HospitalInspections.org

Based on interview and record review the facility failed to ensure:

1. They followed the California State Regulations for Nursing Service Staff, 70217 (a), by assigning a nurse patient care responsibilities and administrative responsibilities at the same time. On hours when the hospital management was not available in the hospital, such as weekends, evenings after 5 PM, and nights, the hospital assigned a nurse as the "Charge Nurse." The nurse had a patient care assignment and was responsible for supervisory duties for the entire hospital (including 9 acute care beds, 7 Emergency Department (ED) beds, and 21 long term care beds). This failure had the potential for a nurse to be involved in management issues and not be available for immediate patient care. This failure had the potential for a patient to have an emergency medical condition that would not be recognized and treated timely by the nurse and had the potential to result in patient harm.

2. They followed the California State Regulations, 70214 (a) (2), that stated "All patient Care Personnel shall be subject to the process of competency validation for the assigned patient care unit." The facility failed to validate all competencies for Telemetry Monitoring Technicians, validate all competencies for all nurses involved with providing respiratory treatments which included Hand Held Nebulization therapy; validate all competencies for all nurses involved with patient care equipment which included management of IV pumps (Intravenous smart pumps); validate all competencies of all nurses that were compounding and mixing sterile medications in the medicine room and validated all competencies of all Respiratory Therapist performing Pulmonary Function Testing Procedures.

3. They followed the California State Regulations, 70053 (a) (2) that stated, "An outpatient means a person who has been registered or accepted for care but not formally admitted as an inpatient and who does not remain over 24 hours" for 4 of 4 sampled observation.


These failure had the potential to negatively effect the quality of care for any patient using the hospital services.

Findings:

1. A review of the staffing sheets for the time period of 5/1/12 through 5/15/12 was conducted. The staffing sheets listed the staff for the acute care hospital, the ED, and the long term care areas of the hospital. On the staffing sheets was a designation "chg" (Charge Nurse) beside a Registered Nurse (RN) name. The designation was made on each evening and night shift, along with day shifts on the weekend. Nurses assigned to acute care beds and patient care areas in the ED, were given the designation of "Charge Nurse".

An interview was conducted with RN 1 on 5/15/12 at 10:30 AM. She stated that she worked as a patient care nurse and sometimes was the designated "Charge Nurse" of the hospital, while she had patient care duties. She stated that as the charge nurse she was responsible for her own patient care and the staffing of the hospital, any patient care issues in the hospital, patient and family complaints, physician complaints or issues, calling in surgical staff for emergency cases, and any other problems that may arise during the shift.

An interview was conducted with the Chief Nursing Officer (CNO) of the hospital, on 5/15/12 at 2 PM. She stated that on "off shifts" (shifts where management was not present in the hospital, such as weekends, evening shifts, and night shifts) the hospital assigned a nurse to act as "Charge Nurse". She stated that there was a job description for the charge nurse duties. She stated that these duties were in addition to the patient care duties of the nurse. The CNO stated that a nurse from the acute care area or the ED could be assigned as "Charge Nurse" if they were on the list of qualified nurses.

A review of the job description, dated March 2011, for a "Charge Nurse" revealed a list of 13 duties, including:

1."Constant evaluation/monitoring of staffing levels for all aspects of nursing department."

2."Bed control: Will acknowledge all admissions, transfers and surgeries to assure appropriate staffing levels."

3. "Supply acquisition: Will assure that appropriate supplies are available/accessible for staff use."

4."Be aware of any unusual occurrences and notify appropriate on-call management."

5."Authorizes call in of available staff resources per core staffing guidelines."

6. "Approves all overtime..."

7. "Acts as resource to staff to aid in the most appropriate course of action for Patient/resident care." (This gave the patient care nurse in the acute care hospital responsibilities for residents in the long term care.)

13."Any other duties as assigned."


The CNO, on 5/16/12 at 10:30 AM, confirmed the duties of the charge nurse. She stated that a nurse would be responsible for all of the duties in addition to their own patient care assignment. She stated that the nurse could delegate some of the telephone calls to another person; however, the nurse remained responsible for the duties. She confirmed that the additional duties were administrative duties. She stated that the nurse was acting as a "Nursing Supervisor" when assigned as a charge nurse.

The CNO confirmed that an acute care nurse could have up to 5 patients and that in the Emergency Department (ED), there were 2 nurses. On of the ED nurses needed to be immediately available to triage patients and one needed to be immediately available for patient care. She acknowledged that a nurse who was acting in an administrative role as a Nursing Supervisor could not be available for immediate patient care.

This is a repeat deficiency.





26502

2. On 5/17/12, a review of personnel files of all Telemetry Monitor Technicians actively employed by the facility revealed that 3 of 9 technicians did not have competencies validated by the Department of Nursing as determined by their job description prior to accepting patient assignments. There was no documented evidence that 3 of 9 telemetry monitor technicians received training in basic cardiac arrhythmia recognition and their competency validated by the Department of Nursing.

On 5/17/12, a review of personnel files of all Licensed Nurses actively employed by the facility revealed that all Licensed Nurses did not have competencies validated by the Department of Nursing in the area of providing respiratory treatments that included Hand Held Nebulization procedures. There was no documented evidence that all licensed Nurses received training in providing respiratory Hand Held Nebulization to the age appropriate patients served and their competency validated by the Department of Nursing.

On 5/17/12, a review of personnel files of all licensed Nurses actively employed by the facility revealed that all Licensed Nurses did not have competencies validated by the Department of Nursing in the area of managing patients requiring the use of Intravenous pumps when administering Intravenous medications through a patient's vein or through a central invasive line. There was no documented evidence that all licensed Nurses received training in Intravenous pump management for age-specific patients requiring IV medication therapy through either the vein or from an invasive central line and their competency validated by the Department of Nursing.

On 5/17/12, a review of personnel files of all licensed Nurses actively employed by the facility revealed that all licensed nurses did not have competencies validated by the Department of Pharmacy and the Department of Nursing in the area of compounding or mixing sterile medications in the facility's medicine room located across from the central nursing station. There was no documented evidence that all licensed nurses received training by the Department of Pharmacy addressing compounding and mixing sterile medications performed in the designated medication room adhering to facility infection control policies and procedures that were validated by the Department of Pharmacy and Department of Nursing.

On 5/17/12, a review of personnel files of all Respiratory Therapist actively employed by the facility revealed that all Respiratory Therapist did not have competencies validated by the Respiratory Department in the area of performing and managing patients undergoing Pulmonary Function Testing procedures. There was no documented evidence that all Respiratory Therapist received training in performing and managing age specific patients undergoing a Pulmonary Function Testing procedure and their competency validated by the Respiratory Department.

On 5/17/12, at the time of findings, the Chief Nursing Officer confirmed that competencies for Telemetry Monitoring Technicians that included continuous patient cardiac monitoring and cardiac arrhythmia recognition; nurses involved with providing respiratory treatments which included Hand Held Nebulizer therapy; nurses involved with patient care equipment which included management of IV pumps; including Intravenous smart pumps; nurses that were compounding and mixing sterile medications in the medicine room, and Respiratory Therapist performing Pulmonary Function Testing Procedures were all lacking validated competencies by their respective departments.


3. a). A review of the medical record for Patient 8 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital as an observation patient (An out-patient status that was used by the hospital to admit patients who did not meet admission criteria, but who ' s physicians thought that the patient required monitoring. The patient may incur an extra cost as an out-patient, due to meeting co-payments.) on 4/15/12 with diagnoses that included intractable vomiting, diarrhea, kidney failure, and dehydration.

On 5/22/12 at 12:15 PM, the medical record was reviewed with the Case Manager (CM 1) who was responsible for determining if the patient met admission criteria. CM 1 reviewed the record and compared the patient's admitting diagnoses with the criteria, along with the patient's laboratory results. According to the criteria used by CM 1, the patient did meet admission criteria.

A review of the "Discharge Planning Review" revealed that the patient was seen by case management for discharge needs; however, there was no documented evidence that the patient was evaluated for his status as an out-patient.

At the time of the review, CM 1 stated that she did not know why the patient had not been evaluated. She stated that the patient did meet admitting criteria and should not have been admitted as an observation patient.

b). A review of the medical record for Patient 7 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital on 3/3/12 with diagnoses that included intractable nausea and vomiting. The patient was admitted as an observation patient. The patient was discharged on 3/6/12.

A review of the case management notes revealed that the record was reviewed on 3/4/12. The review documented that the patient would stay on observation status; however, the CM documented that the patient would be discharged that afternoon.

There was no documentation for 3/5/12 and on 3/6/12 there was a note stating the patient was to be discharged home that day. There was no mention a review for observation status.

An interview was conducted with CM 1 on 5/22/12 at 12:30 PM. She stated that all observation patients should be reviewed each day, as observation status was for 24 hours only and the review needed to be done to justify the patient's stay. She confirmed that the case manager documented that the patient would be discharged on 3/4/12 and did not reevaluate the patient, even though the patient was in the hospital until 3/6/12. She stated that she could not explain why the patient was not evaluated. CM 1 stated that the patient should have been evaluated each day.


3 c). On 5/15/12, a review of Patient 9's medical record was conducted. Patient 9 was admitted to the facility on 5/12/12, at 8:56 AM, with an admitting diagnosis of shortness of breath. Patient 9's admitting status ordered by the physician was classified as an "Observation Outpatient."

On 5/15/12, a review of Patient 9's Physician Admitting Order sheet, dated 5/12/12, timed at 9:15 AM, documented that Patient 9's presenting symptoms warranted an admitting status of "Observation Outpatient."

On 5/15/12, a review of Patient 9's Physicians' Order sheet, dated 5/15/12, timed at 3:15 PM, documented that Patient 9 was to be discharged later that day (5/15/12) with a prescription for antibiotics to be taken at home.

There was no documented evidence in Patient 9's medical record or from other facility sources that a secondary review and assessment was conducted by the case manager of Patient 9's admitting status that followed community accepted, evidence-based criteria that supported the level of care needed to meet the needs of the Patient 9 or be discharged home on 5/13/12 and 5/14/12. This deficient practice resulted in Patient 9 being hospitalized a total 3 days resulting in non-compliance with State requirements, that exceeded State requirements of an "Outpatient" who has registered or accepted for care, but not formally admitted as an inpatient, and who does not remain over 24 hours.

On 5/15/12, a review of the facility's policy and procedure titled, "OBSERVATION STATUS" dated 1/26/12, stipulated, "...Observation status is considered treating patients that are expected to be stabilized and released in 24 hours, and patients will be informed by the treating provider that they will be on observation status and will be considered an outpatient until a decision is made by the physician to admit to the hospital or discharge ..."

On 5/15/12, at approximately 11:15 AM, Case Manager 1 and the Chief Nursing Officer confirmed the finding that a secondary review was not conducted on Patient 9's admitting status as an "Observation Patient" on 5/13/12 and 5/14/12 and Patient 9 exceeded 24 hours in the hospital as an observation status patient.

3 d). On 5/15/12, a review of Patient 10's medical record was conducted. Patient 10 was admitted to the facility on 5/14/12, at 1:12 PM, with an admitting diagnosis of severe diarrhea and dehydration resulting in a low potassium level.

On 5/15/12, a review of Patient 10's Physician Admitting Order sheet, dated 5/14/12, timed at 4:20 PM, documented that Patient 10' presenting symptoms warranted an admitting status of an "Observation Outpatient."

On 5/15/12, a review of Patient 10's Physicians' Order sheet, dated 5/15/12, timed at 3:15 PM, documented that Patient 10 was to be discharged on 5/16/12.

The facility failed to ensure that they followed community accepted, evidence-based criteria that supported the level of care needed to meet the needs of Patient 10 or be discharged home on 5/15/12. This deficient practice resulted in Patient 10 being hospitalized a total 2 days and resulted in non-compliance with State requirements, which exceeded State requirements of an "Outpatient" who has registered or accepted for care, but not formally admitted as an inpatient, and who does not remain over 24 hours.

On 5/15/12, a review of the facility's policy and procedure titled, " OBSERVATION STATUS " dated 1/26/12, stipulated, " ...Observation status is considered treating patients that are expected to be stabilized and released in 24 hours, and patients will be informed by the treating provider that they will be on observation status and will be considered an outpatient until a decision is made by the physician to admit to the hospital or discharge ..."

On 5/15/12, at approximately 11:15 AM, Case Manager 1 and the Chief Nursing Officer confirmed the finding that the facility did not have a discussion between the patient regarding his admission status and possible added financial liability as part of his right to be informed and involved in his plan of care. In addition, they confirmed that Patient 10's hospitalization exceeded State Regulations of an "Observation Outpatient" by a total of 1 day.

Based on interview and record review, the facility failed to ensure that the Governing Body was organized and accepted overall responsibility for conducted of the hospital.

1. The facility failed to ensure that all policies and procedures were reviewed and approved by the medical staff and the governing body. This failure had the potential to negatively effect any patient who used the services of the hospital.

Findings:

On 5/16/12 a review was conducted of the policies for several of the services provided by the hospital. The survey team noted that for some of the services, the polices had no date of approval or had a date of 1999 to 2003 that the polices were reviewed and approved.

An interview was conducted with the Chief Nursing Officer, on 5/17/12 at 2:45 PM. She stated that the medical staff and the governing body had not reviewed all the policies. She stated that some were done and the hospital was working on conducting the review on all of the policies. The CNO stated that she was not sure of when some of the policies were reviewed. She stated that policies that had not been through the approval process were Infection Control, Surgical Services, Human Resources, Radiology, and Administration. The CNO stated that she and the new Chief Operating Officer (who was on a medical leave) came into the hospital in February of 2011 and discovered that the policies were not reviewed, updated, or approved by the medical staff and the governing body. She confirmed that she had her position for well over a year and that the process was not complete. She confirmed that policy review and approval was a priority in the organizational operations of the hospital.

2. Based on interview and record review the facility failed to protect and promote all patient's rights. (Refer to A 115)

a). The facility failed to ensure that they established a process for prompt resolution of patient grievances. (Refer to A 115)

b). The facility failed to ensure that all observation, out-patients, were notified of their hospitalization status. (An out-patient status that was used by the hospital to admit patients who did not meet admission criteria, but who's physicians thought that the patient required monitoring. The patient may incur an extra cost as an out-patient, due to meeting co-payments.) (Refer to A 115)

c). The facility failed to ensure that patients were monitored for restraint usage as directed by hospital policy and that nursing staff and medical staff received the training necessary to restrain a patient safely.(Refer to A 115)
d). The facility failed to ensure that all orders for patient restraints were complete and did not include the use of PRN (as needed) orders. (Refer to A 115)

3. The facility failed to develop, implement, and maintain an effective, ongoing, hospital-wide, data-drive Quality Assessment Performance Improvement (QAPI) program. (Refer to A 263)


4. The facility failed to have an organized nursing service. (Refer to A 385)


a). The facility failed to have a well-organized nursing service when they failed to ensure that all staff that were under nursing supervision had competency validation prior to being assigned patient care. (Refer to A 385)

b). The facility failed to ensure that they followed the California State Regulations for Nursing Service Staff, 70217 (a), by assigning a Registered Nurse patient care responsibilities and administrative responsibilities at the same time. On hours when the hospital management was not available in the hospital, such as weekends, evenings after 5 PM, and nights, the hospital assigned a nurse as the "Charge Nurse" who had total patient care responsibilities and administrative responsibilities, preventing the nurse from being immediately available for patient care. (Refer to A 385)

c). The facility failed to ensure that a Registered Nurse (RN) supervised the nursing care for each patient. (Refer to A 385)

d). The facility failed to ensure that nursing staff developed and kept current a plan of care for all patients. (Refer to A 385)


e). The facility failed to ensure that medications were administered per policy and regulation by failing to ensure that an order was obtained prior to administration of a medication. (Refer to A 385)

5. The facility failed to have pharmaceutical services that met the needs of the patients. (Refer to A 490)

a). Pharmaceutical services failed to ensure that guidelines for the safe intravenous (IV) use of the medication Zofran (a medication for nausea and vomiting that when given IV can cause an abnormal heart rhythm that has the potential to result in a patient's death.) (Refer to A 490)


b). Pharmaceutical services failed to ensure that Patient 1 did not receive an infusion through an epidural catheter (A catheter than infused into the space around the lower spine. The most common side effect of an epidural infusion was low blood pressure caused by redistribution of body fluids.) without direction for monitoring the patient. (Refer to A 490)


c). Pharmaceutical services failed to ensure that approved guidelines were used for the administration of IV drips, including cardiac (heart) and vasoactive medications (very potent medications used for blood pressure control) in the Emergency Department. (Refer to A 490)

d). The facility failed to ensure that medications and biologicals were controlled and distributed in accordance with standards of practice. The facility failed to ensure that the pharmacist reviewed each medication for appropriateness before the first dose was dispensed. This failure resulted in incomplete medication orders identified by the survey process, that were not previously identified and corrected by pharmacy. (Refer to A 490)

e). Pharmaceutical services failed to ensure that medications were compounded by a pharmacist or under the supervision of a pharmacist. Pharmaceutical services failed to ensure that nurses who compounded medications had the competency validation necessary to ensure the medications were mixed to ensure patient safety. (Refer to A 490)

f). Pharmaceutical services failed to ensure that policies were developed and maintained to ensure that medications were administered by licensed personnel only as directed by State regulations. (Refer to A 490)

6. The facility failed to ensure that they had an effective Dietary Service Department that met the needs of all patients. (Refer to A 618)

a). The facility failed to ensure that policies and procedures to meet the nutritional needs of patients were reviewed and approved by the medical staff and the Governing Body. (Refer to A 618)

b). The facility failed to meet the nutrition needs of patients who were at risk for suboptimal nutrition care. The facility failed to provide Dietary consultation to patient's who met the facility's nutritional risk parameters. (Refer to A 618)
c). The facility failed to ensure that the Therapeutic Diet Manual was reviewed and approved by the medical staff. The facility failed to ensure that a detailed nutritional analysis of daily and therapeutic menus was performed. (Refer to A 618)
The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of high quality healthcare in a safe environment.

Based on interview and record review the hospital failed to protect and promote all patient's rights.

1. The facility failed to ensure that they established a process for prompt resolution of patient grievances.

For Grievance 4, the patient stated in a letter to the hospital, that she had a total knee surgery (painful recovery was common with this surgery) and that during the night after surgery, the patient was not treated properly for pain because her Intravenous (IV) line was not inserted correctly. The patient stated and the facility confirmed that the patient received many medications in the morning to control her pain that she was apneic (periods with no breathing) and somnolent (very sleepy). The facility did not document fully the data collected or what was done in behalf of the patient. There was no letter of resolution sent to the patient. (Refer to A 118)

2. The facility failed to ensure that the grievance process was complete and that the patient, who submitted the grievance, was notified of the results of the investigation, the steps taken on behalf of the patient to investigate the grievance, and the date of completion for 3 of 3 grievances reviewed. (Refer to A 123)

3. The facility failed to ensure that 4 of 4 observation, out-patients, were notified of their hospitalization status as an observation patient. (An out-patient status that was used by the hospital to admit patients who did not meet admission criteria, but who's physicians thought that the patient required monitoring. The patient may incur an extra cost as an out-patient, due to meeting co-payments.) The facility failed to actively involve and include in the development, implementation and revision of his/her plan of care. The facility failed to ensure that notification of their admitting status was explained to the patient, including the possibility of an increase in financial liability to the patient, allowing him or her to make an informed decision regarding treatment. (Refer to A 131)

4. The facility failed to ensure that Patient 17, imposed in chemical restraints, had mechanisms and methods in place to ensure patient safety and while eliminating the inappropriate use of restraints in order to ensure that the basic rights of patients to receive care in a safe setting are being promoted. (Refer to A 164)
5. The facility failed to ensure that Patients 14, 17, and 19 , imposed in physical or chemical restraints, had mechanisms and methods in place to ensure patient safety and while eliminating the inappropriate use of restraints in order to ensure that the basic rights of patients to receive care in a safe setting are being promoted. The facility failed to develop and implement a comprehensive individualized "restraint" plan of care for the patients. (Refer to A 166)
6. The facility failed to ensure that for Patients 14, 17, and 19, imposed in physical or chemical restraints, had a physician's order that was specific for the type of restraint, specific behaviors, and/or specific time frame for the restraint. (Refer to A 168)
7. The facility failed to ensure that for Patient 19, imposed in physical and chemical restraints, had a specific physician's order for the restraints that did not include the use of PRN (as needed) restraints. (Refer to A 169)
8. The facility failed to ensure that staff monitored Patients 14, 17, and 19, imposed in physical or chemical restraint, according to the facility policy. The facility also failed to ensure that staff had the training necessary to perform the patient monitoring required for restraint usage. (Refer to A 175)

9. The facility failed to ensure that physicians or other licensed independent practitioners, at minimum, had a working knowledge and had training in appropriate use and management of restraints in age-specific patients as determined by hospital policy. (Refer to A 176)


The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review the facility failed to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven Quality Assessment Performance Improvement (QAPI) program.


1. The QAPI program failed to collect, measure, analyze, and track hospital operations in relation to the discharge planning process and the process for review of the observation patient by the case manager/discharge planner. This failure resulted in several areas of discharge planning deficient practices upon review. (Refer to A 267)


2. The QAPI program failed to collect, measure, and analyze the hospital operations regarding use of high risk medications, nursing competencies related to cardiac monitoring, mixing Intravenous (IV) medications, training for staff for restraint usage, nursing staffing, Dietary and other contracted services, and competencies for respiratory staff conducting out-patient pulmonary function testing. (Refer to A 267)

The cumulative effects of these systemic problems resulted in the hospital's inability to provide quality health care in a safe environment.

Based on interview and record review the facility failed to have an organized nursing service.


1. The facility failed to have a well-organized nursing service when they failed to ensure that all staff that were under nursing supervision had competency validation prior to being assigned patient care. The nursing services entrusted the heart monitoring of patients to technicians and nurses that had no demonstrated competencies to complete their job. The nursing services entrusted the care of patients to nursing staff without validating the nurse's competency to complete the work, such as giving respiratory treatments, mixing intravenous (IV) medications, managing IV pumps and heart monitors, and age specific care of the patient. (Refer to A 386)

2. The facility failed to ensure that they followed the California State Regulations for Nursing Service Staff, 70217 (a), by assigning a nurse patient care responsibilities and administrative responsibilities at the same time. On hours when the hospital management was not available in the hospital, such as weekends, evenings after 5 PM, and nights, the hospital assigned a nurse as the "Charge Nurse". The nurse had a patient care assignment and was responsible for supervisory duties for the entire hospital (including 9 acute care beds, 7 Emergency Department (ED) beds, and 21 long term care beds). This failure had the potential for a nurse to be involved in management issues and not be available for immediate patient care. This failure had the potential for a patient to have an emergency medical condition that would not be recognized and treated timely by the nurse and had the potential to result in patient harm. (Refer to A 392)

3. The facility failed to ensure that a Registered Nurse (RN) supervised the nursing care for each patient Patients 1, 2, 3, 4, 5, 7, 10 and 20. The facility failed to ensure:

a). The RN followed physician's orders for monitoring Patient 1, with an epidural infusion (The epidural space, a potential space that surrounds and protects the spinal cord. An infusion into the space was usually used for pain control.) and failed to monitor the patient's infusion site.


b). An RN evaluated the care for Patients 1, 2, 3, 7, and 5 related to treatment of the patients' pain and monitoring for the potential side effects of pain and pain treatment.

c). An RN evaluated the care for Patients 1, 5, 7, 10 and 20, by failing to complete or act upon the admission nutritional risk screen.

e). An RN evaluated the care for Patients 3 and 4 and provided discharge instructions for the patients being discharged from the Emergency Department (ED). (Refer to A 395)

4. The facility failed to ensure that nursing staff developed and kept current a plan of care for all patients. (Refer to A 396)

5. The facility failed to ensure that medications were administered per policy and regulation by failing to ensure that an order was obtained prior to administration of a medication for Patient 16. (Refer to A 406)

The cumulative effect of these systemic problems resulted in the nursing department's inability to ensure the provision of quality healthcare in a safe environment.

