HospitalInspections.org

Based upon review of Medical Records, Policies/Procedures, Incident/Accident Reports, Administrative and staff interviews, the hospital failed to be in compliance with the Condition of Participation for Nursing Services as evidenced by:

I) a. Failing to ensure a Registered Nurse (RN) performed/evaluated daily shift assessments relative to bowel movements on patients (#s 1, 5, 14) and reported patient/family (#5) complaints relative to lack of bowel movements and abdominal pain before and following PEG tube placement which lead to a transfer to an acute care hospital where patient #5 subsequently expired about 6 hours later after complaining of severe abdominal pain and a firm and distended abdomen (See Findings at A0395).

b. RN failed to follow the hospital's policy/procedure and acceptable nursing standards of practice by discontinuing CPR (cardiopulmonary resuscitation) on patient #4 without the patient being examined by a physician prior to the termination of CPR. Patient #4 was pronounced dead at 8:30am, CPR was terminated at 5:57am by RN Code team leader (See Findings at A0395).

c. RN failed to perform and document re-assessments on patient #7, who was legally blind and confused, when he made 2 elopement attempts (See Findings at A0395).

d. RN failed to follow policy/procedure and ensure an RN evaluated the nursing care on patient #20 when nursing documentation, on 10/28/11 through 10/31/11 7p-7a shift, failed to reflect a problem with patient #20's mobility, until documentation by healthcare provider--Nurse Practitioner (S8) the next morning, 11/01/11, as having a contracted left leg (See Findings at A0395).

II. Failed to ensure each patient received an individualized nursing care plan which was formulated and implemented based upon each of their unique needs as evidenced by a lack of documented nursing care plans (#1, #3, #4, #5, #6, #7, #9, #11, #20) (See Findings at A0396).

III. Failed to ensure nursing personnel only administered medications upon orders as evidenced by Licensed Practical Nurse (S5 LPN) administered Percocet (a narcotic used for pain control) to a patient (#23) without a physician's (or other healthcare provider with prescriptive authority) order (See Findings at A0406).

Based upon reviews of the hospital's Grievance Policy/Process/Reports and interviews the hospital failed to follow it's established Grievance Process and investigate and report findings to the complainant (patient/family) (#5) within the specified time frame of 5 days. Findings:

Interview, 10/24/11 at 9:33 am, with Patient #5's daughter revealed she had placed a telephone call to the hospital's Director of Nursing (S3 DON) on 06/13/11 in order to log her complaint regarding her mother's care.

Patient #5's daughter (complainant) stated her mother was initially evaluated at an acute care hospital's Emergency Department (ED) (identified as Hospital A), on 05/23/11, as a result of a fall she sustained at home. Radiological examinations were performed to rule out any fractures; and the results indicated patient #5 did not have any fractures as a result of her fall. Patient #5 was then transferred, on 05/24/11, to the long term acute hospital for treatment of her malnutrition, deconditioning, anemia, and other medical problems.

Complainant stated she visited her mother (patient #5) every day and had noticed that her mother had not had bowel movements. She (complainant) stated she had mentioned this to the nursing staff on numerous occasions; however, review of Nursing documentation revealed there failed to be documented evidence of her concerns relative to her mother's lack of bowel movements. Review of the Routine and Graphic Record revealed there failed to be documentation patient #5 had bowel movements for greater than 5 days on 2 separate occasions (see information in A0395).

Patient #5 required transfer to an acute care hospital's ED (Hospital A), on 06/11/11, for complaints of severe abdominal pain and distended abdomen. Review of Hospital A's medical record on patient #5 revealed she expired 06/11/11 at 1:45 pm, and the cause of death listed on her Death Certificate was "perforated bowel". It should be noted patient #5 under went a PEG (percutaneous gastrostomy tube) tube placement at Hospital A on 06/09/11 and had complaints of pain at the PEG tube site following its insertion and received pain medication.

The complainant stated she telephoned S3 DON on 06/13/11 to report that her mother had died and felt because the nursing staff and doctors did not evaluate her mother when she did not have bowel movements may have caused her death and that her mother did not receive care. Complainant stated that S3 DON told her those were serious concerns and she would investigate and get back with her (complainant), and that she would receive something in the mail.

Complainant stated as of 10/24/11 she had not received anything from the hospital about her complaint as S3 DON stated she would.

Review of the Grievance Process Information, contained in a handbook given to patients/family members upon admission, revealed: "Grievance Process ...3. The Grievance form shall be reviewed and addressed by the Grievance Committee. Every effort will be made for review and response within 14 days, but no longer than 30 days. 4. The complainant shall receive written notice of the committee's review. The written response shall include the name of the contact person, the steps taken to investigate the grievance, a brief description of the Grievance Committee review, and the date of completion..."

Review of hospital policy #PI. 1.10, 2.10, 2.20, 2.30, 3.10; RI. 2.120, titled "Concern/Complaint/Grievance Process" revealed: "...Policy: Any difference of opinion, concern, complaint or grievance between a patient or his/her representative and Promise Hospital's quality or appropriateness of patient care will be investigated and resolution will occur in a timely manner...Procedure: Complaints are documented on an Occurrence Report and follow the occurrence management process...Grievances are documented on a Grievance Report by the employee as soon as the grievance is received and the report is immediately forwarded to the Department Manager/Supervisor. At a minimum, this must be completed by the end of the working shift...A 'Follow-up' response is provided to the patient within five [5] working days of the event. Concerns/complaints and grievances are logged for data management and filed by the Risk Manager..."

