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Based on observation, interview, and record review, it was determined the General Acute Care Hospital's (GACH) governing body failed to assume full responsibility for determining, implementing, and monitoring policies governing the centers total operation. The governing body failed to ensure:

1. an intensive care unit (ICU - unit of the hospital for close monitoring and critically ill patients) nurse obtained a blood pressure prior to starting a Norepinephrine drip (medication used for life threatening low blood pressure). (Refer to A-0395 and A-0398).

2. post-blood-transfusion assessments were completed one hour after the blood transfusions were completed for patients who received a blood transfusion. (Refer to A-0395).

3. patients were assessed for pain with each VS (Refer to A-0395 and A-0398).

4. a patient's care plan for restraints was updated once the restraints were discontinued (Refer to A-0396).

5. the staff were disinfecting the glucometer (a device used to measure blood sugar) immediately after patient use with an Environmental Protection Agency (EPA - agency that protect human health and the environment) registered disinfectant (chemical used to disinfect) prior to using the glucometer for the next patient (Refer to A-0398 and A-0749).

6. the nurse (Licensed Vocational Nurse [LVN] 3) obtaining blood sugar levels of patients who are on contact precautions (for patients with known or suspected infections that increase the risk for contact [touch] transmission) removed personal protective equipment (PPE) prior to exiting the patient's room (Refer to A-0749 and A-0750).

7. Doctor's order for ventilator setting changes were carried out as ordered for one of 33 patients (Patient 33). (Refer to A-1160)

8. Doctor's order was documented and obtained for ventilator (machine use to help the patient breath) setting changes done at bedside with the pulmonologist (lung doctor) for one of 33 sampled patients (Patient 21). (Refer to A-1164)

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

Based on interview and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met by failing to ensure Registered Nurse (RN):

1. Obtained a blood pressure prior to starting a Norepinephrine drip (medication used for life-threatening low blood pressure) for one of 33 sampled patients (Patient 33). This deficient practice had the potential for inability to to maintain a systolic blood pressure (SBP the top number which indicates the pressure during heart contraction normal is 120/80 mm/Hg [millimeters of mercury a unit of measure]) more than 90 mm/Hg. (Refer to A-0395)

2. Performed a post-blood transfusion assessment one hour after the transfusion was completed for Patient 25, 21 and 29. This deficient practice had the potential for the misidentification of symptoms of blood transfusion reactions (fever, chills, itching). (Refer to A-0395)

3. Assessed pain level Patients 2, 27 and 18. This deficient practice had the potential for untreated pain. (Refer to A-0395)

4. Updated the restraint care plan for one of 33 sampled patients (Patient 18). This failure had the potential for emotional distress and pain as restraint interventions were still active after the restraint was removed. (Refer to A-0396)

5. Developed a pain care plan for one of 33 sampled patients (Patient 18). This failure had the potential for pain due to missed assessment and planning. (Refer to A-0396)

6. Disinfected the glucometer immediately after patient use with an Environmental (Patient Protection Agency (EPA - agency that protect human health and the environment)-registered disinfectant (chemical used to disinfect) prior to using the glucometer for the next patient (Patient 30, 10, 25, & 22). (Refer to A-0398)

7. Took off personal protective equipment (PPE - protect the wearer's body from injury or infection) before exiting a contact precautions room (Patient 10). (Refer to A-0398)

8. Assessed pain level with each vital signs (Patient 2, 27, & 18). (Refer to A-0398)

9. Started levophed (Norepinephrine - used to treat low blood pressure and heart failure) at 10 mcg/min (a unit of measure per minute) in accordance with the facility's Norepinephrine protocol order (Patient 33). (Refer to A-0398)

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

Based on observation, interview, and record review, the facility failed to have an effective infection control program for 47 patients by:

a. Ensuring that the nurse (Licensed Vocational Nurse [LVN] 3) obtaining blood sugar levels of patients who are on contact precautions (for patients with known or suspected infections that increase the risk for contact [touch] transmission) removed personal protective equipment (PPE - protects the wearer from hazards and infection) prior to exiting the patient's room (Refer to A-0749 and A-0750).

b. Ensuring the glucometer (device used to measure blood sugar) was disinfected with an Environmental Protection Agency (EPA - agency that protect human health and the environment)-registered disinfectant (chemical used to disinfect) prior to using the glucometer for the next patient (Refer to A-0749).

c. Ensuring that the nurse (LVN 2) did not walk down the halls with a used glucometer without first disinfecting it (Refer to A-0749 and A-0750).

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

Based on interview and record review, the facility failed to ensure the Condition of Participation for Respiratory Care Services was met by failing to ensure:

1. Carry out doctor's order for ventilator (machine use to aid patient with breathing) setting changes as ordered for one of 33 sampled
patients (Patient 21).

2. Doctor's order was obtained and documented for ventilator (machine use to help the patient breath) setting changes done at bedside with the pulmonologist (lung doctor) for one of 33 sampled patients (Patient 21). (Refer to A-1164)

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

Based on interview and record review, the facility failed to ensure a registered nurse (RN):

1. Obtained a blood pressure prior to starting a Norepinephrine drip (medication used for life-threatening low blood pressure) for one of 33 sampled patients (Patient 33). This deficient practice had the potential for inability to to maintain a systolic blood pressure (SBP the top number which indicates the pressure during heart contraction normal is 120/80 mm/Hg [millimeters of mercury a unit of measure]) more than 90 mm/Hg.

2. Performed a post-blood transfusion assessment one hour after the transfusion was completed for Patient 25, 21 and 29. This deficient practice had the potential for the misidentification of symptoms of blood transfusion reactions (fever, chills, itching).

3. Assessed pain level Patients 2, 27 and 18. This deficient practice had the potential for untreated pain.

Findings:

1. A review of Patient 33's undated admission record indicated the facility admitted Patient 33 on 7/23/2020 with diagnoses including endocarditis (infection of the heart muscles that involves the heart valves).

A review of the physician orders, dated 8/7/2020, indicated the physician ordered the transfer of Patient 33 to the Intensive Care Unit (ICU - provides life support for critically-ill patients). The physician also ordered Norepinephrine to be titrated (amount adjusted) to maintain a systolic blood pressure (SBP - the top number which indicates the pressure during heart contraction - normal is 120/80 mm/Hg [millimeters of mercury - a unit of measure]) more than 90 mm/Hg.

A review of Patient 33's Norepinephrine medication flowsheet, dated 8/7/2020, indicated on 8/7/2020 at 12:08 p.m., norepinephrine was started at two (2) mcg/min (micrograms per minute - unit of measurement) without blood pressure documented.

