HospitalInspections.org

Based on record review and interview the GB failed to ensure that the Medical Staff Bylaws Rules and Regulations had a process in place, approved by the GB, to appoint medical staff to serve as the hospital's directors for the hospital's services as evidenced by no documented process in place for medical staff to be appointed as the hospital's directors for the Director of Medical, Laboratory, Respiratory, and Radiology and no current appointments noted in the 2017 MEC or GB meeting minutes.


Findings:
A review of the MEC meeting minutes and the GB meeting minutes for 2017 revealed no documented evidence of appointments by the Medical Staff for the 2017 hospital's directors for Medical, Laboratory, Respiratory, and Radiology.

A review of the Medical Staff Bylaws Rules and Regulations, as provided by administration as the current Medical Staff Bylaws Rules and Regulations, revealed no documented evidence of a process in place for the medical staff to be appointed as the hospital's directors for the Director of Medical, Laboratory, Respiratory, and Radiology.

In an interview on 08/02/17 at 3:00 p.m. with S9HIM, she indicated that she was responsible for medical staff credentialing and she worked with the Medical Staff Bylaws Rules and Regulations for the hospital as part of the credentialing process. S9HIM indicated that after the hospital's last re-certification survey in 2014, the Medical Staff and the GB appointed and approved the hospital's directors for Medical, Laboratory, Respiratory, and Radiology. She indicated that the hospital's directors for Medical, Laboratory, Respiratory, and Radiology were supposed to be re-appointed annually every January. S9HIM indicated that she was very familiar with the Medical Staff Bylaws Rules and Regulations for the hospital and indicated that there was no documented process in place that addressed the medical staff appointments/reappointments of the hospital's directors for Medical, Laboratory, Respiratory, and Radiology. She indicated that the verbiage on the process used to be present in the Medical Staff Bylaws Rules and Regulations prior to the last revision of the Medical Staff Bylaws Rules and Regulations in 2015 and she did not know why it was not addressed in the new version.

Based on record review and interview, the hospital failed to ensure the medical staff was accountable to the GB for the quality of care provided to patients as evidenced by the medical staff failing to follow hospital policy for the pronouncement of patient death for 1 of 1 (#13) sampled death record reviewed out of a total sample of 30 patients.

Findings:
A review of the hospital policy titled, "Patient Death/Organ Donation", as provided by S4QA as a current policy, revealed in part: Death Pronouncement- A physician must pronounce a patient dead. The attending physician may delegate this to another physician who may be in the hospital at the time of death. A verbal or phone order is needed.

Patient #13
A review of the medical record for Patient #13 revealed she was an 80 year old female admitted on 10/30/14 from an acute care hospital for rehabilitation services. On 11/03/14 the patient became unresponsive. The medical record review revealed the attending physician, S26MD/Dir, was notified of the patient's condition and eventual death by the nurse practitioner. The review revealed documentation that S26MD/Dir was unavailable at the time to pronounce the patient and instructed the staff to call the coroner. A further review of the medical record revealed that the coroner's office was called and that the coroner's non-medical assistant (deputy) pronounced the patient's death, over the telephone, per the coroner.

In an interview on 08/04/17 at 11:40 a.m. with S9HIM (credentialing staff) and S4QA, S9HIM indicated that the Medical Staff Bylaws Rules and Regulations did not address Death Pronouncement protocols. S9HIM further indicated that the coroner was not a credentialed member of the medical staff and she did not think the coroner's assistant (deputy) was a medical doctor. S4QA indicated that the hospital policy indicated that a physician must pronounce a patient's death. S4QA and S9HIM indicated the patient was not pronounced by a credentialed member of the hospital's medical staff as per hospital policy.

Based on record review and staff interview, the Hospital failed to follow their policy and procedure for initiating a Do Not Resuscitate (DNR) Order as evidenced by the physician failing to document in the progress notes the DNR discussion with the family, Power of Attorney and/or patient before DNR status was implemented for 1 of 1 (#1) sampled patients reviewed for DNR status out of a total of 30 sampled medical records.

Findings:

Review of the hospital policy titled, Do Not Resuscitate, Policy No. I-A.1.13, revealed in part the following: Procedure: the patient's attending physician and a consulting physician must determine if a DNR order is medically appropriate, based on the patient's underlying terminal illness or irreversible medical condition. If the attending physician and the consulting physician determine that a DNR order is medically appropriate, the physician must then discuss the matter with the patient, explaining the basis for and the consequences of, a DNR or a Terminal Care Order. If the patient is incompetent, this discussion must be held with the patient's family or legal guardian. All such discussions must be noted on the patient's medical record. The notation of such discussions shall include at least the following information: persons present, information conveyed by physician, date/time of conference with family/patient, and decision of family and legal guardian....If the patient is competent, the patient must consent to the entry of a DNR order. If the patient is not competent, the patient's family members and the legal guardian must consent to the entry of the DNR or Terminal Care Order. In either case, the attending physician must indicate on the patient's record, in the physician progress notes, that consent has been obtained and the procedure by which the consent was obtained.

Patient #1
Review of the medical record for current Patient #1 revealed the patient was an 84 year old admitted to the hospital on 07/18/17 with a diagnosis of CVA. Review of the record revealed the patient had a diagnosis of Dementia.
Review of the physician orders revealed the following: "07/19/17 at 6:30 p.m. DNR per POA (discussed)."
Review of the physician progress notes from admission to present revealed no documented evidence of any discussion with the patient or patient's family related to a DNR status.

