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On the days of the Hospital Validation Survey based on record review and hospital policy review, the hospital failed to ensure that each physician order for restraint was executed (signed, dated, timed, and all required areas completed) according to hospital policy for 3 of 10 closed patient records reviewed. (Patient #5, #9, and #10)


The findings include:


A record review conducted on 4/12/11 at 1030 revealed Patient #5 was admitted to the hospital on 1/11/11 and discharged on 1/23/11. The hospital form, titled, "RESTRAINT ORDER/ASSESSMENT SHEET" dated 1/16/11 at 0850, showed the following sections were not completed on the form: "Daily Comprehensive Assessment, CLINICAL JUSTIFICATION FOR RESTRAINT USE, PLEASE CHECK LESS RESTRICTIVE INTERVENTION ATTEMPTED, YET NOT SUCCESSFUL, OBSERVED, OR REPORTED, BY PATIENT-CARE SERVICES STAFF, and TYPE OF RESTRAINT".

A record review conducted on 4/12/11 at 1400 revealed Patient #9 was admitted to the hospital on 2/10/11 and discharged on 4/6/11 with the diagnosis of Post Traumatic Pulmonary Insufficiency. The hospital form, titled, "RESTRAINT ORDER/ASSESSMENT SHEET" dated 2/20/11 was not timed by the physician and the area "Daily Comprehensive Assessment " was not completed. The "RESTRAINT ORDER/ASSESSMENT SHEET" dated 2/20/11 was not signed by the physician. The "24 HOUR PATIENT RECORD & PLAN OF CARE" dated 3/8/11, 3/9/11, 3/11/11, and 3/21/11 indicated the patient was in restraints, but there was no physician order for restraint in the patient's medical record. The "RESTRAINT ORDER/ASSESSMENT SHEET" dated 3/28/11 showed the following areas were not completed: "PLEASE CHECK LESS RESTRICTIVE INTERVENTION ATTEMPTED, YET NOT SUCCESSFUL, OBSERVED, OR REPORTED, BY PATIENT-CARE SERVICES STAFF; and TYPE OF RESTRAINT", and the physician order for the restraint was not signed, dated, nor timed by the physician.

A record review conducted on 4/12/11 at 1510 revealed Patient #10 was admitted to the hospital on 3/15/11 and discharged on 3/29/11 with the diagnoses of Mechanical Ventilation Weaning, Shortness Of Breath, and Cardiac Arrest. The "RESTRAINT ORDER/ASSESSMENT SHEET" dated 3/16/11, 3/17/11, 3/21/11, and 3/22/11 was not dated and/or timed by the physician.

Facility Policy #R02-N, titled, "RESTRAINTS AND SECLUSION", revised 6/10, states, "...ORDERS TO INITIATE RESTRAINT Any physician of the active medical staff, or licensed practitioner (if allowed under State law) may issue an order for restraint. Orders for restraints must be renewed on a daily basis...MEDICAL RECORD DOCUMENTATION AND PLAN OF CARE: Every use of restraint is to be documented in the patient's record. At a minimum, documentation must include: The alternatives tried prior to restraint use. The justification for restraint. The patient assessment that demonstrates the need for restraint as part of the patient's treatment. A time limited order by a physician, or licensed independent practitioner...". The Medical Staff Rules and Regulations, states, "...C. MEDICAL RECORDS...5. A practitioner's routine orders, when applicable to a given patient shall be reproduced in detail on the order sheet of the patient's record, dated and signed by the practitioner. 6. All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated...".

On the days of the Hospital Validation Survey based on interview, record review, and facility policy review, the hospital failed to ensure that a registered nurse (RN) supervise and evaluate the care for each patient by way of documentation of agreement with the data collection of the licensed practical nurse (LPN) in accordance with hospital policy for 9 of 20 concurrent patient records (Patient #1, 2, 3, 4, 5, 6, 7, 9, and 10) and 6 of 10 closed patient records reviewed for care and services. (Patient #1, 2, 3, 4, 7, and 9)


The findings include:


Closed record review conducted on 4/11/11 at 1315 revealed Patient #1 was admitted to the hospital on 1/21/11 and discharged on 2/8/11. The hospital form, titled, "24 HOUR PATIENT RECORD & PLAN OF CARE" dated 1/31/11, 2/1/11, 2/2/11, and 2/3/11 revealed there was no documentation of Registered Nurse verification of data collected by Licensed Practical Nurse.

Closed record review conducted on 4/11/11 at 1400 revealed Patient #2 was admitted to the hospital on 12/15/10 and discharged on 1/3/11. The hospital form, titled, "24 HOUR PATIENT RECORD & PLAN OF CARE" dated 12/15/10, 12/19/10, 12/25/10, 12/29/10, 12/30/10, and 1/3/11 showed there was no documentation of Registered Nurse verification of data collected by Licensed Practical Nurse.

