HospitalInspections.org

Based on a review of documentation, it was determined that the hospital failed to ensure that they are compliant with the New Jersey Nurse Practice Act.

Findings include:

1. Reference: New Jersey Nurse Practice Act states, "13:37- 5.1 License requirement, Before engaging in nursing practice, as defined in N.J.S.A. 45:11-23(b), or representing oneself as a nurse, an individual shall obtain and maintain a current license that is active. No licensee shall engage in nursing practice if his or her license is expired, suspended, revoked or surrendered."

a. The facility hired Staff #MC20 as Education Coordinator. Staff #MC20 did not have an RN license. However, Staff #MC20 was given by the former CEO, RN responsibilities; providing patient care and administering medications while working in the clinical area in various capacities.

b. Staff #MC20 worked 4 days as nursing coverage, 3 days as a nursing supervisor and 1 day as a bedside RN with a direct patient care assignment. Patients were not under the care of a registered professional nurse in these instances.

Based on observation, document review, and interview, it was determined that the facility failed to ensure that there was an effective governing body responsible for the conduct of the hospital as an institution as evidenced by the lack of compliance with the following Conditions of Participation (CoPs):

482.11--Compliance With Laws: The governing body failed to ensure that the hospital was in compliance with the New Jersey Nurse Practice Act.

482.21--QAPI: The governing body failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.

482.23--Nursing Services: The governing body failed to ensure that there was an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse.

Based on observation, document review and staff interview, it was determined that the facility failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.

Findings include:

1. The facility failed to identify opportunities for improvement and changes that will lead to improvement. (Cross refer to 482.21 (b) (20 (ii)).

2. The facility failed to take actions aimed at performance improvement. (Cross refer to 482.21 (c) (3)).

Based on review of documentation, it was determined that the hospital failed to ensure that there was an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse.

Findings include:

1. The facility failed to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. (Cross Reference 394).

2. The facility failed to ensure that the registered nurse supervised the care of all patients. (Cross Reference 395).

3. The facility failed to ensure that the nursing personnel with the appropriate education, experience, licensure and competence, are assigned to provide nursing care for each patient in accordance with individual needs of each patient. (Cross Reference 397).

4. The facility failed to ensure that medications are administered in accordance with with physician's orders and additional instructions that appear on the medication administration record. (Cross Reference 404).

5. The facility failed to ensure that drugs are administered by licensed nursing personnel. (Cross Reference 405).

6. The facility failed to ensure that verbal orders are used infrequently. (Cross Reference 407).

Based on review of documentation and staff interview, it was determined that the facility failed to ensure that personnel are licensed or meet other applicable standards that are required by State or local laws.

Findings include:

MORRIS COUNTY FACILITY

1. Staff #MC20 started on 9/23/10 as Education Coordinator for this facility.

2. The Job Description for Education Coordinator for this facility, states "... Licenses/Certification: Appropriate state licensure for clinical specialty.... C: Company Specific ...Maintains current licensure/certification for position, if applicable..." This job description was signed by Staff #MC20, Staff #MC1 and Staff #MC10 on 9/15/10.

3. Employee file of Staff #MC20 contained a Complaint Form from the State of New Jersey Office of Attorney General that stated "...Complaint Report Against Staff #20 ... 5. What is the nature of the complaint? Unlicensed Practice (has a check mark next to it) 6. Please describe the facts of your complaint in the order in which they happened... Staff #MC20 was hired on 9/23/10 as the Education Coordinator and stated she/he had applied for a NJ License and had a Florida license. Throughout the months she was asked about the status of her NJ license and she stated they still had not processed. In April once again she was asked about her license, she/he stated she/he would need to take a refresher course. At this time primary source verification for Florida was done. Results indicated Staff #MC20 did not have a Florida license. Although it is not required for Education Coordinator to be licensed, investigation revealed Staff #MC20 worked 4 shifts in the clinical area. Staff #MC20 employment was terminated."

4. Interview with Staff #MC10 on 8/16/11, revealed that Staff #MC10 believed that the position of Education Coordinator did not require a state license. When she/he was pointed out that the Job Description for Education Coordinator states under "Licenses/Certification: Appropriate state licensure for clinical specialty," Staff #MC10 stated, "I must have read it wrong."

Based on review of 4 of 4 patient complaints, review of facility policies and procedures and staff interview, it was determined that the facility failed to maintain a process for prompt response and resolution for patient complaints/grievances.

