - No house supervisor for PM shift
05/19/15 - No house supervisor for PM shift

On 05/19/15 at 3:00 p.m., the Chief Nursing Officer revealed the house supervisor works in the ER (emergency room) and covers the hospital as well during the night. The ER is staffed with two nurses and one ER Technician. If no house supervisor is listed, then one of the staff for 2 East is the house supervisor and the nurse for 2 East".

Based on patient chart review, interview and review of the hospital policy and procedure, the hospital failed to ensure that patient assessments were performed by Registered Nurses (RN) for 2 of 10 patient charts reviewed. (Patient 2 and 3)

The findings are:

On 05/21/15 from 11:30 a.m.- 1:00 p.m., review of Patient 2's chart revealed the patient was admitted to the hospital on 05/17/15 for Dehydration, Hyperkalemia, and wound care. Review of the patient's progress notes dated 05/18/15 at 7:39 p.m. revealed the nursing physical assessment was performed by Licensed Practical Nurse (LPN)
without any documentation follow-up from a Registered Nurse.

On 05/19/15 at 3:15 p.m., review of Patient 3's chart revealed Patient 3 was admitted on 05/19/15 at 1:20 a.m. Patient 3's "Nursing Physical Assessment" was performed on 05/19/15 at 2:18 a.m. by Licensed Practical Nurse (LPN) 3. Further review of the patient's chart revealed that LPN 3 initiated the discharge planning assessment on 05/19/15 at 2:58 a.m.
On 05/19/15 at 3:55 p.m., the Chief Nursing Officer (CNO) revealed that the LPN can perform a patient assessment as long as an RN performs another assessment within 12 hours of the LPN's patient assessment.

Hospital policy, titled, "Assessment/Reassessment of the Patient", reads, " POLICY: Initial patient assessments will be completed by an RN within 12 hours of admission to Med Surg and 8 hours SCU....6. All patients admitted for treatment will have their discharge planning needs initially assessed at the time the RN completes the nursing admission assessment....".

Hospital policy, titled, "Plan of Provision of Patient Care", reads, "....A Licensed Practical Nurse may perform additional acts requiring special education and training approved by the Board, which are proper for the licensee to perform and which are recognized by the Board through its regulations....Licensed Practical Nurse-The LPN supports the RN in the assessment and provision of patient care within the scope of practice defined in the nursing plan of care.... Planning of Care : The plan of care is defined from information collected on assessment. Goals are set to address patient problems by the nurse and other disciplines involved in patient care. Discharge planning begins on admission with the initial RN assessment and continues through the patient stay....".

Based on patient chart review, interview, and review of hospital policy and procedures, staff failed to initiate an individualized patient plan of cares for 3 of 6 open patient charts reviewed (Patient 2, 3 and 5) and 1 of 4 closed patient charts reviewed (Patient 6).

The findings are:

On 05/21/15 from 11:30 a.m.- 1:00 p.m., review of Patient 2's chartrevealed the patient was admitted on 05/17/15 for Dehydration and Hyperkalemia. Review of the patient's problem list on the plan of care revealed Problem 1 as "age related care: older adult with the goals as Patient will understand lifestyle impact of illness, patient will be able to make informed decisions, and age care guidelines will be implemented". Problem 2 was "skin integrity-actual impairment with the goals as patient regains skin integrity evidenced by warm, dry, intact skin, patient has formulation of granulation tissue in/around breakdown area, and no signs of symptoms of infection". There was no further documentation in the patient's plan of care related to problems and monitoring of the Dehydration and/or Hyperkalemia.

On 05/19/15 at 3:15 p.m., review of Patient 3's chart revealed Patient 3 was admitted on 05/19/15 with "Constipation". Review of the patient's History and Physical by the admitting practitioner revealed: "Assessment and Plan: UTI(Urinary Tract Infection)..., Euvolemic Hyponatremia..., New Onset Diabetes Mellitus..., and constipation. Further review of the patient's chart revealed Patient 3's "Problem " was documented as "Pain Acute R/T(related to) abdominal adhesions" with "Goal" as "Recognize causal factors and measures to prevent pain. Report pain to healthcare provider. Use an analgesic and non-analgesic relief measures appropriately". There were no other "Problems" or "Goals" documented.

On 05/19/15 at 3:53 p.m., the Chief Nursing Officer (CNO) revealed the patient's plan of care is the actual physician's orders. The plan of care or "Problem List" is reviewed daily.

On 05/21/15 at 11:50 a.m., review of Patient 5's chart revealed Patient 5 was admitted on 01/21/15 with "Failure to thrive". Review of the admitting diagnoses recorded by the admitting practitioner revealed: "Diagnosis: Amputation of Rt(Right) #2 toe, CVA(Cerebral Vascular Accident), Debilitation, CHF(Congestive Heart Failure)". Further review of Patient 5's "Problem list" showed "Skin Integrity, Impairment" with "Goal" as "Pt demonstrates optimal skin or wound care routine, Resolution of drainage from wound, Labs WNL(Within Normal Limits)". There were no other "Problems" or "Goals" documented.

On 05/21/15 at 11:50 a.m., review of Patient 6's chart revealed Patient 6 was admitted on 01/30/15 with "Pneumonia". Review of the admitting diagnoses recorded by the admitting practitioner revealed Diagnosis: Debilitation-Pneumonia. Further review of Patient 6's "Problem list" showed "Activity Intolerance" with "Goals" as "Participate in necessary physical activity with change in VS(vital signs), verbalizes understanding of need for (O2(oxygen), meds(medications) and/or) for activities, recognizes energy limitations".

