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Based interview and record review the facility the facility failed to:


A. ensure sufficient numbers of nursing staff to provide care from 02/14-27/2018. The facility failed to ensure a sufficient numbers of nurses and techs on the 7:00 a.m.-7:00 p.m. shift and the 7:00 p.m.-7:00 a.m. shift to provide activities of daily living and administer medications.

Refer to A0392 for additional information.



B. ensure medications were administered timely on 6 of 11 sampled patients (Patient #'s 2, 3, 4, 5, 7, and 8). The facility failed to ensure anti-coagulants, antibiotics, blood pressure medications, and enzymes used for patients on dialysis were administered in a timely manner and as ordered.

Refer to A0405 for additional information

Based on record review and interview, the facility failed to ensure that patients or their representatives were provided with risks and benefits as related to their medical prognosis prior to procedures or treatments in 3 (Patient #'s 5, 10, and 11) of 6 charts reviewed. Also, the facility failed to follow their own policy and procedures.


Findings include:


A review of Patient #5's record revealed a consent for "Cat scan guided drainage of abcess" dated February 27, 2018 at 6:21 p.m. The physician listed to perform the procedure was Staff #9. The Disclosure and Consent form was not signed by the physician to confirm risks and benefits were discussed. A review of the history and physical dated February 27, 2018 at 1:44 p.m. does not show any risks and benefits were discussed with the patient about his procedure. There were no progress notes indicating risks and benefits were discussed with the patient.


A review of Patient #5's record revealed a consent for "Peripherally inserted central catheter" dated February 28, 2018 at 9:37 p.m. The physician listed to perform the procedure was Staff #10. The Disclosure and Consent form was not signed by the physician to confirm risks and benefits were discussed. A review of the history and physical dated February 27, 2018 1:44 p.m. does not show any risks and benefits were discussed with the patient about his procedure. There were no progress notes indicating risks and benefits were discussed with the patient.


A review of Patient#10's chart revealed a facility document titled, "General Consent on Admission" dated January 19, 2018. The document was signed by Staff #11. The reason documented for no patient or designee signature was listed as: patient is intubated. No documentation found that any attempt to notify family and obtain consent were done. The facility document titled, "Discharge summary hospitalist" documents physician discussion with family regarding transfer to LTAC (Long Term Care Facility), however no consent was obtained by hospital staff.


A review of Patient #11's chart revealed a facility document titled, "General Consent on Admission" dated May 3, 2017. The document was signed by Staff #12. There was not any documented reason for no patient or designee signature listed. No documentation was found that any attempt to notify family and obtain consent were done. The patient did have family listed when reviewing the chart. Review of facility document titled, "Disclosure of risk for Medical and Surgical Procedures" dated May 4, 2017 shows consent signed by Patient's sister. Review of facility document titled, "Disclosure of risk for Medical and Surgical Procedures" dated May 10, 2017 shows the consent was obtained on the phone from Patient's legal guardian.


An interview with Staff #8 on February 29, 2018 at 9:33 am revealed the following:

Staff #8 was asked where risks and benefits that were discussed with the patient would be documented. Staff #8 state, "Let me go ask." Staff #8 later stated, "According to Staff #1 they would be documented in the history and physical." Staff #8 was asked to show where that was documented. After reviewing the record for patient #5, Staff #8 stated, "I don't see any documentation that risks and benefits were discussed with patient." The finding was confirmed by Staff #8.


A review of the facility policy titled, "Obtaining Informed Consent and Disclosure" dated May 8, 2017 revealed the following:

"PURPOSE: The patient will be protected against unauthorized procedures. The surgeon and hospital will be protected against legal action of claims that an unauthorized procedure was performed. To insure that patient fully understands the procedure including potential complications, risks, benefits, and alternatives ...

... PROCEDURE:

Prior to signing an informed consent, the patient shall:
A. Be told in clear and simple terms by the surgeon what is to be done.

B. Be aware of the risks, benefits, possible complications, disfigurements and removal of parts.

V. Steps for Completion of Form

M. The physician will sign at the bottom of the consent that the undersigned physician has explained the benefits, alternatives, and risk of the above mentioned procedure ..."

