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Based on interview, record review and policy review, the facility failed to ensure there was an effective, ongoing, hospital-wide, data driven Quality Assurance/Performance Improvement (PI) program, responsible to the Governing Body, which could reduce medical errors and improve patient care. This affects the quality of care for all patient services. The facility census was 27.

See the following citations:

- A0274 regarding failure of the hospital to incorporate Performance Improvement data collected from cardiopulmonary services, nursing services (such as medication erros and infection control) and pharmacy (regarding missed dosages of medications) into the facility-wide PI program and to monitor the effectiveness of the services and quality of care for all patients;
- A0275 regarding failure of the facility to ensure PI data was used to monitor the effectiveness and implementation of effective actions to improve patient care services, and ensure all medication errors were reported by nursing;
-A0287 regarding failure of the facility to analyze the causes of medication erros through the PI process to address the underlying cause and promote changes to improve patient safety and medical care for all patients; and
-A0309 regarding failure of the hospital's leadership, including the Governing Body, medical staff, and administrative staff to have an active PI program since December 2010 and failure to address priorities for improved patient care through annual review of the PI program.

The cumulative effect of this systemic practice resulted in the facility's non-compliance with 42 CFR (Code of Federal Regulations) 482.21 Condition of Participation: Quality Assessment and Performance Improvement Program.

Based on interview, review of facility complaint log and policy review, the facility failed to classify unresolved complaints as grievances for two of seven complaints reviewed. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Complaint/Grievance" dated 06/10/09, showed:
-A grievance is defined as a formal or informal written or verbal complaint that is made by the patient, or the patient's representative regarding the patient's care or alleged abuse or neglect. -Grievances include patient care complaints that cannot be resolved at the time of the complaint by staff present, are postponed for later resolution, require investigation or further actions for resolution.
-The co-worker receiving the complaint initiates the notification and documentation process by informing their Manager who will enter the complaint information into an event log.
-All patient complaints will be addressed as quickly as possible with appropriate follow up, resolution and communication with the patient or the patient's representative.
-If the grievance will not be resolved or if the investigation is not or will not be completed within seven days, the hospital will inform the patient or patient's family that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response no later than 30 days from the receipt of the grievance.

2. Review on 03/16/11 of the complaint log showed a complaint made by Patient #37 dated 01/24/11. The patient complained of delayed pain medication administration and general poor nursing care. The log showed the manager logged the complaint on 01/24/11. The complaint log showed the current status of the complaint as open.

3. Review on 03/16/11 of the complaint log showed a complaint made by a family member of Patient #38 dated 01/25/11. The family member complained staff did not get the patient out of bed and up to a chair for three days, delayed pain medication administration and general poor nursing care. The log showed the manager logged the complaint on 01/25/11. The complaint log showed the current status of the complaint as open.

4. During an interview on 03/16/11 at 3:25 PM, Staff A, Administrator, stated the two complaints would now be considered grievances since the issues were not resolved at the time of the complaints. Staff A stated there is no evidence of any investigation of the complaints or any communication with the complainants of the two grievances.

Based on interview, review of Governing Board Bylaws and policy review, the facility failed to formally designate a committee to be responsible for patient grievances. The facility census was 27.

Findings included:

Record review of the facility's policy titled,"Complaint/Grievance" dated 06/10/09, showed:
-The Grievance Committee will meet monthly if there are any grievances that require further review by the committee.
-The Grievance Committee Members are the Medical Director, the Chief of the Medical Staff, the Administrator, Nursing Administration and the Manager of Quality Services.

However, record review of the Governing Board Bylaws showed no delegation of patient grievance responsibiities to a committee to review and resolve grievances.

During an interview on 03/17/11 at 11:30 AM, Staff E, the Director of Accreditation and Licensure, stated that he/she was unable to find any reference to grievance committee delegation in the Governing Board Bylaws.

Based on observation and record review, the facility failed to ensure patient's privacy when it displayed patient information in the patient rooms. This had the potential to affect all patients when information regarding personal information and status of their medical condition was available to others not responsible for their medical care needs. The facility census was 27.

Findings included:

1. Review of the "Statement of Patient Rights and Responsibilities", dated October 2007, showed each patient has the right to security and personal privacy and confidentiality of information.

2. Observation on 03/14/11 at 2:15 PM showed charge sheets (which showed items for which the patients would be charged) were placed in patient rooms. The charge sheets were labeled with a patient sticker that included the patient's name and date of birth. The charge sheets were accessible to anyone entering each patient's room.

3. Observation on 03/14/11 at 2:40 PM, showed clipboards in patient rooms accessible to anyone entering patient rooms. The clipboards contained patient information including: Respiratory Care Flowsheet, Patient Assessment, Intake and Output and vital signs.


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4. Observation on 03/14/11 at 3:45 PM, in Patient #5's room showed a clipboard located just inside the room. The clipboard was easily removed from a wall pocket and accessible to anyone entering the patient's room. The clipboard contained the patient's vital sign sheet, intake and output record, daily weights, and patient labels containing the patient's name, date of birth, and age.

5. Observation on 03/14/11 at 3:55 PM, in Patient #4's room showed a clipboard located just inside the room. The clipboard was easily removed from a wall pocket and accessible to anyone entering the patient's room. The clipboard contained the patient's vital sign sheet, intake and output record, daily weights, and patient labels containing the patient's name, date of birth, and age.

Based on observation, interview, and policy review, the facility failed to ensure one of two crash carts (a mobile cart that contained medication, supplies, and equipment used to resuscitate a patient who was no longer breathing) were maintained with a suction machine ready for use. This had the potential to affect any patient on whom staff would have to use it on a patient who had difficulty or was not breathing. The facility census was 27.

Findings included:

Record review of the facility's policy titled, "Crash Cart Maintenance" dated 06/10, showed the following direction:
- The equipment is maintained in a ready condition for immediate use.

However, observation on 03/14/11 at 3:17 PM, on the patient hall designated by the facility as "Lilac Hall", showed a crash cart. On the top of the crash cart was a portable suction machine (used to clear the airway in order to delivery breaths). Staff D, Charge Nurse, was asked to demonstrate the function of the suction machine. When Staff D turned on the suction machine, there was no suction created from the port that would lead to the patient, making it inoperable. After further investigation, it was noted that a piece of connection tubing from the machine to the collection canister was missing.

Based on interviews, record review and policy review, the facility failed to immediately investigate an abuse allegation for one (#6) patient of two abuse allegations reviewed and failed to protect all patients by not removing an alleged perpetrator from patient care pending the completion of an internal investigation. By allowing an alleged perpetrator to remain in the facilty, the hospital failed to protect 27 of 27 patients from potential abuse. The facility census was 27.

Findings included:

1. Review of the facility's policy RI 1400 titled, "Abuse and Neglect Reporting" dated 06/10/09, showed the following direction:
-To ensure that patients, particularly the elderly and disable patient who, due to physical or mental incapacitation, require protective services to their safety and welfare are reported.
-Co-workers are required to report suspected incidents of Abuse or Neglect against any Elderly or Disabled Patient to the Missouri Department of Health and Senior Services (DHSS).
-Co-workers will report witnessed abuse/neglect, alleged abuse/neglect and signs of suspected abuse/neglect. Alleged abuse and neglect is considered any reports from family members, patients, co-workers of abuse and/or neglect. These reports must be reported even if the co-worker does not believe the allegation is true.
-All hospital co-workers including contract and agency staff must report abuse and neglect to the charge nurse and/or their manager immediately. (Immediately is defined as five minutes).
-The alleged staff member (s) will be escorted from the hospital premises pending further investigation.

