HospitalInspections.org

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Based on interview and record review, the facility failed to ensure confidentiality of patient information in the medical record.

Failure to maintain confidentiality in patient medical records risked divulging personal patient information without the patient's consent.

Findings:

On 2/24/2016 between 9:40 and 11:50 AM, Surveyor #5 toured Ward HMH/W1N and W1S. The surveyor reviewed the record for Patient #11. The surveyor found two entries in the record, (dated 11/22/2015 and 1/6/2016) that referred to another patient (Patient #12) by name and medical record number. At the time of the review, the Nursing Supervisor (Staff Member #1), confirmed the finding.
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Based on record review, the facility failed to obtain a valid physician's order for restraint use.

Failure to obtain a valid order risked restraining a patient without physician evaluation and prescription.

Findings:

On 2/22/2016 at 2:00 PM on Ward C-3, Surveyor #5 reviewed the medical record of Patient #13. The record documented that this patient had been in restraints on 12/10/2015 from 3:55 PM to 8:30 PM. The record contained a notation that the restraint order had been renewed via a telephone order at 7:55 PM per regulatory requirement. However, more than 2-1/2 months following this notation, the order had not been verified (signed, dated, or timed) by the physician.

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Based on interview and review of the hospital's quality program and quality documents, the hospital failed to develop and implement effective performance improvement plans and projects related to data collection and analysis to support goals that the hospital's Governing Body approved in November 2015.

Failure to measure, analyze and track data related to projects based on identified areas of concern revealed in quality data, resulted in an unsafe healthcare environment.

Findings:

1. On 3/2/2016 at 3:08 PM, Surveyor #1 interviewed the Performance Improvement Project manager (Staff Member #29) about the six identified performance improvement "charters" developed and approved through the Governing Body with oversight through the hospital's Quality Program. The charters included: Improving the hospital's Culture of Safety, Reduction in patient-to-patient assaults, Reduction in hours that patients are in restraints or seclusion, Increase in active treatment hours for patients, and Analysis of adverse and near miss events. During the interview, Staff Member #29 explained that s/he tracks each charter through an "action tracker"; a document that identifies tasks to support each strategy within the charter, the status of each task, the report of the status, the report date, the expected outcomes and the next steps. Surveyor #1 reviewed the action tracker for each charter and observed the following:

a. The charter for "Increase in active treatment hours for patients" had only been presented to the Governing Body for approval on 1/8/2016. Data from the action tracker indicated there had been no report on the status of this project since 1/28/2016.

b. The charters for "Patient-to-patient assaults" ,"Reduction in seclusion and restraint hours", and "Patient-to-staff assaults" had deliverables that only included a report and a plan. There was no evidence of project development that included monitoring for progress towards the stated goal, identification of specific project data collection and no defined measurable goals.

2. On 2/22/2016, between 3:15 and 4:30 PM, during the Governing Body meeting, the Department of Quality Management presented a document that included analysis of the Plan of Correction (POC) impact on the areas of restraint and seclusion, physical assaults, and active treatment hours. Although the purpose of each of these analyses was to determine the impact of proposed interventions on the desired outcome (reduction in hours for seclusion/restraint, reduction in physical assaults, and increase in active treatment hours), the summary statement for each analysis stated, "Note that the analysis provides information regarding changes in the variable(s) of interest, not which intervention was responsible for the change." At the time of the meeting, there was no documentation of an analysis plan that examined the results of individual interventions and their effect on desired outcomes.

3. On 2/24/2016 between 1:30 and 4:15 PM, Surveyors #1 and #3 reviewed the quality program with hospital staff. The Research Manager (Staff Member #31) confirmed that the current data analysis did not allow the quality department to determine which interventions contributed to the reported results. Staff Member #31 also reported that at present, there was no sub-setting of the data to allow for tracking and trending of individual wards within each center.

4. The charter for "Near miss/adverse events" deliverable #2 stated,"The Quality Management Department will convene a group to conduct a Performance Improvement Project related to NME (near miss events) including Medication Errors. This group will be convened by January 31, 2016." However, review of the Quality Council minutes contained no evidence that near miss and adverse medical events identified by the Medication Variance Team received monitoring or oversight from the Quality Council.

Cross Reference: Tags A0286, A0385, A0405

5. The charter for the "Culture of safety " action tracker had a line item that stated,"The Quality Management Audit Team will incorporate two questions regarding Culture of safety in their weekly audits on the wards. The information will be used to monitor the Culture of safety. Under the "Expected Outcome" column for this strategy it stated, "Data gathered as a result of the audit is meaningful and contributes to resolving issues around the culture of safety" . There were no described steps in the document to demonstrate how the Quality team will analyze the data or how the results might provide a meaningful contribution to improving the culture of safety in the hospital.

