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Based on observation, interview, and record review, the facility failed to ensure the facility's dietary staff tested the temperature on the dishwashing machine at the rinse cycle to ensure the temperature reached 180 degrees Fahrenheit for sanitation of dishes and utensils, prior to removing dishes and utensils from the dish washing machine; failed to utilize reagent test strips that accurately monitors the temperature of the dish washing machine. Failed to ensure staff was trained on the system used to dispense detergent to the dishwashing machine and ensure dishwasher in the kitchen reached and maintained the manufacturer's recommended temperature of 180 degrees for heat sanitizing of dishes and utensils.

This practice has the potential of exposing individuals to cross contamination and food borne illness, thus putting all individuals at risk who consumed meals from the dietary department.


Findings:

Observation on 12/17/2019, at 8:53 a.m., of the facility's dishwashing room revealed a CMA180 dishwashing machine in place.

A load of dishes was washed using the dishwasher and was sitting at the end of the dishwashing line and the dishwasher was stacked with soiled dishes waiting to be washed.

Observation of the room revealed a Geo center system which dispensed detergent mounted on the wall attached to the machine. The Dietary Manager ran the dishwasher.

Observation of the system mounted on the wall adjacent to the dishwasher revealed a flashing light during the rinse phase of the dishwashing process. Notation below the flashing light indicated "the system is empty of detergent."

Observation also revealed a bucket with a green solution partially filled. There was no gradation on the bucket as to determine if the solution in the bucket was decreasing when it was drawn up.

The surveyor directed the Dietary Manager and CEO's attention to the flashing light on the Geo Center System. The Dietary Manager informed the surveyor that the system was pulling detergent based on the content of the solution in the tubing.

The Dietary Manager then attached a test strip to one of the dishes in the dishwashing machine and ran the load of dishes. During the dishwashing cycle the flashing light activated on the Geo System during the rinse phase. After completion of the cycle, the color indicator that determined the temperature at the rinse phase of the dishwashing cycle did not change color to black as indicated on the strip.


Review of a notation on the indicator strip revealed the following documentation :

"When indicator turns black stated temperature has been achieved." The indicator strip did not turn black.


The Dietary Manager repeated the test utilizing another test strip and and again it did not turn black.


Interview with the Facility's Dietary Manager revealed he had used the strip the day before and it had changed color.


Review of the High Temp Dish Machine Temperature Log revealed the dishwashing machine was not checked for temperature of the rinse cycle on 12/17/2019 prior to being utilized for washing of dishes.


Interview with the Facility's Dietary Manager on 12/17/2019, at 8:55 a.m., when informed that temperature validation was not done for 12/17/2019 prior to washing , sanitizing, and removing utensils from the dishwasher. He stated, " I was not aware of this, this is on me. I did not check it this morning. The dietary aide ran it and she was newly hired."


On 12/17/2019, at 11:00 a.m. the surveyor again observed the dishwashing machine washing a load of dishes. The reagent test strip again did not turn black.


The CEO who was present, instructed the Dietary Manager to borrow test strips from the adjacent nursing facility to test the temperature on the dishwashing machine. During testing with the borrowed strip, the strip changed color.


On 12/17/2019, at 11:37 a.m., a representative from the company which supplied detergent and chemical and the Geo Center System arrived in the facility. Interview with him revealed the flashing light comes on because the Geo Center system shoots water up into the system to the sensor and solid powder goes into the machine. He said, the flashing light indicating the detergent is empty, is because the system is built to also be utilized with larger machines. He said, the system was installed approximately 5 weeks ago.


Interview at that time with the Dietary Manager revealed, he was not aware that the light flashes on the Geo System when the system was washing and sanitizing dishes.

The representative then disabled the system so as to prevent the light indicating the detergent is empty from being activated.


Observation also revealed a manual dispenser with a container with detergent attached to the wall for prewashing of dishes before been placed in the dishwasher.


The label on the container read " Solid State Powder."

The representative then notified the Dietary Manager that the wrong detergent is being used for prewashing of dishes. He said, the current detergent in use is highly caustic and could get into workers eyes. He said, the Solid State Powder is to be used for the dishwashing machine and not prewashing of the dishes.


The Dietary Manager then informed the representative that the company had supplied the wrong detergent.


Review of the Owner's Manual CMA-180-installation and Operation, directs users as follows: "This machine must be operated with an automatic detergent feeder and if applicable, an automatic chemical feeder, including a visual means to verify that detergents and sanitizers are delivered or a visual or audible alarm to signal if the detergent and sanitizers are not available to the respective washing and sanitizing systems."

