HospitalInspections.org

Based on observations, record reviews and interviews the facility:
- failed to provide written grievance resolution within a reasonable timeframe to patients and/or families filing a complaint/grievance(A0122)
- failed to ensure each patient and/or patient's representative is offered the opportunity to establish an advance directive (A0132)
- failed to ensure patients were provided full disclosure of video monitoring by cameras (A0143)
- failed to provide a safe environment on the New Hope unit (behavioral health) by allowing non-suicide- resistant shower water control knobs and non-suicide-resistant handicap grab bars in shower rooms and patient bathrooms and failed to provide a safe environment by allowing a table and a television in the unit dayroom to be unsecured to the floor and/or wall (A0144) and
- failed to immediately obtain an order for the use of medical restraints and failed to ensure the physician signed a telephone order for restraints (A0168).

The cumulative results of these findings resulted in the overall non-compliance with CFR 482.13, Condition of Participation: Patient Rights.

Based on facility policy review and record review, the facility failed to provide written grievance resolution within a reasonable timeframe to patients and/or families filing a complaint/grievance for three (Patients #17, #18, and #20) of seven grievances reviewed.

Findings Included:

Review on 04/20/10 at 11:45 A.M. of the facility policy titled "Resolving Patient Complaints and Grievances," last revised 10/2009, showed the following (in part): "There is an expectation at Missouri Baptist-Sullivan Hospital that all complaints/grievances shall be addressed as quickly as possible with final resolution occurring within seven (7) days of the date received. If expectations are not met, notify Patient Satisfaction/Risk Manager immediately. Patient or patient's representative will be advised of the delay and a time frame for resolution communicated to them at this time."

Review on 04/20/10 at 10:30 A.M. of a grievance filed by Patient # 17 showed the following:
- Patient #17 filed a complaint/grievance with the facility on 03/09/10.
- The investigator contacted the patient on 03/17/10 to discuss the allegations.
- A resolution letter was sent on 03/18/10, nine days after the complaint/grievance was lodged.

Review on 04/20/10 at 10:56 A.M. of a grievance filed by Patient # 18 showed the following:
- Patient #18 filed a complaint/grievance with the facility on 03/05/10.
- The investigator attempted to contact the patient on 03/15/10 and again on 03/17/10. A message was left for the patient to return the call, however the patient did not call back.
- A resolution letter was sent on 03/17/10, twelve days after the complaint/grievance was lodged.

Review on 04/20/10 at 11:15 A.M. of a grievance filed by Patient # 20 showed the following:
- Patient #20 filed a complaint/grievance with the facility on 04/06/10.
- The investigator contacted the patient on 04/16/10 to discuss the allegations.
- A resolution letter was sent on 04/16/10, ten days after the complaint/grievance was lodged.

Based on policy review, document review, record review and interview the facility failed to ensure each patient and/or patient's representative is offered the opportunity to establish an advance directive for one patient (#6) of three patient records reviewed for advance directives. The facility had a census of 23.

Findings included:

Review of facility policy, "Advance Directives" last revised 9/2009 showed the purpose is to outline the management of the patient who wished to initiate an Advance Directive. The policy statement showed at the time of hospital admission and/or registration, the individual will be provided with written information concerning the individual's rights under state and federal law to make decisions concerning his/her medical care including the right to formulate an Advance Directive concerning life sustaining care. The information regarding one's rights under state law shall be provided by the registration clerk as evidenced by the patient signing the "Treatment Authorization" form.

The patient management section of the policy showed the admitting clerk/designee or nurse will document the presence of and type of Advance Directive (title of the document) presented by the patient. If not noted in the record, the admitting nurse should verify with patient if he/she has an Advance Directive.

Review of the facility document, Guide to Patient Rights & Responsibilities, showed in part:
You have the right to an advance directive (such as a living will, healthcare proxy or durable power of attorney for health care) concerning treatment or designating a surrogate decision-maker with the expectation that the hospital will honor the intent of that directive to the extent permitted by state law and hospital policy.

Record review of current Patient #6's admission history and physical showed the patient entered the facility 4/08/10 for treatment of visual hallucinations and major depressive disorder.

Record review of the patient's psychiatric nursing admission assessment form page five of five showed under the Advance Directive section nothing is marked by the staff to indicate if the patient has an advance directive and nothing is marked by the staff to indicate if staff asked Patient #6 if he/she would like to speak with a social worker for information on making an advance directive.

During an interview on 4/19/10 at 3:20 p.m. Program Director staff J said he/she expects staff to document on the nursing admission assessment form if the patient has an advance directive and if not, the staff should ask the patient if they would like information on advance directives.

Based on facility information review, observation, interview the facility failed to ensure patients were provided full disclosure of video monitoring by cameras located in the New Hope unit (Behavioral Health). The hospital had a census of 23 and the unit had a census of six.

Findings included:

1. Review of the facility admission packet titled Guide to Patient Rights and Responsibilities, directed in part the following:
Your right to privacy. As a patient, you are entitled to every consideration of your privacy concerning your medical care. Discussion of your condition, as well as any consultation, examination or treatment is confidential and will be conducted as discretely as possible. You may refuse to talk to or see anyone not directly involved in your care.

2. Observation on 04/19/10 at 2:25 P.M. showed video monitoring of four areas. One area is a ceiling mounted video device monitoring the patient seclusion room. Observation of the unit showed no signage informing anyone of possible video monitoring.

