HospitalInspections.org

Based on contract review, record review, and interview, the hospital failed to ensure all physicians providing services to the hospital were credentialed and granted appropriate privileges when telemedicine services were furnished for radiological services. This deficient practice was evidenced by failure of the hospital to ensure that each physician furnishing radiological telemedicine services was granted privileges at the hospital for 3 (S9RAD, S10RAD, S16RAD of 4 (S9RAD,S10RAD, S16RAD, S17RAD) radiologists reviewed that had interpreted x-rays at the hospital.

Findings:

Review of the hospital's contracted services revealed a contract with an area mobile x-ray company to provide on location radiological services.

Patient #2
Review of Patient #2's hospital record revealed in part, Patient #2 was admitted to the hospital on 12/21/17 with diagnoses that included, Cerebral Cord Syndrome, C3 to C4 Corpectomy, C2 through C5 Cage and Orophangeal Dysphagia. Further review of Patient #2's hospital record revealed an x-ray of the paranasal sinuses dated 12/26/17, that had been interpreted by S10RAD (radiologist) .

Patient #10
Review of Patient #10's hospital record revealed in part, Patient #10 was admitted to the hospital on 12/14/17. Patient #10 had diagnoses that included Hypertension, Type II Diabetes Mellitus and Coronary Artery Disease. Further review of Patient #10's hospital record revealed a chest x-ray dated 12/26/17, that had been interpreted by S10RAD.

Patient #25
Review of Patient #25's hospital record revealed in part, Patient #25 was admitted to the hospital on 11/9/17. Patient #25 had diagnoses that included History of Falls, Gait impairment and Right Knee injury. Further review of the patient's hospital record revealed an x-ray of the right knee for pain dated 11/13/17, that had been interpreted by S16RAD.

Patient #28
Review of Patient #28's medical record revealed the patient had a chest x-ray, dated 11/4/17, that had been interpreted by S9RAD.

Review of the list of the hospital's credentialed physicians, presented as current by S12HIM/PI, revealed the hospital had not credentialed and privileged the above mentioned radiologists.

In an interview on 1/24/18 at 10:59 a.m., S12HIM/PI verified S9RAD, S10RAD and S16RAD had not been credentialed and granted hospital privileges.



34161

Based on QAPI (quality assurance performance improvement) documentation review and interview, the hospital failed to identify opportunities for improvement. This deficient practice was evidenced by failing to identify that fall risk assessments were not being completed on admit and weekly thereafter, vital signs were not being obtained as ordered, and verbal order documentation had not included read back and verified documentation as areas in need of improvement to be addressed through the hospital's QAPI program.


Findings:

Review of the hospital's QAPI plan documentation, presented as current by S12HIM/PI, revealed no documented evidence that the survey findings of fall risk assessments not being completed on admit and weekly thereafter, vital signs not being obtained as ordered, and verbal order documentation not including read back and verified documentation were identified as areas in need of improvement to be addressed through the hospital's QAPI program.


In an interview on 1/24/18 at 2:00 p.m. with S12HIM/PI, she verified the survey findings of fall risk assessments not being completed on admit and weekly thereafter, vital signs not being obtained as ordered, and verbal order documentation not including read back and verified documentation had not been identified as areas in need of improvement to be addressed through the hospital's QAPI program.

Based on record review and interview, the hospital failed to ensure that the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN failed to ensure fall risk assessments were completed on admit and weekly thereafter for 4 (#1, #2, #8, #9) of 6 (#1- #4, #8, #9) sampled patients reviewed for fall risk assessments out of a total patient sample of 31.
2) The RN failed to ensure nutritional screenings were completed within 72 hours of admission as per hospital policy for 2 (#2 ,#4) of 4 (#1- #4) current sampled patients and 1 sampled discharged patient (#9) reviewed for nutritional screenings out of a total patient sample of 31.
3) The RN failed to ensure an apical pulse assessment was documented prior to each administration of Digoxin for 1(#3) of 1 total sampled patients reviewed who were receiving Digoxin out of a total patient sample of 31.
4) The RN failed to ensure vital signs were assessed and documented as ordered on a patient who was subsequently transferred out to a higher level of care for an acute change in mental status/physical condition for 1(#5) of 3 (#5,#6,#7) sampled patients reviewed for acute out transfers to a higher level of care out of a total patient sample of 31.
5) The RN failed to obtain patient weights as per physician's orders and/or per hospital policy for 2 (#2, #4) of 4 (#1- #4) sampled patients reviewed for weights out of a total patient sample of 31.
6) The RN failed to ensure patient vital signs were obtained as ordered for 4 (#22, #24, #26, #30) of 9 (#22 - #30) sampled patients reviewed for vital sign assessment and documentation out of a total patient sample of 31.
7) RN failed to notify the physician of the unavailability of a drug for 1 (#12) of 6 (#2, #4, #6, #8, #11, #12) patient records reviewed for medication errors out of a total patient sample of 31.

Findings:

1)The RN failed to ensure fall risk assessments were completed on admit and weekly thereafter.

