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Based on observation, interview and record review, the hospital failed to meet the requirements of the Conditions of Participation for Patient's Rights. This was evidenced by the hospital's failure to ensure patient care was provided in a safe setting by failing to implement an effective system relative to the provision of care to patients ordered to be on telemetry monitoring.

This failure contributed to a delay in the identification and notification of the licensed nurse regarding a change in a patient's cardiac rhythm for a period of at least 16 minutes for 1 (patient #5) of 1 patient reviewed for telemetry monitoring (unable to determine exact timeframe because of discrepancies in interviews and documentation of staff).

Further, it contributed to S5LPN failure to assess Patient #5 for 5-15 minutes after notification of no detectable cardiac rhythm by the telemetry monitor technician (unable to determine exact timeframe because of discrepancies in interviews and documentation of staff).

This deficient practice resulted in a delay in Cardiopulmonary Resuscitation (CPR) being initiated on Patient #5 while she had no detectable pulse and no respiratory effort. Patient #5 was transferred to an acute care hospital where she later expired. (see findings cited at A0144)


An Immediate Jeopardy situation was identified on 10/30/14 at 4:58 p.m. and reported to S1CEO, S2DON and S3Quality.

The Immediate Jeopardy situation was the result of:

1. A delay of the staff monitoring a telemetry patient (Patient #5) to notify a nurse of a change in Patient #5's rhythm on 9/27/14 at 1:29 p.m. and 1:39 p.m. (from sinus rhythm to junctional rhythm as documented on the telemetry strips) as per the hospital policy. There was no documentation of a nurse being notified of a change in rhythm on Patient #5's telemetry strips until 9/27/14 at 1:45 p.m. (16 minutes after the first change. This rhythm was a flat line with no activity). Further review revealed that the strips had not been printed until 5:00 p.m., 5:05 p.m. and 5:36 p.m. In an interview on 10/30/14 at 9:37 a.m., S5LPN who was assigned to Patient #5 stated she had gone to lunch at 1:30 p.m. and had not been notified of Patient #5 not having a rhythm on telemetry until she returned at 2:00 p.m.;

2. Failure of a nurse to assess a patient for 5-20 minutes after notification on 9/27/14 by the telemetry technician of no rhythm being detected on the telemetry monitor (unable to determine exact time interval based on conflicting documentation in Patient #5's medical record and interviews with staff involved in this patient's care).

S5LPN's documentation and interview revealed once she was made aware that Patient #5 did not have a rhythm on the telemetry monitor she changed the batteries on Patient #5's telemetry pack on the patient and assessed Patient #5's EKG leads without assessing the patient for 5 minutes. Once the patient was assessed by S5LPN, the patient was noted to have no spontaneous respirations or pulse. CPR was initiated and Patient #5 was transferred to an acute care hospital.

As a result of the hospital's action plan, the Immediate Jeopardy situation was removed on 10/30/14 at 6:25 p.m. due to the hospital instituting the following:

1. An ACLS RN will be stationed at the telemetry station in conjunction with the monitor tech for 24 hours daily until staff re-education is completed. The DON or AOC will ensure the compliance through scheduling with the charge nurse assigned for that shift. Education to be completed within 10 days. Observation on 10/30/14 at 6:20 p.m. revealed a RN with ACLS certification and a telemetry technician were stationed at the telemetry station monitoring telemetry patients.

2. Immediate education to be provided to all nursing staff by DON or Nurse Educator to be completed within 10 days.

a) Regarding the policy and procedure for notification of rhythm changes.

b) SWANK training on EKG, dysrhythmia assessment, patient assessment, change in condition, proper documentation of above mentioned.

Observation on 10/30/14 at 6:20 p.m. revealed an "EDUCATION/TRAINING ATTENDANCE ROSTER" was provided to demonstrate current employees at work had been educated on telemetry accountability and printing and notification of rhythm strips. Review of the "EDUCATION/TRAINING ATTENDANCE ROSTER" revealed the signature of 2 Registered Nurses, 2 Licensed Practical Nurses and 2 Telemetry Technicians indicating attendance with the training.

3. Monitor tech accountability log implemented today and staff educated on new log usage.
An observation on 10/30/14 at 6:20 p.m. revealed a new log book at the telemetry station to show accountability for telemetry monitoring.

4. Telemetry rhythm change form changed to include nurse notification implemented today and staff educated on new form.

5. Change in rhythm form implemented today and staff educated on new form.
An observation was made on 10/30/14 at 6:20 of the new RN change in rhythm form.

6. unit secretary will be provided 24/7 in conjunction with monitor tech, To begin immediately. An observation on 10/30/14 at 6:15 p.m. revealed a secretary in conjunction to the monitor technician at the telemetry monitoring station.

7. Buddy system/daily assignment sheets, monitor tech accountability log, telemetry change form, change in condition form, and staffing of unit secretary 24/7 will be monitored daily for a compliance of 100% for 3 months. After 100% compliance is reached, monitoring will continue monthly to ensure continued compliance. The DON or designee will be responsible for monitoring. All data will be reported to quality, MEC monthly and governing board quarterly.

8. Buddy system implemented and indicated on daily assignment sheets immediately to ensure adequate coverage for nursing during their meal breaks.

Non-compliance continues at the condition level.

Based on records review, observations and interview, the hospital failed to meet the requirements of the Condition of Participation for QAPI as evidenced by:

1. Failure to identify and implement corrective action relative to the provision of care to patients ordered to be on telemetry monitoring. Delays were noted in the identification and notification of a licensed nurse regarding a change in a patient's cardiac rhythm and delays were noted in the initiation of a nursing assessment and the implementation of Cardiopulmonary Resuscitation (CPR) on Patient #5 while the patient had no detectable pulse and no respiratory effort. (See findings under tag A-0283).

2. Failure to identify and implement corrective action relative to the need to develop new interventions when statistical data indicated continued staff non-compliance with hospital policies regarding hand hygiene performance and donning of personal protective equipment when caring for patients on contact precautions. (See findings under tag A-0283).

3. Failure to ensure all hospital departments and services, including those services furnished under contract, were involved in the QAPI Plan (See findings under tag A-0308).

Based on records review and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing services as evidenced by:

Failure to ensure that the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:

1) S5LPN failure to assess Patient #5 for 5-15 minutes after notification of no detectable cardiac rhythm by the telemetry monitor technician. This deficient practice resulted in a delay in Cardiopulmonary Resuscitation (CPR) being initiated on Patient #5 while she had no detectable pulse and no respiratory effort. Patient #5 was transferred to an acute care hospital where she later expired;

2) Failure to ensure each patient was assessed at least every 24 hours and with a change in condition by the RN as required by the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs (licensed practical nurses) without documented evidence of an RN assessment at a minimum of every 24 hours and after changes in the patient's condition for 2 (#9, R3) of 4 current inpatients' records (#7, #8, #9, R3) reviewed for RN assessments and 1 (#6) of 1 closed medical record reviewed for RN assessments from a total of 6 (#1 - #6) sampled closed records;

3) Failure to ensure each patient's care was provided according to physician orders as evidenced by having the RN writing wound care orders without first obtaining authorization from the prescribing/admitting practitioner for 2 (#7, #8) of 3 (#7, #8, #9) current inpatients reviewed for wound care from a total of 3 sampled inpatients and 5 random inpatients and 1 (#6) of 1 closed medical record reviewed for wound care from a total of 6 (#1 - #6) sampled closed records;

4) Failure to assess patient wounds upon admit and weekly thereafter as required by hospital policy as evidenced by having no documented evidence of wound assessments at the time of admission for 1 (#8) of 3 (#7, #8, #9) current inpatients reviewed for wound care from a total of 3 sampled inpatients and 5 random inpatients and no documented evidence of wound assessments at the time of admission and weekly thereafter according to hospital policy for 1 (#6) of 1 closed medical record reviewed for wound care from a total of 6 (#1 - #6) sampled closed records (see findings in tag A0395).

Based on record reviews and interview, the hospital failed to meet the requirements of the Condition of Participation for Medical Record Services as evidenced by:

Failure to ensure that medical records were completed no later than 30 days after discharge as evidenced by having an 87.5% (per cent) medical record delinquency rate.

The hospital failed to implement its Medical Staff Rules and Regulations for suspension of physicians with delinquent records greater than 30 days after discharge for 22 (S23, S28, S29, S30, S31, S32, S33, S34, S35, S36, S37, S38, S39, S40, S41, S42, S43, S44, S45, S46, S47, S48) of 96 credentialed physicians on staff (see findings in tag A0438).

Based on observations, records review, and interviews, the hospital failed to meet the requirements for the Condition of Participation for Infection Control as evidenced by:

1) Failure to ensure the person designated as the Infection Control Officer had acquired specialized training in infection control as evidenced by S4Infection Control Officer having no prior work experience or specialized training in infection control. (see findings in tag A0748);

2) Failure to ensure the infection control officer implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:

a) Failure to mitigate the risks associated with patient infections present upon admission and contributing to healthcare-associated infections. The infection control officer failed to investigate, track, and trend all patient infections identified by cultures after admission, failed to ensure isolation precautions were implemented according to CDC guidelines and hospital policy for 4 (#7, #8, #9, R1) of 12 patients on isolation precautions with 13 observations of breaches in the isolation policy, and failed to ensure handwashing hygiene including the utilization of alcohol-based hand sanitizers was implemented according to hospital policy as evidenced by 7 observations of breaches in hand hygiene practices from 10/27/14 through 10/30/14;

b) Failure to ensure the proper PPE (personal protective equipment) was used during accessing of a dialysis shunt as evidenced by S12Dialysis RN (registered nurse) failing to wear protective eye shields during access of 1 of 1 observed dialysis patient whose shunt was being accessed (R4). (see findings in tag A0749); and


3) Failure to ensure that the hospital-wide quality assessment and performance improvement (QAPI) program addressed problems identified by the infection control officer and were responsible for the implementation of successful corrective action plans in the affected problem areas. There was no documented evidence that corrective action plans that included staff training were developed and implemented for identified problems with hand hygiene and the proper use of personal protective equipment (PPE). (see findings in tag A0756).

Based on record review and interviews, the hospital failed to ensure the grievance policy allowed for grievances to be submitted by a patient's representative as evidenced by having a policy that defined a patient as a person admitted to the hospital or that patient's legal guardian or legal representative.

The hospital failed to process a grievance received from Patient #6's representative as evidenced by S3Quality Director reporting that no grievances had been received by the hospital since 06/30/14.
Findings:

Review of the hospital's policy titled "Grievance Resolution Process for Patients," effective 11/11/99 and presented as the current policy by S3Quality Director, revealed that all patients have the right to initiate the grievance resolution process. Further review revealed that "patient" will refer to any person admitted to the hospital or that patient's legal guardian or legal representative. Further review revealed no documented evidence that complaint and grievance were defined in the policy.

In an interview on 10/28/14 at 8:10 a.m., S3Quality Director indicated she had been employed at the hospital since 06/30/14, and the hospital had not received a grievance since that time.

In an interview on 10/28/14 at 4:45 p.m., S3Quality Director indicated that she had received a letter on 10/17/14 from Patient #6's daughter's friend regarding dissatisfaction with the services provided to Patient #6. S3Quality Director indicated that she had the letter when she was asked earlier about grievances, but she didn't consider it a grievance since the complainant was not a legal representative. She further indicated that she reviewed Patient #6's medical record and sent a report of the review to the corporate office. She confirmed that she did not process it as a grievance.

In an interview on 10/30/14 at 3:05 p.m., S2DON (Director of Nursing) indicated that S3Quality Director handles grievances, but she is usually aware of the grievance being submitted. She had no explanation when told that the hospital's policy didn't meet the federal regulations by requiring a grievance to be submitted by a patient or the patient's legal representative.

Based on record review and interviews, the hospital failed to ensure the hospital provided the patient or her representative with written notice of its decision regarding the resolution of a grievance as evidenced by failure to consider a grievance submitted by the patient's representative as a grievance. The hospital did not provide written documentation to Patient #6 within 5 business days from the date the grievance request was received according to the hospital's policy.

Findings:

Review of the hospital's policy titled "Grievance Resolution Process for Patients", effective 11/11/99 and presented as the current policy by S3Quality Director, revealed that all patients have the right to initiate the grievance resolution process. Further review revealed that "patient" will refer to any person admitted to the hospital or that patient's legal guardian or legal representative. Further review revealed the risk manager refers the grievance to the Grievance Review Committee which will meet and provide written documentation to the patient within 5 business days from the date the grievance request was received.

In an interview on 10/28/14 at 8:10 a.m., S3Quality Director indicated she had been employed at the hospital since 06/30/14, and the hospital had not received a grievance since that time.