3. During an interview on 04/19/10 at 2:25 P.M. the Director of New Hope Unit, staff J said the ceiling mounted video camera is operational and he/she does not recall any signage informing anyone of possible video monitoring.

Based on observation and interview the facility failed to provide a safe environment for six of six patients on the New Hope unit (behavioral health) by allowing non-suicide- resistant shower water control knobs and non-suicide-resistant handicap grab bars in one of two hall access shower rooms and allowing non-suicide-resistant toilets and handicap grab bars in five of five patient bathrooms. The configuration of these water control knobs, toilets and handicap grab bars creates a looping hazard for all patients on the unit. The facility also failed to provide a safe environment by allowing a table and a television in the unit dayroom to be unsecured to the floor and/or wall. The facility had a census of 23 and the unit had a census of six.
Findings included:
Observation on the New Hope unit showed a shower room located close to the nurse's station. The shower has regular shower water control knobs, which protrude from the wall approximately two inches. The shower has a handicap grab bar, which has a shelf between the wall and the bar to prevent any item from being looped over the bar. Also located in the shower room is a toilet with grab bars next to the toilet on the back and side walls. The grab bars protrude approximately three inches from the wall and do not have a shelf between the wall and the bars. Items can be looped over the bars. Observation also showed the bathrooms of all five patient rooms have a toilet with exposed plumbing and handicap grab bars protruding from the wall with no shelf between the wall and the bars.
Observation showed all five patient rooms are unlocked and patients have access to their rooms and bathrooms without constant monitoring by staff.
During an interview on 4/19/10 at 2:30 p.m. the Program Director, staff J said that patients are allowed to go to their rooms if not in groups or working with staff. Staff J said staff does not monitor patients while in the bathrooms. Staff J said the facility does admit suicidal patients to the unit at times. Record review showed none of the current patients on the unit are on suicide precautions. Staff J said all patients are checked by the staff every 15 minutes.
Staff J said the contracted service for the unit completed a risk assessment survey 11/24/09 and identified in a written report to the facility that the shower water control knobs and the handicap grab bars are a risk to patient safety. Staff J said the maintenance manager staff AA looked at the shower room and patient bathrooms after the facility received the risk assessment survey and said it would be expensive to correct the problems. Staff J said the facility has taken no further action on these items and is unaware of any facility plan to address this issue.
Observation at 3:00 p.m. on 4/19/10 showed a small corner table in the day room which was unsecured to the wall or floor and a medium sized entertainment center with a television that was not covered or secured from falling.

Based on record review and interview, the facility failed to immediately obtain an order for the use of medical restraints for one patient (#22) and failed to ensure the physician signed a telephone order for restraints for one patient (#22) out of four patients with physical restraints for medical indications selected for review. The facility had a census of 23.

Findings included:

Review of the history and physical for discharged Patient #22 showed the patient entered the facility on 3/31/10 for evaluation of arrhythmia (the heart may beat too fast or too slow).

Review of a restraint flow sheet dated 3/28/10 showed staff placed Patient #22 in bilateral wrist restraints at 12:45 a.m. due to the patient pulling at his/her endotracheal tube (ET tube is a tube inserted into a patient's trachea in order to ensure that the airway is not closed off and that air is able to reach the lungs).

Review of the physician's order sheet showed the order for bilateral wrist restraints obtained from the physician on 3/28/10 at 4:10 a.m. The facility placed the patient in restraints for three hours and 25 minutes without a physician's order.

Review of a physician's telephone order dated 4/01/10 at 7:45 p.m. showed the physician ordered Patient #22 placed in bilateral wrist restraints due to pulling at his/her ET tube. The telephone order is not signed by the physician.

Based on record review and interview the facility failed to ensure the privileges that physicians request within their medical specialties or based on their experience are approved by the medical staff or the governing board according to the facility bylaws. This affects all patients in a census of 23.
Findings included:
Review of credentialing files for four physicians was done on 4/20/10. Physician identified as Staff CC had privileges requested by that physician and dated in 2008. Staff DD had privileges requested and dated in 2002 and 2003. Staff EE had privileges requested and dated in 2002. Staff FF had requested privileges and the form was undated. Only Staff CC had privileges included in the material with the current credentialing packet. The other three physicians had the privileges included with previous credentialing packets.
The forms used to indicate privileges requested were noted to be in various formats but all included either a space for approval signatures and/or columns to the side of a privilege requested to indicate approval. None of the privilege's requested by physicians had approval indicated by either signature on the form or checkmarks in the columns.
The language of the letter from the governing body, included with each current credentialing packet, only indicated that the physician had received approval for appointment to the medical staff.
Medical staff meeting minutes for the last three meetings were reviewed and various physicians were mentioned by name as being up for re-credentialing and approval was noted for the group.
During an interview on 4/22/10 at 10:00 a.m. Staff JJ (physician) who participates as a member of the credentials committee, stated that there had been an effort in the last year to update the privileging form. Staff JJ stated that they recommend to the medical staff preliminary approval of each physician. The focus of the new forms used for the approval process, and approved in 2009, is to group specialties and eliminate procedures that are no longer used and may be included on the previous privileging forms. Staff JJ stated that medical staff will approve privileges after recommendation by the two physicians on the committee.
Record review of the medical staff bylaws under the section "Delineation of Clinical Privileges", stated under section 8.1 that A practitioner providing clinical services at the hospital, unless otherwise provided the in the bylaws, shall exercise only those clinical privileges specifically granted by the board.
There is no indication on any of the documents that the specific privileges requested by the physicians received explicit approval by either medical staff or governing body.

