HospitalInspections.org

Based on record review and interview, the hospital's governing body failed to approve the Medical Staff By-Laws and failed to ensure the Medical Staff had adopted Rules and Regulations.

Findings:
A review of the Medical Staff By-Laws Manual, as provided by S1ADM, revealed no documented evidence that the Medical Staff By-Laws were reviewed and approved by the GB. A review of a cover sheet inside the Medical Staff By-Laws Manual, titled "Medical Staff Bylaws, Rules And Regulations" revealed an amendment to a section of the Medical Staff By-Laws Manual that was approved and dated 12/15/09. A further review revealed no documented evidence that the Medical Staff By-Laws Manual had been reviewed or approved by the GB. A review further revealed no documented evidence that the Medical Staff By-Laws Manual contained Medical Staff Rules and Regulations.

In an interview on 07/11/17 at 3:00 p.m. with S1ADM, the Medical Staff By-Laws Manual was reviewed with S1ADM. She indicated that she was unable to produce any documented evidence that the Medical Staff By-Laws Manual was reviewed and approved by the GB. S1ADM further indicated that she was unable to produce documented evidence that the medical staff had Rules and Regulations. She indicated that she was always under the impression that the Medical Staff By-Laws Manual contained the Medical Staff Rules and Regulations. S1ADM indicated that there may be Medical Staff Rules and Regulations, but she did not know where they might be located. There was no documented evidence provided to the survey team that the Medical Staff By-Laws were approved by the GB or that the medical staff had Medical Staff Rules and Regulations by the exit conference.

Based on record review and interview, the hospital's governing body failed to develop and approve QA indicators for the hospital's contracted services that directly affect patient care.

Findings:
A review of the hospital's Contract Service list, provided by S1ADM, as the most current, revealed that the hospital had 56 Contract Services. A review of the hospital's Contract Service Manual revealed no documented QA indicators for the contracted services.

A review of the GB meeting minutes from 2016 to present, as provided by S1ADM, revealed no documentation that identified QA indicators that had been developed or approved by the GB to evaluate the hospital's Contract Services.

In an interview on 07/11/17 at 3:00 p.m. with S1ADM, the GB meeting minutes were reviewed with S1ADM. She indicated that the GB meeting agendas for 2016-2017 did not include developing and/or approving QA indicators for the hospital's Contract Services and she was not aware of any QA indicators for the hospital's Contract Services being discussed in the GB meetings. She further indicated she was not aware of any QA indicators that were approved by the GB to evaluate the hospital's Contract Services.

Based on record review and interview, the hospital's governing body failed to ensure a system was in place to evaluate the quality of the hospital's Contract Services to assure that each contracted service was provided in a safe and effective manner.

Findings:
A review of the hospital's Contract Service Manual, provided by S1ADM, as the most current, revealed no documented evidence that identified QA indicators or monitoring activities in place to evaluate the contracted services.

A review of the GB meeting minutes, from 2016 to present, revealed no documented evidence that the GB had evaluated the hospital's Contract Services for 2016-2017.

In an interview on 07/11/17 at 3:00 p.m. with S1ADM, the GB meeting minutes were reviewed with S1ADM. She indicated that the GB meeting agendas for 2016-2017 did not include evaluations of the hospital's Contract Services. S1ADM further indicated that the Governing Body had no system in place to evaluate the quality of the hospital's Contract Services to assure that each contracted service was provided in a safe and effective manner.

Based on record review and interview, the hospital's GB failed to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all hospital services in the QAPI program. This deficient practice was evident by failing to include the hospital services of discharge planning, respiratory therapy services, and utilization review in the hospital's QAPI program. Findings:

Review of the hospital policy titled, Improving Organizational Performance Plan, I.E.5.06, revealed the scope of the Performance Improvement Program included measurement and assessment activities which address patients served by the Medical Staff, Nursing, and ancillary services and hospital wide functions. Both clinical and non-clinical departments are included.

Review of the ActionCue Report of All Performance Measures (Quality Indicators Dashboard) provided by S3QA/IC as the updated, complete version of quality indicators and performance measures monitored for 2017 revealed the following services were not included in the QAPI program and no data was collected for: Respiratory Services, Discharge Planning Services, and Utilization Review.

In an interview on 07/12/17 at 10:45 a.m., S3QA/IC reviewed the above ActionCue report of performance measures and confirmed Respiratory Services, Discharge Planning Services and Utilization Review were not included in the QAPI program for 2017.

Based on record review and interview, the hospital's Medical Staff failed to develop and adopt Medical Staff Rules and Regulations in order to provide organization and accountability of its medical staff by failing to develop and adopt Medical Staff Rules and Regulations to be approved by the GB.

Findings:
A review of the Medical Staff By-Laws Manual, as provided by S1ADM, revealed no documented evidence that the hospital's Medical Staff By-Laws Manual also contained Medical Staff Rules and Regulations.

In an interview on 07/11/17 at 3:00 p.m. with S1ADM, the Medical Staff By-Laws Manual was reviewed with S1ADM. The review revealed no documented evidence of Medical Staff Rules and Regulations. S1ADM indicated that she was always under the impression that the Medical Staff By-Laws Manual contained the Medical Staff Rules and Regulations. S1ADM indicated that there may be Medical Staff Rules and Regulations, but she did not know where they might be located. S1ADM indicated that she was unable to produce documented evidence that the medical staff had Rules and Regulations. There was no documented evidence provided to the survey team that the medical staff had Medical Staff Rules and Regulations by the exit conference.

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30984

Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient as evidenced by: 1) failure of the RN to assess a patient after a change in condition for 1 (#7) of 4 (#2, #7, #22, #27) patients reviewed for acute transfer to a higher level of care out of a total sample of 30 patients.

