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Based on review of the clinical record, interview and review of hospital policy and procedure for one patient (Patient #21) that required restraints for his/her safety, the hospital failed to ensure that the physician and/or licensed practitioner wrote an order for the staff to use a restraint. The findings include:

Patient #21 was admitted on 10/14/09 with the diagnosis of respiratory failure and had a past medical history that included status post myocardial infarction with a three-vessel coronary artery bypass graft. Review of the clinical record, from 2/6/10 to 2/8/10, identified that the staff used bilateral wrist restraints for patient safety and there was no physician and/or licensed practitioner order that directed the staff to use the restraints. Interview with RN #2, on 2/9/10, identified that there was no physician and/or licensed practitioner order that directed the staff to apply bilateral wrist restraints to Patient #21. Review of the hospital policy and procedure titled Safety/Behavioral Management Restraint Policy identified that a physician order must be obtained for a restraint and is the order is valid for twenty-four hours.

Based on medical record reviews, review of hospital policies, observations and interviews for one of three patients who had a pressure ulcer (Patient #5), nursing staff failed to assess the area weekly. The findings include:

Patient #5 was admitted to the hospital on 1/15/10 with a diagnosis of quadraparesis and an unstageable sacral pressure ulcer that measured 1 centimeter (cm) long by 0.5 cm wide. The plan of care from 1/15/10 to 1/26/10 directed ulcer protocol. The patient ' s record was reviewed on 2/9/10 at 10:20 AM with the Supervisor of the Lyman II unit and lacked documentation that the patient ' s sacral pressure ulcer was assessed from 1/16/10 to 1/25/10 (9 days). Wound documentation dated 1/26/10 noted that the patient ' s sacral ulcer was unstageable and measured 4.5cm by 0.7cm by 0.1cm deep. The patient ' s record lacked an assessment of the sacral wound from 1/27/10 to 2/9/10 (2 weeks). Observation of the patient ' s sacral ulcer dressing change on 2/9/10 at 10:55 AM identified that the patient ' s wound was measured by the RN and measured 4cm by 3cm by 0.8 cm deep and was classified as a deep tissue injury/unstageable. Interview with the Supervisor of the Lyman II unit on 2/9/10 at 10:10 AM indicated that pressure ulcers were assessed weekly by nursing staff and unit practice was to have the weekend staff assess and measure ulcers. The hospital skin care policy identified that pressure ulcers required weekly assessments to include measurements.





19826

Based on review of clinical records, interviews and review of hospital policy and procedure for three of five patients (Patients #14, #16, and #21) that required cardiac telemetry monitoring, the hospital failed to ensure that interpretation for the telemetry was complete and/or for one patient (Patient #21) that had a change in his/her cardiac rhythm, the hospital failed to ensure that the nurse informed the physician and/or licensed practitioner about the change. The findings include:

1a. Patient #14 was admitted on 2/9/10 with the diagnosis of chronic obstructive pulmonary disease and had a past medical history that included status post myocardial infarction, acute renal failure, uncontrolled Diabetes Mellitus, encephalopathy and complete heart block with status post pacemaker insertion. Review of the clinical record identified that on 2/10/10 at approximately 1:00 A.M., Patient #14 was transferred to a unit that had cardiac telemetry monitoring due to a change in the patient ' s cardiac rhythm. Review of the cardiac telemetry documentation did not include an actual cardiac monitor strip, measurement of the components of the cardiac monitor strip (including the P-R interval and the QRS interval), interpretation of the patients ' cardiac rhythm and/or the signature of the nurse interpreting the rhythm.

b. Patient #16 was admitted on 1/8/10 with the diagnoses of chronic obstructive pulmonary disease and respiratory failure and had a past medical history that included anemia. Review of the cardiac telemetry documentation did not include measurement of the components of the cardiac monitor strip (including the P-R interval, the QRS interval and the heart rate), interpretation of the patients ' cardiac rhythm and/or the signature of the nurse interpreting the rhythm.

c. Patient #21 was admitted on 10/14/09 with the diagnosis of respiratory failure and had a past medical history that included status post myocardial infarction with a three-vessel coronary artery bypass graft.

