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Based on observations, record reviews, and staff interview, the governing body failed to be responsible for contracted dialysis services. This was evidenced by failing to review and approve dialysis services policies and procedures and failing to ensure the actual results of water culture testing were reported.
Findings:

Observations of the hemodialysis treatment room on 07/27/16 at 9:10 a.m. revealed two hemodialysis machines and two reverse osmosis machines. In an interview at this time, S15DialysisRN was asked if dialysis staff had policies and procedures or manufacturer manuals as a reference source for the equipment in use. S15DialysisRN indicated there were no policies or reference materials readily available for dialysis staff for the equipment being used.

A review of dialysis machine and water treatment equipment culture results for June and July 2016 was done with S15DialysisRN on 07/27/16 at 9:21 a.m. Review of the water culture results revealed the results of testing were hand written and documented as no growth at 2 days.

Review of the Dialysis Services Agreement revealed an effective date of 06/05/16.

Review of the Dialysis Policy and Procedure AMG Specialty Hospital Version 1.0 July 1, 2016 manual revealed the policies and procedures were not specific to the services provided by the contracted dialysis service provider. Further review revealed no documented evidence the policies and procedures had been reviewed and approved by the hospital's governing body.

In an interview on 07/27/16 at 2:02 p.m., S1CEO confirmed the contracted dialysis services policies and procedures had not been reviewed and approved. S1CEO indicated the hospital will contact the laboratory used for water cultures to ensure the actual test results would be sent.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) The RN failed to ensure initial wound assessments were conducted by the RN within 8 hours of admission as required by hospital policy for 3 (#1, #2, #23) of 5 patient records reviewed for wound assessments from a total of 17 patients identified by the hospital for wound care.

2) The RN failed to ensure the nurse clarified physician orders for wound care (Patient #21), medications (Patients #2, #9, #21), blood transfusion rate (Patient #17), and hemodialysis treatment (Patient #11) for the 5 (#2, #9, #11, #17, #21) of the 9 patient medical records reviewed for clarification of physician orders from a total sample of 30 patients.

3) The RN failed to ensure the patient's weight was assessed as ordered by the physician for 2 (#10, #24) of 12 patient medical records reviewed for implementation of physician orders related to assessment of weight from a total sample of 30 patients.

4) The RN failed to ensure lab work was obtained as ordered and/or physician orders were present for lab work drawn for 2 (#21, #22) of 13 patient medical records reviewed for implementation of physician orders related to lab work from a total sample of 30 patients.

5) The RN failed to ensure medical consults were obtained and documented as ordered and in accordance with hospital policy for 2 (#21, #25) of 8 patient medical records reviewed for implementation of physician orders related to medical consults from a total sample of 30 patients.

6) The RN failed to ensure wound care was performed as ordered by the physician for 1 (#21) of 7 patient medical records reviewed for wound care from a total of 17 patients identified by the hospital for wound care.

Findings:

1) The RN failed to ensure initial wound assessments were conducted by the RN within 8 hours of admission as required by hospital policy for 3 (#1, #2, #23) of 5 patient records reviewed for wound assessments from a total of 17 patients identified by the hospital for wound care,

A review of the hospital policy titled "Nursing Documentation Guidelines" as provided by S2DON as the most current policy, revealed in part: Initial head-to-toe nursing assessment is initiated within 2 hours of admission and completed within 8 hours of admission.

Review of the hospital policy titled "Initial Assessment/Reassessment of Wounds", presented as a current policy by S2DON, revealed that wounds will be assessed at the time of admission by the RN, by the wound care nurse within 72 hours of consult, by the RN or wound care nurse at the onset of any new wound, and reassessed at least every 7 days by the wound care nurse and as needed by the RN or wound care nurse until the wound is resolved or the patient is discharged.

Patient #1
The patient was a 74 year old male admitted to the hospital on 07/21/16 with an admit diagnosis of acute respiratory failure, altered mental status and metabolic encephalopathy. Other diagnoses included in part: hypertension, chronic venous stasis, Clostridium Difficile (C-Diff), chronic renal failure requiring dialysis and atrial fibrillation. The Initial Nursing Assessment was initiated on 07/21/16 at 3:00 p.m. by S20RN. The "Wound Description" section of the Initial Nursing Assessment indicated to "see the wound round documentation". A review of the "Wound Assessment Detail Report" sheet revealed the patient's wounds were documented as assessed on 07/22/16 at 1:33 a.m. by S17RN (10.5 hours after admission).


Patient #2
A review of the medical record for Patient #2 revealed she was a 91-year-old female admitted to the hospital on 07/12/16 at 4:26 p.m. Diagnoses included Acute Ischemic Right Cerebral Vascular Accident, Malnutrition, Hypertension, Atrial Fibrillation, Anemia, Debility, Bowel and Bladder Incontinence. A further review revealed Patient #2 was placed on Fall Precautions and Aspiration Precautions due to her difficulty swallowing. A review of the RN Initial Assessment dated 07/12/16, under the Wound Assessment and Wound Description sections, "no wounds." A review of the physician admission orders revealed no wound care orders were written.
A review of the wound assessment detail report dated 07/14/16 at 9:00 a.m. revealed Patient #2 had a pressure wound assessed as a Stage II and was "present on admission" and was identified by S14RN/WCC and measurements were documented on 07/13/16 by S14RN/WCC.
Review of the physician orders dated 07/13/16 at 5:20 p.m. revealed a verbal order to cleanse a sacral wound with normal saline and apply Optifoam Gentle every 5 days or as needed, and to apply a waffle mattress.
In an interview on 07/26/16 at 10:00 a.m., S2DON reviewed the medical record with surveyor and confirmed the admit RN did not identify the Stage 2 wound of the buttock, and the admit RN should have identified the wound on admission, documented a detailed wound description upon admission, and obtained wound care orders from the physician upon admission to the hospital.