Review of the hospital policy titled," Fall Prevention", revealed in part: I. Purpose: A. To protect patients and promote patient safety. B. To effectively identify and intervene with patients who are at risk for falling. C. To educate patients/families on measures to prevent falls and promote safety.
II. Policy: All patients will be assessed for risk of falling upon admission, with reassessments routinely performed to determine ongoing need for fall prevention precautions. Any patient determined to be at risk for a fall will be placed on fall prevention precautions. VI. Procedure A. Assessment. 1. Inpatients will be assessed on admission and every week thereafter. C. Ongoing risk assessment: 1. Complete the Fall risk re-evaluation with patient assessment every week and with a change in patient condition. 2. Document score on Assessment Form.

Patient #1
Review of Patient #1's medical record revealed an admission date of 1/15/18 and an admission diagnosis of late effect CVA with right sided hemiparesis. Further review revealed the patient had a history of frequent falls. Additional review revealed the patient ambulated with a walker and was on fall precautions.

Review of Patient #1's fall risk assessment form revealed the form remained blank as of 1/18/18 (when the patient's medical record was reviewed).

Patient #2
Review of Patient #2's hospital record revealed in part, Patient #2 was admitted to the hospital on 12/21/17 with diagnoses that included s/p Pedestrian Injury secondary to traffic accident, Cerebral Cord Syndrome, C3 to C4 Corpectomy, C2 through C5 Cage and Plating, Orophangeal Dysphagia, Paralysis to Bilateral Lower Extremities, Seizure Disorder, Bipolar and Schizophrenia. As of 1/19/18, Patient #2 was a current patient on census in the hospital.

Review of Patient #2's Fall Risk Assessment Screening Tool Nursing Assessment revealed one assessment completed on 12/21/17 indicating Patient #2 was coded as High Risk for falls. There was no other documentation since 12/21/17.

Patient #8
Review of Patient #8's hospital record revealed in part, Patient #8 was admitted to the hospital on 12/18/17 and discharged on 1/11/18. Patient #8 had diagnoses that included Cerebrovascular Accident with Right Hemiparesis, History of Seizures, Hypertension, History of Depression and Anxiety. Further review of the hospital record revealed Admission orders dated 12/18/17 that included Special Precautions: ...Fall ....

Review of Patient #8's Fall Risk Assessment Screening Tool Nursing Assessment revealed an one assessment completed on (date left blank) indicating Patient #8 was coded as High Risk for falls. During the review,S3RN verified the blank entry on the Fall Risk Screening Tool should have been dated 12/18/17. There was no other documentation noted since that entry.

Patient # 9
Review of Patient #9's medical record revealed an admission date of 12/26/17 and a discharge date of 1/9/18 (15 day length of stay) with an admission diagnosis of status post critical illness and COPD with exacerbation.
Further review of Patient #9's medical record revealed one fall risk assessment had been performed on the patient (no date or time of performance) for the duration of the patient's hospital stay.

On 1/19/18 at 1:43 p.m., an interview was held with S3RN. S2DON was present during the interview. S3RN explained the nurses were to complete a fall risk assessment on each patient weekly as per the hospital's policy. Upon review of Patients #2's and #8's Fall Risk Assessment Screening Tool Nursing Assessment form, S3RN verified the forms were not completed weekly.

In an interview on 1/19/18 at 1:52 p.m. with S2DON she confirmed it was hospital policy to perform fall risk assessments on all patients on admit, weekly thereafter, status post falls, and as needed.

2) The RN failed to ensure nutritional screenings were completed within 72 hours of admission as per hospital policy.

Review of the hospital's policy "Screening for Nutritional Status" revealed in part:
All patients are to be screened for nutritional status and identified for potential nutritional risk within the first 72 hours of admission. Procedure: The Dietary Manager or the Dietician will interview all new patients within 72 hours of admission to obtain food allergies, diet modifications, consistency modifications, food preferences, altered weight patterns, etc.

Patient #2
Review of Patient #2's hospital record revealed in part, Patient #2 was admitted to the hospital on 12/21/17 with diagnoses that included s/p Pedestrian Injury secondary to traffic accident, Cerebral Cord Syndrome, C3 to C4 Corpectomy, C2 through C5 Cage and Plating, Orophangeal Dysphagia, Paralysis to Bilateral Lower Extremities, Seizure Disorder, Bipolar and Schizophrenia. Patient #2's hospital record also revealed Patient #2 was receiving prescribed PEG tube feedings. As of 1/19/18, Patient #2 was a current patient on census in the hospital.

Further review of Patient #2's Dietary Risk Assessment revealed the entire form was blank. A Nutritional Screening on Patient #2 was completed by S8Dietician on 1/5/18.

Patient #4
Review of Patient #4's hospital record revealed in part, Patient #4 was admitted to the hospital on 1/5/18 with diagnoses that included Late Affect Cerebrovascular Accident with Right Hemiparesis, Hypertension and Non-Insulin Dependent Diabetes Mellitus.

Further revivew of Patient #4's hospital record revealed no documentation of a Dietary Risk Assessment in the patient's chart. A Nutritional Screening on Patient #4 was completed by S8Dietician on 1/11/8.

Patient # 9
Review of Patient #9's medical record revealed an admission date of 12/26/17 and a discharge date of 1/9/18 (15 day length of stay) with an admission diagnosis of status post critical illness and COPD with exacerbation.

Further review of Patient #9's medical record revealed the patient's nutritional assessment had not been performed until 1/5/18 (11 days after admission).

