HospitalInspections.org

Based on interview, clinical record review and document review, the facility failed to ensure an effective governing body was legally responsible for the conduct of the hospital.

The governing body: failed to ensure an Institutional Plan and Budget was in place (A073); failed to ensure the Institutional Plan was reviewed and updated annually (A076); failed to ensure the Institutional Plan was prepared under the direction of the governing body and by a committee consisting of representatives of the governing body, the administrative staff and the medical staff of the institution (A077); failed to ensure contracted services were provided to meet the needs of the patients (A083); failed to ensure Emergency Services were provided within the regulatory requirements (A091); failed to develop, implement, and maintain an effective, ongoing, hospital-wide quality assessment and improvement program (A263); failed to ensure pharmaceutical services met the needs of the patients (A490); and, failed to ensure respiratory care services were provided within acceptable standards of care (A1151).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutory mandated care to patients.

Based on record review, document review, and interview, the facility: failed to provide an ongoing program that focused on high-risk, high volume, or problem prone areas (A283); 2) failed to ensure quality improvement projects were monitored and tracked, measurable, and reevaluated (A297); failed to ensure adequate resources were allocated for measuring, assessing, improving, and sustaining the hospital's performance and reducing risk to patients. (A315)

Based on observation, record review and interview, the facility: failed to ensure qualified personnel were available to provide respiratory care services (A1152); failed to ensure the director of respiratory services had the appropriate qualifications (A1153) and failed to provide written documentation qualified personnel were available to provide respiratory care services (A1161).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory mandated care to patients.

Based on record review, interview and document review, the facility failed to meet State requirements regarding review and update of 12 of 15 personnel policies. The facility failed to provide documented evidence of orientation, training and competency assessment of 7 of 8 employees reviewed (Employees #4, #5, #8, #11, #17, #18, and #20). The facility failed to provide documented evidence of pre-employment tuberculosis testing for 1 of 8 employees reviewed (Employee #4).

Findings include:

On 6/26/13 at 11:00 AM, the Director of Nursing indicated she was responsible for reviewing and updating the policies, and explained other responsibilities prevented her from completing this task.

Review of eight personnel files including six Registered Nurses, one Licensed Practical Nurse and one Dietary Specialist.

- There was no documented evidence the Emergency Department Registered Nurse Orientation and Skills Checklist was completed for five of eight employees. This orientation included: Hospital Forms, Location of Supplies and Equipment, Review of Department Manuals, Checking Controlled Drugs, Checking the Crash Cart, Checking the Green Cart, Routine Patient Transfers to Other Facilities, Routine Admissions to Hospital, Skills Inventory Checklist - Admission Assessment, Abuse Identification and Reporting, Blood Glucose Monitoring, Blood Withdrawal, Blood/Blood Product, Pain Management, Burn Care Management, Cardiac Care, Code Blue, Sedation and ENT procedures (Employees #4, #5, #8, #17, and #18).

- There was no documented evidence the New Employee General Orientation was completed for four of eight employees. This orientation included Fire and Safety, Infection Control, Ethical Business Standards, Patient Rights and Responsibilities, Elder Abuse/Resident Abuse and Advanced Directives (Employees #4, #5, #18 and #20).

- There was no documented evidence the Annual Competency Assessment was completed for the Director of Nursing. The last Performance/Competency Evaluation was performed in 2010 (Employee #11).

Review of New Employee Orientation (undated) that stated in part:

"... The employee will be assessed for his/her ability to carry out assigned responsibilities safely, competently and in a timely manner upon completion or orientation by his/her department manager/supervisor..."

Review of the Staff Qualifications and Competency Policy (undated) that stated in part:

",,, It is the policy of this organization to demonstrate, assess, maintain and improve staff competence on an ongoing basis..."

"... The competency of all staff, whether they are an employee of this hospital or an employee of a licensed independent practitioner shall be assessed using a single set of criteria..."

The facility failed to follow its policies to ensure the employees possess the required competency and skills to carry out their assigned duties.

Review of the New Employee Orientation Policy (undated) that stated in part:

"Orientation to other related areas of the facility will be determined and conducted by the department managers/supervisors involved and will include as related to job function, but may not be limited to:

- Safety and infection control...
- Cultural diversity and sensitivity
- Patient rights and ethical aspects of care, treatment and services...
- Procedures for responding to unusual clinical events and incidents
- Distinction between administrative and clinical seclusion and restraint..."

The facility failed to follow its policy to ensure new employees receive training on the above subjects.

Review of Staff Qualifications and Competency Policy (undated) that stated in part:

"...Competency assessment for staff, students and volunteers who work in the same capacity as staff providing care, treatment and services is based on the following:

- A 90-day period of probation upon successful completion of orientation and an annual competency assessment on a yearly, and as needed basis, thereafter..."

The facility failed to adhere to its policy regarding annual competency assessment.

On 7/24/13 at 5:00 PM, the Human Resource/Payroll Staff confirmed the New Employee Orientation and Registered Nurse Orientation and Skills Checklist were not started or completed for the above-mentioned employees.

There was no documented evidence the required pre-employment tuberculosis test was completed for Employee #4.

Review of Employee Health Program Policy (undated) that stated in part:

"It is the policy of this hospital to assess each employee's physical ability to perform the job applied for by performing a pre-employment physical examination..."

"... Physical examinations for new employees will be set up in the Human Resources Department before the employee begins work and may include the following:

- Request for chest x-ray or tuberculosis skin test..."

The facility failed to follow its policy concerning required pre-employment tuberculosis testing.

On 7/24/13 at 5:00 PM, the Human Resource/Payroll Staff confirmed Employee #4 did not have documentation for tuberculosis testing.

Based on document review and interview, the facility failed to ensure an operating budget was in place and was prepared according to generally accepted accounting principles.

On 7/24/13 in the morning, the facility was asked to provide the governing body meeting minutes for review. The facility provided two binders which included the Nye Regional Medical Center Bylaws and Rules dated and signed 3/1/02, and the Nye Regional Medical Staff Rules dated March 1999.

The facility was asked for additional information concerning the Governing Body meetings. The facility then produced another binder which was identified as the "Corporate" regulations. This binder included the same information as provided in the first two manuals.

There was no documented evidence of an operating budget provided in any of the manuals.

On 7/24/13 at 12:00 PM, Employee #3 was asked to provide an annual operating budget and a three year plan. The employee verbalized he would try to obtain this.

On 7/25/13 in the morning, Employee #3 verbalized the former CFO (Chief Financial Officer) was working on the budget and would provide this as soon as possible.

On 7/25/13 in the afternoon, the Comptroller (Employee #12) provided an AP (Accounts Payable) Vendor Aging Report with invoice dates through 7/24/13, which totaled $4,683,884.

On 7/26/13 at 10:30 AM, the Director of Nurses (DON) verbalized there had been an issue several months ago where staff paychecks had bounced. The DON acknowledged that some vendors had not been paid. The DON revealed the pharmacist had not come to the facility for some time due to not getting paid. The DON added there had been a problem obtaining medication. The DON indicated the hospital was not able to obtain Morphine for a patient due to the pharmacy not getting paid. The patient brought in medication from home until the Morphine could be purchased. The DON did not provide the name of the patient.

On 7/26/13 at 12:00 PM, the Comptroller provided an annual budget dated 2013. The budget included income from the clinic. The budget did not include the outstanding debt to the vendors.

There was no documented evidence the budget had been reviewed or approved by the governing body.

There was no documented evidence a governing body meeting had taken place in 2013, 2012, or 2011. The only information provided by the facility regarding the governing body meetings was a signed form documenting the approval of the medical staff bylaws dated 7/30/2010.


26251

On 8/6/13 from 7:07 am to 7:50 am, the Administrator indicated the debt should have been addressed in the budget.

Based on document review and interview, the facility failed to ensure an Institutional Plan and operating budget was prepared and reviewed annually.

On 7/25/13 in the afternoon, the Comptroller (Employee #12) provided an AP (Accounts Payable) Vendor Aging Report with invoices dated through 7/24/13, which totaled $4,683,884.

On 7/26/13 at 12:00 PM, the Comptroller provided an annual budget dated 2013. The budget included income from the clinic. The budget did not include the outstanding debt to the vendors.

The facility did not provide information regarding an institutional plan.

There was no documented evidence of an institutional plan or operating budget in place which was reviewed annually.

There was no documented evidence the budget had been reviewed or approved by the governing body.


26251

Based on document review and interview, the facility failed to ensure an Institutional Plan and operating budget was prepared under the direction of the governing body, a committee consisting of representatives of the governing body, the administrative staff, and the medical staff of the institution.

On 7/24/13 in the morning, the facility was asked to provide the governing body meeting minutes for review. The facility provided two binders which included the Nye Regional Medical Center Bylaws and Rules dated and signed 3/1/02, and the Nye Regional Medical Staff Rules dated March 1999.

The facility was asked for additional information concerning the Governing Body meetings. The facility then produced another binder which was identified as the "Corporate" regulations. This binder included the same information as provided in the first two manuals.

There was no documented evidence of an institutional plan or operating budget in place which was prepared under the direction of the governing body or a committee representative of the governing body, the administrative staff, and the medical staff of the facility.