In an interview on 08/01/17 at 2:20 p.m., S3DON/Gr reviewed the record for Patient #1 and confirmed there was no documentation in the progress notes of a discussion of the DNR status.

In an interview on 08/02/17 at 1:55 p.m., S15RN, charge nurse reviewed the DNR order for this patient and confirmed this was how S26MD/Dir writes a DNR order. She confirmed if she saw this order and the manner it was written, she would think the patient was a DNR. She stated S26MD/Dir usually talks to the patient and/or family to see if they know what a DNR means and then he writes the order.

Based on record review and interview, the hospital's GB failed to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all hospital services in the QAPI program. This deficient practice was evident by failing to include the contracted hospital services of dialysis and biomedical in the hospital's QAPI program.

Findings:

Review of the Quality Indicators Dashboard provided by S4QA as the complete version of quality indicators and performance measures monitored for 2017 revealed the contracted services of dialysis and biomedical services were not included in the QAPI program and no data was collected related to those services.

In an interview on 08/03/17 at 5:15 p.m., S4QA confirmed the hospital's QAPI program did not include quality indicators or performance measures for the contracted services of dialysis and biomedical. S4QA confirmed the hospital provided in-house dialysis services and had an agreement with a biomedical company for inspection of the hospital's medical equipment.

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Based on record review and staff interview, the hospital failed to ensure radiologists providing interpretation of radiological tests from the contracted radiological service provider were credentialed and granted privileges to provide the services by the hospital's medical staff and GB for 2 (S28MD/Rad, S32MD/Rad) of 3 (S27Dir/Rad, S28MD/Rad, S32MD/Rad) contracted radiologists reviewed providing services on 5 of 5 (#8, #10, #11, #14, #19) current hospital patients reviewed for radiology services provided by the contracted radiological services.

Findings:
A review of the Physician Roster of the credentialed medical staff for the hospital, as provided by administration, revealed that S28MD/Rad and S32MD/Rad were not listed as credentialed physicians of the medical staff and approved by the GB.

Patient #8
Review of the medical record for Patient #8 revealed the current patient was a 87 year old male admitted to the hospital on 07/21/17 with a diagnosis of CVA. Review of Patient #8's Chest X-ray report dated 07/23/17 revealed it had been interpreted by S32MD/Rad.
Review of the medical staff roster revealed S32MD/Rad was not on the hospital's list of credentialed physicians.

Patient #10
A review of the medical record for Patient #10 revealed the current patient was a 53 year old female admitted to the hospital on 07/07/17 with a diagnosis of bilateral lower extremity paralysis, status post lumbar fusion. A review of Patient #10's Chest X-ray report dated 07/21/17 revealed it had been interpreted by S28MD/Rad.
A review of the medical staff roster revealed S28MD/Rad was not on the hospital's list of credentialed physicians.

Patient #11
Review of the medical record for Patient #11 revealed the current patient was a 69 year old admitted to the hospital on 07/24/17 with a diagnosis of Late Effects of CVA with Left Sided Paresis. Review of Patient #11's Abdominal X-ray reports dated 07/26/17 and 07/27/17 revealed both reports had been interpreted by S28MD/Rad.
Review of the medical staff roster revealed S28MD/Rad was not on the hospital's list of credentialed physicians.

Patient #14
Review of the medical record for Patient #14 revealed the current patient was a 77 year old admitted to the hospital on 07/16/17 with a diagnosis of Late Effects of CVA with Left Sided Paresis. Review of Patient #14's Abdominal X-ray report dated 07/21/17 revealed the report had been interpreted by S28MD/Rad.
Review of the medical staff roster revealed S28MD/Rad was not on the hospital's list of credentialed physicians.

Patient #19
Review of Patient #19's medical record revealed he was a current patient at the hospital's offsite campus. Review of Patient #19's Chest x ray dated 08/02/17 at 8:54 a.m. revealed it had been interpreted by S32MD/Rad. There was no documented evidence that S32MD/Rad was a member of the medical staff of the hospital or that the hospital had conducted an internal review of the physician's credentials.

In an interview on 08/03/17 at 11:30 a.m. with S9HIM, she indicated that she was responsible for the credentialing of the medical staff. She indicated that S28MD/Rad and S32MD/Rad were not credentialed members of the hospital's medical staff and she indicated there was no internal review of the above radiologists' credentials by the hospital.

Based on record review and interview, the hospital failed to ensure the medical staff completed the patient's history and physical in accordance with the Medical Staff Bylaws as evidenced by failing to ensure the patient's H&P was completed and placed on the medical record within 24 hours of admission for 3 (#10, #12, #20) of 3 patients out of of 30 sampled patient medical records.

Findings:

Review of the Medical Staff Bylaws revealed in part, "A physical examination and medical history shall be completed within 24 hours after an admission. This examination must be placed within the patient's medical record within 24 hours of admission."

Patient #10
A review of the medical record for Patient #10 revealed the current patient was a 53 year old female admitted to the hospital on 07/07/17 with a diagnosis of bilateral lower extremity paralysis, status post lumbar fusion.
A review of the patient's H&P revealed the H&P was dictated by S26MD/Dir on 07/08/17 at 2:59 p.m. A further review of the H&P revealed a typed (transcribed) date of 07/10/17 at 6:56 p.m., when the H&P was now available from the transcription company to be printed and placed in the patient's medical record (over 72 hours after admission).

