HospitalInspections.org

Based on record review and staff interviews, the hospital failed to meet the requirements of the Conditions of Participation as evidenced by:

1) The Registered Nurse (RN) failed to supervise and evaluate the nursing care for each patient.

a) The RN failed to develop and implement a system for obtaining admission orders from a licensed practitioner as evidenced by Licensed Practical Nurses (LPNs) writing admission orders based on RN assessments or discharge instructions from other hospitals for 5 of 9 sampled active patients (#1, #2, #3, #5,#9); and

b) The RN failed to obtain wound care orders for a patient admitted with an infected surgical wound for 1 of 1 sampled active patients reviewed for wound care out of a total sample of 9 (#9) (See findings in A-0395).

Based on review of Medical Staff Rules and Regulation, Governing Body By-laws, Policies and Procedures, clinical record review and staff interviews, the Governing Body failed to ensure the Medical Staff was accountable for the quality of care provided to patients by: 1) failing to ensure the nursing staff functioned within their scope of practice as evidenced by Licensed Practical Nurses (LPNs) writing admit orders based on Registered Nurse (RN) assessments and discharge instructions from other facilities for 5 of 9 active sampled patients (#1, #2, #3, #5, #9); and 2) failing to ensure physician's orders were signed within 72 hours in accordance with Medical Staff Rules and Regulations 4 of 9 (#3, #2, #5, #9) active sampled patients. Findings:

1) Failing to ensure the nursing staff functioned within their scope of practice as evidenced by Licensed Practical Nurses (LPNs) writing admit orders based on Registered Nurse (RN) assessments and discharge instructions from other facilities:

Review of the Governing Body By-Laws provided by S1Administrator/Director of Nurses (ADM/DON) as current and approved revealed in part the following: .... Administrator: e. To cooperate with the Medical Staff and to secure the same cooperation on the part of all those concerned with rendering professional service to the end those patients may receive the highest quality of care....Article VIII. Medical Staff By-Laws....Section 2....The Board also requires that each practitioner apply for medical staff membership, and/or clinical privileges, and sign an agreement to abide by the Medical Staff By-Laws, Rules and Regulations....

Review of the Medical Staff Rules and Regulations reviewed 02/12/12 and provided as current by S1ADM/DON revealed in part the following: ....B. Admission and Discharge of Patients: 1. A patient may be admitted to [hospital] only by a member of the Medical Staff. All practitioners shall be governed by the official admitting policy of [hospital] as outlined in the Bylaws and Rules and Regulations....

Review of the hospital policy titled, Admission Assessment, dated 01/02/01, and provided as current policy by S1ADM/DON (Administrator/Director of Nurses) revealed in part the following: Notify the admitting physician of the patients' arrival and obtain orders. If the patient brings admission orders with them, call the attending physician to verify the orders....


Patient #9
Review of the clinical record for Patient #9 revealed the patient was admitted to the hospital on 02/08/13 as a transfer from another hospital. Review of the Admission Orders dated/timed 02/08/13 at 7:30 p.m. revealed the following "Orders received by : Dr. (S13 Medical Director) by: (S2LPN) at: 7:30 p.m. on: 02/08/13." As of 2/15/13, no physician or licensed practitioner had cosigned the orders.
In a face-to-face interview on 02/14/13 at 11:10 a.m. S2LPN verified he documented the Admission Orders for Patient #9. S2LPN stated he did not get the admission orders as a verbal/telephone order from S13Medical Director (and admitting physician for Patient #9), but stated he copied the orders from the patient's discharge documents from the transferring facility. S2LPN verified he copied the above admission orders from the patient's transfer records.


Patient #2
Review of the clinical record for Patient #2 revealed the patient was admitted to the hospital on 02/08/13 from the patient's home. Review of the Admission Orders dated/timed 02/08/13 at 4:15 p.m. revealed the admit orders were received by S13 Medical Director by S4LPN. As of 2/15/13, no physician or licensed practitioner had cosigned the orders.
In a face-to-face interview on 02/14/13 at 12:45 p.m., S4LPN verified she had documented the admission orders for Patient #2 on 02/08/13. S4LPN verified she did not call S13Medical Director (and Patient's admitting physician) and he did not give her the admission orders verbally or by phone. S4LPN also verified she did receive admit orders from the Nurse Practitioner. S4LPN verified she had copied the admit orders from the pre-admission assessment done by S14RN Community Liaison.


Patient #1
Review of the clinical record for Patient #1 revealed the patient was admitted to the hospital on 01/29/13 from the patient's home. Review of the Admission Orders dated/timed 01/29/13 at 12:30 p.m. revealed the admit orders were received by S13 Medical Director by S7LPN. As of 2/15/13, no physician or licensed practitioner had cosigned the orders.
In a face-to-face interview on 02/15/13 at 8:15 a.m., S7LPN verified she did not contact S13Medical Director (also admitting physician) to obtain the orders. S7LPN also verified she did not obtain the admission orders from the Nurse Practitioner. S7LPN verified she had obtained the admit orders from the pre-admission assessment. S7LPN stated she had only worked at the hospital for 2 months and this was the process she was instructed to follow when admitting patients.

In a face-to-face interview on 02/14/13 at 1:15 p.m., S1ADM/DON stated the Pre-Admission nurse (S14RN Community Liaison) verified the patient's medications with the physician when she did the pre-admission assessment. S1ADM/DON verified the LPNs documented the admission orders as received by S13Medical Director. S1ADM/DON then stated she was not aware the nurse's were not calling the physician to obtain the admission orders. S1ADM/DON verified the hospital policy required the physician to write the admission orders or dictate the orders to the nurse.

In a face-to-face interview on 02/15/13 at 8:30 a.m., S3Advance Practice Registered Nurse (APRN) stated when patients are admitted the nurse, "Calls me and lets me know what time the patient got here because I have to see the patient within 24 hours." S3APRN stated if the patient was discharged from another facility they would get the medications from the discharge papers, or if they came from home, from the medication bottles brought in by the patient. When asked if she gave orders when the nurse called her, she stated, "They have standing orders." She stated they (staff nurse and S3APRN) do not go over the orders when the nurse calls her. S3APRN verified she did not document a review of the patient's medications, and stated, "I'm not required to sign the admit orders."

In a face-to-face interview on 02/15/13 at 11:30 a.m., S6RN verified the admit orders documented by the LPN were not obtained from the physician. S6RN stated this was the process she was instructed on when she was hired.

Patient #3
A review on 2/13/13 of Patient #3's medical record revealed she was a 99 year old female admitted to the hospital on 2/7/13. Review of the admission orders for Patient #3 dated/timed 2/7/13 at 1700 revealed the orders were received from S13Medical Director by S7LPN. As of 2/13/13, no physician or licensed practitioner had cosigned the orders.
In an interview on 2/15/13 at 8:20 a.m. with S7LPN, she stated she routinely wrote admission orders and medication orders without talking to a physician or licensed practitioner. S7LPN said she would use the pre admission assessment by a registered nurse or a discharge summary to complete the order sheet. S7LPN also said the physician or nurse practitioner would not examine the patient or review the orders for up to 24 hours after admission. After review of the order set dated/timed 2/7/13 at 1700 for Patient #3, S7LPN stated she had written the admission orders without speaking to a physician or licensed practitioner. S7LPN also said she had falsely written on Patient #3's admission orders that they had been received from S13Medical Director because she had been trained to write his name since he was the physician over the hospital.

Patient #5
Review of the clinical record for Patient #5 revealed that the patient was a 65 year male who was admitted to the hospital on 2/8/13 after being discharged from an area hospital. Review of the admission orders for Patient #5 dated/timed 02/08/13 at 5:15 p.m. revealed the admission orders were written by S4 LPN as being ordered by S13 Medical Director.
In an interview with S4 LPN on 2/14/13 at 3:10 p.m., she stated she had copied the orders and medications from the previous hospital's discharge orders and verified she had not received the admit orders from the physician. Further review of the physician's orders revealed that no physician had signed the orders.


On 02/14/13 and 02/15/13 (Thursday & Friday) multiple requests were made to S1ADM/DON for an interview with S13Medical Director, either in person or by telephone. By 4:30 p.m. on 02/15/13, S1ADM/DON was unable to contact S13Medical Director for an interview.


