HospitalInspections.org

Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) failure to ensure each patient was assessed at least every 24 hours by a Registered Nurse as required by the Louisiana State Board of Nurses' Practice Act and hospital policy. This deficient practice is evidenced by having patient care provided by Licensed Practical Nurses without documented evidence of a RN assessment at a minimum of every 24 hours for 3 (#1, #3, #5) of 6 (#1-#5, #27) current sampled patient reviewed for RN assessments (see findings tag A-0395); and

2) failure to ensure Licensed Practical Nurses were obtaining admission orders from an admitting licensed practitioner prior to writing the admission orders in the medical record for 3 (#2, #4, #27) of 6 current patients (Patient #1, #2, #3, #4, #5, #27) reviewed for admission orders (see findings tag A-0395).

Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation for Radiological Services as evidenced by:

1) failure of the Governing Body to appoint a Medical Director of the hospital's Radiological Services. (See findings tag A-0546).

2) failure to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures (see findings in tag A-0536).

Based on record review and interview, the hospital failed to set priorities for its performance improvement activities that focused on high risk/high volume areas that had the potential to affect health outcomes, patient safety and quality of care. This deficient practice is evidenced by failure to identify deficient practices related to a. patients not being assessed at least every 24 hours by a RN, b. licensed practical nurses not obtaining admission orders from the admitting physician prior to writing the admission orders in the medical record, c. patients' physicians not being notified of blood pressure readings that were out of the ordered blood pressure parameters and d. staff not performing hand hygiene between glove changes and between clean and dirty activities.

Findings:

Review of the QAPI plan presented as current by S1DON and S2Quality revealed no documented evidence that patients not being assessed at least every 24 hours by a RN; licensed practical nurses not obtaining admission orders from the admitting physician prior to writing the admission orders in the medical record; patients' physicians not being notified of blood pressure readings that were out of the ordered blood pressure parameters; and staff not performing hand hygiene between glove changes and between clean and dirty activities were identified as problem areas in need of performance improvement.

An interview was conducted with S1DON and S2Quality on 12/2/15 at 9:00 a.m. They confirmed the problems with RNs not assessing patients within a 24 hour period, LPNs writing admission orders, not notifying the physicians of patients' blood pressure being out of specific parameters and nurses not following correct hand hygiene procedures were not focused or identified as problem areas in need of performance improvement in the Quality Assurance Plan/Performance Improvement Project.

30172





30364




30984

Based on record review, interviews and observations, the hospital failed to ensure that the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) failure to ensure each patient was assessed at least every 24 hours by a Registered Nurse as required by the Louisiana State Board of Nurses' Practice Act and hospital policy. This deficient practice is evidenced by having patient care provided by Licensed Practical Nurses without documented evidence of a RN assessment at a minimum of every 24 hours for 3 (#1, #3, #5) of 6 (#1-#5, #27) current sampled patient reviewed for RN assessments; and

2) failure to ensure Licensed Practical Nurses were obtaining admission orders from an admitting licenced practitioner prior to writing the admission orders in the medical record for 3 (#2, #4, #27) of 6 current patients (Patient #1, #2, #3, #4, #5, #27) reviewed for admission orders; and

3) failure to ensure patients' physicians were notified of blood pressure readings that were outside of the ordered blood pressure parameters for 4 (#2, #3, #4, #5) of 5 current patient records reviewed; and

4) failure of the RN to identify, assess and document patient's wounds upon admit and failing to document measurements of patient wounds for 2 (#4, #9) of 2 patient medical records reviewed for wound assessments out of 30 medical records reviewed.


Findings:

1) Failure to ensure each patient was assessed at least every 24 hours by a RN as required by the Louisiana State Board of Nurse's Practice Act and hospital policy.

Review of the LSBN's Practice Act revealed that RNs may delegate select nursing interventions to the LPN provided the patient is assessed by an RN every 24 hours.

Review of the hospital Policy and Procedure titled Registered Nurse Patient Assessments revealed in part:
It is the policy of the Rehabilitation Hospital of Jennings that every patient will be assessed each shift. This assessment must be performed by a Registered Nurse at least once in a 24 hour time period. There are two twelve hour shifts each day. Every patient must be assessed by a Registered Nurse at least once in a 24 hour period.

Patient #1
Review of Patient #1's nurse's notes dated 11/17/15 and 11/18/15 revealed no RN assessment for 36 hours. Further review of nurse's notes dated 11/23/15 and 11/24/15 revealed no RN assessment for 36 hours was documented.