Based on policy review, record review and interview, the facility failed to identify and/or update the nursing plan of care for each patient to include pertinent, individualized problems and/or interventions for one patient (#6) of 3 care plans reviewed. The facility had a census of 23.

Findings included:

Review of facility policy, "Care Planning" last revised 3/09 showed in part: Using the information learned from the admission history, the registered nurse (RN) will initiate an individualized patient plan of care within 24 hours of admission. The care plan and the problem goal list will be reviewed daily and updated as appropriate to the patient's condition and ongoing health needs.

Record review of current Patient #6's admission history and physical showed the patient entered the facility 4/08/10 for treatment of visual hallucinations and major depressive disorder. The history and physical showed a medical history of diabetes. A medical consult dated 4/09/10 showed an assessment of Type II diabetes mellitus.

Record review of Patient #6's plan of care showed no care plan for diabetes.

During an interview on 4/19/10 at 3:30 p.m. Program Director staff J said Patient #6 is receiving insulin for his/her diabetes and the staff should address diabetes on the care plan.

Based on record and policy review the facility failed to perform criminal background checks and a check of the employee disqualification list (EDL) for two of three agency staff reviewed (Staff H & G) and the facility failed to ensure one agency registered nurse (Staff MM) received restraint/seclusion training. The facility census was 23 and has the potential to affect any patient admitted to the facility.
Findings included:
1. Review of the Missouri State Statute RSMO 2003 Section 660.315 directed facilities licensed under Chapter 197 (hospitals) complete not only pre-employment EDL checks but also quarterly checks of all existing staff against the quarterly updated EDL to ensure no current staff had been recently added to the EDL (The quarterly updated EDLs are available on the Missouri Department of Health and Senior Services web site).

Review of the Missouri State Statute Chapter 660, Department of Social Services, Section 660.317 directed facilities licensed under Chapter 197 (hospitals) to following:
Criminal background checks of employees, required when--persons with criminal history not to be hired, when, penalty--failure to disclose, penalty--improper hirings, penalty--definitions--rules to waive hiring restrictions.

Review of the facility document titled "Request to Fill Position and New Hire Process, dated as revised 03/10, stated in part the following: ... ....Human Resources requests Background Check, checks State Employee Disqualification List (EDL), and .....

Review of personnel file for Registered Nurse, Staff H, showed employment as a temporary agency nurse in the Emergency Department from 09/3/09 to 02/27/10 and there was not documentation of an Employee Disqualification List check.

Review of personnel file for Registered Nurse, Staff G, showed employment as a temporary agency nurse in the Emergency Department from 05/14/09 to 8/15/09, 11/27/09 to 12/31/09, and 02/11/09 to 04/14/10 and there was not documentation of a background check until 04/05/10, after Staff G already worked at the facility.




19957

Review of agency nurse staff MM's personnel file showed no documentation of facility restraint/seclusion training.
Review of the New Hope (behavioral health) unit staffing schedule showed staff MM worked a total of ten shifts from 3/28/10 through 4/18/10.
During an interview on 4/19/10 at 4:35 p.m. the chief nursing officer staff A said agency nurses need to be trained in the use of restraint/seclusion just like any other nurse.
During an interview on 4/21/10 at 2:15 p.m. New Hope program director staff J said agency nurse staff MM has not had any unit specific restraint training.

Based on facility policy review and record review, the facility failed to ensure telephone and verbal orders were signed by a physician within 48 hours for two (Patient #2, and #3). The facility census was 23.

Findings included:
Review of the policy titled "Verbal and Telephone Orders", dated as effective 10/1/2008, stated the following instructions in part .....The ordering practitioner must sign, date, and time the verbal order at the earliest of the below: a. The next time the practitioner provides care to the patient, assesses the patient, or documents information in the patient's medical record. B. Within 48 hours of when the order was given.
Review of the facility document titled "Medical Staff Rules and Regulations", dated as approved 03/14/08, states in the Physician Order Requirements the following: All telephone orders shall be signed by the individual to whom dictated and shall state the name of the telephoning practitioner. The responsible practitioner shall date and authenticate such orders within 48 hours after the order is given.
1. Medical record review on 04/19/10 at 2:30 P.M. for patient #2, admitted on 04/15/10, with a diagnosis of knee replacement showed the following verbal orders not dated or signed by the physician:
-The Medication Reconciliation Order Form is used for medication orders to be continued at admission and showed the following verbal orders for medications written by the nurse on 04/15/10 and untimed:
Coumadin (blood thinner)3 milligrams one per mouth daily in the P.M.; Levaquin (antibiotic) 500 milligram one per mouth daily; Norco (pain medication) 5/325 milligrams one per mouth every four hours as needed; Prilosec (prevents the production of acid in the stomach) 20 milligrams one per mouth daily; Synthyroid (thyroid replacement medication) 75 micrograms one per mouth daily; lisinopril-hydrochlorothiazide (medication to reduce blood pressure) one per mouth 20/12.5 milligrams every day; Lopressor (medication to reduce blood pressure) per mouth 50 milligrams two times daily; Lipitor 20 milligrams per mouth daily; and Estradial (hormone) 0.5 milligrams per mouth daily.
-The following telephone medication order written by the nurse on 04/17/10 at 6:00 P.M.:
Maalox 30 milliliters as needed for reflux.
2. Medical record review on 04/19/10 at 3:30 P.M. for patient #3, admitted on 04/10/10, with a diagnosis of pneumonia showed the following verbal orders not dated or signed by the physician:
-The following verbal orders for medications written by the nurse on 04/11/10 at 1:35 P.M.:
Miralax (oral laxative) in fluid of choice; and Lasix 80 milligrams additional today.
-The following telephone orders medications written by the nurse on 04/12/10 at 11:30 A.M. :
OK to hold oxycontin AM dose if patient is not in pain.
-The following standing/verbal orders medications written by the nurse on 04/13/10 at 11:00 A.M.:
Tylenol 650 milligrams per mouth every 4 hours as need temp 100.4 degrees and above; Tylenol (pain medication) 650 milligrams per mouth every 4 hours as need mild pain; Tylenol #3 (contains codeine), one tablet per mouth every 4 hours as needed severe pain; Restoril (sleeping pill) 15-30 milligrams per mouth every bedtime as needed for insomnia; Fleets (rectal laxative) enema daily as needed or milk of magnesia 30-60 milliliters as needed for constipation, except heart patients; and Senokot-S (oral laxative) tablet per mouth at bedtime as needed for constipation.
-The following telephone medication order written by the nurse on 04/16/10 at 1:45 P.M.:
Discontinue ceftriaxon.

