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1 | CCN | Facility | Address | City | State | Zip Code | DATE SURVEY COMPLETED | Reason for Survey | Survey Visit Tag Cited On | Tag | Tag Short Description | CFR | CoP, SoP or Memo Tag Type | Date the Citation was Corrected | Immediate Jeopardy Situation (At Survey Level) | Provider Deemed by at Time of Survey | Statement of Deficiencies text | Statement of Deficiencies text (cont.) | Statement of Deficiencies text (cont. agin) | |||||||
2 | 010007 | MIZELL MEMORIAL HOSPITAL | 702 N MAIN ST | OPP | AL | 36467 | 07/18/2018 | Complaint Investigation | 1 | 0 | Initial Comments | Memo Tag | N | Not Deemed | 32470 A complaint survey was conducted on July 18, 2018 and the following standard level deficiencies were cited: A 0145, A 0159, A 0168, A 0178, A 0392 and A 0396 and the following conditional level deficiency was cited A 0115. | |||||||||||
3 | 010007 | MIZELL MEMORIAL HOSPITAL | 702 N MAIN ST | OPP | AL | 36467 | 07/18/2018 | Complaint Investigation | 1 | A0115 | Patient Rights | 482.13 | Condition of Participation | 08/29/2018 | N | Not Deemed | 32470 Based on review of medical records(MR) agency policies and interviews with the staff it was determined the facility failed to ensure: 1. All patients on the SBCU were kept safe from harm. 2. The use of a manual restraint which can cause an emotional and physical safety of the patient(s) and a potentially unsafe environment. 3. To have documented orders for restraints. 4. To document a patient face-to-face assessment within the policy time frame. This had the potential to negatively affect all patients served by the facility. Findings include: Refer to: A 145, A 159, A 168 and A 178 for additional findings. | |||||||||
4 | 010007 | MIZELL MEMORIAL HOSPITAL | 702 N MAIN ST | OPP | AL | 36467 | 07/18/2018 | Complaint Investigation | 1 | A0145 | Patient Rights: Free From Abuse/Harassment | 482.13(c)(3) | Standard of Participation | 08/29/2018 | N | Not Deemed | 32470 Based on review of medical records (MR), agency policy and procedure, the posted patient bill of rights form posted on the SBCU (Senior Behavioral Care Unit) and interviews with the staff it was determined the facility failed to ensure all patients on the SBCU were kept safe from harm. This affected 2 of 11 MR's reviewed and did affect Patient Identifier (PI) # 5 and had the potential to negatively affect all patients served by the facility. Findings include: Policy: Patient Rights Revised Date: 9/14/2008 "Purpose: To ensure that care, treatment and services are provided in a way that respects and fosters dignity, autonomy, positive self-regard, civil rights and involvement of patient. Policy/Procedure: It is the policy of the Psychiatric Program that no patient shall be deprived of any rights, benefits, or privileges guaranteed by law, while on the Unit. Procedure: F. The following patient rights are adhered to at all times on the unit: 1. A patient is provided with care, treatment and services in the least restrictive environment in accordance with laws and regulations. 14. Privileges may be reasonably restricted by the attending physician in accordance with state law to protect the patient or others from harm, harassment and intimidation... 16. The patient has the right to be free from mental, physical, sexual and verbal abuse, neglect and/or exploitation." Patient Bill of Rights Form: "The Rights and Responsibilities of Our Patients: Mizell Memorial Hospital, in order to foster better channels of communication, closer patient/hospital relationships and more efficient care, presents the following Bill of Rights for you and your family. As a patient, you have the right to: 1. Be treated with respect and dignity as an individual. 10. Receive considerate and respectful care in a clean and safe environment..." 1. PI # 5 was admitted to the facility on 11/21/17 with admitting diagnoses of Psychosis and Inappropriate sexual behavior. Review of the Patient Progress Notes on dated 11/21/17 revealed the patient weighted 161 pounds (lbs) and 9.6 ounces (oz). Review of the Patient Progress Notes dated 11/26/17 revealed the patient weighted 158 lbs 3 oz. Review of the spread sheet started on 11/21/17 and continues through discharge on 12/5/17 revealed a weight on week one as 158.2 lbs and at discharge or week two a weight of 149 lbs 8 oz. Review of the Patient Progress Notes of the nutritional intake from 11/22/18 to 11/25/17 revealed the following: 11/22/17 8:34 AM - 50% of breakfast consumed. 12:00 PM - 75% of lunch consumed. 5:15 PM - 0% of supper consumed. 11/23/17 8:10 AM - 25% of breakfast consumed. 12:26 PM - 0% of lunch consumed. 5:15 PM - 50% of supper consumed. 11/24/17 8:26 AM - 5% of breakfast consumed. 11:30 AM - 0% of lunch consumed. 6:15 PM - 25% of supper consumed. 11/25/17 7:30 AM - 10% of breakfast consumed. 12:30 PM - 25% of lunch consumed. 5:45 PM - 50% of supper consumed. 11/26/17 7:30 AM - 75% of breakfast consumed. 12:26 PM - 0% of lunch consumed. 5:39 PM - 50% of supper consumed. 11/27/17 8:00 AM - 25% of breakfast consumed 12:45 PM - 50% of lunch consumed 6:00 PM - 100% of supper consumed 11/28/17 7:30 AM - 75% of breakfast consumed 12:46 - 0% of lunch consumed 5:30 PM - 50% of supper consumed 11/29/17 8:07 AM - 0% of breakfast consumed 12:29 PM - 0% of lunch consumed 5:51 PM - 75% of supper consumed 11/30/17 7:55 AM - 0% of breakfast consumed No documentation of lunch consumption 5:57 PM - 25% of supper consumed 12/1/17 7:30 AM - 75% of breakfast consumed 12:15 PM - 25% of lunch consumed 5:30 PM - 75% of supper consumed 12/2/17 7:30 AM - 75% of breakfast consumed No documentation of lunch consumption 6:45 PM - 50% of supper consumed 12/3/17 9:01 AM - 100% of breakfast consumed No documentation of lunch consumption 6:22 PM - 10% of supper consumed 12/4/17 7:30 AM - 75% of breakfast consumed 12:30 PM - 50% of lunch consumed 5:15 - 75% of supper consumed 12/5/17 8:35 AM - 0% of breakfast consumed An interview was conducted on 7/11/18 at 4:34 PM with EI # 15, RN (Registered Nurse) and was asked if a weight loss was noticed on a patient what is typically done by the staff? EI # 15 responded by stating " we order ensure and watch the patient for a couple of days and if not eating any better, then we start pushing fluids like get two cups of juice in him/her especially on night shift. We don't usually report it to Dr. (doctor) (name)." Review of the entire MR revealed no documentation the patient was given a nutritional supplement at any time throughout each day. Review of all the physician orders in the MR revealed no documentation an order was written for a dietary consult or a nutritional supplement to be given daily or with each meal. An interview was conducted on 7/13/18 at 1:15 PM with Employee Identifier (EI) # 1, Director of SBCU, who confirmed the above mentioned findings. Review of all the nursing progress notes dated 11/21/17 to 12/5/17 revealed no documentation the physician was notified of the patient's weight loss. Review of the the patient progress notes dated 11/21/17 - 11/26/17 and 11/29/17 to 12/5/17 revealed the nursing staff documented under the nursing assessment skin: warm, dry, Changes to skin: none and in the wound assessment section of each note was documented N/A (not Applicable). Review of the patient progress note dated 11/27/17 at 5:54 AM by EI # 15 documented under the narrative nurses note "Drsng (dressing) on left forearm changed, skin tear healing well, no bleeding." An interview was conducted on 7/11/18 at 4:34 PM with EI # 15 who stated when asked about the patient's skin tear was not sure how he/she received the skin tear but stated "he was always in the recliner and flailing his/her arms and sometimes they scrape them on the recliners... I remember his/her skin being like so many of the frail older people we get, just typical paper skin and easy to bruise." Review of the patient progress notes dated 11/28/17 at 7:51 AM by EI # 1,Director of SBCU, revealed under the nursing assessment for skin: warm, skin tear to L (left) forearm. Changes to skin: skin tear. Wound assessment N/A. In an interview on 7/12/18 at 2:28 PM EI # 1 was asked if he/she knew when the skin tear occurred. EI # 1 replied by stating" I do not. When I saw it, it had a dressing on it. It had gauze and coban around the outside. The daughter saw it because she asked about it being changed the day before I saw it. No one ever documented when the skin tear occurred only one documentation that it was cleansed, didn't say with what, and telfa on it." Review of the progress note dated 11/28/17 at 4:35 PM by EI # 13, LPN (Licensed Practical Nurse) revealed the following documentation under the narrative nurse note " ...Dressing to arm changed as asked by family member during visitation. Continues to have some bloody discharge. No redness to area surrounding. Cleaned and covered with Telfa and wrapped with Coban." Review of the entire nurse note dated 11/28/18 revealed no documentation of how the wound care was performed. Review of all the physician orders revealed no documentation of an order written for wound care. Review of the all of the nursing notes within the MR from 11/29/17 to 12/5/17 revealed no documentation of the healing of the skin tear or any further documentation of dressing changes. An interview was conducted on 7/13/18 at 1:15 PM with Employee Identifier (EI) # 1 who confirmed the above mentioned findings. | |||||||||
5 | 010007 | MIZELL MEMORIAL HOSPITAL | 702 N MAIN ST | OPP | AL | 36467 | 07/18/2018 | Complaint Investigation | 1 | A0159 | Patient Rights: Restraint Or Seclusion | 482.13(e)(1)(i)(A) | Standard of Participation | N | Not Deemed | 40119 Based on review of medical records, Facility policy and procedure, and interview(s) it was determined that patient(s) were being placed in a manual hold for administration of psychotropic medications. The facility failed to recognize the use of a manual hold as a restraint. This had the potential to affect all patients served by the facility and did affect Patient Identifier (PI) # 10. Findings include: Policy: Restraint and Seclusion Revised Date: 9/21/2017 "Purpose: To establish guidelines for the safe, effective use of seclusion and/or restraints... To ensure the protection of the patient's rights, dignity, physical and psychological well being of individuals requiring restraint and/or seclusion Definitions: A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. B. Behavioral Health Restraint is the restriction of patient movement for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. ...F. Continuous Observations: Face to face in person monitoring. Policy/Procedure: It is the policy of the Psychiatric Program that no patient shall be deprived of any rights, benefits, or privileges guaranteed by law, while on the Unit. Procedure: ...B. ...Any application of restraint must involve assessment within one hour by a qualified registered nurse (RN), physician assistant (PA) or LIP (Licensed Independent Practitioner) as to the degree and likelihood of the harm that may be produced by the restraint ...D. Orders: 1. Restraint shall be ordered by a physician or LIP authorized by the medical staff. ...3. The order shall specify the method of restraint and/or seclusion to be used. ...S. Each instance of restraint or seclusion is documented in the seclusion/restraint log. The log will include date, time, patient name, age, gender, case number, type of restraint/seclusion, time in, time out, staff initiating, and signature of review by the Program Director or Medical Director, and name of RN (Registered Nurse) who initiated the restraint or seclusion time of face to face evaluation and by whom. 1. PI # 10 was admitted to the SBCU (Senior Behavior Care Unit) on 7/11/18 with diagnosis of acute psychosis. Review of the Verbal/Phone/Protocol Order dated 7/11/18 at 11:05 PM revealed physician order for Thorazine (chlorpromazine) Injection 50 mg (milligrams)/ 2 ml (milliters) 50 mg x (times) 1 IM (intramuscular) Review of the patient progress notes dated 7/11/18 revealed a nurse note at 11:10 PM with documentation of patient becoming combative towards staff and MD (Medical Doctor) "notified with 1 x (one time) order for Thorazine 50 mg to be given at this time." Review of the patient progress notes dated 7/11/18 revealed a nurse note at 11:12 PM with the following documentation, "PRN (as needed) Thorazine given at this time. Cleansed area and IM injected to left buttock." An interview was conducted on 7/12/18 at 8:00 AM with EI (Employee Identifier) # 11, RN, during the interview the surveyor asked EI # 11 about how an injection would be given on a combative patient. EI # 11 stated, "We call the doctor. If the doctor gives the order then we don't let them refuse. We usually have someone hold them... We lay them over the bed and hold them down and give it. We had to do one last night." Surveyor then asked EI # 11 what happened "last night." EI # 11 stated, "We laid her/him on bed chest down. She/He was admitted last night. She/He just got one shot." Surveyor then asked EI # 11 how many people held patient for injection. EI # 11 stated, "Three of us held her/him and one gave the shot." An interview was conducted on 7/13/18 at 7:45 AM with EI # 7, Patient Care Technication (PCT). During the interview the surveyor asked EI # 7 what occurred on 7/11/18 night shift with PI # 10. EI # 7 stated, "PI # 10 started going to door, then came at me and tried to grab my boobs. She/He picked up chair and throw it at the LPN (Licensed Practical Nurse). She/He tried to hit my partner in the privates. She was trying to hit us and kick. She wanted to leave. EI # 7 then verbalized that EI # 11 called MD. EI # 7 then stated, "We got a hold of him/her on each side under his/her arms. We got her/him in his/her room sat him/her on the bed and laid him/her down. Then the LPN gave him/her the shot." Surveyor then asked EI # 7 to clarify how PI # 10 was "laid down." EI # 7 stated, "Turned on side and held his/her arm to keep him/her from hitting and holding him/her on the back to keep from rolling back over when the nurse was trying to give the shot." EI # 7 then clarified how patient was placed on the bed. EI # 7 stated, "The nurse picked up his/her legs and put them on the bed. I was at the top part trying to get him/her on the side." Based on the previous, it was determined that PI # 10 was placed in a manual method restraint for the purpose of administration of an injection. An interview was conducted on 7/13/18 at 12:48 PM, with EI # 1 and EI # 2, Director of Nursing, who confirmed the previous findings. | ||||||||||
6 | 010007 | MIZELL MEMORIAL HOSPITAL | 702 N MAIN ST | OPP | AL | 36467 | 07/18/2018 | Complaint Investigation | 1 | A0168 | Patient Rights: Restraint Or Seclusion | 482.13(e)(5) | Standard of Participation | N | Not Deemed | 40119 Based on review of medical records, Facility policy and procedure, and interview(s) it was determined that patient(s) were being placed in a manual hold for administration of psychotropic medications. The facility failed to have a documented order for a restraint. This had the potential to affect all patients served by the facility and did affect Patient Identifier (PI) # 10. Findings include: Policy: Restraint and Seclusion Revised Date: 9/21/2017 "Purpose: To establish guidelines for the safe, effective use of seclusion and/or restraints... To ensure the protection of the patient's rights, dignity, physical and psychological well being of individuals requiring restraint and/or seclusion Definitions: A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. B. Behavioral Health Restraint is the restriction of patient movement for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. Policy/Procedure: It is the policy of the Psychiatric Program that no patient shall be deprived of any rights, benefits, or privileges guaranteed by law, while on the Unit. Procedure: ...D. Orders: 1. Restraint shall be ordered by a physician or LIP authorized by the medical staff. ...3. The order shall specify the method of restraint and/or seclusion to be used. 1. PI # 10 was admitted to the SBCU (Senior Behavior Care Unit) on 7/11/18 with a diagnosis of acute psychosis. Review of the Verbal/Phone/Protocol Order dated 7/11/18 at 11:05 PM revealed a physician order for Thorazine (chlorpromazine) Injection 50 mg (milligrams)/ 2 ml (milliters) 50 mg x (times) 1 IM (intramuscular) Review of the patient progress notes dated 7/11/18 revealed a nurse note at 11:10 PM with documentation of patient becoming combative towards staff and MD (Medical Doctor) "notified with 1 x (one time) order for Thorazine 50 mg to be given at this time." Review of the patient progress notes dated 7/11/18 revealed a nurse note at 11:12 PM with the following documentation, "PRN (as needed) Thorazine given at this time. Cleansed area and IM (Intramuscular) injected to left buttock." An interview was conducted on 7/12/18 at 8:00 AM with EI (Employee Identifier) # 11, RN, during the interview the surveyor asked EI # 11 about how an injection would be given on a combative patient. EI # 11 stated, "We call the doctor. If the doctor gives the order then we don't let them refuse. We hold them down and give it. We lay them over the bed and give it. We usually have someone hold them... We had to do one last night." Surveyor then asked EI # 11 what happened "last night." EI # 11 stated, "We laid her/him on bed chest down. She/He was admitted last night. She/He just got one shot." Surveyor then asked EI # 11 how many people held patient for injection. EI # 11 stated, "Three of us held her/him and one gave the shot." An interview was conducted on 7/13/18 at 7:45 AM with EI # 7, Patient Care Technication (PCT). During the interview the surveyor asked EI # 7 what occurred on 7/11/18 night shift with PI # 10. EI # 7 stated, "PI # 10 started going to door, then came at me and tried to grab my boobs. She/He picked up chair and throw it at the LPN (Licensed Practical Nurse). She/He tried to hit my partner in the privates. She was trying to hit us and kick. She wanted to leave. EI # 7 then verbalized that EI # 11 called MD. EI # 7 then stated, "We got a hold of him/her on each side under his/her arms. We got her/him in his/her room sat him/her on the bed and laid him/her down. Then the LPN gave him/her the shot." Surveyor then asked EI # 7 to clarify how PI # 10 was "laid down." EI # 7 stated, "Turned on side and held his/her arm to keep him/her from hitting and holding him/her on the back to keep from rolling back over when the nurse was trying to give the shot." EI # 7 then clarified how patient was placed on the bed. EI # 7 stated, "The nurse picked up his/her legs and put them on the bed. I was at the top part trying to get him/her on the side." Based on the previous, it was determined that PI # 10 was placed in a manual method restraint for the purpose of administration of an injection. Review of the Verbal/Phone/Protocol Order and Physician Orders dated 7/11/18 revealed no documentation of an order for a manual hold to administer injection. An interview was conducted on 7/13/18 at 12:48 PM, with EI # 1 and EI # 2, Director of Nursing, who confirmed the previous findings. | ||||||||||
7 | 010007 | MIZELL MEMORIAL HOSPITAL | 702 N MAIN ST | OPP | AL | 36467 | 07/18/2018 | Complaint Investigation | 1 | A0178 | Patient Rights: Restraint Or Seclusion | 482.13(e)(12) | Standard of Participation | N | Not Deemed | 40119 Based on review of medical records, Facility policy and procedure, and interview(s) it was determined that patient(s) were being placed in a manual hold for administration of psychotropic medications. The facility failed to document a patient face-to-face assessment. This had the potential to affect all patients served by the facility and did affect Patient Identifier (PI) # 10. Findings include: Definition of restraint: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely... Policy: Restraint and Seclusion Revised Date: 9/21/2017 "Purpose: To establish guidelines for the safe, effective use of seclusion and/or restraints... To ensure the protection of the patient's rights, dignity, physical and psychological well being of individuals requiring restraint and/or seclusion Definitions: A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. B. Behavioral Health Restraint is the restriction of patient movement for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. ...F. Continuous Observations: Face to face in person monitoring. Policy/Procedure: It is the policy of the Psychiatric Program that no patient shall be deprived of any rights, benefits, or privileges guaranteed by law, while on the Unit. Procedure: ...B. ...Any application of restraint must involve assessment within one hour by a qualified registered nurse (RN), physician assistant (PA), or LIP (Licensed Independent Practitioner) as to the degree and likelihood of the harm that may be produced by the restraint ...S. Each instance of restraint or seclusion is documented in the seclusion/restraint log. The log will include date, time, patient name, age, gender, case number, type of restraint/seclusion, time in, time out, staff initiating, and signature of review by the Program Director or Medical Director, and name of RN (Registered Nurse) who initiated the restraint or seclusion time of face to face evaluation and by whom. 1. PI # 10 was admitted to the SBCU (Senior Behavior Care Unit) on 7/11/18 with diagnosis of acute psychosis. Review of the Verbal/Phone/Protocol Order dated 7/11/18 at 11:05 PM revealed physician order for Thorazine (chlorpromazine) Injection 50 mg (milligrams)/ 2 ml (milliters) 50 mg x (times) 1 IM (intramuscular) Review of the patient progress notes dated 7/11/18 revealed a nurse note at 11:10 PM with documentation of patient becoming combative towards staff and MD (Medical Doctor) "notified with 1 x (one time) order for Thorazine 50 mg to be given at this time." Review of the patient progress notes dated 7/11/18 revealed a nurse note at 11:12 PM with the following documentation, "PRN (as needed) Thorazine given at this time. Cleansed area and IM (Intramuscular) injected to left buttock." An interview was conducted on 7/12/18 at 8:00 AM with EI (Employee Identifier) # 11, RN, during the interview the surveyor asked EI # 11 about how an injection would be given on a combative patient. EI # 11 stated, "We call the doctor. If the doctor gives the order then we don't let them refuse. We hold them down and give it. We lay them over the bed and give it. We usually have someone hold them... We had to do one last night." Surveyor then asked EI # 11 what happened "last night." EI # 11 stated, "We laid her/him on bed chest down. She/He was admitted last night. She/He just got one shot." Surveyor then asked EI # 11 how many people held the patient for injection. EI # 11 stated, "Three of us held her/him and one gave the shot." An interview was conducted on 7/13/18 at 7:45 AM with EI # 7, Patient Care Technication (PCT). During the interview the surveyor asked EI # 7 what occurred on 7/11/18 night shift with PI # 10. EI # 7 stated, "PI # 10 started going to door, then came at me and tried to grab my boobs. She/He picked up chair and throw it at the LPN (Licensed Practical Nurse). She/He tried to hit my partner in the privates. She was trying to hit us and kick. She wanted to leave. EI # 7 then verbalized that EI # 11 called MD. EI # 7 then stated, "We got a hold of him/her on each side under his/her arms. We got her/him in his/her room sat him/her on the bed and laid him/her down. Then the LPN gave him/her the shot." Surveyor then asked EI # 7 to clarify how PI # 10 was "laid down." EI # 7 stated, "Turned on side and held his/her arm to keep him/her from hitting and holding him/her on the back to keep from rolling back over when the nurse was trying to give the shot." EI # 7 then clarified how patient was placed on the bed. EI # 7 stated, "The nurse picked up his/her legs and put them on the bed. I was at the top part trying to get him/her on the side." Based on the previous, it was determined that PI # 10 was placed in a manual method restraint for the purpose of administration of an injection. Review of the Patient Progress Notes 7/11/18 through 7/12/18 at 1:23 AM revealed no documentation of an RN assessment. Review of the Patient Progress Notes 7/11/18 through 7/12/18 at 1:23 AM, revealed no documentation of an assessment within one hour by a qualified RN, PA, or LIP as to the degree and likelihood of the harm that may be produced by the restraint or a restraint log with time of face to face evaluation and by whom. An interview was conducted on 7/13/18 at 12:48 PM, with EI # 1 and EI # 2, Director of Nursing, who confirmed the previous findings. | ||||||||||
8 | 010007 | MIZELL MEMORIAL HOSPITAL | 702 N MAIN ST | OPP | AL | 36467 | 07/18/2018 | Complaint Investigation | 1 | A0392 | Staffing And Delivery Of Care | 482.23(b) | Standard of Participation | 08/29/2018 | N | Not Deemed | 32470 Based on review of medical records (MR), facility policies and procedure, the 3M (Brand name of product) wound protocol and interviews with the staff it was determined the facility failed to ensure: 1. The physician was notified of patient weight loss and new wounds 2. Orders were written for wound care 3. 3M (Brand name of product) protocol followed for Skin Tears 4. Wound care orders were documented per physician's orders. This affected 5 of 11 MR's reviewed and did affect PI (Patient Identifier) # 5, # 3, # 4, # 6 and # 7 and had the potential to negatively affect all patient served by the facility. Findings include: Policy: Physician Notification of change in Patient Condition Reference # 9171 Revised Date; 10/17/11 Policy: "The physician will be notified immediately of any adverse changes in the patient' condition. Responsibility: It is the responsibility of the nurse assigned to the patient to determine that the patient's condition has changed significantly and to notify the patient's attending physician, surgeon or consultant." Policy: Wound Staging and Documentation Reference # 9196 Revised Date: 8/5/15 1. MMH (Mizell Memorial Hospital) will utilize adopted 3M Wound Care Protocol c. Institute nursing interventions to include speciality selection, preventive measures, skin protection, appropriate product selection based on stage of wound, exudates, presence of infection. and MMH product availability. d. Make appropriate referrals/consults (Dietary, PT (physical therapy). e. Determine goals/desired outcome of patient care. f. Implement required Wound Care treatment (see protocols). 4. Interim Patient Interventions in lieu of a Physician Order: a. Orders not received within 4 hours of patient arrival to the nursing unit will default to 3M wound care protocols, taking into consideration patient allergies and sensitivities. b. The nurse will initiate such protocol which have been approved by the Medical Staff. ( 3M Wound Care Protocol). c. The attending physician will review the protocol initiated and recommended any changes or variations to established treatment." 3M Wound Care Protocol Reference # 9196 a Revised Date: 8/5/15 F. Skin Tear Definition: Skin tear is a traumatic wound that results in separation of the epidermis from the dermis. It can be partial thickness, usually due to friction and/or shear force. 1. Cleanse wound with 3M Wound Cleanser 2. Apply 3M No Sting Barrier film 3. Cover with 3M Tegaderm Transparent Film Dressing 4. Change every 7 days and as needed. Policy: Physician Order Review- RN (Registered Nurse) Verification Reference # 9172 Revised Date; 5/17/18 Policy: "Every licensed nurse will be responsible to ensure that the physician's orders of each patient has been carried out as intended." 1. PI # 5 was admitted to the facility on 11/21/17 with admitting diagnoses of Psychosis and Inappropriate sexual behavior. Review of the Patient Progress Notes on admission dated 11/21/17 revealed the patient weighted 161 pounds (lbs) and 9.6 ounces (oz). Review of the Patient Progress Notes dated 11/26/17 revealed a patient weight of 158 lbs 3 oz. Review of the spread sheet within the patient's chart revealed it was started on 11/21/17 and continues through discharge on 12/5/17. A weight on week one was documented as 158.2 lbs and at discharge or week two a weight of 149 lbs 8 oz. Review of the Patient Progress Notes of the nutritional intake from 11/22/18 to 12/5/17 revealed the following: 11/22/17 8:34 AM - 50% of breakfast consumed. 12:00 PM - 75% of lunch consumed. 5:15 PM - 0% of supper consumed. 11/23/17 8:10 AM - 25% of breakfast consumed. 12:26 PM - 0% of lunch consumed. 5:15 PM - 50% of supper consumed. 11/24/17 8:26 AM - 5% of breakfast consumed. 11:30 AM - 0% of lunch consumed. 6:15 PM - 25% of supper consumed. 11/25/17 7:30 AM - 10% of breakfast consumed. 12:30 PM - 25% of lunch consumed. 5:45 PM - 50% of supper consumed. 11/26/17 7:30 AM - 75% of breakfast consumed. 12:26 PM - 0% of lunch consumed. 5:39 PM - 50% of supper consumed. 11/27/17 8:00 AM - 25% of breakfast consumed 12:45 PM - 50% of lunch consumed 6:00 PM - 100% of supper consumed 11/28/17 7:30 AM - 75% of breakfast consumed 12:46 - 0% of lunch consumed 5:30 PM - 50% of supper consumed 11/29/17 8:07 AM - 0% of breakfast consumed 12:29 PM - 0% of lunch consumed 5:51 PM - 75% of supper consumed 11/30/17 7:55 AM - 0% of breakfast consumed No documentation of lunch consumption 5:57 PM - 25% of supper consumed 12/1/17 7:30 AM - 75% of breakfast consumed 12:15 PM - 25% of lunch consumed 5:30 PM - 75% of supper consumed 12/2/17 7:30 AM - 75% of breakfast consumed No documentation of lunch consumption 6:45 PM - 50% of supper consumed 12/3/17 9:01 AM - 100% of breakfast consumed No documentation of lunch consumption 6:22 PM - 10% of supper consumed 12/4/17 7:30 AM - 75% of breakfast consumed 12:30 PM - 50% of lunch consumed 5:15 - 75% of supper consumed 12/5/17 8:35 AM - 0% of breakfast consumed An interview was conducted on 7/11/18 at 4:34 PM with EI # 15, RN (Registered Nurse) and was asked if a weight loss was noticed on a patient what is typically done by the staff? EI # 15 responded by stating " we order ensure and watch the patient for a couple of days and if not eating any better, then we start pushing fluids like get two cups of juice in him/her especially on night shift. We don't usually report it to Dr. (doctor) (name)." Review of the entire MR to include patient progress notes and physician order revealed no documentation the patient was given a nutritional supplement at any time throughout each day during his/her stay on the behavioral unit. Review of all the physician orders in the MR revealed no documentation an order was written for a dietary consult or a nutritional supplement to be given daily or with each meal. Review of all the nursing progress notes dated 11/21/17 to 12/5/17 revealed no documentation the physician was notified of the patient's weight loss. Review of the the patient progress notes dated 11/21/17 - 11/26/17 and 11/29/17 to 12/5/17 revealed the nursing staff documented under the nursing assessment skin: warm, dry, Changes to skin: none and in the wound assessment section of each note was documented N/A (not Applicable). Review of the patient progress note dated 11/27/17 at 5:54 AM by EI # 15 documented under the narrative nurses note "Drsng (dressing) on left forearm changed, skin tear healing well, no bleeding." An interview was conducted on 7/11/18 at 4:34 PM with EI # 15 who stated when asked about the patient's skin tear was not sure how he/she received the skin tear but stated "he/she was always in the recliner and flailing his/her arms and sometimes they scrape them on the recliners... I remember his skin being like so many of the frail older people we get, just typical paper skin and easy to bruise." Review of the patient progress notes dated 11/28/17 at 7:51 AM by EI # 1, RN, Director of SBCU, revealed under the nursing assessment for skin: warm, skin tear to L (left) forearm. Changes to skin: skin tear. Wound assessment N/A. In an interview on 7/12/18 at 2:28 PM EI # 1 was asked if he/she knew when the skin tear occurred. EI # 1 replied by stating" I do not. When I saw it, it had a dressing on it. It had gauze,well coban around the outside. The daughter saw it because she asked about it being changed the day before I saw it. No one ever documented when the skin tear occurred only one documentation that it was cleansed, didn't say with what, and telfa on it." Review of the progress note dated 11/28/17 at 4:35 PM by EI # 13, LPN (Licensed Practical Nurse) revealed the following documentation under the narrative nurse note " ...Dressing to arm changed as asked by family member during visitation. Continues to have some bloody discharge. No redness to area surrounding. Cleaned and covered with Telfa and wrapped with Coban." Review of the entire nurse note dated 11/28/18 revealed no documentation of how the wound care was performed and what the wound was cleaned with. Review of all the physician orders revealed no documentation of an order written for wound care. Review of the all of the nursing notes within the MR from 11/29/17 to 12/5/17 revealed no documentation of the healing of the skin tear or any further documentation of dressing changes. An interview was conducted on 7/13/18 at 1:15 PM with Employee Identifier (EI) # 1 who confirmed the above mentioned findings. 40119 2. PI # 3 was admitted to the facility on 10/27/17 with admitting diagnoses of Psychosis and Organic Brain Disease Review of the Patient Progress Notes dated 10/27/17 revealed the patient weighed 138 lbs and 6.4 oz. Review of the Patient Progress Notes dated 10/29/17 revealed the patient weighed 138 lbs and 0 oz and a note dated 11/5/17 revealed the patient weighed 131 lbs and 1.6 oz. Review of the spread sheet within the patient's chart revealed it was started on 10/27/17 and continues through discharge on 11/10/17. A weight was documented on admission of 138 lbs and 6.4 oz. A second weight two days later dated 10/29/17, was documented as 138 lbs and 0 oz. A discharge or week two weight dated 11/5/17, was documented as 131 lbs and 1.6 oz. Based on the previous, PI # 3 had a documented weight loss of 6 lbs and 9 oz in one week and a 7 lbs and 4.8 oz weight loss since admission of 10/27/18. Review of the Patient Progress Notes of the nutritional intake from 10/27/18 to 11/10/17 revealed the following: 10/27/17 6:13 PM - 5% of supper consumed. 10/28/17 10:24 AM - 25% of breakfast consumed. 12:48 PM - 50% of lunch consumed. 6:06 PM - 0% of supper consumed. 10/29/17 7:57 AM - 0% of breakfast consumed. 1:10 PM - 50% of lunch consumed. 6:29 PM - 25% of supper consumed. 10/30/17 7:51 AM - 75% of breakfast consumed. 12:00 PM - 25% of lunch consumed. 6:08 PM - 75% of supper consumed. 10/31/17 8:16 AM - 0% of breakfast consumed. 12:56 PM - 0% of lunch consumed. 5:57 PM - 75% of supper consumed. 11/1/17 8:12 AM - 25% of breakfast consumed. 1:04 PM - 15% of lunch consumed. No documentation of supper consumption 11/2/17 8:11 AM - 25% of breakfast consumed 12:26 PM - 25% of lunch consumed 6:02 PM - 5% of supper consumed 11/3/17 8:10 AM - 25% of breakfast consumed 12:54 - 30% of lunch consumed 5:45 PM - 50% of supper consumed 11/4/17 7:45 AM - 25% of breakfast consumed 12:15 PM - 25% of lunch consumed 6:05 PM - 50% of supper consumed 11/5/17 8:06 AM - 75% of breakfast consumed 12:55 PM - 100% of lunch consumed 5:52 PM - 75% of supper consumed 11/6/17 8:30 AM - 25% of breakfast consumed 12:52 PM - 25% of lunch consumed 6:04 PM - 50% of supper consumed 11/7/17 8:25 AM - 40% of breakfast consumed 1:09 PM - 50% of lunch consumed 6:34 PM - 100% of supper consumed 11/8/17 8:41 AM - 40% of breakfast consumed No documentation of lunch consumption No documentation of supper consumption 11/9/17 9:54 AM - 0% of breakfast consumed 11:45 PM and 2:15 PM- 25% of lunch consumed 5:15 - 50% of supper consumed 11/10/17 No documentation of breakfast consumption 12:30 AM - 100% of lunch consumed An interview was conducted on 7/11/18 at 4:34 PM with EI # 15. EI # 15 was asked if a weight loss was noticed on a patient what is typically done by the staff ? EI # 15 responded by stating " we order ensure and watch the patient for a couple of days and if not eating any better, then we start pushing fluids like get two cups of juice in him/her especially on night shift. We don't usually report it to Dr. (doctor) (name)." Review of the CNA (Certified Nursing Assistant) flow chart revealed that ensure was given on 11/1/17 at 6:01 PM and 11/3/18 at 9:34 AM. No documentation was found of amount of ensure that was consumed by patient on 11/1/17 or 11/3/17. Review of the entire MR revealed no documentation that ensure was offered at any other date(s) or time(s). Review of all the physician orders in the MR revealed no documentation an order was written for a dietary consult or a nutritional supplement to be given daily or with each meal. Review of all the nursing progress notes dated 10/27/17 to 11/10/17 revealed no documentation the physician was notified of the patient's weight loss. An interview was conducted on 7/13/18 at 12:55 PM, with EI # 1 and EI # 2, Director of Nursing, who confirmed the previous findings. 3. PI # 4 was admitted to the facility on 11/20/17 with admitting diagnoses of Alzheimer's dementia with mood disorder secondary to organic brain disease, organic brain disease. Review of the Order Detail/ wound care for nursing report dated 11/30/17 at 1:10 PM revealed the following order: clean Lt (left) buttocks with NS (normal saline), pat dry with 4 x (by) 4 (gauze), apply foam dressing to area and cover with OP site (transparent, adhesive film) every other day and as needed. Review of the patient progress notes dated 11/30/17 at 1:10 PM revealed the following documentation: Pt (patient) has shearing to left buttock area...treatment in progress applied foam dressing to area and cover with op site... There was no documentation of what was used to clean the wound or that it was patted dry with 4x4 gauze. Review of the order detail/ wound care for nursing report dated 11/30/17 at 5:22 PM revealed the following documentation under administrations: Given 1 EA (each) Topical No documentation was found on the order detail/ wound care for nursing report of the actual wound care that was performed or what the "topical" treatment was. Based on the previous the nurse failed to provide wound care per the physician's order on 11/30/17. Review of the patient progress notes dated 12/2/17 revealed no documentation that wound care was provided to left buttock area. Review of the order detail/ wound care for nursing report dated 12/2/17 at 4:15 PM revealed the following documentation under administrations: Given 1 EA Topical No documentation was found on the order detail/ wound care for nursing report of the actual wound care that was performed or what the "topical" treatment was. Based on the previous the nurse failed to document what wound care was provided to left buttock area on 12/2/17. An interview was conducted on 7/13/18 at 12:56 PM, with EI # 1 and EI # 2, who confirmed the previous findings. 4. PI # 6 was admitted to the facility on 12/1/17 with admitting diagnoses of Psychosis NOS (Not otherwise specified). Review of the graphic and I & O (intake and output) spreadsheet revealed the patient weighed 114 lbs and 2 oz on 12/1/17. Review of the graphic I &O spreadsheet revealed the patient weighed of 119 lbs and 2 oz on 12/3/17. This was a weight gain of 5 lbs within two days. Review of the Patient Progress Notes of the nutritional intake from 12/1/18 to 12/3/17 revealed the following: 12/1/17 6:27 PM - 0% of supper consumed. 12/2/17 7:30 AM - 100% of breakfast consumed. No documentation of lunch consumed. 6:50 PM - 100% of supper consumed. 12/3/17 9:31 AM - 50% of breakfast consumed. 12:00 PM - 25% of lunch consumed. 6:27 PM - 10% of supper consumed. Review of the nursing progress notes dated 12/1/17 to 12/4/17 revealed no documentation the physician was notified of the patient's weight gain. An interview was conducted on 7/13/18 at 12:51 PM, with EI # 1 and EI # 2, who confirmed the previous findings. 5. PI # 7 was admitted to the facility on 12/13/17 with admitting diagnoses of Psychosis NOS. Review of the graphic and I & O spreadsheet revealed the patient weighed 134 lbs and 4 oz on 12/13/17. Review of the graphic I &O spreadsheet revealed the patient weighed 169 lbs and 4 oz on 12/17/17. This was a weight gain of 35 lbs within four days. Review of the Patient Progress Notes of the nutritional intake from 12/13/18 to 12/17/17 revealed the following: 12/13/17 6:11 PM - 25% of supper consumed. 12/14/17 7:30 AM - 0% of breakfast consumed. 12:00 PM - 50% of lunch consumed. 5:59 PM - 25% of supper consumed. 12/15/17 8:38 AM - 90% of breakfast consumed. 12:00 PM - 0% of lunch consumed. 5:30 PM - 50% of supper consumed. 12/16/17 7:45 AM - 75% of breakfast consumed. 12:15 PM - 0% of lunch consumed. 5:15 PM - 50% of supper consumed. 12/17/17 8:54 AM - 0% of breakfast consumed. 12:00 PM - 50% of lunch consumed. 6:45 PM - 50% of supper consumed. Review of the nursing progress notes dated 12/13/17 to 12/17/17 revealed no documentation the physician was notified of the patient's weight gain. Review of the physician's orders dated 12/15/17 revealed order for daily dressing change to right big toe stitches as follows: Cleanse with normal saline daily, pat dry, and apply Band-Aid. Review of the physician's orders dated 12/18/17 revealed the following order: Remove sutures to right great toe. Cleanse with soap and water, Bactroban to suture line for 5 days. Review of the nursing progress notes and the wound care for nursing report(s) dated 12/15/17 to 12/22/17 revealed no documentation of the wound care that was provided to the right great toe for dates of 12/15/17 thru 12/20/17. Based on the previous, nursing failed to document wound care that was provided. Review of the nursing progress note dated 12/21/17 at 11:40 AM documentation as follows: Wound to right foot cleansed with wound cleanser, patted dry with gauze, skin prep applied to edges, and two steri-strips applied to close. Further of the nursing progress note dated 12/21/17 at 11:40 AM revealed no documentation that the physician was notified the wound to the right foot was open and required "two steri-strips applied to close." Based on the previous, nurse failed to provide wound care as per the physician's order. Review of the nursing progress notes and the wound care for nursing report(s) dated 12/15/17 to 12/22/17 revealed no documentation of a wound assessment on the right great toe for the dates of 12/16/17 thru 12/20/17. An interview was conducted on 7/13/18 at 1:00 PM, with EI # 1 and EI # 2, who confirmed the previous findings. | |||||||||
9 | 010007 | MIZELL MEMORIAL HOSPITAL | 702 N MAIN ST | OPP | AL | 36467 | 07/18/2018 | Complaint Investigation | 1 | A0396 | Nursing Care Plan | 482.23(b)(4) | Standard of Participation | 08/29/2018 | N | Not Deemed | 32470 Based on review of medical records (MR), facility policy and procedure and interviews with the staff, it was determined the facility failed to ensure each patient's Plan of Care (POC) was complete, individualized and up to date to meet the patients needs. This affected 2 of 11 medical records reviewed, including Patient Identifier (PI) # 5 and PI # 11 and has the potential to negatively affect all patients served by the facility. Findings include: Policy: Care Planning Reference # 9017 Revised Date: 10/17/11 Policy: Care, treatment and services are panned to ensure that they are individualized to the patient's needs. Therefore, it is the policy of Mizell Memorial Hospital to provide and individualized, interdisciplinary plan of care for all patients that is appropriate to the patient's needs, strengths, results of diagnostic testing, limitations and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the patient that are reasonable and measurable. Procedure: The plan of care shall be individualized, based on diagnosis, patient assessment and personal goals of the patient and his/her family. The planning for care, treatment and services will include the following: Regularly reviewing and revising the plan of care, treatment and services. Documenting the plan for care, treatment and services. Monitoring the effectiveness of the care planning and the provisions of care, treatment and services. The plan of care will be individualized to the needs of the patient. The plan of care will be continually evaluated based on the patient's clinical condition, results of diagnostic tests, care goals and the plan for treatment, care and services, and revised as needed to meet the needs of the patient's changing condition. The plan of care shall be updated daily, with revisions reflecting the reassessment of needs of the patient." 1. PI # 5 was admitted to the facility on 11/21/17 with admitting diagnoses of Psychosis and Inappropriate sexual behavior. Review of the the patient progress notes dated 11/21/17 - 11/26/17 and 11/29/17 to 12/5/17 revealed the nursing staff documented under the nursing assessment skin: warm, dry, Changes to skin: none and in the wound assessment section of each note was documented N/A (not Applicable). Review of the patient progress note dated 11/27/17 at 5:54 AM by EI # 15, Registered Nurse (RN) documented under the narrative nurses note "Drsng (dressing) on left forearm changed, skin tear healing well, no bleeding." An interview was conducted on 7/11/18 at 4:34 PM with EI # 15 who stated when asked about the patient's skin tear was not sure how he/she received the skin tear but stated "he was always in the recliner and flailing his/her arms and sometimes they scrape them on the recliners... I remember his/her skin being like so many of the frail older people we get, just typical paper skin and easy to bruise." Review of the patient progress notes dated 11/28/17 at 7:51 AM by EI # 1, Director of SBCU, revealed under the nursing assessment for skin: warm, skin tear to L (left) forearm. Changes to skin: skin tear. Wound assessment N/A. In an interview on 7/12/18 at 2:28 PM EI # 1 was asked if he/she knew when the skin tear occurred. EI # 1 replied by stating" I do not. When I saw it, it had a dressing on it. It had gauze or coban around the outside. The daughter saw it because she asked about it being changed the day before I saw it. No one ever documented when the skin tear occurred only one documentation that it was cleansed, didn't say with what, and telfa on it." Review of the progress note dated 11/28/17 at 4:35 PM by EI # 13, LPN (Licensed Practical Nurse) revealed the following documentation under the narrative nurse note " ...Dressing to arm changed as asked by family member during visitation. Continues to have some bloody discharge. No redness to area surrounding. Cleaned and covered with Telfa and wrapped with Coban." Review of the entire nurse note dated 11/28/18 revealed no documentation of how the wound care was performed. Review of the all of the nursing notes within the MR from 11/29/17 to 12/5/17 revealed no documentation of the healing of the skin tear or any further documentation of dressing changes. Review of the Patient Progress Notes on dated 11/21/17 revealed the patient weighted 161 pounds (lbs) and 9.6 ounces (oz). Review of the Patient Progress Notes dated 11/26/17 revealed the patient weighted 158 lbs 3 oz. Review of the spread sheet started on 11/21/17 and continues through discharge on 12/5/17 revealed a weight on week one as 158.2 lbs and at discharge or week two a weight of 149 lbs 8 oz. Review of the Patient Progress Notes of the nutritional intake from 11/22/18 to 11/25/17 revealed the following: 11/22/17 8:34 AM - 50% of breakfast consumed. 12:00 PM - 75% of lunch consumed. 5:15 PM - 0% of supper consumed. 11/23/17 8:10 AM - 25% of breakfast consumed. 12:26 PM - 0% of lunch consumed. 5:15 PM - 50% of supper consumed. 11/24/17 8:26 AM - 5% of breakfast consumed. 11:30 AM - 0% of lunch consumed. 6:15 PM - 25% of supper consumed. 11/25/17 7:30 AM - 10% of breakfast consumed. 12:30 PM - 25% of lunch consumed. 5:45 PM - 50% of supper consumed. 11/26/17 7:30 AM - 75% of breakfast consumed. 12:26 PM - 0% of lunch consumed. 5:39 PM - 50% of supper consumed. 11/27/17 8:00 AM - 25% of breakfast consumed 12:45 PM - 50% of lunch consumed 6:00 PM - 100% of supper consumed 11/28/17 7:30 AM - 75% of breakfast consumed 12:46 - 0% of lunch consumed 5:30 PM - 50% of supper consumed 11/29/17 8:07 AM - 0% of breakfast consumed 12:29 PM - 0% of lunch consumed 5:51 PM - 75% of supper consumed 11/30/17 7:55 AM - 0% of breakfast consumed No documentation of lunch consumption 5:57 PM - 25% of supper consumed 12/1/17 7:30 AM - 75% of breakfast consumed 12:15 PM - 25% of lunch consumed 5:30 PM - 75% of supper consumed 12/2/17 7:30 AM - 75% of breakfast consumed No documentation of lunch consumption 6:45 PM - 50% of supper consumed 12/3/17 9:01 AM - 100% of breakfast consumed No documentation of lunch consumption 6:22 PM - 10% of supper consumed 12/4/17 7:30 AM - 75% of breakfast consumed 12:30 PM - 50% of lunch consumed 5:15 - 75% of supper consumed 12/5/17 8:35 AM - 0% of breakfast consumed An interview was conducted on 7/11/18 at 4:34 PM with EI # 15, RN and was asked if a weight loss was noticed on a patient what is typically done by the staff? EI # 15 responded by stating " we order ensure and watch the patient for a couple of days and if not eating any better, then we start pushing fluids like get two cups of juice in him/her especially on night shift. We don't usually report it to Dr. (doctor) (name)." Review of the entire MR revealed no documentation the patient was given a nutritional supplement at any time throughout each day. Review of all the physician orders in the MR revealed no documentation an order was written for a dietary consult or a nutritional supplement to be given daily or with each meal. An interview was conducted on 7/13/18 at 1:15 PM with Employee Identifier (EI) # 1, Director of SBCU, who confirmed the above mentioned findings. Review of PI # 5's plan of care dated 11/21/17 revealed no documentation of the patient's agitation, hitting the arms of the recliner, hypersexual inappropriateness and bruising of the skin or prevention of the bruising of the skin. The care plan failed to include interventions to prevent the above mentioned findings. Review of the care plan dated 11/21/17 revealed no documentation the care plan had been updated to include the patient's skin tear or wound care for the skin tear, and the patient's weight loss while admitted at the SBCU or interventions to prevent the loss of 10 pounds during his/her admission. An interview was conducted on 7/18/18 at 10:00 AM with Employee Identifier (EI) # 17, Corporate Executive Officer (CEO) who confirmed the plan of care for each patient should be individualized and updated and confirmed the above mentioned findings. 2. PI # 11 was admitted to the facility on 7/5/18 with an admitting diagnosis of Bipolar Type I Manic Phase. Review of the Psychiatric Evaluation dated 7/8/18 revealed the patient has a past history of schizoaffective disorder. During examination the physician documented under psychiatric examination "mood and affect manic, labile. Thought process grossly disorganized. Psychotic thoughts, delusions and hallucinations. Grandiosity, verbosity and marked hypersexuality..." Review of the physician progress note dated 7/7/18 revealed the physician documented "the patient's thought process has been bizarre and disorganized. He has been physically aggressive with staff. Attempted to publicly masturbate today and had to be sent back to his room". Review of the physician progress note dated 7/9/18 revealed the physician documented "the patients thought process is bizarre and disorganized. The patient has become aggressive with the staff. He becomes easily agitated and has been heard cussing at the staff tonight." Review of the physician progress note dated 7/12/18 revealed the physician documented "the patient was apparently still experiencing auditory hallucinations yesterday.. His thought process is bizarre..." Under the psychiatric examination the physician documented motor activity as tense, Thought process disorganized and Psychotic thoughts, delusions. Review of the Patient Progress note dated 7/6/18 at 7:15 AM EI (Employee Identifier) # 3, Registered Nurse (RN) documented "Pt (patient) pacing around unit pulling pants down with staff redirecting and explaining to him that we could not do that in public. Pt speech pressured and difficulty to understand at times." Review of EI # 3's documentation on 7/6/18 at 7:50 AM revealed the nurse documented Pt pulling his pants down as he is talking to EI # 1, RN Unit Director/Manager. Redirected by EI # 1 and Pt continues to try to pull them down as he is talking at rapid pressured manner. Pt is pacing around pulling his pants down with staff redirecting. Pt restless has problem being still, has no insite into staying out of others personal space, gets very close to them when he talks and while he exposes himself. Review of EI # 3 documentation date 7/6/18 at 10:22 AM revealed the patient continues to pace, beats on wall, very loud with pressured speech, very labile and unable to redirect... Review of EI # 3 documentation dated 7/6/18 at 3:35 PM revealed the patient pacing attempting to ambulate with eyes closed, attempting to wonder in other Pt's rooms, staff redirecting. Review of the Patient Progress note dated 7/7/18 at 7:00 AM revealed the following documentation by EI # 3. Pt attempting to wonder in other Pt's rooms, getting in staffs face and space when attempting to redirect, continue to try to distract and redirect. Review of the interdisciplinary Treatment Plan dated 7/5/18 revealed no documentation of the patients hypersexuality problems or behaviors only "Manic Behavior" is documented. Further review revealed no documentation of interventions to control the aggressive or threatening behavior or inappropriate sexual behavior and wondering into other patients rooms. Review of the short term goals were documented as: A. Patient will demonstrate the ability to socialize with peers with no episodes of inappropriate behavior. B. Patient will demonstrate no violent behavior. C. Pt will verbalize concerns to staff without being abusive or threatening. An interview was conducted on 7/18/18 at 9:53 AM with EI # 1 who confirmed the Treatment Plan was not individualized to the patient. | |||||||||