Patient #3
Review of Patient #3's nurse's note entries revealed no documented evidence of a RN assessment from 11/15/15 (day shift) - 11/20/15 (night shift). All of Patient #3's assessments during that time period had been conducted by LPN nursing staff. Additional review revealed no documented evidence of a RN assessment on 11/24/15 for 24 hours.

In an interview on 11/30/15 at 2:05 p.m. with S2Quality, she confirmed Patient #3 had been assigned to LPNs for care on the above referenced dates. S2Quality also confirmed there was no documented evidence of a RN assessment of Patient #3 every 24 hours for the above referenced dates.

Patient #5
Review of Patient #5's nurse's notes dated 11/22/15 and 11/23/15 day shift revealed no RN assessment for 36 hours.

In an interview on 11/30/15 at 10:40 a.m. with S14RN, she said she did not assess every patient every day. S14RN said she would review the LPN notes and if there was a problem she would assess the patient.

In an interview on 11/30/15 at 10:57 a.m. with S1DON, she said the RN reviewed the LPN notes every shift. If there was anything out of the ordinary they would assess the patients.

2) Failure to ensure Licensed Practical Nurses were obtaining admission orders from an admitting licenced practitioner prior to writing the admission orders in the medical record.
Review of the hospital policy for Admission Process revealed in part, A. Admission Policies: 1. Nurses should phone MD for admit orders. Upon arrival of the patient to the hospital the admitting RN is to check to see if the patient's discharge orders are in his/her possession...C. Information Accompanying the Patient: Listed are those necessities which accompany the patient to the unit if the patient is coming from a hospital: Physician Discharge Orders, MARS (Medication Administration Records), Copies of the Medical Record (History & Physical, Labs/X-Rays, etc.), Advance Directives.
Review of the pre-printed document titled Physician's Orders Admit Orders Rehabilitation Hospital of Jennings revealed there was a sentence at the top of the form directing the person completing the form to "Please check the appropriate Orders." The items that had to be selected by the person completing the form included rehabilitation diagnosis, medical diagnosis, diet level, swallowing precautions, weight bearing status, bloodwork and precautions.

Patient #2
Review of the Admission Orders for the current Patient #2 revealed she was admitted on 11/24/15 at 11:10 a.m. Further review her admission orders had been noted by S7LPN on 11/25/15 at 1:50 a.m. There was no notation of the order being a verbal order by a physician. A space at the end of the admission orders that had the notation "I have approved these orders for Patient #2" had not been signed by the physician.

Patient #4
Review of the Admission Orders for the current Patient #4 revealed he had been admitted to the hospital on 11/23/15 at 4:20 p.m. The orders had been noted by S12LPN on 11/23/15 at 5:00 p.m. There was no notation of the order being a verbal order from a physician. The space at the end of the orders that had the notation "I have approved these orders for Patient #4" had not been signed by the physician until 11/24/15 at 12:45 p.m.

Patient #27
Review of the Admission Orders for the current Patient #27 revealed he was admitted on 11/30/15. Further review of his admission orders had been noted by S7LPN. There no notation of the order being a verbal order by a physician. The space at the end of the orders that had the notation "I have approved these orders for Patient #27" had not been signed by S17MedicalDirector until 12/1/15. No time was documented when the orders were signed by S17MedicalDirector.
In an interview on 12/1/15 at 1:45 p.m. with S2Quality, she said if patients arrived on the unit in the afternoon or evening when the physician was not on the unit, the nurse wrote the admission orders without speaking with the physician. S2Quality said the nurses based the admission orders on the discharge records from the patient's previous hospital. S2Quality said the physician would see the orders when he came into the hospital later in the day or the next day. S2Quality verified they did not call the physician's for admission orders.

An interview was conducted with S1DON on 12/1/15 at 2:00 p.m. She reported most of the time a patient was admitted with the discharge orders from the previous hospital. S1DON said the nurses used the discharge orders (including the discharge medication list) from the previous hospital stay to generate the admission orders for the hospital stay in the rehabilitation hospital. S1DON verified the hospital's pre-printed physician's order sheets had orders that had to be selected by the nurses like diet, labs and special precautions. S1DON further reported the physician was not called for admission orders. S1DON also verified it was not within the scope of practice of a licensed practical nurse to write admission orders for patients.
In an interview on 12/1/15 at 3:00 p.m. with S5LPN, she said she had written the admission orders for Patient #2 on 11/24/15. S5LPN said she did not speak with a physician when writing the orders. S5LPN said she used the information from the previous hospital to generate the orders.