26251

Based on document review and interview, the facility failed to ensure pharmacy services were provided according to regulatory requirements.

On 7/25/13 in the afternoon, the Comptroller (Employee #12) provided an AP (Accounts Payable) Vendor Aging Report with invoice dates through 7/24/13 which totaled $4,683,884.

The statement indicated there was a current outstanding balance due to the pharmacy consultant.

On 7/25/13 at 2:30 PM, the pharmacy consultant confirmed he had not come to the facility for several months due to non payment. The pharmacist indicated he had just signed another contract with the facility, and was due to come to the facility during the last week of July. However, since the pharmacist still had not received payment, he would not come to the hospital to provide consultative services.


26251

On 7/25/13 at 2:30 PM, the consultant Pharmacist indicated the facility did not pay him prior to the quarterly visit due the week of July 22-26, 2013. As a result, the facility did not receive a quarterly visit.

Based on observation, interview, medical record review and document review, the governing body failed to ensure the emergency services requirements were met. (See tags A1104 and A1111).

Based on record review, interview, and policy review, the hospital failed to provide documentation that information was given to 7 out of 30 patients reviewed ( #17, #20, #22, #23, #24, #26 and #7).

Findings include:

On 7/25/13 9:00 AM- Review of patient files revealed that 7 out of 30 files did not have a signed patient's right form.

Patient #22 indicated on Patient Rights form, the patient "was unable to sign ", and did not have documentation that the patient representative was given information on patient rights. There was no signature from patient representative on patient rights form.


26251

Patient #7

On 5/20/13, Patient #7 was under 24 hour observation.

Facility staff members identified two versions of forms used for "Consent for Treatment [and] Financial Agreement". Within both forms was a section entitled "Patient Rights and Responsibilities Acknowledgement" evidencing the recipient's acknowledged notification of patient rights with a dated signature and witness cosigner.

Patient #7's medical record lacked documentation of the aforementioned form including the patient rights notification.

Based on record review, interview, and policy review, the hospital failed to establish resolution of patient grievance in a timely manner.

Findings include:

On 7/26/2013 at 830 AM, review of 5 grievances, (forms #31, #32, #35, #36, and #37), dated from 2/12 to 7/13, showed that 5 out of 30 grievances were not investigated by the hospital.

Patient #31 on 2/29/12, patient incontinent and not changed all night.

Patient #32 on 2/14/12, patient being assisted to bathroom and patient slipped resulting in a fall.

Patient #35 on 7/17/13, one year old vomiting with possible dehydration. Parents concerned due to long wait and delay of care. Wanted to leave against medical advice so hospital discharged pt with no treatment.

Patient #36 on 2/12/13, left Emergency Department against medical advice.

Patient #37- 1/23/13, delay of care, ST elevation on electrocardiogram and chest pain.

According to the facility's policy Patient Grievance Process # 1009, ( revised 1/16/09), "All grievances receive immediate priority and must be investigated with efforts made toward resolution within 24 hours."


On 7/26/2013 at 11:00 AM, the Director of Nursing indicated the grievances were not sent to the Director of nursing for 2-3 months and this is why they were not addressed in a timely manner. The risk manager is not trained to address grievances and redirects them to Director of Nursing.

Based on record review, interview and policy review, the hospital failed to establish an effective operation of the grievance process.

Findings include:

7/26/13 at 11:30 AM, the Director of nursing (DON) revealed that the risk manager was not trained to take this position. The grievances and incident reports are first sent to the risk manager and then sent to the Director of nursing. This process usually takes," two to three months", to reach her desk. The DON also revealed it was impossible for her to investigate the amount of grievances and incident reports that were received due to increased duties and lack of staff.

Based on record review, interview and policy review, the hospital failed to send grievances to quality improvement for review.

Findings include:
Review of 5 grievance forms #31, #32, #35, #36, and #37, (dated from 2/12 to 7/13), showed that 5 out of the 30 grievances were not investigated by hospital or sent to quality improvement for review.

Patient #7

On 5/20/13, Patient #7 was under 24 hour observation for supraventricular tachycardia, chest pain, and left lower lobe pneumonia.

The medical record lacked documentation of a nursing care plan.

The plan of care section of the patient summary was blank.

The problem list in the medical record consisted of medical diagnoses.

Patient #27

On 5/16/13, Patient #27 was admitted with diagnoses of left leg cellulitis, chest pressure, and rule out deep vein thrombosis.

The medical record lacked documentation of a nursing care plan.

The plan of care section of the patient summary was blank.

The nursing problem/goals list in the medical record consisted of nursing diagnoses without any interventions documented.

Patient #28

On 2/24/13, Patient #28 was admitted with diagnoses of acute pansinusitis, dysarthria, and cerebrovascular accident.

The medical record lacked documentation of a nursing care plan.

The plan of care section of the patient summary was blank.

The medical record lacked documentation of a nursing problem/goals section.

On 7/25/13 in the afternoon, the Director of Nursing indicated the medical records lacked a nursing care plan but might have a nursing problem list addressed.


33252

Based on record review the hospital failed to ensure the patients involvement in patient care.

Findings include:


On 7/25/13 at 9:00 AM review of six patient charts showed that 6 out of 6 charts, did not have a copy of Nursing Care Plan, and therefore there was no evidence to show that the patient had involvement in their care.

Patient #17 admitted on 3/4/13 with diagnosis of pneumonia

Patient #20 admitted on 2/11/13 with diagnosis of cholecystitis

Patient #22 admitted on 2/22/13 with diagnosis of rhabdomylysis

Patient #23 admitted on 2/17/13 with diagnosis of abdominal pain, gravida 25 weeks

Patient #24 admitted on 2/27/13 with diagnosis of acute pyelonephritis

Patient #26 admitted on 5/25/13 with diagnosis of head trauma.

Based on record review, interview, and policy review the hospital failed to give patients the right to make informed decisions regarding his or her care.

Findings include:

4 out of 4 patients reviewed (#17, #20, #22 and #24) did not have written notification on lack of in house physicians 24 hours a day, seven days a week and 1 patient's record (#7) lacked consent for treatment.

Patient #17 admitted on 3/4/13, diagnosis of pneumonia.

Patient #20 admitted on 2/11/13, diagnosis of cholecystitis.

Patient #22 admitted on 2/22/13, diagnosis of rhabdomylysis.

Patient #24 admitted on 2/27/13, diagnosis of acute pyelonephritis.

On 7/24/2013 10:00 AM Director of Nursing revealed the physician is not on site 24 hours a day, seven days a week. Physicians are on call during the night hours. The hospital did not have appropriate policies and procedures in place to ensure that written notice of this is provided to all patients.


26251

Patient #7

On 5/20/13, Patient #7 was under 24 hour observation for supraventricular tachycardia, chest pain, and left lower lobe pneumonia.

Facility staff members identified two versions of forms used for "Consent for Treatment [and] Financial Agreement". Within both forms were sections for evidencing consent for treatment and notification regarding the Health Insurance Portability and Accountability Act of 1996.

Patient #7's medical record lacked documentation of the aforementioned form denoting Patient #7's consent for treatment and notification regarding the Health Insurance Portability and Accountability Act of 1996.

Based on observation, the facility failed to provide 1 of 1 patients (Patient #11) with privacy while receiving treatment in the Emergency Department.

Findings include:

On 7/23/13 at approximately 2:00 PM during tour of the Emergency Department, Patient #11 was observed to be lying on a stretcher in the ER (Emergency Room), bed #1 without a privacy curtain pulled around the patient care area. At the time of observation, lab work was being drawn. Bed #1 is the first bed upon entering the ER and in direct view from the hallway and from the staff work area.

Based on interview and document review, the facility failed to ensure the performance improvement activities encompassed all areas of the facility and focused on areas that affected health outcomes, and quality of care.

Findings include:

1) A review of the facility's grievance log revealed there were several complaints regarding slow response of physicians responding to patients in the Emergency Room at the beginning of 2013.

On 7/26/13 at 8:30 AM, the Director of Nurses (DON) acknowledged the problem with slow physician response had been identified. The DON verbalized the issue was brought to the attention of the Medical Director, who indicated the issue would be addressed with the specific physician.

There was no documented evidence the issue was addressed in Quality Improvement (QI) by tracking, trending or analyzing the issue of slow response. The DON verbalized the issue, once identified, should have been followed up to evaluate if there was improvement in the response time which would affect patient care.

2) A problem had been identified by the facility regarding obtaining pharmacy consultative services and receiving medications due to a lack of paying the bills. There was no documented evidence pharmacy services were addressed in QI, except for medication errors.

3) There was no documented evidence the facility included organ procurement within the QAPI program.

4) Review of the QAPI minutes for 2013 revealed there was no documented evidence infection control issues were included in the QI process.

5) On 7/26/13 at 10:30 AM, the DON acknowledged there was a problem responding to patient grievances in a timely manner. Review of the QAPI minutes for 2013 revealed the patient grievance process had not been addressed by the QI committee.


32823


6) There was no documented evidence in meeting minutes that the contracted service provider for reference laboratory services was involved in the hospital's QAPI program.

Based on document review and interview, the facility failed to ensure quality improvement projects were conducted that were distinct to the hospital's services.