On 1/19/18 at 11:30 a.m., interview with S2DON. Upon review of the Dietary Risk Assessment Form, S2DON stated the form was to be completed by the S4OTDir/DM. S2DON stated S4OTDir/DM had been dietary manager for 3 years and was not aware to complete upon admission of a patient. S2DON verified Patient #2 and #4 should have had a completed Dietary Risk Assessment Form or the S8Dietician should have been completed a nutritional assessment within 72 hours

In an interview on 1/19/18 at 1:49 p.m. with S2DON, she confirmed the hospital's policy was for nutritional screens to be performed on all patients within 72 hours of admission.

3) The RN failed to ensure an apical pulse assessment was documented prior to administration of Digoxin.

Review of the hospital's policy titled," Medication Adminsitration", revealed in part: 6. The apical pulse will be checked prior to the administration of any digitalis medication. If the pulse is below 60, the medication will be held and the physician notified. Apical pulse rate will be recorded on the MAR.

Review of Patient #3's medical record revealed an admission date of 12/29/17 with an admission diagnosis of COPD, Emphysemia and Hypoxemia requiring treatment with continuous oxygen via nasal cannula.

Review of Patient #3's MAR revealed an order for Digoxin 0.125 mg one tablet by mouth once daily at 8:00 a.m. Further review of the patient's MAR ( from 12/29/17- 1/16/18) revealed no documented evidence of assessment and documentation of the patient's apical pulse (as per hospital policy) prior to administration of Digoxin .

In an interview on 1/19/18 at 9:55 a.m. with S3RN, she confirmed Patient #3's apical pulse should have been assessed and documented on the MAR prior to administration of Digoxin.

In an interview on 1/19/18 at 10:30 a.m. with S2DON, she reported it was hospital policy for nurses to assess a patient's apical pulse and to dcoument the apical pulse on the patient's MAR prior to administration of Digoxin.

4) The RN failed to ensure vital signs were assessed and documented as ordered on a patient who was subsequently transferred out to a higher level of care for an acute change in status.

Review of Patient #5's medical record revealed an admission date of 9/18/17 and a discharge date of 9/21/17. Further review revealed the patient was transferred as an acute out transfer to an area hospital due to decreasing level of consciousness, decreased blood pressure, decreased output, emesis times three, and being cool to touch.

Review of Patient #5's nursing graphic record revealed the patient had no documented 8:00 a.m. vital signs on 9/21/17. Further review revealed the last documented vital signs on the patient, prior to an assessment at 1:36 p.m. on 9/21/17 (assessment was performed after the patient complained of not feeling well) was on 9/20/17 at 8:00 p.m. (a total of 17 hours and 36 minutes with no documented vital sign assessments).


In an interview on 1/19/18 at 1:40 p.m. with S2DON, she confirmed the above referenced findings after review of Patient #5's medical record. S2DON verified there were no vital signs documented between the entry on 9/20/17 at 8:00 p.m. and the vital signs that had been documented on 9/21/17 at 1:36 p.m. S2DON further verified the vital signs had not been obtained at 8:00 a.m. as ordered.

5) Failed to obtain the patient's weights as per physician's orders and per hospital policy

Review of the hospital's "Patient Weight" policy revealed in part:
Patients will be weighed on admission and weekly unless ordered more frequently ....Weights will be obtained weekly. The patient will be weighed on the wheelchair scale that will accommodate a patient in a wheelchair or in a standing position.

Patient #2
Review of Patient #2's hospital record revealed the patient was admitted on 12/21/17 with diagnoses that included Cerebral Cord Syndrome, C3 to C4 Corpectomy, C2 through C5 Cage and Plating, Orophangeal Dysphagia, Paralysis to Bilateral Lower Extremities, Seizure Disorder, Bipolar and Schizophrenia. Further review of Patient #2's hospital record revealed Patient #2 was receiving prescribed PEG tube feedings. As of 1/19/18, Patient #2 was a current patient on census in the hospital.

Review of the Admission orders dated 12/21/17 for Patient #2 revealed in part:
Weight frequency: q wk (every week)

Review of the weekly Nursing Graphic Record for Patient #2 revealed in part:
12/21/17 - 12/23/17 - 146.9 lbs. (12/21/17)
12/24/17 - 12/30/17 - no weight documented
12/31/17 - 1/6/18 - no weight documented
1/7/18 - 1/13/18 - no weight documented
1/14/18 - 1/19/18 - no weight documented

Patient #4
Review of Patient #4's hospital record revealed the patient was admitted on 1/5/18 with diagnoses that included Late Affect Cerebrovascular Accident with Right Hemiparesis, Hypertension and Non-Insulin Dependent Diabetes Mellitus.

Review of the weekly Nursing Graphic Record for Patient #4 revealed in part:
1/5/18 - 1/6/18 - 147.8 lbs (1/5/18); 148.6 lbs. (1/6/18)
1/7/18 - 1/13/18 - no weight documented

On 1/19/18 at 9:56 a.m., an interview was held with S3RN. She stated the weights were documented on the Nursing Graphic Record in the patient's chart. Upon review of Patient #2's Nursing Graphic Record, S3RN verified there were no documented weekly weights. S3RN explained due to the patient's paralysis status, the hospital did not have the capability of weighing the patient. S3RN stated as of a week and a half ago the patient was able to be transferred to a wheelchair. She stated she guessed the patient could be weighed using the wheelchair scale. S3RN also verified Patient #4 did not have a documented weight the week of 1/7/18 - 1/13/18.

