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Based on record review and interview the hospital failed to meet the requirements of the Condition of Participation for Nursing as evidenced by:

1) Failing to ensure nursing staff assigned to patients receiving respiratory care, in the absence of respiratory therapists, were knowledgeable of oxygen delivery devices utilized in the hospital for 3 of 5 patients reviewed for oxygen delivery out of a total sample of 26 (Patient #13 receiving respiratory care by Registered Nurse (RN) S20 on 12/18/2010, #23 receiving respiratory care by Licensed Practical Nurse(LPN) S15 on 12/28/2010, #24 receiving respiratory care by RN S16 on 1/21/2011) and failing to designate in writing the training and experience of personnel authorized to perform each type of respiratory care service as evidenced by no documented evidence of a competency assessment of all skills performed by the nursing staff providing respiratory care (nebulizer treatment, tracheotomy care, suctioning of the tracheotomy, oxygen therapy, Bi-PAP and C-PAP) services for 6 of 6 RN/LPN personnel files reviewed S5, S11, S14, S17, S30, S31 (See findings cited at A0397)

2) Failing to ensure medications were administered according to the orders of the physician and/or accepted standards of practice for 9 of 26 sampled patients (#2, #4, #5, #17, #18, #20, #21, #22, #25). Patient #22's failure to have Coreg administered as per accepted standards of practice by nursing staff administering Coreg 25 milligrams by mouth on 7 occasions when the patient's heart rate was 60 or less (12/18/2010 x 2 doses, 12/19/2010 x 1 dose, 12/20/2010 x 2 doses, 12/21/2010 x 2 doses) without notifying the patient's physician resulted in the patient experiencing symptomatic Bradycardia for which the patient was transferred to the Emergency Department of an acute care hospital for treatment with a heart rate of 44 on 12/23/2010. Patient #17's failure to receive physician ordered respiratory treatments (Duoneb) as needed for shortness of breath due to inability to cough up thick secretions from his tracheostomy resulted in the patient having to be transferred to the Emergency Department of an acute care hospital for suctioning of his trach and respiratory treatments. (See findings at Tag A0404).

3) Failing to ensure a Registered Nurse supervised and evaluated the nursing care for each patient as evidenced by failing to ensure: a) a Registered Nurse assess patients in the hospital with significant changes in condition; b)failing to ensure a 3-way catheter had been inserted and bladder irrigation begun as ordered by the MD on a male patient who had had a traumatic urinary catherization for 1 of 1 sampled patients with orders for bladder irrigation resulting in the patient continuing to experience hematuria with increasing blood clots and pain and having to be transferred to the Emergency Department of another facility for bladder irrigation (Patient #12); c) updated nursing assessments were performed as needed for 7 of 26 sampled patients (#1, #2, #3, #4, #17, #22, #23) as evidenced by: failing to ensure patient's wounds were assessed by a Registered Nurse weekly as per hospital policy; a patient's needs were assessed prior to the administration of prn (as needed) Haldol for agitation; a registered nurse assessed the blood pressure of a patient being treated for hypertension after a significant decrease in blood pressure (See findings cited at A0395)

Based on record review and interview the hospital failed to ensure the MD was notified immediately of an emergency situation which required intervention and transfer of a patient to a higher level of care for 2 of 8 patients with emergent transfers out of 26 total sampled medical records (#13, #17). Findings:

Review of the medical record for Patient #13 revealed a 49 year old female admitted to the hospital on 12/16/10 for rehabilitation post respiratory failure and placement of a tracheotomy tube. Further diagnoses included morbid obesity, sleep apnea poorly controlled hypertension and asthma.

Review of the Nurses' Notes dated/timed 12/18/10 2200 (10:00pm) for Patient #13 revealed the nurse was called to the room by the CNA and LPN due to the patient's shortness of breath, dusky color and oxygen saturation of 55%.... 2202 (10:05pm) 911 called.... A non-rebreather mask was placed at the trach site... 2214 (10:14pm) Oxygen saturation continues to decrease now at 49%, patient unresponsive with eyes open, beginning to bag patient......2220 (10:20pm) MD S21 notified. Ambulance arrived and report given to them. Further review revealed no documented evidence MD S21 was involved in the management of Patient #13's emergency situation.

In a face to face interview on 03/25/11 at 11:00am MD S10 Medical Director indicated the physician should have been contacted immediately concerning the change in Patient #13's condition. Further S10 verified it is the responsibility of the physician to direct the care provided to the patient in an emergency situation even when the patient is to be transferred. S10 indicated the charge nurse who was on duty that night is no longer employed by the hospital.

Patient #17
Review of Patient #17's medical record revealed the 65 year old male patient had been admitted to the hospital for "aggressive rehabilitation" on 2/03/2011 and was discharged to an Acute Care Hospital (Hospital B) on 2/09/2011. Review of Patient #17's Discharge Summary dictated 3/08/2011 revealed in part, "Date of Admission: 2/03/2011. Date of Discharge: 2/09/2011. Discharge Diagnoses: Debility, status post respirator failure, Non-Q-wave myocardial infarction. Diabetes, mellitus, Malnutrition, status post PEG placement, Sepsis, and Pneumonia. Hospital Course: The patient was evaluated by therapy team, physiatrist, and Internal Medicine doctor. He was found to be stable to continue therapy. He also had a history of DVT (deep vein thrombosis, acute on chronic renal insufficiency, CHF (Congestive Heart Failure), and COPD (Chronic Obstructive Pulmonary Disease). He started his therapy, and on 2/09/2011, he was in severe respiratory distress. His pulse oximetry was around 60 %. A suction was done, but it did not improve his O2 saturations and the patient was sent to the emergency room of (Hospital B) for evaluation and treatment and the patient was admitted to the hospital."

Review of Patient #17's "Daily Nursing Progress Notes" dated 2/09/2011 revealed in part, "1840 (6:40 p.m.), pt (patient) called out "help", when assess, pt. (patient ) was leaning towards side of bed unresponsive, nurse started to suction trachea numerous times producing a lot of mucus return. O2 (oxygen) sats ( saturations) ranging from 84 - 96. . . . EMS (Emergency Medical Services) dispatched, per staff.. . . 1850 (6:50 p.m.) EMS arrived to transport to emergency room for eval (evaluation) . . . Transferred out.. . Notified MD (Medical Doctor)" Review of the entire medical record revealed no documented evidence that Patient #17's physician had been contacted to manage the patient's emergent condition while awaiting EMS.

In a face to face interview on 03/25/11 at 11:00am MD S10 Medical Director indicated the physician should have been contacted immediately when a patient experiences a significant decline in their condition. S10 indicated the attending physician or physician on call should manage emergency conditions until EMS arrives for transfer as needed.


20638

Based on record review and interview the hospital failed to follow policy and procedure for informed consents as evidenced by failing to complete a consent for PICC line to include Material Risks of treatment/procedure and any additional risks (if any) particular to the patient because of a complicating medical condition or reasonable therapeutic alternatives and risks associated with such alternatives (Patient #2) for 1 of 1 medical records reviewed for PICC line insertion. Findings:

Review of the medical record revealed Patient #2 was admitted to the hospital on 03/09/11 for antibiotic therapy after removal of hardware for repair of a hip fracture.

Review of the "Patient Consent for Medical Treatment or Surgical Procedure and Acknowledgement/Authorization" form dated 04/14/11 for Patient #3 revealed no documented evidence the following required information was completed for the consent to insert a PICC line: "3. Patient Conditions; 4. Material risks of treatment/procedure; 5. Reasonable therapeutic alternatives and risks associated with such alternatives".

In a face to face interview on 03/24/11 at 11:00am S13 RHIA indicated all required information should be documented on informed consents before obtaining consent and signatures.

Based on record review and interview the hospital failed to ensure a patient's request for further information regarding advanced directives was provided for 1 of 1 patients requesting additional information about Advanced Directives out of a total sample of 26 and failed to ensure attempts were made to obtain a copy of a patient's advanced directive/ Living Will for 1 of 1 patients with an advanced directive at the time of admission to the hospital out of a total sample of 26 (Patient #5, #15). Findings:

Patient #5:
Review of Patient #5's "Advance Directives Acknowledgement Statement" revealed the patient had a living will that was obtained at the sending hospital. Further review of the comment section revealed, "Pt. reported that he did not receive a copy from (sending hospital) of Living Will." No was checked off in the section titled "Does it still represent your wishes?".

During a telephone interview on 3/22/2011 at 11:00 a.m., Registered Nurse S5 indicated when she had admitted Patient #5 he had indicated that he didn't want to have a new Living Will written and wanted the one from his sending hospital obtained and honored. S5 indicated it would be the Social Worker that obtained the copy from the sending hospital. S5 indicated she was unsure why she had checked off "no" in the section titled, "Does it still represent your wishes?".

During a face to face interview on 3/23/2011 at 10:00 a.m., Licensed Masters Social Worker S4 indicated she had never received a referral regarding the need to locate the Advanced Directive for Patient #5. S4 indicated she (S4) had made no attempts to obtain the patient's (#5)Advanced Directive from the previous hospital.

Patient #15:
Review of Patient #15's "Advance Directive Acknowledgment Statement" located in the medical record for the admission date of 2/2/2011 with no documented date of completion revealed in part, "Do you want to speak to someone who can provide more information on Advance Directives?" Further review revealed a check mark placed by "Yes" with a hand written comment of "Referred to Social Worker." Further review revealed no date and time or signature on the form.

During a face to face interview on 3/22/2011 at 1400 (2:00 p.m.) Licensed Masters Social Worker S4 indicated she had never received any referral regarding Patient #15's request for additional information on Advanced Directives and it had never been provided.

Review of the hospital policy titled, "Advanced Directives in Hospital, #I-A.1.05" presented by the hospital as their current policy revealed in part, "The Hospital will provide written information to each patient admitted concerning: The individual's right under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment and the right to formulate and advance directive and the written policies respecting the implementation of such rights. . . At the time of admission, all adult patients, 18 years or older, or their representative, will be asked by the admitting nurse or Social Worker if he/she has existing living will or durable power of attorney for health care. The admitting nurse or case manager will indicated on the Advance Directive Acknowledgment sheet either "yes" or "no" or "revoked" based on the response from the patient or representative. The admitting nurse or Social Worker will ask the patient or representative to provide the original, to be copied and returned, or a copy of the advance directive. The admitting nurse or case manager will acknowledge receipt of the Advance Directive. If the patient or their representative does not produce a copy of the Advance Directive or Power of Attorney, the Social Worker will request and document that there has been an attempt to secure the documents three times. After the third time it will be assumed that there is no Durable Power of Attorney or Advanced Directive. The Social Worker will then offer the patient or their family member information on how to formulate these documents. . . Social Services or designee may assist any patient who wishes to execute an Advance Directive while a patient is in the hospital."

20177


Based on record review and interview the hospital failed to ensure a Registered Nurse supervised and evaluated the nursing care for each patient as evidenced by failing to ensure:
1) a patient's physician was notified for a change in condition for 1 of 26 sampled patients (#17);
2) a 3-way catheter had been inserted and bladder irrigation begun as ordered by the MD on a male patient who had had a traumatic urinary catheterization for 1 of 1 sampled patients with orders for bladder irrigation resulting in the patient continuing to experience hematuria with increasing blood clots and pain and having to be transferred to the Emergency Department of another facility for bladder irrigation (Patient #12);
3) updated nursing assessments were performed as needed for 7 of 26 sampled patients as evidenced by failing to ensure (#1, #2, #3, #4, #17, #22, #23):
2a) patient's wounds were assessed by a Registered Nurse weekly as per hospital policy for 1 of 26 sampled patients (#4).
2b) patient's needs were assessed prior to the administration of prn (as needed) Haldol for agitation for 1 of 1 patient reviewed for the administration of Haldol out of a total sample of 26 (Patient #3).
2c) re-assess the blood pressure of a patient being treated for hypertension after a significant decrease in blood pressure for 2 of 26 sampled patients (Patient #1, #2.)
2d)) a Registered Nurse assess patients in the hospital with significant changes in condition for 3 of 6 sampled patients reviewed with a significant change in condition out of a total sample of 26 (#17, #22, #23).
Findings:

1)
Patient #17:
Patient #17 was admitted to the hospital on 2/03/2011 and discharged on 2/09/2011 to Acute Care Hospital B as a result of a significant change in condition.

