HospitalInspections.org

Based on interviews, records review and observations, it was determined that the Governing Body failed to effectively discharge its oversight responsibilities based on the findings during the surveys on 12/14/12, 12/18/12, 12/19/12 and 12/21/12. This failed practice had the potential to affect all patients admitted to the hospital.

Findings:

1. Based on observations, clinical records review and interviews, it was determined that the facility failed to assure Patient #8, who was on a respiratory ventilator and receiving a Versed Drip was monitored for blood pressure and the concentration of oxygen in the blood (pulse oximeter) in that the alarm for the pulse oximeter reading audibly alarmed continuously for 40 minutes without staff acknowledgement or intervention. The vital sign monitor at the bedside and attached to Patient #8 had a last blood pressure reading of 92/41 and was not functional from 0855 - 0935, as the vital sign alarm was silenced and the machine visual reading was "leads fail, battery fail". Failure to act or respond to an alarm by the staff placed Patient #8 at risk of Immediate Jeopardy to their health and safety. The failed practice affected Patient #8 and had the potential to affect the patient census of 26. See Tag A386.

2. Based on observations, review of personnel files and interviews, it was determined the facility failed to assure a process was in place to determine the non- employee licensed staff competence and qualifications prior to assigning patient care. The facility could not assure the safety of patients and that care was provided by personnel with the competence and qualifications to meet the individual patient needs. The failed practice affected 14 inpatients that were assigned to Registered Nurse #2, #3 and LPN #1. The failed practice had the potential to affect the census of 26 patients on the Unit at the time of the complaint investigation. See Tag A392.

3. Based on observations, clinical records review and interviews, it was determined that the facility failed to assure the interdisciplinary plan for care was updated to reflect the assessed nursing care needs of the patient. The failed practice created the potential for the patient needs to be unmet. The failed practice affected 6 of 8 open clinical records (Patient #1, #2,#4, # 5, #7 and #8) and 2 of 2 closed records (Patient #9 and #10) selected for review. See Tag A396.

4. Based on observations, review of personnel files and interviews, it was determined that the facility failed to assure a process was in place to determine the non-employee licensed staff competence and qualifications prior to assigning patient care. The facility could not assure the safety of patients and that care was provided by personnel with the competence and qualifications to meet the individual patient needs. The failed practice affected 14 inpatients that were assigned to Registered Nurse (RN) #2, #3 and Licensed Practical Nurse (LPN) #1. The failed practice had the potential to affect the census of 26 patients on the Unit at the time of the complaint investigation. See Tag A397.

5. Based on observations, review of personnel files and interviews, it was determined that the facility failed to: have a process in place to assure non employee licensed nurses were oriented to the facility, emergency procedures and policies and procedures; failed to assure competencies were determined prior to assignment and that assignments were made by a Registered Nurse (RN) based on the competencies; and failed to assure the clinical activities of the non employee licensed nurses were evaluated. The facility could not assure the safety of the patients in the facility. The failed practice affected 14 inpatients that were assigned to Registered Nurse #2, #3 and LPN #1. The failed practice had the potential to affect the census of 26 patients on the Unit at the time of the complaint investigation and any patient admitted to the facility. See Tag A398.

Based on observations, review of personnel files and interviews, it was determined that the facility:

A. failed to have a process in place to assure non employee licensed nurses were oriented to the facility, emergency procedures and policies and procedures;

B. failed to assure competencies were determined prior to assignment and that assignments were made by a Registered Nurse (RN) based on the competencies;

C. failed to assure the clinical activities of the non employee licensed nurses were evaluated;

D. failed to assure documentation of nursing care was completed and patients were monitored when receiving specialized care.

The facility could not assure the safety of the patients in the facility. The failed practice affected 14 inpatients that were assigned to Registered Nurse #2, #3 and Licensed Practical Nurse #1. The failed practice had the potential to affect the census of 26 patients on the Unit at the time of the complaint investigation and all patients admitted to the facility.

Findings:

1. Based on observations, clinical records review and interviews, it was determined the facility failed to assure that the interdisciplinary plan for care was updated to reflect the nursing care needs of the patient. The failed practice created the potential for the patient needs to be unmet. The failed practice affected 6 of 8 open clinical records (Patient #1, #2,#4, # 5, #7 and #8) and 2 of 2 closed records (Patient #9 and #10) selected for review. See Tag A396.