In an interview on 12/2/15 at 10:23 a.m. with S12LPN, she said she wrote the admission orders on 11/23/15 for Patient #4. S12LPN said she used information from Patient #4's discharge paperwork from his previous hospital to fill out the admission orders. S12LPN verified she did not get a verbal order from the physician for the orders. She said the physician would usually review the admission orders and sign them within 24 hours.

A phone interview was conducted with S17Medical Director on 12/2/15 at 10:35 a.m. He reported the admission orders were generated by the nurses from the discharge papers from the previous hospital the patient was discharged from before admission. S17Medical Director further reported he or the other physicians typically are not called for patient's admission orders to the facility by the nurses.


3) Failure to ensure patients' physicians were notified of blood pressure readings that were outside of the ordered blood pressure parameters.

Patient #2
Review of the medical record for Patient #2 revealed an admission date of 11/24/15 with admission diagnoses including Hypertension and Congestive Heart Failure.

Review of Patient #2's admit orders, dated 11/24/15, revealed the following in part: Vital Signs twice a day and as needed; Notify Physician of blood pressure of 10% change from baseline.

Review of Patient #2's vital sign documentation revealed she had a base blood pressure reading of 147/84. Further review revealed on 11/30/15 at 4:24 a.m. the patient ' s blood pressure was 171/81. Additional review revealed no documented evidence that nursing staff had notified the physician of the patient ' s increased blood pressure which had fallen outside of the ordered parameter.

In an interview on 11/30/15 at 1:48 p.m., with S2Quality, she confirmed there was no documented evidence that nursing staff had notified the physician of the patient ' s increased blood pressure which had fallen outside of the ordered parameter.

Patient #3
Review of the medical record for Patient #3 revealed an admission date of 11/13/15 with admission diagnoses including Hypertension, Congestive Heart Failure and Coronary Artery Disease.

Review of Patient #3's admit orders, dated 11/13/15, revealed the following in part: Vital Signs twice a day and as needed; Notify Physician of blood pressure of 10% change from baseline.

Review of Patient #3's vital sign documentation revealed he had a base blood pressure reading of 135/77. Further review revealed on 11/14/15 at 4:43 a.m. the patient's blood pressure reading was 171/72. Additional review revealed no documented evidence that nursing staff had notified the physician of the patient ' s increased blood pressure which had fallen outside of the ordered parameter.

Patient #4
Review of the medical record for Patient #4 revealed he was a current patient. The initial RN assessment on 11/23/15 by S22RN revealed that the patient's baseline blood pressure upon admit was 103/56. A review of the patient's vital sign graphic sheet on 11/26/15 revealed that the patient had a documented blood pressure of 187/52 as documented by S5LPN. A review of S17MD's admit orders dated 11/23/15 revealed an order to notify the physician of a blood pressure that there was a 10% change from baseline. A further review of the patient's medical record revealed no documented evidence that S5LPN had notified the patient's physician of the patient's blood pressure change.
In an interview on 11/30/15 at 1:30 p.m. with S1DON, Patient #4's medical record was reviewed with S1DON. S1DON reviewed the nursing notes and indicated that there were no nursing notes documenting that the patient was assessed by an RN after a change in blood pressure and no documentation that a physician was notified of the blood pressure change. S1DON indicated that S5LPN did not follow physician orders regarding blood pressure changes.
Patient #5
Review of Patient #5's medical record revealed his baseline blood pressure was recorded as 145/68. Further review revealed the admission order dated 11/16/15 ordered to notify the physician if the blood pressure was greater than 10% of baseline.

Review of the blood pressure summary for 11/30/15 at 4:20 a.m. revealed the blood pressure was documented as 138/99. No notification to the physician of the blood pressure being greater than 10% different from the baseline was provided.

In an interview on 11/30/15 at 1:19 p.m. with S1DON, she said the physician should have been notified if the systolic or diastolic varied 10% from the baseline.


In an interview on 11/30/15 at 2:27 p.m., with S2Quality, she confirmed there was no documented evidence that nursing staff had notified the physician of the patient's increased blood pressure which had fallen outside of the ordered parameter.



