HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure Medical Staff enforcement of bylaws as evidenced by failing to suspend one physician (S7) with 18 delinquent medical records with discharge dates from 12/15/2010 through 2/28/2011 for 1 of 1 physician with delinquent medical records, (S7). Findings:

Review of the hospital Medical Staff's Rule and Regulations of the Bylaws revealed in part, "(page 34) Each medical record shall be completed within 30 days after discharge of the patient or the record becomes delinquent. On a continuous basis, the Health Information Director shall review incomplete records. At this time, any physician who has any delinquent charts shall be notified by phone, fax, or letter. If the records are still incomplete two weeks after being notified, he shall automatically suffer suspension of admitting privileges. He shall be notified of such suspension in writing by the Health Information Director. The Physician's privileges may be restored by the Chief Medical Director when he has been notified by the Health Information Director that the delinquent records have been completed."

Review of a list of delinquent medical records for failure to perform discharge summaries revealed 18 patients listed with discharge dates ranging from 12/15/2010 through 2/28/2011. Further review revealed 17 of the 18 delinquent medical records were greater than 60 days delinquent ranging from the discharge dates of 12/15/2010 through 1/28/2011.

During a face to face interview on 4/26/2011 at 1300 (1:00 p.m.), Administrator and Director of Medical Records, (S1) indicated the physician with all 18 delinquent medical records was Physician S7, who was also the Medical Director. S1 indicated he (S7) was the primary admitting physician at the hospital and therefore Medical Staff Bylaws, Rules, and Regulations had not been enforced. S1 indicated S7 had never been suspended as indicated in the bylaws, rules, and regulations. S1 further indicated physicians were informed at monthly meetings of the delinquent medical records. S1 indicated she had no documented evidence of the date she informed Physician, S7 of his delinquent medical records because it had been done verbally.

During a telephone interview on 4/26/2011 at 1625 (4:25 p.m.), Medical Director Physician, S7 confirmed Medical Staff Bylaws, Rules, and Regulations had not been enforced. S7 indicated the hospital had been busy and he had fallen behind in dictating Discharge Summaries.

20638


I. Based on record reviews and interview, the hospital failed to ensure a Registered Nurse supervised and evaluated patient care by failing to immediately assess a patient with a heart rate in the low 50s for 1 of 1 patient reviewed with a heart rate in the 50s out of a total sample of 23 patients, (Patient #5). Findings:

Review of Patient #5's medical record revealed the patient was admitted to the hospital on 1/04/2011 and discharged on 1/11/2011 with diagnoses that included Acute or Chronic Renal Insufficiency, History of Pacer, and Congestive Heart Failure. Further review revealed Patient #5 was prescribed and administered Coreg 12.5 milligrams by mouth twice daily, Metoprolol XL 50 milligrams by mouth twice daily, and Apresoline 25 milligrams by mouth three times daily from admission on 1/04/2011 through discharge on 1/11/2011 with the exception of Apresoline being held on 1/09/2011 at 8:00 a.m. for blood pressure of 104/46. Further review revealed Patient #5 was prescribed and administered Digoxin 0.25 milligrams one tablet by mouth daily from admission on 1/05/2011 until discontinued on 1/07/2011.

Review of Patient #5's "Graphic Record" revealed the following:
1/8/11 (1/08/2011) 4 (4:00 a.m.) pulse 57
1/9/11 (1/09/2011) 4 (4:00 a.m.) pulse 54

Review of Patient #5's entire medical record revealed no documented evidence that the patient was assessed by a nurse, to include a Registered Nurse, regarding the patient's heart rate of less than 60 on the date of 1/08/2011 (pulse 57) and 1/09/2011 (pulse 54) at 4:00 a.m., when the patient had been receiving Metoprolol, Apresoline, and Coreg.