Review of Patient #17's History and Physical dictated on 2/04/2011 (no documented time) revealed in part, "He (#17) had difficulty and complication with weaning off the ventilator. His course of treatment was complicated by difficulty weaning off off the ventilator, and the trach was placed ( Hospital C). After that the patient was admitted to Hospital A for IV antibiotic therapy, for respiratory support, and for medical management. Considering the complexity of the patient's medical issues including coronary artery disease status post non ST-elevated MI (myocardial infarction), CHF (Congestive Heart Failure) , type 2 diabetes mellitus, Percutaneous drainage of gallbladder, severe malnutrition, respiratory failure, PEG tube placement, tracheotomy, left heart catheterization, chronic renal insufficiency, PVD (peripheral vascular disease), UTI (urinary track infection), trach management, the patient will require very aggressive rehabilitation, monitor all his current and possibly future complications in therapy. He is going to be very closely monitored by Nursing and doctors for participating in his care. We are going to very closely monitor all the parameters of his condition in order to prevent any complications. . ."

Review of Patient #17's medical record from Hospital A revealed the patient was receiving Atrovent 0.5 milligrams by hand held nebulizer every 4 hours, Albuterol Sulfate 3 milliliters of 0.83 milligrams per milliliter solution by hand held nebulizer every 4 hours, and Acetylcysteine 10% vial 300 milligrams every 12 hours per hand held nebulizer during his entire hospital stay prior to discharge with transfer to United Medical Healthwest. Review of the discharge orders from Hospital A to United Medical Healthwest revealed no documented evidence of any orders for handheld nebulizer treatments.

Review of Patient #17's Nursing Documentation at United Medical Healthwest revealed in part, "2/03/2011 at 2100 (9:00 p.m.), "suctioned per trach. Minimal secretions." 2/05/2011 at 1530 (3:30 p.m.), "pt. (Patient) C/O (complained of) difficulty coughing, pt.(patient) suctioned by the nurse with yanker and sterile suctioning moderate amount of sputum removed. Pt. sats (saturations) were 98% O2 (oxygen) at 4L (4 liters).", 2/05/2011 at 1900 (7:00 p.m., "pt. required suctioning d/t (due to) inability to expectorate, LS (lung sounds) course and noisy. . ." 2/05/2011 at 1730 (5:30 p.m.), "suction twice this shift; productive mucus, very thick returns. . .", 2/06/2011 at 2050 (8:50 p.m.), "weak cough; pt. required suctioning. Suctioned and enc'd (encouraged) pt. to cough. Suction and cough effective yellow thick flem (phlegm), mod (moderate) amt. (amount) noted. . ." , and 2/08/2011 at 0800 (8:00 a.m.), "C/O 'need to be suctioned', labored breathing noted. Rhonchi and wheezing noted on auscultation, cleared (with) suction. Tol (tolerated) well, 0 distress. Sat 99 %. . .". Review of the entire medical record revealed no documented evidence that Patient #17's physician was notified of the patient's increased sputum viscosity resulting in rhonchi, wheezing, and labored breathing on 2/08/2011 at 8:00 a.m.

Review of Patient #17's "Daily Nursing Progress Notes" for the date of 2/09/2011 at 1840 (6:40 p.m.) revealed in part, "Pt. called out "help" when assess pt. was leaning towards side of bed unresponsive. nurse started to suction trachea numerous times producing a lot of mucus return. O2 (oxygen) sats ranging from 84 - 96%. . . EMS dispatched per staff. . ."

This finding was confirmed by Respiratory Therapist S17 in a face to face interview on 3/23/2011 at 1540 (3:40 p.m.) who further indicated that she (Certified Respiratory Therapist S17) had called the patient's (#17) physician on 2/08/2011 at 1400 (2:00 p.m./ 6 hours after the patient's (#17) episode of labored breathing). S17 indicated she had received a verbal order from Patient #17's physician for "Aerosol tx. (treatment) c (with) Duoneb q4 (every 4 hours) prn (as needed) SOB (shortness of breath)." S17 indicated Albuterol and Atrovent (combined to equal Duoneb) were bronchodilators used to loosen secretions to aide in coughing them up, thus aiding to clear the patient's airway and make breathing easier. Review of Patient #17's entire medical record revealed no documented evidence that the patient had ever been administered prn (as needed) Duneb aerosol treatments during his entire hospital stay at United Medical Healthwest from admission date of 2/03/2011 through the date of transfer to an Acute Care Hospital on 2/09/2011.

2)
Review of the medical record for Patient #12 revealed he was admitted to the hospital on 11/17/10 from home secondary to a decline from previous lumber surgery which included urinary retention.

Review of the Physician's Orders dated/timed 11/21/10 at 11:30am for Patient #12 revealed an order for bladder irrigation. Review of the Nurses' Notes dated 11/21/10 through 11/22/10 revealed no documented evidence the order for bladder irrigation had been performed as ordered. Further review of the nurses' notes revealed on 11/22/10 Patient #12 continued to experience hematuria with blood clots and pain and was transferred to Hospital "B".

In a face to face interview on 03/23/11 at 3:00pm RN S1, ADON (Assistant Director of Nursing) indicated the facility does not stock 3-way catheters even though the hospital does accept patients with catheters or admit patients with conditions who may need catherization at some point during hospitalization. S1 indicated the hospital should have been able to obtain the 3-way catheter and the patient should have had the bladder irrigation performed. After review of the medical record, S1 confirmed the MD orders for bladder irrigation were not carried out by the nursing staff.

RN S20 charge nurse and the nurse caring for Patient #12 could not be interviewed due her termination of employment by the hospital.

3a)
Patient #4:
Patient #4 was admitted to the hospital on 3/05/2011 with an initial Registered Nurse Assessment revealing the patient had 4 wounds: Site #1 was described as a Stage II wound measuring 3 centimeters by 2 centimeters to the back of the patient's head, Site #2 was described as a Stage IV pressure ulcer to the patient's sacrum measuring 9.2 by 6.1 by 4.8 centimeters that was beefy red with slough around the wound, Site #3 was described as 1.5 to 4.5 centimeters pink beefy tissue to the upper left side of the patient's abdomen, and Site #4 was described as 19.5 by 4.5 by 0.5 to the suprapubic region with pink beefy tissue. Further review of Patient #5's entire medical record done on 3/21/2011, revealed no documented evidence that the four wound sites had ever been assessed with measurements and descriptions since 3/05/2011 (19 days after the patient had been admitted to the hospital).

During a face to face interview on 3/21/2011 at 10:20 a.m., Assistant Director of Nursing S1 indicated Patient #4's wounds should have been re-assessed by the Registered Nurse on 3/14/2011 and documented in the patient's medical record. After reviewing the medical record, S1 indicated there was no evidence that a Registered Nurse had assessed Patient #5's wounds weekly as it should have been.

Review of the hospital policy titled, "Wound Assessment Flow Sheet, #II-D.5.29" presented by the hospital as their current policy revealed in part, "At least on a weekly basis, the nurse will complete the flow sheet for each wound type. . . "
3b)
Patient #3:
Patient #3 was admitted to the hospital on 3/17/2011 with diagnoses that included left Cerebral Vascular Accident with right hemiparesis. Review of Patient #3's physician's orders revealed an order dated 3/17/2011 for Haldol 8 milligrams intramuscularly every 8 hours as needed for agitation. Review of Patient #3's Daily Nursing Progress Notes dated 3/17/2011 at 1935 (7:35 p.m.) revealed in part, "pt (patient) is total dependent in ADLs (Activities of Daily Living) and personal care." Further review revealed "2240 (10:40 p.m.), pt (patient) yelling out making incomprehensive sounds. Haldol 8 mg (milligrams) IM (intramuscularly) L (left) gluteal administered using aseptic technique." Review of the entire medical record revealed no documented evidence of a needs assessment for Patient #3 prior to the administration of Haldol to determine if the patient had been agitated due an unmet need such as the need to urinate, need to be changed, need to be repositioned, etc. prior to the administration of Haldol.

During a face to face interview on 3/21/2011 at 3:00 p.m., Assistant Director of Nursing S1 confirmed there was no documented evidence of a needs assessment for Patient #3 prior to the administration of Haldol for agitation. S1 indicated Patient #3 was mentally challenged in addition to having had a stroke. S1 indicated the patient's communication ability varied.

Review of the hospital policy titled, "Chemical Restraints, II-C.3.22" presented by the hospital as their current policy revealed in part, "Patients that are taking medications that include: Anti-psychotics, Tranquilizers or Neuroleptics, will be assessed in regards to their behavior and/or changes in their behavior and changes in the dosages of any of these medications, as needed. . . If the medications are ordered on a prn (as needed) basis, then the patient will be assessed upon admit, then re-assessed with each use of the medication."

3c)
Review of the medical record for Patient #2 revealed he was admitted to the hospital on 03/09/11 for antibiotic therapy for removal of infected hardware in his right hip. Further review revealed additional diagnoses of seizures, anemia and hypertension.

Review of the Physician's Orders for Patient #2 dated 03/09/11 at 1825 (6:25pm) revealed an order for Lopressor (Metoprolol) 25mg po (by mouth) BID (twice a day) Hold for SBP (Systolic Blood Pressure) less than 120, DBP (Diabolic Blood Pressure) less than 60, HR (Heart Rate) less than 60.

Review of the MAR (Medication Administration Record) for Patient #2 revealed no documented evidence blood pressure had been assessed before administration of Metoprolol on 03/09/11 at 2100 (9:00pm) and 03/10/11 at 9:00am.

Review of the "Graphic Sheet" used to document Patient #2's vital signs dated 03/11/11 at 8:00pm revealed a blood pressure of 89/60 and a heart rate of 94 which was taken by the CNA (Certified Nursing Assistant). Further review of the Graphic Sheet and the Nurses' Notes dated 03/11/11 revealed no documented evidence the patient was assessed by the RN or another blood pressure taken.

Patient #1 (Clonidine)
Review of the medical record revealed Patient #1 was admitted to the hospital on 03/08/11 for a subarachnoid hemorrhage and fractured left clavicle. Further review revealed Patient #1 had a history of hypertension.

Review of the Physician's Orders for Patient #1, dated/timed 03/08/11 at 1500 (3:00pm), revealed an order for Clonidine 0.1mg Q6 hours (every six hours) prn (as needed) if SBP (Systolic Blood Pressure) greater than or equal to 160.

Review of the "Graphic Sheet" used for recording vital signs revealed Patient #1's blood pressure was assessed at 8:00am and 8:00pm (every 12 hours).

Review of the MAR (Medication Administration Record) for Patient #1 revealed Clonidine 0.1mg was administered on the following dates and times: 03/17/11 at 1835 (6:35pm) and 03/18/11 at 0315 (3:15am).

Review of the MAR, Graphic Sheet and the Nurses Noted for Patient #1 dated 03/17/11 through 03/18/11 revealed no documented evidence re-assessment of the blood pressure had been performed after receiving prn (as needed) Clonidine for elevated blood pressure.