6) The RN failed to ensure patient vital signs and intake and output were obtained as ordered.

A review of the Nursing Charting Procedure Policy revealed in part: Nursing Flow Sheets - This form is to be documented on each 12-hour shift. Graphic/Intake- Vital signs, weights, accu-checks, intake and output results will be recorded on the graphic form for a weekly comprehensive view of the patient's statistics.

Patient #22
Review of Patient #22's medical record revealed she had been admitted on 11/10/17 and discharged on 11/22/17. Further review revealed she had no documented vital signs and intake/output on 11/12/17 at 8 p.m.

Patient #24
Review of Patient #24 's medical record revealed she had been admitted on 11/09/17 and discharged on 11/22/17. Further review revealed no documented vital signs or intake/output on 11/12/17 at 8 p.m. and 11/21/17 at 8 p.m.

Patient #26
Review of Patient #26 's medical record revealed she had been admitted on 11/07/17 and discharged on 11/21/17. Further review revealed no documented vital signs on 11/12/17 at 8 p.m.

Patient #30
Review of Patient # 30's medical record revealed he had been admitted on 10/27/17 and discharged on 11/10/17.
Further review revealed no documented vital signs on the following dates and times: 10/29/17 at 8 p.m., 10/11/17 at 8 a.m., and 11/3/17 at 8 p.m. On 10/29/17 the record failed to reveal any documented intake and output for the 8 p.m. shift.

An interview was conducted on 1/24/18 at 1:00 p.m. with S2DON who verified vital signs and intake and output are to be documented every 12 hours on every shift.

7) RN failed to notify the physician of the unavailability of a drug for 1 (#12) of 6 (#2, #4, #6, #8, #11, #12) patients reviewed for medication errors out of a total sample of 31.

Review of Patient #12's hospital record revealed in part, the patient was admitted to the hospital on 12/5/17. Patient #12 had diagnoses that included Uremic Myopathy, Diabetes, Hypertension, Osteoarthritis, Muscle weakness and s/p Hip replacement.

Review of the Physician's Progress Note dated 12/7/17 at 640 (a.m. or p.m. was not documented) indicated "Has foul smelly vaginal odor". Signed by S14MD.

Review of Physician Order dated 12/7/17 at 635 (a.m. or p.m. was not documented) for Patient #12 revealed in part: Flagyl 500mg b.i.d. (twice a day) x 5 days .... Noted 12/7/17 by S3RN at 0800. There was not documentation indicating a start time.

Review of Medication Administration Record (MAR) for Patient #12 revealed in part:
Flagyl 500 mg p.o. BID x 5 days (12/7/17) at 0800 and 2000 (8:00 p.m.).
The 0800 and 2000 time block was circled with N/A documented next to the time.

Review of Nurse's Notes dated 12/7/17 and 12/8/17 with S2DON, did not reveal any documentation indicating the reason for the medication time being circled and notification to the physician. The first dose of Flagyl was shown to be administered at 1500 on 12/8/17.

On 1/24/18 at 2:42 p.m., after inquiring, S2DON found the hospital did not have any Flagyl on site to administer to Patient #12. After speaking with the pharmacist, S2DON explained the nurse had called the pharmacy to order the Flagyl. However, the pharmacy was unable to deliver the medication to the hospital due to ice and snowy weather. S2DON verified the nurse caring for Patient #12 should have notified the physician of the unavailability of the medication. S2DON also verified the nurse should have provided written documentation on the nurse's notes.



34161

34161


Based on record review, observation and interview, the hospital failed to ensure the nursing staff develops, and keeps current, a nursing care plan for 5 (#1, #2, #3, #4, #9) of 10 (#1-#10) sampled patient's records reviewed for care plans of out a total patient sample of 31. The deficient practice was evidenced by the hospital failing to revise the patients care plan to reflect the patient's current health status that included identified problems, interventions, measurable goals, target dates for completion, the person responsible to implement the interventions for which the patient is being treated.

Findings:

Review of the hospital's "Nursing Care Plan" policy revealed in part:
A nursing care plan will be initiated within 24 hours of admission to the unit. The primary nurse is responsible for carrying out the care after reviewing the care plan and revising as needed. The care plan serves as a guide for patient care and educational needs during their hospital stay. Each plan is patient specific and the goal is to achieve the highest level of functioning and health status possible prior to discharge. Procedures: The Registered Nurse will initiate the care plan specific to the disease specific medical diagnosis and relate it to the nursing diagnosis.
Medical diagnosis include CVA, arthritis, diabetes, burns, wounds, spinal cord injury, neurological disorders, infections, trauma, amputation, brain injury, total knee or hip replacement, hypertension, CHF, PVD and other.
Nursing related diagnosis include alteration in comfort/pain, impaired gas exchange, ...alteration in skin integrity, nutritional status, tissue perfusion, potential for injury, and other.Education needs are identified. Interventions are checked off as related to specific diagnosis.Goals are checked off as related to expected patient outcomes.
Care plans are evaluated and revised weekly with notation as the patient's participation in the process and the goals/plans for the next week.

Patient #1
Review of Patient #1's medical record revealed an admission date of 1/15/18 with admission diagnoses of Late effect CVA with right sided hemiparesis, Diabetes Mellitus, Right heel ulcer- Stage II, and COPD.