Findings:

Review of the hospital policy titled, "Assessment and Reassessment", policy #: II.I.9.00. Effective date: 08/21/2012, revealed in part: I. Policy: To assure patient care is based on an assessment of the patient's relevant physical, psychological, and social needs.; II. Procedure: 7. Reassessment shall take place when there is a significant change in a patient's condition or a change in diagnosis. 9. Any deteriorating change in a patient's condition shall require an
immediate reassessment and documentation by a Registered Nurse.

Review of Patient #7's medical record revealed an admission date of 01/31/17 with admission diagnoses of Multiple Sclerosis with bilateral lower extremity weakness. Further review revealed the patient was admitted for inpatient rehabilitation services to maximize neuromuscular and functional recovery.

Review of Patient #7's 24 hour Patient Care (nursing) Flowsheet revealed the following entries, in part:
02/01/17 12:15 p.m.: Eating lunch, c/o (complains of ) sharp pain to LLE (left lower extremity). Rates pain 8/10 (on a pain scale of 1-10). Tylenol 650 milligrams administered. S19LPN.;
02/01/17 1:00 p.m.: Rates pain 7/10. S19LPN.;
02/02/17 07:00 a.m. c/o sharp pain to LLE. Rates pain 6/10. Tylenol 650 milligrams administered. S19LPN.;
02/02/17 07:30 a.m. : Rates pain 5/10. Temperature: 101.7 degrees. Will continue to monitor. S19LPN.;
02/02/17 1:00 p.m.: c/o sharp pain to LLE. Tylenol 650 milligrams administered. S19LPN.;
02/02/17 2:00 p.m.: Rates pain 7/10. Scheduled medications reviewed and administered. Tolerated well. Dopplers done. S19LPN.;
02/02/17 3:30 p.m.: Transferred to an area hospital by ambulance. S19LPN,;
Further review of Patient #7's entire medical record revealed no documented evidence of an assessment of Patient #7 by a RN with the change in the patient's condition.

Review of Patient #7's discharge summary, dated 02/02/17 revealed in part: Acute transfer to area hospital
Condition: Serious; Diagnosis: Acute left femoral DVT (deep vein thrombosis), UTI (urinary tract infection), H&H (Hemoglobin and Hematocrit): 6.8 and 20.8.
Hospital course: The patient sent out urgently secondary to acute DVT, H&H: 6.8 and 20.8, and acute fever with development of urinary retention in the setting of recent UTI. The patient medically unstable and transferred out acutely to an area hospital for treatment of complex medical issues.

In an interview on 07/10/17 at 1:30 p.m. with S2DON, she confirmed Patient #7 should have been assessed by a RN with a change in condition. S2DON also confirmed the assessment should have been documented in the patient's medical record.

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30984

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current an individualized, comprehensive nursing care plan for each patient for 5 (#1,#2, #3, #4, #5) of 5 current patients reviewed for care plans out of a total sample of 30 patient records reviewed.

Findings:
A review of the hospital policy titled, "Plan of Care", as provided by S2DON as the most current, revealed in part: The care plan will identify the main problems or potential problem areas that are patient specific including interventions and measurable goals. The patient care plan will be personalized to meet individual patient care needs. Additional problems unique to the patient may be included and reassessed when warranted. Each patient's nursing care plan is based on identified nursing diagnosis. Patient care planning will include interventions, therapy, education specific to the patient's health care needs, discharge planning, continuing care needs, and any potential referrals/consultations.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a current patient that was admitted on 06/27/17 with diagnoses of CVA, Hypertension, Diabetes Mellitus, Type 2, Rheumatoid Arthritis, and Dementia.

Review of the plan of care revealed pre-typed goals and no individualized goals. The following problems were identified:
Mobility: Bed, Impaired related to: Altered neuromuscular functioning. A line was drawn down through all of the pre-typed interventions.
Communication, Impaired Verbal related to: Altered neurological function. A line was drawn down through all of the pre-typed interventions.
Falls, Risk for related to: Neuromuscular deficits. A line was drawn down through all of the pre-typed interventions.
Memory, Impaired related to: Altered neurological function. A line was drawn down through all of the pre-typed interventions.
Self-Care deficit related to: Muscular weakness-alteration in neurological function. A line was drawn down through all of the pre-typed interventions.
There was no documented evidence of any individualized specific problems or interventions.
There was no documented evidence that the patient's Diabetes Mellitus with sliding scale insulin and Hypertension with blood pressure medications was included in the care plan.

In an interview on 07/12/17 at 8:50 a.m., S2DON reviewed the patient's care plan and confirmed the plan of care was not individualized and only included the rehab related problems.


Patient #2
Review of Patient #2's medical record revealed a re-admission date of 07/04/17 with diagnoses including s/p (status post) hospitalization on 07/01/17 for acute left lower leg deep vein thrombosis (DVT), Pulmonary Embolus, Asthma, Hypertension and Anxiety. Further review revealed the patient was being treated with Xeralto (an anticoagulant).

Review of Patient #2's Interdisciplinary plan of care revealed Asthma, Hypertension, Anticoagulant therapy/bleeding precautions, thrombus prevention measures, and Anxiety were not documented as identified problems to be addressed on the patient's plan of care.

Patient #3
A review of Patient #3's medical record revealed the patient was admitted on 07/06/17 with an admit diagnosis of MS exacerbation. The review revealed other patient medical conditions to include in part: intramedullary lesion, urinary incontinence, bleeding rectal polyps, hemorrhoids, and incomplete paraplegia. A further review of Patient #3's medical record revealed the patient had a foley, leg spasms that required pain medication and episodes of rectal bleeding and loose stool. The patient's care plan addressed urinary retention with an intervention to catheterize if needed and the care plan did not address that the patient had a foley with foley needs or foley care. The patient had a care plan for impaired mobility and fall risk, but it did not address her incomplete paraplegia needs. The only other care plan on the patient was on knowledge deficit. There were no other care plans identified that addressed her bowel needs, hemorrhoids and rectal bleeding or the pain due to the spasms.