The wash temperature must be 155 degrees F minimum. The rinse temperature must be 180 degrees minimum. Note "Rinse temperature must be observed during the rinse cycle."


Review of the Dietary Manager's Personal and training file revealed no documentation that the Dietary Manager had training on operating the CMA 180 dishwashing machine.


Interview on 12/17/2019, at 1:13 PM, with the Facility's Dietary Manager revealed the representative partially went over the operation of the dishwashing machine with him but he was not told about the flashing light indicating the dispenser is empty.

He said, none of the other dietary staff were in-serviced by the manufacturer on the operation of the dishwashing machine.


Review of Dietary Aide W's Personal and training file revealed no documentation that she received training on operation of the dishwashing machine.


Review of the Facility's Policy and Procedure on Dishwashing Operation directs staff as follows:"Have dish detergent representatives do preventative maintenance check on dishwasher monthly. Meet with the vendor and administrator to discuss the check results on the report."



30124

Based on records review and interview, the facility failed to ensure that all direct patient care employees maintained current Cardio Pulmonary Resuscitation (CPR) certification in accordance with applicable Federal, State, and local laws and regulations in 1 of 10 files reviewed.

Findings:

Review of the Health & Safety Institute and the National Safety Council website found at revealed that, "No major nationally recognized training program in the United States endorses certification without practice and evaluation of hands-on skills. According to the Occupational Safety and Health Administration (OSHA) online training alone does not meet OSHA first aid and CPR training requirements." Further guidance can be found at .


Review of employee file for Licensed Vocational Nurse ID #K documented no current acceptable CPR card from either the American Heart Association or the American Red Cross that requires testing and hands on demonstration. The CPR card in employee #K's personnel file was from National CPR Foundation Provider Care which states that she demonstrated proficiency by successfully passing the examination, there was no hand on demonstration required.


Interview on 12/13/2019 at 2:00 p.m. with the Chief Nursing Officer Employee ID #C confirmed the CPR card in Licensed Vocational Nurse ID #K employee record was not acceptable. Employee ID #C stated that she needed a hands on demonstration and the CPR card in employee ID #K record was not acceptable.

Based on record review and interview, the Facility's Governing Body failed to ensure a physician was available to provide care and services to 1 (Patient #5) of 1 patient who complained of experiencing pain of 8/10 - 10/10 from 16 sampled patients.

Findings:

Patient #5

Review of Patient #5's nurse's notes, dated 9/29/2019 revealed the following documentation:

1900: "Received pt from outgoing RN, Pt pain 8/10 present at PICC insertion site all the way to her heart. Stat x-ray and venous Doppler ordered stat by MD. Pt requesting PICC be removed. MD notified Per MD call after x-ray result return, continue to monitor patient."

2300: "Called MD to report lab report and obtain orders for pain mgt. No response. Awaiting call back."

09/29/2019
0200: "Attending MD and Med consult called. No response at this time. Awaiting call back."


09/30/2019:
07:15: "Received shift report from outgoing nurse. Patient received lying in bed, complained of pain to ® upper chest on the side of the PICC line. On assessment, the site of pain was inflamed and warm to touch and patient verbalized pain of 10/10. "

0800: "Physician called no answer."

0900: "Physician called back as to find out if patient had any PRN medication and he was going to contact."

1015: "Received orders to obtain blood cultures X 2 also remove PICC line and send to lab for culture and sensitivity."

1130: "Blood cultures obtained and awaiting pickup. Pulmonary doctor came to see patient. Ordered to leave PICC line in place and monitor the site of inflammation for redness and enlargement. And continue IV antibiotic as ordered."

1400: "Internal and Rehab physician notified of the order by pulmonary doctor. Patient received PRN med as ordered. 1st dose given at 10:30 a.m. Patient verbalized less pain 8/10."

2000: "Received Pt reporting severe pain. Called DR ---- recd orders to remove PICC line and refer back to previous orders. Notified Nurse in charge."

2030: "Pt with episode of emesis while being assisted for BRP. Pt request to urinate and get ready for bed before any procedure to be done."

2100: "Notify upon call that BP dropped and Pt vital unstable, O2 sat 90%, BP 86/50, T 95.4, R 18, P 72."

2115: "Dialed 911 emergency response team, order given to transfer pt. Fluid being bolused at this time. PICC line removed by nurse in charge."

2134: "Pt being transferred by EMS at this time via stretcher. BP 85/57. Family notified."


