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26351


Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) Failure to ensure each patient was assessed at least every 24 hours by the RN as required by the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs without documented evidence of a RN assessment at a minimum of every 24 hours for 3 of 3 (#4, #7, #19) current sampled patient records reviewed for RN assessments from a total sample of 30 patient records reviewed (see findings in A0395).

2) Failure to ensure staff assigned to monitor telemetry patients was continuously monitoring the current inpatients on telemetry monitoring. This deficient practice had the potential to affect 2 (#19, #20) current patients reviewed for telemetry/cardiac monitoring at the main campus and 1 (# 8) current inpatient on telemetry monitoring at Offsite Campus "A" (see findings in A0395).

3) Failure to ensure orders relative to the initiation and/or titration of continuous medication infusions were clarified prior to implementation by nursing staff as evidenced by failing to obtain dosing increments and intervals for initiation and/or titration for 6 of 6 (#2, #6, #25, #26, #27, #28) current sampled patient records reviewed for continuous medication infusions out of a total sample of 30 patient records reviewed (see findings in A0395).

4) Failure to ensure patients had been assessed to determine if they met the criteria for delegation of nursing care by the Registered Nurse to the Licensed Practical Nurse according to the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice". This deficient practice was evidenced by the RN assigning responsibility for 3 (#2, #6, #28) current patients receiving continuous infusions of medications to LPNs out 6 (#2, #6, #25, #26, #27, #28) current patients reviewed for treatment with continuous medication infusions out of a total sample of 30 patient records reviewed (see findings in A0397). .

30984

Based on record review and interview, the hospital failed to set priorities for its performance improvement activities that focused on high risk/high volume areas that had the potential to affect health outcomes, patient safety and quality of care as evidenced by:
1) failing to identify that patients who had not met the criteria for delegation of nursing care by the RN to the LPN according to the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice" were being delegated by RN staff to LPN staff;
2) failing to identify that orders for initiation and/or titration of continuous infusion medications were incomplete orders that were not being clarified by nursing staff prior to initiation of the orders, and;
3) failing to identify that staff assigned to monitor patients on continuous telemetry monitoring were not continuously monitoring the telemetry patients without distraction or interruption.

Findings:

1) Failing to identify that patients who had not met the criteria for delegation of nursing care by the RN to the LPN according to the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice" were being delegated by RN staff to LPN staff :

Review of the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice" revealed that the RN retains the accountability for the total nursing care of the individual and is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the RN or by the RN in conjunction with other licensed or unlicensed assistive personnel. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. Any situation where tasks are delegated should meet the following criteria:
a) the person has been adequately trained for the task; b) the person has demonstrated that the task has been learned; c) the person can perform the task safely in the given nursing situation; d) the patient's status is safe for the person to carry out the task; e) appropriate supervision is available during the task implementation; f) the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.

Further review revealed the RN may delegate to LPNs the major part of the nursing care needed by individuals in stable nursing situations, i.e., when the following three conditions prevail at the same time in a given situation:
a) nursing care ordered and directed by the RN or physician requires abilities based on a
relatively fixed and limited body of scientific fact and can be performed by following a
defined nursing procedure with minimal alteration, and responses of the individual to the
nursing care are predictable; and b) change in the patient's clinical conditions is predictable; and c) medical and nursing orders are not subject to continuous change or complex
modification.

Review of the Declaratory Statement by the Louisiana State Board of Nursing on the Role and Scope of Practice of Registered Nurses Delegating IV Therapy Interventions, adopted 5/12/99, reaffirmed, revealed the following, in part: Based on the agency's written policy, the RN's assessment of the patient and availability of the RN to supervise the implementation of the delegated intervention and evaluate the patient's response to therapy, the RN may delegate certain IV therapy interventions to an LPN. An RN may delegate to an LPN the major part of the nursing care needed by individuals in stable nursing situations, when the three conditions (a, b & c referenced above) prevail at the same time, in a given situation.

The following nursing intervention may not be delegated in any practice setting, in accordance with the Board's rules (LAC 46: XLVII.3703.c): Furthermore, the RN may not delegate the administration of medications requiring both titration and continuous patient assessment.

Based on the RN's assessment and accordance with the Board's rules on managing and supervising the practice of nursing, when the RN determines that the patient's condition is unstable, since the RN is accountable for the total nursing care rendered, the RN may initiate changes in nursing care or assignment of the nursing personnel and documentation.

Based on the RN's assessment and in accordance the Board believes that an RN may delegate an LPN selective IV therapy nursing interventions provided that RN supervision is readily available during implementation of the intervention, the patient's condition is determined non-complex and the LPN's level of competence is documented in said LPN's file.

Review of the QAPI documentation presented as current revealed no documented evidence RN delegation of patient care who did not fit the criteria for delegation to LPNs had been identified as a problem/issue to be addressed as a performance improvement project for QAPI.

Review of the medical records for Patient's #2, #6 and #28 revealed all 3 patients were being treated with continuous medication infusions such as Levophed, Diprivan and Precedex. Further review revealed the patients referenced above had been assigned to LPNs by RN staff. Review of the personnel records for S10LPN and S28LPN revealed no documented evidence of training/skills competency assessments for administration of continuous infusions of Levophed, Diprivan, or Precedex.


In an interview on 11/13/15 at 1:40 p.m. with S2DON, she confirmed conscious sedation training and assessment of skills competencies, such as for administration of Diprivan, was provided for RN staff only. She also confirmed the hospital did not provide training or assessment of skills competencies for administration of continuous administration of Levophed, Diprivan, or Precedex.

In an interview on 11/13/15 at 1:50 p.m. with S2DON, she indicated delegation of patient care by RNs to LPNs had not been addressed as an identified area requiring monitoring/performance improvement in QAPI because she had not known it was an issue.



2) Failing to identify that orders for initiation and/or titration of continuous infusion medications were incomplete orders that were not being clarified by nursing staff prior to initiation of the orders.

Review of the medical records for Patients #2, #6, and #26 revealed all 3 patients were receiving continuous infusions. Review of the physician orders for Patient #2 revealed an order dated 11/03/15 at 5:00 p.m. to "Please wean Diprivan gtt in a.m." Review of Patient #6's physician orders revealed the following order: 10/26/15, 01:00 a.m.: Levophed gtt to maintain MAP greater than or equal to 60. Review of Patient #26's physician's orders revealed the following orders: 11/11/15, 5:45 p.m.: Levophed gtt titrate to keep MAP greater than 60; Diprivan gtt titrate for sedation. Further review of the patients' records revealed no documented evidence of clarification of the orders relative to dose increments and intervals to utilize for titrating the Levophed drips. Additional review revealed no documented evidence of clarification of the Diprivan order relative to desired level of sedation to be achieved.

