HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure the medical staff was accountable for providing quality of care to patients. This deficient practice was evidenced by failure of the physician to follow La. R.S. (Louisiana Revised Statute) 9:111 and hospital policy relating to pronouncement of death. The physician failed to assess the irreversible cessation of spontaneous respiratory and circulatory functions and determining and pronouncement of the patient's death for 1 (#27) of 1 patients who expired while admitted to the hospital within the last 12 months from a total sample of 30 patient records. This deficient practice was also cited on the hospital's recertification survey on 7/30/15.

Findings:

Review of La. R.S. 9:111. Definition of death revealed, in part, "... A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions...". Added by Acts 1976, No. 233, §1; Acts 2001, No. 317, §1; Acts 2010, No. 937, §1, eff. July 1, 2010.

Review of the hospital policy titled, "Patient Death", presented as a current policy by S3HR, revealed a physician must pronounce a patient dead. The attending physician may delegate this to another physician who may be in the hospital at the time of death.

Review of Patient #27's medical record revealed he was an 88 year old male admitted on 3/12/18 with a diagnosis of Traumatic Brain Injury (TBI), Subdural Hematoma status post fall, and Acute Respiratory Failure status post tracheostomy (trach).

Review of Patient #27's discharge summary revealed S18MD documented the following: "On March 19, 2018, I received a call from the nursing staff alerting me that the patient had passed away. I was informed that the patient's trach was no longer in place. The patient was DNR, so CPR was not performed. EMS was called and on-call physician pronounced the patient's time of death. The family was later notified by hospital staff and consulting physicians were also notified."

Further review of Patient #27's entire medical record revealed no documented evidence that a physician was present to pronounce death as required by La. R.S. 9:111.

In an interview on 5/22/18 at 1:50 p.m. with S2DON, she reviewed entire medical record for Patient #27. S2DON also confirmed that Patient #27's death was not pronounced by a physician who was onsite at the time of death.

In an interview on 5/23/18 at 12:30 p.m. with S8CNA, she confirmed she had worked the night shift of 3/19/18. S8CNA further confirmed no physician had come to the hospital to pronounce Patient #27's death.

In a phone interview on 5/23/18 at 4:49 p.m. with S4RN, she confirmed she had worked the night shift of 3/19/18. S4RN further confirmed a physician had not come to the hospital to pronounce Patient #27's death. S4RN also reported she was unsure who determined Patient #27's time of death because there was some uncertainty about which physician should be called. S4RN reported she thought the paramedics may have called an area hospital physician who had been on call for the emergency medical service provider and that physician pronounced Patient #27's death/reported time of death via phone report.

30984


Based on record reviews and interviews, the hospital failed to ensure each physician/practitioner providing services in the hospital, including radiologists performing telemedicine (radiology) services, was credentialed and privileged in accordance with the Medical Staff By-laws for 3 (S10Rad, S12Rad, and S13Rad) of 3 (S10Rad, S12Rad, and S13Rad) Radiologist's signed imaging interpretations reviewed on 3 of 3 (#19, #21, # 24) medical records reviewed for radiology reports.

Findings:

Review of the Medical Staff Bylaws provided by S3HR, as current revealed, in part, the following:
Article III. Part B Categories of Membership, Section 3.11, Telemedicine, "Originating site (this facility)-Distant Site (contract entity)-Practitioners who provide health care services by means of electronic technology to patients shall not provide such services without first being granted privileges to do so and shall apply as denoted in these Bylaws. All telemedicine applicants will be reviewed and processed through the medical staff credentialing procedures and their credentialing information will be reviewed by the Medical Staff. Telemedicine practitioner's applications shall be processed in the same manner as mandated in Article V. Privileges." ...Article V, Part C, Other, 4. Exclusive Contracts, "A. Physicians whose sole practice at the Hospital is under benefit of an exclusive contract with the Hospital ( i.e. radiologists, pathologists, anesthesiologists) shall apply for Medical Staff Privileges and, if approved, shall be ranted Medical Staff appointment and privileges only for the purpose of fulfilling the term of their contract with the Hospital..."

Review of the list of credentialed/privileged physicians and practitioners, presented as current by S3HR on 5/21/18, revealed S10Rad, S12Rad, and S13Rad were not listed as credentialed/privileged radiologists providing teleradiology services for the hospital.

Patient #19
Review of the medical record for Patient #19 revealed she had a Left Ankle-2 views X-ray taken 12/06/17 by a contracted mobile X-ray company. Further review of the radiology report revealed the X-ray was read, interpreted, and electronically signed by S10Rad.