In an interview on 10/28/14 at 4:45 p.m., S3Quality Director indicated that she had received a letter on 10/17/14 from Patient #6's daughter's friend regarding dissatisfaction with the services provided to Patient #6. S3Quality Director indicated that she had the letter when she was asked earlier about grievances, but she didn't consider it a grievance since the complainant was not a legal representative. She further indicated that she reviewed Patient #6's medical record and sent a report of the review to the corporate office. She confirmed that she did not process it as a grievance and did not send a resolution letter to Patient #6 according to the hospital's policy..

Based on observation, interview and record review, the hospital failed to ensure patient care was provided in a safe setting by failing to implement an effective system relative to the provision of care to patients ordered to be on telemetry monitoring.

This failure contributed to a delay in the identification and notification of the licensed nurse regarding a change in a patient's cardiac rhythm for a period of at least 16 minutes for 1 (patient #5) of 1 patient reviewed for telemetry monitoring (unable to determine exact timeframe because of discrepancies in interviews and documentation of staff). Further, it contributed to S5LPN failure to assess Patient #5 for 5-15 minutes after notification of no detectable cardiac rhythm by the telemetry monitor technician (unable to determine exact timeframe because of discrepancies in interviews and documentation of staff).

This deficient practice resulted in a delay in Cardiopulmonary Resuscitation (CPR) being initiated on Patient #5 while she had no detectable pulse and no respiratory effort. Patient #5 was transferred to an acute care hospital where she later expired. Findings:

Review of the hospital policy titled Continuous Cardiac Monitory (Telemetry), September 2013, revealed in part:

Policy:

Cardiac Monitoring is initiated and discontinued based upon a physician's order. Once initiated, qualified staff maintains visual surveillance 24 hours a day.

3. Cardiac rhythm will be recorded, interpreted and documented on the initiation of telemetry, every 6 hours thereafter, and more frequently as indicated by the patient's condition.

7. The nurse assigned to the patient must respond immediately if any of the following occurs:
b. any observed change in the patient's rhythm (a strip is to be recorded, assessed and documented).

c. loss of signal

9. The monitor technician notifies the nurse if alarms sound, there is any change in patient rhythm, poor signal or loss of signal, or any change in monitoring lead.

i. if the monitor technician is unable to notify the patient's nurse regarding non-life threatening rhythm changes (and patient is asymptomatic) the monitor technician will immediately notify the person next in authority i.e. Charge nurse.

Review of the medical record for Patient #5 revealed she had been admitted to the hospital on 9/19/14 with diagnosis/problems which included wound care, encephalopathy, end-stage renal disease, and malnutrition. Patient #5 was ordered to be a full code on admission. Further review revealed Patient #5 was transferred to a local acute care hospital on 9/27/14.
Review of the telemetry monitoring strips in the medical record for Patient #5 dated 9/27/14 revealed the following:

1:13 p.m. - "SR (sinus rhythm) with prolonged QT," written by S7Telemetry.

1:29 p.m. - "SR with junctional beats. Heart rate 67," written by S7Telemetry (no documentation of nurse notification of the change in rhythm).

1:39 p.m. - "Junctional, BBB (bundle block branch). Heart rate 55," written by S7Telemetry (no documentation of nurse notification of the change in rhythm).

1:45 p.m. - "returned from lunch. Notified nurse pt (patient) off tele (telemetry)," written by S7Telemetry (no rhythm on the strip).

2:07 p.m. - "when nurses called code," written by S7Telemetry (no interpretation of the strip written).

Further review revealed the telemetry strips had not been printed until 9/27/14 at 5:00 p.m.

Review of the document titled Daily Nursing Re-Assessment 12 Hour Shift for Patient #5 dated 9/27/14 and written by S5LPN revealed in part:

2:00 p.m. - Summoned to room by S7Telemetry, telemetry tech (technician), to check leads (sensors attached to the body for telemetry monitoring of the heart) on patient. Leads checked and batteries checked. No rhythm noted on tele. Gave patient the sternal rub. No response. Checked pulse. No pulse. No breathing. Code blue called. CPR began.

3:00 p.m. - Patient transferred to Hospital " D "

Review of the discharge summary for Patient #5 transcribed 9/27/14 revealed a code blue was called for Patient #5 on 9/27/14 at 2:09 p.m.
In an interview on 10/29/14, at 11:22 a.m., with S7Telemetry, she said the monitor technicians printed routine strips on telemetry patients at 10:00 a.m. and 4:00 p.m.

S7Telemetry said if a patient had an abnormal rhythm she printed a strip, interpreted the data and notified the nurse. S7Telemetry said on 9/27/14 she was at lunch for 30 minutes or less and returned at 1:45 p.m. S7Telemetry said S18LPN was watching the telemetry monitor for her while she was at lunch. S7Telemetry then said when she returned from lunch she saw Patient #5 had no rhythm on the monitor so she asked S18LPN how long Patient #5 had been without a rhythm but she did not get an answer. S7Telemetry also said she did not usually document on the strip when she went to lunch and returned from lunch, but on 9/27/14 she did because she thought the situation was going to be a problem.

S7Telemetry said she notified the nurse, S5LPN, when she saw the strip without a waveform at 1:45 p.m. S7Telemetry said S5LPN went into Patient #5's room and came out twice asking if the patient's waveform was on the monitor yet. S7Telemetry said S5LPN then went into the room and did a sternal rub on Patient #5 and called a code blue. S7Telemetry said she did not print Patient #5's monitor strips as per policy until the afternoon of 9/27/14 at 5:00 p.m. because she was watching the monitor during the code. S7Telemetry also said she functioned as a unit secretary in addition to being a monitor technician.

In an interview on 10/29/14, at 11:35 a.m., with S18LPN, she said she had given S7Telemetry a break for lunch sometime between 11:30 a.m. and 12:30 p.m. not between 1:15 p.m. and 1:45 p.m. S18LPN said S7Telemetry was lying about her (S18LPN) watching the monitor for her (S7Telemetry) during the time she (S7Telemetry) said she (S7Telemetry) went to lunch between 1:15 p.m. and 1:45 p.m. S18LPN verified there was no documentation of who was responsible for the telemetry monitoring at any given time.

In an interview on 10/29/14, at 11:56 a.m., with S3Quality, she said on 9/27/14 the nurse should have been notified about the telemetry strip changes at 1:29 p.m.

S3Quality said S7Telemetry said she (S7Telemetry) had gone to lunch and while she (S7Telemetry) was gone, S18LPN was responsible for watching the telemetry monitor.

S3Quality said they could not identify if S7Telemetry or S18LPN was telling the truth about who was responsible for monitoring telemetry on 9/27/14 between 1:15 p.m. and 1:45 p.m. because she said there was nothing in place for the documentation of the transfer of responsibility between the telemetry technician and the nurse.

S3Quality said there was a log book at one time to chart who was responsible when the technician went to lunch, but did not know if it was utilized anymore.

S3Quality said the hospital did not update any policies or do any training of the staff after Patient #5's code on 9/27/14.

S3Quality said S5LPN was put on a do not return list at the agency after 9/27/14 because she checked the monitor and leads of Patient #5 before she assessed the patient.

S3Quality said since the code on 9/27/14 of Patient #5, there was now a monitor technician and a secretary. S3Quality verified the telemetry technicians still answered the call bells and telephones while responsible for telemetry monitoring.

Review of the log book titled Nursing/Unit Sec (secretary) Lunch Schedule revealed from 9/12/14 through 10/30/14, the staff had only documented on 3 occasions which person was responsible for telemetry monitoring while the telemetry technician was at lunch.
In an interview on 10/29/14, at 2:37 p.m., with S6RN, he said he functioned as the charge nurse at the hospital on 9/27/14. S6RN said when a telemetry monitor technician went to lunch, a qualified nurse was assigned to watch the telemetry monitor.

S6RN also said on 9/27/14 when Patient #5 coded, he could not remember who was watching the telemetry monitor. S6RN said telemetry strips were supposed to be printed when a rhythm was bad, but on 9/27/14 Patient #5's strips were not printed until 5:00 p.m. on that day.

S6RN also said there was no documentation of who was responsible for the telemetry monitoring during lunch breaks. S6RN said there was a unit secretary during the day shift on Monday through Fridays, but the telemetry technician was also the unit secretary on nights and weekends.
In an observation on 10/29/14, at 3:28 p.m., of S7Telemetry, she was transferring orders off a patient's medical record. S7Telemetry said they had a secretary on Monday through Friday but not on the weekend or holidays. S7Telemetry also said when the unit was busy she acted as a telemetry technician and a secretary.
In an interview on 10/30/14, at 9:17 a.m., with S5LPN, she said she was Patient #5's nurse on 9/27/14. S5LPN said S7Telemetry did not inform her until 2:00 p.m. that Patient #5 was off of telemetry because she was at lunch from 1:30 until 2:00 p.m.

S5LPN said someone was supposed to be watching her patient while she was at lunch, but she did not remember who it was and she had no documentation. S5LPN also said S7Telemetry was at the telemetry monitor at 1:30 p.m. when she went to lunch and at 2:00 p.m. when she returned from lunch.

S5LPN said S7Telemetry gave her some batteries and told her to check the leads on Patient #5 at 2:00 p.m. because she was off of her monitor. S5LPN said she changed the batteries on the telemetry monitor on Patient #5 and checked her EKG leads. S5LPN said she went to the door and asked if there was any activity on the telemetry monitor and S7Telemetry replied, "No." S5LPN said she did not assess or even look the patient at first because she was focused on the telemetry leads.

S5LPN said after she could get no activity on the telemetry monitor she noticed Patient #5 was not breathing. S5LPN said it took about 5 minutes from when she was notified of the telemetry monitor not picking up a rhythm and her noticing Patient #5 was not breathing. S5LPN said she then called a code blue.

S5LPN said she had never been counseled about the delay in beginning CPR on Patient #5 or had any discussions about the code blue with staff at the hospital. S5LPN also said she still worked at the facility through an agency and had worked a shift about a week ago.

In an interview on 10/30/14, at 9:30 a.m., with the owner of Staffing Agency "A", she said S5LPN worked for her and had not been placed on a do not return list by the hospital.
In an interview on 10/30/14, at 10:05 a.m., with S2DON, she said she thought S5LPN had been placed on a do not return with the staffing agency because of her delay in assessment during Patient #5's code on 9/27/14. When asked when S5LPN worked last at the hospital, S2DON said on 10/25/14 (5 days earlier). S2DON also said she had not met with S5LPN and discussed anything about the delay in assessment of Patient #5 on 9/27/14.

S2DON verified because of the discrepancies in documentation between S7Telemetry and S5LPN it could not be determined if S5LPN had known about the Patient #5's absence of a rhythm at 1:45 p.m. or 2:00 p.m. S2DON verified a nurse should have been notified at 1:29 p.m. on 9/27/14 when Patient #5's rhythm changed to a junctional BBB. S2DON also verified S5LPN should have assessed Patient #5 immediately upon entering her room instead of assessing the telemetry monitor.

S2DON additional stated since 9/27/14 no new policies had been put in place about telemetry monitoring or assessment, no staff training had taken place about telemetry monitoring or assessment, the log book for handoff of responsibility had not been utilized, and no documentation could be provided about an investigation of the incident although the hospital realized a problem on 9/29/14.

Based on records review and interview, the hospital's QAPI (Quality Assurance Performance Improvement) program failed to break aggregated data down into subsets that allowed comparison among different inpatient hospital units. The data was not divided, for comparison; the documentation/statistical data acquired from observations of staff performance of hand hygiene and donning of PPE (personal protective equipment) between patient care units.

Findings:

Review of the documentation/statistical data obtained by the hospital's QAPI program relative to observations of staff performance of hand hygiene and donning of PPE revealed no division of data into subsets for comparison of staff performance/compliance with hand hygiene/donning PPE between the Floor Inpatient Unit and the High Observation Inpatient Unit.

In an interview on 10/30/14, at 3:20 pm, with S3Quality, she confirmed statistical data obtained by the hospital's QAPI program relative to observations of staff performance of hand hygiene and donning of PPE ( personal protective equipment) was not divided for unit to unit comparison between the Floor Inpatient Unit and the High Observation Inpatient Unit.

30984

Based on records review, observations and interviews, the hospital failed to set priorities for high-risk, high volume and problem prone areas as evidenced by:

1) Failure to identify and implement corrective action relative to the provision of care to patients ordered to be on telemetry monitoring. Delays were noted in the identification and notification of a licensed nurse regarding a change in a patient's cardiac rhythm and delays were noted in the initiation of a nursing assessment and the implementation of Cardiopulmonary Resuscitation (CPR) on Patient #5 while the patient had no detectable pulse and no respiratory effort.