In an interview on 07/10/17 at 5:00 p.m. with S2DON regarding Patient #3's care plan, she indicated that staff are more focused on rehabilitation needs in the development of patient care plans than on the nursing needs.

Patient #4
Review of Patient #4's medical record revealed an admission date of 07/05/17 with diagnoses including Diabetes Mellitus, Chronic Kidney Disease Stage III, Hypertension, and Knee pain. Further review revealed the patient was being treated with sliding scale insulin for the control of Diabetes Mellitus. Additional review revealed the patient had a wound on the plantar surface of the 3rd toe of his left foot requiring treatment.

Review of Patient #4 's Interdisciplinary plan of care revealed Diabetes Mellitus, Chronic Kidney Disease Stage III, Hypertension, the toe wound on his left foot/wound care, and Knee pain were not documented as identified problems to be addressed on the patient's plan of care.


Patient #5
Review of the medical record for Patient #5 revealed the patient was a current patient that was admitted to the hospital on 06/28/17 with diagnoses of T10-L1 Fusion with Removal of Dorsal Column Stimulator and Hypertension. Further review of the record revealed the patient had been on contact isolation for an infection with MRSA, and had a PICC line insertion during his hospital stay. Review of the medical record and the file at the nurse's station where the care plans were filed, revealed no documented evidence of a plan of care for Patient #5.

In an interview on 07/10/17 at 4:45 p.m., S13RN reviewed the patient's record and the care plan file and confirmed there was no documentation of a care plan for Patient #5.

Based on record review and interview, the hospital:
1) failed to ensure drugs and biologicals were administered in accordance with the orders of qualified practitioners responsible for the patient's care and in accordance with hospital policy. This deficient practice was evidenced by the nursing and pharmacy staff transcribing medication orders from the transferring facility and the nurse administering the medications without physician orders from the admitting physician for 4 (#3, #18, #19, #20) of 4 current patients reviewed for admission orders out of a total sample of 30 patients, and;
2) failed to ensure drugs and biologicals were administered in accordance with acceptable standards of practice as evidenced by failing to assess and document the patient's pulse and blood pressure prior to administration of antihypertensive medications and/or Digoxin for 5 (#8, #9, #10, #13, #18) of 5 current patients reviewed for administration of medications out of a total sample of 30 patients.

Findings:

1) failed to ensure drugs and biologicals were administered in accordance with the orders of qualified practitioners responsible for the patient's care and in accordance with hospital policy.

Review of the hospital's policy titled, Medication Administration, Policy number N 11.00 revealed in part the following: Medications shall be administered according to the approved standard dosing schedule by appropriately qualified individuals in accordance with the orders of the physician responsible for the patient's care and accepted standards of practice.

Review of the hospital policy titled, Medication Reconciliation, Policy number II.K.11.05 revealed in part the following: All inpatients and outpatients who convert to inpatient status will have all medications reconciled through the continuum of care. The purpose of this activity is to prevent adverse drug events during the continuum of care and to generate the most accurate medication list available for the patient and primary care physician upon discharge or transfer to another facility.....When the most accurate listing of medications has been completed, the nurse will compare the list to the physician's admission orders....The physician must order each drug, dosage, etc. by written or verbal order....

A review of the hospital policy titled, "Authentication", as provided by S2DON as the most current, revealed in part: Verbal and Telephone orders- RN's, LPN's, Therapists (PT, OT, ST, Respiratory) and Dieticians are authorized to receive and record verbal and telephone orders.

Review of the Medical Staff Bylaws, provided by S1ADM as the current bylaws, revealed no documented evidence of any provisions related to admission orders.

Patient #3
A review of the medical record for Patient #3 revealed the patient was a current patient that was admitted to the hospital on 07/06/17 at 4:30 p.m. from another hospital with a diagnosis of MS exacerbation.

A review of the admission orders dated 07/06/17 at 4:20 p.m. revealed the admit orders documented on the physician order form was written by S33RPh and was documented as, "Admit Orders" and included, in part, written orders for Robaxin, Zofran, and Percocet. The admit orders were noted by S13RN on 07/06/17 at 4:40 p.m. There was no documentation that the medications were received as a verbal order from the physician. A further review of the admission medication orders revealed no authentication of the admit orders, as of 07/10/17, by the admitting physician, S25MD.

In an interview on 07/10/17 at 3:30 p.m. with S2DON she reviewed the medical record for Patient #3. She indicated that the pharmacist had written the medication orders on admission and that they were the medications the patient was receiving at the transferring hospital. S2DON indicated that there was no documented evidence that the admit orders were a verbal or written order from the admit physician. S2DON further indicated that this process was not in accordance with the hospital policy on physician orders or medication reconciliation.


Patient #18
Review of the medical record for Patient #18 revealed the patient was a current patient that was admitted to the hospital on 06/28/17 at 3:10 p.m. from another hospital with a diagnosis of Seroma at L 4-5.

Review of the admission orders dated 06/28/17 at 3:10 p.m. documented by S33RPh revealed the pharmacist documented, "Admit Orders:" and listed the patient's medications and sliding scale for Regular Insulin. The order included the following at the end of the orders, "S22MedDir/S33RPh/S14RN." There was no documentation that the medications were received as a verbal order from the physician. Further review of the admission medication orders revealed S22MedDir, admitting physician, authenticated the orders on 06/29/17 at 8:43 a.m.

In an interview on 07/12/17 at 8:35 a.m., S2DON reviewed of the medical record for Patient #18 and confirmed the pharmacist had written the medication orders on admission and there was no documented evidence of a verbal or written order for the patient's medications on admit. S2DON confirmed this process was not in accordance with the hospital policy on medication reconciliation.