Review of the Grievance Log for January 2011 to 10/28/11 revealed there failed to be documented evidence S3 DON recorded on the "Grievance Report" the telephone grievance patient #5's daughter made on 06/13/11.

Interviews, 11/03/11 at 1:45 pm, with S3 DON and S4 RN Director Quality confirmed a record had not been established for patient #5's daughter's complaint. S3 DON stated she thinks she recalls the telephone conversation and called S25 RN Manager (off-site inpatient location where patient #5 was admitted) and informed him of the complaint. Telephone interview, 11/03/11 at 2:15 pm, with S25 RN Manager revealed he could not recall an investigation and did not have written documentation in regard to this event.

S3 DON agreed she failed to follow the Grievance Process and record all complaints/concerns/grievances, whether she received them via telephone or face to face. She further confirmed that she did not send a written report to S25 RN Manager for him to investigate the complaint logged by patient #5's daughter.

S3 DON and S4 RN Director Quality confirmed an investigation into the complaints telephoned to S3 were not documented and acted upon per policy. As of 11/04/11 the hospital had not investigated patient #5's daughters complaint.

Based upon reviews of the hospital's Grievance Policy/Process/Reports and interviews the hospital failed to follow it's established Grievance Process and investigate and provide a written report of the findings to the complainant (patient/family) (#5). Findings:

Interview, 10/24/11 at 9:33 am, with Patient #5's daughter revealed she had placed a telephone call to the hospital's Director of Nursing (S3 DON) on 06/13/11 in order to log her complaint regarding her mother's care.

Patient #5's daughter (complainant) stated her mother was initially evaluated at an acute care hospital's Emergency Department (ED) (identified as Hospital A), on 05/23/11, as a result of a fall she sustained at home. Radiological examinations were performed to rule out any fractures; and the results indicated patient #5 did not have any fractures as a result of her fall. Patient #5 was then transferred, on 05/24/11, to the long term acute hospital for treatment of her malnutrition, deconditioning, anemia, and other medical problems.

Complainant stated she visited her mother (patient #5) every day and had noticed that her mother had not had bowel movements. She (complainant) stated she had mentioned this to the nursing staff on numerous occasions; however, review of Nursing documentation revealed there failed to be documented evidence of her concerns relative to her mother's lack of bowel movements. Review of the Routine and Graphic Record revealed there failed to be documentation patient #5 had bowel movements for greater than 5 days on 2 separate occasions (see information in A0395).

Patient #5 required transfer to an acute care hospital's ED (Hospital A), on 06/11/11, for complaints of severe abdominal pain and distended abdomen. Review of Hospital A's medical record on patient #5 revealed she expired 06/11/11 at 1:45 pm, and the cause of death listed on her Death Certificate was "perforated bowel". It should be noted patient #5 under went a PEG (percutaneous gastrostomy tube) tube placement at Hospital A on 06/09/11 and had complaints of pain at the PEG tube site following its insertion and received pain medication.

The complainant stated she telephoned S3 DON on 06/13/11 to report that her mother had died and felt because the nursing staff and doctors did not evaluate her mother when she did not have bowel movements may have caused her death and that her mother did not receive care. Complainant stated that S3 DON told her those were serious concerns and she would investigate and get back with her (complainant), and that she would receive something in the mail.

Complainant stated as of 10/24/11 she had not received anything from the hospital about her complaint as S3 DON stated she would.

Review of the Grievance Process Information, contained in a handbook given to patients/family members upon admission, revealed: "Grievance Process ...3. The Grievance form shall be reviewed and addressed by the Grievance Committee. Every effort will be made for review and response within 14 days, but no longer than 30 days. 4. The complainant shall receive written notice of the committee's review. The written response shall include the name of the contact person, the steps taken to investigate the grievance, a brief description of the Grievance Committee review, and the date of completion..."

Review of hospital policy #PI. 1.10, 2.10, 2.20, 2.30, 3.10; RI. 2.120, titled "Concern/Complaint/Grievance Process" revealed: "...Policy: Any difference of opinion, concern, complaint or grievance between a patient or his/her representative and Promise Hospital's quality or appropriateness of patient care will be investigated and resolution will occur in a timely manner...Procedure: Complaints are documented on an Occurrence Report and follow the occurrence management process...Grievances are documented on a Grievance Report by the employee as soon as the grievance is received and the report is immediately forwarded to the Department Manager/Supervisor. At a minimum, this must be completed by the end of the working shift...A 'Follow-up' response is provided to the patient within five [5] working days of the event. Concerns/complaints and grievances are logged for data management and filed by the Risk Manager..."