10 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | 0 | Initial Comments | Memo Tag | N | Not Deemed | 32470 Based on review of the Emergency Preparedness binder and interviews with the staff it was determined the following standard level deficiencies were cited: E 0009, 0024, 0032, and 0037. 32470 A recertification survey was conducted on 8/2/18 and the following condition level deficiencies were cited: 482.21 and 482.25. | |||||||||||
11 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0130 | Patient Rights:participation In Care Planning | 482.13(b)(1) | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of medical records (MR) and interviews with the staff it was determined the facility failed to initiate and up date a plan of care for each patient who receives services provided by the facility and to include the patient or patient representative in the care planning process. This had the potential to negatively affect all patients served by the facility. Finding include: Review of 10 MR's which included 6 closed records and 4 current patient records revealed no documentation of a care plan developed or updated on any of the 10 MR's reviewed. Review of the MR's revealed no documentation the patient or the patient representative were included in the development of the plan of care nor was there documentation the plan of care was discussed with the patient or patient representative. On 8/1/18 at 11:10 AM the surveyor went to Employee Identifier (EI) # 2, Director of Nursing, and inquired about careplans being competed on each patient admitted to the facility. EI # 2 stated "we do no do careplans on the patients." The surveyor then asked EI # 2 how care is provided to each patient during their stay. EI # 2 replied by stating " we go according to the doctors orders. An interview was conducted on 8/1/18 at 11:45 AM with EI # 2 who confirmed the above mentioned findings. | |||||||||
12 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0144 | Patient Rights: Care In Safe Setting | 482.13(c)(2) | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of facility policy and procedures, observations and interviews with the staff it was determined the facility failed to provide as safe environment for repackaging, dispensing and medication administration to each patient. This had the potential to negatively affect all patients served by the facility. Findings include: Policy: Filling Orders Date Revised: 11/13 Policy: All medications dispensed in Georgiana Medical Center must meet specific standards and be dispensed under the direct supervision of a Pharmacist. Procedure: 4. All medications dispensed must be appropriately labeled with medications name, strength and expiration date... Policy: Intravenous Admixture - Laminar Flow Hood Policy Date: September 2009 Policy: "It is the policy of Georgiana Hospital to utilize the laminar flow hood for intravenous admixtures. Any mixtures/medications that are to be added to fluids or medications that are to be diluted, drawn out of a vial/ampule and added to fluids must be prepared in a contamination free environment." A tour of the facility was conducted on 7/31/18 at 9:30 AM by the surveyors. A tour of an empty patient room on the facilities back hall revealed an intravenous hood from pharmacy which was full of dust and dirt and not in working condition. Observations of the medication room revealed in the controlled medication area were medication boxes made of a hard plastic and each box contained individual dividers within the box creating multiple individual compartments. On the outside of the plastic box was the name of the medication and strength written with a pen and no other information was present. EI # 2, Director on Nursing, opened one of the boxes and in each individual compartment was one loose pill. When the surveyor asked Employee Identifier (EI) # 2 why the pills were loose in the box. EI # 2 stated "that's how it has always been." The surveyor asked where the expiration date and the lot number was. EI # 2 stated "the expiration date and lot number have never been put on the box by the pharmacist." EI # 2 stated "the pharmacist removes the pills from the individual dose pack, puts them in an envelope then brings them to the nursing medication room and places each pill in the box and puts the lid on." On 8/1/18 at 9:05 AM the surveyor asked EI # 2 to escort the surveyor to the pharmacy to view how medications are shipped to the pharmacy. The surveyor and EI # 2 entered the pharmacy and observed the medication bins within the pharmacy. The surveyor observed dose packages of multiple medications and larger bottles of other medications. The surveyor asked EI # 2 if the medications come in a dose package why the pharmacist removes them when taken to the medication room at the nurses station or to the patients drawers in the medication cart. EI # 2 stated he/she did not know. The surveyor asked EI # 2 if the pharmacist had empty dose packs that could be filled and labeled for the medications that come in a large quantity bottle. EI # 2 stated "the pharmacist before this one did and he/she made labels and placed the labels on the dose pack. EI # 2 stated the label had the medication name, strength, lot number and expiration date." EI # 2 stated she does not know why the current pharmacist does not do it that way. The surveyor asked EI # 2 how medications are dispensed to the patients. EI # 2 stated "the pharmacist takes them out of the bottle and puts the pill in a small envelope with the name of the medication and strength or he/she takes the pill out of the dose pack and places it in an envelope and put the name of the medication and strength on the envelope." EI # 2 stated he/she was unsure of why the pharmacist removes them from the dose pack the medicine comes in. Further observation of the pharmacy revealed no area within the pharmacy for an intravenous flow hood for mixture of medications in a contamination free environment. An interview was conducted on 8/1/18 at 11:40 AM with EI # 6, Director of Pharmacy. EI # 6 was asked why he/she does not mix the IV admixtures in pharmacy and the nurses are completing this in the nursing medication room. EI # 6 replied by saying "what's the difference all you do is pull the medicine out of one bottle and put it in a bag." The surveyor explained the surveyor was knowledgeable in the procedure but why was he/she not completing the task and labeling it and delivering it to the nursing medication room. EI # 6 replied by saying "Well I guess I can." An interview was conducted on 8/1/18 at 9:30 AM with EI # 2 who confirmed the above mentioned findings. | |||||||||
13 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0263 | QAPI | 482.21 | Condition of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of the Quality Improvement documentation and interviews, it was determined: 1) The facility failed to implement a Quality Improvement Plan to include quality indicators and collection of data. 2) The facility failed to initiate Performance Improvement Projects. 3) The facility failed to identify areas for improvement and high-risk, high-volume or problem-prone areas. 4) The governing body failed to ensure there was Quality Assurance Plan implemented This had the potential to negatively affect all patients served by this facility. Findings include: Refer to A 273, A 283, A 297 and A 308 for findings. | |||||||||
14 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0273 | Data Collection & Analysis | 482.21(a), (b)(1),(b)(2)(i), (b)(3) | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of the Quality Improvement documentation and interviews, it was determined the facility failed to implement a Quality Improvement Plan to include quality indicators and collection of data. This had the potential to negatively affect all patients served by this facility. Findings include: Review of the documentation within the Quality Assurance Performance Improvement (QAPI) binder revealed no documentation of the findings to include measuring and assessing the performance of hospital services through the collection and analysis of data and the conducting of quality improvement initiatives and taking action where indicated, including the design of new services, and or improvement of existing services. The surveyor asked EI # 1 what areas for improvement were identified and what actions were taken for improvement and were these areas tracked and trended. EI # 1 responded by saying there was no documentation of areas identified nor was there any tracking or trending data. An interview was conducted on 8/2/18 at 2:30 PM with EI # 1 who confirmed the above mentioned findings. | |||||||||
15 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0283 | Quality Improvement Activities | 482.21(b)(2)(ii), (c)(1), (c)(3) | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of the Quality Assurance Performance Improvement (QAPI) documentation and interviews with the staff it was determined the facility failed to ensure: 1. Data was collected from each department within the hospital. 2. Areas for improvement were identified. 3. High-risk, high-volume or problem-prone areas were identified. 4. Actions were taken for improvement, those actions were measured and tracked to determine if improvements were achieved. This had the potential to negatively affect all patients served by the facility. Findings include: Review of the QAPI binder presented to the surveyor on 8/2/18 at 9:45 AM revealed no documentation by each department within the hospital for the QAPI program and the results obtained from the indicators performed by each department. An interview was conducted on 8/2/18 at 12:30 PM with Employee Identifier (EI) # 1, Administrator, who stated there were no actual PIP's (Performance Improvement Projects) initiated and there was no documentation as to improvement of each department within the hospital. When asked if the governing body determines the number of improvement projects to be conducted annually EI # 1 stated "no." The surveyor then asked EI # 1 who and how is the QAPI program evaluated EI # 1 states "it is not evaluated by anyone." The surveyor asked EI # 1 what areas for improvement were identified and what actions were taken for improvement and were these areas tracked and trended. EI # 1 responded by saying there was no documentation of areas identified nor was there any tracking or trending data. An interview was conducted on 8/2/18 at 2:30 PM with EI # 1 who confirmed the above mentioned findings. | |||||||||
16 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0297 | Qapi Performance Improvement Projects | 482.21(d) | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of the Quality Assurance Performance Improvement (QAPI) documentation and interviews with the staff it was determined the facility failed to ensure Performance Improvement Projects (PIP) were developed by each area of the hospital, measurable progress was achieved and incorporated into the hospital-wide QAPI program. This had the potential to negatively affect all patients served by the facility. Findings include: An interview was conducted on 8/2/18 at 12:30 PM with Employee Identifier (EI) # 1, Administrator, who stated there were no actual PIP's initiated and there was no documentation as to improvement of each department within the hospital. When asked if the governing body determines the number of improvement projects to be conducted annually EI # 1 stated "no." An interview was conducted on 8/2/18 at 2:30 PM with EI # 1 who confirmed the above mentioned findings. | |||||||||
17 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0308 | Qapi Governing Body, Standard Tag | 482.21 | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on the review of the Quality Assurance documentation and interviews, it was determined the governing body of the facility failed to ensure there was a Quality Assurance Plan implemented. This had the potential to negatively affect all patients served by this facility. Findings include: An interview was conducted on 8/2/18 at 12:30 PM with Employee Identifier (EI) # 1, Administrator. When asked if the governing body determines the number of improvement projects to be conducted annually EI # 1 stated "no." The surveyor then asked EI # 1 who and how is the QAPI (Quality Assurance Performance Improvement) program evaluated EI # 1 states "it is not evaluated by anyone." An interview was conducted on 8/2/18 at 2:30 PM with EI # 1 who confirmed the above mentioned findings. | |||||||||
18 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0392 | Staffing And Delivery Of Care | 482.23(b) | Standard of Participation | 09/19/2018 | N | Not Deemed | 39080 Based on review of medical records (MR) and interviews, it was determined the nursing staff failed to: 1. Follow physician order related to obtaining daily weights. 2. Perform wound assessments and document wound care. This affected 3 of 17 MR's reviewed and did affect Patient Identifier (PI) # 3, PI # 7, PI # 10,and had the potential to negatively affect all patients served by the facility. Findings include: A request was made by the surveyor for a copy of the Wound Assessment policy. The surveyor was provided a page entitled "Wound Care Chart Review, Date Written: July 2012," with the following statement: "The purpose of the Wound Care Chart Review is to ensure that quality care is provided to the patient as per physician orders. Monitoring will be done on all wound care records..." The page contained no instructions for wound assessment, or what was being monitored. 1. PI # 3 was admitted to the hospital on 7/27/18 with an admitting diagnosis of Weakness. Review of the Physician orders dated 7/27/18 revealed an order for "Daily weights". Review of the Patient Progress Notes revealed no documentation of a weight on 7/29/18, 7/30/18, 7/31/18 and 8/1/18. Further review of the Patient Progress Notes revealed documentation on 7/30/18 "attempted to weigh patient, patient too unstable" and on 7/31/18 "weight omitted, patient too weak to stand". An interviewed was conducted on 7/31/18 at 12:40 PM with Employee Identifier (EI) # 2 , Registered Nurse, Director of Nursing, who confirmed the above findings and stated daily weights for PI # 3 were to be taken with the bed scale and not on standing scale. 39098 2. PI # 7 was admitted to the hospital on 7/16/18 at 2:20 PM with diagnoses including Head Injury and Brain Mass. Review of the MR revealed the first wound assessment by the nurse was on 7/17/18 at 10:16 AM. There was no depth of the wound documented. The nurse documented "dressing changed per orders." The surveyor was unable to determine what wound care was performed. There was no documentation of the head laceration. On 7/18/18 at 8:55 AM the nurse documents dressing changed per orders. The surveyor was unable to determine what wound care was performed. During an interview on 8/2/18 at 1:47 PM with EI # 2, the above findings were confirmed. 3. PI # 10 was admitted to the hospital on 7/9/18 with diagnoses including Cellulitis of Right Toe (Primary), Diabetes Mellitus, Type I. Review of the MR revealed orders dated 7/9/18 for wound care as follows: "Dry dressing change BID (Twice a Day), soak foot in betadine and saline prior to dressing." Review of the Nurses' Initial Physical Assessment dated 7/9/18 at 12:10 PM, revealed "...an ulceration noted to the bottom of the right great toe..." There was no measurement documented. The nurse documented on 7/10/18 at 7:13 PM, "Dry dressing performed as ordered." The surveyor was unable to determine what wound care was performed. There was no wound care documented on 7/12/18. On 7/13/18 at 10:31 AM the nursed documented the following, "...pt (patient) in room performing toe soak/ cleaning and dressing change by self per pt request..." There is no documentation the patient was educated on wound care. Further of the MR revealed new wound care orders dated 7/13/18: Dressing change daily with Bactroban and covered with Xeroform gauze. Review of the nursing note dated 7/13/18 at 8:15 PM revealed the following documentation, "...Dressing to R (right) great toe dry/ secure/ intact (Patient does own dressing change)..." The surveyor was unable to determine size of wound, or wound care performed. An interview was conducted on 8/2/18 at 10:45 AM with EI # 2, who confirmed the above findings. | |||||||||
19 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0396 | Nursing Care Plan | 482.23(b)(4) | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of medical records (MR) and interviews with the staff it was determined the facility failed to develop nursing careplans for each patient admitted to the facility. Findings include: Review of 10 MR's which includes 6 closed records and 4 current patients revealed no documentation of a care plan developed or updated on any of the 10 MR's reviewed. The surveyor on 8/1/18 at 11:10 AM went to Employee Identifier (EI) # 2, Director of Nursing, office and inquired about care plans being completed on each patient admitted to the facility. EI # 2 stated "we do no do care plans on the patients." The surveyor then asked EI # 2 how care is provided to each patient during their stay. EI # 2 replied by stating " we go according to the doctors orders." An interview was conducted on 8/1/18 at 1:20 PM with EI # 1, Administrator, who confirmed the above mentioned finding. | |||||||||
20 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0405 | Administration Of Drugs | 482.23(c)(1), (c)(1)(i) & (c)(2) | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of facility policies and procedures, observations, job descriptions and interviews with the staff it was determined the facility failed to ensure: 1. Proper labeling of all medications 2. Proper mixing of intravenous (IV) admixtures 3. Proper dispensing of medications 4. Keys to the narcotic box were held by the charge nurse. 5. Procedures were followed for daily narcotic checks. 6. No out of date drugs were in stock. This had the potential to negatively affect all patients served by the facility. Findings include: Policy: Filling Orders Date Revised: 11/13 Policy: All medications dispensed in Georgiana Medical Center must meet specific standards and be dispensed under the direct supervision of a Pharmacist. Procedure: 4. All medications dispensed must be appropriately labeled with medications name, strength and expiration date... Policy: Intravenous Admixture - Laminar Flow Hood Policy Date: September 2009 Policy: "It is the policy of Georgiana Hospital to utilize the laminar flow hood for intravenous (IV)admixtures. Any mixtures/medications that are to be added to fluids or medications that are to be diluted, drawn out of a vial/ampule and added to fluids must be prepared in a contamination free environment." Policy: Controlled Substances Date Revised: 11/13 "Policy: Strict control will be maintained on all controlled substances. This requires compliance with the following procedures in a joint effort by the nursing staff and the pharmacist. Procedure: ...3. All narcotics are to be under double locks with the charge nurse being responsible for the keys. Keys are to be kept on person, not loose... 4. Controlled drugs are to be accounted for at each shift change, by nurse going off and nurse coming on duty. The daily narcotic check sheet is used for this purpose." Policy: Out of Date Drugs Date Revised: 11/13 "Policy: The pharmacy will have no out of date drugs in stock. The pharmacist is responsible for pulling all out of date drugs..." Review of the Director of Nursing Job Description and the Registered Nurse Job Description revealed no documentation throughout the job descriptions for mixing IV admixtures in the nursing medication room. 1. A tour of the facility was conducted on 7/31/18 at 9:30 AM by the surveyors. A tour of an empty patient room on the facilities back hall revealed an intravenous hood from pharmacy which was full of dust and dirt and not in working condition Observations of the medication room revealed in the controlled medication area were medication boxes made of a hard plastic and in each box contained individual dividers creating multiple individual compartments with in the box. On the outside of the plastic box was the name of the medication and strength written with a pen and no other information was present. EI # 2, Director on Nursing, opened one of the boxes and in each individual compartment was one loose pill. The surveyor asked Employee Identifier (EI) # 2, Director of Nursing, why the pills are loose in the box. EI # 2 stated "that's how it has always been." The surveyor asked where the expiration date and the lot number was. EI # 2 stated "the expiration date and lot number have never been put on the box by the pharmacist." EI # 2 stated "the pharmacist removes the pills from the individual dose pack, puts them in an envelope then brings them to the nursing medication room and places each pill in the box and puts the lid on." On 8/1/18 at 9:05 AM a tour of the pharmacy was conducted. The surveyor observed no hood or an area to prepare IV admixtures to prevent contamination within the pharmacy. EI # 2 was asked about mixing medications and if there was a hood in the pharmacy area, she replied "there is a hood but not in pharmacy. It is in a room and being stored. We no longer use the hood. The RN (Registered Nurse) mixes the medications on the floor if its needed." The surveyor and EI # 2 entered into the medication area of the pharmacy and observed the medication bins within the pharmacy. The surveyor observed dose packages of multiple medications and larger bottles of other medications. The surveyor asked EI # 2 if the medications come in a dose package why the pharmacist removes them when taken to the medication room at the nurses station or to the patients drawers in the medication cart. EI # 2 stated he/she did not know. The surveyor asked EI # 2 if the pharmacist had empty dose packs that could be filled and labeled for the medications that come in a large quantity bottle. EI # 2 stated "the pharmacist before this one did and he/she made labels and placed the labels on the dose pack. EI # 2 stated the label had the medication name, dose, lot number and expiration date." EI # 2 stated she does not know why the current pharmacist does not do it that way. The surveyor asked EI # 2 how medications are dispensed to the patients. EI # 2 stated "the pharmacist takes them out of the bottle and puts the pill in a small envelope with the name of the the medication and strength or he/she takes the pill out of the dose pack and places it in an envelope and put the name of the medication and the strength on the envelope." On 8/2/18 at 11:00 AM EI # 2 was observed mixing IV medication without utilizing Laminar flow hood or in a contamination free environment according to the hospital policy. Review of the Director of Nursing Job Description and the Registered Nurse Job Description revealed no documentation throughout the job descriptions for mixing IV admixtures in the nursing medication room. An interview was conducted on 8/2/18 at 11:30 AM with EI # 2 who confirmed the above mentioned findings. 39098 2. A tour of the medication room located beside the nurses station was conducted on 7/31/18 at 12:35 PM. EI # 2 was also present on the tour. Review of the End of Shift Narcotic Count Sheet located in a notebook in the medication room revealed the following shifts did not contain the On Coming and Off Going nurses' signatures: No On Coming 7P (PM) signature: 7/20/18, 7/27/18. No Off Going 7A (AM) signature: 6/18/18, 6/29/18, 7/25/18, 7/26/18. EI # 2 stated, "...the form should always be signed, but sometimes they forget." The surveyor asked EI # 2 to demonstrate how narcotics are secured. EI # 2 opened a drawer in the medication room and picked up a set of keys, and unlocked the cabinet door, and then unlocked the box containing the narcotics. The surveyor asked if that is where the keys are usually kept and EI # 2 stated, "Yes," then further explained the charge nurse on the floor should keep them in her/his pocket. Review of the narcotic box revealed the following: 1- Morphine Sulfate 100 mg (milligrams)/ 5 ml (milliliters) multidose bottle, opened and unlabeled. 4- Demerol 25 mg/ 0.5 ml ampule's, expired 1 Jun (June) 2018. Multiple narcotics in the pill trays had no expiration dates. Review of the remaining medications in the medicine cabinets revealed the following: Bottom shelf refrigerator: 1- 10 ml multidose vial Humulin 70/ 30 insulin, opened and unlabeled. 1- 10 ml multidose vial Humulin R (Regular) 100 u (units)/ ml, opened and unlabeled. 1- Tuberculin PPD (Purified Protein Derivative) 5 u/ 0.1 ml, labeled opened on 5/22/18. 1- 10 ml multidose vial Lantus insulin 100 u/ ml, opened and unlabeled. 2- 10 ml multidose vials Levemir insulin 100 u/ ml, opened and unlabeled. 1- unopened 5 ml multidose vial Flu Vac (Vaccine), expired 6/30/18. Lower shelf: 3- Racepinephrine Inhalation Solution 2.25 %, 2 expired 11/17, 1 expired 11/15. 1- 60 ml vial Clindamycin, labeled opened 5/16/18. 3- Ampicillin 1 Gram for injection, expired 4/18. 1- 1 ml vial Nalbuphine, expired 2/2018 (Not in locked box). 1- multidose bottle Ranitidine 15 mg/ ml, opened and unlabeled. 1- Jevity 8 ounce, expired 4/1/18. 1- secondary IV (Intravenous) set, expired 9/17. An interview was conducted on 7/31/18 at 2:00 PM with EI # 2, who was present on the tour, confirmed the above findings. | |||||||||
21 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0489 | Condition Of Participation: Pharmaceutical Se | 482.25 | Condition of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of facility policy and procedure, observations and interviews with the staff it was determined the facility failed to ensure: 1) Pharmacy services prepared and dispensed medications in an appropriate manner. 2) Safe dispensing and distribution of all medications. 3) Proper labeling of all medications. 4) Proper mixing of intravenous admixtures using a hood. This had the potential to negatively affect all patients served by the facility. Findings include: Refer to A 491, A 492, A 500 and A 501 | |||||||||
22 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0491 | Pharmacy Administration | 482.25(a) | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of facility policies and procedures, observations and interviews with the staff it was determined the agency failed to ensure pharmacy services prepared and dispensed medications in a safe and appropriate manner. This had the potential to negatively affect all patients served by the facility. Findings include: Policy: Filling Orders Date revised: 11/13 "Policy: All medications dispensed in Georgiana Medical Center must meet specific standards and be dispensed under the direct supervision of a Pharmacist. Procedure: 1. The Pharmacist will fill the medication carts as needed. 4. All medication dispensed must be appropriately labeled with medications name, strength, and expiration date... 5. If the Pharmacist or Pharmacy Technician is unavailable, the Charge Nurse may fill the patients medication order from the pharmacy..." Policy: Medication Carts Date Revised: 11/13 Policy: Georgiana Medical Center Pharmacy uses the unit dose form of medications when possible. The patients' medications are stored in medication carts between dispensing and administration. Policy: Intravenous Admixture - Laminar Flow Hood Policy Date: September 2009 Policy: "It is the policy of Georgiana Hospital to utilize the laminar flow hood for intravenous admixtures. Any mixtures/medications that are to be added to fluids or medications that are to be diluted, drawn out of a vial/ampule and added to fluids must be prepared in a contamination free environment." 1. A tour of the facility was conducted on 7/31/18 at 9:30 AM by the surveyors. During the tour an empty patient room on the facilities back hall revealed an intravenous hood from pharmacy which was full of dust and dirt and not in working condition During the tour the medication storage room across from the nurses station was observed. During the observation of the medication room the surveyors observed in the controlled medication box were plastic boxes with dividers inside creating multiple individual compartments each with one loose pill. On the out side of the plastic box was the name of the medication and dose written with a pen. When the surveyor asked Employee Identifier (EI) # 2, Director of Nursing, why the pills are loose in the box, EI # 2 stated "that's how it has always been." The surveyor asked where the expiration date and the lot number was located. EI # 2 stated "the expiration date and lot number have never been put on the box by the pharmacist." EI # 2 stated "the pharmacist removes the pills from the individual dose pack, puts them in an envelope then brings them to the nursing medication room and places each pill in the box and puts the lid on." On 8/1/18 at 9:05 AM the surveyor asked EI # 2 to escort the surveyor to the pharmacy to view how medications are shipped to the pharmacy. The surveyor and EI # 2 entered the pharmacy and observed the medication bins within the pharmacy. The surveyor observed dose packages of multiple medications and larger bottles of other medications. The surveyor asked EI # 2 if the medications come in a dose package why the pharmacist removes them when taken to the medication room at the nurses station or to the medication cart. EI # 2 stated he/she did not know. The surveyor asked EI # 2 if the pharmacist had empty dose packs that could be filled and labeled for the medications that come in a large quantity bottle. EI # 2 stated "the pharmacist before this one did and he/she made labels and placed the labels on the dose pack. EI # 2 stated the label had the medication name, dose, lot number and expiration date." EI # 2 stated she does not know why the current pharmacist does not do it that way. The surveyor asked EI # 2 how medications are dispensed to the patients. EI # 2 stated "the pharmacist takes them out of the bottle and puts the pill in a small envelope with the name of the medication and strength or he/she takes the pill out of the dose pack and places it in an envelope and put the name of the medication on the envelope." EI # 2 stated he/she was unsure of why the pharmacist removes them from the dose pack. An interview was conducted on 8/1/18 at 9:30 AM with EI # 2 who confirmed the above mentioned findings. | |||||||||
23 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0492 | Pharmacist Responsibilities | 482.25(a)(1) | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of the Director of Pharmacy job description, policy and procedure, observations and interviews with the staff it was determined the facility failed to ensure proper supervision by the pharmacist. This had the potential to negatively affect all patients served by the facility. Findings include: Review of the Director of Pharmacy job description revealed the following: Essential Functions: 1. Oversees and assists with unit-dose preparation 4. Coordinates the pharmacy function with the nursing service and the medical staff. 6. Inspects and re-stocks the crash carts on the unit and in the emergency department. Policy: Medications: Monthly Pharmacy Inspections Date revised 11/13 Policy: To maintain a supply of medications which are in date and safe for use by patients, periodic inspections of the hospital drug supply by pharmacy personnel is needed. Procedure: 1. Each month the pharmacist shall see that all different drug stocks around the hospital are in keeping with hospital standards ( i.e., in date, correct inventory, etc.) 2. Each check will be documented at the site of inspection. That is on each emergency cart, kit, etc. The pharmacy employee will sign his/her name along with the date checked and lock number of the replacing plastic lock. 1. A tour of the facility was conducted on 7/31/18 at 9:30 AM by the surveyors. During the tour the medication storage room across from the nurses station was observed. The surveyor asked Employee Identifier (EI) # 2, Director of Nursing, why the pills are loose in the box and where the expiration date and the lot number was. EI # 2 stated " the expiration date and lot number have never been put on the box by the pharmacist." EI # 2 stated "the pharmacist removes the pills from the individual dose pack, puts them in an envelope then brings them to the nursing medication room and places each pill in the box and puts the lid on." On 7/31/18 during the tour the crash cart in the nursing unit was opened and medications and supplies were observed for expiration dates. During the inspection of the crash cart the following medications were found to be expired: Nitroglycerine Paste in single dose packets all packets expired 8/1/18 3 - Heparin lock prefilled syringes expired May 2018 1 - 0.9 % Normal Saline bottle 250 milliters (ml) expired May 2018 The surveyor informed EI # 2 of the expired medications with in the crash cart on 7/31/18 at 2:30 PM. On 8/1/18 at 9:05 AM the pharmacy area was observed to view how medications are shipped to the pharmacy. The surveyor and EI # 2 entered the pharmacy and observed dose packages of multiple medications and large bottles of medications. The surveyor asked EI # 2 if the medications come in a dose package why the pharmacist removes them when taken to the medication room at the nurses station or to the medication cart. EI # 2 stated he/she did not know. The surveyor asked EI # 2 how medications are dispensed to the patients. EI # 2 stated "the pharmacist takes them out of the bottle and puts the pill in a small envelope with the name of the medication and strength or he/she takes the pill out of the dose pack and places it in an envelope and puts the name of the medication on the envelope." EI # 2 stated he/she was unsure of why the pharmacist removes the pills from the dose pack the medicine comes in. An interview was conducted on 8/1/18 at 11:40 AM with EI # 6, Director of Pharmacy. The surveyor asked EI # 6 why he/she does not mix the IV (Intravenous) medications in the pharmacy and the nurses are completing it in the medication room. EI # 6 responded by saying "what's the difference you pull the medicine out of the bottle and put it in a bag." The surveyor asked EI # 6 if he/she completes any type of supervisor form to ensure RN's (Registered Nurses) are performing the correct procedures for adding medications to the IV bags and his/her response was "no I don't." An interview was conducted on 8/2/18 at 11:30 AM with EI # 2 who confirmed the above mentioned findings. | |||||||||
24 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0500 | Delivery Of Drugs | 482.25(b) | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of facility policies and procedures, observations and interviews with the staff it was determined the facility failed to ensure safe dispensing and distribution of all medications for each patient admitted to the facility. Findings include: Policy: Filling Orders Date revised: 11/13 "Policy: All medications dispensed in Georgiana Medical Center must meet specific standards and be dispensed under the direct supervision of a Pharmacist. Procedure: 1. The Pharmacist will fill the medication carts as needed. 4. All medication dispensed must be appropriately labeled with medications name, strength, and expiration date... 5. If the Pharmacist or Pharmacy Technician is unavailable, the Charge Nurse may fill the patients medication order from the pharmacy..." Policy: Medication Carts Date Revised: 11/13 Policy: Georgiana Medical Center Pharmacy uses the unit dose form of medications when possible. The patients' medications are stored in medication carts between dispensing and administration. 1. A tour of the facility was conducted on 7/31/18 at 9:30 AM by the surveyors. During the tour the medication storage room across from the nurses station was observed. During the observation of the medication room, the medications were observed without proper medication labels according to hospital policy. The surveyor asked where the expiration date and the lot number was. EI # 2 stated "the expiration date and lot number have never been put on the box by the pharmacist." EI # 2 stated "the pharmacist removes the pills from the individual dose pack, puts them in an envelope then brings them to the nursing medication room and places each pill in the box and puts the lid on." On 8/1/18 at 9:05 AM the surveyor entered the pharmacy area to view how medications are shipped to the pharmacy. The surveyor observed dose packages of multiple medications and large bottles of medications. The surveyor asked EI # 2 if the medications come in a dose package why the pharmacist removes them when taken to the medication room at the nurses station or to the medication cart. EI # 2 stated he/she did not know. An interview was conducted on 8/1/18 at 9:30 AM with EI # 2 who confirmed the above mentioned findings. | |||||||||
25 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0620 | Director Of Dietary Services | 482.28(a)(1) | Standard of Participation | 09/19/2018 | N | Not Deemed | 39098 Based on a tour of the Dietary Department, interviews, and review of policies and procedures, it was determined the Dietary Department failed to ensure: 1. Opened foods were labeled appropriately. 2. Expired food was discarded. 3. Menus approved by the Registered Dietitian were being followed. 4. Gloves were worn during food preparation. 5. Employees knew how to extinguish a grease fire in the kitchen. This had the potential to affect all people served by the Dietary Department. Findings include: Policy: Food Service Manager's Responsibilities Date Reviewed: 2010 "Policy: A well-trained food service manager assures that instructions for the food service department are properly carried out, and that all local, state and federal food, food safety and sanitation regulatory requirements are met. Procedure: ...2. The food service manager is familiar with all local, state and federal regulatory requirements related to food, food safety and sanitation; and assures that all requirements are met. 3. Workers are trained, assisted.... 6. ...Staff follows proper sanitation and food handling practices. Food is served as soon as possible after it has been prepared, and at the proper safe temperature. 10. ...Equipment is properly used, cleaned and sanitized, and kept in good repair. 11. There is variety in the menus and in the appearance of the foods. Policy: Food Storage Date Reviewed: 2010 "Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing... Procedure: 8. All stock must be rotated with each new order received... a. Old stock is always used first. b. Supervise the person designated to put stock away to make sure it is rotated properly. c. Food should be dated as it is placed on shelves. d. Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold, or discarded... 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. 14. Refrigerated Food Storage: f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded... 15. Frozen Foods: d. All foods should be covered, labeled and dated..." Policy: Fire Plan for Food Service Department Date Reviewed: 2010 "Policy: All food service employees follow the fire plan for the department. Staff will be well trained on fire safety. Procedure: 2. Staff will be trained on procedures to follow in the event of a fire... 3. Procedures to follow for different types of fires: a. Never put water on a grease fire. c. If a fire is large and uncontrolled and exists in range area or hoods, use overhead fire extinguishers." Policy: Fire Safety Rules Date Reviewed: 2010 "Policy: All employees should be aware of rules to follow in a fire emergency. Procedure: 2. If the fire is small and confined to a burner or a pan skillet fire, smother by covering with a pan lid or using baking soda. 3. DO NOT use water as a means of extinguishing any fire that involves grease. 5. In the event that the fire is large, pull the nearest fire alarm box..." 1. A tour of the Dietary Department was conducted on 7/31/18 at 2:50 PM. The following items were observed: Dry Storage area: 4- 2 oz (ounce) bottles of Tabasco, expiration date 3/14. 1- jar of white, flaky substance, unlabeled for content and date. 2- 2 lb (pound) packages of spaghetti noodles, opened, unsealed, and unlabeled with date. Walk in Cooler: 1- 2 lb bag self rising flour, opened and unlabeled with date. 1- plastic container of red liquid, unlabeled for content, dated 7/19/18. 1- gallon container of pickle relish, opened and unlabeled. 1- box of cranberry sauce packets (1/2 oz each), expired 11/10/16. 1- box of cocktail sauce packets (3/4 oz each), expired 8/24/15. 50- 1000 Island dressing packs (1.5 oz each), expired 5/18/18. Double Refrigerator in kitchen: 2- opened bottles of Powerade (belonged to employees). 1- 5 lb bag shredded cheese, opened and unlabeled. 1- plastic bag of crackers, unlabeled for content and date. 1- pack of sliced turkey breast, expired 4/29/18. 1- container of jelled substance, unlabeled for content and date. Box Freezer in kitchen: 1- large bag of fries, opened and unlabeled. 1- large bag okra, opened and unlabeled. 2- large bundles of hot dogs, out of original packing, wrapped in foil, unlabeled for content and date. 1- large bag of steak nuggets, opened and unlabeled. 1- large bag of chicken breasts, opened and unlabeled, expired 4/19/18. 1- bag of vegetables, opened and unlabeled. 1- bag of sausage, opened and unlabeled. 1- bag of cubed steak, opened and unlabeled. 1- bag of chicken fingers, opened and unlabeled. An interview was conducted on 7/31/18 at 4:00 PM with Employee Identifier (EI) # 8, Dietary Aide, who was also present on the tour and confirmed the above findings. 2. During observation of food preparation and plating of food for patients on 8/1/18 at 11:45 AM, the surveyor observed EI # 9, Dietary Director, preparing chicken breasts for the patients lunches. Review of the Week 5 meal rotation menu, which EI # 9 stated they were following, revealed the following menu for Wednesday lunch: "Chicken and Rice Casserole Green Beans Cheddar Biscuit Cookies" The surveyor asked EI # 9 was she/he preparing any of the food on this list. EI # 9 responded, "No, sometimes we have to go with what we are cooking for employees, we are short handed." Posted on the wall outside the kitchen was the Employee Meal dated 8/1/18 with the following items listed: "Chicken Patty Sandwich French Fries Fruit Cocktails" On 8/2/18 at 11:00 AM, the surveyor returned to the Dietary Department to observe what food items were being prepared for patient lunches. According to the Week 5 schedule, Thursday's lunch should include: "Taco Salad Lettuce Tomato Cheese Ice Cream" The surveyor asked EI # 9 if the above items were being served to patients. She responded "No, the menu for today is hamburger steak and spinach." An interview was conducted by phone on 8/2/18 at 2:20 PM with EI # 10, Registered Dietitian, who confirmed the Dietary Director should not be making substitutions to the approved menus. EI # 10 stated she/he thought the kitchen was now on a 2 week menu rotation. 3. During the plating of patient lunches on 8/1/18 at 12:00 PM, the surveyor observed EI # 9 slicing bread with gloved hands. EI # 9 dropped a white bag used to hold the sliced bread, on the floor. After picking up the bag off of the floor, EI # 9 removed gloves, failed to wash hands, and continued slicing bread with ungloved hands, placed the bread in white bags, and placed the bags on the patient trays. During the temperature monitoring of the patients' food, EI # 9 handled fries and the thermometer with ungloved hands. The surveyor observed EI # 9 use the counter mounted can opener. The opener appeared to have a black greasy substance on the opener that pierces the can. An interview was conducted by phone on 8/2/18 at 2:20 PM with EI # 10, who confirmed staff should wear gloves when handling food. 4. An interview was conducted on 8/1/18 at 1:30 PM with EI # 8, Dietary Aide. The surveyor asked what she/he would do if a grease fire occurred on the stove. EI # 8 stated she would call 911. When the surveyor asked what would he/she do with the fire, she/he stated, "Would I through water on it?" EI # 8 was also unaware of the overhead extinguisher above the stove. During an interview conducted on 8/1/18 at 1:45 PM with EI # 10, it was confirmed EI # 8 had not been trained on fire safety. | |||||||||
26 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0622 | Competent Dietary Staff | 482.28(a)(3) | Standard of Participation | 09/19/2018 | N | Not Deemed | 39080 Based on review of personnel files, the facility failed to document orientation of newly hired dietary personnel. This deficient practice had the potential to negatively affect all patients receiving meals from the hospital dietary department. Findings include: 1. Employee Identifier (EI) # 8, Dietary aide, was hired at the hospital on 7/18/18. Review of the personnel file for EI # 8 was conducted on 8/2/18 at 11:48 AM which revealed no documentation of general or dietary orientation for EI # 8. An interview was conducted on 7/31/18 at 12:40 PM with EI # 2, Director of Nursing, who confirmed the above mentioned findings. | |||||||||
27 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0700 | Physical Environment | 482.41 | Condition of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility. Findings include: Refer to Life Safety Code violations | |||||||||