Patient #23
The patient was a 62 year old male admitted to the hospital on 07/21/16 with an admit diagnosis of profound iron deficiency, anemia, respiratory failure, and malnutrition. Other diagnoses included in part: diabetes, peripheral neuropathy, chronic renal disease and venous stasis ulcers. The Initial Nursing Assessment was initiated on 07/21/16 at 12:06 a.m. by S16RN. The "Wound Description" section of the Initial Nursing Assessment indicated to "see the wound round documentation". A review of the "Wound Assessment Detail Report" sheet revealed the patient's wounds were documented as assessed on 07/22/16 at 9:58 a.m. by S17RN (10 hours after admission).

In an interview on 07/26/16 at 1:00 p.m. with S14RN/WCC she indicated that she was the wound care nurse. She indicated that initial wound assessments should be performed within 8 hours of a patient admission and was usually done by the RN who performed the initial assessment on the patient and did not have to be performed by the wound care nurse. The wound care nurse would assess the patient within 72 hours of a wound care consult.


2) The RN failed to ensure the nurse clarified physician orders:
Wound Care: Patient #21

Patient #21
Review of Patient #21's medical record revealed she was admitted on 07/12/16 status post Incision and Drainage of Pelvic/Rectal Abscesses, Malnutrition, status post Rectal Resection, Rectal carcinoma, and Colostomy. Review of Patient #21's wound care orders at the time of admit revealed orders for treatment of a mid-abdominal surgical wound. There was no documented evidence of physician orders for treatment of the rectal wound, and there was no documented evidence that a clarification order had been received.

Review of S14RN/WCC's documentation of Patient #21's rectal wound assessment of 07/13/16 at 12:11 p.m. revealed the surgical wound to the rectum was 12 cm x 2.5 cm x 0 cm with an area of 30 cm.

Review of Patient #21's TAR revealed the rectal wound was cleansed with Normal Saline, patted dry, covered with gauze, and secured with tape on 07/12/16, 07/13/16, 07/14/16, and 07/15/16 with no documented evidence of physician orders for this treatment.

Review of Patient #21's physician orders revealed an order on 07/15/16 at 10:00 a.m. to change the perineal dressing every 12 hours with dry gauze and tape. Review of the TAR revealed treatment was documented as clean perineal/rectum with Normal Saline and apply gauze and tape twice a day and PRN soiling. There was no documented evidence of a clarification order from the physician that included cleaning the perineal wound with Normal Saline.

In an interview on 07/27/16 at 10:57 a.m., S2DON confirmed there was no physician's order or clarification order for rectal wound care.

Medications: Patients #2, #9, #21
Review of the hospital policy titled "Administration of Medications", presented as a current policy by S2DON, revealed that only appropriate and qualified healthcare personnel, in accordance with state laws and regulations and Medical Staff bylaws, may administer medications. Following the dispensing of drugs from pharmacy, medications are to be administered by the practitioner who prepares them. Further review revealed the 7 "R's" of administering medications will be followed with each medication Administration: "right" patient; "Right" medication; "Right" dose; "Right" time; "Right" route; "Right reason; "Right" documentation. Review of the entire policy revealed no documented evidence that medication administration was to be in accordance with a physician's order and the process for clarifying a physician's order.

Patient #2
A review of the medical record for Patient #2 revealed she was a 91-year-old female admitted to the hospital on 07/12/16 at 4:26 p.m. Further review revealed a verbal order dated 07/16/16 at 1:45 p.m., ordered by S32MedDir which stated, "Accuchecks twice per day with Novolin R sliding scale." Further review of the medical record revealed no physician orders for the sliding scale insulin. Review of the MAR revealed a hand-written sliding scale documented on the MAR.
In an interview on 07/25/16 at 2:30 p.m., S22LPN reviewed the medical record with surveyor and indicated there was usually a sliding scale physician order sheet for sliding scale insulin. S22LPN confirmed there was no documented evidence of physician orders for the sliding scale parameters to be administered to the patient, and there should have been physician orders.
In an in interview on 07/26/16 at 9:00 a.m., S2DON reviewed the medical record with surveyor and confirmed there were no insulin sliding scale orders written by S32MedDir, and there should have been specific insulin sliding scale range orders written by the physician.
Patient #9
A review of the medical record for Patient #9 revealed she was a 70-year-old female admitted to the hospital on 07/09/16 at 8:50 a.m. Diagnoses included Osteomyelitis of Left Foot with Wound, Stage IV, History of Diabetes Mellitus, Type 2, and Hypertension. Further review of the admit physician orders revealed, in part, Accuchecks before meals and at bedtime was checked off as "No," and "Other Accucheck Schedule" was checked off as "Yes," however, the space where the "other schedule" was to be documented was left blank. Review of the MAR revealed the Accuchecks were being performed before meals and at bed time. Review of the MAR revealed the Accuchecks were documented as being performed before meals and at bed time.
In an interview on 07/26/16 at 11:45 a.m., S16RN reviewed the medical record with surveyor, and he confirmed there was no documented evidence of a physician order specifying the frequency of the Accuchecks to be performed, and there should have been documentation in the medical record clarifying the physician's order for the frequency of Accuchecks.

