HospitalInspections.org

Based on review of facility documents, review of medical records and staff interview, the facility failed to inform each patient of the patient's rights, in advance of furnishing patient care whenever possible.

Findings included:

Review of the medical record for patients #1 and #5 revealed patient's rights policies were not discussed in advance of furnishing patient care.

Review of the medical record for patient #1 revealed a utilization review note dated 2/1/19 at 1:44 pm that stated in part, "Patient and husband refused to sign admission paperwork. Patient arrived on 1/31/2019 and left AMA [against medical advice] on 2/1/2019." The patient rights document and admission paperwork were not presented to the patient upon admission, but when patient #1 was discharging AMA.

In an interview with staff #10 on 4/23/19, when asked their process, they stated, "Our admissions department is considered pre-admission, we do all verifications and verify all benefits for them to come here. Patient rights is part of our portion. That consent [to treat form] is placed in the packet with nursing to complete. The other portion, patient rights, we typically have 48 hours to get the whole packet signed." When asked why that is not done on admission, they stated, "There's so much with evals [evaluations] and such, it's hard to get them to sign. So when a patient comes in, consent to treat is done by the nurse. We do the remainder. After they're admitted, case management takes over everything else ... We have patient rights ..." When discussed no mention of timelines for completion of patient rights, they stated, "There it is 2 days." When stated that is for the Medicare paperwork, staff #10 stated, "That's what we use for all forms."

In an interview with staff #11 on 4/23/19, when asked why the consent form was signed for patient #1, they stated, "Before they touch the patient, they need that." When asked if they discuss the patient rights, staff #11 stated, "Uh huh." When asked what they explain, staff #11 stated, "I know they always point out the pictures, if they have wounds they take pictures of the wounds ..." When asked when a patient arrives in the afternoon, if they would talk with them regarding their rights, they stated, "Not necessarily. Nurses are evaluating and doing all that stuff." When asked when they would discuss rights with the patient, staff #11 stated, "Usually the next morning."

The above was confirmed in an interview with staff #1 on the afternoon of 4/23/19.

Based on review of facility documents, review of complaint logs and staff interview, the facility failed to ensure each patient had the right to receive care in a safe setting.

Findings included:

Facility-based policy titled "Patient Rights and Responsibilities" stated in part, "You have the right to: ...Receive care in a safe setting ..."

Facility-based policy titled "Administration of Medications" stated in part, "The 7 'R's' of administering medications will be verified prior to any medication administered: a. 'Right' patient ..."

Review of complaint dated 8/3/18 stated in part, "Possible Exposure with Insulin Pen. Insulin pen labeled for [patient #11]. Insulin administered to Pt. #7.
RCA conducted.
Outcome/resolution: Handdled [sic] as a Blood Borne exposure. Family meber [sic]: 8/7/18 [family member name] in person. Those present: [doctor and administrative staff]. Baseline blood Work done. Removed insulin pens from routine use. Implemented Multidose [sic] Vial.
Nursing depat [department] made aware of the change and the process of administering high laert [sic] medications to patient. Also nursing made aware of medication rights. Blood work results delived [sic] to patient and Daughter at time of discharge."

Nurses #6 and #8 administered a pen labeled for patient #11 to patient #7, violating patient #7's patient rights.

The above was confirmed in an interview with staff #1 on the afternoon of 4/23/19.

Based on review of facility documents and staff interview, the facility failed to have a well-organized nursing service.

Findings included:

Facility-based policy titled "Insulin Preparation" with a review and effective date of 8/2018 stated in part, "Procedure:
A. Pharmacy will store different insulin types in the automated drug machine (ADM) in separate drawers to prevent selection of the wrong strength.
B. Pharmacy generated bar-code stickers will be stored in the ADM bin with the medication ...
C. A second nurse will serve as a witness that the correct insulin and dose was prepared. The nurse will be required to enter their login and password at the ADM.
D. Nursing staff will remove the vial and a sticker for the dose of insulin, aseptically draw up the dose.
E. Label the barrel of the syringe in a manner that does not cover the volume ...
F. The insulin vial will be returned to the ADM drawer; it does not leave the medication preparation room.
G. The labeled syringe will be taken to the patient's room and administered using the bar-code verification process."

