HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiologic Services as evidenced by:

1) Failing 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 by Company A. (see findings in tag A-0535)

2) Failing to ensure there was a radiologist who was a member of the medical staff and supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis. (see findings in tag A-0546)

Based on observations, record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Infection Control as evidenced by:


1) Failing to ensure the infection control officers developed an effective system that included identification, reporting, investigation, and controlling of infections and communicable diseases of patients and personnel, as evidenced by failing to implement correct isolation precautions; failing to maintain a sanitary environment; failing to ensure physicians and employees had annual TB skin test, and failing to ensure the hospital's policy for cleaning multiple patient used glucose monitors followed CDC (Center for Disease Control) guidelines and failing to ensure the glucose monitors were cleaned appropriately between patients (see findings at A-749).

2) Failing to ensure the hospital-wide quality assessment and performance improvement (QAPI) program addressed infection control problems and implemented successful corrective actions plans as evidenced by failing to conduct effective infection control surveillance of the hospital environment, collect data, track and trend and develop corrective actions plans resulting in observed infection control breeches (see findings at A-756).

Based on record review and interview, the facility failed to ensure less restrictive interventions were documented before the use of restraints for 1 (#11) of 2 (#10, #11) patients reviewed for restraint use.
Findings:
Review of the hospital policy titled Restraint or Seclusion, policy number: 9-3.4.0, revealed in part:
Purpose: To define the correct use of restraints or seclusion while ensuring patient rights.
Restraint or seclusion will be implemented only when less restrictive interventions have been determined to be ineffective.
Alternative Record - The following will be implemented by a RN (registered nurse) prior to the use of restraint or seclusion:
1. Alternatives (less restrictive interventions) will be considered prior to each episode of restraint or seclusion and with each renewal order. The patient's response to each alternative that is tried will be documented on the Alternative Record. The RN considering and/or attempting alternatives will complete the form indicating each intervention.
2. There will be documentation in the medical record to explain the rationale for use of restraint or seclusion including documentation that less restrictive measures were attempted before restraint or seclusion was implemented and failed.

Review of the documentation for Patient #11 revealed he was in bilateral wrist restraints on 8/28/14, 8/29/14, 8/31/14, 9/1/14 and 9/2/14. Further review of the medical record for Patient #11 revealed no documentation to indicate that less restrictive interventions were attempted prior to the initiation of restraints on 9/1/14 and 9/2/14.
In an interview on 11/6/14 at 3:28 p.m. with S2ADON, she was unable to locate any less restrictive interventions documented prior to Patient #11 being placed in restraints on 9/1/14 and 9/2/14.

Based on interview and record review, the hospital failed to ensure the use of restraint was in accordance with safe and appropriate restraint and seclusion techniques as per hospital policies and procedures for 1 (#11) of 2 (#10, #11) patients reviewed for restraints. This deficient practice is evidenced by:
1) failing to ensure registered nurses obtained telephone orders for restraints;
2) failing to ensure patients placed in restraints for violent or self-destructive behaviors received vital sign assessments every 2 hours and monitoring by staff every 15 minutes.

Findings:
1) Failing to ensure registered nurses obtained telephone orders for restraints.

Review of the hospital policy titled Restraint or Seclusion, policy number: 9-3.4.0, revealed in part:
Purpose: To define the correct use of restraints or seclusion while ensuring patient rights.
Only a RN may take phone/verbal orders for restraint or seclusion.

Review of the documentation for Patient #11 titled Physicians Order for Restraints for Non-Violent or Non-Self-Destructive Behavior revealed the order had been taken as a telephone order by a LPN on 9/1/14 at 7:00 p.m. and 9/2/14 at 5:00 a.m.

In an interview on 11/6/14 at 3:28 p.m. with S2ADON, she said a Registered Nurse should have obtained all telephone orders for patients' restraints.

2) Failing to ensure patients placed in restraints for violent or self-destructive behaviors received vital sign assessments every 2 hours and monitoring by staff every 15 minutes.

Review of the hospital policy titled Restraint or Seclusion, policy number: 9-3.4.0, revealed in part:
Purpose: To define the correct use of restraints or seclusion while ensuring patient rights.
Orders for the management of violent or self-destructive behaviors will be written to include: the type of restraint or seclusion; the maximum time limit for the restraint or seclusion; the clinical justification for the restraint or seclusion.
Monitoring of the patient for violent or self-destructive behavior will include the following: Vital signs every 2 hours, mental status every 15 minutes, skin integrity every 15 minutes, hygiene/elimination every 15 minutes, circulation checks every 15 minutes, hydration/nourishment every 15 minutes.

Review of the documents for Patient #11 titled Restraint or Seclusion: Less Restrictive Interventions revealed the following:
8/28/14 (not timed) - Clinical Justification for Restraint or Seclusion: Manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others. Explain: Tries to get out of bed, spits at staff when staff goes near patient.
8/31/14 at 2:45 a.m. - Clinical Justification for Restraint or Seclusion: Manage violent or self- destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others. Explain: Pt (patient) hitting, kicking, jumping out of bed, cursing, spitting at staff.

Review of the Restraint Records for Patient #11 dated 8/28/14 and 8/31/14 revealed she had vital signs taken every 4 hours and monitoring every 1 hour while in restraints.

In an interview on 11/6/14 at 3:28 p.m. with S2ADON, she verified the vital signs and monitoring of Patient #11 had not been completed as per policy for violent or self-destructive behavior. S2DON also said the hospital did not have a flow sheet for documenting vitals every hour or monitoring every 15 minutes for violent or self-destructive behavior, so they always used the flow sheet for non-violent or non-self-destructive behaviors. S2ADON verified the flow sheet for non-violent behaviors provided documentation for vital signs every 4 hours and monitoring every 1 hour.

Based on record review and interview, the hospital failed to ensure each order for restraint for the management of violent or self-destructive behavior was renewed every 4 hours for an adult older than 18 years of age for 1 (#11) of 2 (#10, #11) patients reviewed for restraint use.
Findings:

Review of the hospital policy titled Restraint or Seclusion, policy number: 9-3.4.0, revealed in part:
Purpose: To define the correct use of restraints or seclusion while ensuring patient rights.
Orders for the management of violent or self-destructive behaviors will be written to include: the type of restraint or seclusion; the maximum time limit for the restraint or seclusion; the clinical justification for the restraint or seclusion.
Each order for restraint or seclusion for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others, may only be renewed according to the following limits for up to total of 24 hours: 4 hours for adults 18 years of age and older.

Review of the documents for Patient #11 titled Restraint or Seclusion: Less Restrictive Interventions revealed the following:
8/28/14 (not timed) - Clinical Justification for Restraint or Seclusion: Manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others. Explain: Tries to get out of bed, spits at staff when staff goes near patient.
8/31/14 at 2:45 a.m. - Clinical Justification for Restraint or Seclusion: Manage violent or self- destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others. Explain: Pt (patient) hitting, kicking, jumping out of bed, cursing, and spitting at staff.

Review of the medical record for Patient #11 revealed orders for restraints on the following dates and times: 8/28/14 at 6:30 p.m., 8/29/14 at 12:00 p.m., 8/31/14 at 02:45 a.m., 8/31/14 at 1:00 p.m., 9/1/14 at 7:00 p.m., and 9/2/14 at 5:00 a.m.

In an interview on 11/6/14 at 3:28 p.m. with S2ADON, she verified the staff documented Patient #11 had restraints for violent behaviors, but did not obtain a new order every 4 hours.

Based on record review and interview, the hospital failed to ensure a 1 hour face-to-face medical and behavioral evaluation was performed by a physician, licensed independent practitioner, or a trained registered nurse for a patient placed in restraints for the management of violent or self-destructive behavior for 1 (#11) of 2 (#10, #11) patients reviewed for restraint use.

Findings:

Review of the hospital policy titled Restraint or Seclusion, policy number: 9-3.4.0, revealed in part:
Purpose: To define the correct use of restraints or seclusion while ensuring patient rights.
The patient should be assessed face-to face within one hour after the initiation of the restraint or seclusion for the management of violent or self-destructive behavior by a physician/LIP or a RN or PA who has received training through the Crisis Prevention Institute.
Documentation in the medical record will include: The one hour face-to-face evaluation of the patient's behavioral and medical condition if restraint or seclusion is used to manage violent or self-destructive behavior.

Review of the documents for Patient #11 titled Restraint or Seclusion: Less Restrictive Interventions revealed the following:
8/28/14 (not timed) - Clinical Justification for Restraint or Seclusion: Manage violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others. Explain: Tries to get out of bed, spits at staff when staff goes near patient.
8/31/14 at 2:45 a.m. - Clinical Justification for Restraint or Seclusion: Manage violent or self- destructive behavior that jeopardizes the immediate physical safety of the patient, staff or others. Explain: Pt (patient) hitting, kicking, jumping out of bed, cursing, and spitting at staff.

Review of the medical record for Patient #11 revealed no documentation of a 1 hour face-to-face evaluation by a physician, licensed independent practitioner (LIP), or a trained registered nurse after he was placed in restraints on 8/28/14 or 8/31/14 for violent behaviors.