28 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | A0724 | Facilities, Supplies, Equipment Maintenance | 482.41(c)(2) | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on observations, facility policy and procedure and interviews with the staff it was determined the facility failed to ensure all equipment was tested for performance and safety on an annual basis and all medical supplies and medications were not expired and in use for patient care. This had the potential to negatively affect all patient served by the facility. Findings include: Georgiana Medical Center Safety Manual "Equipment Calibration and Preventive Maintenance Georgiana Medical Center has (persons Name) who is certified and responsible for the calibration of new equipment and preventive maintenance of patient service equipment and repairs as needed. (Persons Name) maintains the records of maintenance of equipment used for patient care. These services are performed on an annual basis or as needed for repairs, recalibration's or emergency needs." Policy: Medications: Monthly Pharmacy Inspections Date revised 11/13 "Policy: To maintain a supply of medications which are in date and safe for use by patients, periodic inspections of the hospital drug supply by pharmacy personnel is needed. Procedure: 1. Each month the pharmacist shall see that all different drug stocks around the hospital are in keeping with hospital standards ( i.e., in date, correct inventory, etc.) 2. Each check will be documented at the site of inspection. That is on each emergency cart, kit, etc. The pharmacy employee will sign his/her name along with the date checked and lock number of the replacing plastic lock." 1. A tour of the facility was conducted on 7/31/18 at 9:00 AM. During the tour all patient rooms except the occupied room were entered and inspected. All storage rooms which contained supplies observed. The surveyor entered room 114 which was a patient room but used as a storage room for extra equipment. In the room was a Hoyer lift which did not have a preventive maintance (PM) sticker showing the last time the Hoyer lift was inspected for safety. The surveyor then entered the back hall storage area which contained house keeping supplies and medical supplies and clean equipment i.e., bed side commode chairs. After further observation the surveyor noticed a bucket from a bedside commode was sitting under duct work which was in the ceiling and the bucket was on the floor. Further observation of the bucket revealed a clear liquid in it and the surveyor was unsure of what the liquid was. Observation of the old nurses station on the back hall revealed 5 boxes of 100 each 22 gage 1 inch needles which expired 2/18. The surveyor then went to the second storage room on the back hall. The following items were found: 1 - Adview vital sign pump without a PM sticker . 1- Oxygen concentrator with out a PM sticker. The surveyor then entered the nursing area and opened the crash cart. The following medications and supplies were found in the crash cart and were expired: All packets of Nitroglycerine Paste single dose use expired 8/1/18 3 - prefilled syringes of Heparin lock solution expired 5/2018 4 -Flexi Slip size 12 Fr. (French) 4.0 mm (millimeters) expired 12/17 1 - 250 ml (milliters) bottle of NS (Normal Saline) which was in the Dobutamine package expired 5/18. The surveyor continued the tour of the hospital and behind the nursing station was a storage room. The following items were found in the storage room and were expired: 1- Siemens Multi Stix (used to measure kidney function and blood sugars) expired 6/16. 1 - 500 ml bottle 0.9% Irrigation solution opened and expired 5/18. 1 - Para Pak Ecofix ( stool examination packet) expired 1/18 1 - Para Pak C & S (culture and sensitivity) expired 6/18 1 - Para Pak Ecofix expired 12/16 The surveyor then entered room 117 which is used for overflow for Emergency Room patients. The following supplies were found to be expired: 1 - 500 ml bottle of Sterile water opened with no open date present. 1 - 500 ml bottle of NS opened with no open date present. 1 - 8 fluid ounce bottle of Betadine open with a open date of 10/17/17 which is past the 28 day use after opening. 1 - sterile specimen cup seal broken and lid loose. The surveyor then entered Exam room # 1 of the Emergency Department and the following medications/supplies were expired: 1 - 8 ounce bottle of Betadine had an open date of 4/18. 1 - 8 ounce bottle of Betadine had an open date of 5/1/18. 1 - 500 ml bottle of sterile water with no open date documented. 1 - 8 ounce bottle of Betadine with an open date of 1/1/17. An interview was conducted on 7/31/18 at 1:30 PM with Employee Identifier # 2, Director of Nursing who confirmed the above mentioned findings. 39080 2. The surveyor, accompanied by EI # 7, Emergency Room Registered Nurse, entered Exam room # 1 of the Emergency Department on 8/4/18 at 11:20 AM. The following IV (Intravenous) fluids in a bin on the supply shelf were expired: 8 - 1000 ml bags of D5 (5 percent Dextrose) 1/4 (one forth) Normal Saline, expired 7/2018. The surveyor then inspected the equipment in Exam room # 1. The following item was found: 1 - Adview vital sign pump with a PM sticker that expired 5/18 . An interview was conducted on 7/31/18 at 12:40 PM with EI # 2, who confirmed the above mentioned findings. 39098 3. A tour of the facility was conducted on 7/31/18 at 11:15 AM. The following items were overdue for preventive maintenance (PM), or missing a PM sticker: Room 114 used for storage: 1- Flo Lab machine, Model 2100- SX, no PM sticker. Lab storage room: 1- Horizon Centrifuge, PM due 5/18. Old Nurses' station: 1- Abbott Glucometer, PM due 5/18. Hall storage closet: 1- Nebulizer, PM due 5/18. Hall outside of patient rooms: Oxygen Concentrator, PM due 5/18. During observation of medication passes, the surveyor observed the nurse administer a breathing treatment to an unsampled patient. The nebulizer used for the treatment contained a PM sticker due 5/18. Located in the same room with the medications, was the nurses' breakroom. The following was observed on the shelves: -On the same shelf with O2 (Oxygen) cannula's was an opened personal bottle of water, and opened Coke. -On the same shelf with water bottles for the O2, was an opened jar of dill pickles. -Personal purses and lunch bags were sitting on O2 tubing, face masks, tracheostomy masks, and incentive Spirometry tools. - Bag containing personal food sitting on Air Embolism Stockings. - Paper plates laying on a stethoscope. An interview was conducted on 7/31/18 at 2:00 PM with EI # 2, who was present on the tour, confirmed the above findings. | |||||||||
29 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | E0009 | Local, State, Tribal Collaboration Process | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of the Emergency Preparedness binder and interviews with the administrator it was determined the facility failed to ensure the collaboration with state and local emergency preparedness officials' to include all documentation of the collaboration. This had the potential to negatively affect all patients served by the facility. Findings include: Review of the Emergency Preparedness Program on 8/2/18 at 9:15 AM revealed the facility failed to provide documentation of the collaboration with the state and local officials. During an interview on 8/2/18 at 2:00 PM with Employee Identifier (EI) # 1, Administrator, EI # 1 stated " We did not contact anyone from the state or local fire department or police and we do not have anything documented." EI # 1 confirmed the above mentioned findings. | ||||||||||
30 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | E0024 | Policies/Procedures-Volunteers And Staffing | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of the Emergency Preparedness Program binder and interviews with the staff it was determined the facility failed to include a policy and procedure for the use of volunteers during an emergency. This had the potential to negatively affect all patients served by the facility. Finding include: Review of the Emergency Preparedness Program program on 8/2/18 at 9:15 AM revealed the facility failed to provide a policy and procedure for the use of volunteers during an emergency situation. The surveyor found in the binder a letter stating the hospital does not have volunteers. EI # 1 confirmed the above mentioned findings. | ||||||||||
31 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | E0032 | Primary/Alternate Means For Communication | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of the Emergency Preparedness Program it was determined the facility failed to provide an emergency preparedness communication plan. This had the potential to negatively affect all patients served by the facility. Findings include: Review of the Emergency Preparedness Program on 8/2/18 at 9:15 AM revealed no documentation of a communication plan for the primary and any alternate means of communication with the staff or the local or state agencies during an emergency. An interview was conducted with Employee Identifier # 1, Administrator, who confirmed the above mentioned finding. | ||||||||||
32 | 010047 | GEORGIANA MEDICAL CENTER | 515 N MIRANDA AVENUE | GEORGIANA | AL | 36033 | 08/02/2018 | Recertification | 1 | E0037 | Ep Training Program | Standard of Participation | 09/19/2018 | N | Not Deemed | 32470 Based on review of the Emergency Preparedness Program, review of employee files and interviews with the staff it was determined the facility failed to provide initial or annual training to the employees for emergency preparedness. This had the potential to negatively affect all patients served by the facility. Findings include: Review of the Emergency Preparedness ( EP) Program and employee files on 8/2/18 at 10:00 AM reveled no documentation of the initial training or annual training for the EP Program. An interview was conducted on 8/2/18 at 9:30 AM with Employee Identifier # 1, Administrator, who confirmed the above mentioned findings. | ||||||||||
33 | 010069 | MEDICAL CENTER BARBOUR | 820 W WASHINGTON ST | EUFAULA | AL | 36027 | 10/04/2018 | Complaint Investigation | 1 | 0 | Initial Comments | Memo Tag | N | Not Deemed | 20228 An abbreviated survey was conducted on 10/4/18 to investigate complaint AL35880. During this survey, an Immediate Jeopardy (IJ) identified on 10/1/18 . On 10/4/18, Employee Identifier (EI) # 8, Chief Executive Officer was informed by the surveyors the Immediate Jeopardy could not be relieved due to: Geri-psychiatric Unit (GPU) was not staffed to ensure all patients' nursing needs were met to include 1:1 observations for patients who were high risk for falls. After review of the credible allegation of compliance for removal of the Immediate Jeopardy, it was determined the Immediate Jeopardy could be abated on 10/4/18. The facility put the following steps into place on 10/4/18: Review of the Facility's credible allegation of compliance dated and signed by the Chief Executive Officer on 10/4/18 revealed the following corrective actions related to inadequate staffing to meet the acuity needs of patients: Plan of Correction: 1) Immediate corrective actions include: acuity assessments of patients on unit and staffing increased based on acuity review; appropriate unit staffing ensured by adding 2 MHTs; staff called in and ensured that there is adequate staffing to meet the needs of the current patient load and acuity thru Sunday 10/7/18. 2) Appropriate staffing for the next six weeks will be included on the current schedule which concludes 10/27/18; this schedule will be updated by Sunday 10/7/18. Review and update staffing metrics and guidelines related to patient acuity, effective 10/8/18. 4) An updated acuity scale is to be added to the Geripsych staffing plan (see attached policy), to include a scale rating system from 1-5. High falls risk patients will be rated a 4. Any patient with a rating greater than or equal to a 4 will be a 1:1 observation patient. Completed 10/4/18. 5) Department Director/Charge Nurse will assess staffing plan and will determine acuity scale for Geripsych patients. They will staff based on the acuity scale and staffing plan 4 hours prior to next shift. 6) All Geripsych staff/Department Director's/Charge Nurses will be educated by reviewing the current acuity grid and 1:1 policy. Department Director will have mandatory staff meetings with all shifts to educate on policies and procedures related to staffing by 11/1/18; any staff on the schedule before end of current schedule will be educated before they report to shift. Review of the Staffing Plan Exhibit A - Geriatric Staffing Plan which was included in the Facility's credible allegation of compliance revealed an acuity scale which included 1 through 5, with (4) High Fall Risk with repeated fall and (5) 1:1 (one to one) staffing and "... All scores greater than or equal to 4 will be considered (A One On One)..." After review of the credible allegation of compliance for removal of the Immediate Jeopardy, it was determined the Immediate Jeopardy could be abated on 10/4/18 due to the facility: The complaint survey did result in Condition of Participation cited at: 482.23 - Nursing Service | |||||||||||
34 | 010069 | MEDICAL CENTER BARBOUR | 820 W WASHINGTON ST | EUFAULA | AL | 36027 | 10/04/2018 | Complaint Investigation | 1 | A0144 | Patient Rights: Care In Safe Setting | 482.13(c)(2) | Standard of Participation | 11/21/2018 | N | Not Deemed | 20228 Based on review of facility policies, Geriatric Staffing Plan, Time Detail report, Facility's credible allegation of compliance submitted to the surveyors on 10/4/18 and interviews, it was determined the facility failed to ensure patients were cared for in an environment which promoted a safe environment to decrease the risk for falls and / or injuries. This had the potential to negatively affect all patients admitted to the facility's Geri-psychiatric Unit (GPU). Findings include: Facility policy: Title: Staffing Plan Effective Date 1/1/2007 Policy: ... C. The staffing is reviewed and changes are made as patient volume and acuity dictates at a management level, Routine staffing schedules are established. The Nurse Director is responsible for coordinating staffing needs. If additional staff is required, i.e. 1:1's, special consideration will be taken when scheduling staff. D. Every effort shall be made to provide additional staffing when required by: 1. Reviewing staffing schedules, "on-call" schedules and contacting available staff to the unit. 2. Reviewing staffing schedules and contacting available staff from other areas that are oriented to the unit. The Nurse Director and Nursing Administration will maintain a list of cross-trained staff for reference... E. Recommended staffing ratios: 12.21 x census. Note: Since G/P (Geri-psych) is a restraint free unit, staffing is adjusted to accommodate one on one when indicated. Purpose: The Staffing Plan is based on Patient census and acuity... Review of the Geriatric Staffing Plan revealed the following staff:patient ratios for each shift: Census: 1to 2 = (2) Licensed staff members for 7 AM to 7 PM and 7 PM to 7 AM shifts Census: 3 to 9 = (2) Licensed staff members, (1) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts Census: 10 to 14 = (2) Licensed staff members, (2) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts Census: 15 = (2) Licensed staff members, (3) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts Census: 16 to 18 = (3) Licensed staff members, (3) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts Review of the Staffing Sheet dated 9/26/18 for 7 PM to 7 AM revealed there were a total of 13 patients with the following staff assigned for the shift: (1) Registered Nurse (RN) from 7 PM to 10:30 PM, (2) Licensed Practical Nurses (LPNs) and (1) Mental Health Technician (MHT). According to the Geriatric Staffing Plan above, there should have been at least (2) Licensed Staff Members and (2) Techs and from 10:30 PM to 7 AM there were only (2) Licensed staff members and (1) Tech to care for 13 patients. Review of the Time Detail report dated 9/26/18 revealed the RN's actual time clocked in was from 7:00 PM to 11:00 PM, MHT's time was from 9:01 PM to 6:59 AM, (1) LPN's time was from 6:20 PM to 7:21 AM, (2) LPN's time was from 6:41 PM to 7:21 AM. There was an additional RN who clocked in at 4:00 PM to 8:14 PM. According to the Time Detail report, there were (2) LPNs and (1) MHT from 11:00 PM until 7 AM shift arrived to provide care for 13 patients. Review of the Staffing Sheet dated 9/27/18 for 7 PM to 7 AM revealed there were a total of 10 patients with the following staff assigned for the shift: (1) RN, (1) LPN and (1) MHT. Review of the Time Detail report dated 9/27/18 revealed the staff members present and clocked in from 7 PM to 7 AM were (1) RN, (1) LPN and (1) MHT to care for 10 patients. According to the Geriatric Staffing Plan above, there should have been at least (2) Licensed Staff Members and (2) Techs to care for 10 patients. Review of the Time Detail report dated 9/29/18 revealed the staff members present and clocked in from 7 PM to 7AM were (2) RN and (1) MHT to care for 12 patients. According to the Geriatric Staffing Plan above, there should have been at least (2) Licensed Staff Members and (2) Techs to care for 12 patients. Review of the Staffing Sheet dated 9/30/18 for 7 PM to 7 AM revealed there were a total of 12 patients with the following staff assigned for the shift: (3) LPNs (1 of which was placed in the MHT slot). Review of the Time Detail report dated 9/30/18 revealed the staff members present and clocked in from 7 PM to 7 PM were (3) LPNs to care for 12 patients. According to the Geriatric Staffing Plan above, there should have been at least (2) Licensed Staff Members and (2) Techs to care for 12 patients. An interview was conducted on 10/4/18 at 8:25 AM with Employee Identifier (EI) # 6, LPN. The surveyors asked, "How are the MHTs assigned patients?" EI # 6 stated, "If there are 8 patients and 1 MHT - the MHT does everything. If there are 2 MHTs, they decide how they want to split it up. They take breaks when they can." When questioned about the number of staff on her shift, EI # 6 stated there are usually 3 staff members present, 1 RN, 1 LPN and 1 MHT depending on the number of patients, if there are more patients then there are more staff present. An interview was conducted on 10/4/18 at 9:00 AM with EI # 7, RN. The surveyors asked, "How are the MHTs assigned patients?" EI # 7 stated, "If there are 2 MHTs, they work together. They split the paper load, but they don't take certain patients." When questioned about the number of staff on her shift, EI # 7 stated, "normally 1 RN, 1 LPN and 1 or 2 MHT, if staff are available to work, then we have 2 MHTs." The surveyors asked EI # 7 to explain observation levels. EI # 7 stated the Techs (MHTs) usually have eyes on the patients. When questioned about 1:1 patients, EI # 7 stated that if she is in charge, "we group all 1:1's together and 1 MHT watches all 1:1's together while the other tech does other jobs. Sometime we call other floors to get help. If there is only 1 MHT, patients are brought to the nursing desk and one of the nurses watches the patient." When questioned if the GPU ever does 1:1 observation, EI # 7 stated that sometime they will do 1:1 observation on patients who are high risk. "If there is no order for 1:1; then extra staff are not scheduled." An interview was conducted on 10/4/18 at 9:25 AM with EI # 5, MHT. The surveyors asked, "How are the MHTs assigned patients?" EI # 5 stated, "We all do everything. We only split the paperwork. When questioned about the number of staff on her shift, EI # 5 stated, "1 MHT, 1 RN, 1 LPN." The surveyors asked if she has a 1:1 patient, is she allowed to watch other patients. EI # 5 stated, "Yes. I will take the 1:1 into the activity room & bring other patients in there" An interview was conducted on 10/4/18 at 9:40 AM with EI # 3, MHT. When questioned about the number of staff on her shift, EI # 3 stated, "1 MHT, sometimes 1 RN, 1 LPN or 2 LPNs." The surveyors asked, "How are the MHTs assigned patients?" EI # 3 stated, "It depends if 1:1. Someone sits with 1:1 for an hour and the other MHT does other things then we switch out." The surveyors asked if there is only 1 MHT and more than (1) - 1:1 patient how is that accomplished? EI # 3 stated that the MHT takes all 1:1's into the group room and the MHT watches them while the nurses watch the rest of the patients. When questioned why patients are 1:1, EI # 3 stated, "because they can't walk and try to get up." On 10/4/18 at 11:25 AM, the surveyors met with EI # 1, Director of Senior Care Services, EI # 2, Interim Chief Nursing Officer and EI # 8, Chief Executive Officer to discuss the problems of not having enough staff available to safely care for patients in the GPU and staffing not being provided according to the GPU staffing grid. The surveyors identified the GPU had net been staffed according to the staffing grid and requested a credible allegation of compliance. Review of the Facility's credible allegation of compliance dated and signed by the Chief Executive Officer on 10/4/18 revealed the following corrective actions related to inadequate staffing to meet the acuity needs of patients: Plan of Correction: 1) Immediate corrective actions include: acuity assessments of patients on unit and staffing increased based on acuity review; appropriate unit staffing ensured by adding 2 MHTs; staff called in and ensured that there is adequate staffing to meet the needs of the current patient load and acuity thru Sunday 10/7/18. 2) Appropriate staffing for the next six weeks will be included on the current schedule which concludes 10/27/18; this schedule will be updated by Sunday 10/7/18. Review and update staffing metrics and guidelines related to patient acuity, effective 10/8/18. 4) An updated acuity scale is to be added to the Geripsych staffing plan (see attached policy), to include a scale rating system from 1-5. High falls risk patients will be rated a 4. Any patient with a rating greater than or equal to a 4 will be a 1:1 observation patient. Completed 10/4/18. 5) Department Director/Charge Nurse will assess staffing plan and will determine acuity scale for Geripsych patients. They will staff based on the acuity scale and staffing plan 4 hours prior to next shift. 6) All Geripsych staff/Department Director's/Charge Nurses will be educated by reviewing the current acuity grid and 1:1 policy. Department Director will have mandatory staff meetings with all shifts to educate on policies and procedures related to staffing by 11/1/18; any staff on the schedule before end of current schedule will be educated before they report to shift. Review of the Staffing Plan Exhibit A - Geriatric Staffing Plan which was included in the Facility's credible allegation of compliance revealed an acuity scale which included 1 through 5, with (4) High Fall Risk with repeated fall and (5) 1:1 (one to one) staffing and "... All scores greater than or equal to 4 will be considered (A One On One)..." | |||||||||
35 | 010069 | MEDICAL CENTER BARBOUR | 820 W WASHINGTON ST | EUFAULA | AL | 36027 | 10/04/2018 | Complaint Investigation | 1 | A0286 | Patient Safety | 482.21(a), (c)(2), (e)(3) | Standard of Participation | 11/21/2018 | N | Not Deemed | 20228 Based on review of medical records (MR), facility policy and interview, it was determined the facility failed to ensure all adverse patient events were reported and were included in the performance improvement activities for the hospital. This affected 1 of 13 MRs reviewed, including Patient Identifier (PI) # 3 and had the potential to negatively affect all patients admitted to this facility. Findings include: Policy: Incident Reporting Effective Date: 12/1/2000 Policy: Incidents to be reported on an Risk Management Incident Report Form include those involving patients, visitors, volunteers, and independent contractors (for non-work related injuries), medical staff members (i.e. physicians and mid-level employees) and students... Medical Center Barbour's Risk Manager and others determined by the Risk Manager will investigate risk events. Risk Management incident report forms should be utilized in the following (this is not an all inclusive list): Physical injury of patients, visitors, medical staff or students Hospital acquired skin breakdown or ulcers Falls Elopement (Patient disappears from hospital) without notifying staff AMA (patient leaves Against Medical Advice)... 1. PI # 3 was admitted to the facility's GPU on 5/24/18 with diagnosis of major cognitive disorder secondary to stroke. Review of the Patient Care Note dated 6/13/18 at 10:22 AM revealed the LPN (Licensed Practical Nurse) documented, "... PRN (as needed) medications at this time due to agitation, aggression, being combative and attempting to cause harm to self after being redirected. Patient was sitting at table in dining room attempting to rock in wheelchair with wheels unlocked. After informing (him/her) could hurt (self), (he/she) locked the wheels and began to rock chair harder causing chair to go backwards. Patient almost hit the floor but was caught by staff. Chair was moved away from the table... (patient) yelled out and forcefully threw (his/her) body weight forward between legs attempting to get out of chair. Patient was prevented from falling..." There was no documentation an incident report had been completed for 6/13/18 near fall event. Review of the NP (Nurse Practitioner) Progress Note dated 7/1/18 (electronically signed at 9:25 AM) revealed the NP documented, "... Muscle skeletal... left 5th finger appears to be swollen. There is no bruising. Is able to move all extremities... Plan... Swelling of left 5th finger. It is painful to touch. No obvious evidence of trauma, skin break or bruising. Will obtain plain film..." Review of the Patient Care Notes dated 7/1/18 at 12:10 PM revealed the LPN documented, "... Physician Notified: (NP) Notified about: Dislocated finger, Orders received: Coming to take pt (patient) to ER (Emergency Room)..." On 7/1/18 at 12:33 PM, the LPN documented, "... Pt transported to ER by staff via w/c accompanied by... NP..." The patient was taken to the Emergency Department (ED). According to the Procedural Note dated 7/1/18, a reduction of the closed, nonfractured, volar dislocation of the 5th left finger was performed by the NP and the ED Physician and a splint was placed but, the patient would not leave the splint in place. There was no documentation an event report had been completed for the unexplained injury to the patient's finger on 7/1/18. An interview was conducted on 10/3/18 at 3:25 PM with Employee Identifier # 1, Director, Senior Care Center, who verified the above findings. | |||||||||
36 | 010069 | MEDICAL CENTER BARBOUR | 820 W WASHINGTON ST | EUFAULA | AL | 36027 | 10/04/2018 | Complaint Investigation | 1 | A0385 | Nursing Services | 482.23 | Condition of Participation | 11/21/2018 | N | Not Deemed | 20228 This condition level deficiency was cited based on review of medical records, facility policies, Facility's Corrective Action Plan submitted to the surveyors on 10/4/18 and interviews, it was determined the facility failed to ensure: 1.T he geri-psych unit (GPU) was staffed to ensure all patients' nursing needs were met to include 1:1 observations for patients who were high risk for falls. 2. Patient care assignments were assigned to the Mental Health Technicians (MHT) by the Registered Nurse. Findings include: Refer to A392 and A397 for individual findings. | |||||||||
37 | 010069 | MEDICAL CENTER BARBOUR | 820 W WASHINGTON ST | EUFAULA | AL | 36027 | 10/04/2018 | Complaint Investigation | 1 | A0392 | Staffing And Delivery Of Care | 482.23(b) | Standard of Participation | 11/21/2018 | N | Not Deemed | 20228 Based on review of facility policies, medical records (MR), facility's credible allegation of compliance submitted to the surveyors on 10/4/18 and interviews, it was determined the facility failed to ensure the geri-psych unit (GPU) was staffed to ensure all patients' nursing needs were met to include 1:1 observations for patients who were high risk for falls. This affected 4 of 13 patients, including Patient Identifier (PI) # 3, PI # 1, PI # 2, and PI # 4 and had the potential to negatively affect all patients admitted to the GPU. Findings include: Facility policy Title: Staffing Plan Effective Date 1/1/2007 Policy: ... C. The staffing is reviewed and changes are made as patient volume and acuity dictates at a management level, Routine staffing schedules are established. The Nurse Director is responsible for coordinating staffing needs. If additional staff is required, i.e. 1:1's, special consideration will be taken when scheduling staff. D. Every effort shall be made to provide additional staffing when required by: 1. Reviewing staffing schedules, "on-call" schedules and contacting available staff to the unit. 2. Reviewing staffing schedules and contacting available staff from other areas that are oriented to the unit. The Nurse Director and Nursing Administration will maintain a list of cross-trained staff for reference... E. Recommended staffing ratios: 12.21 x census. Note: Since G/P (Geri-psych) is a restraint free unit, staffing is adjusted to accommodate one on one when indicated. Purpose: The Staffing Plan is based on Patient census and acuity... Review of the Geriatric Staffing Plan revealed the following staff:patient ratios for each shift: Census: 1 to 2 = (2) Licensed staff members for 7 AM to 7 PM and 7 PM to 7 AM shifts Census: 3 to 9 = (2) Licensed staff members, (1) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts Census: 10 to 14 = (2) Licensed staff members, (2) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts Census: 15 = (2) Licensed staff members, (3) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts Census: 16 to 18 = (3) Licensed staff members, (3) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts Facility Policy Title: Observation: One-to-One Effective Date: 7/1/2007 Policy One-to-One Observation shall be initiated for: Patients displaying a high degree of impulsive or irresponsible behavior, or those who present themselves as a danger to themselves or others and have expressed either intent or a plan of action. This would include, but is not limited to... fall risks with repeated fall... One-to-One Observation is to be used only when all other less restrictive means have been utilized and have been unsuccessful in keeping the patient safe. The staff member assigned to the "One-to-One" must be within one (1) arms length of the patient at all times... An order from the psychiatrist shall be obtained within two (2) hours of initiating the "One-to-One." ... The continued need for a "One-to-One" shall be reviewed and documented at a minimum every (48) hours by the psychiatrist and the order rewritten as appropriate. Only the psychiatrist can discontinue "One-to-One" Observation. Upon discontinuation of the "One-to-One" the patient will be placed on Close Observation/Special Precautions... The Special Observation Record will be maintained every fifteen (15) minutes by the staff member assigned to the "One-to-One". Purpose: To provide a mechanism, based on clinical justification, to monitor a patient continuously for safety reasons... Facility Policy Title: Fall Risk Assessment and Intervention Effective Date: 2/1/2004 Responsibility: It is the responsibility of the admitting Registered Nurse to perform a "fall risk assessment" on the patient and implement nursing interventions applicable for the patient and their level of risk. It is the responsibility of the patient's nurse to routinely assess the patient for the need for appropriate interventions related to fall prevention throughout their hospital stay. A low risk to fall patient is to be assessed when there is a significant change in their mental status, gait or mobility, medications and no less than every 24 hours. An at risk to fall patient is to be assessed no less than every shift. All levels of risk to fall: The patient's nurse should assess the patient when there is a change in patient's condition or environment. Appropriate interventions should be implemented, communicated and documented. It is the responsibility of all employees to observe and monitor patients identified At Risk for Falls. Definition: A fall is defined as: Any observed fall of a patient from one surface level to another... Any unobserved fall reported by a patient. Any patient found on the floor and there is reason to believe the patient fell as opposed to sitting on his or her own accord. Any patient assisted to the floor by the staff. Fall Risk Assessment and Intervention: Fall prevention and patient safety is defined as: The identification of At Risk to Fall patients. Implemention of preventive techniques to reduce their risk. Purpose: Targeted (Re) Assessment fr identification of Patients at Risk to Fall. Targeted Interventions to prevent fall for patients identified as Low or At Risk to fall. Reduce patient falls. Reduce severity of injury related to falls. Reduce repeat falls... Procedure: At Risk to fall: (Final risk score 10 or greater) Apply yellow arm band to patient. Keep needed items within reach. Evaluate the need to move the patient closer to the nurse's station. Orient to environment frequently. Side rails up at all times (half up as patient assessment indicates)... Observe patient frequently... 1. PI # 3 was admitted to the facility's GPU on 5/24/18 with diagnosis of major cognitive disorder secondary to stroke. Review of the Psychiatrist's History and Physical (H & P) dated 5/25/18 revealed the patient had no prior history of mental illness, had recently had a cerebral vascular accident (CVA) with hemiplegia. The psychiatrist further documented, "... At the time of my evaluation patient is confused, unable to give much information... Patient is a risk for fall... also been restless and agitated... significant cognitive impairment... unable to care for (himself/herself)... Insight and judgment is poor..." Review of the Nurse Practitioner's (NP) H & P dated 5/25/18 revealed, "... (patient) had stroke like symptoms... Upon further evaluation at (Hospital # 2)... was diagnoses with acute CVA with dysarthria and some mild hemiplegia... also had difficulty with encephalopathy... review of symptoms: Neuro. Alert and Oriented person and year...is able to follow some simple commands,.. answer yes or no questions... does have some degree of confusion... Assessment and Plan: Ischemia CVA. This occurred within the past couple of weeks.... aphasia and some degree of mild hemiplegia..." Review of the Falls Risk Assessment Scoring Tool dated 5/25/18 revealed the patient's fall risk score was 26 - "At Risk" for fall. Review of the medical record revealed the patient sustained falls on 5/27/18 at 7:40 PM and a second incident at 10:00 PM, in which the patient was trying to get up from the wheelchair, turned the wheelchair onto it's side and the patient fell onto the floor. Review of the Patient Care Note dated 6/1/18 at 1:39 PM revealed the LPN documented, "... Patient found on floor in front of...w/c (wheelchair) on knees. Redness to bil (bilateral) knees observed. Small skin tear to upper left arm..." Review of the Patient Care Note dated 6/1/18 at 3:58 PM revealed the LPN documented, "... Resident found in hallway on floor by staff. Patient denies knowing how (he/she) got onto the floor... Patient continues to remove lap buddy and other safety measures put in place for (his/her) safety... continues to lean forward while in wheelchair. Patient is now in dining room in wheelchair, MHT (Mental Health Technician) is observing (him/her)..." On 6/1/18 at 7:15 PM, the LPN documented, "... (Psychiatrist) ordered a mattress to be place on floor for resident to reduce falls..." Review of the Patient Care Notes revealed the nurses documented the following patient falls/incidents: 6/2/18 at 7:10 PM (from geri-chair); 6/4/18 at 2:25 AM (unobserved fall - patient found on lying on floor, in wheelchair on right side); 6/4/18 - (patient was trying to stand up from wheelchair, redirected to sit back down and slid out to floor). Review of the Psychiatrist's Progress Note dated 6/4/18 revealed the psychiatrist documented, "... has been restless and agitated at times... slept only 3 hrs (hours)... trying to get out of... chair and bed... needs constant redirection... is a fall risk..." Review of the Patient Care Notes revealed the nurses documented the following patient falls/incidents: 6/5/18 4:39 (patient slid to floor from wheelchair) and 6/5/18 at 5:05 PM (witnessed fall in dining room). Review of the Psychiatrist's Progress Note dated 6/6/18 revealed the psychiatrist documented, "... restless agitated and appears to be responding to internal stimuli... resisting care and fighting staff... a high risk for fall... Insight and judgement poor... is a danger to self and others... Plan... is on fall precaution..." Review of the Psychiatrist's Progress Note dated 6/8/18 revealed the psychiatrist documented, "... has been confused and restless... has been resisting care... has periods of confusion alternating with lucid intervals... has been agitated and threw the furniture on the floor... Plan... Patient will be on fall precaution..." Review of the Psychiatrist's Progress Note dated 6/11/18 revealed the psychiatrist documented, "... has been trying to crawl out of (his/her) bed... restless and at times agitated... slept 7.5 hours last night... is on fall precaution. Insight and judgment is poor..." Review of the Patient Care Note dated 6/13/18 at 10:22 AM revealed the LPN documented, "... PRN (as needed) medications at this time due to agitation, aggression, being combative and attempting to cause harm to self after being redirected. Patient was sitting at table in dining room attempting to rock in wheelchair with wheels unlocked. After informing (him/her) could hurt (self), (he/she) locked the wheels and began to rock chair harder causing chair to go backwards. Patient almost hit the floor but was caught by staff. Chair was moved away from the table... (patient) yelled out and forcefully threw (his/her) body weight forward between legs attempting to get out of chair. Patient was prevented from falling..." Review of the Psychiatrist's Progress Note dated 6/17/18 revealed the psychiatrist documented, "... patient was evaluated this morning... is confused and restless... is a fall risk... needs one to one observation..." Review of the Psychiatrist's Progress Note dated 6/21/18 revealed the psychiatrist documented, "... confused and restless and agitated... needs total care... alert and oriented to person only. Psychomotor activity decreased. Thought process loose and disorganized. Attention and concentration poor... Plan... is on fall precaution... is one-to-one most of the time..." Review of the Psychiatrist's Progress Note dated 6/22/18 revealed the psychiatrist documented, "... is one-to-one... is high risk for falls..." Review of the Patient Care Notes revealed the nurses documented on 6/22/18 at 9:37 AM the patient held up right leg, noted large raised hard area to the right lower shin area. Review of the Special Observation Lists dated 6/22/18 at 9:30 AM revealed Employee Identifier (EI) # 4, Mental Health Technician (MHT) performed observations on the following patients in the following locations: PI # 3 - Activity Room, PI # 6 - Group Room, PI # 7 - Patient Room # 101A, PI # 8 - Patient Room # 104A, PI # 9 - Hallway, PI # 10 - Patient Room # 103B, PI # 11 - Patient Room # 102A, PI # 12 - Group Room and PI # 13 - Group Room. All of these observations were documented as Every 15 minutes. There was no documentation PI # 3 was placed on One-to-One observation on 6/22/18. Review of the Patient Care Notes dated 6/23/18 at 10:00 AM revealed the nurse documented, "... patient had fall from wheelchair onto floor...MD (Medical Doctor) notified and (NP) also (notified) ..." Review of the Special Observation Lists dated 6/23/18 at 10:00 AM revealed EI # 3, MHT performed observations on the following patients in the following locations: PI # 3 - Activity Room, PI # 7 - Hallway, PI # 9 - Hallway, PI # 10 - Patient Room # 103B, PI # 11 - Hallway, PI # 12 - Group Room and PI # 13 - Dining Room. All of these observations were documented as Every 15 minutes. There was no documentation on the Special Observation List that PI # 3 was placed on One-to-One observation on 6/23/18. Review of the Psychiatrist's Progress Note dated 6/24/18 revealed the psychiatrist documented, "... had a fall and has a black eye... Plan... is on fall precaution..." Review of the NP Progress Note dated 6/24/18 revealed the NP documented, "... Physical Exam... Skin... Bruising noted to the left zygomatic arch and under left eye... Fall with another closed head injury. We have applied ice.. . is on fall precautions and requires constant supervision..." Review of the Patient Care Note dated 6/27/18 at 10:28 AM, 12:13 PM and 2:04 PM revealed the LPN documented the patient was one on one with staff. On 6/27/18 at 3:20 PM, the LPN documented the patient was sliding out of chair, combative with staff and refusing to stay in wheelchair, safety measures were in place and the patient had one on one staff. There was no documentation on the Special Observations List dated 6/27/18 the patient was on one to one observation. Review of the Special Observation Lists dated 7/1/18 revealed EI # 5, MHT performed every 15 minute observations from 7:00 AM to 9:30 AM on the following patients in various locations: PI # 3, PI # 7, PI # 13, PI # 14 and PI # 15. There was no documentation on the Special Observation List that PI # 3 was placed on One-to-One observation on 6/22/18. Review of the NP Progress Note dated 7/1/18 (electronically signed at 9:25 AM) revealed the NP documented, "... Muscle skeletal... left 5th finger appears to be swollen. There is no bruising. Is able to move all extremities... Plan... Swelling of left 5th finger. It is painful to touch. No obvious evidence of trauma, skin break of bruising. Will obtain plain film..." Review of the Patient Care Notes dated 7/1/18 at 12:10 PM revealed the LPN documented, "... Physician Notified: (NP) Notified about: Dislocated finger, Orders received: Coming to take pt (patient) to ER (Emergency Room)..." On 7/1/18 at 12:33 PM, the LPN documented, "... Pt transported to ER by staff via w/c (wheelchair) accompanied by... NP..." The patient was taken to the Emergency Department (ED). According to the Procedural Note dated 7/1/18, a reduction of the closed, nonfractured, volar dislocation of the 5th left finger was performed by the NP and the ED Physician and a splint was placed but, the patient would not leave the splint in place. Review of the medical record revealed the patient sustained a fall on 7/6/18 at 5:44 PM. There was no documentation additional plans were implemented for this patient with multiple falls and injuries to prevent these falls and/or injuries. Throughout the medical record, the psychiatrist and nursing staff documented the patient was one on one. There was no documentation which staff was performing one to one observation. The Special Observation Lists by the MHTs revealed the patient's level of observation was every 15 minutes and the same MHT was performed observations for multiple patients at the same time as observing PI # 3. There was no documentation the nursing staff implemented 1:1 observation for this patient who was at high risk for falls, nor was there documentation the staff performed 1:1 observation, even though the psychiatrist documented the patient "needed" one to one observation. 32470 2. PI # 1 was admitted to the GPS unit on 9/21/18 with admitting diagnoses of AMS (Altered Mental Status) Unspecified, Dementia With Behavioral Disturbance. Review of the Initial Psychiatric Evaluation dated 9/21/18 revealed the psychiatrist documented as past psychiatric history the patient had been diagnosed with Dementia and patient denies any history of mental health problems. Further review of the assessment documentation by the psychiatrist revealed major neurocognitive disorder, severe, with behavioral disturbances. Review of the mental status examination dated 9/21/18 by the psychiatrist revealed patient alert,oriented to self, confused...He/she appears to respond to internal stimuli. Guarded. Patient is a danger to himself / herself and to others. Attention and concentration is limited to poor. Memory is poor. Insite and judgement is poor. Plan: ...Prognosis is poor and guarded. Review of the Senior Care Unit Admitting Orders dated 9/21/18 revealed under Special Precautions/Observations the patient was a fall risk and had agitation. Review of the Patient Care Note dated 9/21/18 revealed the patient was admitted to the GPU at 7:30 PM and was difficult to arouse. Taken to room and placed in bed. Patient then was awake, irritable and restless in bed. Review of the medical doctor's admission history and physical dated 9/22/18 revealed the patient's cognitive status as difficulty processing information and difficulty reasoning and functional status as dependent ADL's (Activities of Daily Living). Review of the Patient Care Notes dated 9/23/18 at 4:00 AM revealed the nurse responded to a yell by the patient. The patient was found lying beside the bed, legs outstretched and head on the floor. The nurse documented the patient was confused to time and place. Patient was assisted off the floor with assistance of 2 staff members and patient was guarding left leg and could not stand without assistance. Review of the Event Submission Report dated 9/23/18 with no time documented revealed the patient had a fall on the GPU. Description of incident revealed the patient found lying with head on the floor and legs extended outward in room. VS (vital signs) taken, patient shows s/s (signs and symptoms) of left side leg weakness. Patient denies striking head. Patient is confused most of the time... Review of the Patient Care Note dated 9/23/18 at 22:00 (10:00 PM) revealed the nurse documented ...Staff sitting 1:1 with patient. Review of the 9/23/18 Special Observation List revealed the patient was on Q 15 minute observations and on fall precautions and not the 1:1 observation as mentioned in the Patient Care Note at 10:00 PM. Further review of the Special Observation List revealed at 12:00 AM patient was asleep in room and observations were Q 15 minutes with fall precautions not 1:1 observation as mentioned in the Patient Care Note. Review of the patient census on 9/23/18 for the 7 AM to 7 PM shift the census was 13 and for the 7 PM to 7 AM shift the census was 14. Review of the staffing grid presented to the surveyor revealed for a census of 13 staffing should have been 2 licensed staff and 2 techs (technicians) and also for a census of 14. Review of the staffing for the 7 AM to 7 PM shift dated 9/23/18 there was 1 RN (Registered Nurse), 1 LPN (Licensed Practical Nurse) , 1 tech for entire shift and 1 tech from 12:45 PM to 7 PM. Further review revealed for the 7 PM to 7 AM shift was 1 RN, 1 LPN, 1 tech for entire shift and 1 tech from 7 PM to 12 AM. Review of the Patient Care Note dated 9/24/18 at 00:00 (12:00 AM) revealed the nurse documented ...Staff sitting 1:1 with pt.