This finding was confirmed by Registered Nurse S12 in a face-to-face interview on 4/26/2011 at 10:35 a.m. S12 indicated vital signs recorded on the graphic were taken by a Certified Nursing Assistant typically with an automated blood pressure/heart rate machine. S12 indicated there was no documented evidence to indicate the low heart rate had been identified or assessed by a nurse to include the Registered Nurse in charge on the dates of 1/08/2011 or 1/09/2011 at 4:00 a.m.

Review of the hospital's Drug Reference Book titled, "Nursing 2011 Drug Handbook" revealed in part:
Metoprolol (page 382), "Nursing Considerations. Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately."
Coreg (page 356), "Adverse Reactions. CV (Cardiovascular): hypotension, postural hypotension, AV (Atrial Ventricular) block, Bradycardia (resting heart rate of under 60 beats per minute). . ."
Digoxin (page 441), "Administration. PO (by mouth). . . Before giving drug, take apical-radial pulse for 1 minute. Record and notify prescriber of significant changes (sudden increase or decrease in pulse rate. . .)"


II. Based on record review and interview, the registered nurse failed to supervise and evaluate the nursing care of 1 of 1 patients (Patient #4) in a total sample of 23 by not reporting the results of a positive culture when the organism was resistant to the antibiotic that the physician prescribed for treatment. Finding:

Review of the medical record revealed Patient #4 was a 91 year-old admitted on 4/21/2011 at 1:35 PM with diagnoses of rheumatoid arthritis and generalized weakness. Review of physician orders revealed at 9:15 PM on 4/21/2011 the attending physician ordered to stop all IV antibiotics and to begin Levaquin 500 mg (antibiotic) daily by mouth for 7 days (medical record did not indicate what the antibiotic was for).

Review of lab results revealed a C&S (culture and sensitivity) of a wound on patient #4's right thumb was collected on 4/20/2011 and reported as a MRSA (methicillin resistant staphylococcus aureus) infection on 4/22/2011 which was resistant to Levofloxacin (Levaquin). Review of the Medication Administration Record (MAR) revealed the nurse administered Levaquin at 8:00 AM on 4/22/2011, 4/23/2011, 4/24/2011 and 4/25/2011. A thorough review of the medical record failed to reveal the nurse reported the C&S results to the physician which resulted in the patient receiving an antibiotic that was resistant to the organism. An interview was held on 4/26/2011 at 4:30 PM with S8 RN who reviewed the medical record for Patient #4 and confirmed that there was no documented evidence the RN notified patient #4's physician of the positive C&S report.

Based on review of 2 closed records and interview with staff, the hospital failed to ensure comprehensive care plans were developed for each patient by not documenting care plan approaches for 2 of 2 patients (#7, #12) in a total sample of 23 patients, who received blood transfusions. Findings:

1. Review of the closed medical record revealed Patient #7 was admitted on 1/11/2011 with diagnoses of classic effects of chemotherapy with resultant neuropathy and malnutrition. Review of the 1/12/2011 at 11:30 PM (p.m.) physician orders revealed an order to type and cross match the patient for 2 units of packed red blood cells (PRBCs). Further review revealed on 1/13/2011 at 2:15 PM the physician wrote an order to transfuse only 1 unit of the PRBCs which the patient received that day. A thorough review of the nursing care plan failed to reveal the nurse documented approaches for the blood transfusion including the potential for a reaction. In an interview on 4/26/2011 at 10:50 AM (a.m.), S12RN confirmed that a nursing plan of care was not documented for the transfusion.

2. Review of the closed medical record revealed Patient #12 was admitted on 2/16/2011 at 1:40 PM with diagnoses of pelvic fracture after a fall and Alzheimer's disease. Review of physician orders dated 2/25/2011 (no time documented) revealed an order to type and cross match the patient for 2 units of PRBCs and to transfuse slowly. Further review of the medical record failed to reveal the nursed modified the patient's care plan to reflect the transfusion. S12RN confirmed in an interview on 4/26/2011 at 10:50 AM that the nurse failed to develop a plan of care for the transfusion.