During an interview with Registered Nurse 9 (RN 9) on 8/14/2020 at 7:44 a.m., RN 9 stated the norepinephrine was started on 8/7/20230 at 2 mcg/min. RN 9 also stated there was no blood pressure documented on the medication flowsheet when it was started. RN 9 further stated the expectation was for the blood pressure to be documented when starting norepinephrine drip.

During a review of the facility policy and procedure titled, CORE: Interdisciplinary Assessment and Re-Assessment, released date June 2020, indicated, "to establish a comprehensive information base for decision making about each patient's care ... to determine the appropriate care, treatment and services to meet the patient's needs during hospitalization." The policy indicated, "routine vital signs will consist of the following: blood pressure, pulse, respirations, temperature, and pain assessment."


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2a. A review of Patient 25's undated admission record, indicated the facility admitted Patient 25 on 6/6/2020 at 10:45 p.m. with diagnose including respiratory failure (the lungs have developed inadequate gas exchange).

A review of the Blood/Blood Component Transfusion Record for Patient 25, dated 8/9/2020, indicated Patient 25 received one unit packed red cells (component of the blood which carries oxygen) from 10:45 p.m. until 8/9/2020 at 12:00 a.m. There were no vital signs recorded one hour after completion of the blood transfusion.

During an interview with Licensed Vocational Nurse (LVN) 4 on 8/13/2020, at 9:51 a.m., LVN 4 stated there was no vital sign recorded one hour after the blood transfusion was done on 8/9/2020. LVN 4 stated vital signs are completed one hour after completion of the blood transfusion to ensure Patient 25 did not have a blood transfusion reaction.

2b. A review of Patient 21's undated admission record, indicated the facility admitted Patient 21 7/10/2020 at 9:39 p.m. with diagnoses including sepsis (infection of the blood which may lead to dead).

A review of Patient 21's Blood/Blood Transfusion Component Transfusion Record, dated 8/11/2020, indicated Patient 21 received 1 unit of packed red cells from 3:15 p.m. until 7:15 p.m. There were no vital signs recorded one hour after completion of the blood transfusion.

During an interview with LVN 4 on 8/13/2020 at 11:25 a.m., LVN 4 confirmed there was no vital sign recorded an hour after the blood transfusion was done on August 11, 2020.

2c. A review of Patient 29's undated admission record indicated the facility admitted Patient 29 5/13/2020 at 9:29 p.m. with diagnoses including pneumonia (lung infection).

A review of Patient 29's Blood/Blood Component Transfusion Record, dated 5/20/2020, indicated Patient 29 received one unit of packed red cells from 5:45 p.m. until 6:00 p.m. Another unit of packed red cells was transfused from 6:05 p.m. until 6:20 p.m. Both transfusions did not have vital signs recorded one hour after transfusion and was transfused within 15 minutes.

During an interview with the LVN 4 on 8/13/2020 at 2:16 p.m., LVN 4 confirmed that the transfusion for the two units of packed red cells was done in 15 minutes and that there were no vital signs recorded one hour after the transfusion.

During the review of the facility policy and procedures titled, CORE: Transfusion Therapy, released date June 2020, indicated, " ...3. Vital signs (VS) will be observed and documented at a minimum at the following intervals/times: ...Check VS at 1 hour post-transfusion ...8. Transfusion initiation: a. A Registered Nurse shall infuse blood or blood components slowly for the first 15 minutes ..."

3a. A review of Patient 2's undated admission record indicated the facility admitted Patient 2 on 7/21/2020 with diagnoses including respiratory failure (the lungs developing inadequate gas exchange) and unspecified hypoxia (inadequate oxygen, element of the air which sustains life, supply to the cells).

A review of Patient 2's History and Physical, dated 7/22/2020, indicated Patient 2 was diagnosed with COVID-19 (A disease caused by severe acute respiratory syndrome coronavirus 2) pneumonia bilaterally (infection to both lungs) and sepsis.

During a concurrent interview and record review on 8/13/2020 at 11:16 a.m. with the Director of Quality, Patient 2's Vital Signs (VS) Flowsheet was reviewed. The VS flowsheet indicated, blank and missing pain scale assessment for 8/12/2020 at 4:00 a.m., 8/12/2020 at 8:00 a.m., and 8/12/2020 at 12:00 p.m. The Director of Quality stated pain assessment should be part of vital signs and should be completed by the nurses.

3b. A review of Patient 18's undated admission record indicated the facility admitted Patient 18 on 8/1/2020 with diagnoses including respiratory failure (the lungs developing inadequate gas exchange), and unspecified hypoxia (inadequate oxygen, element of the air which sustains life, supply to the cells) or hypercapnia (abnormal elevated carbon dioxide level in the blood).

A Patient 18's History and Physical record, dated 8/3/2020, indicated Patient 18 was diagnosed with COVID-19 pneumonia bilaterally, dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD, long-term condition where acid from the stomach comes up into the esophagus), and plan for g-tube placement (tube inserted through the belly that brings nutrition directly to the stomach).

During a concurrent interview and record review, on 8/13/2020 at 11:48 a.m., with the Director of Quality, Patient 18's VS Flowsheet was reviewed. The VS flowsheet indicated, blank and missing pain scale assessment for 8/11/2020 at 12:00 p.m., 8/11/2020 at 4:00 p.m., 8/12/2020 at 8:00 a.m., 8/12/2020 at 12:00 p.m., and 8/12/2020 at 4:00 p.m. The Director of Quality stated, pain assessment should be part of VS and should be completed by the nurses.

3c. A review of Patient 27's undated admission record indicated the facility admitted Patient 27 on 8/7/2020 with diagnoses including respiratory failure and unspecified hypoxia or hypercapnia.

A review of Patient 27's History and Physical record dated 8/8/2020 indicated Patient 27 was diagnosed with COVID-19 pneumonia bilaterally and respiratory failure.

During a concurrent interview and record review, on 8/13/2020 at 11:05 a.m., with the Director of Quality, Patient 27's VS Flowsheet was reviewed. The VS flowsheet indicated, blank and missing pain scale assessment for 8/11/2020 at 4:00 p.m. The Director of Quality stated pain assessment should be part of vital signs and should be completed by the nurses.

During an interview on 8/14/2020 at 2:28 p.m., with Chief Clinical Officer (CCO), the CCO stated pain assessment is part of vital signs. The CCO also stated data is collected to ensure patients are free from pain. The CCO added the facility staff must assess pain as each patient is different.

A review of "CORE: Interdisciplinary Assessment and Re-Assessment" policy, released June 2020, the policy's purpose indicated, "to establish a comprehensive information base for decision making about each patient's care ... to determine the appropriate care, treatment and services to meet the patient's needs during hospitalization." The policy indicated, "routine vital signs will consist of the following: blood pressure, pulse, respirations, temperature, and pain assessment."