Hospital policy, titled, "Plan for the Provision of Patient Care", reads, ".... I. Definition ....Patient care delivery consists of a series of processes's including: data collection during the initial contact, analysis of data, problem identification based on data collected, goal setting, determination of the type of care needed to address the identified problem(s), planning of care based on identified needs, implementation of the plan of care, evaluation of response to the plan of care, reassessment of the plan of care to determine the need for modification....Planning of Care : The plan of care is defined from information collected on assessment. Goals are set to address patient problems by the nurse and other disciplines involved in patient care. Discharge planning begins on admission with the initial RN assessment and continues through the patient stay....".

Based on review of personnel charts, interview, and review of the hospital policy and procedures, the hospital failed to ensure that nurses in 2 of 2 specialized areas: Emergency Department (ED) and Operating Room (OR) had the specialized education for 1 of 1 OR Registered Nurses (RN 12) and 13 of 17 ED RNs (RN 1, 2, 3, 4, 6, 7, 8, 9, 11, 13, 14, 15, and 16) and 1 of 1 Chief Nursing Officer (CNO).

The findings are:

On 05/20/15 at 3:53 p.m., review of the staff personnel record for RN 1 revealed RN 1's Advance Cardiopulmonary Life Support (ACLS) expired on "14-Dec" and Pediatric Advance Life Support (PALS) expired on "15-Feb".

On 05/20/15 at 3:56 p.m., review of staff personnel records for RN 2 revealed RN's 2 ACLS expired on "14-Jan"and Basic Life Support (BLS) expired on "14-Oct".

On 05/20/15 at 3:59 p.m. review of the staff personnel record for RN 3 revealed that RN 3 had no documentation of PALS.

On 05/20/15 at 4:01 p.m., review of the staff personnel records for RN 4 revealed RN 4's BLS expired on "15-Apr(April)" and there was no evidence of PALS completion.

On 05/20/15 at 4:04 p.m., review of the staff personnel records for RN 6 revealed RN 6's BLS expired on "15-Jan".

On 05/20/15 at 4:06 p.m., review of the staff personnel records for RN 7 revealed RN 7 had no evidence of PALS completion.

On 05/20/15 at 4:08 p.m., review of the staff personnel records for RN 8 revealed that RN 8's ACLS expired on "14-Sep".

On 05/20/15 at 4:10 p.m., review of the staff personnel records for RN 9 revealed RN 9 had no evidence of PALS completion.

On 05/20/15 at 4:13 p.m., review of the staff personnel records for RN 11 revealed RN 11's ACLS expired on "14-Dec" and there was no evidence of PALS completion

On 05/20/15 at 4:16 p.m., review of the staff personnel records for RN 12 revealed RN 12's ACLS expired on "14-Sep" and RN 12's PALS expired "13-Apr".

On 05/20/15 at 4:19 p.m., review of the staff personnel records for RN 13 revealed RN 13's BLS expired on "15-Feb".

On 05/20/15 at 4:21 p.m., review of the staff personnel records for RN 14 revealed RN 14 ACLS expired on "15-Feb" and RN 14 had no evidence of PALS completion.

On 05/20/15 at 4:23 p.m., review of the staff personnel records for RN 15 revealed RN 15 had no evidence of PALS completion.

On 05/20/15 at 4:25 p.m., review of the staff personnel records for RN 16 revealed RN 16 had no evidence of ACLS completion.

On 05/20/15 at 4:27 p.m., review of the staff personnel records for the CNO revealed the CNO's ACLS expired on "14-Sep" and the CNO's PALS expired on "15-Feb".

On 05/21/15 at 9:48 a.m., the CNO revealed, "if there is not a copy of the certificate in their folder, then I don't have it or they have not taken the class".

Hospital policy, titled, "Nursing Orientation/Competency Policy", read, "...7. Nursing service employees who work in a speciality unit (OR, ER, ENDO, and SCU) are required to obtain and maintain ACLS and PALS certification....".

Based on interview and record review, the hospital staff failed to follow physician orders for tube feeding administration for 1 of 6 open patient charts reviewed. (Patient 2)

The findings are:

On 05/21/15 from 11:30 a.m.- 1:00 p.m., review of Patient 2's chart revealed the patient was admitted to the hospital on 05/17/15 at 3:30 p.m. for Dehydration, Hyperkalemia, and wound care. Physician orders dated 05/17/15 revealed an order for "Jevity tube feeding QID (four times a day)". Review of the nursing documentation on the patient progress notes revealed the administration of Jevity on the following days and times:
05/17/15 at 4:45 p.m.
05/17/15 at 9:05 p.m.
05/18/15 at 9:00 a.m.
05/18/15 at 8:00 p.m.
05/19/15 at 9:00 a.m.
On 05/22/15 at 10:30 a.m., the Chief Nursing Officer verified the findings.

Based on observations, interviews, and review of hospital policy and procedure, 1 of 1 observed Registered Nurses (RN 17) failed to disinfect the computer on wheels after use in a patient's room.

The findings are:

On 05/19/15 from 2:03 p.m.- 2:10 p.m., random observations on the medical surgical floor revealed the RN 17 failed to disinfect the computer on wheels after medication administration to a patient. On 05/19/15 at 2:15 p.m., RN 17 revealed, "the cows (computer on wheels) don't have to be cleaned between patients unless they are infectious or on isolation".

Hospital policy, titled, "Cleaning and Disinfecting of patient equipment", reads, "frequently used patient equipment including but not limited to vital sign equipment and stethoscopes are to be cleaned immediately after each patient use. Used movable patient equipment (IV pumps, monitor, etc) is cleaned by the nursing staff and housekeeping....The disinfected movable patient equipment is moved to the clean holding area, plugged in (if necessary), and stored until needed....".