Review of Patient #1's care plan revealed Diabetes Mellitus, Right heel ulcer- Stage II, and COPD were not addressed as problems on the patient's plan of care.

Patient #2
Review of Patient #2's medical record revealed the patient was admitted on 12/21/17 with diagnoses that included s/p Pedestrian Injury secondary to traffic accident, Cerebral Cord Syndrome, C3 to C4 Corpectomy, C2 through C5 Cage and Plating, Orophangeal Dysphagia, Paralysis to Bilateral Lower Extremities, Seizure Disorder, Bipolar and Schizophrenia. Further review of Patient #2's hospital record revealed Patient #2 was receiving prescribed PEG tube feedings. As of 1/19/18, Patient #2 was a current patient on census in the hospital.

Review of Patient #2's Care Plan revealed fall risk, aspiration risk, dietary needs including weekly weights and PEG feedings, Acitivities of Daily Living, impaired mobility, cervical collar, lift transfers, seizures, use of anticoagulant, antibiotic, and antianxiety medications, and use of oxygen at 2 liters/minute were not addressed as problems on the patient's plan of care.

Patient #3
Review of Patient #3's medical record revealed an admission date of 12/29/17 with admission diagnoses of Diabetes Mellitus, Anxiety/Depression, Hypoxemia, COPD, and Emphysema. Further review revealed the patient is oxygen dependent with continuous Oxygen at 3 liters/minute via nasal cannula.

Review of Patient #3's care plan revealed Diabetes Mellitus, Hypoxemia, COPD, Emphysema and continuous Oxygen at 3 liters/minute were not addressed as problems on the patient's plan of care.

Patient #4
Review of Patient #4's medical record revealed the patient was admitted to the hospital on 1/5/18 with diagnoses that included Late Affect Cerebrovascular Accident with Right Hemiparesis, Hypertension and Non-Insulin Dependent Diabetes Mellitus. Further review revealed Patient #4's medical record failed to include initiation of a comprehensive plan of care.

On 1/19/18 at 10:44 a.m., upon request, S3RN had presented Patient #4's care plan. S3RN stated that she was in the middle of completing Patient #4's care plan because she had known Patient #4's care plan had not been initiated and completed.

Patient #9
Review of Patient #9's medical record revealed an admission date of 12/26/17 with admission diagnoses of COPD with exacerbation and Influenza A. Further review revealed an order for Droplet Contact Isolation Precautions.

Review of Patient #9's care plan revealed COPD with exacerbation and Influenza A were not addressed as problems on the patient's plan of care. Further review revealed Droplet Contact Isolation Precautions was also not addressed as a problem on the patient's plan of care.

On 1/19/18 at 10:44 a.m. S3RN was interviewed regarding the above referenced care plans not being revised and/or not being comprehensive. S3RN stated "We've got to do better with completing the care plans" in response to the questions regarding the above referenced plans of care.

Based on record, policy and Medical Staff By Law reviews, the hospital failed to ensure all patient medical record entries were complete, dated and timed by the person responsible for providing or evaluating the service provided as evidenced by failure to have the physician or licensed independent practitioner sign/date/time their orders/entries in the patient medical records for 9 (#2, #11, #16, #17, #21, #25 #26, #29 #30) of 31 patient records reviewed for completeness.

Findings:

A review of the Medical Staff By Laws revealed in part: All orders including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner, or practitioner who is responsible for the care of the patient and authorized to write orders by hospital policy in accordance with State Law for up to ten (10) days.

Patient #2
Review of Patient #2's medical record revealed the patient was admitted on 12/21/17. Review of the admission orders and medication reconciliation revealed the orders were received by the S3RN on 12/21/17 at 2:30 p.m., however, S14MD failed to sign, date and time orders.

Patient #11
Review of Patient #11's medical record revealed the patient was admitted on 12/11/17 and discharged on 12/26/17. A review of the Physician Orders dated 12/16/17 at 9:20 p.m. for Levaquin revealed S14MD had not signed, dated, or timed the order.

Patient #13
Review of Patient #13's medical record revealed Patient #13 was admitted on 12/7/17 and discharged on 12/21/17. The Discharge Summary dated 12/21/17 was authenticated but not timed.

Patient #16
Review of Patient # 16's medical record revealed she was admitted on 11/27/17 and discharged on 12/14/17. Further review revealed the Discharge Summary dated 12/15/17 was authenticated but not timed.

Patient #17
Review of Patient #17's medical record revealed he was admitted on 11/30/17 and discharged on 12/14/17. The Discharge Summary dated 12/18/17 was authenticated but not timed. Further review of the medical record revealed the Physical Therapy Daily Progress note dated 12/9/17 was not signed by S20PTA.

Patient #21
Review of Patient #21's medical record revealed she was admitted on 11/10/17 and discharged on 11/27/17. The Discharge Summary dated 11/30/17 was authenticated but not timed.

Patient #25
Review of Patient #25's medical record revealed she was admitted on 11/10/17 and discharged on 11/27/17. The Discharge Summary dated 11/30/17 was authenticated but not timed.

Patient #26
Review of Patient #26 's medical record revealed she had been admitted on 11/07/17 and discharged on 11/21/17. Review of the admission orders and medication reconciliation revealed the orders were received by the RN on 11/7/17 at 1:06 p.m.; however, S14MD's authentication of the orders failed to have a date and time.