Findings include:

Reference: The facility policy titled, 'Patient Complaint/Grievance Process' revised 12/08 states, "POLICY: ...The Hospital maintains a procedure for systematic notification in and resolution of complaints and grievances, including documentation of results.... Step 2 - The department Manager/Supervisor completes Step 2 of the form: Review the issue and document findings, state whether the issue has been resolved or not resolved, document any actions or interventions taken. Step 3-The CCO/COO/Assistant Administrator completes Step 3 of the form, which includes the following actions: Indicate on the form if the resolution is satisfactory or unsatisfactory. If unsatisfactory, the form is forwarded back to the affected department with an explanation, ans the issue is further investigated. Sign and date the form where indicated. Forward the form to the CEO/Administrator or designee, preferably within 72 hours. Step 4-...If resolution is not possible within 7 days, the letter will indicate an anticipated resolution date..."

MORRIS COUNTY FACILITY

1. A review of a complaint filed in regard to Patient #W36, dated 1/5/11, stated the following:
a. "Pt states she has not been bathed since her admission on 1/3/11."

b. 'Step 2' of the 'Patient & Family Grievance Report Form' stated, "review with staff and patient noted that there was an irregularity with that report - both from staff and patient did not seem to remember. Daily Observation, Assessment that patient was cleaned bath given. Confirmed (To be confirmed) by NM or Supervisor. Issue Resolved."

c. 'Step 3' of the 'Patient & Family Grievance Report Form' was blank.

d. There was no evidence that the "NM or Supervisor" confirmed if Patient #W36 was bathed since admission.

e. There is no evidence that 'Step 3' was completed by the CCO/COO/Administrator if the resolution was satisfactory or unsatisfactory, as per the policy stated above.

f. There is no evidence that Patient #W36 was notified of the investigative process and outcome.

2. A review of a complaint filed in regards to Patient #W39 dated 4/14/11 stated the following:

a. Patients sister complained that Dr. M. S___ has not answered any of the patient or family questions regarding prognosis and treatment...

b. 'Step 3' of the 'Patient & Family Grievance Report Form' was blank.

c. There is no evidence that 'Step 3' was completed by the CCO/COO/Administrator indicating if the resolution was satisfactory or unsatisfactory, as per the policy stated above.


RAHWAY FACILITY

1. A review of of the 'Complaint Log' revealed two complaints were logged for the month of August.

a. The first complaint was received on 8/17/11 and stated, "Patient upset stated that his wife was called and told that his roommate in 4051 was moved because he was not getting along with the patient."

b. There is no evidence of the investigative process and outcome of the resolution for this complaint logged on 8/17/11.

2. The second complaint was received on 8/18/11 and stated, "wife called claimed Pt left for 40 min. SW took call. Nurse & Supervisor present... Pt had been checked last 20 min prior. Pt fine after hygiene care provided."

a. There is no evidence that the patient's wife was called back and informed of the investigative process and outcome.


WAYNE FACILITY

1. A review of the 'Complaint and Grievance Summary & Analysis' stated the following:

a. The month of January 2011, 'Conclusion/Analysis' portion of the document stated, "2 complaints related to personal care & RT (Respiratory Therapy) interpersonal relations with pt."

b. 'Actions Taken' portion of the document stated, "Issues addressed at the time by nursing & respiratory therapy manager."

c. 'Evaluation/Follow-up' portion of the document stated, "Patients satisfied."

2. The month of February 'Conclusion/Analysis' portion of the document stated, "Pt's daughter with numerous issues."

b. 'Actions Taken' portion of the document stated, "Nurse Manager addressed all issues to daughters satisfaction."

c. 'Evaluation/Follow-up' portion of the document stated, "None needed."

3. The facility was unable to provide detailed information regarding the investigative process taken by the facility for the above stated complaints.

4. The 'Complaint and Grievance Summary & Analysis' did not include dates the complaints were received and the dates of actions taken to ensure that resolution took place within 7 days of receipt, as per the policy stated above.

Based on review of documentation and staff interview, it was determined that the facility failed to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure.

Findings include:

MORRIS COUNTY FACILITY

1. Staff #MC20 started on 9/23/10 as Education Coordinator for this facility.

2. The Job Description for Education Coordinator, for this facility, states "... Licenses/Certification: Appropriate state licensure for clinical specialty.... C: Company Specific ...Maintains current licensure/certification for position, if applicable..." This job description was signed by Staff #MC20, Staff #MC1 and Staff #MC10 on 9/15/10.