In an interview on 11/7/14 at 3:43 p.m. with S2DON, she verified none of the registered nurses had training in crisis prevention intervention. S2ADON also verified neither a physician nor a LIP assessed Patient #11 within 1 hour of being placed in restraints on 8/28/14 and 8/31/14.

Based on record review and staff interview, the hospital failed to ensure the QAPI program:
1) Used data collected to identify opportunities for improvement and changes that would lead to improvement as evidenced by failing to develop new corrective actions related to identified deficiencies in medical records after the same corrective action was unsuccessful, and;
2) Set priorities for performance improvement that focused on high-risk, high volume, or problem-prone activities as evidenced by the quality indicators selected at the corporate level.

Findings:

Review of the hospital's policy titled, Performance Improvement Plan, Policy Number 1-6.7.0, dated 03/01/14, revealed in part the following: The primary goal of the Performance Improvement Plan is to continually and systematically plan design measure assess and improve performance of hospital-wide key functions and processes relative to patient care....5. Assure that the improvement process is organization-wide, assessing and evaluating the quality and appropriateness of patient care and clinical performance to identify changes that will lead to improved performance and reduce the risk of sentinel events. Corrective actions are taken and evaluated when problems or improvement opportunities are identified....Important key aspects and processes of care to the health and safety of patients are identified. Included are those that occur frequently or affect large numbers of patients; place patients at risk of serious consequences of deprivation of substantial benefit if care is not provided correctly or not provided when indicated, those tending to produce problems for patients, their families or staff, and those that may lead to sentinel events.


1) Used data collected to identify opportunities for improvement and changes that would lead to improvement as evidenced by failing to develop new corrective actions related to identified deficiencies in medical records after the same corrective action was unsuccessful:

Review of the medical records for Patients #1, #3, #4, #5, and #7 revealed physician orders that were not timed and verbal orders that were not authenticated in accordance with the medical staff bylaws.

The quality indicator of Verbal Orders Within 10 Days was reviewed and revealed the following for the first 3 quarters of 2014: Score: .70, Target Value: .90

Review of the Performance Improvement/Corrective Action Report revealed the following:
Indicator: Verbal Orders written within 10 days
Action Plan: Nursing Charge Nurse, DON, ADON, and Case Management will continue to remind MDs to look for and sign verbal order daily.
Corrective Action Taken: Nursing Charge Nurse, DON, ADON, and Case Management will continue to remind MDs to look for and sign verbal order daily.
Evaluation of Actions Taken: Will monitor and report findings at next meeting.

In an interview on 11/07/14 at 9:30 a.m., S1DON confirmed he was responsible for the Hospital's QAPI. S1DON confirmed the indicator for authentication of verbal orders had not been met all year. S1DON stated the staff aggressively remind the physicians to sign/date/time their orders. S1DON confirmed the only corrective action implemented to address dating/timing/authentication of physicians orders was reminding the physician to sign them. S1DON stated he did not know of any other interventions to address this issue. S1DON confirmed the interventions had not been effective.

2) Set priorities for performance improvement that focused on high-risk, high volume, or problem-prone activities as evidenced by the quality indicators selected at the corporate level.

On 11/07/14 at 9:30 a.m., the hospital's QAPI program was reviewed with S1DON who indicated he was responsible for the hospital's QAPI program. When asked if the quality indicators being monitored were based high-risk, high volume or problem prone activities, S1DON stated the hospital's corporate office chose the quality indicators the hospital was to monitor. S1DON indicated he attended corporate meetings for QAPI and could give input then, but the quality indicators were chose at the corporate level and were the same for all the corporation's hospitals. S1DON stated there were no quality indicators specific or individual to this hospital.

Based on record review and staff interview, the hospital failed to ensure the QAPI program identified, analyzed, and implemented preventative actions for medication errors, and the QAPI program failed to establish clear expectations for safety related to infection control surveillance and implementation of corrective actions. This was evidenced by:
1) failing to identify medication errors for 2 (#6, #30) of 7 (#2, #3, #4, #6, #7, #18, #30) sampled patients reviewed for medication administration;
2) failing to document an analysis of the causative factors of medication errors;
3) failing to implement preventative actions for medication errors other than counsel the staff involved, and;
4) failing to conduct infection control surveillance of the hospital environment, collect data, track and trend and develop corrective actions plans resulting in observed infection control breeches.

Findings:
Review of the hospital's policy titled, Performance Improvement Plan, Policy Number 1-6.7.0, dated 03/01/14, revealed in part the following: The Governing Board ensures the Performance Improvement Plan reflects the complexity of the Hospital's services, includes all Hospital departments and campuses including contract service, and focuses on indicators related to improved health outcomes, the prevention and reduction of medical errors and corrective actions as indicated....The primary goal of the Performance Improvement Plan is to continually and systematically plan design measure assess and improve performance if hospital-wide key functions and processes relative to patient care....5. Assure that the improvement process is organization-wide, assessing and evaluating the quality and appropriateness of patient care and clinical performance to identify changes that will lead to improved performance and reduce the risk of sentinel events. Corrective actions are taken and evaluated when problems or improvement opportunities are identified..... Scope of Activities.. The scope of Performance Improvement Program includes performance of the following medical staff functions:....Sentinel Event Monitoring, a. Identify medical errors and adverse events, Infection Control.



1) Failing to identify medication errors for 2 (#6, #30) of 7 (#2, #3, #4, #6, #7, #18, #30) sampled patients reviewed for medication administration:
Patient #6
Review of Patient #6's medical record revealed he was admitted to the hospital on 10/13/14 with an admitting diagnoses of: Dehydration, Stage 4 Decubitus, Stage 3 foot decubitus, Uncontrolled DM (Diabetes Mellitus), Ulcer of the scrotum, Osteomyelitis, Paraplegia and UTI (Urinary Tract Infection). Review of the physician's order for Patient #2 revealed an order for D50W 25 ml (milliliters) (12.5) g (Gram) IV (Intravenous) push.

Review of the MARs (Medication Administration Records) for Patient #6 revealed that on 10/24/14 at 0650 "D5W (Dextrose 5%) one amp. (ampule) was administered by a staff RN ( initials listed). Continued review of the Nurses' Notes for Patient #6 revealed that on 10/24/14 at 0650 reads in part: "D5W 1 amp given per Nurse (name) will continue to monitor."

Review of the hospital's incident log revealed no documented evidence of the medication error for Patient #6 on 10/24/14.

In an interview on 11/06/14 at 10:45 a.m., S2ADON reviewed the MARs, Nurses Notes and Physician Orders and confirmed that on 10/24/14 Patient #6 was administered one ampule of D50W(Dextrose 50%) (50 ml) when only 25 ml had been ordered by the physician. S2ADON confirmed that a medication error had occurred and was discovered by the surveyor during record review.

Patient #30
Review of Patient #30 medical record revealed he was admitted to the hospital on 10/7/14 with the diagnoses of Sacral Decubitus Ulcer, Status Post Right Toe Amputation, Hypertension and Coronary Artery Disease. His physician orders revealed he was on Digoxin .125 mg (milligrams) oral daily.

Review of Patient #30's Medication Administration Records (MAR) revealed Digoxin (Lanoxin) .125 mg oral daily was listed with a reminder to record the patient's Apical Pulse on MAR, Hold if less than
Review of Patient #30's MAR revealed his apical pulse was not documented prior to administration of Digoxin from 11/4/14 to 10/20/14, a total of 15 days out of the 17 days the patient's MARs were reviewed.

Review of Patient #30's heart rate recorded on his vital sign sheet at 8 a.m on 11/4/14 revealed his heart rate was recorded as 57 beats per minute. Documentation on his MAR for 11/4/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 11/4/14.

Review of Patient #30's heart rate recorded on his vital sign sheet at 8 a.m on 10/29/14 revealed his heart rate was recorded as 47 beats per minute. Documentation on his MAR for 10/29/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 10/29/14.

Review of Patient #30's heart rate recorded on his vital sign sheet at 8 a.m on 10/28/14 revealed his heart rate was recorded as 53 beats per minute. Documentation on his MAR for 10/28/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 10/28/14.

Review of Patient #30's heart rate record on his vital sign sheet at 8 a.m on 10/27/14 revealed his heart rate was recorded as 59 beats per minute. Documentation on his MAR for 10/27/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 10/27/14.

Review of Patient #30's heart rate recorded on his vital sign sheet at 8 a.m on 10/25/14 revealed his heart rate was recorded as 60 beats per minute. Documentation on his MAR for 10/25/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 10/25/14.

Review of Patient #30's heart rate recorded on his vital sign sheet at 8 a.m on 10/24/14 revealed his heart rate was recorded as 56 beats per minute. Documentation on his MAR for 10/24/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 10/24/14.

Review of Patient #30's heart rate recorded on his vital sign sheet at 8 a.m. on 10/23/14 revealed his heart rate was recorded as 55 beats per minute. Documentation on his MAR for 10/23/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 10/23/14.