4) failure of the RN to identify, assess and document patient's wounds upon admit and failing to document measurements of patient wounds.
Patient #4
Review of the medical record for Patient #4 revealed the current patient with a History of Falls with bruising and skin tears. The initial RN assessment on 11/23/15 completed by S22RN revealed an entry by S22RN that the patient had bruising on the bilateral arms and left knee and skin tears on the right arm. A review of the Initial Admit Wound Assessment form on 11/23/15 completed by S22RN (during the initial RN admit assessment) revealed no documentation of the wounds or a description and/or measurements of the skin tears/wounds and further indicated that the patient had no wounds. A review of the Daily Nursing Assessment sheets on 11/24/15, 11/25/15 and 11/26/15 indicated that the RNs documented that the patient had no wounds. A review of the Daily Nursing Assessment sheet on 11/27/15 at 11:00 p.m. by S15RN revealed documentation that the patient had skin tears (wounds) on the right arm, that was noted by the S22RN on the initial admit assessment and was not documented on an Initial Admit Wound Assessment form. A review of the Wound Tracking Form dated 11/28/15 that was completed by S15RN indicated that he patient had 2 (two) skin tears (left inner forearm and right outer forearm). A further review of the Wound Tracking Form dated 11/28/15 and completed by S15RN revealed no documentation of wound measurements.
In an interview on 11/30/15 at 1:30 p.m. with S1DON, Patient #4's medical record was reviewed with S1DON. She indicated that the RN (S22RN) who noted the wounds (skin tears) should have documented them on an Initial Admit Wound Assessment form when they were noted during the initial RN admit assessment. She further indicated that the RN (S15RN) who discovered that the wounds were not documented on the Initial Admit Wound Assessment form on 11/23/15 (during the initial RN admit assessment) and then documented them on a Wound Tracking Form on 11/28/15 should have also included wound measurements.
Patient #9
Review of the medical record for Patient #9 revealed her Nursing Admit Wound Assessment form dated 10/16/15 at 10:05 a.m. completed by S14RN (during the RN initial admit assessment) indicated that the patient had a surgical incision and no other wounds. The Daily Nursing Assessment sheet completed by S15RN on 10/16/15 at 4:30 p.m. revealed that the patient had 2 (two) Stage II pressure ulcers to the coccyx. A review of the Wound Tracking Form dated 10/16/15 at 4:30 p.m. and completed by S15RN revealed no documentation of the 2 (two) Stage II pressure ulcer's measurements.
In an interview on 11/30/15 at 1:30 p.m. with S1DON, Patient #9's medical record was reviewed with S1DON. She indicated that S14RN should have identified and assessed the patient's wounds upon admit and that S15RN should have included wound measurements on the Wound Tracking Form dated 10/16/15 at 4:30 p.m. S1DON further indicated that the RNs were not measuring and documenting patient wounds per hospital policy.

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to individualize the patient's nursing care plan to include all the patient's medical diagnoses for which the patient was being treated for 3 (#3, #4, #9) of 3 patient medical records reviewed for nursing care plans out of a total of 30 patient medical records reviewed.

Findings:

A review of the hospital policy titled, "Individual Plan of Care/Treatment", provided by S1DON as the most current, revealed in part: All patients will have an individualized plan of care that is individually tailored, integrated and coordinated in order to establish a comprehensive, goal-oriented, and individualized plan for each patient.
Patient #3
Review of the medical record for Patient #3 revealed an admission date of 11/13/15 with admission diagnoses including Hypertension, Congestive Heart Failure and Coronary Artery Disease. Further review of the patient's medical record revealed admission MD orders for daily weights, accurate intake/output and diuretics (Lasix 20 milligrams 1 time a day by mouth and Hydralazine 50 milligrams-1.5 tablets 3 times a day by mouth).

Review of Patient #3's plan of care revealed Congestive Heart Failure was not identified as a problem on the patient's care plan.

In an interview on 11/30/15 at 2:27 p.m. with S2Quality, she confirmed Congestive Heart Failure was not identified as a problem on Patient #3's care plan. She agreed Congestive Heart Failure should have been identified as a problem on the patient's care plan.

Patient #4
The patient was a 60 year old male admitted from an acute care hospital on 11/23/15 following a CVA (Cerebral Vascular Accident) with incidents of falls and confusion. The admit diagnosis was Cerebral Infarction with occlusion or stenosis of left anterior cerebral artery. Other diagnoses included in part: Anemia and Cirrhosis. Further review of the patient's nursing care plan revealed no documented care plans for Anemia or Cirrhosis.
In an interview on 11/30/15 at 1:30 p.m. with S1DON, Patient #4's medical record and nursing care plan were reviewed with S1DON. She indicated that the patient's nursing care plan should have been comprehensive and the patient should have been care planned for Anemia and Cirrhosis.
Patient #9
The patient was an 87 year old female admitted from an acute care hospital on 10/16/15 with the following diagnoses: Chest Pain and Duodenal Ulcer. The patient was discharged on 10/28/15. Other diagnoses included in part: Reflux and Anemia. The patient ' s Initial Nursing Admit Assessment by S14RN on 10/16/15 at 10:05 a.m. indicated that the patient was at a higher risk for recurrent bleeding. Further review of the patient's nursing care plan revealed no documented evidence that the patient was care planned for Ulcers or Anemia.
In an interview on 11/30/15 at 2:30 p.m. with S1DON, Patient #9's closed medical record and nursing care plan were reviewed with S1DON. She indicated that the patient's nursing care plan should have been comprehensive and the patient should have been care planned for Ulcers and Anemia.