In an interview on 08/02/17 at 12:20 p.m. with S15RN she indicated that the transcription date and time was when the H&P was now available from the transcription company to be printed and placed in the patient's medical record. S15RN further indicated that a patient's transcribed H&P was usually not available within a 24 hours time frame. She indicated that Patient #10's H&P was not available to be placed on the patient's medical record for over 24 hours after admission.

In an interview on 08/03/17 at 9:00 a.m. with S2DON he indicated that transcription date was the time a patient's H&P was available for staff to print and placed on the patient's medical record.


Patient #12
Review of the medical record for current Patient #12 revealed the patient was a 76 year old admitted to the hospital on 07/20/17 at 5:55 p.m. with a diagnosis of Ischemic Encephalopathy.
Review of the H&P revealed the H&P was dictated by S33NP on 07/21/17 at 6:20 p.m. (24 hours and 25 minutes after admission). Review of the H&P revealed a typed (transcribed) date of 07/23/17 at 6:58 p.m., over 72 hours after admission.

In an interview on 08/02/17 at 11:42 a.m., S3DON/Gr reviewed the H&P for Patient #12 and confirmed the H&P was not placed on the patient's medical record within 24 hours.

Patient #20
Review of the medical record for Patient #20 revealed the patient was a 77 year old admitted to the hospital on 05/19/17 at 2:30 p.m. with a diagnosis of Late Effects of Hemorrhagic Stroke.
Review of the H&P revealed the H&P was dictated by S34NP on 05/20/17 at 11:39 a.m., but was not transcribed until 05/21/17 at 6:24 a.m., over 24 hours after the patient was admitted to the hospital.

In an interview on 08/02/17 at 11:55 a.m., S9HIM confirmed the above H&Ps were not transcribed by the dictation service within 24 hours and the H&P was not placed on the patient's medical record within 24 hours of admission. S9HIM stated she thought as long as the H&P was dictated within 24 hours, it was ok. After reviewing the hospital's Medical Staff Bylaws, she confirmed the Bylaws did require the H&P to be placed on the patient's medical record within 24 hours of admission.



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Based on interview and record review, the hospital failed to ensure a RN supervised and evaluated the nursing care for each patient as evidenced by:
1) failure of the RN to notify the physician of a patient's elevated blood pressure readings (4 separate occurrences) for a patient who was status post CVA with a history of uncontrolled hypertension for 1 (#16) of 5 (#15- #19) patients reviewed on the hospital's offsite campus out of a total sample of 30 patients reviewed on both campuses;
2) failure of the RN to notify the physician of a patient's CBG of 427 mg/dl for 1 (#6) of 3 (#6,#8,#14) Diabetic patients reviewed at the main campus out of a total sample of 30 patients reviewed on both campuses;
3) failure of the RN to assess the patient's complaint of pain and the effectiveness of the pain medication administered to the patient for 2 (#10, #11) of 2 current sampled patients reviewed for assessment of pain out of a total sample of 30, and:
4) failure of the RN to assess the patients daily weight as ordered by the physician for 1 (#11) of 3 (#4, #11, #14) sampled patients reviewed for daily weights out of a total sample of 30.

Findings:

1) Failure of the RN to notify the physician of a patient's elevated blood pressure readings for a patient who was status post CVA with a history of uncontrolled hypertension.

A policy on notification of change in patient condition was requested by the survey team on 8/2/17 and 8/3/17. The survey team was notified on 8/3/17 at 3:30 p.m. by S3DON/Gr that the hospital did not have a policy regarding notification of change in patient condition in non-emergent situations.

Review of Patient #16's medical record revealed an admission date of 7/20/17 with a rehabilitation diagnosis of status post CVA (cerebrovascular accident) involving the cerebellum, affecting the right side. Further review revealed the patient had co-morbid diagnoses including congestive heart failure, hypertension, and renal disorder.

Review of Patient #16's Vital Sign Graphics Records revealed the following entries:
7/21/17 at 6 p.m.: Blood pressure 177/116.
Further review of Patient #16's medical record, including review of the nursing notes, MAR, and physician's orders, revealed no documented evidence that the physician had been notified of the patient's elevated blood pressure and no documented evidence of any action taken regarding treatment of the patient's elevated blood pressure.

7/23/17 at 6 p.m.: Blood pressure 171/106.
Further review of Patient #16's medical record, including review of the nursing notes, MAR, and physician's orders, revealed no documented evidence that the physician had been notified of the patient's elevated blood pressure and no documented evidence of any action taken regarding treatment of the patient's elevated blood pressure.

7/24/17 at 6 p.m.: Blood pressure 136/104.
Further review of Patient #16's medical record, including review of the nursing notes, MAR, and physician's orders, revealed no documented evidence that the physician had been notified of the patient's elevated blood pressure and no documented evidence of any action taken regarding treatment of the patient's elevated blood pressure.

7/25/17 at 6 a.m.: Blood pressure 171/104.
Further review of Patient #16's medical record, including review of the nursing notes, MAR, and physician's orders, revealed no documented evidence that the physician had been notified of the patient's elevated blood pressure and no documented evidence of any action taken regarding treatment of the patient's elevated blood pressure.

In an interview on 8/2/17 at 3:40 p.m. with S2DON, he confirmed, after review of the above referenced findings, that the physician should have been notified of Patient #16's elevated blood pressure readings. S2DON also confirmed there was no documented evidence of physician notification and no documented evidence of any interventions to address the patient's elevated blood pressure.