Patient #21
Review of Patient #21's "Medication Reconciliation And Order Form" dated 07/12/16 at 11:30 a.m. revealed the following orders: Dilaudid 1 mg IV every 4 hours PRN severe pain (6 to 8 on a scale of 1 to 10); Morphine 2 mg IV every 1 hour PRN severe pain (6 to 8 on a scale of 1 to 10); Promethazine 25 mg IV every 4 hours PRN N/V or Promethazine 50 mg IV every 4 hours PRN N/V. There was no documented evidence of parameters for when to administer Dilaudid versus Morphine for severe pain and when to administer Promethazine 25 mg versus 50 mg.

In an interview on 07/27/16 at 10:57 a.m., S2DON indicated there should be parameters indicating when each medication should be given. He further indicated the nurse should have clarified the physician's orders for Morphine, Dilaudid, and Promethazine.

Blood Transfusion Rate: Patient #17
Patient #17
A review of the medical record for Patient #17 revealed he was a 70-year-old male admitted on 07/21/16 at 7:57 p.m. Diagnoses included Status/Post Repair of Umbilical Hernia with Obstruction, Abdominal Distention, Cirrhosis of the Liver, Ascites, and Non-bleeding Varices. Further review of the medical record revealed an order dated 07/25/16 at 10:20 a.m. which stated, in part: "Type and cross for one packed red blood cells, transfuse today."
In an interview on 07/26/16 at 3:40 p.m., S2DON reviewed the physician's order for the blood transfusion and confirmed there was no order from the physician regarding the rate of the transfusion, and agreed the nurse should have obtained an order from the physician clarifying the rate the transfusion was to be administered.

Hemodialysis Treatment: Patient #11

Patient #11:

Review of the medical record revealed the patient was admitted to the hospital on 07/06/16. The patient had the diagnoses of end stage renal disease and was receiving hemodialysis treatment at the hospital.

Review of a Physician Order dated 07/19/16 for Hemodialysis treatment revealed Dialysate 3K (potassium), 2.5 Ca (calcium) and Bicarbonate 35.

Review of the AMG Hemodialysis Record dated 07/19/16 revealed the Dialysate section did not have the amount of K (potassium) and Ca (calcium) documented and the Bicarbonate section had 40 documented. Further review of the medical record revealed no documented evidence the nurse clarified the 07/19/16 hemodialysis treatment orders.

In an interview on 07/27/16 at 9:12 a.m., S15DialysisRN indicated the 07/19/16 physician hemodialysis treatment orders for potassium, calcium, and bicarbonate should had been clarified by the nurse.

Review of a Physician Order dated 07/22/16 for Hemodialysis treatment revealed the scheduled treatment time was 4 hours and the amount of minutes for treatment was not documented. Also, the dialysate order did not contain the amount of sodium chloride, bicarbonate, potassium, and calcium.

Review of the AMG Hemodialysis Record dated 07/22/16 revealed the patient dialyzed for 4 hours and 15 minutes. The sodium chloride was 140, bicarbonate 40, potassium 3.0, and calcium 3.0. Further review of the medical record revealed no documented evidence the nurse clarified the 07/22/16 hemodialysis treatment orders.

In an interview on 07/27/16 at 9:14 a.m., S15DialysisRN indicated the 07/22/16 physician hemodialysis treatment orders for time, sodium chloride, bicarbonate, potassium, and calcium should had been clarified by the nurse.

3) The RN failed to ensure the patient's weight was assessed as ordered by the physician: Patients #10, #24

Patient #10:
Review of the medical record revealed the patient was admitted to the hospital on 07/18/16. The patient had the diagnoses of peripheral artery disease, osteomyelitis, diabetes mellitus, and hypertension.

Review of Admit Physician Orders revealed, in part: Weigh patient daily.

Review of the medical record revealed no documented evidence the patient was weighed on 07/19/16, 07/20/16, 07/21/16, 07/22/16, 07/23/16, and 07/24/16.

In an interview on 07/26/16 at 12:12 p.m., S2DON confirmed weights were not done daily for patient #10.

Patient #24
Review of Patient #24's physician admit orders dated 07/07/16 revealed an order to weigh him daily.

Review of Patient #24's "Vital Signs/Intake & (and) Output Records" and the "1st Floor Vital Sign Sheet" revealed no documented evidence that Patient #24 was weighed on 07/09/16, 07/10/16, 07/12/16, 07/15/16, 07/19/16, 07/21/16, 07/22/16, 07/23/16, 07/24/16, and 07/26/16.

In an interview on 07/27/16 at 1:05 p.m., S23LPN confirmed daily weights were not obtained as ordered for Patient #24.


4) The RN failed to ensure lab work was obtained as ordered and/or physician orders were present for lab work drawn: Patients #21, #22

Review of the hospital policy titled "Clinical Laboratory Tests", presented as a current policy by S2DON, revealed the nursing staff notes and signs the lab order and charts the type of lab test completed on the patient chart or the reason why the test was not completed. The nurse records in the progress notes the date and time the lab was done. Upon receipt of the lab results, the nurse informs the attending physician of any abnormal lab results and initials the bottom of the lab result sheets. The nurse places the lab result sheet in the lab section of the patient chart.

Patient #21
Review of Patient #21's physician admit orders revealed an order to draw a CBC, CMP, and Magnesium in the morning.

Review of Patient #21's lab results revealed a blood culture was drawn on 07/12/16 at 10:45 p.m. and 11:00 p.m., and a urine culture was obtained on 07/12/16 at 10:45 p.m. with no documented evidence of a physician's order for the cultures to be obtained.