Patient #21
Review of the medical record for Patient #21 revealed an admission date of 10/25/17 and a discharge date of 12/8/17. Further review revealed the patient had a chest X-ray taken during her hospitalization by a contracted mobile X-ray company. Additional review of the radiology report revealed the X-ray was read and interpreted by S12Rad.

Patient #24
Review of the medical record for Patient #24 revealed he had a chest X-ray taken 5/2/18 by a contracted mobile X-ray company. Further review of the radiology report revealed the x-ray was read, interpreted, and electronically signed by S13Rad.

In an interview on 5/22/18 at 2:30 p.m. with S3HR, she confirmed there were no credentialing files for S10Rad, S12Rad, and S13Rad.

Based on record review and interview, the governing body failed to ensure all services furnished in the hospital, including contracted services, were performed in a safe and effective manner. This deficient practice was evidenced by failing to ensure all services, including contracted services, were included in the quality assurance and performance improvement (QAPI) program.

Findings:

Review of the list of the hospital's current contracted services, presented by S3HR, revealed the following services were provided via contract: Emergency Transport Services (ambulance), Organ Procurement Services, Stericycle Services, and Interpreter/Translator Services (language and for hearing impaired), and contracted therapist service provider (PT,OT, SLP,COTA, PTA).

Review of the hospital's QA plan revealed Emergency Transport Services (ambulance), Organ Procurement Services, Stericycle Services, and Interpreter/Translator Services (language and for hearing impaired), and contracted therapist service provider (PT,OT, SLP,COTA, PTA) were not included in the plan.

In an interview on 5/23/18 at 3:13 p.m. with S15QA, she confirmed the following services were not included in the hospital's QA plan: Emergency Transport Services (ambulance), Organ Procurement Services, Stericycle Services, and Interpreter/Translator Services (language and for hearing impaired), and contracted therapist service provider (PT,OT, SLP, COTA, PTA).

Based on record review and interview the hospital failed to ensure grievance decisions were provided in writing to patients (or their representative) and included the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This deficient practice was evidenced by no documented evidence of Grievance response letters for 7 of 7 patient grievances for 2018 reviewed for written decisions provided to the patient/patient representative.
Findings:

Review of hospital policy No: I-A.1.11 (last reviewed 6/17) revealed a Grievance was a written or verbal concern that could not be resolved at the time of the complaint by the staff present, was postponed for later resolution, referred to other staff for later resolution, and required investigation and/or further action for resolution. Further review revealed the procedure included, in part, if the grievance could not be achieved within 5 business days, the Director of Social Services or case manager would alert the Director of Nursing or Hospital Administrator to assist with the resolution. If, by the 7th day the grievance still could not be resolved the patient or their representative would be sent a written letter informing them that the investigation was still underway and a letter of resolution would be sent to them within 21 days by the Director of Social Services. Further review revealed an Addendum B titled Patient Grievance Investigation Form, that documented Each grievance would be investigated and resolved within 7 days. IF grievance cannot be resolved within 7 days a follow-up letter will be sent to the patient (or representative) communicating that the investigation was still underway and that they would receive a resolution letter within 21 days, containing the named of the hospital contact person, steps taken to investigate, results of investigation, as appropriate, and completion date.

Review of hospital policy #CM1.21, titled "Patient Rights", provided by S3HR as current, revealed under #27, "The patient has a right to voice a complaint/grievance to the hospital and/or the Department of Health and Hospitals and have that complaint/grievance investigated within a reasonable amount of time, usually five (5) days. This is to be followed by a letter to the patient or their representative identifying the results of the investigation and the corrective actions that has been taken."

On entry to the survey 5/21/18 a list of requested documents for surveyor review which included a Grievance log for the last year was submitted to the hospital. No grievance log was provided by 5/23/18 at 8:30 a.m.

Review of the grievance binder for 2018, provided by S17SW on 5/23/18, revealed 3 grievances in January, 1 grievance in February, 1 grievance in March and 2 grievances in April. Further review of the logs and grievance forms revealed no documented evidence that a resolution letter had been provided or sent to the patient (or their representative).

In an interview 5/23/8 at 9:10 a.m. S17SW reported that the grievances were usually handled by the Case Manager, who was out this week and not available for interview. She reported she did not know if there were resolution letters or where they would be if there were letters.

In a phone interview 5/23/18 at 1:10 p.m. S15QA reported that she was ultimately responsible for grievances, but they were usually handled by the staff at this hospital. She reported that in her experience the Case Manager would send letters. S15QA was advised that no grievance resolution letters were provided. She was also advised that on review of the hospital grievance policy and procedure did not specify that a resolution letter with the required components would be sent upon completion of the grievance process/investigation for all grievances, although the Patient Rights policy did include the process of sending a letter identifying the results of the investigation and the results that had been taken. S15QA advised that the surveyor must not have the most current policy and that she would send it through S3HR. S3HR provided a copy of the policy sent by S15QA, and a review revealed it was the same policy previously provided to the surveyor. The policy did not say ALL grievances would be followed up by a letter of resolution with the required components.