Findings include:

The Director of Nurses (DON) provided the report of Quality Improvement (QI) activities that were being followed and reported on monthly. These included admitting consents, respiratory requisitions, fire drills, crash cart checks, medication errors, patient safety issues including verbal orders, temperatures of the refrigerators, foreign objects in the laundry, and radiology testing.

There was no documented evidence the areas being reported had established goals, were monitored and tracked to determine if there was improvement, and reevaluated as appropriate.

Based on document review and interview, the facility failed to ensure there were adequate resources available for overseeing and monitoring the Quality Improvement (QI) program.

Findings include:

On 7/26/13 at 10:30 AM, an interview was conducted with the Director of Nurses (DON). The DON verbalized she was currently in charge of the QI program but had many additional responsibilities. The DON added she did not have sufficient time to devote to the QI program.

The DON verbalized there were concerns regarding the physician response in the Emergency Room, and with the lack of pharmacy consultant services which probably should have been addressed in QI.

The DON added, a Risk Manager had recently been assigned to assist with this function, but needed training, and had not yet functioned in the position.

Based on document review, the facility failed to ensure the medical staff bylaws documented timeframes for completion of history and physicals according to the regulations.

Findings include:

Review of the medical staff bylaws dated 3/1/02, documented in section 2.03, Basic responsibilities of staff membership - Each member of the Medical Staff shall: ... "(p) They physical examination and medical history to be done more than seven (7) days before or forty-right (48) hours prior to admission for each patient by a doctor of medicine or osteopathy." (sic)

Based on document review, the facility failed to ensure allied health professionals were providing patient care within the guidelines established by the governing body.

Findings include:

Review of credentialing files revealed two physician assistants, also considered allied health professionals, were granted privileges at this facility.

The facility's medical staff rules dated March 1999, Rule V-3 Credentialing of Allied Health Professionals, Rule V-3.1 Categories (a) documented "...Such Allied Health professionals shall be subject to the supervision requirements developed by the Interdisciplinary Practices Committee, the Medical Executive Committee, and the Governing Body."

There was no additional documentation provided in any of the facility's manuals which explained the supervisory requirements for Allied Health Professionals.

Based on record review, policy review and interview, the facility failed to ensure nursing care plans were documented within medical records for 3 of 30 patients (Patient #7, #27, and #28).

Findings Include:

According to the facility's policy Documentation (#9001) last revised 5/26/09, "All components of the patient care process, plan of care, evaluation and outcomes will be documented in the patient's medical record..."

Patient #7

On 5/20/13, Patient #7 was under 24 hour observation for supraventricular tachycardia, chest pain, and left lower lobe pneumonia.

The medical record lacked documentation of a nursing care plan.

The plan of care section of the patient summary was blank.

The problem list in the medical record consisted of medical diagnoses.

Patient #27

On 5/16/13, Patient #27 was admitted with diagnoses of left leg cellulitis, chest pressure, and rule out deep vein thrombosis.

The medical record lacked documentation of a nursing care plan.

The plan of care section of the patient summary was blank.

The nursing problem/goals list in the medical record consisted of nursing diagnoses without any interventions documented.

Patient #28

On 2/24/13, Patient #28 was admitted with diagnoses of acute pansinusitis, dysarthria, and cerebrovascular accident.

The medical record lacked documentation of a nursing care plan.

The plan of care section of the patient summary was blank.

The medical record lacked documentation of a nursing problem/goals section.

Based on observation, interview, record and policy review, the facility failed to follow its policies regarding medication preparation and administration for 1 of 30 patients (Patient #2).

Findings include:

On 7/25/13 in the afternoon, two 3 milliliter syringes were stored in the emergency department refrigerator.

Both syringes had an expiration date in black marker of 10/14/13.

Both syringes were initialed by Employee #18, a Registered Nurse (RN).

The initials L.E.T. were visible on the side of the syringe.

The Director of Nursing (DON) identified the contents as 4% Lidocaine, 0.1% Epinephrine, and 0.5% Tetracaine. Directions for the mixture were posted on a nearby cabinet.

The DON was asked how the RN arrived at an expiration date of 10/14/13. The DON indicated 28 days after first opening the vial. After pointing out the expiration date was greater than 28 days away, the DON did not respond.

The DON indicated the L.E.T. was drawn up by nurses and not a pharmacist. The L.E.T. was administered as a viscous, topical anesthetic agent for pediatric patients.

The DON indicated L.E.T. was not available to order or listed in the facility's formulary.

According to the facility's policy, Medication Administration last revised 5/26/09, "...Medications will be prepared immediately prior to administration,...To the maximum extent possible, drugs are to be administered by the person preparing the dose..."

Patient #2

On 5/29/13, Patient #2 was admitted with diagnoses of asthma exacerbation, dehydration, and anaphylactic reaction.

The handwritten emergency department record showed Employee/Registered Nurse (RN) #8 documented Epinephrine 1:1000 1 milliliter intravenous at 10:04 AM.

The Administrator/Physician documented Epinephrine 1:1000 0.2 milliliters intravenous on the bottom of the page. The page lacked a documented time and date.

On 8/1/13 in the morning, the RN indicated 0.2 milliliters was administered, not 1 milliliter. The electronic medication administration record indicated 0.2 milliliters was administered.

The RN indicated if a documentation error was made, a line would be drawn through the incorrect entry. The Epinephrine 1:1000 1 milliliter order did not have a line drawn through it.

The RN, on the morning of 8/1/13, and the Administrator/Physician, on the morning of 8/6/13, indicated the Administrator/Physician wrote 2 milliliters of Epinephrine administered in the narrative notes by mistake. The medical record did not show this correction.

According to the facility's policy Medical Record Amendment/Addendum #2145, (last revised 1/1/13), "...Documents created in a paper format...If information in a paper record must be amended or revised, draw a line through the incorrect entry and annotate the record with the date, time and the reason for the revision noted, and signature of the person making the revision..."

According to the facility's policy Medication Administration #3042, (last revised 5/26/09), on page 4 "...All medication orders are to be timed and dated by the authorized person writing the order..."

On 8/6/13 from 7:07 am to 7:50 am, the Administrator/Physician was asked to describe the proper dilution of Epinephrine, and he indicated he would defer to the nursing staff.

On 8/1/13 from 9:10 am to 10:10 am, the RN indicated 1 milligram/1 milliliter of the Epinephrine was added to 10 milliliters of normal saline. Then the RN administered 2 milliliters of the 11 milliliter solution or less than a fifth of the total solution, resulting in less than the 0.2 milliliters documented. At one point, the RN indicated the entire 11 milliliter solution was administered, including 1 milligram/1 milliliter of Epinephrine. The RN indicated advice on the mixture was obtained from the DON.

According to the facility's policy, Safe Medication Practices #3041 (last revised 5/26/09), "...Always clarify any order you are unsure of with the Pharmacist, ordering physician or current approved literary resource. Do not ask another nurse that may inadvertently provide you with the incorrect answer..."

Based on record review, interview and policy review, the facility failed to document in a medical record in a manner consistent with its policy for 2 of 30 patients (Patient #2 and Patient #20).

Findings include:

Patient #2

On 5/29/13, Patient #2 was admitted with diagnoses of asthma exacerbation, dehydration, and anaphylactic reaction.

The handwritten emergency department record showed a Registered Nurse (RN) documented Epinephrine 1:1000 1 milliliter intravenous at 10:04 AM.

The Administrator/Physician documented Epinephrine 1:1000 0.2 milliliters intravenous on the bottom of the page. The page lacked a documented time and date.

On 8/1/13 in the morning, an RN indicated 0.2 milliliters was administered, not 1 milliliter. The electronic medication administration record indicated 0.2 milliliters was administered.

The RN indicated if a documentation error was made, a line would be drawn through the incorrect entry. The Epinephrine 1:1000 1 milliliter order did not have a line drawn through it.

The RN, on the morning of 8/1/13, and Administrator/Physician, on the morning of 8/6/13, indicated the Administrator/Physician wrote 2 milliliters of Epinephrine administered in the narrative notes by mistake. The medical record did not show this correction.

According to the facility's policy Medical Record Amendment/Addendum #2145, (last revised 1/1/13), "...Documents created in a paper format...If information in a paper record must be amended or revised, draw a line through the incorrect entry and annotate the record with the date, time and the reason for the revision noted, and signature of the person making the revision..."

According to the facility's policy Medication Administration #3042, (last revised 5/26/09), on page 4 "...All medication orders are to be timed and dated by the authorized person writing the order..."



33252


Patient #20
Patient #20 admitted on 2/11/13 with diagnosis of acute cholecystitis revealed that on 2/10/13 on the ED report:
Toradol 30 milligrams (mg) was written on a line with an initial indicating that it was given.The Toradol dosage was then crossed out with no initial indicating who crossed it out. The next line revealed 60 mg intramuscular was written with no initial stating who wrote it and no initial to state if it was actually given.

Based on record review the hospital failed to ensure that all orders, including verbal orders were dated, timed and authenticated promptly by the ordering practitioner for 4 of 30 records (Patient #20, #22, #23, and #24).
Findings include:
Patient #20
Patient #20 admitted on 2/11/13 with diagnosis of acute cholecystitis revealed that on 2/10/13 on ED report:
Toradol 30 milligram written but crossed out with no initial then rewritten to 60 milligram intramuscular on line under order with no initial or no time given.