2) Failure to identify and implement corrective action relative to the need to develop new interventions when statistical data indicated continued staff non-compliance with hospital policies regarding hand hygiene performance and donning of personal protective equipment when caring for patients on contact precautions. There was no documented evidence that staff education was planned to address the identified problem with hand hygiene and use of PPE.

3) Failure to identify and implement corrective action relative to nursing personnel writing wound care orders in the medical record without first obtaining authorization from the prescribing/admitting practitioner. This was identified for 2 (#7, #8) of 3 (#7, #8, #9) current inpatients reviewed for wound care orders from a total of 3 sampled inpatients and 3 random inpatients and 1 (#6) of 1 closed medical record reviewed for wound care orders from a total of 6 (#1 - #6) sampled closed records;

4) Failure to identify and implement corrective action relative to ensuring each patient was assessed at least every 24 hours and with a change in condition by the RN as required by the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs (licensed practical nurses) without documented evidence of an RN assessment at a minimum of every 24 hours and after changes in the patient's condition for 2 (#9, R3) of 4 current inpatients' records (#7, #8, #9, R3) reviewed for RN assessments and 1 (#6) of 1 closed medical record reviewed for RN assessments from a total of 6 (#1 - #6) sampled closed records.

Findings:

1) Failure to identify and implement corrective action relative to the provision of care to patients ordered to be on telemetry monitoring.

Medical record review revealed delays were noted in the identification and notification of a licensed nurse regarding a change in a patient's (Patient #5) cardiac rhythm and delays were noted in the initiation of a nursing assessment and the implementation of Cardiopulmonary Resuscitation (CPR) on Patient #5 while the patient had no detectable pulse and no respiratory effort.

S3Quality was interviewed on 10/29/14, at 11:56 a.m.. S3Quality reviewed the medical record of Patient #5 and verified delays in the identification and notification of a licensed nurse regarding a change in a patient's (Patient #5) cardiac rhythm and delays in the initiation of a nursing assessment and the implementation of Cardiopulmonary Resuscitation (CPR) on Patient #5 while the patient had no detectable pulse and no respiratory effort.

S3Quality could not provide documented evidence to indicate the hospital implemented effective corrective measures relative to the identified delays in the provision of care to telemetry patients.

S3Quality indicated that the hospital did not update any policies or do any training of the staff after Patient #5's code on 9/27/14.

S3Quality said S5LPN was put on a do not return list at the agency after 9/27/14 because she checked the monitor and leads of Patient #5 before she assessed the patient.

S3Quality said since the code on 9/27/14 of Patient #5, there was now a monitor technician and a secretary; however S3Quality verified the telemetry technicians still answer the call bells and telephones while responsible for telemetry monitoring.


In an interview on 10/30/14, at 9:30 a.m., with the owner of Staffing Agency "A", she said S5LPN worked for her and had not been placed on a do not return list by the hospital.


Review of the log book titled Nursing/Unit Sec (secretary) Lunch Schedule revealed from 9/12/14 through 10/30/14, the staff had only documented on 3 occasions which person was responsible for telemetry monitoring while the telemetry technician was at lunch.

In an observation on 10/29/14, at 3:28 p.m., of S7Telemetry, she was transferring orders off a patient's medical record. S7Telemetry said they had a secretary on Monday through Friday but not on the weekend or holidays. S7Telemetry also said when the unit was busy she acted as a telemetry technician and a secretary.

In an interview on 10/30/14, at 10:05 a.m., with S2DON, she said she thought S5LPN had been placed on a do not return with the staffing agency because of her delay in assessment during Patient #5's code on 9/27/14.

When asked when S5LPN worked last at the hospital, S2DON said on 10/25/14 (5 days earlier). S2DON also said she had not met with S5LPN and discussed anything about the delay in assessment of Patient #5 on 9/27/14.

S2DON verified because of the discrepancies in documentation between S7Telemetry and S5LPN it could not be determined if S5LPN had known about Patient #5's absence of a rhythm at 1:45 p.m. or 2:00 p.m. S2DON verified a nurse should have been notified at 1:29 p.m. on 9/27/14 when Patient #5's rhythm changed to a junctional BBB.

S2DON also verified S5LPN should have assessed Patient #5 immediately upon entering her room instead of assessing the telemetry monitor. S2DON additional stated since 9/27/14 no new policies had been put in place about telemetry monitoring or assessment, no staff training had taken place about telemetry monitoring or assessment, the log book for handoff of responsibility had not been utilized, and no documentation could be provided about an investigation of the incident although the hospital realized it was a problem on 9/29/14.


2) Failure to identify and implement corrective action relative to the need to develop new interventions when statistical data indicated continued staff non-compliance with hospital policies regarding hand hygiene performance and donning of personal protective equipment when caring for patients on contact precautions.

Review of the meeting minutes of the QAPI meeting conducted on 07/28/14 revealed that hand hygiene was noted to be at 85% (per cent) for June and PPE usage was at 82%. The action taken was that S4Infection Control Nurse assigned 5 nursing staff members to monitor each other in "hopes of improving hand hygiene and PPD use." There was no documented evidence that staff education was planned to address the identified problem with hand hygiene and use of PPE.

Review of the meeting minutes of the QAPI meeting conducted on 08/25/14 revealed hand hygiene for July was 88%, staff compliance with PPE was 87%, and physician compliance with PPE was 50%. There was no documented evidence of a corrective action plan to address the continued problem with hand hygiene and use of PPE.

Review of the meeting minutes of the QAPI meeting conducted on 09/22/14 revealed that hand hygiene in August was 74% (69% for staff and 100% for physicians), and use of PPE was 81% compliance. When asked by S1CEO why there were less observations, S4Infection Control Nurse indicated that she had received the monitoring report from one of 5 of the nurses assigned the duty of observations. There was no documented evidence that a corrective action plan had been developed that included education and implemented to address the continued problem with hand hygiene and use of PPE.

There were 7 observations of breaches in hand hygiene practices and 13 observations of staff not using proper PPE in handling infectious patients during the survey from 10/27/14 through 10/30/14.

In an interview on 10/29/14 at 2:40 p.m., S4Infection Control Nurse indicated that she had not identified an infection control problem for QAPI since taking on the role of Infection Control Nurse on 09/29/14. She further indicated that she doesn't report a monthly infection rate other than those associated with central lines or urinary catheters. She confirmed that no corrective action plan was in place to address the problem with hand hygiene and use of PPE.


3) Failure to identify and implement corrective action relative to nursing personnel writing wound care orders in the medical record without first obtaining authorization from the prescribing/admitting practitioner.


Review of the hospital policy titled "Wound Care Treatment Protocol", presented as a current policy by S3Quality Director, revealed that a physician's order was to be obtained for treatment of wounds which would specify the treatment modalities and product usage.


Review of the medical records of Patient #6, #7 and #8 revealed orders relative to wound care that were entered into the medical record by the wound care nurse (S8WoundCareRN) and carried out by nursing staff without first obtaining authorization from the prescribing/admitting practitioner.


In an interview on 10/29/14, at 10:05 a.m., S9RN indicated that she was the interim wound care nurse prior to S8Wound Care RN being hired. S9RN confirmed that the wound care orders were not written as verbal or telephone order and were signed by the physician after the treatment had been provided.


In an interview on 10/29/14 at 3:25 p.m., S8WoundCareRN verified that orders relative to wound care or being entered into the medical record by her (S8WoundCareRN) and being carried out by nursing staff prior to obtaining authorization from the prescribing/admitting practitioner.

In an interview on 10/30/14 at 3:25 p.m., S3Quality indicated that the hospital failed to identify and implement corrective action relative to wound care orders being entered into the medical record by the wound care nurse without first obtaining authorization from the prescribing/admitting practitioner.


4) Failure to identify and implement corrective action relative to ensuring each patient was assessed at least every 24 hours and with a change in condition by the RN as required by the Louisiana State Board of Nurse's Practice Act:

Review of the LSBN's Practice Act revealed that RNs may delegate select nursing interventions to the LPN provided the patient is assessed by an RN every 24 hours.

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part,

"3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems.

The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.

a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.

b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification..."


Review of medical records revealed patient care was provided by LPNs (licensed practical nurses) without documented evidence of an RN assessment at a minimum of every 24 hours and after changes in the patient's condition for 2 (#9, R3) of 4 current inpatients' records (#7, #8, #9, R3) reviewed for RN assessments and 1 (#6) of 1 closed medical record reviewed for RN assessments from a total of 6 (#1 - #6) sampled closed records.


In an interview on 10/30/14, at 3:25 pm, with S3Quality, she confirmed Quality Management had failed to identify/address issues requiring intervention through QAPI such as the failure to report changes in patient rhythm strips in a timely manner to allow rapid response to a patient condition change (adverse event); issues relative to patients not being assessed at least every 24 hours and with a change in condition by an RN; and issues relative to RNs writing orders without first obtaining authorization from the prescribing/admitting practitioner.

30984

Based on records review, observations and interviews, the hospital failed to ensure the QAPI program identified an incident as an adverse event and subsequently measured, analyzed and tracked the incident as an adverse event for 1 of 1 incidents reviewed.

Findings:

Review of Patient #5's medical record revealed a delay in the identification and notification of the licensed nurse regarding a change in a patient's cardiac rhythm for a period of at least 16 minutes (unable to determine exact timeframe because of discrepancies in interviews and documentation of staff).

S5LPN failed to assess Patient #5 for 5-15 minutes after notification of no detectable cardiac rhythm by the telemetry monitor technician (unable to determine exact timeframe because of discrepancies in interviews and documentation of staff). Further review revealed there was a delay in Cardiopulmonary Resuscitation (CPR) being initiated on Patient #5 while she had no detectable pulse and no respiratory effort. Patient #5 was transferred to an acute care hospital where she later expired.

In an interview on 10/30/14, at 3:25 pm, with S3Quality, she reported the hospital had no adverse events in the last 12 months.

S3Quality was then asked if the incident related to failure to report changes in a patient's rhythm strip in a timely manner to allow rapid response to a patient condition change should have been identified as an adverse event. S3Quality replied," Yes, in hindsight, that incident should have been identified as an adverse event". She agreed the incident should have been analyzed and tracked through QAPI. S3Quality also said an evaluation of the system/process which led to the incident should have been conducted. She agreed staff education, through inservices, should have been initiated as part of a QAPI performance improvement project addressing the events which led to the incident.

Based on records review and interviews, the governing body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services, including those services furnished under contract, involved in the QAPI Plan.

Findings:

Review of the hospital's QAPI documentation revealed no documented evidence that the following departments had been included in the QAPI Plan:

Dietary (provided directly), Laundry (contracted), Laboratory Services (contracted), Blood Bank Services (contracted) and Physical Therapy (contracted).

In an interview on 10/30/14, at 3:00 pm, with S3Quality she confirmed the following services had not been included in the QAPI Plan: Dietary (provided directly), Laundry (contracted), and Laboratory Services (contracted), Blood Bank Services (contracted) and Physical Therapy (contracted). She acknowledged all services provided, including those provided through contract, should have been included in QAPI Plan.

30364


Based on records review and interviews, the hospital failed to ensure that the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:

1) S5LPN failed to assess Patient #5 for 5-15 minutes after notification of no detectable cardiac rhythm by the telemetry monitor technician. This deficient practice resulted in a delay in Cardiopulmonary Resuscitation (CPR) being initiated on Patient #5 while she had no detectable pulse and no respiratory effort. Patient #5 was transferred to an acute care hospital where she later expired;

2) Failure to ensure each patient was assessed at least every 24 hours and with a change in condition by the RN as required by the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs (licensed practical nurses) without documented evidence of an RN assessment at a minimum of every 24 hours and after changes in the patient's condition for 2 (#9, R3) of 4 current inpatients' records (#7, #8, #9, R3) reviewed for RN assessments and 1 (#6) of 1 closed medical record reviewed for RN assessments from a total of 6 (#1 - #6) sampled closed records;

3) Failure to ensure each patient's care was provided according to physician orders as evidenced by having the RN writing wound care orders without first obtaining authorization from the prescribing/admitting practitioner for 2 (#7, #8) of 3 (#7, #8, #9) current inpatients reviewed for wound care from a total of 3 sampled inpatients and 5 random inpatients and 1 (#6) of 1 closed medical record reviewed for wound care from a total of 6 (#1 - #6) sampled closed records;

4) Failure to assess patient wounds upon admit and weekly thereafter as required by hospital policy as evidenced by having no documented evidence of wound assessments at the time of admission for 1 (#8) of 3 (#7, #8, #9) current inpatients reviewed for wound care from a total of 3 sampled inpatients and 5 random inpatients and no documented evidence of wound assessments at the time of admission and weekly thereafter according to hospital policy for 1 (#6) of 1 closed medical record reviewed for wound care from a total of 6 (#1 - #6) sampled closed records;

5) Failure to ensure patient weights were assessed and documented as ordered by the physician as evidenced by failure to obtain daily weights according to physician orders for 1 (#6 - closed record) of 4 (#6, #7, #8, #9) patient records reviewed for assessment of weights from a total of 9 sampled records and 5 random patient records.