3d)
Review of Patient #17's medical record revealed the patient was receiving nursing care by LPN (Licensed Practical Nurse) S24 on the date of 2/09/2011. Review of Patient #17's "Daily Nursing Progress Notes" revealed in part, "2/09/2011 1840 (6:40 p.m.) pt (patient) called out "help", when assess, pt. (patient ) was leaning towards side of bed unresponsive, nurse started to suction trachea numerous times producing a lot of mucus return. O2 (oxygen) sats ( saturations) ranging from 84 - 96. . . . EMS (Emergency Medical Services) dispatched, per staff.. . ." Review of the entire medical record revealed no documented evidence that Patient #17 had been assessed by a Registered Nurse on the date of 12/23/2010 when the patient had a significant change in condition which required transfer to an Acute Care Hospital (Hospital B) on 2/09/2011 at 1850 (6:50 p.m.). Further there was no documented signature of a Registered Nurse co-signing the documentation by the Licensed Practical Nurse S24 regarding emergency care provided to the patient related to the significant change in condition.

Review of Patient #22's medical record revealed the patient was receiving nursing care by LPN (Licensed Practical Nurse) S24 on the date of 12/23/2010.
Review of Patient #22's "Daily Nursing Progress Notes" revealed in part, "12/23/2010, 1045 (10:45 a.m.), called to therapy gym, pt (patient in distress. . . Blood Pressure 110/59, HRate (heart rate) 44, Sweating, Agitated. Quickly transferred back to room into bed. Placed pt (patient) in Trendelenberg and performed sternum rubs to help stimulate heart rate. . . range from 44 - 52. . . 1110 (11:10 a.m.) Pt. still unstable. . . asked other nurse to go grab crash cart just in case it was needed . . . was continuing to perform sternum rubs to help increase heart rate which had went to 109 - 118. . ." Review of the entire medical record revealed no documented evidence that Patient #22 had been assessed by a Registered Nurse on the date of 12/23/2010 when the patient had a significant change in condition which required transfer to an Acute Care Hospital (Hospital B) on 12/23/2010 at 11:20 a.m. Further there was no documented signature of a Registered Nurse co-signing the documentation by the Licensed Practical Nurse S24 regarding emergency care provided to the patient related to the significant change in condition.

Review of Patient #23's medical record revealed the patient was receiving nursing care by LPN S15 on 12/28/2010. Review of Patient #23's "Daily Nursing Progress Notes" revealed in part, "pt. (with) labored breathing, unable to regulate secretions 2 (secondary) dysphagia T/T (related to) end stage Alzheimer's Disease. DON (Director of Nursing) and Charge Nurse (at) bedside. Pt. dusty in color. suctioned (with) lg (large) amts (amounts) of frothy thick secretions noted in canister. #911 called and (Physician S10) notified (of) pts (patient's) situation. . . " Review of Patient #23's entire medical record revealed no documented evidence that Patient #23 had been assessed by a Registered Nurse on the date of 12/28/2010 when the patient had a significant change in condition which required transfer to an Acute Care Hospital (Hospital B) on 12/28/2010 at 1445 (2:45 p.m.). Further there was no documented signature of a Registered Nurse co-signing the documentation by the Licensed Practical Nurse S15 regarding emergency care provided to the patient related to the significant change in condition.

During a face to face interview on 3/25/2011 at 11:20 a.m., Assistant Director of Nursing S1 indicated it had been the practice at the hospital for Registered Nurses to attend to patients when a significant change in condition occurred, but it had not been their practice to document assessments post event or to sign the nursing notes written by the Licensed Practical Nurse. S1 indicated she had thought the presence of a Registered Nurse during an emergent incident would have been sufficient.




20638

Based on record review and interview the hospital failed to: 1) ensure nursing staff implemented the plan of care as per physicians orders by failing to insert a 3-way catheter and begin bladder irrigation on a male patient who had had a traumatic urinary catherization for 1 of 1 sampled patients with orders for bladder irrigation resulting in the patient continuing to experience hematuria with increasing blood clots and pain and having to be transferred to the Emergency Department of another facility for bladder irrigation (#12), performing a bladder scan on a patient who had already voided (#10), and failing to collect stool samples time three for occult blood on a patient with a history of a Gastrointestinal Bleed (#11) for 3 of 26 sampled medical records; 2) ensure nursing staff developed interventions and measurable goals for a patient with impaired skin integrity (#5), a patient taking Plavix, a blood thinner and Aspirin (ASA) with a history of epistaxis (nosebleeds) (#7), and a patient who developed hematuria and blood clots from a traumatic urinary catherization (#12) for 3 of 26 sampled medical records. Findings:
1) ensure nursing staff implemented the plan of care as per physicians orders Patient #12 Review of the medical record for Patient #12 revealed he was admitted to the hospital on 11/17/10 from home secondary to a decline from previous lumber surgery which included urinary retention.
Review of the Physician's Orders dated/timed 11/21/10 at 11:30am for Patient #12 revealed an order for bladder irrigation. Review of the Nurses' Notes dated 11/21/10 through 11/22/10 revealed no documented evidence the order for bladder irrigation had been performed as ordered. Further review of the nurses' notes revealed on 11/22/10 Patient #12 continued to experience hematuria with blood clots and pain and was transferred to Hospital "B".

In a face to face interview on 03/23/11 at 3:00pm RN S1, ADON (Assistant Director of Nursing) indicated the facility does not stock 3-way catheters even though the hospital does accept patients with catheters or admit patients with conditions who may need catherization at some point during hospitalization. S1 indicated the hospital should have been able to obtain the 3-way catheter and the patient should have had the bladder irrigation performed. After review of the medical record, S1 confirmed the MD orders for bladder irrigation were not carried out by the nursing staff.

RN S20 charge nurse and the nurse caring for Patient #12 could not be interviewed due her termination of employment by the hospital.

Patient #10:
Medical Record review revealed Patient #10 was admitted to the hospital on 9/24/2010 with diagnoses that included recent stroke, right CVA with left hemiparesis, and multiinfarct dementia with behavioral disturbances. Further review revealed a physician's order dated 9/25/2010 at 2025 (8:25 p.m.) for "If patient does not void by a.m. (0500/5:00 a.m.) perform bladder scan and document, then catheterize pt (in and out). . ."

Review of Patient #10's "Daily Nursing Progress Notes" dated 9/25/2010 revealed in part, "1000 (10:00 a.m.) performed in and out cath to obtain U/A (urinalysis) and C&S (culture and sensitivity) specimen as per standing order. .. .", "2315 pt. (patient) incontinent of bladder and linen soiled assisted pt (with) clean up. . . ", 9/26/2010 "0445 (4:45 a.m.), pt. incontinent of bladder. . .", and "0535 (5:35 a.m.), pt remains with outstanding collection of U/A (and) C&S (note it was collected at 10:00 a.m.); bladder scan = 93 ml (milliliter), In (and) out cath performed (with) sterile technique by this nurse. . ."

A face to face interview was conducted with Assistant Director of Nursing S1 on 3/22/2011 at 1330 (1:30 p.m.). S1 indicated Patient #10 should never have received a bladder scan or catheterization on 9/26/2010 at 5:35 a.m. because the patient had already had an in and out cath performed on the day shift to collect the urine sample and the physician's order written at 8:25 p.m. on 9/25/2010 indicated the scan and catheterization were only to be done if the patient failed to urinate; however, the patient had urinated at 2315 and 0445.

Patient #11
The medical record for Patient #11 was reviewed. Documentation revealed an admit date of 09/23/10 with diagnoses of Left Acute Hip Fracture and a history of Gastrointestinal Bleed. Review of the Physician's Orders dated and timed 09/25/10 11:55am revealed an order for "Stools for occult blood times 3." Review of the entire record revealed one stool specimen was collected on 10/02/10. There was no documented evidence of the collection of 2 more stool specimens as ordered. Review of the Graphic Sheet revealed documented evidence Patient #11 had bowel movements on 09/26/10, 09/27/10, 09/29/10, 10/01/10, 10/02/10, 10/03/10, 10/04/10 and 10/05/10.

S1, Assistant Director of Nurses confirmed on 03/22/11 at 2:30pm only one stool specimen had been collected for Patient #11 and there was documented evidence the patient had bowel movements on the above dates.

2) the nursing staff developed and kept current a nursing care plan for each patient: Patient #5: Patient #5 was admitted to the hospital on 1/07/2011 with diagnoses that included Diabetes with Neuropathy and Bilateral amputation with gait abnormality. Further review revealed Patient #5's initial Registered Nurse Assessment of a wound to the left shoulder bright red in color measuring 2 x 2.5 centimeters and a surgical wound to the right wrist described as 4.5 centimeters. Review of Patient #5's Nursing Plan of Care revealed the section titled skin integrity to be blank with no skin problem identified, no treatment interventions, and and no documented measurable goals.
During a face to face interview on 3/22/2011 at 10:35 a.m., Assistant Director of Nursing S1 confirmed there was no documentation in Patient #5's Plan of Care identifying skin integrity as a problem. S1 indicated the nursing staff should have addressed the problem of a wound to Patient #5's shoulder to include interventions and measurable goals.
Patient #7 The medical record for Patient #7 was reviewed. Documentation revealed an admit date of 12/01/10 with a diagnosis of Rhabdomyolysis and Diabetes, type 2.
Review of the Admission Medication Orders dated 12/01/10 revealed medication orders for Plavix 75 mg and ASA 81mg by mouth every am. Review of the Daily Nursing Notes dated 12/03/10 and 12/08/10 revealed Patient #7 had nose bleeds. Review of the Interdisciplinary Plan of Care dated 12/01/10 and updated 12/05/10 and 12/07/10 revealed no documented evidence interventions and goals were established and implemented for the patient's potential for bleeding secondary to the administration of blood thinners.

S1, Assistant Director of Nurses confirmed on 03/11/11 at 10:10am the patient's potential for bleeding and the nosebleeds were not addressed in the Interdisciplinary Plan of Care.

Review of the Initial Nursing Assessment for Patient #9 dated 09/23/10 revealed the patient had a history of breast cancer with a left mastectomy performed. Further review of the Nursing Assessment revealed a blood pressure was taken on admit on the left arm.

Review of the "Graphic Sheet" (used to record vital sign data) dated 09/23/10 through 09/27/10 revealed no documented evidence which arm the blood pressures had been taken.

Review of the Multidisciplinary Treatment Plan for Patient #9 dated 09/22/10 revealed problems identified as communication, knowledge, risk for injury related to falls, pain/comfort alteration and impaired mobility function. Further review revealed no documented evidence precautions for Patient #9's left arm due to a left mastectomy had been care planned.

Patient #12
Review of the medical record for Patient #12 revealed he was admitted to the hospital on 11/17/10 from home secondary to a decline from previous lumber surgery which included urinary retention.

Review of the Nurses' Notes for Patient #12 dated 11/20/10 revealed he complained of frequent urination with burning. Further review revealed urine was obtained for a culture and sensitivity and MD orders were received for the insertion of a Foley catheter. According to the nurses notes, the catheter was inserted after a second try with bloody drainage and small clots.

Review of the Multidisciplinary Plan of Care dated 11/21/10 revealed the Problem of Altered Elimination of the bladder. The Treatment Plan revealed a check by the following:: assess abdomen, bowel sounds, appetite, any straining at stool or oozing of stool, with fluids, foods, toileting at same time each day; assess voiding, urine appearance; with fluids and toileting every 2 hours while awake and before bedtime; and instruct on care of device (ostomy, catheter) and signs and symptoms of complications to report. Further review revealed no treatment plan updates to address the hematuria, blood clots, or ordered bladder irrigation for Patient #12's identified problems as documented in the nurses' notes.

In a face to face interview on 03/23/11 at 3:00pm RN S1, ADON (Assistant Director of Nursing) indicated the plan of care should have been updated to reflect the changes.