Based on observation, record reviews and staff interviews, the hospital condition of participation for Dietary Services was not met as evidenced by:

1. The facility failed to ensure that policies and procedures to meet the nutritional needs of patients were reviewed and approved by the medical staff and the Governing Body. (Refer to A 619)

2. The facility failed to meet the nutrition needs of patients who were at risk for suboptimal nutrition care. The facility failed to provide Dietary consultation to patients who met the facility's nutritional risk parameters. (Refer to A 630)
3. The facility failed to ensure that the Therapeutic Diet Manual was reviewed and approved by the medical staff. The facility failed to ensure that a detailed nutritional analysis of daily and therapeutic menus was performed. (Refer to A 631)

The cumulative effect of these systemic problems resulted in the hospital's inability to provide Dietary Services in a safe environment.

Based on interview and record review, the facility failed to ensure that they established a process for prompt resolution of patient grievances for 2 of 4 grievances reviewed.

For Grievance 4, the patient stated, in a letter to the hospital, that she had a total knee surgery (painful recovery was common with this surgery) and that during the night after surgery, the patient was not treated properly for pain because her Intravenous (IV) line was not inserted correctly. The patient stated and the facility confirmed that the patient received many medications in the morning to control her pain that she was apneic (periods with no breathing) and somnolent (very sleepy). The facility did not document fully the data collected or what was done in behalf of the patient. There was no letter of resolution sent to the patient.

For Grievance 3, the patient stated that he wanted a letter of apology from a physician regarding not giving him (the patient) a medication that he had requested. The steps in the grievance process were not clear and the resolution was not documented.

These failures had the potential to result in the risk of unmet healthcare needs and substandard healthcare for patients using the grievance process.


Findings:

1. A review of Grievance 4 was conducted on 5/23/12. The grievance was initiated by a letter than was sent to the hospital by the patient and dated 2/15/12. The letter stated that the patient had a total knee surgery done and that on the night of the surgery, she was not treated properly for the amount of pain that she was experiencing. The letter stated that the patient informed the nurse several times regarding the pain; however, the nurse did not assess her properly. She stated that in the morning, the day shift nurse had found that the patient's IV was not infusing into her vein, but into her "gown and sheets". The patient stated that when she was treated for pain, the next morning, she had to be given a "several doses" of medication that caused her to become "apneic and somnolent" and required a high dose of oxygen.

A review of the acting Risk Manager's (RM 2) investigation, dated 2/23/12, revealed that the RM reviewed the medical record and documented that the patient's perception of what happened was supported by documentation. She then, sent the grievance to the Nurse Manager (NM). There was no further documentation of what had occurred or what steps were taken for the patient. There was no resolution letter sent to the patient.

An interview was conducted with the Risk Manager (RM 1) on 5/23/12 at 9:30 AM. She stated that she had been off on a medical leave during the timeframe that the grievance was submitted. She stated that RM 2 was covering for her. She confirmed that there was no follow up to what had happened for this patient or what systemic changes (if any) had been put in place to help ensure that it did not happen again to any other patient. She stated that there was a sticky note attached to the grievance that said "response needed from (name of Nurse Manager {NM} on acute care)."

An interview was conducted with the NM on 5/23/12 at 10 AM. She stated that she spoke to the night shift nurse regarding the allegation from the patient and the nurse stated that the patient had slept most of the night. The NM confirmed that the review of the medical record supported the allegation that the IV was found "out" (of the vein) by the AM nurse and that the patient required further pain medications and sedation and was found "apneic and somnolent" soon after and required a high dose of oxygen. She stated that she was aware that the patient had knee surgery and was aware that knee surgery can be very painful, so she counseled the nurse. She stated that the night shift nurse no longer works for the hospital. The NM stated that she did not document the counseling with the nurse and did not send her investigation to the RM 2. She stated that she should have completed the follow-up. She was asked if the staff received an in service regarding how the problem occurred and she stated that they talk about pain management at staff meetings; however, not specific to the events identified during the investigation of this grievance.


2. A review of Grievance 3 was conducted on 5/23/12. The review revealed that the grievance was called into the hospital on 3/23/12. The grievance stated that the patient wanted a letter of apology from a physician regarding not giving him (the patient) a medication that he had requested.


Further review of the grievance revealed that the patient was sent a letter on 3/27/12 stating that RM 2 spoke to the physician and the physician said that he had called the patient's primary physician and been told not to give the patient the requested medications. There was no documentation in the grievance file that backed up the documentation in the letter to the patient.


An interview was conducted with RM 1 on 5/23/12 at 9 AM. She confirmed that there was no record of a conversation with the physician. She stated that she was not sure where RM 2 got the information.

Based on interview and record review, the facility failed to ensure that the grievance process was complete and that the patient, who submitted the grievance, was notified of the results of the investigation, the steps taken on behalf of the patient to investigate the grievance, and the date of completion for 3 of 3 grievances reviewed. This failure had the potential to result in the patients not being satisfied with actions that were taken on behalf of the patient.


Findings:


1. A review of Grievance 4 was conducted on 5/23/12. The grievance was initiated by a letter than was sent to the hospital by the patient and dated 2/15/12. The letter stated that the patient had a total knee surgery done and that on the night of the surgery, she was not treated properly for the amount of pain that she was experiencing. The letter stated that the patient informed the nurse several times regarding the pain; however, the nurse did not assess her properly. She stated that in the morning, the day shift nurse had found that the patient's IV was not infusing into her vein, but into her "gown and sheets". The patient stated that when she was treated for pain, the next morning, she had to be given a "several doses" of medication that caused her to become "apneic (periods of no breathing) and somnolent (very sleepy)" and required a high dose of oxygen.


A review of the acting Risk Manager's (RM 2) investigation, dated 2/23/12, revealed that the RM reviewed the medical record and documented that the patient's perception of what happened was supported by documentation. Further review of the investigation revealed that there was no resolution letter sent to the patient.


An interview was conducted with RM 1 on 5/23/12 at 9 AM. She confirmed that there was no resolution letter sent to the patient. She stated that there should have been a letter sent.


2. A review of Grievance 2 was conducted on 5/23/12. The review revealed that the grievance was concerning the patient's request that a test, completed elsewhere, be read by the hospital. Further review of the grievance revealed that a resolution letter was sent to the patient; however, it did not contain results of the investigation, the steps taken on behalf of the patient to investigate the grievance, or the date of completion.


An interview was conducted with RM 1 on 5/23/12 at 9:15 AM. She confirmed that the resolution letter was not complete and did not inform the patient what actions were taken on his behalf.


3. A review of Grievance 3 was conducted on 5/23/12. The review revealed that the grievance was called into the hospital on 3/23/12. The grievance stated that the patient wanted a letter of apology from a physician regarding not giving him (the patient) a medication that he had requested.


Further review of the grievance revealed that the patient was sent a letter on 3/27/12 stating that RM 2 spoke to the physician and the physician said that he had called the patient's primary physician and been told not to give the patient the requested medications. There was no documentation in the grievance file that backed up the documentation in the letter to the patient.


An interview was conducted with RM 1 on 5/23/12 at 9 AM. She confirmed that there was no record of a conversation with the physician. She stated that she was not sure where RM 2 got the information.

Based on staff interview and facility record review, the facility failed to:
1. Ensure that 4 of 4 observation outpatients (Patients 3, 4, 9, and 10) were notified of their hospitalization status as an observation patient. (An out-patient status that was used by the hospital to admit patients who did not meet admission criteria, but who's physicians thought that the patient required monitoring. The patient may incur an extra cost as an out-patient, due to meeting co-payments.) The facility failed to actively involved and included in the development, implementation and revision of his/her plan of care when the facility failed to ensure that notification of their admitting status was explained by the facility to the patient, including the possibility of an increase in financial liability to the patient allowing him or her to make an informed decision regarding the treatment. This deficient practice resulted in the facility not promoting the rights of patient to make an informed decision regarding his or her care.


2. Follow their policy to provide the patient with informed consent for a surgical procedure. The facility failed to ensure that the surgical procedure was listed on the consent form for 1 of 20 sampled patients (Patient 6). This failure had the potential for the patient to have a surgical procedure that he had not been given all the information to make an informed decision.


Findings:


1 a). A review of the medical record for Patient 8 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital as an observation patient on 4/15/12 with diagnoses that included intractable vomiting, diarrhea, kidney failure, and dehydration.


A review of the record, including physician's notes, nursing notes, and case management notes, revealed that there was no documented evidence that the patient had been informed that he was admitted as an observation patient or that his admission status had been discussed with him.


An interview was conducted with Case Manager 1 (CM 1) who was responsible for evaluating the patient's admission status on 5/22/12 at 12:15 PM. She stated that the patient was not informed and that the hospital did not have a process for informing the patient of their observation status, unless that status was changed from in-patient to out-patient. She confirmed that the patient could incur extra out-of-pocket costs for the hospitalization as an observation patient. She stated that the patient should be fully informed of their hospital care.


b). A review of the medical record for Patient 7 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital on 3/3/12 with diagnoses that included intractable nausea and vomiting.


A review of the record, including physician's notes, nursing notes, and case management notes, revealed that there was no documented evidence that the patient had been informed that she was admitted as an observation patient or that her admission status had been discussed.


An interview was conducted with Case Manager 1 (CM 1) who was responsible for evaluating the patient's admission status on 5/22/12 at 12:15 PM. She confirmed that the patient was not informed of their admission status as an out-patient.





26502

1. c).On 5/15/12, a review of Patient 9's medical record was conducted. Patient 9 was admitted to the facility on 5/12/12, at 8:56 AM, with an admitting diagnosis of shortness of breath. Patient 9's admitting status ordered by the physician was classified as an "Observation Outpatient."

On 5/15/12, a review of Patient 9's Physician Admitting Order sheet, dated 5/12/12, timed at 9:15 AM, documented that Patient 9's presenting symptoms warranted an admitting status of "Observation Outpatient."

On 5/15/12, a review of Patient 9's Physicians' Order sheet, dated 5/15/12, timed at 3:15 PM, documented that Patient 9 was to be discharged later that day (5/15/12) with a prescription for antibiotics to be taken at home.

There was no documented evidence in Patient 9's medical record or from other facility sources that a discussion took place between the facility and Patient 9 regarding his current or updated admission status and the possibility of added financial liability on his part, from 5/12/12 through discharge on 5/15/12.

On 5/15/12, a review of the facility's policy and procedure titled, "OBSERVATION STATUS " dated 1/26/12, stipulated, "...Observation status is considered treating patients that are expected to be stabilized and released in 24 hours, and patients will be informed by the treating provider that they will be on observation status and will be considered an outpatient until a decision is made by the physician to admit to the hospital or discharge ..."

On 5/15/12, a review of the facilities policy and procedure titled, "PATIENT RIGHTS" dated 4/19/12, stipulated in section (5), "...The patient shall receive as much information about any proposed treatment or procedures as the patient may need in order to give informed consent or to refuse the course of treatment. In section (7), it stipulated,"...The patient has the right to participate actively in decision regarding medical care and the course of treatment and to the extent permitted by law, this includes the right to refuse treatment and in section (16), it stipulated, "...The patient has the right to examine and receive an explanation of the bill regardless of source of payment ..."

On 5/15/12, at approximately 11:15 AM, Case Manager 1 and the Chief Nursing Officer confirmed that no discussion between the facility and the patient regarding his admission status and possible added financial liability to the patient as part of his right to be informed and involved in his plan of care.

d). On 5/15/12, a review of Patient 10's medical record was conducted. Patient 10 was admitted to the facility on 5/14/12, at 1:12 PM, with an admitting diagnosis of severe diarrhea and dehydration resulting in a low potassium level.

On 5/15/12, a review of Patient 10's Physician Admitting Order sheet, dated 5/14/12, timed at 4:20 PM, documented that Patient 10' presenting symptoms warranted an admitting status of an "Observation Outpatient."

On 5/15/12, a review of Patient 10's Physicians' Order sheet, dated 5/15/12, timed at 3:15 PM, documented that Patient 10 was to be discharged on 5/16/12.

There was no documented evidence in Patient 10's medical record or from other facility sources that a discussion took place between the facility and Patient 10 regarding his current or updated admission status and the possibility of added financial liability on his part, from 5/14/12 through discharge on 5/16/12.

On 5/15/12, at approximately 11:15 AM, Case Manager 1 and the Chief Nursing Officer confirmed the finding that the facility did not have a discussion between the patient regarding his admission status and possible added financial liability as part of his right to be informed.


2. A review of the medical record for Patient 6 was conducted on 5/21/12. The review revealed that he was admitted to the hospital on 4/3/12 due to a rupture of his small bowel.


A review of the physician's discharge summary, dated 4/10/12, revealed that the patient had an abdominal surgery on the day of admission that started as a diagnostic surgery using a scope but turned into an open surgery due to a "jejunal (part of the small intestine) blowout injury."


A review of the surgical consent form, dated 4/3/12, revealed that there was no surgical procedure listed.


A review of the hospital's policy titled "Informed Consent", dated 3/30/12, revealed that the hospital required the physician to document the "nature and purpose of treatment." The policy also directed nursing staff to review the consent process.


An interview was conducted with the Chief Nursing Officer (CNO) on 5/21/12 at 3:40 PM. She confirmed that the informed consent for the patient's surgery was completed filled out. She stated that the consent form was the document that the hospital used to help ensure all the elements of an informed consent and it should have been complete.

Based on interview and record review, the facility failed to ensure that 1 of 20 patients (Patient 17 ) imposed in chemical restraints, had mechanisms and methods in place to ensure patient safety and while eliminating the inappropriate use of restraints in order to ensure that the basic rights of patients to receive care in a safe setting are being promoted.

For Patient 17, the facility failed to develop and implement a comprehensive individualized " restraint " plan of care and flow-sheet, describing that least restrictive restrain measures were attempted and proven unsuccessful prior to, and while being on the effects of Haldol, a chemical restraint.

This deficient practice had the potential to result in substandard care and inappropriate use of patients in restraints and a violation of their right to be free from restraints.

Findings:

1. On 5/16/12, a review of patient 17's Emergency Department's medical record was conducted. Patient 17 was admitted to the facility on 4/15/12 with an admitting diagnosis of altered mental status.

On 5/16/12, a review of patient 17's emergency room record revealed that patient 17 was found wandering in the woods and while in the emergency room became increasingly agitated, confused and hallucinatory. Clinical impression: Alcohol withdrawal with delirium tremors.

On 5/16/12, a review of the Physician's Emergency Room Order sheet, dated 4/15/12, revealed the following orders:

a. Intravenous solution Normal Saline wide open 1 liter, then 500 cc/hour.

b. Ativan 1 milligram IVP (Intravenous push).

c. Valium 10 milligram IVP

d. Haldol 3 milligrams IM (Intramuscular) at 12:05 PM (deemed by the facility as being a chemical restraint).

e. Haldol 2 milligrams IM at 1:20 PM (deemed by the facility as being a chemical restraint).

There was no documented evidence in Patient 17's medical record or from other facility sources that a comprehensive individualized " restraint plan of care " was developed addressing: assessment; interventions; time frames; and an evaluation of Patient 17 safety while in restraints and possibility of discontinuing the use of restraints at the earliest possible time on 4/15/12.

There was no documented evidence in Patient 17's medical record or from other facility sources that a " restraint flow sheet " was developed and implemented as per facility policy on 4/15/12.

There was no documented evidence in Patient 17's medical record or from other facility sources that a restraint flow sheet was developed with documentation of "least restrictive restraint interventions attempted" or proven unsuccessful prior to administering a chemical restraint.

On 5/26/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed the finding that Patient 17's medical record did not contain a restraint flow sheet with a description of least restrictive restraint measures attempted or proven unsuccessful.

Based on interview and record review, the facility failed to ensure that 3 of 20 patients (Patients 14, 17, and 19 ) imposed in physical or chemical restraints, had mechanisms and methods in place to ensure patient safety and while eliminating the inappropriate use of restraints in order to ensure that the basic rights of patients to receive care in a safe setting are being promoted.

1. For Patient 14, the facility failed to develop and implement a comprehensive individualized " restraint " plan of care and complete all components of the facility's restraint flow-sheet. In addition, the facility failed to ensure that physician orders' written for restraints specify the behaviors to be controlled and at minimum the medical staff and nursing staff had a working knowledge and trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

2. For Patient 17, the facility failed to develop and implement a comprehensive individualized " restraint " plan of care and flow-sheet, prior to, and while being on the effects of Haldol, a chemical restraint. In addition, the facility failed to ensure at minimum, the medical staff and nursing staff had a working knowledge and were trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

3. For Patient 19, the facility failed to develop and implement a comprehensive, individualized " restraint " plan of care and ensured that physicians' orders for restraints specify the behavior to be controlled and orders are never written as a " PRN " (as needed or necessary) order. In addition, the facility failed to ensure at minimum, the medical staff and nursing staff had a working knowledge and were trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

These deficient practices had the potential to result in substandard care and inappropriate use of patients in restraints and a violation of their right to be free from restraints.

Findings:

1. On 5/16/12, a review of patient 14's Emergency Departments' medical record was conducted. Patient 14 was admitted to the facility on 5/14/12 with an admitting diagnosis of alcohol intoxication.

On 5/16/12, a review of patient 14's emergency room record revealed that patient 14 was involved in a fight, found in a field with an apparent head injury. Patient 14 was brought in to the Emergency Department by law enforcement officers in hand cuffs, was combative, hostile and verbally abuse to hospital staff members

On 5/16/12, a review of the Physicians' Emergency Room Order sheet, dated 5/14/12, revealed the following orders:

a. Intravenous solution Normal Saline x 2 liters.

b. Foley Catheter.

c. Consult with anesthesia.

d. Soft restraints.

Thus, the facility failed to ensure that Patient 14's physician had ordered a clear, well defined parameters prior to ordering soft restraints by specifying the specific behavior to be controlled by the soft restraints and duration of its application.

On 5/16/12, a review of the facility's Restraints Flow Sheet, dated 5/14/12, revealed that Patient 14 was placed in a " Chest Belt " as a restraint, was still in hand cuffs and was placed in bilateral soft restraints at 10:48 PM.

Further review of the facility's restraint flow sheet, dated 5/14/12, indicated the following observations/interventions that were documented as required assessment every 15 minutes for behavioral restraint intervention as per facility policy:

a. Circulation/Neuro. (Completed by staff, filled out and evaluated every 15 minutes per policy).

b. Mental Status. (Completed by staff, filled out and evaluated every 15 minutes per policy).

c. Skin integrity. (Completed by staff, filled out and evaluated every 15 minutes per policy).

d. Repositioned. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

e. Range of Motion Performed. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

f. Foods/Fluid. . (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

g. Toileting. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

h. Emotional Support (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

Thus, the facility failed to complete all assessments/components required on the restraint flow-sheet as per facility policy. There was no assessment component in the facility's restraint flow sheet to monitor Patient 14's vital signs while in restraints.

There was no documented evidence in Patient 14 ' s medical record or from other facility sources that a comprehensive individualized restraint plan of care developed addressing: assessment; interventions; time frames; and an evaluation of Patient 14 ' s safety while in restraints and possibility of discontinuing the use of restraints at the earliest possible time.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, at minimum had a working knowledge and were trained and received education in appropriate use and management of restraints in age-specific patients as determined by hospital policy as of 5/14/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by the nursing staff, medical staff and Governing Body as of 5/14/12.

On 5/16/12, a review of the facility's policy and procedure titled, " RESTRAINTS-CHEMICAL AND PHYSICAL " dated 1/26/12, stipulated in section (8), " ...Physical restraints for behavior control shall only be used with a written order designed to achieve a less restrictive way of managing, and ultimately the elimination of the behavior for which the restraint was applied. There shall be no PRN orders for behavioral restraints. Restraint orders will be time limited ... "

In addition, section (9) stipulated, " ...Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method ... "

On 5/16/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed the finding that Patient 14's physician did not specify in his restraint order the behavior to be controlled, the incompleteness of the restraint flow sheet per facility policy, the failure to develop a restraint care plan and lack of formal education of the medical staff and nursing staff in appropriate use and management of restraints in age-specific patients.

2. On 5/16/12, a review of patient 17's Emergency Department ' s medical record was conducted. Patient 17 was admitted to the facility on 4/15/12 with an admitting diagnosis of altered mental status.

On 5/16/12, a review of patient 17's emergency room record revealed that patient 17 was found wandering in the woods and while in the emergency room became increasingly agitated, confused and hallucinatory. Clinical impression: Alcohol withdrawal with delirium tremors.

On 5/16/12, a review of the Physician's Emergency Room Order sheet, dated 4/15/12, revealed the following orders:

a. Intravenous solution Normal Saline wide open 1 liter, then 500 cc/hour.

b. Ativan 1 milligram IVP (Intravenous push).

c. Valium 10 milligram IVP

d. Haldol 3 milligrams IM (Intramuscular) at 12:05 PM (deemed by the facility as being a chemical restraint).

e. Haldol 2 milligrams IM at 1:20 PM (deemed by the facility as being a chemical restraint).

Thus, the facility failed to recognize that Patient 17's physician did not specify in the physicians' order sheet the specific behavior to be controlled or the specific disordered thought process to be eliminated by the chemical restraint Haldol.

There was no documented evidence in the medical record that a time frame (time limited) for use of the chemical restraint was ordered on 4/15/12.

There was no documented evidence in Patient 14's medical record or from other facility sources that a comprehensive individualized " restraint plan of care " was developed addressing: assessment; interventions; time frames; and an evaluation of Patient 17 safety while in restraints with the possibility of discontinuing the use of restraints at the earliest possible time on 4/15/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, at minimum had a working knowledge and were trained in management of age appropriate patients imposed on chemical restraints as of 4/15/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review, approval and accepted by Nursing Administration, the Medical Staff and Governing Body as of 4/15/12.

According to the facility's policy and procedure titled, " RESTRAINTS: CHEMICAL AND PHYSICAL " dated 1/26/12, defined Chemical restraints (drugs) when used to restrain, control behavior or to treat a disordered thought process, the following shall apply:

a. A licensed Independent Practitioner must see the patient prior to administration of the chemical restraint.

b. The specific behavior or manifestation of disordered thought process to be treated with the drug is identified and written in the Physician ' s Order.

c. The plan of care for each patient is collected for use in evaluating the effectiveness of the drugs and the observations necessary to detect possible adverse reactions.

There was no documented evidence in Patient 17's medical record or from other facility sources that a " restraint flow sheet " was developed and implemented as per facility policy on 4/15/12.