Based on record reviews and interviews, the hospital failed to ensure that the "Do Not Resuscitate" policy was implemented for 1 (#27) of 1 total patients who had expired while admitted to the hospital within the last 12 months from a total sample of 30 patient records. The physician failed to obtain an evaluation of the patient from a consulting physician to determine if a DNR (Do Not Resuscitate) order was medically appropriate and to document a discussion with the patient or patient representative relative to DNR. This deficient practice was previously cited on the recertification/relicensure survey on 7/30/15.

Findings:

Review of the hospital policy titled, "Do Not Resuscitate", presented as a current policy by S3HR, revealed the purpose of the policy was to establish procedures when decisions concerning DNR or "Terminal care" orders must be made. Decisions to withhold CPR must be supported by clinical evidence of irreversible illness, which is reasonably expected to result in the patient's death. Such evidence shall be reviewed by at least two physicians who are part of the medical staff. The physician should document his plan of care in the progress note. The physician shall then place an order for "DNR". If the patient is incompetent, this discussion must be held with the patient's family or legal guardian. All codes shall be maximum resuscitation efforts until the physician running the code directs the team to cease with CPR efforts.

Review of Patient #27's medical record revealed he was an 88 year old male admitted on 3/12/18 with a diagnosis of Traumatic Brain Injury (TBI), Subdural Hematoma status post fall, and Acute Respiratory Failure status post tracheostomy (trach). Patient #27 was on contact isolation for MRSA of the sputum.

Further review of Patient #27's medical records revealed S18MD documented an admission history and physical (signed 3/13/18) indicating the following, in part: "The patient is able to nod "yes" and "no" appropriately to questions with minor delay." ... "Expected length of stay is approximately 2 to 3 weeks."

Review of Patient #27's Nursing Notes revealed the following entries by S4RN:
3/19/18 at 9:55 p.m.: Upon entering room noted patient was not breathing; Called for assist and code cart; Unable to feel carotid or brachial pulse; Trach lying in bed bedside patient; Attempted chest compressions started - LPN attempted to ambu (ventilation with a bag manually) patient with face mask, while trach site was covered-attempt unsuccessful trach replaced times 1 attempt, chest compressions continued, ambu'd per trach by S8CNA; Remembered patient was a DNR, CPR stopped, S20LPN, while CPR was in progress, had called 9-1-1, MD, S2DON, and S18MD to notify of change in patient condition.
3/19/18 at 9:10 p.m.: EMS (emergency medical services) arrived entered patient room.
3/19/18 at 9:15 p.m.: Area police department arrived.
3/19/18 at 10:26 p.m.: Pronounced dead per Dr. [blank line left and no signature charted.].

Review of Patient #27's discharge summary revealed S18MD documented the following: "On March 19, 2018, I received a call from the nursing staff alerting me that the patient had passed away. I was informed that the patient's trach was no longer in place. The patient was DNR, so CPR was not performed. EMS was called and on-call physician pronounced the patient's time of death. The family was later notified by hospital staff and consulting physicians were also notified."

In an interview on 5/22/18 at 1:50 p.m. with S2DON, she reviewed entire medical record for Patient #27. S2DON verified there was a verbal order for admission orders written on 3/12/18 at 4:00 p.m. by S2DON and co-signed by MD on 3/13/18 at 4:05 p.m. Included in these admission orders was the box checked to indicate DNR. S2DON verified this finding and stated the order for DNR would be invalid according to their policy because the order was not signed by the physician within 24 hours. S2DON also verified there was no documentation, in the chart, of communication regarding discussion of Patient #27's DNR status with Patient #27 or his family members during the patient's hospital admission (from 3/12/18 - 3/19/18). S2DON further stated she did not witness communication between the physician and the family regarding DNR status of Patient #27.

Based on record reviews and interviews, the hospital failed to ensure:
1) Opportunities for improvement identified during the survey had been identified through its QAPI program as evidenced by:

a) Failure to ensure the medical staff was accountable for providing quality of care to patients as evidenced by failure of the physician to follow La. R.S. (Louisiana Revised Statute) 9:111 and hospital policy relating to pronouncement of death. The physician failed to assess the irreversible cessation of spontaneous respiratory and circulatory functions and determining and pronouncement of the patients' death for 1 (# 27) of 1 total patients who expired while admitted to the hospital from a total sample of 30 patient records.

b) Failure to ensure that each physician/practitioner providing services in the hospital, including radiologists performing telemedicine (radiology) services, was credentialed and privileged in accordance with the Medical Staff By-laws for 3 of 3 (S10Rad, S12Rad, and S13Rad) Radiologist's signed imaging interpretations reviewed on 3 of 3 (#19, #21, # 24) medical records reviewed for radiology reports resulting in patient care services being provided by physicians who were not currently credentialed and privileged as members of the Medical Staff.