Review of the cardiac telemetry documentation did not include measurement of the components of the cardiac monitor strip (including the P-R interval, the QRS interval and the heart rate), interpretation of the patients ' cardiac rhythm and/or the signature of the nurse interpreting the rhythm. Interview with RN #4 on 2/10/10 identified that the cardiac telemetry monitoring documentation includes printing a cardiac monitor strip, measurement of the components of the cardiac monitor strip with calipers (including the P-R interval, the QRS interval and the heart rate), interpretation of the patients' cardiac rhythm and/or the signature of the nurse interpreting the rhythm. In addition RN #4 identified that there were no calipers available on the unit although interview with RN #2, on 2/10/10, identified that there were calipers available on his/her unit. Review of hospital policy and procedure, titled " Cardiac Telemetry " , identified that cardiac monitoring strips are printed at the start of each shift and/or with an rhythm change, and documentation includes measurement of the components of the cardiac monitor strip (including the P-R interval, the QRS interval and the heart rate), interpretation of the patients ' cardiac rhythm and/or the signature of the nurse interpreting the rhythm.

2. Patient #21 was admitted on 10/14/09 with the diagnosis of respiratory failure and had a past medical history that included status post myocardial infarction with a three-vessel coronary artery bypass graft. Review of the cardiac telemetry documentation, dated 2/3/10 at 2:21 P.M., identified that the patient ' s cardiac rhythm was sinus rhythm and on 2/3/10 at 6:53 P.M. the patient ' s cardiac rhythm was sinus rhythm with a prolonged PR interval and there was no documentation the physician and/or the licensed practitioner was informed. Review of the Licensed Practitioner note, dated 2/3/10 at 9:13 P.M., did not identify that the nurse reported any change in the patient ' s cardiac rhythm and the patient ' s cardiac rhythm was sinus rhythm to sinus tachycardia. Interview with RN #2, on 2/10/10, identified that with the identified change in Patient #21 ' s cardiac rhythm (the prolonged PR interval), the nurse should have informed the physician and/or the licensed practitioner.

Based on medical record reviews, review of hospital policy, observations and interviews for one of three patients (Patient #5) who required testing for Clostridium difficile (C-diff), the hospital failed to follow the physician ' s order. The findings include:

Patient #5 was admitted to the hospital on 1/15/10 with a diagnosis of quadraparesis and neurogenic bowel. Physician orders dated 2/3/10 at 2:51 PM directed to obtain three stool specimens to rule out C-diff. The patient ' s record was reviewed with the Supervisor of the Lyman II unit on 2/9/10 at 10:20 AM. The review identified that although the patient had daily stools from 2/4/10 to 2/6/10, the ordered stool specimens were never obtained. Interview with the Supervisor of the Lyman II unit on 2/9/10 at 10:20 AM noted that although the patient's loose stools had subsided (by 2/5/10), nursing staff should have obtained the ordered stool specimens because the physician never discontinued the order.




19952

Based on review of the clinical record, review of hospital policy, review of hospital documentation and interviews with hospital personnel for one patient (Patient #9) who sustained an unwitnessed fall during hospitalization, documentation failed to reflect that the plan of care was followed. The findings include:

Patient #9 was admitted to the facility on 10/18/09 with diagnoses that included respiratory failure and hypoxia. Review of the clinical record reflected that the patient was noted as a high fall risk and had sustained an unwitnessed fall from the wheelchair on 1/28/10 at 5:45 PM. Review of the Nurse's Note dated 1/28/10 at 11:48 PM indicated that the patient was found on the floor with the self-release clip seat belt released. Review of the physician orders and the patient care plan identified that Patient #9 was to have a pelvic release belt applied when sitting in the wheel chair. Documentation failed to reflect that the patient's plan of care was followed.

Based on review of the clinical record, observation, interviews, and review of hospital policy and procedure for one patient (Patient #18) that required medications to be administered, the hospital failed to ensure that the nurse administered medications and/or documented administration of medications according to hospital policy and procedure. The findings include:

Patient #18 was admitted on 1/19/10 with the diagnosis of chronic obstructive pulmonary disease and had a past medical history that included congestive heart failure, pulmonary emboli and clostridium difficile infection. Observation on 2/9/10 identified that there were three pills on the patient ' s overbed table. Patient #18 identified that the nurse left the pills and directed him/her to take them. Interview with LPN #1, on 2/9/10, identified that he/she brought three pills (Potassium, Prevacid and Tums) to Patient #18, left the room before the patient took the medications and documented in the electronic Medication Administration Record (MAR) that Patient #18 had taken the medications. Review of the electronic MAR, dated 2/9/10, identified that Patient #18 had received the Potassium, Prevacid and Tums on 2/9/10 at 8:38 A.M., 8:41 A.M. and 8:41 A.M. Review of the hospital policy and procedure, titled " Medication Administration " , identified that the nurse is to remain with the patient as the patient takes the medication (s), does not leave medication at the patient ' s bedside and after administering a medication the nurse documents the time of administration and signs his/her name.