2. Record review showed current Patient #6 entered the facility 02/16/11 for treatment of end stage renal disease on hemodialysis (a method for removing waste products as well as water from the blood when the kidneys are in failure).

Review of the facility abuse/neglect self-report dated 03/02/11 made to the Missouri Department of Health and Senior Services showed on 02/27/11 at 8:50 AM, Patient #6 reported to Staff EE, Respiratory Therapist, that a staff member, Staff II, working the previous shift hit him/her on the hand with a rubber mallet. The self-report showed the facility did not start the investigation until 02/28/10 at 10:00 AM, more than 24 hours after the patient alleged abuse by the staff.

Review of the facility Abuse/Neglect Checklist showed staff notified the unit manager on 02/28/11 of the allegation made by Patient #6. The checklist also showed the facility did not notify the family/POA (power of attorney) of the patient until 12 Noon on 02/28/11, more than a day after the patient first reported it to facility staff.

During an interview on 03/15/11 at 10:35 AM, Staff J, Registered Nurse, stated that he/she worked with Patient #6 during the night of 02/26/11. Staff J stated that he/she could not remember the exact time, but at approximately 3:00 AM on 02/27/11 the patient told Staff J that the tech (technician), Staff II, hit him/her on the hand when he/she (the patient) reached for something. Staff J stated that Staff II was a good tech and he/she didn't see any bruising on the patient's hands. Staff J stated, "I didn't report it because I didn't see anything." Staff J stated that staff are only required to report an allegation of abuse or neglect if they witness the abuse. Staff J stated that he/she did not chart anything related to the patient's allegation of abuse.

During an interview on 03/16/11 at 3:40 PM, Staff EE, Respiratory Therapist, stated that he/she was in Patient #6's room around 9:00 AM on 02/27/11 and the patient kept rubbing the back of his/her hands. Staff EE stated that the patient sstated that every time he/she touched something a staff member hit his/her hands with a mallet. Staff EE stated he/she saw no signs of bruising and the patient seemed confused. Staff EE stated that he/she reported what the patient had said to the day nurse, Staff L, Registered Nurse, RN.

During an interview on 03/16/11 at 11:00 AM, Staff L, RN, stated that Staff EE told him/her on the morning of 02/27/11 around 9:50 AM, that Patient #6 stated that a staff member hit him/her. Staff L stated that an agency sitter had been with the patient throughout the night. Staff L stated that if the agency sitter had still been on duty he/she would not have allowed that person to be around patients. Staff L stated that the agency sitter left at the end of the night shift, before Staff EE told him/her of the allegation made by the patient. Staff L stated that he/she interviewed the patient about the allegation and the patient stated that the sitter had hit his/her hands with a mallet. Staff L stated that he/she did not document the interview with the patient. Staff L stated that he/she did not see any injuries to the patient. Staff L stated that he/she did not chart any assessment of the patient.

During an interview on 03/16/11 at approximately 2:30 PM, Staff M, Registered Nurse, stated that he/she was the charge nurse on the unit the night of 02/26/11. Staff M stated that the patient had a sitter from a staffing agency, Staff II, in the room the entire shift. Staff M stated that the sitter, Staff II, left at the end of the night shift at approximately 7:30 AM on 02/27/11. Staff M stated that he/she did not know of the abuse allegation until the day charge nurse, Staff L, called him/her at home the morning of 02/27/11. Staff M stated that no staff member reported any issues with Patient #6 during the night.

During an interview on 03/16/11 at 10:30 AM, Patient #6 stated that a staff member had hit his/her knuckles with a mallet on the night shift a week or so ago. The patient stated that his/her knuckles didn't bleed, but they were bruised. Observation during the interview showed no discoloration of either hand. Patient #6 stated that it could have been a dream. During the interview the patient was oriented to name and place, but not time.

Based on interview, record review and policy review, the facility failed to ensure one patient (#9) of seven patients interviewed remained free from a threat by staff of use of a restraint . The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Restraints", dated 10/07/09, showed the following direction:
- To ensure restraint use is driven by acute medical problems, medical necessity, never used in place of staff, and never used as a means of coercion, discipline, convenience, or retaliation by the staff.

Record review of the facility's policy titled, "Patient Rights and Responsibilities", dated 11/05, showed the following direction:
- Each patient at the hospital has the following rights and responsibilities: Restraints - the right to be free from restraints or confinement of any form that is not medically necessary or is used as a means of coercion, discipline, convenience, or retaliation by staff.

2. During an interview on 03/15/11 at approximately 9:15 AM, Patient #9 stated that he/she was admitted on 03/11/11 and had a rough time the first night adjusting to the ventilator, and the nurse told him/her that if he/she didn't settle down, the nurse would put him/her in restraints. Patient #9 stated that he/she was not put in restraints, but felt threatened.

Review of Patient #9's medical record showed a telephone order written 03/12/11 at 1:38 AM, by Staff J, Registered Nurse, for, "Restrain Bil [bilateral] Mitten on". However, the order did not include the name of the physician name who telephoned the order to staff or a physician signature, showing the physician authenticated the order. Further review showed an order written by a physician on 03/12/11 at 1:40 AM, to, "D/C [discontinue] Restraints."

During an interview on 03/15/11 at 3:45 PM, Staff C, Director of Patient Care, stated that he/she would not expect a nurse to tell a patient that if they didn't settle down they would be restrained. Staff C agreed that was a threat. Staff C confirmed the telephone order for the restraint did not include the physician's name and was not signed by the physician.

Based on interview, record review and policy review, the facility failed to obtain a physician's order for each episode when a patient was restrained for one (#1) patient of three restraint records reviewed. The facility census was 27.

Findings included:

1. Review of the facility's policy TX 7100 titled, "Restraints", revised July 2009, showed the following direction:
-The purpose is to provide a structure for the use of restraints that protects and promotes each patient's right, physical and psychological safety and promotes medical healing. To ensure restraint use is driven by acute medical problems, medical necessity, never used in place of staff, and never used as a means of coercion, discipline, convenience, or retaliation by the staff.
-Use of restraint is initiated only by an individual order attained from a licensed independent practitioner which may be the patient's primary or consulting physicians, all of which are members of the medical staff. The order shall be received and recorded by hospital personnel as per hospital policy for receiving orders.
-In the absence of the patient's physician, a trained RN [registered nurse] may initiate restraint use based upon the documented assessment of the medical need. The patient's physician shall be notified immediately and a physician order will be obtained.

2. Observation on 03/17/11 at 10:30 AM, showed Patient #1 in bed with restraints on both wrists.

Review of the medical record found Patient #1's restraint order on 03/17/11 showed an order for bilateral (both) wrist restraints dated 03/16/11. Review of the restraint flow sheet showed Patient #1 in bilateral wrist restraints on 03/16/11 until 9:00 PM. The flow sheet showed Patient #1 not in restraints after 9:00 PM, but placed back in bilateral wrist restraints on 03/17/11 at 1:00 AM.

Review of physician's orders showed no restraint order on 03/17/11 for bilateral wrist restraints.

Staff placed Patient #1 in bilateral wrist restraints for nine and one half hours without a physician's order.