3. Employee file of Staff #MC20 contained a Complaint Form from the State of New Jersey Office of Attorney General that stated "...Complaint Report Against Staff #MC20 ... 5. What is the nature of the complaint? Unlicensed Practice (has a check mark next to it) 6. Please describe the facts of your complaint in the order in which they happened... Staff #MC20 was hired on 9/23/10 as the Education Coordinator and stated she/he had applied for a NJ License and had a Florida license. Throughout the months she was asked about the status of her NJ license and she stated they still had not processed. In April once again she was asked about her license, she/he stated she/he would need to take a refresher course. At this time primary source verification for Florida was done. Results indicated Staff #MC20 did not have a Florida license. Although it is not required for Education Coordinator to be licensed, investigation revealed Staff #MC20 worked 4 shifts in the clinical area. Staff #MC20 employment was terminated."

4. Interview with Staff #MC10, Administrative Assistant for HR, on 8/16/11 revealed that Staff #MC10 believed that the position of Education Coordinator did not require a state license. When she/he was pointed out that the Job Description for Education Coordinator states under "Licenses/Certification: Appropriate state licensure for clinical specialty", Staff #MC10 stated, "I must have read it wrong."

A. Based on review of the nursing schedules and assignment sheets and staff interview, it was determined that the facility failed to ensure that the registered nurse supervised the care of all patients.

MORRIS COUNTY FACILITY

Findings include:

1. A review of the 'Assignment Sheet' for the following dates revealed that Staff #MC20 was assigned as the 'Lead' nurse for the 7p to 7a shift:
a. December 27, 2010
b. December 31, 2010
c. January 21, 2011

2. Staff #MC1 stated during interview on 8/16/11 that the role of the 'Lead' nurse on the schedules reflects the registered nurse that is in charge as the nursing supervisor for that shift.

3. There is no evidence in the personnel record of Staff #MC20 of a valid registered nurse license.

4. The facility was unable to provide evidence that Staff #MC20 was licensed and credentialed at the time of the assigned role as nursing supervisor for the dates stated above.


B. Based on review of nursing schedules and assignment sheets and staff interview, it was determined that the facility failed to ensure that the registered nurse supervises the care of all patients.

MORRIS COUNTY FACILITY

Findings include:

1. A review of the 'Assignment Sheet' for the following dates revealed that the staff assignment sheets were blank for the 7p to 7a shift. It could not be determined if patients were supervised by a registered nurse on the following days:

a. January 24, 2011
b. February 2, 2011
c. February 7, 2011
d. February 8, 2011
e. February 22, 2011

2. Upon request on 8/16/11, Staff #MC1 was unable to provide the nursing assignment sheets for the 7p to 7a shift for the above stated dates.

3. There is no evidence that the facility provided a registered nurse to supervise the care of all patients for the dates and shifts stated above.

A. Based on document review and staff interview, it was determined that the facility failed to ensure that a registered nurse was assigned the nursing care in accordance with the specialized qualifications and competence of the nursing staff available.

MORRIS COUNTY FACILITY

Findings include:

1. A review of the 'Assignment Sheet' dated February 17, 2011 for the 7a to 7p shift and February 18, 2011 for the 7a to 7p shift revealed, that Staff #MC20 was not assigned to any patient for nursing care during that period of time.

2. The 'Assignment Sheet dated February 17, 2011 also revealed that there were 6 other Registered Nurses assigned to the 7a to 7p shift.

3. February 18, 2011 'Assignment Sheet' revealed that there were also 4 other registered nurses assigned for the 7a to 7p shift.

4. A review of Pyxis Medication Station reports (the drug dispensing device used by the facility) revealed that the following medications were removed from the drug dispensing device by Staff #MC20:

a. Two oxycodone/acetaminophen 5/325 tablets, a Schedule II Controlled Dangerous Substance (CDS), on 2/16/11 at 14:29, on 2/17/11 at 15:12 and 2/18/11 at 16:02.

5. Staff #MC1 identified Staff #MC20, as a Nurse Educator and the facility could not provide evidence of a valid registered nurse license to practice in the State of New Jersey for Staff #MC20.

6. There is no evidence that the facility assigned the nursing care of each patient in accordance with the qualifications and competence of the nursing staff available.


20323


B. Based on review of documentation, it was determined that the facility failed to ensure that nursing personnel with the appropriate education, experience, licensure and competence, are assigned to provide nursing care for each patient in accordance with individual needs of each patient.

