HospitalInspections.org

Based on review of medical records (MR), facility policies and procedures and interview with staff, it was determined the hospital failed to ensure the contracted dialysis staff:

1. Obtained and documented complete physician verbal orders.

2. Administered medications and treatments as ordered by the physician.

3. Verified and administered blood products per policy.

4. Documented the correct amount of blood during administration.

5. Documented complete and accurate pre and post treatment assessments.

This affected 1 of 1 records reviewed with newly initiated dialysis treatments and did affect Patient Identifier (PI) # 6, for 7 of the 7 dialysis treatment received. This deficient practice had the potential to negatively affect all patients receiving acute hemodialysis at this facility.

Findings include:

Hospital Services Policy & Procedure, # 1
Title: Prescription Verification and Safety Checks
Policy: 7-05-01
Revision Date: April 2018

Policy:
1. Trained dialysis teammates will verify the prescription and perform safety checks prior to treatment initiation...

7. The following prescription parameters indicate a complete physician order and will be documented on the treatment flowsheet prior to treatment initiation:
- Date the treatment to be performed.
- Dialyzer make and model.
- Dialysate Compilation: Potassium, Calcium, Sodium Dialysate, Bicarbonate
- Blood Flow Rate or Blood Flow Range Orders...
- Dialysate flow rate.
- Duration of treatment
- Heparinization, bolus and hourly, if applicable.
- Access to be used: Needle gauge and Catheter locking solution/ amount...
- Additional orders (labs, meds, blood products, hypotension management, etc.)

Hospital Services Policy and Procedure, # 1, Davita Inc.
Title: Treatment Initiation Utilizing Fresenius 2008 Services Dialysis Delivery Systems with All Single Use Dialyzer Types and Streamline or Combiset or Nipro Blood Lines
Revision Date: April 2019

Procedure:

2. Verify patient prescription. Prescription components include and are not limited to:
- Target Weight...
- Heparinization (intradialytic infusion)...

5. Calculate and set ultrafiltration per procedure. Remember to include and priming volume and rinse back.

6. If applicable, secure the maintenance heparin syringe in the syringe hold. Verify Heparin line... The Heparin pump should be utilized whenever possible rather than administering intermittent injection.

7. Establish access per procedure and administer Heparin loading dose ... Wait a minimum of three (3) to five (5) minutes following administration of heparin loading dose prior to actual initiation of treatment...

11. Unclamp venous line, turn blood pump on flush 250 milliliter (ml) of normal saline...

17. Turn on blood pump to prescribed blood flow rate...

18. Unclamp heparin line and turn heparin pump on to prescribed setting...

Hospital Services Policy and Procedure # 1, Davita Inc.
Title: Intradialytic Treatment Monitoring
Policy: 7-05-03
Revision Date: April 2019

Purpose: To guide treatment checks, monitoring during dialysis and documentation in conformity with his/her individual plan of care.

4. The following should be performed and documented at least every 30 minutes...
Heparin infusion units...

Hospital Services Policy and Procedure, # 1 Davita Inc.
Title: Administration of Blood Products
Procedure: 7-06-05A
Revision Date: March 2016

Procedure:
1. Verify physician order. Prior to starting the blood transfusion, consent must be obtained per hospital policy. Identification of both the patient and the unit of blood must be verified by two (2) licensed personnel, per hospital policy, to verify that the correct blood will be given to the correct patient per hospital policy...

10. Blood is administered during dialysis at a rate of no less than 30 minutes per unit and not to exceed three (3) hours.

Hospital Services Policy & Procedure, # 1 Davita Inc.
Title: Pre and Post Treatment Assessment and Data Collection
Policy: 7-05-02
Revision Date: October 2017

Purpose: to obtain information for planning the dialysis treatment, assessing and reviewing the patient's response to the treatment ...

Pre-treatment data collection
6. Obtain and document data collection on each patient pre dialysis ...

Patient Assessment
9. The licensed nurse teammate assesses the patient and documents findings on the patient flowsheet prior to treatment initiation and notifies the physician as needed of changes in the patient status ...

12. The assessment by the licensed nurse teammate will include: ...
Vascular Access, Respiratory status, and peripheral edema ...

Post Treatment Patient Assessment
16. Assessment of the following systems includes ... Vascular access, Respiratory, Peripheral edema ...

17. The licensed nurse teammate notifies the physician as applicable of changes in the patient status or when the patient cannot tolerate treatment as ordered ...