Closed record review conducted on 4/12/11 at 0900 revealed Patient #3 was admitted to the hospital on 12/22/10 and discharged on 1/7/11. The hospital form, titled, "24 HOUR PATIENT RECORD & PLAN OF CARE" dated 12/24/10, 1/2/11, 1/3/11, and 1/4/11 showed there was no documentation of Registered Nurse verification of data collected by Licensed Practical Nurse.

Closed record review conducted on 4/12/11 at 0935 revealed Patient #4 was admitted to the hospital on 12/28/10 and discharged on 1/18/11. The hospital form, titled, "24 HOUR PATIENT RECORD & PLAN OF CARE" dated 1/4/11, 1/6/11, 1/8/11, and 1/9/11 showed there was no documentation of Registered Nurse verification of data collected by Licensed Practical Nurse.

Closed record review conducted on 4/12/11 at 1200 revealed Patient #7 was admitted to the hospital on 2/7/11 and discharged on 3/20/11 with the diagnosis of Acute Respiratory Failure. The hospital form, titled, "24 HOUR PATIENT RECORD & PLAN OF CARE" dated 2/25/11, 3/2/11, 3/3/11, 3/4/11, 3/5/11, 3/6/11, 3/7/11, 3/10/11, 3/13/11, 3/15/11, and 3/16/11 revealed there was no documentation of Registered Nurse verification of data collected by Licensed Practical Nurse.

Closed record review conducted on 4/12/11 at 1400 revealed Patient #9 was admitted to the hospital on 2/10/11 and discharged on 4/6/11 with the diagnosis of Post Traumatic Pulmonary Insufficiency. The hospital form, titled, "24 HOUR PATIENT RECORD & PLAN OF CARE" dated 3/15/11, 3/21/11, 3/23/11, and 3/24/11 showed there was no documentation of Registered Nurse verification of data collected by Licensed Practical Nurse.

The Chief Nursing Officer, on 4/12/11 at 0930, revealed that a Registered Nurse is to document verification on the 24 HOUR PATIENT RECORD & PLAN OF CARE on page 8 within the section, titled, "RN verification of data collected by LPN".

Facility Policy #A03-G, titled, "ASSESSMENT AND REASSESSMENT OF PATIENTS", revised 4/1/11, states, "...POLICY...Scope of Assessment by Nursing...Reassessment is documented description of the patient's response/status relative to medical and/or nursing interventions, effectiveness of interventions, resolution of patient problems/needs, and discharge preparation. All data collected on patients is reviewed and analyzed by the RN assigned to oversee care for the patient; interdisciplinary team goals are adjusted based upon the changing needs of the patient and/or his response to prescribed interventions...".








29886

Concurrent record review conducted on 4/12/11 at 1245 revealed Patient #2 was admitted on 4/06/11 with the diagnosis of infected Knee Arthroplasty. Patient #2 was not assessed by an Registered Nurse, as evidenced by no Registered Nurse signature on the patient's nurse notes dated 4/09/11.

Concurrent record review conducted on 4/12/11 at 1350 revealed Patient #3 was admitted on 2/28/11 with wound infection and the need for ongoing antibiotics. Patient #3 was not assessed by a Registered Nurse as evidenced by no Registered Nurse signature on the patient's nurse notes dated 4/09/11.

Concurrent record review conducted on 4/11/11 at 1430 revealed Patient #4 was admitted on 1/24/11 with need for wound care with diagnosis of Diabetes, Hypertension, Hyperlipidemia, Hypothyroidism, Obesity, and Chronic Pulmonary Disease on chronic Oxygen. Patient #4 was not assessed by a Registered Nurse as evidenced by no Registered Nurse signature on the patient's nurse notes dated 4/06/11, 4/07/11, and 4/08/11.

Concurrent record review conducted on 4/12/11 at 1320 revealed Patient #5 was admitted on 3/11/11 with history of Respiratory Failure, status post Septic Shock. Patient #5 had no assessment by a Registered Nurse as evidenced by no Registered Nurse signature on the patient's nurse notes dated 4/04/11,4/08/11, and 4/09/11.

Concurrent record review conducted on 4/12/11 at 1530 revealed Patient #9 was admitted on 3/30/11 with a history of bilateral sacral/hip wounds. Patient #9 was not assessed by a Registered Nurse as evidenced by no Registered Nurse signature on the patient's nurse notes dated 4/03/11,4/07/11, and 4/09/11.




30011

Concurrent Review of Patient #1, #6, #8, and #10's chart showed the patient's were assigned to a Licensed Practical Nurse but were identified as not having a Registered Nurse signatures verifying that the patient clinical data collected by the Licensed Practical Nurses assigned to caring for those patients on the following dates was reviewed and assessed by a Registered Nurse.
Patient #1 was admitted on 3/23/11 for intravenous antibiotic therapy for L5(Lumbar)-S1(Sacral) discitis and likely osteomyelitis.
3/27/11 for the 7 pm to 7 am shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.
3/31/11 for the 7 am to 7 pm shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.
4/08/11 for the 7 pm to 7 am shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.
4/11/11 for the 7 am to 7 pm shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.