Findings include:

MORRIS COUNTY FACILITY

1. Staff #20 worked as either a supervisor or primary nurse on 12/27/10, 12/31/10, 1/21/11 and 2/25/11.

2. Staff # 20 did not have a valid nursing license for the dates 12/27/10, 12/31/10, 1/21/11 and 2/25/11. Therefore patients were under the care of an unlicensed individual.

A. Based on document review and staff interview conducted on 8/15/11 it was determined that the facility failed to ensure that drugs are administered by licensed nursing personnel.

MORRIS COUNTY FACILITY

Findings include:

1. Review of Pyxis Med Station reports (the drug dispensing device used by the facility) revealed that the following medications were removed from the drug dispensing device by Staff #MC20, a staff member who was the facility's Nursing Educator and did not have a license to practice in the State of New Jersey:

a. Two oxycodone/acetaminophen 5/325 tablets, a Schedule II Controlled Dangerous Substance (CDS), on 2/16/11 at 14:29; 2/17/11 at 15:12; 2/18/11 at 16:02; 2/25/11 at 23:53; 2/26/11 at 06:37; 3/3/11 at 10:00; 3/23/11 at 12:53; 4/12/11 at 11:38 and 16:08; 3/31/11 at 12:40; 4/5/11 at 05:37, 15:51 and 15:53; 4/11/11 at 11:47, 13:16, 17:41, and 17:42; 4/12/11 at 12:24; and 4/18/11 at 12:20.

b. One Hydromorphone Hydrochloride 1 mg/1 ml injectable, a Schedule II CDS, on 1/22/11 at 00:02, 2/7/11 at 11:21, and 2/26/11 at 01:39.

c. One oxycodone/acetaminophen 5/325 tablet, a Schedule II CDS, on 2/17/11 at 12:54, 2/26/11 at 03:30, 3/11/11 at 12:16, 3/15/11 at 17:35, 3/17/11 at 12:12, 3/23/11 at 14:43, and 3/24/11 at 14:10.

d. Diphenhydramine Hydrochloride 50 mg/1 ml injection on 2/26/11 at 01:39.

2. Upon interview, Staff #MC5 stated that the patient records of the patients the CDS drugs that had been removed from the Pyxis drug dispensing device by Staff #MC20 for had been reviewed by the facility. In all but two instances the administration of the medication had been properly recorded on the medication administration record.


15481


B. Based on observation, it was determined that the facility failed to ensure all drugs were kept under supervision.

MORRIS COUNTY FACILITY

Findings include:

1. On 8/16/11 at 11:30 AM, with Staff #MC3, at the medication room, the door lock combination was written on the wall. Drugs, needles and syringes were in the room.

Based on staff interview and medical record review from all three facilities, it was determined that the facility failed to ensure that verbal orders are used infrequently.

Findings include:

1. A review of physician orders in 13 Medical Records (#MC4, #MC5, #MC6, #MC8, #W24, #W25, #W29, #W32, #W34, #W36, #R38, #R39 and #R42), revealed the following:

MORRIS COUNTY FACILITY

a. Medical Record #MC4, had evidence of 3 verbal orders from 7/22/11 through 7/30/11.

b. Medical Record #MC5, had evidence of 4 verbal orders from 7/13/11 through 7/24/11.

c. Medical Record #MC6, had evidence of 4 verbal orders from 5/19/11 through 6/5/11.

d. Medical Record #MC8, had evidence of 4 verbal orders from 8/5/11 through 8/6/11.

WAYNE FACILITY

a. Medical Record #W24, had evidence of 6 verbal orders from 2/16/11 through 3/15/11.

b. Medical Record #W25, had evidence of 4 verbal orders from 3/4/11 through 3/11/11.

c. Medical Record #W29, had evidence of 18 verbal orders from 7/25/11 through 8/13/11.

d. Medical Record #W32, had evidence of 9 verbal orders from 3/17/11 through 4/14/11.

e. Medical Record #W34, had evidence of 5 verbal orders from 3/6/11 through 4/12/11.

f. Medical Record #W36, had evidence of 8 verbal orders from 6/22/11 through 8/6/11.

RAHWAY FACILITY

a. Medical Record #R38, had evidence of 37 verbal orders from 5/29/11 through 8/16/11.

b. Medical Record #R39, had evidence of 10 verbal orders from 6/22/11 through 8/6/11.

c. Medical Record #R42, had evidence of 5 verbal orders from 7/14/11 through 7/20/11.

The above findings were confirmed with Staff #MC3 on 8/16/11.

