HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure its grievance process was implemented as evidenced by failure to identify a complaint as a grievance for 1 (#R1) of 2 (#21, #R1) sampled patients reviewed for complaints/grievances out of a total patient sample of 30.

Review of the hospital's "Complaint Log" for 2017 revealed an entry dated 3/31/17 indicating a family member of Patient #R1 had complained Patient #R1 was missing their prescription eye glasses.

Review of the hospital's "Problem Identification Sheet" revealed an investigation began on 3/31/17 continuing onto 4/1/17. Further review, revealed no documentation of an outcome or resolution.

In an interview of 2/20/18 at 3:25 p.m., S2DON stated that she was responsible for the hospital's complaints and grievances. After review of the "Complaint Log" and "Problem Identification Sheet", S2DON, acknowledged there was no documentation indicating the complaint referencing Patient #R1 had been resolved. S2DON stated she had not recognized the family's complaint as a grievance and verified it should have been treated as a grievance.

Based on record reviews and staff interview, the hospital failed to ensure the use of restraints was in accordance with the order of the physician as evidence by failing to ensure the ordering physician indicated the type of restraint to be used for 2 (#1, #24) of 3 (#1, #4, #24) sampled patients reviewed for the use of restraints out of a total sample of 30.

Findings:
Review of the hospital's "Restraints" policy (policy #:LTACH ID PC 019) revealed in part:
III. Directive:
P. The physician/LIP will complete the Doctor's Order section of the Restraint Order Form by signing, dating and time the order.

Patient #1
Review of Patient #1's medical record revealed an admission date of 1/5/2018 with diagnoses that included Acute Respiratory Failure, Anxiety, Atrial Fibrillation and Cerebrovascular Accident affecting left non-dominant side. Further review of Patient #1's medical record revealed the patient had a tracheostomy and required mechanical ventilation.

Review of the hospital's "Restraint Order Form, Section III - Physician's Order" for Patient #1 revealed the ordering physician had signed, dated and timed the restraint orders for the following dates: 1/13/18, 1/22/18, 1/23/18, 1/24/18, 1/25/18, 1/26/18, 1/27/18, 1/28/18, 1/29/18, 1/30/18 and 1/31/18. Further review of the Restraint Orders failed to indicate the "Restraint type" that specified the following options: soft limb - mitten - elbow - RU (right upper), LU (left upper), RL (right lower) and LL (left lower).

In an interview on 2/19/18 at 1:15 p.m., S2DON reviewed Patient #1's medical record and verified the physician had not indicated the restraint type on the Restraint Orders for the dates listed above.

Patient #24
Review of Patient #24's medical record revealed an admission date of 2/2/18 with diagnoses that included Acute Kidney failure, Subacute Infective Endocarditis, Protein-calorie malnutrition. Further review of the medical record, revealed Patient #24 had an endotracheal tube and nasogastric tube.

Review of the hospital's "Restraint Order Form, Section III - Physician's Order" for Patient #24 revealed the ordering physician had signed, dated and timed the restraint orders for the following dates: 2/12/18, 2/13/18 and 2/14/18. Further review of the Restraint Orders did not indicate the "Restraint type" that specified the following options: soft limb - mitten - elbow - RU (right upper), LU (left upper), RL (right lower) and LL (left lower).

In an interview on 2/20/18 at 1:55 p.m., S5RN reviewed Patient #24's chart and verified the physician had not indicated the restraint type on the Restraint Orders dated 2/12/18, 2/13/18 and 2/14/18.

Based on record review and interview, the hospital failed to ensure an effective system was in place to ensure that each physician/practitioner providing services in the hospital was credentialed in accordance with the hospital's governing board bylaws for 2 (S11Rad, S12Physician) of 4 medical staff personnel files reviewed.

Findings:

Review of the hospital's Governing Board ByLaws dated January 2018 revealed in part:
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. Further, the Governing Board may determine to exclusively contract with one or more healthcare professionals to provide services to the Hospital or its patients. Such agreements shall contain language requiring that the contracting practitioner adhere to the Bylaws, the Medical Staff Bylaws, rules and regulations, and the policies and procedures of the affected clinical department.
b. A practitioner who is providing ...contract services to the Hospital must meet membership qualifications; must be processed for appointment, reappointment and clinical privilege delineation in the same manner .... If the practitioner's ...clinical privileges are terminated either by physician or Hospital, the contract shall be terminated automatically on the same day.