During an interview on 03/17/11 at 10:35 AM, Staff H, Registered Nurse, stated the staff placed the patient in restraints because the patient was pulling at his/her tubes. Staff H confirmed that staff placed the patient in restraints without obtaining a new order from the physician.

Based on policy review, record review and interview, the facility failed to ensure that an order for a restraint was not written as a PRN (as needed) order for one patient (#22) of three restraint orders reviewed. The facility census was 27.

Findings included:

1. Review of the facility's policy TX 7100 titled, "Restraints", revised July 2009, showed the following direction:
-The purpose is to provide a structure for the use of restraints that protects and promotes each patient's right, physical and psychological safety and promotes medical healing. To ensure restraint use is driven by acute medical problems, medical necessity, never used in place of staff, and never used as a means of coercion, discipline, convenience, or retaliation by the staff.
-Orders for restraint on an as needed basis (prn) ARE NOT [facility punctuation] permitted.

2. Current record review for Patient #22 showed a physician's order dated 03/14/11 at 9:30 AM, for the following:
-May use wrist restraints or mittens as needed to keep patient safe.

3. During an interview on 03/15/11 at 10:45 AM, Staff Y, Physician, stated that he/she did not know a restraint could not be ordered as needed.

Based on interviews and policy review the facility failed to ensure an ongoing Performance Improvement (PI) program was implemented and maintained by the Governing Body, the medical staff and the administrative staff - the leadership of the hospital - by not having an active PI program since December 2010, and the facility failed to address priorities for improved patient care through annual review. This failure of a significant hospital system which will identify problems regarding patient care and services can adversely affect the quality of care for all patients in the facility. The facility census was 27.

Findings included:

1. Review of the "Performance Improvement Plan" showed:
-The goal of the plan is to develop and sustain a health care service structure in which the processes that contribute to patient outcomes and satisfaction are continuously assessed and improved. This is accomplished by focusing on outcomes of treatment, care and services.
-The hospital collects data to answer questions about its current performance, check for continued stability in existing processes, determine opportunities and changes that lead to improvement, and to monitor PI (performance improvement) efforts for sustained effect.
-Information from data analysis is used to make changes that improve performance and patient safety and reduce the risk of sentinel events. Priorities are established and changed in response to undesirable variation, as appropriate by hospital leadership with input from MEC (Medical Executive Committee), staff and standing committees.
-An annual evaluation of the organizational PI plan is conducted to assess the overall effectiveness of the organization's PI processes. The evaluation includes reviews of all aspects of the program with emphasis on determining whether the program has demonstrated improvements in the quality of care and services that are provided by the organization. The annual evaluation includes: an assessment of how the years goals and objective were met, the impact of the PI process on improving healthcare and service to the patient, identification of barriers to achieving goals and recommendations for PI program revisions and modifications resulting from the evaluation. The annual evaluation is reviewed and approved by the Board of Directors. The results of the PI plan evaluation are used to develop and prioritize the annual PI plan for the upcoming year.

2. During an interview on 03/17/11 at 9:45 AM, Staff E, Director of Accreditation and Licensure, stated that there was a PI meeting held in December 2010, but the previous person in charge of PI was no longer employed by the facility and the notes from the December meeting are not available to the facility. There has been no PI meeting since December. The person responsible for collecting and establishing PI plans for nursing was no longer employed by the facility.

Staff E and Staff A, Administrator, stated that the decision was then made that the PI program would be put on hold until a new director could be appointed. However, no director had been appointed by the time of the survey.

Staff E stated that there has been no annual evaluation of the PI plan, which would result in assessing which of the data criteria would be eliminated from the monitoring and improvement process and which data would be added.

The facility has not maintained a PI program since December 2010.

See A275 regarding:
- Lack of consistent progress regarding weights of patients receiving dialysis;
- Lack of reporting seven of nine indicators for cardiopulmonary services since September 2010;
- Potential lack of consistent and accurate reporting of medication errors (including extra doses and wrong doses of medications administered to patients), and omitted medications;
- Lack of consistency to address pain intervention and reassessment with improvment still needed in at least three of the areas; and
- Lack of consistent achievement for documentation of blood product administration for three criteria.

Based on interview and record review, the facility failed to provide a daily bath to five (#4, #5, #10, #9 and #23) of five patients' records reviewed for hygiene. This failure has the potential to promote poor circulation and infection. The facility census was 27.

Findings included:

1. During an interview on 03/14/11 at 3:55 PM, Patient #4 stated that he/she had not been bathed daily or assisted with a bath daily.

Review of Patient #4's medical record on 03/15/11 showed no documentation of him/her receiving a bath on 03/14/11, 03/13/11, 03/11/11, 03/10/11, 03/09/11, 03/05/11, or 03/04/11 (seven of the last 12 days).

During a concurrent interview, Staff C, Director of Patient Care, stated that baths are to be done daily and confirmed the documentation showed Patient #4 was not bathed every day.

2. Review of current Patient #5's medical record on 03/15/11 showed no documentation of him/her receiving a bath on 03/12/11, 03/10/11, 03/08/11, or 03/05/11 (four of the last 10 days).

During a concurrent interview, Staff C confirmed the documentation showed Patient #5 was not bathed every day.

3. Review of current Patient #10's medical record on 03/15/11 showed no documentation of him/her receiving a bath on 03/14/11, 03/13/11, 03/12/11, 03/11/11, 03/10/11, 03/09/11, 03/08/11, 03/07/11, 03/06/11, or 03/05/11 (10 of the last 10 days).

4. During an interview on 03/15/11 at approximately 9:15 AM, Patient #9 stated that he/she had not been bathed daily or assisted with a bath daily.

Review of Patient #9's medical record on 03/15/11 showed no documentation of him/her receiving a bath on 03/12/11 (one of the last three days).


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5. Review of discharged Patient #23's medical record showed the patient entered the facility on 03/02/11 and the physician discharged the patient on 03/07/11. Review of the daily bedside care record showed no documentation of the patient receiving a bath on 03/07/11, 03/06/11, 03/05/11, 03/04/11 or 03/03/11 (five out of the last five days).

6. During an interview on 03/17/11 at 10:30 AM, Staff B, Infection Control and Quality, stated that the facility does not have a policy on hygiene/bathing, but the expectation was to provide a bath every day.

Based on interview, facility policy review and record review, facility staff failed to review nursing care plans according to facility policy to ensure that patients' care needs and response to interventions were assessed daily for five current patients (#2, #8, #4, #5, #10) and one discharged patient (#7) of 35 sampled patients. The facility census was 27.

If not kept current, the written care plan for each patient may not list all patient issues for which nursing is to be aware and and not address through interventions that will meet each patient's needs.

Findings included:

1. Record review of facility policy titled "Interdisciplinary Patient Care Planning", revised September 2009, showed the following direction:
-The care plan is reviewed and updated (if indicated) every shift by the Registered Nurse/Licensed Practical Nurse. The signature of the nurse on the care plan will indicate that the care plan was reviewed.

2. Review of Patient #2's current medical record showed the care plan had several blank signature lines for the day and night nurse signatures.

3. Review of Patient #8's current medical record showed the care plan had several blank signature lines for the day and night nurse signatures.

4. Review of Patient #7's discharged medical record showed the care plan had several blank signature lines for the day and night nurse signatures.



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5. Review of current Patient #4's medical record showed the care plan had several blank signature lines for the day and night nurse signatures.

