HospitalInspections.org

Based on observation, interview, and documentation review the facility failed to maintain the trash chute door closing device, failed to maintain the exit access door to the the public way, and failed to maintain reserved sprinkler heads in the sprinkler head box.(A710) The cumulative effect of these systemic practices resulted in the facility's inability to ensure patients were safe from fire. The facility's census at the time of the survey was 23.

Based on interview, observation and review of the admission packet, the facility failed to ensure patients were provided grievance contact information. This deficient practice had the potential to affect all of the facility's 23 active patients.

Findings include:

During tour of the facility on 2/23/15 observation noted the facility failed to have the phone number and address for lodging a grievance with the State agency posted at the facility.

Staff B provided a copy of the facility's Admission Folder on 2/25/15 at 3:00 PM. The folder did not contain the phone number and address for lodging a grievance with the State Agency. The findings were shared with Staff B and confirmed at this time.

The facility's Patient and Family Handbook was reviewed. The handbook did not contain the phone number and address for lodging a grievance with the State agency.

On 2/25/15 at approximately 4:00 PM, Staff B reported the phone number and address for lodging a grievance with the State agency was being posted in every patient's room.

Based on medical record review and policy review, the facility failed to ensure staff monitored one of one patients in restraints every hour in accordance with the facility policy. (Patient #5) The facility's active census was 23.

Findings include:

The medical record for Patient #5 contained an order for a soft mitt restraint to be placed on Patient #5's left hand on 2/19/15 and 2/20/15. The medical record lacked evidence the restraint was removed for 10 minutes every two hours on 2/19/15 from 11:00 AM through 6:00 PM.

The facility's Restraints and Seclusion policy stated at a minimum, documentation in the medical record must include observations/interventions/findings for periodic observations, to include: safety, comfort, mobility, skin integrity, food/hydration and toileting - to include removal of restraints at least 10 minutes every 2 hours or more often (observations every two hours for medical restraints).

29377

Based on medical record review, policy review and staff interview, the facility failed to ensure medication orders contained approved abbreviations for two patients (Patient #14 and #24) and failed to ensure medications were administered at the ordered frequency for 15 of 30 medical records reviewed. (Patient #2, #3, #4, #5, #8, #12, #13, #15, #17, #18, #20, #21, #23, #24 and #27) This deficient practice had the potential to affect all 23 active patients.

Findings include:

1. The medical record for patient #24 revealed documentation of a physician order dated 2/9/15 at 10:10 AM for Flonase "QD" as needed for sinus congestion.

2. The medical record for Patient #14 revealed documentation of a physician order dated 11/12/14 at 11:30 AM for Prozac 20 mg "QOD".

The facility's Official "Do Not Use" List was reviewed. The list stated not to use "QD" and "QOD". The list stated to write "daily" and "every other day".

The facility's Drug Orders policy #D11-P stated orders that include unapproved abbreviations will not be acted upon, until clarified with the prescribing physician.

On 2/26/15 at 2:30 PM, the findings were shared with Staff B and confirmed.

3. Review of Patient #2's Medication Administration Record (MAR) revealed orders for Neurontin (a medication used as an anticonvulsant and analgesic) 300 milligrams every six hours. The MAR revealed the Neurontin was administered on 1/15/15 at 6:20 AM and not administered again until 1/15/15 at 6:08 PM.

The medical record did not contain the reason for the missed dose and lacked evidence the physician had been notified of the missed dose. The medication administration record revealed Patient #2 was to receive Ceftriaxone Sodium (an antibiotic) every day at 5:00 PM. On 2/2/15, Patient #2 received the Ceftriaxone Sodium at 4:50 PM. On 2/3/15, the Ceftriaxone was administered at 6:47 PM. The medical record did not contain the reason for the late administration and lacked evidence the physician had been notified of the late medication administration.

4. Review of Patient #5's MAR revealed orders for Cefepime (an antibiotic) every 12 hours. The MAR revealed Patient #5 received the Cefepime on 2/14/15 at 10:00 AM and not again until 2/15/15 at 12:01 AM. The medical record lacked documentation for the reason for late administration and did not contain evidence the physician was notified notified.

The findings were shared with Staff A on 2/24/15 at 10:40 AM and confirmed.