30984

Based on record reviews and interviews, the hospital failed to ensure the assignment of nursing personnel for patient care services was done in accordance with the nursing personnel competence by failing to ensure 4 (S4RN, S20LPN, S21LPN,S22LPN) out of 6 contracted agency nurses (S4RN, S20LPN, S21LPN, S22RN, S23LPN,S24LPN) reviewed for competencies had documentation of nursing skills competency evaluations performed by hospital staff.

Findings:

Review of the hospital's policy titled Patient Care, Agency Nurse revealed it is the policy of the hospital that in the instance of staff shortage to employ temporarily a contract nursing agency worker...2. In the instance a RN is required competencies will be checked, nurse shall be briefed on the facility and report given at shift change. An agency RN is able to act as charge nurse when no other employed RN is available. 3. Hospital nurses that work alongside agency nurse for the shift are to fill out an agency packet provided by human resources. They should evaluate the agency nurse and educate as needed. Paperwork filled out and completed will be reviewed by the Director of Nursing and once approved will be placed into the employee file.

Review of S4RN, S20LPN, S21LPN, and S22LPN's personnel files revealed they were contract agency nurses and they had no documented nursing skills competencies.

An interview was conducted on 12/1/15 at 4:00 p.m. with S4HR (Human Resource Manager). She reported the nurses must not have turned in their nursing competencies list as they were instructed to do.

Based on record review and interview, the hospital failed to ensure non-employee registered nurses working as charge nurses were supervised by an appropriately qualified hospital-employed RN.

Findings:

Review of the hospital's policy on Patient Care, Agency Nurse revealed it is the policy of the hospital that in the instance of staff shortage to employ temporarily a contract nursing agency worker...2. In the instance an RN is required competencies will be checked, nurse shall be briefed on the facility and report given at shift change. An agency RN is able to act as charge nurse when no other employed RN is available.

Review of the 11/26/15 Nursing Schedule revealed S4RN was the only RN working on the day shift. S12LPN was the other nurse working on the day shift on 11/26/15.

Review of S4RN's personnel file revealed he was a contract agency nurse and his hospital nursing competencies had not been documented in his personnel file.

An interview was conducted on 12/1/15 at 4:00 p.m. with S4HR (Human Resource Manager). She reported S4RN had not turned in his nursing competencies list as he had been instructed to do.

An interview was conducted with S1DON on 12/2/15 at 4:05 p.m. She reported S4RN was the only RN in the hospital on 11/26/15 and he was functioning as the charge nurse. S1DON confirmed S4RN was a contract agency nurse and was not employed by the hospital.

Based on record review and interview the hospital failed to ensure drugs and biologicals were prepared and administered in accordance with the orders of the practitioner responsible for the patient's care and as directed by hospital policy. This deficient practice is evidenced by failure of the nursing staff to administer patient medications as ordered/as directed by hospital policy for 3 (#2,#3,#11) of 3 patients reviewed for medication administration out of a total sample of 30 patients records reviewed.

Findings:

Review of the hospital policy titled Medication Administration, effective: 4/01 revealed in part: IV. Medication Pass Guidelines: Never give Digoxin without checking and charting the Resident's pulse. Hold dose if pulse is less than 60.

Patient #2
Review of Patient #2's medical record revealed an admission date of 11/24/15 with diagnoses including congestive heart failure and atrial fibrillation.

Further review of Patient #2's medical record revealed no documentation of a heart rate prior to administration of Digoxin on 11/26/15 at 5:00 p.m. and on 11/28/15 at 4:25 p.m.
.
In an interview on 11/30/15 at 2:00 p.m. with S2Quality, she confirmed there was no documentation of a heart rate prior to Digoxin administration for the above referenced dates.

Patient #3
Review of Patient #3's medical record revealed an admission date of 11/13/15 with diagnoses including cerebral infarction and congestive heart failure.