(patient). Review of the Patient Care Note dated 9/24/18 at 1:35 AM revealed the nurse documented patient is in his/her room agitated. Medicated with Haldol po (by mouth) prn (as needed). Review of the psychiatric progress note dated 9/24/18 revealed patient is evaluated and confused...per staff slept 3 hours..patient today was found on the floor. Patient with left hip pain and was followed by nurse practitioner and had hip x-ray done... Review of the Event Submission Report dated 9/24/18 at 1:00 PM revealed the patient had a fall on the GPU. Description of incident revealed the patient found on floor by the quiet room. Review of the event report dated 9/24/18 revealed the patient had a history of falls, was sensory impaired and was ambulating without assistance or without an assistive device. The fall was unassisted and unwitnessed. Review of the Patient Care Note dated 9/24/18 at 15:41 (3:41 PM) revealed the nurse documented pt was propelling self in w/c (wheelchair) without difficulty...Will continue to monitor, eyesight observation. Review of the 9/24/18 Special Observation List the staff documented the patient was on Q 15 minute observations and fall precautions not with in eye sight as documented in the Patient Care Notes at 3:41 PM. Review of all the Special Observation List from 9/21/18 to 10/1/18 revealed the patient was on Q (every) 15 minute observations and on Fall Precautions. Review of the patient census on 9/24/18 revealed for the 7 AM to 7 PM shift the census was 14 patients and for the 7 PM to 7 AM shift census was 12. Review of the staffing grid revealed for a census of 14 staffing should have been 2 licensed staff and 2 techs. Review of the staffing sheet for the 7 AM to 7 PM shift there was 3 RN with one scheduled from 11 AM to 7 PM and 1 tech. Review of the staffing sheet for the 7 PM to 7 AM shift there was 1 RN, 1 LPN, 1 tech the entire shift and 1 tech from 7 PM to 6 AM. 3. PI # 2 was admitted to the facility on 7/3/18 with an admitting diagnosis of Major Neurocognitive Disorder with Psychosis and Behavioral Disturbance. Review of the initial psychiatric assessment dated 7/4/18 revealed the patient has a history of Major Neurocognitive Disorder. Patient at this time is confused and restless...Patient is a fall risk and unable to give history. Appears to be responding to internal stimuli...Patient is paranoid. Thought processes loose and disorganized. Memory poor insite and judgement is poor. Patient is a danger to self as well as others. Review of the mental status examination section of the initial assessment revealed ..alert and oriented to person only. Psychomotor activity increased. Mood irritable and affect blunt. Thought process loose and disorganized. Speech is under-productive, appears to be responding to internal stimuli and is a danger to self and others. Memory poor, insite and judgement poor. Review of the psychiatrist progress note dated 7/7/18 revealed under the mental status examination the patient is oriented to person only. Psychomotor activity increased. Mood irritable and affect labile. Thought process loose and disorganized...appears to be responding to internal stimuli, and is a danger to self not others...Plan will continue the medications, and is on fall precautions. Review of the Interdisciplinary Treatment Plan Data Base dated 7/13/18 revealed the following problems initiated a). Psychosis c) Falls... Review of the treatment plan for psychosis reveled the patient was on Q (every) 15 minute observations daily times 10 days. Review of the Patient Assessment Report dated 7/4/18 at 7:56 AM revealed the patient's fall risk score was 16. Further review revealed at 12:45 AM the fall risk score was 13.0 and at 8:52 PM the fall risk score was 15.0. Review of the documentation on the Patient Assessment Report revealed a score of greater than 10 the patient is at high risk for fall. Review of the treatment plan for falls revealed patient will have o falls by 7/10/18 and the patient will have Q shift safety awareness education 3 times daily. Further review revealed the goal for falls were documented as "Patient will have no falls". Review of the Patient Care Note dated 7/5/18 at 22:00 (10:00 PM) revealed the patient was attempting to get out of bed and is combative. Staff is 1:1. Review of the Patient Care Notes dated 7/8/18 at 18:43 (6:43 PM) patient became combative and pulled IV (intravenous) out, restless...will continue to monitor. Review of the Patient Care Note dated 7/8/18 at 21:50 (9:50 PM) patient found sitting on floor beside bed, awake, alert...no injuries noted. Patient assisted to bed. Review of the Patient Care Note dated 7/10/18 at 00:31 (12: 31 AM) revealed staff is 1:1. At 02:56 (2:56 AM) revealed staff is 1:1. Further review revealed at 0400 (4:00 AM) Staff 1:1 for patient safety. At 21:30 (9:30 PM) patient yelling out and agitated. Staff is sitting 1:1. Review of the 7/10/18 Patient Care Note revealed at 23:03 (11:03 PM) the nurse documented Staff is 1:1. Further review revealed at 23:55 (11:55 PM) the patient continues to be restless, combative... Staff is 1:1. Review of the Patient Care Note dated 7/19/18 at 20:15 (8:15 PM) revealed ...patient continuing to get up by self and patient is hard to redirect, staff sitting 1:1 with patient. Review of the Patient Care Note dated 7/23/18 at 10:00 PM revealed the nurse documented patient found lying on pillow on floor in room, patient assisted to bed, no injuries noted, no distress noted... Review of the Patient Care Note dated 7/23/18 at 23:30 (11:30 PM) the nurse documented patient is restless, agitated and yelling out. Patient is combative with staff when he is redirected. Staff 1:1. Review of the Patient Care Note dated 7/24/18 at 20:10 (8:10 PM) revealed staff assisted patient from room to the dining room via wheelchair to sit 1:1. Further review revealed at 21:36 (11:36 PM) staff is sitting 1:1. Review of the Patient Care Note dated 7/25/18 at 00:15 (12:15 AM) revealed staff sitting 1:1. Further review revealed at 02:16 (2:16 AM) and at 04:00 (4:00 AM) the staff documented Staff is 1:1 with the patient. Review of all the Special Observation List forms from 7/3/18 to 7/28/18 revealed the patient was on Q 15 minute observations and was on fall precautions. Further review revealed no documentation the patient was on 1:1 observations at any time. Review of the staffing sheet dated 7/8/18 for 7 PM to 7 AM shift revealed there was 1 RN, 1 LPN, 1 tech for the full shift, 1 tech from 1 PM to 5 AM and 1 tech from 7 PM to 11 PM and the census was 11. Review of the staffing grid presented to the surveyor revealed the census: 10 to 14 = (2) Licensed staff members, (2) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts Review of the staffing sheet dated 7/23/18 for the 7 PM to 7 AM shift revealed there was 1 RN, 1 LPN, 1 tech and 1 tech orientee and the census was 12. Review of the staffing grid presented to the surveyor revealed the census: 10 to 14 = (2) Licensed staff members, (2) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts 4. PI # 4 was admitted to the facility on 7/10/18 with admitting diagnoses of Unspecified Dementia with Behavioral Disturbance and Alzheimer's Disease Unspecified. Review of the psychiatrist History and Physical dated 7/11/18 at 9:33 PM revealed the patient had a history of Major Neurocognitive disorder. Patient was brought to the Emergency Room with increased confusion and agitation. He is restless and confused. He appears to be responding to internal stimuli and has had a fall recently. The patient has significant cognitive impairment. He is a danger to self and others...He is a fall risk. Review of the mental status exam dated 7/11/18 revealed the patient is alert and oriented to person only, psychomotor activity is decreased, thought process is delayed, speech is rambling, thought process is delayed, mood is irritable, affect is labile and positive for paranoia. The patient has delusional thoughts and appears to be responding to internal stimuli. Memory is poor and he is a danger to self not others and insite and judgement is poor. Review of the Interdisciplinary Treatment Plan Data Base dated 7/10/18 revealed the following problems: 1. Psychosis 3. Falls. Review of the treatment plan revealed under psychosis the patient will be oriented to 1 spheres all day for 3 days, Improved ability to concentrate, follow simple topics of conversation and improved ability to manage frustration/anger without acting out. Further review revealed the patient will be on 15 minute checks daily for 10 days. Review of the treatment plan for falls revealed the goal is no falls by 7/17/18 and patient will have Q shift safety awareness education 3 times daily. Review of the Fall Risk Assessment Form revealed the form stated Fall Risk Level: At risk (total at fall score 10 or greater). Review of the Fall Risk Assessment dated 7/11/18 at 9:26 AM the patient scored 20. Further review revealed at 11:28 PM the patient's fall risk score was 21. On 7/12/18 at 8:22 AM the patient's fall risk assessment was documented as 23 and at 8:03 PM the fall risk score was 22. Review of the Fall Risk Assessment score on 7/23/18 at 8:02 AM revealed the patient's fall risk score was 22 and at 8:15 PM the fall risk score was 21. Review of the Fall Risk Assessment dated 7/24/18 at 8:30 AM revealed the patient's fall risk score was 23 and at 9:20 PM the fall risk score was documented as 20. Review of the Patient Care Notes dated 7/11/18 at 1:00 PM revealed the patient continues to ambulate unassisted. Patient's gait is unsteady. Patient very confused and hard to re-direct. Patient becomes combative... Further review revealed at 1:10 PM the physician was notified and an order was received for Zyprexa 5 mg (milligrams) PO (by mouth) or IM (intramuscular) PRN (as needed) for severe agitation or aggression. New orders carried out. At 1:10 PM the medication was given to the patient as an IM injection. Review of the Patient Care Note dated 7/11/18 at 2:10 PM revealed the nurse documented the patient noted on floor in hallway by bathroom. The patient stated "I did not fall and then said "I did fall". No visible injury noted upon assessment... Review of the Patient Care Note dated 7/17/18 at | 3:07 PM the patient was 1:1 at the nurses station and at 3:42 PM the patient continued to be 1:1 and staff had a hard time re-directing patient. Review of the Patient Care Note dated 7/24/18 at 6:01 PM revealed the nurse documented patient found on floor in dining room, no visible injuries noted upon assessment. Patient assisted to wheelchair and taken to hallway by nurses station for eyesight observation. Review of all the Special Observation List forms fated 7/10/18 to 7/31/18 revealed the patient was on Q 15 minute observations and Fall Precautions. There is no documentation of any 1:1 observation documentation on the forms. Review of the staffing sheet for 7/11/18 for the 7 AM to 7 PM shift revealed the following staff were scheduled: 1 RN, 1 LPN, 2 techs and 1 tech from 9 AM it 4:30 PM. The census for 7/11/18 on the 7 PM to 7 AM shift was 13 patients with 1 patient with an acuity of 4. Review of the staffing grid presented to the surveyor revealed the census: 10 to 14 = (2) Licensed staff members, (2) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts Review of the staffing sheet for 7/24/18 for the 7 AM to 7 PM shift revealed the following staff were scheduled: 1 RN, 1 LPN, 2 tech. The census for 7/24/18 on the 7 PM to 7 AM shift was 12 patients with 2 patient with an acuity of 4. Review of the staffing grid presented to the surveyor revealed the census: 10 to 14 = (2) Licensed staff members, (2) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts Review of the Facility's credible allegation of compliance dated and signed by the Chief Executive Officer on 10/4/18 revealed the following corrective actions related to inadequate staffing to meet the acuity needs of patients: Plan of Correction: 1) Immediate corrective actions include: acuity assessments of patients on unit and staffing increased based on acuity review; appropriate unit staffing ensured by adding 2 MHTs; staff called in and ensured that there is adequate staffing to meet the needs of the current patient load and acuity thru Sunday 10/7/18. 2) Appropriate staffing for the next six weeks will be included on the current schedule which concludes 10/27/18; this schedule will be updated by Sunday 10/7/18. Review and update staffing metrics and guidelines related to patient acuity, effective 10/8/18. 4) An updated acuity scale is to be added to the Geripsych staffing plan (see attached policy), to include a scale rating system from 1-5. High falls risk patients will be rated a 4. Any patient with a rating greater than or equal to a 4 will be a 1:1 observation patient. Completed 10/4/18. 5) Department Director/Charge Nurse will assess staffing plan and will determine acuity scale for Geripsych patients. They will staff based on the acuity scale and staffing plan 4 hours prior to next shift. 6) All Geripsych staff/Department Director's/Charge Nurses will be educated by reviewing the current acuity grid and 1:1 policy. Department Director will have mandatory staff meetings with all shifts to educate on policies and procedures related to staffing by 11/1/18; any staff on the schedule before end of current schedule will be educated before they report to shift. Review of the Staffing Plan Exhibit A - Geriatric Staffing Plan which was included in the Facility's credible allegation of compliance revealed an acuity scale which included 1 through 5, with (4) High Fall Risk with repeated fall and (5) 1:1 (one to one) staffing and "... All scores greater than or equal to 4 will be considered (A One On One)..." | ||||||||
38 | 010069 | MEDICAL CENTER BARBOUR | 820 W WASHINGTON ST | EUFAULA | AL | 36027 | 10/04/2018 | Complaint Investigation | 1 | A0397 | Patient Care Assignments | 482.23(b)(5) | Standard of Participation | 11/21/2018 | N | Not Deemed | 20228 Based on interviews, it was determined the nursing staff failed to ensure patient care assignments were assigned to the Mental Health Technicians (MHT) by the Registered Nurse (RN). This had the potential to negatively affect all patients admitted to the Geri-Psychiatric Unit (GPU). Findings include: An interview was conducted on 10/4/18 at 8:25 AM with Employee Identifier (EI) # 6, Licensed Practical Nurse (LPN). The surveyors asked, How are the Mental Health Technicians (MHT) assigned patients?" EI # 6 stated, "If there are 8 patients and 1 MHT - the MHT does everything. If there are 2 MHTs, they decide how they want to split it up. They take breaks when they can." When questioned about the number of staff on her shift, EI # 6 stated there are usually 3 staff members present, 1 RN, 1 LPN and 1 MHT depending on the number of patients, if there are more patients then there are more staff present. An interview was conducted on 10/4/18 at 9:00 AM with EI # 7, RN. The surveyors asked, "How are the MHTs assigned patients?" EI # 7 stated, "If there are 2 MHTs, they work together. They split the paper load, but they don't take certain patients." When questioned about the number of staff on her shift, EI # 6 stated, "normally 1 RN, 1 LPN and 1 or 2 MHT, if staff are available to work, then we have 2 MHTs." The surveyors asked EI # 7 to explain observation levels. EI # 7 stated the Techs (MHTs) usually have eyes on the patients. When questioned about 1:1 patients, EI # 7 stated that if she is in charge, "we group all 1:1's together and 1 MHT watches all 1:1's together while the other tech does other jobs. Sometime we call other floors to get help. If there is only 1 MHT, patients are brought to the nursing desk and one of the nurses watches the patient." When questioned if the GPU ever does 1:1 observation, EI # 7 stated that sometime they will do 1:1 observation on patients who are high risk. "If there is no order for 1:1; then extra staff are not scheduled." An interview was conducted on 10/4/18 at 9:25 AM with EI # 5, MHT. The surveyors asked, "How are the MHTs assigned patients?" EI # 5 stated, "We all do everything. We only split the paperwork. When questioned about the number of staff on her shift, EI # 5 stated, "1 MHT, 1 RN, 1 LPN." The surveyors asked if she has a 1:1 patient, is she allowed to watch other patients. EI # 5 stated, "Yes. I will take the 1:1 into the activity room & bring other patients in there" An interview was conducted on 10/4/18 at 9:40 AM with EI # 3, MHT. When questioned about the number of staff on her shift, EI # 3 stated, "1 MHT, Sometimes 1 RN, 1 LPN or 2 LPNs." The surveyors asked, "How are the MHTs assigned patients?" EI # 3 stated, "It depends if 1:1. Someone sits with 1:1 for an hour and the other MHT does other things then we switch out." The surveyors asked if there is only 1 MHT and more than (1) - 1:1 patient how is that accomplished? EI # 3 stated that the MHT takes all 1:1's into the group room and the MHT watches them while the nurses watches the rest of the patients. When questioned why patients are 1:1, EI # 3 stated, "because they can't walk and try to get up." | |||||||||
39 | 010109 | PICKENS COUNTY MEDICAL CENTER | 241 ROBERT K WILSON DRIVE | CARROLLTON | AL | 35447 | 11/02/2018 | Complaint Investigation | 1 | 0 | Initial Comments | Memo Tag | N | Not Deemed | 36271 An abbreviated survey was conducted 10/30/18 to 11/2/18 for the investigation of Complaint Number AL00035896. The complaint was substantiated. As a result of the investigation, Condition level deficiencies were cited at: 482.12 Governing Body 482.13 Patient Rights 482.23 Nursing Services 482.24 Medical Records | |||||||||||
40 | 010109 | PICKENS COUNTY MEDICAL CENTER | 241 ROBERT K WILSON DRIVE | CARROLLTON | AL | 35447 | 11/02/2018 | Complaint Investigation | 1 | A0043 | Governing Body | 482.12 | Condition of Participation | 12/12/2018 | N | Not Deemed | 36271 Based on observations, review of the facility policy and procedure, the Environmental Safety Check Log, the facility Event/Occurrence Log, medical records (MR), Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, review of previous survey Plan of Correction, and interviews with staff it was determined the facility Governing Body failed to ensure: 1. The facility implemented an environmental safety risk assessment strategy to include a ligature risk assessment and mitigation plan. 2. A safe and clean environment was provided for patients admitted to the Geriatric Psychiatry (Geri-Psych) Unit. 3. The staff on the Geri-Psych unit were educated regarding ligature risk (points), patient safety risk factors and mitigation strategies. 4. The facility corrected / addressed all ligature risk points in the Geri-Psych unit following the recertification survey on 1/11/18, the resurvey on 2/28/18, and the education program (Assessment of Suicide Risks, Ligature Risks and Suicide Prevention Strategies) provided to all geri-psych staff in March 2018. 5. Patient food and medication refrigerators were maintained at the appropriate temperature daily. 6. A PCA (patient care assistant) was in attendance in the day room on the Geri-Psych Unit at all times when patients were in the day room as directed by facility policy. 7. Patient weights were obtained and documented twice per week as ordered by the physician. 8. The nutritional status of patients were reassessed as appropriate. 9. A dietitian consult was obtained for a patient not eating and experienced weight loss. 10. The physician's ordered diet was provided. 11. The nursing staff assessed and documented patients skin status/injuries and implemented preventive interventions. 12. The nursing staff documented the specific treatment modalities they provided. 13. The nursing staff provided and documented interventions to manage behaviors prior to administering prn (as needed) medications. 14. Intravenous (IV) admixtures were prepared by the pharmacy except in emergencies or when not feasible as directed per facility policy. 15. The nursing staff followed the facility policy for admixtures prepared outside the pharmacy. 16. The nursing staff followed the facility policy and CDC hand hygiene guidelines during medication preparation and administration. 17. The Multidisciplinary Treatment Plan was completed by the 3rd treatment day as directed per policy. 18. Each patient admitted to the Geri-Psych Unit had a psychiatric evaluation completed within 60 hours of admission. 19. Psychosocial admission assessments were completed within 3 treatments days of admission. 20. Dietary staff provided food in a consistency the patient could consume. 21. The dietitian provided diet education / counseling for a patient on a special diet that was not eating / drinking. 22. The dietitian initiated a calorie count as directed per policy for a patient consuming less than 50% of meals. Findings include: Refer to A 115, A 144 A 385, A 392, A 405, A 431, A 449, and A 630. | |||||||||
41 | 010109 | PICKENS COUNTY MEDICAL CENTER | 241 ROBERT K WILSON DRIVE | CARROLLTON | AL | 35447 | 11/02/2018 | Complaint Investigation | 1 | A0115 | Patient Rights | 482.13 | Condition of Participation | 12/12/2018 | N | Not Deemed | 36271 Based on observations, review of the facility policy and procedure, the Environmental Safety Check Log, the facility Event/Occurrence Log, medical records (MR), review of previous survey Plan of Correction, and interviews with staff it was determined the facility failed to: 1. Implement an environmental safety risk assessment strategy to include ligature risk assessment and mitigation plan. 2. Ensure a safe and clean environment was provided for patients admitted to the Geriatric Psychiatry (Geri-Psych) Unit. 3. Ensure staff on the Geri-Psych unit were educated regarding ligature risk (points), patient safety risk factors and mitigation strategies. 4. Correct / address all ligature risk points in the Geri-Psych unit following the recertification survey on 1/11/18, the resurvey on 2/28/18, and the education program (Assessment of Suicide Risks, Ligature Risks and Suicide Prevention Strategies) provided to all geri-psych staff in March 2018. 5. Ensure food and medication refrigerators were maintained at the appropriate temperature daily. 6. Ensure a PCA (patient care assistant) was in attendance in the day room at all times when patients were in the day room as directed by facility policy. These deficient practices had the potential to affect all patients admitted to the Geri-Psych Unit at this facility. Findings include: Refer to A 144 | |||||||||
42 | 010109 | PICKENS COUNTY MEDICAL CENTER | 241 ROBERT K WILSON DRIVE | CARROLLTON | AL | 35447 | 11/02/2018 | Complaint Investigation | 1 | A0144 | Patient Rights: Care In Safe Setting | 482.13(c)(2) | Standard of Participation | 12/12/2018 | N | Not Deemed | 36271 Based on facility tour observations, review of the policies and procedures, the Environmental Safety Check Log, the facility Event/Occurrence Log, medical records (MR), review of the previous survey Plan of Correction, and interviews with staff it was determined the facility failed to: 1. Implement an environmental safety risk assessment strategy to include a ligature risk assessment and mitigation plan. 2. Ensure a safe and clean environment was provided for patients admitted to the Geriatric Psychiatry (Geri-Psych) Unit. 3. Ensure staff on the Geri-Psych Unit were educated regarding ligature risk (points), patient safety risk factors and mitigation strategies. 4. Correct / address all ligature risk points following the recertification survey on 1/11/18, resurvey on 2/28/18, and the education program (Assessment of Suicide Risks, Ligature Risks and Suicide Prevention Strategies) provided to all geri-psych staff in March 2018. 5. Ensure food and medication refrigerators were maintained at the appropriate temperature daily. 6. Ensure a PCA (patient care assistant) was in attendance in the day room at all times when patients were in the day room as directed by facility policy. These deficient practices did affect Patient Identifier (PI) # 4 and PI # 3 and had the potential to affect all patients admitted to the Geri-Psych Unit at this facility. Findings include: Policy: Unit Safety Checks Revised: 2/2/18 Purpose: To ensure a safe patient environment and the safety of each patient on the unit. Procedure: A. The charge RN (Registered Nurse) will walk the entire unit at some time during their shift, preferable near the beginning. B. The inspection will include all the areas of the unit. C. The worksheet will be brought along to note any deficiencies and/or contraband found on the unit. The worksheet will include reminders such as doors secured, seclusion room and hallways clear, patient rooms clean and in order, presence of any nonessential furniture, bed alarms working properly, electrical cords on beds shortened/secured to bed frames, and the like. D. Any contraband, to include but not limited to: sharps, cans, wire hangers, lighters, cords, bottles, personal items except for patient clothing or bed linens, perfume, makeup, plastic bags, medicines including over the counter medications, found in patient areas will be removed immediately, labeled, put in patient locker, and noted on worksheet. E. Any other deficiencies, such as: housekeeping issues, maintenance problems, or needed supplies must also be noted on the log sheet. F. The RN will complete work orders for repairs needed and report deficiencies to the Director as necessary. Policy: Observation Status/Special Precautions Revised: 9/7/16 Purpose: To divine observational/special precautions monitoring and circumstances under which they are utilized to maintain the safety of each patient. V. Special Precautions A. Fall Precaution: All Senior Care patients are considered at high risk for falls. (Reference NSA 25.1) a. Observe every fifteen minutes g. PCA in day room when patients are present 1. A tour of the facility was conducted 10/30/18 at 12:45 PM with Employee Identifier (EI) # 2, Director of Patient Care Services. During the tour of the Geri-Psych Unit (GPU) the surveyor observed open safety bars in the patient bathrooms and showers, exposed plumbing at the sinks/toilets and round door knobs on the closet doors. EI # 2 was asked why the ligature points in the patient rooms had not been corrected and the answer was "it is in process". When asked what that means, the answer was "I'm not sure without checking with the unit Director". The initial tour continued with EI # 2 to the day room which served as the Group Therapy room, Activities room, dining room and patient leisure room. The day room had 2 tables with chairs, a kitchen area with a sink, cabinets, and refrigerator. There were storage cabinets along the wall beside the refrigerator with various games and papers. In an unlocked drawer the surveyor observed a long cell phone charger which could be used as a ligature. There were 2 temperature logs on the patient refrigerator door dated October 2018. Review of the Patient Food Refrigerator Log dated October 2018 revealed no temperature check documented on 10/9/18, 10/18/18, 10/21/18, and 10/24/18. Review of the second log titled Temperature Charts Senior Care, revealed no temperature check documented on 10/10/18, 10/24/18, and 10/29/18. The surveyor asked to see the medication room and was taken to a closet at the nursing station. The nurse on duty unlocked the closet which revealed a medication cart backed into the closet and a shelf above the medication cart with a small refrigerator. The shelf beside the medication refrigerator contained a clear plastic bag with shoes and an envelope labeled with a patient's name and the contents. The nurse on duty was asked if this was a current patient and the answer was no. There was no explanation why shoes and patient belongings were in the medication closet. There was no hand washing sink in the vicinity of the medication closet and no disinfectant hand gel was observed at the nurses desk. EI # 2 was asked where the nurses performed hand washing prior to medication preparation. EI # 2 stated in the staff bathroom which was located directly behind the nurses desk. The tour on 10/30/18 concluded at 2:10 PM to be resumed when the unit Director would be available. 2. A second tour of the GPU was conducted on 10/31/18 at 9:20 AM with EI # 1, Director of Geri-Psych with the following findings: Patient Room 233 A & B: multiple ligature points including the bed with open rails, round door knobs, exposed plumbing, open safety bars, door latch plate with crossbar in opening, and a walk in shower (open to the room with a curtain) with wet paper in the drain. The room had only 1 closet. To access the second closet, as well as the toilet and sink for room 233, the patient goes through a connecting door to an ante room outside of the seclusion room. In the ante room was a closet with a round door knob, a door leading into the bathroom which had exposed plumbing to the toilet and sink, a door leading to the seclusion room, and a door leading to the unit hallway. The anteroom, with all 4 doors closed, was a rectangular enclosure which could not be seen from any area outside the enclosed space, posing a patient safety risk. Patient rooms 234, 235 and 236 had multiple ligature points including the bed with open rails, round door knobs, exposed plumbing and open safety bars. Patient Rooms 237, 238, and 239 had multiple ligature points including the bed with open rails, round door knobs, exposed plumbing, shower faucet, open safety bars and door latch with a solid bar in the plate at both the bathroom door and the door to the hallway. During the tour, EI # 1 stated she did not know what happened because she knew all the door latch plates had been replaced with latch plates without the bar across the center. EI # 1 was asked what had been done since the follow up survey in February 2018 to address the ligature risks. EI # 1 stated "it's a process". When asked if there was any documentation of the process and what progress had been made EI # 1 stated she had no documentation. The tour on 10/31/18 continued to the laundry closet which revealed a stackable washer/dryer combination and 3 shelves beside the laundry unit for supplies. The washer was dirty under the lid, there was dust on top of the dryer and on the 3 storage shelves. The Conference Room across from the nurses station which was used as the staff break room, team conference room, patient/family education room and storage room revealed: a table and chairs, TV, books and videos, a coffee maker and staff refrigerator, 2 portable vital sign monitors, 2 IV (intravenous) pumps, 2 walkers, 1 standing walker, 1 wheelchair, 1 O2 (oxygen) concentrator, 1 portable O2 tank, a covered linen cart and a metal cabinet with medical supplies. The patient equipment was not tagged in any way to indicate it was clean and ready for patient use. Inside the metal cabinet was an Apex Heating pad with a PM (preventive maintenance) date of 7/2015. The O2 concentrator did not have a PM sticker. EI #1 stated it belonged in RT (respiratory therapy) and they just had not picked it up yet. The surveyor asked who had used the O2 concentrator and the answer was "I don't know without researching." Also in the Conference Room was a locked closet containing the patient's personal items. On the top shelf was a space labeled "nail polish" and a plastic bath basin filled with various open and partially used bottles of lotions, shampoos, body butter and mouthwash. EI # 1 was asked if the patients used these items. EI # 1 hesitated and went to get the charge nurse who stated she did not know if the patients used the items. The charge nurse placed all the items in the trash. Also in the closet for patient belongings on the top shelf was a plastic bag which contained a watch and the bag was labeled with a patient's name and dated 1/27/16 (not a current patient). EI # 1 did not know why the patient watch was still there. There was also a white Styrofoam cup, unlabeled, which contained about 1 inch depth of a blue gel-like substance. EI # 1 was asked what the substance was and she did not know. EI # 1 discarded the cup with the blue gel like substance. The nurses station housed one camera monitor with a view of the day room. EI # 1 was asked what areas of the unit had video cameras and if they recorded. The surveyor was informed only the day room and the conference room had cameras and there was no recording. There were no cameras in the hallway. The staff at the nurses station were unable to view the hallway leading to the day room. EI # 6, Registered Nurse, was sitting at the nurses station. EI # 6 was asked if someone was assigned to watch the monitor at all times and the answer was no. Review of the unit Environmental Safety Check Log on 10/31/18 revealed the form had no check/observation/reminder to assess for ligature risks. The form was updated 2/2/18. EI # 1 was asked what was updated on the form in February 2018. EI # 1 stated the section for unessential furniture, specifically, only 1 chair in a private room and 2 in a semi-private room was added to the form. EI # 1 verified a check for ligature risks was not on the Environmental Safety Check Log form. EI # 1 stated the environmental rounds were completed once per shift by the PCA (patient care assistant) and the nurse reviews and signs off on them. EI # 1 was asked what ligature risks training and education had been provided to the staff since the recertification survey in January 2018. EI # 1 stated all staff had a class on ligature risks by Inspirien, an outside company. The surveyor requested copies of the training material. The surveyor reviewed the 4 refrigerator logs for the GPU with EI # 1 on 10/31/18 at 11:00 AM. EI # 1 verified the temperature was not documented each day as required. EI # 1 further clarified the second log in the Day Room was for the freezer but the log failed to identify that as the location. The floors in the patient rooms all had stains and scuff marks, the showers all had dirty tiles and grout, and on 10/31/18 the shower drain in room 233 still had the same wet paper that was observed during the tour on 10/30/18. There was dust on shelves and cabinets. EI # 1 was asked how the cleanliness of the unit was maintained. EI # 1 stated housekeeping cleaned once a day and there was a cleaning schedule assigned to the staff for certain things to be cleaned at certain times. 3. Review of the Event/Occurrence Log on 11/1/18 at 11:55 AM revealed PI # 4 sustained a fall in the day room on 7/20/18 at 7:12 AM. Review of the documentation provided by the facility revealed PI # 4 was admitted to the GPU 7/9/18 with diagnoses including Dementia with Behavior Disturbances. Fall Precautions were ordered for PI # 4 at admission. The documentation by the nurse on the Event report dated 7/20/18 at 7:12 AM revealed "heard noise from day room - looked at monitor - pt (patient) had fallen in day area. Pt assessed, pt was on floor on (his/her) bottom with back against wall on far end of room by cabinets. Assisted off floor back in w/c (wheelchair). Asked pt was (he/she) ok, stated I was getting up." An interview was conducted on 11/1/18 at 4:20 PM with EI # 1 to review the patient fall event. EI # 1 stated she was making rounds with the doctor and heard a noise from the day room. When she entered the day room the patient had fallen out of the wheelchair and was on the floor. EI # 1 was asked if there was a PCA or staff member in the day room at the time of the fall and the answer was no. EI # 1 was asked if patients are to be supervised when in the day room and the answer was yes. EI # 1 was asked what follow up was completed to prevent falls in the future and EI # 1 stated she talked to the staff about not leaving patients alone in the day room. When asked for documentation EI # 1 provided a one page Unit Meeting agenda dated August 2018. Item # 3 on the agenda was "Pt Observation Status A. Dayarea". There was no specific documentation regarding what was discussed and there was no sign in sheet of who was in attendance at the meeting. Further review of the Event/Occurrence Log revealed PI # 3 was in the day room and was pushed by another patient sustaining a head injury with multiple skull fractures and bleeding in the brain. Review of the MR revealed PI # 3 was examined and treated in the ER and subsequently transferred out for further care. An interview with EI # 1 on 11/1/18 at 4:30 PM confirmed the above findings. Additionally, EI # 1 confirmed there was no video recording of the events in the day room. An interview was conducted 11/1/18 at 1:45 PM with EI # 3, PCA Geri-Psych. EI # 3 was asked "What are the environmental rounds and why are they done?" EI # 3 stated "Done for safety purposes- check the bed alarm, check all lights, shower clean, beds locked, 2 chairs for semi-private and 1 for private, no contraband, doors are locked at all times... Checks are one time per shift by PCA and nurse". EI # 3 was asked "What is a ligature risk? What training have you had on identifying ligature risks?" EI # 3 stated "I have no idea what it is" An interview was conducted 11/1/18 at 2:20 PM with EI # 4, PCA Geri-Psych. EI # 4 was asked "What are the environmental rounds and why are they done?" EI # 4 stated "Alarms, check for cords...gloves left in room...bed down low, nothing in room. Check at the beginning and ending of shift. One PCA going off and another one coming on." EI # 4 was asked "What is a ligature risk? What training have you had on identifying ligature risks?" EI # 4 replied "I don't know". An interview was conducted 11/1/18 at 4:30 PM with EI # 1. EI # 1 was asked what changes have you made in your unit since attending the class on Ligature Risks in March 2018? EI # 1 stated she had talked to the staff about contraband and about suicide precautions. "Is this documented in any way?" The answer was "No." EI # 1 was asked "What changes in process have you made on your unit to be ligature free?" EI # 1 stated "We talked about the plumbing in bathrooms, hand rails in the bathrooms and door hinges in our Safety Meeting." The surveyor requested the Safety Meeting documentation and none was provided. An interview was conducted on 11/2/18 at 10:00 AM with EI # 7, Director of Plant Operations. EI # 7 was asked for documentation of the "process" for addressing the ligature risk points in the Geri-Psych Unit and none was provided. EI # 7 stated "it's in my head". EI # 7 showed the surveyor information pages printed from the internet 11/1/18 on various products such as psychiatric compliant safety rails and plumbing enclosures for the bathrooms. The surveyor asked if anything had been ordered and the answer was no. There was no documentation provided to show the facility had taken action to mitigate the ligature risks identified on the Geri-Psych Unit. | |||||||||
43 | 010109 | PICKENS COUNTY MEDICAL CENTER | 241 ROBERT K WILSON DRIVE | CARROLLTON | AL | 35447 | 11/02/2018 | Complaint Investigation | 1 | A0385 | Nursing Services | 482.23 | Condition of Participation | 12/12/2018 | N | Not Deemed | 36271 Based on review of facility policies, medical records (MR), Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, and interviews with staff it was determined the nursing staff failed to: 1. Obtain weights and document twice per week as ordered for patients admitted to the Geri-Psych (Geriatric Psychiatry) Unit. 2. Reassess the nutritional status of a patient that was not eating / drinking. 3. Obtain a dietitian consult for a patient not eating and with weight loss. 4. Ensure the physician ordered diet was provided. 5. Assess and document patient's skin status/injuries and implement preventive interventions. 6. Document specific treatment modalities provided. 7. Provide and document interventions to manage behaviors prior to administering prn (as needed) medications. 8. Ensure Intravenous (IV) admixtures were prepared by the pharmacy except in emergencies or when not feasible. 9. Follow the facility policy for admixtures prepared outside the pharmacy. 10. Follow the facility policy and CDC hand hygiene guidelines during medication preparation and administration. Findings include: Refer to A 392 and A 405 | |||||||||
44 | 010109 | PICKENS COUNTY MEDICAL CENTER | 241 ROBERT K WILSON DRIVE | CARROLLTON | AL | 35447 | 11/02/2018 | Complaint Investigation | 1 | A0392 | Staffing And Delivery Of Care | 482.23(b) | Standard of Participation | 12/12/2018 | N | Not Deemed | 36271 Based on review of facility policy, medical records (MR), and interviews with staff it was determined the nursing staff failed to: 1. Obtain weights and document twice per week as ordered for patients admitted to the Geri-Psych (Geriatric Psychiatry) Unit. 2.Reassess the nutritional status of a patient that was not eating / drinking. 3. Obtain a dietitian consult for a patient not eating and with weight loss. 4. Ensure the physician ordered diet was provided. 5. Assess and document patient's skin status/injuries and implement preventive interventions. 6. Document specific treatment modalities provided. 7. Provide and document interventions to manage behaviors prior to administering prn (as needed) medications. This affected 3 of 4 MRs reviewed including PI # 1, # 2, # 3, and had the potential to negatively affect all patients admitted to the Geri-Psych Unit. Findings include: Policy: Assessment/Reassessment Revised: 09/17 Each inpatient has an initial physical, psychological, and social assessment. The initial assessment is done by the independent licensed practitioner and by an RN (Registered Nurse) in those areas that nursing care is provided... Screening for Nutritional Status Nutritional status is a part of the initial nursing assessment. The attending Dietary Department is notified when the patient fails the nutritional screen and the Dietitian will screen the patient and notify the attending M.D. (Medical Doctor) of a consult order if needed. Reassessment Reassessment is done to determine the patient's response to the treatment outlines in the plan. In other words, has the patient made the progress needed to obtain the goals outlined in the plan for the patient? Periodic reassessment is done at pre-established timeframes: Medical Staff - At least every 24 hours Nursing - At least every 24 hours 1. PI # 1 was admitted to the facility's geri-psych unit on 9/3/18 at 8:50 PM with diagnoses including Dementia with Behavioral Disturbances, and was discharged on 10/12/18. Admission orders included activity as tolerated; cardiac low sodium diet, fall precaution high; special observation 1:1 (one to one) x (for) 48 hours; weight on admission and twice weekly and record; therapeutic programs - activity therapy, nsg (nursing) education, and group therapy five days per week for each program. Review of the MR revealed the patient's weight on admission (9/3/18) was 167 pounds. Subsequent weights were recorded as follows: 9/27/18 - 159 (8 pound loss since admission) 10/1/18 - 156 (11 pound loss since admission) 10/4/18 - 158 (9 pound loss since admission) 10/11/18 - 152 (15 pound loss since admission) The staff failed to obtain and record weights twice a week as ordered. Review of the nursing documentation revealed the following: 9/4/18 at 8:30 PM - not tolerating diet well, refusing to eat at this time 9/5/18 at 9:49 AM - not tolerating diet well, sedated 9/6/18 at 10:14 AM - not tolerating diet well, sedated, lethargic 9/7/18 at 8:22 PM - not tolerating diet well, sedated, lethargic, weakness, refused to eat or drink 9/8/18 at 8:13 PM - tolerating diet well, requires feeding, eating some, needs encouragement, sedated, lethargic, weakness, completely dependent for all ADL's (activities of daily living), unable to ambulate at this time 9/9/18 at 8:03 AM - tolerating diet well, requires feeding, eating some, needs encouragement, confused, resistant to ADL care. Review of the nursing documentation from 9/10/18 - 10/10/18 revealed the patient's intake varied from 0 % to 100% and the diet provided and documented varied from Regular, to 2 Gram Sodium, 4 Gram Sodium, 1 Gram Sodium to 1800 ADA (Americal Diabetes Association) Diabetic Diet documented on 10/8/18 at 2:59 PM. The nursing staff failed to assess PI # 1's nutritional needs, intake, weight, and diet order to ensure PI # 1's needs were met and the physician ordered diet was provided, Further review of the MR and physician's orders revealed PI # 1 required IV (intravenous) fluids for treatment of dehydration on 9/11/18, 9/12/18, and 9/20/18. A reassessment of the patient's nutritional status was not completed and a dietitian consult was not obtained. Record review revealed PI # 1 received prn medications (Haldol and Lorazepam) for agitation at the following times and there was no documentation of non-pharmacological interventions provided to manage the behaviors/symptoms prior to administering the prn: 9/4/18 at 11:45 AM: Haldol 2 mg (milligram) and Lorazepam 0.5 mg IM (intramuscular injection) 9/5/18 at 8:50 AM: Haldol 5 mg and Lorazepam 0.5 mg IM 9/6/18 at 12:09 AM: Haldol 2 mg and Lorazepam 0.5 mg IM An interview was conducted on 11/1/18 at 5:00 PM with Employee Identifier (EI) # 1, Director Geri-Psych, who confirmed the above findings. 2. PI # 2 was admitted to the facility Geri-Psych Unit on 10/18/18 with diagnoses including Bipolar Affective Disorder. PI # 2 was a current patient in the Geri-Psych Unit. Review of the admission orders dated 10/18/18 included diet 1800 ADA (American Diabetes Association) and obtain weight on admission and twice weekly and record. The surveyor requested all the weights for PI # 2 was was provided a weight documented on 10/22/18 of 176 and a weight obtained on 10/30/18 of 185. There was no admission weight documented. The nursing staff failed to obtain and document a weight twice weekly as ordered. An interview was conducted on 11/2/18 at 11:00 AM with EI # 1 who confirmed the above findings. 3. PI # 3 was admitted to the facility geri-psych unit on 9/6/18 with diagnoses including Dementia, Hallucinations and Delusions. PI # 3 was discharged on 9/24/18. Review of the admission documentation revealed the patient's weight on admission was 170 pounds with orders to obtain weights twice weekly and record. There were no further weights recorded in the medical record. Review of the MR record revealed documentation on 9/12/18 at 6:23 PM by the RN: Modality Start Time -11:00 End Time - 11:30 Modality Type: Group Therapy There was no documentation what specific Group Therapy was provided or topic discussed by the RN and how it applied to PI # 3. Review of the RN documentation dated 9/13/18 at 8:48 PM revealed PI # 3 had Bruise/Hematoma to bilateral hands/arms and Abrasions to the left wrist. There was no documentation how/when the bruise/hematoma and abrasion occurred nor interventions put into place for prevention. Review of the RN documentation dated 9/14/18 at 11:50 AM revealed: Modality Start Time -11:00 End Time - 11:40 Modality Type: Group Therapy There was no documentation what specific Group Therapy was provided or topic discussed by the RN. Review of the RN documentation dated 9/18/18 at 7:55 AM revealed PI # 3 had Bruise/Hematoma to bilateral hands and Abrasions to the right elbow and left wrist. There was no documentation how/when the bruise/hematoma and abrasion occurred nor interventions put into place for prevention. An interview conducted on 11/1/18 at 4:55 PM with EI # 1 confirmed the above findings. | |||||||||
45 | 010109 | PICKENS COUNTY MEDICAL CENTER | 241 ROBERT K WILSON DRIVE | CARROLLTON | AL | 35447 | 11/02/2018 | Complaint Investigation | 1 | A0405 | Administration Of Drugs | 482.23(c)(1), (c)(1)(i) & (c)(2) | Standard of Participation | 12/12/2018 | N | Not Deemed | 36271 Based on facility policies and procedures, Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, observations, and interviews with staff it was determined the facility failed to ensure: 1. Intravenous (IV) admixtures were prepared by the pharmacy except in emergencies or when not feasible. 2. The nursing staff followed the facility policy for admixtures prepared outside the pharmacy. 3. Staff followed the facility policy and CDC hand hygiene guidelines during medication preparation and administration. This affected 1 of 1 observation of IV medication preparation and administration for an unsampled patient and 1of 1 observation of medication administration for Patient Identifier (PI) # 2. This deficient practice had the potential to affect all patients served by the facility. Findings include: Policy: Admixtures and Sterile Products Prepared Outside the Pharmacy Date: 3/06 Purpose: To enhance patient safety by: A. Minimizing admixture of sterile medications outside the pharmacy B. Employing safeguards when admixture must occur outside the pharmacy. Policy: A. Intravenous admixtures or other sterile medications requiring admixture are prepared by the pharmacy except in emergencies or when not feasible. D. Safeguards will be in place whenever sterile medications or IV admixtures are prepared outside the pharmacy. These safeguards include the following: 1. Preparation is permitted only by an RN (Registered Nurse) or LIP (Licensed Independent Practitioner). 2. A second licensed employee must check the product. 3. Only standard concentrations and standard admixture procedures are used. 4. Appropriate techniques are used to avoid contamination during preparation. 5. The product is labeled appropriately. Procedure: A. Before preparation, the RN or LIP will refer to an admixture preparation reference and refer to the Standard IV Drip Concentration cabinet in Meditech. B. The medication and supplies needed will be obtained. C. The product will be prepared using clean technique on the top of a clean, uncluttered medication cart. If no medication cart is present, preparation will occur on a clean, uncluttered countertop. D. The supplies and medications used in preparation will be saved of rechecking by a second licensed staff member. E. The product will be labeled with the following information... F. A second licensed staff member will check the accuracy of the preparation. Policy: Hand Hygiene Revised: 09/17 Purpose: To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs, and infections. Statement of Policy: It is the policy of PCMC (Picken's County Medical Center) as recommended by the CDC that health care workers wash their hands with either a non-antimicrobial soap (plain soap) and water or an antimicrobial soap and water when their hands are visibly dirty or contaminated with proteinaceous material or are visible soiled with blood or other body fluids. If hands are not visibly soiled an alcohol-based hand rub can be used. 3. If hands are not visibly soiled, use an alcohol-based handrub (ABHR) for routinely decontamination hands in the following situations: Before direct contact with patients After direct contact with a patient's skin When moving from a contaminated body site to a clean body site during patient care After contact with inanimate objects in the immediate vicinity of the patient After removing gloves Centers for Disease Control and Prevention Hand Hygiene in Healthcare Settings Practicing hand hygiene is a simple yet effective way to prevent infections. Cleaning your hands can prevent the spread of germs, including those that are resistant to antibiotics and are becoming difficult, if not impossible, to treat. On average, healthcare providers clean their hands less than half of the times they should. On any given day, about one in 25 hospital patients has at least one healthcare-associated infection. 1. Employee Identifier (EI) # 8, RN, was observed on 10/30/18 at 3:30 PM preparing and administering an IV antibiotic for an unsampled patient. EI # 8 verified the order, Zithromax 500 mg (milligrams) in 250 ml (milliliters) of normal saline every 24 hours IV. EI # 8 then entered the medication room, obtained the medication vial from the med dispensing drawer without first washing her hands (there was a handwashing sink in the medication room) and placed the vial on a counter top surface work space without first clearing / cleaning a work space. EI # 8 then left the medication room to go to the supply room to obtain the bag of normal saline and returned to the medication room. EI # 8 donned gloves without first performing hand hygiene. EI # 8 then reached into the pocket of her scrub top with the clean gloves on, thereby contaminating the clean gloves, and retrieved 2 alcohol prep pads and placed them on the work space thus contaminating the work space. EI # 8 then opened a drawer and withdrew a prefilled saline syringe, removed the wrapping, obtained a needle, opened and attached the needle to the saline syringe and placed it on the counter top. Then EI # 8 opened an alcohol prep, wiped the rubber septum of the medication vial, inserted the needle and injected the saline into the vial, left the needle and syringe in place while shaking the medication vial to mix, then withdrew the medication into the saline syringe, opened a second alcohol prep pad, wiped the injection port of the and normal saline bag, and injected the mixture into the bag without first changing the needle. EI # 8 then discarded the needle into the sharps container, completed the label and applied the label to the IV bag, removed gloves and exited the medication room without performing hand hygiene after glove removal. EI # 8 went into a room to obtain the COW (computer on wheels), rolled the COW to the patient room, then went to the supply room for IV tubing, returned, performed hand hygiene outside of the room, pushed the COW into the room and made several attempts to scan the medication and the patient's arm band. EI # 8 then applied gloves, tried to scan the armband several more times unsuccessfully. EI # 8 removed the gloves, did not perform hand hygiene, then went to the nursing station to obtain a new armband, returned, donned gloves without first performing hand hygiene, scanned the armband, opened the IV tubing, spiked the bag, and primed the tubing. EI # 8 then reached into her uniform pocket with gloved hand (thus contaminating the glove) for alcohol prep, opened the prep, wiped the IV connection and proceeded to connect the IV medication and reprogram the IV pump. The IV mixture was not verified by a second licensed employee as directed per the facility policy. EI # 8 failed to prepare and administer IV medication in a manner to prevent contamination and promote patient safety as directed per policy. An interview conducted on 11/2/18 at 11:00 AM with EI # 2, Director of Patient Care Services, confirmed the above findings. 2. An observation was conducted on 10/31/18 at 9:00 AM with EI # 9, RN, to observe medication administration. EI # 9 verified the orders for PI # 2 at the request of the surveyor. EI # 9 then unlocked the medication (med) closet, rolled the med cart to the patient day room where the Geri-Psych patients were engaged in activities. EI # 9 verified PI # 2 by checking the patient's armband then asked PI # 2 to leave the table and sit in a chair beside the med cart. EI # 9 reviewed the medications with PI # 2, opened all the oral medications and placed in med cup, performed hand hygiene and administered the medications. EI # 9 failed to perform hand hygiene prior to preparing oral medications. EI # 9 donned gloves, removed a Nicoderm patch from the patient's right deltoid and discarded, reached into her uniform pocket with a dirty gloved hand to retrieve a pen and labeled the new Nicoderm patch. EI # 9 then applied the new Nicoderm patch to the patient's left deltoid with the same gloves. EI # 9 failed to change gloves and perform hand hygiene after removing the used patch and before preparing and applying the new, clean patch. An interview conducted on 11/2/18 at 11:15 AM with EI # 2, Director of Patient Care Services, confirmed the above findings. | |||||||||