Patient #22
Patient #22 admitted 2/22/13 with diagnosis of rhabdomylysis

Clarification on normal saline at 100 milliliters was not signed, ordered 2/24/13
Give regular insulin 5 units subcutaneous now, not signed, ordered 2/24/13
Give novolin regular insulin 5 units subcutaneous now, not signed, ordered 2/26/13
Give novolin regular insulin 5 units subcutaneous now, not signed, ordered 2/27/13
Poytrim eye drops, both eyes, four times a day, not signed, ordered 2/27/13
Discontinue fluids, not signed, ordered 2/27/13

Patient #23
Patient # 23, admitted 2/17/13 with diagnosis of abdominal pain, gravida 25 weeks
Toradol 30 milligram intravenous every 6 hours when needed for pain, not signed ordered 2/7/2013
Zophran 4 milligrams intravenous every 6 hours when needed for nausea, not signed ordered 2/24/13

Patient #24
Patient #24 admitted on 2/27/13 with diagnosis of acute Pyelonephritis Foley catheter, not signed, ordered 2/27/13

Based on record review, interview and policy review, the facility failed to document physician orders for 1 of 30 patients (Patient #27).

Findings include:

Patient #27

On 5/16/13, Patient #27 was admitted with diagnoses of left leg cellulitis, chest pressure, and rule out deep vein thrombosis.

On 5/16/13 at 8:11 PM, Patient #27's medication administration record indicated a nurse administered Enoxaparin 140 milligrams intravenously at 8:11 PM. The order indicated 100 milligrams. The medical record lacked documentation of a physician's order for Enoxaparin 140 milligrams.

On 5/16/13 at 8:12 PM, Patient #27's medication administration record indicated a nurse administered Magnesium Sulfate 1 Gram intravenously. The medical record lacked documentation of a physician's order for Magnesium Sulfate 1 Gram intravenously.

On 5/16/13 at 8:13 PM, Patient #27's medication administration record indicated a nurse administered Potassium Chloride 20 milliequivalents in normal saline intravenously. The medical record lacked documentation of a physician's order for Potassium Chloride 20 milliequivalents in normal saline intravenously.

On 7/26/13 in the morning, the Director of Nursing indicated the medical record lacked documentation of a physician's order for the aforementioned medications.

According to the facility's policy Medical Record Content #8012, (no revision date), on page 3, "...All medications ordered are documented in the medical record..."

Based on observation, interview, record review and policy review, the facility failed to ensure pharmaceutical services met the needs of the facility and its patients. The following processes were not in place: pharmacy management and administration A-0491, pharmacist responsible for coordinating all activities A-492, current and accurate records kept A-494, delivery of services A-500, compounding and packaging under pharmacist supervision A-501, and outdated, mislabeled or otherwise unusable drugs unavailable for use A-505.

The cumulative effect of the systemic practices resulted in the failure of the facility to deliver statutory, safe mandated care to patients.

Based on observation, interview and policy review, the facility failed to follow accepted principles in the storage of stock medications, repackaging of drugs, and pharmacy operations.

Findings include:

On 7/23/13, the following drugs were discovered to be expired and shelved with stock drugs inside the facility's pharmacy room:

Amoxicillin Clavulanate Potassium 875/125 milligrams x 8, lot #BT6346, expiration 6/2013.

Acyclovir 500 milligram/10 milliliter/50 milligram/milliliter, lot #6003208, expiration 6/2013.

Folic Acid tablets, lot #32585, expiration 6/2013.

Kayexalate 473 milliliter container open 2/7/12, lot #910292, expiration 9/2013.

Lidocaine 4% topical open 12/1/12, lot #259691A, expiration 4/2014.

Nystatin Oral Suspension 100,000 units/milliliter x 2 containers, NDC 0603-1481-49, expiration 6/2013.

Spironolactone 25 milligrams unit dose x 2 containers, expiration 6/2013.

Triamcinolone Acetonide Cream 0.1%, expiration 6/2013.

The Director of Nursing indicated all the aforementioned drugs should have been removed from stock for expirations and for exceeding 28-30 days of opened status.

On 7/25/13 in the afternoon, a tour of the emergency department with the Director of Nursing revealed the following:

The emergency department refrigerator contained 2, 20 milligram/milliliter 10 milliliter vials of Succinylcholine, lot #16-129-EV expired July 1, 2013. The Director of Nursing acknowledged the expirations.

The emergency department refrigerator contained 2, 3 milliliter syringes with clear plastic tape on the body of the syringe. L.E.T. was written in black on the tape with an expiration date of 10/14/13. Employee #18's initials were on the syringes. The Director of Nursing was unable to explain how Employee #18 decided an expiration date of 10/14/13.

The Director of Nursing indicated the contents in the syringes were Lidocaine 4%, Epinephrine 0.1%, and Tetracaine 0.5%. The concentration and volume of each medication within the 3 milliliter syringes could not be verified. A recipe for mixing the medications was posted on a nearby cabinet. The Director of Nursing indicated the emergency department used this mixture since she started working at the facility.

According to the facility's policy Safe Medication Practices #3018 (last revised 5/26/09), on page 2 "...Keep all medications in original containers..."

According to the facility's policy Medication Administration #3042 (last revised 5/26/09), on page 3 "...Medications will be prepared immediately prior to administration...To the maximum extent possible, drugs are to be administered by the person preparing the dose..."

On 7/25/13 at 2:30 PM, the consultant Pharmacist indicated he was unaware of nurses compounding medications at the facility. The facility would have to keep a repackaging log when moving a medication from one container to another (and then storing it in the second container for a time prior to administration). The Director of Nursing did not have repackaging logs for Lidocaine 4%, Epinephrine 0.1%, and Tetracaine 0.5%.

According to the facility's policy Storage Of Medications And Solutions In Patient Care Areas #3009, last revised 5/19/09, on page 1 "...The Pharmacist shall make monthly inspections of all storage areas to assure compliance..."

On 7/23/13, a repackaged bottle of Acetaminophen with Codeine Elixir was observed in the narcotic cabinet on the acute floor.

On 7/24/13 in the afternoon, Board of Pharmacy members were asked to observe whether or not repackaging was occurring. Upon seeing the Acetaminophen with Codeine Elixir, a Pharmacy Board member inquired about repackaging logs.

The Director of Nursing provided the controlled medication logs, which showed repackaging of Acetaminophen with Codeine Elixir, Promethazine with Codeine Elixir, and Tussinex being repackaged into smaller bottles, mainly for emergency department use. The Director of Nursing indicated Vicodin and Percocet were repackaged as well.

According to the facility's policy, Storage Of Medications And Solutions In Patient Care Areas #3009 (last revised 5/19/09), on page 1 "...All drugs shall be stored in their original container as issued from the Pharmacy. No drug shall be transferred from one container to another by nursing staff..."

According to the facility's policy Safe Medication Practices #3018 (last revised 5/26/09), on page 2 "...Keep all medications in original containers..."

A tour of the pharmacy room revealed a drawer full of smaller 2-4 ounce bottles used for repackaging.

The controlled medication logs for the aforementioned repackaged medications did not have entries for the manufacturer, drug strength, manufacturer's expiration date, and lot number.

On 7/25/13 at 2:30 PM, the consultant Pharmacist indicated he was unaware nurses were repackaging, and there were no discussions regarding repackaging or repackaging logs on previous visits. The facility would have to ensure labeling information was transferred to the repackaged container, including expiration dates and lot numbers. Orders and expirations were checked when the consultant Pharmacist conducted visits but not otherwise.

On 7/25/13 in the afternoon, the Director of Nursing indicated the pharmacist should check all medication orders; the facility tried to set up a remote software system for the consultant Pharmacist, but it did not work out. Since the consultant Pharmacist did not check medication orders; the nurses were expected to check the medication orders of their patients.

According to the facility's policy, Medication Administration #3042 (last revised 5/26/09), on page 5 "...The Charge Nurse will send copies of the physician's orders sheets to the Pharmacy as soon as possible after a medication or discharge order is written..."

According to the facility's policy, Authorized Access To The Pharmacy #3039 (last revised 5/26/09), on page 2 "...The Pharmacist will review all orders brought in and filled by the Nursing Staff as soon as possible..." The last consultant Pharmacist visit was 4/24/13.

According to the facility's consultant Pharmacist contract, signed 4/24/13, on page 2 "...f. Assist Facility's administrative and medical staff in establishing and implementing policies and procedures for the safe and effective distribution, control, and use of drugs. g. Participate (at least quarterly) in facility's in-service training program for the nursing staff..."

On 7/25/13 at 2:30 PM, the consultant Pharmacist indicated the facility did not pay him for the quarterly visit due the week of July 22-26, 2013. As a result, the facility did not receive a quarterly visit.

Based on observation, interview, record review and policy review, the facility failed to have a supervising pharmacist oversee pharmacy operations.

Findings include:

On 7/25/13 at 2:30 PM, the consultant Pharmacist indicated the facility did not pay him prior to the quarterly visit due the week of July 22-26, 2013. As a result, the facility did not receive a quarterly visit.