There was no documented evidence in Patient 17's medical record or from other facility sources that a " restraint care plan " was developed and implemented as per facility policy on 4/15/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, were trained and received education in appropriate use and management of restraints in age-specific patients as of 4/15/12.

On 5/26/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed the finding that Patient 17 ' s physician did not specify in his order the behavior to be controlled or the disordered thought process to be eliminated by the chemical restraint and not developing and implementing a restraint flow sheet and plan of care. In addition, the Director stated that the medical staff and nursing staff were not trained by the facility in appropriate management of patients receiving chemical restraints in age specific patients.

3. On 5/16/12, a review of patient 19's Emergency Department's medical record was conducted. Patient 19 was admitted to the facility on 5/7/12 with an admitting diagnosis of alcohol intoxication.

On 5/16/12, a review of patient 19's emergency room record revealed that patient 19 was striking walls, agitated and combative while in the emergency room. Clinical Impression: Depression, alcohol abuse and suicide attempt.

On 5/16/12, a review of the Physician's Emergency Room Order sheet, dated 5/7/12, revealed the following orders:

a. Intravenous solution Normal Saline wide open 1 liter.

b. Haldol 5 milligrams IM (Intramuscularly) (deemed by the facility as being a chemical restraint).

c. Wrist restraints as needed.

d. Leg restraints as needed.

Thus, the facility failed to recognize that Patient 19's physician did not specify in the written order the specific behavior to be controlled or the specific disordered thought process to be eliminated by the chemical restraint Haldol on 5/7/12.

There was no documented evidence in the medical record that a time frame (time limited) for use of the chemical restraint was ordered on 5/7/12.

The facility failed to recognize and ensure that all physical and chemical restraints are never written as a PRN (as necessary) order as per facility policy on 5/7/12.

On 5/16/12, a review of the facility's policy and procedure titled, " RESTRAINTS-CHEMICAL AND PHYSICAL " dated 1/26/12, stipulated in section (8), " ...Physical restraints for behavior control shall only be used with a written order designed to achieve a less restrictive way of managing, and ultimately the elimination of the behavior for which the restraint was applied. There shall be no PRN orders for behavioral restraints. Restraint orders will be time limited ... "

In addition, section (9) stipulated, " ...Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method ... "

There was no documented evidence in Patient 19's medical record or from other facility sources that a comprehensive individualized restraint care plan was developed addressing: assessment; interventions; time frames; and an evaluation of Patient 19's safety while in restraints and the possibility of discontinuing the use of restraints at the earliest possible time on 5/7/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, were trained and received education in appropriate use and management of physical and chemical restraints in age-specific patients as of 5/7/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by Nursing Administration, the Medical Staff and Governing Body as of 5/7/12.

5/16/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed that physical and chemical restraint orders are never ordered as a PRN order and that Patient 19's physician did not specify in his order the behavior to be controlled or the disordered thought process to be eliminated by the chemical restraint and not developing and implementing a restraint care plan. In addition, the Director stated that the medical staff and nursing staff were not trained by the facility in appropriate management of patients receiving chemical restraints or in physical restraints in age specific patients.

Based on interview and record review, the facility failed to ensure that 3 of 20 patients (Patients 14, 17, and 19 ) imposed in physical or chemical restraints, had mechanisms and methods in place to ensure patient safety and while eliminating the inappropriate use of restraints in order to ensure that the basic rights of patients to receive care in a safe setting are being promoted.

1. For Patient 14, the facility failed to develop and implement a comprehensive individualized " restraint " plan of care and complete all components of the facility's restraint flow-sheet. In addition, the facility failed to ensure that physician orders ' written for restraints specify the behaviors to be controlled and at minimum the medical staff and nursing staff had a working knowledge and trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

2. For Patient 17, the facility failed to develop and implement a comprehensive individualized " restraint " plan of care and flow-sheet, prior to, and while being on the effects of Haldol, a chemical restraint. In addition, the facility failed to ensure at minimum, the medical staff and nursing staff had a working knowledge and were trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

3. For Patient 19, the facility failed to develop and implement a comprehensive, individualized " restraint " plan of care and ensured that physicians' orders for restraints specify the behavior to be controlled and orders are never written as a " PRN " (as needed or necessary) order. In addition, the facility failed to ensure at minimum, the medical staff and nursing staff had a working knowledge and were trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

These deficient practices had the potential to result in substandard care and inappropriate use of patients in restraints and a violation of their right to be free from restraints.

Findings:

1. On 5/16/12, a review of patient 14's Emergency Departments' medical record was conducted. Patient 14 was admitted to the facility on 5/14/12 with an admitting diagnosis of alcohol intoxication.

On 5/16/12, a review of patient 14's emergency room record revealed that patient 14 was involved in a fight, found in a field with an apparent head injury. Patient 14 was brought in to the Emergency Department by law enforcement officers in hand cuffs was combative, hostile and verbally abuse to hospital staff members

On 5/16/12, a review of the Physicians' Emergency Room Order sheet, dated 5/14/12, revealed the following orders:

a. Intravenous solution Normal Saline x 2 liters.

b. Foley Catheter.

c. Consult with anesthesia.

d. Soft restraints.

Thus, the facility failed to ensure that Patient 14's physician had ordered clear, well defined parameters prior to ordering soft restraints by specifying the specific behavior to be controlled by the soft restraints and duration of its application.

On 5/16/12, a review of the facility's Restraints Flow Sheet, dated 5/14/12, revealed that Patient 14 was placed in a " Chest Belt " as a restraint, was still in hand cuffs and was placed in bilateral soft restraints at 10:48 PM.

Further review of the facility's restraint flow sheet, dated 5/14/12, indicated the following observations/interventions that were documented as required assessment every 15 minutes for behavioral restraint intervention as per facility policy:

a. Circulation/Neuro. (Completed by staff, filled out and evaluated every 15 minutes per policy).

b. Mental Status. (Completed by staff, filled out and evaluated every 15 minutes per policy).

c. Skin integrity. (Completed by staff, filled out and evaluated every 15 minutes per policy).

d. Repositioned. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

e. Range of Motion Performed. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

f. Foods/Fluid. . (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

g. Toileting. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

h. Emotional Support (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

Thus, the facility failed to complete all assessments/components required on the restraint flow-sheet as per facility policy. There was no assessment component in the facility's restraint flow sheet to monitor Patient 14's vital signs while in physical restraints.

There was no documented evidence in Patient 14's medical record or from other facility sources that a comprehensive individualized restraint plan of care developed addressing: assessment; interventions; time frames; and an evaluation of Patient 14's safety while in restraints and possibility of discontinuing the use of restraints at the earliest possible time.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, at minimum had a working knowledge and were trained and received education in appropriate use and management of restraints in age-specific patients as determined by hospital policy as of 5/14/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by Nursing Administration, the Medical Staff and Governing Body as of 5/14/12.

On 5/16/12, a review of the facility's policy and procedure titled, " RESTRAINTS-CHEMICAL AND PHYSICAL " dated 1/26/12, stipulated in section (8), " ...Physical restraints for behavior control shall only be used with a written order designed to achieve a less restrictive way of managing, and ultimately the elimination of the behavior for which the restraint was applied. There shall be no PRN orders for behavioral restraints. Restraint orders will be time limited ... "

In addition, section (9) stipulated, " ...Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method ... "

On 5/16/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed the finding that Patient 14's physician did not specify in his restraint order the behavior to be controlled, the incompleteness of the restraint flow sheet per facility policy, the failure to develop a restraint care plan and lack of formal education of the medical staff and nursing staff in appropriate use and management of restraints in age-specific patients.

2. On 5/16/12, a review of patient 17's Emergency Department's medical record was conducted. Patient 17 was admitted to the facility on 4/15/12 with an admitting diagnosis of altered mental status.

On 5/16/12, a review of patient 17's emergency room record revealed that patient 17 was found wandering in the woods and while in the emergency room became increasingly agitated, confused and hallucinatory. Clinical impression: Alcohol withdrawal with delirium tremors.

On 5/16/12, a review of the Physician's Emergency Room Order sheet, dated 4/15/12, revealed the following orders:

a. Intravenous solution Normal Saline wide open 1 liter, then 500 cc/hour.

b. Ativan 1 milligram IVP (Intravenous push).

c. Valium 10 milligram IVP

d. Haldol 3 milligrams IM (Intramuscular) at 12:05 PM (deemed by the facility as being a chemical restraint).

e. Haldol 2 milligrams IM at 1:20 PM (deemed by the facility as being a chemical restraint).

Thus, the facility failed to recognize that Patient 17's physician did not specify in the Physician's Order Sheet the specific behavior to be controlled or the specific disordered thought process to be eliminated by the chemical restraint Haldol on 4/15/12.

There was no documented evidence in the medical record that a time frame (time limited) for use of the chemical restraint was ordered on 4/15/12.

There was no documented evidence in Patient 14's medical record or from other facility sources that a comprehensive individualized " restraint plan of care " was developed addressing: assessment; interventions; time frames; and an evaluation of Patient 17 safety while in restraints and possibility of discontinuing the use of restraints at the earliest possible time on 4/15/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, at minimum had a working knowledge and were trained in management of patients imposed on chemical restraints on 4/15/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by Nursing Administration , the Medical Staff and the Governing Body as of 4/15/12.

According to the facility's policy and procedure titled, " RESTRAINTS: CHEMICAL AND PHYSICAL " dated 1/26/12, defined Chemical restraints (drugs) when used to restrain, control behavior or to treat a disordered thought process, the following shall apply:

a. A licensed Independent Practitioner must see the patient prior to administration of the chemical restraint.

b. The specific behavior or manifestation of disordered thought process to be treated with the drug is identified and written in the Physician ' s Order.

c. The plan of care for each patient is collected for use in evaluating the effectiveness of the drugs and the observations necessary to detect possible adverse reactions.

There was no documented evidence in Patient 17's medical record or from other facility sources that a " restraint flow sheet " was developed and implemented as per facility policy on 4/15/12.

There was no documented evidence in Patient 17's medical record or from other facility sources that a " restraint care plan " was developed and implemented as per facility policy on 4/15/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, were trained and received education in appropriate use and management of restraints in age-specific patients as of 4/15/12.

On 5/26/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed the finding that Patient 17's physician did not specify in his order the behavior to be controlled or the disordered thought process to be eliminated by the chemical restraint and not developing and implementing a restraint flow sheet and plan of care. In addition, the Director stated that the medical staff and nursing staff were not trained by the facility in appropriate management of patients receiving chemical restraints in age specific patients.

3. On 5/16/12, a review of patient 19's Emergency Department's medical record was conducted. Patient 19 was admitted to the facility on 5/7/12 with an admitting diagnosis of alcohol intoxication.

On 5/16/12, a review of patient 19's emergency room record revealed that patient 19 was striking walls, agitated and combative while in the emergency room. Clinical Impression: Depression, alcohol abuse and suicide attempt.

On 5/16/12, a review of the Physician's Emergency Room Order sheet, dated 5/7/12, revealed the following orders:

a. Intravenous solution Normal Saline wide open 1 liter.

b. Haldol 5 milligrams IM (Intramuscularly) (deemed by the facility as being a chemical restraint).

c. Wrist restraints as needed.

d. Leg restraints as needed.

Thus, the facility failed to recognize that Patient 19's physician did not specify in the written order the specific behavior to be controlled or the specific disordered thought process to be eliminated by the chemical restraint Haldol on 5/7/12.

There was no documented evidence in the medical record that a time frame (time limited) for use of the chemical restraint was ordered on 5/7/12.

The facility failed to recognize and ensure that all physical and chemical restraints are never written as a PRN (as necessary) order as per facility policy on 5/7/12.

On 5/16/12, a review of the facility's policy and procedure titled, " RESTRAINTS-CHEMICAL AND PHYSICAL " dated 1/26/12, stipulated in section (8), " ...Physical restraints for behavior control shall only be used with a written order designed to achieve a less restrictive way of managing, and ultimately the elimination of the behavior for which the restraint was applied. There shall be no PRN orders for behavioral restraints. Restraint orders will be time limited ... "

In addition, section (9) stipulated, " ...Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method ... "

There was no documented evidence in Patient 19's medical record or from other facility sources that a comprehensive individualized restraint care plan was developed addressing: assessment; interventions; time frames; and an evaluation of Patient 19's safety while in restraints and the possibility of discontinuing the use of restraints at the earliest possible time on 5/7/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, were trained and received education in appropriate use and management of physical and chemical restraints in age-specific patients as of 5/7/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by Nursing Administration, the Medical Staff and the Governing Body as of 5/7/12.

5/16/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed that physical and chemical restraint orders are never ordered as a PRN order and that Patient 19's physician did not specify in his order the behavior to be controlled or the disordered thought process to be eliminated by the chemical restraint and not developing and implementing a restraint care plan. In addition, the Director stated that the medical staff and nursing staff were not trained by the facility in appropriate management of patients receiving chemical restraints or in physical restraints in age specific patients.

Based on interview and record review, the facility failed to ensure that 3 of 20 patients (Patients 14, 17, and 19 ) imposed in physical or chemical restraints, had mechanisms and methods in place to ensure patient safety and while eliminating the inappropriate use of restraints in order to ensure that the basic rights of patients to receive care in a safe setting are being promoted.

1. For Patient 14, the facility failed to develop and implement a comprehensive individualized " restraint " plan of care and complete all components of the facility's restraint flow-sheet. In addition, the facility failed to ensure that physician orders ' written for restraints specify the behaviors to be controlled and at minimum the medical staff and nursing staff had a working knowledge and trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

2. For Patient 17, the facility failed to develop and implement a comprehensive individualized " restraint " plan of care and flow-sheet, prior to, and while being on the effects of Haldol, a chemical restraint. In addition, the facility failed to ensure at minimum, the medical staff and nursing staff had a working knowledge and were trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

3. For Patient 19, the facility failed to develop and implement a comprehensive, individualized " restraint " plan of care and ensured that physicians' orders for restraints specify the behavior to be controlled and orders are never written as a " PRN " (as needed or necessary) order. In addition, the facility failed to ensure at minimum, the medical staff and nursing staff had a working knowledge and were trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

These deficient practices had the potential to result in substandard care and inappropriate use of patients in restraints and a violation of their right to be free from restraints.

Findings:

1. On 5/16/12, a review of patient 14's Emergency Departments' medical record was conducted. Patient 14 was admitted to the facility on 5/14/12 with an admitting diagnosis of alcohol intoxication.

On 5/16/12, a review of patient 14's emergency room record revealed that patient 14 was involved in a fight, found in a field with an apparent head injury. Patient 14 was brought in to the Emergency Department by law enforcement officers in hand cuffs was combative, hostile and verbally abuse to hospital staff members

On 5/16/12, a review of the Physicians' Emergency Room Order sheet, dated 5/14/12, revealed the following orders:

a. Intravenous solution Normal Saline x 2 liters.

b. Foley Catheter.

c. Consult with anesthesia.

d. Soft restraints.

Thus, the facility failed to ensure that Patient 14's physician had ordered clear, well defined parameters prior to ordering soft restraints by specifying the specific behavior to be controlled by the soft restraints and duration of its application.

On 5/16/12, a review of the facility's Restraints Flow Sheet, dated 5/14/12, revealed that Patient 14 was placed in a " Chest Belt " as a restraint, was still in hand cuffs and was placed in bilateral soft restraints at 10:48 PM.

Further review of the facility's restraint flow sheet, dated 5/14/12, indicated the following observations/interventions that were documented as required assessment every 15 minutes for behavioral restraint intervention as per facility policy:

a. Circulation/Neuro. (Completed by staff, filled out and evaluated every 15 minutes per policy).

b. Mental Status. (Completed by staff, filled out and evaluated every 15 minutes per policy).

c. Skin integrity. (Completed by staff, filled out and evaluated every 15 minutes per policy).

d. Repositioned. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

e. Range of Motion Performed. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

f. Foods/Fluid. . (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

g. Toileting. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

h. Emotional Support (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

Thus, the facility failed to complete all assessments/components required on the restraint flow-sheet as per facility policy. There was no assessment component in the facility ' s restraint flow sheet to monitor Patient 14 ' s vital signs while in restraints.

There was no documented evidence in Patient 14's medical record or from other facility sources that a comprehensive individualized restraint plan of care developed addressing: assessment; interventions; time frames; and an evaluation of Patient 14's safety while in restraints and possibility of discontinuing the use of restraints at the earliest possible time.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, at minimum had a working knowledge and were trained and received education in appropriate use and management of restraints in age-specific patients as determined by hospital policy as of 5/14/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by Nursing Administration, the Medical Staff and Governing Body as of 5/14/12.

On 5/16/12, a review of the facility's policy and procedure titled, " RESTRAINTS-CHEMICAL AND PHYSICAL " dated 1/26/12, stipulated in section (8), " ...Physical restraints for behavior control shall only be used with a written order designed to achieve a less restrictive way of managing, and ultimately the elimination of the behavior for which the restraint was applied. There shall be no PRN orders for behavioral restraints. Restraint orders will be time limited ... "

In addition, section (9) stipulated, " ...Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method ... "

On 5/16/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed the finding that Patient 14's physician did not specify in his restraint order the behavior to be controlled, the incompleteness of the restraint flow sheet per facility policy, the failure to develop a restraint care plan and lack of formal education of the medical staff and nursing staff in appropriate use and management of restraints in age-specific patients.

2. On 5/16/12, a review of patient 17's Emergency Department's medical record was conducted. Patient 17 was admitted to the facility on 4/15/12 with an admitting diagnosis of altered mental status.

On 5/16/12, a review of patient 17's emergency room record revealed that patient 17 was found wandering in the woods and while in the emergency room became increasingly agitated, confused and hallucinatory. Clinical impression: Alcohol withdrawal with delirium tremors.

On 5/16/12, a review of the Physician's Emergency Room Order sheet, dated 4/15/12, revealed the following orders:

a. Intravenous solution Normal Saline wide open 1 liter, then 500 cc/hour.

b. Ativan 1 milligram IVP (Intravenous push).

c. Valium 10 milligram IVP

d. Haldol 3 milligrams IM (Intramuscular) at 12:05 PM (deemed by the facility as being a chemical restraint).

e. Haldol 2 milligrams IM at 1:20 PM (deemed by the facility as being a chemical restraint).

Thus, the facility failed to recognize that Patient 17's physician did not specify in the written order the specific behavior to be controlled or the specific disordered thought process to be eliminated by the chemical restraint Haldol.

There was no documented evidence in the medical record that a time frame (time limited) for use of the chemical restraint was ordered on 4/15/12.

There was no documented evidence in Patient 14's medical record or from other facility sources that a comprehensive individualized " restraint plan of care " was developed addressing: assessment; interventions; time frames; and an evaluation of Patient 17 safety while in restraints and possibility of discontinuing the use of restraints at the earliest possible time on 4/15/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, at minimum had a working knowledge and were trained in management of patients imposed on chemical restraints on 4/15/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by Nursing Administration, the Medical Staff and Governing Body as of 4/15/12.

According to the facility's policy and procedure titled, " RESTRAINTS: CHEMICAL AND PHYSICAL " dated 1/26/12, defined Chemical restraints (drugs) when used to restrain, control behavior or to treat a disordered thought process, the following shall apply:

a. A licensed Independent Practitioner must see the patient prior to administration of the chemical restraint.

b. The specific behavior or manifestation of disordered thought process to be treated with the drug is identified and written in the Physician's Order.

c. The plan of care for each patient is collected for use in evaluating the effectiveness of the drugs and the observations necessary to detect possible adverse reactions.

There was no documented evidence in Patient 17's medical record or from other facility sources that a " restraint flow sheet " was developed and implemented as per facility policy on 4/15/12.

There was no documented evidence in Patient 17's medical record or from other facility sources that a " restraint care plan " was developed and implemented as per facility policy on 4/15/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, were trained and received education in appropriate use and management of restraints in age-specific patients as of 4/15/12.

On 5/26/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed the finding that Patient 17's physician did not specify in his order the behavior to be controlled or the disordered thought process to be eliminated by the chemical restraint and not developing and implementing a restraint flow sheet and plan of care. In addition, the Director stated that the medical staff and nursing staff were not trained by the facility in appropriate management of patients receiving chemical restraints in age specific patients.

3. On 5/16/12, a review of patient 19's Emergency Department's medical record was conducted. Patient 19 was admitted to the facility on 5/7/12 with an admitting diagnosis of alcohol intoxication.

On 5/16/12, a review of patient 19's emergency room record revealed that patient 19 was striking walls, agitated and combative while in the emergency room. Clinical Impression: Depression, alcohol abuse and suicide attempt.

On 5/16/12, a review of the Physician's Emergency Room Order sheet, dated 5/7/12, revealed the following orders:

a. Intravenous solution Normal Saline wide open 1 liter.

b. Haldol 5 milligrams IM (Intramuscularly) (deemed by the facility as being a chemical restraint).

c. Wrist restraints as needed.

d. Leg restraints as needed.

Thus, the facility failed to recognize that Patient 19's physician did not specify in the written order the specific behavior to be controlled or the specific disordered thought process to be eliminated by the chemical restraint Haldol on 5/7/12.

There was no documented evidence in the medical record that a time frame (time limited) for use of the chemical restraint was ordered on 5/7/12.

The facility failed to recognize and ensure that all physical and chemical restraints are never written as a PRN (as necessary) order as per facility policy on 5/7/12.

On 5/16/12, a review of the facility's policy and procedure titled, " RESTRAINTS-CHEMICAL AND PHYSICAL " dated 1/26/12, stipulated in section (8), " ...Physical restraints for behavior control shall only be used with a written order designed to achieve a less restrictive way of managing, and ultimately the elimination of the behavior for which the restraint was applied. There shall be no PRN orders for behavioral restraints. Restraint orders will be time limited ... "

In addition, section (9) stipulated, " ...Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method ... "

There was no documented evidence in Patient 19's medical record or from other facility sources that a comprehensive individualized restraint care plan was developed addressing: assessment; interventions; time frames; and an evaluation of Patient 19's safety while in restraints and the possibility of discontinuing the use of restraints at the earliest possible time on 5/7/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, were trained and received education in appropriate use and management of physical and chemical restraints in age-specific patients as of 5/7/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by Nursing Administration, the Medical Staff and Governing Body as of 5/7/12.

5/16/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed that physical and chemical restraint orders are never ordered as a PRN order and that Patient 19's physician did not specify in his order the behavior to be controlled or the disordered thought process to be eliminated by the chemical restraint and not developing and implementing a restraint care plan. In addition, the Director stated that the medical staff and nursing staff were not trained by the facility in appropriate management of patients receiving chemical restraints or in physical restraints in age specific patients.

Based on interview and record review, the facility failed to ensure that 3 of 20 patients (Patients 14, 17, and 19 ) imposed in physical or chemical restraints, had mechanisms and methods in place to ensure patient safety and while eliminating the inappropriate use of restraints in order to ensure that the basic rights of patients to receive care in a safe setting are being promoted.