Patient #19
Review of the medical record for Patient #19 revealed the patient was admitted to the hospital from home with a diagnosis of Exacerbation of Multiple Sclerosis on 07/02/17 at 2:50 p.m.

Review of the admission orders dated 07/02/17 (no time) documented by S33RPh revealed the pharmacist documented, "Admit Orders:" and listed the patient's medications. The order was signed by S33RPh and there was no documentation of a verbal order from the physician for the medications. Further review of the admission medication orders revealed S13RN timed the orders at 2:50 p.m. and S25MD, admitting physician, authenticated the orders on 07/04/17 at 8:50 a.m.
Review of the Medication Reconciliation Form documented by S13RN on 07/02/17 at 2:50 p.m., revealed a list of the patient's medications that included the following medications that were not included in the medication orders written by S33RPh:
Acthar Injection 400 units/5cc, give 1 cc a day for 5 days (Medication for Multiple Sclerosis).
Tecfidera 240 mg twice a day (Medication for Multiple Sclerosis).


Patient #20
Review of the medical record for Patient #20 revealed the patient was a current patient that was admitted to the hospital on 06/30/17 at 1:10 p.m. from another hospital with a diagnosis of Craniotomy Left Tumor Resection.

Review of the admission orders dated 06/30/17 (No time) documented by S29RPh revealed the pharmacist documented, "Admit Orders:" and listed the patient's medications and sliding scale for Regular Insulin. The order included the following at the end of the orders, "S29RPh/S33RPh." There was no documentation that the medications were received as a verbal order from the physician. Further review of the admission medication orders revealed S23MD/Resp, admitting physician, authenticated the orders on 06/30/17 at 7:25 p.m.

In an interview on 07/12/17 at 8:40 a.m., S2DON reviewed of the medical record for Patient #20 and confirmed the pharmacist had written the medication orders on admission and there was no documented evidence of a verbal or written order for the patient's medications on admit. S2DON confirmed there was no time documented on the medication orders. S2DON confirmed this process was not in accordance with the hospital policy on medication reconciliation.


In an interview on 07/11/17 at 2:50 p.m., S29RPh was asked to explain the hospital's process for medication orders on admission. S29RPh stated the pharmacist gets the patient's medications from the referring hospital and documents the medications on the physician orders and puts the medications in the system as active orders. S29RPh stated the medications would then be available to administer. S29RPh stated the medications are not taken as verbal orders but copied from the list of medications sent from the transferring hospital. S29RPh stated the physician co-signs the orders when he comes in. S29RPh stated once the orders are entered into the system, a MAR is printed. S29RPh stated the admit medication orders are written before the patient is admitted. When asked what the purpose of the current procedure was, S29RPh stated if a patient arrives after the pharmacy is closed, this process ensures the patient will have the medications they were on prior to admission. He stated the hospital's remote order system that operates after the pharmacy is closed is not able to input orders for new admissions. S29RPh indicated the pharmacy hours were 9:00 a.m. to 3:00 p.m.



2) failed to ensure drugs and biologicals were administered in accordance with acceptable standards of practice as evidenced by failing to assess and document the patient's pulse and blood pressure prior to administration of antihypertensive medications and/or Digoxin:

Review of the hospital policy titled, Medication Administration, Policy number N 11.00 revealed in part the following:
Nurse Responsibilities: 6. When administering medications that require pulse/blood pressure check (i.e. pulse with Digoxin or blood pressure with an antihypertensive) chart the value next to the time administered.

Patient #8
Review of the medical record for Patient #8 revealed the patient was a current patient admitted to the hospital on 07/06/17 with diagnoses of Severe Vasculopathy including Diabetes Mellitus, Hypertension, Pulmonary Emphysema, and CVA with right Hemiparesis. Review of the physician orders dated 7/06/17 revealed the patient was ordered Norvasc (Amlodipine) 10 mg daily (Medication to treat high blood pressure).
Review of the MARs dated 07/08/17 and 07/09/17 revealed the Norvasc was administered by S20LPN at 8:00 a.m., but there was no documentation of the patient's blood pressure on the MAR.

In an interview on 07/12/17 at 8:45 a.m., S2DON reviewed the MARs dated 07/08/17 and 07/09/17 and confirmed the nurse had failed to document the patient's blood pressure on the MAR at the time of administration of the Norvasc as directed in the hospital's policy.


Patient #9
Review of the medical record for Patient #9 revealed the patient was a current patient admitted to the hospital on 07/04/17 with diagnoses of Lumbar Stenosis, Hypertension, Diabetes Mellitus, Type 2, and Coronary Artery Disease.

Review of the physician orders dated 7/04/17 revealed the patient was ordered Toprol XL (Metoprolol) 50 mg daily (Medication to treat high blood pressure).

Review of the MAR dated 07/07/17 revealed S20LPN administered the Toprol XL at 8:00 a.m. but there was no documented evidence of the blood pressure check.
Review of the MAR dated 07/08/17 revealed S20LPN administered the Toprol XL at 8:00 a.m. but there was no documented evidence of the blood pressure check.
Review of the MAR dated 07/09/17 revealed S34LPN administered the Toprol XL at 8:00 a.m. but there was no documented evidence of the blood pressure check.

In an interview on 07/11/17 at 10:30 a.m., S13RN, Charge Nurse reviewed the MARs for Patient #9 and confirmed the nurse did not document the blood pressure on the MAR when the Toprol was administered. After reviewing the nursing flow sheets, she confirmed the nurse documented vital signs on the flow sheets at 6:00 a.m. only.