Hospital Services Policy & Procedure, # 1 Davita Inc.
Title: Hypotension
Procedure: 7-07-01E
Revision Date: September 2016

2. Adjust ultrafiltration (UF) rate as ordered.
3. Turn off ultrafiltration rate (UFR) per physician order.
4. Notify nephrologist for change in condition ...

Hospital Services Policy & Procedure, # 1 Davita Inc.
Title: Medication Policy Including the Use of Volume Replacement and/ or Volume Expanders
Policy: 7-06-01
Revision Date: August 2017

Purpose: To provide guidance for medication management in the acute setting and to provide guidance for ...

4. All dialysis related medications are given by licensed teammates as ordered by the physician and administered per policy and procedure.

5. Medications are administered as prescribed and documented on the patient's flowsheet or medical record...

23. Heparin, Insulin, and blood products will be administered according to the hospital policy.

24. The licensed nurse will be responsible for notifying the patient's nephrologist in the event of a medication error, for implementing any necessary action to counteract the error and prevent a reoccurrence.

1. PI # 6 was admitted to the facility on 5/23/19 with the diagnosis including Acute Onset Chronic Respiratory Failure.

Review of MR revealed dialysis treatments were started on 7/12/19.

Review of 7 of 7 completed treatments received as of the date of the survey revealed:

A. Review of the 7/12/19 Hemodialysis (HD) Treatment Order Set revealed verbal order included the Total Treatment Duration time of 3 hours and 15 minutes. Heparin bolus of 1000 units/ milliliter (ml) Intravenous (IV) push times (X) 1 dose and Heparin maintenance 500 units/ ml IV infusion per hour.

Review of the 7/12/19 Acute HD Flowsheet for pre treatment respiratory status revealed no documentation of a lung assessment, which included Oxygen Saturation, and breath sounds. Edema was documented as pitting and greater than (>) 4+ generalized, facial, left, right, upper and lower extremities.

Further review of the 7/12/19 Acute HD Flowsheet revealed Heparin Bolus 1000 units at 4:40 PM when the treatment started. The staff failed to wait a minimum of 3 to 5 minutes after administering the Heparin, before initiating the treatment.

Then Heparin 1000 units were administered at 5:45 PM, 7:00 PM and at 8:00 PM. The dialysis treatment ended at 8:10 PM. The staff administered a total of 3000 units of Heparin for the hourly maintenance dose and it should have been 1750 units.

Review of the 7/12/19 post assessment revealed documentation for edema as none.

The staff failed to follow physician orders Heparin administration, agency policy for initiation of treatment, document a complete pre assessment and document an accurate post assessment.

In an interview conducted on 7/25/19 at 9:45 AM, EI # 5, confirmed the above findings.

B. Review of 7/13/19 HD Treatment Order Set Verbal Order revealed the Total Treatment Time of 3 hours 15 minutes, Heparin loading/ bolus dose of 1000 units and Heparin maintenance dose of 1000 units hourly.

Review of pre treatment assessment documentation of > 4+ pitting edema in all extremities.

Review of the 7/13/19 Acute HD Flowsheet revealed treatment started at 9:45 AM with Heparin bolus of 1000 units. The staff failed to wait 3 to 5 minutes to begin the treatment after the Heparin bolus was administered.

Review of the Heparin maintenance dose revealed 1000 units were administered at 10:45 AM, 11:45 AM, and 12:45 PM for a total of 3000 units. The dialysis treatment ended at 1:00 PM and the patient should have received Heparin 3250 units for the hourly maintenance dose.

Further review of the 7/13/19 Flowsheet revealed the Post Assessment of Edema as none.

In an interview conducted on 7/25/19 at 9:45 AM, EI # 5 confirmed the dialysis staff failed to follow physician orders for Heparin, facility policy and document an accurate post assessment.

C. Review of the 7/15/19 HD Treatment Order Set revealed revealed HD orders for 3 hours 15 minutes, Heparin loading/ bolus dose of 1000 units and Heparin maintenance dose of 1000 units hourly.

Review of the 7/15/19 Acute HD Flowsheet revealed the treatment started at 12:00 PM and Heparin 1000 units was administered at 12:15 PM (15 minutes after the treatment was started) along with the maintenance doses of 1000 units at 1:00 PM and 2:00 PM. Treatment ended at 3:18 PM. PI # 6 received Heparin 3000 units for the treatment and should have received 4250 units.

In an interview conducted on 7/25/19 at 9:45 AM, EI # 5 confirmed the staff failed to follow physician orders and facility policy for treatment initiation.

