HospitalInspections.org

Based on review of hospital policy, "Education Plan, Initial and Ongoing Education," review of personnel records of respiratory therapists, and interview with the Hospital Educator, training documentation of successful training and competency demonstration was not completed according to policy.

Findings include:
1. "Education Plan, Initial and Ongoing Education," policy #033-35-014.4, stated, " F. Through a skills check list, and specific competencies identified by each department/service, an individual is assessed by department specific and educational staff to identify any education needs. If a pattern or trend in recognized department-wide or hospital-wide, remedial education will be implemented. Annually this process is repeated to assure ongoing current competency."

2. A sample survey of 19 respiratory therapist personnel records revealed the following:
a. Annual competency records for three respiratory therapists requiring evaluations in 2016 could not be located.
b. Two Orientation Competency for Respiratory Therapist forms were not dated and signed by the therapists. One was hired on 7/11/17 and the second on 3/06/18.
c. Two Orientation Competency for Repiratory Therapist forms with dates of hire of 11/07/17 and 12/12/17 were completed with "Date proved Proficient" dates before their hire dates. For the therapist hired on 11/07/17, sections Code Procedures and Response was dated 2/01/17 and Cardiology dated 2/22/17. For the therapist hired on 12/12/17, the "Date proved Proficient," was dated 1/26/17 for the entire form. The Hospital Educator interviewed during the on-site survey on 12/18/18 at approximately 10:00 AM confirmed the findings.

Based on record review, interview, and document review, the facility failed to update a care plan for 1 of 30 patients, (Patient #1).

Findings include:

Patient #1 was a 43 year old, admitted to the facility on 12/4/18, with diagnoses of cellulitis of wound, history of chronic kidney disease, stage II, severe peripheral arterial disease, sleep apnea and chronic pain.

During an interview with Patient #1 on 12/18/18 at 12:30 PM, Patient #1 stated she was refusing kidney dialysis. Patient #1 was a new dialysis patient, having only received three treatments. In review of the Transdisciplinary Plan of Care, there was no mention of kidney dialysis within the care plan. During interview with the Chief Nursing Officer on 12/18/18 at 2:00 PM, she verified the information was not on the care plan and should be on the care plan. The policy and procedure entitled, " Transdisciplinary Care Plan", revised date Jan, 2017 stated on page 1, Policy: "Patient care needs are identified and prioritized and a plan of care, which appropriately addresses priority needs is initiated within 24 hours of admission...and the Transdisciplinary Care Team will meet formally ...to further develop the plan".

Based on review of medical records, interview with the Director of Quality Management, and policy and procedure review, five charts were not signed consistent with hospital policies and procedures for patient's #16, #21, #28, #29 and #30.

Findings include:

Patient #16 was admitted to the facility on 11/21/18, with diagnoses of acute encephalopathy and respiratory failure. The medical record contained six pulmonary progress notes with no recorded time, dated "12/7/18, 12/10, 12/13, 12/14, 12/15 and 12/16", one SOAP note with no recorded time, dated 12/15/18 and seven notes authenticated by an illegible mark dated 12/5/18, 12/6/18, 12/8/18, 12/9/18, 12/9/18, 12/10/18, and 12/12/18. The Director of Quality Management, during interview on 12/19/18 at or about 12:00 PM, verified the missing components and stated chart entries are expected to be legible, timed, dated and signed by provider including a title. The hospital policy and procedure titled, " Medical Record Components", review date March, 2018, indicated on page 2, general medical requirements: B. all entries must be legible, complete, dated, timed and authenticated. The hospital policy and procedure titled, "Medical Record Entry Signature Verification", revision date March, 2014, indicated all entries will include a signature with the appropriate title of the person making the entry and will be dated and timed at the point of entry.

Patient #21 was admitted to the facility on 11/19/18, with diagnoses of respiratory failure with tracheostomy, uncontrolled hypertension, uncontrolled diabetes type 2, and generalized weakness. The medical record contained two pulmonary progress notes with no recorded time, no year dated "12/14 and 12/16". The Director of Quality Management, during interview on 12/19/18 at or about 12:00 PM, verified the missing components and stated chart entries are expected to be legible, timed, dated and signed by provider including a title. The hospital policy and procedure titled, " Medical Record Components", review date March, 2018, indicated on page 2, general medical requirements: B. all entries must be legible, complete, dated, timed and authenticated. The hospital policy and procedure titled, "Medical Record Entry Signature Verification", revision date March, 2014, indicated all entries will include a signature with the appropriate title of the person making the entry and will be dated and timed at the point of entry.

