HospitalInspections.org

Based on staff interview, observation, review of patient records, job descriptions, emergency checklist and contracts, it was determined the facility failed to ensure orders for wound care were followed (A392), failed to ensure all emergency medical equipment were on the emergency crash cart (A395) and failed to administer medications as ordered, ensure orders were complete and document medications administered accurately (A405). The cumulative effects of these systemic practices resulted in the facility's inability to ensure that patients' needs would be met.

Based on observation, the facility's job description and interview, the facility failed to ensure nursing staff completed wound care per physician orders for one (Patient #5) of one wound care observations conducted. The facility's current census was 10.

Findings include:

Staff G was observed performing a dressing change to Patient #5's stage IV sacral ulcer on Thursday, 03/31/16 at 11:46 AM. The dressing Staff L removed from Patient #5 was dated Saturday, 03/26/16. The orders for Patient #5's wound care dated 03/17/16 at 10:50 AM stated to change the dressing three times a week and as needed. At the time of the observation, Staff G confirmed the findings at the time of the observation and reported wound care changes are normally performed on Tuesday, Thursday and Saturdays.

The LPN (licensed practical nurse) Job Description and Performance Standards were reviewed. The job description sated the licensed practical nurse will follow established facility policies and procedures to provide care and treatments to patients in accordance with physician orders.

Based on interview, review of emergency checklist, the facility's contracts and job description, observation and medical record review, the facility failed to ensure staff activated the emergency response system immediately for one patient (#1) of 1 patient reviewed. The facility failed to ensure patient equipment was free from hazards and failed to identify expired supplies for one patient (#3) of one acute dialysis treatment observed. The facility failed to ensure emergency medical equipment contained resuscitative equipment for one (Crash Cart D2) of two crash carts observed. The sample size was 10. The facility's current census was 10.

Findings include:

1. Review of the medicalrecord for Patient #1 revealed the patient was admitted on 01/15/16 with diagnoses including acute and chronic respiratory failure with hypoxia (low oxygen level), end stage renal disease and type 2 diabetes mellitus.

Review of the record revealed a Code Blue Flow Sheet for Patient #1, dated 02/01/16. The Code Blue Flow Sheet documented at 9:50 AM, Patient #1 was in a sinus bradycardia rhythm with a heart rate of 20- 30 on telemetry monitor. The flow sheet documented Atropine (medication to increase heart rate), 1 milligram (mg) was given intravenously (IV). The patient was receiving a hemodialysis treatment with the dialysis technician present at this time. The hospital response was activated.

At 9:58 AM, the patient's rhythm was in asystole (no cardiac activity). Cardiac compressions were started and the patient was bagged for ventilations. The flow sheet indicated one liter of 0.9 percent normal saline bolus was given IV. No epinephrine (medication used during a cardiac arrest) was given. At 10:05 AM, Patient #1 was in a sinus rhythm with heart rate of 76.

At 10:10 AM, the monitor indicated the patient's rhythm was in sinus bradycardia with a heart rate in the 20's. Atropine, 1 mg was given IV. At 10:13 AM, the patient's monitor pattern returned to asystole. One ampule of epinephrine was given IV and the emergency response system (EMS) was activated at 10:13 AM. At 10:16 AM, the rhythm was asystole and the patient was given one ampule of epinephrine IV. At 10:18 AM, the patient's monitored rhythm was supraventricular tachycardia (rapid heart rate). The comments indicated the patient's pulse was thready and the patient had no blood pressure. EMS arrived at 10:21 AM and the patient was transported to a nearby acute care hospital.

On 03/31/16 at 3:05 PM, an observation was made of the crash cart on the unit with Staff B present. With the crash cart was a flow chart titled Cardiac Arrest PEA (pulseless electronic activity)/Asystole Learning Station Checklist. The learning checklist revealed with an adult cardiac arrest the first step was to activate emergency response.



31597

2. Patient #3 was observed receiving dialysis on 03/31/16 at 10:46 AM. The reverse osmosis cart was observed with rust on the top shelf by the carbon tanks. Carbon A was observed with the faceplate missing from the gauge. The dialysis supply cart was observed with expired products. The expired products were:

a. Four, RPC Ultralow Total Chlorine strips use by September 2015 Q301

b. One bottle of Water Check RC Residual Chlorine Reagent Strips. The date written on the top of the bottle was 12/09/15, as being opened. Instructions stated to use within three months after opened.

The findings were shared with Staff F at approximately 11:00 AM and confirmed.

The facility's Dialysis Agreement was reviewed and stated the facility shall assume full responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility and the timeliness of the services.

3. The facility's D2 crash cart was observed on 03/31/16 at 3:00 PM. The crash cart did not have an Ambu bag (manual resuscitator).

The findings were shared with Staff B at the time of the observation and confirmed. Staff B instructed a respiratory therapist to place an Ambu bag on the crash cart.