Review of the hospital policy entitled "Initial Plan of Care" Policy # II-A.1.01 presented as the hospital's current policy revealed in part, "Purpose: to establish a comprehensive, goal oriented, individualized plan for each patient served based on assessment of patient physical, behavioral, communicative, emotional, pharmacological, pain management and social needs. Procedure: 2. The individual treatment plan includes the following information presently behavioral: c. The type of treatment and/or services to be provided, and revised when appropriate. d. Measurable goals with the anticipated time frames of accomplishing these goals. e. Objective measures to be used to assess progress and goal attainment."





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20638

Based on record review and interview the hospital failed to ensure:
1) nursing staff assigned to patients receiving respiratory care, in the absence of respiratory therapists, were knowledgeable of oxygen delivery devices utilized in the hospital for 3 of 5 patients reviewed for oxygen delivery out of a total sample of 26 (Patient #13 receiving respiratory care by Registered Nurse (RN) S20 on 12/18/2010, #23 receiving respiratory care by Licensed Practical Nurse(LPN) S15 on 12/28/2010, #24 receiving respiratory care by RN S16 on 1/21/2011).
2) designate in writing the training and experience of personnel authorized to perform each type of respiratory care service as evidenced by no documented evidence of a competency assessment of all skills performed by the nursing staff providing respiratory care (nebulizer treatment, tracheotomy care, suctioning of the tracheotomy, oxygen therapy, Bi-PAP and C-PAP) services for 6 of 6 RN/LPN personnel files reviewed S5, S11, S14, S17, S30, S31. Findings:

1) Observations on 3/21/2011 at 10:53 a.m. revealed several full e-cylinders located in the hospital's oxygen supply closet.

Patient #13
Review of the medical record for Patient #13 revealed a 49 year old female admitted to the hospital from a Long Term Acute Care facility on 12/16/10 for Chronic Respiratory Failure with trach and a history of Diabetes, Morbid Obesity, Urinary Tract Infection, Hypertension, Asthma and Depression.

Review of the Nurses' Notes dated/timed 12/18/10 at 2200 (10:00pm) for Patient #13 revealed....."complained of shortness of breath, became dusky in color with O2 (oxygen) saturation of 55% and removed 28% from TC (trach collar), applied non-rebreather mask to trach. 2214 (10:14pm) Pt. (Patient) SaO2 (Oxygen Saturation) 42%, non-responsive but eyes remain open, writer began bagging pt via trach with ambu bag. 2215 (10:15pm) BP (Blood Pressure) 131/88, Pulse 81, R (Respirations) 18, T (Temperature) 98.4 degrees Fahrenheit, SAO2 48%". Further review of the nursing notes for Patient #13 revealed she was transferred to Acute Care Hospital "B" where she expired twenty minutes later. Further review of the medical record revealed no documented evidence of the percentage of oxygen delivered with the application of the non-rebreather mask or if oxygen was used when S13 was ambued.

An interview with RN S20, the nurse assigned to her care on 12/18/10, could not be performed due to the termination of S20 by the facility.

Patient #23:
Review of Patient #23's medical record revealed the patient was admitted to the hospital on 12/21/2010 with diagnoses that included Alzheimer's. Further review revealed Daily Nursing Progress Notes dated 12/28/2010 at 1435 (2:35 p.m.) that revealed in part, "pt (patient) (with) labored breathing, unable to regulate secretions 2 (secondary) dysphagia r/t (related to) end stage Alzheimer's Disease. DON (Director of Nursing) and Charge nurse (at) bedside. pt dusty in color. suctioned (with) lg. (large) amts (amounts) of frothy thick secretions noted in canister. #911 called and (Physician S 10) notified pt's situation. Awaiting ambulance arrival. ongoing monitoring." Further review revealed at 1440 (2:40 p.m.), "pt. (patient) placed on 100% venti mask. suctioned pink (at) present.. . sats (at) 94%. continues to monitor, awaiting ambulance arrival. . ."

During a telephone interview on 3/24/2011 at 1325 (1:25 p.m.), Licensed Practical Nurse S15 indicated she was not sure what the oxygen liter flow should have been to deliver 100% oxygen. S15 indicated she had set the liter flow to somewhere between 5 - 8 liters per non-rebreather mask to deliver 100% oxygen. S15 indicated she had called Physician S10 after she had initiated oxygen and called EMS.

Patient #24:
Review of Patient #24's History and Physical dictated 1/15/2011 at 2226 (10:26 p.m.) revealed in part, "Chief Complaint: Deconditioning and gait abnormality. Co-morbidities: COPD (Chronic Obstructive Pulmonary Disease), hepatitis C, lower extremity DVT (Deep Vein Thrombosis), BPH (Benign Prostatic Hypertrophy), anemia, CAD (Carotid Artery Disease), and Barrett's esophatitis. Review of Systems: . . . He has occasional shortness of breath, but no chest pain.. ."

Review of Daily Nursing Progress notes for Patient #24 dated 1/21/2011 at 1730 (5:30 p.m.)" sitting up in chair. O2 (oxygen) sats (saturation) 82, oxygen (increased) to 4 liters/nc (nasal cannula) and placed on non-rebreather."

Review of Daily Nursing Progress notes for Patient #24 dated 1/21/2011 at 1750 (5:50 p.m.) revealed in part, "O2 (oxygen) off - went to bathroom. Sats 55 %. O2 (oxygen) placed on a non-rebreather @ 4L. . . will notify MD."

During a telephone interview on 3/24/2011 at 1315 (1:15 p.m.), Registered Nurse S16 indicated she had placed Patient #24 on a non-rebreather mask on the date of 1/21/2011 at 4 liters even though she knew it should have been on a higher liter flow. S16 indicated the oxygen concentrators used in the hospital would only deliver 4 liters flow. S16 confirmed that she did not attach the non-rebreather to an e-cylinder for higher oxygen flow and did not have a physician's order to administer oxygen with a non-rebreather prior to placing the patient with a history of Chronic Obstructive Pulmonary Disease on a non-rebreather mask, although she indicated she did inform the patient's physician afterwards.

During a face to face interview on 3/23/2011 at 1540 (3:40 p.m.), Certified Respiratory Therapist S17 indicated to deliver 100 % oxygen through the non-rebreather mask the liter flow should be set to 15. Further S15 indicated the oxygen concentrators used for patients throughout the hospital would only deliver up to 5 liters flow. S17 indicated in order to deliver a higher flow rate, the staff would need to use an e-cylinder. Further S17 indicated that any patient with sats below 92% should have their physician notified to obtain orders for oxygen therapy and/or aerosol therapy as needed. S17 indicated she only worked part time at the hospital and averaged a few hours per day on the days the hospital indicated they needed her to evaluate patients. S17 indicated nursing staff provided respiratory care to hospitalized patients in her absence.

During a face to face interview on 3/25/2011 at 10:40 a.m., Medical Director S10 indicated she had not been aware that nursing staff were uncertain how to deliver oxygen through non-rebreather masks. S10 indicated nursing education would be needed to address the failure of nursing staff to understand oxygen concentration delivery per oxygen delivery systems on hand at the hospital.

Review of the hospital policy titled, "Estimation of percentage of oxygen, # RC.6.01" presented by the hospital as their current policy revealed in part, "The following guidelines will provide (an) approximate FIO2 (oxygen percentage) when utilizing low flow oxygen devices. . . Mask with Reservoir Bag . 6 (=) 60 %, 7 (=) 70%, 8( =) 80%, 9( =) 90%, 10( =) 95%.

2)2)Review of the personnel files for RN5, LPN S11, RN S14, RN S30, and LPN S31 revealed no documented evidence of a skills competency assessment for Bi-PAP or C-PAP.

Review of the personnel files for RN S14, and RN S30 revealed no documented evidence of a skills competency assessment for performance of nebulizer treatments, tracheotomy care, suctioning of the tracheotomy, and oxygen therapy.

In a face to face interview on 03/21/11 at RN S1 ADON (Assistant Director of Nursing) indicated it was the responsibility of the DON (Director of Nursing) to make sure all of the nursing staff are competent. Further S1 indicated there have been changes in the DON position with the present DON RN S2 out on medical leave.

Based on record review and interview the hospital failed to ensure medical records were complete as evidenced by failing to fill in blanks on the transcriptions of dictated documents for 2 of 26 sampled patients' medical records (#9, #18). Findings:

Patient #9
Review of the "Discharge Summary" for Patient #9 who was discharged on 10/02/10 revealed physician S21 dictated and signed the document on 10/26/10. Further review of the Discharge Summary revealed S21 left 6 blanks which were not completed before the physician authenticated the document.

Patient #18
Review of Patient #18's "Post Admission Evaluation" form dictated by the physician on 1/08/2011 (no documented time) and signed by Physician S21 on 1/08/2011 at 1800 (6:00 p.m.). Further review revealed two blanks were present on the transcribed document. These blanks had not been filled in/completed when the physician reviewed and signed the form.

Review of the hospital policy titled, "Dictation, III-A.1.20" presented by the hospital as their current policy revealed in part, "Quality Controls: Both routine and periodic review of dictated/transcribed reports shall be carried out to monitor the quality of materials produced. . Each report shall be routinely reviewed for the following. . . correction of typographical errors, spelling errors, mistakes in medical terminology. . ."

Review of the Medical Staff By-Laws "Rules and Regulations" last reviewed 01/11 revealed.... "3.7 Basic Responsibilities of Medical Staff Membership: 4. Accurate, timely, and legible completion of medical records".

In a face to face interview on 03/24/11 at 11:00am S13, RHIA, indicated completion of the dictated summaries were not being reviewed at the present time.

20638

Based on record review and interview the hospital failed to ensure a Medical History and Physical Examination was completed and placed in the patient's medical record within 24 hours after admission to the hospital for 2 of 26 sampled patients (#2, #18). Findings:

Patient #2
Review of the medical record for Patient #2 revealed he was admitted on 03/09/11 for antibiotic therapy after removal of hardware from the hip. Review of the H&P revealed the date of dictation was 03/11/11 and the date the dictation was typed was 03/12/11(no time documented) which was three days after admission.

Patient #18
Review of Patient #18's medical record revealed the patient was admitted to the hospital on 1/07/2011 with documentation revealing an accucheck had been performed at 2100 (9:00 p.m.). Further review revealed Patient #18's History and Physical was dictated on 1/09/2011 with no documented time (2 days after admission to the hospital).

Review of the hospital policy titled, "Time Frames, III-A.1.17" presented by the hospital as their current policy revealed in part, "Physician Health Record Completion Responsibilities: Document- History and Physical. Completion Time- 24 hours."

In a face to face interview on 03/25/11 at 11:00am S13, RHIA, indicated completion of the dictation (making sure all of the blank lines have been addressed by the physician) was not being monitored at the present time.

In a face to face interview on 03/25/10 at 11:00am Medical Director S10 indicated a problem with dictation had been identified; however she thought the problem had been solved.

Based on observation and interview the hospital failed to ensure outdated nutritional supplements were not available for patient use in 1 of 1 storage rooms observed for nutritional supplements. Findings:

Observations made on 3/21/2011 at 11:15 a.m. revealed 6 cans containing 8 fluid ounces of Nepro Carb Steady Nutritional Supplement with expiration dates of 2/01/2011 (expired 47 days prior to the observation) to be located in the Hospital Storage Room located next to the Nursing Station.

This finding was confirmed in a face to face interview on 3/21/2011 at 11:15 a.m. by Human Resource Director S22. S22 further indicated the supplies located in the storage room were there for patient use. S22 indicated she typically checks the supplies for expiration dates and it had been an oversight that the expired Nepro Carb Steady Nutritional Supplements remained in the Storage Room.

Review of the hospital policy titled, "Patient Supplements/Nourishments, II-C.3.30" presented by the hospital as their current policy revealed in part, "All nourishments/supplements will be checked on a weekly basis for expiration dates. If expired, items will be properly discarded."