Patient #10
Review of the medical record for Patient #10 revealed the patient was a current patient admitted to the hospital on 06/28/17 with diagnoses of Subdural Hematoma with Right Hemiparesis, Hypertension, Atrial Fibrillation, and Mitral Valve Prolapse.
Review of the physician orders dated 06/28/17 revealed the patient was ordered Norvasc 10 mg daily and Digoxin 0.25 mg daily.
Review of the MAR dated 06/30/17 revealed S20LPN administered the Norvasc and Digoxin at 8:00 a.m. but there was no blood pressure documented for the Norvasc and there was no pulse documented prior to administering the Digoxin. Further review of the MAR revealed the following was documented under the Digoxin: Check and document patient's pulse before dose."
Review of the MAR dated 07/01/17 revealed S20LPN administered the Norvasc at 8:00 a.m. but there was no blood pressure documented on the MAR.
Review of the MAR dated 07/02/17 revealed S20LPN administered the Norvasc and Digoxin at 8:00 a.m. but there was no blood pressure documented for the Norvasc and there was no pulse documented prior to administering the Digoxin.

In an interview on 07/12/17 at 8:30 a.m., S2DON reviewed the MARs for Patient #10 and confirmed the nurse had failed to document the patient's pulse prior to administration of the Digoxin on 06/30/17 and 07/02/17. S2DON confirmed the nurse had failed to document the patient's blood pressure on all 3 days as indicated above.


Patient #13
A review of the medical record for Patient #13 revealed the patient was a current patient admitted to the hospital on 07/03/17 with an admit diagnosis of CVA with hemiparalysis and other diagnoses to include in part: HTN, CVD, Esophagitis.
A review of the physician orders dated 07/03/17 revealed the patient was ordered Norvasc 10 mg daily, Lopressor 25 mg twice a day, and Inderal 20 mg twice a day.
A review of the MAR dated 07/04/17 at 8:00 p.m. revealed the nurse administered the Lopressor and the Inderal at 8:00 p.m. but there was no blood pressure documented prior to administration.
A review of the MAR dated 07/08/17 at 8:00 p.m. revealed the nurse administered the Lopressor and the Inderal at 8:00 p.m. but there was no blood pressure documented prior to administration.


Patient #18
Review of the medical record for Patient #18 revealed the patient was a current patient admitted to the hospital on 06/28/17 with diagnoses of Seroma L4-L5.
Review of the physician orders dated 06/29/17 revealed the patient was ordered Losartan 50 mg daily.
Review of the MAR dated 07/06/17, 07/08/17, and 07/09/17 revealed S20LPN administered the Losartan at 8:00 a.m. but there was no blood pressure documented on any of the above days.

In an interview on 07/12/17 at 8:35 a.m., S2DON reviewed the MARs for Patient #18 and confirmed the nurse had failed to document the patient's blood pressure prior to administering the Losartan on the above dates.











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30984

Based on record review and interview, the hospital failed to ensure all orders in the patient record, including verbal orders, were dated, timed, and authenticated within 48 hours of being written (as per hospital policy) for 6 (#1, #2, #3, #5, #13, #19) of 6 current patient medical records reviewed for authenticating, dating and timing of verbal orders out of a total sample of 30 patient medical records reviewed.

Findings:
A review of the hospital policy titled, "Authentication", as provided by S2DON as the most current, revealed in part: Verbal and Telephone orders- RN's, LPN's, Therapists (PT, OT, ST, Respiratory) and Dieticians are authorized to receive and record verbal and telephone orders. All order, including verbal/telephone orders, must be timed, dated, and authenticated by the ordering practitioner or other practitioner who is responsible for the care of the patient and is authorized to write orders. Both verbal/telephone orders should be VORB (read back and verified) by the person receiving the order. Verbal orders are to be signed within 48 hours.


Patient #1
Review of the medical record for Patient #1 revealed the patient was admitted to the hospital on 06/27/17 with a diagnosis of CVA.
Review of the physician's orders revealed a verbal order dated 06/30/17 at 1:00 p.m. for a clarification order for Metformin from S31MD that was taken by the nurse. The order had not been signed by the physician as of 07/10/17 (date of chart review).

In an interview on 07/12/17 at 8:50 a.m., S2DON reviewed the above physician orders and confirmed the order dated 06/30/17 from S31MD had not been authenticated within 48 hours of the order as directed in the hospital's policy.


Patient #2
Review of Patient #2's medical record revealed an admission date of 07/04/17. Further review revealed the following verbal orders that had not been dated, timed, and authenticated as of 07/10/17 (date of chart review):

A verbal order for Admit medications, diet, and treatments, taken by the nurse as a VORB (verbal order read back) from S22MedDir, on 07/04/17 at 11:48 a.m.

A verbal order for Norco by mouth every 8 hours as needed for pain, taken by the nurse as a VORB (verbal order read back) from S22MedDir, on 07/04/17 at 2:10 p.m.

A verbal order for Nystatin 3 times a day as needed for itching, taken by the nurse as a VORB (verbal order read back) from S25MD, on 07/08/17 at 12:15 p.m.

In an interview on 07/10/17 at 2:30 p.m. with S2DON, she confirmed it was the hospital's policy to have all verbal orders signed, dated, and timed within 48 hours of being written.


Patient #3
A review of Patient #3's medical record revealed the patient was admitted on 07/06/17 with an admit diagnosis of MS exacerbation. A review of Patient #3's medical record revealed a verbal admit order on 07/06/17 taken by S13RN as a VORB (verbal order read back) from S25MD had not been authenticated as of 07/10/17 by S25MD upon chart review.

In an interview on 07/10/17 at 4:15 p.m. with S13RN, in a review of Patient #3 medical record, she indicated that the nurses usually flag patient's medical records for physicians to remind the physician to authenticate their verbal/telephone orders. She indicated that this verbal order must not have been flagged as a reminder for the physician.