In an interview on 07/27/16 at 10:57 a.m., S2DON confirmed there was no physician's order for the blood and urine cultures obtained for Patient #21.

Patient #22
Review of Patient #22's physician orders revealed an order on 07/16/16 (no time documented) for a renal function panel and CBC early Tuesday morning ((07/19/16). Further review revealed an order on 07/24/16 at 10:55 a.m. for a renal function panel and CBC Tuesday morning (07/26/16).

Review of Patient #22's lab results revealed a CMP (renal function panel) and CBC were collected on 07/18/16 and 07/25/16 without a physician's order. Further review revealed no documented evidence that a CBC and renal function panel were drawn on 07/19/16 and 07/26/16 as ordered.

In an interview on 07/27/16 at 12:00 p.m., S2DON confirmed there was no physician order for labs drawn on 07/18/16 and 07/25/16. He confirmed the labs ordered to be drawn on 07/19/16 and 07/26/16 were not collected as ordered.

5) The RN failed to ensure medical consults were obtained and documented as ordered and in accordance with hospital policy: Patients #21, #25

Review of the hospital policy titled "Consultations", provided as a current policy by S2DON, revealed that the policy was related to protocols for the provision of consultation services to the Psychiatric Service and not related to the long-term acute care hospital.

Patient #21
Review of Patient #21's admit physician orders of 07/12/16 revealed an order to consult S33MD for status post rectal resection.

Review of Patient #21's "Consultation Form" revealed the consult was requested on 07/13/16 at 9:20 a.m. Further review revealed the section titled "Report of Consultation" was blank with no documented evidence of the signature of S33MD with the date and time completed.

Review of Patient #21's "Physician Progress Notes" revealed an entry on 07/19/16 at 12:05 p.m. by S33MD (7 days after the initial consult was ordered).

In an interview on 07/27/16 at 10:57 a.m., S2DON indicated consults should be completed within 72 hours of the order. He confirmed S33MD did not complete the ordered consult within 72 orders of it being ordered.

Patient #25
Review of Patient #25's admit physician orders dated 07/05/16 at 2:00 p.m. revealed an order for a pulmonary consult.

Review of Patient #25's "Consultation Form" revealed S28MD completed the consult on 07/14/16, 9 days after it was ordered.

In an interview on 07/27/16 at 1:30 p.m., S2DON confirmed Patient #25's pulmonary consult was not completed within 72 hours of it being ordered.

6) The RN failed to ensure wound care was performed as ordered by the physician: Patient #21

Review of Patient #21's physician orders dated 07/20/16 at 2:00 p.m. revealed an order as follows for the mid-abdominal wound: clean with Normal Saline, apply Wound Gel, cover with Optifoam every 2 days and PRN soiling. Review of the TAR and nurses' notes revealed the mid-abdominal wound care was not performed on 07/22/16 (due to be done every 2 days) and 07/23/16 and was performed daily on 07/24/16, 07/25/16, and 07/26/16 with no documented evidence that the dressing was soiled and required changing.

He confirmed no mid-abdominal wound care was performed as ordered on 07/22/16 and 07/23/16, and wound care was done daily on 07/24/16, 07/25/16, and 07/26/16 rather than every 2 days as ordered unless soiled. S2DON confirmed there was no documented evidence that the mid-abdominal wound dressing was soiled when it was changed on 07/24/16, 07/25/16, and 07/26/16.



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31048




30172

30172

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a comprehensive nursing care plan for each patient as evidenced by failing to individualize patient's nursing care plans to include all the patient's medical diagnoses for which the patients were being treated for 6 (#1, #2, #5, #6, #9, #11) of 6 patient medical records reviewed out of a total of 8 patient medical records reviewed for nursing care plans out of a sample of 30 patients. The hospital had a current census of 25 patients.

Findings:
A review of the hospital policy titled "Interdisciplinary Care Plans", as provided by S2DON as the most current, revealed in part: Care plans are updated and revised as new actions are appropriately initiated for each patient at least weekly. Care plans will be updated with any changes in the patient's conditions. Care plans must incorporate individuality of the patient.