Findings:

1) S5LPN failed to assess Patient #5 for 5-15 minutes after notification of no detectable cardiac rhythm by the telemetry monitor technician:

Review of the hospital policy titled Continuous Cardiac Monitory (Telemetry), September 2013, revealed in part:

Policy: Cardiac Monitoring is initiated and discontinued based upon a physician ' s order. Once initiated, qualified staff maintains visual surveillance 24 hours a day.

3. Cardiac rhythm will be recorded, interpreted and documented on the initiation of telemetry, every 6 hours thereafter, and more frequently as indicated by the patient ' s condition.

7. The nurse assigned to the patient must respond immediately if any of the following occurs:
b. any observed change in the patient ' s rhythm (a strip is to be recorded, assessed and documented).
c. loss of signal

9. The monitor technician notifies the nurse if alarms sound, there is any change in patient rhythm, poor signal or loss of signal, or any change in monitoring lead.
i. if the monitor technician is unable to notify the patient ' s nurse regarding non-life threatening rhythm changes (and patient is asymptomatic) the monitor technician will immediately notify the person next in authority i.e. Charge nurse.

Review of the medical record for Patient #5 revealed that she was admitted to the hospital on 9/19/14 with diagnosis/problems which included wound care, encephalopathy, end-stage renal disease, and malnutrition. Patient #5 was ordered to be a full code on admission. Further review revealed Patient #5 was transferred to a local acute care hospital on 9/27/14.
Review of the telemetry monitoring strips in the medical record for Patient #5 dated 9/27/14 revealed the following:

1:13 p.m. - " SR (sinus rhythm) with prolonged QT, " written by S7Telemetry.

1:29 p.m. - " SR with junctional beats. Heart rate 67, " written by S7Telemetry (no documentation of nurse notification of the change in rhythm).

1:39 p.m. - " Junctional, BBB (bundle block branch). Heart rate 55, " written by S7Telemetry (no documentation of nurse notification of the change in rhythm).

1:45 p.m. - " returned from lunch. Notified nurse pt (patient) off tele (telemetry), " written by S7Telemetry (no rhythm on the strip).

2:07 p.m. - " when nurses called code, " written by S7Telemetry (no interpretation of the strip written).

Further review revealed the telemetry strips had not been printed until 9/27/14 at 5:00 p.m.

Review of the document titled Daily Nursing Re-Assessment 12 Hour Shift for Patient #5 dated 9/27/14 and written by S5LPN revealed in part:

2:00 p.m. - Summoned to room by S7Telemetry, telemetry tech (technician), to check leads (sensors attached to the body for telemetry monitoring of the heart) on patient. Leads checked and batteries checked. No rhythm noted on tele. Gave patient the sternal rub. No response. Checked pulse. No pulse. No breathing. Code blue called. CPR began.

3:00 p.m. - Patient transferred to Hospital " D "

Review of the discharge summary for Patient #5 transcribed 9/27/14 revealed a code blue was called for Patient #5 on 9/27/14 at 2:09 p.m.


In an interview on 10/29/14, at 11:22 a.m., with S7Telemetry, she said if a patient had an abnormal rhythm she printed a strip, interpreted the data and notified the nurse. S7Telemetry said she notified the nurse, S5LPN, when she saw the strip without a waveform at 1:45 p.m. S7Telemetry said S5LPN went into Patient #5 ' s room and came out twice asking if the patient ' s waveform was on the monitor yet. She said S5LPN then went into the room and did a sternal rub on Patient #5 and called a code blue.

In an interview on 10/29/14, at 11:56 a.m., with S3Quality, she said S5LPN was put on a do not return list at the agency after 9/27/14 because she checked the monitor and leads of Patient #5 before she assessed the patient.

In an interview on 10/30/14, at 9:17 a.m., with S5LPN, she said that she was Patient #5's nurse on 9/27/14. S5LPN said S7Telemetry did not inform her until 2:00 p.m. that Patient #5 was off of telemetry because she was at lunch from 1:30 until 2:00 p.m. S5LPN said someone was supposed to be watching her patient while she was at lunch, but she did not remember who it was and she had no documentation.

S5LPN said S7Telemetry gave her some batteries and told her to check the leads on Patient #5 at 2:00 p.m. because she was off of her monitor. S5LPN said she changed the batteries on the telemetry monitor on Patient #5 and checked her EKG leads. S5LPN said she went to the door and asked if there was any activity on the telemetry monitor and S7Telemetry replied, "No."

S5LPN said she did not assess or even look the patient at first because she was focused on the telemetry leads. S5LPN said after she could get no activity on the telemetry monitor she noticed Patient #5 was not breathing. S5LPN said it took about 5 minutes from when she was notified of the telemetry monitor not picking up a rhythm and her noticing Patient #5 was not breathing. S5LPN said she then called a code blue.


In an interview on 10/30/14, at 9:30 a.m., with the owner of Staffing Agency "A" , she said S5LPN worked for her and had not been placed on a do not return list by the hospital.

In an interview on 10/30/14, at 10:05 a.m., with S2DON, she said she thought S5LPN had been placed on a do not return with the staffing agency because of her delay in assessment during Patient #5 ' s code on 9/27/14.. When asked when S5LPN worked last at the hospital, S2DON said on 10/25/14 (5 days earlier). S2DON also said she had not met with S5LPN and discussed anything about the delay in assessment of Patient #5 on 9/27/14. S2DON also verified S5LPN should have assessed Patient #5 immediately upon entering her room instead of assessing the telemetry monitor.

2) Failure to ensure each patient was assessed at least every 24 hours and with a change in condition by the RN as required by the Louisiana State Board of Nurse's (LSBN) Practice Act:


Review of the LSBN's Practice Act revealed that RNs may delegate select nursing interventions to the LPN provided the patient is assessed by an RN every 24 hours.

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part,

"3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems.

The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.

a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.

b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification..."


Review of the hospital policy titled "Assessment-Reassessment Nursing", effective September 2013 and presented as a current policy by S3Quality Director, revealed that reassessments will be performed by the RN or the LPN within their scope of practice when assuming responsibility for the patient's care. Reassessment will occur at least every shift and more frequently as the patient's condition/circumstances warrant. An RN reassesses the patient every 24 hours at a minimum. The assessment(s) are recorded in the patient medical record. Change of condition assessment will be performed by a registered nurse.

Patient #9

Review of Patient #9's medical record revealed she was 58 year old female admitted on 08/21/14 for intravenous antibiotic therapy, rehabilitation, and management of her Diabetes mellitus. Further review revealed she had a history of Clostridium Difficile and was placed on Contact Precautions.

Review of Patient #9's "Daily Nursing Re-Assessment 12 Hour Shift" revealed her nursing care on 10/24/14 on the day and night shift as well as the day shift of 10/25/14 was provided by LPNs. there was no documented evidence that Patient #9 was assessed by an RN from 7:00 a.m. on 10/24/14 until 7:00 p.m. on 10/25/14 when her care was provided by an RN.

Review of Patient #9's "Daily Nursing Re-Assessment 12 Hour Shift" revealed her nursing care on the day and night shifts of 10/27/14 was provided by an LPN, and her nursing care on the day shift of 10/28/14 was provided by an LPN. There was no documented evidence of an assessment by an RN of Patient #9 from 7:00 a.m. on 10/27/14 through 7:00 p.m. on 10/28/14 (not every 24 hours).


Patient R3

Review of patient R3's medical record revealed he was a 63 year old male admitted on 10/24/14 with diagnoses of MRSA (Methicillin Resistant Staph Aureus) Left groin, Vascular Graft Infection, Malnutrition, and Deconditioning.

Review of Patient R3's "Daily Nursing Re-Assessment 12 Hour Shift" from 7:00 a.m. on 10/24/14 through 7:00 a.m. on 10/28/14 revealed his nursing care was provided by LPNs with no documented evidence of an RN assessment every 24 hours throughout this time.


Patient #6

Review of Patient #6's medical record revealed she was a 72 year old female admitted on 09/16/14 with diagnoses of Mitral and Tricuspid Valve Replacement secondary to Insufficiency, Diabetes Mellitus, and Debilitation.

Review of Patient #6's "Daily Nursing Re-Assessment 12 Hour Shift" for her entire hospital stay from 09/16/14 through 10/07/14 when she was discharged revealed no documented evidence of an RN assessment (as required to be done every 24 hours by the LSBN Practice Act) on 09/17/14, 09/19/14, 09/20/14, 09/23/14, 09/24/14, 09/27/14, 09/28/14, 09/29/14, 09/30/14, 10/01/14, 10/03/14, 10/04/14, 10/05/14, and 10/06/14.

In an interview on 10/28/14, at 2:45 p.m., S10RN confirmed that she worked as the Charge RN on some days during the hospital stays of Patients #9, R3, and #6. She indicated that when she signs the "Daily Nursing Re-Assessment 12 Hour Shift" she is agreeing with the assessment of the patient performed by the LPN.

When asked what her assessment of the patient included, she indicated that she looks to see that the patient is alert, if they're sitting in a chair, if they can ambulate, and looks at the urinary catheter if one is present.

She further indicated that she doesn't always document an assessment in the narrative section of the note. After reviewing the note of 10/04/14 for Patient #6, S10RN confirmed that the LPN documented no wounds were present (while Patient #6 had documented wounds), and she (S10RN) signed that she agreed with the LPN's assessment. When asked how one can tell that the patient is assessed at least every 24 hours by an RN, S10RN indicated they usually try to alternate each shift with an LPN and an RN "if they can." She further indicated that you can tell by the RN signing that he/she agrees with the LPN's assessment. After reviewing the nursing note for 10/05/14 for Patient #6, S10RN confirmed that she did not sign the section saying that she agreed with the assessment of the LPN.


In an interview on 10/29/14, at 9:00 a.m., S18LPN indicated usually patients are cared for by LPNs who report off to an LPN on the following shift, because "we don't have that many RNs" to alternate LPNs with RNs each shift. She indicated that what she usually witnesses is the RN charge nurse gets report, makes rounds, talks with patients, but doesn't usually perform an assessment. She indicated that some RNs perform an assessment, but not all RNs do.

Review of Patient #6's physician orders revealed the following orders:

09/21/14 at 11:00 a.m. - Coumadin 5 mg (milligrams) orally every day;

09/24/14 - PT/INR in the morning;

09/26/14 at 7:30 a.m. - hold Coumadin today; decrease Coumadin to 2.5 mg orally daily on Saturday;

09/30/14 at 2:00 p.m. - Hold Coumadin related to elevated PT/INR;

10/01/14 at 7:00 a.m. - Hold Coumadin; PT/INR in the morning;

10/02/14 at 7:50 a.m. - Coumadin 1 mg on Tuesday, Thursday, Saturday, 2 mg on all other days; PT/INR in the morning;

10/03/14 at 8:00 a.m. - PT/INR in the morning.


Review of Patient #6's PT/INR results revealed the following:

Reference Ranges: PT - 11.5 - 15.3 sec (seconds); INR - 2-3;

09/26/14 - PT 32.8 sec; INR 2.9;

09/29/14 - PT 33.5 sec; INR 2.9;

10/01/14 - PT 39.6 sec; INR 3.5;

10/03/14 - PT 27.9 sec; INR 2.4;

10/04/14 - PT 24.2 sec; INR 2.1.


Review of Patient #6's medical record revealed S51Agency LPN documented on 09/30/14, at 10:00 a.m., that Patient #6 had a "nosebleed (lg [large] amt [amount]). B/P (blood pressure) 118/73; informed charge nurse. PT/INR (Protime/International Normalized Ratio) drawn. Pressure applied to nares noted bleeding decreasing. Will monitor." Further review revealed no documented evidence of an assessment by the RN (Patient #6 was on Coumadin with her PT being 33.5 sec and INR 2.9 on 10/29/14).

Review of Patient #6's medical record revealed S19LPN documented on 10/01/14, at 11:30 a.m., that Patient #6 complained that her thigh-high TED (thromboembolytic device) hoses caused a blister to her thigh and requested knee-high TED hoses. There was no documented evidence of an assessment of the blister with the location (which thigh) performed by an RN until 1 1/2 hours later at 1:00 p.m. Review of her record revealed a physician order was written on 09/29/14 to change to knee-high compression stockings.

In an interview on 10/28/14, at 2:45 p.m., S10RN indicated that the nurse should be removing the TED hose to assess the patient's skin. She further indicated that there is no place on the nursing note to document the assessment of the TED other than to write the assessment in the narrative section of the note. After reviewing Patient #6's medical record, she confirmed there was no documented evidence that of skin assessments related to the use of TED hose.