6. Review of current Patient #5's medical record showed the care plan had several blank signature lines for the day and night nurse signatures.

7. Review of current Patient #10's medical record showed the care plan had several blank signature lines for the day and night nurse signatures.

During an interview on 03/15/11 at approximately 11:10 AM, Staff C, Director of Patient Care, stated that the day and night shift nurses are supposed to sign the care plan every day to show that it was reviewed and updated. Staff C confirmed Patient #4, #5, and #10's care plan had several shifts where staff had not signed.

During an interview on 03/15/11 at 1:40 PM, Staff I Registered Nurse, Charge Nurse, stated staff are to review care plans every shift. Staff I stated staff are to sign the care plan every shift to indicate it was reviewed. Staff I confirmed Patient's #2, #7 and #8's care plan had several shifts where staff had not signed the care plans.

Based on record review, facility policy review and interview, staff failed to follow the facility policy for blood administration to ensure that each patient receiving blood or blood components did not have a life threatening adverse reaction. Concerns were identified for two patients (#19 and #33) of five patients sampled for blood administration. The facility census was 27.

Findings included:

1. Record review of the facility policy titled "Blood/Blood Product Administration", revised June 2010, showed the following direction: Vital signs are monitored and documented on the Blood Transfusion Record 15 minutes, 30 minutes and 60 minutes after the start of the transfusion, every 60 minutes until complete and post transfusion.

2. Record review of Patient #19's Blood Transfusion Record dated 03/14/11 showed the blood administration started at 1:30 PM and ended at 4:15 PM. There were no vital signs recorded for 2:30 PM or 3:30 PM, the 60 minutes after the start and the 60 minutes until completed.

Record review of Patient #19's Blood Transfusion Record dated 03/14/11 showed the blood administration started at 4:15 PM and ended at 6:45 PM. There were no vital signs recorded for 5:15 PM or 6:15 PM, the 60 minutes after the start and the next 60 minutes until completed.

3. Record review of Patient #33's Blood Transfusion Record dated 03/10/11 showed the blood administration started at 1:20 AM and ended at 3:50 AM. There were no vital signs recorded for 2:20 AM or 3:20 AM, the 60 minutes after the start and the next 60 minutes until completed.

Record review of Patient #33's Blood Transfusion Record dated 03/10/11 showed the blood administration started at 5:00 AM and ended at 8:15 AM. There were no vital signs recorded for 6:00 AM or 7:00 AM, the 60 minutes after the start and the next 60 minutes until completed.

4. During an interview 03/17/11 at 8:45 AM, Staff B, Infection Control Officer, confirmed Patients #19 and #33's Blood Transfusion Records did not include the required vital signs. Staff B also confirmed that the vital signs were not documented elsewhere in the medical record.

Based on record review and policy review, the facility failed to have dated and timed physician signatures for discharged patient medical records on the Discharge Summary for four patients (#11, #12, #13 and #14) of six patients reviewed for physician signatures and discharge summaries. The facility census was 27.

Finding included:

1. Review of facility's undated policy "Completion of Discharge Summary" showed the following direction: a Discharge Summary shall be completed and filed in the patient's medical record within thirty (30) days following discharge from the hospital.

2. Record review for Patient #11, admitted from 11/26/10-12/17/10 for protein calorie malnutrition, alkalosis, pressure ulcers, congestive heart failure, chronic obstructive pulmonary disease, and hypertension, showed a discharge summary signed by the physician on 12/18/10, but failed to include the date and time of the signature.

3. Record review for Patient #12, admitted from 12/18/10 to 02/03/11 for respiratory failure, pneumonia, septicemia, protein calorie malnutrition and dehydration, showed a discharge summary that failed to include a physician signature, date and time.

4. Record review for Patient #13, admitted from 01/01/11 to 01/25/11 for respiratory failure, bladder bleeding, cancer, and pressure ulcer, showed a discharge summary dictated on 03/01/11, transcribed on 03/01/11 and signed on 03/03/11. The physician's signature was not timed. The date was past the required thirty (30) day restriction.

5. Record review for Patient #14, admitted from 01/11/11 to 01/22/11 for cellulitis (inflammation and swelling) of the leg, pulmonary infarct and embolism, protein calorie malnutrition, and pressure ulcer, showed a discharge summary dictated on 02/17/11 and transcribed on 02/28/11. The discharge summary was signed by the physician, but failed to include the date and time of signature.

Based on policy review and record review, the facility failed to ensure verbal and/or telephone orders were signed by the physician within 48 hours for two current patients (#6and #2) and two discharged patients (#23 and #7) of 37 patient records reviewed. The facility census was 27.

Findings included:

1. Record review of the facility's undated policy titled,"Physician Orders, Interdisciplinary Policy TX.1510.DHS", provided by the facility, showed the following direction:
-All orders, including verbal orders, must be dated, timed and authenticated within 48 hours by the prescribing physician or another physician responsible for the care of the patient, even if the order did not originate with him or her.

2. Medical record review for current Patient #6 on 03/14/11 showed the following orders:
-A telephone order written 02/28/11 at 1:15 AM for Xanax (used to treat anxiety and panic disorders) 0.25 mg (millegram) x1 (times one) PT (per tube) now.
The physician did not sign the telephone order by the time of record review during the survey that was more than 48 hours after the telephone order was received.

-A telephone order written 03/02/11 at 2:00 PM to change trach (tracheostomy, a surgically created opening in the neck leading directly to the trachea [the breathing tube]) to #6 TTS (tracheostomy tube). The physician did not sign the order by the time of record review during the survey.

-A telephone order written 03/06/11 at 12:20 AM to give 4 mg Zofran (oral medication used to prevent or treat nausea and/or vomiting) per PEG tube (percutaneous endoscopic gastrostomy; using a camera a needle puncture allows a tube to be passed into a patient's stomach through the abdominal wall. The PEG tube is most commonly inserted to provide a means of feeding when oral intake is not adequate) q (every) 6 hours prn (as needed) for nausea/vomiting. The physician did not sign the order by the time of record review during the survey.

3. Medical record review for discharged Patient #23 on 03/17/11 showed the following order:
-A telephone order written 03/06/11 at 1:20 AM for blood cultures x2 (times two) if temperature > (is greater) than 100.
The physician did not sign the order by the time of record review during the survey.





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4. Medical record review for current Patient #2 on 03/15/11 showed the following orders:
-A telephone order written on 03/11/11 at 11:45 PM to give 500 cubic centimeter (cc) bolus of normal saline now; straight catherization and record output and Kayexalate (potassium supplement) 30 grams now and repeat in four hours.
-A telephone order written on 03/11/11 at 12:15 AM to hold the infusion of fistula drainage.
-A telephone order written on 03/11/11 at 2:15 AM for Metoprolol (blood pressure medication) 2.5 milligrams intravenous times one, now.
-A telephone order written on 03/11/11 at 3:30 AM for Metoprolol 2.5 milligrams intravenous times one, now.
The physician signed the telephone orders, but did not date or time his/her signature to indicate the orders were authenticated with 48 hours.

During an interview on 03/17/11 at 9:05 AM, Staff T, Health Information Assistant confirmed Patient #2's telephone orders were signed, but did not include the date or time of the signature.