In an interview on 11/10/15 at 1:40 p.m. with S2DON, she indicated the hospital did not have weaning protocols for continuous medication infusions. She indicated she was not aware that an order to titrate a medication to keep a mean blood pressure greater than or equal to a certain parameter was an incomplete order that required clarification. She also indicated she was not aware that an order to titrate for sedation was an incomplete order that required clarification. She indicated she could see how titration orders written without increments or time intervals required interpretation of the intent of the order by the nursing staff.


In an interview on 11/13/15 at 1:50 p.m. with S2DON, she indicated she had not been aware that an order to titrate a medication to keep a mean blood pressure greater than or equal to a certain parameter was an incomplete order that required clarification. She also indicated she was not aware that an order to titrate for sedation was an incomplete order that required clarification. She confirmed incomplete orders for continuous medication infusions was not an identified area requiring monitoring/performance improvement in QAPI because she had not known it was an issue.



3) Failing to identify that staff assigned to monitor patients on continuous telemetry monitoring were not continuously monitoring the telemetry patients without distraction or interruption.

Main Campus:
Review of the medical records for Patient #19 and Patient #20 revealed both patients had physician orders for cardiac monitoring on admission. Both patients were admitted to the 10th floor.

On 11/10/15 at 11:15 a.m. and on 11/12/15 at 1:30 p.m. observations were made of the telemetry/cardiac monitors in the nurse's station on the 10th floor. The ward clerk was observed to be taking orders off patient records, talking with other staff, answering telephone calls and have her back to the monitors. At no time during the observations was the telemetry monitor continuously observed by either the ward clerk or any other staff members present in the nurses' station.

In an interview on 11/12/15 at 2:50 p.m. S14RN, Charge Nurse on 10th floor, confirmed the Ward Clerk/Telemetry was responsible for the cardiac/telemetry monitoring on the day shift. She stated she relieved the Ward Clerk when needed. S14RN stated there was no Ward Clerk on the 7:00 p.m. to 7:00 a.m. shift and stated the charge nurse was responsible for the monitoring of the telemetry/cardiac monitors then.


Offsite Campus "A":
Review of Patient #8's medical record revealed he was admitted at Offsite Campus "A" on 11/9/15 with the following diagnoses: Aspiration Pneumonitis; Pressure Ulcers and Heart Failure. Further review revealed an admission order, dated 11/9/15, for cardiac monitor; place strip on chart at admit, every shift, and as needed.
On 11/12/15 from 9:50 a.m. -10:15 a.m. an observation was made of the telemetry monitor in the nurses' station at Offsite Campus "A". The unit secretary's back was noted to be turned to the monitor as she performed other duties. At one point the unit secretary was observed leaving the nurses' station. At no time during the observation was the telemetry monitor continuously observed by either the unit secretary or any other staff members present in the nurses' station.
On 11/12/15 at 11:00 a.m. an interview was conducted with S6AssistantDirectorofNurses. She confirmed Patient #8 was currently on continuous telemetry monitoring. She indicated the unit secretary was responsible for observing the telemetry monitor for patients on ordered telemetry monitoring on the day shift. She also indicated the charge RNs were responsible for monitoring the telemetry patients on the night shift.

Review of the QAPI documentation presented as current revealed no documented evidence that staff assigned to monitor patients on continuous telemetry monitoring were not continuously monitoring the telemetry patients without distraction or interruption had been identified as a problem/issue to be addressed as a performance improvement project for QAPI.


In an interview on 11/13/15 at 1:50 p.m. with S2DON, she indicated the identified problem of staff assigned to monitor patients on continuous telemetry monitoring were not continuously monitoring the telemetry patients without distraction or interruption had not been addressed as an identified area requiring monitoring/performance improvement in QAPI because she had not known it was an issue.

26351




30984


Based on record review, interviews and observations, the hospital failed to ensure that the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) Failure to ensure each patient was assessed at least every 24 hours by the RN as required by the Louisiana State Board of Nurse's Practice Act as evidenced by having patient care provided by LPNs without documented evidence of a RN assessment at a minimum of every 24 hours for 3 of 3 (#4, #7, #19) current sampled patient records reviewed for RN assessments from a total sample of 30 patient records reviewed;

2) Failure to ensure staff assigned to monitor telemetry patients was continuously monitoring the current inpatients on telemetry monitoring. This deficient practice had the potential to affect 2 (#19, #20) current patients reviewed for telemetry/cardiac monitoring at the main campus and 1 (# 8) current inpatient on telemetry monitoring at Offsite Campus "A";

3) Failure to ensure orders relative to the initiation and/or titration of continuous medication infusions were clarified prior to implementation by nursing staff as evidenced by failing to obtain dosing increments and intervals for initiation and/or titration for 6 of 6 (#2, #6, #25, #26, #27, #28) current sampled patient records reviewed for continuous medication infusions out of a total sample of 30 patient records reviewed.

Findings:

1) Failure to ensure each patient was assessed at least every 24 hours by the RN as required by the Louisiana State Board of Nurse's Practice Act:

Review of the LSBN's Practice Act revealed that RNs may delegate select nursing interventions to the LPN provided the patient is assessed by an RN every 24 hours.
Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part,
"3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems.
The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.
a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.
b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification..."

Review of the hospital policy titled, "Patient Assessment/Reassessment" policy number 9-1.1.0, revealed in part the following: A reassessment of the patient shall be performed at least every 12 hours by nursing staff. The reassessment of the patient will be supervised and evaluated by a registered nurse. An RN's signature on the daily reassessment indicates that the care of the patient has been supervised and evaluated by a registered nurse.


Patient #4
Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 11/06/15 with diagnoses of Right Sided Flail Chest, Pulmonary Contusion, Diaphragmatic Injury, Subarachnoid Hemorrhage, and Hemoperitoneum. The record revealed the patient was involved in a motor vehicle accident on 10/16/15. Further review of the record revealed the patient had multiple surgeries to repair the injuries including a Tracheostomy on 10/28/15.

Review of his Nurses Daily Flow Sheet revealed on the following days only LPNs assessed Patient #4: 11/07/15 and 11/08/15. The Nurses Daily Flow Sheet dated 11/07/15 and 11/08/15 revealed the nursing assessments of Patient #4 were documented only by LPNs for the day shifts and the night shifts. Review of the flow sheets revealed an RN signed the nursing flow sheet under Day and Night Shift with no indication if the patient was assessed by the registered nurse within a 24 hour period.

In an interview on 11/10/15 at 2:05 p.m., S2DON reviewed the medical record for Patient #4 and confirmed there was no documented evidence of an RN assessment of the patient within a 24 hour period on 11/07/15 and 11/08/15. S2DON confirmed the patient assessments on 11/07/15 and 11/08/15 were documented by LPNs only. S2DON indicated the RNs made rounds and signed the nurse's notes, but they do not routinely assess the patient.


Patient #7
Patient #7 was admitted to the hospital at Campus A on 10/29/15. His diagnoses included: Acute Renal Failure, Multidrug Resistant Urinary Tract Infection, and Dehydration.