20638

Based on record review and interview the hospital failed to ensure medication errors were reported to the patient's physician and the hospital wide Quality Assurance Performance Improvement Committee for 7 of 7 patients with medication errors reviewed for occurrence reporting (#2, #4, #5, #18, #21, #22, #25). Findings:

Review of Medical Error reports revealed no documented evidence of reports regarding the following medication errors:
Patient #22:
Patient #22 had been administered Coreg on 25 milligrams on 12/18/2010 at 9:00 a.m. and 9:00 p.m., 12/19/2010 at 9:00 p.m., 12/20/2010 at 9:00 a.m. and 9:00 p.m., and 12/21/2010 at 9:00 a.m. and 9:00 p.m. when the patient's pulse on the graphic sheet revealed the rate was 60 or less. Further there had been no documented evidence that the patient's apical pulse had been monitored prior to the administration of Coreg (See findings cited at A0404).
Patient #4: Patient #4 received administration of Metoprolol on 3/12/2011 at 9:00 a.m. when the patient's systolic blood pressure was documented as 106 (106/71) and on 3/19/2011 at 9:00 a.m. when the patient's systolic blood pressure was documented as 102 (102/78) (See findings cited at A0404).

Patient #5:
Patient #5 failed to receive 4 units Sliding Scale Humilin Insulin subcutaneously for an accucheck of 203 on 1/07/2011 at 2100 (9:00 p.m.), 211 on 1/08/2011 at 2100 (9:00 p.m.), and 213 on 1/16/2011 at 0600 (6:00 a.m.) as per physician's sliding scale order (See findings cited at A0404).

Patient #18:
Patient #18 failed to receive 4 units Sliding Scale Humilin Insulin subcutaneously for an accucheck of 215 on 1/08/2011 at 0600 (6:00 a.m.) and 241 on 1/09/2011 at 2100 (9:00 p.m.) as per physician's orders (See findings cited at A0404)

Patient #21: Patient #21 received Toprol XL (Metoprolol) 50 milligrams by mouth on 12/18/2010 at 9:00 p.m. when the patient's graphic sheet indicated the patient's pulse was 58 and on 12/19/2010 at 8:00 p.m. when the patient's graphic sheet indicated the patient's pulse was 59 at 8:00 p.m. (See findings cited at A0404)

Patient #2
Review of the MAR (Medication Administration Record) for Patient #2 revealed no documented evidence blood pressure had been assessed before administration of Metoprolol on 03/09/11 at 2100 (9:00pm) and 03/10/11 at 9:00am. Further review revealed Metoprolol was administered when the assessed blood pressure (BP) for Patient #2 was outside of the ordered parameters as follows: 03/11/11 at 2100 (9:00pm) 116/69; 03/15/11 at 0900 (9:00am) 117/66; and 03/18/11 0900 (9:00am) BP 116/74.

Patient #25
Review of the respiratory treatment form used to document assessments and treatments for Patient #25 revealed no documented evidence the following treatments for Ipratropium Bromide 0.02% every 4 hours had been administered as ordered: 12/04/10 1400 (2:00pm) and 1800 (6:00pm); 12/05/10 1000 (10:00am); and 12/13/10 1800 (6:00pm). Further review of the form under "events" revealed no documented evidence the reason the treatment was not administered.

Review of Patient #2, #4, #5, #18, #21, #22, and #25's medical records revealed no documented evidence that the patients' physicians had been notified of the medication errors.

During a face to face interview on 3/25/2011 at 11:20 a.m., Assistant Director of Nursing S1 confirmed there were no medication variance reports/occurrence reports for the above listed medication errors. Further S1 indicated she was unable to find any documented evidence that the patient's physician had been notified of the errors.

Review of the hospital policy titled, "Management of Medication Errors, I-E.5.06" presented by the hospital as their current policy revealed in part, "Reporting: Employees are expected to report medication errors and potential medication errors via the Medication Error and Adverse Drug Reaction Report. . ."

Based on record review and interview the hospital failed to ensure radiologist interpreting x-rays were credentialed by the governing body for 2 of 3 radiologists reviewed for interpreting diagnostic radiology films for the hospital (Physician S7, Physician S8). Findings:

Review of the Radiologist Interpretation of a Right Shoulder X-ray, obtained as ordered by United Medical Health West on Patient #16 dated 11/14/2010, revealed the interpretation was performed by Physician S8 (Radiologist).

Review of the Radiologist Interpretation of a Chest X-ray, obtained as ordered by United Medical Health West on Patient #18 dated 1/13/2011, revealed the interpretation was performed by Physician S7 (Radiologist).

Review of Physician Credentialing files revealed the only Radiologist credentialed at the hospital was Radiologist S6. Further review revealed no documented evidence that Physician S7 or Physician S8 were credentialed as Radiologists at the Hospital.

This finding was confirmed in a face to face interview with Assistant Director of Nursing S1 on 3/22/2011 at 1515 (3:15 p.m.).

Based on observation and interview, the hospital failed to: 1) obtain a three-way catheter for a patient with orders to perform continuous bladder irrigation for 1 of 1 patients with orders for bladder irrigation (#12) and 2) ensure the bladder scan equipment was properly calibrated for one of one bladder scan machines located in the hospital. Findings:

1) obtain a three-way catheter for a patient with orders to perform continuous bladder irrigation
Review of the Physician's Orders dated/timed 11/21/10 at 11:30am for Patient #12 revealed an order for bladder irrigation. Review of the Nurses' Notes dated 11/21/10 through 11/22/10 revealed no documented evidence the order for bladder irrigation had been performed as ordered.

In a face to face interview on 03/23/11 at 3:00pm RN S1, ADON (Assistant Director of Nursing) indicated the facility does not stock 3-way catheters even though the hospital does accept patients with catheters or admit patients with conditions who may need catherization at some point during hospitalization. S1 indicated the hospital should have been able to obtain the 3-way catheter and the patient should have had the bladder irrigation performed.

2) ensure the bladder scan equipment was properly calibrated for one of one bladder scan machines located in the hospital
Observations on 3/22/2011 at 1330 (1:30 p.m.) revealed a display screen that appeared when the hospital's only bladder scan (ultrasound machine that calculates bladder volume based on image) was turned on. Review of the display screen revealed, "Calibration (to determine, check, adjust the graduation of measurements of) due 9/2009 (September 2009)." This observation was confirmed in a face to face interview (at the time of the observation) by the hospital's Assistant Director of Nursing S11. S11 further indicated she had no recall of any calibration being performed on the hospital's bladder scan.

During a face to face interview on 3/23/2011 at 4:00 p.m., Administrator S9 indicated there was no documented evidence that the hospital's bladder scan equipment had been calibrated since it had been purchased. S 9 further indicated the machine had not been calibrated in 2009 when it had been due and had also not been calibrated since that time.

Based on record review (personnel file) and interview the hospital failed to ensure the Infection Control Officer was qualified through current ongoing education, training, experience and/or certification. Findings:

Review of the personnel file for S2, Director of Nursing/Infection Control Officer revealed no documented evidence of current educational training, experience or certification in the development of the Infection Control processes in hospitals in order to implement the Infection Control Program. Further there was no documented evidence of a Job Description for S2's designated position as the Infection Control Officer.

In a face to face interview on 03/23/11 at 10:30am S2, DON/Infection Control Nurse indicated she was not currently enrolled in ongoing educational training in infection control and her experience had been through direct patient care and as the DON participation in Quality Assurance.

Based on observation and interview the hospital failed to ensure infection control measures were implemented regarding the storage of patient's personal belongings on top of clean supplies in the storage room for 1 of 1 storage room observed for storage of patient's personal belongings. Findings:

Observations on 3/21/2011 at 11:15 a.m. revealed a storage room located near the nursing station. Upon entering this storage room, it was observed that the passage way from the front of the storage room to the back of the storage room was packed tightly and did not allow passage from the front of the room to the back of the room. Further observations revealed 4 patient personal belongings bags stacked on top of clean supplies at the entrance to the room which included 2 boxes of potable water and 2 boxes of disposable cups which were stored directly on the floor.

This finding was confirmed in a face to face interview at the time of the observation (3/21/2011 at 11:15 a.m.) by S22 Human Resources. S22 further indicated that the room had been overcrowded due to wheelchairs being placed in the room post patient discharges. S22 indicated there was no room for staff to travel to the back of the storage room where patients' personal belongings were supposed to be stored. S22 confirmed that patients' personal belongings bags would be considered dirty due to having items from home such as shoes, etc placed in the bags and should not have been stored on top of clean supplies. S22 further indicated that boxes of clean supplies should not have been stored on the floor. S22 indicated the room was overcrowded which was interfering with proper storage of items in the room and that it needed to be cleaned up and re-arranged.

Based on record review and interview the hospital failed to ensure a physician supervised the respiratory department as evidenced by no documented evidence a Respiratory Director had been appointed by the medical staff or confirmed by the Governing body. Findings:

In a face to face interview on 03/21/11 at RN S1 ADON indicated she thought the Director of Respiratory Services was the Medical Director MD S10.

In a face to face interview on 03/23/11 at 11:30am MD S10 indicated she was not the Respiratory Director. Further S10 indicated the hospital used to have a Pulmonologist, but he was not longer on staff. S10 indicated she remembered discussion with the former CEO (Chief Operating Officer); however she was not sure which physician had been chosen.

Review of the credentialing file for MD S23 revealed a statement signed in January 2011 by the former CEO S18 and MD 23 agreeing S23 would be the Respiratory Director.

In a face to face interview on 03/23/11 at 2:30pm MD S23 indicated the former CEO S18 had spoken to him about this back in January before he left; however the subject of Respiratory Director had not been discussed since. Further S23 indicated at the present time there is no respiratory department because the nurses are doing all the treatments. S23 indicated he thought the hospital was waiting until respiratory personnel had been hired to develop the department. S23 indicated he was not functioning in the position of respiratory Director at the present time and was not supervising all respiratory care performed by the nursing staff.

Review of the meeting minutes of the Medical Executive Committee and Governing Body dated 02/09/11 (the first meetings conducted in the new year) revealed no documented evidence S23 had been recommended by the Medical Staff or appointed by the Governing Board as Director of Respiratory Services.

Based on record review and interview the hospital failed to ensure oxygen administration was delivered as per hospital policy for 3 of 3 patients experiencing respiratory distress and receiving oxygen out of 26 sampled medical records (Patient #13, #23, #24). Findings:

Observations on 3/21/2011 at 10:53 a.m. revealed several full e-cylinders located in the hospital's oxygen supply closet.

Patient #13
Review of the medical record for Patient #13 revealed a 49 year old female admitted to the hospital from a Long Term Acute Care facility on 12/16/10 for Chronic Respiratory Failure with trach and a history of Diabetes, Morbid Obesity, Urinary Tract Infection, Hypertension, Asthma and Depression.

Review of the Nurses' Notes dated/timed 12/18/10 at 2200 (10:00pm) for Patient #13 revealed....."complained of shortness of breath, became dusky in color with O2 (oxygen) saturation of 55% and removed 28% from TC (trach collar), applied non-rebreather mask to trach. 2214 (10:14pm) Pt. (Patient) SaO2 (Oxygen Saturation) 42%, non-responsive but eyes remain open, writer began bagging pt via trach with ambu bag. 2215 (10:15pm) BP (Blood Pressure) 131/88, Pulse 81, R (Respirations) 18, T (Temperature) 98.4 degrees Fahrenheit, SAO2 48%". Further review of the nursing notes for Patient #13 revealed she was transferred to Acute Care Hospital "B" where she expired twenty minutes later. Further review of the medical record revealed no documented evidence of the percentage of oxygen delivered with the application of the nonrebreather mask or if oxygen was used when S13 was ambued.

An interview with RN S20, the nurse assigned to her care on 12/18/10, could not be performed due to the termination of S20 by the facility.