46 | 010109 | PICKENS COUNTY MEDICAL CENTER | 241 ROBERT K WILSON DRIVE | CARROLLTON | AL | 35447 | 11/02/2018 | Complaint Investigation | 1 | A0431 | Medical Record Services | 482.24 | Condition of Participation | 12/12/2018 | N | Not Deemed | 36271 Based on review of facility policies and procedures, medical records (MR), and staff interviews it was determined the facility failed to ensure: 1. The Multidisciplinary Treatment Plan was completed by the 3rd treatment day as directed per policy. 2. Each patient admitted to the Geri-Psych (Geriatric Psychiatry) Unit had a psychiatric evaluation completed within 60 hours of admission. 3. Admission evaluations were completed with 3 days of admission. Refer to A 449 | |||||||||
47 | 010109 | PICKENS COUNTY MEDICAL CENTER | 241 ROBERT K WILSON DRIVE | CARROLLTON | AL | 35447 | 11/02/2018 | Complaint Investigation | 1 | A0449 | Content Of Record | 482.24(c) | Standard of Participation | 12/12/2018 | N | Not Deemed | 36271 Based on review of facility policies and procedures, medical records (MR), and staff interviews it was determined the facility failed to ensure: 1. The Multidisciplinary Treatment Plan was completed by the 3rd treatment day as directed per policy. 2. Each patient admitted to the Geri-Psych (Geriatric Psychiatry) Unit had a psychiatric evaluation completed within 60 hours of admission. 3. Admission evaluations were completed within 3 days of admission. This affected 3 of 4 MRs reveiwed including Patient Identifier (PI) # 1, # 2, # 3 and had the potential to affect all patients admitted to the Geri-Psych Unit at this facility. Findings Include: Policy: Multidisciplinary Treatment Planning Reviewed: 9/22/16 Purpose: A. To provide individualized care responsive to patient specific needs... Policy: A. Each patient shall have a written individualized treatment plan based on the patient's presenting problems, physical health, emotional and behavioral status, and strengths and weaknesses... B. The plan of care is supervised by the attending psychiatrist. The admitting physician shall formulate a preliminary treatment plan no later than three (3) treatment days following the date of admission... F. The Multidisciplinary Treatment Plan shall be completed by the third (3rd) day of treatment... Policy: Psychiatric Evaluation Revised: 8/22/18 Purpose: To ensure that the physical and psychiatric needs of the patient are assessed by a psychiatrist. Policy: A. The psychiatric evaluation is completed and on the patient's chart within sixty (60) hours of admission. 1. PI # 1 was admitted to the facility's geri-psych unit on 9/3/18 8:50 PM with diagnoses including Dementia with Behavioral Disturbances. Review of the MR revealed a progress note (PN) by the social worker (MSW) dated 9/6/18 Modality Type - Group Therapy which included a plan to continue group therapy participation pending treatment plan development scheduled for 9/7/18 (4 days after admission). Further review of the MR revealed the Psychosocial Assessment was completed 9/7/18 (Friday), 4 days after admission. Review of the MR revealed the Multidisciplinary Treatment Plan was completed on 9/7/18 which was not within 3 treatment days as directed by the facility policy. An interview was conducted on 11/1/18 at 5:00 PM with Employee Identifier (EI) # 1, Director of Geri-Psych. EI # 1 was asked why the MSW waited until Friday (9/7/18) to complete the initial assessment for PI # 1 who was admitted on Monday (9/3/18)? The answer was "he (MSW) was off." The surveyor asked why the assessment was not completed on Thursday (9/6/18) the date the patient attended Group Therapy conducted by the MSW. The answer was "I'm not sure." EI # 1 was asked if there was another social worker available to provide care when EI # 5, Social Worker Geri-Psych, was off and the answer was "no". EI # 1 confirmed the psychosocial assessment was completed 4 days after admission and not within 3 treatment days as directed by facility policy. 2. PI # 2 was admitted to the facility geri-psych unit on 10/18/18 with diagnoses including Bipolar Affective Disorder. Review of the MR revealed the initial psychiatric evaluation was completed on 10/22/18 and was not completed within 60 hours of admission. Further review of the MR revealed the Multidisciplinary Treatment Plan was completed on 10/23/18 which was not within 3 treatment days and the psychosocial assessment was completed on 10/31/18, 13 days after admission. An interview was conducted on 11/2/18 at 11:00 AM with EI # 1 who confirmed the initial psychiatric evaluation, psychosocial assessment, and the treatment plan as not completed timely as directed by the facility policy. 3. PI # 3 was admitted to the facility geri-psych unit on 9/6/18 with diagnoses including Dementia, Hallucinations and Delusions. Review of the MR revealed the psychosocial assessment and the treatment plan was completed on 9/10/18, 4 days after admission and not within 3 treatment days as directed per the facility policy. An interview was conducted on 11/1/18 at 4:55 PM with EI # 1 who confirmed the above findings. | |||||||||
48 | 010109 | PICKENS COUNTY MEDICAL CENTER | 241 ROBERT K WILSON DRIVE | CARROLLTON | AL | 35447 | 11/02/2018 | Complaint Investigation | 1 | A0630 | Diets | 482.28(b)(2) | Standard of Participation | 12/12/2018 | N | Not Deemed | 36271 Based on review of facility policies, medical records (MR), and interviews with staff it was determined the facility dietary staff failed to: 1. Provide a diet consistency the patient could could consume. 2. Provide diet education / counseling for a patient on a special diet that was not eating / drinking. 3. Initiate a calorie count as directed per policy for a patient consuming less than 50%. 4. Ensure the physician ordered diet was provided. This affected 1 of 4 MRs reviewed including Patient Identifier # 1 and had the potential to negatively affect all patients admitted to the facility. Findings include: Policy: Medical Nutrition Therapy Protocol Revised: 09/11 Purpose: To facilitate timely patient nutrition care management and to provide an efficient and effective process to initiate Medical Nutrition Therapy. Protocol: Dietitian may initiate the following: 2) If on assessment the patient is found to be experiencing difficulty chewing, change diet to Soft, Mechanical Soft, or Pureed Diet. 3) If patient or patient's family requests diet education on physician ordered diet, provide education. 4) If on assessment, the patient is found to have average intake less than 50 %, initiate a calorie count to further assess and make appropriate recommendations. Policy: Medical Nutrition Therapy - Nutrition Counseling Revised: 09/11 Purpose: To provide nutrition education for patients on modified diets or with specific nutrition needs. Procedure: A. Nutrition counseling will be provided by a Clinical Dietitian when ordered by a physician or referred by nursing or other heath care personnel ("unordered consults"). Family members or significant others will be included as appropriate. 1. PI # 1 was admitted to the facility's geri-psych unit on 9/3/18 at 2050 (8:50 PM) with diagnoses including Dementia with Behavioral Disturbances and discharged on 10/12/18. Admission orders included activity as tolerated and cardiac low sodium diet. Review of the MR revealed the patient's weight on admission (9/3/18) was 167 pounds. Subsequent weights were recorded as follows: 9/27/18 - 159 (8 pound loss since admission) 10/1/18 - 156 (11 pound loss since admission) 10/4/18 - 158 (9 pound loss since admission) 10/11/18 - 152 (15 pound loss since admission) Review of the nursing documentation revealed the following: 9/4/18 at 8:30 PM - not tolerating diet well, refusing to eat at this time 9/5/18 at 9:49 AM - not tolerating diet well, sedated 9/6/18 at 10:14 AM - not tolerating diet well, sedated, lethargic 9/7/18 at 8:22 PM - not tolerating diet well, sedated, lethargic, weakness, refused to eat or drink 9/8/18 at 8:13 PM - tolerating diet well, requires feeding, eating some, needs encouragement, sedated, lethargic, weakness, completely dependent for all ADL's (activities of daily living), unable to ambulate at this time 9/9/18 at 8:03 AM - tolerating diet well, requires feeding, eating some, needs encouragement, confused, resistant to ADL care. Review of the nursing documentation from 9/10/18 - 10/10/18 revealed the patient's intake varied from 0 % to 100% (less than 50 % on average) and the diet provided and documented varied from Regular, to 2 Gram Sodium, 4 Gram Sodium, 1 Gram Sodium, Regular No Added Salt, to 1800 ADA (American Diabetes Association) Diabetic Diet documented on 10/8/18 at 2:59 PM. The ordered cardiac 2 gram low sodium diet was not provided consistently. The surveyor asked Employee Identifier (EI) # 1, Director Geri-Psych, what interventions were done to address the PI # 1's poor oral intake and was a dietitian consult done. The surveyor was provided a Nutrition Note dated 10/5/18 by the dietitian as follows: "pt visited per phone call with pt's son. Spoke with (spouse) last week for food preferences. Pt po (oral) intake erratic from 0-100 % of meals eaten. Pt still combative at times. Wt=159 # stable since 9/27. Continue chopped meats and Boost at each meal." There was no documentation the Clinical Dietitian provided education regarding the ordered modified / special diet. There was no further documentation by the dietitian provided. PI # 1 was discharged 10/12/18 with a 15 pound weight loss since admission. An interview was conducted on 11/1/18 at 5:00 PM with Employee Identifier # 1, Director Geri-Psych, who confirmed the above findings. | |||||||||
49 | 010118 | VAUGHAN REGIONAL MEDICAL CENTER PARKWAY CAMPUS | 1015 MEDICAL CENTER PARKWAY | SELMA | AL | 36701 | 07/30/2018 | Complaint Investigation | 1 | 0 | Initial Comments | Memo Tag | N | Joint Commission | 36271 An abbreviated survey was conducted at Vaughan Regional Medical Center Parkway Campus on July 25 - July 30, 2018 for the investigation of Complaint number AL00035800. The complaint was substantiated. Condition level deficiencies were cited at 482.13 Patient's Rights; 482.23 Nursing Services; 482.24 Medical Record Services and related standards. | |||||||||||
50 | 010118 | VAUGHAN REGIONAL MEDICAL CENTER PARKWAY CAMPUS | 1015 MEDICAL CENTER PARKWAY | SELMA | AL | 36701 | 07/30/2018 | Complaint Investigation | 1 | A0115 | Patient Rights | 482.13 | Condition of Participation | 09/11/2018 | N | Joint Commission | 36271 Based on facility policies and procedures, review of medical records (MR), Inpatient Request Logs, and interviews with radiology, nursing, transport and management staff it was determined the facility failed to ensure: 1. Patients were transported off/on the nursing unit in a safe manner with oxygen/monitoring according to facility policies. 2. Staff documented the time patients left and returned to the unit. 3. Radiology staff notified nursing and/or the physician of patient's shortness of breath and inability to lie flat which resulted in inability to perform the ordered test. 4. Staff followed the facility policy and procedure for Hand-Off Communication. This affected 1 out of 6 MRs reviewed including Patient Identifier # 1 and had the potential to affect all patients admitted to the facility. Findings include: Refer to A 144 for findings. | |||||||||
51 | 010118 | VAUGHAN REGIONAL MEDICAL CENTER PARKWAY CAMPUS | 1015 MEDICAL CENTER PARKWAY | SELMA | AL | 36701 | 07/30/2018 | Complaint Investigation | 1 | A0144 | Patient Rights: Care In Safe Setting | 482.13(c)(2) | Standard of Participation | 09/11/2018 | N | Joint Commission | 36271 Based on facility policies and procedures, review of medical records (MR), Inpatient Request Logs, and interviews with radiology, nursing, transport and management staff it was determined the facility failed to ensure: 1. Patients were transported off/on the nursing unit in a safe manner with oxygen/monitoring according to facility policies. 2. Staff documented the time patients left and returned to the unit. 3. Radiology staff notified nursing and/or the physician of patient's shortness of breath and inability to lie flat which resulted in inability to perform the ordered test. 4. Staff followed the facility policy and procedure for Hand-Off Communication. This affected 1 out of 6 MRs reviewed including Patient Identifier (PI) # 1 and had the potential to affect all patients admitted to the facility. Findings include: Policy and Procedure Telemetry Monitoring PolicyStat ID: 3631602 Last Revised: 05/2017 Purpose: The purpose of the policy is to establish cardiac monitoring admission, transport, and discharge criteria. High Risk for a Cardiac Event during Transport If a patient requires transport off the nursing unit for test or procedures, the patient should be transported with continuous cardiac monitoring and accompanied by a Licensed Health Care Provider. Policy and Procedure Oxygen Protocol PolicyStat ID: 3346254 Last Revised: 04/2014 AARC (American Association for Respiratory Care) Clinical Practice Guideline Oxygen Therapy for Adults in the Acute Care Facility--2002 Revision and Update OT-AC (Oxygen Therapy Acute Care) 1.0 Procedure: The procedure addressed is the administration of oxygen therapy in the acute care facility other than with mechanical ventilators and hyperbaric chambers. OT-AC 2.0 Definition/Description: Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia. OT-AC 11.0 Monitoring: A. Patient 1. Clinical assessment including but not limited to cardiac, pulmonary, and neurologic status B. Equipment 3. Care should be taken to avoid interruption of oxygen therapy in situations including ambulation or transport for procedures. OT-AC 12.0 Frequency: Oxygen therapy should be administered continuously unless the need has been shown to be associated only with specific situations (eg, exercise and sleep). Policy and Procedure Hand-Off Communication PolicyStat ID: 4891775 Last Revised: 05/2018 Purpose: The primary objective of a "hand-off" communication is to provide accurate information about a patient's care, treatment, and services, current condition and any recent or anticipated changes... Responsibility: It is the responsibility of all persons providing care to ensure that safe hand-off communication takes place when a patient passes from their care into the care of another even if only for a short period of time. Transport Hand-Off Process: 1. The Ticket to Ride form will be completed by a nurse when a patient is being transported by non-clinical staff off of a unit for tests and procedures. Information on the Ticket to Ride includes the patient's fall risk, code status, need for oxygen, and IV's. Staff in the diagnostic or treatment area will add information to the form and send it back to the nurse. The receiving nurse will have an opportunity to ask questions and clarify information. 1. PI # 1 was admitted to the facility medical/surgical unit from the Emergency Department (ED) on 4/14/18 with diagnoses including Chronic Obstructive Pulmonary Disease and Acute on Chronic Systolic Congestive Heart Failure. Review of the physician's orders dated and signed 4/14/18 at 10:34 AM revealed Oxygen Therapy 2 l/m nasal cannula O2 sat goal 92. Cardiac Monitoring: Telemetry, Cardiac Monitoring Required for Transport? Hi Risk Trans (transport)/Monitor Req (required). Review of the nursing narrative dated 4/19/18 at 1335 (1:35 PM) revealed "patient was scheduled for MRI (magnetic resonance imaging) this morning. went to room to ask the patient if (he/she) preferred to go down in a stretcher or wheelchair. patient stated (he/she) could go in a wheelchair.(Employee name) the transporter for radiology department came to take patient down to get the test done and brought (him/her) back to the room and noticed (he/she) was short of breath so we let (him/her) sit in the wheelchair for a minute until we could get (him/her) back in the bed. one (once) in bed patient was placed on O2 via NC. I went to get the vital machine to check (his/her) pulse ox (oxygen) and it was 85, it then came up to 87. respiratory was immediately called to check the orders for the O2 level and see when was the last breathing treatment given, which it was stated (he/she) just had one. noticed shortly after that the patient lips started turning blue so (staff name) called a code 99 and called the primary MD (medical doctor), who gave orders. UAB family medicine MD's and residents responded and ran the code." The above narrative documentation failed to include the time these events happened. Review of the entire medical record revealed no documentation of the time the patient left the unit to go to radiology, how he/she was transported and no documentation of O2 / monitor in use during the transport. There was no documentation of the time PI # 1 returned to the unit from radiology and no documentation of oxygen / monitor in use during the transport. The surveyor requested documentation of the events from 9:30 AM on 4/19/18 (respiratory therapy gave treatment) to 11:00 AM when the documentation revealed PI # 1 was in ICU (Intensive Care Unit) and placed on a ventilator. No documentation was provided to the surveyor. Review of the MR revealed PI # 1 was transferred to ICU on 4/19/18 at 11:00 AM and placed on a ventilator, Code Blue was called 2 more times after admission to ICU and PI # 1 expired at 12:03 PM. The surveyor requested the Ticket to Ride documentation for transport of PI # 1 on 4/19/18. The Ticket to Ride could not be produced. An interview conducted 7/26/18 at 10:00 AM with Employee Identifier (EI) # 2, Radiology Coordinator, confirmed the Ticket to Ride forms are kept in the radiology department for about a week then shredded. EI # 2 was asked if there was documentation anywhere in the radiology department of the date and time inpatients enter and leave the radiology department. EI # 2 stated there was an inpatient request log. EI # 2 was asked if there was any place else where the departure time for PI # 1 was documented. The answer was no, stating that when the ordered test is started Meditech (the electronic medical record) date and time stamped the beginning and end of the procedure. Because the MRI was not started on PI # 1 there was no tracking of the patient in Meditech. EI # 2 was asked if the radiology tech would document that the test was not completed and why and the answer was no, since the test was not started there was no place in Meditech they could document. EI # 2 was asked what the process was if the test could not be completed. The answer was for inpatients, the radiology tech would notify the nurse and/or the doctor the test could not be performed and why. The surveyor asked if it was documented in the MR. The answer was no, because if the test is not started there is no area in Meditech for them to document. Once the test is started they have a place to document comments. Review of the Inpatient Request Log dated 4/19/18 revealed PI # 1 was on the log which documented the transport method as W/C (wheelchair), Sent For 0921 (9:21 AM) Picked Up 10:35 AM and Arrived - no time just employee initials. Further review of the Inpatient Request Log dated 4/19/18 revealed the Ready for Return and Departed Initials spaces were blank. An interview was conducted on 7/26/18 at 3:10 PM with Employee Identifier (EI) # 4, Patient Transporter. EI # 4 was asked to verify the Inpatient Request Log information for PI # 1 dated 4/19/18. EI # 4 stated the Sent For time was the time the radiology tech brought the Ticket to Ride and placed it in the tray for him. The Picked Up time of 10:35 AM was the time he picked up the Ticket to Ride not the time the patient was picked up. EI # 4 was asked why the Ready for Return area on the Inpatient Request Log was blank on 4/19/18 for PI # 1 and the answer was "I'm not sure." An interview conducted 7/30/18 at 1:00 PM with Employee Identifier # 1, Registered Nurse Quality, confirmed there was no documentation in the MR of when and how PI # 1 was transported off the nursing unit and back and no documentation the facility policies were followed. | |||||||||
52 | 010118 | VAUGHAN REGIONAL MEDICAL CENTER PARKWAY CAMPUS | 1015 MEDICAL CENTER PARKWAY | SELMA | AL | 36701 | 07/30/2018 | Complaint Investigation | 1 | A0385 | Nursing Services | 482.23 | Condition of Participation | 09/11/2018 | N | Joint Commission | 36271 Based on facility policies and procedures, review of medical records (MR), review of Code 99/Code Blue Critique Worksheets, and interviews with facility staff it was determined the facility failed to ensure nursing staff: 1. Followed the physician's orders for oxygen therapy. 2. Followed the facility policies for Telemetry Monitoring, Oxygen Protocol and Hand-Off Communication. 3. Ensured patients were transported off/on the nursing unit in a safe manner with oxygen/monitoring according to the physician orders and facility policies. 4. Documented when patients leave and return to the nursing unit. 5. Assessed and documented a respiratory assessment to include oxygen therapy each shift. 6. Interpreted a change in rhythm for patients on telemetry monitoring according to facility policy. 7. Documented events / interventions that occurred during a Code 99 and Code Blue. This affected 1 out of 6 MRs reviewed affecting Patient Identifier # 1 and had the potential to affect all patients admitted to the facility. Findings include: Refer to A 392 for findings. | |||||||||
53 | 010118 | VAUGHAN REGIONAL MEDICAL CENTER PARKWAY CAMPUS | 1015 MEDICAL CENTER PARKWAY | SELMA | AL | 36701 | 07/30/2018 | Complaint Investigation | 1 | A0392 | Staffing And Delivery Of Care | 482.23(b) | Standard of Participation | 09/11/2018 | N | Joint Commission | 36271 Based on facility policies and procedures, review of medical records (MR), review of Code 99/Code Blue Critique Worksheets, and interviews with facility staff it was determined the facility failed to ensure nursing staff: 1. Followed the physician's orders for oxygen therapy. 2. Followed the facility policies for Telemetry Monitoring, Oxygen Protocol and Hand-Off Communication. 3. Ensured patients were transported off/on the nursing unit in a safe manner with oxygen/monitoring according to the physician orders and facility policies. 4. Documented when patients leave and return to the nursing unit. 5. Assessed and documented a respiratory assessment to include oxygen therapy each shift. 6. Interpreted a change in rhythm for patients on telemetry monitoring according to facility policy. 7. Documented events / interventions that occurred during a Code 99 and Code Blue. This affected 1 out of 6 MRs reviewed affecting Patient Identifier (PI) # 1 and had the potential to affect all patients admitted to the facility. Findings include: Policy and Procedure Telemetry Monitoring PolicyStat ID: 3631602 Last Revised: 05/2017 Purpose: The purpose of the policy is to establish cardiac monitoring admission, transport, and discharge criteria. High Risk for a Cardiac Event during Transport If a patient requires transport off the nursing unit for test or procedures, the patient should be transported with continuous cardiac monitoring and accompanied by a Licensed Health Care Provider. Daily Monitoring of Patients on Telemetry C. The patient's primary nurse will document a baseline rhythm strip at the beginning of each shift and every 4 hours with pertinent rate or rhythm changes. If changes occur, the patients' primary nurse will assess the patients and notify the primary physician immediately. H. When being monitored by telemetry, the nursing care is the responsibility of the primary nurse. The interpretation of the strip is the responsibility of the nurse every 8 Hrs. (hours) and with any rhythm change. a. Documentation of the cardiac rhythm should include interpretation of the strip to include, rate, and rhythm. Policy and Procedure Oxygen Protocol PolicyStat ID: 3346254 Last Revised: 04/2014 AARC (American Association for Respiratory Care) Clinical Practice Guideline Oxygen Therapy for Adults in the Acute Care Facility--2002 Revision and Update OT-AC (Oxygen Therapy Acute Care) 1.0 Procedure: The procedure addressed is the administration of oxygen therapy in the acute care facility other than with mechanical ventilators and hyperbaric chambers. OT-AC 2.0 Definition/Description: Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia. OT-AC 11.0 Monitoring: A. Patient 1. Clinical assessment including but not limited to cardiac, pulmonary, and neurologic status B. Equipment 3. Care should be taken to avoid interruption of oxygen therapy in situations including ambulation or transport for procedures. OT-AC 12.0 Frequency: Oxygen therapy should be administered continuously unless the need has been shown to be associated only with specific situations (eg, exercise and sleep). Policy and Procedure Hand-Off Communication PolicyStat ID: 4891775 Last Revised: 05/2018 Purpose: The primary objective of a "hand-off" communication is to provide accurate information about a patient's care, treatment, and services, current condition and any recent or anticipated changes... Responsibility: It is the responsibility of all persons providing care to ensure that safe hand-off communication takes place when a patient passes from their care into the care of another even if only for a short period of time. Transport Hand-Off Process: 1. The Ticket to Ride form will be completed by a nurse when a patient is being transported by non-clinical staff off of a unit for tests and procedures. Information on the Ticket to Ride includes the patient's fall risk, code status, need for oxygen, and IV's. Staff in the diagnostic or treatment area will add information to the form and send it back to the nurse. The receiving nurse will have an opportunity to ask questions and clarify information. Policy and Procedure Code 99 Team PolicyStat ID: 3887565 Last Revised: 08/2017 Purpose: To provide early and rapid intervention in order to promote better outcomes such as... Procedure: 6. Staff nurse responsibilities: Complete Code 99 critique form and place in red notebook 9. Department Director, House Supervisor, or designee responsibilities: Ensure documentation is complete along with insuring appropriate physician is notified... Domentation: A. Process Intervention / Patient Notes, physician orders: 1. Patient Notes: a. Assessment findings and observations b. Interventions / actions c. Reassessment and follow up 5. Code 99 forms Policy and Procedure Code Blue PolicyStat ID: 1975439 Last Revised: 07/2015 Purpose: The Code Blue policy and procedure has been established by Vaughan Regional Medical Center to facilitate and organize personnel in caring for individuals in a life-threatening situation in order to affect maximum care with minimum time elapse. Duties of Personnel Responding to the Code Blue: D. Nursing Supervisor 3. The Primary Nurse for the patient will complete the Code Critique Form. The completed Code Critique Form will be placed in the red notebook... 1. PI # 1 was admitted to the facility medical/surgical unit from the Emergency Department (ED) on 4/14/18 with diagnoses including Chronic Obstructive Pulmonary Disease and Acute on Chronic Systolic Congestive Heart Failure. Review of the medical record on 7/25/18 revealed PI # 1 was on oxygen (O2) at 2 liters per minute (l/m) at home, became increasingly short of breath (SOB) and dizzy and called 911. The ambulance report documented PI # 1's oxygen saturation (sat) was in the low 60's at 2 l/m and the patient was placed on 4 l/m and the O2 saturation increased to 91%. PI # 1 was transported to the ED on 4/14/18, treated and then admitted to the medical/surgical floor. Review of the ED documentation dated 4/14/18 revealed the patient was on O2 at 4 l/m while in the ED. Review of the physician's orders dated and signed 4/14/18 at 10:34 AM revealed Oxygen Therapy 2 l/m nasal cannula O2 sat goal 92. Cardiac Monitoring: Telemetry, Cardiac Monitoring Required for Transport? Hi Risk Trans (transport)/Monitor Req (required). Review of the ED record documentation on 4/14/18 at 11:40 AM revealed PI # 1 was on O2 at 4 l/m and O2 saturation was 96. The patient was transported to 2nd floor via stretcher and oxygen. There was no documentation the patient was transported with cardiac monitoring. Review of the nursing admission assessment dated 4/14/18 at 11:57 AM revealed bilateral breath sounds crackles (rales), respirations regular and unlabored, O2 on at 4 l/m per nasal cannula, not 2 l/m as ordered. There was no documentation the nurse contacted the physician to confirm the oxygen order of 2 l/m. Review of the physician's order dated 4/15/18 at 0109 (1:09 AM) revealed "Nursing Text O2 at 2L/NC (nasal cannula)." Review of the order history data provided by the facility revealed the physician's order dated 4/15/18 at 1:09 AM was entered by nursing. The supplemental text was edited by Respiratory Therapy on 4/16/18 at 1441 (2:41 PM) to state "from O2 at 2L/NC to O2 at 4L/NC." There was no documentation of why the order dated 4/15/18 was changed. Review of the vital signs recorded by the PCT (patient care technician) on 4/15/18 at 8:00 AM revealed blood pressure (BP) 96/51, Pulse 58, respirations 26, and O2 sat 82; comment: O2 sat low notified nurse (employee name). Review of the MR revealed no documentation by the nurse regarding the low O2 sat reported by the PCT on 4/15/18 at 8:00 AM. Review of the nursing shift assessment dated 4/15/18 at 8:30 AM revealed wheezes bilateral to all lung fields, respiratory pattern: dyspnea, uneven and labored, O2 at 2 l/m nasal cannula. There was no documentation the nurse assessed PI # 1's oxygen saturation. There was no documentation of cardiac rhythm. Review of the nursing shift assessment dated 4/15/18 at 2000 (8:00 PM) revealed no documentation of respiratory and cardiac assessments even though these systems were documented as not within defined parameters. Review of the nursing shift assessment dated 4/16/18 at 9:00 AM revealed no documentation of respiratory and cardiac assessments and no documentation of the cardiac rhythm. Review of the telemetry rhythm strip dated 4/19/18 at 06:02 AM revealed HR (heart rate) 40 and rhythm sinus brady. There was no documentation by the nurse of the change in cardiac rhythm and no documentation the rhythm strip was interpreted by the nurse according to the facility policy. Review of the nursing documentation dated 4/19/18 at 8:00 AM revealed vital signs pulse 59, respirations 24, blood pressure 142/81 and O2 sat 95, breath sounds clear, respiratory pattern dyspnea on exertion, O2 on at 4 l/m per nasal cannula and cardiovascular assessment normal sinus rhythm. The record revealed a respiratory therapy treatment was provided to PI # 1 at 9:27 AM on 4/19/18. The next documentation was 4/19/18 at 11:00 AM by respiratory therapy for ventilator set up. The next documentation was a nursing narrative dated 4/19/18 at 1335 (1:35 PM) which revealed "patient was scheduled for MRI (magnetic resonance imaging) this morning. went to room to ask the patient if (he/she) preferred to go down in a stretcher or wheelchair. patient stated (he/she) could go in a wheelchair. (Employee name) the transporter for radiology department came to take patient down to get the test done and brought (him/her) back to the room and noticed (he/she) was short of breath so we let (him/her) sit in the wheelchair for a minute until we could get (him/her) back in the bed. one (once) in bed patient was placed on O2 via NC. I went to get the vital machine to check (his/her) pulse ox (oxygen) and it was 85, it then came up to 87. respiratory was immediately called to check the orders for the O2 level and see when was the last breathing treatment given, which it was stated (he/she) just had one. noticed shortly after that the patient lips started turning blue so (staff name) called a code 99 and called the primary MD (medical doctor), who gave orders. UAB family medicine MDs and residents responded and ran the code." The above narrative documentation failed to include the time these events happened. Review of the entire medical record revealed no documentation of the time the patient left the unit to go to radiology, how he/she was transported and no documentation of O2/monitor in use during the transport. There was no documentation of the time PI # 1 returned to the unit from radiology and no documentation of oxygen/monitor in use during the transport. Further, the narrative documentation by the nurse failed to include the times and sequence of events during the Code 99 and subsequent Code Blue that occurred after PI # 1 returned to the nursing unit from radiology. Review of the Code 99/Code Blue Critique Worksheet revealed no date and time recorded. The Code Blue section of the Code 99/Code Blue Critique Worksheet form revealed incomplete data such as the date and time the Code Blue began, time of intubation, size ET (endotracheal) tube used and who performed the intubation. The time the Code Blue ended was recorded as 10:55 AM per the Code 99/Code Blue Critique Worksheet. The surveyor requested documentation of the events on 4/19/18 from 9:27 AM to 11:00 AM when the record shows PI # 1 in ICU (Intensive Care Unit) on a ventilator. No documentation was provided to the surveyor. Review of the MR revealed PI # 1 was transferred to ICU on 4/19/18 at 11:00 AM and placed on a ventilator, Code Blue was called 2 more times after admission to ICU and PI # 1 expired at 12:03 PM. An interview conducted 7/30/18 at 1:00 PM with Employee Identifier # 1, Registered Nurse Quality, confirmed the above findings. | |||||||||
54 | 010118 | VAUGHAN REGIONAL MEDICAL CENTER PARKWAY CAMPUS | 1015 MEDICAL CENTER PARKWAY | SELMA | AL | 36701 | 07/30/2018 | Complaint Investigation | 1 | A0431 | Medical Record Services | 482.24 | Condition of Participation | 09/11/2018 | N | Joint Commission | 36271 Based on review of policy and procedure, medical records (MR), and interviews with facility staff it was determined the facility failed to ensure the staff: 1. Documented cardiac and respiratory assessments on all patients on telemetry and supplemental oxygen. 2. Documented rhythm strip interpretation with a change in rhythm. 3. Documented the date and time patients left the nursing unit, reason, and when they returned. 4. Documented accurately on the radiology Inpatient Tracking Log. 5. Completed a Code Blue form each time a Code Blue was called. 6. Documented the date, time, and interventions provided during a Code 99. 7. Followed the facility policy for editing and correcting late documentation. This affected 1 out of 6 MRs reviewed including Patient Identifier # 1 and had the potential to affect all patients admitted to the facility. Findings include: Refer to A 449 for findings. | |||||||||
55 | 010118 | VAUGHAN REGIONAL MEDICAL CENTER PARKWAY CAMPUS | 1015 MEDICAL CENTER PARKWAY | SELMA | AL | 36701 | 07/30/2018 | Complaint Investigation | 1 | A0449 | Content Of Record | 482.24(c) | Standard of Participation | 09/11/2018 | N | Joint Commission | 36271 Based on review of policy and procedure, medical records (MR), and interviews with facility staff it was determined the facility failed to ensure the staff: 1. Documented cardiac and respiratory assessments on all patients on telemetry and supplemental oxygen. 2. Documented rhythm strip interpretation with a change in rhythm. 3. Documented the date and time patients left the nursing unit, reason, and when they returned. 4. Documented accurately on the radiology Inpatient Tracking Log. 5. Completed a Code Blue form each time a Code Blue was called. 6. Documented the date, time, and interventions provided during a Code 99. 7. Followed the facility policy for editing and correcting late documentation. This affected 1 out of 6 MRs reviewed including Patient Identifier (PI) # 1 and had the potential to affect all patients admitted to the facility. Findings include: Policy and Procedure Telemetry Monitoring PolicyStat ID: 3631602 Last Revised: 05/2017 Purpose: The purpose of the policy is to establish cardiac monitoring admission, transport, and discharge criteria. High Risk for a Cardiac Event during Transport If a patient requires transport off the nursing unit for test or procedures, the patient should be transported with continuous cardiac monitoring and accompanied by a Licensed Health Care Provider. Daily Monitoring of Patients on Telemetry C. The patient's primary nurse will document a baseline rhythm strip at the beginning of each shift and every 4 hours with pertinent rate or rhythm changes... H. When being monitored by telemetry, the nursing care is the responsibility of the primary nurse. The interpretation of the strip is the responsibility of the nurse every 8 Hrs. (hours) and with any rhythm change. a. Documentation of the cardiac rhythm should include interpretation of the strip to include, rate, and rhythm. Policy and Procedure Oxygen Protocol PolicyStat ID: 3346254 Last Revised: 04/2014 OT-AC (Oxygen Therapy Acute Care) 1.0 Procedure: The procedure addressed is the administration of oxygen therapy in the acute care facility other than with mechanical ventilators and hyperbaric chambers. OT-AC 11.0 Monitoring: A. Patient 1. Clinical assessment including but not limited to cardiac, pulmonary, and neurologic status Policy and Procedure Code 99 Team PolicyStat ID: 3887565 Last Revised: 08/2017 Purpose: To provide early and rapid intervention in order to promote better outcomes such as... Procedure: 6. Staff nurse responsibilities: Complete Code 99 critique form and place in red notebook 9. Department Director, House Supervisor, or designee responsibilities: Ensure documentation is complete along with insuring appropriate physician is notified... Domentation: A. Process Intervention / Patient Notes, physician orders: 1. Patient Notes: a. Assessment findings and observations b. Interventions / actions c. Reassessment and follow up 5. Code 99 forms Policy and Procedure Code Blue PolicyStat ID: 1975439 Last Revised: 07/2015 Purpose: The Code Blue policy and procedure has been established by Vaughan Regional Medical Center to facilitate and organize personnel in caring for individuals in a life-threatening situation in order to affect maximum care with minimum time elapse. Duties of Personnel Responding to the Code Blue: D. Nursing Supervisor 3. The Primary Nurse for the patient will complete the Code Critique Form. The completed Code Critique Form will be placed in the red notebook... Policy and Procedure Entering, Editing Correcting Late Documentation Effective Date: 04/01/06 Purpose: to describe procedures for entering late documentation, editing documentation and correcting errors. 3. To Enter/Edit/Undo Late Documentation Greater Than 24-48 Hours Old a. Intervention The first line of text in the note should record the date and time of occurrence. Also the note should document the reason for the late entry... 1. PI # 1 was admitted to the facility medical/surgical unit from the Emergency Department (ED) on 4/14/18 with diagnoses including Chronic Obstructive Pulmonary Disease and Acute on Chronic Systolic Congestive Heart Failure. Review of the physician's orders dated and signed 4/14/18 at 10:34 AM revealed Oxygen Therapy 2 l/m nasal cannula O2 sat goal 92. Cardiac Monitoring: Telemetry, Cardiac Monitoring Required for Transport? Hi Risk Trans (transport)/Monitor Req (required). Review of the ED record documentation on 4/14/18 at 11:40 AM revealed PI # 1 was on O2 at 4 l/m and O2 saturation was 96. The patient was transported to 2nd floor via stretcher and oxygen. There was no documentation the patient was transported with cardiac monitoring. Review of the nursing admission assessment dated 4/14/18 at 11:57 AM revealed bilateral breath sounds crackles (rales), respirations regular and unlabored, O2 on at 4 l/m per nasal cannula, not 2 l/m as ordered. There was no documentation the nurse contacted the physician to confirm the oxygen order of 2 l/m. Review of the physician's order dated 4/15/18 at 0109 (1:09 AM) revealed "Nursing Text O2 at 2L/NC (nasal cannula)." Review of the order history data provided by the facility revealed the physician's order dated 4/15/18 at 1:09 AM was entered by nursing. The supplemental text was edited by Respiratory Therapy on 4/16/18 at 1441 (2:41 PM) to state "from O2 at 2L/NC to O2 at 4L/NC." There was no documentation of why the order dated 4/15/18 was changed. Review of the vital signs recorded by the PCT (patient care technician) on 4/15/18 at 8:00 AM revealed blood pressure (BP) 96/51, Pulse 58, respirations 26, and O2 sat 82; comment: O2 sat low notified nurse (employee name). Review of the MR revealed no documentation by the nurse regarding the low O2 sat reported on 4/15/18 at 8:00 AM. Review of the nursing shift assessment dated 4/15/18 at 8:30 AM revealed wheezes bilateral to all lung fields, respiratory pattern: dyspnea, uneven and labored, O2 at 2 l/m nasal cannula. There was no documentation the nurse assessed PI # 1's oxygen saturation. There was no documentation of cardiac rhythm as directed by facility policy. Review of the nursing shift assessment dated 4/15/18 at 2000 (8:00 PM) revealed no documentation of respiratory and cardiac assessments even though these systems were documented as not within defined parameters. Review of the nursing shift assessment dated 4/16/18 at 9:00 AM revealed no documentation of respiratory and cardiac assessments and no documentation of the cardiac rhythm. Review of the telemetry rhythm strip dated 4/19/18 at 06:02 AM revealed HR (heart rate) 40 and rhythm sinus brady. There was no documentation of interpretation by the nurse of this change in rhythm as directed by the facility policy. The record revealed a respiratory therapy treatment was provided to PI # 1 at 9:27 AM on 4/19/18. The next documentation was 4/19/18 at 11:00 AM by respiratory therapy for ventilator set up. There was no documentation of what happened between 9:27 AM and 11:00 AM on 4/19/18. The next documentation was a nursing narrative dated 4/19/18 at 1335 (1:35 PM) which revealed "patient was scheduled for MRI (magnetic resonance imaging) this morning. went to room to ask the patient if (he/she) preferred to go down in a stretcher or wheelchair. patient stated (he/she) could go in a wheelchair. (Employee name) the transporter for radiology department came to take patient down to get the test done and brought (him/her) back to the room and noticed (he/she) was short of breath so we let (him/her) sit in the wheelchair for a minute until we could get (him/her) back in the bed. one (once) in bed patient was placed on O2 via NC. I went to get the vital machine to check (his/her) pulse ox (oxygen) and it was 85, it then came up to 87. respiratory was immediately called to check the orders for the O2 level and see when was the last breathing treatment given, which it was stated (he/she) just had one. noticed shortly after that the patient lips started turning blue so (staff name) called a code 99 and called the primary MD (medical doctor), who gave orders. UAB family medicine MDs and residents responded and ran the code." The above narrative documentation failed to include the time these events happened. Review of the entire medical record revealed no documentation of the time the patient left the unit to go to radiology, how he/she was transported and no documentation of O2/monitor in use during the transport. There was no documentation of the time PI # 1 returned to the unit from radiology and no documentation of oxygen/monitor in use during the transport. Further, the narrative documentation by the nurse failed to include the times and sequence of events during the Code 99 and subsequent Code Blue that occurred after PI # 1 returned to the nursing unit from radiology. Review of the Code 99/Code Blue Critique Worksheet provided by the facility revealed no date and time recorded. The Code Blue section of the Code 99/Code Blue Critique Worksheet form revealed incomplete data such as the date and time the Code Blue began, time of intubation, size ET (endotracheal) tube used and who performed the intubation. The time the Code Blue ended was recorded as 10:55 AM per the Code 99/Code Blue Critique Worksheet. The surveyor requested documentation of the events on 4/19/18 from 9:27 AM to 11:00 AM when the record shows PI # 1 in ICU (Intensive Care Unit) on a ventilator. No documentation was provided to the surveyor. During chart review on 7/26/18 at 3:00 PM EI # 1, RN Quality, provided a nursing narrative note dated 5/8/18 and stated it was an amendment to the nursing narrative dated 4/19/18. EI # 5, Medical Records, who was also present, stated the nursing narrative dated 5/8/18 would not be part of the official medical record. Review of the nursing narrative note provided by the facility dated 5/8/18 revealed "on 4/19 patient was scheduled for an MRI. (name) the transporter came to the room to take (him/her) down for the scheduled test. (He/she) came with a wheelchair and an oxygen tank. (He/she) transported the patient via wheelchair on 4L (liters) of oxygen. (He/she) took (him/her) down and brought (him/her) back and stated that the radiology team stated that the patient was unable to complete the test because (he/she) was too short of breath. (He/she) then transported (him/her) back to the floor and told me that the test did not get completed because the patient was short of breath. We allowed the patient to sit in the wheelchair until we felt (he/she) could move to the bed. Once we got (him/her) back in (his/her) bed we discontinued the portable oxygen tank and hooked (him/her) up to the oxygen on the wall and tried to get (him/her) stable. We noticed (his/her) lips started turning blue (name) RN called for a code 99." There was no time documented when these events took place and no reason why the documentation was amended 19 days after the patient expired. An interview conducted 7/30/18 at 1:00 PM with Employee Identifier # 1, Registered Nurse Quality, confirmed the above findings. | |||||||||
56 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 1 | 0 | Initial Comments | Memo Tag | Y | Joint Commission | 22965 Amended 7/18/18 The complaint was substantiated. An Immediate Jeopardy (IJ) was identified when hospital staff failed to ensure: 1. The staff responsible for monitoring heart rhythm failed to notify the the patient's nurse of Dysrhythmias. 2. The staff responsible for monitoring blood pressure (BP) failed to notify the patient's nurse of the patient's hypotension resulting in a stroke and as a result of the deficient practice PI # 2 had to extend hospitalization with cardiac and physical rehabilitation. 3. The staff followed their own policy for elopement in the Partial Hospitalization program. This deficient practice resulted in 1 patient's death. Condition level deficiencies were cited at 482.12: Govering Body, 482.13: Patient Rights and 482.23 Nursing Service with related standards. The State Survey Agency recommends an IJ level citation at A-057, A-144, and A-392. | |||||||||||
57 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 2 | 0 | Initial Comments | Memo Tag | Y | Joint Commission | 17650 A follow up survey was conducted on 8/9/18 for an Immediate Jeopardy (IJ) identified on the survey dated 7/12/18. This resulted in Conditions of Participation cited at: 482.12 - Governing Body 482.13 - Patient Rights 482.23 - Nursing Service On 8/8/18 at 1:30 PM Employee Identifier (EI) # 13, Chief Executive Officer was informed by the surveyors the Immediate Jeopardy could not be relieved due to: 1. A PHP (Partial Hospitalization Program) patient who scored a high risk score on a Suicide Risk Assessment was left alone for more than thirty minutes in a room with multiple objects that could be used for self harm such as large windows covered with mini blinds and cords hanging the length of the windows (ligature risk), plastic trash bags, non collapsible metal coat hooks, unsecured wall pictures, cabinet with doors sitting on the floor; not secured to the wall and ceramic flower pots sitting by the window. 2. A patient was off the telemetry monitor from 11:00 AM to 3:38 PM without notification to the patient's nurse. 3. A patient having episodes of bigeminy (a cardiac rhythm in which each normal beat is followed by an abnormal one) and trigeminy (a cardiac arrhythmia in which the beats are grouped in trios, usually composed of 2 sinus beats followed by 1 an abnormal one) on the monitor, later with a 17/18 run of PVCs (premature ventricular contractions) and treatments were provided without evidence of the above abnormal rhythms. A credible allegation of compliance was submitted on 8/8/18 and revised on 8/9/18. The facility put the following steps into place on 8/8/18: 1. The Partial Hospitalization Program was temporarily suspended. The Medical Director of Psychiatry evaluated each of the current patients to determine which patients required admission to an inpatient unit and which patients were appropriate for discharge with follow-up by a psychiatrist. The Medical Director determined all seven patients to be clinically appropriate for outpatient treatment. All seven patients were scheduled to be seen by the Medical Director at his/her private clinic on 8/9/18. One of the seven patients elected to resume care with her/his private psychiatrist. An interview was conducted on 8/9/18 at 6:55 PM with the Medical Director, who confirmed the patients were evaluated at his clinic on 8/9/18, and a plan of care was developed for each patient. Physician progress notes were provided to the surveyor. 2. Prior to the evening of 8/8/18 the Telemetry Monitoring was in a centralized location away from the patient care areas. This required telephone communication to any staff member caring for the patient whether on the floor, in X-Ray, Laboratory, etc. The Telemetry Monitoring staff may not know the location of each patient and this may have required multiple phone calls by personnel to inform the staff of the patients abnormal cardiac rhythm. On 8/8/18 the facility decentralized the Telemetry Monitoring. All the telemetry patients were evaluated for the need for telemetry and discontinued after consultation with the physician, if appropriate. The remaining patients who required telemetry where moved to five different floors with telemetry monitoring and staff were relocated along with the telemetry monitoring equipment. The surveyors observed all five patient care areas with telemetry units. The Monitor Tech were observed and saw immediate communication with the patient care staff. After review of the credible allegation of compliance for removal of the Immediate Jeopardy, it was determined the Immediate Jeopardy could be abated on 8/9/18 due to the facility: The follow up survey did result in Conditions of Participation cites at: 482.12 - Governing Body 482.13 - Patient Rights 482.23 - Nursing Service 482.24 - Medical Record Services 482.28 - Food and Dietetic Services | |||||||||||