An interview was conducted with S1DON on 11/7/14 at 2:45 p.m. He verified the apical pulse was not documented prior to Patient #30 being administered Digoxin for 11/4/14 to 10/20/14. He also verified the patient's pulse was documented below 60 (57) beats per minute on the vital sign sheet for 11/4/14 and the nurse failed to document an apical pulse prior to the 9 a.m. of Digoxin administration on 11/4/14. S1DON reported the nurses are suppose to check the patient's apical pulse prior to administration, document the patient's apical pulse on the MAR, and notify the MD if the patient's apical pulse is equal and/or below 60 beats per minute.

2) Failing to document an analysis of the causative factors of medication errors:
Review of the Quality Indicator for Medication Errors revealed the data collection consisted of the number of medication errors, the date of the error, and the number of doses dispensed from the pharmacy. Review of the quarterly QAPI reports revealed the following number of medication errors for the year 2014 was 12 out of 323,575 doses dispensed by pharmacy. There was no documented evidence of any analysis of the causative factors related to the identified medication errors.

In an interview on 11/07/14 at 9:30 a.m., S1DON (Director of Nursing) verified he was responsible for the hospital's QAPI program. S1DON verified the hospital relied on self-reporting of medication errors. S1DON confirmed the hospital did not have a process of record review to identify medication errors. When asked for the analysis of the medication errors, S1DON was unable to provide any documentation of the analysis and stated he only had documentation of the number of errors. When asked if the hospital was accurately capturing the number of medication errors when only 12 errors had been identified out of 323,575 doses administered, S1DON stated he was unable to answer that.

3) Failing to implement preventative actions other than counsel the staff involved:
Review of the Quality Indicator for Medication Errors revealed the data collection consisted of the number of medication errors, the date of the error, and the number of doses dispensed from the pharmacy. Review of the quarterly QAPI reports revealed the following number of medication errors for the year 2014 was 12 out of 323,575 doses dispensed by pharmacy.

Review of the hospital's Performance Improvement/Corrective Action Report revealed no documented evidence of any corrective actions to address medication errors.

In an interview on 11/07/14 at 9:30 a.m., S1DON (Director of Nursing) verified he was responsible for the hospital's QAPI program. When asked for the analysis of the medication errors, S1DON was unable to provide any documentation of the analysis and stated he reviewed the error with the individual staff member only. S1DON confirmed there was no hospital wide corrective/preventative actions related to medication errors other than counseling the staff involved.

4) Failing to conduct infection control surveillance of the hospital environment, collect data, track and trend and develop corrective actions plans resulting in observed infection control breeches:

Review of the Quality Indicators monitored by the Hospital for 2014 revealed the following Infection Control/Housekeeping indicators:
Healthcare Associated GI (Gastro Intestinal) Infection
Employee TB compliance
TST (Tuberculin Skin Test) conversion
Room Cleanliness Compliance
Floor Maintenance Compliance
Housekeeping Infection Control Compliance

Review of the Quarterly Reports of Quality Indicator data collected revealed no documented evidence that any of the indicators were out of compliance except 1 employee TB test in the first quarter.

Review of the Methodology of data collection for Housekeeping services revealed surveillance of 10 random rooms per month would be conducted by administrative staff. The methodology revealed the following would be documented during the room visits:
Room cleanliness compliance - document if the rooms are in good condition in regards to the housekeeping department.
Floor maintenance compliance - document if the floors are cleaned and well maintained.
The methodology also indicated surveillance of the housekeeping staff with a minimum of 4 surveillance's per month was to be conducted and included proper use of PPE (Personal Protective Equipment), proper handling of trash and/or linen, proper cleaning of equipment after each use in an isolation room, changing dust/mop head, and hand hygiene.

Review of the the Performance Improvement/Corrective Action Report revealed there were no corrective action plans related to infection control or housekeeping. Further review of the QAPI records revealed no documented evidence of the housekeeping data collected.

In an interview on 11/07/14 at 9:30 a.m., S1DON (Director of Nursing) verified he was responsible for the hospital's QAPI program. S1DON also verified he conducted the surveillance of the patient rooms and housekeeping staff. S1DON stated he had done the room checks and he had missed the tape, tape adhesive, and unclean floors. S1DON further stated he had made observations of housekeeping staff, but had not identified any breeches. S1DON stated he had done the room visits and staff surveillance but did not document his observations and findings. S1DON was unable to provide any documentation of the the surveillance. S1DON further stated the the TB testing monitoring included the physicians and mid-level practitioners. S1DON confirmed the monitoring process had not identified the lack of TB testing for 7 of 8 physicians reviewed and 3 of 11 hospital staff reviewed.

Based on record review and staff interview, the hospital failed to ensure the performance improvement project conducted was specific to the hospital's scope and complexity of services and included documentation of the reasons for conducting the project. Findings:

Review of the hospital's Performance Improvement Plan, Policy Number 1-6.7.0, dated 03/01/14, revealed no documented evidence of any provisions for selecting and conducting performance improvement projects.

On 11/07/14 at 9:30 a.m., S1DON (Director of Nursing) provided documentation of the hospital's Quality Improvement Project for review.
Review of the documentation revealed in part the following: Medical Care Evaluation Study 2014. Subject: The following medical evaluation study will be conducted at (hospital) for the calendar year 2014.
Study Groups: Review of discharged Respiratory patients with the diagnosis of Pneumonia and/or CHF (Congestive Heart Failure). The purpose of this study is to promote the most efficient and effective use of available health facilities and services consistent with patient needs and professionally recognized standards of healthcare.
Format: Retrospective chart review will be conducted on a quarterly basis....
Data collection will be done by the Lead therapist (Respiratory) or designee using the attached spread sheet.

In an interview on 11/07/14 at 9:30 a.m., S1DON (Director of Nursing) verified he was responsible for the hospital's QAPI program. S1DON confirmed the Medical Care Evaluation Study for Pneumonia and CHF was the hospital's current PI project. S1DON stated the study was selected by the hospital's corporate office and was implemented at all the LTACs. S1DON confirmed the project was not chosen based on an identified problem or opportunity for improvement at this hospital. S1DON verified the quarterly audits had not identified any problems with Pneumonia/CHF and the audits had not identified any opportunities for improvement at this hospital. S1DON stated the corporate office picked different disciplines, "So we can hit all departments."

Based on record reviews and interview, the governing body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services including those services furnished under contract involved in the QAPI Program.
Findings:

Review of the hospital's policy titled, Performance Improvement Plan, Policy Number 1-6.7.0, dated 03/01/14, revealed in part the following: The Governing Board ensures the Performance Improvement Plan reflects the complexity of the Hospital's services, includes all Hospital departments and campuses including contract service, and focuses on indicators related to improved health outcomes, the prevention and reduction of medical errors and corrective actions as indicated.

Review of the QAPI monitoring provided for review revealed no documented evidence that the following contracted services were included in the QAPI program: Laboratory Services, Radiology Services, Biohazardous Waste Services, Linen/Laundry Services, Anesthesia Services, and Surgical Services.

In an interview on 11/07/14 at 10:30 a.m., S1DON stated he was responsible for the hospital's QAPI program. S1DON confirmed the hospital had contracted services of Laboratory Services, Radiology Services, Biohazardous Waste Services, Linen/Laundry Services, Anesthesia Services, Surgical Services and none of these services were monitored in the QAPI program.

Based on record review and interview the hospital failed to provided psychiatric consults for patients timely and in accordance to the hospital's policy for 2 (Patient #23, #26 ) out of 2 (Patient # 23, #26) patients reviewed for psychiatric consults out of a total sample of 30 patients(Patient #1-#30) Findings:

Review of the hospital policy for Documentation Completion and Time Frames, Policy Number: 5-3.8.0, revealed in part,"...Physician Health Record Completion Responsibilities:
Consultations: Time Frame 72 hours..."

Patient #23

Patient #23 was a 87 year old female admitted to the hospital on 10/16/14 for an Infected Left Hip Wound and a Sacral Decubitus Ulcer.

Review of the Physician Orders dated 10/21/14 at 0900 revealed an order for a Consult for Psychiatry Re: agitation/confusion.

Review of the Psychiatric Consult revealed the consult was conducted by S18Psychiatrist on 10/29/14 (8 days after the consulted was requested). The Psychiatric Diagnosis was listed as Dementia, mild with depressed mood. The recommendations revealed the following, "We will restart the patient on Lexapro in the morning and 5 at 3 p.m. We will discontinue Ativan order. We will use Xanax 0.25 mg prn (as needed) q (every) 8 hours for agitation. Hold Xanax if patient is sedated, hypertensive, or shows respiratory distress."

An interview was conducted with S3Adm on 11/7/14 at 11:15 a.m. He reported there was only one (1) psychiatrist in Kenner and sometimes it takes him a while to do a consult. S3Admin verified the consult took S18Psychiatrist 9 days to accomplish on Patient #23.

Patient #26

A review of the medical record for Patient #26 revealed he had been admitted on 10/17/14 for management of necrotizing fasciitis.