2. Based on observations, review of personnel files and interviews, it was determined that the facility failed to assure a process was in place to determine the non-employee licensed staff competence and qualifications prior to assigning patient care. The facility could not assure the safety of patients and that care was provided by personnel with the competence and qualifications to meet the individual patient needs. The failed practice affected 14 inpatients that were assigned to Registered Nurse (RN) #2, #3 and Licensed Practical Nurse (LPN) #1. The failed practice had the potential to affect the census of 26 patients on the Unit at the time of the complaint investigation. See Tag A397.

3. Based on observations, review of personnel files and interviews, it was determined that the facility failed to: have a process in place to assure non employee licensed nurses were oriented to the facility, emergency procedures and policies and procedures; failed to assure competencies were determined prior to assignment and that assignments were made by a Registered Nurse (RN) based on the competencies; and failed to assure the clinical activities of the non employee licensed nurses were evaluated. The facility could not assure the safety of the patients in the facility. The failed practice affected 14 inpatients that were assigned to Registered Nurse #2, #3 and LPN #1. The failed practice had the potential to affect the census of 26 patients on the Unit at the time of the complaint investigation and any patient admitted to the facility. See Tag A398.

Based on observations, clinical records review and interviews, it was determined that the facility failed to assure Patient #8, who was on a respiratory ventilator and receiving a Versed Drip was monitored for blood pressure and the concentration of oxygen in the blood (pulse oximeter) in that the alarm for the pulse oximeter reading audibly alarmed continuously for 40 minutes without staff acknowledgement or intervention. The vital sign monitor at the bedside and attached to Patient #8 had a last blood pressure reading of 92/41 and was not functional from 0855 - 0935, as the vital sign alarm was silenced and the machine visual reading was "leads fail, battery fail". Failure to act or respond to an alarm by the staff placed Patient #8 at risk of Immediate Jeopardy to their health and safety. The failed practice affected Patient #8 and had the potential to affect the patient census of 26. The findings were:

A. Patient #8 was admitted to the facility on 11/30/12 with a diagnosis of respiratory failure and pneumonia. Patient #8 was on a respiratory ventilator and receiving Versed to attain sedation while on the ventilator. The orders for Versed were for "concentration 100 milligrams/100 milliliters in Normal Saline and to "titrate to sedation".

B. Continuous observation by the surveyor from 0855-0935 on 12/18/12 revealed that the alarm for the pulse oximeter reading audibly alarmed continuously for 40 minutes without staff acknowledgement or intervention. The vital sign monitor at the bedside and attached to Patient #8 had a last blood pressure reading of 92/41 and was not functional from 0855 - 0935, as the vital sign alarm was silenced and the machine visual reading stated "leads fail, battery fail".

C. At 0935, the Surveyor sought out the charge nurse, Charge RN #2 and asked her to check the patient. She assessed the patient and stated "the little probe just came off, it does that sometimes. She then adjusted the oxygen sensor on Patient #8. Regarding the blood pressure reading, charge RN #2 stated "sometimes because the alarm continuously beeps and the patient is on a ventilator and heart monitor at the nursing station, the staff will turn it off or silence it." Charge RN #2 then reviewed the machine reading, "Leads fail; Battery Fail" and stated "looks like this machine is broken." The vital sign monitoring equipment was replaced at 0945. The blood pressure reading was 129/76 with a heart rate of 101.

D. Review of the "Five Day Graphic" revealed on 12/18/12 at 0700 the pulse was 81 and the blood pressure was 93/42; at 1100 the pulse was 82, blood pressure was 98/55. Charge RN #2 reported to the nurse caring for the patient, RN #3, who was a non-employee (agency) RN. RN #3 confirmed the patient was ventilator dependant and receiving a Versed drip, "she is getting the Versed at 1:1 concentration because she is on the vent". Upon her exit from the room 12/18/12 at 1012, the blood pressure monitor was not functioning and all fields were blank.