D. Review of 7/17/19 HD Treatment Order Set Verbal Order revealed the Total Treatment Time of 3 hours 30 minutes, Blood Flow Rate / Range 300 ml/minute (min) Advance to 400 ml/min. Heparin loading/ bolus dose of 1000 units and Heparin maintenance dose of 1000 units hourly.

Review of 7/17/19 Acute HD Flowsheet revealed Heparin Bolus 1000 units administered at 8:43 AM, and maintenance doses of 1000 units were administered at 9:45 AM, 10:45 AM, and 11:45 PM for a total of 4000 units. The dialysis treatment ended at 12:06 PM. The patient should have received a total of 4500 units of Heparin and not 4000 units for the 3 hour 30 minute treatment.

Further review of the 7/17/19 HD Flowsheet revealed the BFR of 375 8:43 AM to 12:06 PM (the entire treatment). There was no documentation the staff tried to increase the BFR to 400.

In an interview conducted 7/25/19 at 9:45 AM, EI # 5 confirmed staff failed to follow physician orders advance the BFR to 400, treatment initiation policy and administer Heparin as ordered.

E. Review of the 7/19/19 HD Treatment Order Set revealed verbal orders were received at 10:30 AM and included Total Treatment Duration time of 2 hours and 30 minutes. ("See Pink Order Sheet" was written in).
Heparin bolus of 1000 units and Heparin maintenance dose 1000 Units/ ml hr.
Other Medications/ Interventions and Additional Orders were blank.

Review of the MR revealed pink physician order dated 7/19/19 (no time documented) revealed infuse 1 Unit PRBC during dialysis (T&CM (Type and Cross Match) now.) The physician's ordered was signed off by secretary at 10:50 AM and noted by Registered Nurse (RN) at 11:20 AM.

Review of the Acute HD Flowsheet dated for 7/19/19 revealed Heparin 1000 units bolus was administered at 11:07 AM to initiate treatment and again at 12:15 PM a maintenance dose of 1000 units for a total of Heparin 2000 units. The patient should have received a total of 2500 units of Heparin.

Further review of the 7/19/19 Flowsheet revealed blood was administered 12:30 PM to 12:45 with no amount documented.

After the treatment ending at 1:37 PM revealed documentation, PRBC (Packed Red Blood Cells) 200 as the amount given.

On 7/24/19 at 4:00 PM the surveyor asked EI # 1, Chief Clinical Officer, "How many ml are in a unit of PRBC's?" EI # 1 stated, "300 ml."

Review of the Blood Administration Bedside Verification Form revealed the instructions Bedside Verification Information Verified included:

Consent for the Transfusion Signed and on Chart
Physician order verified
I have confirmed the identity of the patient
The pt (patient) name/ Med Rec (Medical Record) number agree
Unit # marked on tag agree with # on unit
ABO and Rh on tag agree with unit
The blood is not outdated
Compatibility status is on tag.

The following verification checks were left blank:

The patients name.
The patient's medical record number..
The unit of blood number on the bag..
If the unit of blood was in date.
The compatibility status of the unit of blood.

The dialysis staff failed to document blood safety checks before administering blood, document the amount of blood administered on the treatment flowsheet, failed to infuse blood over a minimum of 30 minutes and administer Heparin as ordered and per policy.

In an interview conducted on 7/25/19 at 9:45 AM with EI # 5, confirmed the above findings.

F. Review of the 7/22/19 Hemodialysis Orders revealed BFR 300 to 400 and Heparin 1000 units bolus and no hourly Heparin maintenance was ordered and the total treatment time of 3 hours.

Review of the 7/22/19 Acute HD Flowsheet revealed treatment started at 10:48 AM and ended at 1:48 PM, the BFR was 375, and no documentation of an attempt to increase to 400.

Further review of the 7/22/19 Flowsheet revealed Heparin 1.0 units was administered at 10:48 AM to start treatment and 1.0 units were administered at 11:45 AM and 12:45 PM.

The dialysis staff failed to follow physician orders for Heparin administration, BFR and follow facility policy for treatment initiation. The staff failed to obtain physicians' orders for the hourly Heparin administered.

In an interview conducted on 7/25/19 at 9:45 AM, EI # 5 confirmed the above findings.

G. Review of the 7/24/19 Hemodialysis Orders revealed verbal orders were received at 1:00 PM. Anticoagulation Heparin loading dose/bolus was marked through and written Other Anticoagulation 2000 Bolus X (times) 1.

The surveyor asked EI # 5, "What anticoagulant was ordered?" EI # 5 responded, "It is not documented."