2) Failure to thoroughly investigate an unanticipated death (Patient #27) as a sentinel/adverse event in order to identify possible causative factors/devise an action plan to be addressed through the hospital's QA/PI program.

Findings:

Review of the hospital's Quality Improvement Strategic Plan revealed in part: Program Methodology: To have an approach to clinical and service quality improvement that is consistent with the scientific principles of PDCA (Plan Do Check Act). Further review revealed the following: Plan: recognize opportunities and plan a change. Involves identifying top priorities for improvement, data to be collected, and individuals responsible for various performance improvement. Do: Test the change: Involves what processes need to be fixed or redesigned, and determining possible causes of identified issues in these processes. Check: Review the change: Involves gathering and analyzing data to determine if a process is producing desired results. Are we doing the right thing? Are we doing the right thing well? Act: Involves developing action plans, assigning responsibilities, providing education, and putting actual improvements in place. Patient focused functions include: Provision of patient care, treatments and services ....patient safety. Quality indicators: Indicators are developed to measure and monitor the performance and stability of processes used in delivering patient care and associated outcomes. Special attention will be given for those processes that are high risk, high volume, problem-prone. The QA/PI plan includes identifying and implementing opportunities to improve the quality of patient care, measuring, analyzing, and tracking quality indicators and other aspects of performance that assess process of care, hospital services, and operations.
Regulatory Compliance: Adverse events as defined by OIG and HHS are monitored at this hospital. All adverse events that occur will be documented into the Incident Reporting System and will be reported to HHS as appropriate. A comprehensive root cause analysis will be conducted by the Quality/Risk Director for any adverse event occurrence.

1. a) Failure to ensure the medical staff was accountable for providing quality of care to patients as evidenced by failure of the physician to follow La. R.S. (Louisiana Revised Statute) 9:111 and hospital policy relating to pronouncement of death.

Review of La. R.S. 9:111. Definition of death revealed, in part, "... A. A person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions...". Added by Acts 1976, No. 233, §1; Acts 2001, No. 317, §1; Acts 2010, No. 937, §1, eff. July 1, 2010.

Review of the hospital policy titled "Patient Death/Organ Donation", presented as a current policy by S3HR (Human Resources), revealed a physician must pronounce a patient dead. The attending physician may delegate this to another physician who may be in the hospital at the time of death.

Review of Patient #27's medical record revealed no documented evidence that a physician was present to pronounce death.

In an interview on 5/23/18 at 3:13 p.m. with S15QA, she reported she had not been aware that Patient #27 had not been pronounced by direct examination of a physician at the time of his death. She confirmed failure of a physician to assess Patient #27 in order to pronounce death had not been identified as an area in need of improvement to be addressed through the hospital's QA/PI plan.

1. b) Failure to ensure that each physician/practitioner providing services in the hospital, including radiologists performing telemedicine (radiology) services, was credentialed and privileged in accordance with the Medical Staff By-laws.

Review of the Medical Staff Bylaws provided by S3HR, as current, revealed, in part: Article III. Part B Categories of Membership, Section 3.11, Telemedicine, "Originating site (this facility)-Distant Site (contract entity)-Practitioners who provide health care services by means of electronic technology to patients shall not provide such services without first being granted privileges to do so and shall apply as denoted in these Bylaws. All telemedicine applicants will be reviewed and processed through the medical staff credentialing procedures and their credentialing information will be reviewed by the Medical Staff. Telemedicine practitioner's applications shall be processed in the same manner as mandated in Article V. Privileges." ...Article V, Part C, Other, 4. Exclusive Contracts, "A. Physicians whose sole practice at the Hospital is under benefit of an exclusive contract with the Hospital ( i.e. radiologists, pathologists, anesthesiologists) shall apply for Medical Staff Privileges and, if approved, shall be granted Medical Staff appointment and privileges only for the purpose of fulfilling the term of their contract with the Hospital..."

Review of the list of credentialed/privileged physicians and practitioners, presented as current by S3HR on 5/21/18, revealed S10Rad, S12Rad, and S13Rad were not listed as credentialed/privileged radiologists providing tele-radiology services for the hospital.

Patient #19
Review of Patient #19's medical record revealed S10Rad had read and interpreted an ankle X-ray taken 12/06/17 by a contracted mobile X-ray company.