Review of the Patient's clinical record revealed a physician's order dated 09/30/ 2019 at 10:15 a.m. for Tramadol 50 mg po Q 6 hourly for severe pain and Tylenol #3 1 PO Q 6 hourly PRN for severe pain.

Review of the Patient's Medication Administration Record dated 09/30/2019 revealed the Patient was administered the following medications:

1030: Tylenol #3, I tablet orally for severe pain

1515: Tramadol 50 mg I tablet po Q 6 hrs PRN moderate pain orally for severe pain.

2000:Tramadol 50 mg I tablet po Q 6 hrs PRN moderate pain orally for severe pain.

1830:Tylenol #3, I tablet orally for severe pain

The record indicated the Patient complained of experiencing severe pain at on 12/29/2019 at 1900 and the Patient was administered pain medication at 1030 a.m. on 9/30/2019.


On 12/16/2019, at 12:30 p.m., the Patient's clinical record was reviewed with the Facility's Chief Executive Officer. She said she would discuss with the Physician the Patient's care.

Subsequent interview on 12/17/2019, at 9:00 a.m., with the Facility's Chief Executive Officer revealed she had spoken to the Physician and he could not confirm or recall the nurse had called him at 2300.

The record indicated the Patient complained of experiencing severe pain at 1900 p.m. on 9/29/2019 and the Patient was administered pain medication at 1030 a.m. on 9/30/2019. The record indicated the facility's staff received results of tests ordered but was unable to contact the patient's physician in a timely manner.

Review of the Patient's acute hospital record dated 10/01/2019 revealed the following general surgery consultation:" 10/01/2019 patient is a 79- year -old female who recently was readmitted to the hospital with massive acute hemorrhage in her right pectoralis muscle. She was hypotensive and anemic secondary to acute blood loss She also presented with to hospital with DVT and PE despite being on Lovinox."



30124

Interview with the Employee ID #D 12/12/2019 at 10:30 a.m. during observation of the emergency treatment room was asked for the physician call schedule for emergency treatment. Employee ID # D checked a binder titled "call schedule" and stated there was just one month in the binder. No other physician call schedules were presented.

Based on observation, interview, and record review , the facility's Governing Body failed to provide orientation to agency nurses who provide nursing care to patients to which they are assigned. There was no documentation of hospital specific orientation for agency licensed nursing staff used at the facility for 6 of 6 agency records reviewed. (Employee IDs #F, R, Q, T, U, & V).

(B) the facility failed to assess the skills competency of contract/agency licensed nurses in 2 of 6 sampled licensed nurses personal and training records reviewed for competency. Licensed Vocational Nurse (F) and Registered Nurse (R)


Findings:

Interview on 12/16/2019, at 2:20 p.m., with Chief Nursing Officer ID #C stated he or the Lead Nurse are the ones that provide orientation to the agency nurses. Employee ID #C stated that the first day of assignment that the agency nurse will come in about 30 minutes earlier than their shift and are shown the patient area on the 2nd floor. Employee ID #C stated, the staff are orientated to fire exits, crash cart location and their names are entered into the Pyxis so they can get medication. Employee ID #C stated, he has no documentation of orientation for agency staff to facility's policies and procedures.


Record review on 12/16/2019, at 2:00 p.m., staff personnel and training files for agency licensed nursing staff, revealed they did not have documentation of orientation to the unit to which they were assigned and the facility's Policies and Procedures in 6 out of 6 records reviewed:

Licensed Vocational Nurse Employee ID #Q. Date of hire 11/8/2019

Registered Nurse Employee ID #T. Date of hire 12/12/2019

Registered Nurse Employee ID #U. Date of hire 12/12/2019

Registered Nurse Employee ID #V. Date of hire 4/16/2019



10802


Licensed Vocational Nurse (F)
On 12/12/2019, at 10: 18 a.m., Licensed Vocational Nurse (F) was observed in the medication room of the nursing unit. The Licensed Vocational Nurse was preparing medication to administer to Patient #10.

On 12/12/2019, at 10:45 a.m., Licensed Vocational Nurse (F) was observed in the Patient's room. The Licensed Vocational Nurse was administering medication to the Patient.

Review on 12/16/2019 of Licensed Vocational Nurse (F) personnel and training file revealed, he started working at the facility on 07/02/2019 as an agency licensed nurse.

Review of the record revealed no documentation that Licensed Vocational Nurse (F) conducted a period of hospital specific orientation.


Registered Nurse (R)
On 12/12/2019, at 8:50 a.m., Registered Nurse (R) was observed on the nursing unit at the nurses' station.