In an interview on 10/29/14, at 9:00 a.m., S18LPN indicated she removes patients TED hose to assess their skin and check for pedal pulses, but she doesn't document the presence of TED hose, the removal of the TED hose, or the assessment of the skin and pulses.

In an interview on 10/29/14, at 10:05 a.m., S9RN indicated she usually documents the presence of TED hose and removes the hose to check for pedal pulses and edema. She further indicated that "most of the time" she documents the assessment.

In an interview on 10/29/14, at 10:30 a.m., S19LPN indicated that he removed Patient #6's TED hose at some time during the shift to assess her skin. After reviewing his note for Patient #6 on 10/01/14, he indicated that he couldn't remember if she had an open blister or not, but he documented that Patient #6 complained about a blister. He further indicated that Patient #6 had a dressing on, so he didn't remove the dressing. When informed that his assessment documented was at 11:30 a.m. and the wound care nurse's documentation was at 1:00 p.m., S19LPN indicated that he remembered it as being an old wound. He further indicated that "must have told them (wound care nurse) and they get to it when they get to it."

Review of Patient #6's medical record revealed S18LPN documented on 10/03/14 from 7:30 a.m. through 6:00 p.m. the following:

8:30 a.m. - heart rate per Dinamap (blood pressure monitoring device) 132, apically 122; patient has no complaints or shortness of breath (SOB);

9:30 a.m. - saline lock initiated with 22 gauge Jelco to right arm; orders for Digoxin IVP (intravenous push) obtained from S17Physician (documented on medication administration record as given by RN); patient teaching done and telemetry applied as ordered; normal rhythm noted, rate 100s - 120s, then up to 130s;

10:30 a.m. to 11:00 a.m. - "comfortable with nasal cannula of pain or SOB";

12:00 p.m. to 1:00 p.m. - patient is in bed; heart rate 106; patient made comfortable;

4:00 p.m. to 5:00 p.m. - patient complaining of SOB; no distress noted; respiratory rate 18; heart rate 106; oxygen saturation 94% to 96%; oxygen at 3 liters per nasal cannula and respiratory treatment given;

6:00 p.m. - patient is resting in no acute distress.

Review of the entire documentation revealed no documented evidence that an RN assessed Patient #6 when she began to have increased heart rate that required Digoxin to be ordered. There was no documented evidence that Patient #6 was assigned to an RN until it was determined that her condition was stable and able to be delegated to the LPN as required by the LSBN's delegation tree.

In an interview on 10/29/14, at 9:00 a.m., S18LPN indicated that she was assigned the care of Patient #6 on 10/03/14. She further indicated that S17Physician was walking out the room when she was walking into the room. She further indicated that this was the first time she had Patient #6 as her patient since returning to work from her days off. She confirmed that she reported to S17Physician and the charge nurse that she (S18LPN) had to start an IV and get Patient #6 on telemetry.

S18LPN indicated that when she reported to the charge nurse that Patient #6 was in Atrial Fibrillation (Fib) with a rapid ventricular response (RVR), the charge nurse to the room and auscultated Patient #6's apical heart rate but didn't document an assessment in Patient #6's medical record. She further indicated that she (S18LPN) did not document that she reported Patient #6's condition to the charge nurse. She further indicated that the RN administered the ordered IV Digoxin, but Patient #6's care was not transferred to an RN after the episode of Atrial Fib with RVR until it was determined that Patient #6 was stable.

Review of Patient #6's medical record revealed documentation on 10/04/14 at 9:30 a.m. by S18LPN of "mild nosebleed and stopped immediately (hx [history] of nosebleed. Further review revealed no documented evidence that an RN assessed Patient #6's nosebleed (remained on Coumadin with her PT being 24.2 sec and her INR 2.1).

In an interview on 10/28/14, at 2:45 p.m., S10RN indicated that she was the charge nurse on 10/04/14 (day Patient #6 had a nosebleed). She further indicated the LPN would come to tell her about the nosebleed, and she may be the one to call the physician. She further indicated that she goes to the patient's room to assess the patient, but sometimes she doesn't document her assessment on the narrative section of the note. S10RN indicated if the physician didn't order any new orders, she may not document an assessment. She further indicated that she knows that she has to document an assessment if a rapid response is called, but she doesn't know if she has to document for a nosebleed. After reviewing Patient #6's medical record, she confirmed that she can't tell if the LPN notified her and the physician of the nosebleed.

In an interview on 10/29/14, at 9:00 a.m., S18LPN indicated Patient #6 had oxygen per nasal cannula when she left her room on 10/04/14, and she knew that oxygen can dry the nares and sometimes cause some nasal bleeding. She further indicated that she didn't document that she reported the nosebleed to S10RN and doesn't remember if S10RN assessed Patient #6. When asked if she considered Patient #6's recent abnormal PT/INRs a factor to be assessed, she indicated that it "was a concern but Patient #6 said she had a history of nosebleeds but hadn't had one for a long time."

In an interview on 10/29/14, at 10:05 a.m., S9RN, when asked how she would handle a situation where a patient was assessed to be in Atrial Fib with RVR or a nosebleed and was on Coumadin, she indicated that would assess what medications the patient was taking and call the physician to report the change in condition.

In an interview on 10/30/14, at 3:05 p.m., S2DON (Director of Nursing) indicated that the hospital's policy is that if an RN hasn't been assigned to the patient in 24 hours, the charge RN is to co-sign the LPN's assessments. She further indicated that the RN's signature means that the RN agrees with the LPN's assessment. S2DON indicated that the premise is that in order for the RN to agree with the LPN's assessment, the RN has "to lay eyes on the patient." She indicated that Patient #6 should have been monitored by an RN after experiencing Atrial Fib with RVR until Patient #6 returned to her baseline rhythm.


3) Failure to ensure each patient's care was provided according to physician orders as evidenced by having the RN writing wound care orders without first obtaining authorization from the prescribing/admitting practitioner:

Review of the hospital policy titled "Wound Care Treatment Protocol", presented as a current policy by S3Quality Director, revealed that a physician's order was to be obtained for treatment of wounds which would specify the treatment modalities and product usage.


Patient #7

Review of Patient #7's medical record revealed that he was a 53 year old male admitted on 10/23/14 with the following admitting diagnoses: Sepsis; Multi-Resistant Poly Microbial Urinary Tract Infection (Enterobacter Aerogenes, Acinetobactor Baumanii, Pseudomonas Aeruginosa, Proteus Mirabilis and Yeast) and Quadriplegia. Further review revealed the patient also had multiple chronic wounds listed as additional co-morbidities.

Review of Patient #7's Admission Medical Doctor (MD) orders, dated 10/23/14, revealed the following:

Wound Care Clinician Consult: Reason: Multiple wounds (copied to WC-Wound care).
Specialty mattress/bed: low air loss mattress (fax to supply).

Review of Patient #7's Wound Care Nurse Consult documentation, dated 10/24/14, revealed the patient had the following wounds:

Wound #1, #2, #3
Left heel, left posterior leg, left 2nd toe.

Wound #4 and #5:
Right Ischial, Left lower back

Wound #6 and #7:
Right elbow and Left buttock

Wound #9:
Penis- excoriated skin

Wound #10:
Left Dorsal 4th toe- Trauma- Full thickness.

Further review of the Wound Care Nurse Consult documentation, dated 10/24/14, revealed orders for wound treatments/dressings, pressure relief interventions (float heels and turn every 2 hours). The consult also included instructions to keep the wounds clean/dry and to notify wound care of any change in wound condition.

The documentation was signed by S8WoundCare RN on 10/24/14 at 11:30 am. Further review revealed the wound care orders were signed by the MD on 10/27/14 at 8:00 am. The orders were not documented as telephone order read back and verified or as verbal orders.


Patient #8

Review of Patient #8's medical record revealed he was a 70 year old male admitted on 10/13/14. Review of his History and Physical conducted on 10/14/14 revealed diagnoses of Bilateral Lower Extremity Wounds with positive wound culture for Serratia marcescens, Hypotension with Ischemic Cardiomyopathy with a low ejection fraction of 40% (per cent), moderate to severe Tricuspid Regurgitation with Pulmonary Hypertension, status post Atrial Fibrillation with rapid ventricular response status post Ablation and Pacemaker Placement, End-Stage Renal Disease, Diabetes Mellitus, and a history of Arterial Hypertension in the past.

Review of Patient #8's medical record revealed wound care orders dated 10/14/14 at 3:00 p.m. and signed by S8Wound care RN for treatment of wounds to the left foot and heel, right foot, and left buttock.

Further review revealed no documented evidence that orders were written by S8Wound Care RN as a verbal or telephone order from the physician. Further review revealed the physician signed the orders on 10/16/14 at 1:00 p.m., 2 days after the orders were written and the treatment had been performed.

Further review revealed a wound care order dated 10/20/14 at 6:00 p.m. and signed by S8Wound Care RN that had no documented evidence that it had been received by verbal or telephone order from a physician. Further review revealed the physician signed the order on 10/24/14 at 2:30 p.m., 4 days after the order was written and treatment had been rendered.

In an interview on 10/29/14 at 3:25 pm with S8Wound Care RN, confirmed she was a Certified Wound Care Nurse. She explained her function at the hospital was to perform wound care consults/provide wound care.

S8WoundCareRN further explained she had written wound care orders after she had completed patient wound care assessments. She confirmed the orders she had written for wound care interventions/treatments were initiated right away so as not to delay treatment of complex wounds. She said she had written wound care orders under the assumption that the Patient's MD was coming right behind her to sign the order. S8WoundCareRN confirmed the orders had not been written as verbal orders or telephone orders. She agreed if the order had not been written as a verbal order and the MD had not signed the order until several days later it was like she had written the order for wound care without obtaining a MDs authorization until several days after the order had been written.

Patient #6
Review of Patient #6's medical record revealed she was a 72 year old female admitted on 09/16/14 with diagnoses of Mitral and Tricuspid Valve Replacement secondary to Insufficiency, Diabetes Mellitus, and Debilitation.

Review of Patient #6's wound care orders revealed an order was written by S9RN on 09/17/14 (no documented evidence of the time) with no documented evidence of the order being received by telephone or verbally from the physician. Further review revealed the orders were signed by the physician on 09/26/14 at 7:30 a.m., 9 days after the order was written and implemented. Further review revealed an order for wound care was written by S8Wound Care RN on 10/01/14 at 4:40 p.m. with no documented evidence that the order was received verbally or by telephone from a physician. Further review revealed the physician signed the order on 10/03/14 at 5:00 a.m., 2 days after the order was written and implemented.

In an interview on 10/29/14, at 10:05 a.m., S9RN indicated that she was the interim wound care nurse prior to S8Wound Care RN being hired. She further indicated that she usually just took pictures of incisions that were open to air but did not measure the incisions. She confirmed that she took pictures of the incisional wounds but did not document an assessment of the surrounding skin or the appearance of the incisions. She confirmed that the picture of the sacral wound was not dated or timed. She confirmed that the wound care orders were not written as verbal or telephone order and were signed by the physician after the treatment had been provided.

4) Failure to assess patient wounds upon admit and weekly thereafter as required by hospital policy:
Review of the hospital policy titled "Admission of a Patient", effective September 2013 and presented as a current policy by S3Quality Director, revealed that the "Admission Assessment" was to be completed by the nurse admitting the patient "within four (12) hours of admission. It may be signed by an LVN (licensed vocational nurse) and co-signed by an RN indicating assessment by the R.N... All admission assessment data is to be recorded in the patient's medical record." There was no documented evidence that assessment of and documentation of wounds was addressed in the policy.

Review of the "Wound Care Department Guidelines For Encounters Initial Skin Assessment", presented by S3Quality Director as the current protocol for skin assessments, revealed that all patients were to have a head to toe skin assessment completed by a wound care department nurse upon admission. Assessment findings will be verbally communicated to nursing as soon as wound care completes the assessment, and all documentation will be complete and filed in the patient's chart before the end of each day.

Further review revealed that the wound care department will complete head to toe skin assessments no more than 48 hours after admission. :However, we strive to complete all skin assessment within 24 hours." Nursing is responsible for completing head to toe skin assessments every shift on all patients and notifying wound care immediately of any new wound or skin integrity concern throughout the patient's length of stay. The initial evaluation will begin with obtaining a clear photo of each wound by placing a disposable ruler at the distal edge of the wound bed with the date, medical record number, and the wound number written dark and legible on the ruler. All photos should be taken in the anatomical head to toe position. Wound measurements should be documented in order of length (L) by (X) width (W) X depth (D) using centimeters. A detailed assessment o

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current an individualized nursing care plan for each patient that included nursing interventions treatment goals by failure to have designated nursing interventions and measurable goals as required by hospital policy for 2 (#7, #8) of 2 current inpatients' records reviewed for care plans from a total of 3 current inpatients (#7, #8, #9) and 1 (#6) of 1 closed medical record reviewed for care plans from a total of 6 (#1 - #6) sampled closed records. There was a total of 9 sampled patient records and 5 random patient records.
Findings:

Review of the hospital policy titled "Care Plans", effective September 2014 and presented as the current policy for care plans by S3Quality Director, revealed that all patients will have an individualized plan of care that is tailored, integrated, and coordinated by competent professionals. The individual treatment plan includes the type of treatment and/or services to be provided and revised when appropriate, measurable goals with the anticipated time frames of accomplishing the goals, and objective measures to be used to assess progress and goal attainment.