Patient #5
Review of the medical record for Patient #5 revealed an admission date of 06/28/17. Further review of the record revealed the following verbal orders that had not been dated, timed and authenticated as of 07/10/17 (date of chart review):
6/30/17 at 1:15 p.m. verbal order to discontinue Foley taken by a physician's assistant.
07/02/17 at 10:00 a.m. verbal order for Vancomycin through taken by the pharmacist.
07/03/17 at 3:45 p.m. verbal order to continue contact isolation and okay for patient to attend therapies in the gym taken by the nurse.
07/05/17 at 8:50 a.m. verbal order to discontinue contact precautions and order for Nystatin swish & swallow taken by the nurse.
07/05/17 at 10:48 a.m. verbal order to send Ensure with breakfast and lunch taken by the dietician.
07/05/17 at 10:30 p.m. verbal order for labs taken by the nurse, signed by the physician, but not dated or timed when authenticated.
07/06/17 at 8:00 a.m. verbal order to hold therapies taken by the nurse.
07/06/17 at 10:05 a.m. verbal order to culture PICC line taken by the nurse.
07/06/17 at 2:22 p.m. verbal order to discontinue culture of PICC line, discontinue PICC line and replace taken by the nurse.
07/06/17 at 5:45 p.m. verbal order for PICC line taken by the nurse.
07/07/17 at 8:09 a.m. verbal order for Colace and Miralax taken by the nurse.
07/07/17 at 8:30 a.m. verbal order to resume therapies taken by the nurse.

In an interview on 07/10/17 at 4:45 p.m., S13RN, Charge Nurse reviewed the above verbal orders and confirmed the verbal orders had not been dated/timed/signed by the physician giving the verbal orders.


Patient #13
A review of the medical record for Patient #13 revealed the patient was a current patient admitted to the hospital on 07/03/17 with an admit diagnosis of CVA with hemiparalysis and other diagnoses to include in part: HTN, CVD, Esophagitis. A review of Patient #13's medical record revealed a verbal order on 07/04/17 was taken by S13RN that was not documented as a VORB (verbal order read back) from S22MedDir. A further review revealed the order had been signed by S22MedDir, but it was not dated and timed by S22MedDir as of 07/10/17 upon chart review.


Patient #19
Review of the medical record for Patient #19 revealed the patient was admitted to the hospital on 07/02/17 with a diagnosis of Multiple Sclerosis Exacerbation.
Review of the physician's orders revealed a verbal order dated 07/07/17 for Macrobid 100 mg twice a day for 7 days taken by the nurse. There was no documented evidence that the physician S22MedDir had authenticated the order as of 07/11/17 when the record was reviewed.

In an interview on 07/12/17 at 8:30 a.m., S2DON reviewed the medical record for Patient #19 and confirmed the verbal order dated 07/07/17 had not been authenticated by the physician within 48 hours of the order.

Based on occurrence report reviews, record review, and staff interview, the hospital failed to ensure medication administration errors were documented in the patients' medical records for 3 of 3 (#24, #25, #26) sampled patients reviewed with known medication errors out of a total sample of 30.

Findings:

Review of the hospital policy titled Medication Variances, I.E.5.01, revealed no provisions for how the medication variance was to be documented other than an online event report.

Patient #24
Review of an incident report for Patient #24 revealed on 02/06/17 the patient should have received 40 mg of Lipitor but 20 mg was returned to the pharmacy, indicating the patient only received a partial dose of Lipitor. Further review of the incident reports revealed a medication variance for Patient #24 on 02/15/16 that revealed the patient had only received half the dose of Lipitor.

Review of the medical record for Patient #24 revealed no documentation of the medication error on 02/06/17 or notification of the error to the attending physician. There was no documentation of the medication error on 02/15/17 or notification of the error to the attending physician in the patient's medical record.


Patient #25
Review of an incident report for Patient #25 revealed on 05/09/17 the patient received only 500 mg of a 750 mg dose of Levaquin at 9:00 p.m.

Review of the medical record for Patient #25 revealed no documentation of the medication error on 5/09/17 or notification of the error to the attending physician.


Patient #26
Review of an incident report for Patient #26 revealed on 05/09/17 the patient should have received 10 mg of Lipitor but the medication was returned to the pharmacy, indicating the patient did not receive the Lipitor.

Review of the medical record for Patient #26 revealed no documentation of the medication error on 05/09/17 or notification of the error to the attending physician.

In an interview on 07/12/17 at 8:15 a.m., S2DON reviewed the medical records and medication variances for Patients #24, #25, and #26 and confirmed there was no documentation in the patients' medical records of the medication error or the notification to the physician. S2DON stated the medication error should be documented on the Order Notification Record and stated the form was located in the record in front of the physician orders.

Based on record review and interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.

Findings:

A review of the contracts provided by S2DON revealed the hospital had a contract with Hospital A to provide Radiology services.

A review of the hospital's Policy and Procedure Manual, provided by S2DON as the most current, revealed 2 radiology policies that discussed the procedure to follow when x-rays were ordered for patient in the hospital setting and procedures to follow when x-rays were to be done in other facilities. A further review revealed no policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital and/or the use and care of the radiology equipment.

In an interview on 07/12/17 at 8:15 a.m. with S2DON she was asked if the hospital had any policies and procedures for proper safety precautions against radiation hazards, such as, adequate shielding for patients and personnel and determining that a female patient was not pregnant prior to performing the procedure or in the disinfection of the radiology equipment. S2DON provided the Radiology Policy and Procedure Manual from Hospital A, as the hospital's Radiology Policy and Procedure Manual. She indicated that the hospital used the contract hospital's (Hospital A) Radiology Policy and Procedure Manual and indicated that the hospital had not developed their own Radiology policies. S2DON had no further hospital Radiology policies to present.