Review of the physician's orders for Patient #26 dated 10/28/14 at 6:01 a.m. revealed an order to consult psychiatry for Depression.

Review of a document titled Consultation Form revealed S18Psychiatrist's office had been consulted for a psychiatric consult on 10/28/14 at 3:50 p.m.

In an interview on 11/7/14 at 1:54 p.m. with S2ADON, she verified there had not been a psychiatric consult performed on Patient #26 since it was ordered on 10/28/14 (10 days earlier).


30364

Based on record review and interview the hospital failed to ensure the registered nurse supervised and evaluated the nursing care of each patient as evidenced by:
1. failing to notify the physician of a change in an EKG (Electrocardiogram) rhythm for Patient #25's EKG rhythm baseline for 1 (Patient #25) out 2 (Patient # 3 and #25) patient's EKG strips reviewed;
2. failing to ensure dialysis was administered as per physician's orders for 1 (#1) of 3 (#1, #3, #6) dialysis patients reviewed.

Findings:

1. Review of the hospital's policy on Cardiac Monitoring revealed in part, "Documentation- The cardiac rhythm displayed on the cardiac monitor will be documented on the Daily Nurses Notes each shift by the nurse completing the assessment. Any subsequent rhythm changes will be noted in the narrative notes...Notify the MD (Medical Doctor) for any of the following:
Any change from the patient's baseline rhythm;
Any new dysrhythmia;..."

Review of Patient #25's medical record revealed he was 67 year old male admitted to the hospital on 10/30/14 for Mitral Value Endocarditis secondary to Streptococcus in his blood culture. Patient #25 also had a history of Severe Coronary Artery Disease and Ischemic Cardiomyopathy.

Review of his Admission orders dated 10/30/14 revealed a physician's order for telemetry.

A review of Patient #25's EKG strips were done from 10/30/14 to 11/6/14 (2 EKG strips a day). Review of the EKG strip from 11/2/14 at 6 p.m. revealed the patient's EKG strip was read as the patient having PVCs (Premature Ventricular Contraction).

A review of the patient's medical chart was conducted with S2ADON on 11/7/14 at 1:30 p.m. The review conducted by the S2ADON revealed no evidence of notification of the patient's physician by the nurse or the telemetry technician. S2ADON confirmed the physician should have been notified because the patient's EKG rhythm was different from his baseline EKG strip. S2ADON reported S26Telemetry Technician reviewed the strip and documented the rhythm and the patient's nurse, S27RN, did not document in the medical chart if she was aware of the abnormal EKG.

2. Failing to ensure dialysis was administered as per physician's orders.

Review of the Physician's Routine Orders for Patient #1 dated 10/28/14 at 2:00 p.m. revealed an order for Hemodialysis every Monday, Wednesday and Friday using a 4K (Potassium) and 2.5 Ca (Calcium) bath with a dialysate flow rate of 600 ml/min.

Review of the Hemodialysis Flow Sheet for Patient #1 dated 10/29/14 revealed she had received dialysis from 1:40 p.m. until 4:45 p.m. Further observation revealed her dialysate flow rate was 500 during the treatment. No explanations were written for the altered flow rate.

Review of the Hemodialysis Flow Sheet for Patient #1 dated 11/3/14 revealed the bath administered was 3K and 2.5 Ca. No explanation was written for the altered Potassium.

In an interview on 11/7/14 at 10:10 a.m. with S17RN, she said the potassium is changed based on the patient's labs, but there should have been a physician's order written. S17RN also said she mistakenly ran the dialysate flow rate for Patient #1 at 500 instead of 600 on 10/29/14 because she thought it was another physician who usually has a rate of 500 managing Patient #1 instead of the physician that ordered a rate of 600.


30364

Based on record review and staff interview, 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 develop an individualized nursing care plan for patients' medical problems for 5 (#1, #2, #4, #6, #3) of 5 current patient care plans reviewed out of a total of 30 sampled patients (#1-#30).
Findings:

Patient #1
A review of the medical record for Patient #1 revealed she had been admitted on 10/23/14 with diagnosis including Acute Kidney Failure, End Stage Renal Disease, Diabetes Mellitus II (DM II), Hypertension, and Heart failure.

Review of the medical record revealed Patient #1 had a right subclavian catheter.

Review of the fall risk assessment for Patient #1 dated 10/23/14 revealed she had been given a score of 40 which was indicative of being high risk for falls.

Review of the care plans for Patient #1 revealed she had the problems identified of self-care deficit, impaired physical mobility, and potential for infection r/t (related to) indwelling urinary catheter. Further review revealed she had no care plans for hemodialysis, a right subclavian catheter, DM II, or being a fall risk.

Patient #2
Review of Patient #2's medical record revealed he was admitted to the hospital on 10/13/14 with an admitting diagnoses of: Dehydration, Stage 4 Decubitus, Stage 4 foot decubitus, Uncontrolled DM (Diabetes Mellitus), Ulcer of the scrotum, Osteomyelitis, Paraplegia and UTI (Urinary Tract Infection). Review of the physician orders revealed orders for insulin administration, sliding scale, foley catheter insertion, supra pubic catheter, consult for leaking constant leaking of supra pubic catheter, Psychology consult for agitation and order of IV (Intravenous)/IM (Intramuscular) medications for agitation.

Review of Patient #2's Plan of Care revealed health issues which addressed: Impaired Physical Mobility (Paraplegia), Risk for injury, Alteration in Comfort Pain and Potential for Infection. There was no documented evidence that Patient #2' nursing care plan included interventions for the supra pubic catheter, foley catheter (leaking), capillary blood sugars and behavioral monitoring.

Patient #4
Review of Patient #4's medical record revealed he was admitted to the hospital on 10/20/14 with admitting diagnoses of : Urinary Tract Infection (UTI), Large Cellulitis/Paniculitis/Leukocytosis, Severe Morbid Obesity with BMI (Body Mass Index) > (greater than) 70, Debility/Immobility and Urinary Retention.

Review of Patient #4's Plan of Care revealed health issues which addressed: Noncompliance (Actual), Risk for Injury, Impaired Physical Mobility, and. Activity Intolerance. There was no documented evidence that Patient #4's nursing care plan included interventions and goals related to his infection process, urinary or cellulitis.

In an interview with S2ADON on 11/6/14 at 2:15 p.m. She reported Patient #4's infection process related to his urinary tract infection and his cellulitis should have been included in his plan of care.

Patient # 6
Review of Patient #6's medical record revealed he was admitted to the hospital on 10/22/14 with admitting diagnoses of : Hyperglycemia, ESRD (End-Stage Renal Disease) on dialysis, HTN (High Blood Pressure), HIV (Human Immune Deficiency Virus) and Pseudoaneurysm of surgical AV(Arterial Venous) fistula left. Review of the physician orders revealed orders for contact isolation, hemodialysis, daily weight and Insulin administration with sliding scale.

Review of Patient #6's Plan of Care revealed health issues which addressed: Potential for Infection ( skin integrity- buttocks), Risk for Injury, Alteration in Comfort: Pain (Inflammation). There was no documented evidence that Patient #6's nursing care plan included interventions and goals related to Dialysis which he was receiving hemodialysis 3 times a week ( Monday, Wednesday & Friday) and Diabetes which he was on insulin, sliding scale with fluctuation of blood sugars.

In an interview on 11/06/12 at 2:00 p.m., S2ADON (Assistant Director of Nursing) confirmed that Patients #2's and #6's nursing care plans did not include nursing interventions and goals related to their medical diagnoses.


Patient #3
Review of the medical record for Patient #3 revealed the patient was a 67 year old male admitted to the hospital on 09/11/14 with diagnoses of Respiratory Failure, Chronic Pancreatitis, End Stage Renal Disease with Hemodialysis, Tracheostomy, Pneumonia, Multiple Pressure Ulcers, Diabetes Mellitus, Hypertension, Debility, and Malnutrition. Review of the physician's orders revealed orders for sliding scale insulin, PEG (Percutaneous Endoscopic Gastrostomy) tube feedings, aspiration precautions, telemetry, and contact isolation.

Review of the plan of care for Patient #3 revealed health issues which addressed: Potential for Infection, Impaired Skin Integrity, Risk For Injury, and Alteration in Bowel Elimination: Incontinence. There was no documented evidence that Patient #3's care plan included goals and nursing interventions for Hemodialysis, PEG tube feedings, telemetry, aspiration precautions, sliding scale insulin and glucose monitoring, and contact isolation. There was no documented evidence that the patient's diagnoses of Respiratory Failure, Tracheostomy and Pneumonia were addressed in the plan of care. The patient's debility and malnutrition were not addressed in the plan of care.

In an interview on 11/06/14 at 10:30 a.m., S2ADON reviewed the medical record for Patient #3 and confirmed the nursing care plan did not include the above medical problems and interventions ordered for the patient. S2ADON confirmed the nursing care plan was not individualized to the patient's needs.