30984


Patient #7

Review of Patient #7's medical record revealed he was a 53 year old male admitted on 10/23/14 with the following admitting diagnoses: Sepsis; Multi-Resistant Poly Microbial Urinary Tract Infection (Enterobacter Aerogenes, Acinetobactor Baumanii, Pseudomonas Aeruginosa, Proteus Mirabilis and Yeast) and Quadriplegia. Further review revealed the patient also had multiple chronic wounds listed as additional co-morbidities.

Review of Patient #7's Admission Medical Doctor (MD) orders, dated 10/23/14, revealed the following:

Wound Care Clinician Consult: Reason: Multiple wounds (copied to WC-Wound care).
Specialty mattress/bed: low air loss mattress (fax to supply).

Review of Patient #7's Wound Care Nurse Consult documentation, dated 10/24/14, revealed the patient had the following wounds:

Wound #1, #2, #3
Left heel, left posterior leg, left 2nd toe.

Wound #4 and #5:
Right Ischial, Left lower back

Wound #6 and #7:
Right elbow and Left buttock

Wound #9:
Penis- excoriated skin

Wound #10:
Left Dorsal 4th toe- Trauma- Full thickness.

Further review of the Wound Care Nurse Consult documentation, dated 10/24/14, revealed orders for wound treatments/dressings and pressure relief interventions (float heels and turn every 2 hours). The consult also included instructions to keep the wounds clean/dry and to notify wound care of any change in wound condition.

Review of the hospital's care plan form revealed instructions indicating all interventions with boxes had to be checked in order for the intervention to be initiated.

Review of Patient#7's Admission Care Plan, dated 10/23/14, revealed the following identified problems:

Skin/Wound: At risk for skin breakdown; Desired Outcomes: Maintains skin integrity by 10/28/14; Interventions: No interventions had been selected for this problem and no boxes had been checked.

Skin Integrity: Alteration: Wound; Desired Outcome: Progress towards healing of wound by 10/28/14; Interventions: No interventions had been selected for this problem and no boxes had been checked.

In an interview on 10/28/14 at 3:36 pm with S10RN, she confirmed the interventions on Patient #7's care plan should have been checked to initiate/individualize the care plan regarding Skin/Wound Risk for Skin Breakdown and Alteration in Skin Integrity: Wounds. S10RN also confirmed Patient #7 was quadriplegic and had wounds. She said the boxes of the interventions should have been checked/chosen to initiate interventions, such as turn every 2 hours, float heels, and should have included any other interventions reflective of the patient's orders.


Patient #8

Review of Patient #8's medical record revealed he was a 70 year old male admitted on 10/13/14. Review of his History and Physical conducted on 10/14/14 revealed diagnoses of Bilateral Lower Extremity Wounds with positive wound culture for Serratia marcescens, Hypotension with Ischemic Cardiomyopathy with a low ejection fraction of 40% (per cent), moderate to severe Tricuspid Regurgitation with Pulmonary Hypertension, status post Atrial Fibrillation with rapid ventricular response status post Ablation and Pacemaker Placement, End-Stage Renal Disease, Diabetes Mellitus, and a history of Arterial Hypertension in the past.

Review of Patient #8's "Admission Plan of Care" revealed a problem identified was comfort with the goals stated as "receives the highest level of pain relief that can be provided and understands diagnosis and therapeutic regimen(s) needed to achieve wellness and demonstrates skills needed to achieve wellness."

There was no documented evidence that the goals were stated in objective, measurable terms to be able to assess progress and goal attainment. Further review revealed the problem of safety was identified with a list of interventions to be selected and checked in order to activate the intervention.

There was no documented evidence that any interventions had been checked by the nurse. Further review revealed the identified problem of skin/wound at risk for breakdown was selected with no documented evidence of any interventions selected.

Further review revealed that the goals for skin at risk for breakdown was "maintains integrity of skin... site remains free from infection... prevention of phlebitis/infiltration... understands diagnosis and therapeutic regimen(s) needed to achieve wellness and demonstrates skills needed to achieve wellness." There was no documented evidence that the goals were stated in objective, measurable terms to be able to assess progress and goal attainment.


Patient #6

Review of Patient #6's medical record revealed she was a 72 year old female admitted on 09/16/14 with diagnoses of Mitral and Tricuspid Valve Replacement secondary to Insufficiency, Diabetes Mellitus, and Debilitation.
Review of Patient #6's care plan revealed the problem of safety was identified with a list of interventions to be selected and checked in order to activate the intervention. There was no documented evidence that any interventions had been checked by the nurse. Further review revealed the identified problem of skin/wound at risk for breakdown was selected with no documented evidence of any interventions selected. Further review revealed that the goals for skin at risk for breakdown was "maintains integrity of skin... site remains free from infection... prevention of phlebitis/infiltration... understands diagnosis and therapeutic regimen(s) needed to achieve wellness and demonstrates skills needed to achieve wellness." There was no documented evidence that the goals were stated in objective, measurable terms to be able to assess progress and goal attainment.

Review of Patient #6's medical record revealed she experienced nose bleeds on 09/30/14 and 10/04/14 and an episode of atrial Fibrillation with RVR (rapid ventricular response) on 10/03/13. Review of the "Interdisciplinary Patient care Conference Record" revealed Patient #6's care plan was reviewed on 10/06/14 with no documented evidence that the nose bleeds and Atrial Fibrillation with RVR had been addressed and her care plan revised.

In an interview on 10/30/14 at 3:05 p.m., S2DON (Director of Nursing) indicated the nurse is supposed to check the box if the intervention is to be implemented for a patient's identified problem. She further indicated that goals should be written in measurable terms.

Based on record reviews and interviews, the hospital failed to ensure drugs and biologicals were administered according to the hospital's policy as evidenced by medications ordered to be given now or times one dose not being administered for more than 4 hours after the order was given for 1 (#6 - closed medical record) of 4 (#6, #7, #8, #9) patient records reviewed for medication administration from a total of 9 sampled records.

Findings:

Review of the hospital policy titled "Medications - Timely Administration," effective September 2013 and presented as a current policy by S3Quality Director, revealed that medications will be administered in a timely manner. Further review revealed that medications not eligible for scheduled dosing times are STAT and now doses, first doses and loading doses, and one-time doses.

Review of Patient #6's medical record revealed she was a 72 year old female admitted on 09/16/14 with diagnoses of Mitral and Tricuspid Valve Replacement secondary to Insufficiency, Diabetes Mellitus, and Debilitation.
Review of Patient #6's physician orders revealed the following medication orders:

09/17/14 at 1:50 p.m. - Furosemide (Lasix) 40 mg (milligrams) by mouth 1 now;

09/18/14 at 7:00 a.m. - Furosemide 40 mg by mouth 1 dose and 1 dose in the morning;

09/25/14 at 7:00 a.m. - Lasix 40 mg by mouth every morning;

09/27/14 at 10:00 a.m. - Lasix 20 mg by mouth today times 1 dose.


Review of Patient #6's MARs (medication administration records) revealed:

Lasix 40 mg was administered orally at 5:30 p.m. on 09/17/14, 3 hours and 40 minutes after the order was given.

Lasix 40 mg was administered on 09/18/14 at 11:00 a.m., 4 hours after the order was given.

Lasix 40 mg was administered at 11:30 a.m. on 09/25/14, 4 hours and 30 minutes after it was ordered.

Lasix 20 mg was administered on 09/27/14 at 1:00 p.m., 3 hours after it was ordered as a one-time dose.

In an interview on 10/30/14 at 3:05 p.m., S2DON (Director of Nursing) indicated that patient medications ordered to be given now or as a one-time dose should not be given as long as 4 hours after the order was received.

Based on record reviews and interviews, the hospital failed to ensure medical records were completed no later than 30 days after discharge as evidenced by having an 87.5% (per cent) medical record delinquency rate.

The hospital failed to implement its Medical Staff Rules and Regulations for suspension of physicians with delinquent records greater than 30 days after discharge for 22 (S23, S28, S29, S30, S31, S32, S33, S34, S35, S36, S37, S38, S39, S40, S41, S42, S43, S44, S45, S46, S47, S48) of 96 credentialed physicians on staff.


Findings:

Review of the hospital's Medical Staff Rules and Regulations, presented by S3Quality Director as the current rules and regulations, revealed that delinquent records are those that are incomplete, including signatures and authentication, after 30 days following discharge of the patient.

Further review revealed that the Medical Records/Information Management department will advise practitioners of incomplete records by letter within 14 days following discharge. At the end of 28 days practitioners may be notified by telephone reminding them of their delinquent records and that a suspension will occur in 2 days if their records are not complete. If the record remains incomplete at the end of the 30th day, the Chief executive Officer (CEO) will notify the physician in writing, via certified letter, that his/her privileges to admit patients, perform surgical procedures, or provide new consultations have been temporarily suspended until the records have been completed.

There was no documented evidence that the rules and regulations distinguished between physicians who were active or consulting on the Medical Staff.

Review of the "Unresolved Chart Deficiencies By Patient 1/01/13 Thru 9/30/14", presented as the current list of delinquent records by S24Director of Case Management and Health Information Management (HIM) on 10/30/14 at 3:00 p.m. revealed the following physicians had delinquent records (with dates of records causing the delinquency):

S23Infectious Disease MD (medical doctor) - 10/13/13, 10/29/13, 11/26/13, 03/24/14, 05/28/14, 06/24/14, 06/25/14, 06/27/14, 07/09/14, 07/30/14, 08/05/14, 08/20/14, 09/03/14, 09/17/14, 09/23/14;

S28Physician - 11/26/13, 05/26/14, 06/13/14, 06/23/14, 08/11/14, 08/25/14, 09/29/14, 09/30/14;

S29Physician - 12/28/13;

S30Physician - 06/13/14, 07/15/14, 08/07/14, 08/20/14;

S31Physician - 02/22/14, 05/26/14, 06/13/14, 08/09/14;

S32Physician - 05/27/14, 05/28/14, 06/03/14, 06/26/14, 06/27/14, 08/07/14, 08/09/14, 08/19/14;

S33Physician - 05/06/14, 09/17/14;

S34Physician - 12/28/13, 05/16/14, 06/12/14, 07/30/14, 08/20/14, 08/21/14, 09/03/14, 09/12/14;

S35Physician - 06/03/14;

S36Physician - 06/07/14;

S37Physician - 06/19/14;

S38Physician - 07/11/14; 08/20/14;

S39Physician - 08/21/14;

S40Physician - 08/21/14;

S41Physician - 08/03/14, 08/25/14, 09/15/14, 09/18/14, 09/23/14 (2 patients), 09/25/14, 09/26/14, 09/29/14;

S42Physician - 08/21/14;

S43Physician - 08/20/14, 09/23/14;

S44Physician - 08/20/14;

S45Physician - 09/10/14;

S46Physician - 09/14/14, 09/15/14, 09/17/14, 09/23/14;

S47Physician - 09/17/14;

S48Physician - 11/26/13, 02/22/14, 07/30/14, 08/04/14, 08/20/14, 08/27/14, 09/17/14.


Review of the "Notification Of Suspension" letters dated 05/01/14 and 06/02/14 addressed to S30Physician and signed by S1CEO (Chief Executive Officer) revealed that S30Physician was suspended in accordance with the Medical Staff By-laws due to failure to complete medical records within 30 days of discharge.

Review of the hospital's action plan dated 02/05/14 for addressing the Health Information Management Department's delinquent medical records, presented by S24Director of Case Management and HIM, revealed that "presently, only suspending admit/attending physicians for records that are incomplete at 30 days post discharge."

Further review revealed that the issue of verbal/telephone orders "not being signed within 10 days as per State Regulations" had been identified with an action to begin tracking unauthenticated verbal/telephone orders not authenticated within 10 days of the order being received.

In an interview on 10/30/14, at 1:05 p.m., S24Director of Case Management and HIM indicated that the hospital's current medical record delinquency rate was 87.5%.

She further indicated that the hospital began having a problem with delinquent medical records in 2009, but she had only been in her position since 2010. She further indicated that she developed a corrective action plan when she took her position in 2010, and she has been working on it since then.