2) Failing to ensure physician's orders were signed within 72 hours in accordance with Medical Staff Rules and Regulations:

Review of the hospital policy titled, "Signing Verbal Orders" dated 01/02/01 and provided as current policy by S1ADM/DON revealed in part the following: ....All verbal orders will be signed within 72 hours of documentation in the patient's medical record.....
Review of the Medical Staff Rules & Regulations, reviewed 02/02/12 revealed the following: All orders dictated by telephone shall be signed by the responsible practitioner within 72 hours.
Patient #3
A review on 2/13/13 of Patient #3's medical record revealed she was a 99 year old female admitted to the hospital on 2/7/13. Review of the admission orders for Patient #3 revealed they had been written by S7LPN as having been ordered by S13 Medical Director on 2/7/13 at 1700. Further review revealed no physician had signed the orders.
Review of the Physician's Orders for Patient #3 revealed an order on 2/8/13 at 10:00 a.m. to obtain cx (culture) on drainage from R (right) ankle skin tear (done). Other orders on 2/8/13 at 10:00 a.m. had been written for a house supplement at HS (bedtime), to include skin on special precautions, and O2 (oxygen) at 2L (2 Liters/minute) per NC (nasal cannula) PRN (as needed) O2 sat (saturations) less than 92% / SOB (shortness of breath). The orders had been written by S4 Licensed Practical Nurse (LPN) as a RBVO (Read Back Verbal Order) from S13 Medical Director. Further review revealed no physician had signed the order.
In an interview on 2/15/13 at 2:20 p.m., S1 ADM/DON verified Patient #3 had Physician's orders on 2/7/13 at 1700 and 2/8/13 at 10:00 a.m. that had not been signed by a physician in the 72 hours allowed by the hospital policy.

Patient #2
Review of the clinical record for Patient #2 revealed the patient was admitted to the hospital on 02/08/13 from the patient's home. Review of the admission orders for Patient #2 revealed they had been written by S4LPN as having been ordered by S13 Medical Director on 02/08/13 at 4:15 p.m.. Further review revealed no physician had signed the orders.

Patient #5
Review of the clinical record for Patient #5 revealed that the patient was a 65 year male who was admitted to the hospital on 2/8/13 after being discharged from an area hospital. Review of the admission orders for Patient #5 revealed they had been written by S4LPN as having been ordered by S13 Medical Director on 02/08/13 at 4:15 p.m.. Further review revealed no physician had signed the orders.
In an interview with S4 LPN on 2/14/13 at 3:10 p.m., she verified the admission physician's orders had not been signed by the physician.

Patient #9
Review of the clinical record for Patient #9 revealed the patient was admitted to the hospital on 02/08/13 as a transfer from another hospital with the following diagnoses. Review of the admission orders for Patient #9 revealed they had been written by S2LPN as having been ordered by S13 Medical Director on 02/08/13 at 7:30 p.m. Further review revealed no physician had signed the orders.

Review of the physician's orders revealed a verbal order dated/timed 02/09/13 at 9:00 a.m. to type and match for 2 units of Packed Red Blood Cells and transfuse 2 units in a.m. Further review of the order revealed no physician had signed the order.

In an interview on 02/15/13 at 1:15 p.m. with S1ADM/DON, she verified the above orders had not been signed by S13 Medical Director and verified it had been 7 days since the orders were documented in the record. S1ADM/DON stated S13 Medical Director only came to the hospital one day a week, and stated usually he came on Thursday. S1ADM/DON verified S13 Medical Director had not been to the hospital this week.

Based upon observations, review of hospital policy/procedures, and Administrative interviews, the hospital failed to ensure: 1) the address and telephone number for the State of Louisiana Department of Health and Hospitals--Health Standards Section were made available to patients/family members to file a complaint; 2) a policy/procedure was developed and implemented for dealing with grievances/complaints that identified the difference between a complaint and a grievance and when a written response was required. Findings:

An observation conducted on 02/13/13 at 11:58 a.m. revealed the hospital failed to post the correct address and correct telephone number for the Louisiana Department of Health and Hospitals--Health Standards Section. The posted hotline number was the number to report home health complaints and the address listed was to the Louisiana Department of Transportation. S1ADM/DON (Administrator/Director of Nurses)confirmed at the time of the observation that the posted address and telephone number were incorrect. S1ADM/DON stated the information provided to the patient on admission had been updated.

Review of the packet of information provided to patients/families on admission revealed a Grievance Procedure with a different address and hotline number, but both were incorrect. The Grievance Procedure also failed to identify Health Standards Section as the agency to lodge complaints.

Review of the hospital policy titled, Patient/Client Grievance, dated 02/04, and provided as current policy by S1ADM/DON, revealed in part the following: ....The patient and/or his representative have the right to file a grievance with [hospital]. A grievance may include, but is not limited to, the care received, the persons providing the care, the environment of care, etc.
Your complaints are important to us so that we may improve upon it if at all possible. We will give full consideration the problem or complaint and make every effort to resolve the issue in an agreeable manner.... If you have a complaint, please submit it in writing or verbally to the supervisor on duty or the Administrator.
The Chief Executive Officer has designated the Administrator and the director of Nurses to receive and initiated an investigation into patient grievances. The above noted would contact you with-in forty-eight hours and make every effort to resolve the complaint to your satisfaction. The patient will receive a written statement within seven working days....
Regardless of the above, the charge nurse will take specified, immediate action and/or the Administrator, to remedy the complaint related to the situation (i.e. a room change, plan of care, etc.)
If the complaint cannot be resolved to your satisfaction, you may request the Administrator to submit your complaint to the facility's Governing Board of Directors.
Please be advised that you may lodge complaints with the consumer protection division of the Attorney General's office, the Commissioner of the State Department of Public Health, and with any other person or facility.

In a face-to-face interview on 02/14/13 at 9:00 a.m., S1ADM/DON stated the hospital has not had any grievances. When asked to explain the difference between a complaint and a grievance, she stated a complaint was, "something minor" and a grievance was, "more serious". S1ADM/DON verified the hospital's policy did not define what a complaint was or what a grievance was, nor did it explain how each one was to be handled. S1ADM/DON verified the policy did not include when a written response to the complainant was required. S1ADM/DON verified the Grievance Procedure provided to patients/families on admission did not have the correct address and hotline number, and did not include Health Standards Section as the agency to lodge complaints.

Based on clinical record review and staff interviews, the hospital failed to ensure the nursing service had adequate numbers of personnel to meet the needs of the patients resulting in the staff calling the local law enforcement agency for assistance in moving a patient from the floor to the wheel chair for 1 of 9 (#1) active sampled patients. Findings:

Patient #1
Review of the clinical record for Patient #1 revealed the patient was admitted to the hospital on 01/29/13 from the patient's home with the following diagnoses: CVA with Right Hemiparesis (Stroke with right side weakness), Congestive Heart Failure, Renal Failure with hemodialysis, Seizure Disorder, Hypertension, Insulin Dependent Diabetes Mellitus, Depression, and Gastro-Esophageal Reflux Disease.

Review of the nurse's notes dated/timed 02/01/13 at 6:15 a.m. revealed the staff was attempting to transfer the patient from the bed to the wheel chair, the patient was unable to bear weight, and the staff eased the patient to the floor. Further review revealed the local law enforcement agency assisted the patient into the wheel chair.

In an interview on 02/13/13 at 11:50 a.m., with S1Administrator/Director of Nurses (ADM/DON) and S17 Assistant Director of Nursing (ADON), S17ADON verified the local law enforcement agency was called to assist the staff in getting the patient from the floor to the wheel chair. S17ADON stated the Registered Nurse (RN) was pregnant and cannot lift patients. S17ADON stated on the night shift they have 1 RN, 1 Licensed Practical Nurse (LPN), and 1 Certified Nursing Assistant (CNA). S17ADON stated, "better to be safe than sorry-to get police instead of pregnant RN hurting herself lifting patients." When asked if additional staff were scheduled since the RN had limited job duties, S1ADM/DON stated they would have to call in staff and it would take awhile to get to the hospital. When asked if it was the hospital's policy to call law enforcement to lift patients, she stated yes. When asked for the policy, S1ADM/DON stated it was not a written policy and verified it was a current practice.

Based on review of the clinical records, policies and procedures, and staff interviews, the Registered Nurse (RN) failed to supervise and evaluate the nursing care for each patient.

1) The RN failed to develop and implement a system for obtaining admission orders from a licensed practitioner as evidenced by Licensed Practical Nurses (LPNs) writing admission orders based on RN assessments or discharge instructions from other hospitals for 5 of 9 sampled active patients (#1, #2, #3, #5,#9); and

2) The RN failed to obtain wound care orders for a patient admitted with an infected surgical wound for 1 of 1 sampled active patients reviewed for wound care out of a total sample of 9 (#9).

Findings:

1) The RN failed to develop and implement a system for obtaining admission orders from a licensed practitioner:

Review of the hospital policy titled, Admission Assessment, dated 01/02/01, and provided as current policy by S1ADM/DON (Administrator/Director of Nurses) revealed in part the following: Notify the admitting physician of the patients' arrival and obtain orders. If the patient brings admission orders with them, call the attending physician to verify the orders....

Review of the hospital policy titled, Transcribing Orders, dated 03/04, and provided as current policy by S1ADM/DON revealed in part the following: ....Admission Orders: The physician will write admission orders on the physician order form. If the doctor is not present, the nurse will receive telephone orders from the physician and denote the orders on the physician order form....