6.On 2/24/2016, between 1:30 and 4:30 PM, during a meeting to review the hospital's quality program, the Quality auditor (Staff Member #30) indicated that data collection occurred on 100 percent of wards every month with rounding occurring on 1 to 4 wards every day. When Surveyor #3 asked how they were evaluating the collected data, Staff Member #30 indicated they had not conducted any analysis on the results, since they had only collected 294 responses.

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Item #1- Patient Identification

Based on observation, interview, document review, and review of hospital policies and procedures, the hospital failed to ensure all hospital staff members followed its procedure for identification of patients prior to medication administration.

Failure to follow the hospital's patient identification policy places patients at risk of injury or death.

Findings:

1. The hospital's Nursing Services Standards manual under the policy titled "PATIENT IDENTIFICATION PHOTOGRAPHS" (Procedure 242) (Revised August 2015), read in part: "In order to enhance patient safety and to improve the accuracy of patient identification, a patient's picture can be used as one of two patient identifiers when administering medications, treatments, and obtaining clinical testing specimens. A patient's photograph will be obtained during admission, readmission, and any time during hospitalization when appearance changes to the extent identification is jeopardized."

The hospital's medication policy manual under the subsection titled "Patient Identification" (Revised May 2015) read:
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"1.0 PURPOSE

To provide a method for identification of patients prior to administration of medications. A minimum of two patient identifiers shall be used when administering medications.
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2.0 PATIENT PHOTOGRAPH MANAGEMENT
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All patients shall have a photo taken upon admission or readmission and any time a patient's appearance changes to the extent that identification is jeopardized (WSH Policy 4.1.11). Cache Web has a process for any user to request a new photo, if necessary. The patient's photo appears on their MediMAR computer profile.
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3.0 PATIENT IDENTIFICATION PROCEDURE
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A minimum of two patient identifiers shall be used prior to administering medication. The following are acceptable patient identifiers: 3.1 Compare patient with photograph ensuring match 3.2 Assign staff familiar with the patients to assist the medication nurse who may not be familiar with patients' identities 3.3 Ask the patient his/her name and check it against the MAR 3.4 Ask the patient his/her birth date and check it against the MAR 3.4 Provide wristband identification (mostly used in PTRC East) 3.6 Identifying mark (tattoo, mole, etc.) A second staff shall be present with the patient when a medication needs to be administered to the patient away from the medication room."
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The hospital policy and procedure titled "Patient Identifiers (including Photograph)" (Revised 2/26/2016), under the section titled "Procedure" read in part: "1. All patients will have their photograph taken during the admission or readmission procedure. Patients have a right to be informed of the reason for and use of the photographs: a. To provide identification for receiving treatments prescribed. b. To assist staff persons unfamiliar with the patient's identity. c. To provide a means for identification during disaster or ward evacuation situations, such as fire, earthquakes. d. to provide a means for identification as needed in situations such as unauthorized leave (UL) or escape. 2. The patient photograph is displayed in the electronic MAR (MediMAR), the patient clinical record, electronic database . . . The patient photographs will be placed before patient's medication administration record (MAR) on wards which utilize paper MARS. . . 3. Patients may not refuse to have their photograph taken. . .4. Retaking of photographs will occur under the following circumstances: a. Changes in the patient ' s physical appearance. b. Loss, damage, or destruction of the photograph(s). c. Update annually if patient remains in hospital. . Other Identifiers Acceptable 1. Patient Name: staff must ask the patient to give their first and last name (Do not state "you are Bob Jones, aren't you"). 2. Date of Birth: staff must ask the patient to give their date of birth. 3. Medical Record Number: staff may confirm medical record number with name given. 4. Another staff member that is familiar with the patient."


2. On 2/22/2016 at 11:15 AM on Ward C-3 Surveyor #5 observed a Licensed Practical Nurse (LPN) (Staff Member #18) perform a blood glucose test. The LPN called Patient #14 by his/her first name rather than asking the patient to state full name, and used no other method of identification prior to the test. Results of the test determined the insulin dosage the staff member administered to the patient.