Interviews, 11/03/11 at 1:45 pm, with S3 DON and S4 RN Director Quality confirmed a record had not been established for patient #5's daughter's complaint. S3 DON stated she thinks she recalls the telephone conversation and called S25 RN Manager (off-site inpatient location where patient #5 was admitted) and informed him of the complaint. Telephone interview, 11/03/11 at 2:15 pm, with S25 RN Manager revealed he could not recall an investigation and did not have written documentation in regard to this event.

S3 DON agreed she failed to follow the Grievance Process and record all complaints/concerns/grievances, whether she received them via telephone or face to face. She further confirmed that she did not send a written report to S25 RN Manager for him to investigate the complaint logged by patient #5's daughter.

S3 DON and S4 RN Director Quality confirmed an investigation into the complaints telephoned to S3 were not documented and acted upon per policy. As of 11/04/11 the hospital had not investigated patient #5's daughters complaint and responded with a written report per policy.

Based upon reviews of 1 of 24 Medical Records (#7), Accidents/Incident/Occurrence Reports, Quality Assurance/Performance Improvement Data, and interviews, the hospital failed to implement safety measures and revise patient #7's plan of care in order to ensure the patient's safety after two attempted elopements.
Findings:

Review of patient #7's Medical Record revealed an admission date of 05/18/11, with diagnoses of ETOH (Alcohol) Encephalopathy, Transient Ischemic Attacks, being legally blind, and confusion. The patient was discharged on 06/08/11.

Review of a Progress Note, dated 06/03/2011, revealed S10 Physician documented "...The patient was very upset this morning stating that he does not want to go to a nursing home and cannot be forced to go. Apparently, there was a meeting between his son and him yesterday stating that they wished for him to go to a nursing home. Nursing staff reports he had tried to escape twice out the back door last night with all of his belongings. He was redirected..."

Review of nursing documentation revealed there failed to be evidence the nursing staff documented patient #7's elopement attempts. There failed to be documentation nursing staff completed an Occurrence Report for Elopement as well.

Interview, on 11/01/11 at 1:45 pm, with S25 Registered Nurse (RN) Manager confirmed nursing staff had not documented information relative to patient #7's elopement attempts; nor did they re-assess patient #7 for these attempts to ensure his safety. S25 confirmed an Occurrence Report for Elopement was not documented and sent for inclusion in the Quality Assurance/Performance Improvement data.

Based upon review of 1 of 24 medical records (#1), medical staff bylaws, medical staff credential files, and interviews, the medical staff failed to ensure: 1) the medical care provided by Registered Nurse Practitioner (RNP) S34 was within the scope of granted privileges as evidenced by RNP S34 performing an invasive procedure (right internal jugular triple lumen catheter placement) on patient #1which resulted in an adverse event, and 2) failure to verify Allied Health Professional Physician Assistant S23 prescriptive authority for writing orders for legend medications. Findings:

1) Review of patient #2's medical record revealed the patient was admitted to the 2nd floor of the hospital on the morning of 04/06/10 with the diagnosis of multiple decubiti. At approximately 4:50 PM, the patient went into respiratory distress and required endotracheal intubation. The patient was transferred to the intensive care floor on 04/06/11 at 5:06 PM. According to the intensive care nursing notes, at 6:00 PM, RNP S34 placed a right internal jugular triple lumen catheter after two attempts. Review of the Critical Care Physician S18 progress notes revealed the patient had a right pneumothorax due to malposition of the right internal jugular catheter placed by RNP S34 and the patient required a chest tube to re-inflate the lung. The patient died on 04/06/10 at 10:40 PM.

Review of the credential file for Registered Nurse Practitioner S34 revealed a Delineation Of Privileges form approved by the sponsoring physician, Psychiatrist S35, the Medical Executive Committee and Governing Board on 02/01/10. The requested privileges included:
1) obtaining histories and perform physical exams,
2) primary care (diagnosis and treatment of common medical problems)
3) order/perform diagnostic procedures as delegated by the supervising physician,
4) implement physician directed treatment plans to write orders for treatments, tests, IV fluids, etc., which are countersigned by the supervising physician within 24 hours,
5) implement physician directed treatment plans to write orders for medications which are countersigned by the supervising physician within 24 hours,
6) monitor the effectiveness of therapeutic interventions,
7) suture wounds as delegated by the supervising physician,
8) "other" "supervision of outpatient psych".

Review of the Medical Staff Bylaws revealed Article VI. Clinical Privileges "A. Every Practitioner or other professional practicing at this Hospital providing direct clinical services by virtue of Medical Staff membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him/her by the Governing Body, except as otherwise provided in this Article and to which the Practitioner has the ability to safely and competently exercise the clinical privileges approved."

Interview with RN S4 on 11/03/11 at 9:55 AM, revealed in April of 2010, RNP S34 was the hospital's Chief Nursing Officer and also "rounded" on Psychiatrist S35's addictive disease patients that were located on the 3rd floor. When asked if RNP S34 was also responsible for any other patients in the hospital, RN S4 responded "no" just Psychiatrist S35's patients.

Interview with the hospital administrator S1 on 11/03/11 at 2:00 PM, revealed when asked if he was aware RNP S34 was practicing beyond what he was credentialed for, S1 did not respond to the question.

There failed to be documented evidence RNP S34 was credentialed and approved by the medical staff to perform the insertion of an right internal jugular catheter.