Patient #28 was admitted to the facility on 12/14/18, with diagnoses of congestive heart failure, acute respiratory failure and recurrent pneumonia. The medical record contained one progress note with no recorded signature, dated 12/14/18. The Director of Quality Management, during interview on 12/19/18 at or about 12:00 PM, verified the missing signature and stated chart entries are expected to be legible, timed, dated and signed by provider including a title. The hospital policy and procedure titled, " Medical Record Components", review date March, 2018, indicated on page 2, general medical requirements: B. all entries must be legible, complete, dated, timed and authenticated. The hospital policy and procedure titled, "Medical Record Entry Signature Verification", revision date March, 2014, indicated all entries will include a signature with the appropriate title of the person making the entry and will be dated and timed at the point of entry.









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Patient #29

Patient #29 was admitted to the facility on 10/28/18, with diabetes mellitus, paraplegia secondary to lightning strike and falling off the roof and multiple decubitus ulcer with debridement and skin graft.

On 12/19/18 at 10:00 AM, Patient #29's consultation notes dated 11/01/18 and 12/08/18 lacked documented evidence of the physicians' signatures.

Patient #30

Patient #30 was admitted to the facility on 11/28/18, with diagnoses including sepsis secondary to epidural abscess, staphylococcus aureus bacteremia and osteomyelitis.

On 12/19/18 at 10:15 AM, Patient#30's history and physical record, dated 11/29/18, lacked documented evidence of the physician's signature.

On 12/19/18 at 12:15, the Director of Quality Management, verified the missing physicians' signatures for Patient #29 and #30. The Director of Quality Management verbalized the chart entries were expected to be legible, timed, dated and signed by provider including the appropriate title.

The hospital policy and procedure titled, "Medical Record Components," reviewed on March 2018, indicated as general medical requirements: all entries had to be legible, complete, dated, timed and authenticated.

The hospital policy and procedure titled, "Medical Record Entry Signature Verification," reviewed on March 2014, indicated all entries had to include a signature with the appropriate title of the person making the entry and had to be dated and timed at the point of entry.

Based on review of medical records, interview with the Chief Nursing Officer and Director of Quality Management, and policy and procedure review,eight verbal orders were not signed consistent with hospital policies and procedures for patient's #1, #7, #25, #11, #19, and #22).

Findings include:

Patient #1 was admitted to the facility on 12/4/18, with diagnoses of cellulitis of wound, history of chronic kidney disease, stage II, severe peripheral arterial disease, sleep apnea and chronic pain. On 12/12/18, a verbal order was obtained for "saline flushes,Heparin 1000u/ml vial, all to bedside today". The verbal order was never signed. The Chief Nursing officer stated during interview on 12/18/18, at 11 AM, " all verbal orders should be signed within 48 hours". The hospital policy and procedure entitled," Medical Record Components", review date of March, 2018, indicated on page 4, #6a: "all verbal orders and/or telephone orders shall be written...and cosigned and dated by the ordering physician...within 48 hours".

Patient #7 was admitted to the facility on 12/6/18, with diagnoses of polytrauma from a motor vehicle accident on 11/10/18. The most severe injuries were C7 burst fracture with resultant paralysis. The patient had traumatic ventilator-dependent respiratory failure and a right vertebral artery dissection which was embolized, and was diagnosed with pulmonary embolist with ongoing fevers. A verbal order was obtained on 12/9/18, "Vancomycin 125 mg. P.O. every 6 hours X 14 days for positive Cdiff." A second verbal order was obtained on 12/11/18 to "DC muco myst in Neb per Dr. " The two verbal orders were never signed. The Chief Nursing officer stated during interview on 12/18/18, at 11 AM, "all verbal orders should be signed within 48 hours". The hospital policy and procedure entitled, " Medical Record Components", review date of March, 2018, indicated on page 4, #6a: "all verbal orders and/or telephone orders shall be written...and cosigned and dated by the ordering physician...within 48 hours".

Patient #25 was admitted to the facility on 12/06/18, with diagnoses of wound care post surgery and lower extremity paraplegia. A verbal order was obtained on 12/11/18 at 1536, "continue daptomycin 480 mg IV Q 24 hours through 12/12/18. Start daptomycin 500 mg IV Q 24 hours at 1500 on 12/13/18." The verbal order was not signed by the physician. The Director of Quality Management, during interview on 12/19/18 at or about 12:00 PM, verified the missing signature and stated verbal orders should be signed within 48 hours. The hospital policy and procedure entitled, " Medical Record Components", review date of March, 2018, indicated on page 4, #6a: "all verbal orders and/or telephone orders shall be written...and cosigned and dated by the ordering physician...within 48 hours".










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Patient # 11

Patient #11 was admitted to the facility on 11/23/18, with diagnoses including Methicillin -susceptible Staphylococcus aureus (MSSA) and septic prosthetic joint.

A verbal physician order was received on 11/23/18 at 16:00, for peripherally inserted central catheter (PICC).

On 12/17/18 at 2:30 PM, Patient #11's verbal order was not signed by the physician.

On 12/18/18 at 11:10 AM, the Chief Nursing Officer (CNO) confirmed the verbal order for Patient #11 was not signed by the physician. The CNO verbalized all verbal orders had to be signed within 48 hours.