Based on medical record review and review of facility documents, it was determined that the facility failed to ensure that verbal/telephone orders were verified and countersigned, with date and time, by the prescribing practitioner within 48 hours.

Findings include:

Reference #1: Policy: "Receiving and Transcribing Physician's Orders, Policy: Physician orders are to be written only on the Physician Order Sheet in the patient chart. Telephone orders may only be accepted by the Registered Nurse (RN) and must be signed by the ordering physician within 48 hours..."

Reference #2: Medical Staff Rules and Regulations, approved 4/23/09 states,
"2. Telephone/verbal orders: ...b. ... Telephone orders shall be dated, timed and countersigned by the physician within 48 hours or the next physician visit, whichever is sooner..."

MORRIS COUNTY FACILITY

The following verbal orders were not signed dated or timed by the physician within 48 hours or upon the next physician visit as per the reference stated above:

1. The following verbal orders in Medical Record #MC4 were not countersigned, dated or timed by the physician:

a. A verbal order dated 7/22/11 at 1620.

b. A verbal order dated 7/29/11 at 1950.

c. A verbal order dated 7/30/11 at 1740.

2. The following verbal orders in Medical Record #MC5 were signed by the physician, but not dated or timed:

a. A verbal order dated 7/20/11 at 2130.

b. A verbal order dated 7/24/11 at 4:10 PM.

(i) Without the date or time you can not determine whether the orders were signed within the appropriate time frame.

3. The following verbal orders in Medical Record #MC5 were not countersigned, dated or timed by the physician:

a. Verbal orders dated 7/13/11 at 0930, 1430, and 1600.

b. Verbal orders dated 7/14/11 at 0750 and 1235.

4. The following verbal orders in Medical Record #MC5 were signed by the physician, but not dated or timed:

a. A verbal order dated 7/11/11 at 2000.

b. A verbal order dated 7/12/11 at 1:00 PM.

(i) Without the date or time, it can not be determined whether the orders were signed in the appropriate time frame.

5. The following verbal orders in Medical Record #MC6 were signed by the physician, but not dated or timed:

a. A verbal order dated 5/19/11 at 2040.

b. A verbal order dated 5/21/11 at 0430.

c. A verbal order dated 5/22/11 at 11:20 AM.

d. A verbal order dated 6/5/11 at 8:30 AM.

(i) Without the date or time, it can not be determined whether these orders were signed in the appropriate time frame.

6. The following verbal orders in Medical Record #MC8 were not signed, dated or timed by the physician within 48 hours.

a. A verbal order dated 8/5/11 at 2020.

b. A verbal order dated 8/5/11 at 2100.

c. A verbal order dated 8/6/11 at 01:00 AM.

d. A verbal order dated 8/6/11 at 2:00 AM.

(i) Without the date or time, it can not be determined whether the orders were signed within the appropriate time frames.

WAYNE FACILITY

The following verbal orders were not signed dated or timed by the physician within 48 hours or upon the next physician visit as per reference stated above:

1. The following verbal orders in Medical Record #W24 were not countersigned, dated or timed by the physician:

a. A verbal order dated 2/16/11 at 7:30 PM.

b. A verbal order dated 2/19/11 at 5:20 PM.

c. A verbal order dated 2/17/11 (no time indicated on order).

d. A verbal order dated 3/7/11 at 3:30 PM.

e. A verbal order dated 3/13/11 at 2035.

f. A verbal order dated 3/15/11 at 2040.

2. The following verbal orders in Medical Record #W25 were signed by the physician, but not dated or timed:

a. A verbal order dated 3/4/11 at 1845.

b. A verbal order dated 3/5/11 at 0415.

c. A verbal order dated 3/8/11 2220.

d. A verbal order dated 3/11/11 at 2:00 AM.

(i) Without the date and time, it can not be determined whether the orders were signed within the appropriate time frames.

3. The following verbal orders in Medical Record #W32 were signed by the physician, but not dated or timed:

a. A verbal order dated 3/17/11 at 9:50 AM.

b. Verbal orders dated 3/18/11 at 3:30 PM and 6:15 PM.

c. A verbal order dated 3/23/11 6:45 PM.

d. A verbal order dated 3/25/11 at 1015.

e. A verbal order dated 4/2/11 at 3:30 PM.

f. A verbal order dated 4/4/11 at 1750.

g. A verbal order dated 4/5/11 at 4:45 PM.

h. A verbal order dated 4/7/11 (no time indicated on order).

i. A verbal order dated 4/14/11 at 1730.

