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Based on interview, record, and document review, the hospital's Quality Assessment and Performance Improvement (QAPI) program failed to ensure that accurate and complete audits were performed to determine the staff's compliance with its own newly revised "Pain Management" policy. The hospital also failed to ensure that the Consent To Treat audits identified all inpatients that had incomplete consent forms in accordance with the hospital's Consent To Admission and Treatment policy.

Inaccurate and incomplete audits related to pain reassessments and consents, impeded the hospital from identifying improvement opportunities, determining staff compliance, and monitoring the safety of services, and quality of care provided to all patients.

Findings:

1. A review of the hospital's Performance Improvement Plan, dated 2014, was conducted. The Plan's responsibilities included the following:

-The identification and monitoring of the hospital-wide performance measures;

-Evaluating the effectiveness of action taken to improve a process; and

-Assuring that results, findings and improvement information are communicated.

Per the same Plan, it defined measurement as a systematic collection of data. The collected data was used to evaluate the design of new procedures and processes. The data was also used for the identification of opportunities for improvement related to the hospital's processes and outcomes.

On 7/16/14 at 3:35 P.M., a review of the hospital's data for pain assessment and reassessment was conducted with the Chief Clinical Officer (CCO), Past Director of Quality Management (PDQM), and Interim Director of Quality Management (IDQM). The document, dated 6/30/14, contained the following data: "Patient Name, Pain Scale Before and After, Common Drug name, Comment, Admin Date and Time". The CCO stated that the audits did not capture specific pain reassessment times. He stated that the data collected from the audits did not demonstrate whether or not the staff were performing pain reassessments within the specific timeframes stipulated in the hospital's newly revised Pain Management policy.

The hospital's policy and procedure titled "Pain Management", revision date of 5/14, indicated "Procedure: Pain assessment and management will be clearly documented in the medical record. Pain scale rating will be reassessed and the pain scale will be documented by a licensed nurse within 30 minutes for IV (intravenous) medication administration and within 1 hour for all other medication administration routes."

On 7/17/14 at 11:15 A.M., a Quality Assessment and Performance Improvement (QAPI) group interview was conducted. The IDQM, Chief Executive Officer (CEO), Director of Respiratory Therapy (DRT), CCO, Admissions Manager (AM 1), PDQM, Medical Director and the Chief of Staff (Physician 1) were in attendance. Physician 1 acknowledged that the hospital's pain management audits did not completely capture time specific data during pain reassessments, necessary to determine that staff were in compliance with their newly revised pain management policy.


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2. A review of the hospital's Performance Improvement Plan, dated 2014, was conducted. The Plan's responsibilities included the following:

-The identification and monitoring of the hospital-wide performance measures;

-Evaluating the effectiveness of action taken to improve a process; and

-Assuring that results, findings and improvement information are communicated.

Per the same Plan, it defined measurement as a systematic collection of data. The collected data was used to evaluate the design of new procedures and processes. The data was also used for the identification of opportunities for improvement related to the hospital's processes and outcomes.

A review of Patient 7's medical record was conducted on 7/15/14 at 8:00 A.M. Patient 7 was admitted to the hospital on 6/13/14 with diagnoses that included methicillin-resistant staphylococcus aureus (MRSA - an infection that is resistant to antibiotics) per the History and Physical, dated 6/13/14.

The document "Consent to Treat", dated 6/13/14, indicated that Patient 7 was "unable to sign above because: medical condition." However, Patient 7's Advance Directive was signed and dated on 6/22/14 by a family member.

A review of Patient 6's medical record was conducted on 7/15/14 at 3:45 P.M. Patient 6 was admitted to the hospital on 4/16/14 with diagnosis that included traumatic brain injury with a subdural hematoma (a collection of blood outside the brain due to trauma per the History and Physical, dated 4/17/14.

The document "Consent to Treat", dated 4/16/14, contained two hospital employee's signatures and read Patient 6 was "unable to sign at time of admit due to medical condition." However, Patient 6's Advance Directive and Patient Self-Determination, dated 4/19/14, was signed by Patient 6.

An interview and joint review of the tracking tool with the Admissions Manager (AM) 1 and the Interim Director of Quality Management (IDQM) was conducted on 7/17/14 at 8:55 A.M. The audit tool indicated that all medical records were 100% compliant with signatures on the Consent to Treat and the Advance Directives. AM 1 stated that the audit was based on quantity versus quality. She stated that she had since changed the process and re-educated the admission staff to ensure that consents and advance directive forms were completed.

AM 1 acknowledged that Patient 6 and Patient 7 were listed on the audit as 100% compliant when the audit should have indicated that the patients' and/or the responsible party's signatures were missing.

Based on observation, interview and record review, the hospital failed to ensure that pain reassessments were documented in accordance with the policy and procedure for 1 of 30 sampled patient's (22). Failure to document the reassessment of the patients' pain status after administration of the pain medication made it difficult to determine whether or not the patients' pain status was reassessed. It also prevented staff and other healthcare providers' the ability to determine the effectiveness of the pain medication administered and the patients' comfort level.