Based on interview and record review, the facility failed to ensure sufficient numbers of nursing staff to provide care from 02/14-27/2018. The facility failed to ensure a sufficient numbers of nurses and techs on the 7:00 a.m. - 7:00 p.m. shift and the 7:00 p.m. - 7:00 a.m. shift to provide activities of daily living and administer medications.

This deficient practice had the likelihood to cause harm in all patients on the unit.

Findings include:



Review of nurse staffing sheets and staffing matrix revealed the following shortages on both shifts:


7:00 a.m.-7:00 p.m. 7:00 p.m.- 7:00 a.m.
02/14/2018 one nurse and one tech one nurse and one tech

02/15/2018 one nurse and one tech two nurses and one tech

02/16/2018 one tech one nurse

02/17/2018 one tech one nurse

02/18/2018 one tech one nurse

02/19/2018 one tech

02/20/2018 one tech

02/21/2018 one tech

02/23/2018 one nurse two nurses

02/24/2018 one nurse one nurse

02/25/2018 one nurse one nurse

02/26/2018 one nurse two nurses

02/27/2018 one nurse one nurse


Staff #5 confirmed the staffing numbers and confirmed that they had staffing problems. Staff #5 reported she had 4 RN jobs posted for over a year now. By the time she gets the information from human resources on the applicant they have already taken another job.


Staff #1 confirmed they needed nurses and techs. Staff #1 confirmed the problems they were having with human resources processing applications.


During an interview on 02/28/2018 after 8:50 a.m., Staff #5 reported they had a total of 14 beds on the 5th floor. The fifth floor was the only unit they were currently using and they were averaging 8 patients. Staff #5 reported the staffing was as follows:


On 7:00 a.m.-7:00 p.m.- 3-4 nurses, 1 tech, and 1 unit secretary, 1 respiratory therapist;

On 7:00 p.m.-7:00 a.m.- 3-4 nurses, 1 tech,and 1 respiratory therapist.


During an interview with nursing staff on 02/28/2018 the following was revealed about staffing:

"Staffing is up and down. We work with 2 -3 nurses. Sometimes we work short. If there is no tech we try to do patient baths. Sometimes we can't get to baths. They are passed on to the next shift and you pray and hope they give them." Sometimes you "just do the most pertinent things."


"Staffing could be better. We just lost a tech last month and we are losing another one in 2 weeks. I stay late sometimes to get my work done. When were short of staff you can not get to the baths. You have to pass it on to the next shift. Sometimes medications are delayed and late. Sometimes its also because pharmacy is late filling orders."






39801


An interview on February 29, 2018, with Staff #4 revealed the following:

Staff #4 was asked if she felt like staffing was adequate on the floor to maintain a sanitary environment and get all the patient care done. Staff #4 stated, "To be honest with you, No. We are short on PCT all the time. We don't have a free charge nurse to help because they are taking patients. Sometimes we don't even have a secretary. It makes it very hard on us. I don't feel like I can get all patient care done. Some days are totally overwhelming. Patients deserve better. I know they give us an excuse of productivity, etc. But, we need help." Staff #4 was asked what care would be delayed because of short staffing. Staff #4 stated, "medications are delayed, baths, keeping rooms cleaned. And then we are here late trying to catch up on charting."

Based on observation, interview and record review, the facility failed to ensure medications were administered timely on 6 of 11 sampled patients (Patient #'s 2, 3, 4, 5, 7, and 8). The facility failed to ensure anti-coagulants, antibiotics, blood pressure medications, and enzymes used for patients on dialysis were administered in a timely manner and as ordered.

This deficient practice had the likelihood to cause harm to all patients on the unit.

Findings include:


During an interview with nursing staff on 02/28/2018 the following was revealed about medications and staffing:

" ... Staffing could be better ....Sometimes medications are delayed and late. Sometimes its also because pharmacy is late filling orders."



Review of medication administration records and history reports revealed some of the following about late medications:

Patient #8

The anti-coagulant Lovenox was scheduled for every 12 hours. It was scheduled to be given at 10:00 a.m. and was administered at 11:03 a.m. on 02/22/2018, and on 02/26/2018 it was administered at 11:49a.m.