5. Medical record review for discharged Patient #7 on 03/14/11 showed the following orders:
-A telephone order written on 02/27/11 at 12:30 AM to give 16 units of Humulin R subcutaneous (sq)(insulin) now, draw a basis metabolism panel (lab) now and recheck accucheck in two hours.
-A telephone order written on 02/27/11 at 3:00 AM to give one liter Normal Saline bolus over one hour, give 12 units Regular insulin (sq) now, and recheck accucheck in two hours.
The physician did not sign the telephone orders.

6. During an interview on 03/17/11 at 9:05 AM, Staff T, Health Information Assistant, confirmed Patient #7's telephone orders were signed, but did not include the date or time of the signature.

Based on observation, interview, record review and facility policy review, staff failed to follow facility policy for the disposal of controlled substance patches for one patient (#8) which has the potential for staff diversion of controlled substances, and failed to have two staff verify insulin prior to administration for one patient (#2) of five patients observed during medication pass which affects patient safety for all patients receiving insulin. The facility census was 27.

Findings included:

1. Record review of the facility policy titled "Medication Management - Controlled Substances" effective 6/09, showed the following direction:
-Disposal of Controlled Substance Patches: The nurse should remove the patch from the patient and fold the patch in half so the adhesive backing is folded together and adheres to itself. The patch should then be disposed of in a sharps container. Two nurses must witness the disposal. The destruction shall be documented and countersigned on the Medication Administration Record (MAR). The signatures of both nurses involved must be documented.

However, observation on 03/15/11 at 3:25 PM, during medication pass, Staff G, Registered Nurse removed the Fentanyl (narcotic pain medication) patch from Patient #8. Staff G disposed of the patch in the patient's room with no other staff present in the room.

Record review of Patient #8's MAR showed only Staff G's initials for the administration of the new Fentanyl patch. No other staff signed as witnessing the waste of the removed patch.

During an interview on 03/16/11 at 1:15 PM, Staff I, Registered Nurse, Charge Nurse, stated that narcotic wastes must be witnessed. Staff I confirmed the waste had not been documented as witnessed on the MAR.

2. Record review of the facility policy titled "Medication Management - Administration of Insulin Products", effective 11/08, showed the following direction:
-All doses of insulin, with no exceptions will be verified by a second authorized staff member. Both individuals will initial the MAR that the dose has been verified prior to the administration.

However, observation on 3/15/11 at 9:55 AM, during the medication pass, Staff H, Registered Nurse, prepared and administered Lantus (insulin) 30 units subcutaneous to Patient #2. Staff H did not have a second staff member verify the dose of Lantus before administering the insulin to Patient #2.

During an interview on 3/15/11 at 10:30 AM, Staff H stated that he/she did not have someone verify the dose of Lantus. Staff H said, "We are supposed to always have a second set of eyes look at insulin."

Based on facility policy review, observation, and interview, the facility failed to ensure medications are kept in a locked or secured area to prevent unauthorized access. This has the potential to affect all patients. The facility census was 27.

Findings included:

1. Record review of the facility's undated policy titled "Medication Management - Storage", showed: All drugs and biological must be stored in a manner to prevent access by non-authorized personnel.

2. Observation on 03/14/11 at 2:20 PM, showed medications in a zip-lock bag in a notebook at the nurses' station. The medications included: Heparin (blood thinner), Cefepime (antibiotic), Loperamide (diarrhea medication) and Sodium Chloride (saline water). No staff were present at the nurses' station.

During an interview on 03/14/11 at 2:35 PM, Staff D, Registered Nurse, Charge Nurse, stated the medications in the notebook are medications the nurse had pulled to be administered. Staff D stated that the nurse should administer the medications right away, keep them with him/her, or lock them in the medication cart.

3. Observation on 03/14/11 at 2:40 PM, showed two pre-filled normal saline syringes and a bottle of Nystop (fungal medication) on the bedside table in Patient #2's room.

4. Observation on 03/14/11 at 2:45 PM, showed a pre-filled normal saline syringe and a bottle of Tobramycin (eye drops) on the bedside table in Patient #3's room.

5. Observation on 03/15/11 at 12:25, showed a tube of Triple Antibiotic Ointment, a bottle of Nystop and a tube of Hydrocortisone Miconazole cream (steroid antifungal cream) on the bedside table in Patient #20's room.

6. During an interview on 03/15/11 at 12:35 PM, Staff S, Pharmacist, stated that normal saline syringes are considered a medication and should be locked. Staff S stated that medications are only allowed to be in the patient's rooms if they have a physician's order to leave the medication in the room. Staff S stated that often the physicians write orders for medications to be left in the room for patients on isolation.

However, during an interview on 03/16/11 at 9:00 AM, Staff I, Registered Nurse, Charge Nurse, stated that there were no physician orders for Patient's #2, #3 or #20 to have medications in their room.

Based on interview, record review and policy review, the facility failed to ensure all medication errors were reported by nursing and failed to ensure the Director of Pharmacy was aware of all medication errors. This failure resulted in the facility's inability to assess if their medication error reporting system to effectively identify medication errors and adverse drug reactions. This has the potential to affect the safety and quality of care for all patients. The facility census was 27.

Findings included:

1. Record review of the facility's policy titled, "Medication Errors", dated 08/04/08, showed:
-A medication error is any preventable event that may cause or lead to inappropriate use or patient harm, while the medication is in the control of the health care professional, patient or consumer. Such event may be related to professional practice, health care products, procedures and systems, including: prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution administration; education; monitoring and use.
-The person who discovers the error (or other person designated by the individual in charge) shall prepare a medication error report on the facilities approved form.
-All copies of medication error reports shall be distributed as specified by the facility's policy. Reports shall be available to the responsible physician, the Director of Nursing and the Director of Pharmacy.
-The medical staff, in collaboration with the pharmacy, nursing and other staff as appropriate, shall periodically assess the facility's effectiveness to detect significant medication errors.

2. During an interview on 03/15/11 at 2:25 PM, Staff S, Director of Pharmacy, stated that he/she does not see medication error reports from nursing. Staff S stated that he/she completes medication error reports for missed dosages of medications, identified when medications signed out to patients were returned unused from the nursing units. Staff S stated that without the information on medication errors he/she was unable to determine any adverse drug reactions if incorrect medications were given to patients.

3. During an interview on 03/15/11 at 4:30 PM, Staff B, Director of Quality Improvement, stated that the nursing staff does not always complete a medication error report when a medication error is made. Staff B stated that staff has been educated and reminded to complete medication error reports, but not all staff is complying with the expectations. Staff B stated that the total number of medication errors is unknown.

4. Review of a medication error report summary for September 2010 through February 2011 showed 29 medication errors reported by nursing to Administration, but not reported to the Director of Pharmacy.

5. Review of the Pharmacy Department performance improvement data showed a total of 319 missed dosages of medications for September 2010 through February 2011. The Pharmacy dispensed an average of 26,470 doses of medications per month. Staff S stated that he/she received no medication error reports from nursing on these 319 missed dosages.

6. See also the deficiency at A309 regarding failure to ensure all medication errors were reported by nursing.

Based on observation, interview, record review and policy review, the facility failed to:
- Ensure the contract service for Food Service maintained the dishwasher at adequate temperature for dish and utensil sanitation. This potentially affects all patients receiving meals by traditional meal trays. Contageous infections may be carried to all patients, if not decontaminated and sanitized by the dish machine. The average tray service was for approximately 20 patients per meal. Seventeen current patients were identified with contageous infections and were on Isolation Precautions.
- Ensure outdated supplies were not available for immediate patient use.
- Check the temperature of the specimen refrigerator to ensure the specimens were stored in a manner so they could be used for laboratory testing.
- Perform preventative maintenance on equipment used to determine oxygenation status in patients. and
- Perform daily maintenance and quality checks on equipment used to determine oxygenation status in patients.
This had the potential to affect all patients in the facility. The facility census was 27.