Review of his Nurses Daily Flow Sheet revealed the following days only LPNs assessed Patient #7: 11/5/15 and 11/10/15 The Nurses Daily Flow Sheet dated 11/5/15 revealed S20LPN and S19LPN documented Patient's #7's assessment. S4RN and S21RN signed the nursing flow sheet under Day and Night Shift no indication if the patient was assessed by the registered nurse within a 24 hour period. The Nurses Daily Flow sheet dated 11/10/15 revealed S22LPN and S19LPN documented Patient #7's assessment . S4RN and S16RN signed the nursing flow sheet under Day and Night Shift with no indication if the patient was assessed by the registered nurse within a 24 hour period.

An interview was conducted with S6RN ADON on 11/12/15 at 10:45 a.m. She reported the LPNs fill out the assessment and the Registered Nurse signs the Nurses Daily Flow sheet on the RN signature area. S6RN ADON agreed when questioned, there was no evidence the patient was assessed by a registered nurse within a 24 hour period.


Patient #19
Review of the medical record for Patient #19 revealed the patient was admitted to the hospital's 10th floor on 10/26/15 with diagnoses of Fournier Gangrene with Necrosis of Urethra, Ischemic changes to Bladder Wall, MRSA in wounds, and Supra Pubic Catheter.

Review of his Nurses Daily Flow Sheet revealed on the following days only LPNs assessed Patient #19: 11/06/15, 11/07/15, 11/08/15, 11/09/15, 11/10/15, and 11/11/15. The Nurses Daily Flow Sheets dated 11/06/15 through 11/11/15 revealed the nursing assessments of Patient #19 were documented only by LPNs for the day shifts and the night shifts. Review of the flow sheets revealed an RN signed the nursing flow sheet under Day and Night Shift with no indication if the patient was assessed by the registered nurse within a 24 hour period.

In an interview on 11/12/15 at 2:50 p.m. S14RN, Charge Nurse (10th floor) stated the hospital policy is that the RN co-signs and verifies the LPN is charting. She stated she assesses the patient but stated she cannot tell what other nurses do. S14RN confirmed she does not document the assessments she does. After reviewing the medical record for Patient #19, she confirmed there was no documented evidence of an RN assessment from 11/06/15 through 11/11/15 (6 days). S14RN confirmed the 10th floor was staffed with one (1) RN Charge Nurse for each shift and LPNs were assigned to the patients (18 beds).



2) Failure to ensure staff assigned to monitor telemetry patients was continuously monitoring the current inpatients on telemetry monitoring:

Main Campus:
Review of Patient #19's medical record revealed he was admitted at the Main Campus on 10/26/15 with the following diagnoses: Fournier Gangrene with Necrosis of Urethra, Ischemic changes to Bladder Wall, MRSA in wounds, and Supra Pubic Catheter. Further review revealed an admission order, dated 10/26/15, for cardiac monitor; place strip on chart at admit, every shift, and as needed.

Review of Patient #20's medical record revealed she was admitted at the Main Campus on 10/20/15 with the following diagnoses: Psoas Muscle Abscess, Discitis, Hemiplegia, and Acute Kidney Failure. Further review revealed an admission order, dated 10/20/15, for cardiac monitor; place strip on chart at admit, every shift, and as needed.

In an interview on 11/10/15 at 10:35 a.m., S24RN stated S26Ward Clerk/Telemetry was ultimately responsible for monitoring the telemetry and cardiac monitors for the 9th and 10th floors. She stated she monitors from the 10th floor nursing station. She stated if she has to leave the desk, she lets the charge nurse know and she covers for her.

On 11/10/15 at 11:15 a.m. an observation was made of the telemetry/cardiac monitors in the nurse's station on the 10th floor. S26Ward Clerk/Telemetry was observed to be standing away from the telemetry monitors with her back to the monitors. S26Ward Clerk/Telemetry was observed to return briefly to the desk where the monitors were located, and then she was observed to walk away again from the monitors. S26Ward Clerk/Telemetry later returned to the desk to answer the phone. She was observed to make another call, return to the first call and document a message. S26Ward Clerk/Telemetry was observed to be looking away from the monitors while using the telephone and taking a message. S26Ward Clerk/Telemetry confirmed she monitored both the 9th and 10th floor telemetry and cardiac monitors on the screens at her desk. She stated the monitor screen in the middle of the nurse's station was only telemetry monitoring for both floors. S26Ward Clerk/Telemetry stated when she goes to lunch or leaves the floor the Charge Nurse on the 10th floor relieved her. At 11:20 a.m. S26Ward Clerk/Telemetry was observed to receive a record for a patient returning to the unit. S26Ward Clerk/Telemetry then began reviewing orders on the record and other charts on her desk. S26Ward Clerk/Telemetry was observed to be looking away from the monitors during this process. No other staff were observed to be monitoring the telemetry monitors during this observation.

On 11/12/15 at 1:30 p.m. S25Ward Clerk/Telemetry was observed to be seated at her desk in front of the telemetry/cardiac monitors on the 10th floor. She was observed to be talking with another staff member and looking away from the monitors repeatedly. At 1:35 p.m. to 1:44 p.m. S25Ward Clerk was observed to be answering the telephone with her head turned away from the monitor. S25Ward Clerk was also observed to be taking orders off patient records with her head turned away from the monitor screen. No other staff were observed to be monitoring the telemetry monitors during this observation.

In an interview on 11/12/15 at 2:50 p.m. S14RN, Charge Nurse on 10th floor, confirmed the Ward Clerk/Telemetry was responsible for the cardiac/telemetry monitoring on the day shift. She stated she relieved the Ward Clerk when needed. S14RN stated there was no Ward Clerk on the 7:00 p.m. to 7:00 a.m. shift and stated the charge nurse was responsible for the monitoring of the telemetry/cardiac monitors then.


Offsite Campus "A":
Review of Patient #8's medical record revealed he was admitted at Offsite Campus "A" on 11/9/15 with the following diagnoses: Aspiration Pneumonitis; Pressure Ulcers and Heart Failure. Further review revealed an admission order, dated 11/9/15, for cardiac monitor; place strip on chart at admit, every shift, and as needed.
On 11/12/15 from 9:50 a.m. -10:15 a.m. an observation was made of the telemetry monitor in the nurses' station at Offsite Campus "A". The unit secretary's back was noted to be turned to the monitor as she performed other duties. At one point the unit secretary was observed leaving the nurses' station. At no time during the observation was the telemetry monitor continuously observed by either the unit secretary or any other staff members present in the nurses' station.
On 11/12/15 at 11:00 a.m. an interview was conducted with S6AssistantDirectorofNurses. She confirmed Patient #8 was currently on continuous telemetry monitoring. She indicated the unit secretary was responsible for observing the telemetry monitor for patients on ordered telemetry monitoring on the day shift. She also indicated the charge RNs were responsible for monitoring the telemetry patients on the night shift.