(i) Without the date and time, it can not be determined whether the orders were signed within the appropriate time frame.

4. The following verbal orders in Medical Record #W34 were not countersigned, dated or timed by the physician:

a. A verbal order dated 3/6/11 at 2115.

b. A verbal order dated 3/18/11 at 1950.

c. A verbal order dated 3/20/11 at 2000.

d. A verbal order dated 3/29/11 at 6:45 PM.

e. A verbal order dated 4/12/11 at 9:25 PM.

RAHWAY FACILITY

The following verbal orders were not signed dated or timed by the physician within 48 hours or upon the next physician visit as per reference stated above:

1. The following verbal orders in Medical Record #R39 were signed by the physician, but not dated or timed:

a. Verbal orders dated 6/22/11 at 4:45 PM and 5:00 PM.

b. A verbal order dated 7/6/11 at 3:33 PM.

c. A verbal order dated 7/11/11 at 1535.

d. A verbal order dated 7/17/11 at 11:05 AM.

e. Verbal orders dated 7/18/11 at 12:30 PM and 4:30 PM.

f. Verbal orders dated 7/20/11 at 7:00 PM and 9:00 PM.

g. A verbal order dated 7/28/11 at 10:30 AM.

h. A verbal order dated 8/6/11 at 9:30 AM.

(i) Without the date and time, it can not be determined whether the orders were signed within the appropriate time frames.

2. The following verbal orders in Medical Record #R39 were not countersigned, dated or timed by the physician:

a. A verbal order dated 7/29/11 at 12:20 PM.

b. A verbal order dated 7/17/11 at 9:00 AM.

3. The following verbal orders in Medical Record #R42 were signed by the physician, but not dated or timed:

a. A verbal order dated 7/14/11 at 11:06 PM.

b. A verbal order dated 7/16/11 at 10:00 AM.

c. Verbal orders dated 7/17/11 at 4:10 PM and 6:00 PM.

d. A verbal order dated 7/19/11 at 9:20 PM.

e. A verbal order dated 7/20/11 at 2:35 PM.

(i) Without the date and time, it can not be determined whether the orders were signed within the appropriate time frames.

Based on observation and staff interview it was determined that the facility failed to ensure that only pharmacists or pharmacy-supervised personnel label drugs.

Findings include:

MORRIS COUNTY FACILITY

1. During a tour of the medication storage area on 8/15/11 it was noted that the pharmacy label was partially affixed to the outerwrap of Levaquin 500 mg/100 ml intravenous solution. Upon interview, Staff #MC47 stated the nurse would remove the pharmacy label from the outerwrap and place it on the inside bag just prior to administration. Pharmacy labels are affixed to containers prior to being dispensed from the pharmacy. The label not only includes patient information but also the initials of the pharmacist who dispensed the medication. Once this process is completed, the label cannot be removed by a nurse and placed on a different container since he/she is not under the supervision of the pharmacist.

WAYNE FACILITY

1. During a tour of the medication storage area on 8/23/11 it was noted that the pharmacy label was partially affixed to the outerwrap of Ciprofloxacin 400mg/100ml intravenous solution. Upon interview, Staff #W30 stated the nurse would remove the pharmacy label from the outerwrap and place it on the inside bag just prior to administration. Pharmacy labels are affixed to containers prior to being dispensed from the pharmacy. The label not only includes patient information but also the initials of the pharmacist who dispensed the medication. Once this process is completed, the label cannot be removed by a nurse and placed on a different container since he/she is not under the supervision of the pharmacist.

Based on document review and staff interview, it was determined that the facility failed to ensure the development and implementation of policies and procedures addressing the prevention and control of the spread of communicable diseases among patients and staff in accordance with state regulations.

Findings include:

Reference #1: N.J.A.C. Title 8 Chapter 43G- Hospital Licensing Standards, Subchapter 20.2(e.)1 states, "Each new employee, including members of the medical staff employed by the hospital, shall be given a rubella screening test upon employment."

Reference #2: N.J.A.C. Title 8 Chapter 43G- Hospital Licensing Standards, Subchapter 20.2(f.)1 states, "Each new employee, including members of the medical staff employed by the hospital, born in 1957 or later shall be given a rubeola screening test, upon employment."

MORRIS COUNTY FACILITY

1. Upon request on 8/15/11, Staff #MC49 was unable to provide evidence that a rubella and rubeola screening had been done for any of the pharmacy staff. This is a contracted service.