Findings included:

1. Review of facility policy regarding the temperature for dish machine sanitation showed the expected final rinse temperature to be 180 degrees Fahrenheit. However, during the kitchen tour on 03/16/11 at 9:30 AM, the dish machine was checked by a temperature sensitive test strip, attached to a clean plate. The test strip failed to turn color to the required black inidcating the temperature of 160 degrees Fahrenheit. The test was repeated two additional times, for a total trial of three testings.

During an interview on 03/16/11 at 9:30 AM, Staff FF, Registered Licensed Dietitian, Food Service Manager, and the Maintenance Director confirmed the observation and the findings.


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2. Observation on 03/17/11 at 10:00 AM, of a supply room showed the following expired respiratory supplies:
- Transtracheal catheter (small catheter inserted into an airway opening in the neck that delivers oxygen directly to the lungs), count of two, expired 11/08;
- Transtracheal catheter, count of 12, expired 10/10;
- Easy Cap II CO2 Detector (monitor placed on the end of an airway tube that is used to verify correct tube placement), count of eight, expired 08/10;
- Trach Vent (used on end of endotracheal - tube inserted through nose or mouth into the airway or tracheostomy - tube inserted into the neck for breathing); count of three, expired 08/10.

During a concurrent interview, Staff C, Director of Patient Care, confirmed the supplies listed above had expired.

During an interview on 03/17/11 at 10:50 AM, Staff B, Infection Control and Quality Officer, stated that the facility did not have a policy on checking for expired respiratory supplies.

3. Record review of the facility's undated policy titled, "Refrigerator and Freezer Temperatures Monitoring" showed the following direction:
- Temperatures on refrigerators containing laboratory specimens should be checked and recorded daily and fall within the ranges indicated below.
- When temperature fall above desired range, check with (other facility laboratory) to ensure the specimens are still adequate for testing.

However, review of the temperature log for the refrigerator used for specimens (tissue and blood awaiting transport for testing) showed the temperature was not checked on 03/12/11, 03/11/11, 03/10/11, 03/09/11, 03/08/11, 03/05/11, or 03/03/11 during the current month.

During a concurrent interview, Staff C, Director of Patient Care, and Staff EE, Respiratory Therapist, stated that they are not the staff responsible for checking the refrigerator temperature.

During an interview on 03/17/11 at 10:25 AM, Staff C stated that it is the responsibility of the unit secretary to check the refrigerator temperature.

4. Record review of the facility's undated policy titled, "Equipment Management Plan" showed the following direction:
- The purpose of the inspection, testing and preventative maintenance program is to minimize the clinical and physical risk associated with medical equipment.
- All equipment which is classified as therapeutic and diagnostic or may come into direct contact with patient care will require periodic maintenance or performance testing according to the risk assessment and manufacturer's specifications not to exceed one year.
- Scheduled Preventative Maintenance - The prior inspection sticker will be removed and a new one placed on the equipment with the appropriate information.

Observation on 03/17/11 at 9:55 AM, of the blood gas analyzer (machine that performed blood test on patient to determine amount of oxygen, carbon dioxide, and acidity of the blood) showed a sticker that indicated the last preventative maintenance performed was 11/08.

During a concurrent interview, Staff C, Director of Patient Care, confirmed the last preventative maintenance was done 11/08.

5. Record review of the facility's document titled, "Quality Control Testing" showed the following direction:
- Control tests are performed each day.

Review of the facility's document titled, "Daily Accu-Chek Inform Schedule & Daily IRMA Maintenance Schedule" (blood gas analyzer daily maintenance checks) on 03/17/11 showed maintenance and quality checks were not completed on 03/16/11, 03/06/11, 03/02/11, or 03/01/11. Further investigation showed maintenance and quality checks were not completed on 02/28/11, 02/23/11, 02/16/11, 02/15/11, 02/14/11, 02/09/11, 02/07/11, 02/02/11, or 02/01/11.

During a concurrent interview, Staff EE, stated that the maintenance and quality checks were to be performed every day.

During an interview on 03/17/11 at 11:15 AM, Staff B, Infection Control Officer, provided information that blood gas tests were completed on the following dates when the maintenance and quality checks were not completed:
- 03/02/11 on Patient #1 four times and Patient #25;
- 02/02/11 on Patient #35 and Patient #36;
- 02/01/11 on Patient #35 and Patient #36.

Based on observation and interview, the facility staff:

- failed to perform hand hygiene (cleanse their hands) before donning personal protective equipment (PPE) to, then, enter isolation rooms for two patients (#1 and #2),

- failed to perform hand hygiene during wound care for one patient (#20),

- failed to perform hand hygiene after contact with his/her own secretions for one staff (HH),

- failed to perform hand hygiene after removing gloves during care to one patient (#9),

- failed to correctly don isolation gown for one patient (#10),

- failed to ensure staff maintained isolation precautions for one patient (#10) during medication administration,

- failed to maintain cleanliness for two of two crash carts (mobile cart of medication, supplies, and equipment used in resuscitation), and

- failed to ensure complete sanitization of dishes with inadequate dish machine rinse temperatures.

Seventeen current patients were identified with contageous infections and were on Isolation Precautions, but the failure to consistently implement infection control practices had the potential to affect all patients. The facility census was 27.

Findings included:

1. Record review of the facility's undated policy titled "Hand Hygiene" showed the following direction:
- Hand hygiene should be performed: After glove removal.

Record review of the facility's undated policy titled "Standard Based Precautions" showed the following direction:
- Hands must be washed or disinfected as soon as possible after gloves are removed;
- Wearing gloves does not replace the need for hand washing, because gloves may have small, un-apparent defects or may be torn during use and hands can become contaminated during removal of gloves;
- Hands must be washed/disinfected with an alcohol foam/gel before and after all patient and specimen contact;
- Hands must be washed/disinfected with an alcohol foam/gel or disinfected immediately when gloves and any other personal protective equipment are removed;
- Select a gown that is appropriate. Securing it at the neck and waist.
- Elements of Respiratory Hygiene/Cough Etiquette include ...hand hygiene after contact with respiratory secretions.

Record review of the facility's undated policy titled "Transmission Based Precautions" showed the following direction:
- Contact Precautions ...wear gloves each time entering the contact isolation room, wear a clean, non-sterile gown when entering the contact isolation room;
- After glove removal and hand hygiene, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments.

Record review of the facility's policy titled "Crash Cart Maintenance", dated 06/10, showed the following direction:
- Charge nurses are responsible for checking each shift: Top of crash cart dust free.

2. Observation on 03/14/11 at 2:15 PM, showed Patient #1's room had a sign on the door indicating Contact Isolation Precautions. Staff V, Registered Nurse (RN), donned a gown and gloves to enter Patient #1's room without using hand gel or washing his/her hands.

3. Observation on 0315/11 at 10:30 AM, showed Patient #2's room had a sign on the door indicating Contact Isolation Precautions. Staff H, RN, donned a gown and gloves to enter Patient #2's room without using hand gel or washing his/her hands.

During an interview on 03/15/11 at 10:30 AM, Staff I, RN, Charge Nurse, stated staff should perform hand hygiene when donning PPE and before entering patients' rooms.