2) Failure of the RN to notify the physician of a patient's CBG of 427 mg/dl.

A policy on notification of the physician regarding hyperglycemia was requested on 8/2/17 and 8/3/17. The survey team was notified on 8/3/17 at 3:30 p.m. by S3DON/Gr that the hospital did not have a policy regarding hyperglycemia parameters requiring notification of physician.


Review of Patient #6's medical record revealed an admission date of 6/20/17 with an admission diagnosis of heart failure and restrictive lung disease. Further review revealed the patient also had a co-morbid diagnosis of Diabetes Mellitus.

Review of Patient #6's History and Physical, dated 6/20/17, revealed the patient was being treated with Metformin 250 mg twice a day with meals. Further review of the patient's medical record revealed no other ordered medication for treatment of the patient's diagnosis of Diabetes Mellitus.

Review of Patient #6's medical record revealed a CBG result of 427 mg/dl on 6/26/17 at 11:30 a.m. Further review of Patient #6's nurses' notes, MAR, and physician's orders revealed no documented evidence of notification of the physician of the 427 mg/dl CBG and no documentation of action of any kind to address the patient's elevated CBG.

In an interview on 8/2/17 at 3:45 p.m. with S2DON, he confirmed he had reviewed Patient #6's medical record and had found no documented evidence that the physician had been notified of the 427 mg/dl CBG result on 6/27/17 at 11:30 a.m. He also confirmed he had found no documented evidence of any coverage being given for the 427 mg/dl CBG result. S2DON indicated the hospital's standard practice is to notify the physician when CBG results are in the upper 200 mg/dl's -350 mg/dl. He said the physician would then usually order coverage with sliding scale insulin.



3) Failure of the RN to assess the patient's complaint of pain and the effectiveness of the pain medication administered to the patient:

Patient #10
A review of the medical record for Patient #10 revealed the current patient was a 53 year old female admitted to the hospital on 07/07/17 with a diagnosis of bilateral lower extremity paralysis, status post lumbar fusion. A review of the physician orders dated 07/08/17 revealed an order for Hydrocodone/APAP (Norco) 10-325 mg 1 tablet every 6 hours as needed for pain. A review of the MAR dated 07/31/17 revealed the patient was administered the Hydrocodone/APAP at 8:15 a.m., 3:12 p.m., and 10:20 p.m. on 07/31/17 by S16RN. A further review of the MAR and the Daily Nursing Flowsheets for 07/31/17 revealed no documented evidence of an assessment of the location, duration, or intensity of the patient's pain, nor was there any documentation of an assessment of the effectiveness of the pain medication administered.

In an interview on 08/03/17 at 9:30 a.m. with S2DON he reviewed the medical record for Patient #10 and indicated that there was no documented evidence of an assessment of the patient's pain nor was there an assessment of the effectiveness of the pain medication administered on 07/31/17 by S16RN.

Patient #11
Review of the medical record for Patient #11 revealed the patient was a 69 year old admitted to the hospital on 07/24/17 with a diagnosis of Late Effects of CVA with Left Sided Paresis.
Review of the physician orders dated 07/25/17 revealed an order for Hydrocodone/APAP (Norco) 5-325 mg 1 tablet every 6 hours as needed for pain.
Review of the MARs dated 08/01/17, 07/31/17, and 07/29/17 revealed the patient was administered the Hydrocodone/APAP at 8:00 p.m. on all three days. Further review of the MAR and the Daily Nursing Flowsheets for the above dates revealed no documented evidence of an assessment of the location, duration, or intensity of the patient's pain, nor was there any documentation of an assessment of the effectiveness of the pain medication administered.

In an interview on 08/02/17 at 11:00 a.m., S3DON/Gr reviewed the medical record and confirmed there was no documentation of an assessment of the patient's pain nor was there an assessment of the effectiveness of the pain medication administered.



4) Failure of the RN to assess the patient's daily weight as ordered by the physician:

Patient #11
Review of the medical record for Patient #11 revealed the patient was a 69 year old admitted to the hospital on 07/24/17 with a diagnosis of Late Effects of CVA with Left Sided Paresis.
Review of the physician's admission orders dated 07/24/17 at 11:35 a.m. revealed daily weights were ordered.
Review of the Nursing Graphic Sheet and the Daily Nursing Flowsheet revealed no documented evidence of the patient's weight on 07/25/17 and 07/26/17.

In an interview on 08/02/17 at 11:00 a.m., S3DON/Gr reviewed the medical record for Patient #11 and confirmed the patient's weight was not documented on the Nursing Graphic Sheet or Daily Nursing Flowsheet. After reviewing the vital sign sheets for 07/25/17 and 07/26/17, she confirmed she was unable to find documentation of the patient's weight for 07/25/17 and 07/26/17.

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered in accordance with the orders of the practitioner responsible for the patient's care. This deficient practice was evidenced by failure of the nursing staff to administer patient medications as ordered for 1 (#8) sampled patient out of a total sample of 30 medical records.

Findings:

Patient #8
Review of the medical record for current Patient #8 revealed the patient was an 87 year old admitted to the hospital on 07/21/17 at 2:56 p.m. with a diagnosis of CVA.

Review of the admission orders dated/timed 07/21/17 at 7:30 p.m. revealed the following medication orders:
Atorvastatin 80 mg at bedtime
Carvedilol 3.125 mg every 12 hours
CBG with Sliding Scale Insulin ordered before meals and at bedtime.
Heparin 5000 units SQ every 8 hours.