58 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 3 | 0 | Initial Comments | Memo Tag | Y | Joint Commission | 17650 Based on an on site follow up survey conducted 9/26/18 it was determined Brookwood Baptist Medical Center was in substantial compliance with the following Conditions of Participation: 482.12 - Governing Body 482.13 - Patient Rights 482.23 - Nursing Service 482.24 - Medical Record Services 482.28 - Food and Dietetic Services A standard level deficiency was cited. | |||||||||||
59 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 1 | A0043 | Governing Body | 482.12 | Condition of Participation | 09/26/2018 | Y | Joint Commission | 22965 Based on the complaint survey the facility failed to assure the Governing Body was responsible for the operation of the hospital. In addition, the Governing Body failed to assure that all hospital policy and procedures were approved on an annual basis. This had the potential to affect all patients served by the facility. 1. Notify patient nurse of changes in patient's vital signs including alerts on the telemetry strips by the Central Monitoring Unit. 2. Provide an environment free from falls by following agency Falls Protocol. 3. Provided a safe enviromnent by documenting constant observation checks every 15 minutes. 4. Provided a safe environment by performing hourly rounds. 5. Ensure staff followed their own policy for elopement in the Partial Hospitalization program and completed the Biopsychosocial Assessment intake form. 6. Assure Physicians were notified of changes in patient's conditions and needs. Findings include: Refer to A 057, A 115, A 144, A 385, A 392, and A 449 for findings. | |||||||||
60 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 2 | A0043 | Governing Body | 482.12 | Condition of Participation | 09/26/2018 | Y | Joint Commission | 17650 Based on review of medical records (MR), policies and procedures, facility monitoring data, observations and interviews with staff, tour of the Partial Hospitalization Program (PHP), and review of the Behavioral Health Risk Assessment, it was determined the Governing Body failed to: 1. Implement an effective and safe setting for patient care for patients in the PHP. Refer to A 115 and A 144. 2. Provide supervision and oversight for nursing services to ensure safe and effective care for patients on telemetry and in the PHP. Refer to A 385 and A 392. 3. Ensure the staff provided medical record documentation that was accurate and complete to indicate the patients' condition, treatments, and care provided during the hospital stay for telemetry and PHP patients. Refer to A 431 and A 449. 4. Ensure the dietary department provided a sanitary environment to store and prepare the patients meals and snacks. Refer to A 618 and A 619. Findings include: Refer to A 115, A 144, A 385, A 392, A 431, A 449, A 618 and A 619 for findings. | |||||||||
61 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 1 | A0057 | Chief Executive Officer | 482.12(b) | Standard of Participation | Y | Joint Commission | 17650 Based on the complaint survey the facility failed to assure the Governing Body was responsible for the operation of the hospital. In addition, the Governing Body failed to assure that all hospital policy and procedures were approved on an annual basis. This had the potential to affect all patients served by the facility. 1. Notify patient nurse of changes in patient's vital signs including alerts on the telemetry strips by the Central Monitoring Unit. 2. Provide an environment free from falls by following agency Falls Protocol. 3. Provided a safe enviromnent by documenting constant observation checks every 15 minutes. 4. Provided a safe environment by performing hourly rounds. 5. Ensure staff followed their own policy for elopement in the Partial Hospitalization program and completed the Biopsychosocial Assessment intake form. 6. Assure Physicians were notified of changes in patient's conditions and needs. Findings include: Refer to A 057, A 115, A 144, A 385, A 392, and A 449 for findings. | ||||||||||
62 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 1 | A0115 | Patient Rights | 482.13 | Condition of Participation | 09/26/2018 | Y | Joint Commission | 22965 Based on a review of medical records (MR), Unit Activity Report, Qantros Safety Event Manager Reports, RL Solutions Complaint Reports, Constant Observer Flow Sheet, facility policies and procedure, observations, and interviews, it was determined the facility failed to: 1. Notify patient nurse of changes in patient's vital signs including alerts on the telemetry strips by the Central Monitoring Unit. This deficient practice resulted in 1 patient's death. 2. Provide an environment free from falls by following agency Falls Protocol and performing hourly rounds. 5. Ensure staff followed their own policy for elopement in the Partial Hospitalization program. This deficient practice resulted in 1 patient's death. Findings include: Refer to A- 0144 - Patient's Rights for findings. | |||||||||
63 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 2 | A0115 | Patient Rights | 482.13 | Condition of Participation | 09/26/2018 | Y | Joint Commission | 22965 Based on review of medical records (MR), policies and procedures, interviews with staff, tour of the Partial Hospitalization Program (PHP), and review of the Behavioral Health Risk Assessment, it was determined the hospital failed to implement an effective and safe setting for patient care in the Partial Hospitalization Program. This had the potential to affect all patients served by the facility, and did affect Patient Identifier (PI) # 23, one of five records reviewed from the PHP. Findings Include: Refer to A 144 for findings. | |||||||||
64 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 1 | A0144 | Patient Rights: Care In Safe Setting | 482.13(c)(2) | Standard of Participation | 09/26/2018 | Y | Joint Commission | 39080 Based on a review of medical records (MR), Unit Activity Report, Qantros Safety Event Manager Reports, RL Solutions Complaint Reports, Constant Observer Flow Sheet, facility policies and procedure, observations, and interviews, it was determined the facility failed to: 1. Notify patient nurse of changes in patient's vital signs including alerts on the telemetry strips by the Central Monitoring Unit. 2. Provide an environment free from falls by following agency Falls Protocol. 3. Provided a safe enviromnent by documenting constant observation checks every 15 minutes. 4. Provided a safe environment by performing hourly rounds. 5. Ensure staff followed their own policy for elopement in the Partial Hospitalization program. This affected 13 of 30 MRs reviewed and 4 unsampled patients, including Patient Identifier (PI) # 1, # 3, # 20, # 16, 3 unsampled patients, # 14, # 15, # 5, unsampled patient, # 12 and # 10, and had the potential to negatively affect all patients served by the facility. Findings include: Policy: Falls Prevention and Resources Policy Number: P_GN_PC_24-0318 Dated: 03/18 II. Purpose: "The purpose of this policy is to: ...B. Establish a framework for assessing risk factors for patient falls, implementing intervention for reducing the risk for falling and protecting patients from injury if a fall should occccur.... IV. Policy: ....The ultimate goal of a falls program is prevention of injury... V. Procedure A. Initial Falls Risk Assessment 1. Upon entry into the hospital system or through emergency services, a Registered Nurse (RN) should first complete the Morse Fall Scale Risk Screening Tool in Cerner as part of the patient's admission assessment.... B. Falls Risk Assessment 1. Morse Scale Assessment: a) Patients who score 0-24 are considered at "Low Risk" for falls. b) Patients who score 25-44...are considered "Moderate Risk" for falls. c) Patients who score 45 and above are considered "High Risk" for falls.... E. Mandatory Fall Alert Intervention: 1. All patients identified as at risk for falls should have interventions implemented to alert other healthcare workers, family and visitor of the fall potential. 2. Minimally, all of the following measures will be implemented at all times: a) For high risk, a yellow armband must be placed on the wrist and yellow no-slip/skid socks be applied.... c) A sign (star) identifying the patient is at risk for falls is placed outside the patient's door frame.... e) Make sure the bed is secured locked, locked in low position and bed alarm on...." Policy: Constant Observer Assessment, Implementation, and Discontinuation Policy Number: SYS_NRS 20 Dated: 5/18/18 Policy: "The Hospital recognizes the Constant Observers may be utilized in order to provide continuous observation of a patient to support safety.... A. If an assessment reveals that a patient is a danger to self and/or others a Constant Observer will be implemented immediately.... C....Definitions of levels of constant observation: 1. One on one observation - one competent Constant Observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area.... 2. Close observation - one competent Constant Observer to one or more patients in the same room/area. 3. Line of sight observation - one competent Constant Observer in direct line of sight with one or more patients.... D. Implementation of Constant Observer... 5. The Constant Observer will document patient observations at intervals not to exceed 15 minutes on the designated flow sheet as indicated...." Policy: Central Nurse Call System Policy Number: N_GN_NC_01_0716 Dated: 09/82 III. Policy: "The RN, Licenced Practical Nurse (LPN), and Patient Care Assistants (PCAs) with the assistance of the Central Nurse Call System (CNCS) operator, will respond to patient needs and requests by utilizing the CNCS. This system identifies proper staff members based on patient needs and location and enhances efficient use of nursing staff time." Policy: Management of Medical/ Surgical Patients on Telemetry Monitoring Policy Number: N_GN_PC_31 Dated: 11/2017 II. Purpose: The purpose of this policy is to provide guideliens for the management of patients requiring telemetry monitoring. III. Policy: B. Communication: 1. The monitor tech will promptly comunicate non-life thratening rhythm problems/ changes to the nurse who is in charge of the patient within 5 minutes of alarm. 2. When patients are monitored from the central station outside of their home unit, the monitor tech will: b) The monitor tech will communicate rhythm problems/ changes and questions by phoning the assigned nurse of the patient. c) If non-threatening issue is not resloved at central station whin 5 minutes, the monitor tech will call the charge nurse . .... 3. b) The nurse will notify the physician of the following rhythm changes: 1. Asystole 2. Thrid degree heart block 3. V Tach 4. V tach - 6 beats 5. V Fib C. Patient Care 1. The RN will review/ communicate rhythm strip data during shift report. I. All Alarms will be set at default unless otherwise prescribed by a [hysician. The standing alarms are aa follows, unless specified by the physician: a) Heart Rate (HR) less than (<) 40; pause 3 seconds. b) HR greater than (>) 150 c) SA02 < 90% d) ST Segment Elevation or Depression (+/- 2 mm) e) Complex ventricular ectipy > 6 beats VT; sustained V- Tach > 15seconds, sustained bigeminy, sustained treigiminy. f) New supraventricular arrhythmia g) Absence of signal h) Any ither sunstantial changes in rhythm 4. All rhythm interpretations will be verified by an RN and physician notified before treatment is initiated. Policy: Elopement Policy Number: D-PS-PG-11.069 Date Reviewed: 09/09 "Policy: While the independence of the Partial Hospitalization patient is recognized, when a patient has left without notifying staff, this procedure will be followed. Procedure: 1. When a patient fails to appear to the next scheduled group, staff will attempt to locate the patient and/or immediate grounds. 2. If the patient cannot be found, the attending physician, Medical Director, Operations Leader, or designee and the patient's family will be notified..." 1. PI # 1 was admitted to the facility on 5/30/18 with the diagnoses including Altered Mental Status and Rule Out Sepsis. Review of the MR 7/5/18 at 11:00 AM revealed patient was admitted on 6/28/18 at 3:31 PM to Room 379 3 West/ Medical Cardiac Unit) with the chief complaint of Altered Mental Status, Rule Out Sepsis. Review of the Nursing/ Clinical Information Note dated 6/10/18 at 3:47 AM had the documentation "the patient complained of indigestion and was given as needed (PRN) medication with no relief. Patient also complained of pain and was given PRN Norco x 2 doses with no relief. Patient was also given Restoril to help his/ her relax, but none of these mediations seemed to help the patient. Hospitalist was notified, no further orders given Review of the Nursing/ Clinical Information Note 6/10/18 at 8:15 AM had the documentation the family requested that patient not be awaken. At 9:00 AM the patient's daughter was walking in the hallway stating that patient was not breathing. The nurse went into the patient's room and found patient unresponsive and not breathing, Code Blue was called @ 9:02 AM Review of the Emergency/ Urgent Care Emergency Room (ER) Physician (MD) Summary dated 6/10/18 at 7:34 PM revealed documentation that he/ she responded to a Code Blue called to Room .... When the ER MD arrived full cardiopulmonary resuscitation was in progress. The Registered Nurse (RN) informed the ER MD that the patient was pulseless and apneic when he/ she found the patient. The RN further stated that he/ she called the Telemetry Room and was informed by a monitor technician that the patient has not had a rhythm for 15 minutes. After stabilizing the patient and his/ her attending physician was notified and came in to the patient's room. The patient was then transferred to Coronary Care Unit on a ventilator with full support. Review of the 24 Hour Telemetry strips revealed the last cardiac strip was printed on 6/10/18 at 7:09 AM (09 seconds (sec) , the cardiac strips showed heart rate (HR) at 64 beats per minutes (bpm) There were no printed cardiac strips until 8: 44 (14 seconds) when the HR dropped the he 46 beats per minutes (bpm); at 8:44 (34 sec) HR was 32 bpm; and at 8:44 (54 sec) HR was 28 bpm. . Review of the Progress Note by the Physician Hospitalist dated 6/10/18 at 8:50 PM revealed the patient was pronounced dead at 7:58 PM . An interview was conducted with Employee Identifier (EI) # 4, Director of 3 West and Central Monitoring who conducted on 7/6/18 at 11:00 AM, EI # 4 showed the surveyor a copy of Performance Management Program Record Conference done 6/13/18. at It was documented the reason for the conference was " EI # 5, Monitor Technician failed to notice the decrease in PI # 1 Heart Rate for over a 15 minute period. EI # 4 further documented " The patient subsequently coded and was transferred to the Intensive Care Unit." The Action Plan For Improvement section which was completed by EI # 4 and had this documentation, " Notify patients RN for any sudden or gradual rhythm/ rate change. The surveyor asked if there were any further action taken such as education, etc. EI # 4 answered "no". 2. PI # 3 was discharged from the facility's inpatient psychiatric care on 1/15/18 and admitted to the Partial Hospitalization Program (PHP) on 1/22/18, with diagnoses including Bipolar Disorder, and Depression. Review of the synopsis received on 7/10/18 at 8:25 AM from EI # 3, Vice President, Quality, included the following order of events: "PI # 3 discharged 1/15/18 from inpatient psych (psychiatric) admission for depression/ anxiety. (She/he) completed (her/his) intake assessment for Partial Psych Hospitalization day program on 1/19/18 and attended sessions on 1/22/18 and 1/23/18. (Husband/wife) dropped (her/him) off for the 1/24/18 sessions. PI # 3 registered at approximately 0840 (8:40 AM). At approximately 0919 (9:19 AM), Brookwood Security was notified by Homewood Police Department (HPD) that they had received a call from someone stating a body was seen at the base of the parking span on the hospital campus. ...We reconciled the Partial Psych Hospitalization (day program) census and were unable to locate (PI # 3). Staff reported that (she/he) had checked in but did not come to the first group session at 0900 (9:00 AM). At this time, we informed the HPD that we may have identified a person of interest. (He/she) was able to pull up (her/his) AL (Alabama) driver's license which the coroner used for initial identification when he/she arrived..." Review of the MR revealed a progress note dated 1/22/18 at 4:00 PM, written by EI # 12, Clinical Therapist, which stated, "Informed that patient's spouse called several times throughout day to check on pt (patient), as (she/he) may be an elopement risk. ...Will add concerns to tx (treatment) plan and discuss w/ (with) pt..." Review of the PHP Interdisciplinary Care Plan dated 1/19/18, the date of the patient's intake appointment, revealed Safety, under category of Areas of Need, had been marked through with a line, and initialed by the Clinical Therapist. Further review of the Therapy Progress Notes, dated 1/22/18 and 1/23/18, revealed no update to the Care Plan, and "Areas of need addressed" did not change to include Safety/ Elopement Risk. A tour of the facility and interview was conducted on 7/10/18 at 9:00 AM with EI # 6, Administrative Director, Psychiatric Services. EI # 6 stated PI # 3 was escorted by the spouse up to the third floor, to the PHP's waiting room on the morning of 1/24/18. The spouse kissed the patient and then left the premises. Review of the documents provided to the surveyor on 7/10/18 revealed a patient sign in sheet for the PHP dated 1/24/18. PI # 3 was listed on the form, and 8:40 (AM) was written in the column labeled "Arrival Time." EI # 6 stated PI # 3's purse and other belongings were discovered after the event in the casual gathering room, an area located beyond the waiting room of the office. The staff failed to recognize PI # 3 had left without notifying staff, and failed to follow the procedure outlined in their elopement policy to attempt to locate the patient. During an interview conducted on 7/10/18 at 11:00 AM with EI # 6, the above findings were confirmed. 3 . PI # 20 was admitted to the facility on 5/20/18 with an admitting diagnosis of New Onset of Atrial Fibrillation. PI # 20 experienced a fall on 5/20/18 at 20:10 which resulted in a fracture of the superior part of the L1(Lumbar one) vertebral body. Review of the Quantros Safety Event Manager event summary revealed the following: a. The patient was determined to be at risk for a fall prior to the fall. b. The Morse Fall Risk score was 75 (High risk) c. Interventions in place prior to the fall included: assistive device, call light in reach, bed/chair alarm, non-slip footware and siderails. Further review of the Quantros Safety event summary revealed the patient did not have on the non-slip footware as per the agency Falls protocol.The staff failed to implement all of the required falls interventions as per facility policy for PI # 20. A telephone interview was conducted on 7/6/18 at 9:58 AM with Employee Identifier (EI) # 4, Director, 3 West and Central Monitoring, who stated all patients identified as falls risk must have the following: A star sign placed on their door, bed/Posey chair alarm, yellow non-skid socks and call light and personal items in reach. If a patient refuses any of the precautions, such as non-skid socks, it is to be documented on a "Refusal of Care " form. No Refusal of Care from was in the MR for PI # 20. An interview was conducted on 7/9/18 at 10:40 AM with EI # 4, Director, 3 West and Central Monitoring, who confirmed the above findings. 4. PI # 16 was admitted to the facility on 7/4/18 with an admitting diagnosis of Pneumonia. On 7/5/18 the surveyor asked EI # 8, 5 Main Nurse Manager, to identify a patient that was a high falls risk. EI # 8 identified PI # 16 due to the Morse Falls score was greater than 45. Upon entering into room 527, room of PI # 16, the surveyor noted a star sign on the door, indicating the patient is a falls risk. The surveyor observed the PI # 16 lying in the middle the bed with his/her feet dangling on the floor, attempting to lie down. He/she was attempting to pull off some multi-colored socks as the surveyor and EI # 8 approached the bed. The surveyor asked EI # 8 if the PI # 16 was wearing non-skid socks? EI # 8 responded "no". There were no yellow non-skid socks in the room. The surveyor asked EI # 8 to whether the bed alarm was on? EI # 8 responded "no it is not". The surveyor asked EI # 8 if PI # 16 had on a yellow falls bracelet? EI # 8 responded "no". The staff failed to implement all of the required falls interventions as per facility policy for PI # 16. Upon further touring of the 5 main unit with EI # 8, the surveyor noted the star signs, which indicate the patient is a falls risk, on the doors of rooms 538, 539 541 and 543 but there were no patients currently assigned to these rooms. The surveyor asked EI # 8 why there were star signs on those doors. EI # 8 responded " I guess no one ever took them down". An interview was conducted on 7/5/18 at 1:00 PM with EI # 8, who confimed the above findings. 5. Unsampled patient # 1 was located in room 357. The surveyor asked EI # 4 to identify patients on the 3 West unit that were at risk for falls. Unsampled patient # 1 had a Morse Falls risk score of 80. Upon entering room 357 the surveyor noted a star sign on the door indicating the patient is a falls risk. The surveyor asked EI # 4 whether the bed alarm was on? EI # 4 stated "no". The staff failed to implement all of the required falls interventions as per facility policy for Unsampled patient # 1. An interview was conducted on 7/9/18 at 10:40 AM with EI # 4, who confirmed the above findings. 6. Unsampled patient # 2 was located in room 359. EI # 4 identified Unsampled patient # 2 as a high falls risk. Unsampled patient # 2 had a Morse Falls risk score of 70. Upon entering room 359 the surveyor noted a star sign on the door indicating the patient is a falls risk. The surveyor asked EI # 4 whether the Unsampled patient # 2 was wearing a yellow falls bacelet? EI # 4 stated "no". The staff failed to implement all of the required falls interventions as per facility policy for Unsampled patient # 2. An interview was conducted on 7/9/18 at 10:40 AM with EI # 4, who confirmed the above findings. 7. Unsampled patient # 3 was an 84 year old patient admitted to 3 West who had a documented fall incident on 2/5/18 at 3:50 AM. Review of the Safety Event entry revealed the "nurse heard a loud noise" and found the patient on the floor. Review of the Safety Event Classification section revealed the question: "Prior to the fall, was this patient determined to be at risk for a fall?" with the documented reply as "unknown". Further review of the Safety Event Classification section revealed the question: "Prior to the fall, was a formal fall risk assessment performed?" with the documented reply as "No". The facility failed to document the Morse Falls Risk assessment and implement interventions to prevent falls as per facility policy for Unsampled patient # 3. An interview was conducted on 7/9/18 at 10:40 AM with EI # 4, who confirmed the above findings. 8. PI # 14 was admitted to room 540 on 6/25/18 with an admitting diagnosis of a Right Stump Infection. Review of the MR revealed an order on 7/2/18 and 7/3/18 for Constant Observer, One to One Observation. Review of the Constant Observer flow sheet for 7/2/18 revealed no documentation of Patient Activity/Behavior/Location or Staff initial on 7/2/18 for the 2:00 AM, 2:15 AM and 2:30 AM time slots. Review of the Constant Observer flow sheet for 7/3/18 revealed no documentation of the Patient Location on 7/3/18 for the 5:15 AM, 5:30 AM, 5:45 AM, 6:00 AM, 6:30 AM and 6:45 AM time slots. An interview was conducted on 7/5/18 at 1:00 PM with EI # 8, who confirmed the above findings. 9. PI # 15 was admitted to room 541 on 6/27/18 with an admitting diagnosis of Near Syncope, Urinary Tract Infection. Review of the MR revealed an order on 7/4/18 for Constant Observer, Line of Sight. Review of the Constant Observer flow sheet for 7/4/18 revealed no documentation of Patient Activity/Behavior/Location or Staff initial on 7/4/18 for the 6:45 AM time slot. An interview was conducted on 7/5/18 at 1:00 PM with EI # 8, who confirmed the above findings. 10. PI # 5 was admiited to the facility from 5/6/18. A patient grievance was entered into the RL Solutions Patient Tracking System on 5/16/18 after a phone call interview by the Patient Experience Supervisor. In the grievance, the PI # 5 alleged the staff "told her she had seven patients and that responding in four hours was good". Review of the response letter sent to PI # 5, dated 5/23/18, from the Patient Experience Supervisor, revealed the following: "Based on your shared comments and the review of the nurse call response report, the specific staff members did not consistently meet our expectations for providing timely patient care and communicating with our patients. The Nursing Director has followed up with all staff involved in your care to share a learning moment on the importance of purposeful hourly rounding." The surveyor requested of EI # 1, Accreditation Manager, Safety Officer, the Unit Activity Report for the room that PI # 5 was admitted to during the admission of the grievance and was provided a Unit Activity Report for Room 522. Review of the Unit Activity Report for room 522 from 5/6/18 to 5/9/18 revealed the following: Page 2 of 16: "(LPN, PCT (Patient Care Technician), RN) entered room on 5/6/18 at 11:41 PM Page 3 of 16: "(LPN, PCT, RN) entered room on 5/7/18 at 2:59 AM There was no documented staff presence in the room between 11:41 PM ro 2:59 AM. Page 13 of 16: RN entered room on 5/8/18 at 2:36 PM Page 14 of 16: a summary of Totals By Date Page 15 of 16: RN entered room on 5/9/18 at 12:36 AM There was no documented staff presence in the room between 2:36 PM to 12:36 AM to show hourly rounds. An interview was conducted on 7/5/18 at 1:00 PM with EI # 8, who stated hourly rounds were the expectation of administration for patient safety. The above concerns were communciated to EI # 2, Cheif Nursing Officer, on 7/12/18. 11. Unsampled Patient # 4 was admitted to 5 Main on 10/27/18. A patient grievance was entered into the RL Solutions Patient Tracking System on 3/15/18 related to an incident that occurred during the admission. In the grievance, Unsampled Patient # 4 alleged " an enema was ordered on 11/29/17 at 4:00 AM and was given that morning....when my daughter arrived, she found me lying in my own feces and there wasn't a nurse or assistant to be found. When my daughter finally saw a nurse, she was told someone would be in after report". Review of the response letter sent to the Unsampled Patient # 4, dated 3/20/18, from the Patient Experience Supervisor, revealed the following: "Our expectation is that team members respond timely to our patient's needs and Nurse Call activations. Based on the review of the nurse call response report, we did not meet our goal of responding to your needs". An interview was conducted on 7/5/18 at 1:00 PM with EI # 8, who stated hourly rounds were the expectation of administration for patient safety. 39098 13. PI # 10 was transferred from MICU (Medical Intensive Care Unit) to inpatient psychiatric care on 7/3/18 with diagnoses including Major Depressive Disorder without Psychosis, Substance Abuse Disorder, and Suicidal Ideations. Review of the MR revealed the Psychiatry History and Physical dated 7/4/18 with the following documentation by the physician: "...And in the ICU he tried to elope and was found in the woods nearby." Review of the orders dated 7/1/18 and in effect at the time of the elopement revealed an order for Precautions: Continuous, Suicide. Review of the nursing documentation on 7/3/18 revealed the following order of events: "0735 (7:35 AM) Patient sitting on side of bed ripped IV (Intravenous) tubing apart... Patient agitated. 0740 (7:40 AM) Patient at room door attempting to leave. Psych (Psychiatric) rapid response team called to obtain suicide risk assessment. Patient with continued agitation... 0745 (7:45 AM) Psych rapid response at bedside. ...Dr. Bell called related to patient behavior: left message. 0845 (8:45 AM) Patient pacing refusing care, removed monitoring device. Patient ran past CO (Constant Observer) out unit doors..." Review of the statement of the CO, dated 7/3/18, revealed, "...the patient asked the nurse the best way out of the hospital. The patient was located in MICU bed 1, next to the doors to the ICU. The doors were opening and closing. He asked the nurse where the doors led. The CO reported to other nurses that (she/he) felt like the patient was going to try and leave..." According to a narrative statement dated 7/3/18 by EI # 13, RN, Administrative Director, the patient was located by a Homewood Police officer. An involuntary commitment was obtained, and the patient was brought back to the hospital at 10:06 AM and admitted to psychiatry. According to the Nursing Note dated 7/3/18 at 1:00 PM, PI # 10 hung himself/ herself on 6/28/18 with a belt, on the porch of his/her home and lost consciousness. He/she was rescued by the spouse. During an interview conducted on 7/10/18 at 3:55 PM with EI # 1, Accreditation Manager/ Safety Officer the above findings were confirmed. The surveyor asked if a patient on suicide precautions exhibited increasing agitation over one hour and ten minutes, pulled out IV, asked where the doors led, and no orders received back from physician, would justify initiating a Code Brown (Pyschiatric emergency code)? EI # 1 answered "Yes." | |||||||||
65 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 2 | A0144 | Patient Rights: Care In Safe Setting | 482.13(c)(2) | Standard of Participation | 09/26/2018 | Y | Joint Commission | 39098 Based on review of medical records (MR), policies and procedures, interviews with staff, tour of the Partial Hospitalization Program (PHP), and review of the Behavioral Health Risk Assessment, it was determined the hospital failed to ensure: 1. Staff followed their own policy for patients who scored Moderate or above on the Suicide Risk Assessment. 2. The physical environment in the PHP was safe and free of ligature risks. 3. PHP patients did not have access to items to cause self harm. 4. Administrative areas of the PHP were secured to prevent patient access to items that could be used for self harm or harming others such as glass mirrors, paint, unattached grab bars, plastic trash bags, etc. This had the potential to affect all patients served by the facility, and did affect Patient Identifier (PI) # 23, one of five records reviewed from the PHP. Findings include: Policy: Action to Safety and Security Risks Date Reviewed: 12/15 "I. Policy: It is the policy of Brookwood Medical Center to use the results of the Environment of Care (EC) Risk Assessment to evaluate and improve the Safety and Security Program and any other applicable EC Programs. II. Scope: A Risk Assessment is used to evaluate the impact of the physical environment on the ability of the organization to perform clinical and business activities. Where risks are identified, the current programs and processes to manage those risks are compared to the risks that have been identified. Where identified risks are not appropriately handled, action must be taken to eliminate or minimize the risk... III. Responsibility: The Safety Officer is responsible for managing the risk assessment process. The responsibilities include: A. Use results of the risk assessment to identify risks that require new, changed, or updated policies, procedures, and activities to control the risks... C. In conjunction with other managers, identifying key practices and activities that should be changed or improved to better control the potential for injury, illness, or other adverse results. ...IV. Procedure: A. After conducting a risk assessment, the results are reviewed and used to determine the appropriate controls or measures implemented to reduce the risk, whether new policy, procedures, training, or equipment is needed to control the risks. ...G. All of the results of these activities will be monitored and reported to the EC Committee on a periodic basis... The activities will be monitored until the next risk assessment evaluates that the risks have been controlled." Policy: Suicide Risk Assessment Policy Number: PSY 051 Date Revised: 7/10/2018 "Policy ...Partial Hospitalization: Partial Hospital staff must complete the Suicide Risk Assessment on all partial hospital patients on day of admission and prior to discharge. Each day thereafter, the patient will complete the PHP Daily Check-In Form. In the event of a "yes" response to any one of the three (3) screening questions, a PHP Therapist will complete a Suicide Risk Assessment and notify the physician and document accordingly. Procedure: ...Moderate Risk Patients: ...Partial Hospitalization: Physician will be notified... Patient will be under direct observation until determination of disposition has been made. High Risk Patients: ...Partial Hospitalization: Physician will be notified and patient will be taken to the Emergency Department for further evaluation." Behavioral Health Risk Assessment Dated: 1/18 "Inpatient Behavioral Health Environment of Care Design Requirements. Used as a Guide for Development of Outpatient Partial Hospitalization Program Area. A. Hinges for doors will not be an anchor point. Solution: Continuous hinges are preferred for all patient accessible areas because they minimize possible attachment points. B. Handles on doors in common areas accessible to patients do not have ligature points. Solution: Locksets- All doors in patient accessible areas are recommended to have some type of ligature resistant lockset... C. Light fixtures are secure, no access to light globe, tamper resistant screws, cannot be used as an anchor point. Solution: If located at a height or location that is not easily assessable to patients, these may be normal fixtures and lamps as long as staff observation from the nursing station is good and staff are in attendance, but tamper resistant fixtures are preferred. Where they can be reached by the patients or are in areas that are not readily observable by staff, they must be tamper-resistant type... Neither incandescent light bulbs nor fluorescent tubes should ever be accessible to patients. D. Window coverings are flush mounted, no cords or chains. All windows are covered by polycarbonate secured with safety screws or glazing of glass to keep the glass in the frame when broken and not yield glass shards. Solution: All glazing that is exposed in patient accessible areas should stay in the frames when broken and not yield sharp shards of glass that patients could use as weapons. E. No plastic trash can liners used, paper trash bags. No plastic bags in unlocked areas. Solution: No plastic trash can liners should be allowed in any space accessible to the patient. Breathable paper liners should be provided. F. Cabinet pulls are recessed or closed. Solution: Cabinet pulls should be either recessed, with no protruding openings or of a closed ligature resistant type. G. Furniture is heavy and securely anchored when possible. Solution: ...heavy as possible to minimize likelihood of patients throwing chairs, tables, etc. H. All pictures have polycarbonate glazing and heavy frames, screwed to the wall with minimum of one tamper resistant screw per side. Solutions: ...The frames should be screwed to the walls with a minimum of one tamper-resistant screw per side... I. Coffee pots are not glass and location observable by staff, monitor hot liquid. Solution: ...The location of the coffeemaker should be chosen so it is readily observable by staff. Glass coffee pots should never be available to patients... J. Only open shelves used for storage... Solution: Wardrobe units should not have doors... They should be securely anchored in place and have sloped tops. K. Windows do not present a hazard. Solution: (None listed) L. Blinds openers do not pose a ligature risk. Solution: (None listed) M. Robe hooks are removed or will not bear weight. Solution: ...If they are required, they should be collapsible type. N. Installed grab bars are closed. Solution: ...There is now a ligature resistant grab bar... O. Sinks are closed underneath. Solution: ...waste and supply piping should be enclosed..." The following documentation was listed for each item listed above: "Checklist: Not met in Outpatient Area Mitigation: 1. Identification of patients at risk for suicide by performing Suicide Risk Screen at each patient visit to OPHP (Outpatient Partial Hospitalization Program); Conduct Suicide Risk Assessment for any patient who screens positive. 2. Patients who score Moderate or above on Suicide Risk Assessment remain under Constant Observation, including bathroom. 3. Perform environmental assessment of area and remove items as able." PI # 23 was admitted to the PHP on 8/1/18 with diagnoses including Major Depressive Disorder, and Generalized Anxiety Disorder. Review of the Initial Treatment Plan dated 8/1/18 included monitor for safety and symptoms, and provide group, milieu, and individual therapy. Review of the PHP Interdisciplinary Care Plan dated 7/30/18 (completed on intake) included Safety: Thoughts of harm to self or suicidal ideation, and Psychiatric Symptoms: Depression, Anxiety, SI (Suicidal Ideations), and Anger. Review of the PHP Daily Check-In form dated 8/2/18 at 9:30 AM, revealed the patient checked "yes" to one of the three suicide screen questions on the form. A Suicide Risk Assessment (SRA) dated 8/2/18 at 10:05 AM, was documented by Employee Identifier (EI) # 6, Clinical Therapist (CT). The documented SRA score was 35 in the High Risk category. EI # 6 documented the following narrative in the CT notes dated 8/2/18: "...Patient presents agitated... Patient verbalized having passive thoughts of SI, with a vague plan to smother himself/ herself or drink himself/ herself to death. He/she reports frustration with anxiety and treatment team. Patient was difficult to redirect and amplified anger towards his/her peers in treatment program and staff. Patient is a high risk for suicide and refused to report to ER (Emergency Room) per policy. Clinical therapist notified manager and medical director. Manager unavailable and MD (Medical Doctor) could not be reached. Other staff were occupied and could not stay with patient. Patient verbally contracted for safety. No other staff was available to assist. Due to patient's irritability, clinical judgement was used to keep patient isolated from other patients. Patient was left in group room alone. All objects that could be used as a weapon were removed from the room..." A tour of the PHP was conducted on 8/6/18 at 8:50 AM which included the group room where the patient was placed and left alone. The following items were observed in the room: a. 2 large windows covered with mini blinds, cords hanging the length of window, which was a ligature risk. b. Garbage can with plastic garbage bag. c. Non collapsible metal coat hook mounted on the inside of the door. d. Picture hanging on wall, not secured. e. 5 chairs and one round table, unsecured. f. A black cabinet with doors standing on floor, not secured to wall. g. 2 ceramic flower pots setting by window. An interview was conducted on 8/7/18 at 7:00 PM, with EI # 5, RN (Registered Nurse), Administrative Director, who stated if a patient scores Moderate or higher on the SRA, the patient would never be left alone, according to policy. During a phone interview conducted on 8/8/18 at 9:40 AM with EI # 6, it was confirmed on 8/2/18 she/he first left the patient alone for 10 minutes, to check on the other patients in the PHP. At approximately 10:24 AM, EI # 6 stated she/he left PI # 23 alone for the second time with some activities to do, and went back to conduct group therapy with the other patients. At 11:05 AM, the office coordinator notified EI # 6 that PI # 23 was wanting to leave. EI # 6 stated she/he gave the patient a popsicle and talked with him/her until 11:25 AM. EI # 6 returned to group therapy and left the patient alone for the third time. EI # 6 stated at 11:50 AM she/he heard EI # 10, CT, Patient Relations Manager, in the hallway going to talk with the patient. EI # 6 verified PI # 23 was left alone in the group room on 8/2/18. EI # 6 stated EI # 10 contacted the MD at approximately 12:00 PM. A progress note dated 8/2/18 at 3:04 PM written by EI # 10, revealed the following documentation, "...Since he/she was refusing to go to the ER (Emergency Room), high SRA, and current intense symptoms, the physician recommends filing a petition." At 1:15 PM the patient was escorted by EI # 10 and an employee from the inpatient hospital facility, to the hospital for inpatient admission. During an interview on 8/8/18 at 12:12 PM with EI # 5, the above findings were confirmed. 2. During a tour of the PHP conducted on 8/6/18 at 8:50 AM the following items were observed: Group Room (First room on left past waiting room) -1 picture hanging on wall, not secured. -1 white erase board hanging on wall, not secured. -1 garbage can with plastic liner. -1 table lamp with bulb, plug cord approximately 60 inches long. -1 glass jar on table. Hall -2 pictures hanging, not secured. Group Room (Back Hall with windows) -2 large windows covered with mini blinds, cords hanging the length of window, which is a ligature risk. -1 garbage can with plastic garbage bag. -1 metal coat hook mounted on the inside of the door that was not collapsible. -1 picture hanging on wall, not secured. -5 chairs and one round table, unsecured. -1 black cabinet with doors standing on floor, not secured to wall. -2 ceramic flower pots setting by window. Patient Bathrooms (2) -2 grab bars, open, which is a ligature risk. -Plumbing exposed under wall mounted sinks. -Glass mirror. -Non collapsible metal coat hook mounted on inside of door. -Inside door hinge, v-shaped. -Dead bolt locks. -Garbage can with plastic liner. Patient Breakroom -2 glass coffee pots. -2 ceramic coffee mugs in cabinet. -1 container of Saran Wrap in drawer. -1 roll of plastic garbage bags on top of refrigerator. -1 large garbage can with plastic bag. -2 drawers with plastic bags. Administrative Area, Unsecured and accessible by PHP patients -Multiple Clinical Therapists' offices, scissors, assorted supplies, unsecured. -Filing cabinets, unsecured. -Standing black cabinet with doors, unsecured. -Exam Room 6- black metal hanger attached to wall. -File/storage room- shelves not secured, various cleaning chemicals. -Data/Electrical Room- loose grab bar leaning against wall, hooks mounted to wall, strips of baseboard material, paint, and other chemicals. Staff Breakroom -Wall mounted cabinet containing PPE (Person Protective Equipment), items in plastic bags, Isolyser, biohazard bags. Door unsecured. -Non collapsible metal coat hook on back of door. -Soap and glass vase under sink. -Cups with plastic sleeve covers. -Picture on wall, unsecured. All electrical outlets and light switches, plastic without tamper resistant screws. During an interview conducted on 8/7/18 at 7:20 PM with EI # 5, the above findings were confirmed. The surveyor asked EI # 5 if patients were continuously monitored while in the PHP treatment area. EI # 5 answered, "No." | |||||||||
66 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 1 | A0385 | Nursing Services | 482.23 | Condition of Participation | 09/26/2018 | Y | Joint Commission | 22965 Based on hospital policy, record review and interview the hospital failed to: 1). Ensure nurses were alerted/ informed of changes in the patients medical condition and vital signs. 2). Assure Physicians were notified of changes in patient's conditions and needs. This resulted in a death of the 1 medical patient. 3). Ensure the Clinical Therapist accurately completed the Partial Hospitalization Program, Biopsychosocial Assessment intake form . This resulted in the death of 1 psychiatry patient. This had the potential to affect all patients served. Findings include: Refer to A 0392 for findings. | |||||||||
67 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 2 | A0385 | Nursing Services | 482.23 | Condition of Participation | 09/26/2018 | Y | Joint Commission | 17650 Based on the review of the facility policies and procedures, observations, medical record (MR) review, facility monitoring data and interviews it was determined the facility failed provide supervision and oversight for nursing services to ensure safe and effective care for patients on telemetry and in the PHP. Findings include: Refer to A 392. | |||||||||