WAYNE FACILITY

1. Upon request on 8/23/11, Staff #MC30 was unable to provide evidence that a rubella and rubeola screening had been done for any of the pharmacy staff. This is a contracted service.

RAHWAY FACILITY

1. Upon request on 8/24/11, Staff #R43 was unable to provide evidence that a rubella and rubeola screening had been done for any of the pharmacy staff, with the exception of Staff #R43. This is a contracted service.

2. Upon request, Staff #MC5 was unable to provide facility policies and procedures that included the screening of employees upon hire for rubella and rubeola. He/she confirmed that the contracted pharmacy services did not screen employees for rubella and rubeola upon hire.

Based on review of 4 of 4 medical records (#W30, #W31, #R40 and #R41) of patients receiving rehabilitation services and staff interview, it was determined that the facility failed to ensure that all services are furnished in accordance with practitioners orders.

Findings include:

WAYNE FACILITY

1. A review of Medical Record #W30 indicated a physician's order dated 8/15/11 that stated, "PT Evaluation."

a. A review of a 'Physical Therapy Evaluation' dated 8/16/11 for Patient #W30 stated on page 2 of 2, "Treatment Plan: Skilled Physical Therapy Services to treat 5 x/week x 4 week(s) BID (Requires Physician Order).

b. There was no evidence in Medical Record #W30 of a physician's order to provide physical therapy 5 times per week for 4 weeks as per the treatment plan stated above.

2. Staff #W26 stated during interview on 8/23/1, that it is the practice of the facility to obtain a physician's order for evaluations of candidacy for rehabilitation services but once it is determined if the patient is appropriate for rehabilitation services another physician's order is not obtained to initiate the treatment plan. This practice was confirmed by Rehabilitation Staff at each of the other two remaining facility locations.


RAHWAY FACILITY

1. A review of Medical Record #R40 indicated a physician's order dated 8/22/11 stated, "OT Evaluation and Treatment..."

a. A review of the 'Occupational Therapy Evaluation' dated 8/23/11 stated, "Short Term Goal 1. Pt will ^ bed mobility 2. Pt will ^ UB(upper body) strength by 1/2 grade Time Frame 7 Days...Long Term Goal 1. Pt will ^ bed mobility to moderate Time Frame 15 days..."

b. There is no evidence of a physician's order to continue to treat and provide occupational services to Patient #R40 for 7 or 15 days as per the treatment plan stated above.

c. A review of the undated 'Interdisciplinary Care Conference Record' did not provide evidence of the patients progress with occupational therapy services being provided.

d. The 'Short term Goals & Recommendations' portion of the treatment plan for occupational services was blank.

2. A review of Medical Record #R41 indicated a physician's order dated 7/12/11 stated, "PT Evaluation and Treatment OT Evaluation and Treatment..."

a. A review of the 'Occupational Therapy Evaluation' dated 7/15/11 stated, "Short Term Goal 1. Pt will ^ bed rolling 2. ^ UB (upper body) strength by 1/2 grade Time Frame 2 weeks...Long Term Goal 1. ^ UB strength by one grade Time Frame 4 weeks..."

b. There is no evidence of a physician's order to continue to treat and provide occupational services to Patient #R41 for 2 weeks or 4 weeks as per the treatment plan stated above.

Based on document review and staff interview, it was determined that the facility failed to ensure that all data is collected to result in opportunities identified for improvement and change.

Findings include:

MORRIS COUNTY FACILITY

1. A review of the 'Quality Council' meeting minutes from the Morris County facility, dated October 21, 2010, January 20, 2011 and April 21, 2011, did not include data from the Human Resources Department.

2. Staff #MC10 stated the following during interview on 8/13/11:

a. The facility did not have a mechanism in place to ensure that all credentials and licensing requirements for all job descriptions and positions in the nursing department were reviewed and obtained before the start of employment.

b. Staff #MC20 was hired on 9/23/10 as the Education Coordinator which required a license within the speciality of nursing.

c. Staff #MC20 stated at the time of hire, that he/she had applied for a Registered Nurse License and had possession of a valid Registered Nurse license from the State of Florida.

d. From 9/23/10 to 4/14/11, Staff #MC20 had not provided evidence of a current Florida Registered Nurse license or a New Jersey Registered Nurse license.

e. On 4/14/11 a primary source verification for the State of Florida was completed and the results indicated that Staff #MC20 did not possess a Registered Nurse License in the State of Florida.

f. A review of the nursing 'Assignment Sheets' dated 12/27/10, 1/21/11, 2/25/11 and 2/26/11 indicated that Staff #MC20 was assigned duties in a clinical area caring for admitted patients.

g. Staff #MC20 remained employed at the facility in the job title of 'Education Coordinator' from 4/14/11 through 5/11/11 until his/her employment was terminated.

h. There is no evidence of data collected from the Human Resources Department during 'Quality Council' meetings held on October 21, 2010, January 20, 2011 and April 21, 2011.