Review on 12/16/2019 of Registered Nurse (R's) personnel and training file revealed she works as an agency registered nurse.
Review of the record revealed no evidence that the registered nurse participated in a facility specific orientation.

On 12/16/2019, at 2:30 p.m., the Surveyor reviewed the record with the Chief Executive Officer. None was found.


Review of the Facility's current Policy and Procedure on Administration of Medication; Policy # PH directs staff as follows: "All personnel for Medication Administration must Have passed The Medication Core Competency prior to administering medication.


Review of the Facility's current Policy and Procedure on Plan for the Provision of Care; Policy # AD001 directs staff as follows: "Clinical employees who enter Sugar Land Rehab Hospital are assessed as novices to the facility. Assessment upon hire includes the completion of a self -assessment and validation evaluation, understanding of age specific job requirements, universal precautions and patient and family education. Unit specific orientation and training will be completed under the guidance of the department director.

Competency will be assessed at the following times:

Prior to hire (interview, credentials, experience)

Initiation of orientation (self-assessment) and validation and at completion of initial three months employment.

Annually, based on unit specific skills, equipment usage and clinical competency.

Anytime the need for reassessment is identified."


Contracted Services Providing Clinical Care or Support for Clinical Care:
"Procedures / services provided by Sugar Land Rehab Hospital from outside contracted healthcare systems / providers will be monitored and evaluated as to effectiveness, utilization, and performance outcomes."


COMPETENCY

Licensed Vocational Nurse (F)
On 12/12/2019, at 10: 18 a.m., Licensed Vocational Nurse (F) was observed in the medication room of the nursing unit. The Licensed Vocational Nurse was preparing medication to administer to Patient #10.

On 12/12/2019, at 10:45 a.m., Licensed Vocational Nurse (F) was observed in the Patient's room. The Licensed Vocational Nurse was administering medication to the Patient. During administration of the Patient's eye drop, the cap for Timoptic vial fell to the floor.

Licensed Vocational Nurse (F) wearing a pair of gloves searched on the floor for the cap for the vial and retrieved it. After retrieving the contaminated vial cap, he continued administering medication of Timoptic into the patient's eyes using his contaminated gloved hands.

On 12/12/2019, at 11:00 a.m., the Surveyor notified Licensed Vocational Nurse of the break in infection control technique, of using his contaminated gloved hands to instill eye drops in the patient's eyes. He stated " Thank you."
The Chief Executive Officer was present during the observation.

Review on 12/16/2019 of Licensed Vocational Nurse (F) personnel and training file revealed he started working at the facility on 07/02/2019 as an agency licensed vocational nurse.

Review of the record revealed a self -skill assessment which was completed by Licensed Vocational Nurse (F). There was no Skills Competency Assessment completed by the facility on the Licensed Vocational Nurse.


Registered Nurse (R)
On 12/12/2019, at 8:50 a.m., Registered Nurse (R) was observed on the nursing unit at the nurses' station.
Review on 12/16/2019 of Registered Nurse (R's) personnel and training file revealed she works as an agency registered nurse.

Review of the record revealed a self -skill assessment which was completed by Registered Nurse R. There was no Skills Competency Assessment completed by the facility on the Registered Nurse.

On 12/16/2019, at 12:10 p.m., the Surveyor reviewed the personnel and training record of Licensed Vocational Nurse (F) and Registered Nurse (R) with the Facility's Chief Executive Officer. She confirmed that the self evaluation was done through the nurse's contracted agency and there was no competency evaluation completed by the facility on agency staff.

Based on observation, interview, and record review, the facility failed to ensure patients received care in a safe environment. The facility failed to ensure its own policies were enforced for 2 of 2 emergency carts that were observed, did not have the required emergency equipment, no emergency physician call schedules, and staff did not have the required CPR certification.

Facility's staff failed to monitor patients' blood glucose level as ordered by the Physician in 2 of 6 Patients' records reviewed for blood glucose monitoring;

Facility's staff failed to notify a Patient's Physician of abnormal laboratory values;

Facility's staff failed to document daily wound care dressing change in 4 )Patient #s 2, 6, 7, and 15) of 16 patients.


Findings:

Policy reviewed:

Record review on 12/12/2019, at 3:00 p.m., of the current policy presented titled "Emergency Services," Approved by: GB/MED/Medical Staff.

Purpose: To provide guidelines regarding emergency services at Sugar Land Rehab Hospital.

Policy: Sugar Land Rehab Hospital does not have an emergency department. If an individual present to the hospital in a medical, the charge nurse will call the physician on call, while awaiting response, stabilize the patient and call 911 to transport the individual to a hospital that can manage the emergency. The organization of the emergency services at Sugar Land Rehab Hospital is appropriate to the scope of the services offered.