Based on record review, the facility failed to ensure physicians updated history and physical examinations for one of five patients (#27) sampled prior to receiving a surgical procedure and the facility failed to ensure the history and physical is completed within 24 hours of admission for one patient (#12) of five records reviewed. The facility census was 23.
Findings included:
Review of the facility document titled "Medical Staff Rules and Regulations", dated as approved 03/14/08, states in part the following: ....A complete history and physical examination must be performed within 24 hours of admission or not greater than 7 days prior to the patient's admission to the hospital. For history and physicals performed prior to admission, an interval admission note that includes all additions to the history and any subsequent changes in the physical examination must also be recorded .....
Review of medical record showed discharged patient # 27 admitted for a laparoscopic tubal ligation (procedure for sterilization), peritoneal biopsy and right ovarian cystectomy (removal of cyst from the ovary) with a general anesthesia on 03/15/10. The history and physical is dated 02/17/10 and there is not documentation in the medical record of an update condition on the patient prior to the surgical procedure 03/15/10.






19957

Record review for current Patient #12 showed the patient entered the facility 4/12/10 for treatment of major depression. Review of the history and physical showed the physician dictated the history and physical on 4/15/10, three days after admission.

Based upon record review and interview, the staff failed to document the consumption of tube feeding for one (Patient #8) of one patient receiving continuous tube feeding and failed to document the consumption of nutritional supplement for one (#9) of one patient reviewed for supplement intake, failed to document that the facility offered Shaken Baby video to the mother for 2 (#33, 34) of 3 cases reviewed. The current census was 23
Finding included:
For documentation of tube feedings:
Record review for Patient # 8, currently admitted since 04/15/10 showed the patient to receive Nutren at 60 cc (cubic centimeters, same as milliliters) per hour per gastrostomy tube (a tube inserted directly into the stomach for feeding of a prepared liquid).
Review of the intake / output record for Patient #8, showed all days to be documented with tube feeding recorded as 60 cc for each hour. This does not accurately reflect the exact amount that is infused by the tube feeding pump and directly consumed by the patient. The total amount consumed is available on the pump and should be document in the patient ' s record.
For documentation of nutritional supplements:
Record review for Patient #9, currently admitted since 04/17/10 showed the patient to receive Mighty Shakes TID (three times per day), as noted by the Registered Dietitian ' s note of 04/19/10. Review of the patient ' s intake record showed no documentation of the nutritional supplement by the time of review on 04/20/10.
During interview on 04/20/10 at 11:00 A.M., the Nurse Manager of Medical Surgical Critical Care Unit, Employee O, stated, " we do not necessarily expect charting on Mighty Shakes. "
For documentation related to the Shaken Baby video:
Review of the Missouri Revised Statutes: Chapter 191 Health and Welfare Section 191.748, Shaken baby syndrome video, showed a requirement, " every hospital and any health care facility licensed in this state that provides obstetrical services shall offer to all new mothers an opportunity to view with the father and other persons of the mother's choosing a video on the dangers of shaking a baby and shaken baby syndrome before the mother's discharge from the facility. Such video shall be approved by the department of health and senior services. "
Review of Patient #33, admitted as delivered newborn 02/9/10, showed the record lacked documented evidence that the mother had been offered the Shaken Baby video.
Review of Patient #34, admitted as delivered newborn 03/22/10, showed the record lacked documented evidence that the mother had been offered the Shaken Baby video.
During interview on 04/22/10 at 11:00 A.M., the Director of Obstetrics, Employee II stated that the documentation was kept on a clipboard and that record did not become part of the permanent patient medical record. Employee II also said that the baby ' s record should have a small page that was used as a form, to document that the video had been offered.

Based on policy review and record review the facility failed to ensure patient discharge summaries were completed within thirty days of discharge for one patient (#25) of three discharged psychiatric patient medical records reviewed for discharge summaries completed within thirty days of discharge. The facility census was 23 patients.