Based on review of the clinical record, review of hospital policy, review of hospital documentation and interviews with hospital personnel for one patient (Patient #9) who sustained an unwitnessed fall during hospitalization, documentation failed to reflect the clinical assessment of the patient post fall. The findings include:

Patient #9 was admitted to the facility on 10/18/09 with diagnoses that included respiratory failure and hypoxia. Review of the clinical record reflected that the patient was noted as a high fall risk and had sustained an unwitnessed fall from the wheelchair on 1/28/10 at 5:45 PM. Review of the Nurse ' s Note dated 1/28/10 at 11:48 PM indicated that the patient was found on the floor with the right side of the head on the floor and with his buttocks still on the leg rest of the wheel chair. The note identified that the fall response team, that included a physician, responded and a fall physical assessment was completed. Review of the clinical record failed to reflect documentation of the physician ' s post fall assessment findings, medical evaluation and/or neurological assessment.

Based on medical record reviews, review of hospital policy and interviews for one of three patients who were discharged (Patient #27), the physician failed to complete the discharge summary in a timely manner. The findings include:

Patient #27 was admitted to the hospital on 12/14/09 with a diagnosis of toxic megacolon with postoperative shock. The discharge summary identified that the patient was discharged on 12/29/09. The attending physician was MD #1 and PA #1dictated the discharge summary on 1/13/10. The summary further indicated that PA #1 electronically signed the discharge summary on 1/30/10 (31 days after discharge) and MD #1 electronically signed the summary 32 days after the patient was discharged. Interview with the Director of Medical Records on 2/11/10 at 10:20 AM noted that e-mails were sent to PA #1 to alert him/her of the need to complete Patient #27 ' s record and e-mails were routinely sent every 2 weeks. He/she further indicated that the hospital did not have a system in place to notify the attending physician of impending late records when the PA had dictated a summary and had not yet signed. The hospital policy for documentation requirements by medical staff identified that an in-patient discharge summary must be dictated within 5 days of discharge, authenticated within 14 days of discharge and discharge summaries completed by the PA or APRN require a co-signature by the attending of record.

Based on review of hospital policy, tour of the hospital, observations and interviews the hospital failed to maintain equipment for one of five code carts and/or for six of seven therapy treatment tables. The findings include:

1. A tour of the Lyman II unit was conducted on 2/9/10 at 9:40 AM with the unit ' s Supervisor. Observation identified that the code cart in the Lyman II hallway was checked off as complete for 2/9/10 and the cardiac board for the cart was missing. Interview with the Lyman II Supervisor at this time indicated that he/she was unaware that the board was missing and was not aware of its location. A subsequent observation on 2/11/10 at 8:45 AM noted that the white cardiac board was in place on the backside of the Lyman II unit code cart. The hospital code cart utilization and maintenance guidelines identified that equipment required at the back of the code cart included one intravenous pole and one cardiac board.

2. A tour of the in- patient therapy room was conducted on 2/9/10 at 1:15 PM with the Director of In-Patient Rehab. Observations identified one or two breaks in the vinyl- like covering on 6 of 7 therapy treatment tables. Rough edges were noted around the broken areas and the inner padding beneath was exposed and rendered the tables a potential hazard. Interview with the Rehab Director on 2/9/10 at 1:25 PM noted that the disrepair of the therapy tables were from contact with patient wheelchairs. Interview with the Infection Control Nurse on 2/11/10 at 11:15 AM indicated that prior recommendations were made to the Rehab Staff to cover the exposed areas with duct tape until the tables could be resurfaced.