Review of the hospital policy titled, Orders for Treatment, dated 01/26/11, and provided as current policy by S1ADM/DON revealed in part the following: All orders for treatment shall be in writing....A verbal order shall be considered to be in writing if dictated to a licensed professional nurse functioning within his/her sphere of competency....All orders dictated over the telephone shall be signed by the appropriately authorized person to whom dictated with the name of the practitioner per his/her name. The responsible practitioner shall authenticate such orders within forty eight (48) hours, and failure to do so shall be brought to the attention of the Executive Committee for appropriate action.

Patient #9
Review of the clinical record for Patient #9 revealed the patient was admitted to the hospital on 02/08/13 as a transfer from another hospital with the following diagnoses: Infected Surgical Wound, Right Knee Osteomyelitis, Septic Arthritis Right Knee, Acute Renal Failure and Chronic Renal Failure-Stage III, and Insulin Dependent Diabetes Mellitus. Further review of the record revealed the patient was admitted with a PICC Line (Peripherally Inserted Central Catheter) for Intravenous antibiotics.

Review of the Admission Orders dated/timed 02/08/13 at 7:30 p.m. revealed the following orders were checked: Full resuscitation, Vital sign/pulse oximetry/weight/accucheck frequency, and diet. Laboratory tests were checked as follows: Complete Blood Count (CBC), Complete Metabolic Panel (CMP), Urinalysis with Culture & Sensitivity, Hemoglobin A1C, Pre-Albumin, and 25-Hydroxyvitamin D. Also ordered were Doppler to Bilateral Lower Extremities. IV (Intravenous) access: PICC was checked with orders to flush every shift and change the dressing every 7 days. Physical Therapy, Dietician consult, and wound care specialist were checked. Also included in the Admission Orders were the patient's current medications including Insulin injection, Lovenox injection and IV Vancomycin (antibiotic for resistant bacterial infections). The Admission Orders revealed the following: "Orders received by : Dr. (S13 Medical Director) by: (S2LPN) at: 7:30 p.m. on: 02/08/13."

Further review of the physician's orders revealed S2LPN documented a verbal order on 02/08/13 at 7:30 p.m. for the following: "Written order to check Vanc (Vancomycin) trough level weekly and AM for target trough of 15-20 mcg/ml. Check weekly CBC, CMP, ESR (Erythrocyte Sedimentation Rate), CRP (C-Reactive Protein). Closely monitor renal for iron and Vancomycin trough level. Adjust Vancomycin doses for renal function. Monitor liver enzymes on Vancomycin. V.O. (Verbal Order) Dr. (S13 Medical Director)/S2LPN."

Review of the record for Patient #2 revealed on 02/15/13, the admission orders were not signed by S13Medical Director (7days).

In a face-to-face interview on 02/14/13 at 11:10 a.m. S2LPN verified he documented the Admission Orders for Patient #9. S2LPN stated he did not get the admission orders as a verbal order from S13Medical Director (and admitting physician for Patient #9), but stated he copied the orders from the patient's discharge documents from the transferring facility. S2LPN verified he copied the above admission orders and the verbal orders for Vancomycin trough levels from the patient's transfer records.


Patient #2
Review of the clinical record for Patient #2 revealed the patient was admitted to the hospital on 02/08/13 from the patient's home with the following diagnoses: Cellulitis to Left Lower Extremity, Edema, Hypertension, Diabetes Mellitus, Bipolar Disorder, Schizoaffective Disorder, Osteoarthritis, and Gout.

Review of the Admission Orders dated/timed 02/08/13 at 4:15 p.m. revealed the following orders were checked: Full resuscitation, Vital sign/pulse oximetry/weight/accucheck frequency, and diet. Laboratory tests were checked as follows: CBC, CMP, Thyroid Stimulating Hormone (TSH), and Depakote level. Also ordered were Doppler to Bilateral Lower Extremities. Physical Therapy, Dietician consult, Discharge Planning, Wound care specialist, and Wound Debridement were checked. Also included in the Admission Orders were the patient's current medications including Depakote Extended Release (Bipolar medication), Tirosint (Thyroid medication), Lisinopril (Antihypertensive), Allopurinal (Gout medication), and Naprosyn (Osteoarthritis medication). The Admission Orders revealed the following: "Orders received by : Dr. (S13 Medical Director) by: (S4LPN) at: 4:15 p.m. on: 02/08/13."

In a face-to-face interview on 02/14/13 at 12:45 p.m., S4LPN verified she had documented the admission orders for Patient #2 on 02/08/13. S4LPN stated she got the patient's current medications from the bottles the patient brought with him to the hospital. S4LPN stated she obtained the patient's diagnoses from the "Pre-Admission Assessment" done by S14RN Community Liaison. S4LPN stated after she completed the Admission Orders, she faxed them to the pharmacy. S4LPN stated she called the Nurse Practitioner and informed her the patient was admitted and gave her the patient's diagnoses. She stated she notified the Nurse Practitioner of the time of the admit, "because she has to see the patient within 24 hours". S4LPN verified she did not call S13Medical Director (and Patient's admitting physician) and he did not give her the admission orders verbally or by phone. S4LPN stated, "S13Medical Director does not want us to call him, we are to go through the Nurse Practitioner first." S4LPN stated S13Medical Director makes rounds at the hospital one day a week and usually his rounds were on Thursday. S4LPN verified S13Medical Director had not made rounds today (Thursday). S4LPN also verified she did receive admit orders from the Nurse Practitioner.

Review of the record for Patient #2 revealed on 02/15/13, the admission orders were not signed by S13Medical Director (7days).


Patient #1
Review of the clinical record for Patient #1 revealed the patient was admitted to the hospital on 01/29/13 from the patient's home with the following diagnoses: CVA with Right Hemiparesis (Stroke with right side weakness), Congestive Heart Failure, Renal Failure with hemodialysis, Seizure Disorder, Hypertension, Insulin Dependent Diabetes Mellitus, Depression, and Gastro-Esophageal Reflux Disease.

Review of the Admission Orders dated/timed 01/29/13 at 12:30 p.m. revealed the following orders were checked: Full resuscitation, Vital sign/pulse oximetry/weight/accucheck frequency, and diet. Swallowing problems: yes, Liquid consistency: Honey. Laboratory tests were checked as follows: CBC, CMP, TSH, Urinalysis with Culture & Sensitivity, Hemoglobin A1C, Pro time with INR (International Normalized Ration), and 25 Hydroxyvitamin D. Also ordered were Doppler to Bilateral Lower Extremities and a TB (Tuberculin) test. Physical Therapy, Speech Therapy, Dietician consult, and Discharge Planning were checked. Also included in the Admission Orders were the patient's current medications including Insulin (Routine and Sliding Scale), Coumadin, Risperdal, Seroquel, Plavix, Norvasc, Coreg, and Keppra. The Admission Orders revealed the following: "Orders received by : Dr. (S13 Medical Director) by: (S7LPN) at: 4:15 p.m. on: 02/08/13."

In a face-to-face interview on 02/15/13 at 8:15 a.m., S7LPN verified she had documented the patient's admission orders from the pre-admission assessment done by S14RN Community Liaison. S7LPN stated the admission orders were obtained from transfer/discharge documents, or the pre-admission assessments. S7LPN verified she did not contact S13Medical Director (also admitting physician) to obtain the orders. S7LPN also verified she did not obtain the admission orders from the Nurse Practitioner. S7LPN stated she had only worked at the hospital for 2 months and this was the process she was instructed to follow when admitting patients.

In a face-to-face interview on 02/14/13 at 1:15 p.m., S1ADM/DON stated the Pre-Admission nurse (S14RN Community Liaison) verified the patient's medications with the physician when she did the pre-admission assessment. S1ADM/DON verified S14RN Community Liaison did not write any admission orders. S1ADM/DON verified the LPNs documented the admission orders as received by S13Medical Director. S1ADM/DON then stated she was not aware the nurse's were not calling the physician to obtain the admission orders. S1ADM/DON verified the hospital policy required the physician to write the admission orders or dictate the orders to the nurse. S1ADM/DON also verified the nursing staff were to call the Nurse Practitioner (APRN) first. S1ADM/DON verified S13Medical Director only came to the hospital one day per week and usually on Thursdays. S1ADM/DON verified S13Medical Director had not made rounds yet today.