Patient #1
The patient was a 74 year old male admitted to the hospital on 07/21/16 with an admit diagnosis of acute respiratory failure, altered mental status and metabolic encephalopathy. Other diagnoses included in part: hypertension, chronic venous stasis, C-Diff, chronic renal failure requiring dialysis, atrial fibrillation, A review of the medical record revealed care plans for impaired mobility, decline in ADL's (activities of daily living) , pain, impaired skin integrity, injury and infection to include C-Diff. A further review of the patient's nursing care plan revealed no documented care plans for respiratory failure, hypertension, atrial fibrillation and dialysis.
Patient #2
A review of the medical record for Patient #2 revealed she was a 91-year-old female admitted to the hospital on 07/12/16 at 4:26 p.m. Diagnoses included Acute Ischemic Right Cerebral Vascular Accident, Malnutrition, Hypertension, Atrial Fibrillation, Anemia, Debility, Bowel and Bladder Incontinence. A further review revealed Patient #2 was placed on Fall Precautions and Aspiration Precautions due to her difficulty swallowing.
A review of the document "LTAC Interdisciplinary Plan of Care" revealed she was not care planned for the diagnoses of Hypertension, Atrial Fibrillation, Altered Bowel and Bladder Elimination, Fall Precautions, and Impaired Skin Integrity.
In an in interview on 07/26/16 at 9:00 a.m., S2DON reviewed the medical record with surveyor and confirmed Patient #2 was not care planned for the above-referenced diagnoses, and should have had care plans for all diagnoses.
Patient #5
The patient was a 68 year old male admitted to the hospital on 07/12/16 with an admit diagnosis of acute pleural effusion with acute respiratory failure, urinary tract infection with pseudomonas, atrial fibrillation and chronic obstructive pulmonary disease. Other diagnoses included in part: diabetes and hypertension. A review of the medical record revealed care plans for impaired mobility, decline in ADL's, respiratory failure, pain, fluid volume excess, injury, impaired skin integrity, altered urine and infection. A further review of the patient's nursing care plan revealed no documented care plans for diabetes or hypertension.
Patient #6
The patient was a 51 year old male admitted to the hospital on 07/15/16 with an admit diagnosis of cellulitis right knee with MRSA (Methicillin-Resistant Staphylococcus Aureus), altered mental status, ventricular tachycardia and pneumonia. Other diagnoses included in part: hypertension, end stage renal disease requiring dialysis, chronic pain and depression. A review of the medical record revealed care plans for impaired mobility, decline in ADL's, pain, fluid volume excess, knowledge deficit and impaired skin integrity, injury and infection to include MRSA. A further review of the patient's nursing care plan revealed no documented care plans for hypertension, ventricular tachycardia and dialysis.
In an interview on 07/26/16 at 2:30 p.m. with S18RN she indicated that the patients are mostly care planned for their admitting diagnoses and they do not care plan for all the patient's medical diagnoses.
In an interview on 07/27/16 at 9:30 a.m. with S2DON he indicated that all of the patient's medical diagnoses should be care planned and not just their admitting diagnoses.
Patient #9
A review of the medical record for Patient #9 revealed she was a 70-year-old female admitted to the hospital on 07/09/16 at 8:50 a.m. Diagnoses included Osteomyelitis of Left Foot with Wound, Stage IV, History of Diabetes Mellitus, Type 2, Hypertension, and Alternation in Nutritional Status. Further review of the medical record revealed Patient #9 was not care planned for diabetes mellitus, accuchecks and insulin sliding scale, anemia, and alteration in nutritional status.
In an interview on 07/26/16 at 11:00 a.m., S2DON reviewed the medical record and confirmed the above findings, and agreed the patient should have been care planned for all active and/or relevant diagnoses.
Patient #11:

Review of the medical record revealed the patient was admitted to the hospital on 07/06/16. The patient had the diagnoses of end stage renal disease and was receiving hemodialysis treatments at the hospital.

Review of the patient's Interdisciplinary Plan of Care revealed the patient was not care planned for end stage renal disease and hemodialysis treatment.

In an interview on 07/26/16 at 2:09 p.m., S4DirCM confirmed there was no care plan for end stage renal disease and hemodialysis treatment developed for the patient.


31048

Based on record reviews and interviews, the hospital failed to ensure all verbal orders had been authenticated (signed, dated and timed) within 10 days as required by hospital policy for 4 (#2, #5, #6, #9) of 4 patient medical records reviewed for authentication of verbal orders out of 5 medical records reviewed for authentication of verbal orders out of 30 sampled medical records.

Findings:

A review of the hospital policy titled "Authentication" as provided by S2DON as the most current policy, revealed in part: The health care provider who treats the patient shall have the responsibility for documenting and authenticating the care provided. All verbal orders must be timed, dated and authenticated by the ordering practitioner who is responsible for the care and treatment of the patient. Verbal orders are to be signed in accordance with the "Timeframes" policy which states the verbal orders are to be timed, dated and authenticated within 10 days.
Patient #2
A review of the medical record for Patient #2 revealed she was a 91-year-old female admitted to the hospital on 07/12/16 at 4:26 p.m. Further review revealed the verbal orders for admission dated 07/12/16 from S32MedDir had not been authenticated, dated, or timed by the physician. A verbal order dated 07/13/16 at 11:37 p.m. by S32MedDir had not been authenticated, dated, or timed by the physician.
In an in interview on 07/26/16 at 9:00 a.m., S2DON reviewed the medical record with surveyor and confirmed the above-referenced verbal orders had not been authenticated, dated, and timed by the ordering physician, and the verbal orders should have been authenticated within 10 days.

Patient #5
A review of the medical record for Patient #5 on 07/25/16 revealed the following verbal orders had not been authenticated (signed, dated and timed) by S31MD within 10 days: the verbal orders dated 07/12/16 and the verbal orders dated 07/13/16.

Patient #6
A review of the medical record for Patient #6 on 07/26/16 revealed the following verbal orders had not been authenticated (signed, dated and timed) by S27MD within 10 days: the verbal orders dated 07/15/16.

In an interview on 07/26/16 at 9:30 a.m. with S2DON, he indicated that verbal orders should have been authenticated (signed, dated and timed) by the ordering physician within 10 days. S2DON further indicated that the hospital was having issues with some physicians not authenticating their verbal orders within 10 days.

Patient # 9
A review of the medical record for Patient #9 revealed she was a 70-year-old female admitted to the hospital on 07/09/16 at 8:50 a.m. Diagnoses included Osteomyelitis of Left Foot with Wound, Stage IV, History of Diabetes Mellitus, Type 2, and Hypertension. Further review of the medical record revealed verbal orders given by S32MedDir, dated and timed on: 07/11/16 at 9:20 a.m.; 07/11/16 1:10 p.m.; 07/11/16 at 4:20 p.m.; 07/14/16 at 8:00 p.m.; 07/15/16 at 9:10 a.m.; and 07/15/16 at 6:30 p.m., were not authenticated, dated, or timed by the physician. The "Current/Home Medications, Medication Reconciliation and Order Form" had not been authenticated by the physician on the admission.
In an interview on 07/26/16 at 11:00 a.m., S2DON reviewed the medical record with surveyor and confirmed the above referenced verbal orders and the medication reconciliation and order form (which is part of the physician admission orders) had not been authenticated, dated, and timed by the physician, and the verbal orders should have been authenticated within 10 days of receipt of the verbal orders by the physician.