1. For Patient 14, the facility failed to develop and implement a comprehensive individualized " restraint " plan of care and complete all components of the facility's restraint flow-sheet. In addition, the facility failed to ensure that physician orders ' written for restraints specify the behaviors to be controlled and at minimum the medical staff and nursing staff had a working knowledge and trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

2. For Patient 17, the facility failed to develop and implement a comprehensive individualized " restraint " plan of care and flow-sheet, prior to, and while being on the effects of Haldol, a chemical restraint. In addition, the facility failed to ensure at minimum, the medical staff and nursing staff had a working knowledge and were trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

3. For Patient 19, the facility failed to develop and implement a comprehensive, individualized " restraint " plan of care and ensured that physicians' orders for restraints specify the behavior to be controlled and orders are never written as a " PRN " (as needed or necessary) order. In addition, the facility failed to ensure at minimum, the medical staff and nursing staff had a working knowledge and were trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

These deficient practices had the potential to result in substandard care and inappropriate use of patients in restraints and a violation of their right to be free from restraints.

Findings:

1. On 5/16/12, a review of patient 14's Emergency Departments' medical record was conducted. Patient 14 was admitted to the facility on 5/14/12 with an admitting diagnosis of alcohol intoxication.

On 5/16/12, a review of patient 14's emergency room record revealed that patient 14 was involved in a fight, found in a field with an apparent head injury. Patient 14 was brought in to the Emergency Department by law enforcement officers in hand cuffs was combative, hostile and verbally abuse to hospital staff members

On 5/16/12, a review of the Physicians' Emergency Room Order sheet, dated 5/14/12, revealed the following orders:

a. Intravenous solution Normal Saline x 2 liters.

b. Foley Catheter.

c. Consult with anesthesia.

d. Soft restraints.

Thus, the facility failed to ensure that Patient 14's physician had ordered clear, well defined parameters prior to ordering soft restraints by specifying the specific behavior to be controlled by the soft restraints and duration of its application.

On 5/16/12, a review of the facility's Restraints Flow Sheet, dated 5/14/12, revealed that Patient 14 was placed in a " Chest Belt " as a restraint, was still in hand cuffs and was placed in bilateral soft restraints at 10:48 PM.

Further review of the facility's restraint flow sheet, dated 5/14/12, indicated the following observations/interventions that were documented as required assessment every 15 minutes for behavioral restraint intervention as per facility policy:

a. Circulation/Neuro. (Completed by staff, filled out and evaluated every 15 minutes per policy).

b. Mental Status. (Completed by staff, filled out and evaluated every 15 minutes per policy).

c. Skin integrity. (Completed by staff, filled out and evaluated every 15 minutes per policy).

d. Repositioned. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

e. Range of Motion Performed. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

f. Foods/Fluid. . (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

g. Toileting. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

h. Emotional Support (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

Thus, the facility failed to complete all assessments/components required on the restraint flow-sheet as per facility policy. There was no assessment component in the facility ' s restraint flow sheet to monitor Patient 14 ' s vital signs while in restraints.

There was no documented evidence in Patient 14 ' s medical record or from other facility sources that a comprehensive individualized restraint plan of care developed addressing: assessment; interventions; time frames; and an evaluation of Patient 14 ' s safety while in restraints and possibility of discontinuing the use of restraints at the earliest possible time.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, at minimum had a working knowledge and were trained and received education in appropriate use and management of restraints in age-specific patients as determined by hospital policy as of 5/14/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by the nursing staff, medical staff and Governing Body as of 5/14/12.

On 5/16/12, a review of the facility's policy and procedure titled, " RESTRAINTS-CHEMICAL AND PHYSICAL " dated 1/26/12, stipulated in section (8), " ...Physical restraints for behavior control shall only be used with a written order designed to achieve a less restrictive way of managing, and ultimately the elimination of the behavior for which the restraint was applied. There shall be no PRN orders for behavioral restraints. Restraint orders will be time limited ... "

In addition, section (9) stipulated, " ...Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method ... "

On 5/16/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed the finding that Patient 14 ' s physician did not specify in his restraint order the behavior to be controlled, the incompleteness of the restraint flow sheet per facility policy, the failure to develop a restraint care plan and lack of formal education of the medical staff and nursing staff in appropriate use and management of restraints in age-specific patients.

2. On 5/16/12, a review of patient 17's Emergency Department ' s medical record was conducted. Patient 17 was admitted to the facility on 4/15/12 with an admitting diagnosis of altered mental status.

On 5/16/12, a review of patient 17's emergency room record revealed that patient 17 was found wandering in the woods and while in the emergency room became increasingly agitated, confused and hallucinatory. Clinical impression: Alcohol withdrawal with delirium tremors.

On 5/16/12, a review of the Physician's Emergency Room Order sheet, dated 4/15/12, revealed the following orders:

a. Intravenous solution Normal Saline wide open 1 liter, then 500 cc/hour.

b. Ativan 1 milligram IVP (Intravenous push).

c. Valium 10 milligram IVP

d. Haldol 3 milligrams IM (Intramuscular) at 12:05 PM (deemed by the facility as being a chemical restraint).

e. Haldol 2 milligrams IM at 1:20 PM (deemed by the facility as being a chemical restraint).

Thus, the facility failed to recognize that Patient 17's physician did not specify in the written order the specific behavior to be controlled or the specific disordered thought process to be eliminated by the chemical restraint Haldol.

There was no documented evidence in the medical record that a time frame (time limited) for use of the chemical restraint was ordered on 4/15/12.

There was no documented evidence in Patient 14's medical record or from other facility sources that a comprehensive individualized " restraint plan of care " was developed addressing: assessment; interventions; time frames; and an evaluation of Patient 17 safety while in restraints and possibility of discontinuing the use of restraints at the earliest possible time on 4/15/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, at minimum had a working knowledge and were trained in management of patients imposed on chemical restraints on 4/15/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by the nursing staff, medical staff and Governing Body as of 4/15/12.

According to the facility's policy and procedure titled, " RESTRAINTS: CHEMICAL AND PHYSICAL " dated 1/26/12, defined Chemical restraints (drugs) when used to restrain, control behavior or to treat a disordered thought process, the following shall apply:

a. A licensed Independent Practitioner must see the patient prior to administration of the chemical restraint.

b. The specific behavior or manifestation of disordered thought process to be treated with the drug is identified and written in the Physician ' s Order.

c. The plan of care for each patient is collected for use in evaluating the effectiveness of the drugs and the observations necessary to detect possible adverse reactions.

There was no documented evidence in Patient 17's medical record or from other facility sources that a " restraint flow sheet " was developed and implemented as per facility policy on 4/15/12.

There was no documented evidence in Patient 17's medical record or from other facility sources that a " restraint care plan " was developed and implemented as per facility policy on 4/15/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, were trained and received education in appropriate use and management of restraints in age-specific patients as of 4/15/12.

On 5/26/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed the finding that Patient 17 ' s physician did not specify in his order the behavior to be controlled or the disordered thought process to be eliminated by the chemical restraint and not developing and implementing a restraint flow sheet and plan of care. In addition, the Director stated that the medical staff and nursing staff were not trained by the facility in appropriate management of patients receiving chemical restraints in age specific patients.

3. On 5/16/12, a review of patient 19's Emergency Department's medical record was conducted. Patient 19 was admitted to the facility on 5/7/12 with an admitting diagnosis of alcohol intoxication.

On 5/16/12, a review of patient 19's emergency room record revealed that patient 19 was striking walls, agitated and combative while in the emergency room. Clinical Impression: Depression, alcohol abuse and suicide attempt.

On 5/16/12, a review of the Physician's Emergency Room Order sheet, dated 5/7/12, revealed the following orders:

a. Intravenous solution Normal Saline wide open 1 liter.

b. Haldol 5 milligrams IM (Intramuscularly) (deemed by the facility as being a chemical restraint).

c. Wrist restraints as needed.

d. Leg restraints as needed.

Thus, the facility failed to recognize that Patient 19's physician did not specify in the written order the specific behavior to be controlled or the specific disordered thought process to be eliminated by the chemical restraint Haldol on 5/7/12.

There was no documented evidence in the medical record that a time frame (time limited) for use of the chemical restraint was ordered on 5/7/12.

The facility failed to recognize and ensure that all physical and chemical restraints are never written as a PRN (as necessary) order as per facility policy on 5/7/12.

On 5/16/12, a review of the facility's policy and procedure titled, " RESTRAINTS-CHEMICAL AND PHYSICAL " dated 1/26/12, stipulated in section (8), " ...Physical restraints for behavior control shall only be used with a written order designed to achieve a less restrictive way of managing, and ultimately the elimination of the behavior for which the restraint was applied. There shall be no PRN orders for behavioral restraints. Restraint orders will be time limited ... "

In addition, section (9) stipulated, " ...Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method ... "

There was no documented evidence in Patient 19's medical record or from other facility sources that a comprehensive individualized restraint care plan was developed addressing: assessment; interventions; time frames; and an evaluation of Patient 19's safety while in restraints and the possibility of discontinuing the use of restraints at the earliest possible time on 5/7/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, were trained and received education in appropriate use and management of physical and chemical restraints in age-specific patients as of 5/7/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by the nursing staff, medical staff and Governing Body as of 5/7/12.

5/16/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed that physical and chemical restraint orders are never ordered as a PRN order and that Patient 19 ' s physician did not specify in his order the behavior to be controlled or the disordered thought process to be eliminated by the chemical restraint and not developing and implementing a restraint care plan. In addition, the Director stated that the medical staff and nursing staff were not trained by the facility in appropriate management of patients receiving chemical restraints or in physical restraints in age specific patients.

Based on interview and record review, the facility failed to ensure that 3 of 20 patients (Patients 14, 17, and 19 ) imposed in physical or chemical restraints, had mechanisms and methods in place to ensure patient safety and while eliminating the inappropriate use of restraints in order to ensure that the basic rights of patients to receive care in a safe setting are being promoted.

1. For Patient 14, the facility failed to develop and implement a comprehensive individualized " restraint " plan of care and complete all components of the facility's restraint flow-sheet. In addition, the facility failed to ensure that physician orders ' written for restraints specify the behaviors to be controlled and at minimum the medical staff and nursing staff had a working knowledge and trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

2. For Patient 17, the facility failed to develop and implement a comprehensive individualized " restraint " plan of care and flow-sheet, prior to, and while being on the effects of Haldol, a chemical restraint. In addition, the facility failed to ensure at minimum, the medical staff and nursing staff had a working knowledge and were trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

3. For Patient 19, the facility failed to develop and implement a comprehensive, individualized " restraint " plan of care and ensured that physicians' orders for restraints specify the behavior to be controlled and orders are never written as a " PRN " (as needed or necessary) order. In addition, the facility failed to ensure at minimum, the medical staff and nursing staff had a working knowledge and were trained in appropriate use and management of restraints in age-specific patients as determined by hospital policy.

These deficient practices had the potential to result in substandard care and inappropriate use of patients in restraints and a violation of their right to be free from restraints.

Findings:

1. On 5/16/12, a review of patient 14's Emergency Departments' medical record was conducted. Patient 14 was admitted to the facility on 5/14/12 with an admitting diagnosis of alcohol intoxication.

On 5/16/12, a review of patient 14's emergency room record revealed that patient 14 was involved in a fight, found in a field with an apparent head injury. Patient 14 was brought in to the Emergency Department by law enforcement officers in hand cuffs was combative, hostile and verbally abuse to hospital staff members

On 5/16/12, a review of the Physicians' Emergency Room Order sheet, dated 5/14/12, revealed the following orders:

a. Intravenous solution Normal Saline x 2 liters.

b. Foley Catheter.

c. Consult with anesthesia.

d. Soft restraints.

Thus, the facility failed to ensure that Patient 14's physician had ordered clear, well defined parameters prior to ordering soft restraints by specifying the specific behavior to be controlled by the soft restraints and duration of its application.

On 5/16/12, a review of the facility's Restraints Flow Sheet, dated 5/14/12, revealed that Patient 14 was placed in a " Chest Belt " as a restraint, was still in hand cuffs and was placed in bilateral soft restraints at 10:48 PM.

Further review of the facility's restraint flow sheet, dated 5/14/12, indicated the following observations/interventions that were documented as required assessment every 15 minutes for behavioral restraint intervention as per facility policy:

a. Circulation/Neuro. (Completed by staff, filled out and evaluated every 15 minutes per policy).

b. Mental Status. (Completed by staff, filled out and evaluated every 15 minutes per policy).

c. Skin integrity. (Completed by staff, filled out and evaluated every 15 minutes per policy).

d. Repositioned. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

e. Range of Motion Performed. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

f. Foods/Fluid. . (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

g. Toileting. (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

h. Emotional Support (Found incomplete and not filled out or evaluated every 15 minutes by staff per facility policy).

Thus, the facility failed to complete all assessments/components required on the restraint flow-sheet as per facility policy. There was no assessment component in the facility ' s restraint flow sheet to monitor Patient 14 ' s vital signs while in restraints.

There was no documented evidence in Patient 14 ' s medical record or from other facility sources that a comprehensive individualized restraint plan of care developed addressing: assessment; interventions; time frames; and an evaluation of Patient 14 ' s safety while in restraints and possibility of discontinuing the use of restraints at the earliest possible time.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, at minimum had a working knowledge and were trained and received education in appropriate use and management of restraints in age-specific patients as determined by hospital policy as of 5/14/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by the nursing staff, medical staff and Governing Body as of 5/14/12.

On 5/16/12, a review of the facility's policy and procedure titled, " RESTRAINTS-CHEMICAL AND PHYSICAL " dated 1/26/12, stipulated in section (8), " ...Physical restraints for behavior control shall only be used with a written order designed to achieve a less restrictive way of managing, and ultimately the elimination of the behavior for which the restraint was applied. There shall be no PRN orders for behavioral restraints. Restraint orders will be time limited ... "

In addition, section (9) stipulated, " ...Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method ... "

On 5/16/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed the finding that Patient 14 ' s physician did not specify in his restraint order the behavior to be controlled, the incompleteness of the restraint flow sheet per facility policy, the failure to develop a restraint care plan and lack of formal education of the medical staff and nursing staff in appropriate use and management of restraints in age-specific patients.

2. On 5/16/12, a review of patient 17's Emergency Department ' s medical record was conducted. Patient 17 was admitted to the facility on 4/15/12 with an admitting diagnosis of altered mental status.

On 5/16/12, a review of patient 17's emergency room record revealed that patient 17 was found wandering in the woods and while in the emergency room became increasingly agitated, confused and hallucinatory. Clinical impression: Alcohol withdrawal with delirium tremors.

On 5/16/12, a review of the Physician's Emergency Room Order sheet, dated 4/15/12, revealed the following orders:

a. Intravenous solution Normal Saline wide open 1 liter, then 500 cc/hour.

b. Ativan 1 milligram IVP (Intravenous push).

c. Valium 10 milligram IVP

d. Haldol 3 milligrams IM (Intramuscular) at 12:05 PM (deemed by the facility as being a chemical restraint).

e. Haldol 2 milligrams IM at 1:20 PM (deemed by the facility as being a chemical restraint).

Thus, the facility failed to recognize that Patient 17's physician did not specify in the written order the specific behavior to be controlled or the specific disordered thought process to be eliminated by the chemical restraint Haldol.

There was no documented evidence in the medical record that a time frame (time limited) for use of the chemical restraint was ordered on 4/15/12.

There was no documented evidence in Patient 14's medical record or from other facility sources that a comprehensive individualized " restraint plan of care " was developed addressing: assessment; interventions; time frames; and an evaluation of Patient 17 safety while in restraints and possibility of discontinuing the use of restraints at the earliest possible time on 4/15/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, at minimum had a working knowledge and were trained in management of patients imposed on chemical restraints on 4/15/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by the nursing staff, medical staff and Governing Body as of 4/15/12.

According to the facility's policy and procedure titled, " RESTRAINTS: CHEMICAL AND PHYSICAL " dated 1/26/12, defined Chemical restraints (drugs) when used to restrain, control behavior or to treat a disordered thought process, the following shall apply:

a. A licensed Independent Practitioner must see the patient prior to administration of the chemical restraint.

b. The specific behavior or manifestation of disordered thought process to be treated with the drug is identified and written in the Physician ' s Order.

c. The plan of care for each patient is collected for use in evaluating the effectiveness of the drugs and the observations necessary to detect possible adverse reactions.

There was no documented evidence in Patient 17's medical record or from other facility sources that a " restraint flow sheet " was developed and implemented as per facility policy on 4/15/12.

There was no documented evidence in Patient 17's medical record or from other facility sources that a " restraint care plan " was developed and implemented as per facility policy on 4/15/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, were trained and received education in appropriate use and management of restraints in age-specific patients as of 4/15/12.

On 5/26/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed the finding that Patient 17 ' s physician did not specify in his order the behavior to be controlled or the disordered thought process to be eliminated by the chemical restraint and not developing and implementing a restraint flow sheet and plan of care. In addition, the Director stated that the medical staff and nursing staff were not trained by the facility in appropriate management of patients receiving chemical restraints in age specific patients.

3. On 5/16/12, a review of patient 19's Emergency Department's medical record was conducted. Patient 19 was admitted to the facility on 5/7/12 with an admitting diagnosis of alcohol intoxication.

On 5/16/12, a review of patient 19's emergency room record revealed that patient 19 was striking walls, agitated and combative while in the emergency room. Clinical Impression: Depression, alcohol abuse and suicide attempt.

On 5/16/12, a review of the Physician's Emergency Room Order sheet, dated 5/7/12, revealed the following orders:

a. Intravenous solution Normal Saline wide open 1 liter.

b. Haldol 5 milligrams IM (Intramuscularly) (deemed by the facility as being a chemical restraint).

c. Wrist restraints as needed.

d. Leg restraints as needed.

Thus, the facility failed to recognize that Patient 19's physician did not specify in the written order the specific behavior to be controlled or the specific disordered thought process to be eliminated by the chemical restraint Haldol on 5/7/12.

There was no documented evidence in the medical record that a time frame (time limited) for use of the chemical restraint was ordered on 5/7/12.

The facility failed to recognize and ensure that all physical and chemical restraints are never written as a PRN (as necessary) order as per facility policy on 5/7/12.

On 5/16/12, a review of the facility's policy and procedure titled, " RESTRAINTS-CHEMICAL AND PHYSICAL " dated 1/26/12, stipulated in section (8), " ...Physical restraints for behavior control shall only be used with a written order designed to achieve a less restrictive way of managing, and ultimately the elimination of the behavior for which the restraint was applied. There shall be no PRN orders for behavioral restraints. Restraint orders will be time limited ... "

In addition, section (9) stipulated, " ...Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method ... "

There was no documented evidence in Patient 19's medical record or from other facility sources that a comprehensive individualized restraint care plan was developed addressing: assessment; interventions; time frames; and an evaluation of Patient 19's safety while in restraints and the possibility of discontinuing the use of restraints at the earliest possible time on 5/7/12.

In addition, there was no documented evidence from facility sources that the medical staff and nursing staff, were trained and received education in appropriate use and management of physical and chemical restraints in age-specific patients as of 5/7/12.

There was no documented evidence that a formal policy and procedure for restraint use and educational training was developed for review and approval by the nursing staff, medical staff and Governing Body as of 5/7/12.

5/16/12, at the time of the finding, the Director of the Emergency Department and Acute Care Unit confirmed that physical and chemical restraint orders are never ordered as a PRN order and that Patient 19 ' s physician did not specify in his order the behavior to be controlled or the disordered thought process to be eliminated by the chemical restraint and not developing and implementing a restraint care plan. In addition, the Director stated that the medical staff and nursing staff were not trained by the facility in appropriate management of patients receiving chemical restraints or in physical restraints in age specific patients.

Based on interview and record review, the facility failed to have a well-organized nursing service when they failed to ensure:

1. All staff that were under nursing supervision had competency validation prior to being assigned patient care. The nursing services entrusted the heart monitoring of patients to technicians and nurses that had no demonstrated competencies to complete their job. The nursing services entrusted the care of patients to nursing staff without validating the nurse's competency to complete the work, such as giving respiratory treatments, mixing intravenous (IV) medications, managing IV pumps and heart monitors, and age specific care of the patient. This failure had the potential to result in patient harm for any patient using the nursing services of hospital.

2. Nursing staff had annual or 90 day performance evaluations according to hospital policy for 4 of 10 members, including the Chief Nursing Officer (CNO), of the nursing staff who's files were reviewed. This failure had the potential for a member of the nursing staff to be allowed to take care of patients and have performance deficits not identified by the hospital.

Findings:

1. On 5/17/12, a review of personnel files of all Telemetry Monitor Technicians actively employed by the facility, and under the supervision of nursing, revealed that 0 of 9 technicians did not have competencies validated by the Department of Nursing as determined by their job description prior to accepting patient assignments. There was no documented evidence that 3 of 9 telemetry monitor technicians received training in basic cardiac arrhythmia recognition and their competency validated by the Department of Nursing.

On 5/17/12, a review of personnel files of the Licensed Nurses actively employed by the facility revealed that not all of Licensed Nurses (6 nurses had validated competencies out of a staff of 21 nurses) had competencies validated by the Department of Nursing in the area of providing respiratory treatments that included Hand Held Nebulization procedures. There was no documented evidence that all licensed Nurses received training in providing respiratory Hand Held Nebulization to the patients served and their competency validated by the Department of Nursing.

On 5/17/12, a review of personnel files of all licensed Nurses actively employed by the facility revealed that all Licensed Nurses did not have competencies validated by the Department of Nursing in the area of managing patients requiring the use of Intravenous pumps when administering Intravenous medications through a patient's vein or through a central invasive line. There was no documented evidence that all licensed Nurses received training in Intravenous pump management for patients requiring IV medication therapy through either the vein or from an invasive central line and their competency validated by the Department of Nursing. There was no evidence that all nursing staff had competency validation for age specific care of the patients.

On 5/17/12, a review of personnel files of all licensed Nurses actively employed by the facility revealed that all licensed nurses did not have competencies validated by the Department of Pharmacy and the Department of Nursing in the area of compounding or mixing sterile medications in the facility's medicine room located across from the central nursing station. There was no documented evidence that all licensed nurses had competency validation conducted by the Department of Pharmacy addressing compounding and mixing sterile medications performed in the designated medication room adhering to facility infection control policies and procedures that were validated by the Department of Pharmacy and Department of Nursing.

On 5/17/12, a review of personnel files of all Respiratory Therapist actively employed by the facility revealed that all Respiratory Therapist did not have competencies validated by the Respiratory Department in the area of performing and managing patients undergoing Pulmonary Function Testing procedures. There was no documented evidence that all Respiratory Therapists received training in performing and managing patients undergoing a Pulmonary Function Testing procedure and their competency validated by the Respiratory Department.

On 5/17/12 at 3 PM, at the time of findings, the Chief Nursing Officer confirmed that competencies for Telemetry Monitoring Technicians that included continuous patient cardiac monitoring and cardiac arrhythmia recognition; nurses involved with providing respiratory treatments which included Hand Held Nebulizer therapy; nurses involved with patient care equipment which included management of IV pumps; including Intravenous smart pumps; nurses that were compounding and mixing sterile medications in the medicine room, age specific care, and Respiratory Therapist performing Pulmonary Function Testing Procedures were all lacking validated competencies by their respective departments.

2. A review of the hospital policy titled "Performance Evaluation", dated 9/99, revealed that performance evaluations were to be completed on an annual basis. In addition the policy documented that for new employees a 90 performance evaluation was required.