In a face-to-face interview on 02/15/13 at 8:30 a.m., S3Advance Practice Registered Nurse (APRN) stated when patients are admitted the nurse, "Calls me and lets me know what time the patient got here because I have to see the patient within 24 hours." S3APRN stated the nurse informed her of the patient's name and diagnosis. She stated if there were issues with medications, the nurse would ask, but they do not go over all the medications. S3APRN stated the nurses get the patient's medications from, "where they were previously." S3APRN stated if the patient was discharged from another facility they would get the medications from the discharge papers, or if they came from home, from the medication bottles brought in by the patient. When asked if she gave orders when the nurse called her, she stated, "They have standing orders." She stated they (staff nurse and S3APRN) do not go over the orders when the nurse calls her. S3APRN verified she did not document a review of the patient's medications, and stated, "I'm not required to sign the admit orders." S3APRN stated S13Medical Director usually made rounds on Thursdays at the hospital. S3APRN verified S13Medical Director did not make rounds on Thursday (02/14/13) this week and was not going to make rounds today (Friday-02/15/13). S3APRN stated S13Medical Director will probably make rounds tomorrow (Saturday).

In a face-to-face interview on 02/15/13 at 11:30 a.m., S6RN stated during the admission process they use the medications the patient was on prior to admission until the Nurse Practitioner or the physician make rounds and change them. S6RN stated, "usually we just tell the Nurse Practitioner or the physician the admit is here." S6RN stated she looked at the patient's medications when she does the assessment and called the physician, "if she sees something she doesn't like." S6RN stated the way it was explained to her S14RN Community Liaison and S1ADM/DON communicated with the physician and they had to qualify the patient for admission. S6RN stated the nurses base the admit orders on the pre-admission assessment done by S14RN Community Liaison, or the discharge or transfer forms from the other facilty. S6RN stated she thought S14RN Community Liaison had cleared all the orders with the physician. S6RN verified the admit orders documented by the LPN were not obtained from the physician. S6RN stated this was the process she was instructed on when she was hired.

On 02/14/13 and 02/15/13 (Thursday & Friday) multiple requests were made to S1ADM/DON for an interview with S13Medical Director, either in person or by telephone. By 4:30 p.m. on 02/15/13, S1ADM/DON was unable to contact S13Medical Director for an interview.


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Patient #3
A review on 2/13/13 of Patient #3's medical record revealed she was a 99 year old female admitted to the hospital on 2/7/13 after being found on the floor for an unspecified amount of time. Patient #3's diagnosis included Congestive Heart Failure, Insulin Dependent Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Hypertension, and Dementia.
Review of the admission orders for Patient #3 dated/timed 2/7/13 at 1700 revealed the following orders were checked: Full Resuscitation; Vital Sign Frequency: Q (every) shift; Accucheck Frequency: Q a.m. HS (hour of sleep) and prn (as needed); Diet: 1800 cal ADA (calorie American Diabetic Association) Low Na (sodium); Weight Frequency: Q day; Lab (to be done in a.m.): CBC, CMP, TSH, U/A C&S, 25 Hydroxy Vit D, Pre-Albumin; Diagnostics: Doppler to BLE's (bilateral lower extremities); Activity: Ad lib (as tolerated) Up with walker, cane or wc (wheelchair); Weight Bearing Status: FWB (Full weight bearing); Special Precautions: Cardiac and Fall; Bowel/Bladder: Incontinent; Supplies/Equipment: W/C cushion; Services to Eval/Treat if Rec: PT (physical therapy), Discharge Planning, Wound Care Specialist, Wound Debridement prn.
Further review of the admission orders revealed the following entry: Orders Received From: S13Medical Director By: S7LPN At: 1700 on 2/7/13. As of 2/13/13, no physician or licensed practitioner had cosigned the orders.
In an interview on 2/15/13 at 8:20 a.m. with S7LPN, she stated she routinely wrote admission orders and medication orders without talking to a physician or licensed practitioner. S7LPN said she would use the pre admission assessment by a registered nurse or a discharge summary to complete the order sheet. S7LPN also said the physician or nurse practitioner would not examine the patient or review the orders for up to 24 hours after admission. After review of the order set dated/timed 2/7/13 at 1700 for Patient #3, S7LPN stated she had written the admission orders without speaking to a physician or licensed practitioner. S7LPN also said she had falsely written on Patient #3's admission orders that they had been received from S13Medical Director because she had been trained to write his name since he was the physician over the hospital.



31206

Patient #5
Review of the clinical record for Patient #5 revealed that the patient was a 65 year male who was admitted to the hospital on 2/8/13 after being discharged from an area hospital with the following admission diagnoses: Atypical CP (Chest Pain), IDDM (Insulin Dependent Diabetes Mellitus), High Blood Pressure, Coronary Artery Disease, Peripheral Vascular Disease, Hyperlipidemia (High cholesterol), and Aortic Stenosis.
Review of the admission orders for Patient #5 dated/timed 02/08/13 at 5:15 p.m. revealed the admission orders were written by S4 LPN as being ordered by S13 Medical Director. The following orders were checked off : Full Resuscitation, vital sign every shift, pulse oximetry every shift, weight everyday , accucheck ,1800 cal ADA (diabetic diet), labs (CBC, CMP, UA & C&S, Hgb A1C, 25 Hydroxy Vitamin D, and pre-albumin (order for all wound patients), Doppler to Right Lower Extremity, up with wheelchair, full weight bearing, cardiac and fall precautions, PT (Physical Therapy), Dietician, and Discharge Planning.

In an interview with S4 LPN on 2/14/13 at 3:10 p.m., she stated she had copied the orders and medications from the previous hospital's discharge orders. Further review of the physician's orders revealed that no physician had signed the orders.


2) The RN failed to obtain wound care orders for a patient admitted with an infected surgical wound:

Review of the hospital policy, titled "Wound Care", with no date/number, provided by S1ADM/DON as current, revealed in part the following: Wound care is one aspect of the care that the patient receives while here at this facility. There is ongoing assessment of the wound and the prescribed treatment to reduce complications and promote the best possible environment for healing.....There will be an order written for any treatment performed to the wound....The wound is assessed daily by the registered nurse or the physical therapist with documentation. The physician will be notified of any negative changes to the wound.

Review of the hospital "Standing Orders for Wound Care" provided by S17Assistant Director of Nursing (ADON), revealed in part the following: These are guidelines to use for different types of wounds. This is to be utilized if no wound orders are available....Incisions - Cleanser: Normal Saline with gentle touch. Use moistened q-tip to remove dry blood. Frequency: At least daily. Dressing Type: Non-adherent pad. Special Needs: Assess for drainage and open areas.


Patient #9
Review of the clinical record for Patient #9 revealed the patient was admitted to the hospital on 02/08/13 as a transfer from another hospital with the following diagnoses: Infected Surgical Wound, Right Knee Osteomyelitis, Septic Arthritis Right Knee, Acute Renal Failure and Chronic Renal Failure-Stage III, and Insulin Dependent Diabetes Mellitus. Further review of the record revealed the patient was admitted with a PICC Line (Peripherally Inserted Central Catheter) for Intravenous antibiotics.

Review of the initial nursing assessment dated 02/08/13 at 7:30 p.m. revealed the patient had a "16 inch incision right knee with sutures in place and purulent drainage."

Review of the Admission Orders dated/timed 02/08/13 at 7:30 p.m. revealed no documented evidence of any orders for wound care.
Review of the physician's orders dated/timed 02/09/13 at 11:30 a.m. revealed an order written by S3APRN to consult Ortho (Orthopedics) regarding the wound care.
There was no documented evidence of any wound care orders until 02/11/13 at 5:15 p.m. when a verbal order was received for wound care from the patient's orthopedic physician.

In a face-to-face interview on 02/14/13 at 11:10 a.m., S2LPN stated he had received verbal report from the transferring hospital to follow up with the patient's orthopedic physician for wound care orders. He stated the Charge Nurse called the patient's orthopedic physician repeatedly and the physician did not respond until Monday (02/11/13). S2LPN stated S12Physical Therapist (PT) and the charge nurse removed the dressing because it was irritating the patient. S2LPN stated the dressing was "nasty". When asked if the patient's admitting physician was notified for wound care orders, he stated no and further stated the physician (S13Medical Director) was not called for any of the admission orders. S2LPN stated the admission orders were obtained from the discharge orders from the transferring hospital. S2LPN also verified there was no documented evidence the Nurse Practitioner was notified of the need for wound care orders.

In a face-to-face interview on 02/14/13 at 2:20 p.m., S12PT stated he removed the dressing from Patient #9's right leg on Saturday (02/09/13). He stated he assessed the wound, took pictures and placed a telfa dressing on the wound. S12PT stated the dressing he placed on the wound on Saturday stayed on until the nurse received wound care orders on 02/11/13. S12PT stated the physicians trust him to determine the wound care and he tells the nurse what orders to write. S12PT verified there were no wound care orders until 02/11/13.

In a face-to-face interview on 02/15/13 at 8:30 a.m., S3APRN verified there were no wound care orders for Patient #9 on admission. S3APRN stated she saw the patient on 02/09/13 and the patient told her the dressing had not been changed in 3-4 weeks. S3APRN stated she was concerned and instructed the nursing staff to call whoever was on call for wound care orders. She stated she did not want to change the dressing and disrupt anything. S3APRN stated the nursing staff informed her they had called the physician on call and he had instructed them to call back on Monday (02/11/13). She stated she instructed the staff to call back to the physician on call because they needed to get wound care orders. S3APRN stated she did not know if the nursing staff had followed up with the physician.