Further review of Patient #3's medical record revealed no documentation of a heart rate prior to administration of Digoxin on the following dates: 11/14/15 through 11/21/15 and 11/24/15 through 11/29/15.

In an interview on 11/30/15 at 2:27 p.m., with S2Quality, she confirmed there was no documentation of a heart rate prior to Digoxin administration for the above referenced dates.

Patient #11
Review of Patient #11's medical record revealed an admission date of 10/6/15 with diagnoses including Hypertension and Atherosclerosis.

Review of Patient #11's medication administration record revealed the patient was receiving Clonidine HCL 0.1 milligrams, 1 tablet by mouth every 6 hours as needed for treatment of hypertension for systolic blood pressure greater than 180 or diastolic blood pressure greater than 95. Further review of Patient #11's medication administration record revealed the as needed Clonidine dose was not administered as ordered on 10/6/15 at 11:54 a.m. for a blood pressure of 185/85 and on 10/7/15 at 4:37 a.m. for a blood pressure of 188/82.

Review of Patient #11's nurses notes revealed no documented explanation for not administering the Clonidine as ordered on the above referenced dates.

In an interview on 12/1/15 at 9:04 a.m. with S8Medical Records, he confirmed, after review of Patient #11's medical record, that there was no documentation of administration of Clonidine and no explanation for failure to administer Clonidine as ordered for blood pressures that fell outside of the ordered parameters.

Based on record reviews and interview, the hospital failed to ensure all patient medical record entries were complete as evidenced by failing to ensure the ordering licensed practitioner dated and timed his authentication of orders and/or progress notes for 4 (#1,#5, #7, #8) of 4 patient records reviewed for dating and timing of orders out of a total sample of 30 patient records reviewed.

Findings:

Review of the Hospital's Medical Staff Bylaws revealed in part: All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated.

A review of the hospital policy titled, "Content of Record", provided by S1DON as the most current, revealed in part: All entries must be legible, complete and authenticated by the ordering provider. Authentication - Timing documents the time and date of each entry. Timing and dating entries is necessary for patient safety and quality of care and establishes a baseline for future actions or assessments and establishes a timeline of events.

Patient #1
Review of Patient #1's medical record revealed he was a current patient admitted on 11/17/15. Further review revealed a verbal order dated 11/20/15 at 9:37 a.m. that had been authenticated by the physician, but his authentication had not been dated or timed.

Patient #5
Review of Patient #5's medical record revealed he was a current patient admitted on 11/16/15. Further review revealed he had a physician's order that had been written and authenticated on 11/22/15, but the order had not been timed.

Patient #7
Review of the medical record for Patient #7 revealed he was admitted on 11/2/15 and discharged on 11/21/15. Further review revealed verbal orders dated 11/11/15 and 11/12/15 had been authenticated by the physician, but had not been timed or dated.

Patient #8
Review of Patient #8's medical record on 11/30/15 revealed the patient was admitted on 9/3/15 and discharged on 9/15/15. Further review revealed the following orders and progress notes had been authenticated, but not dated or timed, by the ordering licensed practitioner:
Verbal orders written on 9/14/15 at 9:21 a.m., 9/14/15 at 6:37 a.m., 9/11/15 at 10:42 a.m. and 9/7/15 at 10:56 a.m.
Further review of Patient #8's medical record revealed MD Progress Notes dated 9/7/15, 9/9/15, 9/10/15, 9/11/15 and 9/12/15 had been authenticated, but not dated and timed as of 11/30/15.

In an interview on 11/30/15 at 4:48 p.m. with S1DON, she confirmed the above referenced orders and MD progress notes had been authenticated but not dated and timed as of 11/30/15. S1DON further indicated that the hospital was having issues with the physicians not authenticating their orders with dates and times.




30364




30984

Based on record reviews and interviews, the hospital failed to ensure all verbal orders had been authenticated within 10 days as required by the Medical Staff Bylaws for 4 (#1, #3, #4, #30) of 10 patient medical records reviewed for authentication of verbal orders out of a total of 30 medical records.

Findings:

Review of the Hospital's Medical Staff Bylaws revealed in part:
A verbal order shall be considered to be in writing if dictated to a physician assistant, nurse practitioner, registered nurse, licensed practical nurse, physical therapist, occupational therapist, speech therapist or registered dietician and signed by the responsible physician within 10 days.