Based on record review and interview, the hospital failed to ensure a physician was appointed as the Director of Radiology Services for the hospital. This deficient practice was evidenced by failing of the hospital's GB to appoint a physician to serve as the Director of Radiology Services after the Director of Radiology Services term of service had expired.

Findings:
A review of the hospital's organizational chart revealed S24MD/Rad was identified as the Director of Radiology Services

A review of the hospital's GB meeting minutes for August 2014 revealed S24MD/Rad was appointed as the Director of Radiology Services for the hospital. There was no documented evidence of the re-appointment of S24MD/Rad as the Director of Radiology Services since August 2014.

A review of the credentialing file for S24MD/Rad revealed the physician was reappointed to the medical staff in 2015 for a 2 year term. There was no documented evidence that S24MD/Rad was reappointed as Director of Radiology Services in 2015. A further review of the credentialing file revealed a letter signed by the GB president, dated 08/26/14 and titled, "Radiology Director Appointment." The letter revealed the following: "This letter is to provide notice that S24MD/Rad has accepted his unanimous appointment by the Governing Board as Radiology Director. The effective date of this appointment is August 26, 2014. This appointment is for one year."

In an interview on 07/12/17 at 11:00 a.m. with S1ADM she indicated that she was not aware that the Directors, appointed in 2014, were appointed for only one year terms. She further indicated that the Directors have not been reappointed since 2014 and the hospital still noted S24MD/Rad as the Director of Radiology Services. S1ADM indicated it was discussed during reappointment of S24MD/Rad, but it was not documented.

Based on record review and interview, the hospital failed to ensure the UR (Utilization Review) committee consisted of 2 or more physicians who were not professionally involved in the care of the patients whose cases were being reviewed by the UR committee.

Findings:

Review of the UR committee member list, presented as current by S2DON, revealed S22MedDir, and S25MD were the physician members of the UR committee.

In an interview on 07/11/17 at 10:50 a.m., S2DON confirmed the hospital did not have 2 physicians on the UR committee that were not involved in the care of the patient. S2DON confirmed there were no independent physician reviewers on the UR committee.

Based on record review and staff interview, the hospital failed to ensure the UR Plan was implemented as evidenced by failing to document a review all admissions, continued stays, cases discussed, worksheets used for review function, recommendations of the committee and focused reviews.

Findings:

Review of the hospital's Utilization Management Plan, policy number I.E.5.07 dated 01/08/13, and provided as current by S2DON, revealed in part the following: The Utilization Management Function of the QAPI Committee will maintain written records of all its activities. Minutes of each committee meeting shall be documented and will include:...A summary of reviews of admissions, continued stays and all subsequent reviews which will include number in each category, committee action for cases not approved, copies of written notification letters sent, cases discussed, worksheets used for committee review function, recommendations of the committee, and focused reviews, including subject studied, the reason for the study, the date the study was started, the date the study was completed, as well as the follow up recommendations made from the previous studies that have been implemented.

Review of the Utilization Management Committee minutes dated 05/08/17, 02/13/17, 11/14/16, and 08/22/16 revealed the following topics were included in the meeting: Acute transfers, blood utilization, restraint usage, mortality rate, DVT studies, and Quarterly FIM change. There was no documentation of the results of any utilization review for any specific patient. There was no documentation of admission reviews, continued stay reviews, or focused reviews.

In an interview on 07/10/17 at 5:00 p.m., S2DON confirmed she was responsible for UR. When asked for the UR plan, she was unable to confirm the hospital had a plan. S3DON stated the Utilization Management Committee Minutes that were provided for review is a quarterly meeting that is more of a facility function and it was not a review of patient records.

In an interview on 07/11/17 at 10:50 a.m., S2DON confirmed she was unable to provide any documentation of UR record reviews. S2DON confirmed the UR plan for committee records was not implemented regarding written records of UR activities and confirmed the hospital's UR plan was not implemented.

30172

Based on record review, observation and interview, the hospital failed to ensure the Infection Control officer developed a system for investigating and monitoring infection control practices and breaches as evidenced by:
1) failing to ensure that staff adhered to the EPA disinfectant's MFU when cleaning/disinfecting of patient multiple-use equipment and failing to disinfect multiple-use patient equipment,
2) failing to ensure that staff adhered to acceptable hand hygiene practices during patient care procedures,
3) failing to ensure that drugs and biologicals are stored according to acceptable infection control practices, and
4) failing to maintain a sanitary environment.

Findings:
1) failing to ensure that staff adhered to the EPA disinfectant's MFU when cleaning/disinfecting of patient multiple-use equipment and failing to disinfect multiple-use patient equipment.

A review of the MFUs on the EPA disinfectant wipe and the EPA disinfectant spray used by the hospital for disinfecting multiple-use patient equipment revealed in part: The contact time on the EPA disinfectant wipe is 2 minutes and the item(s) to be disinfected is to remain visibly wet for 2 minutes and allowed to dry. The contact time on the EPA disinfectant spray is 10 minutes and the item(s) to be disinfected is to remain visibly wet for 10 minutes and allowed to dry.

In interviews on 07/12/17 from 8:30 a.m. to 9:00 a.m. with S26Tech, S27Tech, and S28Tech, they indicated that the 2 minute or the 10 minute contact time was the time you had to wait before reusing the patient care equipment for another patient and that the EPA disinfectant solution did not have to remain visibly wet on the item (s) for the 2 minutes or 10 minutes.

A review of the hospital policy titled, "Nursing Unit Cleaning Guidelines", as provided by S2DON as the most current, revealed in part: Accucheck Meter (glucometer) - After each use Accucheck meter should be cleaned with alcohol pad and dry with a dry paper towel. Once meter is dried, disinfect with an EPA disinfectant wipe according to the MFU.