Patient #21
Review of Patient #21's medical record for revealed an admission date of 10/25/17 and a discharge date of 12/8/17. Further review revealed S12Rad had read and interpreted a chest X-ray taken contracted mobile X-ray company during her hospitalization.

Patient #24
Review of Patient #24's medical record revealed S13Rad had read and interpreted a chest X-ray taken 5/2/18 by a contracted mobile X-ray company.

Review of the hospital's QA/PI plan revealed no documented evidence that failure to have all radiologists credentialed and privileged who performed tele-radiology services had been identified problem to be addressed through the hospital's QA/PI plan.

In an interview on 5/22/18 at 2:30 p.m. with S3HR, she confirmed there were no credentialing files for S10Rad, S12Rad, and S13Rad.

2) Failure to thoroughly investigate an unanticipated death (Patient #27) as a sentinel/adverse event in order to identify possible causative factors.

Review of the hospital's incident reports/deaths for 2017 - 2018, provided by S3HR, revealed Patient #27 had been admitted to the hospital for rehabilitation services on 3/12/18 and had expired on 3/19/18.

Review of Patient #27's medical record revealed an admission date of 3/12/18 with admission diagnoses of Traumatic Brain Injury, Subdural Hematoma status post fall, and Acute Respiratory Failure status post tracheostomy (trach). Patient #27 was on contact isolation for MRSA (Methicillin-Resistant Staphylococcus Aureus) of the sputum [bacterial infection to tracheal secretions that is resistant to many antibiotics].

Further review of Patient #27's medical records revealed S18MD documented an admission history and physical (signed 3/13/18) indicating the following, in part: "The patient is able to nod yes and no appropriately to questions with minor delay." ... "Expected length of stay is approximately 2 to 3 weeks."

Review of Patient #27's Nursing Notes revealed the following entries by S4RN:
3/19/18 at 9:55 p.m.: Upon entering room noted patient was not breathing; Called for assist and code cart; Unable to feel carotid or brachial pulse; Trach lying in bed beside patient; Attempted chest compressions started - LPN attempted to ambu patient with face mask, while trach site was covered-attempt unsuccessful trach replaced times 1 attempt, chest compressions continued, ambu'd per trach by S8CNA; Remembered patient was a DNR, CPR stopped. S20LPN, while CPR was in progress, had called 9-1-1, MD, S2DON, and S18MD to notify of change in patient condition.
3/19/18 at 9:10 p.m.: EMS (emergency medical services) arrived entered patient room.
3/19/18 at 9:15 p.m.: Area police department arrived.
3/19/18 at 10:26 p.m.: Pronounced dead per Dr. [blank line left and no signature charted.]

Review of Patient #27's physician's orders revealed a telephone order, taken by S2DON, indicating Patient #27 was DNR status (a box denoting DNR had been checked). The telephone order had not been signed off within 24 hours, by the licensed practitioner, as required by hospital policy making the order void. S2DON confirmed failure of the licensed practitioner to sign off on a verbal DNR order within 24 hours made the order void per hospital policy.

In an interview on 5/22/18 at 10:35 a.m. with S2DON, she reported a root cause analysis had been initiated related to the above referenced unanticipated death of Patient #27. S2DON further reported she had not completed the root cause analysis because S15QA (corporate compliance) had informed her a root cause analysis had not been required because the patient had been DNR status.

In an interview on 5/23/18 at 3:13 p.m. with S15QA, she confirmed Patient #27's unanticipated death had been considered an adverse event even though the patient had been DNR status. S15QA indicated any adverse event, including an untoward medical event that causes injury or death required a root cause analysis. S15QA reported S2DON had begun an investigation into the sequence of events and had stopped because the patient had been DNR status. S15QA indicated continuance of the process had been the expectation. She said their PI process was to look at the event, identify causative factors, and to develop a corrective action plan. S15QA indicated a physician mortality review should also have been conducted.

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:
1) failure to ensure hospital RN coverage was maintained on the day shift of 2/9/18 to assure the immediate availability of a registered nurse for bedside care of any patient 24 hours a day/7 days a week;
2) failure to verify a patient's DNR status/DNR orders prior to performing CPR for 1 of 1 (#27) total patient death records reviewed from a total patient sample of 30 records reviewed;
3) failure to obtain and document weights as ordered by the physician for 3 (#1, #2, #6) of 6 (#1, #2, #3, #4, #5, #6) medical records reviewed for weights from a total patient sample of 30 records reviewed; and
4) failure to document discharge/transfer orders for 2 (#22, #23) of 6 (#21, #22, #23, #24, #25, #28) records reviewed for discharge/transfer orders from a total patient sample of 30 records reviewed.

