HospitalInspections.org

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Based on record review and staff interviews the facility failed to ensure that the patient or the patient representative received the standardized Medicare Notice within two (2) days of admission for 10 of 15 patients or the advanced discharge notification for 4 of 15 patients as per their policy. (patient #1, #2, #3, #4, #5, #7, #9, #10, #11 and #12)

Findings:

Review of the medical records for patient ' s #1, #2, #3, #4, #5, #7, #9, #10, #11 and #12 revealed the patients' "An Important Message (IM) from Medicare" form was not signed by the patient or patient representative and there are no signatures for the advanced "Notice of Discharge" for patient ' s #3, #4, #10 and #11.

The hospital policy titled, " Discharge Appeal Rights, Medicare Beneficiaries " dated 06/2008 delineated the responsibility for how the IM is provided to the patient. The admitting staff will attach a label to the face sheet if the IM is not given. Social Services reviews the face sheets daily and completes the appropriate area on the "social service admission screening" form.

Review of the face sheets for these patient's revealed no attached labels indicating a need for social services to follow up. Review of the " social service admission screening " form revealed the section for documenting that the IM was given was blank.

On 12/22/11 at 09:45 AM, staff member #8 stated the Admitting staff will attach a label to the face sheets whenever the IM ' s were not provided and give a list of patient admissions/discharges daily to the social worker to follow up.

On 12/22/11 at 10:30 AM, staff member #9 confirmed on interview that in the section in the medical record designated for " Important Message from Medicare" was blank for the above noted records.
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Based on medical record review and staff interview, the facility failed to ensure that the patient or patient representative signed and dated the "Consents for Basic Diagnostic and/or Treatment procedures" as per hospital policy in eleven (11) out of thirteen (33) records reviewed. (patient #1,#2,#3,#4,#5,#7,#8,#9,#11,#12 and #13)


Findings:


Review of the medical record for patient ' s #1,#2,#3,#4,#5,#7,#8,#9,#11,#12 and #13 revealed that the "Consents for Basic Diagnostic and/or Treatment Procedures" were not completed and there is no patient / representative's signature on the forms.

On 12/22/11 at 9:45 AM, an interview with staff member #8 confirmed the above findings.

Review of the facility's policy titled, " Procedures that require Consent " dated 11/2010, stated that "The Consent Form must be complete with date and signature of the patient or appropriate representative."
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Based on medical record review and staff interview the Admitting staff and Nursing Staff failed to implement hospital policy and ensure that the patient or patient representative received " Your Rights as a Hospital Patient. " for eight (8) of thirty three (33) medical records reviewed (Patients #1, #2, #3, #4, #9,#10,#11 and #12).


Findings:


Review of the medical records for patients #1, #2, #3, #4, #9, #10, #11 and #12 revealed no patient or patient representative signature on the "Advance Directive Information / Acknowledgement of Patient Rights" forms.

On 12/19/11 at 11:45 AM Staff member #1 confirmed on record review that nursing staff failed to ensure the Acknowledgement of Patient Rights form was completed for the above noted records.

Review of the facility's policy titled, "Advance Directives " dated 01/2009 documented, "The Admitting Office will provide patient/significant other with the information packet, " Your Rights as a Hospital Patient. " The Admitting Office will obtain patient/significant other signature on the " Receipt of Patient Advance Directive Information Acknowledgement Form. " The Nursing department (RN) will receive this paper work with the admission papers and check for completion of this form.
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Based on record reviews and interviews the facility failed to ensure in two (2) out of five (5) medical records that the "Physician Order Restraint Sheet" was completed in accordance with the hospital policy. (patient # 7 and #9)


Findings:

Medical record review for patient #7 revealed the application of bilateral wrist restraints to the patient on 12/07/11 to prevent self extubation. Review of the "Physician Order Restraint Sheet" dated 12/07/11, 12/08/11 and 12/13/11 revealed an untimed physician ' s signature.

Review of medical record for patient #9 revealed the application of a soft vest restraint and bilateral wrist restraints on 12/19/11 at 5:00 PM but the physician order was not obtained until three hours later at 8:00 PM.

Review of the policy titled " Restraints " dated 03/2010 revealed that the use of Non Behavior Health physical restraints requires a physician written order within one hour of application and all orders must include a date and time.

On 12/20/11 at 11:50 AM these findings were confirmed with staff member #1.
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Based on record review and staff interview the hospital failed to ensure that a patient (patient #2) placed in four point restraint was monitored as required by the facility policy.


Findings:


Medical record review for patient #2 revealed the ' Restraint Assessment Form ' dated 09/16/11 timed 8:00 AM documented four point restraints were applied to the patient and a physician order was obtained. The restraints were released at 10:45 AM.

The "Restraint Assessment Form" revealed four point restraints were reapplied on 09/16/11 at 11:15 AM. There was no documented evidence of patient monitoring from 11:15 AM to 12:15 PM while the patient was in restraints.

The Restraint form dated 09/16/11 timed 12:15 pm documented monitoring began and continued until 3:00 PM. There was no nurse progress note for discontinuation of restraint.

The policy titled, " Restraints. " Dated 03/2010 documented, "The RN must document every fifteen minutes from the time the restraints are initiated and document discontinuation/release and the reasons why. "

On 12/20/11 at 11:15 AM these findings were confirmed with staff #1.
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Based on interviews and review of personnel files the facility failed to ensure that security staff has the required training in the use of first aid techniques and certification in the use of cardiopulmonary resuscitation (CPR) for 16 out 16 personnel records reviewed. (staff members #6, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28 and #29)

Findings:

Review of 16 personnel education and training records for the security guards who participate in " Code White" (physical holds, take downs and application of restraints) did not provide evidence of basic first aid or CPR.