Based on observation and interview, the hospital failed to ensure medical records were protected from water damage in the event the sprinkler system were to be triggered for 47 of 48 boxes stored on crates on the floor in the Medical Records room. Findings:

Observations on 4/26/2011 at 9:05 a.m. revealed 48 boxes containing medical records that were stored on top of wooden crates in the Medical Records room. Further observations revealed a sprinkler system located on the ceiling of the Medical Records room.

During a face-to-face interview on 4/26/2011 at 9:05 a.m., Administrative Assistant S11 confirmed the observations. S11 indicated the Medical Records stored in boxes on the floor were to be scanned. S11 indicated only one box had already been scanned and the other 47 boxes had not been scanned. S11 confirmed that the Medical Records could be damaged from water in the event that the sprinkler system was to be triggered.

20638


I. Based on record reviews and interviews, the hospital failed to ensure a pharmacist supervised and coordinated all the activities of pharmacy services as evidenced by failing to ensure Standing Orders for Pain Protocol were complete; to include parameters for defining the hospital's pain scale and parameters defining time intervals between switching from one medication listed on the Protocol to another medication listed on the protocol when 4 different pain medications and 5 different orders were included in the Pain Protocol Standing Orders for 1 of 1 pain protocol reviewed. Findings:

Review of Patient Medical Records revealed an order for "Pain Protocol", which included Tylenol 500 milligrams 2 tablets by mouth every 6 hours as needed for mild pain, Ibuprofen 500 milligrams 3 tablets by mouth every 6 hours as needed for mild-moderate pain, Ultram 50 milligrams 1 tablet by mouth every 4 hours as needed for moderate pain, Norco 5/325 milligrams 1 tablet by mouth every 4 hours as needed moderate severe pain, and Norco 10/325 milligrams 1 tablet by mouth every 4 hours as needed severe pain, ordered for Patient #1 on 4/12/2011 at 0955 (9:55 a.m.), Patient #2 on 4/18/2011 at 1450 (2:50 p.m.), Patient #5 on 1/04/2011 at 10:30 a.m., and Patient #8 on 1/11/2011 at 1240 (12:40 p.m.). Review of the entire medical records for these patients (#1, #2, #5, #8) revealed no documented evidence to indicate the time intervals/frequency between administrations of various medications ordered on the pain scale.

Review of the hospital's policy and procedure manual revealed no documented evidence of a policy defining mild, mild-moderate, moderate, moderate-severe, or severe pain. Further review revealed no documented evidence of a policy defining how the hospital's pain protocol was to be implemented/administered.

During a face-to-face interview on 4/25/2011 at 1625 (4:25 p.m.), Registered Nurse S8 indicated the hospital had no policy defining implementation of Standing Orders for Pain Protocol. S8 indicated physicians would check off the standing order for Pain Protocol if they wanted it used with their patients. S8 indicated time intervals between switching from one medication to another on the Protocol would be based on nursing judgment. S8 confirmed there was no physician's order indicating the time intervals between switching from one medication order to another on the Pain Protocol.

Pharmacist S10 was asked how staff would know, based on the standing order for "Pain Protocol", what the intended time interval would be when switching from Tylenol to Ibuprofen to Ultram to Norco 5/325 to Norco 10/325.

During a face-to-face interview on 4/26/2011 at 8:15 a.m., Pharmacist S10 indicated there was no clarification of the hospital's Pain Protocol Standing Orders in Patient's Medical Records and no Policy regarding how to implement the Pain Protocol to include time intervals between switching from one medication to another or defining the hospital's pain scale. Pharmacist S10 confirmed the order was not clear as to how long staff should wait after administering one medication before administering another medication listed on the protocol.

II. Based on review of Pharmacy Monthly Meeting Minutes and interviews with the consultant pharmacist and the Chief Executive Officer (CEO), the hospital failed to ensure the contract pharmacist was responsible for developing and coordinating all activities of pharmacy services by not having documented evidence that the pharmacist participated in, or attended pharmacy and therapeutic committee meetings. Findings:
Review of Pharmacy and Therapeutic (P&T) Meeting Minutes for 1/17/2011, 2/14/2011 and 3/21/2011 failed to reveal a pharmacist was in attendance. S10 contract pharmacist stated in an interview on 4/26/2011 at 8:15 AM (a.m.) that he "never" attended a pharmacy and therapeutic meeting or submitted information for the committee to review. In an interview on 4/26/2011 at 8:50 AM S1CEO stated P&T meetings are held monthly but the pharmacist was "never" in attendance.