Based on observation, review of hospital policy and interview with hospital personnel, the hospital failed to ensure that nursing personnel implemented infection control practices. The findings include:

a. Observation of a dressing change completed on 2/9/10 at approximately 10:30 AM by the Charge Nurse of the medical unit identified that clean technique was utilized for a dressing change to a contaminated abdominal wound. During observation the nurse was noted to remove soiled gloves following removal of the old dressing. The nurse then donned clean gloves to proceed with the dressing without washing hands. Hospital policy directed that hands should be cleansed following removal of gloves.
b. Further observation of the dressing change identified that the nurse donned clean gloves then proceeded to gather additional packets of gauze and rearranged the patient's bedding adjacent to the wound perimeter. The nurse proceeded to pack the wound with moistened kling gauze and patted the gauze into place with the right hand. During interview on 2/9/10 at 11:10 AM, the nurse stated she didn't realize she had touched adjacent surfaces with the same gloves used to dress the wound.



14528

Based on medical record reviews, review of hospital policy, observations and interviews for one of three patients (Patient #5) who required testing for Clostridium difficile (C-diff), the hospital failed to follow isolation policies. The findings include:

1. Patient #5 was admitted to the hospital on 1/15/10 with a diagnosis of quadraparesis and neurogenic bowel. Physician orders dated 1/15/10 directed standard precautions. Bowel records noted that the patient had soft, formed stools on 1/29/10, 1/31/10, 2/1/10 and 2 liquid stools on 2/2/10. Physician orders dated 2/3/10 directed to obtain three stool specimens to rule out C-diff. Observation on 2/9/10 at 10 AM identified that an isolation sign was not posted nor was protective equipment present outside the patient ' s room. The patient ' s record was reviewed with the Supervisor of the Lyman II unit on 2/9/10 at 10:20 AM and noted that the record lacked documentation that the patient was placed on contact precautions from 2/3/10 to 2/9/10. Interview with the ICN on 2/11/10 indicated that the nurse could place a patient on isolation precautions without a physician order. The hospital policy for isolation precautions directed contact (not standard) isolation precautions is to be utilized when a patient has or is suspected to have C-diff.

2. A tour of the in- patient therapy room was conducted on 2/9/10 at 1:15 PM with the Director of In-Patient Rehab. Observations identified one or two breaks in the vinyl- like covering on 6 out of 7 therapy treatment tables. Observations also noted germicidal wipes (Asepti- Wipes) located throughout the department. Rough edges were noted around the broken areas and the inner, porous padding beneath was exposed and rendered the tables difficult to clean. Interview with the Infection Control Nurse on 2/11/10 at 11:15 AM indicated that the tables were wiped down with Asepti- Wipes after each patient use and allowed to air dry. He/she also identified that prior recommendations were made to the Rehab Staff to cover the exposed areas with duct tape until the tables could be resurfaced. The Asepti- Wipe directions identified that the wipes were for use on hard non- porous surfaces and equipment and required that the surface remain visibly wet for a full 5 minutes.





19826

Based on observation, interviews and hospital documentation the soiled utility room of one unit was not maintained to ensure a sanitary environment. The findings include:

During a tour of Milne 1, on 2/9/10, it was observed that the soiled utility room contained an abundance of "soiled" patient care items-including walkers, commodes, intravenous pumps and bedside chairs. Interview with RN #2 and RN #5 on 2/9/10 identified that the unit staff are required to clean the "soiled" patient care items, move the items to the clean utility room then notify the central supply department to pick up the cleaned items from the unit and the staff ensures that this process is carried out when they complete the environmental rounds every shift. Review of the "environmental rounds" documentation identified that the staff on all shifts monitor that items are returned to central supply daily and there was no documentation that the rounds had been completed since 10/30/09.
In addition, the soiled utility room contained housekeeping equipment which included a floor buffer, a vacuum, a ceiling vacuum, a cart containing housekeeping supplies and unsecured cleaning chemicals present (bleach and floor wax ). Interview with the Supervisor of Environmental Services on 2/9/10, identified that the housekeeping equipment and cleaning supplies should not be stored in the soiled utility room.

Based on observation, review of the clinical record, review of hospital policy and interviews with hospital personnel for one patient (Patient #2) who required antibiotic therapy, the hospital ' s intravenous policy was not followed. The findings include:

Patient #2 was admitted to the hospital with the diagnosis of brain abcess. An observation was made during tour that identified that the patient was receiving an intermittent antibiotic infusion and that the tubing was outdated and had expired. Review of the hospital ' s IV Maintenance and Schedule of Equipment Changes and interview with the nursing supervisor indicated that for a primary intermittent infusion, the administration set would be changed every 24 hours.