Patient #19

Patient #19 was admitted to the facility on 11/29/18, with diagnosis including acute-on-chronic respiratory failure requiring high flow oxygen.

A verbal physician order was received at 12/10/18 at 11:15 AM, to extubate patient and keep the peripheral capillary oxygen saturation (SpO2) higher than 88%.

A verbal physician order was obtained on 12/16/18 at 12:15 for Racemic Epinephrine 0.5 milliliters (ml) for stridor inhalation.

On 12/19/18 at 10:30 AM, Patient #19's both verbal physician orders were not signed.

Patient #22

Patient #22 was admitted to the facility on 12/03/18, with diagnoses including management of antiseizure medication, intravenous antibiotics, recovery from severe encephalopathy secondary to acute subdural hematoma, status post craniotomy and history of hypothyroidism.

A verbal physician order was obtained on 12/14/18 for Thyroid-stimulating hormone (TSH) with the morning labs on 12/15/18.

On 12/19/18 at 11:00 AM, Patient #22's verbal order was not signed by the physician.

On 12/19/18 at 12:10 PM, the Director of Quality Management, verified the missing physician signatures on patient #19 and 22's verbal orders. The Director of Quality Management verbalized the verbal orders had to be signed within 48 hours.

The facility policy, "Medical Record Components," dated January 2009, last reviewed on March 2018, documented all verbal orders and/or telephone orders had to be written ...and cosigned and dated by the ordering physician ...within 48 hours.

Based on document review, observation, and interview, the facility failed to secure discarded medications in one of two Stericycle medication waste containers and to ensure four out of four emergency carts were maintained in a secure area.

Record review of the facility's policy titled, "Automated Dispensing-Returns," revised on March 2013, specified medications must be wasted or disposed of in compliance with federal, state and local environmental regulations. The facility's policy titled, "Pharmaceutical Waste Disposal Policy," revised on 5/15, indicated the pharmacy technicians check canisters during rounds; however, the Stericycle Rx system container is not listed on the policy.

Observation on 12/18/18 at 4:30 PM showed a Stericycle RX system container attached to the wall between the odd and even patient room hallways. The container did not have a cover and medication tablets were exposed on the top screen open to the surrounding area. The hallway was available for public access. A second Stericycle Rx system container was located on the wall in the wound care hallway near the medication cart. The second container was covered with a lid and no medications were visible on the top screen.

During an interview on 12/18/18 at 4:45 PM, the Director of Quality Management confirmed the unsecured medications exposed in the Stericycle container. The Director stated that the containers are disposed of by the host hospital and the first container was missing the cover which exposed the discarded medications in the container. The Director stated that action would be taken to secure container and exposed medications as well as educate staff on appropriate disposal of medications and container usage. The Director of Quality Management stated the containers had not been checked during environmental rounds.




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On 12/17/18 at 8:45 AM, during the tour of the primary location and throughout the survey period ending 12/19/18, the portable emergency carts were kept in the High-level and the Low-level hallways.

On 12/18/18 at 1:30 PM, during the tour of the secondary location and throughout the survey period ending 12/19/18, the emergency carts were kept in the Odd and Even hallways.

The hallways were used by staff, patients and visitors.

The emergency carts containing medications were found locked with the break-away locks, however they could have been easily opened. The emergency carts contained Adenosine, Amiodarone, Atropine, Calcium Chloride, Dextrose, Dopamine, Epinephrine, Lidocaine, Magnesium Sulfate, Naloxone, Procainamide, Vasopressin and Verapamil.

On 12/17/18 at 9:30 AM, Registered Nurse (RN) #1 verbalized the emergency cart located in the High-level hallways was not continuously observed. The RN #1 confirmed the patients or visitors could have access to the emergency cart and to the medication inside.

On 12/17/18 at 10:30 AM, RN #2 admitted the emergency cart in the Low-level hallway was accessible to patients and visitors because it was unsupervised when the RN went in patients' rooms. The RN #2 confirmed the medications were dangerous if used by unauthorized persons.

On 12/17/18 at 11:00 AM the Chief Nursing Officer (CNO), acknowledged the emergency carts were in the High-level and Low-level hallways and were easily accessible to patients, visitors and unauthorized persons.

On 12/18/18 at 2:30 PM, RN#3 confirmed the emergency carts at the secondary location were kept in the Odd and Even hallways, and they were not always under direct supervision. The RN #3 verbalized the emergency carts contained medication, were easy to open, and accessible to patients and visitors.

On 12/18/18 at 3:30 PM the Pharmacist Manager confirmed the emergency carts were in the Odd and Even hallways and accessible to patients and visitors.

The facility policy titled "Crash cart checks," dated March 1998 and revised December 2017, documented the emergency cart had to be maintained in a location that was readily available to the patient care staff but not accessible to patents, visitors, and unauthorized personnel.