A. Personnel: There shall be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the hospital.

B. Guidelines for managing an emergency: i. A registered nurse who has Advanced Cardiac Life Support training will be available at all times . ii. One or more physicians shall be available at all times for emergencies. iii. Schedules, names and telephone numbers of all physicians and others on emergency call duty including alternates, shall be maintained. Schedules shall be retained for no less than one year.

C. Supplies and Equipment: Adequate age appropriate supplies and equipment shall be available and in readiness for use. At a minimum the age appropriate emergency equipment and supplies shall include the following: vi. Laryngoscopes and endotracheal tubes.

Record review on 12/12/2019, at 3:00 p.m., of the current policy presented titled "Emergency Situation Management," Approved by GB/MEC/Medical Staff.

Purpose: To provide guidelines for the management of a medical emergency at Sugar Land Rehab Hospital that involves patient or a visitor, in the absence of a managing physician.

Policy: The following emergency equipment will be available to assist in the management of an emergency 1. Crash Cart which contains: emergency medications, intubation supplies, IV catheters and IV fluids.


Observation along with the Director of Pharmacy, Employee ID #A on 12/12/2019, at 9:00 a.m., of the physical therapy patient treatment area, it was observed the crash cart did not contain the required emergency equipment per the facility's policy.

Observation with Employee ID #A along with Chief Nursing Officer, Employee ID #C on 12/12/2019, at 11:50 a.m., of the crash cart located on the 2nd floor patient treatment area revealed the crash cart did not contain the required suction equipment, laryngoscopes and endotracheal tubes.


Interview at 9:30 a.m. with Directory of Pharmacy, Employee ID #A confirmed the crash cart in the physical therapy patient treatment area did not contain the required suction equipment, laryngoscopes and endotracheal tubes.

Interview at 11:50 a.m. with the Chief Nursing Officer, Employee ID #C confirmed the crash cart on the 2nd floor patient treatment area did not contain the required suction equipment, laryngoscopes and endotracheal tubes.

Interview with the Employee ID #D 12/12/2019 at 10:30 a.m. during observation of the emergency treatment room was asked for the physician call schedule for emergency treatment. Employee ID # D checked a binder titled "call schedule" and stated there was just one month in the binder. No other physician call schedules were presented.


Review of employee file for Licensed Vocational Nurse ID #K revealed no documented current acceptable CPR card from either the American Heart Association or the American Red Cross that requires testing and hands on demonstration. The CPR card in employee #K's personnel file was from National CPR Foundation Provider Care which states that she demonstrated proficiency by successfully passing the examination, there was no hand on demonstration required.


37492

Patient #15
Record review of Patient #15's clinical record revealed a physician's order dated 9/23/19, at 11:00, for blood sugar monitoring four times a day (before meals and at hour of sleep) then to follow a sliding scale for Insulin administration according to results, as follows:

Follow the sliding scale below to administer subcutaneous Regular Insulin based on QID glucose checks.
60-149 00 units of Regular Insulin
150-199 02 units of Regular Insulin
200-249 03 units of Regular Insulin
250-299 05 units of Regular Insulin
300-349 08 units of Regular Insulin
350 & > 10 units of Regular Insulin and call doctor

Record review of patient #15's Medication Administration Record revealed no blood sugar was completed at hour of sleep.

Review of Medication Administration Record dated 9/25/19, at 2000, of Patient #15's blood sugar level revealed documentation of a result of 210. Per MD order 3 units of Regular Insulin was to be administered to the Patient. The medication was not administered as prescribed.

Review of Patient #15 Medication Administration Record dated 9/26/19, at 20:00, revealed the Patient's blood sugar level was 223, per MD order 3 units of Regular Insulin was to be administered to the patient. The medication was not administered as prescribed.


Record review of the Patient's Medication Administration Records revealed on the following date and time, the Patient's blood glucose level was not monitored as prescribed by the physician:

9/27/19 at 20:00 blood sugar level was not completed as prescribed.

9/28/19 at 20:00 blood sugar level was not completed as prescribed.

9/29/19 at 20:00 blood sugar level was not completed as prescribed.

9/30/19 at 20:00 blood sugar level was not completed as prescribed.

10/1/19 at 20:00 blood sugar level was not completed as prescribed.

09/28/19, 09/29/29 no blood sugar was completed at hour of sleep.