2) Review of the credential file for PA S23 revealed during the credential process, dated 11/17/09, there failed to be evidence the PA's prescriptive authority was verified. Interview with Medical Staff Coordinator S41 on 11/02/11 at 2:45 PM, revealed when asked if PA S23's prescriptive authority was every verified, S41 responded she was not aware this was required.

Based upon reviews of 6 of 24 medical records (#s 1, 4, 5, 7, 14, 17, 20), policies/procedures, Quality Assurance/Performance Improvement Data, and interviews the hospital failed to ensure:
a. A Registered Nurse (RN) performed/evaluated daily shift assessments relative to bowel movements on patients (#s 1, 5, 14) and reported patient/family (#5) complaints relative to lack of bowel movements and abdominal pain before and following PEG tube placement which lead to a transfer to an acute care hospital where patient #5 subsequently expired about 6 hours later after complaining of severe abdominal pain and a firm and distended abdomen.

b. RN failed to followed the hospital's policy/procedure and accepted nursing standards and stopped CPR (cardiopulmonary resuscitation) on patient #4 without the patient being examined by a physician prior to the termination of CPR. Patient #4 was pronounced dead at 8:30am, CPR was terminated at 5:57am by RN Code team leader.

c. RN failed to perform and document re-assessments on patient #7 when he made 2 elopement attempts.

d. RN failed to follow policy/procedure and ensure an RN evaluated the nursing care on patient #20 when nursing documentation, on 10/28/11 through 10/31/11 7p-7a shift, failed to reflect a problem with patient #20's mobility, until documentation by healthcare provider--Nurse Practitioner (S8) the next morning, 11/01/11, as having a contracted left leg.

e. RN failed to ensure oral hygiene was performed on patient #17 who was later identified as having thrush.
Findings:

a. Patient #5 was admitted on 05/24/11 with diagnoses of IVVD (Intravascular volume depletion), failure to thrive and anemia.

Review of Routine and Graphic Records revealed:
05/24 through 05/25/11 lacked documented evidence of bowel movement/s (BM)
05/26 and 05/27/11 revealed one BM on each day on the 7a-7p shifts
05/28/11 no documentation
05/29/11 BM on 7a-7p shift
05/30/11 through 06/04/11 no BM documented
06/05/11 BM X (times) 3 on 7a-7p shift; no BM on 7p-7a
06/06/11 through 06/11/11 no BM documented.

Review of the Initial Nursing Admission Assessment, dated 05/24/11, revealed "Abdomen soft NT (non-tender), BS (bowel sounds) x (times) 4".

Review of System Observation Data Collection sheets, dated 05/25/11 through 05/30/11 revealed nursing staff documented abdomen as soft, bowel sounds present X 4 quadrants.

Review of a Nursing Progress Note Page, dated 05/30/11, revealed nursing staff documented: "1930 (7:30 pm) ...Abd (abdomen) soft BS active..."

System Observation Data Collection sheet, dated 05/31/11, revealed on the 7a-7p and 7p-7a shifts, patient #5's abdomen was documented as soft, bowel sounds present x 4 quadrants, and bowel sounds were hypoactive.

System Observation Data Collection sheets, dated 06/01/11 through 06/05/11, revealed nursing staff documented abdomen as soft, bowel sounds present 4 quadrants.

Review of Nursing Progress Note Page, dated 06/05/11, revealed S20 Licensed Practical Nurse (LPN) documented at 9:00 am, "...Prune juice given. O (no) record of BM x 6 days...1400 (2:00 pm) Dulcolax suppository given...1520 (3:20 pm) lg (large) BM noted..."

From 06/05/11 through 06/11/11 there lacked documentation patient #5 had a BM.

Review of Nursing Progress Note Page, dated 06/08/11 at 6:00 pm, S21 LPN documented "c/o (complains of) constipation PRN (as needed) supp. (suppository) admin (administered)...". Further review revealed there failed to be documentation if the suppository had been effective.

Review of Nursing Progress Note Page, dated 06/09/11, revealed at 7:30 am, patient #5 was transferred to Hospital A and underwent PEG (percutaneous gastrostomy) tube placement and returned at 11:15 am. Continued review revealed at 11:50 am, patient #5 was complaining of pain at the PEG tube site and was given pain medication. (Review of Physician's Orders, dated 05/27/11 at 7:55 am, revealed "Lortab 5 mg (milligrams) PO (by mouth) q (every) 4 hours PRN (as needed) for pain" was ordered.) Patient #5 received Lortab at 11:50 am, she complained of pain again at 5:15 pm and received Lortab per order. At 6:00 pm, S 21 LPN documented patient #5 complained of pain again and was told it "was too soon for pain med (medication)".

Review of patient #5's Medication Administration Record (MAR) revealed: 06/09/11 she received Lortab 5 mg at 11:50 am, 5:15 pm, and 11:30 pm; 06/10/11 Lortab 5 mg administered at 4:45 am, 9:25 am.

Continued review of the MAR revealed Morphine 1 mg IVP (intravenous push) every 4 hours as needed for pain was added per physician's order, dated 06/10/11 at 6:30 am.