30364




17091




26351

Based on record record review and interview the hospital
1. failed to ensure that drugs and biologicals were administered according to current nursing standards and in accordance with hospital policy for 15 out 17 days of Digoxin administered to Patient #30.
2. failed to ensure that drugs and biologicals were administered in accordance with the orders of the physician and hospital policy for 1 (#6) of 7 (#2, #3, #4, #6, #7, #18 and #30) patient records reviewed for medication administration from a total of 30 sampled patients. Findings:

Findings:

1. Review of the hospital policy for Medication Administration, Policy Number: 9-4.13.0, revealed in part;"...g. Verify that the patient's blood pressure, heart rate, and other vital signs, as indicated are within the prescribed limits prior to administration of certain prescribed medications.."

Review of Patient #30 medical record revealed he was admitted to the hospital on 10/7/14 with the diagnoses of Sacral Decubitus Ulcer, Status Post Right Toe Amputation, Hypertension and Coronary Artery Disease. His physician orders revealed he was on Digoxin .125 mg (milligrams) oral daily.

Review of Patient #30's Medication Administration Records (MAR) revealed Digoxin (Lanoxin) .125 mg oral daily was listed with a reminder to record the patient's Apical Pulse on MAR, Hold if less than
Review of Patient #30's MAR revealed his apical pulse was not documented prior to administration of Digoxin from 11/4/14 to 10/20/14, a total of 15 days out of the 17 days the patient's MARs were reviewed.

Review of Patient #30's heart rate recorded on his vital sign sheet at 8 a.m on 11/4/14 revealed his heart rate was recorded as 57 beats per minute. Documentation on his MAR for 11/4/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 11/4/14.

Review of Patient #30's heart rate recorded on his vital sign sheet at 8 a.m on 10/29/14 revealed his heart rate was recorded as 47 beats per minute. Documentation on his MAR for 10/29/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 10/29/14.

Review of Patient #30's heart rate recorded on his vital sign sheet at 8 a.m on 10/28/14 revealed his heart rate was recorded as 53 beats per minute. Documentation on his MAR for 10/28/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 10/28/14.

Review of Patient #30's heart rate record on his vital sign sheet at 8 a.m on 10/27/14 revealed his heart rate was recorded as 59 beats per minute. Documentation on his MAR for 10/27/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 10/27/14.

Review of Patient #30's heart rate recorded on his vital sign sheet at 8 a.m on 10/25/14 revealed his heart rate was recorded as 60 beats per minute. Documentation on his MAR for 10/25/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 10/25/14.

Review of Patient #30's heart rate recorded on his vital sign sheet at 8 a.m on 10/24/14 revealed his heart rate was recorded as 56 beats per minute. Documentation on his MAR for 10/24/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 10/24/14.

Review of Patient #30's heart rate recorded on his vital sign sheet at 8 a.m. on 10/23/14 revealed his heart rate was recorded as 55 beats per minute. Documentation on his MAR for 10/23/14 revealed no documentation his apical pulse was checked by the nurse prior to administration of his Digoxin at 9 a.m. on 10/23/14.

An interview was conducted with S1DON on 11/7/14 at 2:45 p.m. He verified the apical pulse was not documented prior to Patient #30 being administered Digoxin for 11/4/14 to 10/20/14. He also verified the patient's pulse was documented below 60 (57) beats per minute on the vital sign sheet for 11/4/14 and the nurse failed to document an apical pulse prior to the 9 a.m. of Digoxin administration on 11/4/14. S1DON reported the nurses are suppose to check the patient's apical pulse prior to administration, document the patient's apical pulse on the MAR, and notify the MD if the patient's apical pulse is equal and/or below 60 beats per minute.


31206


2. Review of the Hospital's Policy & Procedure title, "Medication Administration" presented by S1DON (Director of Nursing) as being current (03/01/14) reads in part: "Patient safety: iv. Right dose: ensure that the dosage of the medication matches the prescribed dose and the prescription itself does not reflect an unsafe dosage level."

Review of the Hospital's Policy & Procedure title, "Medication Variance" presented by S1DON as being current (03/01/14) reads in part: "Administration Variance- A variance originating during the processes directly associated with medication administration at the unit. These variance include, but are not limited to: Wrong dose administered."

Review of Patient #6's medical record revealed he was admitted to the hospital on 10/13/14 with an admitting diagnoses of: Dehydration, Stage 4 Decubitus, Stage e foot decubitus, Uncontrolled DM (Diabetes Mellitus), Ulcer of the scrotum, Osteomyelitis, Paraplegia and UTI (Urinary Tract Infection). Review of the physician's order for Patient #2 revealed an order for D50W 25 ml (milliliters) (12.5) g (Gram) IV (Intravenous) push.

Review of the MARs (Medication Administration Records) for Patient #6 revealed that on 10/24/14 at 0650 "D5W (Dextrose 5%) one amp. (ampule) was administered by a staff RN ( initials listed). Continued review of the Nurses' Notes for Patient #6 revealed that on 10/24/14 at 0650 reads in part: "D5W 1 amp given per Nurse (name) will continue to monitor."

In an interview on 11/06/14 at 10:45 a.m., S2ADON after review of the MARs, Nurses Notes and Physician Orders confirmed that on 10/24/14 Patient #6 was administered one ampule of D50W(Dextrose 50%) (50 ml) when only 25 ml had been ordered by the physician. S2ADON confirmed that a medication error had occurred and was discovered by the surveyor during record review.

Based on observation and interview, the hospital failed to ensure 347 patients medical records were retained in a manner that would protect them from water damage in the event the sprinkler system was activated.

Findings:
Review of the hospital policy titled Storage and Retrieval, Policy Number: 5-3.7.0, revealed in part:
I. A. The policies and procedures of the centralized system and related functions shall be developed to achieve the following:
Safeguard records and documents from tampering, loss, and advertent destruction.
III. A. Storage Space Specifications: Storage space shall be selected and maintained to protect records from unauthorized access, loss and destruction. Storage space shall be selected to meet the following specifications: protection against fire, including sprinkler system; freedom from hazards, such as flooding or damage from broken water pipes.

In an observation on 11/6/14 at 8:38 a.m. of the medical records department, there was a table in the main room with 46 paper medical records waiting to be filed or signed by a physician. An open shelving unit in the main room contained 17 paper medical records. In an additional room, 5 open shelving units approximately 3 feet long and 6 feet high contained 284 paper medical records. Further observation revealed all of the areas mentioned contained water sprinklers in the ceiling.

In an interview on 11/6/14 at 8:30 a.m. with S16MedicalRecords, she said there were 347 medical records in the medical department dating back to July of 2013. S16MedicalRecords verified that if the sprinkler system was activated there was no protection of the medical records from water damage. S16MedicalRecords also stated there were no photocopies or scanned copies of the medical records.

Based on record review and staff interview, the hospital failed to ensure all orders, including verbal orders, were dated, timed and authenticated in accordance with medical staff bylaws and policy/procedures for 5 out of 5 (#1, #3, #4, #5, #7) sampled patient records reviewed for physician order completeness out of a total sample of 30. Findings:

Review of the hospital's policy for Documentation Completion Time Frame, Policy Number 5-3.8.0 revealed in part, "...Document: Verbal Orders. Time Frame: 10 days..."

Review of the hospital's policy, titled, Documentation and Authentication, Policy Number 5-2.3.0 revealed in part, "All orders, including verbal orders, must be timed, dated, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and is authorized to write orders....All verbal orders will be authenticated within 10 days....

Review of the hospital's current Medical Staff Rules & Regulations revealed all physician's verbal orders would be authenticated within 10 days.

Patient #1
Review on 11/5/14 of the documents for Patient #1 titled Physical Therapy Orders and Occupational Therapy Orders revealed they had been written as telephone orders on 10/24/14. Further review revealed the orders had not authenticated by a physician.

Patient #3
Review of the medical record for Patient #3 revealed the patient was admitted to the hospital on 09/11/14. Review of the physician's orders revealed the following orders were documented by the physician but were not timed:
09/29/14 - Lab orders
10/01/14 - Lab orders
10/16/14 - Lab orders and Foley catheter orders
10/24/14 - Medication orders
10/27/14 - Hemodialysis orders and medication orders
11/03/14 - Lab orders
Review of the physician's orders revealed the following verbal orders were not authenticated by the physician according to the hospital policy & procedures:
09/12/14 - Respiratory therapy orders not authenticated with signature/date/time.
09/12/14 - Wound care orders signed and dated by the physician but not timed.
09/15/14 - Medication orders signed by the physician but not dated or timed.
09/26/14 - Hemodialysis orders signed by the physician but not dated or timed.
09/29/14 - Hemodialysis orders signed by the physician but not timed.
10/02/14 - Wound care orders not authenticated with signature/date/time.
10/06/14 - Consult for re-suture of PEG site and X-ray not authenticated with signature/date/time.
10/27/14 - Speech Therapy orders signed by the physician but not dated/timed.
Further review of the physician's orders revealed the following verbal orders did not include a read back verification process:
09/26/14 - Hemodialysis orders and medication orders.
10/13/14 - Hemodialysis orders and medication orders.
In an interview on 11/06/14 at 10:30 a.m., S2ADON (Assistant Director of Nursing) reviewed the physician's orders for Patient #3 and verified the above physician's orders were not dated/timed/authenticated according to hospital policy. S2ADON confirmed the hospital policy was to document a read back verification and stated the hospital used a sticker to document the process. S2ADON stated the above orders that did not have read back verification were documented by the contracted dialysis nurses.