Patient #2

Record review of Patient #2's Medication Administration Record revealed a Physician's verbal order dated 11/01/19 at 23:00 for blood sugar monitoring four times a day before meals and at hour of sleep and to follow a sliding scale for insulin administration as follows:

Follow the sliding scale below to administer subcutaneous Regular Insulin based on QID glucose checks.
60-149 00 units of Regular Insulin
150-199 02 units of Regular Insulin
200-249 03 units of Regular Insulin
250-299 05 units of Regular Insulin
300-349 08 units of Regular Insulin
350 & > 10 units of Regular Insulin and call Doctor

Record review of Patient #2's clinical record ( Nurses' notes and medication administration record showed that no blood sugars were obtained as prescribed by Doctor (M) from Date of admission 11/01/19 @ 23:30 till discharge on 11/12/19.


Patient #7
Record review of patient #7's medical chart (Doctor's Orders) showed an order written by Doctor (Y), dated 12/3/19 at 1000, to obtain a complete blood count (CBC), stat and call with abnormal values. Nurse (G) noted the order dated 12/09/19, no time noted.

Record Review of patient #7's medical chart showed a lab report, dated 12/9/19, that showed the following Laboratory information:
Collected: 12/09/19 12:19 CST
Received: 12/09/19 13:46 CST
Faxed: 12/09/19 16:02 CST
White Blood Count: 15.2
Reference /range for White Blood Count 3.8 - 10.8 Thousand/uL (microliter)


Interview with Nurse (G) dated 12/17/19 at 1330 showed that the Nurse said, "Doctor (M) was called and he was aware."When asked where the information was documented, she indicated she could not locate it. When asked, "did the doctor give any further orders," she could not recall.

Review of patient #7's medical chart showed that no documentation was found that Doctor (Y) was notified, subsequently the Patient was discharged with an elevated White Blood Count.


Record review of facility's policy titled, "Dressing Change," no date provided, showed that the following information should be documented:
Location, assessment of wound, including any edema, odor or erythema in electric medical record.
Patient's response to treatment.

Record review of facility's policy titled, "Pressure Ulcer Treatment," no date provided, showed the following,
Assess wound every shift or when dressing changed and record in nurse's progress notes.
Measure wounds every Tuesday and document.


Patient #6
Record review of Patient #6's medical chart showed a Doctor's Order, dated 12/02/19 for a dressing change (foam dressing) by Doctor (M) to the sacral wound decubitus, Stage 2, to be changed daily.

The record indicated the dressing changes were not performed as prescribed by the Doctor on the following dates:
12/04/19, 12/05/19, 12/06/19, 12/07/19. there was no documentation in the Patient's record that the dressings was done as ordered by the physician.

Interview with Employee (C) 12/17/19 at 1130, revealed that the dressing changes should be documented on the wound care sheet.

Based on observation, record review and interview, the Facility's interdisciplinary team failed to develop and initiate Nursing Care Plan which were individualized for 2 of 9 sampled patients reviewed for Care Plan, from 16 sampled patients according to the patient's needs. Patient #s 6 and 7

Findings:

Record review of facility's current policy titled, "Patient Care Plan," no date noted, showed the following requirements:
"The Plan of Care will be individualized, based on the diagnosis and patient assessment. The Plan of care will address learning needs current diagnoses complications.
The registered nurse will review the Plan of Care daily with revisions reflecting the reassessment of the patient's needs."

Patient #6
Record review of patient #6's medical record showed a History and Physical completed by Doctor (M) dated 12/02/19 (no time).
Medical History:
" Stage 2 sacral Decubitus
" End stage Renal Disease (ESRD)
" Gastric Bypass
" Diabetes Mellitus

Review of patient #6's (Nursing Care Plan) showed that the medical chart did not have a Nursing Care Plan addressing the Patient's diagnosis of Altered Elimination (ESRD), Altered skinned integrity (Stage 2 sacral decubitus), Gastric Bypass (alteration in Nutrition), and Diabetes Mellitus.

On 12/17/2019 at 3:00 at the Surveyor reviewed the Patient's record with the Chief Nursing Officer. He confirmed that there was no Care plan developed and initiated to address Altered Elimination (ESRD), Altered skinned integrity (Stage 2 sacral decubitus), Gastric Bypass (alteration in Nutrition), and Diabetes Mellitus.


Patient #7
On 12/12/2019 at 8:55 a.m. Patient #7 was observed in her room sitting in a chair. The Patient was alert but displayed continuous involuntary movement.
Interview with Patient #7 during the observation revealed she had a diagnosis of Parkinson's. The Registered Nurse was observed administering oral medication to the Patient.