The antibiotic Merrem was scheduled for every 8 hours. It was scheduled to be given at 10:00 a.m. on 02/22/2018 and was administered at 11:03 a.m., and on 02/26/2018 and it was administered at 11:38 a.m.

On 02/26/2018 the following medications were scheduled to be administered at 10:00 a.m., but were listed "Med Initially Unavailable":

Sodium bicarbonate was administered at 12:10 p.m.;
Nystatin cream was administered at 11:21 a.m.;
Entresto tablet was administered at 11:21 a.m.


Patient #2

Synthroid (thyroid hormone) was scheduled for once a day intravenously. On 02/25/2018 it was scheduled for 7:00 a.m. and it was administered at 9:24 a.m.. On 02/26/2018 it was scheduled for 7:00 a.m. and it was given at 9:37 a.m.


Patient #3

The antibiotic Zyvox was scheduled every 12 hours intravenously. The medication was scheduled for 7:00 p.m. on 02/22/2018 and was given at 8:01 p.m.


Patient #5

The anti- hypertensive Lisinopril was scheduled for once a day. The medication was scheduled for 4:00 p.m. on 02/27/2018 and was given at 5:32 p.m.


Patient #7

Carafate (gastrointestinal agent) was scheduled before meals and at bedtime. The medication was scheduled for 10:00 a.m. on 02/26/2018 and was administered at 12:10 p.m.. The following was documented about the medication "Med Initially Unavailable."


Patient #4

The antibiotic Merrem was scheduled for every 8 hours. It was scheduled to be given at 2:00 a.m. on 02/22/2018 and it was administered at 3:18 a.m. . It was scheduled to be given at 10:00 a.m. on 02/22/2018 and was administered at 11:44 a.m..

The anti-hypertensive Toprol Xl was scheduled for once a day. It was scheduled to be given at 10:00 a.m. on 02/22/018 and it was administered at 11:44 a.m.

Pancrease (enzynme) was scheduled for three capsules before meals. It was scheduled to be given at 12:00 p.m. on 02/23/2018 and it was administered at 1:20 p.m.




Review of a facility policy named "Administration of Drugs:General" dated 02/2016 revealed the following:

"Standard medication times will be used unless the physician directs otherwise:

The following standard times will be used unless the physician directs otherwise:
Daily---------------10
BID-----------------10 and 22
TID-----------------10, 16, 22
QID-------------------10,14,18,and 22
HS--------------------22

...There may be a one hour variance (before or after) from the administration time.

AC-------------------6:30, 11, and 16
PC--------------------9, 13, 18
BID with meals--------8,17
QID pc and hs---------9,13, 18, 22
Q hr---------------------every hour on the hour
Q2 hrs ----------------- every even hour
Q3 hrs -----------------10, 05,08,11,14,17,20,23
Q4 hrs-------------------04,08,12,16,20,24
Q6 hrs ------------------04,10,16,22
Q8 hrs-------------------02,10,18
Ql2 hrs------------------10 and 22

There may be a 30 variance (before or after) from the administration time.


...Vancomycin, gentamicin, tobramycin, amikacin, Arixtra, and Lovenox are administered at exact times and not according to the standard administration times ..."

Based on observation, interview, and record review the facility failed to ensure the infection control officer had an adequate system in place to prevent the following unsanitary conditions. Six (room #540, #536, #534, #526, and Patient treatment room) of six patient care areas were found to be unsanitary. Patient rooms were found with urine stored on bedside table with food products, equipment stored uncovered and not labeled clean or dirty, dirty bedsheets, computers being used in multiple patient rooms without being sanitized between patients, unsanitary bedside commodes, rusted patient equipment, dirty baseboards, stained bathtub caulking, Foley catheters laying on floor, and patient treatment chair with torn coverings.

This deficient practice had the likelihood to cause harm to all patients admitted for care to the LTAC (Long Term Care Facility).


During a tour on February 29, 2018 at 0933 a.m.,

Patient #5's room (room 540)

Urinal filled half full with urine sitting on bedside tray with one bowl of jello and empty cracker packages next to it. Bed sheets were dirty. Dust found around base boards. Patient #5 was spitting into an empty water bottle. The bottle was full of spit from the patient dipping tobacco.