Patient #29
Review of Patient #29's medical record revealed Patient #29 was admitted on 10/26/17 and discharged on 11/10/17. The Discharge Summary dated 11/15/17 was authenticated but not timed.

Patient #30
Review of Patient # 30's medical record revealed he had been admitted on 10/27/17 and discharged on 11/10/17. Review of the admission orders and medication reconciliation revealed the orders were received by the RN on 10/27/17 at 11:39 a.m.; however, S14MD's authentication of the orders failed to have a date and time.

In an interview on 1/19/18 at 9:56 a.m., S3RN reviewed the physician's orders and she verified the ordering physicians did not either sign, date and/or time the orders.

Based on record review and interview, the hospital failed to ensure the receiver of patient verbal orders documented that the orders had been read back and verified for 6 (#1, #23, #25, #26, #27, #30) of 9 (#1, #2, #11, #12, #23, #25 #26,#27,#30) sampled patient records reviewed for verbal orders out of a total patient sample of 31.

Findings:

Review of the hospital policy titled," Verbal/Telephone Orders", revealed in part: Procedures: Verbal orders and test results whne allowed, will be immediately written down by the recipient, read back by the recipient, and confirmed or corrected by the presciber.


Patient #1
Review of Patient #1's medical record revealed an admission date of 1/15/18. Further review revealed the patient's admission orders had been obtained verbally by S2DON from S14MD on 1/15/18 at 12:00 p.m. Additional review revealed no documented evidence that the orders had been read back and verified when they had been received

Patient #23
Review of Patient #23's medical record revealed an admission date of 11/10/17. Further review revealed the patient's admission orders had been obtained verbally by S2DON from S13MD on 11/10/17 at 7:00 p.m. Additional review revealed no documented evidence that the orders had been read back and verified when they had been received.

Patient #25
Review of Patient #25's medical record revealed an admission date of 11/9/17. Further review revealed the patient's admission orders had been obtained verbally by S3RN from S14MD on 11/9/17 at 6:15 p.m. Additional review revealed no documented evidence that the orders had been read back and verified when they had been received.

Patient #26
Review of Patient #26 's medical record revealed she had been admitted on 11/07/17 and discharged on 11/21/17. Further review revealed the admission orders and medication reconciliation revealed the orders were received by the S3RN from S14MD on 11/7/17 at 1306. Additional review revealed no documented evidence that the orders had been read back and verified when they had been received.

Patient #27
Review of Patient #27's medical record revealed an admission date of 10/31/17. Further review revealed the patient's admission orders had been obtained verbally by S3RN from S15MD on 10/31/17 at 10:30 a.m. Additional review revealed no documented evidence that the orders had been read back and verified when they had been received.

Patient #30
Review of Patient # 30's medical record revealed he had been admitted on 10/27/17 and discharged on 11/10/17. Further review revealed the patient's admission orders and medication reconciliation had been verbally obtained by S21RN from S14MD on 10/27/17 at 11:39 a.m.. Additional review revealed no documented evidence that the orders had been read back and verified when they had been received.


In an interview on 1/23/18 at 1:46 p.m. with S2DON, she confirmed the hospital's inpatient admit orders were verbal orders. She also confirmed the person taking the orders should have indicated the source of the order (verbal/telephone) and read back verification of the order with the ordering practitioner.

38777


Based on record review, observations, and interviews, the hospital failed to ensure all drugs and biologicals were kept locked to prevent unmonitored access by unauthorized individuals. This deficient practice was evidenced by failure to ensure the crash cart was locked, at all times, when not in use.

Findings:

Review of the hospital's "Crash Cart Check Documentation" form for January 2018 revealed from January 1 - January 22 "No Tag" was documented under the "Tag Number" column. Documentation in the Comments section read, "Crash cart opened in error. Nothing removed. Waiting on new tag from pharmacy ... S3RN

On 1/24/18 at 8:30 a.m., a review of the hospital's crash cart was conducted with S2DON. The crash cart was located behind the nurse's station next to the front lobby. The drawers on the crash cart were not secured with any type of locking device. At this time, S2DON retrieved a metal bar off the counter in the nurse's station and placed it over the drawers to demonstrate how to lock the crash cart. After searching, S2DON was unable to find any red tags to lock the crash cart. Upon review, the crash cart contained items including several medications, needles, intravenous supplies and syringes. When asked, S2DON stated no one had reported there were no red tags available to lock the crash cart. S2DON verified the crash cart should have been locked to secure the emergency drugs and emergency supplies.

38777

Based on record review, observation, and interview the hospital failed to ensure expired medications were not available for staff use and administration to patients. This deficient practice was evidenced by having expired intravenous fluids, in the crash cart, available for staff use.

Findings:

Review of the hospital's "Crash Cart List" dated 1/14/17 revealed an inventory count of the emergency drugs and supplies contained in the crash cart.

On 1/24/18 at 8:30 a.m. a review of the crash cart was conducted with S2DON. Upon review of the contents within the crash cart, S2DON verified the following observations:
a. 2nd drawer - 1 - 0.9% Sodium Chloride 500 milliliter bag expired 11/2017. Pharmacy label expiration was dated of 1/14/18.
c. 5th drawer - 2 bags of 1000 milliliters of Lactated Ringers expired 12/2017.

