HospitalInspections.org

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Based on record review and staff interview during the Federal Allegation Survey, the facility failed to ensure that the Nursing staff developed and revised patient specific Care Plans that were based on the patients' Nursing care needs in three (3) out of sixteen (16) Medical Records reviewed (Patients #5, #7 and #13).

Findings:

Review of the Medical Record for Patient #5 revealed that the patient was admitted on 06/27/14 for left foot metatarsal fractures with ruptured tendons and underwent ORIF (Open Reduction and Internal Fixation) surgery on 06/28/14. The Nurse documented that the patient continued to have complaints of numbness with decreased sensation on 06/29/14 at 6:00AM and the Physician ordered a CAT scan of the left foot with Doppler study. Review of the record revealed that the Nursing staff implemented an Electronic Nursing Care Plan on 06/27/14 titled "Clinical Practice Guideline (CPG): Impaired Physical Mobility" but there was no Nursing Care Plan related to the fractures or post-operative care.

This was confirmed by Staff #6 during the record review who stated that "there is no specific Care Plan for surgery" and that "no Plan of Care was added for post-operative care for the extremity fracture. "

Review of the Medical Record for Patient #7 revealed that the patient was admitted on 06/26/14 for Anemia, Renal Insufficiency and Pleural Effusion. The Nursing documentation revealed the patient had two (2) Stage II pressures ulcers on admission. Review of the record revealed that the Nursing staff implemented an Electronic Nursing Care Plan on 06/26/14 titled "CPG: Gastrointestinal Bleeding and CPG: Acute Renal Failure" but there was no Nursing Care Plan related to the pressure ulcer. This was confirmed with Staff #8.

Review of the Medical Record for Patient #13 revealed that the patient was admitted on 06/13/14 for Sepsis and Pneumonia with ESRD (End Stage Renal Disease). The patient was on Hemodialysis prior to admission and was receiving wound care to his left foot. The Nursing documentation revealed that the patient had a right below the knee amputation, Stage II pressures ulcers of the sacrum, and four (4) Diabetic foot ulcers to the left foot on admission that required surgical debridement. Review of the record revealed that the Nursing staff implemented an Electronic Nursing Care Plan on admission titled "CPG: Hemodialysis and CPG: Pneumonia" but there was no Nursing Care Plan related to the pressure ulcers, immobility, or status of the Diabetic ulcers of his left foot. This was confirmed on interview with Staff #9 at 12:30PM on 07/01/14.

Review of the facility's Policy titled: "Patient Care Services: Knowledge Based Charting Documentation", dated 07/26/13, reveals that "the Clinical Practice Guidelines (CPG) are part of the care-planning process and are selected on the unique needs of each patient / family" and the "Plan of Care (POC) is the individualized interdisciplinary directions for the care of a patient that prioritizes healthcare needs for the patient". "The Registered Nurse is responsible for the presence of the Plan of Care which may be amended or updated by any discipline involved in the patient's care." The Policy then states that "each inpatient will have at least one (1) CPG added to the Plan of Care" but does not include a requirement for revisions or additions to the POC if the patient's needs change.
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Based on record review and staff interview during the Federal Allegation Survey, the facility failed to ensure that the Nursing staff developed and revised patient specific Care Plans that were based on the patients' Nursing care needs in three (3) out of sixteen (16) Medical Records reviewed (Patients #5, #7 and #13).

Findings:

a) Review of Patient #1's Medical Record revealed a Physician's Order dated 06/27/14 for Ferrous Sulfate 325mg po (orally) three (3) times a day with meals.

Review of the EMR (Electronic Medical Record) on 06/30/14 at 10:55AM with Staff #1 revealed there was no documented evidence that the 06/29/14 4:00PM dose of medication was administered.

During an interview with Staff #1 at that time, the staff member confirmed the finding and stated they did not know if the medication was given.

Review of Patient #12's Medical Record revealed a Physician's Order dated 05/21/14 for Decadron 4mg po every six (6) hours and Keppra 500mg po two (2) times a day.

Review of the EMR on 07/01/14 at 1:36PM with Staff #3 revealed there was no documented evidence that the 05/20/14 6:00PM doses of Keppra and Decadron were administered.

During an interview with Staff #3 at that time, the staff member confirmed the findings and stated there is no documented reason in the record why the patient did not get the medications.

b) Review of Patient #22's Emergency Department Nursing Care Record documented on 07/01/14 at 11:25PM a 20 gauge Heparin Lock was placed in the right arm and on 07/02/14 at 4:31AM a 1000cc bolus of .9 Normal Saline was infused.

Review of the EMR on 07/02/14 at 10:00AM with Staff #1 revealed there was no Physician's Order to implement the Heparin Lock or to infuse the 1000cc bolus of Normal Saline.

Staff #1 confirmed the findings.

Review of Patient #24's Emergency Department Nursing Care Record documented on 07/02/14 at 5:30AM that a Heparin Lock was placed in the left arm.

Review of the EMR on 07/02/14 at 10:20AM with Staff #1 revealed that there was no Physician's Order to implement the Heparin Lock.

Staff #1 confirmed the findings.

3) Review of Patient #25's Emergency Department Nursing Care Record documented on 07/02/14 at 08:10AM that a 20 gauge Heparin lock was placed.

Review of the EMR on 07/02/14 at 10:30AM with Staff #1 revealed that on 07/02/14 at 8:59AM the Physician ordered blood work, an EKG and a chest x-ray. However, there was no Physician's Order to implement the Heparin lock.