Review of policy titled "Code White" dated 06/2009 documented, " Code White" is initiated to manage aggressive patient behavior. Assistance may include a physical take down and restraining of violent patients. The code team includes security guards who can put hands on patients.

During an interview on 12/19/11 at 11:45 AM and 12/22/11 at 1:00 PM staff member #2 confirmed that security will assist in the physical holds and patient take downs during a "Code White" and assist with the application of restraints.

During an interview on 12/21/11 at 1:30 PM staff member #6 confirmed that security guards are involved in patient take downs and physical holds and they do not get first aid or CPR training.
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(A) Based on record review and interview, the physician's verbal orders/telephone orders were not authenticated as required by the facility's policy in 4 out of 17 records. Review of the Physician's Bylaws revealed that the physician authentication requirements did not correspond with the nursing policy. (patient #6, #13, #23 and #27)

Findings:

Review of medical record on 12/21/11 for patient #13, revealed that on 11/17/11 at 9:40 PM a telephone order was taken for Ativan every 4 hours for agitation and on 11/18/11 at 4:40 PM an order for a blood culture, D5 ?, Vancomycin 1 gram IV Piggy Back and Tylenol by mouth every four hours for temperature. Neither order was not authenticated by the physician.

Review of medical record on 12/21/11 for patient #27 revealed that a telephone order was taken on 11/10/11 at 3:00 PM to change diet to low sodium puree with honey thick liquids and was not authenticated by the physician.

Review of Medical Record on 12/21/11 for patient #23 revealed that a telephone order was taken on 09/19/11 for a " DNR. " and was not authenticated by the physician.

Medical record review for patient #6 on 12/19/11 at 11:50 AM revealed a physicians untimed telephone order was obtained on 12/15/11 stating, " Renew Ativan Drip as previously ordered. " This telephone order was not authenticated by a physician.

The facility ' s policy titled " Medication Preparation/Administration/Recording " dated 11/10, documents that " Telephone or verbal orders are signed by responsible practitioner within 48 hours. "

The facility ' s current Bylaws dated 04/2011 document under " General Conduct of Care " that " Verbal orders (including telephone orders) shall be authenticated by the responsible practitioner as soon as possible but no later that 30 days from the date of discharge, " which does not correspond with the nursing policy.






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(B) Based on observations, record review and interview the facility failed to ensure the nursing staff administered medications with a current physician's order as required by policy.


Findings:


On 12/19/11 at 11:45 AM, patient #6 was observed in the Intensive care unit (ICU) sedated with an Intravenous drip infusing Ativan 40 mgs in 250 cc D5W at 1 mg an hour.

Medical record review for patient #6 on 12/19/11 at 11:50 AM revealed the physicians order dated 12/13/11 timed 3:45 PM for " 40mg Ativan in 250 cc D5W and titrate to mild sedation. "

The physicians order sheet dated 12/15/11 revealed an untimed telephone order was obtained stating, " Renew Ativan Drip as previously ordered. " This telephone order had not been authenticated by a physician.

Review of the medication administration record (MAR) on 12/19/11 at 11:55 AM indicated the Ativan drip was initiated at 5:45 PM on 12/13/11 and the patient was receiving this preparation daily through 12/19/11, although the order had expired on 12/16/11.

On 12/19/11 at 11:55 AM, these findings was confirmed by Staff members #1 and #2. Staff member #2 verified that Ativan drips require a physicians order and need renewal every third day.

Review of the hospital policy entitled "Medication Administration Recording" dated 11/2010, documented, intravenous medicines and narcotics must be renewed every three days.
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Based on record review, the facility failed to ensure that the patient ' s temperature and/or vital signs were consistently taken during the transfusion in 2 out of 3 transfusion records reviewed as per hospital policy. (patient #18 and #8)

Findings:

Review of the Medical Record of patient #18 revealed that on 12/16/11 a blood transfusion was started at 10:20 AM and completed at 1:45 PM. The 2nd unit was started at 3:10 PM and there is no documented temperature, blood pressure, pulse or respirations when it was started. There is no documented temperature at 6:00 PM or at 7:00 PM while the transfusion was in progress and there is no documentation on the Vital Signs Worksheet of what time the 2nd unit was completed.

Review of the medical record of patient #8 revealed that on 12/20/11 there were no documented vital signs on completion of the blood transfusion at 8:30 AM.

The facility ' s policy entitled " Transfusion Therapy " dated 1/2010 documents that the nurse:
1) Obtain and record baseline vital signs prior to picking up the blood.
2) Monitor the patient for 15 minutes of the blood transfusion by direct observation and document a second set of vital signs.
3) Observe patient closely and check vital signs every hour while transfusion is infusing.
4) Obtain vital signs upon completion of transfusion and document.
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Based on observation and interview the facility failed to ensure that the drugs and biologicals were stored in a locked secure storage area on 3 out of 3 nursing units. (Units 2 North, 2 West and 3 Central).

Findings:

During observations from 12/19/11 to 12/21/11, the medication carts on 2 North, 2 West and 3 Central were not able to be locked, even though the carts had a locking mechanism attached.

Interviews with staff members #13 and #14 on 12/21/11 at 10:50 AM, confirmed that the carts are unable to be locked because the locks have been broken for at least 1 year.

The facility ' s policy titled, " Medication Preparation / Administration / Recording." dated 11/10, documented " Medications are stored on the nursing unit in medication rooms that are locked at all times and in medication carts that are locked at all times when not in locked medication rooms or in view of the RN. "
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