Findings included:

Review of facility policy 10.004 "Psychiatric Discharge Summary" showed it is program policy that a comprehensive psychiatric discharge summary be completed by the attending psychiatrist within 30 days of the patient's discharge or per Medical Staff by-laws.

Review of the discharge summary for Patient #25 showed the physician admitted the patient 2/06/10 and discharged the patient 2/15/10. The physician dictated the discharge summary on 3/22/10, more than 30 days post discharge.

Based on facility policy review, record review and interview the facility failed to ensure the policy and procedure manuals for pharmaceutical services were reviewed and revised according to facility policy, and failed to have secure prescription pad storage. The facility census was 23.

Findings included:

Review on 04/21/10 at 4:10 P.M. of the facility policy titled, "Development, Distribution, and Review of Nursing Policies and Procedures," last revised 03/2009, showed the following (in part): "Each procedure should be reviewed every three years at a minimum and revised as necessary."

Review of the Pharmacy policy and procedure manual on 04/20/10 at 3:10 P.M. revealed policies too numerous to count that were revised greater than 3 years ago.

In an interview on 04/20/10 at 2:30 P.M., Pharmacy Manager Staff T stated the Pharmacy Services policy and procedure manual had not been kept current. Staff T indicated the policy and procedure manual was in the process of revision and Staff T was attempting to merge policies from several governing bodies.


17865

During an observation of the operating room known as #3 (c-section room-used during a surgical procedure to deliver a baby), a pad of blank prescriptions plus four loose prescriptions are found in an unsecured drawer.
During an interview on 04/20/10 at 2:06 P.M. Surgical Services Registered Nursing Manager Staff P said that this is where the prescription pads are usually stored. Staff P said that housekeeping has access to the unsecured operating room after the regular staff has left for the day.

Based upon review of the policy book and interview and review of manufacturer's guidelines for tube feeding products, the staff failed to keep the tube feeding product under safe and sanitary conditions for one (#11) of one patient receiving; bolus tube feeding; and theFood and Nutrition Department failed to have current policies and procedures for the guidance of the staff. This applied to all patients in a current census of 23.
Finding included:
Review of manufacturer ' s guidelines for the safe usage of tube feeding products, Ross Nutrition, " Best Practice Guidelines for tube Feeding " , stated in part on pg 21, " Cover opened, unused formula and store in refrigerator. "
Record review for Patient #11, currently admitted since 04/15/10, showed the physician orders of 04/19/10 requiring the patient to have Jevity 1.5 (a specially pre-prepared liquid feeding product) at 200 ml (milliliters) every 4 hours.
During interview on 04/19/10 at 2:00 P.M., the Director of Food and Nutrition Services stated that all tube feeding products were in 1 liter bottles, and used as a ' closed ' system (directly infused from the feeding liquid bottle into the patient ' s stomach, without contact to air).
During interview on 04/19/10 at 3:00 P.M., the Program Manager of the Geri-Psychiatric Behavior Health Unit , Employee J said, when asked how the product was given, that the bottle was opened and the 200 ml was poured into a graduated measurement cup; and then poured into the patient ' s gastrostomy (surgically placed tube which goes directly into the patient ' s stomach) tube. For the remaining product, the cap is replaced and it is stored on the counter, at room temperature. Employee J stated that the Registered, Licensed Dietitian said that the tube feeding product could remain at room temperature because it had a 24 hour stability.

Regarding Department Policies and Procedures:
Review of the Morrison Policy and Procedure Book, as resourced for the contract service for Food and Nutrition Services, showed that the Book lacked any approval by the Department Management or the Hospital Administrative staff.
During interview on 04/19/10 at 2:00 P.M., the Director of Food and Nutrition Services stated that the policies were still under development, since the systems had changed with the move to the new kitchen, last fall.



19957

Observation on 4/20/10 at 9:00 a.m. of the medication room on the New Hope Unit showed a partially full bottle of Jevity (a specially pre-prepared liquid feeding product) sitting on the counter. Registered nurse (RN) staff M said the tube feeding is for Patient #11. Staff M said staff opened the bottle the evening before and the Jevity is good until 7:00 p.m. Staff M said Jevity can be opened and kept on the counter for 24 hours and does not need to be refrigerated after opening.
Observation on 4/20/10 at 9:40 a.m. showed staff M poured 200 ml of Jevity into a graduated measurement cup; then poured the liquid into the patient's gastrostomy tube.

Based upon record review, review of facility policy, and interview, the Registered Dietitian failed to have a timely Medical Nutritional assessment for one (#10) patient of five patients reviewed for nutritional assessments. The current census was 23.
Finding included:
During interview on 04/20/10 at 12:00 P.M., the Registered Licensed Dietitian (RDLD) stated that the policy expectation for Medical Nutritional Assessments was at least with 72 hours to allow for weekend days; but that the general goal was to have the nutritional assessment within the first 24 hours of admission for each patient.
Record review for Patient #10, currently admitted since 04/14/10 showed the nutritional screening review, done by nursing on 04/14/10, showed the need for Medical Nutritional assessment. The record failed to have a Medical Nutritional assessment by the day of the survey review on 04/20/10 at 11:35 A.M.
During interview on 04/10/10 at 2:00 P.M., the Program Director for the Geri-Psychiatric Behavior Health Unit, Employee J, said, " The RDLD has put her assessment in the chart. "