Patient #23:
Review of Patient #23's medical record revealed the patient was admitted to the hospital on 12/21/2010 with diagnoses that included Alzheimer's. Further review revealed Daily Nursing Progress Notes dated 12/28/2010 at 1435 (2:35 p.m.) that revealed in part, "pt (patient) (with) labored breathing, unable to regulate secretions 2 (secondary) dysphagia r/t (related to) end stage Alzheimer's Disease. DON (Director of Nursing) and Charge nurse (at) bedside. pt dusty in color. suctioned (with) lg. (large) amts (amounts) of frothy thick secretions noted in canister. #911 called and (Physician S 10) notified pt's situation. Awaiting ambulance arrival. ongoing monitoring." Further review revealed at 1440 (2:40 p.m.), "pt. (patient) placed on 100% venti mask. suctioned pink (at) present.. . sats (at) 94%. continues to monitor, awaiting ambulance arrival. . ."

During a telephone interview on 3/24/2011 at 1325 (1:25 p.m.), Licensed Practical Nurse S15 indicated she was not sure what the oxygen liter flow should have been to deliver 100% oxygen. S15 indicated she had set the liter flow to somewhere between 5 - 8 liters per non-rebreather mask to deliver 100% oxygen. S15 indicated she had called Physician S10 after she had initiated oxygen and called EMS.

Patient #24:
Review of Patient #24's History and Physical dictated 1/15/2011 at 2226 (10:26 p.m.) revealed in part, "Chief Complaint: Deconditioning and gait abnormality. Co-morbidities: COPD (Chronic Obstructive Pulmonary Disease), hepatitis C, lower extremity DVT (Deep Vein Thrombosis), BPH (Benign Prostatic Hypertrophy), anemia, CAD (Carotid Artery Disease), and Barrett's esophatitis. Review of Systems: . . . He has occasional shortness of breath, but no chest pain.. ."

Review of Daily Nursing Progress notes for Patient #24 dated 1/21/2011 at 1730 (5:30 p.m.)" sitting up in chair. O2 (oxygen) sats (saturation) 82, oxygen (increased) to 4 liters/nc (nasal cannula) and placed on non-rebreather."

Review of Daily Nursing Progress notes for Patient #24 dated 1/21/2011 at 1750 (5:50 p.m.) revealed in part, "O2 (oxygen) off - went to bathroom. Sats 55 %. O2 (oxygen) placed on a nonrebreather @ 4L. . . will notify MD."

During a telephone interview on 3/24/2011 at 1315 (1:15 p.m.), Registered Nurse S16 indicated she had placed Patient #24 on a non-rebreather mask on the date of 1/21/2011 at 4 liters even though she knew it should have been on a higher liter flow. S16 indicated the oxygen concentrators used in the hospital would only deliver 4 liters flow. S16 confirmed that she did not attach the non-rebreather to an e-cylinder for higher oxygen flow and did not have a physician's order to administer oxygen with a non-rebreather prior to placing the patient with a history of Chronic Obstructive Pulmonary Disease on a non-rebreather mask, although she indicated she did inform the patient's physician afterwards.

During a face to face interview on 3/23/2011 at 1540 (3:40 p.m.), Certified Respiratory Therapist S17 indicated to deliver 100 % oxygen through the non-rebreather mask the liter flow should be set to 15. Further S15 indicated the oxygen concentrators used for patients throughout the hospital would only deliver up to 5 liters flow. S17 indicated in order to deliver a higher flow rate, the staff would need to use an e-cylinder. Further S17 indicated that any patient with sats below 92% should have their physician notified to obtain orders for oxygen therapy and/or aerosol therapy as needed. S17 indicated she only worked part time at the hospital and averaged a few hours per day on the days the hospital indicated they needed her to evaluate patients.

During a face to face interview on 3/25/2011 at 10:40 a.m., Medical Director S10 indicated she had not been aware that nursing staff were uncertain how to deliver oxygen through non-rebreather masks. S10 indicated nursing education would be needed to address the failure of nursing staff to understand oxygen concentration delivery per oxygen delivery systems on hand at the hospital.

Review of the hospital policy titled, "Estimation of percentage of oxygen, # RC.6.01" presented by the hospital as their current policy revealed in part, "The following guidelines will provide (an) approximate FIO2 (oxygen percentage) when utilizing low flow oxygen devices. . . Mask with Reservoir Bag . 6 (=) 60 %, 7 (=) 70%, 8( =) 80%, 9( =) 90%, 10( =) 95%.

Based on record review and interview the hospital failed to designate in writing the training and experience of personnel authorized to perform each type of respiratory care service as evidenced by no documented evidence of a competency assessment of all skills performed by the nursing staff or the part-time respiratory therapist providing respiratory care (nebulizer treatment, tracheotomy care, suctioning of the tracheotomy, oxygen therapy, Bi-PAP and C-PAP) services for 6 of 6 RN/LPN/CRT personnel files reviewed S5, S11, S14, S17, S30, S31). Findings:

Review of the personnel files for RN5, LPN S11, RN S14, RN S30, and LPN S31 revealed no documented evidence of a skills competency assessment for Bi-PAP or C-PAP.

Review of the personnel files for RN S14, RN S30 and CRT S17 revealed no documented evidence of a skills competency assessment for performance of nebulizer treatments, tracheotomy care, suctioning of the tracheotomy, and oxygen therapy.

In a face to face interview on 03/21/11 at RN S1 ADON (Assistant Director of Nursing) indicated it was the responsibility of the DON (Director of Nursing) to make sure all of the nursing staff are competent. Further S1 indicated there have been changes in the DON position with the present DON RN S2 out on medical leave.

Based on record review and interview the hospital failed to ensure medication variances and incidents were accurately identified resulting in inaccurate data for the number of mediation variances occurring in the hospital and failure to implement corrective action to reduce medical errors. Findings:

Review of the Quality Assurance/Performance Improvement data submitted for the Fourth Quarter of 2010 and the First Quarter of 2011 revealed the following reported medication errors: December 2010 - 2 medication errors; January 2011 - 0 medication errors; and
February 2011 - 1 medication error.

Review of the sampled medical records for Patients #2, #4, #5, #12, #18, #21, #22, and #25 revealed a total of 52 unreported medication variances for the month of December 2010; 5 unreported medication variances for the month of January 2011; and 8 unreported medication variances for the month of March 2011.

Review of the meeting minutes for the Performance Improvement Committee revealed the following "Actions/Improvements" implemented as corrective action taken to improve medication errors: 01/17/11- Charge nurse to query staff nurses at the end of each shift to ensure med (medication) errors are averted. Continue ongoing communication with physicians to eradicate ambiguous and range orders and 02/21/11- Continue ongoing audits and educating of MD, pharmacy and nursing staff to ensure all orders are correct, and administered as such.
Further review revealed no trends had been identified related to administration of medication with ordered parameters, sliding scale insulin or respiratory treatments.

In a face to face interview on 03/21/11 at 2:00pm RN S1, ADON, indicated the DON who is out on medical leave is responsible for data collection for QA/PI (Quality Assurance/Performance Improvement. Further medication variances are self-reported as well as reported via the pharmacy from reports out of the Pyxsis System.

See findings at Tag A0404.

Based on observation, record review, and interview the hospital failed to ensure Quality Control Testing data (Quality Indicators) of the hospital's Capillary Blood Glucose Monitoring Device was analyzed for Quality for 1 of 1 Monitoring Device reviewed. (Findings)

Observations on 3/21/2011 at 11:15 a.m. revealed the Hi and Low Control Solutions used for Quality Control Checks on the hospital's Capillary Blood Glucose Monitoring Device contained no labeling as to the date the solution had been opened. Further review of the Hospital's Quality Control Log for Capillary Blood Glucose Monitoring revealed no documented evidence of the date the current solution had been opened.

Review of a handout provided by the hospital as current, titled, "Assure Pro Control Solution" revealed in part, "Use the control solution within 90 days (3 months) of first opening. It is recommended that you write the date of opening on the control solution bottle label ("Date Opened") as a reminder to dispose of the opened solution after 90 days."

Review of the hospital policy titled, "Glucometer Quality Testing, II-C.3.32" presented by the hospital as their current policy revealed in part, "Quality Control on the glucometer will be performed to ensure accurate and reliable testing using the low and high level control solutions. Quality Control testing will be performed nightly by the nursing staff. Quality Control log is maintained on the nursing unit and results are monitored by the DON (Director of Nursing)."

Review of the hospital's "Quality Control: Capillary Blood Glucose Monitoring" log revealed in part, "2/18/11 6p (6:00 p.m.) . Low Glucose Control Range 80- 100. Obtained Value: 103.; 2/19/2011 6p. Low Glucose Control Range 80 - 100. Obtained Value 104.; 11/25 (2010)) 7p (7:00 p.m.). Low Glucose Control Range 80 - 100. Obtained Value 104.; 11/28 (2010) 6p. Low Glucose Control Range 80 - 100. Obtained Value 102.; 11/29 (1010). Low Glucose Control Range 80 - 100. Obtained Value 101.; 11/20 (1010). Low Glucose Control Range 80 - 100. Obtained Value 102." Review of the entire log revealed no documented evidence that the machine had been re-tested when "obtained values" on the control testing were outside of the testing range. Further review revealed no documented evidence of any interventions to ensure the machine was properly functioning when control testing was outside the expected range.

During a face to face interview on 3/21/2011 at 11:50 a.m., Assistant Director of Nursing S1 indicated the control solution for testing quality of the hospital's Capillary Glucose Monitoring Device should have been labeled with the date that it had been opened. S1 indicated that without labeling the date the solution had been opened, the staff would not know when 90 days had passed and the solution needed to be discarded. Further S1 indicated staff should have rechecked the machine when they obtained values during Quality Testing that were outside the expected parameters. S1 indicated further, the Director of Nursing should have been notified of "Obtained Values" that were outside the expected range. S1 indicated she had not been aware of Quality testing outside the normal range and knew of no corrective action that had been taken.

Based on record review and interview the hospital failed to focus on the high-risk of emergent patient transfers to a higher level of care who were transferred for 4 of 8 patients (#12, #13, #22, #25) in order to identify problems affecting outcomes and the quality of care out of 26 sampled medical records. Findings:

Patient #12
Review of the medical record for Patient #12 revealed he was admitted to the hospital on 11/17/10 from home secondary to a decline from previous lumber surgery which included urinary retension.

Review of the Physician's Orders dated/timed 11/21/10 at 11:30am for Patient #12 revealed an order for bladder irrigation. Review of the Nurses' Notes dated 11/21/10 through 11/22/10 revealed no documented evidence the order for bladder irrigation had been performed as ordered. Further review of the nurses' notes revealed on 11/22/10 Patient #12 continued to experience hematuria with blood clots and pain and was transferred to Hospital "B". Patient #12 was re-admitted on 11/23/10 after receiving bladder irrigation and pain medication.

Patient #13
Review of the medical record from LTAC Hospital A revealed Patient #13 was admitted on 11/22/10 with the diagnosis of respiratory failure with mechanical ventilatory support. Further review revealed the goal for Patient #13 was to wean from ventilator which was accomplished on 11/26/10.

Review of the medical record for Patient #13 revealed she was admitted to the hospital on 12/16/10 from Long Term Acute Care (LTAC) Hospital A with the diagnosis of Critical Illness Myopathy with a history of COPD (Chronic Obstructive Pulmonary Disease), Asthma, CHF (Congested Heart Failure), and tracheostomy.