68 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 1 | A0392 | Staffing And Delivery Of Care | 482.23(b) | Standard of Participation | Y | Joint Commission | 22965 Based on reviews of medical records (MR), policies and procedures and interviews, it was determined the staff in failed to ensure: 1). Nurses were alerted/ informed of changes in the patients medical condition and vital signs. 2). Physicians were notified of changes in patient's conditions and needs This deficient practice affected 4 of 5 patient records that were monitored by the Central Monitoring Unit including Patient Indentifier (PI) # 1, # 2, # 29 and # 30 and have a potential to negatively affect all patients served by the facility. Finding includes: Policy: Management of Medical/ surgical Patients on Telemetry Monitoring Policy Number: N_GN_PC_31 Dated: 11/2017 II. Purpose: The purpose of this policy is to provide guidelines for the management of patients requiring telemetry monitoring. I. Purpose The purpose of this policy is to provide guidelines for the management of patients requiring telemetry monitoring. III. Policy: B. Communication: 1. The monitor tech will promptly communicate non-life threatening rhythm problems/ changes to the nurse who is in charge of the patient within 5 minutes of alarm. 2. When patients are monitored from the central station outside of their home unit, the monitor tech will: b) The monitor tech will communicate rhythm problems/ changes and questions by phoning the assigned nurse of the patient. c) If non-threatening issue is not resolved at central station within 5 minutes, the monitor tech will call the charge nurse . .... 3. b) The nurse will notify the physician of the following rhythm changes: 1. Asystole 2. Third degree heart block 3. V Tach 4. V tach - 6 beats 5. V Fib C. Patient Care 1. The RN will review/ communicate rhythm strip data during shift report. I. All Alarms will be set at default unless otherwise prescribed by a [physician. The standing alarms are aa follows, unless specified by the physician: a) Heart Rate (HR) less than (<) 40; pause 3 seconds. b) HR greater than (>) 150 c) SA02 < 90% d) ST Segment Elevation or Depression (+/- 2 mm) e) Complex ventricular ectopy > 6 beats VT; sustained V- Tach > 15 seconds, sustained bigeminy, sustained treigiminy. f) New supraventricular arrhythmia g) Absence of signal h) Any other substantial changes in rhythm 4. All rhythm interpretations will be verified by an RN and physician notified before treatment is initiated. Subject: Medical Surgical Nursing Documentation - Routine Shift Assessment Revised Date: 11/17 III. Policy: " ... B. Nursing Documentation: Assessment: 1. An assessment at the beginning of the shift, at transfer to another unit by the transferring unit and receiving unit is required, and throughout shift when changes are identified... 2. Blocks left blank in sections other than the assessment section denote treatment activity, or other interventions are not ordered and/ pr appropriate or this patient or it is charted in another place in the patient's record. .. ***** Subject: Management of Medical/Surgical Patients on Telemetry Monitoring Revised Date: 11/17 " ... III. Policy: A. Telemetry Initiation Guidelines: 1. Decision for telemetry is ordered by the primary care provider... C. Patient Care: 1. The RN will review/communicate rhythm strip data during shift report ..." 1. PI # 1 was admitted to the facility on 5/30/18 with the diagnoses including Altered Mental Status and Rule Out Sepsis. Review of the MR 7/5/18 at 11:00 AM revealed patient was admitted on 6/28/18 at 3:31 PM to Room 379, 3 West/ Medical Cardiac Unit) with the chief complaint of Altered Mental Status, Rule Out Sepsis. Review of the Nursing/ Clinical Information Note dated 6/10/18 at 3:47 AM had the documentation "the patient complained of indigestion and was given as needed (PRN) medication with no relief. Patient also complained of pain and was given PRN Norco x 2 doses with no relief. Patient was also given Restoril to help his/ her relax, but none of these mediations seemed to help the patient. Hospitalist was notified, no further orders given. " Review of the Nursing/ Clinical Information Note 6/10/18 at 8:15 AM had the documentation the family requested that patient not be awaken. At 9:00 AM the patient's daughter/ son was walking in the hallway stating that patient was not breathing. The nurse went into the patient's room and found patient unresponsive and not breathing, Code Blue was called @ 9:02 AM. Review of the Emergency/ Urgent Care Emergency Room (ER) Physician (MD) Summary dated 6/10/18 at 7:34 PM revealed documentation that he/she responded to a Code Blue called to Room 379. When the ER MD arrived full cardiopulmonary resuscitation was in progress. The Registered Nurse (RN) informed the ER MD that the patient was pulseless and apneic when he/ she found the patient. The RN further stated that he/she called the Telemetry Room and was informed by a monitor technician that the patient has not had a rhythm for 15 minutes. After stabilizing the patient and his/her attending physician was notified and came in to the patient's room. The patient was then transferred to Coronary Care Unit on a ventilator with full support. Review of the 24 Hour Telemetry strips revealed the last cardiac strip was printed on 6/10/18 at 7:09 AM (09 seconds) (sec) , the cardiac strips showed heart rate (HR) at 64 beats per minutes (bpm) There were no printed cardiac strips until 8:44 AM (14 seconds) when the HR dropped the he 46 beats per minutes (bpm); at 8:44 (34 sec) HR was 32 bpm; and at 8:44 (54 sec) HR was 28 bpm. . Review of the Progress Note by the Physician Hospitalist dated 6/10/18 at 8:50 PM revealed the patient was pronounced dead at 7:58 PM . An interview was conducted with Employee Identifier (EI) # 4, Director of 3 West and Central Monitoring who conducted on 7/6/18 at 11:00 AM, EI # 4 showed the surveyor a copy of Performance Management Program Record Conference done 6/13/18 which revealed documentation on the reason for the conference was " EI # 5, Monitor Technician failed to notice the decrease in PI # 1 Heart Rate for over a 15 minute period ". EI # 4 further documented " The patient subsequently coded and was transferred to the Intensive Care Unit." The Action Plan For Improvement section which was completed by EI # 4 and had this documentation, Notify patients RN for any sudden or gradual rhythm/ rate change." The surveyor asked if there were any further action taken such as education, etc. EI # 4 answered "no". 2. PI # 2 was admitted to the facility on 5/15/18 with the primary diagnoses of Acute Myocardial Infarction. Review of the medical records on 7//918 at 2:15 PM revealed patient was admitted on 5/15/18 on 3 West/ Medical Cardiac Unit) with the chief complaint of Acute Myocardial Infarction. Review of the Cardiovascular/ Cardiology Admission History and Physical dated 5/15/18 revealed patient was transfer from another hospital due to progressive shortness of breath since the "age of 35". Patient did complain of chest pains "but not bad". Review of the patient's Vital Signs report revealed BP on 5/15/18 was in the range of 120/63 to 136/76 with runs of low BP ranging from 84/55. There was no documentation the physician was notified. Review of the Vital Signs report dated 5/27/18 revealed blood pressure (BP) at 6:10 AM was 97/60; 12:00 PM was 70/44. There was no documentation the patient's nurse notified the physician of the low blood pressure. Review of the Consultation Notes 5/27/18 revealed documentation at 3:00 PM, a Code Stroke was called due to the patient being unresponsive. Further review of the notes revealed the documentation" the patient had been hypotensive and hypoxic for a long period of time." Review of the Nursing/ Clinical Information dated 5/27/18 at 3:15 PM had the following documentation Code Stroke called. "Upon arrival, patient found unresponsive, unable to assess for National Institute of Health Stroke Scale (NIHSS). Last known well time: 05/27/18 at 1:)) AM.". ... "Patient was transported per Advanced cardiovascular Life Support (ACLS) support to Computerized Tomography (CT) then transported to Intensive Care Unit (ICU/ Coronary Care Unit (CCU). Review of the neurology/neurosurgery consultation revealed due to Hypoxemia and unstable condition, patient was intubated and placed on a ventilator. Patient was in ICU/CCU from 5/27/18 to 6/4/18. On 6/4/18 patient was transferred out of ICU/ CCU to 3 West (Cardiac Floor) where he/ she rehabilitation services. Review of the Discharge Summary date 7/6/18 revealed the patient was discharged to home in stable condition with home health agency referral and will over the home care service at the patient's residence. In an interview conducted on 7/8/18 at 5:15 PM with EI # 4 who confirmed the above mentioned findings. 3. PI # 30 was admitted on 2 General Surgery (Gastro Intestinal (GI)/ Genito-Urinary (GU) Unit on 7/1/18 at 3:40 PM to Room GS 277 with the chief complaints of Right Leg Cellulitis On 7/10/18 at 3:15 PM, the surveyor surveyed the Central Monitoring Unit and found 3 monitor technician's on duty. The surveyor noted that 2 patients heart rate parameters were decreased from low of 50 to 40 bpm with the high range of 150 bpm. The surveyor asked EI # 16, Monitor Technician who was responsible for changing the patient's cardiac parameters, EI # 16 responded " I don't know who changed the parameters, it was that way when I got here this morning". The surveyor The surveyors reviewed the records of PI # 29 and # 30 to Station 2 Gastro Intestinal (GI)/ Genito-Urinary) GU Unit and reveiwed the 2 telemetry patients. Review of the Physician Orders dated 7/2/10 at 3:45 PM revealed there was no order to decrease the heart rate parameters to 40 bpm. An interview was conducted on 7/10/18 at 4:00 PM with EI # 4. The surveyor with EI # 4 went back to the Central Monitoring Unit and clarify as to who gave the order to change the heart rate low level to 40 bpm. The surveyors noted the patient telemetry monitor was adjusted back to 50 bpm, when the surveyor asked who adjusted the heart rate back to 50 bpm, EI # 16, Monitor Technician stated that he/ she did. The surveyor asked if EI # 16 received an order from the patient's nurse or for the physician, he/ she answered "no." *** A tour of the Central Telemetry Unit conducted on 7/5/18 at 10: 45 AM with a staff of (2) Monitor Technicians (MT) with 1 Patient Care Assistant (PCA) whose duty was to log in returned telemetry boxes, issue telemetry boxes and pulse oximetry. The surveyor notes that 1 MT had 42 patients and the other had 34 patients. When asked how many patients are each MT should monitor, the surveyor was told that their manager told them that they are to monitor 35 patients per MT. An interview was conducted with Employee Identifier (EI) # 14, Monitor Techncian (MT) and EI # 17, MT. The surveyor asked EI # 14 what are the parameters set for the heart rate, EI # 14 stated the HR parameters were on defaulted at low range of 50 beats per minunte (bpm) and high range of 150 bpm. The surveyor further asked who can change the ranges of the HR parameters both stated they receive a call from the patient's registered nurse (RN) to change the HR parameters. When the MT receives the call to adjust, they are to call the Biomedical Support to unlock the temetry monitor so the MT can change the parameters. The surveyor then asked the MTs if the get any documents example copy of the physician's order, both MTs answered no. The surveyor further asked EI # 14, MT who verbalized that the monitor technician on duty prints out the patient's cardiac strips every 4 hours unless there is noted Dysrhythmias or irregularities. EI # 14 further stated that when any irregularities and when patient is "off the monitor such as dislodged leads or in the bathroom, they are call the patient's nurse and informed of findings. The surveyor noted that each monitor has a note indicating when and how to call a code blue in the event patient is on Third Degree Heart Block, Asystole, Ventricular Tachycardia, Ventricular Fibrillation and Ventricular Tachycardia - 6 beats. 36271 4. PI # 29 was admitted to the 2nd floor GI/GU unit from the Emergency Department on 7/6/18 with diagnoses including Abdominal Pain with history of Irritable Bowel Syndrome. An tour of the Central Monitor Station was conducted on 7/10/18 at 8:55 AM. All the HR (heart rate) alarms were set at 50 - 150 with the exception of 2 patients which were being monitored EI # 16, Monitor Tech (Technician). The HR alarm for PI # 29 was set at 40 - 150. The surveyor asked EI # 16 why PI # 29's alarm was set at 40 and not 50. The answer was PI # 29 was alarming at 50 because he/she runs a low heart rate. Review of all the physician's orders from 7/6/18 to 7/10/18 revealed no order for telemetry monitoring and no specific alarm parameters. Review of telemetry monitor strips in PI # 29's chart from 7/6/18 to 7/9/18 revealed a HR range of 90 for the high documented on 7/8/18 at 6:00 PM to a low of 40 documented on 7/7/18 at 8:00 AM. There was no documentation on the strips that the nurse had reviewed the rhythm strips. On 7/10/18 at 9:11 AM a medical record review was completed with EI # 11, 2 GI/GU Unit Manager, using the Workstation on Wheels. Review of the nursing shift assessments revealed no documentation of PI # 29's heart rhythm in the cardiac assessment section. EI # 11 was asked what the expectation was for the nursing assessment of patients on telemetry. EI # 11 stated there should be documentation of the heart rhythm with each shift assessment. On 7/10/18 at 9:30 AM EI # 11 confirmed the nursing staff failed to assess and document the heart rhythm for patients on cardiac telemetry monitoring. | ||||||||||
69 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 2 | A0392 | Staffing And Delivery Of Care | 482.23(b) | Standard of Participation | Y | Joint Commission | 36271 Based on the facility policy and procedure, observations, medical record (MR) review, facility monitoring data and interviews it was determined the facility failed to ensure the staff followed the policy and procedure for Management of Medical/Surgical Patients on Telemetry Monitoring and provided patient safety in the Partial Hospitalization Program (PHP) as evidenced by: 1. Registered Nurse (RN) failed to document interpretation of abnormal rhythms. 2. Monitor tech failed to print abnormal rhythm strips according to facility policy. 3. RN failed to assess the patient and document patient status when notified of an abnormal cardiac rhythm and prior to initiation of treatment. 4. Monitor tech failed to notify the nurse a patient was off the monitor from 11:00 AM to 3:38 PM. 5. Staff failed to take measures necessary to ensure the telemetry monitor recorded a clear rhythm without artifacts for a patient scheduled for a pacemaker implantation. 6. Staff followed their own policy for patients who scored Moderate or above on the Suicide Risk Assessment. 7. The physical environment in the PHP was safe and free of ligature risks. 8. PHP patients did not have access to items to cause self harm. This affected 3 of 10 telemetry patient and 1 of 5 PHP medical records (MR) reviewed including Patient Identifier (PI) # 3, PI # 10, PI # 24, PI # 23 and had the potential to negatively affect all patients requiring telemetry monitoring. Findings include: Policy and Procedure Management of Medical/Surgical Patients on Telemetry Monitoring No. N-GN-PC-31-0718 Approved Date: 7/10/18 "Policy: B. Communication: 1. The monitor tech will promptly communicate non-life threatening rhythm problems/ changes to the nurse who is in charge of the patient alarm. 2. When patients are monitored from the central station outside of their home unit, the monitor tech will: b) The monitor tech will communicate rhythm problems, changes, time and reason patient is off monitor by phoning the assigned nurse of the patient and documenting these activities on the Communication and Activity Log. C. Patient Care: 5. All rhythm interpretations will be verified by an R.N. (Registered Nurse) and physician notified before treatment is initiated. A copy of all rhythms requiring treatment will be printed and placed in the patient's medical record at the time of occurrence. D. Documentation 1. Each patient will have a "Twenty-Four Hour Telemetry Report" labeled and dated each day he/she is on telemetry... 2. A continuation "Twenty-Four Hour Telemetry Report" is utilized to document changes in rhythm... 3. c) Abnormal rhythms and rhythm changes will be documented by running a monitor strip of the occurrence and placing the strip on the "Twenty-Four Hour Continuation Telemetry Report." Patient response and treatment of the abnormality will be documented in the nurses' notes." Policy: Suicide Risk Assessment Policy Number: PSY 051 Date Revised: 7/10/2018 "Policy ...Partial Hospitalization: Partial Hospital staff must complete the Suicide Risk Assessment on all partial hospital patients on day of admission and prior to discharge. Each day thereafter, the patient will complete the PHP Daily Check-In Form. In the event of a "yes" response to any one of the three (3) screening questions, a PHP Therapist will complete a Suicide Risk Assessment and notify the physician and document accordingly. Procedure: ...Moderate Risk Patients: ...Partial Hospitalization: Physician will be notified... Patient will be under direct observation until determination of disposition has been made. High Risk Patients: ...Partial Hospitalization: Physician will be notified and patient will be taken to the Emergency Department for further evaluation." 1. PI # 3 was admitted to the facility on 8/4/18 with diagnoses including Pulmonary Edema With Congestive Heart Failure with Preserved LV (left ventricular) Function and Shortness of Breath. During observation in the Central Monitoring Station on 8/6/18 from 8:45 AM to 11:30 AM the surveyor observed episodes of bigeminy (a cardiac rhythm in which each normal beat is followed by an abnormal one) and trigeminy (a cardiac arrhythmia in which the beats are grouped in trios, usually composed of 2 sinus beats followed by 1 abnormal one) on the monitor for Patient Identifier (PI) # 3. The surveyor asked Employee Identifier (EI) # 2, Monitor Tech assigned to PI # 3 at 9:50 AM, if abnormal rhythms were reported to the nurse. The answer was "only if it is different from their normal rhythm." At 9:53 AM on 8/6/18 EI # 2, made a phone call and reported PI # 3 was having bigeminy and trigeminy. EI # 2 then reported to the surveyor that PI # 3 was in CT (Computerized Tomography). The surveyor asked EI # 2 who was responsible for notifying CT of the abnormal rhythm and the answer was, "the nurse". The surveyor did not observe a strip being printed of the abnormal rhythm reported by EI # 2 at 9:53 AM. The surveyor asked EI # 2 if a rhythm strip was required to be printed when an abnormal cardiac rhythm was reported to the nurse. The answer was "No, we don't have to do that." The surveyor observed EI # 2 make a phone call at 10:14 AM on 8/6/18 and reported PI # 3 was having "some trigeminy." The surveyor asked what the response was and the answer was "the patient is still in CT." No rhythm strip was printed. At 10:35 AM on 8/6/18 the surveyor observed PI # 3 continued to have bigeminy and trigeminy on the monitor. No monitor strips were printed of the abnormal rhythms. Review of the Central Monitor Telemetry Disconnection / Event Log documentation dated 8/6/18 revealed at 9:53 AM the patient was "going to CT monitor stayed on". At 10:14 AM the nurse was notified "trigeminy". There was no signature or initials by each entry to identify who reported and documented the patient event. Review of the MR revealed no cardiac rhythm strips with bigeminy and trigeminy as observed and reported on 8/6/18. An interview was conducted on 8/7/18 at 4:30 PM with EI # 1, Administrative Director, Nursing, who confirmed the documentation on the Central Monitor Telemetry Disconnection / Event Log failed to identify who observed and reported the abnormal rhythms. Further review of the MR revealed a cardiovascular assessment by the nurse on 8/6/18 revealed the cardiac rhythm was normal sinus rhythm at 7:40 AM and at 12:00 PM. There was no documentation of a cardiovascular assessment by the nurse during the time of 8:45 AM to 10:35 AM on 8/6/18 when bigeminy and trigeminy rhythm had been observed by the surveyor and reported by the Monitor Tech to the nurse. There was no documentation the CT department was notified of the abnormal rhythm that occurred while PI # 3 was in CT on 8/6/18. Review of the cardiovascular nursing assessments on 8/6/18 revealed the cardiac rhythm was normal sinus rhythm at 16:53 (4:53 PM) and at 22:06 (10:06 PM). Review of nursing documentation dated 8/6/18 at 20:22 (8:22 PM) revealed the following: "It was reported to this nurse that the monitoring room stated patient had a 17 beat run of PVC's (premature ventricular contractions). EKG (electrocardiogram) completed and CVA (Cardiovascular Associates) paged x (times) 2. Orders received from (name of nurse practitioner) as follows: Potassium chloride 40 mEq (milliequivalents) PO (by mouth) now, BMP (basic metabolic profile) and mag (magnesium) in am. Orders read back and entered into Cerner (the Electronic medical record system)." Review of the EKG dated 8/6/18 at 19:34 (7:34 PM) revealed Sinus Rhythm with Occasional Ventricular Premature Complexes with Occasional Supraventricular Premature Complexes; Marked Left Axis Deviation; Low QRS Voltage in Precordial Leads; Possible Anterior Myocardial Infarction, Probably Old; Abnormal EKG. Review of the 24-Hour Telemetry Report rhythm strips revealed no documentation of the 17 beat run of PVC's as reported by central monitoring 8/6/18 at 8:22 PM. Further review of the Central Monitor Telemetry Disconnection / Event Log documentation dated 8/6/18 revealed the following: at 1903 (7:03 PM) Type of Event was "High PVC-18" and at 20:10 (8:10 PM) Type of Event was "frequent / Bigeminy PVCs" reported to the nurse. There was no signature or initials by each entry to identify who reported and documented the patient event. An interview was conducted 8/7/18 at 3:00 PM with EI # 1 who verified he/she was responsible for Central Telemetry Monitoring. The surveyor reviewed the MR documentation for PI # 3 regarding the 17 beat run of PVC's with EI # 1 and requested documentation of the reported rhythm. At 3:30 PM on 8/7/18 EI # 1 reported to the surveyor there was no documentation of the 17 beat run of PVC's. EI # 1 further stated he/she did not think the patient had a 17 beat run of PVC's and that this was an error. The surveyor asked EI # 1 if PI # 3 received interventions and medications based on an error? EI # 1 stated, "yes I think so." An interview was conducted on 8/7/18 at 4:00 PM with EI # 3, Registered Nurse assigned to PI # 3 on 8/6/18. EI # 3 was asked to describe the events on 8/6/18 regarding PI # 3's report of PVC's. EI # 3 stated the LPN (Licensed Practical Nurse) working with him/her on 8/6/18 came to him/her and reported the central monitoring room had called reporting the patient had a 17 beat run of PVC's. EI # 3 was asked what time this occurred and EI # 3 verified the documentation occurred at 8:22 PM on 8/6/18 and the event happened sometime between 7:00 PM and 7:30 PM on 8/6/18. EI # 3 stated he/she called for an EKG then called the on call staff for CVA who gave new orders for Potassium and labs. The surveyor asked EI # 3 if the nurses usually received a strip when the monitoring room called to report an abnormal rhythm. The answer was "no we don't get a strip of the abnormal rhythm." MR review revealed Potassium Chloride 40 mEq oral was administered 8/6/18 at 22:15 (10:15 PM) as ordered. An interview was conducted on 8/7/18 at 4:30 PM with EI # 5, Certified Registered Nurse Practitioner. EI # 5 verified he/she received a call concerning PI # 3 on 8/6/18 and the nurse reported the patient had a 17 beat run of PVC's. EI # 5 was asked if he/she was in the facility and viewed the rhythm strip or monitor and EI # 5 verified he/she not in the building. An interview was conducted on 8/7/18 at 6:25 PM with EI # 1. The surveyor reviewed the policy Management of Medical/Surgical Patients on Telemetry Monitoring with EI # 1 and asked EI # 1 to define "sustained bigeminy and sustained trigeminy". The answer was "when the rhythm is continuous". EI # 1 was asked if a rhythm strip would be run if a patient had bigeminy or trigeminy and the answer was "if it is not their regular rhythm, if it is a change from their normal." The surveyor reviewed with EI # 1, the section of the policy that read "abnormal rhythm strips will be documented by running a strip of the occurrence and placing the strip of the Twenty-Four Hour Continuation Telemetry Report." EI # 1 was asked if the monitoring process would reveal if abnormal strips were not run for the medical record and the answer was "no, the audit form does not ask about rhythm strips." 22965 2. PI # 10 was admitted to the hospital on 7/31/18 with the diagnoses including Dyspnea, Etiology Unknown, Newly Diagnosed Congestive Heart Failure and Hypertensive Emergency. Review of the Physician's Orders dated 8/1/18 at 11:45 AM revealed the order for Routine Telemetry. Review of the Nursing/ Clinical Information Note dated 8/4/18 at 3:38 PM revealed documentation from the RN assigned to the patient on Medical Floor 3 West as "Charge Nurse from Telemetry just came to the floor and notified me that the patient has been off the monitor since 11:00 AM. I was never made aware of this. I did receive a phone call about 15 minutes before, to replace the battery in the same patient." Review of the Telemetry Disconnection/ Event Log dated 8/4/18 from 7:00 AM to 7:00 PM revealed no documentation the Monitor Tech observed and/ or documented the patient was off telemetry from 11:00 AM to 3:38 PM. An interview was conducted with EI # 1 who confirmed the above mentioned findings. 3. PI # 24 was admitted to the hospital on 8/2/18 with the primary diagnosis of New Onset Atrial Fibrillation With Orthostatic Hypotension. An observation was conducted on 8/6/18 at 9:15 AM at the telemetry Central Monitoring Unit, the surveyor was interviewing EI # 7, Monitor Tech. The surveyor observed PI # 24's telemetry monitor was not showing clear rhythm with occasional artifacts, this was also noticed by EI # 7 who commented "yes" they were artifacts had been showing up on the telemonitoring screen on and off since the start of her/ his shift. EI # 7 further stated the Telemetry Resource RN assigned to the Telemetry Room just changed the patient's telemetry box and lead/ wires. EI #7 further stated the 7 PM to 7 AM shift Monitor Tech had the same problem during the shift and had the leads/ wires changed. The surveyor asked EI # 7 what would be the process to make sure the patient is "ok". EI # 7 stated that she either would call the patient's nurse or ask the Telemetry Resource RN to check PI # 24. At 9:45 AM, the artifact rhythm was showing up more frequent on the telemetry screen. The surveyor asked EI # 7, what should she/ he do when the "artifacts" are more frequent than earlier. EI # 7 did not answer the surveyor. After a few minutes EI # 7 asked EI # 8, Telemetry Resource RN to check on PI # 24. EI # 8 stated that she/ he just changed the telemetry box and leads earlier that morning and further stated that PI # 24 maybe moving around or laying on one of the leads/ wires No telemetry staff checked on the PI # 24, nor was PI # 24 nurse notified. At 10:45 AM, the patient telemetry rhythm was still showing artifacts with sinus rhythm and periods of sinus bradycardia (abnormally slow heart rate). The surveyor asked EI # 7 what should she/ he do in this situation when the telemonitoring rhythm was showing artifacts and not the patient cardiac rhythm, EI # 7 initially did not answer the surveyor then after a few minutes asked EI # 8 to check on the patient. When EI # 8 came back into the Telemetry Room, she/ he stated PI # 24 was not laying on the leads/ wires and no other assessment or intervention was implemented. At 11:15 AM, the patient telemetry rhythm was showing more artifacts and no rhythm for PI # 24. The surveyor asked EI # 7, again what she/ he should do in this case. EI # 7 answered "I guess we need to move the patient to another room since we have changed the telemetry box and leads/ wires ". EI # 7 then asked EI # 8 to talk to the patient's nurse and proceed with the move. At 11:30 AM patient was moved to another room and after 15 minutes, the patient's telemetry screen was showing a normal sinus rhythm/ occasional sinus bradycardia without artifacts. At 11:35 AM, EI # 8 informed the surveyor the floor nurse will be sending a work order request to have the telemetry antenna checked by Biomedical Technician in the room PI # 24 was having artifacts. Review of the Every 4 hours Rhythm strips print out revealed the artifacts were captured one time only, which was on 8/6/18 at 11:15 AM. Review of the Telemetry Disconnection/ Event Log dated 8/6/18 revealed EI # 7 failed to document the persistent appearance of artifacts during the events. The last Event Notification was documented at 8:45 AM when the telemetry box and wires were changed. An interview was conducted on 8/7/18 at 3:30 PM with EI # 1 who confirmed the above mentioned findings. At 5:15 PM on 8/7/18, EI # 1 presented the surveyor a copy of the patient surgical procedures dated 8/6/18. PI # 24 underwent a Dual- Chamber Pacemaker Implantation due to Sick Sinus Rhythm, Paroxysmal Atrial Fibrillation, Post Operative and Near Syncope. 4. During an observation of care conducted on 8/7/18 at 5:15 AM in the Telemetry Central Monitoring Room, the surveyor asked EI # 9, Monitor Tech what types of abnormal rhythm are reported to the patient's RN. EI # 9 stated that runs of 10, bigeminy/ trigeminy, bradycardia, etc. EI # 9 further stated that when the patient's monitor shows runs of abnormal rhythm, she/ he picks up the telephone and calls the patient's nurse. If the patient's nurse does not answer, she then calls the charge nurse and/or ask the Telemetry Resource RN, who is assigned in the Telemetry Room with her/him to check on the patient. The surveyor asked EI # 9 if and when does she/he print out the abnormal rhythm. EI # 9 stated that she/he prints out the history under Full Disclosure to catch the abnormal rhythm but not during the actual run of the abnormal rhythm. EI # 9 further stated that she/ he takes the Every 4 hour rhythm strips form and Full Disclosure form to the floor/ unit where the patient is located. An interview was conducted on 8/7/18 at 4:30 PM with EI # 1, who confirmed the above mentioned findings. 39098 5. PI # 23 was admitted to the PHP on 8/1/18 with diagnoses including Major Depressive Disorder, and Generalized Anxiety Disorder. Review of the Initial Treatment Plan dated 8/1/18 included monitor for safety and symptoms, and provide group, milieu, and individual therapy. Review of the PHP Interdisciplinary Care Plan dated 7/30/18 (date of intake assessment) included Safety: Thoughts of harm to self or suicidal ideation, and Psychiatric Symptoms: Depression, Anxiety, SI (Suicidal Ideations), and Anger. Review of the PHP Daily Check-In form dated 8/2/18 at 9:30 AM, revealed the patient checked "yes" to one of the three suicide screen questions on the form. A Suicide Risk Assessment (SRA) dated 8/2/18 at 10:05 AM, was documented by Employee Identifier (EI) # 6, Clinical Therapist (CT). The documented SRA score was 35 in the High Risk category. EI # 6 documented the following narrative in the CT notes dated 8/2/18: "...Patient presents agitated... Patient verbalized having passive thoughts of SI, with a vague plan to smother himself/ herself or drink himself/ herself to death. He/she reports frustration with anxiety and treatment team. Patient was difficult to redirect and amplified anger towards his/her peers in treatment program and staff. Patient is a high risk for suicide and refused to report to ER (Emergency Room) per policy. Clinical therapist notified manager and medical director. Manager unavailable and MD (Medical Doctor) could not be reached. Other staff were occupied and could not stay with patient. Patient verbally contracted for safety. No other staff was available to assist. Due to patient's irritability, clinical judgement was used to keep patient isolated from other patients. Patient was left in group room alone. All objects that could be used as a weapon were removed from the room..." A tour of the PHP was conducted on 8/6/18 at 8:50 AM which included the group room where the patient was placed and left alone. The following items were observed in the room: a. 2 large windows covered with mini blinds, cords hanging the length of window, ligature risk. b. Garbage can with plastic garbage bag. c. Metal coat hook, non collapsible, mounted on the inside of the door. d. Picture hanging on wall, not secured. e. 5 chairs and one round table, unsecured. f. A black cabinet with doors standing on floor, not secured to wall. g. 2 ceramic flower pots setting by window. An interview was conducted on 8/7/18 at 7:00 PM, with EI # 5, RN (Registered Nurse), Administrative Director, who stated if a patient scores Moderate or higher on the SRA, the patient would never be left alone, according to policy. During a phone interview conducted on 8/8/18 at 9:40 AM with EI # 6, it was confirmed on 8/2/18 she/he first left the patient alone for 10 minutes, to check on the other patients in the PHP. At approximately 10:24 AM, EI # 6 stated she/he left PI # 23 alone for the second time with some activities to do, and went back to conduct group therapy with the other patients. At 11:05 AM, the office coordinator notified EI # 6 that PI # 23 was wanting to leave. EI # 6 stated she/he gave the patient a popsicle and talked with him/her until 11:25 AM. EI # 6 returned to group therapy and left the patient alone for the third time. EI # 6 stated at 11:50 AM she/he heard EI # 10, CT, Patient Relations Manager, in the hallway going to talk with the patient. EI # 6 verified PI # 23 was left alone in the group room on 8/2/18. EI # 6 stated EI # 10 contacted the MD at approximately 12:00 PM. A progress note dated 8/2/18 at 3:04 PM written by EI # 10, revealed the following documentation, "...Since he/she was refusing to go to the ER (Emergency Room), high SRA, and current intense symptoms, the physician recommends filing a petition." At 1:15 PM the patient was escorted by EI # 10 and an employee from the inpatient hospital facility, to the hospital for inpatient admission. During an interview on 8/8/18 at 12:12 PM with EI # 5, the above findings were confirmed. | ||||||||||
70 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 3 | A0392 | Staffing And Delivery Of Care | 482.23(b) | Standard of Participation | Y | Joint Commission | 36271 22965 Based on reviews of the facility's policies and procedures, medical records (MR) and interview, it was determined the staff failed to failed to ensure: 1. Each patient on telemetry with a run of arrhythmias had a print out of the Full Disclosure form signed by two (2) Registered Nurse (RN). 2. Patient being transported to another department will have an accurate, complete and up-to date Ticket to Ride form. This affected 2 of 10 MRs reviewed and did affect MR # 7 and. This had the potential to affect all telemetry patients. Findings include: Title: Management of Medical/ Surgical Patients on Telemetry Monitoring Number: N-GN- PC- 31-0918 Medical Approval Date: 09/04/2018 Purpose: The purpose of this policy is to provide guidelines for management of patients requiring telemetry monitoring. Procedure: C. Patient Care for Alarm/ Arrhythmia Alarm / Arrhythmia - Critical Alarms: Asystole, Ventricular Fibrillation, Ventricular Tachycardia greater (>) fifteen (15) seconds. Monitor Technician Responsibilities - Documentation: Print Full Disclosure/ Log event in Telemetry Event Log Sheet. RN Responsibilities - Documentation: Review, sign/ date and time Full Disclosure/ Place on Chart/ Document the Notification to Physician/ Document description of event and interventions in the chart. Warning Alarms - Limits Outside Default or Physician ordered parameters/ Heart rate less than 50 beats per minutes (bpm) or > 140 bpm as determined by physician orders/ Bigeminy > 30 seconds/ Trigeminy > 30 seconds/ Any rhythm change outside of patient's baseline (even if no alarm is triggered). Monitor Technician Responsibilities - Documentation: Print Fill Disclosure/ Log event in Telemetry Event Log Sheet, RN Responsibilities - Documentation: Review sign/ date and time Full Disclosure/ Place in chart/ Document in Notification to Physician/ Document description of Event and interventions on the note. D. RN Shift Documentation 3. The RN will review/ communicate rhythm strip data during shift report. In- coming and off- going nurse will co-sign the 12 hour telemetry report. ***** Policy Name: Ticket to Ride Policy Number: A-RM- 20-0918 Approved: 09/11/18 Purpose: To provide accurate up-to date information about a patient's care when traveling away from their primary nurse that will promote a culture of safety. Policy: 2. The Ticket To Ride will be completed in its entirety for any patient being transported within the hospital unless the nurse/ technician is accompanying the patient during the transport and remaining with the patient. If the nurse transports but does not remain with the patient, the Ticket To Ride must be filled out and used as hand off to the receiver. 3. A report from the nurse to the transporting personnel is required and a verbal hand off will take place with time allowed for questions. ... Each hand off requires the signature of the nurse and the transporter Documentation: The Ticket To Ride should be placed in the hard chart and will be part of the medical record. 1. MR # 7 was admitted to the hospital on 9/10/18 with diagnoses including Perforated Diverticulitis Status Post Sigmoid Colectomy and End Colostomy and Paroxysmal Atrial Fibrillation. Review of the MR on 9/25/18 at 2:00 PM revealed the Full Disclosure telemetry form dated 9/11/18 at 2:42 AM did not contain the signature of the outgoing RN and the incoming RN. An interview was conducted on 9/26/18 at 9:45 AM with Employee Identifier (EI) # 1, Vice President of Regulatory Compliance who confirmed the aforementioned findings. 2. MR # 10 was admitted to the hospital on 9/10/18 with diagnoses including Sepsis and Left Lower Extremity Ischemia. Review of the Ticket to Ride form dated 9/14/18 at 2:25 PM revealed the transporter failed to sign his/ her section under the departure section. Further review of the Ticket to Ride form dated 9/14/18 at 2:25 PM revealed the nurse and the transporter failed to document the date and time the patient returned. An interview with EI # 1 conducted on 9/26/18 at 9:35 AM who confirmed the staff failed to follow newly revised policy and procedures. 39098 | ||||||||||
71 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 1 | A0449 | Content Of Record | 482.24(c) | Standard of Participation | 09/26/2018 | Y | Joint Commission | 39098 Based on review of the medical record (MR), PHP (Partial Hospitalization Program) Chart Audit Form and interview with staff, it was determined the facility failed to ensure the Clinical Therapist completed the PHP Biopsychosocial Assessment intake form, and accurately completed the PHP Interdisciplinary Care Plan, for 1 of 1 record reviewed with elopement and suicide. This had the potential to affect all patients served by the facility, and did affect Patient Identifier (PI) # 3. Findings include: PHP Chart Audit Date Approved: None Listed "...Treatment Plan: Completed by physician: Date/Initials Completed by therapist: Date/Initials... Therapist: Assessment Completed: Date/Initials SRA (Suicide Risk Assessment) at admission: Date/Initials Initial Certification: Date/Initials Therapy Notes Dated and Signed: Date/Initials..." ***** 1. PI # 3 was admitted to the PHP on 1/22/18 with diagnoses including Bipolar Disorder, and most recent episode Depressed. Review of the MR revealed an intake appointment on 1/19/18. Review of the PHP Biopsychosocial Assessment dated 1/19/18 was completed by Employee Identifier (EI) # 15, Clinical Therapist. Demographic Information included: "60 yr (year) old seeking tx (treatment) for Depression, SI (Suicidal Ideations), and Anxiety." Review of the assessment revealed no documented work history listed under category of Educational, Vocational, and Occupational History. Additional instructions listed on form: "Include highest education level completed, work history." PI # 3 is listed as retired on the Hospital Information page. Further review of Page 2 of the assessment revealed the Mental Status Examination is left blank. Included in this section was Affect (Blunted, Flat, Labile, Restricted, Appropriate), Orientation (Person, Place, Time), Demeanor (Cooperative, Uncooperative, Optimistic, Pessimistic, Suspicious, Fearful, Other: ), Hallucinations ( None, Auditory, Visual, Olfactory, Somatic, Tactile), and Delusions (None, Grandiose, Of Reference, Somatic, Tactile, Thought Broadcasting, Thought Insertion). Under the category of "Capacity for Self-Harm," EI # 15 documented "Yes. Pt (patient) verbally contracts for safety." Under the category of "Deficits in Activities of Daily Living," EI # 15 documented "Pt not able to function due to worry (Anxiety, Depression, SI)." Review of the PHP Interdisciplinary Care Plan dated 1/19/18, revealed EI # 15 drew a line threw "Safety: ...Thoughts of harm to self or suicidal ideation..." and did not include Safety in the Plan of Care. This contradicts above documentation by EI # 15. An interview conducted on 7/10/18 at 9:30 AM with EI # 18, PHP Patient Relations Manager, confirmed the above findings. | |||||||||
72 | 010139 | BROOKWOOD BAPTIST MEDICAL CENTER | 2010 BROOKWOOD MEDICAL CENTER DRIVE | BIRMINGHAM | AL | 35209 | 07/12/2018 | Complaint Investigation | 2 | A0449 | Content Of Record | 482.24(c) | Standard of Participation | 09/26/2018 | Y | Joint Commission | 39098 Based on medical record (MR) reviews, policies, and interview with staff, it was determined the hospital failed to ensure: 1. Staff in the PHP (Partial Hospitalization Program) completed the Suicide Risk Assessment (SRA) to include Observation Level of a patient scoring High Risk for suicide. 2. Staff followed policy and procedure for making corrections to the MR. 3. Patient information was filed in the correct MR. 4. Monitor Techs failed to print abnormal rhythm strips according to facility policy. This affected 3 of 5 medical records reviewed in the PHP, and did affect Patient Identifier (PI) # 23, PI # 13, 1 unsampled patient, and PI # 16. This also affected 1 of 10 records review with telemetry monitoring, which included PI # 3. This had the potential to affect all patients served by the hospital. Findings include: Policy: Suicide Risk Assessment Policy Number: PSY 051 Date Revised: 7/10/2018 "Policy ...Partial Hospitalization: Partial Hospital staff must complete the Suicide Risk Assessment on all partial hospital patients on day of admission and prior to discharge. Each day thereafter, the patient will complete the PHP Daily Check-In Form. In the event of a "yes" response to any one of the three (3) screening questions, a PHP Therapist will complete a Suicide Risk Assessment and notify the physician and document accordingly. Procedure: ...Moderate Risk Patients: ...Partial Hospitalization: Physician will be notified... Patient will be under direct observation until determination of disposition has been made. High Risk Patients: ...Partial Hospitalization: Physician will be notified and patient will be taken to the Emergency Department for further evaluation." Policy: General Guidelines for Medical Records Date Reviewed: 03/18 "...II. Purpose: To set forth guidelines for hospital medical records. ...IV. Procedure: A. Every patient who enters the hospital for treatment has a record that includes identification date, history and physical examination by the attending physician,...reports... G. Corrections to the (paper) Medical Record 1. Do Not: ...c) Completely obliterate the error. 2. Do: a) Draw a line through the error. b) Write in the correction (if any). c) Initial, date and time..." Policy and Procedure Management of Medical/Surgical Patients on Telemetry Monitoring No. N-GN-PC-31-0718 Approved Date: 7/10/18 "Policy: D. Documentation 3. c) Abnormal rhythms and rhythm changes will be documented by running a monitor strip of the occurrence and placing the strip on the "Twenty-Four Hour Continuation Telemetry Report." Patient response and treatment of the abnormality will be documented in the nurses' notes." 1. PI # 23 was admitted to the PHP on 8/1/18 with diagnoses including Major Depressive Disorder, and Generalized Anxiety Disorder. Review of the SRA dated 8/2/18 at 10:05 AM revealed the SRA score of 35, High Risk. There was no documentation of the Observation Level performed on the patient, as this was left blank. An interview was conducted on 8/7/18 at 7:10 PM with Employee Identifier (EI) # 5, Registered Nurse (RN), Administrative Director, who confirmed any patient scoring Moderate or above on the SRA would be under direct observation at all times and verified the above findings. 2. PI # 13 was admitted to the PHP on 7/31/18 with diagnoses including Anxiety and Depression. Review of the PHP Daily Check-In form dated 8/3/18, revealed the patient's "yes" answer to question number one had a line drawn through it, and a different type of check mark was placed beside "no." There was no date, time, or initials beside the correction. An interview was conducted on 8/7/18 at 7:10 PM with EI # 5, who confirmed the hospital has no way of knowing who made the correction to the MR. 3. During review of the audited records, an unsampled patient's PHP Daily Check-In form was reviewed. The patient's answer to question number 3 was "yes." The check mark was scribbled over, and a different kind of check mark was placed beside "no." An interview was conducted on 8/7/18 at 7:10 PM with EI # 5, who confirmed the hospital has no way of knowing who made the correction to the MR. 4. PI # 16 was admitted to the PHP on 8/1/18 with diagnoses including Suicidal and Major Depression. Review of the MR revealed a Psychiatry History and Physical with another patient's name and MR number, but contained the sticker and barcode of PI # 16. Further review of the MR revealed a second different patient's name and MR number on 8 pages of information, including a referral note, discharge record and clinical summary, but contained the sticker and barcode of PI # 16. An interview was conducted on 8/7/18 at 7:10 PM with EI # 5, who confirmed PI # 16's MR contained the information of 3 different patients. 17650 5. PI # 3 was admitted to the facility on 8/4/18 with diagnoses including Pulmonary Edema With Congestive Heart Failure with Preserved LV (left ventricular) Function and Shortness of Breath. During observation in the Central Monitoring Station on 8/6/18 from 8:45 AM to 11:30 AM the surveyor observed episodes of bigeminy (a cardiac rhythm in which each normal beat is followed by an abnormal one) and trigeminy (a cardiac arrhythmia in which the beats are grouped in trios, usually composed of 2 sinus beats followed by 1 abnormal one) on the monitor for Patient Identifier (PI) # 3. The surveyor did not observe a strip being printed of the abnormal rhythm. The surveyor asked EI # 2 if a rhythm strip was required to be printed when an abnormal cardiac rhythm was reported to the nurse. The answer was "No, we don't have to do that." The surveyor observed EI # 2 make a phone call at 10:14 AM on 8/6/18 and reported PI # 3 was having "some trigeminy." The surveyor asked what the response was and the answer was "the patient is in CT." No rhythm strip was printed. At 10:35 AM on 8/6/18 the surveyor observed PI # 3 continued to have bigeminy and trigeminy on the monitor. No monitor strips were printed of the abnormal rhythms. Further review of the Central Monitor Telemetry Disconnection / Event Log documentation dated 8/6/18 revealed the following: at 1903 (7:03 PM) Type of Event was "High PVC (premature ventricular contractions) -18" and at 20:10 (8:10 PM) Type of Event was "frequent / Bigeminy PVCs" reported to the nurse. There was no signature or initials by each entry to identify who reported and documented the patient event. An interview was conducted on 8/7/18 at 6:25 PM with EI # 1, Administrative Director, Nursing. EI # 1 was asked if a rhythm strip would be run if a patient had bigeminy or trigeminy and the answer was "if it is not their regular rhythm, if it is a change from their normal." | |||||||||
73 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | 0 | Initial Comments | Memo Tag | N | Not Deemed | 22965 Based on the recertification survey conducted at Evergreen Medical Center on 10/4/18, it was determine the facility failed to: a) provide initial or annual training to all the employees for emergency preparedness. b) document facility staff participation in a table top exercise and a community-based exercise. This deficient practice affected all the staff the facility employed. An interview was conducted on 10.4.18 at 12:00 PM with Employee Identifier (EI) # 1, Chief Operations Officer who confirmed the above mentioned findings. 22965 A recertification survey was conducted on 10/4/18 at Evergreen Medical Center resulting in a condition level deficiency and standard level deficiencies. 482-51 -Condition of Participation - Surgical Services | |||||||||||
74 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | A0169 | Patient Rights: Restraint Or Seclusion | 482.13(e)(6) | Standard of Participation | 11/21/2018 | N | Not Deemed | 22965 Based on review of the facility's policy and procedures, medical record (MR) and an interview it was determined physician's order was not appropriately written according the hospital policy that affected Patient Identifier (PI) # 23. This affected 1 of 1 records reviewed for restraints and had the potential to affect all patients served. Findings include: Subject: Use of Restraints Reviewed: 05/11 Purpose: ...This facility creates and environment that helps hospital staff focus on the patient's well being. Our goal is an organization- wide approach to restraints that protects the patient's health and safety and preserves his or her dignity, rights and well being. This facility ensures that restraint interventions are safely and appropriately used.... V. Procedures E. Orders for Restraints Written or verbal orders for initial and continuing use of restraints are time limited. i) ... Physicians ordering restraint must have a working knowledge of hospital policy regarding restraint a) Be for each use of the restraints and related to a specific episode of the patien's behavior and not for unspecified future time or episode. ... 1. PI # 23 was admitted through the Emergency Department of the hospital on 3/29/18 with the diagnosis of Increased Agitation, Hallucination and Altered Mental Status. Review of the Physician's Order dated 3/29/18 at 8:45 PM revealed the following order: Chemical Restraint and Physical Restraint for patient safety. May use 4 point/ Vest Posey restraints as (PRN) needed for patient and staff safety. May administer Ativan 1 mg. (milligram), Benadryl 50 mg. and Haldol 5 mg IM (intramuscular) x 1 dose PRN An interview was conducted with Employee Identifier (EI) # 2, Director of Nursing on 10/4/18 at 11:00 AM confirmed the staff failed to follow facility's policy and procedures. | |||||||||
75 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | A0175 | Patient Rights: Restraint Or Seclusion | 482.13(e)(10) | Standard of Participation | 11/21/2018 | N | Not Deemed | 22965 Based on review of the facility's policy and procedures, medical record (MR) and a interview it was determined the staff failed to monitor Patient Identifier (PI) # 23 while placed in a 4 (four) point Vest Posey jacket,. This affected 1 of 1 records reviewed for restraints and had the potential to affect all patients served. Findings include: Subject: Use of Restraints Reviewed: 05/11 Purpose: ...This facility creates and environment that helps hospital staff focus on the patient's well being. Our goal is an organization- wide approach to restraints that protects the patient's health and safety and preserves his or her dignity, rights and well being. This facility ensures that restraint interventions are safely and appropriately used.... IV. Policy: iv) Monitor and meet the patient's needs while in restraints. v) Reassess and encourage the release of restraints as soon as possible V. Procedures: E. Orders for Restraints iv) ... Standing or PRN (As needed) orders for restraints are not acceptable. viii) Content of Individual Orders: Time limited. F. Periodically Assessing, Assisting And Monitoring The Patient In Restraint ii) A Registered Nurse must assess the patient at established timeframes. Assessment, as appropriate to the type of restraint includes: nutrition/ hydration circulation and range of motion in the extremities iii) Care provided at least every 2 (two) hours to include: offer fluids/ nourishment hygiene care as required toileting as required release of extremities and range of motion exercises provided. iii) Documentation Each episode of restraint is documented in the patient's medical record on the Restraint Flowsheet, consistent with policies and procedures. vii) All assessments and monitoring of the patient. viii) Patients response to the intervention, including the rationale for continued use of the intervention. 1. PI # 23 was admitted through the Emergency Department of the hospital on 3/29/18 with the diagnosis of Increased Agitation, Hallucination and Altered Mental Status. Review of the Physician's Order dated 3/29/18 at 8:45 PM revealed the following order: Chemical Restraint and Physical Restraint for patient safety. May use 4 point/ Vest Posey restraints as (PRN) needed for patient and staff safety. May administer Ativan 1 mg. (milligram), Benadryl 50 mg. and Haldol 5 mg IM (intramuscular) x 1 dose PRN. Review of the Registered Nurse (RN) Initial Interview Form dated 3/29/18 at 10:51 PM and Daily Nursing Assessment dated 3/3018 at 9:40 AM revealed there was no documented care and assessment provided to the patient every 2 hours to include reassessment of the restraints and physical needs of the patient such as hydration. An interview was conducted with Employee Identifier (EI) # 2, Director of Nursing on 10/4/18 at 11:00 AM confirmed the staff failed to follow facility's policy and procedures. | |||||||||