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

1. Update the restraint care plan for one of 33 sampled patients (Patient 18). This failure had the potential for emotional distress and pain as restraint interventions were still active after the restraint was removed.

2. Develop a pain care plan for one of 33 sampled patients (Patient 18). This failure had the potential for pain due to missed assessment and planning.

Findings include:

1. During a review of Patient 18's Patient registration data, the record indicated an admission date of 8/1/2020, with diagnoses including respiratory failure (the lungs developing inadequate gas exchange), and unspecified hypoxia (inadequate oxygen, element of the air which sustains life, supply to the cells) or hypercapnia (abnrmal elevated carbon dioxide level in the blood).

During a review of Patient 18's History and Physical record, dated 8/3/2020 , the record indicated Patient 18 was diagnosed with COVID-19 pneumonia bilaterally (corona virus infection of the ai sacs of the lungs), dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD, long-term condition where acid from the stomach comes up into the esophagus), and plan for g-tube placement (tube inserted through the belly that brings nutrition directly to the stomach).

During a concurrent interview and record review on 8/13/2020 at 11:48 am, with the Director of Quality, Patient 18's "Restraint Monitoring (Non-Violent, Non-Self Destructive Behavior)" form was reviewed. The Restraint Monitoring form indicated, safety checks and monitoring was last documented on 8/6/2020 at 6:00 am. The Director of Quality stated, restraint safety check and monitoring was discontinued on of 8/7/2020 at 8:00 am. The Restraint Monitoring form did not indicate answer for the question: "Is the need for restraint resolved?" The Restraint Monitoring form was blank or missing documentation also for the name, date, time the restraint was removed. The Restraint Monitoring form indicated also answer to the question: "Care plan resolved?"

During a review of "CORE: Physical Restraints (Violent and Non-Violent Behavior) and Seclusion" policy, release date 6/2020, the policy indicated, "The RN will create and modify the patient's plan of care." The policy indicated, "All documentation of patient status should be in real time."

2. During a review of Patient 18's Patient registration data, the record indicated an admission date of 8/1/2020, with diagnoses including respiratory failure (the lungs developing inadequate gas exchange), and unspecified hypoxia (inadequate oxygen, element of the air which sustains life, supply to the cells) or hypercapnia (abnrmal elevated carbon dioxide level in the blood).

During a review of Patient 18's History and Physical record, dated 8/3/2020 , the record indicated Patient 18 was diagnosed with COVID-19 pneumonia bilaterally (corona virus infection of the ai sacs of the lungs), dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD, long-term condition where acid from the stomach comes up into the esophagus), and plan for g-tube placement (tube inserted through the belly that brings nutrition directly to the stomach).

During a concurrent interview and record review, on 8/14/2020 at 8:24 am, with RN (Registered Nurse) 2. RN 2 stated, Patient 18 was awaiting feeding tube placement, pending physician clearance and surgery schedule. RN 2 stated, Patient 18 was currently on restraints due to attempts to pull out his tubes. RN 2 stated, Patient 18 did not have a current care plan for pain or potential for pain. RN 2 stated, Patient 18 should have a pain care plan for appropriate pain management and interventions.

During a review of "CORE: Pain Management Plan" policy, release date 6/2020, the policy's purpose indicated, "The registered nurse will develop a patient specific plan of care with identification of pain when conducting the patient's admission assessment and/or anytime during the patient's hospital stay. A licensed nurse involved in the care of the patient will update the patient specific plan of care as needed."

Based on observation, interview, and record review, the facility failed to adhere to the policies and procedures of the hospital for eight of 33 sampled patients, by:

1. disinfecting the glucometer immediately after patient use with an Environmental (Patient Protection Agency (EPA - agency that protect human health and the environment)-registered disinfectant (chemical used to disinfect) prior to using the glucometer for the next patient (Patient 30, 10, 25, & 22);

2. ensuring the nurse took off personal protective equipment (PPE - protect the wearer's body from injury or infection) before exiting a contact precautions room (Patient 10);

3. assessing pain with each vital signs (Patient 2, 27, & 18); and

4. starting levophed (Norepinephrine - used to treat low blood pressure and heart failure) at 10 mcg/min (a unit of measure per minute) in accordance with the facility's Norepinephrine protocol order (Patient 33).

These deficient practices had the potential for the spread of infection that are multi-drug resistant organisms (MDRO - germs resistant to antibiotics that kill germs), hypotension (low-blood pressure), and pain.

1. A review of the Patient Registration Data, dated 8/13/2020, indicated the facility admitted Patient 30 on 6/29/2020 with diagnoses including kidney failure. Patient 30 did not have any MDROs.

A review of the physician's orders for Patient 30, dated 8/13/2020, indicated the physician ordered the evaluation of blood glucose levels before administering oral hypoglycemic agents (medication which may cause low blood sugar) every shift at 10:00 a.m. and 10:00 p.m.

A review of the medication administration record (MAR) for Patient 30, dated 8/13/2020, indicated LVN 2 obtained Patient 30's blood sugar levels on 8/12/2020, at 4:01 p.m.
During an observation on 8/12/2020, at 3:55 p.m., LVN 2 was observed obtaining Patient 30's blood sugar using a glucometer. After obtaining Patient 30's blood sugar, LVN 2 placed the glucometer on the counter next to the sink. LVN 2 then moved the glucometer to the utility cart outside of Patient 30's room after documenting the procedure. LVN 2 brought the utility cart with the used glucometer to Nurses' Station where he attempted to locate disinfecting wipes. When LVN 2 was unsuccessful, he walked down the hall to the next Nurse's Station where he was able to locate disinfecting wipes outside of a patient's room. During a concurrent interview, LVN 2 acknowledged that locating disinfecting wipes is difficult "all the time." LVN 2 acknowledged he walked down the hall with a used glucometer and dirty gloves but should not have. LVN 2 admitted the glucometer should "ideally" be disinfected immediately after its use but did not. LVN 2 stated walking down the hall with a used glucometer and with dirty gloves has the potential to spread infection.

A review of the Patient Registration Data, dated 8/13/2020, indicated the facility admitted Patient 10 on 5/1/2020 with diagnoses including respiratory failure.

A review of Patient 10's infection precautions, dated 8/13/2020, indicated Patient 10 was on contact precautions for the following MDROs:

a. Escherichia coli in the sputum (saliva and mucous)
b. Pseudomonas species in the sputum
c. Carbapenem (antibiotic) in the rectum (end of large intestine)

A review of the MAR for Patient 10, dated 8/13/2020, indicated LVN 3 obtained Patient 10's blood sugar on 8/13/2020 at 11:12 a.m.