An observation on 07/11/17 at 12:00 p.m. of S17RN performing an accucheck on Patient #18 revealed that S17RN was not observed disinfecting the glucometer after use on the patient and replaced the glucometer back into its case and closed the case without disinfecting it.

An observation on 07/11/17 at 4:30 p.m. of S19LPN performing an accucheck on Patient #8 revealed that S19LPN was observed disinfecting the glucometer after use on the patient with an alcohol wipe and was not observed disinfecting the glucometer with an EPA disinfectant wipe before returning it to it's case.


2) failing to ensure that staff adhered to acceptable hand hygiene practices during patient care procedures.

An observation on 07/11/17 at 12:00 p.m. of S17RN performing an accucheck on Patient #18 revealed that S17RN was not observed sanitizing her hands after she removed her soiled gloves.

An observation on 07/11/17 at 4:30 p.m. of S19LPN performing an accucheck on Patient #8 revealed that S19LPN was not observed immediately sanitizing her hands after she removed her soled gloves and performed other tasks before sanitizing her hands.

An observation on 07/11/17 at 4:45 p.m. of S19LPN, preparing a medication for a patient, was not observed sanitizing her hands after she removed her gloves.

In an interview on 07/12/17 at 10:00 a.m. with S3QA/IC she was made aware of the above surveyor findings regarding disinfection and hand hygiene. S3QA/IC indicated that staff were not adhering to the hospital's infection control policies.


3) failing to ensure that drugs and biologicals are stored according to acceptable infection control
practices

Medication room:
10 - 3.5 ml (milliliter) vacutainer blood collection tubes with coagulant, expired 01/2017
1 - 2 ml vacutainer blood collection tube expired 07/2016
1 - Anaerobic Blood Culture bottle, expired 04/12/17
1 - Aerobic Blood Culture bottle expired 05/19/17
1 box of Insulin Syringes stored on the floor of the medication room
1 large box of Gauze pads stored on the floor of the medication room
6 drawstring bags of unclaimed patient belongings stacked on the floor of the medication room for storage
1 opened package of Adult briefs stored on the floor of the medication room
The cabinet to the left of the refrigerator was observed to have loose Formica type covering on the ledge of the door that was taped with scotch tape. Multiple areas of tape/tape residue were observed on the refrigerator, and the cabinet doors. Dust and debris were observed on the counter top around the emergency drug kit, insulin vials, behind the sink, and on the floor.


4) failing to maintain a sanitary environment.

On 7/10/17 from 11:25 a.m. - 12:30 p.m. the following observations were made on the patient care unit:

Patient Room "a": the left front edge of the over-bed table was noted to have part of the surface missing, leaving a rough exposed edge. Further observation revealed 2 patient basins, not sealed or wrapped, were also stored on the floor of the patient bathroom. A white substance was observed on the stand of the overbed table. S3QA/IC stated this was the cleaning solution and she was observed to wipe the white substance off with a damp paper towel. An approximate 3 inch by 2 inch area of Formica type covering was missing from the edge of the bathroom door at the bottom. S3QA/IC confirmed, during the observation, that Patient Room "a" was considered clean and ready for a new patient admission.

Observation of the nursing station revealed the wall below the ledge had a missing area of Formica type covering from the wall approximately 3 inches long by 2 inches wide. S3QA/IC confirmed the area did not have a smooth wipeable surface for disinfection.

Patient Room "b": The call light speaker over the head of the bed was observed to have a sticky substance visible on the speaker. S3QA/IC stated the staff sometime tape over the speaker because it is too loud for some patients. Tape residue was observed on the foot of the bed. S3QA/IC confirmed the findings.

Nourishment room:
The upper cabinets to the right of the refrigerator were observed to have the Formica type covering on the edge of the cabinet doors missing for all 5 cabinet doors. The lower cabinet door was observed to have loose covering and the section horizontal on the bottom of the cabinet was observed to be loose and separated from the porous surface underneath. The right and left side of the lower cabinet doors were missing the covering material, leaving a porous surface that was not a smooth wipeable surface for disinfection. S3QA/IC confirmed the above findings.

S3QA/IC confirmed the above referenced findings during the observations conducted on 07/10/17 from 11:25 a.m. - 12:30 p.m.


30984

Based on record reviews and interview, the hospital failed to ensure a physician was appointed as the director of the hospital's respiratory care services. This deficient practice was evidenced by failure of the hospital's governing body to appoint a physician to serve as director of the hospital's respiratory care services.

Findings:

Review of the Hospital's organizational chart revealed S23MD/Resp was identified as director of respiratory services.


Review of the hospital's Governing Body meeting minutes for August 2014 revealed S23MD/Resp was appointed as the medical director of the hospital's respiratory care services. There was no documented evidence of the re-appointment of S23MD/Resp as the director of respiratory services since August 2014.

Review of the credentialing file for S23MD/Resp revealed the physician was reappointed to the medical staff on 10/06/15 for a 2 year term. There was no documented evidence that S23MD/Resp was reappointed as Director of Respiratory on 10/06/15. Further review of the credentialing file revealed a letter signed by the governing body president, dated 08/26/14 and titled, "Respiratory Director Appointment." The letter revealed the following: "This letter is to provide notice that S23MD/Resp has accepted his unanimous appointment by the Governing Board as Respiratory Director. The effective date of this appointment is August 26, 2014. This appointment is for one year."

In an interview on 07/12/17 at 1:20 p.m., S1ADM confirmed there was no current appointment for S23MD/Resp as the Director of Respiratory. S1ADM confirmed the credentialing file documents indicated the appointment as Director of Respiratory was only for one year in 2014. S1ADM stated it was discussed during reappointment of S23MD/Resp, but it was not documented.