Review of the MARs revealed no documented evidence of a MAR for 07/21/17. There was no documented evidence that the patient received any of the above medications until 07/22/17. Further review of the MARs revealed the above medications were scheduled to be administered as follows:
Atorvastatin - 8:00 p.m.
Carvedilol - 8:00 a.m. and 8:00 p.m.
CBG with Sliding Scale Insulin - 7:30 a.m., 11:30 a.m., 4:30 p.m., 8:00 p.m.
Heparin - 8:00 a.m., 4:00 p.m., 12:00 a.m.

Further review of the MARs for Patient #8 revealed on 07/26/17 Rocephin 1 Gm/50 ml IV was scheduled to be administered at 8:00 p.m. but was circled, indicating it was not administered. Review of the physician's ordered dated 07/24/17 revealed the Rocephin was to be administered once daily for 7 days.

In an interview on 08/02/17 at 10:00 a.m. S3DON/Gr reviewed the patient's record and was unable to explain why there was no MAR for 07/21/17 and why the above prescribed medications were not administered on 7/21/17. After reviewing the MAR for 07/26/17 she confirmed there was no documentation that the Rocephin was administered to the patient that day.

In an interview on 08/04/17 at 12:45 p.m., S2DON confirmed he was aware of the medication error for Patient #8 when the Rocephin was not administered at 8:00 p.m. on 07/26/17. S2DON stated he worked as staff the following day and knew the medication was not given at 8:00 p.m. S2DON confirmed he did not document an incident report or investigate what happened. S2DON stated he did talk to the nurse about why the medication was missed and the nurse indicated she was not sure if the patient had received the medication at the other campus. S2DON stated the nurse should have checked with the other campus. When asked what the system was for identifying medication errors, he confirmed they relied on self-reporting.

Based on record reviews and interview, the hospital failed to ensure all patient medical record entries were legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided as evidenced by failure to have the physician or LIP that dictated the H&P sign/date/time the H&P for 5 of 5 (#10, #11, #12, #14, #20) patient records reviewed for H&Ps from a total sample of 30 patients medical records.

Findings:

Review of the Medical Staff Bylaws presented as the current medical staff rules and regulations revealed: All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures....H&P, Discharge summaries and all orders for Schedule IV medications written by dependent, credentialed AHP's must be countersigned by the supervising physician.

Patient #10
A review of the medical record for Patient #10 revealed the current patient was a 53 year old female admitted to the hospital on 07/07/17 with a diagnosis of bilateral lower extremity paralysis, status post lumbar fusion. A review of the patient's H&P revealed an H&P was dictated by S25NP on 07/08/17. A further review of the medical record on 08/01/17 revealed the H&P had not been authenticated by S25NP. The H&P had only been co-signed by S26MD/Dir on 07/10/17.

Patient #11
Review of the medical record for Patient #11 revealed the patient was a 69 year old admitted to the hospital on 07/24/17 with a diagnosis of Late Effects of CVA with Left Sided Paresis.
Review of the H&P revealed S33NP dictated the H&P on 07/25/17 at 9:07 a.m. and the H&P was transcribed on 07/25/17 at 11:34 a.m. There was no documented evidence that S33NP had signed/dated/timed the H&P. The H&P revealed only the co-signed signature of S26MD/Dir.


Patient #12
Review of the medical record for Patient #12 revealed the patient was a 76 year old admitted to the hospital on 07/20/17 at 5:55 p.m. with a diagnosis of Ischemic Encephalopathy.
Review of the H&P revealed S33NP dictated the H&P on 07/21/17 at 6:20 p.m. and the H&P was transcribed on 07/23/17 at 6:58 p.m. There was no documented evidence that S33NP had signed/dated/timed the H&P. The H&P revealed only the co-signed signature of S26MD/Dir.

In an interview on 08/02/17 at 11:42 a.m. S3DON/Gr reviewed the medical record for Patient #12 and confirmed the H&P was not signed by S33NP who had dictated the H&P.

In an interview on 08/02/17 at 11:55 a.m., S9HIM confirmed S33NP had dictated the H&P but had not dated/time/signed the H&P. She stated she did not think the person dictating the H&P had to sign it as long as the physician cosigned it.


Patient #14
Review of the medical record for Patient #14 revealed the patient was a 77 year old admitted to the hospital on 07/16/17 with a diagnosis of Late Effects of CVA.
Review of the H&P revealed S35MD dictated the H&P on 07/17/17 at 12:45 a.m. There was no documented evidence that S35MD had signed/dated/timed the H&P. The H&P was co-signed only by S26MD/Dir.


Patient #20
Review of the medical record for Patient #20 revealed the patient was a 77 year old admitted to the hospital on 05/19/17 at 2:30 p.m. with a diagnosis of Late Effects of Hemorrhagic Stroke.
Review of the H&P revealed S34NP dictated the H&P on 05/20/17 at 11:39 a.m. There was no documented evidence that S34NP had signed/dated/timed the H&P. The H&P was co-signed only by S26MD/Dir.

In an interview on 08/02/17 at 11:55 a.m., S9HIM confirmed the above patients' H&Ps were not signed by the physician or nurse practitioner that dictated it.