Based on observation, interview, record review and policy review, the facility failed to keep a complete an accurate record of its repackaged, scheduled drugs.

Findings include:

On 7/23/13, a repackaged bottle of Acetaminophen with Codeine Elixir was observed in the narcotic cabinet on the acute floor.

On 7/24/13 in the afternoon, Board of Pharmacy members were asked to observe whether or not repackaging was occurring. Upon seeing the Acetaminophen with Codeine Elixir, a Pharmacy Board member inquired about repackaging logs.

The Director of Nursing provided the controlled medication logs, which showed repackaging of Acetaminophen with Codeine Elixir, Promethazine with Codeine Elixir, and Tussinex being repackaged into smaller bottles, mainly for emergency department use. The Director of Nursing indicated Vicodin and Percocet were repackaged as well.

According to the facility's policy, Storage Of Medications And Solutions In Patient Care Areas #3009 (last revised 5/19/09), on page 1 "...All drugs shall be stored in their original container as issued from the Pharmacy. No drug shall be transferred from one container to another by nursing staff..."

According to the facility's policy Safe Medication Practices #3018 (last revised 5/26/09), on page 2 "...Keep all medications in original containers..."

A tour of the pharmacy room revealed a drawer full of smaller 2-4 ounce bottles used for repackaging.

The controlled medication logs for the aforementioned repackaged medications did not have entries for the manufacturer, drug strength, manufacturer's expiration date, and lot number.

On 7/25/13 at 2:30 PM, the consultant Pharmacist indicated he was unaware nurses were repackaging, and there were no discussions regarding repackaging or repackaging logs on previous visits. The facility would have to ensure labeling information was transferred to the repackaged container, including expiration dates and lot numbers. Orders and expirations were checked when the consultant Pharmacist conducted visits but not otherwise.

Based on observation, interview, record review and policy review, the facility failed to control and distribute drugs and biologicals in a safe manner consistent with applicable standards of practice.

Findings include:

On 7/23/13 in the afternoon, the following drugs were discovered to be expired and shelved with stock drugs inside the facility's pharmacy room:

Amoxicillin Clavulanate Potassium 875/125 milligrams x 8, lot #BT6346, expiration 6/2013.

Acyclovir 500 milligram/10 milliliter/50 milligram/milliliter, lot #6003208, expiration 6/2013.

Folic Acid tablets, lot #32585, expiration 6/2013.

Kayexalate 473 milliliter container open 2/7/12, lot #910292, expiration 9/2013.

Lidocaine 4% topical open 12/1/12, lot #259691A, expiration 4/2014.

Nystatin Oral Suspension 100,000 units/milliliter x 2 containers, NDC 0603-1481-49, expiration 6/2013.

Spironolactone 25 milligrams unit dose x 2 containers, expiration 6/2013.

Triamcinolone Acetonide Cream 0.1%, expiration 6/2013.

The Director of Nursing indicated all the aforementioned drugs should have been removed from stock for expirations and for exceeding 28-30 days of opened status.

On 7/25/13 in the afternoon, a tour of the emergency department with the Director of Nursing revealed the following:

The emergency department refrigerator contained 2, 20 milligram/milliliter 10 milliliter vials of Succinylcholine, lot #16-129-EV expired July 1, 2013. The Director of Nursing acknowledged the expirations.

The emergency department refrigerator contained 2, 3 milliliter syringes with clear plastic tape on the body of the syringe. L.E.T. was written in black on the tape with an expiration date of 10/14/13. Employee #18's initials were on the syringes. The Director of Nursing was unable to explain how Employee #18 decided an expiration date of 10/14/13.

The Director of Nursing indicated the contents in the syringes were Lidocaine 4%, Epinephrine 0.1%, and Tetracaine 0.5%. The concentration and volume of each medication within the 3 milliliter syringes could not be verified. A recipe for mixing the medications was posted on a nearby cabinet. The Director of Nursing indicated the emergency department used this mixture since she started working at the facility.

According to the facility's policy Safe Medication Practices #3018 (last revised 5/26/09), on page 2 "...Keep all medications in original containers..."

According to the facility's policy Medication Administration #3042 (last revised 5/26/09), on page 3 "...Medications will be prepared immediately prior to administration...To the maximum extent possible, drugs are to be administered by the person preparing the dose..."

On 7/25/13 at 2:30 PM, the consultant Pharmacist indicated he was unaware of nurses compounding medications at the facility. The facility would have to keep a repackaging log when moving a medication from one container to another (and then storing it in the second container for a time prior to administration). The Director of Nursing did not have repackaging logs for Lidocaine 4%, Epinephrine 0.1%, and Tetracaine 0.5%.

According to the facility's policy Storage Of Medications And Solutions In Patient Care Areas #3009, (last revised 5/19/09), on page 1 "...The Pharmacist shall make monthly inspections of all storage areas to assure compliance..."

On 7/23/13, a repackaged bottle of Acetaminophen with Codeine Elixir was observed in the narcotic cabinet on the acute floor.

On 7/24/13 in the afternoon, Board of Pharmacy members were asked to observe whether or not repackaging was occurring. Upon seeing the Acetaminophen with Codeine Elixir, a Pharmacy Board member inquired about repackaging logs.

The Director of Nursing provided the controlled medication logs, which showed repackaging of Acetaminophen with Codeine Elixir, Promethazine with Codeine Elixir, and Tussinex being repackaged into smaller bottles, mainly for emergency department use. The Director of Nursing indicated Vicodin and Percocet were repackaged as well.

According to the facility's policy, Storage Of Medications And Solutions In Patient Care Areas #3009 (last revised 5/19/09), on page 1 "...All drugs shall be stored in their original container as issued from the Pharmacy. No drug shall be transferred from one container to another by nursing staff..."

According to the facility's policy Safe Medication Practices #3018 (last revised 5/26/09), on page 2 "...Keep all medications in original containers..."

A tour of the pharmacy room revealed a drawer full of smaller 2-4 ounce bottles used for repackaging.

The controlled medication logs for the aforementioned repackaged medications did not have entries for the manufacturer, drug strength, manufacturer's expiration date, and lot number.

On 7/25/13 at 2:30 PM, the consultant Pharmacist indicated he was unaware nurses were repackaging, and there were no discussions regarding repackaging or repackaging logs on previous visits. The facility would have to ensure labeling information was transferred to the repackaged container, including expiration dates and lot numbers. Orders and expirations were checked when the consultant Pharmacist conducted visits but not otherwise.

Based on observation, interview, record review and policy review, the facility failed to have a supervising pharmacist oversee repackaging pharmacy operations.

Findings include:

On 7/23/13, a repackaged bottle of Acetaminophen with Codeine Elixir was observed in the narcotic cabinet on the acute floor.

On 7/24/13 in the afternoon, Board of Pharmacy members were asked to observe whether or not repackaging was occurring. Upon seeing the Acetaminophen with Codeine Elixir, a Pharmacy Board member inquired about repackaging logs.

The Director of Nursing provided the controlled medication logs, which showed repackaging of Acetaminophen with Codeine Elixir, Promethazine with Codeine Elixir, and Tussinex being repackaged into smaller bottles, mainly for emergency department use. The Director of Nursing indicated Vicodin and Percocet were repackaged as well.

According to the facility's policy, Storage Of Medications And Solutions In Patient Care Areas #3009 (last revised 5/19/09), on page 1 "...All drugs shall be stored in their original container as issued from the Pharmacy. No drug shall be transferred from one container to another by nursing staff..."

According to the facility's policy Safe Medication Practices #3018 (last revised 5/26/09), on page 2 "...Keep all medications in original containers..."

A tour of the pharmacy room revealed a drawer full of smaller 2-4 ounce bottles used for repackaging.

The controlled medication logs for the aforementioned repackaged medications did not have entries for the manufacturer, drug strength, manufacturer's expiration date, and lot numbers.

On 7/25/13 at 2:30 PM, the consultant Pharmacist indicated he was unaware nurses were repackaging, and there were no discussions regarding repackaging or repackaging logs on previous visits. The facility would have to ensure labeling information was transferred to the repackaged container, including expiration dates and lot numbers. Orders and expirations were checked when the consultant Pharmacist conducted visits but not otherwise.

According to the facility's policy, Authorized Access To The Pharmacy #3039 (last revised 5/26/09), on page 2 "...The Pharmacist will review all orders brought in and filled by the Nursing Staff as soon as possible..." The last consultant Pharmacist visit was 4/24/13.

On 7/25/13 at 2:30 PM, the consultant Pharmacist indicated the facility did not pay him for the quarterly visit due the week of July 22-26, 2013. As a result, the facility did not receive a quarterly visit.

Based on observation, interview and policy review, the facility failed to ensure outdated, mislabeled, or otherwise unusable drugs and biologicals were unavailable for patient use.
Findings include:

During departmental tour conducted 7/23/13 at approximately 1:30 PM, the following expired medications were discovered in the Emergency Department:

Succinylcholine 200mg (milligram), 20mg/ml (milliliter), 10 ml. Four (4) vials located in the RSI (Rapid Sequence Intubation) kit with expiration date of 7/1/13.