S11RAD
A review of the medical staff credentialing files with S3HIM on 2/21/18 at 9:55 a.m. revealed there was no credentialing file for S11Rad.

On 2/20/18 at 12:48 p.m., S2DON stated S11Rad's credentials and clinical privileges had expired on 1/7/18. S2DON reviewed and acknowledged S11Rad interpreted a Radiology report dated 1/24/18 for Patient #14.

On 2/21/18 at 9:55 a.m., S1Adm verified S11Rad's credentials and clinical privileges had expired on 1/7/18. S1Adm stated S11Rad had not submitted any information to be re-credentialed.

S12Physician
Review of the hospital's Governing Body meeting minutes dated 1/26/18 revealed S12MD was appointed as Medical Director of the hospital's contracted lab services by the Governing Body.

Review of S12Physician credentialing file revealed he was not currently credentialed/privileged by the hospital.

In an interview on 2/21/18 at 9:55 a.m. with S3HIM, she verified S12MD was not currently credentialed/privileged at this hospital.

Review of S12Physician's file for credentialing with S3HIM revealed there were no current documents. S12Physician was approved by the governing board for the hospital lab director on 01/05/18.


30984






34161

Based on record review and staff interview, the hospital failed to ensure a radiologist providing interpretation of radiological tests from the contracted radiological service provider were credentialed and granted privileges to provide the services by the hospital's medical staff and governing board for 1 (S11Rad) of 4 medical staff credentialing files reviewed.

Findings:

Review of the hospital's Governing Board ByLaws dated January 2018 revealed in part:
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. Further, the Governing Board may determine to exclusively contract with one or more healthcare professionals to provide services to the Hospital or its patients. Such agreements shall contain language requiring that the contracting practitioner adhere to the Bylaws, the Medical Staff Bylaws, rules and regulations, and the policies and procedures of the affected clinical department.
b. A practitioner who is providing ...contract services to the Hospital must meet membership qualifications; must be processed for appointment, reappointment and clinical privilege delineation in the same manner .... If the practitioner's ...clinical privileges are terminated either by physician or Hospital, the contract shall be terminated automatically on the same day.
c. The Governing Board has decided to permit the provision of clinical services via telemedicine. ...The Governing Board expressly chooses to have Hospital's Medical Staff rely on the credentialing and privileging decisions made by the distant hospital when making its recommendation on privileges for the individual distant-site physician(s) or practitioner(s) providing telemedicine services. Any written agreement with a distant-site hospital for the provision of telemedicine services shall require that:
(2) The individual distant-site physician or practitioner who will provide telemedicine services is privileged at the distant-site hospital ....

Review of Patient #14's medical record revealed a chest x-ray report dated 1/24/18 that was interpreted by S11Rad.

A review of the medical staff credentialing files with S3HIM on 2/21/18 at 9:55 a.m. revealed there was no credentialing file for S11Rad.

On 2/20/18 at 12:48 p.m., S2DON stated S11Rad's credentials and clinical privileges had expired on 1/7/18. S2DON reviewed and acknowledged S11Rad interpreted a Radiology report dated 1/24/18 for Patient #14.

On 2/21/18 at 9:55 a.m., S1Adm verified S11Rad's credentials and clinical privileges had expired on 1/7/18. S1Adm stated S11Rad had not submitted any information to be re-credentialed.

Based on record reviews and interview, the hospital failed to ensure that the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:

1) The RN failed to ensure an apical pulse assessment and/or blood pressure assessments were documented as directed on the patients' medication administration record prior to medication administration for 7 (#1, #2, #3, #7, #11, #22, #30) of 10 total sampled patients reviewed for vital sign documentation with medication administration out of a total patient sample of 30.

2) The RN failed to clarify an incomplete medication order for Levophed and Dopamine continuous infusions prior to administration for 1(#23) of 1 total patients reviewed for continuous infusions requiring titration.

3) The RN failed to ensure an order was obtained to transfer a patient out to a higher level of care prior to transfer of the patient for 1 (#23) of 2 (#18, # 23) patients reviewed for acute out transfers to a higher level of care out of a total patient sample of 30.

Findings:

1) The RN failed to ensure an apical pulse assessment and/or blood pressures were documented as directed on the patients' medication administration records prior to medication administration.