S24Director of Case Management and HIM indicated in 2011 the hospital's delinquency rate was 1228%. She further indicated that there was a problem in medical records that she had not been aware of until the person doing that job ceased her employment with the hospital. She further indicated that she identified deficient medical records in July 2014 that had not been identified.

She indicated that S30Physician's suspension had been resolved when she presented to the two "Notification Of Suspension" letters. She offered no explanation relative to S30Physician having deficient medical records from 06/13/14, 07/15/14, 08/07/14, and 08/20/14 and currently not being on suspension. She offered no explanation for the above-listed 22 physicians not being currently suspended according to the Medical Staff Rules and Regulations for having delinquent records beyond 30 days after discharge of their patients. She could not explain why the S24Director of Case Management and HIM indicated they are not suspending consulting physicians presently. She offered no explanation for the consulting physicians not being suspended while the Medical Staff Rules and Regulations made no differentiation between admitting/attending physicians and consulting physicians regarding suspension for delinquent medical records. S24Director of Case Management and HIM indicated she has not been tracking verbal/telephone orders unauthenticated within 10 days of the order being received as stated in her corrective action plan. She confirmed that she had not implemented the medical record correction action plan as written.

Based on record reviews and interview, the hospital failed to ensure that the person designated as the Infection Control Officer had acquired specialized training in infection control as evidenced by S4Infection Control Officer having no prior work experience or specialized training in infection control.

Findings:

Review of S4Infection Control Officer's job description revealed experience required was 3 to 5 years of pertinent clinical experience in a hospital setting preferred and demonstrates proficiency in clinical practice and theory of care.

The education and training included graduation from an accredited school of professional nursing, current licensure as a Registered Nurse, Bachelor's degree in nursing preferred, and certification in Infection Control preferred.

The knowledge, skills, and abilities included working knowledge of infection control practices and the ability to disseminate this information to others and knowledge of the use of statistical programs to trend occurrence of nosocomial infections.

Review of the job description revealed no documented evidence that prior work experience or specialized training in infection control was required for this position.

Review of S4Infection Control Officer's prior work history revealed that was a staff and charge registered nurse in ICU (Intensive care Unit). There was no documented evidence that she had worked in a position related to infection control.

In an interview on 10/29/14, at 2:40 p.m., S4Infection Control Officer indicated that she had been the Infection Control Officer since 09/29/14. She further indicated that she was not certified in infection control, had no prior work experience in infection control, and had received no specialized training in infection control.

Based on record reviews, interviews and observation the hospital failed to ensure that the infection control officer implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:

1) Failure to mitigate the risks associated with patient infections present upon admission and contributing to healthcare-associated infections as evidenced by:

a) Failure to investigate, track, and trend all patient infections identified by cultures after admission;

b) Failure to ensure isolation precautions were implemented according to CDC guidelines and hospital policy for 4 (#7, #8, #9, R1) of 12 patients on isolation precautions with 13 observations of breaches in the isolation policy;

c) Failure to ensure hand washing hygiene including the utilization of alcohol-based hand sanitizers was implemented according to hospital policy as evidenced by 7 observations of breaches in hand hygiene practices from 10/27/14 through 10/30/14;

2) Failure to ensure the proper PPE was used during accessing of a dialysis shunt as evidenced by S12Dialysis RN (registered nurse) failing to wear protective eye shields during access of 1 of 1 observed dialysis patient whose shunt was being accessed (R4).

Findings:

1a) Failure to investigate, track, and trend all patient infections identified by cultures after admission:

Review of the hospital policy titled "Infection Surveillance," effective September 2013 and presented as the current policy by S3Quality Director, revealed that the Infection Control Nurse leads the infection surveillance program and presents surveillance data to the Infection Control Committee for review and intervention. The data is presented as infection rates and also includes prior year data for comparison. Investigation of clusters of infections and outbreaks are investigated by the Infection Control Nurse.

Review of the meeting minutes of the Infection Control Committee from 02/21/14 through 10/16/14 revealed no documented evidence that the hospital's infection rate with a comparison to the prior year's data was reported as required by hospital policy.

In an interview on 10/29/14, at 2:40 p.m., S4Infection Control Officer indicated she is monitoring urinary catheter and central line use (number of days), hand hygiene and use of personal protective equipment on surveillance rounds, and central line dressings (dressing changes, whether the dressing is intact, date of dressing change on the label), and intravenous tubings (whether the tubing is dated). She further indicated that she does not track and trend all identified patient infections to determine if there are clusters of infection and outbreaks. S4Infection Control Officer indicated that she still needs assistance in determining if wounds are a healthcare-acquired infection or community-acquired. She further indicated that she doesn't compute a monthly infection rate other than for central lines and urinary catheters.


1b) Failure to ensure isolation precautions were implemented according to CDC guidelines and hospital policy:

Review of the hospital's policy titled "Transmission Based Precautions", effective September 2013 and presented as a current policy by S3Quality Director, revealed that contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important organisms, which are spread by direct or indirect contact with the patient or the patient's environment.

Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment.

Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens. Transmission-Based Precautions may be implemented while test results are pending based on clinical presentation and likely pathogens.

Patients who require transport outside their room environment will change into a clean hospital gown, and all draining areas will be covered. If ambulatory the patient will don an isolation gown, do hand hygiene, and don gloves. If patient transport is via bed or cart, the rails of the beds will be wiped with bleach wipes. The staff will remove PPE they wore in the room and don new PPE outside the room for duration of transport. They will ensure they do not contaminate any surfaces in the environment during transport and try to maintain a 3 foot spatial boundary. The patient will be considered contaminated.

Review of the signs used outside patient rooms designating that Contact Precautions are to be used are as follows:

Green sign - "Contact Precautions to prevent the spread of infection, anyone entering this room must wear gloves, gown, applies whether or not contact with the patient or the patient's environment is anticipated" and

Red sign - "Contact Precautions to prevent the spread of infection, anyone entering this room must wear gloves, gown and perform hand hygiene with soap and water applies whether or not contact with the patient or the patient's environment is anticipated."


Patient #7

Review of Patient #7's medical record revealed that he was a 53 year old male admitted on 10/23/14 with the following admitting diagnoses: Sepsis; Multi-Resistant Poly Microbial Urinary Tract Infection (Enterobacter Aerogenes, Acinetobactor Baumanii, Pseudomonas Aeruginosa, Proteus Mirabilis and Yeast) and Quadriplegia. Further review revealed the patient also had multiple chronic wounds listed as additional co-morbidities.

Review of Patient #7 ' s Admission Medical Doctor (MD) orders, dated 10/23/14, revealed the following:

Wound Care Clinician Consult: Reason: Multiple wounds (copied to WC-Wound care).

Further review of Patient #7's MD orders, dated 10/23/14 at 1905 pm (7:05 pm) revealed the patient had been placed on strict contact precautions for MDROs (multiple drug resistant organisms).

Review of Patient #7's Wound Care Nurse Consult documentation, dated 10/24/14, revealed the patient had the following wounds:

Wound #1, #2, #3
Left heel, left posterior leg, left 2nd toe.

Wound #4 and #5:
Right Ischial, Left lower back

Wound #6 and #7:
Right elbow and Left buttock

Wound #9:
Penis- excoriated skin

Wound #10:
Left Dorsal 4th toe- Trauma- Full thickness.

On 10/24/14 at 1:15 pm an observation was made of Patient #7, who was on contact precautions, sitting outside, in his wheelchair, at the entry of the hospital. He was not wearing an isolation gown and his catheter bag, which contained urine, was not covered.

On 10/24/14 at 2:30 pm an observation was made of Patient #7 who remained on strict contact isolation precautions, returning to his room in the High Observation Unit from another unit of the hospital. He was not wearing an isolation gown and his catheter bag, which contained urine, was not covered.

On 10/27/14 at 3:00 pm, an observation was made of Patient #7, who remained on contact precautions, sitting outside, in his wheelchair at the entry of the hospital. He was not wearing an isolation gown and his catheter bag, which contained urine, was not covered.

Observation on 10/28/14 at 11:30 a.m. revealed S11RN (registered nurse) rolling Patient #7's motorized chair with stacked wound care supplies on the seat down the hall toward Room C. Further observation revealed S11RN had gloves on, was not wearing a protective gown, and did not maintain a 3 foot spatial boundary from the contaminated chair. Observation revealed S11RN stopped at the nursing station and touched the counter with her contaminated, gloved hand. Further observation revealed she then touched a rolling bedside table located in the hall that had glucometer equipment on it with her contaminated, gloved hand.

In an interview on 10/28/14 at 11:35 a.m. after the observations, S11RN confirmed that Patient #7 is on Contact Precautions. She further indicated that "he goes down the hall, and we're not supposed to wear gowns outside the patient's room." She confirmed that her gloved hands were contaminated when she touched the nursing station counter and the rolling table in the hall.

On 10/28/14 at 12:30 pm an observation was made of the Contact Isolation Precaution signage (Green Sign) posted on Patient #7's door /room in the High Observation Unit. The verbiage on the sign was as follows: "Contact Precautions to prevent the spread of infection, anyone entering this room must wear gloves, gown, applies whether or not contact with the patient or the patient's environment is anticipated".

On 10/28/14 at 12:35 pm an observation was made of S41MD entering Patient #7's room. He entered the patient's room in his lab coat and failed to don a gown and gloves as instructed per contact precaution signage on the patient's room indicating all persons entering the patient's room were required to don a gown and gloves.

On 10/28/14 at 12:40 pm an observation was made of S41MD re-entering Patient #7's room, in his lab coat, again without donning a gown and gloves.

In an interview on 10/29/14 at 10:06 am with S9RN she confirmed Patient #7 was in Contact Isolation. She explained Contact Isolation precautions required donning of PPE and gloves upon entering the patient's room. S9RN also indicated the patient should have been gowned and his catheter bag, containing urine, should have been bagged when he left his room because the contact precautions did not just apply to staff. S9RN explained donning of gowns and gloves also applied to the people who visited patients on contact isolation.

In an interview on 10/30/14 at 2:05 pm with S3Quality, she said compliance with use of PPE during patient care was monitored through QAPI. She said over the last couple of months staff compliance with PPE use had declined. She explained no written plan of action with new interventions had been initiated to address the decline in compliance with use of PPE. S3Quality explained she had continued the previous interventions of continued monitoring for compliance and on the spot counseling for non-compliant staff. S3Quality said she had no documented evidence of staff counseling (noncompliance with PPE use). S3Quality confirmed said she had no written plan regarding a set number of staff observations for PPE compliance. She also confirmed she had no written plan with established times frames/goals for achieving compliance or re-evaluation of success/failure of current interventions.

Patient #8

Review of Patient #8's medical record revealed he was admitted on 10/13/14. Review of his History and Physical conducted on 10/14/14 revealed diagnoses of Bilateral Lower Extremity Wounds with positive wound culture for Serratia marcescens, Hypotension with Ischemic Cardiomyopathy with a low ejection fraction of 40% (per cent), moderate to severe Tricuspid Regurgitation with Pulmonary Hypertension, status post Atrial Fibrillation with rapid ventricular response status post Ablation and Pacemaker Placement, End-Stage Renal Disease, Diabetes Mellitus, and a history of Arterial Hypertension in the past.

Review of Patient #8's "Lab Reports" revealed he cultured positive for Moderate Serratia marcescens and Moderate Enterococcus faecalis to the right foot and tested positive for Clostridium Difficile (C Diff).

Observation on 10/27/14 at 10:50 a.m. revealed an unidentified nurse was in Patient #8's room (Room E) with no protective gown or gloves.


Patient #9

Review of the medical record for Patient #9 revealed she was admitted to the hospital on 09/03/14 with the admitting Diagnoses of IV (Intravenous) Therapy, Rehabilitation, DM (Diabetes Mellitus) Management and History of C-Difficile.

Review of admit orders revealed an order for contact isolation.

Review of wound assessment revealed the following:

09/09/14- #1 Mid- right abdomen

09/09- #2 Left abdomen upper

09/ 09 #3 Left middle abdomen

09/09- #4 Left upper abdomen

10/02- #1 Right mid abdomen

10/07- # 2 Abscess right abdomen

10/10- Old JP (Jackson Pratt) drain site

10/20- #1 JP drain

10/20- #2 Right Abdomen with wound vac.

Observation on 10/28/14 at 9:50 a.m. revealed a red contact (C-Difficile) isolation sign posted on the outside of Patient #9's door. The door to Patient #9's room was open, and S50LPN was noted standing at the bedside with his back to the door removing his gown and gloves. On the way out of the room S50 was observed picking up a plastic medication cup which contained unopened medications. The plastic cup was located on two open boxes of gloves stored on a small brown plastic box attached to the wall in the anteroom of Patient #9. Continued observation revealed S50 exited the room with the contaminated plastic cup in his hand, walked back to the medication room, and placed the contaminated plastic cup on the medication counter. Further observation revealed at no time did S50 wash his hands.