31048

Based on record reviews and staff interviews, the hospital failed to ensure medical history and physical examinations (H&P's) were completed and documented for each patient no more than 30 days before or 24 hours after admission or registration for 5 (#3, #13, #15, #16, #20) of 11 patients reviewed for completed H&P's from a sample of 30 patients.
Findings:

Review of the AMG Specialty Hospital Time Frames, O.15.15 policy revealed, in part: The health record documentation shall be completed in an ongoing manner through the stay. Document: History and Physical. Completion Time: 24 hours.

Patient #3:
Review of the medical record revealed the patient was admitted to the hospital on 07/20/16. The patient had the diagnoses of infected leg wound, coronary artery disease, congestive heart failure, and hypertension.

Review of the History and Physical section of the medical record revealed a form that read: There is no original H&P from previous facility. You cannot use addendum without an original H&P. Please complete the H&P form attached. Review of the attached History and Physical form revealed a note that it was due on 07/21/16 at 3:00 p.m. Further review of this History and Physical form revealed it was not completed.

In an interview on 07/26/16 at 8:24 a.m., S4DirCM indicated the History and Physical should be completed within 24 hours after admission. S4DirCM confirmed the History and Physical for patient #3 was not completed timely.

Patient #13:
Review of the medical record revealed the patient was admitted to the hospital on 07/21/16. The patient had the diagnoses necrotizing soft tissue infection of right leg, diabetes mellitus, and hypertension.

Review of the History and Physical section of the medical record revealed: History and Physical Addendum (Must be completed within 24 hours of admit). Review of the History and Physical Addendum revealed a note that it was due on 07/22/16 at 7:00 a.m. Further review of this History and Physical Addendum revealed it was completed on 07/25/16 at 7:35 p.m.

In an interview on 07/26/16 at 2:36 p.m., S4DirCM confirmed the History and Physical for patient #13 was not completed timely.


Patient #15:
Review of the medical record revealed the patient was admitted to the hospital on 07/20/16. The patient had the diagnoses of septic left hip joint, renal cell carcinoma, and hypertension.

Review of the History and Physical section of the medical record revealed: History and Physical Addendum (Must be completed within 24 hours of admit). Further review of this History and Physical Addendum revealed it was not completed.

In an interview on 07/26/16 at 2:39 p.m., S4DirCM confirmed the History and Physical for patient #15 was not completed.


Patient #16:
A review of the medical record for Patient #16 revealed he was a 78-year-old male admitted on 07/22/16. Diagnoses included Status Post a Pericardial Window secondary to Hemorrhagic Pericarditis, Shortness of Breath, Atrial Fibrillation, Anemia, and Hypertension. Further review revealed a "History and Physical Addendum (Must Be Completed Within 24 Hours of Admit)" was blank and not completed. Review of the entire medical record on 07/27/16 revealed there was no documented evidence that a H&P addendum had been completed within 24 hours of admission.
In an interview on 07/27/16 at 1:40 p.m., S2DON reviewed the medical record and confirmed there was no documented evidence that a H&P (addendum) had been completed and available in the medical record within 24 hours of admission to the hospital.
Patient #20:
A review of the medical record for Patient #20 revealed she was an 81-year-old female admitted to the hospital on 07/19/16 at 6:30 p.m. Diagnoses included Acute/Chronic Respiratory Failure, Tracheostomy, Ventilator Dependent, Congestive Heart Failure, Stroke, Diabetes Mellitus, and Parkinson's. Further review of the medical record revealed a "History and Physical Addendum (Must Be Completed Within 24 Hours of Admit)" completed on 07/22/16 at 5:00 p.m., and it should have been available on the medical record within 24 hours of admission to the hospital.
In an interview on 07/27/16 at 1:45 p.m., S2DON reviewed the medical record with surveyor and confirmed the H&P (Addendum) was not completed and available on the medical record within 24 hours of admission, and it should have been available on the medical record within 24 hours of admission to the hospital.


31048

Based on record reviews and interviews the hospital failed to ensure medical records included a properly executed informed consent for procedures and treatments specified by the medical staff for 4 (#1, #6, #9, #17) of 4 patient medical records reviewed for properly completed and executed informed consents out of 30 sampled medical records. This deficient practice was evidenced by informed consents that were not completed as per hospital policy when information required was omitted in the informed consent and/or left blank.

Findings:
A review of the Medical Staff By Laws under Section 4 "Informed Consents" as provided by S1CEO as the most current, revealed in part: It shall be the responsibility of the attending physician to obtain informed consent for any treatment or procedure. Consents shall be obtained in writing on forms provided by the hospital. Consents are obtained for all invasive procedures with risk involved including but not limited to the following: Excisional Debridement, Blood transfusions, Central Line Placement, Dialysis and Biopsies.