Further review of the record for Patient #9 revealed the wound care orders received on 02/11/13 included to cleanse the right leg incision daily with Dakin's solution and gauze and apply a dry dressing and secure with tape. Review of the physician's orders dated/timed 02/14/13 at 5:30 p.m. revealed the patient had a wound vac applied to the right leg incision at the physician's office.

Based on observation, clinical record review and staff interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to have an individualized patient care plan that provided interventions to meet the needs of the patient, had measurable goals, and included all identified patient problems and needs for 5 of 9 sampled active patients (#1, #2, #3, #4, #9). Findings:

Review of the hospital policy titled, "Nursing Care Plan", revised dated of 11/02, provided by S1 Administrator/Director of Nursing (ADM/DON) as current, revealed in part the following: 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 prior to discharge....Care plans are evaluated and revised weekly with notation as to the patient's participation in the process and the goals/plans for the next week.

Patient #1
Review of the clinical record for Patient #1 revealed the patient was admitted to the hospital on 01/29/13 from the patient's home with the following diagnoses: CVA with Right Hemiparesis (Stroke with right side weakness), Congestive Heart Failure, Renal Failure with hemodialysis, Seizure Disorder, Hypertension, Insulin Dependent Diabetes Mellitus, Depression, and Gastro-Esophageal Reflux Disease.

Review of the nursing care plan revealed only 3 problems were identified for Patient #1: Activity Intolerance, Impaired Physical Mobility, and Discharge Care Plan. Review of the care plan revealed a checklist of goals and interventions. There was no documented evidence any goals or interventions to address the patient's medical diagnoses in the nursing plan of care.

On 02/13/13 at 9:45 a.m., Patient #1 was observed seated in a wheel chair in front of the nurse's station. The patient was observed to be crying.

On 02/15/13 at 1:45 p.m., Patient #1 was again observed seated in a wheel chair in front of the nurse's station crying.

Review of the nursing plan of care revealed no documented evidence the patient's depression was included in the plan of care.

Review of the nurses' notes revealed on 02/01/13 at 6:15 a.m., a transfer of the patient from bed to chair was attempted, but the patient was unable to bear weight and had to be assisted down to the floor by two nursing staff. Further review of the record revealed the patient was assessed on admission as a high risk for falls. There was no documented evidence the patient's fall risk was included in the plan of care, and there were no revisions/updates to the plan of care after the patient sustained a fall. The plan of care failed to include the level of assistance the patient required for transfer, and the patient's inability to bear weight.

Review of the nurses' notes revealed on 02/06/13 at 4:15 a.m. the patient was found unresponsive with a blood sugar of 35. An injection of Glucagon (medication that increases blood sugar) was administered to the patient, and new orders were obtained for an IV access and parameters to address the patient's low blood sugar. There was no documented evidence the nursing care plan was revised/updated with the patient's Insulin Dependent Diabetes or the patient's low blood sugar level.

On 02/13/13 at 2:10 p.m., S4LPN (Licensed Practical Nurse) was interviewed and verified Patient #1 cried often and was depressed. S4LPN stated 2 people were needed to transfer the patient. S4LPN stated the number of staff needed for transfer should be documented in the nurse's notes. After reviewing the patient's record, she verified the number of staff needed for transfers was not documented.

On 02/13/13 at 2:35 p.m., S16CNA (Certified Nursing Assistant) was interviewed and stated Patient #1 needed 2 people to transfer and stated the patient was unable to bear weight. S16CNA stated they had to physically lift the patient to transfer her.

On 02/13/13 at 2:50 p.m., S5RN (Registered Nurse) was interviewed and verified the RN was responsible for developing and updating the nursing plan of care. After reviewing the record for Patient #1, S5RN verified the nursing plan of care only addressed the patient's Activity Intolerance, Impaired Physical Mobility, and Discharge. S5RN verified the patient was assessed as a high risk for falls on admission but there were no fall precautions included in the plan of care. S5RN stated Physical Therapy verbally tells the nursing staff the level of assistance a patient needed, but verified it was not included in the plan of care. S5RN verified the plan of care was not updated after the patient's fall on 02/01/13. S5RN verified none of the patient's medical diagnoses, including Insulin Dependent Diabetes and Depression were included in the plan of care.


Patient #2
Review of the clinical record for Patient #2 revealed the patient was admitted to the hospital on 02/08/13 from the patient's home with the following diagnoses: Cellulitis to Left Lower Extremity, Edema, Hypertension, Diabetes Mellitus, Bipolar Disorder, Schizoaffective Disorder, Osteoarthritis, and Gout.

Review of the nursing plan of care revealed only 2 problems were identified for Patient #2: Potential for Impaired Physical Mobility and Discharge Care Plan. Review of the both problems sheets revealed no goals or interventions were checked for the identified problems. There was no documented evidence any of the patient's medical diagnoses were addressed in the nursing plan of care.

In a face-to-face interview on 02/13/13 at 2:50 p.m., S5RN verified the only problems identified in the patient's plan of care were the potential for impaired mobility and discharge. S5RN verified there were no goals or interventions identified for these two problems. S5RN verified the patient's Medical Diagnoses of Cellulitis, Diabetes, Bipolar Disorder, and Schizoaffective Disorder were not addressed in the plan of care.

Patient #9
Review of the clinical record for Patient #9 revealed the patient was admitted to the hospital on 02/08/13 as a transfer from another hospital with the following diagnoses: Infected Surgical Wound, Right Knee Osteomyelitis, Septic Arthritis Right Knee, Acute Renal Failure and Chronic Renal Failure-Stage III, and Insulin Dependent Diabetes Mellitus. Further review of the record revealed the patient was admitted with a PICC Line (Peripherally Inserted Central Catheter) for Intravenous antibiotics.

Review of the nursing plan of care revealed only 2 problems were identified for Patient #9: Actual Activity Intolerance and Discharge Care Plan. There was no documented evidence any of the patient's medical diagnoses, wound care, or PICC line care were addressed in the nursing plan of care.

In a face-to-face interview on 02/14/13 at 11:00 a.m., S5RN verified Actual Activity Intolerance and Discharge were the only 2 problems identified in the plan of care. S5RN verified none of the patient's medical diagnoses were included in the nursing plan of care.

In a face-to-face interview on 02/15/13 at 2:20 p.m., S1ADM/DON stated she was aware the care plans were not being done and stated the current format of nursing care plans was antiquated.


30364


Patient #3
A review on 2/13/13 of Patient #3's medical record revealed she was a 99 year old female admitted to the hospital on 2/7/13 after being found on the floor for an unspecified amount of time. Patient #3's diagnosis included Congestive Heart Failure, Insulin Dependent Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Hypertension, and Dementia.
Review of the care plan book for the hospital revealed no care plans had been initiated for Patient #3. On 2/3/13 at 2:15 p.m., S5RN verified no care plans had been initiated for Patient #3.

Patient #4
A review of Patient #4's medical record revealed she was an 84 year old female who had been admitted to the hospital on 1/23/12 with diagnosis which included Cellulitis, Urinary Tract Infection, uncontrolled Diabetes Mellitus, Congestive Heart Failure (CHF), Hypertension, and Chronic Obstructive Pulmonary Disease.
Review of the care plans for Patient #4 revealed she only had care plans for Impaired Skin Integrity, Impaired Physical Mobility, and Discharge Care Planning. Further review revealed no care plans had been initiated to address Patient #4's medical problems of infection, diabetes, CHF, Hypertension, or pulmonary disease. On 2/3/13 at 2:00 p.m., S5RN verified the care plans for Patient #4 were not inclusive of all of her medical problems.
In an interview on 2/15/13 at 2:20 p.m. with S1ADM/DON, she stated the nursing staff were not initiating enough care plans for the patients needs.



31206

Patient #5
Review of the clinical record for Patient #5 revealed that the patient is a 65 year male who was admitted to the hospital on 2/8/13 after being discharged from an area hospital with the following admission diagnoses: Atypical CP ( Chest Pain), IDDM (Insulin Dependent Diabetes Mellitus), High Blood Pressure, Coronary Artery Disease, Peripheral Vascular Disease, Hyperlipidemia ( High cholesterol), and Aortic Stenosis.

Review of the History and Physical date/time 2/7/13 at 3:30 p.m. stated that the chief complaint was: problem with left leg and needs assistance to walk on it. Infected wound of the abdomen. History and Physical Narratives revealed that the patient had frequent falls and need education and training to use left prosthesis.