Findings:

1) Failure to ensure hospital RN coverage was maintained on the day shift of 2/9/18 to assure the immediate availability of a registered nurse for bedside care of any patient 24 hours a day/7 days a week.

Review of the hospital's incident reports for 2017 and 2018, provided by S3HR, revealed on the day shift of 2/9/18 S16RN left the hospital, without notifying S2DON. S16RN's departure from the hospital premises left the hospital with no RN coverage in her absence.

Review of the staffing schedule for the day shift of 2/9/18 revealed there were 10 inpatients on the unit and S16RN had been the only RN on the schedule for that shift. S2DON confirmed S16RN had been the only RN remaining on shift that day as she (S2DON) had already left for the day when the incident occurred.

In an interview on 5/22/18 at 2:02 p.m. with S2DON, she confirmed the hospital staffed with one RN per shift. S2DON confirmed on the day shift of 2/9/18 S16RN had left the hospital without notifying her (the DON) and had not called in any other RN to maintain RN coverage at the hospital in her absence. S2DON reported S16RN had assumed she (S2DON) was still in the hospital when she left the premises. S2DON reported S16RN had left near the end of her shift, due to personal reasons, and had been seen at an area drugstore by S3HR when she was scheduled to be working (day shift of 2/9/18). S2DON was unable to provide the time the nurse left the hospital or how long she had left the patients unattended by an RN. S2DON confirmed S16RN had been the only RN remaining on shift that day as she (S2DON) had already left for the day when the incident occurred.

2) Failure to verify a patient's DNR status/DNR orders prior to performing CPR.

Policy review of "Do Not Resuscitate", presented as a current policy by S3HR revealed), revealed the purpose of the policy was to establish procedures when decisions concerning DNR or "Terminal care" orders must be made. Decisions to withhold CPR must be supported by clinical evidence of irreversible illness, which is reasonably expected to result in the patient's death. Such evidence shall be reviewed by at least two physicians who are part of the medical staff. The physician should document his plan of care in the progress note. The physician shall then place an order for "DNR". If the patient is incompetent, this discussion must be held with the patient's family or legal guardian. All codes shall be maximum resuscitation efforts until the physician running the code directs the team to cease with CPR efforts.

Review of Patient #27's medical records revealed an admission history and physical signed 3/13/18 by S18MD which documented, "The patient is able to nod yes and no appropriately to questions with minor delay." ... "Expected length of stay is approximately 2 to 3 weeks."

Review of Patient #27's medical record revealed S18MD documented the following discharge summary: "On March 19, 2018, I received a call from the nursing staff alerting me that the patient had passed away. I was informed that the patient's trach was no longer in place. The patient was DNR, so CPR was not performed. EMS was called and their on-call physician pronounced the patient's time of death. The family was later notified by hospital staff and consulting physicians were also notified."

In an interview on 5/22/18 at 1:50 p.m. with S2DON, she reviewed Patient #27's entire medical record. S2DON verified there was a verbal order for admission orders written on 3/12/18 at 4:00 p.m. (taken by S2DON) and co-signed by MD on 3/13/18 at 4:05 p.m.

Further review of Patient #27's admission orders revealed a box was checked to indicate the patient was DNR status. S2DON verified this finding and stated the verbal order for DNR would have been invalid according to their policy because the order was not signed by the physician within 24 hours.

S2DON also verified, after review of Patient #27's medical record, there was no documentation in the medical record of communication with Patient #27 or Patient #27's representative/family regarding discussion of appropriateness of DNR status during the patient's hospital admission (3/12/18 - 3/19/18). S2DON further stated she had not witnessed communication between the physician and the family regarding DNR status of Patient #27.

In an interview on 5/23/18 at 4:49 p.m. with S4RN, she confirmed she was the charge nurse and the primary nurse assigned to Patient #27. S4RN walked into Patient #27's room a while after suctioning him and S4RN saw that Patient #27 was not breathing and Patient #27's trach was out in the bed next to Patient #27. S4RN indicated she had yelled to them (the staff) to come and help her, to call 9-1-1, and to bring the code cart. Patient #27's color was very pale. S4RN stated she started chest compressions on Patient #27 right away. S4RN stated she put the trach back in Patient #27 and it went in easy. S4RN stated she felt for a femoral pulse and there was no pulse. S4RN stated she had not known how long Patient #27 had been like that (not breathing). S4RN stated S20LPN was at the desk, S20LPN called 9-1-1 and she called S2DON. S4RN stated S20LPN told her Patient #27 was a DNR. S4RN stated, "I had forgotten but I stopped doing CPR as soon as S20LPN told me Patient #27 was a DNR."