3) Failure to ensure orders relative to the initiation and/or titration of continuous medication infusions were clarified prior to implementation by nursing staff as evidenced by failing to obtain dosing increments and intervals for initiation and/or titration.

Review of the hospital policy titled, "Patient Care Orders" policy number 9-5.3.0, revealed in part the following: Clarification of Orders: Medication orders that are unclear, illegible, written with unqualified range doses or times, written without an indication (prn medications), deemed to be a patient safety issue or indicate a possible drug-drug interaction must be clarified prior to implementation.... Medication Orders: All medication orders must be legible and contain the drug name, dosage, frequency, time and route of administration.

Patient #2
Review of Patient #2's medical record revealed an admission date of 10/27/15 and admission diagnoses including the following: Respiratory Failure, Coronary Artery Disease, Congestive Heart Failure and Cerebrovascular Accident with left hemiparesis. Further review revealed Patient #2 was intubated and on a ventilator. Additional review revealed he was receiving continuous infusions of Levophed (drug used for treatment of hypotension) and Diprivan (general anesthetic used for moderate sedation).
Review of Patient #2's physician's orders revealed the following orders: 11/3/15, 5:00 p.m.: Please wean Diprivan gtt in a.m. The order was written by the nurse as a RBVO read back verbal order. Further review revealed no documented evidence of clarification of the order relative to dose increments and intervals to utilize for weaning the Diprivan drip.

Patient #6
Review of Patient #6's medical record revealed an admission date of 10/23/15 with admission diagnoses including the following: Pressure Ulcers, Hypertension, Diabetes Mellitus-Type II and Edema. Additional review revealed she was receiving a continuous infusion of Levophed.

Review of Patient #6's physician orders revealed the following order: 10/26/15, 1:00 a.m.: Levophed gtt to maintain MAP greater than or equal to 60. The order was written by the nurse as a RBVO. Further review revealed no documented evidence of clarification of the order relative to dose increments and intervals to utilize for titrating the Levophed drip.

Patient #25
Review of the medical record for Patient #25 revealed the patient was admitted to the hospital on 10/20/15 with diagnoses of Respiratory Failure, Acute Kidney Failure, Protein Calorie Malnutrition, Status Post Craniotomy. The record revealed the patient was admitted intubated and on a ventilator. On 11/02/15 a bedside tracheostomy was performed.
Review of the physician's orders revealed the following order:
11/02/15 at 0900 - Diprivan gtt for sedation, discontinue 2 hours post operative.
Further review revealed no documented evidence of clarification of the order relative to the starting dose, increments and intervals to utilize for titrating the Diprivan drip, and there was no clarification of the order relative to desired level of sedation to be achieved.

Review of the Vital Sign Flow Sheet revealed only, "Diprivan gtt started" on 11/02/15 at 0800. There was no documented evidence of the starting dose of Diprivan.

In an interview on 11/13/15 at 10:40 a.m., S2DON reviewed the physician orders for the Diprivan and confirmed the nurse failed to clarify the order to include the starting dose, increments and intervals for titrating and the desired level of sedation to be achieved. S2DON confirmed the nurse failed to document the starting dose of the Diprivan infusion.


Patient #26
Review of Patient #26's medical record revealed an admission date of 10/26/15 and admission diagnoses of Acute Respiratory Failure with hypoxia and Atrial Fibrillation. Additional review revealed he was receiving continuous infusions of Levophed and Diprivan.
Review of Patient #26's physician's orders revealed the following orders: 11/11/15, 5:45 p.m.: Levophed gtt titrate to keep MAP greater than 60; Diprivan gtt titrate for sedation. The order was written by the nurse as a RBVO. Further review revealed no documented evidence of clarification of the order relative to dose increments and intervals to utilize for titrating the Levophed drip. Additional review revealed no documented evidence of clarification of the Diprivan order relative to desired level of sedation to be achieved.

In an interview on 11/10/15 at 1:40 p.m. with S2DON, she indicated the hospital did not have weaning protocols for continuous medication infusions. She indicated she was not aware that an order to titrate a medication to keep a mean blood pressure greater than or equal to a certain parameter was an incomplete order that required clarification. She also indicated she was not aware that an order to titrate for sedation was an incomplete order that required clarification. She indicated she could see how titration orders written without increments or time intervals required interpretation of the intent of the order by the nursing staff.


Patient #27
Patient #27 was admitted to the hospital on 10/6/15 with the diagnoses of Respiratory Distress and Status-Post Respiratory Failure following Coronary Artery By-Pass Surgery.

Review of the Physician's Routine Orders, dated 11/12/15, revealed the following physician's order: If heart rate stays > (greater than) 130 resume Cardizem Drip.

Review of the Vital Sign Flow Sheet reveals the Cardizem gtt (drip) was started at 5 mg/hr (milligrams/hour) at 0915 on 11/12/15. The patient's pulse was 138. At 10:00 a.m. the patient's pulse was 135 and the Cardizem Drip was increased to 10 mg/hr. At 2:00 p.m. the patient's heart rate was 70 beats/min (beats/minute) and the Cardizem drip was decreased to 8 mg/hr. At 6:00 a.m. on 11/13/15 the drip was decreased to 5 mg/hr and the patient's heart rate was 66 beats/min.

An interview was conducted with S2DON on 11/12/15 at 11:00 a.m. She reported that Cardizem drip is usually started at 5 mg/hr and weaned by 2.5 mg/hr or 5 mg/hr depending on the nurse. S2DON reported there were no specific protocols on how to wean Cardizem and the physician's order typically does not address weaning of the Cardizem drip.



Patient #28
Review of the medical record for Patient #28 revealed an admission date of 11/03/15 and admission diagnoses including the following: Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease Exacerbation, Acute Respiratory Acidosis, C-diff Colitis, Hypotensive Shock, and Protein Calorie Malnutrition. Further review revealed Patient #28 was intubated and on a ventilator.
Review of the physician's orders revealed a verbal order dated 11/03/15 at 5:00 p.m. to continue a Precedex infusion (drug used for sedation in intubated patients) and "titrate." Further review revealed no documented evidence of clarification of the order relative to the starting dose, increments and intervals to utilize for titrating the Diprivan drip, and there was no clarification of the order relative to desired level of sedation to be achieved.

Review of the physician's orders revealed a verbal order dated 11/03/15 at 7:00 p.m. for, "Levophed gtt (double strength) titrate to keep MAP < (less than or equal to) 60." There was no documented evidence of clarification of the order relative to the starting dose or dose increments and intervals to utilize for titrating the Levophed drip.

In an interview on 11/13/15 at 12:00 p.m., S2DON confirmed there were no clarification orders relative to the Precedex or Levophed infusion. S2DON confirmed the order to titrate the Levophed to the MAP was written incorrectly and should have indicated a MAP of greater than or equal to 60.

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30984


Based on record review and interview, the hospital failed to ensure the nursing staff developed, and kept current individualized and comprehensive nursing care plans for each patient for 4 of 4 (#2, #4, #7, #9) sampled patients reviewed for care planning out of a total sample of 30 patient records reviewed.