Based on record review, observation and interview, the facility failed to remove outdated supplies from immediate patient access, failed to ensure refrigerator temperatures are checked and failed to clean the microwave oven used to warm patient foods. The facility census was 23.
Findings included:
Crash Carts:
Review of the policy titled "Crash Cart Checks" dated as revised 2/10 states in part the following instructions for checking: ...The other drawers should be checked by the unit nurse. This assignment includes: A. Assessing expiration dates of medication and equipment.
During an observation on 04/20/10 at 10:00 A.M. in the intensive care unit, the crash cart (used in emergency situations) had the following outdated supplies found:
Drawer #1
? One-package of pediatric cardiac electrodes with an expiration date of 11/15/09
Drawer #5
? One-Sterile Introsseous (needle that can be injected through the bone's hard cortex and into the soft marrow interior) infusion needle labeled as "do not use after 2010/03"
? Three purple top blood collection tubes with an expiration date of 02/10
? Two green top blood collection tubes with an expiration date of 02/10
? Two blue top blood collection tubes with an expiration date of 12/09
? Two black/orange top blood collection tubes with an expiration date of 01/10
? Two gold top blood collection tubes with an expiration date of 10/090
? Three red top blood collection tubes with an expiration date of 02/10
? Three orange top blood collection tubes with an expiration date of 02/10
? One Sterile Right angle Huber needle with Y injection site with an expiration date of 01/10
During an observation on 04/20/10 at 10:20 A.M. on the second floor nursing unit, the crash cart (used in emergency situations) had the following outdated supplies found:
Drawer #1
? Three blue top blood collection tubes with an expiration date of 12/09
? Two purple top blood collection tubes with an expiration date of 2/10
? One green top blood collection tubes with an expiration date of 02/10
? One red top blood collection tubes with an expiration date of 02/10
? Two gold top blood collection tubes with an expiration date of 10/09
? Two orange/black top blood collection tubes with an expiration date of 01/10
? Two orange top blood collection tubes with an expiration date of 02/10
During an observation on 04/20/10 at 1:30 P.M. in the Surgical Services Department, the crash cart (used in emergency situations) had the following outdated supplies found:
Drawer #5
? Three blue top blood collection tubes with an expiration date of 09/09
? Three green top blood collection tubes with an expiration date of 06/09
? One Dressing change tray labeled as single use only with an expiration date of 2/1/10
During an interview on 04/20/10 at 10:00 A.M. Registered Nursing Supervisor, Staff N said that the crash cart is checked two time daily by the supervisor, and if the supervisor is busy the checking would be delegated to another staff person.
Refrigerator Temperatures:
Review of the policy titled "Refrigerator/Freezer Temperatures" dated as revised 11/09 stated, in part the following instructions for checking: ...All refrigerated drug storage areas will be inspected daily to ensure compliance with drug storage standards.
Review of the document staff record daily temperatures for the drug storage refrigerator on the medical surgical nursing unit showed no temperatures during the month of April on 4/3, 4/6, 4/8, 4/10, 4/11, 4/15, 4/17, & 4/18.
Review of the document staff record daily temperatures for the drug storage refrigerator on the obstetrical nursing unit showed no temperatures during the months of:
January 2010 on 1/2, 1/4, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, 1/14, 1/15, 1/17, 1/18, 1/19, 1/20, 1/22, 1/23, 1/24, 1/25, 1/26, 1/29, 1/30, & 1/31.
February 2010 on 2/2, 2/3, 2/6, 27, 2/8, 2/9, 2/13, 2/14, 2/15, 2/16, 2/19, 2/20, 2/21, 2/24, 2/25, 2/26, & 2/28.
March 2010 on 3/1, 3/2, 3/7, 3/8, 3/9, 3/12, 3/13, 3/14, 3/15, 3/16, 3/21, 3/22, 3/23, 3/24, 3/27, 3/28, & 3/29.
April 2010 on 4/2, 4/2, 4/3, 4/4, 4/5, 4/6, 4/7, 4/11, 4/12, 4/13, 4/14, & 4/18.

Microwave cleaning:
During an observation on 4/19/10 at 2:30 P.M. the microwave on the second floor nursing unit used to heat up patient foods is found to be dirty with brown colored substances on the wall surfaces of the microwave and is need of cleaning.
During an observation on 4/20/10 at 10:40 A.M. the microwave on the second floor nursing unit used to heat up patient foods is found to be still dirty with brown colored substances on the wall surfaces of the microwave and is need of cleaning.
During an interview on 04/20/10 at 10:45 A.M. Registered Nurse Manager Staff O said that the unit secretary on the night shift is responsible for cleaning the microwave oven, but there is no checklist to remind the staff.

Based on record review and interview, the facility failed to ensure two of two swing bed patients sampled (#2 & #3) and admitted to the hospital received assessments related to discharge planning services in a timely manner. The facility census was 23.
Findings included:
Review of the facility policy titled "Discharge Planning for Swing Patients", dated as revised 10/19/05, and states in part the following procedure: ...A. Social Services will do an assessment on all residents that are designated Swing Bed status within three days of admission.
Review of the facility document titled "What services are offered by our swing bed program?" stated in part the following: A social worker will be working with you and your family throughout your stay in a swing bed. She will assist you with admission and explain the program to you. ... ...
Medical record review on 04/19/10 at 2:30 P.M. for patient #2, admitted on 04/15/10, with a diagnosis of knee replacement showed the social service department has not seen or assessed the patient for discharge needs. Patient #2 is on day four of admission.
Medical record review on 04/19/10 at 3:30 P.M. for patient #3, admitted on 04/10/10, with a diagnosis of pneumonia showed the social service department has not seen or assessed the patient for discharge needs. Patient #2 is on day nine of admission.
During an interview on 04/19/10 at 3:00 P.M. the Manager of Social Services/Case Management, Staff LL, confirmed the facility policy is to see patients with in three days of admission. Staff LL said that he/she has not seen patient #2 yet.