A review of the Patient Registration Data, dated 8/13/2020, indicated the facility admitted Patient 25 on 6/6/2020 with diagnoses including respiratory failure.

A review of Patient 25's infection precautions, dated 8/13/2020, indicated Patient 25 was on contact precautions for the following MDROs:

a. Methicillin Resistant Staph Aureas (MRSA) in the sputum.
b. Extended Spectrum Beta Lactamase (ESBL) in the sacrum (the structure below the lower back) wound.

A review of the Patient Registration Data, dated 8/13/2020, indicated the facility admitted Patient 22 on 8/4/2020 with diagnoses including respiratory failure.

A review of the MAR for Patient 22, dated 8/13/2020, indicated LVN 3 obtained Patient 22's blood sugar on 8/13/2020 at 11:17 a.m. Patient 22 did not have any MDROs.

During an observation on 8/13/2020, at 11:08 a.m., LVN 3 was observed obtaining Patient 10's blood sugar levels. LVN 3 put on PPE appropriately (gown and gloves) prior to touching the curtain to ensure privacy and touching Patient 10 to identify him at bedside. After identifying Patient 10, LVN 3 returned to the utility cart which was outside of the room with the PPE to obtain the glucometer, lancet (used to poke a small hole to obtain blood), and test strip. After obtaining the blood sugar, LVN 3 wiped the glucometer with a wipe. LVN 3 did not know if the wipe was an EPA-registered disinfectant. After placing the wiped glucometer back on the utility cart, LVN 3 removed her gloves and returned to the computer across from Patient 10's foot-of-bed and documented without gloves. LVN 3 did not disinfect the computer after documenting. LVN 3 was then observed to take off her gown by untying the ties at the front of her gown with her bare hands. LVN 3 did not sanitize the utility cart.

During an observation on 8/13/2020, at 11:14 a.m., LVN 3 was observed to try to obtain Patient 25's blood sugar levels. LVN 3 put on PPE appropriately (gown and gloves) prior to touching the curtain to ensure privacy and touching Patient 25 to identify him at bedside. LVN 3 was unsuccessful because Patient 25 did not have a wrist band which is used to identify the patient. LVN 3 proceeds wipe the glucometer without gloves by the wall where the gloves were kept. LVN 3 returned the glucometer to the utility cart outside of the room with the gown. The utility cart was not disinfected.

During an observation on 8/13/2020, at 11:20 a.m., LVN 3 was observed obtaining Patient 22's blood sugar. After obtaining the blood sugar, LVN 3 returned to the utility cart outside of the room with the used gloves. LVN 3 grabbed a single alcohol pad and used it to clean the glucometer. The glucometer was placed back on the utility cart outside of the room. The cart was not disinfected.

During an interview with the Chief Clinical Officer (CCO) in the presence of the Director of Quality and Nurse Manager on 8/13/2020 at 1:42 p.m., the CCO stated used glucometers must be disinfected with EPA-registered disinfectants immediately after use. The CCO also stated that PPE used for isolation precautions must be taken off prior to exiting the room and computers in rooms with isolation precautions must be disinfected with EPA-registered disinfectants immediately after use. The DON admitted LVN 2 should not have walked down the halls with a used glucometer. The DON also admitted LVN 3 should not have exited the rooms with used PPE and should have disinfected the glucometer, computer, and the utility cart with an EPA-registered disinfectant immediately after use. The Nurse Manager stated LVN 3 should not have touched the front of her used gown, as it is potentially contaminated. According to the Nurse Manager and DON, disinfecting the glucometers immediarely after use, taking of PPE prior to exiting the room are indicated in the facility's policies and procedures. The Nurse Manager stated taking off PPE when used in isolation precaution rooms, disinfecting the glucometer, and computer immediately after use prevents the spread of infection.

A review of the instructions for use manual for the StatStrip Glucose Hospital Meter System (the glucometer used by the facility), dated 9/13/18, indicated the StatStrip Hospital Meter should be cleaned and disinfected after each patient use to minimize the risk of transmission of blood-borne pathogens between patients and healthcare professionals. NovaBiomedical recommends the use of EPA Registration #67619-12, or any disinfectant product with EPA Registration #67619-12 may be used.

A review of the policy, CORE: Transmission-Based Precautions, release June 2019, indicated equipment should be cleansed and disinfected before use on another patient using an EPA Registered disinfectant. Items are to be cleaned in the patient's room, then brought out and left to air dry.

A review of the policy, CORE: Cleaning of Shared Patient Medical Equipment, released June 2019, indicated blood glucose monitors (glucometers) should be disinfected after patient use.

A review of the addendum to CORE: Cleaning of Shared Patient Medical Equipment, released September 2019, indicated, how to clean equipment: wear gloves.

A review of the policy, CORE: Donning and Doffing Personal Protective Equipment, release June 2019, indicated the policy of the facility is to utilize PPE when transmission based precautions dictate; PPE will be doffed upon exiting the patient room in a manner to prevent cross contamination. The gown front and sleeves are contaminated. Unfasten gown ties, taking care that sleeves don't contact your body when reaching for ties. Pull gown away from neck and shoulders, touching the inside of gown only.


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3a. During a review of Patient 2's Patient registration data, the record indicated an admission date of 7/21/2020, with diagnoses including respiratory failure (the lungs developing inadequate gas exchange), and unspecified hypoxia (inadequate oxygen, element of the air which sustains life, supply to the cells) or hypercapnia (abnrmal elevated carbon dioxide level in the blood).

During a review of Patient 2's History and Physical record, dated 7/22/2020, indicated Patient 2 was diagnosed with COVID-19 pneumonia bilaterally (corona virus infection of the ai sacs of the lungs) and sepsis (infection of the blood).

During a concurrent interview and record review, on 8/13/2020 at 11:16 am, with the Director of Quality, Patient 2's Vital Signs (VS) Flowsheet was reviewed. The VS flowsheet indicated, blank and missing pain scale assessment for 8/12/2020 at 4:00 am, 8/12/2020 at 8:00 am, and 8/12/2020 at 12:00 pm. The Director of Quality stated, pain assessment should be part of vital signs, and should be completed by the nurses.

During an interview on 8/14/2020 at 2:28 pm, with the CCO (Chief Clinical Officer), the CCO stated, pain assessment ishould be part of the vital signs. The CCO stated, data was collected to ensure patients were free from pain.The CCO stated, facility staff needed to assess pain as each patient is different.

During a review of "CORE: Interdisciplinary Assessment and Re-Assessment" policy, release date 6/2020, the policy's purpose indicated, "to establish a comprehensive information base for decision making about each patient's care ... to determine the appropriate care, treatment and services to meet the patient's needs during hospitalization." The policy indicated, "routine vital signs will consist of the following: blood pressure, pulse, respirations, temperature, and pain assessment."