Review of the Care Plan revealed 2 problems had been identified and addressed for Patient #5: Activity Intolerance and Discharge Care Plan. Review of the Care Plan revealed a check list of goals and interventions with nothing checked on either Care Plan except dates listed for the initial date of 2/8/13 and a target date of 3/8. There was no documented evidence of any goals or interventions to address the patient's wound, prothesis, fall and other medical diagnoses. On 2/13/13 at 3:00 p.m., S 4 LPN verified that the care plan did not include any of the patient's medical issues, wound care or falls.

On 2/14/13 at 10:00 a.m. & 1:30 p.m,. Patient #5 was observed up in a motorized wheelchair traveling down the hallway. On 2/15/13 at 1:45 p.m. & 3:00 p.m., Patient #5 was observed in a motorized wheelchair in front of nurses station. Patient #5 was also observed as having an above the knee amputation on the left leg with no prothesis in place during the 2 days of observations.

Patient #6
Review of the clinical record for Patient #6 revealed the patient was a 64 year old male who was admitted to the hospital on 2/5/13 from home with diagnosis which included: Bronchitis, Congestive Heart Failure, High Blood Pressure, Insulin Dependent Diabetes Mellitus, CVA (Stroke), Peripheral Vascular Disease, Hyperlipidemia (High Cholesterol), Osteoarthritis, Malaise, and Fatigue.

Review of the Physician progress notes dated 2/9/13 at 1:10 p.m. revealed the patient had Bactrim DS ordered for a UTI (urinary tract infection). On 2/10/13 at 2:30 p.m. Bactrim DS was discontinued and the patient was started on Fortaz 1 gram IVPB (intravenous) every 12 hours for 7 days.

Review of the Care Plan for patient #6 revealed plans of care for Impaired Physical Mobility and Discharge Care Plan. There were no documented plans of care which addressed any of the patient's medical conditions, UTI or intravenous antibiotics. On 2/14/13 at 3:10 p.m., S4 LPN verified Patient #6's care plans were not inclusive of his medical issues or UTI but should have been.

Based on interview and record review, the hospital failed to ensure all drugs and biologicals were administered in accordance with the order of the practitioner responsible for the patient's care and acceptable standards of practice for 2 of 9 active sampled patients (#1, #4).
Findings:
Patient #4
A review of Patient #4's medical record revealed she was an 84 year old female who had been admitted to the hospital on 1/23/12 with diagnosis which included Cellulitis, Urinary Tract Infection, uncontrolled Diabetes Mellitus, Congestive Heart Failure (CHF), Hypertension, and Chronic Obstructive Pulmonary Disease.
Review of the MAR (medication administration record) for Patient #4 revealed a Nexium 20 mg (milligram) CAP (capsule) by mouth once daily had been charted as having been given on 1/24/13, 1/25/13, and 1/26/13.
Review of the Physician's Orders for Patient #4 revealed no order for Nexium 20 mg CAP by mouth once daily. Further review revealed the first order for Nexium was not until 1/27/13 at 8:30 a.m. for 40 mg PO (by mouth) Q day (every day).
In an interview on 2/15/13 at 11:00 a.m. with S7LPN, she stated she had written the MAR for Patient #4 on admission. S7LPN said she did not receive a physician's order for Nexium 20 mg CAP by mouth daily. She said she had written the Nexium on the MAR because it was one of Patient #4's discharge medications from a previous facility.



17091

Patient #1
Review of the clinical record for Patient #1 revealed the patient was admitted to the hospital on 01/29/13 from the patient's home with the following diagnoses: CVA with Right Hemiparesis (Stroke with right side weakness), Congestive Heart Failure, Renal Failure with hemodialysis, Seizure Disorder, Hypertension, Insulin Dependent Diabetes Mellitus, Depression, and Gastro-Esophageal Reflux Disease.

Review of the physician's orders dated/timed 01/29/13 at 12:30 p.m. revealed an order for Risperdal 0.5 mg. by mouth at bedtime.

Review of the MAR dated 02/03/13 to 02/09/13 revealed no documented evidence that Risperdal was administered on 02/09/13, nor was there any documentation why the medication was not administered.

In an interview on 02/15/13 at 2:20 p.m. with S1Administrator/Director of Nurses (ADM/DON), she verified there was no documentation the medication was administered and verified an omission would be considered a medication error.

Based on interview and record review, the hospital failed to ensure all verbal orders were dated, timed and authenticated by the ordering practitioner within 72 hours as allowed by the hospital policy for 4 of 9 (#3, #2, #5, #9) patients sampled.
Findings:
Review of the hospital policy titled, "Signing Verbal Orders" dated 01/02/01 and provided as current policy by S1Administrator/Director of Nurses (ADM/DON) revealed in part the following: ....All verbal orders will be signed within 72 hours of documentation in the patient's medical record.....
Review of the Medical Staff Rules & Regulations, reviewed 02/02/12 revealed the following: All orders dictated by telephone shall be signed by the responsible practitioner within 72 hours.
Patient #3
A review on 2/13/13 of Patient #3's medical record revealed she was a 99 year old female admitted to the hospital on 2/7/13 after being found on the floor for an unspecified amount of time. Patient #3's diagnosis included Congestive Heart Failure, Insulin Dependent Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Hypertension, and Dementia.
Review of the admission orders for Patient #3 revealed they had been written by S7 Licensed Practical Nurse (LPN) as having been ordered by S13 Medical Director on 2/7/13 at 1700. Further review revealed no physician had signed the orders.
Review of the Physician's Orders for Patient #3 revealed an order on 2/8/13 at 10:00 a.m. to obtain cx (culture) on drainage from R (right) ankle skin tear (done). Other orders on 2/8/13 at 10:00 a.m. had been written for a house supplement at HS (bedtime), to include skin on special precautions, and O2 (oxygen) at 2L (2 Liters/minute) per NC (nasal cannula) PRN (as needed) O2 sat (saturations) less than 92% / SOB (shortness of breath). The orders had been written by S4 Licensed Practical Nurse (LPN) as a RBVO (Read Back Verbal Order) from S13 Medical Director. Further review revealed no physician had signed the order.
In an interview on 2/15/13 at 2:20 p.m., S1 Administrator verified Patient #3 had Physician's orders on 2/7/13 at 1700 and 2/8/13 at 10:00 a.m. that had not been signed by a physician in the 72 hours allowed by the hospital policy.


17091

Patient #2
Review of the clinical record for Patient #2 revealed the patient was admitted to the hospital on 02/08/13 from the patient's home with the following diagnoses: Cellulitis to Left Lower Extremity, Edema, Hypertension, Diabetes Mellitus, Bipolar Disorder, Schizoaffective Disorder, Osteoarthritis, and Gout.

Review of the admission orders for Patient #2 revealed they had been written by S4LPN as having been ordered by S13 Medical Director on 02/08/13 at 4:15 p.m.. Further review revealed no physician had signed the orders.

Patient #5
Review of the clinical record for Patient #5 revealed that the patient was a 65 year male who was admitted to the hospital on 2/8/13 after being discharged from an area hospital with the following admission diagnoses: Atypical CP (Chest Pain), IDDM (Insulin Dependent Diabetes Mellitus), High Blood Pressure, Coronary Artery Disease, Peripheral Vascular Disease, Hyperlipidemia (High cholesterol), and Aortic Stenosis.
Review of the admission orders for Patient #5 revealed they had been written by S4LPN as having been ordered by S13 Medical Director on 02/08/13 at 4:15 p.m.. Further review revealed no physician had signed the orders.
In an interview with S4 LPN on 2/14/13 at 3:10 p.m., she verified the admission physician's orders had not been signed by the physician.

Patient #9
Review of the clinical record for Patient #9 revealed the patient was admitted to the hospital on 02/08/13 as a transfer from another hospital with the following diagnoses: Infected Surgical Wound, Right Knee Osteomyelitis, Septic Arthritis Right Knee, Acute Renal Failure and Chronic Renal Failure-Stage III, and Insulin Dependent Diabetes Mellitus. Further review of the record revealed the patient was admitted with a PICC Line (Peripherally Inserted Central Catheter) for Intravenous antibiotics.

Review of the admission orders for Patient #9 revealed they had been written by S2LPN as having been ordered by S13 Medical Director on 02/08/13 at 7:30 p.m. Further review revealed no physician had signed the orders.

Review of the physician's orders revealed a verbal order dated/timed 02/09/13 at 9:00 a.m. to type and match for 2 units of Packed Red Blood Cells and transfuse 2 units in a.m. Further review of the order revealed no physician had signed the order.

In an interview on 02/15/13 at 1:15 p.m. with S1ADM/DON, she verified the above orders had not been signed by S13 Medical Director and verified it had been 7 days since the orders were documented in the record. S1ADM/DON stated S13 Medical Director only came to the hospital one day a week, and stated usually he came on Thursday. S1ADM/DON verified S13 Medical Director had not been to the hospital this week.