Based on quality assessment review and interview, the facility failed to ensure there is a post discharge evaluation of the discharge planning process. This affects all patients in a current census of 23.
Finding included:
Review of the discharge planning process quality improvement showed no assessment or reassessment of the discharge planning process.
During an interview on 4/22/10 at 9:50 PM, the Discharge Planning Manager, staff LL said there is no follow-up contact after discharge to determine if the discharge plans for specific patients were appropriate and followed.

Based on interview and record review, the facility failed to credential and delineate specific surgical privileges for three registered nurse surgical first assistants (staff P, R, and S) sampled and employed. The facility census was 23.
Findings included:
Review of the job description for Registered Nurse First Assistant specifies the following duties as a requirement for the position: This includes assessing patient, checking for accurate and proper documentation i.e.: surgical consent, blood consent, H & P (history and physical, patient identification, assist anesthesia with induction, position and drape patient, retraction of tissue for exposure, clamping and ligation of vessels, assist with sub-q and skin closure, applies the dressings.
During an interview on 04/21/10 at 9:10 A.M. the Assistant Administrator said that he/she is responsible for the credentialing process at present and the registered nurse first assistants are not included at this time. Facility employed registered nurse first assistants are not credentialed for specific surgical privileges.
On 04/21/10 at 9:10 A.M the Manager of Surgical Services, Staff P said the facility employs a total of three registered nurse first assistants. Staff P said that he/she has functioned as a registered nurse first assistant since 2005 at hire until the present time. The other two employed registered nurses have functioned as registered nurse first assistants since 2003. Staff P said that registered nurse first assistant duties included independently closing subcutaneous tissue and skin with sutures, holding retractors, and assisting the physician with stapling, tying and cutting suture during surgical procedures. Staff P said that the physician does sometimes leave the room prior to the patient incision closure.
Review of personnel file for Staff P, registered nurse first assistant has a hire date of 11/2005 and is a full time employee. There is no documentation of credentialing or the delineation of privileges.
Review of personnel file for Staff R, registered nurse first assistant has a hire date of 09/14/81 and is a full time employee. There is no documentation of credentialing or the delineation of privileges.
Review of personnel file for Staff S, registered nurse first assistant has a hire date of 05/15/89 and is a full time employee. There is no documentation of credentialing or the delineation of privileges.

Based on record review and interview, the facility failed to include the supervision of anesthesia services in the delineation of privileges for the physician Medical Director of Anesthesia. The facility census was 23.
Findings included:
Review of the credentialing file, specifically delineation of privileges, for the Medical Director of Anesthesia Services, dated as approved 03/30/09 did not show any privileges specific to anesthesia services.
Review of the facility document titled "Anesthesia-Core Policy", job description for CRNA (certified registered nurse anesthetist), stated the purpose of the policy as follows: The CRNA's are administratively responsible for the services provided. The CRNA has full authority over the administration of anesthetics in the Hospital. The CRNA's are clinically responsible to the Chief of Surgery and administratively to the Administrator of the hospital.
During a phone interview on 04/21/10 at 3:30 P.M. Staff DD said that he/she is the Medical Director of Anesthesia. Staff DD said he/she does not have any specialized training in anesthesia. Staff DD said that he/she has twenty years of experience as a surgeon.

Based on policy and closed record review, the facility failed to provide post anesthesia evaluations for 4 of 6 sampled (open #13 and closed #36, 37, & #38), within 24 hours after receiving a general anesthesia. The facility census was 23.

Findings:

Review of the policy titled "Post-Anesthesia Visit", dated as revised 11/2005 stated, in part "....It is the policy of the Missouri Baptist Hospital of Sullivan Anesthesiology Department to follow the below listed procedure in Post-Anesthesia Visit .....A. all patients receiving anesthesia services will receive a post-operative visit within 24 hours after surgery. ...B. This visit shall be documented as a post anesthetic visit and that patient shall also be informed of this post-anesthesia visit. ..."

Open record review for patient #13, age 47, surgical procedure of total abdominal hysterectomy, bilateral salping-ooperectomy (removal of uterus, fallopian tubes and ovaries) on 04/19/10. On 04/21/10 at 2:45 P.M. review of the document titled " Pre-Op Anesthesia Evaluation " (also used to document the anesthesia post-operative visit at the bottom of the form), dated as revised 08/25/09 revealed the section for the post-operative evaluation is signed by the anesthesiologist, however, the rest of the assessment is blank. There is no indication the anesthesiologist assessed the patient within twenty-four hours.


Closed medical record review for patient #36, age 33, surgical procedure of Cesarean Section (surgical delivery of a baby) on 03/15/10. Review of the document titled " Pre-Op Anesthesia Evaluation " (also used to document the anesthesia post-operative visit at the bottom of the form), dated as revised 08/25/09 reveals the section for the post-operative evaluation is blank. There is no indication the anesthesiologist assessed the patient within twenty-four hours.