Findings:

Review of the hospital policy titled, The Nursing Process-Care Planning, Policy Number:9-1.2.0, revealed the following: Purpose to provide each patient with an individualized plan of nursing care...The nursing plan of care provides a collaborative/systematic method of individualized nursing care that focused on the patient's responsive to an actual or potential alteration in health....

Patient #2
Review of the medical record for Patient #2 revealed he had been admitted on 10/27/15 with admission diagnoses including Respiratory Failure, Chronic Kidney Disease and Congestive Heart failure. Further review revealed the patient was receiving hemodialysis.
Review of the care plan for Patient #2 revealed the problem Fluid Volume Excess related to Renal Disease was left blank. Additional review revealed hemodialysis and assessment/maintenance of Patient #2's hemodialysis access was also absent from the plan of care. The care plan was not specific and not individualized to the patient's care/needs.

Patient #4
On 11/10/15 at 9:20 a.m., an observation was made of Patient #4 during respiratory therapy. The patient was observed to have a large amount of respiratory secretions requiring tracheal suctioning twice during the administration of a nebulizer treatment. The patient was also observed to have a cervical spine immobilization collar in place.

Review of the medical record for Patient #4 revealed the patient was admitted on 11/06/15 with admission diagnoses including Right Sided Flail Chest, Pulmonary Contusion, Diaphragmatic Injury, Subarachnoid Hemorrhage, and Hemoperitoneum. The record revealed the patient was involved in a motor vehicle accident on 10/16/15. Further review of the record revealed the patient had multiple surgeries to repair the injuries including a Tracheostomy on 10/28/15.
Review of the nursing care plan for Patient #4 revealed Impaired Verbal Communication related to Tracheostomy was not included in the plan of care. Self-care deficit was not included in the plan of care and the cervical spine immobilization was not included. The care plan was not specific and not individualized to the patient's care/needs.

In an interview on 11/13/15 at 1:35 p.m., S2DON confirmed the nursing care plan did not include all the patient's problems and diagnoses.

Patient #7
Review of the medical record for Patient #7 revealed he had been admitted on 10/29/15 at Campus A with the diagnoses of Acute Renal Failure, Urinary Tract Infection and Dehydration. Review of his urine culture results revealed he had a multidrug resistant urinary tract infection. On admission (10/29/15) Patient #7 was placed in maximum contact isolation.
Review of Patient #7's current plan of care revealed no indication the patient had a multidrug resistant bacteria in his urine and he was on contact isolation.
An interview was conducted with S6RN ADON on 11/12/15 at 10:45 a.m. She reported the patient's care plan should have included information related to Patient #7 having a multidrug resistant bacteria in his urine and also that Patient #7 was in maximum contact isolation.


Patient # 9
Review of the medical record for Patient #9 revealed he had been admitted on 11/4/15 at Offsite Campus "A" with diagnoses which included status post Coronary Artery Bypass Graft with infected sternal wound and uncontrolled Diabetes Mellitus. Review of Patient #9's admit History and Physical revealed the patient's " Accu-checks" (capillary blood glucose checks) were being monitored while the patient was in-house and he was being treated with Metformin (antidiabetic medication)

Review of the care plan for Patient #9 revealed the problem Alteration in Nutrition, less than body requirements related to Diabetes was left blank. The care plan was not specific and not individualized to the patient's care/needs.

In an interview on 11/13/15 at 1:40 p.m. with S2DON, she agreed Diabetes should have been identified as a problem on Patient #9's plan of care. She also agreed patient diagnoses requiring interventions should be identified as problems and addressed on the plan of care.

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Based on record review and interview, the hospital failed to ensure patients had been assessed to determine if they met the criteria for delegation of nursing care by the Registered Nurse to the Licensed Practical Nurse according to the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice". This deficient practice was evidenced by the RN assigning responsibility for 3 (#2, #6, #28) current patients receiving continuous infusions of medications to LPNs out 6 (#2, #6, #25, #26, #27, #28) patients reviewed for treatment with continuous medication infusions out of a total sample of 30 patient records reviewed. .

Findings:

Review of the LSBN's "Administrative Rules Defining RN Practice LAC46: XLVII §3703. Definition of Terms Applying to Nursing Practice" revealed that the RN retains the accountability for the total nursing care of the individual and is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the RN or by the RN in conjunction with other licensed or unlicensed assistive personnel. The RN shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. Any situation where tasks are delegated should meet the following criteria:
a) the person has been adequately trained for the task;
b) the person has demonstrated that the task has been learned;
c) the person can perform the task safely in the given nursing situation;
d) the patient's status is safe for the person to carry out the task;
e) appropriate supervision is available during the task implementation;
f) the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all.

Further review revealed the RN may delegate to LPNs the major part of the nursing care needed by individuals in stable nursing situations, i.e., when the following three conditions prevail at the same time in a given situation:
a) nursing care ordered and directed by the RN or physician requires abilities based on a
relatively fixed and limited body of scientific fact and can be performed by following a
defined nursing procedure with minimal alteration, and responses of the individual to the
nursing care are predictable; and
b) change in the patient's clinical conditions is predictable; and
c) medical and nursing orders are not subject to continuous change or complex
modification.

Review of the Declaratory Statement by the Louisiana State Board of Nursing on the Role and Scope of Practice of Registered Nurses Delegating IV (Intravenous ) Therapy Interventions, adopted 5/12/99, reaffirmed, revealed the following, in part:

Based on the agency's written policy, the RN's assessment of the patient and availability of the RN to supervise the implementation of the delegated intervention and evaluate the patient's response to therapy, the RN may delegate certain IV therapy interventions to an LPN. An RN may delegate to an LPN the major part of the nursing care needed by individuals in stable nursing situations, when the three conditions (a, b & c referenced above) prevail at the same time, in a given situation.

The following nursing intervention may not be delegated in any practice setting, in accordance with the Board's rules (LAC 46: XLVII.3703.c):
Furthermore, the RN may not delegate the administration of medications requiring both titration and continuous patient assessment.

Based on the RN's assessment and accordance with the Board's rules on managing and supervising the practice of nursing, when the RN determines that the patient's condition is unstable, since the RN is accountable for the total nursing care rendered, the RN may initiate changes in nursing care or assignment of the nursing personnel and documentation.

Based on the RN's assessment and in accordance the Board believes that an RN may delegate an LPN selective IV therapy nursing interventions provided that RN supervision is readily available during implementation of the intervention, the patient's condition is determined non-complex and the LPN's level of competence is documented in said LPN's file.


Patient #2
Review of Patient #2's medical record revealed an admission date of 10/27/15 and admission diagnoses including the following: Respiratory Failure, Coronary Artery Disease, Congestive Heart Failure and Cerebrovascular Accident with left hemiparesis. Further review revealed Patient #2 was intubated and on a ventilator. Additional review revealed he was receiving continuous infusions of Levophed (drug used for treatment of hypotension) and Diprivan (general anesthetic used for moderate sedation).