Patient #1
Review of Patient #1's medical record revealed an admission date of 1/5/2018 with diagnoses that included Acute Respiratory Failure, Anxiety, Atrial Fibrillation and Cerebrovascular Accident affecting left non-dominant side. Further review of Patient #1's medical record revealed the patient had a tracheostomy and required mechanical ventilation.

Review of Patient #1's MAR (Medication Administration Record) revealed the following ordered medication and directive for assessment and documentation of an apical pulse on the MAR prior to medication administration:

Bisoprolol fumarate (Zebeta) 5 milligrams per PEG tube daily at 0900. Further review revealed directions to assess and document the patient's apical pulse on the MAR next to the time given; and to hold dose if the patient's pulse was less than or equal to 60 and to the notify MD. Additional review revealed the nurse failed to document the patient's apical pulse prior to medication administration on the MAR as indicated for the following dates: 1/15/18, 1/19/18, 1/23/18, 1/24/18, 1/25/18, 1/26/18, 1/27/18, 1/28/18, 1/30/18, 1/31/18, 2/4/18, 2/8/18, 2/12/18, 2/13/18 and 2/16/18.

Patient #2
Review of Patient #2's medication administration record revealed an admission date of 2/10/18 with an admission diagnosis of Acute Respiratory Failure with the following co-morbid conditions: history of Atrial Fibrillation and CVA. Additional review revealed the patient had a tracheostomy and was requiring mechanical ventilation.

Review of Patient #2's MAR revealed the following ordered medications and directives for assessment and documentation of vital signs on the MAR, prior to medication administration:

Clonidine HCL (hydrochloric acid) 0.1 mg (milligrams) -1 tablet q (every) 8 hours p.o. (by mouth). Further review revealed directions to document the patient's recent BP (blood pressure) before administering the medication. Additional review, revealed the nurse failed to document the patient's most recent blood pressure on the MAR as indicated for the following dates and times: 2/11/18 2:00 p.m.; 2/13/18 2 p.m. , 10 p.m., and 6 a.m.; 2/15/18 2 p.m.; 12/16/18 2 p.m.; and 2/17/18 2 p.m.

Metoprolol Tartrate (Lopressor) 25 mg tablet - 1 tablet p.o. twice a day at 9 a.m. - 9 p.m. Further review revealed directions to assess and document the patient's apical pulse on the MAR next to the time given, and to hold dose if the patient's pulse was less than or equal to 60 and to the notify MD. Additional review revealed the nurse failed to document the patient's apical pulse prior to medication administration on the MAR as indicated for the following dates and times: 2/13/18 9 a.m. and 9 p.m.; 2/14/18 9 p.m.; 2/15/18 9 a.m.; 2/16/18 9 a.m. and 9 p.m.; 2/17/18 9a.m.; and 2/19/18 9 p.m.

Vasotec 5 mg tablet - 1 tablet p.o. daily at 9:00 a.m. Further review revealed directions to document the patient's recent BP before administering the medication. Additional review revealed the nurse failed to document the patient's most recent blood pressure prior to medication administration on the MAR as indicated for the following dates and times: 2/13/18 9:00 a.m.; 2/15/18 9:00 a.m.; and 2/17/18 9:00 a.m.

Patient #3
Review of Patient #3's medical record revealed an admission date of 1/31/18 with an admission diagnosis of Acute Osteomyelitis and co-morbid diagnoses of Hypertension and End-stage Renal Disease.

Review of Patient #3's MAR revealed the following ordered medication and directive for assessment and documentation of vital signs, on the MAR, prior to medication administration:
Clonidine HCL (hydrochloride) 0.1 mg (milligrams) -1 tablet p.o. at 9:00 a.m. and 9:00 p.m. Further review revealed directions to document the patient's recent BP before administering the medication. Additional review revealed the nurse failed to document the patient's most recent blood pressure as indicated on the MAR for the following dates and times: 1/31/18 9 p.m. ; 2/1/18 9 a.m. and 9 p.m.; 2/2/18 9 a.m. and 9 p.m.; 2/3/18 9 a.m. and 9 p.m.; 2/10/18 9 a.m. and 9 p.m., 2/11/18 9 a.m. and 9 p.m.; 2/12/18 9 a.m. and 9 p.m.; 2/13/18 9 a.m. and 9p.m.; 2/14/18 9 a.m. and 9 p.m.; 2/15/18 2 p.m.; 2/16/18 9 a.m. and 9 p.m.; 2/17/18 9 a.m. and 9 p.m. ; and 2/18/18: 9 a.m. and 9 p.m.