Patient #4
Review of the Physician's Orders for Patient #4 revealed numerous orders not timed by the physician:
10/31/14 -Not timed. Urinalysis (UA), Microalbumin/creatinine Ratio
CMP (Complete Metabolic Panel), CBC (Complete Blood Count), Mg Phos (Magnesium Phosphate). The order was signed by S24MD.
10/30/14- Not timed. CMP, CBC, Mg Phos in a.m. The order was signed by S24MD.
10/29/14-Not timed. 1. Renal U/s (ultrasound) 2. UA, Uric Acid, 24 hour urine. The order was signed by S24MD.

An interview was conducted with S2ADON on 11/6/14 at 9:30 a.m. She confirmed the orders were not timed and she was aware S24MD did not time his orders frequently.

Review of the Physician's Order for Patient #4 revealed verbal orders not authenticated by the physician:
10/20/14 at 1920 1. Add to allergies: Bell Peppers-n/v (nausea/vomiting), Aspartame- brain cancer 2. Mycozole cream 2% under breast bil( bilaterally) daily. The order was not authenticated by the physician (16 days after order written).
10/22/14 at 2250 Hold Vancomycin and Rocephin IVPB (Intravenous Piggy Back) due to no IV (intravenous) access. The order was not authenticated by the physician (14 days after written).

S2ADON verified the orders were not authenticated on 11/6/14 at 9:30 a.m.

Patient #5
A review on 11/5/14 at 2:40 p.m. of the medical record for Patient #5 revealed a telephone order dated 10/7/14 stating MD (medical doctor) aware of Allergies. Further review revealed the physician had not authenticated the verbal order.


Patient #7
Review of the Physician's Order for Patient #7 revealed a verbal order for 10/20/14 for Vancomycin trough not authenticated 15 days after the order was written. S2ADON confirmed the order has not been authenticated on 11/6/14 at 9:45 a.m.


In an interview on 11/07/14 at 9:30 a.m., S1DON (Director of Nursing) stated the nursing staff aggressively reminded physicians to date/time/sign their orders. S1DON stated the reminders were the only intervention implemented to get the physicians to sign their orders, and stated he did not know of any other interventions.



26351

Based on record review and interview, the hospital failed to ensure errors in medication administration were reported to the attending physician for 3 (#20, #21, #24) of 3 (#20, #21, #24) patients and documented in the medical record for 2 (#20, #21) of 3 (#20, #21, #24) patients reviewed for known medication errors.

Findings:

Review of the hospital policy titled Medication Variance, Policy Number: 9-4.15.0, revealed in part:
When a medication variance is discovered, (whether or not patient injury has occurred), the incident must be reported immediately to the charge RN (registered nurse) and/or the Director of Nursing and/or the employee's supervisor. The variance should be reported to the physician as soon as possible. The drug administered is error/omitted in error and the action taken should be documented in the patient's medical record.

Patient #20
Review of the medical record for Patient #20 revealed he had been admitted on 6/30/14 at 8:00 p.m. His admitting diagnosis included acute respiratory failure, systolic diastolic heart failure, malignant hypertension, UTI, and acute kidney failure.

Review of the physician's Orders for Patient #20 revealed an order dated 7/2/14 at 9:00 a.m. for the following:
Hold Diovan, Lasix
Kayexalate 30 g (grams) po (by mouth) x 1 dose now
Normal Saline at 70 cc/hr (milliliters/hour) x 1 liter
Further review revealed the order was not signed off and executed until 7/2/14 at 9:00 p.m.

Review of an incident report for Patient #20 dated 7/2/14 revealed the medication error for Patient #20 had been discovered by the night shift on 7/2/14.

Review of the medical record for Patient #20 revealed no documentation that the physician was notified of the medication error or a description of the medication error from 7/2/14.

Patient #21

Review of the medical record for Patient #21 revealed he had been admitted on 2/14/14 for IV (intravenous) antibiotics for an infected right hip.

Review of the MAR for Patient #21 dated 3/31/14 revealed S12LPN documented she had given 4 2.5 mg Marinol tabs at 9:00 a.m.

Review of an incident report log revealed S12LPN had given 6 Marinol tablets instead of 4 to Patient #21 on 3/31/14.

Review of the medical record for Patient #21 revealed no documentation of physician notification of the extra doses of Marinol on 3/31/14 or documentation of the error in the medical record.

Patient #24
Review of the medical record for Patient #24 revealed he had been admitted on 5/15/14 for IV antibiotics for sacral osteomyelitis.

Review of the MAR for Patient #24 dated 6/18/14 revealed at 4:00 p.m. 2 mg of Morphine was documented as having been given for pain instead of the 1 mg ordered.

Review of the medical record for Patient #24 revealed no documentation that the physician had been notified of the medication error.

In an interview on 11/7/14 at 11:14 a.m. with S2ADON, she verified there was no documentation in Patient #20, #21, or #24's record of physician notification of identified medication errors. S2ADON also verified there was also no documentation in Patient #20's or Patient #21's medical record of the medication errors.

Based on record review and staff 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 by Company A. Findings:

Review of the contracts provided by S2DON revealed the hospital had a contract with Company A to provide radiological services.

Review of the hospital's policy titled, "Services and Goals", policy number 1-3.0.0, provided by S3ADM (Administrator) as the hospital's policy related to radiology services, revealed the following: Purpose: To define the overall services and goals of the hospital. Further review of the policy revealed no documented evidence that radiology services were included in the policy.

In an interview on 11/05/14 at 4:05 p.m., S1DON and S3ADM confirmed the policy titled, "Services and Goals" did not include any mention of radiological services. S1DON and S3ADM confirmed the hospital did not have any policies and procedures that addressed procedures for the safety of patients and personnel during radiological testing performed in the hospital.

In an interview on 11/07/14 at 10:30 a.m., S1DON also indicated radiological services were not monitored by the hospital's Quality Assurance and Performance Improvement program.

Based on record review and interview, the hospital failed to ensure there was a radiologist who was a member of the medical staff and supervised the radiology services and interpreted the radiological tests on either a full-time, part-time, or consulting basis.
Findings:

Review of the Governing Body Bylaws dated May 2009, revealed in part the following: Section 5. Practitioners providing contractual professional services:
a. The Governing Board may determine as a matter of policy that certain Hospital clinical facilities may be used on an exclusive basis in accordance with written agreements between the Hospital and qualified professionals....Such agreements shall contain language requiring that the contracting practitioner adhere to Bylaws, the Medical Staff Bylaws, rules and regulations, and the policies and procedures of the affected clinical department....
b. A practitioner who is providing such contract services to the Hospital must meet the same membership qualifications; must be processed for appointment, reappointment, and clinical privilege delineation in the same manner; and must fulfill all of the obligations for his/her membership category as any other applicant of staff member.

Review of the list of credentialed physicians on the Medical Staff, presented as a current list by S3ADM revealed no documented evidence that a radiologist was credentialed and privileged as a member of the Medical Staff.

Review of the contracts provided by S1ADM revealed the hospital had a contract with Company A to provide radiology services.

In an interview on 11/05/14 at 4:05 p.m., S1DON and S3ADM confirmed the hospital did not have a credentialed and privileged Radiologist on its medical staff to supervise radiology services. S3ADM confirmed the radiologists for Company A interpreting radiological tests were not credentialed and privileged by the hospital's Medical Staff and Governing Body.

In an interview on 11/07/14 at 10:30 a.m., S1DON also indicated radiological services were not monitored by the hospital's Quality Assurance and Performance Improvement program.

Based on observation, record review, and staff interview, the hospital failed to ensure supplies and equipment were maintained to ensure an acceptable level of safety and quality. The was evidenced by:

1) failing to ensure the functionality of a call button labeled, "Nurse" located in the handrails of the patient beds for 5 of 32 hospital beds currently in use;

2) failing to ensure expired patient care items were not available for patient use, and:

3) storing cardboard boxes of medical supplies on the floor in the hallway outside the supply room.

Findings:

1) Failing to ensure the functionality of a call button labeled, "Nurse" located in the handrails of the patient beds:
Observations were made on the patient care unit of the hospital on 11/05/14 between 10:30 a.m. and 11:10 a.m. with S2ADON (Assistant Director of Nursing). A button labeled "Nurse" and a cross over the call button was noted to be on the handrail of the bed in rooms 566, 577B and 578B The button was noted to be non- functional as it failed to activate any type of nurse call system. S2ADON stated the hospital had, "Several" types of beds and confirmed the nurse call buttons located in the handrails of the patient's beds were non-functional. S2ADON stated the hospital used the call button located on the cord and instructed the patient to use the nurse call button located on the cord. When asked if it would be possible for a patient who may be confused or sedated to press the nurse call button on the handrail of the bed thinking they are calling for assistance without the nursing staffs' knowledge due to the call button not working, S2ADON indicated yes that would be possible.