A review of the employee files was conducted on 5/17/12 and 5/21/12. The following employee files did not have performance evaluations completed as instructed by hospital policy:

? CNO, last performance evaluation - 2/23/11 ( nearly 3 months overdue)
? Case Manager (CM 1) - last performance evaluation - 1/3/11 (over 4 months overdue)
? RN 6 - last performance evaluation - 1/9/11 (over 4 months overdue)
? RN 7 - hire date 6/15/11 - no 90 day evaluation

An interview was conducted with the Director of Human Resources on 5/21/12 at 3 PM. She confirmed that the nursing staff identified by the survey process did not have annual and 90 day performance evaluation conducted according to hospital policy.

Based on interview and record review the facility failed to ensure that they followed the California State Regulations for Nursing Service Staff, 70217 (a), by assigning a nurse patient care responsibilities and administrative responsibilities at the same time. On hours when the hospital management was not available in the hospital, such as weekends, evenings after 5 PM, and nights, the hospital assigned a nurse as the "Charge Nurse". The nurse had a patient care assignment and was responsible for supervisory duties for the entire hospital (including 9 acute care beds, 7 Emergency Department (ED) beds, and 21 long term care beds). This failure had the potential for a nurse to be involved in management issues and not be available for immediate patient care. This failure had the potential for a patient to have an emergency medical condition that would not be recognized and treated timely by the nurse and had the potential to result in patient harm.

This failure had the potential to negatively effect the quality of care for any patient in the hospital.


Findings:


A review of the staffing sheets for the time period of 5/1/12 through 5/15/12 was conducted. The staffing sheets listed the staff for the acute care hospital, the ED, and the long term care areas of the hospital. On the staffing sheets was a designation "chg" (Charge Nurse) beside a Registered Nurse (RN) name. The designation was made on each evening and night shift, along with day shifts on the weekend. Nurses assigned to acute care beds and patient care areas in the ED, were given the designation of "Charge Nurse".


An interview was conducted with RN 1 on 5/15/12 at 10:30 AM. She stated that she worked as a patient care nurse and sometimes was the designated "Charge Nurse" of the hospital, while she had patient care duties. She stated that as the charge nurse she was responsible for her own patient care and the staffing of the hospital, any patient care issues in the hospital, patient and family complaints, physician complaints or issues, calling in surgical staff for emergency cases, and any other problems that may arise during the shift.


An interview was conducted with the Chief Nursing Officer (CNO) of the hospital, on 5/15/12 at 2 PM. She stated that on "off shifts" (shifts where management was not present in the hospital, such as weekends, evening shifts, and night shifts) the hospital assigned a nurse to act as "Charge Nurse". She stated that there was a job description for the charge nurse duties. She stated that these duties were in addition to the patient care duties of the nurse. The CNO stated that a nurse from the acute care area or the ED could be assigned as "Charge Nurse" if they were on the list of qualified nurses.


A review of the job description, dated March 2011, for a "Charge Nurse" revealed a list of 13 duties, including:

1. "Constant evaluation/monitoring of staffing levels for all aspects of nursing department."

2. "Bed control: Will acknowledge all admissions, transfers and surgeries to assure appropriate staffing levels."

3. "Supply acquisition: Will assure that appropriate supplies are available/accessible for staff use."

4. "Be aware of any unusual occurrences and notify appropriate on-call management."

5. "Authorizes call in of available staff resources per core staffing guidelines."

6. "Approves all overtime..."

7. "Acts as resource to staff to aid in the most appropriate course of action for Patient/resident care." (This gave the patient care nurse in the acute care hospital responsibilities for residents in the long term care.)

13."Any other duties as assigned."


.
The CNO, on 5/16/12 at 10:30 AM, confirmed the duties of the charge nurse. She stated that a nurse would be responsible for all of the duties in addition to their own patient care assignment. She stated that the nurse could delegate some of the telephone calls to another person; however, the nurse remained responsible for the duties. She confirmed that the additional duties were administrative duties. She stated that the nurse was acting as a "Nursing Supervisor" when assigned as a charge nurse.


The CNO confirmed that an acute care nurse could have up to 5 patients and that in the Emergency Department (ED), there were 2 nurses. On of the ED nurses needed to be immediately available to triage patients and one needed to be immediately available for patient care. She acknowledged that a nurse who was acting in an administrative role as a Nursing Supervisor could not be available for immediate patient care.

Based on interview and record review the facility failed to ensure that a Registered Nurse (RN) supervised the nursing care for each patient for 8 of 20 sampled patients (Patient 1, 2, 3, 4, 5, 7, 10 and 20). The facility failed to ensure:

1. The RN followed physician's orders for monitoring Patient 1, with an epidural infusion (The epidural space was a potential space that surrounds and protects the spinal cord. An infusion into the space was usually used for pain control.) and failed to monitor the patient's infusion site. These failures had the potential to result in the patient suffering low blood pressure (which left untreated can lead to organ failure and death), low oxygen levels, and infection into the spine from the epidural catheter.


2. An RN evaluated the care for Patients 1, 2, 3, 7, and 5 related to treatment of the patients' pain and monitoring for the potential side effects of pain and pain treatment. This failure had the potential for the patient to have inadequate treatment of their pain and to have side effects related to pain or the treatment of pain that were not recognized by the RN.

3. An RN evaluated the care for Patients 1, 5, 7, 10 and 20, by failing to complete or act upon the admission nutritional risk screen. This failure resulted in a lack of Registered Dietician (RD) assessment and follow up for patients who met the facility criteria for consultation by an RD.

4. An RN evaluated the care for Patients 3 and 4 and provided discharge instructions for the patients being discharged from the Emergency Department (ED). This failure resulted in the patients being discharged from the hospital without all the information necessary to provide self-care.

Findings:

1. A review of the medical record for Patient 1 was conducted on 5/16/12. The patient was admitted to the hospital on 5/1/12 with diagnoses that included abdominal pain with distention.

A review of the operative reports revealed that the patient had an abdominal surgery on 5/4/12. After the surgery, a review of the physician's orders, dated 5/4/12 at 5 PM, revealed that the Certified Nurse Anesthetist (CRNA) ordered a medication for pain control, bupivacaine (local anesthetic, can be toxic to the heart if not given properly) to be run through an epidural catheter (A catheter than infused into the space around the lower spine. The most common side effect of an epidural infusion was low blood pressure caused by redistribution of body fluids). The order stated to call the CRNA if the patient's blood pressure was low. There was no order to increase the timeframe on taking the patient's blood pressure from every 4 hours, that was ordered on the physician's post operative orders, dated 5/4/12.

Further review of the physician's orders, dated 5/5/12 at 11 AM, revealed that an order was written by the CRNA to monitor the patient's oxygen levels constantly (done by using an external probe usually placed on the finger).

A review of the nurse's notes revealed that the epidural infusion was discontinued on 5/7/as at 11:30 AM.

A review of the Medication Administration Record from 5/4/12 through 5/7/12 revealed that the patient received a narcotic pain medication intravenously several times during the time period that the patient had the epidural infusion. (The use of narcotic pain medication through the intravenous route can cause respiratory depression and given along with the epidural infusion was usually monitored by continuous oxygen monitoring.)

A review of the "Nursing Flow Sheet" dated 5/4/11 revealed that the patient's vital signs (including blood pressure and oxygen levels) were taken one time from 5:45 PM (when the patient returned to the unit from the recovery room) until 11 PM. The vital signs were documented at 7 PM. On 5/5/12 the patient's vital signs were documented 5 times, at midnight, 4 AM, 9 AM, 2 PM, and 8 PM. On 5/6/12 the patient's vital signs were taken at midnight, 5 AM, 8 AM, noon, 6 PM, and 8 PM. On 5/7/12 the patient's full vital signs were documented 5 times at midnight, 6 AM, 10 AM, 4 PM, and 8 PM. (Blood pressures were not taken every four hours, as ordered, or increased based on the potential for low blood pressure with the epidural infusion.)

A review of the nurse's notes from 5/4/12 through 5/7/12 revealed that there was no indication that the patient had continuous oxygen monitoring. There was no indication that the patient had his blood pressure assessed at any other time other than what was listed on the flow sheet. There was no indication that the patient had continuous oxygen level monitoring. There was no documentation by nursing of the epidural site or the condition of the epidural dressing. There was no documentation of the patient's motor strength. (An epidural infusion can cause decrease in motor strength {strength in the extremities} and was customarily monitored for a patient receiving an epidural infusion.)

A review of the care plans for the patient revealed that there was no plan of care developed for monitoring of the patient's epidural catheter.

An interview was conducted with the Chief Nursing Officer (CNO) on 5/16/12 at 3:20 PM. She confirmed the documentation findings. She was asked if the hospital had a protocol for the nurses to follow regarding the monitoring required with an epidural infusion. She stated that the hospital did not have a protocol or any other direction for monitoring the patient with an epidural infusion. She acknowledged that patients receiving an epidural infusion have a greater risk for complications, such as low blood pressure and motor weakness. She acknowledged that there was also a potential for migration of the epidural cathter or infection at the site. She acknowledged that it was customary for the nurses to follow a protocol for monitoring the epidural infusion. She stated that the nursing staff should have, at least, followed the physician's orders and should have documented the epidural site.

2. a). A review of the medical record for Patient 1 was conducted on 5/16/12. The patient was admitted to the hospital on 5/1/12 with diagnoses that included abdominal pain with distention.

A review of the Medication Administration Record (MAR), dated 5/5/12 and 5/6/12 to 7 AM revealed that the patient received Morphine Sulfate (narcotic pain medication) 2 milligrams (mg) intravenously (IV) several times. A review of the nursing documentation, for the same dates and times, showing patient assessment and reassessment for pain was conducted. The following was noted:


5/5/12 at 4 AM, the patient received MS 2 mg IV for pain, there was an assessment of pain; however, no reassessment after the treatment of the patient's pain.

5/5/12 at 850 AM, the patient received MS 2 mg IV for pain, there was a rating of pain at 9 AM; however, no other assessment or reassessment of the patient's pain (such as location, quality and response to treatment).

5/5/12 at 2:50 PM, the patient received MS 2 mg IV for pain, there was no assessment or reassessment for pain.

5/5/12 at 6:30 PM, the patient received MS 2 mg IV for pain, there was no assessment or reassessment for pain.

5/5/12 at 8 PM, the patient received MS 2 mg IV for pain there was no assessment or reassessment for pain.

5/5/12 at 10 PM, the patient received MS 2 mg IV for pain, there was no assessment or reassessment for pain.


5/6/12 at midnight, the patient received MS 2 mg IV for pain, there was no assessment or reassessment of pain, there was a pain rating scale done; however, the patient rated his pain a 1 out of 10.


5/6/12 at 2 AM, the patient received MS 2 mg IV for pain, there was no assessment or reassessment for pain.


An interview was conducted with the Chief Nursing Officer (CNO) on 5/16/12 at 3:20 PM. She confirmed the findings. She acknowledged that nursing had not conducted an adequate plan for the treatment of the patient's pain.


A review of the hospital's policy titled "Pain Management", dated 1/26/12, revealed "each patient will attain or maintain his/her highest practicable physical, mental and psychosocial well-being as per the resident's (patient's) individual plan of care, assuring adequate pain control using a process of assessment, intervention and reassessment ... "The policy spoke to an admission assessment of pain and a shift assessment of pain; however, there was no mention of assessment of pain as it occurred or reassessment timeframe after intervention for pain.


A review of the hospital's policy titled "Assessment/Reassessment of Patients", dated 3/30/12, revealed that there were no timeframes established for assessment of pain as it occurred or the reassessment of pain after intervention.


An interview was conducted with the Nurse Manager (NM) of the hospital on 5/17/12 at 3 PM. She stated that the hospital had not established timeframes for the reassessment of pain after intervention. She confirmed that the hospital's policy for pain did not include the assessment of pain as it occurred.


b). A review of the medical record for Patient 2 was conducted on 5/16/12. The review revealed that the patient was admitted to the hospital on 5/14/12 with diagnoses that included pain caused by a respiratory infection.


A review of the nursing admission assessment, dated 5/14/12 at 1:50 PM revealed that there was an assessment of the patient's pain. The assessment revealed that the patient's pain was 8 out of 10.


A review of the nursing flow sheet (where a pain level was indicated on the form) for 5/14/12 from 4 PM through midnight revealed that there was no further assessment of the patient's pain.


An interview was conducted with the Nurse Manager of the hospital on 5/16/12 at 3 PM. She confirmed that the nursing flow sheet lacked a pain assessment on 5/14/12. She stated that the patient's pain level should have been recorded.


c). A review of the medical record for Patient 7 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital on 3/3/12 with diagnoses that included intractable nausea and vomiting.


A review of the MAR, dated 3/3/12 through 3/4/12 revealed that the patient had received Dilaudid 0.5 mg IV for pain several times. A review of the nursing documentation related to assessment and reassessment of pain, for the same time period, revealed the following:

3/3/12 at 9:45 PM, Dilaudid 0.5 mg IV was given, the nurse documented a reassessment of pain; however, there was no assessment of the pain that necessitated an intervention and no numerical rating of the pain.


3/4/12 at 1:20 AM, Dilaudid 0.5 mg IV was given, there was assessment and reassessment of the pain, however; there was no numerical rating of pain on the reassessment.


3/4/12 at 7:10 AM, Dilaudid 0.5 mg IV was given, there was assessment of the pain; however, there was no reassessment conducted.


3/4/12 at 11 AM, Dilaudid 0.5 mg IV was given, there was no assessment or reassessment of the patient's pain.


3/4/12 at 3 PM, Dilaudid 0.5 mg IV was given, there was no assessment of the patient's pain there was a reassessment conducted.


3/4/12 at 7:30 PM,Dilaudid 0.5 mg IV was given, there was no assessment or reassessment of the patient's pain.


A review of the care planning for the patient revealed that the plan for pain had one intervention "Pt (patient) will rate pain of scale of 0 to 10." There were goals listed for the patient.


An interview was conducted with the CNO on 5/22/12 at 10 AM. She confirmed the medical record findings and stated that the nursing care plan was not compressive. She confirmed that the nurses should plan for the treatment of the patient's pain and were required to do an assessment and reassessment of the patient's pain.


d). A review of the medical record for Patient 5 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital for an abdominal surgery.


A review of the MAR, for 4/24/12, revealed that the patient had received Dilaudid 1 mg IV for pain several times. A review of the nursing documentation related to assessment and reassessment of pain, for the same time period, revealed the following:


4/24/12 at 9 AM, Dilaudid 1 mg IV was given, there was no assessment or reassessment of pain.


4/24/12 at 12:47 PM, Dilaudid 1 mg IV was given, there was no assessment or reassessment of pain.


4/24/12 at 4: 57 PM, Dilaudid 1 mg IV was given, there was no assessment or reassessment of pain.


4/24/12 at 9:45 PM, Dilaudid 1 mg IV was given, there was an assessment of pain; however, there was no reassessment conducted.


A review of the care planning for the patient revealed that the plan for pain had one intervention "Explain pain scale 0-10." There were goals listed for the patient.


An interview was conducted with the CNO on 5/22/12 at 10:30 AM. She confirmed the lack of assessment and reassessment of the patient's pain. She also confirmed that the care plan did not have goals and was not comprehensive or individualized.


e). A review of the medical record for Patient 3 was conducted on 5/21/12. The review reveled that the patient came into the ED on 5/21/12 with chief complaint of right knee pain.


A review of the nursing assessment for the visit revealed that there was an area for the nurse to document the patient's pain level. Further review revealed that there was no pain assessment conducted on the patient.


An interview was conducted with the NM of the hospital on 5/21/12 at 3:20 PM. She confirmed that there was no assessment of pain conducted for Patient 3 and that the patient's chief complaint was knee pain.


3 a). A review of the medical record for Patient 1 was conducted on 5/16/12. The patient was admitted to the hospital on 5/1/12 with diagnoses that included abdominal pain with distention. The patient was still present in the hospital on the date of review, 5/16/12.


Further review revealed that the patient had two abdominal surgeries on 5/1/12 and again on 5/4/12. Review of the physician's progress notes for the hospitalization revealed that the patient had been on " NPO " (nothing by mouth) status on and off during the hospital stay and that attempts at giving the patient a diet had failed.


A review of the physician's orders, dated 5/6/12, revealed that the patient had been placed on intravenous nutrition.


Review of the record revealed that there was no assessment conducted by the Registered Dietician (RD).


An interview was conducted with RD 1 on 5/16/12 at 3:30 PM. She stated that she was not given a referral to see this patient. She reviewed the record, including the nursing admission screening, and stated that she should have been notified regarding this patient. She stated that the patient certainly met the hospital's guidelines for requiring a consultation by an RD. She stated that any patient on intravenous nutrition should be referred for an evaluation by an RD.


b). A review of the medical record for Patient 5 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital on 4/24/12 for an abdominal surgery. The patient was discharged on 4/29/12.


A review of the "Nutritional Risk Screen", completed on admission, revealed that the screen was not conducted by nursing.


A review of the nursing discharge information, including discharge teaching, revealed that the patient's diet was listed as full (arrow) bland diet. The nurse documented to slowly advance diet as tolerated. There was no further documented evidence that any explanation was given to the patient as to what a types of foods constituted a full liquid or a bland diet.


A review of the entire medical record revealed no assessment or teaching conducted by the Registered Dietitian (RD) or the dietary department.


An interview was conducted with the Chief Nursing Officer (CNO) on 5/22/12 at 10:30 AM. She confirmed that the nursing admission assessment for the nutritional screen was not completed and that there was no documentation that the patient had been seen by the RD. She stated that according to hospital policy, the RD should have been notified to see this patient. She acknowledged that the RD could have helped the patient understand his discharge diet.


c). A review of the medical record for Patient 7 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital on 3/3/12 with diagnoses that included intractable nausea and vomiting.


A review of the "Nutritional Risk Screen", completed on admission, revealed that the nurse had completed the assessment and the patient required an assessment by the RD.


A review of the entire record revealed that there was no assessment conducted by the RD.


An interview was conducted with the Chief Nursing Officer (CNO) on 5/22/12 at 11 AM.

She confirmed that the patient met the requirement for a consult by the RD. She stated that there was no RD assessment in the record. She could not explain why the patient had not been assessed by the RD. She acknowledged that the nurse must not have followed through and sent a referral to the RD.


3 d). On 5/15/12, a review of Patient 10's medical record was conducted. Patient 10 was admitted to the facility on 5/14/12 with an admitting diagnosis of severe diarrhea and dehydration.

On 5/15/12, a review of the initial nursing assessment sheet dated 5/14/12 revealed that Patient 10 had a gastrostomy tube in place, had experienced severe diarrhea for the past 3 days, had experienced nausea and vomiting last evening with abdominal pain.

On 5/15/12, at approximately 10:45 AM, an interview with the facility's Registered Dietician was conducted. When asked if a nutritional assessment consult for Patient 10 was received from the admitting nurse on 5/14/12, or a requisition was obtained from the admitting nurse on 5/14/12, triggering a nutritional assessment consult for Patient 10, she stated, " No. "

On 5/15/12, a review of the facility's policy and procedure, from the Department of Nursing ,titled
"ASSESSMENT/REASSESSMENT OF PATIENTS-INTERDISCIPLINARY " dated 3/30/12, stipulated, " ...Initial nutritional screen shall be done upon admission assessment by the Registered Nurse. Dietary consult shall be completed within 48 hours of written order ... "

There was no documented evidence that the Registered Nurse upon admission, on 5/14/12, initiated/triggered a dietary consult assessment based on her initial nutritional screening examination in light of Patient 10 ' s admitting symptoms of having a gastrostomy tube in place, experiencing severe diarrhea for 3 days and complaints of nausea and vomiting with accompanying abdominal pain prior to admission as per the Department of Nursing's policy.

e). On 5/15/12, a review of Patient 20's medical record was conducted. Patient 20 was admitted to the facility on 4/18/12 with an admitting diagnosis of liver failure and a history of alcoholism with ascites (accumulation of fluid in the abdomen due to liver failure).

On 5/15/12, a review of Patient 20's history and physical assessment sheet, dated 4/19/12 indicated that Patient 20 was thin, ill appearing, jaundiced (yellow appearing skin color) with facial signs of temporal wasting. Patient 10 was discharged from the hospital on 4/20/12.

On 5/15/12, a review of Patient 10's Nutritional Risk Screen, dated 4/19/12, indicated that Patient 10 had a poor appetite which according to facility policy automatically initiates/triggers a nutritional consult.

On 5/15/12, a review of Patient 10's Physician Order Sheet, dated 4/19/12, documented that Patient 10 would be placed on a 1200 milliliter fluid restriction, a low protein, 2 gram low salt diet. Patient 10 was also on Lasix 20 milligrams and Aldactone 25 milligrams daily (diuretics-eliminate excess water in the body).

There was no documented evidence that the admitting Registered Nurse had initiated/triggered a dietary assessment consult per facility policy on 4/19/12.

On 5/15/12, the facility's Registered Dietician and Chief Nursing Officer confirmed the finding that some dietary consults were not correctly initiated by admitting registered nurses as per facility policy.


4. a). A review of the medical record for Patient 3 was conducted on 5/21/12. The review reveled that the patient came into the ED on 5/21/12 with chief complaint of right knee pain.


A review of the nursing notes revealed that there was no documented information provided to the patient on discharge regarding his self-care.


An interview was conducted with the NM of the hospital on 5/21/12 at 3:20 PM. She confirmed that there were no documented discharge instructions given to the patient. She acknowledged that the discharge instructions were important to help the patient provide self-care at home.


b). A review of the medical record for Patient 4 was conducted on 5/21/12. The review revealed that the patient came into the ED on 4/7/12 with a chief complaint of nausea, vomiting, and hypoglycemia (low blood sugar).


A review of the physician's documentation on, 4/7/12, revealed that the patient was discharged with the diagnoses of gastroenteritis (abdominal infection) and hypoglycemia.


A review of the discharge instructions, documented by nursing, revealed that there was no instructions given to the patient for hypoglycemia.


An interview was conducted with the NM of the hospital on 5/21/12 at 3:20 PM. She confirmed that there were no documented instructions given to the patient for her low blood sugar. She stated that hypoglycemia can be dangerous for the patient and the nursing staff should have provided discharge instructions to the patient.




















26502

Based on interview and record review, the facility failed to ensure that nursing staff developed and kept current a plan of care for 6 of 20 sampled patients (Patients 1, 2, 7, 5, and 10). This failure had the potential to result in a negative patient outcome due to a failure to plan and monitor the nursing care provided.


Findings:


1. A review of the medical record for Patient 1 was conducted on 5/16/12. The patient was admitted to the hospital on 5/1/12 with diagnoses that included abdominal pain with distention.


A review of the operative reports revealed that the patient had an abdominal surgery on 5/4/12. After the surgery, a review of the physician's orders, dated 5/4/12 at 5 PM, revealed that the Certified Nurse Anesthetist (CRNA) ordered a medication for pain control, bupivacaine (local anesthetic, can be toxic to the heart if not given properly) to be run through an epidural catheter (A catheter than infused into the space around the lower spine. The most common side effect of an epidural infusion was low blood pressure caused by redistribution of body fluids). The order stated to call the CRNA if the patient's blood pressure was low. There was no order to increase the timeframe on taking the patient's blood pressure from every 4 hours, that was ordered on the physician's post operative orders, dated 5/4/12.


Further review of the physician's orders, dated 5/5/12 at 11 AM, revealed that an order was written by the CRNA to monitor the patient's oxygen levels constantly (done by using an external probe usually placed on the finger).