5. The MAR for Patient #8 revealed the patient was scheduled to receive Valtrex (an antiviral medication) every eight hours. The medication administration record revealed Patient #8 received the Valtrex on 2/23/15 at 5:10 AM and not again until 2/24/15 at 9:07 PM. There was no evidence of reason for late administration or notification of physician.

The findings were shared with Staff A on 2/25/15 at 9:41 AM and confirmed.

6. The medical record review for Patient #13 revealed an order on 1/26/15 for Cardizem (used in the treatment of hypertension, angina pectoris, and some types of arrhythmia) every six hours and Digoxin (used to treat abnormal heart rhythms) daily. The order did not contain parameters for which to hold the Cardizem and Digoxin.

The MAR revealed Patient #13 received the Cardizem on 2/1/15 at 5:37 PM and did not receive the next dose until 2/2/15 at 2:00 AM. Patient #13 received the Cardizem on 2/3/15 at 4:59 AM and did not receive the next dose until 2/3/15 at 2:48 PM. Patient #13 received the Cardizem on 2/9/15 at 5:01 PM and did not receive the next dose until 2/10/15 at 5:11 AM.

Patient #13's blood pressure was 122/64 and heart rate was 73 on 2/10/14 at 12:00 AM. The MAR revealed Patient #13 received the Cardizem on 2/10/15 at 5:30 PM and did not receive the next dose until 2/11/15 at 1:40 AM.

The medical record did not contain evidence the physician was notified of the missed doses and did not contain evidence the physician was notified of the late doses. The MAR did not contain evidence of the Digoxin being administered on 2/17/15.

On 2/25/15 at 11:37 AM, Staff A provided a copy of the Missed Dose Medication Administration Record for Patient #13. On 2/17/15, a nurse documented the Digoxin was held per parameters. The nurse documented Patient #13's heart rate as 50. The medical record did not contain evidence the physician was notified of the missed dose.

7. Review of the MAR for Patient #3 revealed Patient #3 was to receive Cefepime (an antibiotic) every 12 hours through 2/14/15, Cefepime every eight hours through 2/24/15 and Vancomycin (an antibiotic) every twelve hours. Patient #3 received the Cefepime on 2/13/15 at 9:06 AM and did not receive the next dose until 2/14/15 at 12:35 AM.

On 2/14/15 at 5:30 AM, a nurse documented Patient #3's temperature was elevated to 101.1 and Tylenol was administered.

Patient #3 received Cefepime on 2/23/15 at 5:09 AM and did not receive the next dose until 2/23/15 at 4:35 PM.
Patient #3 received Vancomycin on 2/13/15 at 9:13 AM and did not receive the next dose until 2/14/15 at 12:35 AM.

The medical record did not contain evidence the physician was notified of the late doses or elevated temperature.

8. Review of the MAR for Patient #15 revealed orders for Cardizem every six hours and Digoxin daily. Patient #15 did not receive the Cardizem on 12/17/14 at 12:00 PM, 12/18/14 at 6:00 AM, 12/19/14 at 6:00 AM and 6:00 PM, 12/20/14 at 12:00 AM and 6:00 AM, 12/22/14 at 12:00 PM and 6:00 PM, 12/25/14 at 6:00 PM, 12/28/14 at 6:00 AM, 12/30/14 at 12:00 AM and 6:00 AM and on 12/31/14 at 12:00 AM. Patient #15 did not receive the scheduled Digoxin on 12/22/14.

On 2/25/15 at 4:03 PM, Staff A provided a Missed Dose Medication Administration Record for Patient #15. The record contained the following:
On 12/17/14 at 11:41 AM, a nurse documented the Cardizem was held per parameters.
On 12/18/14 at 5:15 AM, a nurse documented Patient #15 was off the unit and recorded Patient #15's heart rate as 64.
On 12/19/14 at 5:11 AM, a nurse documented the Cardizem was held per parameters and recorded Patient #15's heart rate as 65-70.
On 12/19/14 at 6:11 PM, a nurse documented the Cardizem was held per parameters and recorded Patient #15's heart rate as 65.
On 12/20/14 at 6:00 AM, a nurse documented the Cardizem was held per parameters and documented Patient #15's blood pressure as 102/84.
On 12/22/14 at 10:13 AM, a nurse documented the Cardizem was held per parameters and recorded Patient #15's heart rate as 69.
On 12/22/14 at 11:35 AM, a nurse documented the Cardizem was held per parameters and recorded Patient #15's heart rate as 69.
On 12/30/15 at 12:28 AM, a nurse documented the Cardizem was held per parameters and recorded Patient #15's heart rate as 67 and blood pressure as 118/42.
On 12/30/14 at 6:10 AM, a nurse documented the Cardizem was held per parameters.
On 12/31/14 at 11:52 AM, a nurse documented the Cardizem was held per parameters and recorded Patient #15's heart rate as 68.