Based on interview and record review, the hospital failed to provide patient safety by controlling and distributing drugs and biologicals with applicable standards of practice as evidenced by failing to ensure that all first doses of non-emergent medications were reviewed by a pharmacist for therapeutic appropriateness, duplication, correct drug, dose, route, and frequency, interactions, allergies, or other contraindications before the first dose was administered. This practice had the potential to affect 8 of 8 patients in the hospital.
Findings:
Review of the hospital policies and procedures revealed no policies for a first dose review by a pharmacist before a non-emergent medication could be administered. In an interview on 2/15/13 at 2:20 p.m., S1ADM/DON verified the hospital did not have a policy on first dose review of non-emergent medications by a pharmacist.
In an interview with S7LPN on 2/15/13 at 8:25 a.m., she said if medications were ordered and were in stock, she would administer the medications before it was reviewed and approved by a pharmacist. S7LPN said all of the nurses administered medications from stock without prior approval if they were due to be given. S7LPN said that was how she was trained at the hospital.
In an interview on 2/15/13 at 8:30 a.m. with S3APRN, she stated if a medication was ordered by herself or the physician and it was in stock at the hospital, it was administered by the nurses before the first dose was reviewed by a pharmacist.
In an interview on 2/15/13 at 10:20 a.m. with S10 Pharmacist, he stated he and his wife owned the pharmacy contracted with the hospital. He stated he did not know if the pharmacy was reviewing first doses of medications or not. S10 Pharmacist also stated if a doctor gave the order for a medication, even if they were routine medications, the nurse could administer the medication before the pharmacist reviewed it for appropriateness.
In an interview on 2/15/13 at 11:25 a.m. with S2LPN, he stated if a doctor wrote an order for a medication that was in stock, the staff did not have to wait for the pharmacy to review the medication before it was administered.
In an interview on 2/15/13 at 11:30 a.m. with S6RN, she stated she did not have to wait on the pharmacist to review the patient's medications before she administered the medications to the patient. S6RN stated if they have the medication in stock, they go ahead and administer the medication to the patient. S6RN stated she had not seen any reviews done by the pharmacist, and stated if the physician ordered the medication, it was ok to go ahead and give it.

Based on interview and record review, the hospital failed to have a system in place to accurately gather data about drug administration errors for quality assurance purposes. This deficient practice had the potential to affect 9 of 9 current patients at the hospital.
Findings:
Review of the monthly Pharmacy and Therapeutics report for 2012 revealed no documentation of medication errors by the hospital staff being tracked and trended. The only medication errors being tracked were dispensing errors by the pharmacy, which was listed as 0 for the year.
Review of the monthly review reports of the hospital by S10 Pharmacist revealed he had identified the following medication errors since 9/30/12:
1/12/13- Patient #R1- Blood Pressure and pulse not recorded with 2100 dose of Carvedilol (anti-hypertensive medication) on 1/11/13.
1/12/13- Patient #R2- Patient admitted with Macrobid (antibiotic) 100 mg (milligrams) bid (twice per day) with no DC (discontinue) date. Patient has been taking since admit date of 12/17/12.
11/27/12- Patient #R3- Avelox (antibiotic) 400 mg IVPB (intravenous piggy back) ordered at 1940 on 11/19 and first dose not initialed as given until 1800 on 11/20.
Avelox 400 mg IVPB not initialed as given on 11/24 with no reason indicated.
11/27/12- Patient #R4- Lovenox (blood thinner) 40 mg not initialed as given on 11/18 with no reason indicated.
Carbamazepine (anti-convulsant) 100 mg not initialed as given at 2100 on 11/21 and 11/22 with no reason indicated.
10/29/12- Patient # R5- Diltiazem 90 mg tid (three times daily) only initialed as given twice on 10/23.
10/29/12- Patient #R6- IV (intravenous) Ceftriaxone (antibiotic) q 12 h (every 12 hours) not initialed as given on 10/20/12 at 0900 with no reason.
IV Cubicin (antibiotic) 400 mg qd (every day) not initialed as given on 10/20/2012 with no reason indicated.
9/30/12-Patient #R7- Forteo (osteoporosis medication) ordered at 0900 on 9/27 and first dose not given until 9/28.
9/30/12- Patient #R8- Prazosin (blood pressure medication) 5 mg not initialed as given at 2100 on 9/20.
Vitamin C 500 mg not initialed as given at 2100 on 9/20.

In an interview on 2/15/13 at 8:15 a.m. with S7LPN, she stated she did not know how to report a medication error because she had only been at the hospital for a few months.

In an interview on 02/15/13 at 11:30 a.m. with S6RN, she stated the night shift RN had found medication errors in her chart checks according the the shift change report she had received. S6RN stated she had been employed since December and was aware of 1 transcription error on the admission orders.

In an interview on 2/15/13 at 9:30 a.m. with S1ADM/DON, she stated the hospital had no other system for tracking medication errors than self-reporting by the staff. When asked how many medication errors the hospital had in 2012 and 2013, S1ADM/DON said they had zero medication errors. S1ADM/DON also said medication errors were not followed in Quality Assurance since the hospital had none.

In an interview on 2/15/13 at 10:20 a.m. with S10 Pharmacist, he said he reviewed charts at the hospital monthly for physician's orders and MAR (medication administration record) accuracy. S10 Pharmacist stated that he sent his medication error findings to the hospital and they tracked and trended the errors, not the pharmacy. S10 Pharmacist also said a zero error rate for the year was not reasonable because he had found several errors during his reviews of medical records.

Based on observations, record review, and staff interview, the hospital failed to ensure the condition of the physical plant and overall environment was maintained to ensure the safety and well-being of the patients by failing to ensure the patient care areas were connected to the emergency generator and by failing to develop an emergency plan to meet the needs of the patients. Findings:

Review of the hospital policy titled, "Standard: Buildings", dated 09/12, provided by S1Administrator/Director of Nurses (ADM/DON) as current, revealed in part the following: There must be emergency power and lighting in at least the operating, recovery, intensive care, and emergency rooms, stairwells. In all other areas not serviced by the emergency supply source, battery lamps and flashlights must be available. The facility is powered by a natural gas generator. The generator runs minimal lighting and electrical sockets. There are flashlights available for use at the nurses' station and the kitchen. The stove is operated by natural gas. Lanterns are available for use as well in case of a power outage.

Review of the Emergency Preparedness Plan dated 05/01/01 revealed in part the following: The purpose of this plan is to describe the actions to be taken in assisting patients served by the facility to survive emergencies and disasters that may threaten them....The Director of Nursing is responsible for developing technical parts of the plan, standard operating procedures and assessing the clinical aspect post-disaster....Emergency Generators: The hospital has a generator that is tied in with hospital on the patient side of the building and the emergency exit signs. There are a few designated plugs that are tied in with generator. There are window unit air conditioners that can be plugged into the emergency plugs for patient comfort. The generator is fueled by natural gas and can last at least as long as available by the city supply.

In an interview on 2/13/13 at 9:30 a.m. with S2LPN, he stated he was over maintenance at the hospital. He said he had been told that only half of the hospital had emergency power, but he was not sure exactly what areas of the hospital the generator powered. S2LPN also said of the 13 patient rooms, he believed only 3 had an emergency power outlets powered by the generator. He said he tested the generator once per week to see if it was functional, but never shut the power off in the building to test which areas of the hospital were powered by the generator. When asked what he would do if an unexpected power outage happened, S2LPN said he would pull the patients who needed power into the front hall where some emergency plugs were located.
In an interview on 2/14/13 at 11:00 a.m. with S1ADM/DON, she stated she was not exactly sure what areas of the hospital were powered by the generator. S1ADM/DON said if the generator was activated, she thought power would be supplied to every other light in the hall, the refrigerator and freezer in the kitchen, the therapy room, the fax machine and the nurse's station. She also said there should be a plug in every room powered by the generator, but it has never been tested. S1ADM/DON said the hospital ordered a generator that would supply the whole building with power, but it got stolen. She said the subsequent generator was not the capacity that was originally requested. S1ADM/DON said the electrician never gave the hospital a diagram of what areas were powered by the generator.
In an interview on 02/14/13 at 2:25 p.m. with S1ADM/DON, she stated the current generator was purchased in September 2011 and was installed a couple of months later. S1ADM/DON verified the Emergency Preparedness plan was not updated after the new generator was installed and powered different parts of the building. She verified the current plan did not include directives on where to move patients with electrical equipment or what areas were powered by the generator.