E. On 12/18/12, at 1105, a copy of the facility policy and procedure for the administration of Versed was requested and received from the Director of Nursing. The policy, "Conscious Sedation", Policy # CSM 15 A, item 1. "Simple sedation for the purpose of pain relief and ventilator management the ventilated patient may be ordered by a credentialed physician, given by a Registered ACLS certified Nurse and monitored according to a specific physician order and/or patient's condition."

F. The Director of Nursing provided a policy on 12/18/02 at 1105 of the "Versed (midazolam) Intravenous Infusion Protocol". The policy stated "Versed is a benzodiazepine used to provide induction and maintenance of sedation in mechanically ventilated patients to alleviate agitation and/or anxiety." The policy stated "Versed intravenous infusions should only be administered by healthcare professional skilled in the medical management of critically ill patients and trained in cardiovascular resuscitation and airway management." Item F. "Monitor EKG (electrocardiogram), SpO2, BP (blood pressure), and RR (respiratory rate) during Versed administration"

G. The Director of Nursing Confirmed the findings on 12/18/12 at 1500.

Based on observations, review of personnel files and interviews, it was determined that the facility failed to assure a process was in place to determine the non- employee licensed staff competence and qualifications prior to assigning patient care. The facility could not assure the safety of patients and that care was provided by personnel with the competence and qualifications to meet the individual patient needs. The failed practice affected 14 inpatients that were assigned to Registered Nurse #2, #3 and LPN #1. The failed practice had the potential to affect the census of 26 patients on the Unit at the time of the complaint investigation. See A 397

Based on observations, clinical records review and interviews, it was determined that the facility failed to assure the interdisciplinary plan for care was updated to reflect the nursing care needs of the patient. The failed practice created the potential for the patient needs to be unmet. The failed practice affected 6 of 8 open clinical records (Patient #1, #2,#4, # 5, #7 and #8) and 2 of 2 closed records (Patient #9 and #10) selected for review. The findings were:
A. In an interview with Charge Nurse #1 and the Director of Nursing on 12/14/12, they confirmed the "Interdisciplinary Patient Plan of Care" was individualized by the nurses by selecting the interventions/approaches, outcomes and patient problems. Sometimes they initial them or just mark them. If a problem is resolved they should date and initial it under (resolved).
B. Clinical Record review 12/14/12 - 12/19/12 revealed:

1) Patient #1 was admitted on 10/12/12 with a diagnosis of Bacteremia and multiple wounds. The plan of care, initially dated 10/12/12, did not include individualized approaches and interventions for 3 of 5 patient problems identified. Confirmed by Director of Nursing 12/14/12 at 1230.

2) Patient #2 was admitted on 11/27/12 with a diagnosis of Respiratory failure, pneumonia. The plan of care, initially dated 11/27/12, did not include individualized approaches and interventions for 2 of 6 problems identified. the findings were confirmed by the Director of Nursing 12/14/12 at 1330.

3) Patient #4 was admitted on 11/21/12 with a diagnosis of cellulitis, diabetes and decubitus. The plan of care, initially dated 11/21/12, did not include individualized approaches and interventions for 3 of 5 patient problems identified.

4) Patient #5 was admitted on 10/09/12 with a diagnosis of entercutaneous fistula, history of ischemic bowel, severe malnutrition, and intestinal obstruction. The plan of care, initially dated 10/19/12, did not include individualized approaches and interventions for 9 of 12 patient problems identified.

5) Patient #7 was admitted on 11/20/12 with a diagnosis of non healing surgical wound, malnutrition, hemodialysis and osteomyelitis. The plan of care, initially dated 11/20/12, did not include individualized approaches and interventions for 3 of 6 patient problems identified.

6) Patient #8 was admitted on 11/30/12 with a diagnosis of Acute respiratory failure, ventilator dependent, malnutrition and deconditioning, she has a gastrostomy tube in place, mental retardation, history of acute on chronic anemia, thrombocytopenia, fluid and electrolyte disorder. The plan of care, initially dated 11/30/12, did not include individualized approaches and interventions for 3 of 10 patient problems identified.
C. Closed record review revealed:

1) Patient #9 was admitted to the facility on 10/15/12 with a diagnosis of candida in blood, acute/chronic respiratory failure. The plan of care, initiated 10/15/12, did not include individualized approaches and interventions for 4 of 13 patient problems identified.