A review of the hospital policy titled, "Content of Record", provided by S1DON as the most current, revealed in part: All entries must be legible, complete and authenticated by the ordering provider. Authentication - Timing documents the time and date of each entry. Timing and dating entries is necessary for patient safety and quality of care and establishes a baseline for future actions or assessments and establishes a timeline of events.

A review of the hospital policy titled, "Health Information Management" , provided by S1DON as the most current, revealed in part: Verbal and Telephone Orders - The practitioner shall countersign, date, and time verbal and telephone orders within 10 (ten) days.

Patient #1
Review of the medical record for Patient #1 on 11/30/15 revealed a verbal order dated 11/17/15 at 12:05 p.m. that had not been authenticated by the physician.

Review of the medical record for Patient #1 on 11/30/15 revealed a verbal order dated 11/18/15 at 4:00 a.m. that had not been authenticated by the physician.

Patient #3
Review of the medical record for Patient #3 on 11/30/15 revealed a verbal order dated 11/19/15 at 12:00 p.m. that had not been authenticated by the ordering physician.

In an interview on 11/30/15 at 2:27 p.m. with S2Quality, she confirmed the above referenced order had not been authenticated within 10 days of being written.

Patient #4
Review of the medical record for Patient #4 revealed he was a current patient admitted on 11/23/15 with an admission diagnosis of Cerebral Infarction with occlusion or stenosis of left anterior cerebral artery.
A review of Patient #4's physician verbal order from S16MD, dated 11/25/15, and confirmed by S5LPN, revealed that S16MD had signed the verbal order but did not date or time when he signed the verbal order.
Patient #30
Review of Patient #30's medical record revealed an admission date of 9/24/15 with an admission diagnosis of status post CVA (Cerebral Vascular Accident) with right sided weakness. A review of S17MD's verbal orders dated 9/25/15, 10/05/15, and 10/07/15 revealed that S17MD had signed the verbal orders but did not date or time when he signed the verbal orders.
In an interview on 12/01/15 at 3:00 p.m. with S1DON, she verified verbal orders should have been authenticated (signed, dated and timed) by the ordering physician within 10 days. S1DON further indicated that the hospital was having issues with the physicians not authenticating their orders with dates and times.


30364




30984

Based on record reviews and interviews, the Hospital failed to ensure all patient records included documentation of outcomes of hospitalization, disposition of care and provisions for follow-up care as evidenced by the failing to ensure the treating licensed practitioner completed a discharge summary for 3 (#9, #11, #12) of 3 patient records reviewed for discharge summaries out of a total sample of 30 patient medical records reviewed.

Findings:

Review of the hospital's Bylaws of the Medical Staff, Article XVI: Rules and Regulations for the professional Medical Staff, effective 4/14, Section 2. Medical Records, revealed in part: A discharge clinical resume (summary) shall be documented on all medical records of patients hospitalized over 48 hours. In all instances, the content of the medical record shall be sufficient to justify the diagnosis and warrant the treatment and end result. All summaries shall be authenticated by the responsible physician.
Each medical record shall be completed within 30 days after discharge of the patient or the record becomes delinquent.

A review of the hospital policy titled, "Content of Record", provided by S1DON as the most current, revealed in part: Discharge Summary- All medical records must contain a final diagnosis. All medical records must be complete within 30 days of discharge

Patient #9
Review of Patient #9's medical record revealed an admission date of 10/16/15 and a discharge date of 10/28/15.
In an interview on 12/01/15 at 10:15 a.m. with S19Medical Records she indicated that Patient #9's discharge summary was not dictated until 11/30/15 and was not completed within 30 days of the patient's discharge on 10/28/15 as per hospital policy.

Patient #11
Review of Patient #11's medical record revealed an admission date of 10/06/15 and a discharge date of 10/22/15. Further review revealed the patient's medical record did not have a discharge summary as of 12/01/15.
In an interview on 12/01/15 at 9:04 a.m. with S8MedicalRecords, he confirmed Patient #11's medical record did not contain a discharge summary as of 12/01/15 (at the time of the medical record review).

Patient #12
Review of Patient #12's medical record revealed an admission date of 10/16/15 and a discharge date of 10/28/15. Further review revealed the patient's medical record did not have a discharge summary as of 12/01/15 (at the time of the record review).
In an interview on 12/01/15 at 10:30 a.m. with S2Quality, she confirmed Patient #12's medical record did not contain a discharge summary as of 12/01/15 at the time of the medical record review.




30984

Based on policy review, observation and interview, the hospital failed to date and time multi-dose vials of Lidocaine when opened to ensure outdated drugs and biologicals were not available for patient use.