In addition, the hospital failed to ensure that a Registered Nurse (RN) accurately documented the medication administration times for 1 of 30 sampled patients (4). RN 9 documented the administration of two medications before the actual time the medications were dispensed. Inaccurate documentation of medication administration times had the potential to place the patient at risk of receiving subsequent doses of the medications in error, which could negatively impact the patient's fragile medical status.

Findings:

1. A review of Patient 22's medical record was conducted on 7/15/14 at 1:55 P.M. with RN 22 and the 4th floor medical surgical nursing manager (NM) 23.

Patient 22 was admitted to the hospital on 6/20/14 with diagnoses that included history of renal (kidney) failure which required hemodialysis (filters blood to remove excess water and waste products) per the History and Physical, dated 6/20/14.

Physician's orders dated 6/20/14 at 4:38 P.M., indicated an order for Patient 22 to receive oxycodone (pain medication) 5 milligram (mg) tablet via NGT (nasogastric tube- thin catheter tubing inserted through the nostrils into the stomach) every 4 hours as needed for moderate pain (scale 4-6).

Physician's orders dated 6/20/14 at 4:55 P.M., indicated an order for Patient 22 to receive oxycodone 10 mg tablet via NGT every 6 hours as needed for severe pain (scale 7-10).

A medication administration documentation, dated 7/3/14 at 11:47 A.M., indicated that Patient 22 received oxycodone 10 mg via NGT. There was no documented evidence to demonstrate that Patient 22's pain status was assessed prior to the time of administration and reassessed after administration, to determine the pain medication's effectiveness.

Patient 22's pain management care plan, dated 7/2/14, indicated assess for pain and medication effectiveness.

An interview with RN 22 and NM 23 was conducted on 7/15/14 at 2:26 P.M. Both RN 22 and NM 23 acknowledged that there was no documented evidence to demonstrate that Patient 22's pain assessment and reassessment had been performed.

The hospital's Pain Management policy, revised 5/14, indicated that pain will be assessed after the administration of pain medication to identify effectiveness. Furthermore, the policy indicated that a pain scale rating will be documented prior to pain medication administration and reassessed within 30 minutes for intravenous medication administration and within 1 hour for all other medication administration routes. This policy was not implemented when there was no documented evidence to demonstrate that Patient 22's pain assessment and reassessment had been performed.









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2. A joint observation of Patient 4 and interview with Registered Nurse (RN) 2 was conducted on 7/14/14 at 10:00 A.M. Patient 4 was resting in the bed on the left side with both eyes closed. RN 2 stated that Patient 4 had multiple pressure ulcers and was on intravenous (IV) antibiotic for an infection in the stool.

A joint review of Patient 4's medical record was conducted with the Director of Nursing (DON) and the Staff Educator (SE) on 7/15/14 at 1:15 P.M. Patient 4 was admitted to the hospital on 6/27/14 with diagnoses that included recurrent pressure ulcers located on the sacrum and the right hip per the History and Physical (H&P), dated 6/27/14. Per the H&P, Patient 4 was transferred to the hospital for wound care and IV antibiotics.

The Admission Note, dated 6/28/14 at 2:29 A.M., indicated that Patient 4 arrived to the hospital at 9:45 P.M. Per the same Note, the admission orders were verified with the primary physician. The orders were faxed to pharmacy and the IV antibiotic had been started.

The Administration Documentation, dated 6/27/14 at 10:00 P.M., indicated the following physician's order:

1. "IV Medication Name/Strength: Piperacillin Sod-Tazobactam So (Zosyn-antibiotic) 3-0.375 grams [gm] with Dextrose 5% 50 milliliters [ml] soln ml. Ordered route: IV. Ordered frequency every [q] 8 hours [hrs]. Scheduled date/time: 6/27/14 10:00 P.M. [2200]... Administration Detail: ...Administered Date/Time: 6/27/14 at 11:30 P.M. [2330]. Administered by: RN 9's name. Documented by: RN 9's name.

2. IV Medication Name/Strength: Vancomycin Solr milligram [mg] with Dextrose 5% soln ml. Ordered route: IV. Ordered frequency q 12 hrs. Scheduled date/time: 6/28/14 9:00 A.M... Administration Detail: ...Administered Date/Time: 6/28/14 at 01:00 A.M. Administered by: RN 9's name. Documented by: RN 9's name. Pharmacy [RX]notes: RN 9's name: Date: 6/27/14 at 1:00 A.M.- Given first dose taken from Med Dispense (RN 9's name)."

A joint review of the physician's order and interview with the Director of Pharmacy (DP) and the SE was conducted on 7/17/14 at 9:50 A.M. The DP stated when patients were admitted, the transfer orders once verified with the primary physician were faxed to pharmacy. Once the orders were received by pharmacy, a medication reconciliation against the sending facility's medication administration record (MAR) was conducted. The DP stated that for Patient 4, the orders were processed on 6/27/14 at 10:00 P.M.