A review of the nurse's notes revealed that the epidural infusion was discontinued on 5/7/as at 11:30 AM.


A review of the "Nursing Flow Sheet" dated 5/4/11 revealed that the patient's vital signs (including blood pressure and oxygen levels) were taken one time from 5:45 PM (when the patient returned to the unit from the recovery room) until 11 PM. The vital signs were documented at 7 PM. On 5/5/12 the patient's vital signs were documented 5 times, at midnight, 4 AM, 9 AM, 2 PM, and 8 PM. On 5/6/12 the patient's vital signs were taken at midnight, 5 AM, 8 AM, noon, 6 PM, and 8 PM. On 5/7/12 the patient's full vital signs were documented 5 times at midnight, 6 AM, 10 AM, 4 PM, and 8 PM. (Blood pressures were not taken every four hours, as ordered, or increased based on the potential for low blood pressure with the epidural infusion.)


A review of the nurse's notes from 5/4/12 through 5/7/12 revealed that there was no indication that the patient had continuous oxygen monitoring. There was no indication that the patient had his blood pressure assessed at any other time other than what was listed on the flow sheet. There was no documentation by nursing of the epidural site or the condition of the epidural dressing. There was no documentation of the patient's motor strength. (An epidural infusion can cause decrease in motor strength {strength in the extremities} and was customarily monitored for a patient receiving an epidural infusion.)


A review of the care plans for the patient revealed that there was no plan of care developed for monitoring of the patient's epidural catheter.


An interview was conducted with the Chief Nursing Officer (CNO) on 5/16/12 at 3:20 PM. She confirmed the documentation findings. She confirmed that nursing staff did not develop a plan of care for the epidural catheter infusion. She acknowledged that the nursing staff should have developed a plan of care and that may have directed the nurses to do appropriate monitoring of the patient.



2 a). A review of the medical record for Patient 2 was conducted on 5/16/12. The review revealed that the patient was admitted to the hospital on 5/14/12 with diagnoses that included pain caused by a respiratory infection.


A review of the nursing documentation, dated 5/14/12 and 5/15/12 revealed that the patient had varying levels of pain (from 8/10 to 0/10 on a pain rating scale from 0 to 10 with 10 being the most pain) and the patient was refusing to have narcotic pain medication.


A review of the care planning for the patient revealed that there was no plan of care developed to address the patient ' s pain. Pain was listed as a contributing factor to the patient's respiratory distress; however, there was no plan for the actual problem of pain and no interventions specific to treating the patient's pain.


An interview was conducted with Nurse Manager (NM) of the hospital on 5/16/12 at 3 PM. She confirmed that there was no care plan developed to address the patient's pain.


b). A review of the medical record for Patient 7 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital on 3/3/12 with diagnoses that included intractable nausea and vomiting.


A review of the MAR, dated 3/3/12 through 3/5/12 revealed that the patient had received Dilaudid 0.5 mg IV for pain several times. A review of the nursing documentation revealed that the patient had varying levels of abdominal pain.


A review of the care planning for the patient revealed that the plan for pain had one intervention "Pt (patient) will rate pain of scale of 0 to 10." There were goals listed for the patient.


An interview was conducted with the CNO on 5/22/12 at 10 AM. She confirmed the medical record findings and stated that the nursing care plan was not comprehensive. She confirmed that the nurses should plan for the treatment of the patient's pain and that the care plan should be comprehensive and individualized.


c). A review of the medical record for Patient 5 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital for an abdominal surgery.


A review of the MAR, for 4/24/12 through 4/26/12, revealed that the patient had received Dilaudid 1 mg IV for pain several times.


A review of the nursing documentation, dated 4/24/12 through 4/26/12, revealed that the patient had varying levels of pain ranging from 9 to 0 out of 10.


A review of the care planning for the patient revealed that the plan for pain had one intervention "Explain pain scale 0-10." There were goals listed for the patient.


An interview was conducted with the CNO on 5/22/12 at 10:30 AM. She confirmed that the care plan did not have goals and was not comprehensive or individualized.





26502

3. On 5/15/12, a review of Patient 10's medical record was conducted. Patient 10 was admitted to the facility on 5/14/12 with an admitting diagnosis of severe diarrhea and dehydration.

On 5/15/12, a review of Patient 10's Emergency Room sheet dated 5/14/12 indicated that Patient 10 was experiencing severe diarrhea (x4) for the last 3 days prior to being seen in the emergency room and was being treated for possible Clostridia Difficile colon infection (antibiotic-caused infection causing server diarrhea).

On 5/15/12, a review of Patient 10's medical record revealed no documented evidence on 5/14/12 (admission) through 5/16/12 (discharge), that a comprehensive individualized nursing care plan was developed addressing her complaints of severe diarrhea for the last 3 days.

On 5/15/12, a review of the facility's policy and procedure titled, "NURSING PROCESS; CARE PLAN" dated 3/20/12, stipulated in section (3), "...The nurse formulates the nursing diagnosis by analyzing and interpreting the assessment data. These diagnosis statements reflect the client ' s health status the requires nursing intervention. Nursing care planning develops goals and outcomes to help restore, maintain, and promote the patient's health status ..."

On 5/15/12, at the time of the finding, the Director of the Acute Unit confirmed the finding that the nurses on the Acute Unit failed to develop a comprehensive individualized care plan addressing Patient 10's admitting diagnosis of severe diarrhea.

Based on interview and record review, the facility failed to ensure that medications were administered per policy and regulation by failing to ensure that an order was obtained prior to administration of a medication for 1 of 20 sampled patients (Patient 16). This failure resulted in the patient receiving a medication that had not been ordered by her physician. This failure had the potential for the patient to have an adverse reaction to a medication that was given without proper authorization.


Findings:


A review of the medical record for Patient 16 was conducted on 5/22/12 at 4 PM accompanied by the Chief Nursing Officer (CNO). The review revealed that the patient was admitted to the hospital on 4/20/12 to have an out patient surgical procedure performed.


A review of the recovery room nursing documentation, dated 4/20/12, revealed that the nurse had administered and eye drop with proparacaine (used in the eye as an anesthetic to numb the pain that may occur during eye procedures) to the patient's left eye.


A review of the physician's orders, dated 4/20/12, revealed an order sheet that covered the entire operative time, pre, intra, and post operative. Further review of the physician's orders revealed that there was no order written for proparacaine or any other eye drops in the recovery room.


A review of the hospital's policy, titled "Administration of Medications and Treatments, dated 2/28/12, revealed, "no medication or treatment shall be administered except on the order of a person lawfully authorized (physician or physician extender) to give such order."


The CNO stated that there was no physician's order for the nurse to give the medication. She stated that the nurse should not give any medication without a physician's or a physician extender's order.

Based on observation, interview and record review, the facility failed to ensure that all unauthorized access or dissemination of clinical records is not permitted at any location of the hospital. The facility failed to ensure that RN 3 covered up and secured the Medication Administration Record for 3 of 4 patients during the medication pass process. This deficient practice had the potential to result in unauthorized breach of each patient's protected healthcare information.

Findings:

On 5/21/12, at 9:30 AM, during the medication pass inspection process on the Acute Care Unit, RN 3 was observed failing to cover and secure from view the Medication Administration Record of 3 of 4 of her patients receiving medications. RN 3 was observed preparing each individual patient medications to be administered at the time scheduled and leaving the area leaving the Medication Administration Record uncovered and exposed to other patients, staff and visitors. It was observed at that time that RN 3 neglected to cover and secure from view the Medication Administration Record Sheet of her patients, stored on top of the medication dispensing unit (Pyxis Machine), and was found exposed and unattended and in plain view to all other patients, staff and visitor in that area.

On 5/21/12, a review of the facility's policy and procedure titled, "VALID AUTHORIZATIONS FOR RELEASE OF PROTECTED HEALTHCARE INFORMATION" dated 3/20/12, it stipulated in section (1), " ...A valid authorization is required to release and protect all patient ' s healthcare information in the facility ... "

On 5/21/12, at the time of the finding, the Chief Nursing Officer confirmed the finding that RN 3 did not protect the confidentiality of 3 of her patients while passing medications, leaving in plain view the Medication Administration Records of those patients exposed to other patients, staff and visitors.

The facility failed to have pharmaceutical services that met the needs of the patients.

1. Pharmaceutical services failed to ensure that guidelines for the safe intravenous (IV) use of the medication Zofran (A medication for nausea and vomiting that when given IV can cause an abnormal heart rhythm that has the potential to result in a patient's death.) (Refer to A 491)

2. Pharmaceutical services failed to ensure that Patient 1 did not receive an infusion through an epidural catheter (A catheter than infused into the space around the lower spine. The most common side effect of an epidural infusion was low blood pressure caused by redistribution of body fluids.) without direction for monitoring the patient. (Refer to A 491)

3. Pharmaceutical services failed to ensure that approved guidelines were used for the administration of IV drips, including cardiac (heart) and vasoactive medications (very potent medications used for blood pressure control) in the Emergency Department (ED). (Refer to A 491)

4. The facility failed to ensure that medications and biologicals were controlled and distributed in accordance with standards of practice. The facility failed to ensure that the pharmacist reviewed each medication for appropriateness before the first dose was dispensed. This failure resulted in incomplete medication orders identified by the survey process, that were not previously identified and corrected by pharmacy. (Refer to A 500)

5. Pharmaceutical services failed to ensure that medications were compounded by a pharmacist or under the supervision of a pharmacist. Pharmaceutical services failed to ensure that nurses who compounded medications had the competency validation necessary to ensure the medications were mixed to ensure patient safety. (Refer to A 501)

6. Pharmaceutical services failed to ensure that policies were developed and maintained to ensure that medications were administered by licensed personnel only as directed by State regulations. (Refer to A 501)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of pharmaceutical services in a safe environment.

Based on interview and record review, the facility failed to ensure that the pharmaceutical services were administered in accordance with accepted professional principles. The pharmaceutical services failed to:

1. Ensure that guidelines for the safe intravenous (IV) use of the medication Zofran (a medication for nausea and vomiting that when given IV can cause an abnormal heart rhythm that has the potential to result in a patient's death.),

2. Ensue that Patient 1 did not receive an infusion through an epidural catheter (A catheter than infused into the space around the lower spine. The most common side effect of an epidural infusion was low blood pressure caused by redistribution of body fluids.) without direction for monitoring the patient.

3. Ensure that approved guidelines were used for the administration of IV drips, including vasoactive medications (very potent medications used for blood pressure control) in the Emergency Department (ED).

These failures had the potential to result in a negative outcome for any patient in the ED or acute care unit in the hospital.

Findings:



1. On 5/15/12, a review of Patient 2's medical record was conducted. Patient 2 was admitted to the facility on 5/14/14, at 1:12 PM, with admitting diagnoses that included severe diarrhea and symptomatic hypokelemia and volume depletion. Patient 2's admitting status was classified as an " Observation Outpatient."

On 5/15/12, a review of Patient 3's medical record was conducted. Patient 3 was admitted to the facility on 5/14/12, at 7:13 PM, with an admitting diagnosis of orbital cellulitis.

According to the Federal Drug Association (FDA) Drug Safety Communication Alert to all healthcare providers and to the general public, dated September 15, 2011, documented, " ...the medication Zofran (an anti-emetic) may increase the risk of developing abnormal changes in the electrical activity of the heart, which can result in a potentially fatal abnormal heart rhythm (Torsades-de-pointes). Patients at particular risk for developing Torsade include those with underlying heart conditions, such as congenital long Q-T interval syndrome, those who are predisposed to low levels of potassium and magnesium in the blood, and those taking other medication that can lead to Q-T prolongation. "

According to the Physician Desk Reference (PDR-drug reference manual), dated 1/27/12, it documented that the medication " Zofran " is administered to prevent nausea and vomiting in patients undergoing chemotherapy for cancer. It is also used to prevent post-operative nausea and vomiting. The recommended dosages and rate of infusion are as follows:

a. " Adults " greater than 12 years of age; dosage: 4 milligrams x 1. Intravenous infusion rate: to be administered over 2 to 5 minutes.

b. " Pediatrics " 1 month to 12 years, and over 40 kilograms; dosage: 4 milligrams x 1. Intravenous infusion rate: to be administered over 2 to 5 minutes.
On 5/15/12, a review of Patient 2's Physician's Emergency Room Order sheet, dated 5/14/12, timed at 5:17 PM, revealed the following written order for the medication Zofran:

a. Give Zofran 8 milligrams IV (Intravenously) now.

On 5/15/12, a review of Patient 3's Physician's Emergency Room Order sheet, dated 5/14/12, timed at 7:40 PM, revealed the following written order for the medication Zofran:

a. Give Zofran 8 milligrams IV (Intravenously) now.

On 5/15/12, a review of Patient 2's Medication Administration Record sheet, dated 5/14/12, revealed that RN 1 administered Zofran 8 milligrams Intravenously at 12:00 PM and at 4:00 PM.

There was no documented evidence that a 12-lead EKG procedure was performed, on 5/14/12, as recommended by the FDA Zofran Alert, to rule out the possibility of an existing prolonged Q-T interval condition prior to Zofran administration.

There was no documented evidence that a comprehensive cardiac assessment was conducted to assess Patient 2 ' s previous cardiac history of a possible prolonged Q-T interval condition existing prior to the administration of Zofran on 5/14/12 at 12:00 PM and at 4:00 PM.

There was no documented evidence in Patient 2's medical record that Zofran 8 milligrams was administered over 2-5 minutes, slow IV push, on 5/14/12 at 12:00 PM and at 4:00 PM as recommended by the Physician Desk Reference (PDR) drug manual by RN 1.

On 5/23/12, at approximately 10:00 AM, an interview with RN 1 was conducted. RN 1 confirmed that a 12-lead EKG procedure was not performed prior to administering Zofran and Patient 2 was not on a continuous cardiac monitor. In addition, RN 1 stated that she did not check Patient 2's electrolyte status and could not remember if she administered Zofran over 2-5 minutes, slow Intravenous push, otherwise she would have documented it that way.

On 5/15/12, a review of Patient 3's Emergency Room Record sheet, dated 5/14/12 was conducted. The Emergency Room Record sheet, dated 5/14/12 indicated that RN 2 administered Zofran 8 milligrams intravenously at 3:15 PM.

There was no documented evidence that a 12-lead EKG procedure was performed, on 5/14/12, as recommended by the FDA Zofran Alert, to rule out the possibility of an existing prolonged Q-T interval condition prior to Zofran administration.

There was no documented evidence that a comprehensive cardiac assessment was conducted to assess Patient 3 ' s previous cardiac history of a possible prolonged Q-T interval condition existing prior to the administration of Zofran on 5/14/12 at 3:15 PM.

There was no documented evidence in Patient 3's medical record that Zofran 8 milligrams was administered over 2-5 minutes, slow IV push, on 5/14/12 at 3:15 PM as recommended by the Physician Desk Reference (PDR) drug manual by RN 2.

On 5/23/12, at approximately 10:15 AM, an interview with RN 2 was conducted. RN 2 confirmed that a 12-lead EKG procedure was not performed prior to administering Zofran and Patient 3 was not on a continuous cardiac monitor during the Zofran administration.

The facility's Department of Pharmacy failed to develop a process/system to incorporate external alerts and/or recommendations from national associations and governmental agencies for review and facility policy and procedure revision consideration on 9/15/11. For example, National associations could include Institute of Safe Medication Practices and Food and Drug Administration.

The facility's Department of Pharmacy did not provide medication-related information to hospital health care professionals (medical staff and nursing staff) regarding the FDA's warnings of Zofran administration and to the patients receiving Zofran necessary to optimize therapeutic outcomes and minimizing patient risk on 9/15/11 or as soon as possible.

The facility failed to collect and organize patient-specific information (current laboratory results and previous or current EKG reports) for Patient 2 and Patient 3 as per FDA recommendations on 5/14/12.

The facility failed to determine the presence of medication-therapy problems during review of the medication profile of both potential and actual problems for Patient 2 and Patient 3 on 5/14/12.

The facility failed to implement a monitoring plan in collaboration with Patient 2 and Patient 3, prior to and during administration of Zofran (continuous cardiac telemetry monitoring) on 5/14/12.

The facility failed to develop policies and procedures to minimize medication errors that were based on accepted professional principals; external alerts and proactive review of patient 2 and Patient 3's medical history and current condition to decrease morbidity and mortality due to medication errors in the hospitalized setting on 9/15/11 or as soon as possible.

The facility failed to develop policies and procedure, reviewed and approved by the Pharmacy and Therapeutic Committee, medical staff and Governing Body regarding the administration of High-Alert Medications (Zofran); its dosing limits (give 4 milligrams) and administration guidelines (such as, give slow Intravenous Push over 2 to 5 minutes, not less than 30 seconds) on 9/15/11 or as soon as possible.

On 5/15/12, at approximately 11:30 PM, the Director of Pharmaceutical Services and Chief Nursing Officer confirmed that the facility failed to follow the FDA's recommendation to monitor the patient's cardiac status for an existing prolong Q-T interval condition and to monitor the electrolyte status of all patients receiving Zofran.



2. A review of the medical record for Patient 1 was conducted on 5/16/12. The patient was admitted to the hospital on 5/1/12 with diagnoses that included abdominal pain with distention.

A review of the operative reports revealed that the patient had an abdominal surgery on 5/4/12. After the surgery, a review of the physician's orders, dated 5/4/12 at 5 PM, revealed that the Certified Nurse Anesthetist (CRNA) ordered a medication for pain control, bupivacaine (local anesthetic, can be toxic to the heart if not given properly) to be run through an epidural catheter. The order stated to call the CRNA if the patient's blood pressure was low. There was no order to increase the timeframe on taking the patient's blood pressure from every 4 hours, that was ordered on the physician's post operative orders, dated 5/4/12.

Further review of the physician's orders, dated 5/5/12 at 11 AM, revealed that an order was written by the CRNA to monitor the patient's oxygen levels constantly (done by using an external probe usually placed on the finger).

A review of the nurse's notes revealed that the epidural infusion was discontinued on 5/7/as at 11:30 AM.

A review of the Medication Administration Record from 5/4/12 through 5/7/12 revealed that the patient received a narcotic pain medication intravenously several times during the time period that the patient had the epidural infusion. (The use of narcotic pain medication through the intravenous route can cause respiratory depression and along with the epidural infusion was usually monitored by continuous oxygen monitoring.)

A review of the "Nursing Flow Sheet" dated 5/4/11 revealed that the patient's vital signs (including blood pressure and oxygen levels) were taken one time from 5:45 PM (when the patient returned to the unit from the recovery room) until 11 PM. The vital signs were documented at 7 PM. On 5/5/12 the patient's vital signs were documented 5 times, at midnight, 4 AM, 9 AM, 2 PM, and 8 PM. On 5/6/12 the patient's vital signs were taken at midnight, 5 AM, 8 AM, noon, 6 PM, and 8 PM. On 5/7/12 the patient's full vital signs were documented 5 times at midnight, 6 AM, 10 AM, 4 PM, and 8 PM. (Blood pressures were not taken every four hours, as ordered, or increased based on the potential for low blood pressure with the epidural infusion.)

A review of the nurse's notes from 5/4/12 through 5/7/12 revealed that there was no indication that the patient had continuous oxygen monitoring. There was no indication that the patient had his blood pressure assessed at any other time other than what was listed on the flow sheet. There was no documentation by nursing of the epidural site or the condition of the epidural dressing. There was no documentation of the patient's motor strength. (An epidural infusion can cause decrease motor strength {strength in the extremities} and was customarily monitored for a patient receiving an epidural infusion.)

An interview was conducted with the Chief Nursing Officer (CNO) on 5/16/12 at 3:20 PM. She confirmed the documentation findings. She was asked if the hospital had a protocol or other information for the nurses to follow regarding the monitoring required with an epidural infusion. She stated that the hospital did not have a protocol for the epidural infusion. She acknowledged that for a patient receiving an epidural infusion have a greater risk for complications, such as low blood pressure and motor weakness. She acknowledged that there was also a potential for migration of the epidural cathter or infection at the site.


An interview was conducted with Pharmacist 1 on 5/21/12 at 2 PM. He confirmed that the pharmacy mixed the medication for the epidural drip and that the hospital did not have a protocol developed for the nurses to administer an epidural drip. He stated that it was an unusual order and that he could not remember another order for an epidural drip in the hospital. He confirmed that the patient can have complications from an epidural drip and that the patient needed to be closely monitored. The Pharmacist confirmed that complications could include a low blood pressure and loss of motor strength. He confirmed that, for patient safety, there should be a protocol developed by the hospital before an epidural drip was administered by nursing.


3. On 5/21/12 at 10 AM an interview was conducted with the Nurse Manager (NM) of the hospital. She was asked if the hospital had a quick reference for nurses to administer vasoactive IV drips. She stated that the IV drips were administered only in the ED. The NM produced a folder with information for the nurses to administer the IV drips. A review of the folder revealed several typewritten pages with hand written entries. The some of the pages were hanging out of the folder and none of the pages had an indication of who provided the information to the nurses or what authority the authorized information. The pages had the name of the medications (including Dopamine, Nitroprusside, Levophed, Cardizem and other vasoactive and heart specific medications that required very close monitoring and very specific dosing), directions for the concentration of the medications, and directions on dosing the medications. The NM stated that she had recognized that running IV drips was a very exacting procedure and was potentially a patient safety issue if the drip was not administered correctly and that the folder was not an acceptable reference for nursing. She acknowledged that the patient could suffer negative consequences, including death, if the medication was not administered correctly.

An interview was conducted with Pharmacist 1 on 5/21/12 at 2 PM. He stated that he thought that the folder was provided by the the hospital ' s previous pharmacist and that he had looked at some of the information in the folder; however, he had not reviewed the entire folder. He confirmed that none of the information contained what authority authorized the information. Pharmacist 1 stated that the nursing staff should only use reference material that was approved by the pharmacy.














26502

Based on interview and record review, the facility failed to ensure that medications and biologicals were controlled and distributed in accordance with standards of practice. The facility failed to ensure that the pharmacist reviewed each medication for appropriateness before the first dose was dispensed. This failure resulted in incomplete medication orders identified by the survey process, that were not previously identified and corrected by pharmacy. This failure had the potential to result in a negative outcome due to a medication error for any patient admitted to the acute care unit of the hospital.

Findings:


1. A review of the medical record for Patient 1 was conducted on 5/16/12. The patient was admitted to the hospital on 5/1/12 with diagnoses that included abdominal pain with distention.

A review of the physician's orders, dated 5/4/12, revealed and order for morphine sulfate (pain medication) every 2 hours as needed for pain. A review of the order directly underneath the morphine revealed an order for a medication for nausea with the dosage of the mediation and then ditto marks.

An interview with the Chief Nursing Officer was conducted, on 5/16/12 at 3:20 PM. She confirmed the findings and stated that the physician probably wrote the ditto marks to indicate that both medications should be given by the same route and the same time frame. She confirmed that the order was not clear and that it was not corrected.

A review of the medical record for Patient 5 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital on 4/24/12 after an abdominal surgery.

A review of the physician's orders, dated 4/29/12, revealed an order for Dilaudid (pain medication) 1 milligram every 2 hours as needed for pain. Directly below this order was an order for Dilaudid 2 with ditto marks for dosage (milligrams) route and frequency.