Closed medical record review for patient #37, age 26, surgical procedure of diagnostic laparoscopic tubal ligation (female sterilization) and cyst removal on 03/15/10. Review of the document titled " Pre-Op Anesthesia Evaluation " (also used to document the anesthesia post-operative visit at the bottom of the form), dated as revised 08/25/09 reveals the section for the post-operative evaluation is blank. There is no indication the anesthesiologist assessed the patient within twenty-four hours.

Closed medical record review for patient #38, age 23, surgical procedure of Cesarean Section on 03/15/10. Review of the document titled " Pre-Op Anesthesia Evaluation " (also used to document the anesthesia post-operative visit at the bottom of the form), dated as revised 08/25/09 reveals the section for the post-operative evaluation is blank. There is no indication the anesthesiologist assessed the patient within twenty-four hours.

Based on record review and interview the facility failed to ensure that the medical director of the emergency department had the proper certifications to fulfill this responsibility.

Findings included:

Review of the personnel file on 04/21/10 at 11:00 A.M. showed that ED Medical Director Staff GG did not have current certification in Advanced Cardiac Life Support (ACLS).

During an interview on 04/21/10 at 5:10 P.M., Staff GG confirmed that the ACLS certification was not current.

Based on record review and interview the facility failed to ensure that Registered Nurse (RN) staff within the Emergency Department (ED) had the proper certifications to fulfill this responsibility.

Findings included:

Review of the facility job description for nursing staff showed current certification in Pediatric Advanced Life Support (PALS) and Advanced Cardiovascular Life Support (ACLS) was a requirement for this position.

Review of the ED staff certification database on 04/19/10 at 4:10 P.M. showed that 7 of 21 RNs working in the emergency department did not have proof of current certification in ACLS and 4 of 21 RNs working in the emergency department did not have proof of current certification in PALS.

During an interview on 04/20/10 at 9:40 A.M., Staff I confirmed that the ACLS and PALS certification was not current for these individuals.

Based upon observation and interview, the facility failed to have a safety emergency call system in place for the Rehabilitation Outpatient Services, patient use restroom. This applied to all outpatients, using the offsite gym. The current inpatient census was 23.
Finding included:
Observation during the tour of the offsite Rehabilitation Gym, on 04/21/10 at 2:00 p.m. revealed the patient use restroom to have no emergency call system, should the patient need emergency medical attention during his/her private use of the restroom.
During interview on 04/21/10 at 2:00 P.M., the Director of Rehabilitation Services, Employee C shared the observation and confirmed this finding.

Based upon review of facility documents and interview, the facility failed to assure qualified staff for t he testing of the swimming pool chemicals. This applied to all outpatients who would use the swimming pool for therapeutic treatments. The current census was 23.
Finding included:
Review of the facility documents for the quality maintenance of the swimming pool, on 04/21/10 at 2:30 P.M., showed the chemical test reports as read by color responsive test strips and recorded by the Rehabilitation Gym staff.
During interview on 04/21/10 at 2:30 P.M., the Director of Rehabilitation Services stated that the staff had not been tested for any degree of colorblindness to determine if there would be a failure to read the color responsive test strips.

Based on review of the New Hope Unit (behavioral medicine) Quality Improvement Summary and interview the facility failed to ensure the unit has a quality improvement program that tracks or identifies opportunities for improvement for indicators that affect patient safety and quality of care. The facility had a census of 23 and the unit had a census of 6.
Findings included:
Review of the Quality Activity Summary report for the time span of January 2010 through March 2010 showed the unit tracking patient falls and medication errors. The summary report showed the plan is for less than three patient falls per month. The summary showed 12 falls in three months for an average of four falls a month. The summary showed the goal is not met. There is no follow up plan other than for the team to re-evaluate.
The summary for medication errors showed a three month average of medication errors is two per month. The goal is not identified; however the summary showed goal not met. There is no follow up plan documented.
During an interview on 4/20/10 at 4:00 p.m. the Program Director staff J said the quality improvement plan should include steps the staff will take to improve these two patient centered processes.

Based on record review and interview, the facility failed to ensure two of two swing bed patients sampled (#2 & #3) and admitted to the hospital received assessments related to discharge planning services in a timely manner. The facility census was 23.
Findings included:
Review of the facility policy titled "Discharge Planning for Swing Patients", dated as revised 10/19/05, and states in part the following procedure: ...A. Social Services will do an assessment on all residents that are designated Swing Bed status within three days of admission.
Review of the facility document titled "What services are offered by our swing bed program?" states in part the following: A social worker will be working with you and your family throughout your stay in a swing bed. She will assist you with admission and explain the program to you. ... ..."
Medical record review on 04/19/10 at 2:30 P.M. for patient #2, admitted on 04/15/10, with a diagnosis of knee replacement showed the social service department has not seen or assessed the patient for discharge needs. Patient #2 is on day four of admission.
Medical record review on 04/19/10 at 3:30 P.M. for patient #3, admitted on 04/10/10, with a diagnosis of pneumonia showed the social service department has not seen or assessed the patient for discharge needs. Patient #2 is on day nine of admission.
During an interview on 04/19/10 at 3:00 P.M. the Manager of Social Services/Case Management, Staff LL, confirmed the facility policy is to see patients with in three days of admission. Staff LL said that he/she has not seen patient #2 yet.