3. On 2/22/2016 at 11:30 AM on Ward C-3 Surveyor #5 observed a LPN (Staff Member #19) administer a medication to Patient #14. The LPN called the patient by his/her first name and asked for the last name, rather than asking for the full name consistent with hospital policy. The LPN did not employ a second form of identification prior to giving the medication. The LPN indicated there was no photo available to help identify the patient who had been admitted three days ago.
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4. On 2/22/2016 at 11:45 AM on Ward C-3 Surveyor #5 observed a LPN (Staff Member #19) administer an insulin injection to Patient #14. The surveyor observed that the LPN failed to use any means of identifying the patient prior to administering their medication.
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5. On 2/23/2016 at 9:35 AM on Ward C-3, a Nursing Supervisor (Staff Member #23) told Surveyor #5 that the hospital had obtained a photograph for Patient #14, subsequent to a previous conversation with the surveyor about its absence. The supervisor stated that the nurse should have "gotten it done" previously. Staff Member #23 told the surveyor that there were problems getting photos done due to lack of staffing.
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6. On 2/22/2016 between 3:10 and 3:30 PM on Ward C-3, Surveyor #5 observed a LPN (Staff Member #24) administering medications to 12 patients. The LPN called the patients by their first name rather than asking the patients to state their full name as required by hospital policy. On 2/25/2016 at 4:00 PM, Surveyor #5 interviewed Staff Member #24 about her observations regarding medication administration. The staff member indicated that what the surveyor had observed was his/her routine method of identifying patients. S/he indicated that the hospital sometimes took up to two weeks to provide a photo for new patients. Staff Member #24 acknowledged that s/he had made a medication error in the past by giving the wrong medications to a patient due to their resemblance to another patient.
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7. On 2/23/2016 between 3:30 and 4:00 PM on Ward C-7, Surveyor #5 observed a LPN (Staff Member #20) give medications to 8 patients. During the first observation, the staff member used the photograph and patient's first name rather than asking the patient's full name prior to giving the medication as required in hospital policy. For the remaining patients, Surveyor #5 observed the staff member using the patients' first names only and inconsistently referred to the patients' identification photographs while administering medication. On 2/25/2016 at 4:45 PM, in subsequent interview with Staff Member #20, s/he indicated that s/he sometimes called the patients by their full names (rather than asking them to state their full name as required by hospital policy).
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8. On 2/25/2016 at 11:10 AM on Ward E-2, Surveyor #5 observed a LPN (Staff Member #17) perform a point of care blood glucose testing for two patients. These tests formed the basis for determining how much insulin if any, the patients would receive. In both cases, the staff member called the patients by their first name, rather than asking them to state their full name, and did not use any other form of identification as required by hospital policy.
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9. On 3/3/2016 at 10:00 AM, Surveyor #2 reviewed a document that displayed the status of the hospital's patient identification photographs. Surveyor #2 noted that 367 patients had identification photographs that were over 1 year old; 24 patients had identification photographs not taken during this current admission; 3 patients with missing identification photographs; and 2 patients who had refused to have an identification photograph taken.
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Item #2- Safe Medication Practices
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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to adhere to safe medication practices for 1 of 1 patients (Patient #4).
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Failure to follow safe medication practices risks patient safety and medication errors.
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Findings:
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1. The hospital's medication policy manual under the subsection titled "Medication Administration" (Revised May 2015) read in part: "The medication nurse shall use the MAR and compare with the Pyxis screen to ensure the accuracy of the dose and time of medication administration. Medications that are in unit dose (UD) packaging shall remain in the UD package until administration for proper medication identification. . . . Setting up medication in advance of medication pass is unacceptable . . . The medication nurse shall: . . . Identify the patient prior to administration using two patient identifiers . . . Verify that there is no contraindication(s) for administering the medication . . . Discuss any unresolved, significant concerns about the medication with the patient's physician and/or relevant staff involved with the patient's care . . . Immediately following administration and prior to proceeding to the next patient, document medication administration according to MP 70:02."

2. On 2/25/2016 at 9:30 AM, Surveyor #2 reviewed the daily nurse manager report dated February 24, 2016. The report indicated that Patient #4 had received his medications as well as a peer's medications during the previous evening. A review of the SBAR Intershift report for the off-going evening shift for Ward F-2 for Patient #4 under the section titled "MEDICAL CONCERNS" read in part: "(S) PATIENT RECEIVED PEER'S MEDICATION AS WELL AS HIS OWN. (B) PEER'S MEDICATION INCLUDED DEPAKOTE, WHICH PATIENT HAD ADVERSE REACTION TO IN THE PAST. (A) PATIENT ACTIVE IN DAY AREA . . . MOD AND POD NOTIFIED . . . POISON CONTROL CONTACTED-ADVISED EKG. MOD ORDERED STAT EKG AND ACTIVATED CHARCOAL 50 GRAMS NOW. . ."
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3. On 2/25/2016 at 3:30 PM on Ward F-2, Surveyor #2 interviewed the licensed practical nurse (LPN) (Staff Member #11) about the medication error involving Patient #4. Staff Member #11 indicated that around 7:05 PM, Patient #4 came to the medication window requesting his/her evening medications. The staff member stated, "I have gotten in the habit of pre pouring his/her meds. Familiarity breeds complacency." Staff Member #11 acknowledged that s/he pre pours or prepares medications ahead of their scheduled time routinely for nine patients and places them in the patient's unit dose medication drawer until they are ready for administration. Surveyor #2 asked Staff Member #11 to describe the sequence of events that led to the medication error and its subsequent discovery. The staff member related the following information:

a. Staff Member #11 stated, "I know exactly how it happened. I got in a hurry. We have fights when the patients are in line. I try to get it (sic - the line) moving."

b. The staff member indicated that he/she pulled medications from Patient #5's unit dose drawer and gave them to Patient #4 noting that the two drawers are right next to each other.

c. Staff Member #11 gave the next patient in line their medications, and then proceeded to go back and record the medications that s/he gave to Patient #4 on his/her medication administration record rather than recording the information at the time of administration as required by hospital policy.

d. Staff Member #11 recognized s/he had given Patient #4 the medications ordered for Patient #5. Approximately five minutes later, Staff Member #11 called Patient #4 back to the medication window and administered his/her ordered scheduled medications. S/he then notified the charge nurse (Staff Member #13) of the medication error.

e. The charge nurse contacted the psychiatrist on call and the medical officer (hospitalist) of the day about the medication error. The charge nurse received treatment and monitoring orders for Patient #4. The charge nurse also contacted the nursing house supervisor (Staff Member #14).

f. Staff Member #11 finished passing the remaining scheduled evening medications for the ward's patients. The staff member remained the medication nurse for the rest of the evening shift.

g. Near the end of the shift, Staff Member #11 indicated that Patient #4 came to the medication window requesting two prn (as needed) medications (diphenhydramine, an antihistamine and benztropine, an anti-tremor medication) which Patient #4 commonly requested prior to bedtime. The staff member gave those requested medications to Patient #4 without informing the charge nurse even though earlier s/he had given the patient activated charcoal as a treatment order for the medication error. Staff Member #11 stated, "I did not check with the RN prior to giving the prn medications." The staff member indicated that Patient #4 appeared to be behaving normally and s/he had no concerns about possible additional side effects from the medication error that had occurred earlier in the shift.
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4. On 2/25/2016 at 4:30 PM on Ward F-2, Surveyor #2 reviewed the medical records and medication administration records of Patient #4 and #5 and noted the following:
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a. The charge nurse (Staff Member #13) wrote a nursing note on 2/24/2016 at 8:30 PM indicating the medication nurse notified the charge nurse that Patient #4 received his/her medications along with Patient #5's medications.
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b. The staff notified the on call physician, who ordered treatment and monitoring for the patient.
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c. Hospital staff members contacted Poison control who recommended giving activated charcoal, fluids, and obtaining an electrocardiogram. In addition, poison control indicated the patient will "most likely be sleepy" and that hospital staff will need to monitor him/her for hypotension (low blood pressure) and tachycardia (fast heart rate).
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d. Staff Member #13 reported Patient #4 presented as "lethargic" but awake and alert to person, place, and time. The registered nurse noted the "Patient stated he feels "loopy" and "I am probably gonna be rolling around later".
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e. A staff physician internist (Staff Member #5) progress note dated 2/24/2016 at 9:18 PM confirmed that Patient #4 received another patient ' s medications (Patient #5) in addition to his/her own. Patient #4 's regular evening medications included olanzapine 30mg (an antipsychotic), lithium 600mg (mood stabilizer), haloperidol 10mg (an antipsychotic), clonazepam 0.5mg (a sedative) and benztropine 1mg (an anti-tremor medication). Patient #15's evening medications included risperidone 4mg (an antipsychotic medication), quetiapine 400mg (an antipsychotic medication), and divalproex 750mg (an anticonvulsant and mood stabilizer).
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f. Physician orders written between 8:10 PM and 9:16 PM included: administering 50 grams of activated charcoal; obtain a stat electrocardiogram; to check neurological status with vital signs every hour for 4 hours then every 4 hours until evaluated by ward physician; to push fluids; monitor intake and output every shift; and to notify physician if systolic blood pressure falls below 90 mm Hg or if heart rate exceeds 100 beats a minute.
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g. A brief physical examination by the physician (Staff Member #15) described Patient #4 as alert, ambulatory, in no acute distress with blood pressure of 156/89, pulse 94, respiratory rate of 20 and pulse oximetry of 98 percent oxygen saturation with neurological exam within normal limits. Patient was monitored throughout the night without any further sequela.
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5. On 2/26/2016 at 10:00 AM, Surveyor #2 requested the pyxis automated medication dispensing station access reports for Ward F-2 between the hours of 3:00 PM and 12:00 AM. A review of that report indicated that Patient #5's scheduled medications for 8:00 PM were removed from the pyxis automated medication dispensing station at 6:32 PM, an hour and 28 minute before they were due to be administered in non-compliance with hospital policy which required staff members to remove medications just prior to administration to the patient.
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Based on observation, interview, and review of policy and procedures, the hospital failed to designate a qualified infection preventionist(s) to ensure an active hospital -wide infection control program.