Further review of the MAR revealed patient #5 complained of pain and received Morphine on 06/10/11 at 6:15 am, 2:10 pm, and 7:30 pm. On 06/11/11 Morphine was administered again at 1:30 am.

Review of Physician's Order Sheet, dated 06/10/11 at 6:30 am, revealed S23 Physicians Assistant (PA) documented "1. Notify (name S24 Physician) of pt's (patient's) abd pain 2. Abd Xray: Flat/Erect 3. Morphine 1mg IVP q 4 hours prn pain 4. Nothing per PEG until assessed by (name S24 Physician) 5. Dulcolax supp. i (one) PR (per rectum) now. Repeat dose in 4 hours 6. EKG this AM 7. Cardiac Enzymes q 8 hours x 3 sets".

Review of Nursing Progress Note Page, dated 06/10/11 revealed S26 LPN documented patient #5 complained of "peg tube pain" at 9:25 am; and at 6:00 pm. During the 7p-7a shift, on 06/10/11, there was documentation that patient #5 complained of pain; however, the RN failed to document where the pain was located.

Review of the Abdominal xrays report indicated patient #5 had "...2. Moderate to severe constipation particularly involving the cecum and right colon..."

Review of Physician Order Sheet, dated 06/10/11 at 1:13 pm, revealed an order to begin PEG feedings (order signed by S28 Physician); at 2:30 pm, S10 Physician documented orders for "1. Lactulose 30 mL (milliliters) DPT (down PEG tube) now", then again in every 4 hours until good BMs (Bowel Movements). 2. "After good BMs, can start Jevity at 35 cc/hour (cubic centimeters) flush q (every) 4 hours with 100 cc of H20 (water). Check residual hold next TF (tube feeding) 1 hour if residual >50cc".

Review of System Observation Data Collection sheet, dated 06/11/11 for the 7a-7p shift, revealed S26 LPN documented patient #5's abdomen was distended-circumference and bowel sounds were absent. Review of Nursing Progress Note Page, dated 06/11/11 at 7:15 am, revealed S26 LPN documented "...Pt (patient) is moaning and in Resp. (respiratory) distress...(name of S29 Physician) was rounding in house" at 7:30 am...Orders to ship to (name of Hospital A) ER...Left...ambulance at 8:05 am..." There failed to be documented evidence an RN assessed patient #5 prior to her transfer to Hospital A.

Review of the results of a CT (computerized tonography) scan (dated 06/11/11, performed at Hospital A), indicated "Moderate to large amount of pneumoperitoneum status post gastrostomy tube placement...source of pneumoperitoneum remains indeterminate, may be related to recent placement of gastrostomy tube, although at this time, the possibility of bowel perforation cannot be ruled out". (Twentieth Edition of Taber's Cyclopedic Medical Dictionary defines this as: "1. A condition in which air or gas collects in the peritoneal cavity. This may occur catastrophically when internal organs rupture. 2. Air or gas that has been injected into the peritoneal cavity to facilitate laparoscopy.")

Review of patient #5's Death Certificate has "perforated bowel" as the cause of death.

Patient #1 was admitted 06/15/11--last bowel movement documented 06/14/11--half dollar size bowel movement after Fleets enema administered on 06/25/11--patient expired 06/26/11, without bowel movements documented. The RN failed to evaluate or perform an assessment on patient #1 relative to the lack of bowel movements. Patient #1 did not have a documented bm (bowel movement) in 11 days.

Patient #14 was admitted on 05/13/11 and discharged 06/08/11. Review of the "Routine and Graphic Record" revealed:
05/13/11, 05/14, and 7a-7p shift on 05/15 patient #14 did not have a BM.
05/15/11 7p-7a shift BM recorded.
05/20 through 05/22/11 and 05/25/11 through 05/29/11 no BM recorded, lack of documentation
05/31/11, 06/03 through 06/05/11 there failed to be documentation on record.

The RN failed to evaluate/perform assessment on patient #14 when she lacked documented bowel movements.

Interview, on 11/01/11, with S3 Director of Nursing confirmed the RN must either evaluate or perform an assessment on patients every shift. S3 was questioned in regard to what was expected if a patient had not had a bowel movement within 3 days, she replied the nurse should have informed the physician or assessed the patient's need for bowel movement.

b. Review of a Nursing 24 Hour Care Record, dated 06/25/11, revealed, on page 1, "Code Status: Full". Further review of patient #4's medical record revealed a "Nursing Progress Note Page", dated 06/26/11 at 5:47 am, on which S13 RN documented: "Found laying on R (right) side s (without) spontaneous respirations and cold. Code Blue Called CPR started. (Name of S9 Physician) called [and] talked to (name of S14 RN)." At 6:10am, 06/26/11, S13 RN documented she called and informed patient #4's wife of his condition, "wife informed 'will be coming up there--he wasn't doing well yesterday'...8:30am (name S9 Physician) here--pronounced pt (patient)..."