Review of the 7/24/19 Acute HD Flowsheet revealed treatment started at 1:30 PM and 1000 normal saline (NS) was given and Heparin 2000 units.

The treatment ended at 4:00 PM and no documentation of the amount of NS used to rinse back the blood after treatment.

The surveyor asked EI # 5, "Would the treatment start with 1000 NS?" She replied, "It should not."

The staff failed to obtain complete physician orders for anticoagulant therapy, document rinse back, and follow policy for Initiation and Discontinuation of treatment.

In an interview conducted on 7/25/19 at 9:45 AM, EI # 5 confirmed the above findings.

Based on review of facility compliant documentation, facility policies and interview it was determined the staff failed to investigate patient /family complaints of mold smell.

This had the potential to negatively affect all patients admitted to the facility.

Findings include:

Facility Policy: Patient - Family Grievances
Policy Number: A.1.02
Revision Date: 06/2019

Policy:
The Hospital will protect and promote patient's rights...

A. Complaints...

5. Complaints that are made by the patient, family member or representative that are related to quality of care...

B. Grievance...

4. If resolution was not achieved by the actions taken by the Case Manager, Chief Clinical Officer and/ or Administrative Representative, the Administration will attempt to identify an acceptable solution. If a solution can be reached a written notice will be forwarded to the patient within 7 working days of receipt of the grievance...

Review of facility complaint follow up documentation from Employee Identifier (EI) # 1, Chief Clincial Officer, dated 5/31/19 revealed, "The fan blades in the room on the fan were extremely dusty."

Review of facility email documentation dated 6/7/19 from EI # 1 to EI # 6, Quality Director, revealed a patient's family had complained of the smell on mold on the unit.

Letter from facility to complainant provided to surveyor on 7/23/19
From: North Alabama Speciality Hospital (NASH)
Employee Identifier (EI) # 6, Director of Quality.
Dated: 6/10/19, Postmarked: 6/11/19

"The following concerns have been brought to my attention:
1. Distinct smell of mold in room.
2. Patient not being turned timely.
3. Reuse of BMS (Bowel Movement System).
4. Nursing care.
5. Radio etiquette.
6. Dusty fan.
7. Floors not being cleaned during stay.

Because of the concerns you have highlighted, ...

Environmental Services were made aware of sanitary concerns and they have advised their staff on proper cleaning techniques.
Environmental services are investigating any orders (odors) present in the patients' room..."

Facility Policy: Terminal Cleaning of Isolation Rooms
Policy Number: Q.17.08
Revision Date: 2/2018

All rooms housing patients in isolation will be terminally cleaned in a manner that will prevent the spread of infection.

O. Wet mop the entire floor with the appropriate hospital approved and EPA regulated cleaning solution that kills C-diff spores. Move furniture to mop entire floor.

Facility Policy: Cleaning of Non-Critical, Reusable Patient Care Equipment
Policy Number: R.18.37
Reviewed Date: 1/2019

Policy:
In accordance of existing infection prevention and control policies and procedures this hospital will implement and maintain processes to ensure all non-critical reusable patient care equipment is routinely cleaned before and after reuse.

Procedure:
A. All equipment must be cleaned immediately if visibly soiled and immediately after use on patient's regardless of cleaning schedule.

B. Patient care equipment should if feasible, be dedicated to the use of a single patient ...

1. On 7/23/19 at 10:15 AM the surveyor conducted a tour of 17 occupied and unoccupied patient rooms with Employee Identifier (EI) # 2, Clinical Director the following observations were made:

Room 261: Mold in toilet.

Room 260: A dirty 60 cubic centimeter (cc) syringe in the bathroom beside the sink.

Room 258: Mold in toilet, dirt and a plastic Intravenous (IV) cap in the corner of the room between the air conditioner and wall. The bottom drawer of the 3 drawer bedside was stuck and unable to open. There was also a white paper sticker on the handle of the closet that had been partially removed.

Room 257: Single Use Suction Canister remained in room and covered with dust, on top of the dusty suction canister was a can of air freshener.

EI # 2 confirmed the above findings during the tour and stated, "We have had a problem before with mold in the toilets and we were told, we just need to flush the toilets more often."

EI # 3, Director of Environmental Services (EVS), arrived during the tour and re-stated, "The toilets need to be flushed more often." The surveyor asked EI # 3, "How often does supervisory staff make rounds to ensure the rooms are clean?" He replied, "When possible. I have staff that is dedicated to this unit for 4 hours a day."