Succinylcholine 200mg (milligram), 20mg/ml (milliliter), 10 ml. Two (2) vials located in the emergency department medication refrigerator with expiration date of 7/1/13.

One (1) Heplock flush 10 units/ml. 5ml. in a 12 ml. syringe with expiration date 7/2010.


Employee # 5, a licensed nurse, acknowledged the expiration dates on the medications. The licensed nurse shared the DON (Director of Nursing) was responsible for replacing medications, but all employees were responsible to check for expiration dates.

A patient's home medication was discovered in the Emergency Department's refrigerator in a clear plastic bag without label. Label on the medication box read as follows:
_______ (Patient name) "Take Directly to Clinic". Prescription date 6/1/11. Prescription expiration date 8/6/11. Zostavax Injection 1 vial with expiration date 6/9/12. Sterile diluent 1 vial with expiration date 3/2012. Employee #5 revealed no knowledge of why medication was stored in the emergency department refrigerator.

Review of facility policy titled, "Medication Administration"- Emergency Department, reference #3017, effective date 3/1/2002, revised date 1/8/2009 read as follows: "Medications from home that the patient brings to the hospital will be disposed of in one of two ways: Sent home with an immediate relative, Sent to the hospital pharmacy to be stored until the patient is discharged. Medications are placed in a labeled bag and sent to the Pharmacy. If the patient expires, all personal medication will be destroyed".



26251

On 7/23/13 in the afternoon, the following drugs were discovered to be expired and shelved with stock drugs inside the facility's pharmacy room:

Amoxicillin Clavulanate Potassium 875/125 milligrams x 8, lot #BT6346, expiration 6/2013.

Acyclovir 500 milligram/10 milliliter/50 milligram/milliliter, lot #6003208, expiration 6/2013.

Folic Acid tablets, lot #32585, expiration 6/2013.

Kayexalate 473 milliliter container open 2/7/12, lot #910292, expiration 9/2013.

Lidocaine 4% topical open 12/1/12, lot #259691A, expiration 4/2014.

Nystatin Oral Suspension 100,000 units/milliliter x 2 containers, NDC 0603-1481-49,
expiration 6/2013.

Spironolactone 25 milligrams unit dose x 2 containers, expiration 6/2013.

Triamcinolone Acetonide Cream 0.1%, expiration 6/2013.

The Director of Nursing indicated all the aforementioned drugs should have been removed from stock for expirations and for exceeding 28-30 days of opened status.

On 7/25/13 in the afternoon, a tour of the emergency department with the Director of Nursing revealed the following:

The emergency department refrigerator contained 2, 20 milligram/milliliter 10 milliliter vials of Succinylcholine, lot #16-129-EV expired July 1, 2013. The Director of Nursing acknowledged the expirations.

The emergency department refrigerator contained 2, 3 milliliter syringes with clear plastic tape on the body of the syringe. L.E.T. was written in black on the tape with an expiration date of 10/14/13. Employee #18's initials were on the syringes. The Director of Nursing was unable to explain how Employee #18 decided an expiration date of 10/14/13.

The Director of Nursing indicated the contents in the syringes were Lidocaine 4%, Epinephrine 0.1%, and Tetracaine 0.5%. The concentration and volume of each medication within the 3 milliliter syringes could not be verified. A recipe for mixing the medications was posted on a nearby cabinet. The Director of Nursing indicated the emergency department used this mixture since she started working at the facility.

According to the facility's policy Safe Medication Practices #3018 (last revised 5/26/09), on page 2 "...Keep all medications in original containers..."

According to the facility's policy Medication Administration #3042 (last revised 5/26/09), on page 3 "...Medications will be prepared immediately prior to administration...To the maximum extent possible, drugs are to be administered by the person preparing the dose..."

Based on site observation and interview with laboratory personnel, there was no documented evidence as to what laboratory tests were to be immediately available to meet the needs of the patients.

Findings include:

There was no documented evidence that the medical staff had developed a list that reflected current emergency laboratory services available to meet the needs of patients in the hospital or for those patients who came to the hospital in an emergency situation.

Based on observation and interview, the facility failed to ensure staff compliance with the infection control policies.

Findings include:

During the emergency department tour on 7/23/13 at approximately 2:00 PM, a nurse was observed applying pressure to a patient's venipuncture site without wearing gloves. During interview, the nurse revealed the lab technician had just drawn blood from the patient and was in a hurry to get the results. The nurse held pressure on the site to help the lab technician out and had not thought to grab gloves. The nurse indicated this was not normal practice.

Review of facility policy titled, "Standard Precautions" Emergency Department, reference #4010, effective date 3/1/2002, revised date 1/8/2009 read as follows:

"Policy: Standard precautions combine the features of universal precautions and body substance isolation. Standard precautions apply to all patients regardless of their diagnosis or suspected infection status. Standard precautions apply to the following: 1. Blood, 2. All body fluids, secretions and excretions except sweat whether or not they contain visible blood, 3. Non-intact skin, 4. Mucous membranes. Standard precautions include the following: Gloves - Gloves are to be worn when touching blood, body fluids, secretions, excretions and other contaminated items."

Based on record review, interview and document review, the facility failed to implement established procedures to carry out its organ procurement responsibilities. The facility failed to notify the Organ Procurement Organization about the death of 1 of 5 patients (Patient #6). The facility failed to notify the families of 3 of 5 deceased patients about the option to donate or decline to donate organs, tissues or eyes (Patient #6, #13 and #29). The facility failed to coordinate with the Organ Procurement Organization to provide staff training on approaching potential donor families.

Findings include:

Patient #6

Patient #6 presented to the emergency department on 6/13/13 after the patient was found unresponsive at home. CPR was initiated and resumed at the hospital. The patient expired on 6/13/13 due to cardiopulmonary arrest.
Review of Nevada Donor Network (NDN) Notification Log for the period 1/21/11 to 6/27/13, revealed no documented evidence the NDN was notified of Patient #6's death.

Review of electronic nursing notes dated 6/13/13 revealed the family was not notified about the option to donate or decline to donate organs, tissues or eyes.

Patient #13

Patient #13 was admitted on 4/12/13 at 8:57 AM, with symptoms including shortness of breath. Patient #13 had a history of diabetes mellitus, colon cancer, hypertension, atrial fibrillation, coronary artery disease, degenerative joint disease, homocysteinemia and had pacemaker insertion. On 4/12/13 at 6:05 PM, Patient #13 expired due to cardiopulmonary arrest.

Review of the patient's electronic nursing notes dated 4/12/13 revealed the family was not notified about the option to donate or decline to donate organs, tissues or eyes.

Patient #29

Patient #29 was admitted on 4/15/13 at 2:05 PM with diagnoses including back pain with difficulty walking, chronic obstructive pulmonary disease and osteoporosis. Patient #29 expired on 4/20/13 at 2:26 PM due to community acquired bibasilar pneumonia, hypoxemia, exacerbation of chronic obstructive pulmonary disease and dehydration.

Review of electronic nursing notes dated 4/20/13 revealed the patient's family was not notified of the options to donate or decline to donate organs, tissues or eyes.

Review of the Requirements for Management of Organ and Tissue Donation (revised 1/8/2009), stated in part:

Procedure:
"... Upon the death of any patient, the family will be informed that the Tissue Donation Hotline personnel would like to contact them regarding donation of the deceased tissues and/or organs..."

"... Information regarding notification of the family of the proposed contact by the Tissue Donation Hotline and the family's response (wishes to be contacted, does not wish to be contacted) will be recorded in the medical record on the nursing notes, including: Name of the hotline contact personnel member, case number assigned by Hotline personnel, family response and desire, date and time of call and name, level of licensure of individual reporting to the Hotline..."

The facility failed to follow the procedures for notifying the families of deceased patients about the option to donate organs, tissues or eyes, or the option to decline to donate.

On 7/26/13 at approximately 11:30 AM, the Director of Nursing verified by reviewing the electronic nursing notes, and confirmed the families of the above patients were not notified.

Review of personnel files of six registered nurses revealed no documented evidence of training by Nevada Organ Network, the hospital's Organ Procurement Organization.

On 7/26/13 at 8:05 AM, Employee #2, RN indicated all registered nurses were trained to call the Nevada Donor Network in the event of a patient's death. Employee #2 stated they did not have a formal training, however, there was a manual prepared by the Director of Nursing.

Employee #2 provided a copy of a memorandum from the Director of Nursing dated 6/25/04, reminding all nursing staff to report all deaths to the Nevada Donor Network, with the telephone number. It included instructions to complete the log and document in medical records.

On 7/26/13 at approximately 11:30 AM, the Director of Nursing stated the staff has not received formal training from Nevada Donor Network.

Review of the Memorandum of Understanding and Agreement between Nye Regional Medical Center and Nevada Donor Network, Inc. signed on 4/9/2011, stated in part:

NDN Services and Responsibilities:
"...The provision of educational programs for hospital staff at no charge. Programs will be scheduled at the convenience of the hospital..."

The facility had not scheduled staff training with Nevada Donor Network.

Based on record review, interview and document review, the facility failed to notify the Organ Procurement Organization about the death of 1 of 5 patients (Patient #6). The facility failed to notify the families of 3 of 5 deceased patients about the option to donate or decline to donate organs, tissues or eyes (Patient #6, #13 and #29).