Continued review of patient #4's Medical Record revealed a form titled "Code Blue Notes", dated 06/26/11. (This form was utilized any time a patient was "coded"/required Cardiopulmonary Resuscitation--CPR). Code Blue Notes revealed: "Time Code Called: 0547 (5:47 am) Code Team Arrival Time: 0547 Diagnosis: Sepsis, ESRD, Resp. (respiratory) failure Code MD: (name S9 Physician) MD Arrival Time: 0555" (**It should be noted that S9 Physician did not come to the hospital when called for the Code, S9 pronounced patient #4 at 8:30am, 06/26/11.) Further review of the Code Blue Notes revealed an absence of blood pressure (b/p), pulse (p), respirations at 5:47 am, 5:50am, 5:55am, 5:57am. Patient #4 had Epinephrine administered at 5:52 am, no amount or route documented, and Atropine administered at 5:53 am, no amount or route documented. Patient #4 received oxygen 100% via mask, no intubation; and the EKG (electrocardiogram) revealed asystole (no heartbeat) at 5:50am and 5:55am. The section labeled "Notes" on the Code Blue Notes revealed: "Code call and team reported to room. No BP, heart rate, or respirations. Pt (patient) skin was cool and dry to touch. Fingers and toes cyanotic. Arms and legs were hard to reposition because they were rigid. Checked in 2 leads which showed asystole. Family notified status...OUTCOME STATUS: Expired".

Review of hospital policy # PC. 9.30, titled "Code Blue/Cardio-Pulmonary Arrest" revealed: "Scope: To all Personnel Purpose: To provide efficient, quality care and timely intervention in the event of cardio-pulmonary arrest or medical emergency. To ensure resuscitation services are systematically available throughout the hospital...Assignment of Code Team: The Nursing staff on the Code Team will be assigned each shift on the staff assignment sheet...Procedure: A. Initiation of Code Blue: Personnel discovering the arrest shall notify the Nurses station to announce the Code Blue...and immediately initiate Basic Life Support...The physician will be notified immediately utilizing all available phone numbers and beeper numbers. Designated team members shall respond immediately and initiate ACLS (Advanced Cardiac Life Support) Protocol until the Physician arrives to direct the Code. An ICU Registered Nurse who has successfully completed an ACLS course shall be designated the team leader during the absence of a physician. B. Documentation: The events of the Code shall be documented thoroughly and accurately on the Code Blue Record...The record shall be signed by the nurse and physician present at the code...maintained as a permanent part of the patient medical record...The events should be included in the narrative portion of the Nursing Notes of the patient record..."

Review of policy #HR. 2.10, titled "Delayed Physician Response" revealed: "Policy: 1. In an emergent situation, Monday thru Friday, 8 AM to 5 PM, the primary physician should be paged. After 5 PM and before 8 AM, Monday thru Friday and on Saturday and Sunday, 24 hours a day, the Medical On-Call Physician should be paged for the Medical units and the Pulmonary/Critical Care On-Call should be paged for ICU. 2. In an emergent situation, if the M.D. has been called, but has not responded in a timely manner (within 30 minutes), the nurse will notify the House Supervisor. 3. The House Supervisor will assess the situation...call Chief of Staff for orders on the medical units...

Interviews, 10/31/11 at 2:00 pm, with S2 Chief Clinical Officer (CCO) and S3 Director of Nursing (DON) revealed when questioned how the hospital reviewed code blue results, S2 CCO stated they all go to Quality Assurance/Performance Improvement for evaluation. Further questioning revealed S14 RN was the team leader for the Code Blue and left the room during CPR to call the on-call medical physician, identified as S9 Physician. Questions were asked as to why the team leader of the code blue would leave the code blue to telephone the on-call physician, S2 CCO and S3 DON, did not know why she (S14 RN) left the room to make the telephone call. Review of the investigation conducted by S4 RN Director Quality Assurance/Performance Improvement (QA/PI), the code blue was not implemented per the hospital's Code Blue/Cardio-Pulmonary Arrest policy #PC. 9.30 (as listed above).

Interview, 10/31/11 at 2:15pm, with S4 RN Director QA/PI revealed she conducted an investigation into the Code Blue on patient #4 and obtained written statements from all personnel involved in the code. S4 RN was questioned as to how she became aware of the code blue on patient #4 since it was not captured by the QAPI process they had in place; she responded the DON told me.

Interview, 10/31/11 at 2:15pm, with S3 DON revealed when questioned how she was made aware of the code blue on patient #4 when it had not been reported, she replied, "I heard (name S9 Physician) talking to S18 Physician's nurse in the hallway then told (name of S4 RN)."

c. Review of patient #7's medical record lacked documentation from an RN when it was discovered he had attempted to elopement on 2 occasions.

Interview, on 11/01/11 at 2:30 pm, with S25 RN confirmed patient #7's medical record lacked documentation by an RN relative to assessments for elopement; and S25 confirmed there lacked any documentation (i.e. Occurrence Report) that identified patient #7 had attempted to elope, other than on 06/03/11 a Physician's Progress Note had documentation relative to patient #7 attempts to elope.

d. Review of the Initial Nursing Admission Assessment, dated 10/15/11, revealed the RN failed to assess patient #20's Musculoskeletal system (page 4 of 6). Review of patient #20's medical record revealed Nursing Notes (dated 10/28/11, 10/29/11, 10/30/11, 10/31/11), failed to have documentation by an RN that patient #20 received or had the assessment (which was performed by Licensed Practical Nurse) evaluated by an RN. On the 7p-7a shift, 10/31/11, S7 RN documented an assessment that revealed the patient could move her upper and lower extremities but was weak. On 11/01/11, S8 Nurse Practitioner (NP) documented on Progress Notes, "unable to straighten left leg anymore--contracted"; "Ext (external)--L (left) leg contracted".