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Based on observation and interview, the hospital failed to ensure unusable, expired, and opened, undated multidose IV fluids and topical antiseptics/disinfectants were unavailable for patient use. This deficient practice was evidenced by having unlabeled, opened insulin vials, IV fluids, expired 0.9% Normal Saline bottles (used for irrigation and suctioning), and opened, unlabeled topical antiseptics/disinfectants available for patient use in the hospital's medication room.

Findings:

On 08/01/17 from 10:49 a.m. to 11:15 a.m. an observation was conducted of the hospital's medication room. The following findings were identified during the observation:

2-16 ounce bottles of opened Hydrogen Peroxide, unlabeled with date and time of opening.;
1-4 ml bottle of Betadine solution, opened, unlabeled with date and time of opening, expired in 6/2017;
16 foil covered bottles of 0.9% Normal Saline used for irrigation and suction, expired 4/2017;
1-1000 ml bag of 0.9% Normal Saline spiked and unlabeled with date and time of opening.

The above referenced findings were confirmed by S2DON during observation. S2DON also confirmed the above referenced expired and opened, unlabeled items should have not been available for patient use.

On 08/03/17 at 12:45 p.m. an observation was made of the medication refrigerator in the medication room at the main campus with S2DON. An opened vial of Novolin N insulin was observed in the refrigerator. The opened vial was not dated with a date the vial was opened. S2DON confirmed the observation and stated the vials were to be dated when they were first opened.

Based on occurrence report reviews, record review, and staff interview, the hospital failed to ensure medication administration errors were documented in the patients' medical records and reported to the attending physician as evidenced by:
1) failing to ensure known medication errors were documented in the patients medical record for 3 of 3 (#20, #21, #22) sampled patients reviewed with known medication errors out of a total sample of 30, and;
2) failing to document an incident report and notify the physician of a medication error for 1 of 1 (#8) current sampled patients with a medication error out of a total sample of 30.

Findings:

1) Failing to ensure known medication errors were documented in the patients medical record:

Review of the hospital policy titled Medication Administration - Medication Errors, policy number MED.ADMIN.11 revealed in part the following: Medication errors shall be reported in a timely manner to the practitioner who ordered the medication....The medication administered in error or omitted in error and the action taken shall be properly recorded in the patient's medical record. The entry in the patient's medical record need not indicate that an error occurred. The person who discovers the error (or other person designated by the individual in charge) shall prepare a medication error report on the facility's approved form....


Patient #20
Review of the incident report dated 06/03/17 revealed Patient #20 received 21 doses of the wrong dose of Keppra (Medication used to treat seizures) from 05/22/17 to 06/03/17. The incident report revealed the order for the Keppra had been clarified on 05/19/17 as 500 mg twice a day, but the pharmacy did not change the dose in the automated medication dispensing system or on the MAR. The incident report also revealed the nurses performing the 24 hour chart checks did not correct the dose on the MAR. The incident report revealed the patient received Keppra 1500 mg twice a day from 05/22/17 to 06/03/17. Further review of the incident report revealed the physician was notified of the medication error but there was no documentation of the date or time the physician was notified.

Review of the medical record for Patient #20 revealed the patient was a 77 year old admitted to the hospital on 05/19/17 with a diagnosis of CVA. Review of the record revealed no documented evidence of the medication error in the record. Review of the MARs from 05/22/17 to 06/03/17 revealed the patient had received 1500 mg. of Keppra twice a day and only 500 mg. twice a day was ordered by the physician on 05/19/17.

In an interview on 08/03/17 at 12:20 p.m., S2DON reviewed the incident reports and the medical record for Patient #20 and confirmed there was no documentation in the medical record of the medication error and there was no documented evidence that the physician was notified of the error in the medical record. He confirmed there was no date or time the physician was notified on the incident report. He confirmed Patient #20 received the wrong dose of Keppra for 21 doses and stated,"everyone was written up over that." S2DON confirmed the dose was not changed on the MAR and should have been caught by nursing and pharmacy.


Patient #21
Review of the incident report dated 02/16/17 at 8:00 a.m. revealed Patient #21 was found with 3 Fentanyl patches dated 02/07/17, 02/20/17, and 02/13/17 still on the patient. The incident report indicated all the patches were removed and a new patch applied. Further review of the incident report revealed the section for notification of the attending physician was left blank.

Review of the medical record for Patient #21 revealed the patient was a 59 year old admitted to the hospital on 02/03/17 with a diagnosis of Bilateral Knee Replacements. Review of the record revealed no documented evidence that the medication error was documented in the record and there was no documented evidence that the physician was notified.

In an interview on 08/03/17 at 12:30 p.m., S2DON reviewed the medical record for Patient #21 and confirmed there was no documentation in the patient's medical record of the medication error, nor was there documentation that the physician was notified of the error.


Patient #22
Review of the incident report dated 02/27/17 at 8:00 p.m., Patient #22 was administered Patient #R1's evening medications by mistake. The incident report revealed Patient #22 received the following medication in error:
Singulair 10 mg, MS Contin ER (Morphine) 30 mg, and Trazodone 50 mg. Further review of the incident report revealed S26MD/Dir was notified but there was no date/time of the notification. The incident report revealed, "Patient was watched closely, and can give Narcan if need. Patient rested the whole night with no problems. Vital signs stayed stable."

Review of the medical record for Patient #22 revealed the patient was a 65 year old admitted to the hospital on 02/23/17 with a diagnosis of CVA. Review of the record revealed no documentation of the medication error or that the physician was notified.

In an interview on 08/03/17 at 12:40 p.m., S2DON reviewed the medical record for Patient #22 and the incident report dated 02/27/17 and confirmed the medication error and the physician notification was not documented in the patient's record.