Review of Patient #2's nurses daily flowsheet revealed S10LPN had cared for Patient #2 on the night shift of 11/3/15.

Review of the personnel record for S10LPN revealed no documented evidence of training/skills competencies for administration of Diprivan or Levophed. Further review of the Core Competency Checklist utilized by the hospital to evaluate skills competency revealed the section on moderate sedation titled, "Moderate Sedation" and it indicated the section was for RNs only. This section of the skills competency check off list for S10LPN was left blank. Further review of the competency checklist revealed no documented evidence of training/skills competency assessment for administration of continuous infusions of Levophed.


Patient #6
Review of Patient #6's medical record revealed an admission date of 10/23/15 with admission diagnoses including the following: Pressure Ulcers, Hypertension, Diabetes Mellitus-Type II and Edema. Additional review revealed she was receiving a continuous infusion of Levophed.

Review of Patient #6's nurses daily flowsheet revealed S11LPN had cared for Patient #6 on the night shift of 10/26/15 and 10/27/15.

Review of the personnel record for S11LPN revealed no documented evidence of training/skills competencies for administration of continuous infusions of Levophed.

In an interview on 11/13/15 at 9:49 a.m. with S2DON, she confirmed Patient #6 had been assigned to S11LPN on the night shifts of 10/26/15 and 10/27/15. She confirmed Patient #6 was on a Levophed Drip on the night shifts of 10/26/15 and 10/27/15. She indicated she was not aware that the care of the patients (Patients #2 and #6) referenced above could not be delegated to LPNs by the RN staff.

In an interview on 11/13/15 at 1:40 p.m. with S2DON, she confirmed conscious sedation training and assessment of skills competencies, such as for administration of Diprivan, was provided for RN staff only. She also confirmed the hospital did not provide training or assessment of skills competencies for administration of continuous administration of Levophed.


Patient #28
Review of the medical record for Patient #28 revealed an admission date of 11/03/15 and admission diagnoses including the following: Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease Exacerbation, Acute Respiratory Acidosis, C-diff Colitis, Hypotensive Shock, and Protein Calorie Malnutrition. Further review revealed Patient #28 was intubated and on a ventilator. Additional review revealed the patient was receiving a continuous infusions of Levophed (drug used for treatment of hypotension). The record also revealed the patient was receiving a Precedex infusion (drug used for sedation of intubated patients) on admission.

Review of Patient #28's nurses daily flowsheet revealed S28LPN had cared for Patient #28 on the night shift of 11/09/15, 11/10/15 and 11/11/15. Review of the 11/10/15 daily flow sheet revealed S28LPN titrated the Levophed infusion from 18 mg/minute to 16 mg/minute at 11:00 p.m. Further review of the 11/10/15 daily flow sheet revealed S28LPN titrated the Levophed infusion down to 14 mg/minute at 6:00 a.m. (11/11/15). Review of the nurses daily flow sheet also revealed S10LPN had been assigned to Patient #28 on the night shift of 11/04/15 and 11/05/15, when the patient was receiving Levophed and Precedex infusions.

Review of the personnel record for S28LPN revealed no documented evidence of training/skills competencies for administration of Levophed. Further review of the Core Competency Checklist utilized by the hospital to evaluate skills competency revealed the section on moderate sedation titled, "Moderate Sedation" and it indicated the section was for RNs only. This section of the skills competency check off list for S28LPN was left blank. Further review of the competency checklist revealed no documented evidence of training/skills competency assessment for administration of continuous infusions of Levophed.

In an interview on 11/13/15 at 12:00 p.m., S2DON reviewed the medical record for Patient #28 and confirmed S28LPN had been assigned to Patient #28 on the night shifts of 11/10/15 and 11/11/15. S2DON confirmed S28LPN documented the titration of the Levophed infusion. S2DON stated, "But the RN did the titration." S2DON confirmed there was no documentation that indicated an RN titrated the Levophed infusion on 11/10/15 and 11/11/15. S2DON also confirmed S10LPN was assigned to Patient #28 on the night shifts of 11/04/15 and 11/05/15 when the patient was receiving both Precedex and Levophed infusions.

Based on record review and interview, the hospital failed to ensure all patient medical record entries were complete as evidenced by failing to ensure the ordering licensed practitioner dated and timed his authentication of orders for 4 of 4 ( #1, #2, #19, #20) current patient records reviewed for dating and timing of orders out of a total sample of 30 patient records reviewed.

Findings:

Review of the hospital policy titled, "Documentation and Authentication" policy number 5-2.3.0, revealed in part the following: All orders, including verbal orders, must be timed, dated, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and is authorized to write orders. All verbal orders will be authenticated within 10 days.

Patient #1
Review of Patient #1's medical record revealed he had been admitted on 10/23/15. Further review revealed the following orders had been authenticated, but not dated or timed, by the ordering licensed practitioner:
A read back phone order dated 10/26/15 at 11:45 a.m. to consult wound care to evaluate and treat wounds.
A verbal order for Occupational Therapy dated 10/24/15 at 8:30 a.m.;
A verbal order for Physical Therapy dated 10/26/15 at 1:30 p.m.;
A verbal order for Speech Therapy dated 10/30/15 at 10:40 a.m.

Patient #2
Review of Patient #2's medical record revealed the patient was admitted on 10/27/15. Further review revealed the following orders had been authenticated, but not dated or timed, by the ordering licensed practitioner:
11/3/15 5:00 p.m. Please wean Diprivan gtt in a.m.
11/7/15 9:15 a.m. RBTO to increase Vinpat.
In an interview on 11/13/15 at 1:40 p.m. with S2DON she indicated failure of physician's to date and time their orders when they authenticated them was an ongoing issue.

Patient #19
Review of the medical record for Patient #19 revealed the patient was admitted on 10/26/15.
Further review of the record revealed the following verbal order had been authenticated, but not dated or timed by the ordering licensed practitioner:
10/29/15 at 11:25 a.m. Regular Diet.

In an interview on 11/12/15 at 2:50 p.m., S14RN reviewed the medical record for Patient #19 and confirmed the verbal order dated 10/29/15 for a Regular Diet had been signed by the ordering practitioner, but the practitioner had not dated or timed the authentication.