Based on observation, record review, and interview, the hospital failed to ensure opened multi-dose insulin bottles were labeled with the date they were opened for 2 of 4 multi-dose open bottles reviewed. Findings:

Observations on 4/25/2011 at 1400 (2:00 p.m.) revealed 4 open multiple dose bottles of insulin in the hospital's medication refrigerator. Further observation revealed two of the bottles were not labeled with the date they were opened (Novalin R U 100 multi-dose bottle and Lantus U 100 multi- dose bottle). A third bottle containing Humalog U 100 revealed an open date of 2/15/2011.

During a face-to-face interview on 4/25/2011, LPN (Licensed Practical Nurse) S3 confirmed the observations. Further LPN S3 indicated Insulin should be discarded 30 days after opening a multi-dose vial. LPN S3 indicated there would be no way to know when to discard an open bottle of insulin without labeling it at the time the bottle was opened. LPN S3 indicated the bottle of Humalog U 100 that was opened on 2/15/2011 should have been discarded on 3/15/2011.

Review of the hospital policy titled, "Pharmacy, Receiving Drugs from the Pharmacy, effective 4/01" presented by the hospital as their current policy revealed in part, "All bottles (especially insulin) are dated on color dot and initialed by the nurse when opened."

Based on review of personnel files maintained by the hospital and staff interviews, the hospital failed to ensure a qualified full-time employee was responsible for managing dietary services. Findings:

In an interview on 4/26/2011 at 2:00 PM, the Administrator (S1) stated the hospital does not have a dietary manager and it is the nurses' responsibility to ensure patients receive their prescribed diet. Review of personnel files for 3 Licensed Practical Nurses (S3, S5, S6) and 3 Registered Nurses (S2, S8, S12) failed to reveal a job description that addressed dietary duties. An interview was conducted with the unit secretary on 4/25/2011 at 2:10 PM (p.m.), who confirmed that the hospital does not have a dietary manager and that the dietitian only comes to the hospital when a new patient is admitted or a patient needs a dietary consult.

Based on record reviews and interviews, the hospital failed to ensure the position of Infection Control Officer (ICO) was performed by staff with experience, education or training in Infection Control for 1 of 1 staff members currently acting as the Infection Control Officer at the hospital, (S6, Interim Infection Control Officer). Findings:

During the entrance conference conducted on 4/25/11 at 1:30 p.m., S1, Chief Executive Officer (CEO) indicated the Director of Nursing (S2DON) was the Infection Control Officer. S1 further indicated S2 was on vacation the week of the survey and would not be available during the survey. S1 stated S6, was the Interim Infection Control Officer. S1 indicated the Director of Nursing (S2) was APIC certified; however, the CEO, S1 was unable to provide any evidence of this certification prior to the exit date on 4/26/11 at 5:00 p.m..

Review of the personnel files for LPN, (S5) and LPN, (S6) revealed no documented evidence that the individuals were qualified through education, training or certification in infection control. Although S1, CEO indicated the Director of Nursing (S2DON) was the Infection Control Officer and was APIC certified in infection control, she was unable to provide any documented evidence of current certification and/or training in infection control during the survey. Further review revealed there was no documented evidence that the LPN, S6 had ever been supervised by the Director of Nursing.