Review of policy IM. 6.10, titled "DOCUMENTATION" revealed: "...Purpose: Nursing staff will provide correct documentation on patients' charts. Policy: 1. All components of the patient care process, plan of care, evaluation and outcomes will be documented in the patient's medical record...2. The nursing process is used in the delivery of patient care and is evidenced in the following documentation: a. Initial nursing assessment and evaluation, performed or verified by a Registered Nurse. b. An established plan of care. c. Documented nursing interventions...related to...patient problems identified in the plan of care...3. ...The evaluation of the data for identifying patient care needs/problems and planning of care must be documented by the RN..."

Interview, 11/2/11 at 7:15 am, with S8 Nurse Practitioner (NP) revealed when questioned about patient #20's left leg contracture and the lack of documentation by nursing service as well as physician progress notes, she did not respond. S8 was questioned if a patient could develop a contracture of a leg in less than 24 hours, she replied "No". S8 NP agreed patient #20's medical record lacked documentation by nursing relative to her left leg contracture.

Observation of patient #17 on 10/24/11 at 11:55 AM, revealed the patient was in the process of having a dialysis treatment. When the patient smiled, a thick white film was noted on the patient's teeth. The patient's tongue also had a thick white substance with white spots noted. Interview with the Nursing Supervisor RN S29 on 10/24/11 at 1:10 PM revealed the patient had oral thrush and her physician had been called for medication orders. Review of patient #17's medical record revealed there failed to be documented evidence the patient had oral care performed or the nursing staff identified this patient had thrush prior to the surveyor's observation on 10/24/11.

There lacked documentation of assessments on the above patients by an RN or documentation that an RN had evaluated the care provided to these patients.
















22538

Based upon reviews of 7 of 24 medical records (#s 1, 4, 5, 6, 7, 9, 20), policies/procedures, and interviews, the hospital failed to ensure each patient received an individualized nursing care plan which was formulated and implemented based upon each of their unique needs as evidenced by a lack of documented nursing care plans. Findings:

Review of patient #1's medical record revealed there failed to be documented Nursing Care Plans. Patient was admitted 06/15/11 with multiple diagnoses including Acute and Chronic Respiratory Failure and Congested Heart Failure. Patient #1 expired on 06/26/11. Patient #1 did not have a bowel movement for 11 days and there failed to be documented evidence nursing personnel provided on-going assessments and interventions relative to patient #1 lack of bowel movements.

Review of patient #s 4, 5, 6, 9 and 20 medical records revealed there failed to be documented Nursing care plans in their medical records.

Review of patient #7's medical record revealed after the patient had made an elopement attempt

Based upon reviews of Medication Reconciliation and Order Sheets (1 of 23, #23), policies/procedures, Controlled Substance Discrepancy Form, and Administrative interviews, the hospital failed to ensure nursing personnel only administered medications upon orders as evidenced by Licensed Practical Nurse (S5 LPN) administered Percocet (a narcotic used for pain control) to a patient (#23) without a physician's (or other healthcare provider with prescriptive authority) order. Findings:

Review of patient #23's medical record revealed a form titled "Medication Reconciliation and Order Sheets", dated 10/17/2011. Review of this form revealed a statement, "List below all of the patient's medications including OTC (over the counter) and herbal medications Practitioner, note a checkmark in the 'Yes' or 'No' column" for the medication to be continued upon admission. Continued review of the form revealed under the above statement were sections for the medication name, dose, route, frequency, last taken date/time, yes/no continue on admission, and continue on discharge yes or no. Further review of the Medication Reconciliation and Order Sheets revealed a checkmark was placed in the "No" section for continue on admission.

Review of a policy titled "MEDICATION ERRORS" revealed: "Purpose: To follow-up on any error and prevent duplicate errors. To track problems for QA purposes to prevent future problems. Procedure: 1. If a medication error is made, the person making the error will immediately inform the attending physician and the Charge Nurse/Nurse Manager. 2. The person making the error will complete a Medication Error Report...If Nurse in error is not available to fill out the Medication Error Report, it will be filled out by the Nurse who found the error and cosigned by the Nursing Supervisor..."

Review of Controlled Substance Discrepancy Form, dated 10/18/2011, revealed a checkmark was placed next to "Other", with the following documentation by pharmacy personnel, "Percocet-5, 1 1/2 tabs given to (name patient #23) order on Med-Rec (medication reconciliation sheet) Admit Sheet was checked 'Do Not Continue' Nurse over-ride on Med Dispense Machine".

Interview, on 10/26/11 at 2:30pm, with S6 Director of Pharmacy, Registered Pharmacist (RPh) revealed when the pharmacy conducted their review of the medications administered from the Med-Dispense Machine (automated medication dispense machine) they must make certain narcotics were administered in accordance with physician/providers orders. S6 stated a review of the physician's orders that were faxed to the pharmacy failed to show Percocet as having been ordered.