Facility-based policy titled "Administration of Medications" stated in part, "The 7 'R's' of administering medications will be verified prior to any medication administered: a. 'Right' patient ..."

Facility-based policy titled "High risk/Alert Medications" stated in part, "7. Protocols and precautions are established for the safe and efficient storage, preparation, distribution and administration of each high alert medication.
...15. Prior to the administration of a High Risk Medication, 2 licensed individuals must verify that the correct medication, dosage and medication form are being given. The 2 licensed individuals must document this review by signing the signature lines provided on the MAR/eMAR [medication administration record].
Attachment A - Hospital High Alert Medications List
Insulin ... Verify dose with second nurse prior to administer ..."

Review of In-Services following the incident where patient #7 received insulin from another patient's insulin pen revealed the following:
*10/11/18 titled "Medication Administration 10 rights" revealed 11 nurses completed the training.
*Dated 8/9/18 stated in part, "Topic: Insulin Vials (converting from pens) revealed only four nurses signed in.
*Titled "Medication Management Program" revealed several classes (dated 8/14, 8/9 8/8, 8/16, 8/7) were taught and 15 nurses signed they were educated.
*Titled "High risk/Alert Medication" (classes 8/7, 8/8, 8/9, 8/16) revealed several classes were taught and 23 nurses that signed they received the education.

In an interview with the CNO on the afternoon of 4/23/19, on reviewing the incident, another nurse was identified as using the pen on the same patient. Review of staff #8's personal file revealed there was no write-up related to the incident and it was unsure if they had completed all the training. When asked what her actions would be if she was the CNO at the time this incident happened, she stated, "I would have met with both of them [nurses #6 and #8] so they can give me their feedback of what happened. I would have included both of them in their education. What we did for one, I would do for the other one, basically. I don't know if throughout the investigation, I don't know if they realized that one nurse had nothing to do versus the other one ... Looks like they just re-educated all the nurses." She provided education sign-in sheets. When asked how many nurses they had at that time, she stated, "I don't know. When I came on, I hired a lot of new nurses and we got rid of some." When asked how many nurses she has on staff, she stated, "I have 25 nurses ... We added 10-12 nurses." When asked how she could know they were all re-educated with the old policies and educated on the new process, she stated, "I would keep a list of my nurses and have them sign-off as they completed education."

It was unable to be determined if all nurses received education after the incident occurred. It was unable to be determined if nurse #8, one involved in the incident, received education.

The above was confirmed in an interview with the CNO on the afternoon of 4/23/19.

Based on facility policy review, medical record review and interview, the facility failed to ensure nursing notes, reports of treatment and other information necessary to monitor the patient's condition were documented.

Findings included:

Facility-based policy titled "Leaving Against Medical Advice (AMA)" stated in part, "Purpose: To provide for the informed responsibility of the patient, proper documentation, and financial consideration when circumstances of patient leaving against medical advice prevail.
...Procedure:
1. It is the responsibility of the attending physician and the hospital staff to ensure that the patient and family are aware of the parameters of leaving AMA. The nurse assigned to the patient will be responsible to inform the patient/family; The Charge Nurse, Case Management, Administrator on Call, and Staff (if available) will be apprised of the circumstances.
...4. Documentation in the nursing notes must include circumstances of the incident, family involvement, and physician notification.
5. Documentation on a physician order sheet must affirm order and proceed with discharge AMA."

Review of the medical record for patient #1 revealed a nursing note dated 2/1/19 at 8:10 am stated in part, "Verbalized does not want to be here and husband will be coming for her."

Nursing note dated 2/1/19 at 9:00 am stated in part, "Charge nurse has spoken with husband and reports patient will be leaving AMA, and has signed AMA form..."

There was no documentation discussing the circumstances of the incident, family involvement, physician notification, or physician order sheet.

The above was confirmed in an interview with staff #1 on the afternoon of 4/23/19.