In an interview on 4/26/11 at 2:50 p.m., S6, Interim ICO indicated she became the Interim, ICO about two (2) months ago. S6 indicated to her knowledge S5 was the Infection Control Officer (ICO) prior to her assuming the role about 2 months ago. S6 stated she was not sure if she was tracking, trending and monitoring the infections in the hospital correctly. S6 indicated she became the Interim Infection Control Officer after S5 was assigned to work night shifts at the hospital. S6 stated she did not see S5, the ICO during the day shift. S6 indicated S5 did not train her on how to manage the program prior to assuming the role of ICO. S6 indicated the Infection Control Officer (S5) was not available for interview because she was out in the field performing an evalation on a patient. S6 reported she did not know what time the Infection Control Officer, S5 would return to the facility, today, 4/26/11. S6 indicated she had no supervision by an experienced Infection Control Officer. S6 further indicated she had no education or training prior to being placed in the position as acting Infection Control Officer about 2 months prior to the survey.

Based on record reviews and interview, the hospital failed to ensure a physician was appointed as Director of Respiratory. Findings:

Review of Physician Credentialing Files, Physician Roster, and Governing Body Minutes revealed no documented evidence that a physician had been appointed as Director of Respiratory.

During a face-to-face interview on 4/26/2011 at 1300 (1:00 p.m.), Administrator S1 indicated the hospital had never appointed any physician as Director of Respiratory. S1 indicated the nursing staff was administering respiratory treatments/therapy at the hospital. S1 indicated she had been unaware of the need to have a physician supervise the Respiratory Services provided at the hospital. This finding was confirmed by Physician, S7 on 4/26/2011 at 1625 (4:25 p.m.) during a telephone interview.

Based on observation, record review, and interview, the hospital failed to ensure the Respiratory Policy for storage of oxygen tanks was followed for 6 of 8 tanks observed. Findings:

Observations on 4/25/2011 at 1405 (2:05 p.m.) revealed 6 unsecured E-cylinder Oxygen tanks to be sitting on the floor in the storage room located across from the nursing station. This finding was confirmed by Licensed Practical Nurse S3 during a face-to-face interview at the time of the observation (4/25/2011 at 1405). S3 further indicated staff should follow hospital policy regarding storage of oxygen tanks.

Review of the hospital policy titled, "Cylinder Safety Policy, Effective 3/00" presented by the hospital as their current policy revealed in part, "Cylinders shall be correctly stored and secured. A. cylinders may be left on transport cart if secured. Cylinders not on cart must be secured by a strap or chain. B. Small size (E) cylinders must be stored upright in a sectional storage box or bracket holder. . ."

Based on review of the QA/PI (Quality Assurance/Performance Improvement) data and interview with the contract pharmacist (S10), the hospital failed to have an ongoing QA/PI program by not having documented evidence that the pharmacist provided indicators to track and evaluate the pharmacy services. Findings:

Interview with S10 Contract Pharmacist on 4/26/2011 at 8:15 AM revealed he visits the Rehabilitation Hospital during the last week of every month. The survey team asked S10 to review the QA/PI data for pharmacy and asked if he participated in the QA/PI program. S10 stated he does not track or trend quality indicators for pharmacy services. S10 stated although he makes monthly visits, the report of his findings are submitted every 6 months and not monthly as problems arise.

Based on record reviews and staff interview, the hospital failed to ensure quality control testing on the hospital's Elite Glucometer was performed as per manufacturer's recommendations for 1 of 1 glucometer observed for quality testing (Glucometer # 7545291). Findings:

Review of the hospital's "Glucometer Log" for Glucometer #7545291 revealed Strip Lot #DWOJC3DO5E was used for calibration of the machine from the dates of 3/20/2011 through 4/11/2011. Review of the box containing "Control Solution Ranges" revealed the Lo: Range to be listed as 35 - 48 mg/dl (milligrams per deciliter) and the Hi: Range to be listed as 315 - 435 mg/dl. Review of the Glucometer Log for evaluating quality controls of the glucometer revealed "Range 109 - 150" as "range" parameters for testing. Further review revealed no documented evidence indicating if this range was designated for Lo, Normal, or Hi testing. Further review revealed Strip Lot # DWOEC3DO1A was used from the dates of 4/12/2011 through 4/24/2011. Observations revealed no label to determine what the manufacturer's ranges for Lo, Normal, and Hi were for that Lot number.