2) Failing to document an incident report and notify the physician of a medication error:

Review of the hospital policy titled Incident Reports revealed in part the following: An incident report should be completed immediately when an incident occurs....The following are some instances when an incident report would be completed and forwarded to the Director of Nursing: medication errors.

Patient #8
Review of the medical record for current Patient #8 revealed the patient was an 87 year old admitted to the hospital on 07/21/17 at 2:56 p.m. with a diagnosis of CVA.

Review of the physician orders dated 07/24/17 revealed Rocephin 1 Gm/50 ML IV was ordered once daily for 7 days.

Review of the MARs for Patient #8 revealed on 07/26/17 Rocephin 1 Gm/50 ml IV was scheduled to be administered at 8:00 p.m. but was circled, indicating it was not administered.

Review of the hospital incident reports revealed no documented evidence of an incident report for omitted medication on 7/26/17.

In an interview on 08/04/17 at 12:45 p.m., S2DON confirmed he was aware of the medication error for Patient #8 when the Rocephin was not administered at 8:00 p.m. on 07/26/17. S2DON stated he worked as staff the following day and knew the medication was not given at 8:00 p.m. S2DON confirmed he did not document an incident report or investigate what happened. S2DON stated he did talk to the nurse about why the medication was missed and the nurse indicated she was not sure if the patient had received the medication at the other campus. S2DON stated the nurse should have checked with the other campus. When asked what the system was for identifying medication errors, he confirmed they relied on self-reporting. S2DON confirmed an incident report should have been completed for the medication error.

30984


Based on observation and interview, the hospital failed to ensure all equipment was maintained to ensure an acceptable level of safety and quality as evidenced by 8 of the 20 patient beds at the hospital's main campus and 1 of 21 patient beds at the hospital's offsite having an emergency call button on the side rail that was not functional.

Findings:

Main Campus:
In an observation on 08/01/17 at 10:50 a.m. with S5CIC revealed bed number 405 had a nurse call button in the side rail of the bed (white cross inside red square on the side rail). When pressed, this call button did not function. S36WC entered the room and confirmed some of the beds had nurse call buttons in the side rails, but none of the nurse call buttons in the side rails were functional. S36WC stated they only use the call lights on the cord.
Observation of bed 409 revealed a nurse call button in the side rail of the bed that was non-functional.
Observation of bed 412 and bed 417 revealed a nurse call button in the side rail of the bed that was non-functional.

In an interview on 08/01/17 at 11:25 a.m. S5CIC confirmed the above findings. S5CIC was asked to provide a list of beds with the call light in the side rails. S5CIC confirmed none of the call lights in the side rails were functional because they were not programmed to work.

In an interview on 08/01/17 at 4:42 p.m., S2DON was asked about the list of beds with call buttons in the side rails that was requested earlier. S2DON confirmed none of the beds in the hospital that had a call button in the side rails were functional. He stated there was no system to enable those call buttons to work. He confirmed he could understand that a confused patient or a family not present for the staff education on the use of the call cord could mistake the call button on the side rail for a functioning emergency call device.

In an interview on 08/02/17 at 10:20 a.m., S3DON/Gr provided a list of beds that had nurse call buttons in the side rails and confirmed 8 of the hospital's beds currently in use had a non-functional call button in the side rails of the beds.


Offsite campus:
In an observation on 08/02/17 at 9:50 a.m., 1 of the 21 beds at the hospital had an emergency call feature on the side rail indicating it could be pushed in an emergency to call staff. Further review revealed the button did not work when pushed.

In an interview on 08/02/17 at 9:50 a.m. with S2DON, he verified, by pushing the emergency call feature button on the bed's siderail, that the side rail emergency call feature was non-functional. S2DON indicated patients were instructed to use the corded call button, but acknowledged a confused patient may mistake the call bell on the side rail for a functioning emergency call device.

30172


Based on record review, observation, and interview, the hospital failed to ensure the Infection Control officer developed a system for investigating and monitoring infection control practices and breaches as evidenced by:
1) failing to ensure the contracted dialysis nurses adhered to the dialysis machine's cleaning policy,
2) failing to ensure that staff adhered to the MFU's EPA disinfection protocols when cleaning/disinfecting of the patient multiple-use glucometer,
3) failing to ensure that staff adhered to acceptable hand hygiene practices during patient care procedures when removing gloves, and
4) failing to maintain a sanitary environment.


Findings:
1) failing to ensure the contracted dialysis nurses adhered to the dialysis machine's cleaning policy,

A review of the hospital policy titled, "Dialysis", as provided by S5CIC, revealed in part: Daily Cleaning- Dialysis machines are chemically disinfected (bleach solution) between each patient use.

An observation and record review on 08/02/17 of Dialysis Machine #12's binder indicated that it was on loan from an acute care hospital for use on a dialysis patient at the Rehab hospital. Dialysis Machine #12's binder documented that the machine was last disinfected on 07/31/17. An observation on 08/02/17 revealed that Dialysis Machine #12 had visibly dusty sediment on it. Dialysis Machine #12 was used for a patient's dialysis needs on 08/02/17 after the above observation.

In an observation on 08/02/17 at 2:30 p.m. of S29RN/Dialysis, she was observed setting up Dialysis Machine #12 in the Dialysis area without cleaning the machine of the visibly dusty sediment.