An interview with the Chief Nursing Officer was conducted, on 5/12/12 at 3 PM. She confirmed the findings and stated that the physician probably wrote the ditto marks to indicate that both medications should be given in the same dosage, by the same route and the same frequency. She confirmed that the order was not clear and that it was not corrected.

An interview was conducted with the hospital's pharmacist on 5/17/12 at 9:30 AM. He stated that he reviews all medication orders that come in to the acute care unit during the hours that he was in the hospital, usually day time hours. He stated that when he was not in the hospital, there was no system in place to ensure that medication orders were reviewed by pharmacy prior to dispensing the first dose. He stated that he did review orders that came in when he was not in the hospital the next time he was at the hospital; however, often times, the first dose of the medication had already been given.

















26502


2. On 5/15/12, a review of Patient 9's medical record was conducted. Patient 9 was admitted to the facility on 5/12/12 with an admitting diagnosis of shortness of breath.

On 5/15/12, a review of Patient 9's Physicians' Order sheet dated 5/12/12 revealed the following order for pain control:

a. Vicodin every 4 hours PRN (as necessary) for pain.

The facility failed to identify that Patient 9's physician failed to order the exact dose and strength of the Vicodin medication.

On 5/15/12, at the time of the finding, the Director of Pharmacy confirmed the finding that Patient 9's physician failed to order the exact dose and strength of the medication Vicodin.

3. On 5/21/12, at approximately 9:20 AM, during the medication pass inspection process on the Acute Care Unit, it was observed that RN 3, for 3 of 4 patients receiving medications, did not check the identity of those patients prior to administering the medications.

On 5/21/12, a review of the facility ' s policy and procedure titled, " ADMINISTRATION OF MEDICATIONS AND TREATMENTS " dated 2/28/12, it stipulated in section (3), " ...Medications and treatments shall be administered as prescribed, taking into account the drug name, dosage, frequency, route and patients identification ... "

On 5/21/12, at the time of the finding, the Chief Nursing Officer confirmed the finding that RN 3 did not check the identity of 3 of 4 of her patients during the medication pass process.

Based on interview and record review, the facility failed to ensure:

1. Medications were compounded by a pharmacist or under the supervision of a pharmacist. The facility failed to ensure that nurses who compounded medications had competency validation necessary to ensure the medications were mixed to ensure patient safety. This failure had the potential for any patient in the acute care unit of the hospital to suffer negative consequences from inaccurate preparation of medications, including inaccurate dosing and a potential for infection.

2. Policies were developed and maintained to ensure that medications were administered by licensed personnel only as directed by State regulations. This failure had the potential for medications to be administered inaccurately by unlicensed personnel and had the potential to negatively effect patient medication safety.

Findings:

1. An interview was conducted with the hospital's Pharmacist, Pharmacist 1 on 5/17/12 at 9:30 AM. He stated that when he was present in the pharmacy, usually during the day time hours, he compounded most of the medications. Pharmacist 1 stated that when he was not present, the nurses mixed some medications. He stated that the medications were usually antibiotics. He stated that he had provided in-services to the nursing staff; however, he confirmed that the nurses did not have competencies to ensure adherence to pharmacy procedures.

On 5/15/12, at approximately 11:00 AM, it was observed that RN 3 did not wash her hands prior to mixing sterile admixture medications (one or more additional drugs or solutions have been added or to join the contents of two sterile products) prior to administering the medication to her patient.


On 5/17/12, at approximately 10:30 AM, it was observed that RN 4 did not follow recommended manufactures instruction for disinfecting a surface area when she was observed disinfecting her medicine preparation work area, in the designated medicine preparation room, by disinfecting her work area with only one disinfecting wipe down, which was not followed with a second disinfecting wipe down as recommended by the manufactures instructions. RN 4 did not disinfect her work area with a second wipe down after the initial wait of 2 to 3 minutes allowing the disinfecting solution/agent to remain on a non-porous surface and allowed to air dry for thorough disinfection to take place.

There was no documented evidence that the facility's Quality Assurance and Performance Improvement Department developed quality indicators for monitoring infection control measures regarding personnel involved in mixing medications in the designated medicine preparation room.

On 5/23/12, the Director of the Pharmacy Department and Chief Nursing Officer confirmed the findings that RN 3 did not wash her hands prior to mixing sterile admixture medications on 5/14/12, that RN 4 did not follow recommended manufactures instruction for disinfecting a surface area when she was observed disinfecting her medicine preparation work area, in the designated medicine preparation room, by disinfecting her work area with only one disinfecting wipe down, which was not followed with a second disinfecting wipe down as recommended by the manufactures instructions.


An interview was conducted with the Chief Nursing Officer (CNO) on 5/17/12 at 3 PM. She confirmed that the nursing staff did not have demonstrated competencies to compound medications. She confirmed that nurses were compounding medications, mostly antibiotics, and that they should have demonstrated competencies to ensure patient safety for accurate dosing of the medication and to prevent potential infection control problems.

2. A review of the pharmacy policy titled "Medication Administered by Unlicensed Personnel", dated 2/28/12, was conducted on 5/21/12. The policy stated that certain unlicensed staff could administer:

Medicinal shampoos and baths,
Laxatives and suppositories and laxative enemas,
Non-prescription topical ointments, creams, and solutions on intact skin surfaces.

An interview was conducted with the hospital's pharmacist, Pharmacist 1, on 5/21/12 at 2 PM. He confirmed that the pharmacy policy identified certain medications that could be given by an unlicensed person. He acknowledged that State regulations prohibited anyone other than a licensed person from administering medications in the hospital setting.

Based on observation, interview and record review, the facility failed to ensure that all Radiology Department's Administrative Policies and Procedures were reviewed, approved and accepted by the Medical Staff and Governing Body and the Radiologist provide supervision ensuring that emergency care is provided to all age appropriate patients who experience an adverse reaction to diagnostic agents or other emergency event in the radiology department in a universe of 16 patients. These deficient findings had the potential to result in substandard care delivered affecting the health and safety of all age appropriate patients receiving care in the Radiology Department.

Findings:

On 5/16/12, at approximately 2:00 PM, during the Radiology Department's inspection tour, it was observed that the department did not have proper resuscitative and monitoring equipment immediately available for all age appropriate patients being treated in the department.

There was no evidence that an adult and pediatric crash cart with specialized monitoring capability and availability of emergency medications was immediately assessable in the Radiology Department for all age appropriate patients being treated.

There was documented evidence that the Radiology Department's Administrative Policies and Procedures were reviewed, approved and accepted by the Medical Staff and Governing Body within the last 3 years (2009 through 2012).

There was no documented evidence that the Quality Assurance Performance Improvement Department had identified or tracked and developed quality indicators addressing policy and procedures not being reviewed or revised in a timely manner by the Medical Staff and Governing Body and the Department did not have resuscitative and monitoring equipment for all age specific patients being treated in the Department.

On 5/16/12, at the time of the findings, the Director of Acute Patient Care confirmed the findings that the Radiology Department did not have administrative policies and procedures reviewed, accepted and approved by the Medical Staff and Governing Body within the last 3 years and the Department did not have age appropriate resuscitative equipment and monitoring for all patients being treated.

Based on interview and record review, the facility failed to ensure that policies and procedures were in place to meet the nutritional needs of age appropriate patients that were reviewed and approved by the medical staff and the Governing Body. The facility also failed to ensure that the Therapeutic Diet Manual was reviewed and approved by the medical staff. These deficient practices had the potential to negatively affect the nutritional needs of any patient admitted to the facility.



Findings:


A review of the Dietary policies and procedures was conducted on 5/21/12. The review revealed that there was no documented evidence that the Dietary Department's Administrative Policy and Procedure manual, formulated and developed by an outside dietary contracted service, was reviewed, approved and accepted by the medical staff and Governing Body.

A review of the Therapeutic Diet Manual was conducted on 5/21/12. The review revealed that the Therapeutic Diet Manual had not been reviewed and approved by the medical staff.


On 5/21/12 at 10:30 AM, the facility's Registered Dietician (RD) and Chief Nursing Officer (CNO) confirmed the findings that the Dietary Department's Administrative policy and procedures, developed and formulated by an outside contracted service, was not reviewed, approved and accepted by the medical staff and Governing Body as of 5/13/12. They also confirmed that the Therapeutic Diet Manual had not been approved by the medical staff. The CNO stated that she thought that the hospital could use the contracted company's policies. The RD stated that she was aware that approval of the policies and the diet manual by the hospital were required.

Based on staff interview and facility record review, the facility failed to ensure that policies and procedures were in place to meet the nutritional needs of age appropriate patients that were reviewed and approved by the medical staff. The facility failed to ensure that nutritional assessments were performed in a timely manner, detailed nutritional analysis of daily and therapeutic menus were performed and a system was developed to re-evaluate ongoing nutritional needs of patients were being met for 2 of 20 patients (Patient 10 and 20). These deficient practices had the potential to affect the nutritional needs of age appropriate patients admitted to the facility.

Findings:

1. On 5/15/12, a review of Patient 10's medical record was conducted. Patient 10 was admitted to the facility on 5/14/12 with an admitting diagnosis of severe diarrhea and dehydration.

On 5/15/12, a review of the initial nursing assessment sheet dated 5/14/12 revealed that Patient 10 had a gastrostomy tube in place, had experienced severe diarrhea for the past 3 days, had experienced nausea and vomiting last evening with abdominal pain.

On 5/15/12, at approximately 10:45 AM, an interview with the facility's Registered Dietician was conducted. When asked if a nutritional assessment consult for Patient 10 was received from the admitting nurse on 5/14/12, or a requisition was obtained from the admitting nurse on 5/14/12, triggering a nutritional assessment consult for Patient 10, she stated, " No. "

On 5/15/12, a review of the facility's policy and procedure, from the Department of Nursing, titled,
"ASSESSMENT/REASSESSMENT OF PATIENTS-INTERDISCIPLINARY " dated 3/30/12, stipulated, " ...Initial nutritional screen shall be done upon admission assessment by the Registered Nurse. Dietary consult shall be completed within 48 hours of written order ... "

There was no documented evidence that the Registered Nurse upon admission, on 5/14/12, initiated/triggered a dietary consult assessment based on her initial nutritional screening examination in light of Patient 10 ' s admitting symptoms of having a gastrostomy tube in place, experiencing severe diarrhea for 3 days and complaints of nausea and vomiting with accompanying abdominal pain prior to admission as per the Department of Nursing's policy.

There was no documented evidence that Patient 10's physician had written an order for a Nutritional Assessment Consult on 5/14/12.

There was no documented evidence in the Dietary Department's policy and procedure manual addressing routine assessments of all age appropriate patients admitted to the facility conducted on a daily bases ensuring that all patients were being nutritionally screened appropriately in the event of Registered Nurses not initiating/triggering correctly a dietary consult or Physicians failing to order a dietary assessment consult.

There was no documented evidence that the Dietary Department's Administrative Policy and Procedure manual, formulated and developed by an outside dietary contracted service, was reviewed, approved and accepted by the medical staff and Governing Body as of 5/23/12.
There was no documented evidence in the Dietary's Administrative Policy and Procedure manual or from other facility sources that a detailed nutritional analysis was performed according to nationally recognized associations, such as the Food and Nutrition Board Institute of Medicine, National academies, of recommended dietary allowances and adequate intakes for the facility's daily menus and therapeutic diets.

2. On 5/15/12, a review of Patient 20's medical record was conducted. Patient 20 was admitted to the facility on 4/18/12 with an admitting diagnosis of liver failure and a history of alcoholism with ascites (accumulation of fluid in the abdomen due to liver failure).

On 5/15/12, a review of Patient 20's history and physical assessment sheet, dated 4/19/12 indicated that Patient 20 was thin, ill appearing, jaundiced (yellow appearing skin color) with facial signs of temporal wasting. Patient 10 was discharged from the hospital on 4/20/12.

On 5/15/12, a review of Patient 10's Nutritional Risk Screen, dated 4/19/12, indicated that Patient 10 had a poor appetite which according to facility policy automatically initiates/triggers a nutritional consult.

On 5/15/12, a review of Patient 10's Physician Order Sheet, dated 4/19/12, documented that Patient 10 would be placed on a 1200 milliliter fluid restriction, a low protein, 2 gram low salt diet. Patient 10 was also on Lasix 20 milligrams and Aldactone 25 milligrams daily (diuretics-eliminate excess water in the body).

There was no documented evidence that the admitting Registered Nurse had initiated/triggered a dietary assessment consult per facility policy on 4/19/12.

There was no documented evidence that Patient 10's physician, on 4/19/12, had written a " Dietary Assessment Consult " in light of Patient 10's presenting symptoms and special dietary restrictions.

There was no documented evidence that a dietary assessment was performed on Patient 10, on 4/19/12, by the Registered Dietician.

There was no documented evidence in the " INTERDISCIPLINARY TEACHING AND CARE PLAN " dated 4/19/12, that the Registered Dietician had developed a nutritional care plan for Patient 10 on 4/19/12.

On 5/15/12, the facility's Registered Dietician and Chief Nursing Officer confirmed the findings that the Dietary Department's Administrative policy and procedures, developed and formulated by an outside contracted service, was not reviewed, approved and accepted by the medical staff and Governing Body as of 5/13/12. In addition, they confirmed the finding that some dietary consults were not correctly initiated by admitting registered nurses as per facility policy, dietary consults were not initiated in a timely manner in some cases and a detailed nutritional analysis was not conducted on daily menus and therapeutic diets.

Based on staff interview and facility record review, the facility failed to meet the nutrition needs of 4 of 7 sampled patients (Patients 10, 20, 1, and 5) who were reviewed for nutrition care.
For Patient 10, the facility failed to ensure that the patient who was admitted with a tube feeding had a consultation conducted by the Registered Dietician (RD).
For Patient 20, the facility failed to ensure that the patient who was admitted with liver failure, poor appetite, and "thin" appearance had a consultation by the RD.
For Patient 1, the facility failed to ensure that the patient who was admitted with abdominal pain, had abdominal surgery, and required intravenous nutrition, had a consultation conducted by the Registered Dietician (RD).
For Patient 5, the facility failed to ensure that the patient who was admitted for abdominal surgery and was discharged home on a specialized diet, had a consultation conducted by the Registered Dietician (RD).

These deficient practices had the potential to negatively affect the nutritional needs of the patients admitted to the facility.

Findings:

1. On 5/15/12, a review of Patient 10's medical record was conducted. Patient 10 was admitted to the facility on 5/14/12 with an admitting diagnosis of severe diarrhea and dehydration.

On 5/15/12, a review of the initial nursing assessment sheet dated 5/14/12 revealed that Patient 10 had a gastrostomy tube in place, had experienced severe diarrhea for the past 3 days, had experienced nausea and vomiting last evening with abdominal pain.

On 5/15/12, at approximately 10:45 AM, an interview with the facility's Registered Dietician was conducted. When asked if a nutritional assessment consult for Patient 10 was received from the admitting nurse on 5/14/12, or a requisition was obtained from the admitting nurse on 5/14/12, triggering a nutritional assessment consult for Patient 10, she stated, " No. "

On 5/15/12, a review of the facility's policy and procedure, from the Department of Nursing ,titled "ASSESSMENT/REASSESSMENT OF PATIENTS-INTERDISCIPLINARY " dated 3/30/12, stipulated, " ...Initial nutritional screen shall be done upon admission assessment by the Registered Nurse. Dietary consult shall be completed within 48 hours of written order ... "

There was no documented evidence that the Registered Nurse upon admission, on 5/14/12, initiated/triggered a dietary consult assessment based on her initial nutritional screening examination in light of Patient 10 ' s admitting symptoms of having a gastrostomy tube in place, experiencing severe diarrhea for 3 days and complaints of nausea and vomiting with accompanying abdominal pain prior to admission as per the Department of Nursing's policy.

There was no documented evidence that Patient 10's physician had written an order for a Nutritional Assessment Consult on 5/14/12.

There was no documented evidence in the Dietary Department's policy and procedure manual addressing routine assessments of all age appropriate patients admitted to the facility conducted on a daily bases ensuring that all patients were being nutritionally screened appropriately in the event of Registered Nurses not initiating/triggering correctly a dietary consult or Physicians failing to order a dietary assessment consult.

There was no documented evidence that the Dietary Department's Administrative Policy and Procedure manual, formulated and developed by an outside dietary contracted service, was reviewed, approved and accepted by the medical staff and Governing Body as of 5/23/12.

There was no documented evidence in the Dietary's Administrative Policy and Procedure manual or from other facility sources that a detailed nutritional analysis was performed according to nationally recognized associations, such as the Food and Nutrition Board Institute of Medicine, National academies, of recommended dietary allowances and adequate intakes for the facility's daily menus and therapeutic diets.

2. On 5/15/12, a review of Patient 20's medical record was conducted. Patient 20 was admitted to the facility on 4/18/12 with an admitting diagnosis of liver failure and a history of alcoholism with ascites (accumulation of fluid in the abdomen due to liver failure).

On 5/15/12, a review of Patient 20's history and physical assessment sheet, dated 4/19/12 indicated that Patient 20 was thin, ill appearing, jaundiced (yellow appearing skin color) with facial signs of temporal wasting. Patient 10 was discharged from the hospital on 4/20/12.

On 5/15/12, a review of Patient 10's Nutritional Risk Screen, dated 4/19/12, indicated that Patient 10 had a poor appetite which according to facility policy automatically initiates/triggers a nutritional consult.

On 5/15/12, a review of Patient 10's Physician Order Sheet, dated 4/19/12, documented that Patient 10 would be placed on a 1200 milliliter fluid restriction, a low protein, 2 gram low salt diet. Patient 10 was also on Lasix 20 milligrams and Aldactone 25 milligrams daily (diuretics-eliminate excess water in the body).

There was no documented evidence that the admitting Registered Nurse had initiated/triggered a dietary assessment consult per facility policy on 4/19/12.

There was no documented evidence that Patient 10's physician, on 4/19/12, had written a " Dietary Assessment Consult " in light of Patient 10's presenting symptoms and special dietary restrictions.

There was no documented evidence that a dietary assessment was performed on Patient 10, on 4/19/12, by the Registered Dietician.

There was no documented evidence in the " INTERDISCIPLINARY TEACHING AND CARE PLAN " dated 4/19/12, that the Registered Dietician had developed a nutritional care plan for Patient 10 on 4/19/12.

On 5/15/12, the facility's Registered Dietician and Chief Nursing Officer confirmed the findings that the Dietary Department's Administrative policy and procedures, developed and formulated by an outside contracted service, was not reviewed, approved and accepted by the medical staff and Governing Body as of 5/13/12. In addition, they confirmed the finding that some dietary consults were not correctly initiated by admitting registered nurses as per facility policy, dietary consults were not initiated in a timely manner in some cases and a detailed nutritional analysis was not conducted on daily menus and therapeutic diets.




22233


3. A review of the medical record for Patient 1 was conducted on 5/16/12. The patient was admitted to the hospital on 5/1/12 with diagnoses that included abdominal pain with distention. The patient was still present in the hospital on the date of review, 5/16/12.

Further review revealed that the patient had two abdominal surgeries on 5/1/12 and again on 5/4/12. Review of the physician's progress notes for the hospitalization revealed that the patient had been on " NPO " (nothing by mouth) status on and off during the hospital stay and that attempts at giving the patient a diet had failed.

A review of the physician's orders, dated 5/6/12, revealed that the patient had been placed on intravenous nutrition (TPN).

Review of the record revealed that there was no assessment conducted by the Registered Dietician (RD).

An interview was conducted with RD 1 on 5/16/12 at 3:30 PM. She stated that she was not given a referral to see this patient. She reviewed the record, including the nursing admission screening, and stated that she should have been notified regarding this patient. She stated that the patient certainly met the hospital ' s guidelines for requiring a consultation by an RD. She stated that her timeframe for seeing patients was to see them in 48 hours of referral. She stated that any patient on intravenous nutrition should be referred for an evaluation by an RD.

4. A review of the medical record for Patient 5 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital on 4/24/12 for an abdominal surgery. The patient was discharged on 4/29/12.

A review of the "Nutritional Risk Screen", completed on admission, revealed that the screen was not conducted by nursing.

A review of the nursing discharge information, including discharge teaching, revealed that the patient's diet was listed as full (arrow) bland diet. The nurse documented to slowly advance diet as tolerated. There was no further documented evidence that any explanation was given to the patient as to what a types of foods constituted a full liquid or a bland diet.

A review of the entire medical record revealed no assessment or teaching conducted by the Registered Dietitian (RD) or the dietary department.

An interview was conducted with the Chief Nursing Officer (CNO) on 5/22/12 at 10:30 AM. She confirmed that the nursing admission assessment for the nutritional screen was completed and that there was no documentation that the patient had been seen by the RD. She stated that according to hospital policy, the RD should have been notified to see this patient. She acknowledged that the RD could have helped the patient understand his discharge diet.

A review of the medical record for Patient 7 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital on 3/3/12 with diagnoses that included intractable nausea and vomiting.

A review of the " Nutritional Risk Screen " , completed on admission, revealed that the nurse had completed the assessment and the patient required an assessment by the RD.

A review of the entire record revealed that there was no assessment conducted by the RD.

An interview was conducted with the Chief Nursing Officer (CNO) on 5/22/12 at 11 AM.

She confirmed that the patient met the requirement for a consult by the RD. She stated that there was no RD assessment in the record. She could not explain why the patient had not been assessed by the RD.

Based on staff interview and facility record review, the facility failed to ensure that the Therapeutic Diet Manual was reviewed and approved by the medical staff. The facility failed to ensure that a detailed nutritional analysis of daily and therapeutic menus were performed. These deficient practices had the potential to affect the age appropriate nutritional needs of any patient admitted to the facility.

Findings:
A review of the Therapeutic Diet Manual was conducted on 5/18/12. The diet manual was developed and formulated by an outside contracted service. The review revealed that the Therapeutic Diet Manual had not been reviewed and approved by the medical staff.

A review on 5/18/12 of the daily therapeutic menus was conducted. The menus did not contain a detailed nutritional analysis of the diet. There was no complete breakdown of what nutritional needs the foods supplied.


On 5/22/12 at 11 AM, the facility's Registered Dietician (RD) and Chief Nursing Officer (CNO) confirmed that the Therapeutic Diet Manual had not been approved by the medical staff, prior to the start of the survey on 5/15/12.











1. On 5/15/12, a review of Patient 10's medical record was conducted. Patient 10 was admitted to the facility on 5/14/12 with an admitting diagnosis of severe diarrhea and dehydration.

On 5/15/12, a review of the initial nursing assessment sheet dated 5/14/12 revealed that Patient 10 had a gastrostomy tube in place, had experienced severe diarrhea for the past 3 days, had experienced nausea and vomiting last evening with abdominal pain.

On 5/15/12, at approximately 10:45 AM, an interview with the facility's Registered Dietician was conducted. When asked if a nutritional assessment consult for Patient 10 was received from the admitting nurse on 5/14/12, or a requisition was obtained from the admitting nurse on 5/14/12, triggering a nutritional assessment consult for Patient 10, she stated, " No. "

On 5/15/12, a review of the facility's policy and procedure, from the Department of Nursing, titled, " ASSESSMENT/REASSESSMENT OF PATIENTS-INTERDISCIPLINARY " dated 3/30/12, stipulated, " ...Initial nutritional screen shall be done upon admission assessment by the Registered Nurse. Dietary consult shall be completed within 48 hours of written order ... "

There was no documented evidence that the Registered Nurse upon admission, on 5/14/12, initiated/triggered a dietary consult assessment based on her initial nutritional screening examination in light of Patient 10 ' s admitting symptoms of having a gastrostomy tube in place, experiencing severe diarrhea for 3 days and complaints of nausea and vomiting with accompanying abdominal pain prior to admission as per the Department of Nursing's policy.
There was no documented evidence that Patient 10's physician had written an order for a Nutritional Assessment Consult on 5/14/12.