Review of the Nurses' Notes dated/timed 12/18/10 at 2200 (10:00pm) for Patient #13 revealed....."complained of shortness of breath, became dusky in color with O2 (oxygen) saturation of 55% and removed 28% from TC (trach collar), applied non-rebreather mask to trach. 2214 (10:14pm) Pt. (Patient) SaO2 (Oxygen Saturation) 42%, non-responsive but eyes remain open, writer began bagging pt via trach with ambu bag. 2215 (10:15pm) BP )Blood Pressure) 131/88, Pulse 81, R (Respirations) 18, T (Temperature) 98.4 degrees Fahrenheit, SAO2 48%". Further review of the nursing notes for Patient #13 revealed she was transferred to Acute Care Hospital "B" where she expired twenty minutes later. Further review of the medical record revealed no documented evidence of the percentage of oxygen delivered with the application of the nonrebreather mask or if oxygen was used when S13 was ambued.

Patient #22:
Patient #22 was admitted to the hospital on 12/08/2010 with diagnoses that included Cerebral Vascular Accident with left Hemiplegia, Diabetes Type II, Carotid Artery Disease, and Dysphagia. Patient #22 was discharged on 12/23/2010 to Acute Care Hospital B due to a significant change in condition.

Review of Patient #22's Physician's orders dated 12/08/2010 at 0930 (9:30 a.m.) revealed an order for Coreg 25 milligrams by mouth twice per day. Further review of Patient #22's medical record revealed no documented evidence that an apical pulse was taken immediately prior to the administration of Coreg from the dates of 12/08/2010 through the day of discharge 12/23/2010. Review of Patient #22's graphic sheet revealed the patient's pulse to be documented as 59 at 8:00 a.m. on 12/18/2010, 57 at 8:00 p.m. on 12/18/2010, 56 on 12/19/2010 at 8:00 p.m., 58 on 12/20/2010 at 8:00 a.m., 56 on 12/20/2010 at 8:00 p.m., 60 on 12/21/2010 at 8:00 a.m. and 60 on 12/21/2010 at 8:00 p.m. Review of Patient #22's Medication Administration Record revealed Patient #22 was administered Coreg 25 milligrams on 12/18/2010 at 9:00 a.m. and p.m., 12/19/2010 at 9:00 p.m., 12/20/2010 at 9:00 a.m. and p.m., and 12/21/2010 at 9:00 a.m. and p.m. when the patient's pulse on the graphic sheet revealed the rate was 60 or less. Review of the entire medical record revealed no documented evidence that an apical pulse had been assessed immediately prior to the administration of Coreg or that the physician had been notified of the rate of 60 or less on the dates of 12/18/2010, 12/19/2010, 12/20/2010, or 12/21/2010.

Patient #22 returned for re-admission to United Medical Health West on 12/27/2010 from Hospital B. Review of #22's History and Physical dictated 12/28/2010 revealed in part "(Patient #22) is a 62 year old right hand dominant female who was recently a patient here who was transferred to (Hospital B) on 12/22/2010 secondary to complaints of generalized weakness and slow heart rate. It was found the patient to have (as written) bradycardic heart at 55 in the emergency room. . . her medication was adjusted by holding the beta blocker medication and recommending restart with a very low dose of beta blocker. . ."


Patient #25
Review of the medical record for Patient #25 revealed a 48 year old male admitted to the hospital on 12/03/10 for Critical Illness Myopathy with diabetes, lower GI (Gastrointestinal) Bleed, Morbid Obesity and COPD (Chronic Obstructive Pulmonary Disease) with C-PAP at night . Patient #25 was discharged to Acute Care Hospital B on 01/01/2011 due to a significant change in condition.

Review of the Physician's orders dated 12/03/10 revealed an order for Ipratropium Bromide 0.02% every 4 hours. Review of the respiratory treatment form used to document assessments and treatments for Patient #25 revealed no documented evidence the following treatments for Ipratropium Bromide 0.02% every 4 hours had been administered as ordered: 12/04/10 1400 (2:00pm) and 1800 (6:00pm); 12/05/10 1000 (10:00am); and 12/13/10 1800 (6:00pm). Further review of the form under "events" revealed no documented evidence the reason the treatments were not administered.

Review of the Respiratory documentation dated 12/03/10 through 01/01/11 revealed no documented evidence Patient #25 was placed on B-PAP or C-PAP at night.

Patient #25 returned for re-admission to United Medical Health West on 01/02/2011 from Hospital B. Review of the Emergency Room Physician Notes revealed..... " oxygen saturation with 4L (Liters) O2 (oxygen) per NC (Nasal Cannula) 89% on admit......present to the ED (Emergency Department) with shortness of breath and increased sleepiness. Symptoms were reported to nursing home facility (United Medical Healthwest). Patient is on C-PAP at facility and it is described in the medical record that patient was not appropriately compliant with non-invasive ventilation. Patient reports some difficulty breathing at baseline currently, but feels improvement with either supplemental oxygen and non-invasive ventilation".







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Based on record review and interview the hospital failed to ensure medications were administered according to the orders of the physician and/or accepted standards of practice for 9 of 26 sampled patients (#2, #4, #5, #17, #18, #20, #21, #22, #25). Findings:

Patient #22:
Patient #22 was admitted to the hospital on 12/08/2010 with diagnoses that included Cerebral Vascular Accident with left Hemiplegia, Diabetes Type II, Carotid Artery Disease, and Dysphagia. Patient #22 was discharged on 12/23/2010 to Acute Care Hospital B due to a significant change in condition.

Review of Patient #22's Physician's orders dated 12/08/2010 at 0930 (9:30 a.m.) revealed an order for Coreg 25 milligrams by mouth twice per day. Further review of Patient #22's medical record revealed no documented evidence that an apical pulse was taken immediately prior to the administration of Coreg from the dates of 12/08/2010 through the day of discharge 12/23/2010. Review of Patient #22's graphic sheet revealed the patient's pulse to be documented as 59 at 8:00 a.m. on 12/18/2010, 57 at 8:00 p.m. on 12/18/2010, 56 on 12/19/2010 at 8:00 p.m., 58 on 12/20/2010 at 8:00 a.m., 56 on 12/20/2010 at 8:00 p.m., 60 on 12/21/2010 at 8:00 a.m. and 60 on 12/21/2010 at 8:00 p.m. Review of Patient #22's Medication Administration Record revealed Patient #22 was administered Coreg 25 milligrams on 12/18/2010 at 9:00 a.m. and p.m., 12/19/2010 at 9:00 p.m., 12/20/2010 at 9:00 a.m. and p.m., and 12/21/2010 at 9:00 a.m. and p.m. when the patient's pulse on the graphic sheet revealed the rate was 60 or less. Review of the entire medical record revealed no documented evidence that an apical pulse had been assessed immediately prior to the administration of Coreg or that the physician had been notified of the rate of 60 or less on the dates of 12/18/2010, 12/19/2010, 12/20/2010, or 12/21/2010.

Review of the hospital's Medication Resource Manual titled, "Nursing Drug Handbook 2008" presented by the hospital as their current resource revealed in part, "Coreg/Carvedilol: (page 195), Adverse Effects/Toxic Reactions: Overdose may produce profound Bradycardia, hypotension, bronchospasm, cardiac insufficiency, cardiogenic shock, cardiac arrest. . . Nursing Considerations: Assess B/P (blood pressure), apical pulse immediately before drug is administered (if pulse is 60/min (60 beats per minute) or less or systolic B/P is less than 90 mm (millimeters) HG (mercury), withhold medication, contact physician)."

Review of Patient #22's "Daily Nursing Progress Notes" revealed in part, "12/23/2010, 1045 (10:45 a.m.), called to therapy gym. pt. (patient) in distress. . . Heart Rate 44. . . notified MD (medical doctor), ordered to transfer to emergency room for evaluation. . ."

Patient #22 returned for re-admission to United Medical Health West on 12/27/2010 from Hospital B. Review of #22's History and Physical dictated 12/28/2010 revealed in part "(Patient #22) is a 62 year old right hand dominant female who was recently a patient here who was transferred to (Hospital B) on 12/22/2010 secondary to complaints of generalized weakness and slow heart rate. It was found the patient to have (as written) bradycardic heart at 55 in the emergency room. . . her medication was adjusted by holding the beta blocker medication and recommending restart with a very low dose of beta blocker. . ."

During a face to face interview on 3/25/2011 at 11:20 a.m., Assistant Director of Nursing S1 confirmed there had been no assessment of Patient #22's apical heart rate immediately prior to the administration of Coreg. S1 further confirmed there had been no documented evidence that Patient #22's physician had been notified that the patient's pulse had been 60 or below on the dates of 12/18, 12/19, 12/20, and 12/21/2010 prior to the administration of Coreg. S1 indicated nursing staff should have followed the guidelines as written in the Drug Resource Manual unless the patient's physician had written other parameters.

Patient #17:
Patient #17 was admitted to the hospital on 2/03/2011 and discharged on 2/09/2011 to Acute Care Hospital B as a result of a significant change in condition.

Review of Patient #17's History and Physical dictated on 2/04/2011 (no documented time) revealed in part, "He (#17) had difficulty and complication with weaning off the ventilator. . His course of treatment was complicated by difficulty weaning off off the ventilator, and the trach was placed (at Hospital C). After that the patient was admitted to Hospital A for IV antibiotic therapy, for respiratory support, and for medical management. Considering the complexity of the patient's medical issues including coronary artery disease status post non ST-elevated MI (myocardial infarction), CHF (Congestive Heart Failure) , type 2 diabetes mellitus, Percutaneous drainage of gallbladder, severe malnutrition, respiratory failure, PEG tube placement, tracheotomy, left heart catheterization, chronic renal insufficiency, PVD (peripheral vascular disease), UTI (urinary track infection), trach management, the patient will require very aggressive rehabilitation, monitor all his current and possibly future complications in therapy. He is going to be very closely monitored by Nursing and doctors for participating in his care. We are going to very closely monitor all the parameters of his condition in order to prevent any complications. . ."

Review of Patient #17's medical record from Hospital A revealed the patient was receiving Atrovent 0.5 milligrams by hand held nebulizer every 4 hours, Albuterol Sulfate 3 milliliters of 0.83 milligrams per milliliter solution by hand held nebulizer every 4 hours, and Acetylcysteine 10% vial 300 milligrams every 12 hours per hand held nebulizer during his entire hospital stay prior to discharge to United Medical Healthwest. Review of the discharge orders from Hospital A to United Medical Healthwest revealed no documented evidence of any orders for handheld nebulizer treatments.

Review of Respiratory Progress Notes for Patient #17 dated 2/08/2011 at 1430 (2:30 p.m.) revealed in part, "Pt (patient) (with) #8 Shirley trach plugged. . . Pt C/O (complained of) shortness of breath when he over exerts himself. . ."

Review of Patient #17's medical record revealed physician's orders dated 2/08/2011 at 1400 (2:00 p.m.) for "Aerosol tx (treatment) (with) Duoneb Q4 (every 4 hours) prn (as needed) SOB (shortness of breath)."

Review of Patient #17's Daily Nursing Progress Notes dated 2/08/2011 at 2000 (8:00 p.m.) revealed in part, "0 (no) SOB (shortness of breath) noted, however, pt was unable to expectorate sputum on his own . . . thick yellow (sputum) noted (with) suctioning". Further review revealed no documented evidence Patient #17 had been administered prn Duoneb treatments.

Review of Patient #17's Daily Nursing Progress Notes dated 2/09/2011 at 0310 (3:10 a.m.) revealed in part, "weak cough, inability to expectorate sputum. Pt. Suctioned x 2 passes, suction effective, yellow thick sputum noted. . ." Further review revealed no documented evidence Patient #17 had been administered prn Duoneb treatments.

Review of Patient #17's Daily Nursing Progress Notes dated 2/09/2011 at 1840 (6:40 p.m.) revealed in part, "Pt. called out :help", when assess pt. was leaning towards side of bed, unresponsive, nurse started to suction trachea numerous times providing a lot of mucous return. O2 (oxygen) sats (saturations) ranging from 84 - 96 %. . . EMS (Emergency Medical Services) dispatched per staff." Further review revealed no documented evidence Patient #17 had been administered prn Duoneb treatments.