At that time Staff #1 confirmed the finding.

Review of the Policy titled "Peripheral IV Insertion-Adult", dated 08/09/12, documented peripherally inserted short intravenous catheters shall be placed as ordered by a prescriber.

Review of the Policy titled "Medication Administration and Monitoring", dated 12/12/13, documented one (1) of the steps for medication administration included the individual administering the medication verifying the medication selected matches the Medication Order and product label.
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Based on record review and staff interview during the Federal Allegation Survey, the Nursing staff failed to consistently implement the facility's Policy and Procedure for monitoring patients' vital signs during blood transfusions for two (2) out of four (4) patients in seven (7) out of thirteen (13) "Transfusions Administration Record" Forms reviewed (Patients #8 and #19).

Findings:

Review of the Medical Record for Patient #8 revealed that there was no "Transfusions Administration Record" Form contained in the Medical Record for a unit of Packed Red Blood Cells (PRBC) transfused on 06/27/14. The Nurse documented the pre-transfusion vital signs at 10:45AM but the documentation is incomplete and does not include the transfusion verification, start time, and vital signs fifteen (15) minutes after initiation of the transfusion or at the completion of the transfusion.

Review of the "Transfusions Administration Record" Form for Patient #19, dated 06/29/14, revealed that the unit of PRBCs was started at 12:15PM and completed at 2:30PM. The Nurse obtained the patient's vital signs at 11:00AM, one (1) hour and fifteen (15) minutes before starting the blood transfusion. This is over the thirty (30) minutes required by the facility's Policy. The Nurse then documented the post-transfusion vital signs at 3:00PM, thirty (30) minutes after completing the transfusion, and not immediately after the transfusion, as required by the facility's Policy.

Review of the "Transfusions Administration Record" Form for Patient #19, dated 06/25/14, revealed that a unit of Plasma was started at 9:45PM and completed at 1:00AM on 06/26/14. The Nurse documented the patient's post-transfusion vital signs at 1:30AM, thirty (30) minutes after completing the transfusion, and not immediately after the transfusion, as required by the facility's Policy.

Similar finding were identified for transfusions administered to Patient #19 on 06/26/14 at 3:00AM, 06/28/14 at 4:30PM, 06/28/14 at 10:00PM and 06/29/14 at 3:40PM.

Review of the Policy titled "Blood and Blood Product Transfusions", dated 04/01/14, states that "pre-transfusion vital signs are assessed within thirty (30) minutes prior to the initiation of the transfusion" then "vital signs must be documented fifteen (15) minutes after the transfusion has begun" and "immediately post-transfusion".

These observations were confirmed with Staff Members #5, #6 and #8.
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Based on observation and interview during the Federal Allegation Survey, it was determined that the facility did not ensure that expired biologicals and drugs were not available for patient use.

Findings:

Observations on 07/02/14 at 09:45AM during a tour of the Emergency Department revealed a total of thirty-six (36) expired angiocatheters in the Medication Room.

Twenty (20) 24 gauge .75 inch angiocatheters:
-Nine (9) labeled with an expiration date of 06/11.
-Two (2) labeled with an expiration date of 07/12.
-Seven (7) labeled with an expiration date of 10/13.
-One (1) labeled with an expiration date of 11/13.
-One (1) labeled with an expiration date of 04/14.

Sixteen (16) 18 gauge 1.16 inch angiocatheters:
-One (1) labeled with an expiration date of 02/12.
-One (1) labeled with an expiration date of 04/12.
-One (1) labeled with an expiration date of 08/12.
-Ten (10) labeled with an expiration date of 09/13.
-Two (2) labeled with an expiration date of 11/13.
-One (1) labeled with an expiration date of 03/14.

Staff #1 confirmed this observation and removed the angiocatheters.

During a tour of the 1 E Unit on 06/30/14 at 10:15AM, six (6) Lithium Heparin 4.5ml BD vacutainers labeled with an expiration date of 05/14 and two (2) gold top 5ml BD vacutainers with an expiration date of 05/14 were observed in the Medication Room.

Staff #2 acknowledged this finding and removed the vacutainers.



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Observations during a tour of Unit 2 D on 06/30/14 at 11:00AM revealed one (1) open multi-dose 3cc vial of Humalog U-100 Insulin with no label indicating when it was opened, or when it should be discarded, and one (1) expired (03/14) Huber Plus Infusion Set was observed.

Staff #6 acknowledged this finding and discarded the items.

Observation on Unit 2 C during the morning of 07/01/14 revealed one (1) multi-dose 30cc vial of Acetylcysteine 20% opened on 07/01/14 with no documented discard date.

Staff #7 confirmed this observation and discarded the item.

Observations on Unit 1B at 11:30AM on 07/01/14 revealed two (2) multi dose 30cc vials of Acetylcysteine 20% opened on 06/14/14 with no documented discard date and one (1) opened tube of Nitrobid 2% paste 30 grams which expires on 08/16, with no label indicating when it was opened or when it should be discarded.

Staff #6 confirmed this observation and removed the items.

Review of the Policy titled "Pharmacy Services: Multi-dose Vials" dated 07/28/12 indicated "in instances when multi-dose vials must be used, it will be the policy that all vials when open will have a twenty-eight day (28) expiration and a label is affixed to the vial noting the date opened, the initial of the Nurse and the date of expiration".