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Based on observation, medical record review and interview, the facility failed to maintain a safe environment for one (#15) of thirty patients reviewed.

The findings included:

Patient #15 was admitted to the facility on September 28, 2010 with diagnoses to include Status Post Intracranial Hemorrhage. Observation of the patient with the Director of Quality in the patient's room on October 4, 2010 at 8:25 a.m., revealed the patient lying in the bed resting quietly. Continued observation revealed the bed was elevated to a medium height with the side rails raised bilaterally. Continued observation revealed floor pads folded and leaning against the wall behind the vacant bed in the patient's room. Continued observation revealed no staff present in the room.

Medical record review of the 24 Hour Patient Record and Plan of Care, dated October 3, 2010 and timed 7:00 a.m. - 7:00 p.m. and 7:00 p.m. - 700 a.m., revealed the assessment of patient # 15 included, "Fluctuating mental status" with disorganized thinking, inattention, drowsy; Mobility was limited with dependence on staff with minimal assistance at times; and had a Specialty Bed - Low Boy (low bed). Review of the Fall Risk Assessment revealed Altered Mental/Cognitive Status; had a history of falls; medications with intent of persistent sedation; and the Plan of Care included, "LOW BED with floor pads..."

Interview in the patient's room with the Director of Quality on October 4, 2010 at 8:30 a.m., confirmed the patient had a history of falls prior to admission; evaluation of the patient revealed the patient continued to be at risk for falls; and the Plan of Care required the patient on fall precautions was to have floor pads bilaterally at the beside and the bed in the low position to provide for the safety of the patient. Continued interview confirmed the patient's safety measures for fall precaution were not maintained.

Based on medical record review, facility policy review and interview, the facility failed to ensure the Physician's Order for the use of restraints was followed for one (#23) of five restraint records reviewed.

The findings included:

Medical record review revealed patient #23 was admitted to the facility on September 15, 2010 with diagnoses to include Multiple Trauma and Respiratory Failure.

Medical record review revealed the patient required the use of bilateral wrist restraints to prevent the patient form pulling out medical devices (such as trach tube, ventilator tubing, intravenous devices, catheter). Medical record review of the Physician's Orders for the use of the wrist restraints revealed the restraint order began on September 15, 2010 at 9:00 a.m. and ordered to expire in 24 hours from the initiation of the order.

Continued medical record review of the Nurse's Notes, dated September 15 - 24, 2010, revealed the patient continued to attempt to remove medical devices when the restraints were removed for patient care.

Continued medical record review of the daily Physician's orders, dated September 15 - 24, 2010 revealed orders for the use of bilateral wrist restraints as the patient continually required the use of restraints until September 24, 2010; and the orders were to expire in 24 hours from the initiation of each of the daily orders.

Continued medical record review revealed the Physician's order for the use of wrist restraint, dated September 18, 2010 at 3:15 p.m., was written 5 hours and 45 minutes after the order dated September 17, 2010 at 10:30 a.m., had expired. Continued medical record review revealed the Physician's Order for the use of wrist restraints, dated September 21, 2010 at 6:00 p.m., was written 8 hours and 50 minutes after the order dated September 20, 2010 at 9:10 a.m., had expired.

Review of the facility's policy "Restraint and Seclusion", revised June 2010, revealed "...Medical Record Documentation...A time-limited order by a physician, or licensed independent practitioner (if allowed under State Law)...Demonstration of the need for continuing restraint beyond the initial order or the satisfaction of criteria for release..."

Interview at the Nurses' Station with the Quality Manager on October 5, 2010 at 9:40 a.m., confirmed the patient continued in the wrist restraints beyond 24 hours on September 18 and 21, 2010; and the Physician's Orders for restraints on September 18 and 21, 2010 were not followed.

Based on observation, medical record review and interview, the facility failed to ensure RN (Registered Nurse) supervision and evaluation of care for two (#1 and #15) of thirty patients reviewed.

The findings included:




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Patient #1 was admitted to the facility on July 27, 2010 with diagnosis including Acute Respiratory Failure on a Ventilator, and Morbid Obesity. Observation on October 4, 2010 at 8:55 a.m., revealed patient #1 on mechanical ventilation and in bilateral soft wrist restraints.