The facility's Registered Nurse Job Description and Performance Standards were reviewed. The job description stated the registered nurse will administer and document direct patient care, medications and treatments per physician orders and accurately record all care provided. The registered nurse will be responsible for the safety of patients under his/her supervision and observe infection control procedures.

Based on interview and medical record review, the facility failed to ensure nurses administer medications as ordered by physician for two patients (#1 and #7); failed to ensure orders were complete for three patients (#1, #3 and #6); and failed to ensure medications were documented accurately for one patient (#1) of 10 patients reviewed. The facility's current census was 10.

Findings include:

1. Review of the record for Patient #1 revealed the patient was admitted on 01/15/16 with diagnoses including acute and chronic respiratory failure with hypoxia, end stage renal disease and type 2 diabetes mellitus.

Review of the physician's orders revealed orders dated 01/15/16 for "Physician Orders - Insulin Sliding Scale". The orders revealed to test fingerstick blood glucose every six hours. The orders documented regular insulin was to be given subcutaneously using the mild scale as follows: blood glucose under 60 use the hypoglycemia protocol; blood glucose of 60-100 give 0 units of regular insulin; blood glucose of 101-150 give 0 units of regular insulin; blood glucose of 151-200 give 2 units of regular insulin; blood glucose of 201-250 give 4 units of regular insulin; blood glucose 251-300 give 6 units of regular insulin; blood glucose of 301-350 give 8 units of regular insulin and 351-400 give 10 units of regular insulin. If the blood glucose was over 400, the scale documented to give regular insulin as ordered for 351-400 and notify the physician.

Review of the Daily Patient Care Record for Patient #1, dated 01/22/16, revealed at 5:00 AM Patient #1's blood glucose was 280. There was no documentation in the record that regular insulin was given for coverage.

Review of the Daily Patient Care Record for 01/28/16 revealed at 12:00 PM, Patient #1's blood glucose was 254. The print out of the electronic medication system revealed on 01/28/16 at 1:01 PM 4 units of regular insulin was documented as removed from the system. The physician ordered sliding scale coverage documented 6 units of regular insulin was to be given for a blood glucose of 254.

Review of the Diabetic Record for Patient #1 revealed on 01/24/16 at 5:41 AM, the patient's blood glucose was 438. The record indicated 10 units of regular insulin was given. Also on 01/24/16 at 11:55 AM, the blood glucose was 500. The registered nurse (RN) documented 10 units of regular insulin was given. There was no documentation in the record the physician was notified for blood sugars over 400, as specified in the sliding scale orders.

On 03/31/16 at 3:30 PM, Staff A confirmed the above findings.



31597

Further review of the medical record review for Patient #1 revealed Patient #1 was receiving dialysis on the nursing unit. On 01/25/16, Patient #1 had an order to receive a bath with 2 mEq K and 2.5 mEq Ca. The medical record contained orders for dialysis which did not include the specific bath to be used on 01/26/16. The Acute Treatment Sheet from 01/26/15, showed Patient #1 received a bath of 3 mEq K and 2.5 mEq Ca. An order which corresponded to Patient #1's 01/18/16 Acute Treatment Sheet, did not contain the date or time the order was written. The orders for dialysis written on 01/20/16, 01/22/16, 01/25/16, 01/26/15, 01/27/16, 01/28/16, 01/29/16, 01/30/16, and 02/01/16 did not contain the time the orders were written.

The medical record review for Patient #1 revealed Patient #1 was transferred out of the facility on 02/01/16 at 10:25 AM. The medication record showed Patient #1 received Albuterol / Ipratropium 3 ml nebulizer on 02/01/16 at 11:25 AM.

The findings were shared with Staff A on 03/31/15 at 4:15 PM and confirmed. Staff A reported the medication was probably administered during Patient #1's code and the staff member forgot to change the time administered.






2. The medical record review for Patient #3 revealed Patient #3 was receiving dialysis on the nursing unit. The Physician's Dialysis Orders from 03/22/16, 03/24/16, 03/26/16, and 03/29/16 did not contain the time the orders were written and did not list Patient #3's allergies in the drug allergy section of the order form. The History and Physical for Patient #3 dictated on 03/18/16 stated Patient #3 is allergic to Heparin- severe thrombocytopenia.

3. The medical record review for Patient #6 revealed Patient #6 was receiving dialysis on the nursing unit. The Physician Dialysis Orders which corresponded to the dialysis treatment Patient #6 received on 03/24/16 did not contain the date or time the orders were written. The Physician Dialysis Orders from 03/29/16 did not contain the time the orders were written.

The findings were shared with Staff A on 03/31/16 at approximately 3:00 PM and confirmed.

4. The medical record review for Patient #7 revealed Patient #7 did not receive Insulin for a blood glucose level of 187 on 03/19/16 at 12:00 PM. The Physician Orders - Insulin Sliding Scale ordered on 03/12/16 stated to administer two units of Regular Insulin for a blood glucose level of 151 to 200.

The findings were shared with Staff A on 03/31/16 at 2:50 PM and confirmed.