During a face-to-face interview on 4/25/2011 at 1415 (2:15 p.m.), Licensed Practical Nurse (LPN) S3 in the Absence of the Director of Nursing who was on vacation, confirmed the documentation on the Glucometer Log failed to show parameters for testing Lo and Hi Controls to ensure Quality Measurements for testing patient's capillary blood glucose levels were within an acceptable range. S3 indicated each individual Lot Number contained its own parameters of "Lo" and "Hi" ranges for testing. LPN S3 indicated nursing staff would need the numbers in order to determine if the machine were testing in the proper range or not. LPN S3 indicated there was no evidence on the Glucometer Log that the readings documented by nursing staff for Lo and Hi testing fell into the appropriate range. LPN S3 indicated with Lot # DWOJC3DO5E the hospital still had the box and she could determine what should have been written on the Glucometer Log. S3 indicated all other testing of the Glucometer Log had no documented testing ranges and no box to reveal the range. LPN S3 indicated she would not be able to know with certainty that quality testing of the glucometer fell in the proper range when tested without the coinciding box or without proper documentation by the nursing staff.

Review of an Internet article titled, "How to Calibrate the Ascencia Elite Glucometer" revealed in part, "Remove the check strip from the package. With the tab pointing right, insert it into the Ascencia Elite Meter. Wait for meter and for the display to show a check mark, and then note the reading. This should be within the range listed on the package's insert. . . Look at the display to find the result. compare the reading with the information printed on the test strip carton. . ."

Based on record reviews and interviews, the hospital failed to ensure medications were administered in accordance with orders of the practitioner for 1 of 23 sampled patients (#2). Findings:

Review of Patient #2's medical record revealed the patient was admitted to the hospital on 4/18/2011 with diagnoses that included Cervical Spinal Stenosis Status Post Discectomy.

Review of Patient #2's Physician's orders dated 4/18/2011 at 1450 (2:50 p.m.) revealed in part, "Pain Protocol", Tylenol 500 milligrams 2 tablets by mouth every 6 hours as needed mild pain, Ibuprofen 200 milligrams 3 tablets by mouth every 6 hours as needed mild-mod pain, Ultram 50 milligrams 1 tablet by mouth every 4 hours as needed moderate pain, Norco 5/325 1 tablet every 4 hours as needed moderate severe pain, and Norco 10/325 milligrams every 4 hours as needed severe pain. Further review revealed Physician's orders dated 4/18/2011 at 2000 (8:00 p.m.) for Norco 10/325 milligrams one tablet by mouth as needed severe pain every 4 hours and Norco 10/325 milligrams two tablets by mouth as needed very severe pain every 4 hours.

Review of Patient #2's Medication Administration Record revealed Patient #2 was administered Norco 5/325 1 tablet by mouth on 4/18/2011 at 1805 (6:05 p.m.) and Norco 10/325 1 tablet by mouth on 4/18/2011 at 1945 (7:45 p.m./ 1 hour and 40 minutes after receiving Norco 5/325 at 6:05 p.m.). Further review of Patient #2's Medication Administration Record revealed the patient was administered Norco 10/325 one tablet by mouth on 4/19/2011 at 8:00 a.m. which was repeated at 11:00 a.m. (3 hours between dosages). Further review of Patient #2's Medication Administration Record revealed the patient was administered Norco 10/325 milligrams one tablet by mouth on 4/20/2011 at 6:40 a.m. which was repeated at 9:00 a.m. (2 hours and 20 minutes between dosages). These findings were confirmed in a face-to-face interview with Registered Nurse S8 on 4/25/2011 at 1635 (4:35 p.m.).

During a face-to-face interview on 4/26/2011 at 8:15 a.m., Pharmacist S10 indicated nursing staff should have followed physician's orders for frequency of administration of pain medication to Patient #2. Pharmacist S10 indicated Patient #2 had received pain medication at intervals closer than that allowed by the Physician's order.