During an interview on 03/15/11 at 11:10 AM, Staff B, Infection Control Officer, stated staff should perform hand hygiene when donning PPE and before entering patients' rooms.

4. Observation on 3/15/11 at 12:25 PM, during wound care, Staff O, RN, wore gloves to remove Patient #20's dressing. Staff O changed gloves without using hand gel or washing his/her hands.

During an interview on 3/15/11 at 12:45 PM, Staff I stated that staff are to perform hand hygiene between clean and dirty procedures, even if they change gloves.


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5. Observation on 03/14/11 at 3:50 PM, showed Staff HH, RN, sitting at the nurses' desk documenting in a patient's chart. Staff HH blew his/her nose and returned to writing in the patient's chart without performing hand hygiene.

During an interview on 03/16/11 at 11:10 AM, Staff B confirmed that staff members are to perform hand hygiene after blowing their nose.

6. Observation on 03/15/11 at 8:50 AM, showed Staff N, RN, administer medications to Patient #9. Staff N donned gloves, administered IV (intravenous - a catheter inserted into the patient's vein) medications, removed the gloves and left the patient's room without performing hand hygiene. After leaving the patient's room, Staff N went to the medication cart (a mobile cart holding medications and supplies for all patients in that hallway), retrieved a paper cup and then went down the hall to get water for the patient.

During an interview on 03/16/11 at 11:10 AM, Staff B stated that the expectation is for staff to perform hand hygiene after removing gloves. Staff B stated that the facility is not doing any formal hand hygiene surveillance. Staff B stated that he/she is doing active surveillance mostly on day shift and the patients and night shift charge nurse tell him/her if there is a problem on night shift.

7. Observation on 03/15/11 at 9:45 AM, showed Staff O, RN, administer medications to Patient #10. A sign on Patient #10's door indicated "Contact Isolation Precautions". Staff O did not tie the isolation gown at his/her waist, leaving the ties and gown to dangle on the patient's bed linen. While administering IV medications, Staff O reached under his/her isolation gown and retrieved two syringes from his/her pocket (a potentially infectious location). The syringes were not in their protective plastic wrap. One of the syringes of medication was not used on the patient, but handled by Staff O while at the patient's bedside. Staff O left the patient's room, carrying the "dirty" syringe and returned it to his/her pocket.

During an interview on 03/15/11 at 9:55 AM, Staff O stated that he/she returned the medication/syringe to his/her pocket after hand washing. Staff O stated that he/she would normally use the medication/syringe or leave it in the patient's room. After a pause, Staff O stated that since he/she did not leave the medication/syringe in the patient's room, he/she would dispose of it.

During an interview on 03/15/11 at 10:00 AM, Staff C, Director of Patient Care, stated that an isolation gown should be tied at the waist and would not expect the nurse to reach under his/her gown to retrieve a supply. Staff C stated that a medication/syringe should not be returned to the nurse's pocket after being contaminated.

8. During an observation on 03/14/11 at 3:17 PM, on the patient hall designated by the facility as "Lilac Hall" showed a crash cart. The top of the crash cart and equipment was covered with a layer of dust and black-colored flecks. Staff F, Vice President of Performance Improvement, confirmed the crash cart and equipment was dusty. This was the only crash cart on Lilac Hall and would be used for patients/visitors in that area.

During an observation on 03/14/11 at 3:35 PM, on the patient hall designated by the facility as "Rose Hall" also showed a crash cart. The top of the crash cart and equipment was covered with a layer of dust. This was the only crash cart on Rose Hall and would be used for patients/visitors in that area.

During an interview on 03/14/11 at 3:35 PM, Staff D, Charge Nurse, confirmed the Rose Hall crash cart was dusty and stated that he/she was not sure who was responsible for cleaning the crash carts.


09117

9. Review of the facility policy regarding the sanitizing temperature for the dish machine rinse cycle showed that the expected final rinse temperature should be at least 180 degrees Fahrenheit.

During the kitchen tour on 03/16/11 at 9:30 AM, the dish machine was in use for the breakfast dishes. A temperature-sensitive test strip was used to check the water temperature. The test strip failed to turn the required color change from grey to black (this color change would indicate a minimum temperature of 160 degrees Fahrenheit, hot enough to sanitize objects inside the dish machine). The test strip was repeated two more times, for a total of three trial tests. None of the trial tests showed a temperature of at least 160 degrees Fahrenheit.

During an interview of shared observations of this test with Staff FF, Food Service Manager- Registered Licensed Dietitian, and the Maintenance Director, both confirmed the observation and the findings.

Based on record review and interview, the facility failed to maintain a current log of staff-related infections and communicable diseases. This had the potential to affect all patients in the facility. The facility census was 27.

Findings included:

Review of the Infection Control paperwork on 03/16/11 showed no current log of staff incidents related to infections and communicable diseases, including those identified through employee health services.

During an interview on 03/16/11 at 10:15 AM, Staff B, Infection Control Officer, stated that he/she did not maintain a log on employee health. Staff B stated that he/she remembered that a year ago 25% (percent) of staff were out with a virus and this was reported to city officials. Staff B stated that one patient was infected with the same virus.

Based on interview, record review and policy review, the facility failed to incorporate Performance Improvement (PI) data collected from cardiopulmonary services, nursing services (such as medication errors and infection control) and Pharmacy (missed dosages of medications) into the facility wide PI program to monitor the effectiveness of services and quality of care for all patients. The facility census was 27.

Findings included:

1. Review of the "Performance Improvement Plan" showed:
-The goal of the plan is to develop and sustain a health care service structure in which the processes that contribute to patient outcomes and satisfaction are continuously assessed and improved. This is accomplished by focusing on outcomes of treatment, care and services.
-The hospital collects data to answer questions about its current performance, check for continued stability in existing processes, determine opportunities and changes that lead to improvement, and to monitor PI (performance improvement) efforts for sustained effect.
-Information from data analysis is used to make changes that improve performance and patient safety and reduce the risk of sentinel events.

2. During an interview on 03/17/11 at 9:45 AM, Staff A, Administrator and Staff E, Director of Accreditation and Licensure, stated that there is a lapse in data collection for the area of cardiopulmonary services, but it is available somewhere (but the location was not specified).

Staff E stated that there was a PI meeting held in December 2010, but the previous person in charge of PI was no longer employed by the facility and the notes from the December 2010 meeting are not available. There has been no PI meeting since then. The person responsible for collecting and establishing PI plans for nursing was also no longer employed by the facility.

3. Review of the PI data from the July 2010 through December 2010 report showed that seven of the nine indicators for the area of cardiopulmonary services were not reported after September, and one PI data point was reported only until October.

4. Review of the information submitted related to medication errors showed for months in 2010 included:
-Extras doses of medication given to patients occurred 29 times in July, zero times in August, 116 times in September, zero times in October, 24 times in November and 21 times in December.
-Omitted medications (that were not given to patients) occurred ten times in July and August, zero times in September, 40 times in October, three times in November and zero times in December.
-Wrong doses of medications were administered by staff to patients 22 times in July, 21 times in August, zero times in September and October and one time in November and December.

Review of the Pharmacy Department PI data showed a total of 319 missed dosages of medications for the months of September 2010 through January 2011. However, the facility did not incorporate this PI data that can directly affect patients and their medical condition from Pharmacy into their overall PI program.