3b. During a review of Patient 18's Patient registration data, the record indicated an admission date of 8/1/2020, with diagnoses including respiratory failure (the lungs developing inadequate gas exchange), and unspecified hypoxia (inadequate oxygen, element of the air which sustains life, supply to the cells) or hypercapnia (abnrmal elevated carbon dioxide level in the blood).

During a review of Patient 18's History and Physical record, dated 8/3/2020 , the record indicated Patient 18 was diagnosed with COVID-19 pneumonia bilaterally (corona virus infection of the ai sacs of the lungs), dysphagia (difficulty swallowing), gastroesophageal reflux disease (GERD, long-term condition where acid from the stomach comes up into the esophagus), and plan for g-tube placement (tube inserted through the belly that brings nutrition directly to the stomach).

During a concurrent interview and record review, on 8/13/2020 at 11:48 am, with Director of Quality, Patient 18's VS Flowsheet was reviewed. The VS flowsheet indicated missing pain scale assessment on 8/11/2020 at 12:00 pm, 8/11/2020 at 4:00 pm, 8/12/2020 at 8:00 am, 8/12/2020 at 12:00 pm, and 8/12/2020 at 4:00 pm. The Director of Quality stated, pain assessment should be part of vital signs, and should be completed by the nurses.

During an interview on 8/14/2020 at 2:28 pm, with the CCO (Chief Clinical Officer), the CCO stated, pain assessment ishould be part of the vital signs. The CCO stated, data was collected to ensure patients were free from pain.The CCO stated, facility staff needed to assess pain as each patient is different.

During a review of "CORE: Interdisciplinary Assessment and Re-Assessment" policy, release date 6/2020, the policy's purpose indicated, "to establish a comprehensive information base for decision making about each patient's care ... to determine the appropriate care, treatment and services to meet the patient's needs during hospitalization." The policy indicated, "routine vital signs will consist of the following: blood pressure, pulse, respirations, temperature, and pain assessment."

3c. During a review of Patient 27's Patient registration data, the record indicated an admission date of 8/7/2020, with diagnoses including respiratory failure, and unspecified hypoxia or hypercapnia.

During a review of Patient 27's History and Physical record, dated 8/8/2020 , the record indicated Patient 27 was diagnosed with COVID-19 pneumonia bilaterally (corona virus infection of the ai sacs of the lungs), and respiratory failure (the lungs developing inadequate gas exchange).

During a concurrent interview and record review, on 8/13/2020 at 11:05 am, with the Director of Quality, Patient 27's VS Flowsheet was reviewed. The VS flowsheet indicated, blank and missing pain scale assessment for 8/11/2020 at 4:00 pm. The Director of Quality stated pain assessment should be part of vital signs, and shopuld be completed by the nurses.

During an interview on 8/14/2020 at 2:28 pm, with the CCO (Chief Clinical Officer), the CCO stated pain assessment should be part of vital signs. The CCO stated data was collected to ensure patients were free from pain. The CCO stated facility staff needed to assess pain as each patient is different.

During a review of "CORE: Interdisciplinary Assessment and Re-Assessment" policy, release date 6/2020, the policy's purpose indicated, "to establish a comprehensive information base for decision making about each patient's care ... to determine the appropriate care, treatment and services to meet the patient's needs during hospitalization." The policy indicated, "routine vital signs will consist of the following: blood pressure, pulse, respirations, temperature, and pain assessment."





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2. During a review of Patient 33's inpatient admission face sheet, Patient 33 was admitted on July 23, 2020 with diagnosis of endocarditis (infection of the heart muscles that involves the heart valves).

During a review of the Physician Order for Patient 33 on August 7, 2020 at 10:45 AM, indicated, transfer to ICU, Levophed (norepinephrine - medication for life threatening blood low blood pressure) titrate (regulate) to keep SBP (systolic blood pressure - numerator of the blood pressure) more than 90.

During review of the medication flowsheet for norepinephrine for Patient 33 on August 7, 2020 at 12:08 PM, norepinephrine was started at 2 mcg/min (micrograms per minute - unit of measurement) without blood pressure indicated.

During an interview with Registered Nurse 9 on August 14, 2020 at 7:44 AM, RN 9 said the norepinephrine was started on August 7, 2020 at 2 mcg/min. RN 9 added the protocol for norepinephrine had to be followed at 10 mcg/min for the initial titration.

During a review of the facility's Standardized Titration for Norepinephrine, indicated start Norepinephrine at 10 mcg/min or as indicated by the physician.

Based on observation, interview, and record review, the facility failed to employ methods for preventing and controlling the transmission of infections for 33 sampled patients by:

1a. ensuring that the nurse (Licensed Vocational Nurse [LVN] 3) obtaining blood sugar levels of patients who are on contact precautions (for patients with known or suspected infections that increase the risk for contact [touch] transmission) removed personal protective equipment (PPE) prior to exiting the patient's room;

1b. ensuring the glucometer (device used to measure blood sugar) was disinfected with an Environmental Protection Agency (EPA - agency that protect human health and the environment)-registered disinfectant (chemical used to disinfect) prior to using the glucometer for the next patient; and,

1c. ensuring that the nurse (LVN 2) did not walk down the halls with a used glucometer without first disinfecting it.

2. two ICU (Intensive Care Unit) Nurses without face shield (curved plastic or panel that is worn over the face, primarily used for eye protection) as part of personal protective equipment (PPE) while in the unit.

3. RN disinfecting a glucometer with an alcohol pad inside the patient's room after using it with the patient.

These deficient practices had the potential for the spread of infection in the facility.

Findings:

A review of the Patient Registration Data, dated 8/13/2020, indicated the facility admitted Patient 30 on 6/29/2020 with diagnoses including kidney failure. Patient 30 did not have any MDROs.

A review of the physician's orders for Patient 30, dated 8/13/2020, indicated the physician ordered the evaluation of blood glucose levels before administering oral hypoglycemic agents (medication which may cause low blood sugar) every shift at 10:00 a.m. and 10:00 p.m.

A review of the medication administration record (MAR) for Patient 30, dated 8/13/2020, indicated LVN 2 obtained Patient 30's blood sugar levels on 8/12/2020, at 4:01 p.m.