Medical record review revealed patient #1 required an emergency bedside Bronchoscopy (procedure to examine the airway using a Bronchoscope) on August 26, 2010. Medical record review revealed patient #1 received 50 mcg (micrograms) of Fentanyl (a potent narcotic analgesic with rapid onset) and 2 mg (milligrams) of Versed (short-acting Benzodiazepine to induce sedation/amnesia before medical procedures) for the procedure. (The use of Fentanyl and Versed prior medical procedure is conscious sedation.) Medical record review revealed the medications were administered by a registered nurse (RN #6).

Review of the Moderate Sedation Flowsheet for patient #1 during the Emergency Bronchoscopy revealed no documentation of the time the medications were administered; what time the procedure started; vital signs (blood pressure/temperture/respirations/Oxygen saturation); and no electrocardiogram strip. The Flowsheet contained lines and boxes for the information. Review of the lines were blank and the boxes were not marked.

Review of the Flowsheet and interview with the Director of Quality on October 5, 2010 in the conference room at 10:15 a.m., verified the facility policy includes the assessment and documentation of the vital signs (including oxygen saturation) and electrocardiogram before sedation and during the procedure, and confirmed the facility failed to complete the assessment of patient #1 during the procedure requiring sedation.


Patient #15 was admitted to the facility on September 28, 2010 with diagnoses to include Status Post Intracranial Hemorrhage.
Observation with the Director of Quality in the patient's room on October 4, 2010 at 8:25 a.m., revealed the patient in bed lying on their back with the head of the bed (HOB) elevated approximately 10-15 degrees and a Nasogastric (NG) Tube Feeding (TF) solution being administered via pump at 65 ml (milliliters) per hour (hr). Continued observation revealed the bed was raised to a medium height with the side rails raised bilaterally. Continued observation revealed floor pads folded and against the wall behind the vacant bed in the patient's room. Continued observation revealed no staff present in the room.

Medical record review of the 24 Hour Patient Record and Plan of Care, dated October 3, 2010 and timed 7:00 a.m. - 7:00 p.m. and 7:00 p.m - 7:00 a.m, revealed "...(named) NG TF solution at 65 ml/hr...Feeding pump...HOB > (greater than) 30 degrees...Neuro (neurological) - Fluctuating mental status...inattention...disorganized thinking...drowsy...Mobility- Dependent Min (minimal) assist (assistance) x (time) 2...Specialty Bed - Low Boy (low bed)...Fall Risk Assessment - Altered Mental/Cognitive Status...History of Falls...Meds (medications) with intent of persistent sedation...LOW BED with floor pads..."

Interview in the patient's room with the Director of Quality on October 4, 2010 at 8:30 a.m., confirmed the HOB of a patient receiving TF is not to be less than 30 degrees to prevent risk of aspiration; and a patient on fall precautions is to have floor pads and the bed in the low position to provide for the safety of the patient. Continued interview confirmed the nursing staff did not ensure the supervision of the patient's care for TF and fall precaution was maintained.

Based on medical record review and interview, the facility failed to ensure Physician's Orders were complete for one (#16) of thirty patients reviewed.

The findings included:

Patient #16 was admitted to the facility on September 30, 2010 with diagnoses to include Respiratory Failure with Ventilator Wean.

Medical record review of the Physician's Orders revealed the following verbal orders: October 2, 2010 at 6:35 p.m., "Stat (immediately) Port (portable) abdominal X-ray for feeding tube placement"; and October 3, 2010 at 4:00 a.m., "Lasix (medication to remove excess fluid) 20 mg IV (intravenous) NOW x (times) 1." Continued medical record review revealed the Physician's Verbal Orders had not been authenticated by the physician.

Interview at the Nurses' Station with the Director of Quality on October 5, 2010 at 8:15 a.m., confirmed Physician's Verbal Orders are to be authenticated by the physician within forty-eight hours after the order is given. Continued interview confirmed the Physician's Verbal Orders had not been authenticated by the physician.

Based on observation, review of manufacturer's instructions, and interview, the facility failed to discard an outdated topical anesthetic for one (#4) of twenty-four patients reviewed.