A joint telephone interview with RN 9, the DON, and the SE was conducted on 7/17/14 at 2:45 P.M. RN 9 confirmed that Patient 4 had arrived at the hospital on 6/27/14 at 9:45 P.M. She stated that she called the primary physician to verify the admission orders. She checked the transfer orders, gave the medication, and then she put the orders into the system.

The DON and the SE stated all medications were to be administered with a physician's order.

A joint review of the MedDispense Station Patient Transaction form with the DP and the SE was conducted on 7/17/14 at 3:50 P.M. The form indicated, "medDispense Station: Patient Transactions Form: 6/28/14 12:00 A.M. To: 6/28/14 5:00 A.M." indicated that the Zosyn had been dispensed on 6/28/14 at 12:56 A.M. and the Vancomycin dispensed on 6/28/14 at 4:11 A.M." The DP and the SE both stated that RN 9 documented the medication was administered prior to the actual time the medications were dispensed.

The hospital's policy and procedure titled "Administration of Medications", undated was reviewed. The policy indicated under "Documentation: 7. Document the administered dose on the MAR after given." Both the DP and the SE acknowledged that the documented administration time did not match the time registered on the MedDispense record.

Based on observation, interview and record review the hospital failed to ensure sanitary conditions when the bottle of enteral nutrition (nutritional supplement given via tube directly into the stomach) was hung without the date and time for one of 30 sampled patients (14) and one randomly observed patient (21). Without the date and time, staff would not have the knowledge of when to change the bottle and tubing.

Failure to maintain infection control practices could potentially lead to the transmission of infections and the increase incidence of hospital acquired infections throughout the entire hospital.

Findings:

1. On 7/14/14 at 10:14 A.M., an initial tour of the telemetry, medical/surgical floor was conducted with the Director of Pharmacy (DP) and the Director of Case Management (DCM).

On 7/14/14 at 10:25 A.M., an observation of Patient 14 was conducted with licensed vocational nurse (LVN) 12. Patient 14 was in a wheelchair in his/her room with family at bedside. The enteral bottle was observed hanging on a pole. LVN 12 stated the enteral bottle had no date or time written on the bottle to indicate when it was hung. LVN 12 stated it was the policy of the hospital to have the date and time written on the enteral bottle at the time it was hung.

On 7/14/14 at 3:40 P.M., a review of Patient 14's medical record was conducted with the Director of Pharmacy (DP) and the Director of Case Management (DCM). Patient 14 was admitted to the hospital on 6/3/14 with diagnoses that included post traumatic brain injury per the History and Physical dated 6/3/14. The physician order dated 7/9/14 at 1:41 P.M. indicated, "2 Cal HN (name of enteral nutrition) Rate: 55 ml (milliliter)/hr continuous."

07/15/14 at 3:35 P.M., an interview was conducted with the prior Director of Quality Management (PDQM) and the Chief Clinical Officer (CCO). The PDQM acknowledged that all enteral bottles were to be dated/timed when hung.

On 7/17/14 at 10:25 A.M., a review of the hospital's policy and procedure titled "Tube Feeding Administration/Care of", review date of 3/13, indicated "Procedure: II. Implementation: B. Continuous infusion method: 5) ... Label the bottle and tubing with the date, time and your initials." This policy was not implemented when the Patient 14's enteral bottle had no date, time or initials written on the bottle.

2. On 7/14/14 at 10:14 A.M., an initial tour of the telemetry, medical/surgical floor was conducted with Director of Pharmacy (DP) and the Director of Case Management (DCM).

On 7/14/14 at 10:18 A.M., an observation of Patient 21 was conducted with Registered Nurse (RN) 3. Patient 21 was lying in bed in his/her room. The enteral bottle was observed hanging on a pole. RN 3 stated the enteral bottle had no date or time written on the bottle to indicate when it was hung. RN 3 stated it was the policy of the hospital to have the date and time written on the enteral bottle at the time it was hung.

On 7/14/14 at 10:20 A.M., an interview was conducted with Registered Nurse (RN) 4. RN 4 acknowledged that enteral bottles were to have the date and time written on the bottle when it was hung.

07/15/14 at 3:35 P.M., an interview was conducted with the prior Director of Quality Management (PDQM) and the Chief Clinical Officer (CCO). The PDQM acknowledged that all enteral bottles were to be dated/timed when hung.

On 7/17/14 at 10:20 A.M., a review of Patient 21's medical record was conducted. Patient 21 was admitted to the hospital on 7/11/14 with diagnoses that included CVA (cerebrovascular accident-stroke) per the History and Physical dated 7/12/14. The physician orders dated 7/12/14 at 2:22 P.M., indicated "Jevity 1.5 (name enteral nutrition) Rate: 45 ml (milliliter)/hr continuous."

On 7/17/14 at 10:25 A.M., a review of the hospital's policy and procedure titled "Tube Feeding Administration/Care of", review date of 3/13, indicated "Procedure: II. Implementation: B. Continuous infusion method: 5) ... Label the bottle and tubing with the date, time and your initials." This policy was not implemented when Patient 14's enteral bottle had no date, time or initials written on the bottle.