Patient #7
Review of Patient #7's medical record revealed an admission date of 02/08/18 with an admission diagnosis of Aortic Valve replacement, Bradycardia, and Acute Renal failure.

Review of Patient #7's MAR revealed the following ordered medication and directive for assessment and documentation of apical pulse on the MAR next to time given - hold if less than or equal to 60 and notify physician, prior to medication administration:

Metoprolol Tartrate (Lopressor) 25 mg 1 tablet po BID at 9:00 a.m. and 9:00 p.m. Further review revealed the nurse failed to document the patient's most recent apical pulse as indicated on the MAR for the following dates and times: 02/09/18 9:00 a.m.; 02/10/18 9:00 a.m. and 9:00 p.m.; 02/11/18 9:00 a.m. and 9:00 p.m.; 02/12/18 9:00 p.m.; 02/13/18 9:00 p.m.; 02/14/18 9:00 a.m. and 9:00 p.m.; 02/15/18 9:00 p.m.; 02/17/18 9:00 a.m. and 9:00 p.m.; 02/18/18 9:00 a.m. and 9:00 p.m.; 02/19/18 9:00 p.m.

Patient #11
Review of Patient #11's medical record revealed an admission date of 02/16/18 with an admission diagnosis of Respiratory Distress, Hypertension, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Osteoarthritis and Anemia.

Review of Patient #11's MAR revealed the following ordered medication and directive for assessment and documentation of apical pulse on the MAR next to the time given prior to medication administration:

Coreg 12.5 mg 1 tablet po BID at 8:00 a.m. and 5:00 p.m. Further review revealed the nurse failed to document the patient's most recent apical pulse as indicated on the MAR for the following dates and times: 02/17/18 8:00 a.m. and 5:00 p.m.; 02/18/18 8:00 a.m. and 5:00 p.m.

Patient #22
Review of Patient #22's medical record revealed an admission date of 10/20/17 with an admission diagnosis of Subdural Hemorrhage, Acute Kidney Failure, Atrial Fibrillation, and Diabetes.

Review of Patient #22's MAR revealed the following ordered medication and directive for assessment and documentation of apical pulse on the MAR next to the time given prior to medication administration:

Coreg 12.5 mg 1 tablet po BID at 9:00 a.m. and 9:00 p.m. Further review revealed the nurse failed to document the patient's most recent apical pulse as indicated on the MAR for the following dates and times: 10/20/17 9:00 p.m.; 10/21/17 9:00 p.m.; 10/22/17 9:00 p.m.; 10/24/17 9:00 a.m. and 9:00 p.m.; 10/26/17 9:00 a.m. and 9:00 p.m.; 10/27/17 9:00 a.m. and 9:00 p.m.; 10/28/17 9:00 a.m. and 9:00 p.m.; 10/29/17 9:00 a.m. and 9:00 p.m.; 10/30/17 9:00 a.m. and 9:00 p.m.; 10/31/17 9:00 a.m. and 9:00 p.m.; 11/01/17 9:00 a.m. and 9:00 p.m.; 11/02/17 9:00 p.m.; 11/03/17 9:00 p.m.; 11/04/17 9:00 a.m. and 9:00 p.m.; 11/05/17 9:00 a.m. and 9:00 p.m.; 11/06/17 9:00 a.m. and 9:00 p.m.; 11/07/17 9:00 a.m. and 9:00 p.m.; 11/08/17 9:00 p.m.

Patient #30
Review of Patient #30's medical record revealed an admission date of 01/02/18 with an admission diagnosis of Acute Respiratory Failure, Congestive Heart Failure, Acute Kidney Failure, Atrial Fibrillation, and Coronary Artery Disease.

Review of Patient #30's MAR revealed the following ordered medication and directive for assessment and documentation of apical pulse on the MAR next to time given - hold if less than or equal to 60 and notify physician, prior to medication administration:

Bisapropol Fumarate (Zebeta) 5 mg 1 tablet po BID at 9:00 a.m. and 9:00 p.m. Further review revealed the nurse failed to document the patient's most recent apical pulse as indicated on the MAR for the following dates and times: 01/07/18 9:00 p.m.; 01/09/18 9:00 p.m.; 01/10/18 9:00 a.m. and 9:00 p.m.; 01/12/18 9:00 9:00 p.m.; 01/13/18 9:00 a.m. and 9:00 p.m.; 01/14/18 9:00 a.m. and 9:00 p.m.; 01/18/18 9:00 a.m. and 9:00 p.m.; 01/20/18 9:00 a.m. and 9:00 p.m.; 01/21/18 9:00 a.m. and 9:00 p.m.; 01/22/18 9:00 p.m.