During an observation on 8/12/2020, at 3:55 p.m., LVN 2 was observed obtaining Patient 30's blood sugar using a glucometer. After obtaining Patient 30's blood sugar, LVN 2 placed the glucometer on the counter next to the sink. LVN 2 then moved the glucometer to the utility cart outside of Patient 30's room after documenting the procedure. LVN 2 brought the utility cart with the used glucometer to Nurses' Station where he attempted to locate disinfecting wipes. When LVN 2 was unsuccessful, he walked down the hall to the next Nurse's Station where he was able to locate disinfecting wipes outside of a patient's room. During a concurrent interview, LVN 2 acknowledged that locating disinfecting wipes is difficult "all the time." LVN 2 acknowledged he walked down the hall with a used glucometer and dirty gloves but should not have. LVN 2 admitted the glucometer should "ideally" be disinfected immediately after its use but did not. LVN 2 stated walking down the hall with a used glucometer and with dirty gloves had the potential to spread infection.

A review of the Patient Registration Data, dated 8/13/2020, indicated the facility admitted Patient 10 on 5/1/2020 with diagnoses including respiratory failure.

A review of Patient 10's infection precautions, dated 8/13/2020, indicated Patient 10 was on contact precautions for the following MDROs:

a. Escherichia coli in the sputum (saliva and mucous)
b. Pseudomonas species in the sputum
c. Carbapenem (antibiotic) in the rectum (end of large intestine)

A review of the MAR for Patient 10, dated 8/13/2020, indicated LVN 3 obtained Patient 10's blood sugar on 8/13/2020 at 11:12 a.m.

A review of the Patient Registration Data, dated 8/13/2020, indicated the facility admitted Patient 25 on 6/6/2020 with diagnoses including respiratory failure.

A review of Patient 25's infection precautions, dated 8/13/2020, indicated Patient 25 was on contact precautions for the following MDROs:

a. Methicillin Resistant Staph Aureas (MRSA) in the sputum.
b. Extended Spectrum Beta Lactamase (ESBL) in the sacrum (the structure below the lower back) wound.

A review of the Patient Registration Data, dated 8/13/2020, indicated the facility admitted Patient 22 on 8/4/2020 with diagnoses including respiratory failure.

A review of the MAR for Patient 22, dated 8/13/2020, indicated LVN 3 obtained Patient 22's blood sugar on 8/13/2020 at 11:17 a.m. Patient 22 did not have any MDROs.

During an observation on 8/13/2020, at 11:08 a.m., LVN 3 was observed obtaining Patient 10's blood sugar levels. LVN 3 put on PPE appropriately (gown and gloves) prior to touching the curtain to ensure privacy and touching Patient 10 to identify him at bedside. After identifying Patient 10, LVN 3 returned to the utility cart which was outside of the room with the PPE to obtain the glucometer, lancet (used to poke a small hole to obtain blood), and test strip. After obtaining the blood sugar, LVN 3 wiped the glucometer with a wipe. LVN 3 did not know if the wipe was an EPA-registered disinfectant. After placing the wiped glucometer back on the utility cart, LVN 3 removed her gloves and returned to the computer across from Patient 10's foot-of-bed and documented without gloves. LVN 3 did not disinfect the computer after documenting. LVN 3 was then observed to take off her gown by untying the ties at the front of her gown with her bare hands. LVN 3 did not sanitize the utility cart.

During an observation on 8/13/2020, at 11:14 a.m., LVN 3 was observed to try to obtain Patient 25's blood sugar levels. LVN 3 put on PPE appropriately (gown and gloves) prior to touching the curtain to ensure privacy and touching Patient 25 to identify him at bedside. LVN 3 was unsuccessful because Patient 25 did not have a wrist band which is used to identify the patient. LVN 3 proceeds wipe the glucometer without gloves by the wall where the gloves were kept. LVN 3 returned the glucometer to the utility cart outside of the room with the gown. The utility cart was not disinfected.

During an observation on 8/13/2020, at 11:20 a.m., LVN 3 was observed obtaining Patient 22's blood sugar. After obtaining the blood sugar, LVN 3 returned to the utility cart outside of the room with the used gloves. LVN 3 grabbed a single alcohol pad and used it to clean the glucometer. The glucometer was placed back on the utility cart outside of the room. The cart was not disinfected.

During an interview with the Chief Clinical Officer (CCO) in the presence of the Director of Quality and Nurse Manager on 8/13/2020 at 1:42 p.m., the CCO stated used glucometers must be disinfected with EPA-registered disinfectants immediately after use. The CCO also stated that PPE used for isolation precautions must be taken off prior to exiting the room and computers in rooms with isolation precautions must be disinfected with EPA-registered disinfectants immediately after use. The DON admitted LVN 2 should not have walked down the halls with a used glucometer. The DON also admitted LVN 3 should not have exited the rooms with used PPE and should have disinfected the glucometer, computer, and the utility cart with an EPA-registered disinfectant immediately after use. The Nurse Manager stated LVN 3 should not have touched the front of her used gown, as it is potentially contaminated. The Nurse Manager stated taking off PPE when used in isolation precaution rooms, disinfecting the glucometer, and computer immediately after use prevents the spread of infection.

A review of the instructions for use manual for the StatStrip Glucose Hospital Meter System (the glucometer used by the facility), dated 9/13/18, indicated the StatStrip Hospital Meter should be cleaned and disinfected after each patient use to minimize the risk of transmission of blood-borne pathogens between patients and healthcare professionals. NovaBiomedical recommends the use of EPA Registration #67619-12, or any disinfectant product with EPA Registration #67619-12 may be used.

A review of the policy, CORE: Transmission-Based Precautions, release June 2019, indicated equipment should be cleansed and disinfected before use on another patient using an EPA Registered disinfectant. Items are to be cleaned in the patient's room, then brought out and left to air dry.

A review of the policy, CORE: Cleaning of Shared Patient Medical Equipment, released June 2019, indicated blood glucose monitors (glucometers) should be disinfected after patient use.

A review of the addendum to CORE: Cleaning of Shared Patient Medical Equipment, released September 2019, indicated, how to clean equipment: wear gloves.

A review of the policy, CORE: Donning and Doffing Personal Protective Equipment, release June 2019, indicated the policy of the facility is to utilize PPE when transmission based precautions dictate; PPE will be doffed upon exiting the patient room in a manner to prevent cross contamination. The gown front and sleeves are contaminated. Unfasten gown ties, taking care that sleeves don't contact your body when reaching for ties. Pull gown away from neck and shoulders, touching the inside of gown only.



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2. During a review of Patient 16's patient registration data, the record indicated an admission date of 6/6/2020, with diagnoses including other postprocedural complications and disorders of digestive system.

During a review of Patient 16's History and Physical record, dated 6/7/2020, , the record indicated Patient 16 is an 84 year-old male with sepsis (potentially life-threatening condition caused by the body's response to an infection) secondary to aspiration pneumonia (type of lung infection) and suspected Clostridium difficile colitis (bacterium that causes diarrhea and inflammation of the colon), chronic kidney disease, and status post replacement of a dislodged g-tube (tube inserted through the belly that brings nutrition directly to the stomach).