Findings include:

Patient #6

Patient #6 presented to the emergency department on 6/13/13 after the patient was found unresponsive at home. CPR was initiated and resumed at the hospital. The patient expired on 6/13/13 due to cardiopulmonary arrest.
Review of Nevada Donor Network (NDN) Notification Log for the period 1/21/11 to 6/27/13, revealed no documented evidence the NDN was notified of Patient #6's death.

Review of electronic nursing notes dated 6/13/13 revealed the family was not notified about the option to donate or decline to donate organs, tissues or eyes.

Patient #13

Patient #13 was admitted on 4/12/13 at 8:57 AM, with symptoms including shortness of breath. Patient #13 had a history of diabetes mellitus, colon cancer, hypertension, atrial fibrillation, coronary artery disease, degenerative joint disease, homocysteinemia and had pacemaker insertion. On 4/12/13 at 6:05 PM, Patient #13 expired due to cardiopulmonary arrest.

Review of the patient's electronic nursing notes dated 4/12/13 revealed the family was not notified about the option to donate or decline to donate organs, tissues or eyes.

Patient #29

Patient #29 was admitted on 4/15/13 at 2:05 PM with diagnoses including back pain with difficulty walking, chronic obstructive pulmonary disease and osteoporosis. Patient #29 expired on 4/20/13 at 2:26 PM due to community acquired bibasilar pneumonia, hypoxemia, exacerbation of chronic obstructive pulmonary disease and dehydration.

Review of electronic nursing notes dated 4/20/13 revealed the patient's family was not notified of the options to donate or decline to donate organs, tissues or eyes.

Review of the Requirements for Management of Organ and Tissue Donation (revised 1/8/2009), stated in part:

Procedure:
"... Upon the death of any patient, the family will be informed that the Tissue Donation Hotline personnel would like to contact them regarding donation of the deceased tissues and/or organs..."

"... Information regarding notification of the family of the proposed contact by the Tissue Donation Hotline and the family's response (wishes to be contacted, does not wish to be contacted) will be recorded in the medical record on the nursing notes, including: Name of the hotline contact personnel member, case number assigned by Hotline personnel, family response and desire, date and time of call and name, level of licensure of individual reporting to the Hotline..."

The facility failed to follow the procedures for notifying the families of deceased patients about the option to donate organs, tissues or eyes, or the option to decline to donate.

On 7/26/13 at approximately 11:30 AM, the Director of Nursing verified by reviewing the electronic nursing notes, and confirmed the families of the above patients were not notified.

Based on record review, interview and document review, the facility failed to coordinate with the Organ Procurement Organization to provide staff training on approaching potential donor families.

Findings include:

Review of personnel files of six registered nurses revealed no documented evidence of training by Nevada Organ Network, the hospital's Organ Procurement Organization.

On 7/26/13 at 8:05 AM, Employee #2, RN indicated all registered nurses were trained to call the Nevada Donor Network in the event of a patient's death. Employee #2 stated they did not have a formal training, however, there was a manual prepared by the Director of Nursing.

Employee #2 provided a copy of a memorandum from the Director of Nursing dated 6/25/04, reminding all nursing staff to report all deaths to the Nevada Donor Network, with the telephone number. It included instructions to complete the log and document in medical records.

On 7/26/13 at approximately 11:30 AM, the Director of Nursing stated the staff has not received formal training from Nevada Donor Network.

Review of the Memorandum of Understanding and Agreement between Nye Regional Medical Center and Nevada Donor Network, Inc. signed on 4/9/2011, stated in part:

NDN Services and Responsibilities:
"...The provision of educational programs for hospital staff at no charge. Programs will be scheduled at the convenience of the hospital..."

The facility has not scheduled staff training with Nevada Donor Network.

Based on interview and document review, the facility failed to provide policies demonstrating the integration of outpatient with inpatient services.

Findings include:
On 7/26/13 at 11:15 AM, the DON (Director of Nursing) acknowledged there were no policies available for the Outpatient services to guide the process and integration of outpatient services and inpatient services.

Based on interview, record and document review, the facility failed to ensure staff compliance with emergency department policies and procedures for 5 of 5 patients (Patient #'s 8, 9, 10, 11 and 12).

Findings include:

Review of a facility policy titled, "Triage"- Emergency Department, reference #2005, effective date 3/1/2002, revised date 12/5/2007 read as follows:
"Policy: Emergency patients will be treated in order according to severity of illness and need for care. Patients presenting for care will receive a brief initial assessment performed by the Charge Nurse or physician, primary intervention for life threatening conditions, and priority classification.
Procedure: B) Emergency Severity Index Five Tier Triage System (assigning 1-5). Policy continues on to describe each of the 5 levels of severity."

Review of a facility policy titled, "Standards of Practice"- Emergency Department, reference #2001, effective date 3/1/2001, revised date 1/7/2009 read as follows:
"Policy: It is the policy of the Emergency Department of Nye Regional Medical Center to utilize the standards of practice based on the nursing process from the American Nurses Association and the Emergency Nurses Association. The emphasis is based on the process of assessment and problem identification. The standards are divided into assessment, diagnosis, outcomes identification, planning, implementation, evaluation and triage. Assessments and supportive data are thoroughly documented, properly stored and retrievable in the: 1) Emergency Department Nurses' Notes, 2) Clinical Laboratory results, 3) Progress Notes, 4) History and Physical, 5) Nursing Flowsheets, and 6) Imaging Services/Radiology Results.
Standard VII: The Emergency Department RN (Registered Nurse) triages every patient that presents to the Emergency Department. The Emergency Department RN determines the priority of care to facilitate patient flow through the emergency care system.
- Ensures timely evaluation of patient needs
- Medical screening is in compliance with the hospital's policies and procedures and state and federal rules and regulations including EMTALA (Emergency Medical Treatment and Active Labor Act)."

Review of a facility policy titled, "Assessment of the Emergency Department Patient"- Emergency Department, reference #2006, effective date 3/1/2002, revised date 1/7/2009 read as follows:
"Purpose: Establish assessment criteria for all Emergency Department patients.
Policy: All patients presenting to the Emergency Department will be triaged and categorized as either Resuscitative, Emergency, Urgent, Semi-Urgent or Routine."

Patient #8 presented to the emergency department on 7/23/13 with chief complaint of SOB (shortness of breath). Facility form titled, "Emergency Department Form" lacked documentation of a triage acuity categorization or an assigned ESI (Emergency Severity Index) acuity.

Patient #9 presented to the emergency department on 7/23/13 with chief complaint of SOB (shortness of breath). Facility form titled, "Emergency Department Form" lacked documentation of a triage acuity categorization or an assigned ESI acuity.

Patient #10 presented to the emergency department on 5/31/13 with chief complaint of Contractions at 36 weeks Gestation. Facility form titled, "Emergency Department Form" lacked documentation of a triage acuity categorization or an assigned ESI acuity.

Patient #11 presented to the emergency department on 5/4/13 with chief complaint of disorientation. Facility form titled, "Emergency Department Form" lacked documentation of a triage acuity categorization or an assigned ESI acuity.

Patient #12 presented to the emergency department on 5/7/13 with chief complaint of fall. Facility form titled, "Emergency Department Form" lacked documentation of a triage acuity categorization or an assigned ESI acuity.

On 7/25/13 at approximately 2:00 PM, during an interview, the DON (Director of Nursing) acknowledged the emergency department policies as being the most current. Additionally, the DON shared the emergency department prioritized patients but did not utilize or document an acuity. The DON acknowledged there was no documented way to identify which patient was a priority to be examined.

Review of a facility policy titled, "Emergency Delivery"- Emergency Department, reference #2123, effective date 3/1/2002, revised date 1/7/2009 read as follows:
"Policy: On arrival to the Emergency Department, any patient who is in active labor and is 16 to 18 weeks or more pregnant, shall be escorted directly to the LDR (Labor Delivery Room) for evaluation."

Review of a facility policy titled, "Standards of Care: Maternity Admission/Assessment" - Emergency Department, reference #2134a, effective date 3/1/2002, revised date 9/24/2007 read as follows:
"Actions/Interventions: Care plan will be initiated within 2 hours of admission."

Patient #10 presented to the emergency department on 5/31/13 with chief complaint of contractions at 36 weeks gestation. Review of patient's medical record revealed the patient remained in the emergency room for approximately 2.5 hours with no documented transfer to the obstetrical area. No documented evidence of a care plan established within two hours of admission was available in the medical record.

On 7/25/13 at approximately 2:00 PM, during an interview, the DON (Director of Nursing) acknowledged the emergency department policies as being the most current. Additionally, the DON acknowledged the 36 week pregnant patient should have been transferred to the obstetrical area.

Based on interview, record and document review, the facility failed to ensure a physician was available in the emergency department during all times emergency services were available.
Findings include:

Patient #11:

Patient #11 is a 63 year old that presented to the Emergency department on 5/4/13 with a chief complaint of disorientation, lethargy, nausea and weakness. Patient was transferred to an acute facility with a discharge diagnosis of acute MI (Myocardial Infarction) and renal failure.