On 11/05/14 at 12:30 p.m., S3ADM (Administrator) provided a list of the hospital's current patient beds. Review of the list revealed a nurse call button was located in the handrails of the patient bed in rooms 557, 566, 574A, 577B, and 578B. S3ADM confirmed the hospital had 5 patient beds with nurse call light buttons located in the handrails of the bed that were non-functional. S3ADM stated the nursing staff oriented the patients to the call light system on the cord and confirmed confused patients may attempt to use the call light in the handrail and not reach the nurse when needed.


2) Failing to ensure expired patient care items were not available for patient use:
An observation was conducted on 11/5/14 at 10 a.m. of the supply room/clean utility room having expired patient care items available for patient use. Five (5) Silvercel wound care items were found with a 10/14 expiration date and Seven (7) Hydropolymer adhesive dressing with liqualock were found with an expiration date of 10/14. The expired items were confirmed with S7LPN.


3) Storing cardboard boxes of medical supplies on the floor in the hallway outside the supply room:
On 11/05/14 at 10:20 a.m., an observation was made with S2ADON. 15 cardboard boxes of medical supplies were observed to be stacked on top each other on the floor outside the supply room and the Soiled Utility room, near patient room #576. S2ADON stated the supplies were delivered this morning and the CNAs (Certified Nursing Assistants) would put the supplies up when they had time. S2ADON indicated this was the hospital's current practice for receiving supplies.

Based on observations, record review, and interview the hospital failed to ensure the infection control officers developed an effective system that included identification, reporting, investigating and control of infection and communicable diseases of patients and personnel as evidenced by:
1. failure to implement correct isolation procedures
2. failure to maintain a sanitary environment
3. failure to have physicians and midlevel practitioners tested annually for TB for 7 ( S19APRN, S20MD, S21MD, S22APRN, S23MD, and S25MD)out of 8 physician/midlevel practitioners' personnel records reviewed and failure to have 3 (S26Telemetry Techician, S30Telemetry Techician, and S31CNA) employees tested annually for TB (Tuberculosis)out of 11 staff personnel records reviewed.
4. failure to have housekeeping personnel use appropriate dwell time for disinfectants when cleaning patients' rooms/equipment.
5. failure to have a hospital policy for cleaning multiple patient use glucose monitors according to CDC (Center for Disease Control) guidelines/recommendations, and failure to have nursing personnel disinfect/clean a multiple patient use glucose monitors according to CDC guidelines/recommendations.

Findings:
1. Isolation Precautions:
Review of the hospital's policy for Isolation Precautions revealed in part, "...Contact Isolation- Gloves, Gowns and Hand Hygiene- In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, nonsterile gloves are adequate) when entering the room. During the course of providing care for a patient, change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage). Remove gloves before leaving the patient's room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent...Note: A gown will always be worn when entering the room of a patient designated as requiring Maximum Contact Precautions. Remove the gown before leaving the patient's environment..."

In an observation on 10/5/14 at 10:04 a.m., S10Housekeeper was transferring red biohazardous waste bags from a garbage can into a bin in the contaminated utility room without wearing a gown or gloves. S10Housekeeper was observed repeating the task at 10:07 a.m. without gloves or a gown.

In an observation on 10/5/14 at 10:15 a.m., S10Housekeeper was cleaning a contact isolation patient's room and emptying trash without wearing a gown.

In an observation on 10/5/14 at 10:45 a.m., S10Housekeeper was observed cleaning the room of a patient on contact isolation without wearing gloves or a gown.

An interview was conducted with S1DON on 11/7/14 at 9:55 a.m. He reported all staff are to wear gowns at all time in the room with patients in contact isolation. All patients in contact isolation are considered in Maximum Contact Isolation according to the hospital policy.

2. Sanitary Environment

Review of the hospital policy, Cleaning and Disinfecting of Equipment, Policy Number 6-6.2.0, revealed in part, "...Patient scales, All patient scales will be cleaned and wiped with a disinfectant laden cloth at least weekly... Medicine Carts/Wound Care Carts/Crash Carts- The inside and outside of all medicine carts and wound care carts will be cleaned and wiped with a disinfectant laden cloth at least weekly. The inside of Crash Carts will be inspected for cleanliness at least monthly when opened to inspect medications. The outside of the crash cart and the defibrillator will be wiped with a disinfectant cloth at least weekly..."

Review of the hospital policy, Separation of Clean and Dirty Supplies, Policy Number 8-5.5.0, revealed in part, "... Boxes of patient care supplies are not stored on floor...Storage must allow sufficient space for a mop to go under the bottom storage shelf in order to clean the floor..."

On 11/05/14 at 10:20 a.m., an observation was made with S2ADON. 15 cardboard boxes of medical supplies were observed to be stacked on top each other on the floor outside the supply room and the Soiled Utility room, near patient room #576. S2ADON stated the supplies were delivered this morning and the CNAs (Certified Nursing Assistants) would put the supplies up when they had time. S2ADON indicated this was the hospital's current practice for receiving supplies.

On 11/05/14 from 10:20 a.m. to 11:15 a.m., observations of patient care areas were made with S2ADON (Assistant Director of Nursing) and revealed the following:
Patient Room #577: The left side rail of the A bed was noted to have a 3 inch piece of adhesive tape on the side rail. The right side rail was observed to have multiple areas of a brown/black substance. The overbed table for bed B was observed to have a sticky residue. The cabinet of drawers adjacent to bed B revealed a paper sign, "Wound Care Supplies" taped to the middle drawer with the tape edges peeling off. S2ADON confirmed the above findings and verified the side rail with the black/brown substance had not been cleaned properly and verified the tape and tape residue did not provide a clean, wipeable surface for disinfection. The above findings were confirmed by S2ADON.

Patient Room #564: Adhesive tape was noted on the foot of the bed and the bath room door. Multiple pieces of adhesive tape were noted on the hallway door to the patient room. S2ADON confirmed the presence of adhesive tape on multiple surfaces in the room.

Patient Room #566: The cabinet of drawers adjacent to the bed revealed a paper sign, "Wound Care Supplies" taped to the middle drawer with the tape edges peeling off. A strip of adhesive tape was noted on the towel rack. An accumulation of dust/dirt/trash was noted along the baseboards in the room. The above findings were confirmed by S2ADON.

Patient Room #575: The cabinet of drawers adjacent to both of the beds revealed a paper sign, "Wound Care Supplies" taped to the middle drawer with the tape edges peeling off. Adhesive label residue was noted on the foot of the A bed. Adhesive tape residue was noted on the side rails of the B bed. Adhesive tape was noted on the hallway door. The above findings were confirmed by S2ADON.

Patient Room #579: The cabinet of drawers adjacent to the bed was observed to have a sticky substance on the top of the cabinet. Adhesive tape was noted on the side rails of the bed. The above findings were confirmed by S2ADON. S2ADON was asked if there was any inspection of the patient rooms after the room was cleaned. S2ADON stated she or S1DON (Director of Nursing) checked the room before a patient was placed in the room. S2ADON further stated the hospital's housekeeping services were out-sourced.

In an interview on 11/06/14 at 11:00 a.m., S9Housekeeping Supervisor stated no training on tape/residue removal had been done with the housekeeping staff. S9Housekeeping Supervisor stated he had instructed the staff to scrape the tape and tape residue off. S9Housekeeping Supervisor confirmed he was aware of the above findings.

In an observation on 10/5/14 at 10:10 a.m. of the medication room, there was a large amount of a white powder on the wall and floor near the refrigerator. There was also a sticky substance, debris, paper and a white powder between the refrigerator and a work table. The front of the refrigerator was observed to have a brown substance that had dripped down the doors and tape residue. At the base of a shelving unit containing supplies was trash consisting of dirt, rubber bands, dust, and a tourniquet. In an interview at 10/5/14 at 10:12 a.m., S2ADON verified it had been a while since the room had been cleaned.

An observation was conducted on 11/5/14 at 10:15 a.m. in the Nourishment Room. Two (2) boxes of foam cups/1000 cups per box, were being stored on the floor. A can of Thick It was opened with the scoop in the powder in the can. Two (2) microwaves were located in the Nourishment Room and both had dried food caked on the inside of the microwaves. S8RD (Registered Dietician) confirmed the observations.

An observation was made on 11/5/14 at 10:20 a.m. of Medication Cart #1. The medication cart had brown/black tape residue stuck to all the medication drawers. The observation was confirmed by S6RN.

An observation was made on 11/5/14 at 10:40 a.m. of Medication Cart #3. The medication cart had a dried liquid on cart in the cracks of the drawers and brown/black adhesive tape residue stuck to the patient drawers. The observations was confirmed by S5LPN.

An observation was made of the wheelchair scale and the hoyer lift scale on 11/5/14 at 10:45 a.m. The wheelchair scale had a thick build up of dust and a liquid substance on the area where the wheelchair rolls onto the scale. The hoyer lift had a dark substance spill on the legs of the scale. The scales were stored in an alcove of the hallway in the hospital. The observations were confirmed by S10Housekeeper. S10Housekeeper reported she thought the nurses cleaned the equipment, but she was new to the job and wasn't sure.