An observation on 08/02/17 of the hospital's Dialysis Machine #15 that was stored in the locked storage area and prior to it being removed from the storage area for a patient use was observed to have visibly dusty sediment on it and water was noted on the bottom metal shelf. Dialysis Machine #15's binder documented that the machine was last disinfected on 07/31/17. Dialysis Machine #15 was used for a patient's dialysis needs on 08/02/17 after the above observation.

In an observation on 08/03/17 of Dialysis Machine #12 and Dialysis Machine #15, after they were both used for patients' dialysis needs on 08/02/17, revealed the visibly dusty sediment was still present on both machines. A review of the cleaning binders for Dialysis Machine #12 and Dialysis Machine #15 revealed that they were not documented as being disinfected on 08/02/17 prior to patient use or after patient use on 08/02/17.

In an interview and an observation on 08/03/17 at 10:00 a.m. with S5CIC she observed the visibly dusty sediment on both Dialysis Machines. She indicated that the contracted Dialysis nurses were not adhering to the Dialysis Machine's daily cleaning (disinfection) policy after patient use.


2) failing to ensure that staff adhered to the MFU's EPA disinfection protocols when cleaning/disinfecting of the patient multiple-use glucometer,

A review of the MFU on the disinfecting of the glucometer after patient use revealed in part: The glucometer should be disinfected with an approved EPA disinfectant as listed by the manufacturer.

A review of the hospital policy titled "Equipment Clean", as provided by S5CIC as the most current, revealed in part: Multi use equipment such as glucometers will be cleaned with a disinfectant wipe between patient use.

In an observation on 08/02/17 at 11:30 a.m. of S17LPN disinfecting the glucometer after patient use, she was observed disinfecting the glucometer with an alcohol pad only.

In an interview on 08/03/17 at 5:15 p.m. with S5CIC she was made aware of the observation of the glucometer cleaning by staff. S5CIC indicated that staff did not follow the hospital's policy on glucometer cleaning after patient use.


3) failing to ensure that staff adhered to acceptable hand hygiene practices during patient care procedures when removing gloves,

In an observation on 08/02/17 at 11:30 a.m. of S17LPN performing an accucheck and in preparing an insulin injection for a patient, she was observed removing her soiled gloves several times and was not observed sanitizing her hands each time.

In an interview on 08/03/17 at 4:15 p.m. with S5CIC she indicated that staff did not follow the hospital's infection control policy for sanitizing their hands each time after removing of gloves.


4) failing to maintain a sanitary environment.

On 08/01/17 at 10:50 a.m. observations of the patient rooms were made with S5CIC and revealed the following:
Room/bed 404: The foot of the bed was observed to have signage indicating the bed was cleaned on 07/28/17. The overbed table was observed to have missing covering along the entire front edge, and covering lifted in places on the edge without a handle. S5CIC confirmed the overbed table did not have smooth wipe able surface for disinfection.
Room/bed 405: The bedside table/cabinet was observed to have a triangle shaped area of the left corner with exposed wood or particle board with sharp edges. The cabinet was observed to have a label partially peeling off with a sticky surface. S5CIC confirmed the observations.
Room/bed 408: The light fixture over the head of the bed was observed to have tape and tape residue and peeling labels on the front. S19CNA who was present in the room at this time stated the front of both lights was missing. Tape was noted on the bedside table. S5CIC confirmed the observations.
Room/bed 409: The light fixture over the head of the bed was observed to have tape and tape residue and peeling labels on the front. Tape was observed on bathroom door latch and door frame. The findings were confirmed by S5CIC at the time of the observation.
Room/bed 412: Tape was observed on the foot of the bed.
Room/bed 413: Signage attached to the foot of the bed indicated the room was cleaned on 07/19/17. There was tape residue observed on the left side rail.
Room/bed 414: The corner of bed side table was observed to have exposed wood and sharp edges.
Room/bed 416: Tape residue was observed on the left side rail of the bed.
Room/bed 417: The corner of the bed side table was observed to have exposed wood or particle board with sharp edges.
Room/bed 418: Signage attached to the foot of the bed indicated the room was cleaned on 07/26/17. A white substance in a drip pattern was observed in the corner of room from the ceiling down the wall. Tape was observed on the light over the head of the bed.
Room/bed 419: Signage on the foot of the bed indicated the bed was cleaned on 07/14/17. The corner of the bed side table was observed to have exposed wood/particle board with sharp edges. Tape was observed on the bathroom door. S5CIC confirmed all of the above findings at the time of the observation.

An observation on 08/01/17 of the hospital's Gym Therapy Area revealed rust on the floor by the window where the therapy metal weights, used during patient therapy, were stored.

In an interview on 08/01/17 at 11:30 a.m. with S21Therapy he indicated that the metal weights were probably placed on the floor before the floor was completely dry after the floors were mopped by the housekeeper or it might be a moisture issue by the window.

An observation on 08/01/17 at 12:30 p.m. of the ADL shower room revealed dusty bathroom counters and the shower floor's non-slip rubber round pads were peeling up in several spots.

In an interview on 08/01/17 at 12:30 p.m. with S21Therapy he indicated that only the part of the shower room that was used by patients was cleaned and that the other half of the room by the bathroom counters were not used so it was not routinely cleaned.

In an interview on 08/01/17 at 12:30 p.m. with S5CIC she indicated that the shower floor was unable to be disinfected properly due to the peeling non-slip rubber pads and that the entire ADL room should be cleaned/disinfected after patient use.