On 7/25/13 in the afternoon, a review of the patient's medical record revealed the following nursing documentation:

1315 (1:15 PM) - Dr. (Doctor) notified. Orders received.

1355 (1:55 PM) - (Physician's name) at bedside to examine pt. (patient).

A document titled, "Emergency Department Form" revealed the following time frame:

Provider notified: 1315 (1:15 PM)


Triage/MSE (Medical Screening Exam) initiated: 1255 (12:55 PM)

Provider Exam: 1329 (1:29 PM)

On 7/26/13 at 11:10 AM, an interview with the DON (Director of Nursing) revealed the time in the nursing documentation would be the accurate time the patient was seen by the physician, and that the provider exam time should be documented as the time the patient is physically seen by the physician. The DON acknowledged a 40 minute delay to physician exam is not acceptable.

Review of documents revealed a facility policy titled, "Physician On-Call", Reference #2302b, effective date 3/1/2002, revised date 7/28/2009 read as follows:

"Policy: EMTALA (Emergency Medical Treatment and Active Labor Act) requires facilities to adopt policies and procedures establishing "a reasonable amount of time" for the on-call physician to respond to the Emergency Department. "A reasonable amount of time" for Nye Regional Medical Center will be thirty (30) minutes. The ED (Emergency Department) nurse notifying the on-call physician will document the time the physician was notified on the ED chart. The ED nurse will document the time the on-call physician responded to the ED. These response times will be monitored as a monthly Quality Indicator."

Additional document review revealed a facility policy titled, "Scope of Service"- Emergency Department, Reference #6003, no effective date, no revised date which read as follows:

"Policy: The Emergency Department of this hospital is a Level 3 Emergency Medical Service Department. This hospital has a 3 bed Emergency Department with 24-hour per day care. Scope and Complexity of Patient Care Needs: All patients that present to Nye Regional Medical Center's premises for a non-scheduled visit and are seeking care shall receive a medical screening exam by an Emergency Department physician that includes providing all necessary testing and on-call services within the capability of Nye Regional Medical Center to reach a diagnosis. Support services including but not limited to clinical laboratory studies and x-rays will be provided to the patient in a timely manner. An on-call list of specialty physicians is maintained to assist in stabilizing patients. Staffing: A minimum of one (1) Emergency Department physician is on-duty at all times."

Additional document review revealed a facility policy titled, "EMTALA Guidelines for Emergency Department Services"- Emergency Department, Reference #2302, effective date 3/1/2002, revised date 1/7/2009, bullet point #4, which read as follows: "Nye Regional Medical Center will provide an on-call physician specialty list which includes all specialties privileged at this facility. The oncall list will be openly posted in the Emergency Department and a record of all oncall lists shall be maintained for five (5) years. (EMTALA requires that the hospital adopt written standards to follow when a specific specialist is not available. In addition, under certain circumstances protocols may allow referral to a specialist's office rather than the specialist coming to the Emergency Department. Consultation with your hospital's liability carrier and legal counsel is recommended.)"

An "On-Call Physician List" was provided by the DON. The list contained emergency department physicians and physician assistant names and numbers. During interview on 7/26/13 in the morning, the DON acknowledged the policy titled, "Physician On-Call" was the most current policy and were the guidelines used for the Emergency department physicians. The DON stated, "we definitely don't have 24/7 physician coverage in the ED". During the interview regarding specialty physicians on-call for the ED, the DON revealed the facility had no specialists on-call, but would transfer the patients to another facility if necessary.



26251

On 8/6/13 from 7:07 am to 7:50 am, the Administrator/Physician indicated in the recent past a physician was not on site half the day, but now either a physician or physician assistant was available 24 hours a day on site.

Based on observation, interview and record review, the facility failed to ensure qualified personnel were available to provide respiratory care services.

Findings include:

Interview with the DON (Director of Nursing) on 7/24/13 at 9:20 AM revealed there has been no respiratory therapist on staff since 7/12/13. Prior to 7/12/13, respiratory services were available on a limited basis as there was one therapist employed. The DON explained if there was a need for respiratory services, the nurses were able to provide the service.

The DON revealed the nursing staff had completed ACLS (Advanced Cardiac Life Support) education, and PALS (Pediatric Advanced Life Support) education, which would provide the competency for intubation and nursing staff would be expected to intubate a patient if required. The DON acknowledged no nurse had current NALS (Neonatal Advanced Life Support) certification in ENPC (Emergency Nursing Pediatric Certification).

The DON inferred additional education was provided to the nursing staff when respiratory services were no longer available. The DON provided two documents titled, "In-Service Summary and Attendance."

The attendance record dated 2/21/13 titled, "Nursing Orientation" included a 45 minute presentation on SVNs (Small volume nebulizers), Respiratory Medication, EKG (Electrocardiogram), ICG (Impedence Cardiogram) crash cart review including intubation, precipitus birth, intraosseous options, rapid sequence intubation kit, pleural vacuum set up and care, chest tube dressing and removal, and crash cart medication tray- activity. The DON was listed as presenter for this inservice.

The attendance record dated 3/21/13 titled, "General Orientation" included a 20 minute presentation by Respiratory therapy on EKGs/ ICGs.

During interview with Employee # 23 on 7/24/13 at 10:45 AM, the Registered Nurse had not intubated a patient and had received no additional education to supplement the loss of respiratory services but "has just learned things, such as the EKGs". Employee #23 shared the respiratory therapist had provided a "cheat sheet" prior to leaving with some helpful tips for the nursing staff.

A telephone consultation with the Nevada Board of Nursing on 7/24/13 at 9:50 AM indicated it was within the scope of practice for the registered nurse to intubate patients if training has been provided, but the practice must be in the facility's policy and documented competencies should be in the employee's file per NRS 632.225.

On 7/26/13 in the morning, the DON acknowledged the facility was not able to provide a policy outlining the practice of nursing staff providing respiratory therapy services.

A review of two employee files (Employee #5 and #17), nurses working in the Emergency Room, lacked evidence of orientation competencies, respiratory therapy training or intubation competencies.

A review of a facility document titled, "Annual Competency Clinical Skills Assessment- Emergency Department Registered Nurse" lists competencies for Pulmonary as the following: "Assessment of patient's breath sounds and rate, pulse oximetry application, application of oxygen, Airway management/medication delivery systems: Nasal cannula, mask, humidification, oral airway, nasal trumpet, bag and mask, external CPAP (Continuous positive airway pressure), nebulizer, inhalers, t-piece, trach collar, suctioning, assist with thoracentesis, ventilator management, measurement of peak flow, Chest tubes: assist with insertion, set-up of chest drainage system, ABGs (Arterial blood gases): obtaining, interpretation of results, assist with intubation setup and assist with extubation."

Based on interview, the facility failed to ensure the respiratory care services director held the appropriate qualifications to properly supervise the service.

Findings include:


26907

On 7/26/13 in the morning, the Hospital Support Director (HSD) (Employee #6) verbalized he was responsible for oversight of respiratory services.

On 8/2/13 at 1:30 PM, the HSD reiterated he had oversight of the respiratory services for approximately 1.5 months. The employee indicated he did not have training or experience in respiratory services, was not a physician, a doctor of osteopathy or a nurse.

Based on interview and document review, the facility failed to ensure the personnel performing respiratory procedures had the appropriate qualifications and the amount of supervision required.

Findings include:

Interview with the DON (Director of Nursing) on 7/24/13 at 9:20 AM revealed there has been no respiratory therapist on staff since 7/12/13. Prior to 7/12/13, respiratory services were available on a limited basis as there was one therapist employed. The DON explained if there was a need for respiratory services, the nurses were able to provide the service.

The DON inferred additional education had been provided to the nursing staff when respiratory services was no longer available. The DON provided two documents titled, "In-Service Summary and Attendance."

The attendance record dated 2/21/13 titled, "Nursing Orientation" included a 45 minute presentation on SVNs (Small volume nebulizers), Respiratory Medication, EKG (Electrocardiogram), crash cart review including intubation, precipitus birth, intraosseous options, rapid sequence intubation kit, pleural vacuum set up and care, chest tube dressing and removal, and crash cart medication tray- activity. The DON was listed as presenter for this inservice.

The attendance record dated 3/21/13 titled, "General Orientation" included a 20 minute presentation by Respiratory therapy on EKGs.

On 7/26/13 in the morning, the DON acknowledged the facility was not able to provide a policy outlining the practice of nursing staff providing respiratory therapy services.

A review of two employee files (Employee #5 and #17), nurses working in the Emergency Room, lacked evidence of orientation competencies, respiratory therapy training or intubation competencies.

A review of a facility document titled, "Annual Competency Clinical Skills Assessment- Emergency Department Registered Nurse" lists competencies for Pulmonary as the following: "Assessment of patient's breath sounds and rate, pulse oximetry application, application of oxygen, Airway management/medication delivery systems: Nasal cannula, mask, humidification, oral airway, nasal trumpet, bag and mask, external CPAP (Continuous positive airway pressure), nebulizer, inhalers, t-piece, trach collar, suctioning, assist with thoracentesis, ventilator management, measurement of peak flow, Chest tubes: assist with insertion, set-up of chest drainage system, ABGs (Arterial blood gases): obtaining, interpretation of results, assist with intubation setup and assist with extubation."