Patient #20
Review of the medical record for Patient #20 revealed the patient was admitted on 10/20/15.
Further review of the record revealed the following verbal orders had been authenticated, but not dated or timed by the ordering licensed practitioner:
10/20/15 at 5:20 p.m. Norco 5 mg. by mouth every 4 hours as needed for mild pain. Norco 10 mg. by mouth every 4 hours as needed for severe pain. Norvasc 5 mg. by mouth daily.
10/21/15 at 9:00 a.m. Physician Therapy 5 times a week until discharge. Treatment to include: Therapeutic Exercise, Therapeutic Activity, and Gait Training.
10/21/15 at 2:43 p.m. Strawberry Glucerna, 1 can by mouth three times a day with meals.
10/21/15 at 3:40 p.m. Occupational Therapy 5 days/week for length of stay or goals met. Treatment to include: Self-Care Training, Transfer Training, Strengthening/Endurance, Safety/Judgement, Coordination/Fine Motor, Range of Motion, Balance, Joint Protection, and Patient/Family education.
Review of the order dated 10/26/15 documented by the licensed practitioner to discontinue Morphine, Protonix, Rocaltrol, and Foley catheter revealed the order was signed by the physician, but did not include a time.

In an interview on 11/12/15 at 3:30 p.m., S14RN reviewed the medical record for Patient #20 and confirmed the above orders did not include the date and time of the authentication, and the physician's order dated 10/26/15 did not include the time of the order.

Based on record reviews and interviews, the hospital failed to ensure all orders, including verbal orders, were dated, timed, and authenticated by the practitioner in accordance with hospital policies for 2 (#19, #20) of 2 patient records reviewed for authentication of physician orders from a sample of 30 patients. Findings:

Review of the Medical Staff Bylaws, Rules & Regulations, dated 09/01/15 revealed telephone/verbal orders shall be authenticated by the person who dictated the order within ten (10) days.

Review of the hospital policy titled, "Documentation and Authentication" policy number 5-2.3.0, revealed in part the following: All orders, including verbal orders, must be timed, dated, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and is authorized to write orders. All verbal orders will be authenticated within 10 days.



Patient #19
Review of the medical record for Patient #19 revealed the patient was admitted on 10/26/15.
Further review of the record revealed the following verbal orders had not been authenticated by the practitioner within 10 days of the order:
10/27/15 at 9:55 a.m. Consult Wound Care Associates to evaluate and treat wounds.
10/27/15 at 11:00 a.m. Santyl ointment to scrotum daily with dressing changes.
10/27/15 at 11:00 a.m. Occupational Therapy Orders.
10/27/15 at 1:15 p.m. Speech Therapy Orders.
10/27/15 at 1:30 p.m. Physical Therapy Orders.
10/27/15 at 5:50 p.m. Benadryl 25 mg. IV X 1 (intravenous injection one time) Now, then every 8 hours as needed for itching/redness.
10/27/15 at 7:25 p.m. Capillary Blood Glucose Scale.
10/28/15 at 1:55 p.m. Ok to have ice chips with supervision. Schedule Modified Barium Study for Thursday, 10/29/15 via bed transport.
10/30/15 at 9:23 a.m. Change diet to Soft diet.
10/31/15 at 8:00 a.m. Change CBG's to ACHS (blood glucose to before meals and bedtime).
11/01/15 at 9:00 p.m. Ok to replace Foley Catheter. Ok to hold Ditropan for now.

In an interview on 11/12/15 at 2:50 p.m., S14RN reviewed the medical record for Patient #19 and confirmed the above verbal orders had not been signed by the ordering practitioner. S14RN confirmed the orders had not been signed within 10 days of the order.


Patient #20
Review of the medical record for Patient #20 revealed the patient was admitted on 10/20/15.
Further review of the record revealed the following verbal order had not been authenticated by the licensed practitioner within 10 days of the order:
10/26/15 at 4:35 a.m. Clinimix without lytes 4.25/10 at 75 ml/hour.

In an interview on 11/12/15 at 3:30 p.m., S14RN reviewed the medical record for Patient #20 and confirmed the above order had not been authenticated by the practitioner within 10 days of the order.

Based on observation and interview, the hospital failed to ensure unusable and undated multidose drugs and biologicals were unavailable for patient use as evidenced by having undated, opened multi-dose liquid medications (oral and topical) and expired wound care supplies available for patient use.

Findings:

An observation was conducted on 11/09/15 at 2:00 p.m. of the 9th floor equipment storage room. The observation revealed the following findings: four opened, undated 100 milliliter bottles of oral 2% Lidocaine Viscous Hydrochloride and two opened, undated 50 milliliter bottles of topical 4% Lidocaine Hydrochloride.

An observation was conducted on 11/09/15 at 2:05 p.m. of the 10th floor supply room. The observation revealed the following findings: 14 tubes of MediHoney wound paste with an expiration date of 6/15 and 2 tubes of MediHoney wound paste with an expiration date of 5/15.

An interview was conducted on 11/09/15 at 2:30 p.m. with S2DON and she confirmed the above referenced opened, undated and expired items should have been unavailable for patient use.

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by:
1) Failing to ensure the functionality of a nurse call button located on the handrails of the beds for 36 of 40 beds currently in use at the main campus of the hospital, and;
2) Failing to ensure oxygen E-Cylinders were stored in a secure manner.

Findings:

1) Failing to ensure the functionality of a nurse call button located on the handrails of the beds for 36 of 40 beds currently in use at the main campus of the hospital:

On 11/10/15 at 10:05 a.m. with S13RN in the room of Patient #4 an observation was made of the nurse call button. On the siderails of the patient's bed was a white cross inside a red square, indicating a button to press to call for assistance. The button was noted to be non-functional as it failed to activate any type of nurse call system. S13RN confirmed the white cross in the red square was a nurse call button, but stated the call button was not functional. S13RN indicated that the hospital does have a nurse call system which includes a cord with a button and reported that patients are instructed to use this call system. When asked if it would be possible for a patient who may be sedated and/or confused to press the white cross button on the handrail of the bed thinking they are calling for assistance without the nursing staffs knowledge due to the call button not working, S13RN confirmed that was possible.

In an interview on 11/10/15 at 11:30 a.m. with S1Adm and S2DON a list of the type of beds used in the facility was requested. S1Adm and S2DON confirmed the Stryker beds used in the hospital had nurse call buttons in the side rails that were non-functioning. Both confirmed the only nurse call system that was functioning in the hospital was the call button on the cord.

On 11/10/15 at 1:00 p.m., S1Adm provided a list of beds in the hospital that indicated 36 of the 40 current patient beds had Stryker beds with nurse call buttons in the side rails that were non-functional.


2) Failing to ensure oxygen E-Cylinders were stored in a secure manner:

During an observation on 11/09/15 at 1:55 p.m. of the Soiled Utility room on the 9th floor of the main campus, two (2) E-Cylinder oxygen tanks were observed to be stored free-standing on the floor. The oxygen tanks were not secured. S23RN was present for the observation and confirmed the Oxygen tanks were not secured to prevent the tanks from falling onto the floor.

Based on observation and interview, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable diseases of patients and personnel was implemented according to hospital policy and acceptable standards of infection control practices as evidenced by:
1) Failure to maintain a sanitary environment as evidenced by observations of patient care equipment with tape/tape residue and/or dust accumulation, patient care equipment not stored in a sanitary manner, and a patient nourishment refrigerator with sticky residue;
2) Failure of staff to sanitize/wash hands after removing gloves;
3) Failure to secure a Foley catheter and position the catheter tubing for proper drainage for 1 (#4) of 4 (#2, #4, #30, #R1) observations of Foley catheters;
4) Failure to disinfect a hand held housekeeping cart of cleaning supplies between patient rooms, and;
5) Failure to maintain food sanitation as evidenced by failing to discard expired patient food items that remained available for patient consumption.