WAYNE FACILITY
1. A review of the 'Quality Council' meeting minutes from the Wayne facility for January 25, 2011 and February 17, 2011, did not include data reported from the Infection Control Department.

There is no evidence that the facility consistently collected data from each hospital department, to identify opportunities for change and improvement.

Based on review of the performance improvement data, it was determined that the facility failed to ensure that actions are initiated upon problems identified.

Findings include:

1. A review of the 'Quality Council' meeting minutes from the Morris County facility for the dates of October 21, 2010 and April 21, 2011, did not include any data reported from the Infection Control Department.

a. The 'Quality Council' meeting minutes dated January 21, 2011 included data collected from the Infection Control Department that states within the 'Recommendations/Conclusions,' portion of the minutes, "a. Donning gowns when doing bedside care at 80%...C. Oral Care is at 50%. Will be addressed at staff meeting and reeducation of all staff..."

b. The 'Action/Follow-Up' portion of the 'Quality Council' meeting minutes dated January 21, 2011 stated, "Dr' s M___ & G-__ stressed this must be addressed as it not currently acceptable."

c. There is no evidence of any actions or measurements set forth that will lead to improvement from the data collected and reported from the Infection Control Department for January/2011.

2. A review of 13 closed medical records from all three sites revealed the following:

a. MORRIS COUNTY FACILITY: 4 Medical Records, (#MC4, #MC5, #MC6 and MC#8) had verbal orders that were not authenticated by the medical staff in 48 hours.

b. WAYNE FACILITY: 6 Medical Records, (#W24, #W24, #W29, #W32, #W34, and #W36) had verbal orders that were not authenticated by the medical staff in 48 hours.

c. RAHWAY FACILITY: 3 Medical Records, (#R38, #R39, and #R42) had verbal orders that were not authenticated by the medical staff in 48 hours.

d. Each Medical Record stated above included between 3 to 37 verbal orders that were not authenticated by the medical staff within 48 hours.

3. A review of the 'Quality Counsel' meeting minutes from the facility dated 2/17/11, stated: "KHNJ -- All sites continue to struggle with authentication of telephone orders and dating and timing entries."

a. The 'Action /Follow-up' portion of the minutes stated, "Each site, please forward a list of physicians who continue not to comply with this policy."

There is no evidence in the 'Quality Counsel' meeting minutes of any detailed actions implemented with measurements in place to monitor success for the above stated problem of authenticating records.

Based on observation and medical record review conducted on 8/24/11, it was determined that the facility failed to ensure that medications are administered in accordance with with physician's orders and additional instructions that appear on the medication administration record.

RAHWAY FACILITY

Findings include:

1. During a medication pass observation, Staff #R44 was observed administering Protonix 40 mg intravenously to Patient #R44 on 8/24/11 at 11:35 AM. The following discrepancies were identified:

1. The medication was ordered daily, with an administration time of 10:00 AM. The medication was not administered at the time ordered by the physician. Upon interview, Staff #R44 was unable to provide a reason for the late administration.

2. Additional directions on the Medication Administration Record (MAR) include, "...add 10ml NSS [Normal Saline Solution] to Protonix, infuse over 2 minutes..." The Protonix was administered intravenously over 45 seconds instead of 2 minutes.

Based on review of 5 of 5 medical records (#M9, #M10, #M11, #M13, and #M15, ), it was determined that the facility failed to ensure that medical records were kept secure at all times.

MORRIS COUNTY FACILITY

Findings include:

1. A review of 5 of 5 medical records (#M9, #M10, #M11, #M13, and #M15,) on 8/16/11 revealed that all of the 24 hour nursing documentation was missing from each record for the period of February 25, 2011 through February 26, 2011.

2. A review of the facility 'Assignment Sheet' dated 2/25/11 through 2/26/11 indicated that Staff #MC20 was assigned to the care of the five patients whom portions of the medical records were missing.

3. The facility was unable to provide any of the missing information from the medical record.

4. As per interview with Staff #MC1 on 8/16/11, there was no explanation to where or why the documentation was missing from each of the medical records stated above.