In an interview on 2/19/18 at 1:22 p.m. with S1Adm and S2DON, both confirmed the above referenced patients' vital signs should have been assessed as ordered/directed on the MAR.

2) The RN failed to clarify an incomplete medication order for Levophed and Dopamine continuous infusions prior to administration.

Review of Patient #23's medical record revealed an admission date of 1/26/18. Further review revealed the patient had been transferred acute out for a higher level of care (ICU) due to respiratory failure and sepsis on 1/29/18. Additional review revealed the patient also had new onset of seizures.

Review of Patient #23's physician's orders revealed the following orders for vasoactive drugs:
1/29/18 6:00 p.m.: Dopamine 5 mcg/kg/min titrate to MAP (mean arterial pressure) greater than 60 and HR (heartrate) greater than 50. Further review revealed the orders had no ordered increments and timeframes for titrating the dose.

1/29/18 4:15 p.m.: Levophed titrate per protocol. Further review revealed the orders had no ordered increments and timeframes for titrating the dose. Additional review revealed no documented evidence that a protocol had been placed on the chart.

In an interview on 2/20/18 at 1:45 p.m. with S2DON, she indicated the hospital did have protocols for both Dopamine and Levophed Infusions and they should have been on the patient's chart. She agreed the nurse should have clarified the order by obtaining increments and timeframes for titration of the doses.

Review of Patient #23's medical record revealed an admission date of 1/26/18. Further review revealed the patient had been transferred acute out for a higher level of care (ICU) due to respiratory failure and sepsis on 1/29/18. Additional review revealed the patient also had new onset of seizures.

Review of Patient #23's physician's orders revealed the following orders for vasoactive drugs:

1/29/18 4:15 p.m.: Levophed titrate per protocol. Further review revealed the orders had no ordered increments and timeframes for titrating the dose. Additional review revealed no documented evidence that a protocol had been placed on the chart.

1/29/18 6:00 p.m.: Dopamine 5 mcg/kg/min titrate to MAP (mean arterial pressure) greater than 60 and HR (heartrate) greater than 50. Further review revealed no ordered increments and timeframes for titrating the dose.

In an interview on 2/20/18 at 1:45 p.m. with S2DON, she indicated the hospital did have protocols for both Dopamine and Levophed Infusions and they should have been on the patient's chart. She agreed the nurse should have clarified the order by obtaining increments and timeframes for titration of the doses.

3) The RN failed to ensure an order was obtained to transfer a patient out to a higher level of care prior to transfer of the patient.

Review of Patient #23's medical record revealed an admission date of 1/26/18. Further review revealed the patient had been transferred acute out for a higher level of care (ICU) due to respiratory failure and sepsis on 1/29/18. Additional review revealed the patient also had new onset of seizures.

Review of the out of hospital transfer form completed when Patient #23 was transferred as an acute out to another hospital for a higher level of care due to Sepsis and Respiratory Failure on 1/29/18.

Review of Patient #23's physician's orders revealed no documented evidence that an order had been obtained to transfer the patient to a higher level of care on 1/29/18.

In an interview on 2/20/18 at 3:30 p.m. with S2DON, she confirmed she had reviewed the patient's medical record and had not found physician's orders for the patient's transfer to a higher level of care.





30984




34161

Based on record reviews and interview, the hospital failed to ensure the nursing staff developed and kept current an individualized comprehensive nursing care plan for each patient for 3 (#1, #13, #14) of 5 current patients reviewed for nursing care plans out of a total sample of 30 patients.

Findings:

Patient #1
Review of Patient #1's medical record revealed an admission date of 1/5/2018 with diagnoses that included Acute Respiratory Failure, Anxiety, Atrial Fibrillation and Cerebrovascular Accident affecting left non-dominant side. Further review of Patient #1's medical record revealed the patient had a tracheostomy and required mechanical ventilation.

Review or Patient #1's current Care Plan had not addressed the following nursing diagnoses: Impaired Physical Mobility, Inability to Sustain Spontaneous Ventilation, Self-Care Deficit and Swallowing Impairment that included goals, interventions and target completion date. Further review of the Care Plan revealed the nursing diagnosis: Infection was initiated, however had not identified Patient #1 having been infected with MRSA and the ordered type of isolation precaution.