3) Failure to obtain and document weights as ordered by the physician

Patient #1
Review of the medical record for Patient #1 revealed she was admitted to the hospital on 5/10/18 for rehabilitation services following a CVA (Cerebrovascular Accident) with left hemiparesis. Other diagnoses for Patient #1 included Hypertension, Abdominal Aortic Aneurysm, Chronic Kidney Disease stage 4-5, Congestive Heart Failure and diastolic dysfunction, Paroxysmal Atrial Fibrillation, and Non-insulin Dependent Diabetes. Review of Patient #1's admission orders included an order for weights on admission and daily. Further review of the patient's medical record revealed no documented weights for 5/18/18 , 5/19/18, and 5/20/18.

In an interview 5/21/18 at 2:15 p.m. S2DON verified weights were not documented for 5/18/18, 5/19/18, 5/20/18 . S2DON verified the physician ordered daily weights for Patient #1.

Patient #2
Review of the medical record for Patient #2 revealed she was a 56 year old female admitted to the hospital on 5/17/18 with a Rehabilitation Diagnosis of Critical Illness Myopathy. Other diagnoses for Patient #2 include Type 2 Diabetes, Chronic Kidney Disease, stage 3, Transient Ischemic Attack, Congestive Heart Failure, and Cerebral Infarction without residual deficits. Review of Patient #2's admission orders included an order for daily weights. Further review of the patient's medical record revealed no documented weights for 5/20/18, 5/21/18, 5/22/18.

In an interview 5/22/18 at 4:00 p.m. S2DON verified weights were not documented for 5/20/18, 5/21/18, 5/22/18. S2DON verified the physician ordered daily weights for Patient #2.

Patient #6
Review of the medical record on 5/22/18 for Patient #6 revealed he was a 26 year old male admitted on 5/11/18 for rehabilitation with a history of Intracranial Abscess, Hypertension, and Malnutrition.

Additional review of Patient #6's medical records on 5/23/18 at 10:30 a.m. revealed no documented weights for 5/22/18 or 5/23/18, verified by S2DON on 5/22/18.

In an interview on 5/22/18 at 4:06 p.m. with S2DON, she verified the medical records for Patient #6 had no weights documented on the chart. S2DON also verified the patient has a diagnosis of malnutrition. S2DON further verified the physician had ordered daily weights for Patient #6.

In an interview on 5/23/2018 at 10:45 a.m. with S5Dietician, she agreed Patient #6 (admitted with a diagnosis, in-part, of malnutrition) should have been weighed as ordered on admit and weekly to monitor the patient's nutritional status.


4) Failure to document discharge/transfer orders.

Review of hospital policy #HW.14.5 titled, "Transfer of Patients to Another Level of Care", provided by S3HR as current, revealed in part that "once there is an order to transfer the patient, the charge nurse will make the appropriate call to the emergency transport team."

Patient #22
Review of the medical record for Patient #22 revealed he was admitted 1/9/18 for rehabilitation therapy, following a surgical repair of a fractured femur, and discharged 1/18/18. Further review of his medical record revealed he was transferred to an ED at a local acute care hospital for a change in condition 5/11/18, returned to the rehabilitation hospital, and was discharged 1/18/18 to a nursing facility. Review of physician orders revealed no documented physician's orders for his transfer to the ED for evaluation.

Patient #23
Review of the medical record for Patient #23 revealed she was admitted 2/21/8 for therapy to help her regain her lost strength and functional mobility following an acute care hospitalization in a critical care unit. Her admitting diagnoses included Critical illness myopathy, COPD, Bilateral pulmonary effusion, Schizophrenia, Dysphasia, impaired ADLs, gait, and functional mobility. Further review revealed she was transferred to a local ED when she developed acute respiratory distress with tachycardia and stridor. Further review of her medical record revealed no documented transfer or discharge orders.

In an interview 5/21/18 at 3:55 p.m. S2DON verified no transfer orders were on the records for Patient's #22 and #23.



30984







39791

Based on record review and interview, the Hospital failed to ensure identified medication variances were documented in the patient's medical record for 2 ( #29, #30 ) of 2 hospital identified medication variances reviewed.

Findings:

Patient #29
Review of the hospital's medication variance/incident report list revealed the following 2 medication variances related to administration of Labetalol:

Patient #29 had an order to receive Labetalol 200 mg by mouth every 4 hours with instructions to hold for systolic blood pressure less than 110 mg/Hg. Patient received 1 dose on 9/6/17 in the a.m. with blood pressure below parameters. Dose to be administered on 9/5/17 at midnight was not documented as having been given and there was no supportive documentation to indicate why the dose had not been given as ordered .

Review of Patient #29's medical record revealed no documented evidence that the medication variance was documented in the record. Further review revealed no documented evidence that the physician had been notified of the medication variances.