There was no documented evidence in the Dietary Department's policy and procedure manual addressing routine assessments of all age appropriate patients admitted to the facility conducted on a daily bases ensuring that all patients were being nutritionally screened appropriately in the event of Registered Nurses not initiating/triggering correctly a dietary consult or Physicians failing to order a dietary assessment consult.

There was no documented evidence that the Dietary Department's Administrative Policy and Procedure manual, formulated and developed by an outside dietary contracted service, was reviewed, approved and accepted by the medical staff and Governing Body as of 5/23/12.
There was no documented evidence in the Dietary's Administrative Policy and Procedure manual or from other facility sources that a detailed nutritional analysis was performed according to nationally recognized associations, such as the Food and Nutrition Board Institute of Medicine, National academies, of recommended dietary allowances and adequate intakes for the facility's daily menus and therapeutic diets.

2. On 5/15/12, a review of Patient 20's medical record was conducted. Patient 20 was admitted to the facility on 4/18/12 with an admitting diagnosis of liver failure and a history of alcoholism with ascites (accumulation of fluid in the abdomen due to liver failure).

On 5/15/12, a review of Patient 20's history and physical assessment sheet, dated 4/19/12 indicated that Patient 20 was thin, ill appearing, jaundiced (yellow appearing skin color) with facial signs of temporal wasting. Patient 10 was discharged from the hospital on 4/20/12.

On 5/15/12, a review of Patient 10's Nutritional Risk Screen, dated 4/19/12, indicated that Patient 10 had a poor appetite which according to facility policy automatically initiates/triggers a nutritional consult.

On 5/15/12, a review of Patient 10's Physician Order Sheet, dated 4/19/12, documented that Patient 10 would be placed on a 1200 milliliter fluid restriction, a low protein, 2 gram low salt diet. Patient 10 was also on Lasix 20 milligrams and Aldactone 25 milligrams daily (diuretics-eliminate excess water in the body).

There was no documented evidence that the admitting Registered Nurse had initiated/triggered a dietary assessment consult per facility policy on 4/19/12.

There was no documented evidence that Patient 10's physician, on 4/19/12, had written a " Dietary Assessment Consult " in light of Patient 10's presenting symptoms and special dietary restrictions.

There was no documented evidence that a dietary assessment was performed on Patient 10, on 4/19/12, by the Registered Dietician.

There was no documented evidence in the " INTERDISCIPLINARY TEACHING AND CARE PLAN " dated 4/19/12, that the Registered Dietician had developed a nutritional care plan for Patient 10 on 4/19/12.

On 5/15/12, the facility's Registered Dietician and Chief Nursing Officer confirmed the findings that the Dietary Department's Administrative policy and procedures, developed and formulated by an outside contracted service, was not reviewed, approved and accepted by the medical staff and Governing Body as of 5/13/12. In addition, they confirmed the finding that some dietary consults were not correctly initiated by admitting registered nurses as per facility policy, dietary consults were not initiated in a timely manner in some cases and a detailed nutritional analysis was not conducted on daily menus and therapeutic diets.

Based on observation, interview and record review, the facility failed to provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases in a universe of 16 patients when it failed to ensure the following:

1. On 5/15/12, at approximately 11:00 AM, RN 3 was observed not washing her hands prior to mixing sterile medications before administration of the antibiotic medication to her patient.

2. On 5/17/12, at approximately 10:30 AM, it was observed that RN 4 did not follow recommended manufactures instruction for disinfecting a surface area when she was observed disinfecting her medicine preparation work area, in the designated medicine preparation room, with only one disinfection wipe down which was not followed with a second disinfection wipe down of her work surface area after 2 to 3 minutes of the initial dwell time as recommended by the manufacturer.

3. On 5/21/12, at approximately 10:00 AM, it was observed that RN 5 did not follow recommended manufactures instruction for disinfecting a surface area by not allowing the disinfecting solution/agent to remain on a non-porous surface to air dry for a least 2 to 3 minutes while disinfecting the mattress and side rails of emergency room gurney (beds) in between patient use.
4. That all employee skin tests for Tuberculosis (TB) were conducted yearly according to accepted standards of practice and state regulation for 7 of 17 employee files reviewed. This failure had the potential for the employee to have contacted TB and for the bacteria to be spread to the public.

5. That the infection control officer reviewed and evaluated the cleaning practices in the Physical Therapy (PT) department. This failure had the potential for any patient receiving PT to come into contact with an infectious agent on the PT equipment between weekly cleaning and disinfecting.

These deficient findings had the potential to result in cross contamination and transmission of microorganism causing disease and infections to other patients and staff in the facility.

Findings:

1. On 5/15/12, at approximately 11:00 AM, it was observed that RN 3 did not wash her hands prior to mixing sterile admixture medications (one or more additional drugs or solutions have been added or to join the contents of two sterile products) prior to administering the medication to her patient.

2. On 5/17/12, at approximately 10:30 AM, it was observed that RN 4 did not follow recommended manufactures instruction for disinfecting a surface area when she was observed disinfecting her medicine preparation work area, in the designated medicine preparation room, by disinfecting her work area with only one disinfecting wipe down, which was not followed with a second disinfecting wipe down as recommended by the manufactures instructions. RN 4 did not disinfect her work area with a second wipe down after the initial wait of 2 to 3 minutes allowing the disinfecting solution/agent to remain on a non-porous surface and allowed to air dry for thorough disinfection to take place.

3. On 5/21/12, at approximately 10:00 AM, it was observed that RN 5, in the Emergency Room, did not follow recommended manufactures instruction for disinfecting a surface area by not allowing the disinfecting solution/agent to remain on a non-porous surface to air dry for a least 2 to 3 minutes while disinfecting the mattress, side rails of emergency room gurney (bed) and patient equipment between each patient use.


There was no documented evidence that the facility's Infection Control Preventionist conducted active surveillance and developed quality infection control measures addressing nursing personnel involved in admixtures of medications in the designated medicine preparation room and disinfection of patient care equipment in the Emergency Room.

There was no documented evidence that the facility's Quality Assurance and Performance Improvement Department developed quality indicators for monitoring infection control measures regarding personnel involved in mixing medications in the designated medicine preparation room.

On 5/23/12, the Director of the Pharmacy Department and Chief Nursing Officer confirmed the findings that RN 3 did not wash her hands prior to mixing sterile admixture medications on 5/14/12, that RN 4 did not follow recommended manufactures instruction for disinfecting a surface area when she was observed disinfecting her medicine preparation work area, in the designated medicine preparation room, by disinfecting her work area with only one disinfecting wipe down, which was not followed with a second disinfecting wipe down as recommended by the manufactures instructions. on 5/17/12 and that RN 5, in the Emergency Room, did not follow recommended manufactures instruction for disinfecting a surface area by not allowing the disinfecting solution/agent to remain on a non-porous surface to air dry for a least 2 to 3 minutes while disinfecting the mattress, side rails of emergency room gurney (bed) and patient equipment between each patient use.






22233



4. A review of the PT space was conducted, on 5/23/12 at 10:30 AM, and an observation was made of the equipment and beds that were used by patients.

An interview was conducted with the PT Manager (PTM) at the same time. She was asked how often the beds and equipment were cleaned and sanitized. She stated "once a week." She stated that for the beds, they did change the cover sheet with each patient; however, they did not clean the beds. The PTM confirmed that some of the patient's in PT were post operative patients. She was asked if the hospital's infection control officer had reviewed the practice of cleaning and sanitizing the PT equipment and beds weekly and she stated "no." She confirmed that the cleaning practice should be reviewed to help prevent the spread of infection.



5. A review of the employees files was conducted on 5/17/12 and 5/21/12. The following employee files did not have annual TB testing completed or did not have an annual screening completed for those employees who tested positive.

Cook 1 - last TB testing, 3/17/11
Diet Aide 1 - last TB testing, 3/11/11
Chief Nursing Officer - last TB testing, 2/23/11
Registered Nurse (RN) 8 - last TB testing, 8/28/10
RN 9 - last TB screening, 1/8/11
Case Manager 1 - last TB testing/screening, 1/21/09
RN 6 - last TB testing/screening, 1/23/09

A review of the hospital policy titled "Tuberculosis Screening Policy and Treatment Plan", dated 10/18/11, revealed that there was no policy requirement for an annual TB testing or screening.

A review of the State regulations for employee health records 70723 (b) (3) revealed that an annual skin test was required for employees who previously tested negative.

An interview was conducted with the Human Resource Manager (HRM) on 5/21/12 at 3 PM. She confirmed that the above employees did not have TB testing completed as required. She stated that the hospital's practice was to have annual testing completed. She stated that if the employee had tested positive and been cleared by a chest X-ray, then the employee would require a yearly screening questioner to be completed.

Based on interview and record review, the facility failed to ensure:

1. The discharge plan for 1 of 20 sampled patients (Patient 6) was reassessed when there were factors identified that could affect the continuing care needs and the appropriateness of the discharge plan. The facility failed to reassess the discharge plan for the patient (after an abdominal surgery) when it was determined that his discharge home included an airline flight to another state in the midwest on the day of discharge. This failure had the potential for the patient to suffer complications related to the discharge plan.

2. Patient's placed on observation status (An out-patient status that was used by the hospital to admit patients who did not meet admission criteria, but who's physicians thought that the patient required monitoring. The patient may incur an extra cost as an out-patient, due to meeting co-payments.) had an evaluation of their status completed as directed by facility policy and according to the criteria used by hospital for 3 of 4 patients (Patients 8, 7, and 9) admitted on observation status. This failure resulted in Patient 8 not having a review of his observation status and upon surveyor review, the patient met admission status. This failure resulted in Patients 7 and 9 not having review of their status as an observation patient on a every 24 hour basis as required by the hospital's criteria and resulted in a length of stay greater than 24 hours (as defined by State regulation).



Findings:

1. A review of the medical record for Patient 6 revealed that he was admitted to the hospital on 4/3/12 due to a rupture of his small bowel.

A review of the physician's discharge summary, dated 4/10/12, revealed that the patient had an abdominal surgery on the day of admission that started as a diagnostic surgery using a scope but turned into an open surgery due to a "jejunal (part of the small intestine) blowout injury." The patient was discharged from the hospital on 4/10/12.

A review of the nursing form titled "Patient Shift Assessment", dated 4/10/12, revealed that the nurse had documented a referral to the discharge planner because the patient was discharged to "fly home today."

A review of the discharge planning notes revealed that there was no mention of the patient's intention to fly home on the day of discharge. There was an entry on 4/10/12 that stated "Home stable condition (with) family."

An interview was conducted with Case Manager (CM 1) who was responsible discharge planning on 5/22/12 at 12 noon. She reviewed the medical record and stated that she was not aware that the patient was going to fly home. She stated that she thought that the patient was just "going home" with his family. She acknowledged that because of the plane flight, the patient should have had a reassessment of his discharge plan. She confirmed that the reassessment was not conducted.


2. a) A review of the medical record for Patient 8 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital as an observation patient on 4/15/12 with diagnoses that included intractable vomiting, diarrhea, kidney failure, and dehydration.


On 5/22/12 at 12:15 PM, the medical record was reviewed with the Case Manager (CM 1) who was responsible for determining if the patient met admission criteria. CM 1 reviewed the record and compared the patient's admitting diagnoses with the criteria, along with the patient's laboratory results. According to the criteria used by CM 1, the patient did meet admission criteria.


A review of the "Discharge Planning Review" revealed that the patient was seen by case management for discharge needs; however, there was no documented evidence that the patient was evaluated for his status as an out-patient.


At the time of the review, CM 1 stated that she did not know why the patient had not been evaluated. She stated that the patient did meet admitting criteria and should not have been admitted as an observation patient. CM 1 stated that according to the criteria used by the hospital, the patient needed to be reviewed each 24 hours for continuing observation status.


A review of the hospital policy titled "Observation Status", dated 1/26/12, revealed "Case management will review all observation status patient. The case management department is responsible to review patient status for the appropriateness and medical necessity of the level of care assigned, outpatient observation or inpatient status."


A review of the State regulations revealed that an out patient status was defined as less than 24 hours.


b). A review of the medical record for Patient 7 was conducted on 5/22/12. The review revealed that the patient was admitted to the hospital on 3/3/12 with diagnoses that included intractable nausea and vomiting. The patient was admitted as an observation patient. The patient was discharged on 3/6/12.


A review of the case management notes revealed that the record was reviewed on 3/4/12. The review documented that the patient would stay on observation status; however, the CM documented that the patient would be discharged that afternoon.


There was no documentation for 3/5/12 and on 3/6/12 there was a note stating the patient was to be discharged home that day. There was no mention a review for observation status.


An interview was conducted with CM 1 on 5/22/12 at 12:30 PM. She stated that all observation patients should be reviewed each day, as observation status was for 24 hours only and the review needed to be done to justify the patient's stay. She confirmed that the case manager documented that the patient would be discharged on 3/4/12 and did not reevaluate the patient, even though the patient was in the hospital until 3/6/12. She stated that she could not explain why the patient was not evaluated. CM 1 stated that the patient should have been evaluated each day.





26502

2 c). On 5/15/12, a review of Patient 9's medical record was conducted. Patient 9 was admitted to the facility on 5/12/12, at 8:56 AM, with an admitting diagnosis of shortness of breath. Patient 9's admitting status ordered by the physician was classified as an "Observation Outpatient."

On 5/15/12, a review of Patient 9's Physician Admitting Order sheet, dated 5/12/12, timed at 9:15 AM, documented that Patient 9's presenting symptoms warranted an admitting status of "Observation Outpatient."

On 5/15/12, a review of Patient 9's Physicians' Order sheet, dated 5/15/12, timed at 3:15 PM, documented that Patient 9 was to be discharged later that day (5/15/12) with a prescription for antibiotics to be taken at home.

There was no documented evidence in Patient 9's medical record or from other facility sources that a secondary review and assessment was conducted by the case manager of Patient 9's admitting status that followed community accepted, evidence-based criteria that supported the level of care needed to meet the needs of the Patient 9 or be discharged home on 5/13/12 and 5/14/12. This deficient practice resulted in Patient 9 being hospitalized a total 3 days resulting in non-compliance with State requirements, that exceeded State requirements of an "Outpatient" who has registered or accepted for care, but not formally admitted as an inpatient, and who does not remain over 24 hours.

On 5/15/12, at approximately 11:15 AM, Case Manager 1 and the Chief Nursing Officer confirmed the finding that a secondary review was not conducted on Patient 9's admitting status as an "Observation Patient " on 5/13/12 and 5/14/12.

Based on interview and record review, the facility failed to ensure that the discharge planning process, which included the assessment of the appropriateness of the observation patient (A patient who was in the hospital as an outpatient and not actually admitted to the hospital.), was reassessed on an on-going basis. The facility failed to integrate the discharge planning process in the the facility quality program. This failure resulted in patients not having complete discharge planning and observation patients not having a full and continuing review of their admission status. (Refer to A 821 and A 822)

Findings:

A review of the hospital's quality program was conducted on 5/22/12 at 11 AM. The review revealed that the hospital had not included the discharge process or the evaluation for the observation patient in the hospital wide quality program.

An interview was conducted with the Director of Quality Management at the same time, 5/22/12 at 11 AM. She stated that the quality program had not reviewed the hospital's discharge process or the evaluation of the observation patient. She stated that it the observation patient was a high volume concern, as there are as many patients in the hospital on observation as patients admitted to the hospital. She confirmed that the discharge process could also be problem prone area and as such should be included in the over quality program.

Based on staff interview and facility record review, the Respiratory Department failed to ensure that policies and procedures for Pulmonary Function Testing procedures were developed and reviewed and approved by the medical staff and Governing Body for all age appropriate patients and that all Respiratory Therapist receive training and were validated as being competent to perform those procedures. These deficient practices had the potential result in substandard care affecting the health and safety of all age appropriate patients undergoing Pulmonary Function Testing procedures delivered by the facility.

Findings:

On 5/14/12, at approximately 1:40 PM, an interview with the lead respiratory therapist was conducted. When asked what basic functions were being performed by the respiratory therapist in the facility, she stated, " Breathing treatments, acute respiratory oxygen interventions, ABG's (Arterial Blood Gas) draws and testing, EKG ' s (Electrocardiogram) testing and Pulmonary Function Testing (PFT) procedures.

In addition, when asked if the facility's Quality Assurance Nurse or the Infection Control Preventionist provided oversight to all Pulmonary Function Testing procedures delivered by the Department to all age appropriate patients, she stated, " No. "
There was no documented evidence that the facility developed and implemented policies and procedures for delivery of all Pulmonary Function Testing procedures for all age-specific patients treated and receiving care at the facility.

There was no documented evidence that the facility's policies and procedures for delivery of all Pulmonary Function Testing procedures were reviewed or revised every 3 years by the Medical Staff as required.

There was no documented evidence that the facility's Governing Body were reviewing and revising current Pulmonary Function Testing policies and procedures ensuring oversight of all Respiratory Therapist performing those procedures.

There was no documented evidence that administrative oversight or supervision of personnel performing Pulmonary Function Testing procedures were being performed consistently ensuring safety, infection control standards and quality of care standards were being met to meet the needs of all age appropriate patients.

There was no documented evidence of administrative oversight of staff competencies performing Pulmonary Function Testing services for all age appropriate patients receiving care and treatment in the facility.

There was no documented evidence that annual performance evaluations or education were provided to personnel performing Pulmonary Function Testing procedures being delivered to all age appropriate patients in the facility.

On 5/21/12, at approximately 1:45 PM, an interview with the Infection Control Preventionist was conducted. When asked if active infection control surveillance was being conducted with all age appropriate patients undergoing pulmonary function testing procedures in the Respiratory Department, he stated, " No. "

On 5/23/12, at approximately 9:45 AM, an interview with the Quality Assurance Nurse was conducted. When asked if quality measures were being tracked or monitored on all age appropriate patients undergoing pulmonary function testing procedures in the facility, she stated, " No. "

On 5/23/12, at approximately 10:00 AM, the Chief Nursing Officer confirmed the findings that policies and procedures for Pulmonary Function Testing were not reviewed, approved or accepted by the Medical Staff and Governing Body. In addition, she confirmed that all Respiratory Therapist did not have current competencies and training for performing Pulmonary Function Testing procedures on all age appropriate patients in the facility.

Based on interview and record review the facility failed to ensure:


1. The Quality Assessment Performance Improvement (QAPI) program collected data to measure, analyze and track hospital operations in relation to the discharge planning process and the process for review of the observation patient by the case manager/discharge planner. This failure resulted in several areas of discharge planning deficient practices upon review. (Refer to A 843)


2. The QAPI program collected data to measure and analyze the hospital operations regarding use of high risk medications, nursing competencies related to cardiac monitoring, mixing Intravenous (IV) medications, performing other nursing functions, training for staff for restraint usage, nursing staffing, Dietary and other contracted services, and competencies for respiratory staff conducting out-patient pulmonary function testing.

These failures resulted in the facility's inability to identify problems and proactively correct systems to promote safe patient care for any patient in the hospital system.


Findings:

1. A review of the hospital's quality program was conducted on 5/22/12 at 11 AM. The review revealed that the hospital had not included the discharge process or the evaluation for the observation patient in the hospital wide quality program.

An interview was conducted with the Director of Quality Management (DQM) at the same time, 5/22/12 at 11 AM. She stated that the quality program had not reviewed the hospital's discharge process or the evaluation of the observation patient. She stated that the observation patient was a high volume concern, as there are as many patients in the hospital on observation as patients admitted to the hospital. She confirmed that the discharge process could also be problem prone area and as such should be included in the over quality program.

2. A review of the hospital's quality program was conducted on 5/22/12 at 11 AM. The review revealed that several areas of deficient practice were found in the survey process, that were not previously identified through the hospital's quality program. There was also no quality review found of the hospital's contracted services.

An interview was conducted with the DQM on 5/22/12 at 11 AM. She stated that the hospital had not collected data regarding the staff's competency validation related to telemetry monitoring, nurses compounding IV medications, nurse staffing, and respiratory competency to perform out-patient pulmonary function testing. She stated that these are high risk areas and that quality measures should have been instituted. The DQM stated that the quality department had not collected data on the pharmacy's response to high risk medication alerts. She stated that the hospital was collecting data and monitoring the restraint process for compliance to regulations; however, they had not identified the deficiencies related to the training required by both nursing staff and medical staff.

In the same interview, the DQM was asked if the hospital had measured, analyzed, and tracked any quality indicators regarding their contracted services. She stated that the hospital used contracted services including Dietary, X-ray services for reading X-rays, Emergency Department physicians, and Medical Records. She stated that the hospital had not developed quality indicators on any of the contracted services.

Based on interview and record review, the facility failed to ensure that 1 of 20 sampled patients (Patient 5) had teaching and counseling to prepare for discharge and self care related to dietary concerns. This failure resulted in the patient being discharged home on a specialized diet without complete information regarding the diet and had the potential for the patient to suffer negative consequences related to the inability to follow his diet has prescribed by the physician.

Findings:

A review of the medical record for Patient 5 was conducted 5/22/12. The review revealed that he was admitted to the hospital on 4/24/12 for a repair of an incarcerated hernia (protrusion of part of an organ through an abnormal opening). The patient was discharged home on 4/29/12.

A review of the physician ' s orders dated, 4/29/12, reveled an order for full liquid to bland diet as tolerated.

A review of the nursing discharge information, including discharge teaching, revealed that the patient ' s diet was listed as full (arrow) bland diet. The nurse documented to slowly advance diet as tolerated. There was no further documented evidence that any explanation was given to the patient as to what a types of foods constituted a full liquid or a bland diet. There was no assessment done by nursing to evaluate the patient ' s knowledge of his dietary needs.

A review of the entire medical record revealed no assessment or teaching conducted by the Registered Dietitian (RD) or the dietary department.

An interview was conducted with the Chief Nursing Officer (CNO) on 5/22/12 at 3 PM. She confirmed the findings and stated that the RD should have seen this patient and that nursing should have provided him with the information necessary for a safe discharge.

Based on interview and record review the facility failed to ensure that the discharge policy included instruction to the discharge planner regarding a discharge to long term care (LTC) to ensure that a list of LTC providers was given to the patient to ensure the patient's choice of facilities was honored. This failure had the potential to result in any patient who was discharged to LTC to not be given the information necessary to make an informed choice regarding their placement in LTC.

Findings:

A review of the facility's policy titled "Discharge of a Patient from (hospital name)", dated 1/26/12, revealed that there was no provision for the patient being either discharged or transferred to LTC.

An interview was conducted with the Case Manager (CM 1) who was responsible for discharge planning on 5/22/12 at 12 noon. She stated that she was aware of the requirement to provide the patient with a choice of LTC facilities; however, there was no indication of the requirement in the hospital's policy. She stated that there were no other policies where the information might be required. CM 1 confirmed that the information should be in policy to ensure consistent compliance with the regulations.