Findings:

Review of the Hospital Policy and Procedure titled Medication Administration revealed in part: All multi-dose vials must have the label on the final container. Date and initial the vial when initially opened.

An observation of the medication cart revealed 2 opened multi-dose vials of Lidocaine HCl 10mg/ml that had been opened but had not been dated or timed.

In an interview on 11/30/15 at 10:45 a.m. with S1DON, she said multi-dose vials should have been dated, timed and initialed when opened.

Based on record review and interview, the hospital failed to ensure drug administration errors were documented in the patients' medical records for 2 (#24,#25) of 2 patients reviewed for medication errors.

Findings:

Patient #24
Review of the hospital's occurrence reports revealed a medication error involving Patient #24. Further review revealed Patient #24 had received 5 extra doses of Flagyl.
Review of Patient #24's medical record revealed no documented evidence of an account of the medication error referenced in the occurrence report.
Patient #25
Review of the hospital's occurrence reports revealed a medication error involving Patient #25. Further review revealed Patient #25 had received Percocet 7.5/325 milligrams instead of the ordered Percocet 5/325 milligrams.
Review of Patient #25's medical record revealed no documented evidence of an account of the medication error referenced in the occurrence report.
In an interview on 12/1/15 at 1:43 p.m. with S2Quality, she confirmed, after review of Patient #24 and Patient #25's medical records, that there was no documentation of the medication errors referenced above in the patients' records.

Based on record review and interview, the hospital failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.
Findings:
Review of hospital policies and procedures revealed no policy and procedure for radiological services.
In an interview on 11/30/15 at 9:32 a.m. with S1DON, she confirmed had failed to develop policies and procedures that addressed proper safety precautions against radiation hazards to provide for the safety of staff and patients during radiological procedures performed in the hospital.

Based on record review and interview, the hospital failed to ensure radiological services were under the direction of a Radiologist as evidenced by failure of the Governing Body to appoint a Medical Director of the hospital's Radiological Services.
Findings:
Review of the hospital's organizational chart revealed no documented evidence of an appointed Medical Director of Radiological Services.

Review of the hospital's medical staff roster revealed no documented evidence of an appointed Medical Director of Radiological Services.

A review of the Governing Body minutes from 2012 to present, as provided by S1DON as the complete Governing Body minutes, revealed no documented evidence that the Governing Body had appointed a Medical Director of Radiological Services.

In an interview on 11/30/15 at 9:32 a.m. with S1DON, she confirmed the hospital's Governing Body had not appointed a radiologist to serve as Medical Director of the hospital's Radiological Services.

Based on policy review, observation and interview, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable diseases of patients and personnel was implemented according to hospital policy and acceptable standards of infection control practices. This deficient practice is evidenced by observations of staff not washing their hands between glove changes or between clean and dirty activities.

Findings:

Review of the hospital infection control manual revealed in part:
D. 4. b. Gloves are changed between patients. Remove gloves before leaving the patient room/area so as not to contaminate the environment. Wash hands after removing gloves.

In an observation on 12/1/15 beginning at 10:30 a.m., S10RN entered Patient #26's room and donned gloves without first washing or sanitizing her hands. S10RN assisted S11RN with a dressing change to Patient #26's right ankle. S10RN removed her gloves and left the room without washing or sanitizing her hands. When she returned to the room, S10RN donned new gloves without washing or sanitizing her hands. S10RN removed some toilet paper from the roll in the bathroom with the gloved hands and handed it to Patient #26's wife. S10RN then touched the external pin insertion site into Patient #26's skin with the dirty gloves. S10RN then removed the gloves and exited the room again without washing or sanitizing her hands.

In an observation on 12/1/15 beginning at 10:30 a.m., S11RN donned gloves and began removing the dressings from both ankles on Patient #26. S11RN removed her gloves and donned new gloves. S11RN finished removing Patient #26's dressings and then used the hospital camera to take pictures of the wound while still wearing the dirty gloves. S11RN then cleaned the external pin insertion site and put clean dressings on the insertion sites without changing gloves. S11RN was never observed washing or sanitizing her hands between glove changes.

In an observation on 12/1/15 at 2:35 p.m. S13LPN was providing a nebulizer treatment for Patient #2. S13LPN changed her gloves three times during the treatment without washing or sanitizing her hands between the glove changes.

In an interview on 12/1/15 at 4:00 p.m. with S1DON, she verified the staff members should have washed or sanitized their hands between clean and dirty activities and between glove changes.