During an interview on 03/17/11 at 9:45 AM, Staff E stated that there is a possibility the PI data for medication errors was being batched (that is, not reported at the time, but at a later date and for multiple months) and that it appears to be a high number for one month and a low number for another month, when actually the PI data may be from both months and reported under one month only.

5. Review of the PI data showed that management of infections was listed through September of 2010, but stopped at that point.

During an interview on 03/17/11 at 11:15 AM, Staff B, Infection Control Nurse, stated that there is PI data available through the month of February 2011 for the management of infections. However, although requested, facility staff did not provide the PI data.

Review of the PI data dated 01/15/11 did not show infection control data collected or presented to the PI program after September 2010.

6. Record review and requests for material presented as part of the PI program showed the facility did not have any PI data since December 2010 to incorporate into the overall PI program to improve patient care.

Based on interview and record review, the facility failed:
- to ensure Performance Improvement (PI) data was used to monitor the effectiveness and implementation of effective actions to improve patient care services, and
- failed to ensure all medication errors were reported by nursing.
These failures resulted in the facility's inability to assess if their medication error reporting system effectively identifies medication errors and adverse drug reactions. The facility census was 27.

Findings included:

1. Review of the "Performance Improvement Plan" showed:
-The goal of the plan is to develop and sustain a health care service structure in which the processes that contribute to patient outcomes and satisfaction are continuously assessed and improved. This is accomplished by focusing on outcomes of treatment, care and services.
-The hospital collects data to answer questions about its current performance, check for continued stability in existing processes, determine opportunities and changes that lead to improvement, and to monitor PI (performance improvement) efforts for sustained effect.
-Information from data analysis is used to make changes that improve performance and patient safety and reduce the risk of sentinel events.

2. Review of the facility policy for "Weights", approved 06/10/09, showed the policy did not address which staff would be responsible for obtaining patient(s) weight(s).
During an interview on 03/16/11 at 12:00 Noon, Staff GG, Dialysis Nurse, stated that patients were to be weighed before and after dialysis treatments. Staff GG stated that he/she sometimes helped the CNA (Certified Nurses' Aide) if there was a need for help with weighing the dialysis patients. Staff GG stated that there is some confusion about who is supposed to do the weights for the dialysis patients. (It is a standard of practice to weigh patients before and after dialysis to determine the amount of fluid that was removed during dialysis.)
Review of the facility documents for PI data showed that patient weights were still being monitored with generally good results; however the month of October, 2010 was only 69%. This issue has been monitored by the facility since 2009, more than a year without implementing actions to consistently address this problem. The PI process showed limited analysis of why the issue was still a problem and why progress for improvement was very slow.
3. Review of the PI data from the July through December 2010 report showed that seven of the nine indicators for the area of cardiopulmonary services were not reported after September and one data point was reported only until October 2010. Record review did not indicate if the PI data was not available or reported past this point due to successful completion of the criteria or lack of reporting from the department.
4. During an interview on 03/17/11 at 9:45 AM, Staff A, Administrator and Staff E, Director of Accreditation and Licensure, stated that there was a lapse in PI data collection for the area of cardiopulmonary services, but it is available somewhere (although the location was not specified) and there is an action plan for proficiency testing (which is due to a change in directors of the department).
Staff E stated that there was a meeting for PI held in December 2010, but the previous person in charge of PI was no longer employed by the facility and the notes from the December meeting are not available. There has been no meeting for PI since the December 2010 meeting (a period of at least two months). The person responsible for collecting and establishing PI plans for areas of nursing is no longer employed by the facility.
Staff E stated that there has been no annual evaluation of the PI plan which would result in assessing which of the data criteria would be eliminated from the monitoring and improvement process and which data needed to be added.
Staff A and Staff E stated that after the previous person (responsible for oversight of the performance improvement-PI) left the employment of the facility in January 2011 the decision was made that the PI program would be put on hold until a new director could be appointed. They stated that there does not appear to be a list of completed PI projects which could be eliminated due to successful completion. Some of the December 2010 PI data is available, but it was unclear which data from all the components of the PI program was available and which data was not available. The actions to improve performance are not robust (effective) and the plans are to continue monitoring the data without effective action plans for improvement.
5. During an interview on 03/17/11 at 9:45 AM, Staff E stated that there was a possibility the PI data for medication errors was being batched (not reported at each month but at a later date and for multiple months) and that it appears to be a high number for one month and a low number for another month, when the data may actually be from both months and reported under one month only.

Review of PI information dated 01/15/11 related to medication errors showed:
-Extra doses of medication occurred 29 times in July, zero times in August, 116 times in September, zero times in October, 24 times in November and 21 times in December.
-Omitted medications occurred ten times in July and August, zero times in September, 40 times in October, three times in November and zero times in December.
-Wrong doses of medications were administered 22 times in July, 21 times in August, zero times in September and October and one time in November and December. (See also A0508).

6. Review of the manual titled "Performance Improvement (PI), July to December of 2010" showed data through December of 2010 for each of the PI criteria and the report was dated 01/15/11. However, review of the PI data contained in the report showed that areas such as management of infections was listed through September of 2010 and stopped at that point.
During an interview on 03/17/11 at 11:15 AM, Staff B, Infection Control Nurse, stated that there is PI data available through February 2011 for the management of infections. Review of the data present in the manual did not indicate if this data through February had been collected or presented to the PI program since September 2010 except for the portions that are listed under care plan audits.
7. Review of the PI data from the report dated "December 2010" for pain intervention and reassessment showed that compliance with the six criteria noted was between 77% and 100%. The actions indicated were to continue to monitor and to provide written counseling along with documentation examples. Review of the PI data from the July to December 2010 report indicated that data had been reported through December with varied compliance rates indicating that improvement was still needed in at least three of the areas. However, although requested, no data was available to determine if the corrective actions were successful after December 2010.
8. Review of the document dated "December 2010" for blood product documentation compliance showed that of the three criteria mentioned the compliance rate was from 55% to 100%. Under the section for "actions" it mentioned new documentation and forms utilized and education was to continue for nurses. Review of the PI data indicated eight criteria for blood administration being monitored through December with no data available after December.


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Based on interview, record review and policy review, the facility failed to analyze the causes of medication errors through their Performance Improvement (PI) process and, therefore, was unable to address the underlying cause and promote changes to improve patient safety and medical care for all patients in the facility. The facility census was 27.

Findings included:

1. Review of the "Performance Improvement Plan" showed:
-The goal of the plan is to develop and sustain a health care service structure in which the processes that contribute to patient outcomes and satisfaction are continuously assessed and improved. This is accomplished by focusing on outcomes of treatment, care and services.
-The hospital collects data to answer questions about its current performance, check for continued stability in existing processes, determine opportunities and changes that lead to improvement, and to monitor PI (performance improvement) efforts for sustained effect.
-Information from data analysis is used to make changes that improve performance and patient safety and reduce the risk of sentinel events.

2. Review of PI information dated 01/15/11 related to medication errors showed:
-Extra doses of medication occurred 29 times in July 2010, zero times in August, 116 times in September, zero times in October, 24 times in November and 21 times in December 2010.
-Omitted medications occurred ten times in July and August 2010, zero times in September, 40 times in October, three times in November and zero times in December.
-Wrong doses of medications were administered 22 times in July 2010, 21 times in August, zero times in September and October and one time in November and December.

The PI documentation does not show any analysis of this medication error data.