Patient #1
The patient was a 74 year old male admitted to the hospital on 07/21/16 with an admit diagnosis of acute respiratory failure, altered mental status and metabolic encephalopathy. Other diagnoses included in part: hypertension, chronic venous stasis, C-Diff, chronic renal failure requiring dialysis, atrial fibrillation. A review of the medical record revealed the patient received dialysis three times a week. A review of the Dialysis Consent dated 07/23/16 revealed under the "additional risks" section that the section was left blank. Under the "Physician Certification" section there was a place for the physician's signature with a line for the date and the time the consent was signed by the physician. A further review revealed that the "Physician Certification" section was blank. The Dialysis Consent revealed the consent was signed by the patient on 07/23/15 and the witness was S15Dialysis RN.
Patient #6
The patient was a 51 year old male admitted to the hospital on 07/15/16 with an admit diagnosis of cellulitis right knee with MRSA, altered mental status, ventricular tachycardia and pneumonia. Other diagnoses included in part: hypertension, end stage renal disease requiring dialysis, chronic pain and depression. A review of the Dialysis Consent dated 07/16/16 revealed under the "additional risks" section that the section was left blank. Under the "Physician Certification" section there was a place for the physician's signature with a line for the date and the time the consent was signed by the physician. A further review revealed that the "Physician Certification" section was blank. The Dialysis Consent revealed the consent was signed by the patient on 07/16/15 and the witness was S15Dialysis RN.
A review of Patient #6's "Blood Transfusion" consent dated 07/19/16 revealed the following sections were left blank: "Additional Risks" of treatment/procedure and "Reasonable Therapeutic Alternatives and the Risks associated with such Alternatives". Under the "Physician Certification" section there was a place for the physician's signature with a line for the date and the time the consent was signed by the physician. A further review revealed that the "Physician Certification" section was blank. The Blood Transfusion Consent revealed the consent was signed by the patient on 07/19/16 and the witness was S35LPN.
In an interview on 07/26/16 at 9:15 a.m. with S19RN she indicated that after a physician ordered a blood transfusion for a patient that the nurses could obtain the Blood Transfusion consent from the patient. She further indicated that the risks and alternatives are not discussed with the patient by the nurses and was probably discussed with the patient by physician.
In an interview on 07/27/16 at 1:30 p.m. with S15DialysisRN he indicated that after a physician ordered dialysis for a patient that the dialysis nurses obtained the Dialysis consents from the patient. He indicated that the risks and alternatives were probably discussed by the physician with the patient, but they were not documented on the consent form. He further indicated that he thought the physician discussed all dialysis risks and alternatives with the patients upon admit, but he was not sure.
In an interview on 07/27/16 at 3:30 p.m. with S2DON he indicated that he thought the nurses were allowed to obtain Blood Transfusion consents and Dialysis consents after those procedures were ordered by a physician. S2DON indicated that this was the present practice at the hospital.
Patient # 9
A review of the medical record for Patient #9 revealed she was a 70-year-old female admitted to the hospital on 07/09/16 at 8:50 a.m. Diagnoses included Osteomyelitis of Left Foot with Wound, Stage IV, History of Diabetes Mellitus, Type 2, and Hypertension. Further review of the medical record revealed Patient #9 received a blood transfusion for anemia on 07/25/16. Review of the "Consent for Transfusion of Blood and Blood Components" dated 07/15/16 revealed, under section 6. (e) and (f), the was no physician's signature on the consent.
In an interview on 07/26/16 at 9:30 a.m., S2DON confirmed the blood transfusion consent was not signed by the ordering physician.
Patient #17
A review of the medical record for Patient #17 revealed he was a 70-year-old male admitted on 07/21/16 at 7:57 p.m. Diagnoses included Status/Post Repair of Umbilical Hernia with Obstruction, Abdominal Distention, Cirrhosis of the Liver, Ascites, and Non-bleeding Varices. Further review of the medical record revealed Patient #17 received a blood transfusion for anemia on 07/25/16. Review of the "Consent for Transfusion of Blood and Blood Components" dated 07/25/16 revealed, under section 6. (e) and (f), the was no physician's signature on the consent.
In an interview on 07/26/16 at 9:30 a.m., S2DON confirmed the blood transfusion consent was not signed by the ordering physician.




31048

Based on record reviews, observations and interviews, the hospital failed to ensure the infection control officer developed a system for investigating and controlling infections and communicable diseases of patients and personnel as evidenced by: 1) failing to include a sample of all disciplines and physicians on all shifts in the audit of hand hygiene practices. S23LPN observed only nurses on the day shift for implementation of hand hygiene practice and 2) failing to ensure that hospital staff followed acceptable infection control standards of practice regarding patients on Isolation Precautions for 1 (#1) of 5 patients identified by the hospital on isolation precautions out of a census of 25.

Findings:

1) Failing to include a sample of all disciplines and physicians on all shifts in the audit of hand hygiene practices:
Review of the hospital policy titled "Infection Control Plan", presented as a current policy by S3QA/IC/UR, revealed that strategies to minimize, reduce, or eliminate risks included auditing hand hygiene practices among all caregivers quarterly, including nurses, therapists,and licensed independent practitioners.

Review of the "Hand washing Observation Audit Form", presented by S3QA/IC/UR, revealed the audits done in April, May, and June 2016 only included surveillance of nurses. There was no documented evidence that surveillance had included all shifts and other staff, physicians, and allied health professionals.

In an interview on 07/27/16 at 3:20 p.m., S23LPN confirmed hand hygiene surveillance was not done on all shift and didn't include any staff other than nurses.


2) failing to ensure that hospital staff followed acceptable infection control standards of practice regarding patients on Isolation Precautions for 1 (#1) of 5 patients identified by the hospital on isolation precautions out of a census of 25.