During an observation on 8/13/2020 at 1:48 pm, in Patient 16's room, located inside the ICU Department, RN (Registered Nurse) 3 was observed standing by Patient16's bedside without wearing a face shield as part of PPE.

During an observation on 8/13/2020 at 1:49 pm, in ICU Department's nursing station, Supervisor 1 was observed without a face shield as part of PPE.

During an interview on 8/13/2020 at 2:02 pm, with Supervisor 1, Supervisor 1 stated, face shields are required in clinical areas such as ICU Department. Supervisor 1 stated, if staff are entering patient's room, staff should have a face shield per CDC infection control guidelines that the hospital follows.
During an interview on 8/14/2020 at 2:01 pm, with CCO (Chief Clinical Officer), CCO stated, staff are expected to wear masks and face shield in clinical areas, in nursing stations, and inside patient rooms. CCO stated, purpose of the face shield is to add an extra infection protection for patients and staff.
During a review of "Covid-19 and other Novel Virus Respiratory Infectious Diseases Contingency Plan", dated 8/3/2020, the contingency plan indicated, "Clinical staff should wear face shields over their face mask during their shift" as part of education topic for reducing the spread.

During a review of "CORE: Standard Precautions" policy, release date 6/2018, the policy's purpose indicated, "This policy establishes guidelines for the use of standard precautions. Standard precautions are evidence-based practices are designed to both protect healthcare personnel and prevent the spread of infections among patients and staff." The policy indicated, "Facility staff wears Personal Protective Equipment (PPE) involving specialized clothing or equipment for protection against infectious materials ... PPE may include but are not limited to: gloves, masks/procedural masks, gowns, face shield, and goggles.




33483

3. During an observation in room 219 on August 13, 2020 at 9:24 AM, a Registered Nurse (RN 5) was observed coming out of room 219 with a glucometer (machine used to test for blood sugar level) on his gloved hands. RN 5 placed the glucometer on top of the linen cart, parked in between room 219 and room 218, beside a black plastic case. RN 5 then went in a small room in between room 219 and 218 to remove gloves, and washed hands on the sink inside the room. RN 5 went back to the linen cart and transferred the glucometer on top of the black plastic case.

During a concurrent interview with RN 5, RN 5 said he disinfected the glucometer with an alcohol pad inside room 219 after using it with the patient. RN 5 added he should have cleaned the glucometer with an EPA (Environmental Protection Agency) approved wipes, and should have done this outside of the patients room.

During an interview with the Nursing Manager on August 13, 2020 at 9:30 AM, the Nursing Manager said cleaning of the glucometer should be done outside of the patient's room and with an EPA approved wipes.

During a review of the facility policy and procedure titled, CORE: Cleaning of Shared Patient Medical Equipment, released date June 2019, indicated, An Environmental Protection Agency (EPA) registered disinfectant that has been approved by the Infection Prevention and Control Committee shall be used for cleaning and may include: a. Approved germicidal disinfectant b. Equipment specific cleaner c. Approved bleach disinfectant.

Based observation, interview and record review, the facility failed to maintain a clean and sanitary environment when:

1. RN staff in the ICU were reconstituting (mixing powdered medications with a diluent) inside the medication room, on top of the automated medication dispensing cabinet, without available alcohol to sanitize hands, and EPA (Environmental Protection Agency) approved disinfecting wipes to clean surfaces.

2. An LVN brought out a contaminated glucometer (machine used to measure blood sugar levels) after using with the patient to the hallway.

3. An LVN went out of the isolation room with a personal protective equipment (PPE -is protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) on to the hallway.

These deficient pratices had the potential for the spread of infection.

Findings:

1. During an observation tour in the ICU (intensive care unit - unit for close monitoring and critical patients) inside the medication room on August 12, 2020 at 3:43 PM with ICU Registered Nurse (RN 6), there was an automated medication dispensing machine, refrigerator, and racks with medical supplies. The automated medication dispensing cabinet was about chest level high. There was no alcohol for hand hygiene and available EPA approved disinfecting wipes.

During a concurrent interview with RN 6, RN 6 said she used the top of the automated medication dispensing cabinet to mix medications for patients. RN 6 added there were times when she brought IV (intravenous - through the veins) medications, like Protonix (IV medication in a powder form to be mixed with normal saline for severe stomach problems)inside the patient's room. RN 6 also said there were no alcohol gels to sanitize the hands, and EPA approved disinfecting wipes inside the medication room. RN 6 also stated she has to go out of the medication room to wash hands to prepare medication, then touching the door handles in the process.

During an interview with RN 7 and RN 8, RN 7 and RN 8 confirmed that there were no available alcohol to sanitize hands, and EPA approved disinfecting wipes inside the medication room. Both of them added that they have to bring a patient's bedside table inside to use to reconstitute the medications.

During a review of the facility policy and procedure titled, CORE: Nursing Preparation of IV Admixtures in the Absence of a Pharmacist or Urgent Situations, released date June 2018, indicated, The workstation will be prepared with the following guidelines: a. Select a clean, uncluttered work station surface, above waist level in the med room. B. clean the surface with an antibacterial surface wipe.

2. A review of the Patient Registration Data, dated 8/13/2020, indicated the facility admitted Patient 30 on 6/29/2020 with diagnoses including kidney failure. Patient 30 did not have any MDROs.

A review of the physician's orders for Patient 30, dated 8/13/2020, indicated the physician ordered the evaluation of blood glucose levels before administering oral hypoglycemic agents (medication which may cause low blood sugar) every shift at 10:00 a.m. and 10:00 p.m.

A review of the medication administration record (MAR) for Patient 30, dated 8/13/2020, indicated LVN 2 obtained Patient 30's blood sugar levels on 8/12/2020, at 4:01 p.m.
During an observation on 8/12/2020, at 3:55 p.m., LVN 2 was observed obtaining Patient 30's blood sugar using a glucometer. After obtaining Patient 30's blood sugar, LVN 2 placed the glucometer on the counter next to the sink. LVN 2 then moved the glucometer to the utility cart outside of Patient 30's room after documenting the procedure. LVN 2 brought the utility cart with the used glucometer to Nurses' Station where he attempted to locate disinfecting wipes. When LVN 2 was unsuccessful, he walked down the hall to the next Nurse's Station where he was able to locate disinfecting wipes outside of a patient's room. During a concurrent interview, LVN 2 acknowledged that locating disinfecting wipes is difficult "all the time." LVN 2 acknowledged he walked down the hall with a used glucometer and dirty gloves but should not have. LVN 2 admitted the glucometer should "ideally" be disinfected immediately after its use but did not. LVN 2 stated walking down the hall with a used glucometer and with dirty gloves has the potential to spread infection.