During the review, S2DON stated that she was responsible for checking the non-pharmaceutical contents monthly and S19Pharm checked the emergency medications monthly. Upon request of a most recent inventory list, S2DON provided the list dated 1/14/17. She stated S19Pharm had been checking the emergency medications and had not left any documentation of the review.

A telephone interview was conducted on 1/24/18 at 9:30 a.m. with S19Pharm who verified she provided contracted pharmacy services to the hospital. S19Pharm reported she completed monthly inspections for expired medications. She also verified she was responsible for checking for expired medications, including the crash cart. S19Pharm indicated she had failed to complete the check for the month of January 2018; therefore, she had not caught the expired 500 milliliter bag of normal saline and 2- one liter bags of expired Lactated Ringers in the crash cart.

Based on interview, the hospital failed to meet the Utilization Review committee member requirement by failing to ensure the Utilization Review committee consisted of two physicians that were not involved in the care of the patients.

Findings:

On 1/24/18 at 10:59 a.m., an interview was held with S12HIM/PI. When asked, S12HIM/PI stated the Utilization Review committee consisted of herself, SDON, S5RN, S13MD, and S18MD. S12HIM/PI acknowledged that she was aware S13MD and S18MD were both involved in management of patients at the hospital.

38777


Based on observations and interviews, the hospital failed to maintain the physical plant and overall hospital environment in such a manner that the safety and well-being of patients was ensured.

Findings:

On 1/16/18 from 10:33 a.m. - 11:00 a.m. during the physical environment tour, the following observations were made:

1. Patient room 100
a. call bell re-set button on wall covered with clear tape;
b. white substance noted on counter and around sink in bathroom;
c. bedside dresser has plastic tray semi- attached to the top of the dresser with sticky substance on dresser top;
d. wall is scuffed with peeling paint.

2. Patient room 101
a. bed in the first bay area covered with white substance;
b. the over bed light was not operational;
c. the bedside table in the second bay area had a dirty plastic tray on the top of the dresser and a sticky substance around the tray.

An interview was conducted with S5RN during the observation on 1/16/18 at 10:50 a.m. S5RN verified the above concerns and stated she would have maintenance correct them.

3. Room 111
a. Patient's bed contained a non-functioning nurse call feature button (occupied by Patient #4);
b. Left and Right upper side rails contained brown debris.;
c. Call light above the patient's room door did not light up when the emergency call light was activated.

4. Room 112
a. Brownish-orange stains observed on an exposed mattress;
b. 4 Allyn wrenches were observed in the patient room;
c. Worn outer layer on the left side rail with clear tape adhered to the side rail;
d. Sink faucet contained multiple white spots;
e. Damaged sheetrock (verified by S2DON on 1/24/18 at 11:05 a.m.)

During the tour, S6LPN verified the above findings in Rooms 111 and 112 on 1/16/18 at 10:42 a.m. When asked, S6LPN stated Room 112 had been cleaned was deemed ready for patient occupancy and should have been cleaned and maintained.

38777


Based on observation and interview, the hospital failed to ensure equipment was maintained to ensure an acceptable level of quality and safety as evidenced by: 1) Patient's rooms having a nurse call feature on the wall that was non- functional in the hall for 1 (#100) of 3 (#100, #102, #106) patient rooms. 2) Patients' beds having a nurse call feature on the handrails that was non-functional for 4 (#100, #102, #106, #111) of 4 (#100, #102, #106, #111) patient beds.

Findings:

On 1/16/18 from 10:33 a.m. - 11:00 a.m. during the physical environment tour, the following observations were made:

1) Patient room 100 hallway calllight was not operational.

2) Patient room 102 was observed having 2 Stryker beds with the emergency nurse call feature button on the bedrail that was not operational.

3) Patient room 106 had one Stryker bed with the emergency call feature on the bed rail that was not operational.

An interview was conducted with S5RN on 1/16/18 at 10:50 a.m. during the observation. S5RN verified the hallway call light and emergency bedrail nurse call buttons were not functioning and stated she would have maintenance correct them.

4) Patient room 111
a. Patient's bed contained a non-functioning nurse call feature button (occupied by Patient #4)
b. Call light above the patient's room door did not light up when the emergency call light in the patient's bathroom was activated.

During the tour, S6LPN tested the nurse call feature on the patient's bed and verified nurse call feature did not work. S6LPN also tested the emergency call light and verified the light above the patient's door did not light up.

Based on record review and interview, the hosptital failed to ensure the infection control officer developed a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:
1) failing to ensure a newly admitted patient who was positive for Influenza A was placed on Droplet Contact Isolation precautions as ordered for 1 (#9) of 1 sampled patients reviewed for isolation precuations out of a total patient sample of 31.
2) failing to obtain a stool culture to rule out C. difficile infection for 1 (#28) of 4 (#9, #11, #12, #28) sampled patients reviewed for infections/rule out infections out of a total patient sample of 31.
3) failing to ensure the blood glucose meter was disinfected, per hospital protocol, during capillary blood glucose sampling for 1 (#1) of 1 patients observed during capillary blood glucose sampling.
4) failing to maintain a sanitary environment.


Findings:

1) Failing to ensure a newly admitted Patient (#9) who was positive for Influenza A was placed on Droplet Contact Isolation Precautions as ordered.