Patient #30
Review of the hospital's medication variance/incident report list revealed on 2/15/18 Patient #30 had been administered Colace stool softener by mouth and the patient had been NPO outside of ST therapy trials at the time it was administered. Further review revealed no documented evidence that the physician had been notified of the medication error.

In an interview on 5/23/18 at 9:20 a.m. in with S2DON, she confirmed the medication errors referenced above (Patients #29 and #30) would not have been documented in the patient's medical record. S2DON indicated it was not the hospital's policy to document medication errors in patient medical records upon discovery. S2DON indicated staff documented medication errors on incident reports and she confirmed the incident reports were not a part of the patients' permanent medical record.

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call feature located on the handrails of 6 of 19 current inpatient beds.

Findings:

On 5/23/18 at 1:00 p.m. an observation was made of the hospital beds currently in use. During the observation a nurse call feature ( a red cross) was noted on the handrail of the patient bed. S2DON verified, during the observation, that the nurse call feature on the bed handrail in room 160 was non functional (demonstrated by S2DON during the observation). The room also had a corded nurse call bell, attached to the wall, that was functional.

In an interview on 5/23/18 at 1: 30 p.m. S2DON reported 6 of the 19 current patient beds in use had the non-functional nurse call feature on the handrail. She agreed she could see how patients with traumatic brain injuries and memory impairments could become confused and use the non-functional call feature to call for assistance.

Based on record review, observation, and interview the infection control officer failed to ensure the hospital's system for controlling infections was implemented by hospital staff. This deficient practice was evidenced by:
1) observed breeches in hand hygiene and glove use by staff;
2) failure to maintain a sanitary environment; and
3) failure to ensure contracted housekeeping staff were educated and knowledgeable on infection control practices, proper techniques for disinfecting isolation rooms, and correct dwell time for disinfection agents used.
Findings:

1) Breeches in hand hygiene and glove use by staff.

Review of CDC guidelines for Hand Hygiene in Healthcare Settings revealed, in part, hand hygiene should be performed after contact with inanimate objects in the immediate vicinity of the patient, and after glove removal.

An observation 5/21/18 at 10:35 a.m. revealed S7PT assist Patient #10 to a wheelchair and transport him to the gym for physical therapy. After the patient was in the wheelchair in his room, S7PT was observed to manipulate the Foley catheter drainage tube, draining urine into the collection bag, using his ungloved hands. S7PT then wheeled the patient to the adjoining hallway and into the therapy gym. S7PT was observed to lock the wheelchair into position, then walked to the hallway to speak with surveyors. S7PT did not perform any hand hygiene during or after manually touching the patient's catheter tubing, or transporting him to the gym. In an interview at the same time, S7PT verified he had touched the catheter tubing without gloves, and had failed to perform hand hygiene. S7PT verified he should have used gloves to touch the catheter tubing, and should have performed hand hygiene after he touched the catheter tubing, before touching the wheelchair handles or anything else.

2) Failure to maintain a sanitary environment.

Observations during a tour of the hospital 5/21/18 from 9:45 a.m. to 10:45 a.m. revealed infection control breeches than included the following:
-a wide shower chair with a covered pad that contained tears and breaks in the plastic covering, leaving the inner padding exposed to contamination;
-a step stool with a tall metal handle on one side which had parts of torn paper stuck to the metal with adhesive, and residual adhesive on the rest of the handle. The edges of the paper and the residual adhesive was soiled a brown color;
-Patient Room (not currently occupied) with dust and small dark brown particles in the window sill,
-Dialysis bathroom:: soiled towels left on floor under sink area, and 1 of 3 sharps boxes full;
-file cabinet in nursing station, next to nutrition room with soiled areas in a "drip" pattern down the side, which was easily removed by S2DON using a cleaning/disinfecting wipe.

3) Failure to ensure contracted housekeeping staff were educated and knowledgeable on infection control practices, proper techniques for disinfecting isolation rooms, and correct dwell time for disinfection agents used.

In an interview 5/22/18 at 1:58 a.m. S14HK was asked how long the dwell time was for the disinfecting agent she was using to clean and disinfect the hospital. She reported she left it on for a bit. She retrieved the cleaning agent from her housekeeping cart and on review of the directions it was discovered that the cleaning agent should be left wet for 10 minutes. She said that was good to know. When asked what she used to clean rooms of patients in isolation, such as Clostridium Difficile, or C-diff, she reported she didn't know what that was. She was asked if she used a bleach based product, she reported that they (the contracted housekeeping staff) were not allowed to use bleach. S14HK said she did not remember getting training on these topics.

In an interview 5/22/18 at 11:20 a.m. S9IC reported she was not aware that the contracted housekeeping staff did not have the adequate infection control training required, and would ensure training was accomplished.