On 12/22/14 at 10:13 AM, a nurse documented the Digoxin was held per parameters and documented Patient #15's heart rate as 69.

The medical record did not contain evidence the physician was notified of the missed doses.

9. Review of the MAR for Patient #12 revealed orders for Patient #12 to receive Cardizem every six hours. The MAR revealed Patient #12 did not receive the Cardizem on 2/20/15 at 6:00 PM, 2/21/15 at 12:00 AM and 12:00 PM, 2/23/15 at 12:00 AM, 12:00 PM and 6:00 PM.

On 2/25/15 at 12:20 PM, Staff A provided a Missed Dose Medication Administration Record for Patient #15. The record contained the following nursing documentation:
2/20/15 at 5:29 PM, dose held per parameters blood pressure 88/52
2/21/15 at 12:08 PM, dose held per parameters
2/23/15 at 11:40 AM, dose held per parameters blood pressure 100/50
2/23/15 at 5:02 PM, dose held per parameters blood pressure 104/50

The medical record did not contain evidence the physician was notified of the missed doses.

10. Review of the MAR for Patient #4 revealed orders for Lopressor (used to treat high blood pressure) two times a day. The MAR revealed Patient #4 did not receive the 10:00 PM dose on 2/20/15.

On 2/25/15 at 12:20 PM, Staff A provided a Missed Dose Medication Administration Record for Patient #4. The record revealed a nurse held the Lopressor for a blood pressure of 98/64.

The medical record did not contain evidence the physician was notified of the missed dose.

Staff A provided a copy of the Nursing 2014 Drug Handbook which staff A stated the nursing staff uses as a guideline when administering medications. The handbook stated to withhold the Cardizem dose and notify prescriber if the systolic blood pressure is below 90 mmHg or heart rate is below 60 beats per minute.

The facility's Medication Administration policy #M01-N stated to take a patient's apical heart rate before giving any form of Digitalis (Digoxin). If the apical heart rate is 60 or less, notify physician prior to giving mediation.

11. Patient #17 was admitted to the hospital on 02/06/15 with diagnosis of Multiple Wounds. Patient #17 was also receiving hemodialysis three days a week while hospitalized, on Monday, Wednesday and Friday.

Review of the electronic Medication Administration Record (MAR) for Patient #17 revealed on 02/09/15 the RN failed to perform Patient #17's scheduled 5:00 PM accu-check (blood sugar check) and to administer her insulin (Aspart, if needed) and calcium acetate because the patient was "off unit." Patient #17 was at dialysis.

A Patient Hand-Off Communication Sheet for Dialysis is to be filled out every time a patient goes off the floor for hemodialysis. The sheet is filled out by hospital staff prior to sending the patient to dialysis and subsequently filled out by dialysis staff prior to the patient returning to the hospital floor. The sheet allows for documentation of vital signs, accu-checks that need to be completed and medications to be administered.

There was no documented Patient Hand-Off Communication Sheet for Dialysis on 02/09/15 to indicate the check was performed during dialysis. There was also no documented evidence that revealed whether or not the patient received insulin (Aspart) while at dialysis.

On 02/13/15 per the MAR, the RN failed to administer Patient #17's scheduled 10:00 AM insulin (Detemir), to perform her scheduled 12:00 PM accu-check and to administer her scheduled 12:00 PM insulin (Aspart) because the patient was "off unit" and "at dialysis."

A documented Patient Hand-Off Communication Sheet for Dialysis dated 02/13/15 was reviewed. Per the sheet, the hospital's RN marked accu-checks were to be performed "ACHS", meaning before meals and at bedtime. The RN left blank the checkbox for "Medications to be given."

Upon returning from dialysis at 2:00 PM, dialysis staff failed to document Patient #17's blood sugar was checked.

On 02/16/15 per the MAR, the RN failed to administer any of Patient #17's scheduled 8:00 AM, 10:00 AM or 12:00 PM medications and also failed to perform the scheduled accu-checks at those times. Patient #17 was noted to be "off unit."