Patient #1
The patient was a 74 year old male admitted to the hospital on 07/21/16 with an admit diagnosis of acute respiratory failure, altered mental status and metabolic encephalopathy. Other diagnoses included in part: hypertension, chronic venous stasis, C-Diff, chronic renal failure requiring dialysis and atrial fibrillation.

Observation on 07/25/16 at 1:40 p.m. revealed signage on Patient #1 door indicating that the patient was on contact precautions. The sign indicated that staff were to don gowns and gloves before entering the patient's room and to perform hand hygiene with soap and water following patient and environmental contact. S24CNA was observed entering the patient's room without donning gown and gloves and was not observed performing hand hygiene with soap and water following patient and environmental contact.

In an interview on 07/25/16 at 1:50 p.m. with S24CNA she indicated that the patient was on contact precautions. She further indicated that she only entered the patient's room to give him juice and did not think that she had to don gowns and gloves upon entering or perform hand hygiene with soap and water upon exiting if she did not touch the patient.

Observation on 07/25/16 at 2:20 p.m. revealed that S26RRT entered the patient's room to perform a respiratory treatment and was observed sanitizing his hands with the hand sanitizer outside of the patient's room after he removed his gown and gloves and then donned fresh gown and gloves to enter Patient #5's room.

In an interview on 07/25/16 at 3:20 p.m. with S26RRT he indicated that Patient #1 and Patient #5 were on contact precautions. He indicated that staff are supposed to perform hand hygiene with soap and water after removing their gown and gloves on exiting Patient #1's room. He indicated that he did not perform hand hygiene with soap and water after removing his gown and gloves on exiting Patient #1's room because the trash container was by the door and he would have to walk back into the patient's room to perform hand hygiene with soap and water, so he just used the hand sanitizer outside of Patient #1's room and then donned fresh gown and gloves to enter Patient #5's room who was also on contact precautions for MRSA.

Observation on 07/25/16 at 3:45 p.m. revealed S18RN exiting Patient #1's room and was observed sanitizing her hands with the hand sanitizer outside of the patient's room and not perform hand hygiene with soap and water after removing the gown and gloves after exiting Patient #1's room.

In an interview on 07/25/16 at 3:50 p.m. with S18RN she indicated that Patient #1 was on contact precautions due to C-Diff. She indicated that she would perform hand hygiene with soap and water only if she had contact with the patient in his room, other than that she would use a hand sanitizer.

In an interview on 07/27/16 at 8:30 a.m. with S3QA/IC/UR she indicated that she was the Infection Control Officer for the hospital. She was made aware of the above observations and interviews. S3QA/IC/UR indicated that she was surprised that staff did not understand contact precautions relating to C-Diff and performing hand hygiene with soap and water after removing their gown and gloves as she has gone over this many times with them.



30172

Based on record reviews and interview, the hospital failed to ensure each patient and/or caregiver(s) was counseled to prepare them for post-hospital care as evidenced by failure to provide a list and educate the patients and/or caregivers of all medications the patients should be taking when discharged home, with clear indications and instructions of changes in the patients' pre-admission medications and post-discharge medications, for 4 (#26, #27, #28, #29) of 5 (#26, #27, #28, #29, #30) discharged records reviewed; and failure to provide in-hospital education/training to the patient and/or to the patient's caregiver(s) who will be providing care in the patient's home after discharge for proper use of equipment for 1 (#26) of 5 (#26, #27, #28, #29, #30) discharged records reviewed for discharge planning and implementation in a total sample of 30 patients. Findings:

Review of a Policy entitled Patient/Family Participation in Program, C.3.08, revealed, in part: "Policy: To ensure the patient and the caregiver/support person(s) are involved in the development of discharge plan, goal setting and inform them of the final plan to prepare them for post-hospital care. Procedure: . . . 3. Case manager will speak with the patient/family regularly in reference to progress, questions, concerns, goal and the care givers capability/availability to provide the necessary post-hospital care, and discharge plan, and arrange for family training/education, if applicable. Discharge Conference: . . 2. Materials discussed at discharge includes: b. Operation of any specific equipment ..."

A review of the medication list provided to patients upon discharge revealed the medications the patient was to take at home upon discharge were written with the name, dosage, frequency, and route in layman's terms. A review of the discharge medical records for Patients #26, #27, #28, and #29 revealed no documented evidence the patients and/or caregiver(s) were provided with clear indications and instructions on the changes in the patients' pre-admission medications and discharge medications.

In an interview on 07/27/16 at 3:30 p.m., S34SW reviewed the discharge medical records for Patients #26, #27, #28, and #29 with the surveyor, and she confirmed the above-referenced findings.

In an interview on 07/27/16 at 4:45 p.m., S2DON confirmed patients' discharged to home only receive the current medication instruction sheet with the discharge medications listed that were written by the physicians discharging the patients from the hospital. S2DON agreed there was no clear indication and instructions of changes in the patients' pre-admission medications and post-discharge medications documented on the forms provided to patients at discharge, and there was no documented evidence this information was being provided to patients at discharge.

Patient #26
A review of the discharge medical record for Patient #26 revealed he was a 47 year-old male admitted on 05/07/16 and discharged on 05/29/16. Further review revealed the patient had not had use of a Hoyer lift in his home prior to admission to the hospital. Patient #26 had a Hoyer lift ordered for use at home after discharge from the hospital. Review of the medical record revealed there was no documented evidence Patient #26 or his caregiver(s) was evaluated for knowledge on the proper use of a Hoyer lift, or provided any in-hospital training on the proper use of a Hoyer lift.

In an interview on 07/27/16 at 3:30 p.m., S34SW reviewed the discharge medical records with surveyor and confirmed the above-referenced findings.