Review of the hospital's policy titled," Droplet Precautions" revised May 2015, revealed in part: Purpose: To prevent the transmisison of infection from persons who are infected with diseases transmitted by large respiratory droplets that usually travel up to 10 feet from the patient. Droplet precuations are required in addition to Standard Precautions. Further review revealed indications or conditions for which Droplet Precaution Contact Isolation was indicated included Influenza- Human, Avian, and H1N1 (Droplet and Contact).

Review of Patient # 9's medical record revealed an admission date of 12/26/17 and a discharge date of 1/9/18. Further review revealed Patient #9 was positive for Influenza A on admission.

Review of Patient #9's admission orders, dated 12/26/17, revealed an order for Droplet Contact Isolation Precautions for Influenza A.

Review of Patient #9's medical record revealed no documented evidence that Patient #9 had been placed on Droplet Contact Isolation Precautions as ordered.

Review of Patient #9's nursing note documentation revealed no documented evidence that the patient had been
placed on Droplet Contact Isolation Precautions for Influenza A (as ordered on admission).

In an interview on 1/19/18 at 1:49 p.m. with S2DON, she confirmed, after review of Patient #9's medical record, that there was an order for Droplet Isolation precuations for Influenza Aon the patient's admission orders. S2DON further confirmed, after review of the patient's medical record, there was no documented evidence that the patient had been placed on Droplet Contact Isolation Precautions for Influenza A (as ordered on admission) and no documented evidence that the order had been discontinued.


2) Failing to obtain a stool culture to rule out C. difficile infection.

Review of Patient #28's medical record revealed an admission date of 11/3/17 and a discharge date of 11/13/17. Further review of Patient #28's medical record revealed an order dated 11/9/17 at 5:25 p.m. to obtain a stool culture times one for rule out C. difficile (a highly contagious spore forming bacterium).

Additional review of Patient #28's entire medical record revaled no documented evidence that the stool culture had been obtained and no documented evidence of any C. difficile stool culture results.

In an interview on 1/24/18 at 2:00 p.m. with S2DON, she confirmed the C. difficile stool culture had never been sent.

3) Failing to ensure the blood glucose meter was disinfected, per hospital protocol, during capillary blood glucose sampling.


On 1/23/18 at 4:10 p.m. an observation was made of S11LPN performing a capillary blood glucose fingerstick on Patient #1. S11LPN was observed cleaning the glucose meter with a patient pericare wipe and an alcohol wipe prior to obtaining the patient's fingerstick blood sample. S11LPN was also observed cleaning the glucose meter with an alcohol wipe and a pericare wipe after obtaining the patient's capillary blood glucose sample. S11LPN was interviewed during the observation and she reported she routinely cleaned the glucose meter with an alcohol wipe because the bleach disinfectant wipes irritated her skin. She reported the glucose meter could be cleaned with either an alcohol wipe or an approved EPA (environmental protection agency) disinfectant. After being questioned regarding proper disinfection of the glucose meter, S11LPN proceeded to wipe the meter with a disinfectant wipe, but this was after being prompted to do so because of the surveyor's questions.

In an interview on 1/24/18 at 1:00 p.m. with S5RN, she confirmed the hospital's policy/protocol for disinfecting the glucose meter was to wipe the meter with the bleach disinfectant wipes prior to and after each patient use.


4) Failing to maintain a sanitary environment.

On 1/16/18 between 10:30 a.m. - 11:00 a.m., a physical environment tour was conducted with S6LPN. The following observations were made:
Room 111
a. Left and Right upper side rails contained brown debris.
b. An empty urinal sitting on top of the patient's accent table.
c. White paper covering the nurse call feature located on the left and right upper side rails of the patient's bed (verified by S2DON on 1/24/18 at 11:10 a.m.).

Room 112
a. Brownish-orange stains observed on an exposed mattress.
b. Worn outer layer on the left side rail with clear tape adhered to the left side rail.

During the physical environment tour, S6LPN verified Rooms 111 and 112 should have been cleaned and maintained.

On 1/16/18 from 10:33 a.m. - 11:00 a.m. during the physical environment tour, the following observations were made:
a. Patient room 100 the sharps container was full.
b. Patient room 101 had a wheelchair stored with acewraps on both armrest (acewraps impeded staff's ability to properly disinfect the wheelchair).

An interview was conducted with S5RN on 1/16/18 at 10:50 a.m. during the observation. S5RN verified the above concerns and stated she would have maintenance correct them.

On 1/23/18 at 9:40 a.m. an observation was made of the patient shower room. During the observation the following findings were noted:
a. Broken tiles were noted on the threshold of the shower (potential for patient injury and also prevents proper disinfection) and along the wall to the left of the shower room entry doorway (where the patient scale was housed).
b. 4 shower chairs were observed stacked one on top of the other, placed in the hydrotherapy tub.
c. A patient oxygen conentrator unit was housed in the tub of the hydromassage unit.
d. Kangaroo patient feeding pump and feeding tubing stored on a shelf in the patient shower room.
e. Equipment stand covered with a whitish-gray powdery substance.
f. A patient bedside table with portions of the surface missing, exposing the particle board (unable to properly disinfect).

The above referenced findings were confirmed with S5RN (Infection Control Officer) during the observation. She agreed the equipment should not have been stored in the patient shower room. She also agreed the shower chairs should not have been stacked on top of each other and stored in the hydrotherapy tub. S5RN also acknowleged the oxygen concentrator unit should not have been stored in the hydromassage tub in the patient shower room.