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Based on observation and interview, the hospital failed to ensure electrical medical equipment was maintained to ensure an acceptable level of safety and quality by failing to have a preventative maintenance program or a biomedical engineer available.
Findings:
In an observation on 2/13/13 at 9:44 a.m., an oxygen (O2) concentrator in room "a" did not have a sticker indicating the equipment had been inspected by a biomedical engineer for safety before use or that preventative maintenance had been performed.
In an observation on 02/13/13 at 9:50 a.m., a nebulizer in room "b" did not have sticker indicating the equipment had been inspected by a biomedical engineer for safety before use or that preventative maintenance had been performed.
In an observation on 02/13/13 at 11:15 a.m., a suction machine and the defibrillator in room "c" did not have stickers indicating the equipment had been inspected by a biomedical engineer for safety before use or that preventative maintenance had been performed.
In an interview on 2/13/13 at 9:45 a.m. with S2LPN, he stated he was in charge of maintenance at the hospital. S2LPN also stated the hospital did not have a contract for preventative maintenance of their electrical medical equipment or a biomedical engineer.
In an interview on 2/13/13 at 1:05 p.m. with S1ADM/DON, she stated the hospital has not had a preventative maintenance program since 2011. She said the hospital had a local electrician they used when equipment broke, but she could not provide evidence that the electrician had been trained in repairing medical equipment. S1ADM/DON also stated the hospital did not have a policy on preventative maintenance for medical equipment.
Review of a list provided by S2LPN revealed the hospital had the following medical equipment that had not had preventative maintenance performed: 5 suction pumps, 4 oxygen concentrators, 6 intravenous pumps, 3 feeding pumps, 2 Hoyer lifts, 1 patient scale, 14 electrical beds, and 1 defibrillator.

Based upon review of personnel files, policy and procedure review, and staff interview, the hospital failed to ensure the designated infection control officer S1ADM/DON (Administrator/Director of Nurses) was qualified through education, training, experience or certification. Findings:

Review of the hospital policy titled, Infection Control, dated 10/12, and provided by S1ADM/DON as current policy, revealed in part the following: The Director of Nurses is the Infection Control Officer along with the assistance of the Medical Director or physician designated as the Infection Control Physician....

In a face-to-face interview on 02/13/13 at 10:20 a.m., S1ADM/DON stated she was the designated infection control officer for the hospital.

Review of the personnel file for S1ADM/DON revealed there failed to be evidence this employee had a job description specific for an infection control officer. S1ADM/DON's prior work history failed to identify any past experience with infection control nor was there evidence the employee had obtained any education, training or certification in infection control.

A face-to-face interview with S1ADM/DON on 02/14/13 at 3:30 p.m. revealed she had been the Infection Control Officer since the end of November, 2012 when the former Director of Nursing resigned. S1ADM/DON confirmed she has had no prior experience, had not obtained any type of certification, and had not received any training or ongoing education in infection control.

Based on observations, policy and procedure review, staff interview, and review of Dietary and Infection Control logs, the hospital failed to ensure the infection control officer implemented and maintained a system to identify and control infections and maintain a sanitary physical environment as evidenced by: 1) Failing to develop a system for ensuring daily temperature logs and sanitization logs were properly maintained in the kitchen for 4 of 4 log sheets; 2) Failing to ensure housekeeping staff adhered to infection control practices; 3) Failing to ensure sanitary storage of patient supplies and equipment; and 4) Failing to identify patient infections as hospital or community acquired.
Findings:
1) Failing to ensure daily temperature logs and sanitization logs were properly maintained in the kitchen.
A review was made of the policy, provided by the hospital as current, titled Food and Nutrition Temperature Logs. The policy read in part:
Refrigerator and freezer temperatures are logged daily. This ensures that equipment utilized and the storage of perishable food products is in optimum functioning capacity. Logging the temperatures ensures that food products have been maintained at a temperature providing a safe environment of perishable food products.

A request was made on 2/13/13 at 2:50 p.m. to S1ADM/DON for a policy on maintaining logs for the dishwasher and three compartment sink, but the hospital had none.

A review was made on 2/13/13 at 10:30 a.m. of the 2/13/13 Dish Washing Machine Chlorine Test Log, the Dish Machine Temperature Log, the Freezer temperature log and the Refrigerator temperature log. Review of the Refrigerator and the Freezer log sheets for 2/13/13 revealed the p.m. temperature had been entered in advance. Review of the Dish Washing Machine Chlorine Test Log sheet revealed the lunch and dinner entries had been entered in advance on the sheet. Review of the Dish Machine Temperature Log revealed the lunch wash and rinse temperatures and the dinner wash and rinse temperatures had been entered in advance.
In an interview on 2/13/13 at 10:30 a.m. with S8 Dietary Manager, she verified the Dish Washing Machine Chlorine Test Log, the Dish Machine Temperature Log, the Freezer temperature log and the Refrigerator temperature logs had all of the entries for the day filled out in advance. She stated the lunch and dinner temperatures and chlorine levels should have only been filled out for breakfast and the refrigerator and freezer temperatures should have only been filled out for the a.m. She stated S9 dietary worker must have filled out the entries for the entire day that morning. S8 Dietary Manager stated filling the kitchen logs out in advance was not an acceptable practice.
In an interview on 2/13/13 at 10:35 a.m. with S9 Dietary Worker, she stated she always filled out the Dish Washing Machine Chlorine Test Log, the Dish Machine Temperature Log, the Freezer temperature log and the Refrigerator temperature log for the entire day in the mornings.


2) Failing to ensure housekeeping staff adhered to infection control practices:

Review of the hospital policy titled, "Infection Control", dated 10/12 and provided by S1ADM/DON as current policy, revealed in part the following: ....The hospital has a housekeeper that maintains the cleanliness of the facility to assist in prevention of transmission of infections....All employees are to maintain infection control procedures when treating patients and interacting with other staff members and visitors....

On 02/13/13 at 8:55 a.m. S17Housekeeping was observed to have disposable gloves on while using the telephone in the reception area.

On 02/13/13 at 9:59 a.m. S17Housekeeping was observed cleaning room "d" and room "e". S17 Housekeeping was observed to wipe the walls and doors of the rooms with the same cloth used to clean the toilets. S17Housekeeping was observed to place the cloth on her cart between cleaning the rooms and after cleaning the toilets. S17Housekeeping was observed to use the same gloves to clean both rooms and repeatedly enter the housekeeping cart with the same gloves on. S17Housekeeping stated she usually changed her gloves between rooms. S17Housekeeping stated she had not received any instructions from the hospital on when to change her gloves.

On 02/14/13 at 2:25 p.m., S1Administrator/Director of Nursing (ADM/DON) stated she had done an inservice on infection control recently, but S17Housekeeping did not attend. S1ADM/DON verified the cleaning cloth should have been changed after cleaning the toilets and gloves should be removed after cleaning contaminated surfaces.


3) Failing to ensure sanitary storage of patient supplies and equipment:

On 02/13/13 at 10:50 a.m. an observation was made of the clean equipment storage room with S2LPN. 5-6 wheelchairs were observed stored in the room. Bedside commode chairs and walkers were also stored in the room. A white substance was noted on the wheelchairs stored in the room. Inside the storage room a smaller room was observed to house a washing machine and a dryer. There was no door between the rooms. The vent of the dryer was observed to be open into the room. S2LPN verified the wheelchairs had a white substance on them and verified the dryer was not vented to the outside of the room.

On 02/13/13 at 11:15 a.m. an observation was made of room "c" with S2LPN. Patient care supplies were observed to be stored in the room, along with the emergency "crash" cart. An accumulation of a brown substance was noted on top of the crash cart and on the suction machine that was on the crash cart. A black substance was noted in the Fracture bedpans located on shelving adjacent to the crash cart and in front of a window. A black/brown substance was observed on the window blinds. The above findings were confirmed by S2LPN.

On 02/14/13 at 9:00 a.m. S1ADM/DON verified she was aware the dryer was vented inside the room. She stated there was a door between the room housing the dryer and the room with patient equipment, but it was too hot in the dryer room with the door closed. S1ADM/DON stated the door was removed. S1ADM/DON stated the hospital did not have a policy on the storage of patient supplies and equipment.


4) Failing to identify patient infections as hospital or community acquired:
Review of the hospital policy titled, "Infection Control", dated 10/12 and provided by S1ADM/DON as current policy, revealed in part the following: The hospital must provide a sanitary environment to avoid sources and transmission of infection and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases. There is a hospital wide program to tract, investigate and report infections to the appropriate personnel. The hospital maintains a log of infections that is monitored by the DON for trends, clustering and mode of transmission....The infections are tracked according to community acquired, hospital acquired, catheter associated, central line infection....

Review of the Infection Control Log for October, November, and December, 2012 revealed the following:
October - 4 infections, 1 hospital acquired Urinary Tract Infection identified.
November - 6 infections, hospital acquired yes/no was left blank.
December - 7 infections, hospital acquired yes/no was left blank.

In a face-to-face interview on 02/15/13 at 4:50 p.m., S1ADM/DON reviewed the Infection Control Logs and verified the determination of community or hospital acquired had not been completed for November and December. S1ADM/DON stated the analysis of the patient infections, including any trends was done verbally and was not documented.


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