3. A review of the Patient Registration Data, dated 8/13/2020, indicated the facility admitted Patient 10 on 5/1/2020 with diagnoses including respiratory failure.

A review of Patient 10's infection precautions, dated 8/13/2020, indicated Patient 10 was on contact precautions for the following MDROs:

a. Escherichia coli in the sputum (saliva and mucous)
b. Pseudomonas species in the sputum
c. Carbapenem (antibiotic) in the rectum (end of large intestine)

A review of the MAR for Patient 10, dated 8/13/2020, indicated LVN 3 obtained Patient 10's blood sugar on 8/13/2020 at 11:12 a.m.

During an observation on 8/13/2020, at 11:08 a.m., LVN 3 was observed obtaining Patient 10's blood sugar levels. LVN 3 put on PPE appropriately (gown and gloves) prior to touching the curtain to ensure privacy and touching Patient 10 to identify him at bedside. After identifying Patient 10, LVN 3 returned to the utility cart which was outside of the room with the PPE to obtain the glucometer, lancet (used to poke a small hole to obtain blood), and test strip.

During an interview with the Chief Clinical Officer (CCO) in the presence of the Director of Quality and Nurse Manager on 8/13/2020 at 1:42 p.m., the CCO stated used glucometers must be disinfected with EPA-registered disinfectants immediately after use. The CCO also stated that PPE used for isolation precautions must be taken off prior to exiting the room and computers in rooms with isolation precautions must be disinfected with EPA-registered disinfectants immediately after use. The Nurse Manager stated taking of PPE prior to exiting the room with contact precautions maintains a clean and sanitary enviroment.

A review of the instructions for use manual for the StatStrip Glucose Hospital Meter System (the glucometer used by the facility), dated 9/13/18, indicated the StatStrip Hospital Meter should be cleaned and disinfected after each patient use to minimize the risk of transmission of blood-borne pathogens between patients and healthcare professionals. NovaBiomedical recommends the use of EPA Registration #67619-12, or any disinfectant product with EPA Registration #67619-12 may be used.

A review of the policy, CORE: Transmission-Based Precautions, release June 2019, indicated equipment should be cleansed and disinfected before use on another patient using an EPA Registered disinfectant. Items are to be cleaned in the patient's room, then brought out and left to air dry.

A review of the policy, CORE: Donning and Doffing Personal Protective Equipment, release June 2019, indicated the policy of the facility is to utilize PPE when transmission based precautions dictate; PPE will be doffed upon exiting the patient room in a manner to prevent cross contamination.

Based on interview and record review, the facility failed to carry out doctor's order for ventilator (machine use to aid patient with breathing) setting changes as ordererd for one of 33 sampled patients (Patient 21). This failure had the potential to prolonged patient's dependence to the ventilator.

Findings:

During a review of the doctor's order for Patient 21 on August 9, 2020, indicated: "Leave on CPAP (Constant Positive Airway Pressure - setting which works only for patients who are breathing spontaneously) QNOC (every night) if tolerated. ABG (Arterial Blood Gas - A test which measures the oxygen, carbon dioxide, and pH levels in the blood) in A.M. (morning)."

During a review of Patient 21's Registration Data, Patient 21 was admitted on July 10, 2020 at 9:39 PM with diagnosis of sepsis (infection of the blood stream).

During a review of the Respiratory Care flowsheet with the Registered Nurse (RN 4) for Patient 21 from August 9, 2020 at 12:25 AM to August 10, 2020 at 2:35 PM, RN 4 verified there was no documentation of Patient 21 placed on CPAP the night of August 9, 2020. The ABG was only done at 2:35 PM on August 10, 2020. It was not clear if Patient 21 was actually placed on CPAP prior to the ABG test.

During an interview with RN 4 on August 13, 2020 at 10:46 AM, RN 4 stated after reviewing the Respiratory Care flowsheet that Patient 21 was placed on CPAP on August 11, 2020 at 8:20 PM.

During an interview with the Respiratory Therapy Manger (RTM) on August 14, 2020 at 11:05 AM, RTM said the respiratory therapist should document what ventilator setting changes has been done and what was the response of the patient [Patient 21] on the ventilator setting changes. The RTM added the respiratory therapist failed to do this part.

Based on interview and record review, the facility failed to ensure a doctor's order was documented and obtained for ventilator (machine use to help the patient breath) setting changes done at bedside with the pulmonologist (lung doctor) for one of 33 sampled patients (Patient 21). This failure had the potential for inappropriate amount oxygen (element of the air needed to sustain life) would administered to the patient.

Findings:

During a review of Patient 1's Respiratory Care flowsheet on August 11, 2020 at 8:20 AM, Patient 21's ventilator setting was placed on CPAP (Constant Positive Airway Pressure - setting which works only for patients who are breathing spontaneously). Previously, Patient 21 was on AC mode ventilator setting (Assist Control - delivers oxygen at the preset volume or pressure in response to the patient's inspiratory effort but will initiate the breath if the patient does not do so within the set amount of time).

During a review of Patient 21's Registration Data, Patient 1 was admitted on July 10, 2020 at 9:39 PM with diagnosis of sepsis (infection of the blood stream).

During an interview with RN 4 on August 13, 2020 at 10:46 AM, RN 4 stated that Patient 1 was connected to the ventilator with setting on CPAP. RN 4 also added that Patient 1 was being weaned off the ventilator. RN 4 also said Patient 21 was placed back on AC of 22 per minute because Patient 1 was unable to tolerate the CPAP setting. RN 4 further stated there was no transcribed doctor's order for CPAP for Patient 21.

During a review of the doctor's orders for Patient 21, there was no order from the doctor to place Patient 21 to CPAP ventilator setting for weaning off from the ventilator.

During an interview with Respiratory Therapy Manager (RTM) on August 13, 2020 at 11:25 AM, RTM said the respiratory therapist would be with the [name of the pulmonologist - lung doctor] and discuss his plan for ventilator management for the patient [Patient 21]. The respiratory therapist would then execute his plan at bedside changing the ventilator settings for the patient [Patient 21]. RTM also said that the pulmonologist would write his recommendations but not a doctor's order for the ventilator changes made at bedside. RTM added the respiratory therapist should write the recommendations and ventilator setting changes made at beside as a telephone order, and document on the respiratory care flowsheet what was done with the vent and how the patient [Patient 21] responded.

During a review of the facility's Medical Staff General Rules and Regulations, undated, indicated: "Attending physicians are responsible for all medical orders regarding their patients. All patient orders for medication, treatment, procedures, diagnostic services or therapy shall be recorded in the medical record ...Verbal orders shall be communicated only in emergency situations. The use of verbal orders is strongly discouraged and should not be done on an infrequent basis.