Patient #6 was admitted on 3/25/11 for Malnutrition, Debilitation, Gastrocutaneous fistula, and Multiple other medical issues with wound dehiscence.
3/25/11 for the 7 pm to 7 am shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.
3/28/11 for the 7 am to 7 pm shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.
3/29/11 for the 7 pm to 7 am shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.
4/3/11 for the 7 am to 7 pm shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.
4/6/11 for the 7 am to 7 pm shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.
4/11/11 for the 7 am to 7 pm shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.

Patient #8 was admitted on 3/23/11 for Morbid Obesity, Obstructive Sleep Apnea, Obesity Hyperventilation Syndrome and Congestive Heart Failure for long term wound therapy.
3/25/11 for the 7 pm to 7 am shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.
4/3/11 for the 7 am to 7 pm shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.
4/7/11 for the 7 am to 7 pm shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.
4/8/11 for the 7 pm to 7 am shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.

Patient #10 was admitted 3/17/11 for Long-term intravenous antibiotics and wound care.
4/2/11 for the 7 pm to 7 am shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.
4/3/11 for the 7 pm to 7 am shift: Assigned to a Licensed Practical Nurse but had no Registered Nurse signature verifying the clinical data obtained by the Licensed Practical Nurse.

On the day of the Hospital Validation Survey based on observation, hospital policy review, and interview, the facility failed to discard expired medications and biologicals in the hospital pharmacy and crash cart.


The findings are:


On 4/11/11 at 1130, observation of the Pharmacy Department revealed the following drugs were expired:
A. 32 individual doses of Prandin 0.5 mg (milligrams) expired 03/31/11,
B. 5 individual doses of Actos 30 mg expired 02/28/11,
C. 4 bottles Norepinephrine 4 mg/4 ml expired 03/11,
D. 1 bottle Pamidrenate Disodium Injection 9 mg/1 ml (milliliter) expired 03/11, and
E. 2 bottles Sodium Thiosulfate 250 mg/ml expired 03/11.
The findings were verified by Pharmacy Staff #1.

On 4/11/11 at 1440, random observation of the crash cart revealed one (1) multi-lumen central venous catheter tray that expired 02/2010. The finding was verified by Staff #2.


Hospital policy, revised 01/2008, reads, "Drug Storage In The Pharmacy, Purpose: To promote efficient, safe storage of pharmaceuticals, #14. No expired or otherwise unusable drugs may be stored with "active" inventory. These drugs must be segregated in an area that would preclude their inadvertent use. Expired products should be removed from the pharmacy at least every 6 months by a contracted returns company....".

On the day of the Hospital Validation Survey based on patient record review, interview, and tour of the facility, the facility failed to ensure that supplies and equipment were maintained to ensure an acceptable level of safety and quality. (Bed scales and Lab supplies)


The findings are:


On 4/11/11 at 1430, a review of Patient #4's chart revealed a 66 year old admitted to the hospital with physician orders for wound care. Review of the patient's chart showed no documented weights for the past thirteen days. Written in the section for weights was ".... bed is broken." The finding was verified with the Chief Nursing Officer. The hospital had no work order for the broken bed.




30011

On the day of the Hospital Validation Survey based on observation and interview, the facility failed to remove expired lab tubes from patient care areas in the nursing units.


The findings are:


On 04/11/11 at 1110, random observations revealed the following types of blood collection tubes were expired on the nursing unit and the findings were verified with Staff Member #5:
A. 39 Red top tubes expired 03/11
B. 59 Green top tubes expired 03/11
C. 2 Red/Gray top tubes expired 02/11
D. 1 Gray top tube expired 08/10
E. 2 Blue top tubes expired 12/10

On the days of the Hospital Validation Survey based on random observation, staff interview, and review of hospital policy and procedures, the hospital failed to ensure the glucometer was disinfected between patient use to prevent cross contamination. (Nursing Unit)


The findings are:


On 4/12/2011 at 1215, Registered Nurse (RN) #1 was randomly observed in patient Room 522 using the glucometer and testing strips to measure the patient's blood sugar by finger stick. RN #1 returned to the Nurse Station with the testing strips and glucometer to record the results and to discard the bloody test strip. Then, RN #1 proceeded to enter patient Room 567 to test the patient's blood sugar with the same glucometer and test strip vial without disinfecting the equipment prior to entering the patient's room. The patient in Room 522 and 567 were under isolation precautions. The findings were verified by the Chief Nursing Officer who stated that the glucometer was to be disinfected between patient use and a disposable plastic sleeve was to be placed on the glucometer prior to use on each patient.

Hospital Policy: IC VII-4, read, "Equipment Cleaning. Purpose: Equipment can serve as a vehicle for transmitting pathogens...Whenever possible, there will be no shared equipment. ...When not possible (weights, glucose monitoring, EKG [electrocardiography], certain respiratory equipment, etc) a sleeve device will be used or the equipment will be disinfected after use by the clinical staff, immediately after use."