Review of patient #7's medical record showed a History and Physical completed by Doctor (Y) dated 12/03/19 (no time).
Medical History:
" Chronic Obstructive Pulmonary Disease
" Asthma

Review of Patient #7's (Nursing Note), dated 12/9/19, timed 7 PM to 7 AM, written by Nurse (O) under the section for Neurological- revealed the patient was Confused.

Review of Patient #7's (Nursing Note) dated 12/9/19 at 0800 and timed 7 PM to 7 AM written by Nurse (O) under the section for Neurological-Alert and Awake, indicating patient was not oriented.

Review of Patient #7's (Nursing Care Plan) showed that the medical record did not have a Nursing Care Plan addressing the Patient's current diagnosis and problems for Alteration in Mental Status (AMS) confusion, Alteration in Air exchange (Asthma, Chronic Obstructive Pulmonary Disease (COPD).

Interview with Employee (C) on 12/16/19 at 1430 showed that a Nursing Care Plan should be developed for all of a patient's current diagnosis and problems.

Based on observation, record review, and interview, the facility's nursing staff failed to ensure medications were administered to patients in a timely manner in 2 of 3 patients observed during medication administration on the unit and 2 sampled patients' records reviewed from 16 sampled patients. Patient #s 9, 10, 2, and 15.

Findings

Patient #9
On 12/12/2019 at 9:50 a.m. while at the nurses' station on the second floor, revealed two family members complained that Patient #9 did not get her 8:00 a.m. on time.

On 12/12/2019, at 9:50 a.m., during an interview with Licensed Vocational Nurse (F) assigned to the patient, revealed, he stated he was busy with another patient and calling the physician so he did not administer the prescribed medications to the Patient.


Review of Patient #9's clinical record revealed physician's orders for the following medications:

Amoxicillin (Augmentin) 1 tablet 875 mg po , twice daily orally: scheduled 0800 and 2000.

Carbidopa - Levodopa 25/100 I tablet 4 times daily: scheduled 0800, 1200, 1600 and 2000.

Docusate Sodium I capsule 100 mg orally twice a day: scheduled 0800 and 2000

Ferrous Sulfate 1 tablet 325 mg three times daily: scheduled 0800 1400 and 2000

Lisinopril (Zestril) 5 mg po once: scheduled at 0800

Potassium Chloride 8 mEq po twice daily Scheduled 0800 a.m. and 2000

Simethicone 80 mg po three times a day scheduled 0800 a.m. ( final dose of medication)

Observation revealed the Patient's medications scheduled to be administered at 8:00 a.m. were administered at 10:15 a.m. Two hours and 15 minutes post schedule time.


Patient #10
On 12/12/2019, at 10:18 a.m., Licensed Vocational Nurse (F) was observed in the medication room of the nursing unit. The Licensed Vocational Nurse was preparing medication to administer to Patient #10.

At 10:20 a.m., Licensed Vocational Nurse (F) approached the Patient's room to administer medication to the Patient but the Patient was in the bathroom.

On 12/12/2019, at 10:45 a.m., the Licensed Vocational Nurse was observed administering the medications to Patient#10. The Licensed Vocational Nurse administered the following medications to the Patient:

Acetaminophen 500 mg orally,

Alprazolam 0.25 mg one tablet orally,

(Midodrine) Proamatine 5 mg one tablet,

Librium 5 mg one tablet orally,

Reglan 5 mg BID,

Timoptic 0.5 mg eye drop,

Brimonidine eye drop,

Dorzolamide HCL eye drop, and

Levemir 6 units subcutaneous once a day.


Review of the Patient's clinical record revealed the following medications were prescribed by the Physician to be administered to Patient #10:

Acetaminophen orally three a day: scheduled 0800, 1400, and 2000

Midodrine) Proamatine 5 mg one tablet every eight hours: scheduled to be administered at 0800, 1600, and 2400

Reglan 5 mg orally Twice daily: scheduled to be administered at 09:00 and 1700

Librium 5 mg every 12 hours; Scheduled to be administered at 0900 and 2100.

Xanax 0.25 Mg every 12 hours: Scheduled to be administered at 0900 and 2100

Brimonidine eye drop one drop to both eyes twice daily: scheduled at 08:00 and 20:00

Dorzolamide 2% I drop both eyes three a day: scheduled 0800, 1400, and 2000.

Levemir 6 units subcutaneous once a day: scheduled to be administered at 0800 a.m.

Timoptic 0.5% I drop both eyes three times a day: scheduled to be administered at 0800 a.m., 1400, and 2000.