Two thermometers hanging on the wall in the nurse's station. The thermometers were not covered and did not indicate if the equipment was clean or dirty.


Several computers on wheels were in the hallway. Staff were noted to push these computers in and out of rooms. The computers were not cleaned in-between patients when observing.


An interview on February 29, 2018, with Staff #3 revealed the following:

Staff #3 was asked about staffing on floor. Staff #3 stated, "Yes I think staffing is ok." Staff #3 was asked how often patients were given a bath. Staff #3 stated, we try to give baths every 1-2 days and change the linen at that time." Staff #3 was asked how the kitchen trays were delivered and picked up. Staff #3 stated, "The kitchen takes care of those." Staff #3 was asked how long the trays are left in room. Staff #3 stated, "They are usually picked up within an hour, but if not we can get them for patient." Staff #3 was asked where the urinals were stored in the room. Staff #3 stated, "I like to keep them in bathroom unless patient asks for them."


An interview on February 29, 2018, with Staff #4 revealed the following:

Staff #4 was asked about staffing on the floor. Staff #4 stated, "To be honest with you, we don't have enough staff. We are short on PCT all the time. We don't have a free charge nurse to help because they are taking patients. Sometimes we don't even have a secretary. It makes it very hard on us. I don't feel like I can get all patient care done. Some days are totally overwhelming. Patients deserve better. I know they give us an excuse of productivity, etc. But, we need help." Staff#4 was asked what care would be delayed because of short staffing. Staff #4 stated, "medications are delayed, baths, keeping rooms cleaned. And then we are here late trying to catch up on charting."


An interview on February 29, 2018 with Patient #5 revealed the following:

Patient #5 was asked about care on floor. Patient #5 stated, I guess its ok. I have only been here one day but so far everything is ok. I am supposed to have surgery today." Patient #5 was dipping tobacco and spitting into a water bottle. Patient #5 was asked if he ate the jello today that was on the bedside table next to the urine bottle. Patient #5 stated, "Oh yes, but that was left on the table from last night.


Review of hospital policy titled. "Infection Prevention" dated March 2, 2017 revealed the following:


Purpose
To provide guidelines that minimizes the risk of indirect transmission of microorganisms on patient cares devices and healthcare worker devices.


Policy

All patient care devices should be cleaned with hospital approved disinfectant per the manufacturer guidelines before and after patient uses.

Guidelines

o All patient care devices including but not limited to IV poles, blood pressure machines, and patient transfer devices should be cleaned with a hospital approved
disinfectant.

o Adhere to contact and dry time of the hospital approved disinfectant.

o Any patient care item that is not cleanable with a hospital approved disinfectant including but not limited to paper covered supplies, tape, and gauze will be
discarded.

o Clean equipment will be stored in designated locations.






10135

During an observation on 02/28/2018 after 9:15 a.m. the following was observed:

Room #536


Patient #3 had an indwelling Foley catheter and the bag was directly on the floor.

The bedside toilet had dried brown substance on the seat and on the frame which had the appearance of feces. The frame was also rusted.

A shower chair in the bathroom was found to be covered in rust. With the rust on the chair there was no way it could be sanitized.

An open bottle of Sterile water was at the bedside. The bottle had no open date recorded on it.

Staff #1 confirmed the observations.

Review of the facility's undated policy titled "Infection Control" revealed the following:

"..Use sterile distilled water and saline in single dose vials in the medication nebulizers. Water for large reservoirs should be dispensed aseptically from 500 cc or 1000 cc bottles. Unused portions should be dated and discarded within 24 hours after opening."


Room #534

An open bottle of Sterile water was at the bedside. The bottle had an open date of 02/26/2018 without a time (2 days ago).

The baseboards in the room had a build-up of brown substance. The floor tile as you enter the bathroom were cracked. There was a brown water ring in the ceiling from a leak in the bathroom. The caulking around the tub was brown (supposed to be white).

Staff #1 confirmed the observations.



Room 526

The base of the intravenous pole in the room was rusted. The floor tiles as you enter the bathroom were separating and were found with a build-up of brown substance in the cracks.



Treatment room

A patient transport chair was found with tears and the cushion inside was exposed. The frame of the chair was rusted. There was no way the chair could be sanitized.