Interviews, on 10/27/2011 at 11:15am, with S3 Director of Nursing (DON) and S4 Registered Nurse Quality Assurance confirmed the nurse (S5 LPN) should not have administered the Percocet to patient #23. They further confirmed the policy/procedure relative to Medication Errors was followed as a Medication Error Occurrence report was not completed and sent for investigation.

Based upon review of 5 of 24 medical records, policies and procedures, and interview, the hospital failed to ensure a medical history and physical examination was completed and documented 24 hours after admission ( #10) or complete an updated note on patients #9, #18, #19, #21 when the history and physical examination was completed no more than 30 days prior to admission. Findings:

Review of policy #PC. 2.120 titled "History and Physicals" revealed "#1. History and Physicals shall be completed within twenty-four (24) hours of admission including weekend and holiday admissions." "#3. In the event that a history and physical has been performed within 30 days prior to patient's admission, a durable, legible copy may be used in the medical record. The attending physician must sign that history and physical. This along with a history and physical addendum can be used in the patient's medical record, providing any changes that may have occurred are recorded on the addendum at the time of admission.

Review of patient #10's medical record on 11/04/11 revealed the patient was admitted on 11/01/11 from a nursing home. There failed to be documented evidence a history and physical examination was completed.

Review of patient #'s 9, 18, 19, and 21 revealed the medical record contained a history and physician from the transferring hospital; however, there failed to be evidenced an addendum was recorded at the time of admission.

Interview with the Medical Records Director S11 on 11/04/11 at 11:30 AM, revealed he was aware there were history and physicals that were delinquent and confirmed some were delinquent by 123 days.

Based upon review of 1 of 24 medical records (#2), policies and procedures, Medical Staff Bylaws, Rules and Regulations, patient adverse events, and staff interview, the hospital failed to ensure all adverse patient events were analyzed through the Quality Assurance Program as evidenced by failing to conduct a focused professional practice evaluation on the medical care provided on 04/06/10 to patient #2 by Nurse Practitioner S34. Findings:

Review of patient #2's medical record revealed upon admission to the hospital on 04/06/10, the patient went into respiratory arrest, requiring endotracheal intubation, and was transferred from the 2nd floor to the Intensive Care Unit on 04/06/10 at 5:06 PM. Review of the nursing notes dated 04/06/10, at 6:00 PM, Nurse Practitioner S34 inserted a right internal jugular triple lumen catheter successfully after the 2nd attempt. According to documentation by Pulmonary and Critical Care Specialist S18, dated 04/06/10, timed 6:55 PM to 7:48 PM, patient #2 had a pneumothorax and questioned if this was due to the central line placement. Review of the physician progress notes dated 04/06/10 at 8:50 PM revealed procedures: "(1) chest tube - right lateral indication: PTX (pneumothorax)" and "(2) Right IJ (Internal Jugular" TLC (Triple Lumen Catheter) - indication: malpositioned TLC."
At 10:40 PM, the patient became breathless and pulseless and was pronounced deceased.

Review of the credential file for Nurse Practitioner S34 revealed there failed to be evidence this individual was privileged to insert central line catheters. The privileges listed for S34 were specifically for the addictive disease patients and the sponsoring physician was a Psychiatrist.

Interview with Quality Assurance RN S4 on 11/03/11 at 2:30 PM, revealed all mortalities and morbidities were reviewed through the hospitals Quality Assurance Program. RN S4 identified a process titled "Ongoing Professional Practice Evaluation", which was designed to review all mortalities/morbidities, and was used to continuously evaluate each practitioner's professional practice. If quality of care issues were identified during the ongoing professional practice evaluation, a focused professional practice evaluation would be conducted related to a practitioner's competence in performing a specific privilege.

Review of policy # MS-01-01, titled "Ongoing Professional Practice Evaluation" (OPPE), revealed this process was defined as "A documented summary of ongoing data collected for the purpose of assessing a practitioner's clinical competence and professional behavior. The information gathered during this process factors into decisions to maintain, revise or revoke existing privilege (s)." The purpose of this review was to define the process used for continuous evaluation of each practitioner's professional practice, and ensure the process for collecting, investigating, and addressing clinical practice concerns, including the process used to identify trends that impact quality of care and patient safety. The criteria/indicators included adverse patient events. The Risk Manager/Designee was to forward on to the Chief of Staff all cases scored as a "3, 4 or 5" The policy identified the 3, 4, and 5 scores as problems with process or quality of care, treatment or services.

Review of the OPPE's from April 2010 to October 2011 revealed there failed to be evidence a mortality review was conducted on the medical record of patient #2 even though the patient expired in the hospital less than 24 hours after admission. An adverse event occurred after Nurse Practitioner S34 placed a central line into the patient's right internal jugular after the 2nd attempt resulting in a collapsed lung which required treatment of a chest tube to re-inflate the lung. There failed to be evidence the QA Program analyzed this adverse event to ensure processes of care were reviewed and it was identified Nurse Practitioner S34 was credentialed by the medical staff to do this procedure.