The Patient's medications were not administered as ordered on scheduled.


Review of the Facility's current Policy and Procedure on Administration of Medication; Policy # PH directs staff as follows: "The Hospital PNT will be responsible for determining the scheduled administration times and making any recommendations for alterations, as needed based on monitoring and evaluation data. ProTouch defaults to standard times of administration. All personnel for Medication Administration must Have passed The Medication Core Competency prior to administering medication.


Review of the Facility's current Policy and Procedure Timely Administration of Scheduled Medications:
"Time critical scheduled medications shall be administered within 30 minutes before or after the scheduled dose time. Time critical medications lists will include a listed number of drugs where delayed or early administration of more than 30 minutes may cause harm or sub-therapeutic effect."
Non- time critical scheduled prescribed less frequently than daily shall be administered within 2 hours before or after the scheduled time."


"Non- time- critical scheduled prescribed medications prescribed more frequently than daily, but no more frequently than every 4 hours shall be administered Conducted Medicare Complaint survey.
Mobile worker within I hour before or after the scheduled time."


Time Critical Medication
Time-critical scheduled medications are those where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy or pharmacological effect.

Review of Physician Desk Reference Prescribers Digital Reference: directs uses as follows: Levodopa "Administer at regular intervals as prescribed to provide therapeutic coverage and lessen "wearing off" time.
"Do not administer at the same time as a multivitamin containing iron or iron supplements as these may reduce absorption."

Augmentin: "In general, all dosage forms are recommended to be taken at the start of a standard meal."

Brimonidine may be used concomitantly with other topical ophthalmic agents used to lower IOP. Administer each agent at least 5 minutes apart

Dorzolamide: The solution may be used concomitantly with other topical ophthalmic drug products to lower intraocular pressure. If more than one topical ophthalmic drug is being used, the drugs should be administered at least 5 minutes apart.


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Policy Reviewed:

Review of the current policy titled "Medication Administration." Approved By: GB/MEC/Medical Staff. Purpose: To provide guidelines regarding who is approved to administer medication at Sugarland Rehab Hospital. Policy: The governing Board has approved the following professionals to administer medications. 1. Registered Nurses 2. Licensed Vocational Nurses/LPNs 3. Physicians.

Review on 12/12/2019, at 1:30 p.m., of Patient ID #2 closed record, (medication administration record) documented medication of Morphine 15 mg oral tablet and Ibuprofen 400 mg oral tablet given by initials BU and dated and timed on 11/08/2019.

Interview on 12/12/2019, at 10:30 a.m., with Directory of Pharmacy, Employee ID #A stated that she had gone up to the floor and heard Patient ID #2 yelling for pain medication. Employee ID #A stated she asked the nurse if she had given the pain medication and the nurse told her that she had just given the medication.

Employee ID #A stated, she went to the patient's room and the patient said he had not gotten his pain medication. Employee ID #A stated, she checked to see when the last time his pain medication was removed from the Pyxis and saw it was from hours ago. Employee ID #A stated that she took the medication out of the Pyxis and gave the medication to the patient. Employee ID #A stated she dated, timed and initialed the medication sheet that she had administered the drugs.


Interview on 12/12/2019 at 3:00 PM with Chief Executive Officer ID #D was asked who was authorized to give medications to the patients. Employee ID #D stated it should only be the registered nurses, licensed vocation nurses and the physicians. Employee ID #D confirmed that the pharmacist should not be giving patients medications, it is out of their scope of practice in the hospital setting



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Record review of Patient #15's Medication Administration Record dated 9/23/19 at 11:00, revealed The Patient's physician (M) wrote an order for blood sugar monitoring four times a day (before meals and at hour of sleep) then to follow a sliding scale for Insulin administration according to results, as follows:

Follow the sliding scale below to administer subcutaneous Regular Insulin based on QID glucose checks.
60-149 00 units of Regular Insulin
150-199 02 units of Regular Insulin
200-249 03 units of Regular Insulin
250-299 05 units of Regular Insulin
300-349 08 units of Regular Insulin
350 & > 10 units of Regular Insulin and call doctor


Review of the Patient's Medication Administration Record dated 9/25/19 at 2000 of Patient #15's blood sugar level monitoring record revealed documentation of of a blood sugar level of 210. Per MD order 3 units of Regular Insulin was not administered as prescribed.

Review of Patient #15 Medication Administration Record dated 9/26/19 at 20:00 revealed the Patient's blood sugar level was 223. Per MD order 3 units of Regular Insulin was not administered as prescribed.