The findings included:

Observation of the room of patient #4 on October 4, 2010 at 9:00 a.m., revealed a 1000 ml (milliliter) bottle of 0.9% Normal Saline with a label of Chlorpactin (topical antiseptic) with a mixture date of September 11, 2010. The bottle was at room temperature.
Review of the manufacturer's instructions for Chlorpactin revealed the solutions "should be used as soon as possible after preparation...If stored at room temperature...solutions should be used within 7 days after preparation.
Interview with the Chief Nursing Officer in the hall outside the room of patient #4 on October 4, 2010 at 9:25 a.m., confirmed the facility failed to discard the solution within the recommended time; and failed to not have outdated medication available for patient use.

Based on observation and interview, the facility failed to ensure infection control practices were carried out for two (#13 and #14) of thirty patients reviewed.

The findings included:

Patient #13 was admitted to the facility on September 17, 2010 with diagnoses to include Respiratory Failure.

Observation of the patient on September 4, 2010 at 8:10 a.m., in the patient's room with the Director of Quality revealed the patient lying in bed with the Head of the bed elevated. Continued observation revealed the patient had a tracheostomy (trach). Continued observation revealed an open plastic bag containing a disposable plastic obturator (device utilized to open a closed trach opening or stoma) with dried brown material covering the tip of the obturator.

Interview in the patient's room on September 4, 2010 at 8:10 a.m., with the Director of Quality confirmed the obturator was soiled; had not been either cleaned or disacrded; was to be discarded after use; and was available for patient use.

Patient #14 was admitted to the facility on September 27, 2010 with diagnoses to include Sacral Decubitus Ulcer and History of Deep Vein Thrombosis. Observation of the patient on September 4, 2010 at 8:15 a.m., in the patient's room with the Director of Quality revealed the patient lying in bed asleep. Continued observation revealed the right leg thrombus guard (utilized to apply intermittent pressure to the patient's leg for prevention of blood clots) was lying on the floor and connected to the air pump and ready for patient use.

Interview in the patient's room on September 4, 2010 at 8:15 a.m., with the Director of Quality confirmed the thrombus guard device was to be kept clean and not to be on the floor.



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Based on medical record review and interview, the facility failed to ensure Physician's Orders were received for a transferred or discharged patient; and failed to ensure the receiving facility of the transferred or discharged patient had the necessary medical information for follow-up care for one (#27) of five discharged patients reviewed.

The findings included:

Patient #27 was admitted to the facility on April 14, 2010 with diagnoses to include Ventilator Weaning, Quadriplegia, Sacral Decubitus, and Seizure Disorder.

Medical record review of the Physician's Progress Notes, dated May 23, 2010 revealed (the patient was to be) "...transfer to (named) hospital for (Decubitus Ulcer repair) flap procedure and GI (gastrointestinal) workup for recent GI bleed..." on May 24, 2010.
Medical record review of the Physicians' Order revealed there was no order for transfer or discharge on May 24, 2010. Continued medical record review of the Nurses' Progress Notes revealed no documentation the patient was transferred or discharged with any information provided to the receiving facility on May 24, 2010.

Interview in the conference room with the Manager of Quality on October 5, 2010 at 1:10 p.m., confirmed the patient had been discharged to (named) hospital on May 24, 2010. Continued interview confirmed a Physician's Order is required for discharge and there was no documentation the receiving facility was provided necessary medical information.

Based on observation and interview, the facility failed to ensure medications were secured and properly labeled for one (#24) of thirty patients reviewed.

The findings included:

Patient #24 was admitted to the facility on September 15, 2010 with diagnoses to include Respiratory Failure and Pneumonia.

Observation in the room of patient #24 with the Director of Quality on October 4, 2010 at 9:30 a.m., revealed a MDI (Multi Dose Inhaler) of a (named) bronchodilator which was taped to the wall at the head of the patient's bed. Continued observation revealed the MDI was not labeled to indicate a patient name, dose to be administered or frequency of administration.

Medical record review revealed the MDI was not listed on the current MAR (Medication Administration Record) of the patient.

Interview in the room of the patient with the Director of Respiratory on October 4, 2010, at 9:35 a.m., confirmed it could not be determined how long the medication had been taped to the wall; it could not be determined the pateint for whom the MDI was prescribed; and the patient was not receiving this medication.

Interview in the room of the patient with the Director of Quality on October 4, 2010 at 9:35 a.m., confirmed the medication was not labeled to include all required information (such as a pateint name, and dose and frequency to be administered); the medication was not a current medication prescribed for the patient; the medication was not secured; and the medication was available for patient use.