Failure to ensure a qualified infection control professional risks delayed prevention, control, and investigations of infections and communicable diseases.

Findings:
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1. On 2/24/2016 at 8:15 AM, Surveyor #4 reviewed credentials for the current infection control preventionists, Staff Member #8 and #9, both registered nurses.
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2. Review of the job descriptions for Staff Member #8 and #9 revealed no requirements for infection control training or experience.
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3. Review of education for Staff Member #8 and #9 revealed that both staff members completed the 2015 on-line, hospital-wide infection control training provided to all staff.

4. On 2/24/2016 at 8:15 AM, Staff Member #8 and #9 along with the Chief Nursing Officer (Staff Member #32) revealed to date, neither staff member #8 nor staff member #9 had completed training on principles and practices related to implementing and maintaining an infection control program. Staff Member #32 reported that there are plans for Staff Member #9 to attend the APIC (Association of Professionals in Infection Control and Epidemiology) conference summer of 2016.
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Based on interview, document review and review of quality documents, the hospital failed to ensure that the Chief Executive Officer, Medical Staff and Director of Nursing reported and implemented activities and interventions identified through the infection control program as part of the hospital's overall quality program.

Failure to have oversight for infection control activities and responsibility for implementation of corrective actions to address infection control problems, puts patients, staff and visitors at risk of communicable disease and healthcare-acquired infections.

Findings:

1. The hospital's Infection Prevention and Control Committee meeting minutes from 3rd Quarter 2015 and 4th Quarter 2015 includes the following description of the reporting structure for the committee: "Minutes of the Infection Prevention and Control Committee are recorded and filed with the Patient Care Committee. Activities for any monitoring and evaluation are included in the minutes and are discussed in the Patient Care Committee."

The Patient Care Committee minutes from the 1/28/2016 meeting included documentation of the meeting minutes from the 12/15/2015 Infection Control Committee Meeting. The Infection Control Committee meeting minutes included the following line items:
Areas Identified for Improvement:
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- Increase influenza vaccination compliance rate by WSH employees to 50%.
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- Improve hand hygiene compliance rate by WSH Employees to 100%.
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- Improve the TB screening compliance rate by WSH employees to 100% as required.
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Plan for Improvement:
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- Update Infection Control manual and policies with Infection Control Committee.
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- Increase education regarding missed opportunities with employee hand hygiene. DOH/CMS citations provided guidance with implementing educational tools for staff.
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- Determine barriers and develop improvement strategies to increase employee annual TB screening compliance. Collaborate with WSH leadership regarding strategies to increase compliance with employees and existing staff.
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There was no evidence in the Patient Care Committee meeting minutes to indicate the committee reviewed or discussed the Infection Prevention and Control meeting minutes or provided monitoring or evaluation of any of the identified areas for program improvement.
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The hospital's plan of correction, submitted on 2/2/2016 stated, "The CNO will report status of the Infection Control action plan based on the recommendations of the consultant and discuss any concerns with progress to Quality Council monthly."
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2. Between 3/1/2016 and 3/3/2016, Surveyor #3 reviewed the 2016 Quality Council meeting minutes, which included the meetings held in January and February. There was no documentation in the minutes to indicate that either the Patient Care Committee or the Director of Nursing had provided the Quality Council with a report on the status of the Infection Control Program or its activities.

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3. On 3/3/2016 at 10:50 AM, Surveyor #3 interviewed the hospital's Medical Director (Staff Member #27) and the hospital's Quality Director (Staff Member #28) regarding the implementation of action items developed by the infection control department. Staff Member #28 stated, "Only problems identified in Patient Care Committee get reported to Quality". Staff Member #27 indicated that the Patient Care Committee meeting agenda is not presented in a way that people know how to move forward and that they had not yet developed the format.


Cross Reference: Tag A0286

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