Findings:

1) Failure to maintain a sanitary environment as evidenced by observations of patient care equipment with tape/tape residue and/or dust accumulation, patient care equipment not stored in a sanitary manner, and a patient nourishment refrigerator with sticky residue:

Review of the hospital policy titled "Cleaning and Disinfecting of Equipment" policy number 6-6.2.0 revealed all equipment that is visibly soiled will be cleaned with soap and water prior to disinfecting with an EPA approved disinfectant.

An observation was conducted on 11/09/15 at 1:55 p.m. on the 9th floor of a Portable Electronic Vital Sign machine in the hallway between rooms 905 and 907. A large amount of black, sticky tape residue was observed on the machine.

An observation was conducted on 11/09/15 at 2:05 p.m. on the the 9th floor of the Portable Electronic Vital Sign machine in the hallway between rooms 935 and 937. The Portable Vital Sign machine was observed to have a large amount of black, sticky tape residue on the side of the machine and on the electrical cord.

In an interview on 11/09/15 at 3:15 p.m., S13RN confirmed the tape residue on the Electronic Vital Sign machines.


An observation was conducted on 11/09/15 at 2:00 p.m. of the 9th floor equipment storage room. 3 clumps of gray colored dust were noted on the floor and on the wheels of the tracheostomy cart. The tracheostomy cart was also covered with a thick coating of dust.

An observation was conducted on 11/9/15 at 2:35 p.m. of the 10th floor patient nutritional refrigerator in the nutritional room. The observation revealed the left side drawer of the patient nutritional refrigerator had a dried, orange sticky residue on the bottom of the drawer.

An observation was conducted on 11/09/15 at 2:38 p.m. of the 10th floor soiled utility room. 3 blue colored, triangular shaped cloth wedges were noted, one stacked on the sink on top of a metal rod and 2 were lying on the floor. A white towel with multiple yellowish-brown spots was noted to be lying across a utility bin and not contained in a soiled linen bag or bin.

The above referenced observations were confirmed with S2DON at the time of the observations. She indicated the above referenced issues needed to be addressed and corrected.


An observation was conducted on 11/09/15 at 2:45 p.m. of the 10th floor clean supply room with S14RN. A bed side monitor was observed to have a large accumulation of dust and a piece of tape on the pole of the monitor. The Bladder Scanner was observed to have a large accumulation of dust. The Accu Vein finder was observed to have a large accumulation of dust. An opened normal saline syringe connected to tubing was observed in the supply box of the Accu Vein finder. Three (3) portable suction machines were observed to have a large accumulation of dust. S14RN confirmed the above findings.

An observation was conducted on 11/09/15 at 2:55 p.m. of the 10th floor soiled utility room with S14RN. A wheelchair was observed to be stored in the soiled utility room. S14RN stated the wheel chair was not to be stored in the soiled utility room.

An observation was conducted on 11/10/15 at 10:20 a.m. with S27RN in Patient #2's room. The right side rail was observed to have 2 pieces of tape across the top of the side rail. S2RN confirmed the side rail had 2 pieces of tape on the top of the rail, and confirmed the side rail could not be properly disinfected with tape on the surface.


2) Failure of staff to sanitize/wash hands after removing gloves:

Review of the hospital policy titled, "Hand Hygiene" policy number 8-5.0.0, revealed in part the following: If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands. Decontaminate hands: After removing gloves.

On 11/10/15 at 9:40 a.m., an observation was made of S8RT performing respiratory treatments for Patient #4 in isolation for droplet and maximum contact precautions. After performing tracheostomy care for Patient #4, S8RT was observed to remove his gloves, reach inside his isolation gown and retrieve his cell phone from his scrub shirt. S8RT answered the call and then replaced the cell phone inside his scrub shirt underneath the isolation gown. S8RT was observed to then sanitize his hands before reapplying gloves. When asked about the hospital policy for hand sanitizing after removal of gloves, he stated, "I must have missed it."


3) Failure to secure a Foley catheter and position the catheter tubing for proper drainage for 1 (#4) of 4 (#2, #4, #30, #R1) observations of Foley catheters:

On 11/10/15 at 10:05 a.m., an observation was made of Patient #4 in isolation with S13RN. The patient's Foley catheter tubing was observed to be looped down to the floor and back up to the urimeter, preventing unobstructed flow of urine. S13RN confirmed the tubing should be positioned to ensure unobstructed flow of urine. S13RN was asked to assess the patient's catheter to ensure the catheter was secured. S13RN confirmed the patient's catheter was not secured to the patient's leg, but should have been.


4) Failure to disinfect a hand held housekeeping cart of cleaning supplies between patient rooms:

Review of the hospital policy titled "Cleaning-Occupied Isolation Rooms" policy number 7-3.9.0, revealed the following: When leaving an isolation room, remove the protective equipment and dispose of in the trash liner. Remove gloves, perform hand hygiene and don clean gloves. Wash all supplies and equipment with an EPA-registered disinfectant.

On 11/10/15 at 1:55 p.m., an observation was made of S15HK cleaning Patient #27's room. Patient #27 was observed to have signage on the door indicating the patient was in isolation for contact precautions. S15HK was observed to don a isolation gown and gloves. S15HK then carried a metal cart with cleaning supplies into the patient's room and place it on the floor between the patient's bed and the door to the room. After cleaning the room, S15HK, removed the isolation gown and gloves and was observed to pick up the metal cart with cleaning supplies and set it on top of her cart. S15HK then placed the metal cart with cleaning supplies on the floor in Patient #2's room. In an interview at 2:10 p.m., S15HK confirmed she takes the metal cart with cleaning supplies into each patient's room and places it on the floor. She confirmed the metal cart goes from cart to patient's floor, back to the cart, and then to the next patient's room. S15HK confirmed the metal cart was not disinfected between patient rooms.

5) Failure to maintain food sanitation as evidenced by failing to discard expired patient food items that remained available for patient consumption:

An observation was conducted on 11/09/15 at 2:35 p.m. of the 10th floor patient nutritional refrigerator in the nutritional room. The observation revealed the following findings: 17 "Kozy Shack" Sugar-free Smart Gels gelatin tubs with an expiration date of 9/15.

An interview was conducted on 11/09/15 at 2:40 p.m. with S12CNA to confirm the findings referenced above. S12CNA, confirmed, after observation, that the above referenced tubs of Sugar Free gelatin had expired in 9/2015.

An interview was conducted on 11/09/15 at 2:45 p.m. with S2DON and she confirmed the above referenced expired items should have been discarded and unavailable for patient use.





















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