A wound care cart was observed in the hallway on 11/5/14 at 10:50 a.m. The wound care cart had black tape residue all over the top of the cart, with a dark substance on the bottom rim of the cart. The observation was confirmed by S2ADON.


On 11/07/14 at 8:45 a.m., an observation of the hospital's two "Crash Carts" was made with S28RN, Charge Nurse. Both crash carts were observed to have an accumulation of dust on the defibrillators and the suction machines. S28RN stated housekeeping was responsible for cleaning the carts. S6RN confirmed that the crash carts were in need of cleaning and there was dust present on the equipment located on top of the crash carts.

3. Tuberculin Skin Test
Review of the Medical Staff Bylaws revealed the following: Attachment: Policy and Procedure on Tuberculosis (TB) Screening. Tuberculosis requirement as part of staff membership. Purpose: To ensure that the facility is in compliance with its infection control efforts to protect patients and safeguard co-workers from possible infection.
Policy: Documentation of a screening and assessment for tuberculosis is a condition of appointment, reappointment and continued staff membership. Annually, each practitioner must provide documentation of a tuberculin skin testing (TST) unless there is a documented history of positive purified protein derivative (PPD) findings. Positive PPD reactors must provide evidence of a clear chest x-ray done within the last 10 years....A medical TB assessment will be requested thereafter....Failure to provide requested information annually may result in suspension of all clinical privileges until the information is provided....

Review of the sampled medical staff credentialing files revealed the following physicians and mid-level practitioners did not have documentation of current TB testing/screening: S19APRN, S20MD, S21MD (Medical Director), S22APRN, S23MD, S24MD, and S25MD.

In an interview on 11/06/14 at 4:45 p.m., S16Medical Records confirmed she was responsible for the credentialing files. S16Medical Records verified the above physicians and APRNs did not have current TB tests in their credentialing files. S16Medical Records stated she filed whatever the physician submitted in their credentialing packet.

In an interview on 11/07/14 at 9:20 a.m., S3ADM (Administrator) confirmed the above physicians and APRNS did not have current TB testing and stated he did not hold up the credentialing process for documentation of TB testing.


Review of the hospital policy Employee Health Program, Policy Number 8-6.0.0 revealed in part, "...All personnel should receive a tuberculin skin test every 12 months..."

Review of the personnel record for S29CNA revealed her Tuberculin (TB) Skin Test was due on 2/25/13.

In an interview on 11/7/14 at 3:43 p.m. with S2ADON, she verified employees should have a TB skin test annually.
Review of the personnel record for S26Telemetry Technician revealed no documented evidence of a current TB Test or screening for Tuberculosis.
In an interview on 11/07/14 at 4:00 p.m., S2ADON verified S26Telemetry Technician did not have a current (annual) screening for TB.

Review of the personnel record for S30Telemetry Technician revealed no documented evidence of a current TB skin test or screening for Tuberculosis.

Review of the personnel record for S31CNA revealed no document evidence of a current TB skin test or screening for Tuberculosis.

In an interview on 11/7/14 at 3:30 p.m., S2ADON verified S30Telemetry Technician and S31CNA did not have current (annual) screening for TB.


4. Cleaning of patients' room by housekeeping
Review of the instructions on the Virex II 246 disinfectant presented as the product housekeeping uses to clean and disinfectant patients' room and equipment revealed the following, Remove gross fifth. Apply solution to hard nonporous surface. Allow to remain on for 10 minutes. Wipe or let air dry.

An interview was conducted with S11Housekeeper on 11/6/14 at 11 a.m. She reported she used Virex 11 246 disinfectant to disinfectant the patients' rooms and equipment and she allows the disinfectant to sit three (3) minutes and then she wipes it off.

An interview was conducted with S9Housekeeping Supervisor on 11/6/14 at 11:05 a.m. He reported the Virex II 246 should sit 10 minutes prior to wiping it off. He also reported S11Housekeeper regularly worked in the hospital.


5. Glucose Monitor Cleaning between patients
Review of the hospital's policy on Accu-Check Inform II Glucose Meter, Policy Number: 9-6.0.0, Effective Date 3/1/14, Revised date 6/1/14, revealed in part, "....The meter will be cleaned weekly and when soiled with a disinfectant laden cloth. The towelette should be slightly damp, NOT wet. Do not allow excess moisture to seep into the meter by squeezing off excess cleaning solution from the pre-moistened cleaning cloth before cleaning the surface of the meter and the base unit..."

An observation was made of S5LPN of performing a glucose monitoring test on 11/6/14 at 11:10 a.m. At the conclusion of the performance of the test, S5LPN wiped down the monitor with an alcohol wipe. When questioned on how she cleaned the glucose monitor since the monitor was used on different patients and brought into different patients' room, she reported she wiped the monitor off with alcohol wipes prior and after use and at the end of her shift she would wipe off the glucose monitor with disinfectant wipes.

An observation was made of S6RN of performing a glucose monitoring test on 11/6/14 at 3:15 p.m. She was observed cleaning the glucose monitor prior to performing the glucose test with an alcohol wipe and after the test was completed. She confirmed the monitor was used on different patients and brought into different patients' rooms.

An interview was conducted with S2ADON on 11/6/14. She reported the nurses cleaned the glucose monitors with disinfectant wipes after use. When the two observations were reported to her, she reported she had thought they were using disinfectant wipes. The hospital policy was reviewed with S2ADON and she confirmed the policy was incorrect and reported she thought the glucose monitor were cleaned more than weekly. With review of the equipment cleaning log, the glucose monitors were documented as cleaned only weekly, S2ADON again reported she thought the monitors were cleaned more frequently.



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Based on observation, interview, and record review, the Chief Executive Officer, the Medical Staff, and the Director of Nursing failed to ensure the hospital-wide quality assessment and performance improvement (QAPI) program addressed infection control problems and implemented successful corrective actions plans as evidenced by failing to conduct effective infection control surveillance of the hospital environment, collect data, track and trend and develop corrective actions plans resulting in observed infection control breeches.

Findings:

Review of the hospital's policy titled, Performance Improvement Plan, Policy Number 1-6.7.0, dated 03/01/14, revealed in part the following: The Governing Board ensures the Performance Improvement Plan reflects the complexity of the Hospital's services, includes all Hospital departments and campuses including contract service, and focuses on indicators related to improved health outcomes, the prevention and reduction of medical errors and corrective actions as indicated....The primary goal of the Performance Improvement Plan is to continually and systematically plan design measure assess and improve performance if hospital-wide key functions and processes relative to patient care....5. Assure that the improvement process is organization-wide, assessing and evaluating the quality and appropriateness of patient care and clinical performance to identify changes that will lead to improved performance and reduce the risk of sentinel events. Corrective actions are taken and evaluated when problems or improvement opportunities are identified.... Scope of Activities.. The scope of Performance Improvement Program includes performance of the following medical staff functions:....Infection Control.

Review of the Quality Indicators monitored by the Hospital for 2014 revealed the following Infection Control/Housekeeping indicators:
Healthcare Associated GI (Gastro Intestinal) Infection
Employee TB compliance
TST (Tuberculin Skin Test) conversion
Room Cleanliness Compliance
Floor Maintenance Compliance
Housekeeping Infection Control Compliance

Review of the Quarterly Reports of Quality Indicator data collected revealed no documented evidence that any of the indicators were out of compliance except 1 employee TB test in the first quarter.

Review of the Methodology of data collection for Housekeeping services revealed surveillance of 10 random rooms per month would be conducted by administrative staff. The methodology revealed the following would be documented during the room visits:
Room cleanliness compliance - document if the rooms are in good condition in regards to the housekeeping department.
Floor maintenance compliance - document if the floors are cleaned and well maintained.
The methodology also indicated surveillance of the housekeeping staff with a minimum of 4 surveillances per month was to be conducted and included proper use of PPE (Personal Protective Equipment), proper handling of trash and/or linen, proper cleaning of equipment after each use in an isolation room, changing dust/mop head, and hand hygiene.

Review of the the Performance Improvement/Corrective Action Report revealed there were no corrective action plans related to infection control or housekeeping. Further review of the QAPI records revealed no documented evidence of the housekeeping data collected.

In an interview on 11/07/14 at 9:30 a.m., S1DON (Director of Nursing) verified he was responsible for the hospital's QAPI program. S1DON also verified he conducted the surveillance of the patient rooms and housekeeping staff. S1DON stated he had done the room checks and he had missed the tape, tape adhesive, and unclean floors. S1DON further stated he had made observations of housekeeping staff, but had not identified any breeches. S1DON stated he had done the room visits and staff surveillance but did not document his observations and findings. S1DON was unable to provide any documentation of the the surveillance. S1DON further stated the the TB testing monitoring included the physicians and mid-level practitioners. S1DON confirmed the monitoring process had not identified the lack of TB testing for 7 of 8 physicians reviewed and 3 of 11 hospital staff reviewed.




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