2) Patient #10 was admitted to the facility on 10/22/12 with a diagnosis of multiple decubitus ulcers, including a Stage IV to the left hip and a Stage III to bilateral gluteal areas, anterior abdominal wounds, status post diverting colostomy and urostomy, history of Gastro esophageal reflux, anxiety, constipation, quadriplegia, Stage I pressure ulcer in bilateral heel, malnutrition and history of urinary tract infection. The plan of care, initiated 10/22/12, did not include individualized approaches and interventions for 8 of 9 patient problems identified.

D. The findings were confirmed after document review and by interview with the Director of Nursing and 01/19/12 1500.

Based on observations, review of personnel files and interviews, it was determined that the facility failed to assure a process was in place to determine the non-employee licensed staff competence and qualifications prior to assigning patient care. The facility could not assure the safety of patients and that care was provided by personnel with the competence and qualifications to meet the individual patient needs. The failed practice affected 14 inpatients that were assigned to Registered Nurse (RN) #2, #3 and Licensed Practical Nurse (LPN) #1. The failed practice had the potential to affect the census of 26 patients on the Unit at the time of the complaint investigation.

A. The staffing and assignments for 12/18/12 was reviewed and revealed a facility staff RN Charge Nurse and another RN, a facility staff LPN and a facility staff Patient Care Technician (PCT). Non-employee licensed staff (Agency) included RN #2, RN #3, LPN #1 and two PCT staff.

1) Observation on 12/18/12 revealed RN #2 was assigned to three patients, which included Patient (Pt.) # 2 who was on a respiratory ventilator. RN #2 was also assigned to perform the RN assessment for three patients assigned to a staff Licensed Practical Nurse (LPN). RN #2 was interviewed on 12/18/12 at 0935 regarding his orientation. He stated today was his first day at the facility and "a nurse walked around with me this morning".

2) Observation on 12/18/12 revealed RN #3 was assigned to four patients, which included Pt. #8 who was on a respiratory ventilator. RN #3 was also assigned to perform the RN assessment for four patients assigned to a non-employee LPN. RN #3 was interviewed on 12/18/12 at 0955 regarding her orientation and she stated "today is my first day".

3) Observation on 12/18/12 revealed LPN #1 was assigned to seven patients. LPN #1 was interviewed on 12/18/12 at 1130 and stated he had been working at the facility for about four weeks and had received "a half a day of orientation".

4) Observation on 12/14/12 at 1340, revealed Agency PCT #2 was at the bedside of room 206, identified as "Contact isolation" by door signage. PCT #2 was not wearing a gown while at the bedside and then was observed to exit the room without cleaning the portable vital sign equipment. The basket of the equipment contained open disposable blood pressure cuffs and opened glove boxes. PCT #2 was interviewed at the time of observation and stated "today is my first day here" and stated they gave her a "tour" as orientation. The findings were confirmed by the Infection Control Nurse at the time of observation.

B. RN Charge Nurse #2 was interviewed on 12/18/12 at 1055 and asked her how the staffing was determined. Stated they used the acuity policy and that "The regular staff always would take more than the Agency staff." The Surveyor asked RN Charge Nurse #2 how she determined who was assigned each patient, she stated "I've worked Agency before and they come to us with training and basic skills."

C. The Chief Nursing Officer was interviewed 12/18/12 at 1500 and stated she did not have specific training, orientation or evaluation of the Agency staff and that "all of their training and skills are in their folder from the Agency". On 12/18/12, the personnel folders for the non-employee licensed staff were reviewed for RN #2, RN #3, LPN #1 and PCT #1. There was no evidence of staff orientation to the facility, emergency procedures, policies and procedures or an assessment of competencies by the facility. The personnel file from the Agency for RN #2 did not include a determination of experience caring for a patient on a respiratory ventilator. RN #2 was assigned to Pt. #2 who was respiratory ventilator dependant.