In an interview at 10:00 a.m. on 10/28/14, S50LPN indicated that the plastic medication contained unopened medication for Patient R2 and confirmed that the plastic cup with medications was placed on top of the box of gloves located in the anteroom of Patient #9. S50LPN confirmed that Patient #9 was on contact precautions for C-Difficile. S50LPN indicated that he was administering medication and entered Patient #9's room to attend to Patient #9's IV (intravenous). S50LPN confirmed that the plastic cup with medications was contaminated after taking it into Patient #9's room. He confirmed that he took the contaminated plastic cup into the medication room and placed it on the counter.


Patient R1

Review of Patient R1's medical record revealed he was admitted on 10/07/14 with diagnoses of Diskitis, Osteomyelitis Thoracic Spine, status post Laminectomy with Abscess Evacuation on 10/02/14. Further review revealed he was placed on Contact Precautions secondary to his wound culture being positive for MRSA (Methicillin Resistant Staph Aureus).

Review of Patient R1's Lab report revealed a urine culture collected 10/22/14 tested positive on 10/24/14 for Proteus Mirabilis.

Observation on 10/27/14 at 10:20 a.m. revealed Patient R1 rolling himself in a wheelchair with S13Contract PT (Physical Therapist) walking along side of the wheelchair. Patient R1 was noted to be dressed in his personal clothing (shirt & pants) and bilateral contracture boots. S13Contract PT had no PPE's on.

In an interview on 10/27/14 at 10:2 0 a.m., S13Contract PT indicated that R1 was on his way to the gym for PT. He further indicated that Patient R1 was on contact precaution, and he (S13Contract PT) had changed Patient R1's personal clothing before leaving the room to go the gym for PT.

Observation in the gym on 10/27/14 at 10:45 a.m. revealed Patient R1 was seated in his wheelchair performing arm exercises using equipment on a rolling table. Further observation revealed S13Contract PT (physical therapist) was working with Patient R1 and was not wearing a protective gown and gloves. Further observation revealed S13Contract PT touched Patient R1's shoulder strap and waist belt with his ungloved hands.

Observation on 10/28/14 at 10:15 a.m. revealed Patient R1, who was on Contact Precautions, in a wheelchair in the hallway escorted by S13Contract PT. S13Contract PT did not have a plastic gown and gloves on while with Patient R1.

In an interview on 10/28/14 at 10:15 a.m., S13Contract PT confirmed that R1 was his way to the gym for PT. He offered no explanation for not wearing PPE.

In an interview on 10/30/14 at 8:55 a.m., S13Contract PT indicated that Patient R1 should have had a protective gown on, since he was on Contact Precautions. When informed that he (S13Contract PT) was observed to not be wearing a gown and gloves while performing PT with Patient R1 in the gym, S13Contract PT indicated that he did not touch Patient R1. When informed that he was observed to touch Patient R1's waist belt and shoulder strap, S13Contract PT answered, "O.k." He indicated they never wear gloves and gowns in the gym and was told not to by the former administration.

Patient R2
Observation of Patient R2 on 10/27/14 at 10:50 a.m. revealed Patient R2 was in a wheelchair in the hallway in the gym. S13Contract PT indicated that Patient R2 was on contact precaution and was taking a rest while his therapist stepped out for a minute.

In an interview on 10/27/14 at 2:30 p.m. S4Infection Control Nurse confirmed that Patient R1 and Patient R2 were on contact isolation. She further indicated that patients who are on contact isolation are allowed to move around the hospital provided they wear an isolation gown. She further indicated that patients who are on contact precaution for C-Difficile are not allowed out of his/her room.

In an interview on 10/30/14 at 3:05 p.m., S2DON (Director of Nurses) indicated that PT is not supposed to take patients on Contact Precautions out of their room. She further indicated that there had been a conversation with S13Contract PT by herself and S1CEO (Chief Executive Officer) about infected patients having their PT in the patient's room if possible or having the patient properly gowned. She further indicated that the conversation had occurred about 6 to 8 weeks ago, and she had not received any complaints that this process was not happening.

Observation on 10/28/14 at 11:28 a.m. revealed S14Contract PTA (physical therapy assistant) was in Patient R1's room (Room A) removing his plastic protective gown. S14Contract PTA was observed to not wearing a plastic protective gown or gloves while touching Patient R1, exiting the room without washing her hands or using hand sanitizer, and touching the gown and glove holder containers on the wall outside Room A with her contaminated hands.

In an interview after the observation on 10/28/14 at 11:28 a.m., S14Contract PTA indicated that she forgot to don PPE.

A request was made to speak with S23Infectious Disease Physician who was reported to be the Infectious Disease Chairman for the hospital. On 10/30/14 at 11:10 a.m. S3Quality Director informed the surveyor that S23Infectious Disease Physician indicated that he only had time at the present to speak with the surveyor. S3Quality Director attempted unsuccessfully to reach S23Infectious Disease Physician by telephone in the presence of the surveyor, but the call continued to go to voice mail. An opportunity for interview with S23Infectious Disease Physician did not occur as of the completion of the survey on 10/30/14 at 6:25 p.m.


1c) Failure to ensure hand washing hygiene including the utilization of alcohol-based hand sanitizers was implemented according to hospital policy:

Review of the hospital policy titled "Hand Hygiene", effective July 2013 and presented as a current policy by S3Quality Director, revealed that hand hygiene is an important measure in reducing healthcare associated infection rates. Hand hygiene is to be performed at a minimum in the following circumstances: before beginning of a work shift and at the end of a work shift; before and after patient contact; before applying gloves and after removing gloves; before performing a clean, aseptic procedure; after exposure to body fluids; after touching patient surroundings.

Observation on 10/28/14 at 11:28 a.m. revealed S14Contract PTA (physical therapy assistant) was in Patient R1's room (Room A) removing his plastic protective gown. S14Contract PTA was observed to not wearing a plastic protective gown or gloves while touching Patient R1, exiting the room without washing her hands or using hand sanitizer, and touching the gown and glove holder containers on the wall outside Room A with her contaminated hands.

In an interview after the observation on 10/28/14 at 11:28 a.m., S14Contract PTA confirmed that she did not perform hand hygiene prior to or after exiting Patient R1's room.

On 10/28/14 at 12:35 pm an observation was made of S41MD entering Patient #7's room. He entered the patient's room in his lab coat without performing hand hygiene. S41MD was observed leaving the patient's room, again without performing hand hygiene upon exit.

On 10/28/14 at 12:40 pm an observation was made of S41MD re-entering Patient #7's room, in his lab coat, again without performing hand hygiene.

On 10/28/14 at 12:45 pm an observation was made of S41MD leaving Patient #7's room without performing hand hygiene. He touched the desk and other patient charts in the High Observation Unit. He was observed leaving the unit, without performing hand hygiene, and he proceeded to enter the nursing station of another patient care unit. S41MD touched the desk and handled patient charts from that unit and was not observed performing hand hygiene prior to entry of the second unit's nursing station.

In an interview on 10/29/14 at 10:06 am with S9RN she confirmed Patient #7 was in Contact Isolation. S9RN confirmed hand hygiene should have been performed prior to entering the patient's room, before and after donning gloves, and upon exiting the patient's room.

On 10/28/14 at 3:40 pm an observation was made of S8Wound Care RN performing wound care on 4 of 10 of the documented wounds for Patient #7. The patient had multiple wounds and was on contact precautions for multiple drug resistant organisms in his urine. S8Wound Care RN was observed changing gloves multiple times while performing wound care and she failed to perform hand hygiene after each glove removal/prior to donning a new pair of gloves throughout the observation of the patient's wound care except for an initial performance of hand hygiene prior to initiating wound care.

Observation on 10/28/14 at 4:15 p.m. revealed S8Wound Care RN performed wound care on Patient #8 who was cultured positive for Moderate Serratia marcescens and Moderate Enterococcus faecalis to the right foot and tested positive for C Diff. Observation revealed that S8Wound Care RN gloved, removed the dressing to Patient #'s foot, changed her gloves and re-donned gloves, cleaned the wound, removed her gloves, re-donned gloves, applied honey for debridement to the wound, removed her gloves and re-donned gloves, wrapped the wound, removed her gown and gloves, and washed her hands with soap and water. There was no observation of S8Wound Care RN washing her hands after removing her gloves and before re-donning gloves during the wound care procedure.

In an interview on 10/28/14 at 4:25 p.m., S8Wound Care RN confirmed that she did not perform hand hygiene when removing her gloves and before re-donning gloves. She further indicated that there was no hand sanitizer in Room E. She confirmed that there was sink in Room E that could be used for hand washing, since Patient #8 was positive for C Diff.

Observation in the medication room on 10/30/14 at 8:45 a.m. revealed S21RN and S22LPN (licensed practical nurse) were preparing injectable medications. Observation revealed neither of the two nurses performed hand hygiene before preparing the injectable medication.

In an interview on 10/30/14 at 8:52 a.m., S22 LPN confirmed that she did not perform hand hygiene prior to preparing the injectable medications.

In an interview on 10/30/14 at 2:05 pm with S3Quality, she said compliance with hand hygiene performance during patient care was monitored through QAPI. She said over the last couple of months staff compliance with hand hygiene had declined. She explained no written plan of action with new interventions had been initiated to address the decline in compliance with hand hygiene. S3Quality explained she had continued the previous interventions of continued monitoring for compliance and on the spot counseling for non-compliant staff. S3Quality said she had no documented evidence of staff counseling (noncompliance with hand hygiene). S3Quality confirmed said she had no written plan regarding a set number of staff observations for hand hygiene. She also confirmed she had no written plan with established time frames/goals for achieving compliance or re-evaluation of success/failure of current interventions.


2) Failure to ensure the proper PPE was used during accessing of a dialysis shunt:

Review of the hospital policy titled "Standard Precautions", effective September 2013 and presented as a current policy by S3Quality Director, revealed that mask, eye protection, or face shield are indicated to protect mucous membranes of the eyes, nose, and mouth during activities that may generate splashes or sprays of blood or body fluids.

Observation on 10/27/14 at 10:34 a.m. in the dialysis room revealed S12Dialysis RN, contracted with Dialysis C, accessing Patient R4's dialysis shunt. Further observation revealed S12Dialysis RN was wearing no protective eye shield during the access, and his plastic protective gown was not tied and continued to flap away from his body when he moved around the patient.


In an interview on 10/29/14 at 2:40 p.m., S4Infection Control Nurse confirmed that eye protection should be worn when accessing a dialysis shunt due to the potential for splashing of blood.



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Based on record reviews and interviews, the hospital failed to ensure that the hospital-wide quality assessment and performance improvement (QAPI) program addressed problems identified by the infection control officer and were responsible for the implementation of successful corrective action plans in the affected problem areas. There was no documented evidence that corrective action plans that included staff training were developed and implemented for identified problems with hand hygiene and the proper use of personal protective equipment (PPE).

Findings:

Review of the meeting minutes of the QAPI meeting conducted on 07/28/14 revealed that hand hygiene was noted to be at 85% (per cent) for June and PPE usage was at 82%. The action taken was that S4Infection Control Nurse assigned 5 nursing staff members to monitor each other in "hopes of improving hand hygiene and PPD use." There was no documented evidence that staff education was planned to address the identified problem with hand hygiene and use of PPE.

Review of the meeting minutes of the QAPI meeting conducted on 08/25/14 revealed hand hygiene for July was 88%, staff compliance with PPE was 87%, and physician compliance with PPE was 50%. There was no documented evidence of a corrective action plan to address the continued problem with hand hygiene and use of PPE.

Review of the meeting minutes of the QAPI meeting conducted on 09/22/14 revealed that hand hygiene in August was 74% (69% for staff and 100% for physicians), and use of PPE was 81% compliance. When asked by S1CEO why there were less observations, S4Infection Control Nurse indicated that she had received the monitoring report from one of 5 of the nurses assigned the duty of observations. There was no documented evidence that a corrective action plan had been developed that included education and implemented to address the continued problem with hand hygiene and use of PPE.

There were 7 observations of breaches in hand hygiene practices and 13 observations of staff not using proper PPE in handling infectious patients during the survey from 10/27/14 through 10/30/14.

In an interview on 10/29/14 at 2:40 p.m., S4Infection Control Nurse indicated that she had not identified an infection control problem for QAPI since taking on the role of Infection Control Nurse on 09/29/14. She further indicated that she doesn't report a monthly infection rate other than those associated with central lines or urinary catheters. She confirmed that no corrective action plan was in place to address the problem with hand hygiene and use of PPE.