Review of Patient #17's entire medical record revealed no documented evidence that the patient was ever administered prn (as needed) Duoneb aerosol treatments at United Medical Healthwest Hospital during his admission from 2/03/2011 through 2/09/2011.

Respiratory Therapist S17 was interviewed face to face on 3/23/2011 at 1540 (3:40 p.m.). Respiratory Therapist S17 reviewed the medical record of Patient #17 to include nursing documentation. S17 indicated she had called Patient #17's physician on 2/08/2011 at 1400 (2:00 p.m.) and received a verbal order for Duoneb aerosol treatments to be administered every 4 hours as needed Shortness of Breath. S17 indicated Albuterol and Atrovent (combined to equal Duoneb) were bronchodilators used to loosen secretions and would aide in coughing the secretions up, thus aiding to clear the patient's airway and making breathing easier. S17 indicated Patient #17 should have received the physician ordered prn (as needed) treatments of Duoneb for thick secretions when having difficulty coughing them up which would be associated with the patient's (#17's) shortness of breath.

Review of the medical record for Patient #17 at Recipient Hospital B revealed in part, 2/10/2011 Emergency Department Systems Review," Respiratory Coarse upper airway sounds, lungs bilaterally clear, tachypnea to 30s. . . " Further review of Emergency Department documentation revealed Atrovent Inhalation Neb 0.5 milligrams administered 2/09/2011 at 1928 (7:28 p.m.) and Albuterol 2.5 milligrams inhalation administered on 2/09/2011 at 1928 (7:28 p.m.) x3. Review of Patient #17's Consultation Report from Hospital B dated 2/10/2011 (no documented time) revealed in part, "This gentleman (#17) has now been transferred back to this facility because apparently when he (#17) was at United Medical Rehab (Healthwest), he (#17) had a spell where he (#17) got short of breath at rest and apparently had a pre-syncopal episode. It appears that in the ER (Emergency Room/ Hospital B), he was sucked out . . . At this time the patient was able to speak to me. He denies any shortness of breath. . ."

Patient #4:
Patient #4 was admitted to the hospital on 3/05/2011 with diagnoses that included Hypertension and Multiple ostomy breakdown. Review of Patient #4's physician's orders revealed an order dated 3/05/2011 for Lopressor (Metoprolol) 50 milligrams by mouth every 12 hours; hold if systolic blood pressure is less than 110. Further review revealed an order dated 3/19/2011 at 2000 (8:00 p.m.) for Metoprolol 25 milligrams by mouth twice per day and hold if systolic blood pressure is less than 110 or heart rate is less than 60.

Review of Patient #4's Medication Administration Record revealed #4 received administration of Metoprolol on 3/08/2011 at 9:00 a.m. with no documented evidence that the patient's blood pressure or apical pulse had been taken immediately prior to administration of the medication to ensure the patient's systolic blood pressure was not less than 110 or the apical heart rate less than 60.

Review of Patient #4's Medication Administration Record revealed #4 received administration of Metoprolol on 3/12/2011 at 9:00 a.m. when the patient's systolic blood pressure was documented as 106 (106/71).

Review of Patient #4's Medication Administration Record revealed #4 received administration of Metoprolol on 3/19/2011 at 9:00 a.m. when the patient's systolic blood pressure was documented as 102 (102/78).

During a face to face interview on 3/21/2011 at 10:20 a.m., Assistant Director of Nursing S1 indicated nursing staff should follow physician's order regarding the administration of Metoprolol. After reviewing Patient #4's medical record, S1 indicated she could find no documented evidence that Patient #4's physician had been contacted regarding vital signs outside parameters for administration of Metoprolol when nursing staff administered the medication to Patient #4 when his systolic blood pressure had been less than 110.

Patient #5:
Patient #5 was admitted to the hospital on 1/07/2011 with diagnoses that included Diabetes with Neuropathy. Review of Physicians orders for Patient #5 revealed an order for sliding scale insulin dated 1/07/2011 at 2100 (9:00 p.m.) with dosage for blood sugar of 200 - 250 to be 4 units Humulin R subcutaneously. Further review revealed a physician's order dated 1/15/2011 at 1939 (7:39 p.m.) for Clonidine 0.1 milligrams by mouth every 8 hours as needed for systolic blood pressure greater than 150 or Diastolic blood pressure greater than 110.

Review of Patient #5's "Diabetic Flow Sheet" revealed the patient's blood sugar per accucheck was 203 on 1/07/2011 at 2100 (9:00 p.m.) with no documented evidence to indicate 4 units of Regular insulin was administered per sliding scale physician's order. Further review revealed Patient #5's blood sugar per accucheck was 211 on 1/08/2011 at 2100 (9:00 p.m.) with no documented evidence to indicate 4 units of Regular insulin was administered per sliding scale physician's order. Further review revealed Patient #5's blood sugar per accucheck was 213 on 1/16/2011 at 0600 (6:00 a.m.) with no documented evidence to indicate 4 units of Regular Insulin was administered per sliding scale physician's order. Review of Patient #5's entire medical record revealed no documented evidence that Sliding Scale insulin was administered for an accucheck revealed blood sugar was between 200 - 250 on the dates of 1/07/2011, 1/08/2011, or 1/16/2011.

These findings were confirmed in a face to face interview with Assistant Director of Nursing S1 on 3/22/2011 at 10:35 a.m. S1 indicated sliding scale insulin should have been administered as per physician's orders and Blood Pressure should be taken at intervals specified in the physician's prn (as needed) order for administration purposes because without taking the blood pressure, it would not be known if the medication should be administered or not.

During a telephone interview on 3/22/2011 at 11:00 a.m., Registered Nurse S5 confirmed that she had not administered insulin to Patient #5 on the dates of 1/07/2011, 1/08/2011, or 1/16/2011 because she did not want the patient to become hypoglycemic. S5 indicated she did not call the patient's physician and did not complete an occurrence report regarding her failure to follow physician's orders for sliding scale insulin.

Patient #2
Review of the medical record for Patient #2 revealed he was admitted to the hospital on 03/09/11 for antibiotic therapy for removal of infected hardware in his right hip. Further review revealed additional diagnoses of seizures, anemia and hypertension.

Review of the Physician's Orders for Patient #2 dated 03/09/11 at 1825 (6:25pm) revealed an order for Lopressor (Metoprolol) 25mg po (by mouth) BID (twice a day) Hold for SBP (Systolic Blood Pressure) less than 120, DBP (Diabolic Blood Pressure) less than 60, HR (Heart Rate) less than 60.

Review of the MAR (Medication Administration Record) for Patient #2 revealed no documented evidence blood pressure had been assessed before administration of Metoprolol on 03/09/11 at 2100 (9:00pm) and 03/10/11 at 9:00am. Further review revealed Metoprolol was administered when the documented blood pressure (BP) for Patient #2 was outside of the ordered parameters as follows: 03/11/11 at 2100 (9:00pm) 116/69; 03/15/11 at 0900 (9:00am) 117/66; and 03/18/11 0900 (9:00am) BP 116/74. Further review of the medical record revealed no documented evidence the physician was contacted concerning administration of Metoprolol when outside of the ordered parameters.

Patient #18:
Patient #18 was admitted to the hospital on 1/07/2011 with diagnoses that included Morbid Obesity, Multiple abdominal surgeries, Diabetes Type 2, Colostomy, and Ileostomy. Review of Physician's orders for Patient #18 revealed an order for sliding scale insulin dated 1/08/2011 (no documented time) with dosage for blood sugar of 200 - 250 to be 4 units Humulin R subcutaneously.

Review of Patient #18's "Diabetic Flow Sheet" revealed the patient's blood sugar per accucheck was 215 on 1/08/2011 at 0600 (6:00 a.m.) with no documented evidence to indicate 4 units of Regular Insulin was administered per sliding scale physician's order. Further review revealed Patient #18's blood sugar per accucheck was 241 on 1/09/2011 at 2100 (9:00 p.m.) with no documented evidence to indicated 4 units of Regular Insulin was administered per sliding scale physician's order. Review of Patient #18's entire medical record revealed no documented evidence that Sliding Scale insulin was administered when the patient's accucheck revealed the patient's blood sugar was between 200 - 250 on the dates of 1/08/2011, or 1/09/2011.

These findings were confirmed in a face to face interview with Assistant Director of Nursing S1 on 3/22/2011 at 10:35 a.m. S1 indicated sliding scale insulin should have been administered as per physician's orders..

Patient #20
The medical record for Patient #20 was reviewed. Documentation revealed an admit date of 12/13/10 with diagnoses of Peripheral Vascular Disease, End Stage Renal Disease and Chronic Obstruction Pulmonary Disease. Review of the Admission PRN Medication Order Form dated 12/03/10 and signed by the physician revealed an order for Clonidine 0.1 mg by mouth every 4 hours for Hypertension with a systolic blood pressure greater than 160. Review of the entire record revealed Patient #20's blood pressure was not monitored every 4 hours on 12/13/10 and 12/14/10 for hypertension to determine if the Clonidine was to be administered.

S1, Assistant Director of Nurses confirmed on 03/23/11 at 1:14pm the blood pressures for Patient #20 were not done every 4 hours as ordered to determine if the Clonidine was to be administered.

Patient #21
Patient #21 was admitted to the hospital on 12/10/2010 with diagnoses that included Diabetes Type II, Hypertension, Acute Respiratory Failure, and Anemia. Review of #21's Physician's orders dated 12/10/2010 at 1040 (10:40 a.m.) revealed an order for Toprol XL (Metoprolol) 50 milligrams by mouth twice per day. Review of Patient #21's Medication Administration Record revealed Patient #21 was administered Metoprolol on 12/18/2010 at 9:00 p.m. when the patient's graphic sheet indicated the patient's pulse was 58. Further review revealed Patient #21 was administered Metoprolol on 12/19/2010 at 8:00 p.m. when the patient's graphic sheet indicated the patient's pulse was 59 at 8:00 p.m. Review of Patient #21's entire medical record revealed no documented evidence that an apical heart rate had been assessed immediately prior to the administration of Metoprolol during the patient's entire hospital stay.

During a face to face interview on 3/25/2011 at 11:20 a.m., Assistant Director of Nursing S1 confirmed there had been no notification of Patient #21's physician prior to the administration of Metoprolol when the patient's graphic sheet indicated the patient's pulse was less than 60. Further S1 indicated there was no documented evidence that nursing staff evaluated an apical heart rate immediately prior to the administration of Metoprolol. S1 indicated nursing staff should monitor patients according to recommendations in the Hospital's Resource Book and/or physician's orders.

Patient #25
Review of the medical record for Patient #25 revealed a 48 year old male admitted to the hospital on 12/03/10 for Critical Illness Myopathy with diabetes, lower GI (Gastrointestinal) Bleed, Morbid Obesity and COPD (Chronic Obstructive Pulmonary Disease) with C-PAP at night .

Review of the Physician's orders dated 12/03/10 revealed an order for Ipratropium Bromide 0.02% every 4 hours.

Review of the respiratory treatment form used to document assessments and treatments for Patient #25 revealed no documented evidence the following treatments for Ipratropium Bromide 0.02% every 4 hours had been administered as ordered: 12/04/10 1400 (2:00pm) and 1800 (6:00pm); 12/05/10 1000 (10:00am); and 12/13/10 1800 (6:00pm). Further review of the form under "events" revealed no documented evidence the reason the treatment was not administered.

Review of the hospital's Drug Reference Resource Book titled, "Nursing Drug Handbook 2008" presented by the hospital as their current resource book revealed in part, "(page 765) Assess B/P (blood pressure), apical pulse immediately before drug administration (if pulse is 60/min (60 beats per minute) or less or systolic B/P is less than 90 mm (millimeters) HG (mercury), withhold the medication, contact physician.