The surveyor requested documentation for:

1. Past actions taken for mold in this hospital and none was provided.

2. New complaints regarding the smell of mold /mildew in the facility. The surveyor was provided a follow up letter dated 6/10/19 to patient/ family regarding the distinct smell of mold smell in the patient room.

3. Documentation taken by EVS for the patient complaint related to cleaning and smell of mold.

EI # 3 stated the housekeeping staff were to complete a daily worksheet of the daily tasks assigned and completed for the day. The surveyor requested copies of the completed forms for May /June 2019.

Review of the 28 completed worksheets dated 5/20/19 to 6/30/19 revealed none had documentation all the tasks had been fully completed and there was no documentation of supervisory review.

There were no worksheets provided for the dates 5/1/19 to 5/19/19, 5/31/19, 6/4/19, 6/9/19, 6/10/19, 6/16/19, 6/19/19, 6/23/19, 6/24/19, 6/27/19 and 6/28/19.

The surveyor requested from for EVS, and hospital administration staff for the follow up/ investigation for the 5/31/19 complaint of mold smell, the education provided to housekeeping, daily rounds or the supervision of housekeeping staff by EVS. None was provided.

The surveyor conducted an interview with EI # 4, Housekeeping staff, on 7/25/19 at 9:15 AM and ask, "How often and what time is required to perform housekeeping duties for 1 patient room?" EI # 4 replied, "We are supposed to be on this unit for 4 hours, and that includes cleaning rooms after discharges. It is impossible to complete everything on the list." EI # 4 "It takes about 90 minutes to terminally clean a contact isolation room."

At the time of the survey 5 of the 13 patients were on contact isolation.

The staff failed to adequately clean rooms 257, 258, 260 and 261.

In an interview conducted on 7/25/19 at 9:30 AM, EI # 1, confirmed the above findings.

Based on review of medical records (MR), facility policies, and interview, it was determined the Respiratory Staff failed to document complete lung assessments for 3 of 3 ventilator patient records reviewed.

This affected Patient Identifier (PI) # 3, PI # 6, PI # 5 and had the potential to negatively affect all patient admitted to the facility with respiratory therapy services.

Findings include:

Facility Policy: Daily Documentation Requirements
Policy Number: S.19.04
Revision Date: 7/2019

Policy:
To provide uniform charting of daily respiratory therapy procedures performed and to provide documentation of ongoing processes and changes in patients requiring respiratory therapy.

B. All Respiratory Care Partners (RCPs) shall document all procedures on the Respiratory Flowsheet.

C. RCPs will perform ventilator checks at minimum of every two hours...

D. d. Clinical Observations...

F. Patient receiving treatments will be charted on flowsheet...

Facility Policy: Respiratory Therapy Routine
Policy Number: S.19.05
Revision Date: 06/2016

Procedure:
3. All treatments as ordered (plus or minus 1 hour)...
7. Chart all procedures...
13. Patient assessment every shift...

1. PI # 3 was admitted to the facility on 5/29/19 with diagnoses including Acute Respiratory Failure, Acute Onset of Chronic Systolic Heart Failure, Ischemic Cardiomyopathy with Ejection Fraction of 15 - 20%, and Chronic Renal Failure.

Review of Ventilator Flowsheets dated 5/29/19 to 5/31/19 (3 day hospital stay) revealed no documentation the Respiratory Staff assessed all lung fields every shift.

The respiratory staff failed to document complete lung assessments.

In an interview conducted on 7/25/19 at 9:00 AM, Employee Identifier (EI) # 1, Chief Clinical Officer, confirmed the above findings.

2. PI # 6 was admitted to the facility on 5/23/19 with diagnosis including Acute Respiratory Failure.

Review of Ventilator Flowsheets dated 5/23/19 to 6/4/19 and 7/13/19 to 7/23/19 (27 days) revealed no documentation the Respiratory Staff assessed all lung fields every shift.

The respiratory staff failed to document complete lung assessments.

In an interview conducted on 7/25/19 at 9:00 AM, EI # 1 confirmed the above findings.

3. PI # 5 was admitted to the facility on 5/28/19 with diagnosis including Acute Respiratory Failure.

Review of the 5/28/19 to 6/7/19 Ventilator Flowsheets (11 days) revealed no documentation the Respiratory Staff assessed all lungs fields every shift.

The Respiratory Staff failed to document complete lung assessments.

In an interview conducted on 7/25/19 at 9:00 AM, EI # 1 confirmed the above findings.