Patient #13
Review of Patient #13's medical record revealed an admission date of 2/16/18 with diagnoses that included Anemia, Atrial fibrillation, Acute Respiratory Failure and Metabolic Acidosis.

Review of Patient #13's Care plan had not addressed the nursing diagnosis of Ineffective Breathing Pattern that included goals, interventions and target completion date.

Patient #14
Review of Patient #14's medical record revealed an admission dated of 1/10/18 with diagnoses that included Acute Tubular Necrosis, Acute/chronic Kidney Injury (Stage II), Pneumonia, IDDM, Acute Encephalopathy, Hypoxic Respiratory Failure, Metabolic Acidosis, Atrial Fibrillation, and Lung abscess. Additional review revealed Patient #13's medications included Aspirin, Lovenox, Plavix and Insulin.

Review of Patient #14's Care Plan had not addressed the nursing diagnoses of Alteration in Nutrition, Less than Body requirements, Fluid Volume Excess and Ineffective Breathing Pattern that included goals, interventions and target completion date. Further review of the care plan revealed the nursing diagnosis: Risk for Injury related falls had been initiated. However, the Risk for Injury had not addressed medication administration, altered clotting factors and supporting interventions.

In an interview on 2/20/18 at 12:30 p.m., with S2DON, she verified the Care Plan for Patients #1, #13 and #14 should have addressed the appropriate nursing diagnoses listed above along with the appropriate goals, interventions and target dates. S2DON explained the new care plan document was implemented on 2/15/18 and the nurses were not completely familiar with the paperwork.

Based on record review and interviews, the hospital failed to promptly retrieve in a timely manner, the complete medical record of patients who were treated in the hospital within the last 5 years as evidenced by failing to provide a closed medical record prior to September 1, 2017 due to being stored at an offsite location out of town.

Findings:

Review of the hospital's Restraint/Seclusion Death Report Worksheet revealed Patient #10 was admitted to the hospital on 8/31/17 and had expired on 9/2/17 while in Restraints.

Upon request of Patient #10's medical record on 2/20/18 at 8:30 a.m.via S1Adm and S3HIM, S3HIM stated the closed medical record was not currently available for review as the record was stored in Erving, Texas. S3HIM stated she would have to see about getting them. S1Adm explained the hospital had been under new management. S1Adm stated former management no longer wanted any of their property onsite including the patient's closed medical records prior to September 1, 2017.

In an interview with S1Adm on 2/20/18 at 4:45 p.m., she stated as of 4:30 p.m. before S3HIM reported off duty, she stated S3HIM had not received Patient #10's medical records.

On 2/21/18 at 8:41 a.m., after checking the status, S2DON stated Patient #10's medical records had not been received.

On 2/21/18 at 10:40 a.m., upon continued request for Patient #10's medical record, S3HIM stated she had followed up with the corporate staff. S3HIM reported "they were still working on getting Patient #10's medical records scanned or faxed".

Upon the exit of the survey on 2/21/18 at 12:30 p.m., Patient #10's medical record had not been received for review.

Based on observation and interview, the hospital failed to ensure all medical records were properly stored in secure locations where they were protected from water damage in the event that the sprinkler system in the storage room was activated. Findings:

Observation on 02/20/18 at 9:50 a.m. of the medical records room revealed approximately 113 paper folders containing patient records stored on open wooden shelves that were exposed to the sprinkler system in the room.

Interview on 02/20/18 at 9:55 a.m. with S3HIM confirmed that the patient records were not protected from water damage if the sprinkler system was activated.

Based on occurrence report reviews, record reviews, and interviews the hospital failed to ensure medication administration errors were documented in the patient's medical record and reported to the attending physician for 5 (#16, #17, #18, #19, #20) of 5 medical records reviewed for known errors from a total sample of 30 medical records. Findings:

Patient #16
Review of the hospital occurrence report dated 11/05/17 revealed the MAR for patient #16 documented Meropenem 1 gram IVPB was missed at 12:00 a.m., and was picked up and credited by the pharmacy.

Review of the medical record on 02/20/18 at 10:15 a.m. for patient #16 revealed no documentation of physician notification of the medication error in the medical record.