D. The facility policy was provided by the CNO on 12/19/12 at 1330, "Nurse Staffing/Acuity Plan", #235. The Policy stated "At a minimum, the staffing levels are based on the following factors:" item E. "Staff characteristics including: Tenure, preparation and experience, number and competencies of clinical and non-clinical support staff the nurse must collaborate with or supervise." Item #6 of the policy stated "For Patient care assignments, the following will be taken into consideration: A. "The training, experience and capability of the person to whom the task is delegated. The degree and availability of supervision required for the staff member, including student nurses and orientees, the condition of the patient, identified needs, complexity of assessment and care required by each patient., Patient safety and infection control issues."

E. The findings were discussed and confirmed with the Clinical Nurse Manager 12/18/12 at 1600.

Based on observations, review of personnel files and interviews, it was determined that the facility:

a. failed to have a process in place to assure non employee licensed nurses were oriented to the facility, emergency procedures and policies and procedures;

b. failed to assure competencies were determined prior to assignment and that assignments were made by a Registered Nurse (RN) based on the competencies;

c. failed to assure the clinical activities of the non employee licensed nurses were evaluated.

The facility could not assure the safety of the patients in the facility. The failed practice affected 14 inpatients that were assigned to Registered Nurse #2, #3 and LPN #1. The failed practice had the potential to affect the census of 26 patients on the Unit at the time of the complaint investigation and any patient admitted to the facility. The findings were:

A. The staffing and assignments for 12/18/12 was reviewed and revealed a facility staff RN Charge Nurse and another RN, a facility staff LPN and a facility staff Patient Care Technician (PCT). Non-employee licensed staff (Agency) included RN #2, RN #3, LPN #1 and two PCT staff.

1) Observation on 12/18/12 revealed RN #2 was assigned to three patients, which included Patient (Pt.) # 2 who was on a respiratory ventilator. RN #2 was also assigned to perform the RN assessment for three patients assigned to a staff Licensed Practical Nurse (LPN). RN #2 was interviewed on 12/18/12 at 0935 regarding his orientation. He stated today was his first day at the facility and "a nurse walked around with me this morning".

2) Observation on 12/18/12 revealed RN #3 was assigned to four patients, which included Pt. #8 who was on a respiratory ventilator. RN #3 was also assigned to perform the RN assessment for for four patients assigned to a non-employee LPN. RN #3 was interviewed on 12/18/12 at 0955 regarding her orientation and she stated "today is my first day".

3) Observation on 12/18/12 revealed LPN #1 was assigned to seven patients. LPN #1 was interviewed on 12/18/12 at 1130 and stated he had been working at the facility for about four weeks and had received "a half a day of orientation".

4) Observation on 12/14/12 at 1340, revealed Agency PCT #2 was at the bedside of room 206, identified as "Contact Isolation" by door signage. PCT #2 was not wearing a gown while at the bedside and then was observed to exit the room without cleaning the portable vital sign equipment. The basket of the equipment contained open disposable blood pressure cuffs and opened glove boxes. PCT #2 was interviewed at the time of observation and stated "today is my first day here" and stated they gave her a "tour" as orientation. The findings were confirmed by the Infection Control Nurse at the time of observation.

B. RN Charge Nurse #2 was interviewed on 12/18/12 at 1055 and asked how the staffing was determined. RN Charge Nurse #2 stated they used the acuity policy and that "The regular staff always would take more than the Agency staff." The Surveyor asked RN Charge Nurse #2 how she determined who was assigned each patient, she stated "I've worked Agency before and they come to us with training and basic skills."

C. The Chief Nursing Officer was interviewed 12/18/12 at 1500 and stated she did not have specific training, orientation or evaluation of the Agency staff and that "all of their training and skills are in their folder from the Agency". On 12/18/12, the personnel folders for the non-employee licensed staff were reviewed for RN #2, RN #3, LPN #1 and PCT #1. There was no evidence of staff orientation to the facility, emergency procedures, policies and procedures or an assessment of competencies by the facility. The personnel file from the Agency for RN #2 did not include a determination of experience caring for a patient on a respiratory ventilator. RN #2 was assigned to Pt. #2 was respiratory ventilator dependant.

D. A list of all Agency staff who had worked at the facility from 10/01/12 - 12/19/12 was requested and received 12/19/12 at 1350.

E. The findings were discussed and confirmed with the Clinical Nurse Manager 12/19/12 at 1600.