A documented Patient Hand-Off Communication Sheet for Dialysis dated 02/13/15 was reviewed. The hospital RN documented accu-checks were to be performed "ACHS", but there was no documented evidence any accu-checks were performed while Patient #17 was at dialysis.

Documented Patient Hand-Off Communication Sheets for Dialysis dated 02/18/15 and 02/20/15 were reviewed. The hospital RN documented accu-checks were to be performed "ACHS", but there was no documented evidence any accu-checks were performed while Patient #17 was at dialysis.

On 02/23/15 per the MAR, the RN failed to administer Patient #17's scheduled 10:00 AM insulin (Detemir) because she was "off unit" and "in dialysis." The documented Patient Hand-Off Communication Sheet for Dialysis dated 02/23/15 was reviewed and revealed the RN failed to document accu-checks were to be performed "ACHS", and there was no documented evidence any accu-checks were performed while Patient #17 was at dialysis.

A documented Patient Hand-Off Communication Sheet for Dialysis dated 02/25/15 was reviewed. The hospital RN documented accu-checks were to be performed "ACHS", but there was no documented evidence any accu-checks were performed while Patient #17 was at dialysis.

12. Patient #18 was admitted to the hospital on 01/26/15 with a diagnosis of Left Foot Gangrene. Review of the MAR revealed on 01/30/15 at 10:00 AM staff failed to administer Patient #18's ordered 100 milligrams (mg) of Lopressor (anti-hypertensive), on 01/31/15 at 10:00 AM staff failed to administer her 6 mg/ml of Liraglutide (for blood sugar), and on 02/09/15 at 5:00 PM staff failed to perform Patient #18's scheduled accu-check.

13. Patient #20 was admitted to the hospital on 01/28/15 with diagnosis of Acute Pancreatitis. Review of the MAR revealed Patient #20 refused to take at least one of the scheduled medications on 01/28/15, 01/29/15, 02/03/15 and 02/07/15 - 02/24/15. There was no documented evidence of communication with the physician about Patient #20's refusal to take some of his/her medications and no evidence of patient education.

14. Patient #21 was admitted to the hospital on 02/20/15 with a diagnosis of Alcoholism. Review of the MAR revealed staff administered the scheduled every six hour Duoneb breathing treatment outside of the allowed 2 hour window on the following days: 02/20/15 at 11:00 PM, 02/21/15 at 11:00 AM and 11:00 PM, 02/22/15 on 5:00 AM and 11:00 PM and on 02/23/15 at 5:00 AM. Staff failed to document why the Duoneb was given either too early or too late.

15. Patient #23 was admitted to the hospital on 02/20/15 with a Non-Healing Left Hip Wound. Review of the MAR revealed staff failed to administer the ordered dose of Lovenox on 02/21/15 at 6:00 PM.

16. Patient #24 was admitted to the hospital on 02/05/15 with diagnosis of Cellulitis. Review of the MAR revealed Patient #24 refused to take at least one of the scheduled medications on 02/05/15, 02/07/15, 02/08/15 and 02/09/15. There was no documented evidence of communication with the physician about Patient #24's refusal to take some of the ordered medications and no evidence of patient education.

Staff A was made aware of the above findings on 02/26/15 beginning at 9:42 AM and confirmed them on 02/26/15 beginning at 12:08 PM.

17. Review of the admission physician's orders for Patient #27 revealed an order for Cymbalta (antidepressant), 60 milligrams (mg), by mouth, two times per day. Review of the MAR revealed Cymbalta was given two times per day on 11/21/14 and 11/22/14. On 11/23/14, the MAR revealed Cymbalta was not available for the 10:00 AM dose and the next dose of Cymbalta was not given until 11:04 PM.

On 2/26/15 at 10:20 AM, Staff A confirmed the 10:00 AM dose of Cymbalta was not given on 11/23/14. Staff A stated 11/23/14 was on Sunday and the Cymbalta was not in the medication drawer. Staff A confirmed the physician was not notified of the missed dose.




31597

Based on observation, interview, and documentation review, the facility failed to ensure the facility was safe from fire. This had the potential to affect all patients, visitors, and staff to the facility.The facility's active census was 23.

Findings include:
1. The facility failed to maintain the door to the trash chute. Please refer to K71.
2. The facility failed to maintain the exit access door to the public way. Please refer to K72.
3. The facility failed to maintain reserve sprinkler heads in the sprinkler head box. Please refer to K62.