Patient #17
Review of the hospital occurrence report dated 12/18/17 revealed the MAR for patient #17 documented Vancomycin 1000 mg IVPB dose was missed at 4:00 a.m. and was picked up and credited by the pharmacy.

Review of the medical record on 02/20/18 at 10:25 a.m. for patient #17 revealed no documentation of physician notification of the medication error in the medical record.

Patient #18
Review of the hospital occurrence report dated 12/22/17 revealed the patient #18 was admitted at 6:00 p.m. on 12/22/17 and MAR documented Tylenol 500 mg every 8 hours, Zovirax 800 mg 5 times daily, Norvasc 5mg BID, Asorbic acid 500 mg BID, Sinemet 10-100 mg TID, Celexa 20 mg daily, Aricept 10 mg at bedtime, Doxycycline 100 mg BID, Artificial Tears 1 drop each eye TID, Hydrochlorothiazide 25 mg daily, Ritalin 5 mg daily, MVI daily, Metanx 2.8-2-25 mg daily, K-Dur 20 MEQ daily, Exelon patch 9.5 mg/24 hour daily, Requip 5 mg TID, Trusopt Ocumeter 2% TID, Alphagan 0.2% 1 drop each eye TID, and Vancomycin 750 mg IVPB every 8 hours and was not given until 12/23/17.

Review of the medical record on 02/20/18 at 10:35 a.m. for patient #18 revealed no documentation of physician notification of the medication error in the medical record.


Patient #19
Review of the hospital occurrence report dated 10/19/17 revealed the MAR for patient #19 documented Diflucan 800 mg IVPB first dose then 400 mg. 400 mg was given as first dose.

Review of the medical record on 02/20/18 at 10:45 a.m. for patient #19 revealed no documentation of physician notification of the medication error in the medical record.

Patient #20
Review of the hospital occurrence report dated 01/22/18 revealed physicians order for patient #20 to restart Lovenox 130 mg every 12 hours on 01/19/18. Lovenox was not restarted until 01/22/18, patient #20 missed 6 doses.

Review of the medical record on 02/20/18 at 10:55 a.m. for patient #20 revealed no documentation of physician notification of the medication error in the medical record.

Interview on 02/20/18 at 11:00 a.m. with S2DON confirmed that med errors/variances were not documented in the patients' medical record.

Based on record review and interview, the hospital failed to ensure food and dietetic services were under the direction of a full time employee, qualified by experience or training, as evidenced by the governing board failing to grant and approve a Director of Dietary Services.

Findings:

Review of the hospital's Governing Body meeting minutes dated 1/26/18 revealed no appointment of the Dietary Services director by the Governing Body.


On 2/20/18 at 11:02 a.m., an interview was held with S9RD. She stated she had been a contracted employee since September 2017. S9RD stated she was informed that she was the Dietary Service Director. However, S9RD stated she was not sure if her appointment had been approved by the governing board and medical staff for the operation of dietary services. When asked S9RD stated S8PT/DM was the dietary manager.

On 2/20/18 at 4:15 p.m., S1Adm explained stated S9RD over sought food services of the hospital and S8PT/DM ordered supplies for the hospital. However, S1Adm stated, at the end of the day, S8PT/DM was the Dietary Manager. When asked, S1Adm verified no one had been approved by governing board to serve as the hospital's Food Service Director.

Based on record review and interviews the hospital failed to ensure that technical personnel were competent in their duties. This failed practice was evidenced by the Director of Therapy services also titled as the Dietary Manager, supervised Registered Dieticians on staff and having no documented evidence of any education or specialized training in food services.

Review of S8PT/DM's personnel file revealed no documented evidence of a job description of Dietary Manager and training that included a ServSafe course.

On 2/20/18 at 9:43 a.m., an interview was held with S8PT/DM. He stated that he was the Director of Therapy Services and also the dietary manager. S8PT/DM stated he had been the dietary manager since 2012. When asked, S8PT/DM stated he had not received any training in dietary service. S8PT/DM explained as dietary manager his job duties included supervising and evaluating the Registered Dieticians on staff, informing S9RD of the nutritional supplies in need of replenishing and ensuring enough bottled water was ordered and available for emergency events.

On 2/20/18 at 4:15 p.m., S1Adm explained S9RD over sought the hospital's dietary services and S8PT/DM ordered supplies for the hospital. However, S1Adm stated, at the end of the day, S8PT/DM was the Dietary Manager. When asked, S1Adm verified S8DM/PT had not received training in dietary services.