76 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | A0395 | Rn Supervision Of Nursing Care | 482.23(b)(3) | Standard of Participation | 11/21/2018 | N | Not Deemed | 22965 Based on record review, interview and hospital policy the nursing staff failed to assess and document wounds, document specific wound care that was provided and follow physician orders for wound care. This affected Patient Identifier (PI) # 21, 1 of 1 wound care chart reviewed. Findings include: Subject: Wound Care Revised 01/16 Policy It is the policy of Evergreen Medical Center to evaluate patient with a wound on admission or that develops after admission and obtain treatment orders from the physician. All treatment will be documented in the Electronic Health Record. Procedure 1. The following information will be evaluated and documented by the nurse a. Location of the wound b. Stage if a decubitus and ... c. Dimensions (Length x Width x Depth) in centimeters. Length being head to toe and width being side to side. ... 3. If when nursing is performing the dressing change and a worsening of the wound is noted, the physician should be notified for changes in treatment. 1. PI # 21 was admitted on 5/25/18 with the primary diagnosis of Diabetic Foot Ulcer. Review of the Physician's Order Sheet 5/25/18 revealed wound care order as follows: Wet to dry dressing to foot every 12 hours. Review of the Admission Nursing Admission dated 5/25/18 at 8:15 AM, 8:50 PM, revealed the Registered Nurse (RN) failed to document the wound depth and wound care dressing as ordered by the physician. Review of the Daily Nursing Assessments dated and 5/26/18 at 8:45 AM and 9:00 PM, 5/27/18 at 8:18 AM and 9:45 PM, 5/28/18 at 9:34 AM, 5/29/18 at 9:33 AM and 10:54 PM, 5/30/18 at 10:45 AM and 10:03 PM, 5/31/18 at 10:14 AM and 9:30 PM, 6/1/18 at 7:48 AM and 11:16 PM, 6/2/18 at 7:50 AM revealed the RN failed to assess, perform and document wound care every 12 hours according to the physician's orders. An interview was conducted on 10/14/18 at 11:10AM with Employee Identifier (EI) # 2, Director of Nursing who confirmed the above mentioned findings. | |||||||||
77 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | A0438 | Form And Retention Of Records | 482.24(b) | Standard of Participation | 11/21/2018 | N | Not Deemed | 39098 Based on review of medical records (MR), policy, and interview with staff it was determined the hospital failed to ensure: a) Physician's signatures included the date and time. b) Consents for Anesthesia Services contained date and time signed by witnesses, including the RN (Registered Nurse) and CRNA (Certified Registered Nurse Anesthetist) signatures. This affected 6 of 6 surgery records reviewed and did affect Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 4, PI # 5, PI # 6 and had the potential to affect all patients served by the hospital. Finding include: Policy: Medical Staff Policies and Procedures Date Approved: 2/8/18 "...Medical Records ...6.) Clinical Entries All clinical entries in the patient's medical record should be accurately dated, timed, and signed." ***** 1. PI # 1 was admitted to the hospital on 5/23/18 with a diagnosis of Chronic Tonsillitis. The patient was scheduled for a Tonsillectomy on 5/23/18. Review of the MR revealed a H&P dated 3/28/18. The electronic physician's signature contained no date or time. Review of the MR revealed an Operative Procedure note dated 5/23/18. The electronic physician's signature contained no date or time. Review of the Consent for Anesthesia Services form dated 5/23/18 contained no date and time the form was witnessed by the RN and CRNA. During an interview conducted on 10/4/18 at 10:24 AM with Employee Identifier # 3, Operating Room (OR) Supervisor, the above findings were confirmed. 2. PI # 2 was admitted to the hospital on 6/4/18 with the diagnosis of Recent Gastric Ulcer, and scheduled for a Esophagogastroduodenoscopy (EGD). Review of the MR revealed a Surgical Consultation dated 5/9/18. The electronic physician's signature contained no date or time. Review of the MR revealed an Operative Procedure note dated 6/4/18. The electronic physician's signature contained no date or time. During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed. 3. PI # 3 was admitted to the hospital on 6/11/18 for a Screening Colonoscopy. Review of the MR revealed a H&P dated 5/30/18. The electronic physician's signature contained no date or time. Review of the MR revealed an Operative Procedure note dated 6/11/18. The electronic physician's signature contained no date or time. During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed. 4. PI # 4 was admitted to the hospital on 7/16/18 with the diagnosis of Chronic Osteomyelitis with Exposed Bone Left Great Toe and Left Second Toe. The patient was scheduled for amputation of left great toe and left second toe. Review of the MR revealed a H&P dated 7/2/18. The electronic physician's signature contained no date or time. Review of the MR revealed an Operative Procedure note dated 7/16/18. The electronic physician's signature contained no date or time. During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed. 5. PI # 5 was admitted to the hospital on 7/23/18 with diagnoses including Symptomatic Cholelithiasis, and Abscess Left Groin. The patient was scheduled for a Laparoscopic Cholecystectomy and I (Incision) and D (Drainage) Abscess Left Groin. A review of the MR revealed a H&P dated 7/11/18. The electronic physician's signature contained no date or time. Review of the MR revealed an Operative Procedure note dated 7/23/18. The electronic physician's signature contained no date or time. Review of the Consent for Anesthesia Services form dated 7/23/18 contained no date and time the form was witnessed by the RN and CRNA. During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed. 6. PI # 6 was admitted to the hospital on 7/9/18 with the diagnosis of Right Inguinal Hernia. The patient was scheduled for a Right Inguinal Hernia Repair with Mesh. A review of the MR revealed a H&P dated 6/25/18. The electronic physician's signature contained no date or time. Review of the MR revealed an Operative Procedure note dated 7/9/18. The electronic physician's signature contained no date or time. During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed. | |||||||||
78 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | A0505 | Unusable Drugs Not Used | 482.25(b)(3) | Standard of Participation | 11/21/2018 | N | Not Deemed | 40119 Based on review of the facility's policies, observations, and interviews it was determined the facility failed to ensure 1. All expired medications were removed and not available for patient use. 2. All medications available for patient use were correctly labeled according to facility policy. This had the potential to negatively affect all patients served by this facility. Findings include: Policy: Medication Area Review Subject: Medication Area Review Policy Revised Date: 1/2018 Policy: "The director of pharmacy or his qualified designee shall inspect all areas where medications are administered or stored. This shall be done monthly. A report shall be prepared and shall include,.... 4. Labeling 5. Out-dated, discontinued, recalled, and unusable drugs..." Policy: Licenses, Privileges, and Medications Subject: Medication-Who May Dispense Revised Date: 8/15/18 Policy: "Labeling requirements: Name of medications, Strength, Preparation Date, Expiration Date, Preparer's Name, Lot Number" 1. A tour of the facility pharmacy was conducted on 10/3/18 at 9:45 AM with Employee Identifier (EI) # 9, Pharmacy Director. The surveyor observed the following medications on the pharmacy shelves and available for patient use: Bottle labeled as Ferrous Sulfate Elixir with no documentation of the strength, preparation date, expiration date, preparer's name, or lot number. Bottle labeled as Rynex DM 5 ml (milliliter) UD (unit dose) elixir with no documentation of the preparation date, expiration date, preparer's name, or lot number. Bottle labeled as Hydroxyzine 10 mg (milligrams)/5 ml with no documentation of the preparation date, expiration date, preparer's name, or lot number. Bottle labeled as Cypropheptadine Syrup 2 mg/ 5 ml 60 ml bottle with no documentation of the preparation date, expiration date, preparer's name, or lot number. Bottle labeled as Rondec DM with no documentation of the strength, preparation date, expiration date, preparer's name, or lot number. Levetiracetam 100 mg/ ml with documented expiration date of 2/18. Medroxy-progesterone Acetate 10 mg tablet with documented expiration date of 9/18. Provera 10 mg tablets x (times) 9 tablets with documented expiration date of 9/18. The previous findings were verified by EI # 9, prior to surveyor leaving pharmacy. 2. A tour of the facility Emergency Department was conducted on 10/3/18 at 1:00 PM with EI # 6, Registered Nurse (RN). The surveyor observed the following medications in the Pyxis (medication dispensing system) and available for patient use: Bottle labeled as GI (Gastrointestinal) Cocktail (Mylanta 10 oz (ounce), Bentyl 4 oz, Viscous Lidocaine 2 oz) 1 dose equal to 30 ml with no documented expiration date. Hydrogen Peroxide 3 % (percent) with documented expiration date of 3/18. 25 % Mannitol 250 mg / ml x 2 vials with documented expiration date of 10/1/18. Haloperidol Injection IM (Intramuscular) 1 ml (5 mg) x 3 ampule's with documented expiration date of 3/13. 5 % Dextrose Injection 1000 ml with documented expiration date of 8/18. EI # 6 confirmed the expiration dates prior to surveyor leaving the Emergency Department. An interview was conducted on 10/3/18 at 2:30 PM with EI # 2, Director of Nursing, who verified the previous findings. | |||||||||
79 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | A0592 | Potentially Infectious Blood/Blood Products | 482.27(b) | Standard of Participation | 11/21/2018 | N | Not Deemed | 40119 Based on policy review and interview with Employee Identifier (EI) # 10, Laboratory Director, it was determined the facility failed to ensure a system was in place to take appropriate action when notified that blood or blood components it received are at increased risk of transmitting Human Immunodeficiency virus (HIV) or Hepatitis C Virus (HCV). This had the potential to negatively affect all patients receiving blood or blood products. Review of the policy and procedure book on 10/3/18 at 10:45 AM revealed there was no policy or procedure available for identifying the correct procedure for dealing with Infectious Blood and Blood Products. On 10/3/18 at 1:45 PM, EI # 10 gave surveyor a copy of "Policy and Procedure for Quarantine of Blood Product(s)" for facility. Review of the facility Policy and Procedure for Quarantine of Blood Product (s) revealed no documentation of the date policy and procedure was reviewed and accepted by the facility. The Surveryor asked EI # 10, for documentation of when the Policy and Procedure for Quarantine of Blood Products (s) was reviewed and accepted by the facility. EI # 10 then verbalized that the policy and procedure was created on 10/3/18 and did not have a signature(s) for the acceptance of the policy and procedure to the facility. An interview was conducted on 10/4/18 at 7:52 AM with EI # 1, Chief Operations Officer, confirmed there was no policy or procedure for dealing with Infectious Blood and Blood Products prior to 10/3/18. | |||||||||
80 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | A0700 | Physical Environment | 482.41 | Condition of Participation | 11/21/2018 | N | Not Deemed | 22965 Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility. Findings include: Refer to Life Safety Code violations | |||||||||
81 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | A0749 | Infection Control Program | 482.42(a)(1) | Standard of Participation | 11/21/2018 | N | Not Deemed | 40119 Based on observations, review of CDC guidelines and interviews, it was determined the staff failed to: a) Perform hand hygiene per policy. b) Maintain reusable equipment per facility policy This affected unsampled patient # 1, unsampled patient # 2, and unsampled patient # 3 from the Operating Room (OR) department, and had the potential to negatively affect all patients served by the facility. Findings include: CDC Guidelines to Hand Hygiene Volume 51, Published 2002 Recommendations "1. Indications for handwashing and hand antisepsis B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J. C. Decontaminate hands before having direct contact with patients. F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient). G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care. I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. J. Decontaminate hands after removing gloves ..." Policy: Management of Clean Equipment Effective Date: 10/2004 "Purpose: To ensure appropriate technique in maintaining clean equipment. Policy: ...III. ...When equipment is shared, disinfection of equipment should take place prior to next patient use." 1. An observation visit was conducted on 10/4/18 at 9:45 AM in the Emergency Department with EI (Employee Identifier) # 6 RN (Registered Nurse) to observe an IV (intravenous) placement on unsampled patient # 1. At the end of the IV placement EI # 6 secured IV with a transparent dressing then removed glove to right hand. Glove to left hand remained in place on EI # 6 left hand. EI # 6 then used right hand to search both left and right side pockets of uniform and stated she/he was looking for a marker without performing hand hygiene after glove was removed. After EI # 6 searched pockets of uniform and was unable to find a marker, EI # 6 donned glove to right hand without hand hygiene prior to donning of glove. Facility staff failed to perform hand hygiene according to the CDC guidelines and perform hand hygiene after removing glove. An interview was conducted on 10/4/18 at 9:59 AM with EI # 2, Director of Nursing, who confirmed the previous findings. 2. An observation visit was conducted on 10/4/18 at 9:15 AM with EI # 5, RN, on the medical surgical floor to observe a medication pass with IV administration on unsampled patient # 2. After administration of oral medication, EI # 5 donned gloves and prepared Protonix for IV administration without performing hand hygiene prior to gloves being donned. After IV Protonix administration, EI # 5 gathered trash and placed in the trash then opened door to patient room with gloved hands and existed patient room to obtain a supply that was needed from the nursing station without removing gloves or hand hygiene prior to leaving patient room. Facility staff failed to remove contaminated gloves and perform hand hygiene according to the CDC guidelines. An interview was conducted on 10/4/18 at 10:01 AM with EI #2, who confirmed the previous findings. 39098 3. An observation was conducted on 10/3/18 at 7:49 AM, of a colonoscopy performed on unsampled pt # 3 in the endoscopy room of the OR department. During the procedure, the circulating RN assisted in the biopsy of a polyp. The physician ordered more sedation for the patient. The circulating RN removed her/his gloves and failed to perform hand hygiene before retrieving additional medication. Following the colonoscopy, EI # 3, OR Supervisor, suctioned clean solution through the used scope, laid the scope on machine, removed gloves, and failed to perform hand hygiene before donning clean gloves. EI # 3 carried the scope to the cleaning room, immersed the scope in disinfectant, cleaned the scope lumens with disposable brush and removed gloves. EI # 3 failed to perform hand hygiene before donning a new pair of gloves. EI # 3 placed the scope in the automatic washer, along with the used guide wire. EI # 3 removed her/his gloves and failed to perform hand hygiene. An interview was conducted on 10/4/18 at 10:37 AM with EI # 3, who confirmed the above findings. | |||||||||
82 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | A0940 | Surgical Services | 482.51 | Condition of Participation | 11/21/2018 | N | Not Deemed | 39098 This Condition of Participation is not met as evidenced by: Based on observations in the surgery department, review of facility surgery policy and procedure manuals, and interview with staff, it was determined the facility failed to: a) monitor and document temperature and humidity levels in the Operating Room (OR), Procedure room, Central Sterile Processing and Storage. A 951 b) perform preventative maintenance on Surgery and Central Sterile equipment. A-951 c) maintain an environment in the endoscopy suite free of pests. Refer to A-951 d) ensure staff followed hospital policy for OR attire. Refer to A- 951 e) history and physicals were updated prior to procedures requiring anesthesia services. Refer to A-952 f) provide control of traffic in the OR and Central Sterile departments. Refer to A-956 This had the potential to negatively affect all patients served by the facility. Findings include: Refer to A940, A951, A952 and A956 for findings. | |||||||||
83 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | A0951 | Operating Room Policies | 482.51(b) | Standard of Participation | 11/21/2018 | N | Not Deemed | 39098 Based on observations in the surgery department, review of facility surgery policy and procedure manuals, and interview with staff, it was determined the facility failed to: a) monitor and document temperature and humidity levels in the Operating Room (OR), Procedure room, Central Sterile Processing and Storage. b) perform preventative maintenance on Surgery and Central Sterile equipment. c) maintain an environment in the endoscopy suite free of pests. d) ensure staff followed hospital policy for OR attire. e) provide control of traffic in the OR and Central Sterile departments. These deficient practices have the potential to affect all patients served by the hospital. Findings include: Policy: Infection Control: Pest Control Effective Date: October 2004 "Purpose: To provide an environment free of pests. Policy: The facility will have a pest contract that provides frequent treatment of the environment for pests... There will be emphasis on the pest control program in... central sterile supply, operating rooms... Monitoring of the environment will be done by the facility's staff. Pest control problems will be reported promptly..." Policy: Attire, Surgical Date Reviewed: 06/17 "Purpose Surgical attire provides a barrier between personnel and between patient... through which contamination may pass. Policy All personnel entering restricted areas of the surgical suite shall be in Operating Room attire. OR attire consist of standard cotton scrub suit..., shoe covers and a standard hat, hood, or bonnet. Operating Room attire which is soiled or wet shall be changed. All reusable attire shall be laundered after each use in the hospital laundry. Operating Room attire shall be stored in an enclosed area. Cover gown or lab coat is to be worn whenver leaving the surgical suite..." Policy: Traffice Control Effective Date: October 2004 "Purpose: To provide for control of traffic by personnel and visitors in the hospital. Policy: Area: Surgery The Surgery Suite is kept closed. Only authorized persons are permitted to enter. Limit amount of personnel in surgery suite as much as possible... Visitors and personnel are excluded from the Surgery Suite..." Policy: Prevention of Cross Contamination Related to: Surgical Services/ Central Sterile Date Reviewed: 6/16 "Policy: The following policies are to be followed for the prevention of cross contamination in Central Service: - Soiled items are confined to decontamination clean-up area and are kept separated from clean and sterile supplies... - ...Once monthly, all shelves on which sterile supplies are stored are to be dusted and wiped with alcohol solution. Wipe all sterile storage area monthly or as needed, with hospital approved cleaner... -Weekly, all surface areas... in the department are cleaned thoroughly with soap and water..." ***** During a tour of the surgery department on 10/2/18 at 11:15 AM, with Employee Identifier (EI) # 3, OR Supervisor, the surveyor asked to review temperature and humidity logs for the surgery suite and central sterile areas. EI # 3 stated there were no logs kept for temperature and humidity. In the endoscopy suite the surveyor observed two black insects with wings, floating in the floor stand wash hopper. The sink next to the hopper contained lime stains, an old brush, 3 used cleaning brushes coiled in bottom of sink, a piece of white plastic pipe, bits of white paper, 1 extra purge valve, and an old suction canister used to fill the cleaning container to immerse the endoscopes. The emergency eye wash station was also located at this sink, and was observed to be leaking. In the OR suite, on the blue anesthesia cart, 1 intubating stylet was observed open and lying out of packaging. On the second anesthesia cart, an Intubating Laryngeal Airway was observed opened, and moisture on the inside of the packaging. No surgery has been performed in the OR suite for over a week due to lighting replacement. Electricians are present during tour. The surveyor asked EI # 3 to describe their OR attire. EI # 3 explained the nurses wear their personal scrubs to the hospital from home. EI # 3 stated only the scrub nurse wears a cover gown in the OR. The surveyor asked if OR personnel wear a lab coat when leaving the surgery suite area. EI # 3 stated, "No." The tour continued to Central Sterile, which was located across the hall. An exterior door was located at the end of the hall. The Emergency Room waiting area was also accessed on this hall. During the time the surveyor was on site, multiple visitors were observed on this hall, asking for water or directions. The doors to the surgery suite, endoscopy room, and Central Sterile do not have locked/ controlled entries. Inside the Central Sterile receiving area, the surveyor observed a plastic bin containing instruments submerged in a liquid. EI # 3 stated those were from the last hernia repair that was performed a week ago. The surveyor observed clean instruments setting on a shelf, on top of an opened sterile pack. EI # 3 explained the used pack was from a doctor's office, "...and she had not had time to come in here and clean all these instruments." The storage of sterile instrument packs, was located in the room with the sterilizer. Located less than 12 inches above the sterile cloth packs was a sprinkler head. Also located in this room, were 6 shelves containing orthorpedic boots, wrist braces, splints, shoulder immobilizers, cervical collars etc., which EI # 3 stated were used by the ER. EI # 3 also stated the ER staff comes in to retrieve supplies and sterile instruments needed in the ER. There was no control of traffic/ personnel coming in to Central Sterile. The surveyor observed spider webs, dust, and hair on the floor. The surveyor asked if the shelves containing sterile packs were wiped down monthly with an alcohol solution, per policy, and all other surface areas wiped down weekly, per policy. EI # 3 answered, "No." During an interview conducted on 10/4/18 at 10:37 AM with EI # 3, the above findings were confirmed. | |||||||||
84 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | A0952 | History And Physical | 482.51(b)(1) | Standard of Participation | 11/21/2018 | N | Not Deemed | 39098 Based on review of medical records (MR), policy, and interview with staff, it was determined the facility failed to ensure the physician updated the History and Physical (H&P) 24 hours after admission or prior to procedures requiring anesthesia services. This affected 6 of 6 surgical records reviewed and did affect Patient Identifier (PI) # 1, PI # 2, PI # 3, PI # 4, PI # 5, PI # 6, and had the potential to affect all patients served by the hospital. Findings include: Policy: Evergreen Medical Staff Rules and Regulations/ Policies and Procedures Date Approved: 2/8/18 "...History and Physical ...2.) Complete history and physical examinations must be performed and documented no more than thirty (30) days before or twenty four (24) (hours) after admission. When using a history and physical performed prior to admission, an update must be documented at the time of admission. This update must be attached to the history and physical, usually writing the update directly onto the previous history and physical. This addendum must be dated and signed by the physician. For patients with no changes, the update may state that the history and physical was reviewed, the patient was examined, and physician concurs with the findings of the history and physical previously performed... 4.) The history and physical examination must be recorded on the medical record prior to any operative or other invasive procedure requiring anesthesia or moderate sedation..." ***** 1. PI # 1 was admitted to the hospital on 5/23/18 with a diagnosis of Chronic Tonsillitis. The patient was scheduled for a Tonsillectomy. Review of the MR revealed a H&P dated 3/28/18, which was 56 days prior to admission. There was no documentation the physician updated the H&P. During an interview conducted on 10/4/18 at 10:24 AM with Employee Identifier # 3, Operating Room (OR) Supervisor, the above findings were confirmed. 2. PI # 2 was admitted to the hospital on 6/4/18 with the diagnosis of Recent Gastric Ulcer, and scheduled for a Esophagogastroduodenoscopy (EGD). Review of the MR revealed a Surgical Consultation dated 5/9/18. There was no documentation the H&P was updated by the physician prior to the procedure. During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed. 3. PI # 3 was admitted to the hospital on 6/11/18 for a Screening Colonoscopy. Review of the MR revealed a H&P dated 5/30/18. There was no documentation the H&P was updated by the physician prior to the procedure. During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed. 4. PI # 4 was admitted to the hospital on 7/16/18 with the diagnosis of Chronic Osteomyelitis with Exposed Bone Left Great Toe and Left Second Toe. The patient was scheduled for amputation of left great toe and left second toe. Review of the MR revealed a H&P dated 7/2/18. There was no documentation the H&P was updated by the physician prior to surgery. During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed. 5. PI # 5 was admitted to the hospital on 7/23/18 with diagnoses including Symptomatic Cholelithiasis, and Abscess Left Groin. The patient was scheduled for a Laparoscopic Cholecystectomy and I (Incision) and D (Drainage) Abscess Left Groin. A review of the MR revealed a H&P dated 7/11/18. There was no documentation the H&P was updated by the physician prior to surgery. During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed. 6. PI # 6 was admitted to the hospital on 7/9/18 with the diagnosis of Right Inguinal Hernia. The patient was scheduled for a Right Inguinal Hernia Repair with Mesh. A review of the MR revealed a H&P dated 6/25/18. There was no documentation the H&P was updated by the physician prior to surgery. During an interview conducted on 10/4/18 at 10:24 AM with EI # 3, the above findings were confirmed | |||||||||
85 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | A0956 | Required Operating Room Equipment | 482.51(b)(3) | Standard of Participation | 11/21/2018 | N | Not Deemed | 39098 Based on observations, review of the facility's Preventive Maintenance Log, and interviews with staff it was determined the facility failed to ensure all equipment was tested for performance and safety on an annual basis. This had the potential to negatively affect all patients served by the facility. Findings include: Policy: Equipment Care and Maintenance Policy Number: 1101.8 Date Reviewed: None Listed "Autoclaves- Central Service personnel are responsible for cleaning and clinical monitoring of all sterilizers." 1. A tour of OR (Operating Room) department was conducted on 10/2/18 at 11:15 AM, with Employee Identifier (EI) # 3, OR Supervisor. The surveyor requested to see the OR defibrillator and was told by EI # 3 it was located in the PACU (Post Anesthesia Care Unit), a room also used for overflow Emergency Room patients. The surveyor observed the defibrillator in the PACU and it was determined there was no PM (Preventive Maintenance) sticker on the equipment. A review of the Preventive Maintenance Log dated July 2018, performed by Anatech Inc. (Incorporated), revealed 2 defibrillators had PM performed. An interview was conducted on 10/2/18 at 11:45 AM with EI # 2, Director of Nursing, who confirmed the hospital had a total of three defibrillators, and the PACU defibrillator failed to have PM performed. 2. A tour of the Central Sterile department was conducted on 10/2/18 at 1:20 PM with EI # 3. The surveyor observed a Steris Sterilizer and asked EI # 3 when the last PM and cleaning was performed. EI # 3 stated the last maintenance and professional cleaning of the sterilizer had been performed in September of 2015. During an interview conducted on 10/4/18 at 10:37 AM with EI # 3, the above findings were confirmed. 3. A tour of the only OR suite was conducted on 10/3/18 at 2:00 PM with EI # 3. The following equipment in the OR failed to have a PM sticker: a) Zimmer Tourniquet machine on a rolling stand. b) Ritter stand light with no PM. Two hospital maintenance employees were in the OR suite working on the installation of new overhead lighting. One of the employees stated he/she had brought the light in to the OR from a storage room. An interview was conducted on 10/4/18 at 10:37 AM with EI # 3, who confirmed the above findings. | |||||||||
86 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | E0037 | Ep Training Program | Standard of Participation | 11/21/2018 | N | Not Deemed | 40119 Based on review of the Emergency Preparedness Program, review of employee files and interviews with the staff it was determined the facility failed to provide initial or annual training to all the employees for emergency preparedness. This had the potential to negatively affect all patients served by the facility. Findings include: Review of the Emergency Preparedness ( EP) Program and employee files on 10/4/18 at 10:30 AM reveled no documentation of the initial training or annual training for the EP Program. An interview was conducted on 10/4/18 at 7:56 AM with Employee Identifier (EI) # 1, Chief Operations Officer, who verbalized that the initial EP training was incorporated into the facility's annual orientation. EI # 1 further verbalized the facility had provided 2 months of annual orientation that included initial EP training. The surveyor was given two Annual Orientation Sign-in Sheets, by EI # 1 on 10/4/18 at 12:00 PM, dated 8/15/18 and 9/24/18. Review of the Annual Orientation Sign-in Sheet dated 8/15/18 revealed 6 employee names. No documentation of the title of the employee or what area of the hospital the employee was employed in was documented. Review of the Annual Orientation Sign-in Sheet dated 7/24/18 revealed 3 employee names. No documentation of the title of the employee or what area of the hospital the employee was employed in was documented. Review of the Facility List of Employees that was printed and given to the surveyor by the facility on 10/2/18 revealed the facility had a total of 157 current employees. Based on the previous, the facility had provided initial EP training to 9 of the 157 current employees. A second interview was conducted on 10/4/18 at 12:00 PM with Employee Identifier (EI) # 1, who confirmed that only the employee's that were listed on the Annual Orientation Sign-in Sheets dated 8/15/18 and 9/24/18 had received initial EP training and that no other EP training has been completed. | ||||||||||
87 | 010148 | EVERGREEN MEDICAL CENTER | 101 CRESTVIEW AVENUE | EVERGREEN | AL | 36401 | 10/04/2018 | Recertification | 1 | E0039 | Ep Testing Requirements | Standard of Participation | 11/21/2018 | N | Not Deemed | 40119 Based on review of the Emergency Preparedness (EP) Program and facility staff interview it was determined the facility failed to document facility staff participation in a table top exercise and a community-based exercise. Findings include: Review of the EP Program reveled no documentation that the facility performed or participated in a table top or a community-based exercise. An interview was conducted on 10/4/18 at 12:00 PM with Employee Identifier (EI) # 1, Chief Operations Officer, who verified that the facility had not performed or participated in a EP table top or community-based exercise. | ||||||||||
88 | 022001 | ST ELIAS SPECIALTY HOSPITAL | 4800 CORDOVA STREET | ANCHORAGE | AK | 99503 | 08/31/2018 | Complaint Investigation | 1 | 0 | Initial Comments | Memo Tag | Y | Joint Commission | 27425 . The following deficiencies were noted during an unannounced Medicare/Medicaid complaint survey conducted 8/28-31/18. Department of Health and Social Services Division of Health Care Services Health Facilities Licensing and Certification 4501 Business Park Blvd, Ste 24, Bldg L Anchorage, Alaska 99503 . | |||||||||||
89 | 022001 | ST ELIAS SPECIALTY HOSPITAL | 4800 CORDOVA STREET | ANCHORAGE | AK | 99503 | 08/31/2018 | Complaint Investigation | 1 | A0385 | Nursing Services | 482.23 | Condition of Participation | 10/31/2018 | Y | Joint Commission | 27425 . Based on record review and interviews the facility failed to ensure care was provided in a safe manner in conjunction with nursing practice standards according to the Condition of Participation: CFR 482.23 Nursing Services. Findings: The facility failed to: ensure patients were monitored during blood transfusions for 5 patients (#s 3, 12, 16, 17, and 18), out of 5 sampled patients who received blood transfusions. Specifically, nurses failed to 1) document vital signs (VS) within the set time frames according to standards of practice and procedures and/or failed to document a complete set of VS within these time frames to include blood pressure (BP), heart rate (Pulse: P), respirations (R), and temperature (T) and 2) ensure deviations in VS during blood transfusions were reported to the physician or supervisor, documented accurately within nurse's notes, and/or followed appropriate protocol for incident reporting. This failed practice constituted an immediate jeopardy to patient health and safety. This situation was brought to the attention of the facility's administration on August 30, 2018 at 5:00 pm, at which time the facility was notified of the deficient practice and the high risk to patients. The immediacy was removed by the facility by August 30, 2018 at 9:30 pm. The facility was out of compliance with the Condition during the investigation. Findings: . | |||||||||
90 | 022001 | ST ELIAS SPECIALTY HOSPITAL | 4800 CORDOVA STREET | ANCHORAGE | AK | 99503 | 08/31/2018 | Complaint Investigation | 1 | A0409 | Blood Transfusions And Iv Medications | 482.23(c)(4) | Standard of Participation | 10/31/2018 | Y | Joint Commission | 27425 . Based on record review, interview, and facility policy review the facility failed to ensure patients were monitored during blood transfusions in 5 patients (#s 3, 12, 16, 17, and 18), out of 5 sampled patients who received blood transfusions. Specifically, nurses failed to 1) document vital signs (VS) within the set time frames according to standards of practice and procedures and/or failed to document a complete set of VS within these time frames to include blood pressure (BP), heart rate (Pulse: P), respirations (R), and temperature (T) and 2) ensure deviations in VS and/or symptoms, during blood transfusions, were reported to the physician or supervisor, documented accurately within nurse's notes, and appropriate protocol for reporting was followed. This failed practice constituted an immediate jeopardy to patient health and safety. Findings: This situation was brought to the attention of the facility's administration on August 30, 2018 at 5:00 pm, at which time the facility was notified of the deficient practice and the high risk to patients. The immediacy was removed by the facility by August 30, 2018 at 9:30 pm. Patient #3 Record review from 8/29-30/18 revealed Patient #3 was admitted with diagnoses that included acute respiratory failure with hypoxia (blood supply is shunted away from inside the lung resulting in airspace filling with fluid or airway collapse) and anemia (a condition in which the blood doesn't have enough healthy red blood cells). Additional review revealed Patient #3 was on mechanical ventilation. Transfusion #1 Record review revealed a transfusion of red blood cells was ordered on 6/11/18 due to Patient #3 having abnormal lab values of hemoglobin (protein component of red blood cells) and hematocrit (packed cell volume: the volume percentage of red blood cells in the whole blood). Review of Patient #3's VS documentation, dated 6/11/18, revealed BP, P and R were not documented during the transfusion at standard intervals. Additionally, the transfusion rate was increased 30 minutes after the transfusion started without documentation of Patient #3's tolerance to the transfusion. The first set of VS after the transfusion ended revealed an increase in all VS to include P 122, R 48, ronchi breath sounds (a continuous low pitched rattling that indicates obstruction or secretions in larger airways) in both lungs, and T 100.2 F. VS and transfusion were documented as follows: 12:42 pm - VS documented prior to transfusion BP 128/60, P 102, R 30, T 99.8 F 1:02 pm - Transfusion started 50 milliliters and hour (mL/hr) 1:05 pm - Only T documented 98.8 F 1:15 pm - Only T documented 98.7 F 1:30 pm - Only T documented 98.9 F 1:32 pm - Transfusion rate increased to 250 mL/hr 1:45 pm - Only T documented 98.9 F 2:15 pm - Only T documented 98.9 F 2:45 pm - Only T documented 98.9 F - transfusion stopped 3:14 pm - 1st set of VS documented after transfusion BP 134/62, P 122, R 48, T 100.2 F, SpO2 94% (O2 concentration 40%) documented large amounts of secretions; yellow, pale in color; thick, thin consistency; and ronchi breath sounds on left and right. Documented aeration increased (increase in the amount of oxygen-rich air taken into and expelled from the lungs) for posttreatment of breath sounds. Documented no suspected reaction. Review of Patient #3's nurse's note, dated 6/11/18 at 6:38 pm, written by LN #1, revealed "[Patient] given blood today. Temp of 100.2 F resolved after Tylenol given. Fentanyl given after observing pulse 130+ which helped lower pulse." Further review VS documentation revealed no documentation of an elevated P of 130, nor a P that exceeded 130. There was no documentation that the provider was notified of the increase in T and P. Transfusion #2 Record review revealed a transfusion of red blood cells was ordered on 6/20/18 due to Patient #3 having abnormal lab values of hemoglobin and hematocrit. Review of Patient #3's VS documentation, dated 6/20/18, revealed no complete set of VS documented at any time during the transfusion. Additionally, no VS were documented 30 minutes after the transfusion stopped. The first set of VS after the transfusion occurred (1 hour and 8 minutes later) revealed a drop in BP, and increase in R. VS and transfusion were documented as follows: 1:10 pm - VS documented at time of transfusion BP 117/59, P 115, R 32, T 99.2 F - Transfusion started at 75 mL/hr 1:15 pm - VS documented BP 120/59, no P, R 33, T 99.3 F 1:30 pm - VS documented BP 96/59, no P, no R, T 99.0 F 2:30 pm - VS documented BP 118/65, no P, no R, T 99.0 F 3:12 pm - VS documented no BP, P 110, R 41, no T 3:17 pm - Documented large amounts of secretion; yellow, creamy color; thick consistency; breath sounds course on left, right, upper airway. Aeration increased posttreatment breath sounds 3:26 pm - VS documented BP 124/62, P 109, R 23, T 99.0 F - Transfusion stopped 4:34 pm - 1st set of VS documented 1 hour, 8 minutes after transfusion stopped: BP 107/62, P 108, R 36, T 100.2 F Additional review of Patient #3's VS documentation revealed the next set of VS documented after 4:34 pm was at 7:22 pm: BP 126/63, P 105, R 39, T 97.7. Review of Patient #3's nurse's note, dated 6/20/18 at 5:35 pm, written by LN #2 revealed "[Vital signs] were critical at the beginning of shift. [Patient] received 2 liters of [normal saline] and one unit of blood. VS are currently stable." Further review revealed no documentation that the provider was notified of the blood pressure or respiratory changes. Transfusion #3 Record review revealed a transfusion of red blood cells was ordered on 6/30/18 due to Patient #3 having abnormal lab values of hemoglobin and hematocrit. Review of Patient #3's VS documentation, dated 6/30/18, revealed fluctuations in blood pressure were documented throughout the transfusion and increased from 104/60 at the start of the transfusion to 140/56 30 minutes after the transfusion ended. VS and transfusion were documented as follows: 10:20 am - VS documented prior to transfusion started BP 104/60, P 88, R 22, T 97.8 F, SpO2 99% 10:24 am - Transfusion started at 50 mL/hr 10:30 am - VS documented BP 109/66, P 89, R 22, T 97.7 F, SpO2 100% 10:45 am - VS documented BP 109/66, P 87, R 22, T 99.7 F - Transfusion rate increased to 150 mL/hr 10:48 am - VS documented BP 119/70, P 89, R 22, T 99.7 F 11:00 am - VS documented BP 113/66, P 88, no R, T 97.6 F 11:32 am - VS documented BP 103/64, P 84, R 22, T 97.7 F, SpO2 98% 12:00 pm - VS documented BP 109/68, P 82, no R, T 97.6 F, SpO2 99% 12:15 pm - VS documented BP 119/74, P 82, no R, T 97.7 F, SpO2 100% 12:35 pm - VS documented no BP, no P, R 24, T 97.7 F, SpO2 99% -- Transfusion stopped 12:45 pm - VS documented no BP, P 90, R 25, no T, SpO2 96% 1:02 pm - VS documented BP 140/56, P 86, R 25, T 97.7 F, SpO2 96% Review of Patient #3's nurse's note, dated 6/30/18 at 6:16 pm, written by LN #3 revealed "Infused 1 unit [packed red blood cells] with no adverse reaction." Patient #12 Record review from 8/29-30/18 revealed Patient #12 was admitted with diagnoses that include diverticulitis of intestine, with perforation and abscess without bleeding (diverticulosis: the formation of numerous tiny pockets, or diverticula, in the lining of the bowel formed by increased pressure on weakened spots in the intestinal wall. Perforation: holes in the intestine. Abscess: a pocket of inflamed tissue filled with pus in the intestine) and anemia (a condition in which the blood doesn't have enough healthy red blood cells). Further review revealed a transfusion of red blood cells was ordered on 6/28/18 due to Patient #12 having abnormal lab values of hemoglobin and hematocrit. Review of Patient #12's VS documentation, dated 6/28/18, revealed no VS were documented 30 minutes after the transfusion stopped. The first set of vital signs after the transfusion occurred (56 minutes later) revealed an increase in all VS which included BP 163/82, P 83, R 20, and T 100.2 F. VS and transfusion were documented as follows: 4:17 pm - VS documented prior to transfusion BP 148/82, P 68, R 19, T 97.7 F 4:44 pm - Transfusion started 50 mL/hr 4:49 pm - VS documented BP 149/79, P 70, R 20, T 98.9 F - Transfusion rate increased to 75 mL/hr 4:59 pm - VS documented BP 145/66, P, 70, R 16, T 99.2 F 5:07 pm - Only T documented 98.8 F - Transfusion rate increased to 150 mL/hr 5:15 pm - VS documented BP 152/87, P 80, R 16, T 99.1 F 5:30 pm - No VS documented -- Transfusion rate increased to 200 mL/hr 5:45 pm - VS documented BP 159/80, P 82, R 16, T 99.5 F 6:15 pm - VS documented BP 155/76, P 69, R 18, T 99.2 F 6:45 pm - VS documented BP 140/71, P 77, R 16, T 98.8 F 7:00 pm - VS documented BP 158/89, P 69, R 18, T 99.7 F 7:05 pm - Transfusion stopped, documents no suspected reaction 8:01 pm - VS documented after transfusion (56 minutes later) BP 163/82, P 83, R 20, T 100.2 F Review of Patient #12's nurse's note, dated 6/28/18 at 2:57 pm, written by LN #4 revealed "Patient had one unit of blood infused today. Patient monitored closely. No transfusion reactions noted." This note was written 1 hour and 47 minutes before the transfusion started. Patient #16 Record review from 8/29-30/18 revealed Patient #16 was admitted with a diagnoses that included bullous pemphigoid (a rare skin condition causing large, fluid-filled blisters) and acute post hemorrhagic anemia (a condition in which a person quickly loses a large volume of circulating blood). Further review revealed a transfusion of 2 units of red blood cells was ordered on 6/2/18 due to Patient #16 having abnormal lab value of hemoglobin. Transfusion # 1 (2 units) First Unit Review of Patient #16's VS documentation of the first transfusion, dated 6/2/18, revealed no VS were documented 5 minutes after the transfusion started. VS and transfusion were documented as follows: 1:26 pm - VS documented at start of transfusion BP 114/49, P 65, R 16, T 97.9 F 1:26 pm - Transfusion started at 100 mL/hr 1:39 pm - VS documented BP 111/45, P 65, R 14, T 97.8 F 1:44 pm - VS documented BP 112/50, P 65, R 14, T 98.9 F 1:54 pm - VS documented BP 111/49, P 65, R 16, T 98.4 F - Transfusion rate increased to 400 mL/hr 2:25 pm - VS documented BP 122/57, P 60, no R, T 99.1 F 2:30 pm - Transfusion stopped Second Unit Review of Patient #16's VS documentation of the second transfusion, dated 6/2/18, revealed no VS were documented 5 minutes after the transfusion started. Additionally, VS were not documented 30 minutes after the transfusion stopped. Only the BP and P were documented 1 hour and 48 minutes later. VS and transfusion were documented as follows: 2:25 pm - VS documented prior to start of transfusion BP 122/57, P 60, no R, T 99.1 F 2:35 pm - R 16 - Transfusion started at 100 mL/hr 2:45 pm - VS documented BP 133/57, P 68, R 18, T 99.2 F - Documented no suspected reaction 2:54 pm - VS documented BP 140/58, P 67, R 18, T 99.0 F 3:08 pm - VS documented BP 138/64, P 66, R 18, T 99.4 F 3:21 pm - VS documented BP 133/57, P 67, R 18, T 98.8 F 3:48 pm - VS documented BP 129/58, P 68, R 16, T 98.9 F - Transfusion rate increased to 400 mL/hr 4:23 pm - Transfusion stopped, documented no suspected reaction 6:11 pm - 1st set of VS documented after transfusion occurred (1 hour, 48 minutes later) BP 125/81, P 71, no R, no T Review of Patient #16's nurse's note, dated 6/2/18 at 7:59 pm, written by LN #5 revealed "Two units of PRBCs given as ordered for [hemoglobin] of 6.8. [Patient] stable by end of shift, no reaction noted." Transfusion #2 Further review revealed a Physician's note, dated 6/12/18 at 5:00 pm, which documented, "In light of significant bone marrow depression from the rituximab (a medication used to treat certain autoimmune diseases and types of cancer), multiple oozing skin lesions in spite of platelet transfusion, and general debilitated state I elect to give 1 unit of packed red blood cells ..." Further review revealed a transfusion of red blood cells was ordered on 6/12/18 due to Patient #16 having abnormal lab values of hematocrit. Review of Patient #16's VS documentation, dated 6/12/18, revealed no documentation as to when the blood transfusion stopped. No VS after 30 minutes of blood transfusion could be ascertained. VS and transfusion were documented as follows: 5:29 pm - VS documented prior to transfusion BP 162/74, P 72, R 20, T 97.7 F 5:37 pm - Transfusion started 50 mL/hr 5:42 pm - VS documented BP 154/58, P 75, R 18, T 99.7 F 5:52 pm - VS documented BP 162/63, P 75, R 18, T 98.2 F 5:56 pm - Transfusion rate increased to 150 mL/hr 6:02 pm - VS documented BP 142/74, P 77, R 18, T 99.7 F 6:11 pm - VS documented BP 155/67, P 74, R 22, T 99.0 F 6:46 pm - VS documented BP 156/63, P 76, R 19, T 98.8 F 8:02 pm - VS documented BP 157/75, P 71, R 19, T 99.5 F Review of Patient #16's nurse's note, dated 6/12/18 at 7:48 pm, written by LN #5 revealed, "[Patient] received 1 unit of platelets at end of shift. Infusion of 1 unit of [packed red blood cells] started during shift, still running at shift change. No transfusion reaction observed." Patient #17 Record review from 8/29-30/18 revealed Patient #17 was admitted with a diagnoses that included mitral valve replacement with deconditioning and remaining chest tubes (heart valve from the left atrium to the left ventricle replaced. Chest tubes: a flexible plastic tube inserted through the chest wall into the chest cavity outside of the lung) and acute post hemorrhagic anemia (a condition in which a person quickly loses a large volume of circulating blood). Further review revealed a transfusion of red blood cells was ordered on 3/2/18 due to Patient #17 having abnormal lab values of hemoglobin and hematocrit. Review of Patient #17's VS documentation, dated 3/2/18, revealed no VS were documented 5 minutes after the transfusion started. Further review revealed Patient #17 had a drop in blood pressure after the first 9 minutes of the transfusion from 118/48 to 103/50. Additionally, no VS were documented 30 minutes after the transfusion stopped. The first set of VS documented after the transfusion stopped occurred 42 minutes later. VS and transfusion were documented as follows: 10:06 pm - VS documented at time of transfusion BP 118/48, P 90, R 20, T 98.2 F 10:06 pm - Transfusion started 50 mL/hr 10:15 pm - VS documented BP 103/50, P 109, R 18, T 98.0 F - documented no suspected reaction 10:32pm - VS documented BP 117/62, P 88, R 16, T 98.0 F - documented no suspected reaction 10:32 pm - Transfusion rate increased to 150 mL/hr 11:00 pm - VS documented BP 112/53, P 119, R 16 T 98.2 F 11:15 pm - VS documented BP 110/54, P 86, R 18, T 98.0 F 12:00 am - VS documented BP 114/54, P 105, R 18, T 98.1 F - Transfusion stopped - documented no suspected reaction 12:42 am - First set of VS documented after transfusion BP 118/60, P 115, R 18, T 98.1 F (42 minutes later) Review of Patient #17's medical record revealed a nurses note, dated 3/3/18 at 3:51 am, written by LN #6 that documented "[Patient] tolerated well no signs or symptoms of transfusion reaction." Patient #18 Record review from 8/29-30/18 revealed Patient #18 was admitted to facility after a surgical operation for coronary artery bypass graft (a procedure to restore normal blood flow to an obstructed coronary artery of the heart). He/she also has a diagnosis of iron deficiency anemia (too few healthy red blood cells due to too little iron in the body). Further review revealed a transfusion of red blood cells was ordered on 1/2/18 due to Patient #18 having abnormal lab values of hemoglobin and hematocrit. Review of Patient #18's VS documentation, dated 1/2/18, revealed no VS were documented 5 minutes, nor 15 minutes after the transfusion started. Further review revealed documentation of a low oxygen level in the blood (SpO2), 86%, and Patient #18 required oxygen to correct this. Diminished breath sounds were also documented in both lungs. Additionally, no VS were documented 30 minutes after the transfusion ended. VS and transfusion were documented as follows: 2:14 pm - VS documented prior to transfusion BP 99/69, P 61, R 16, T 98.0 F, SpO2 96% 2:30 pm - Transfusion started 50 mL/hr 2:55 pm - VS documented BP 115/65, P 69, R 16, T 97.6 F 3:10 pm - VS documented BP 116/57, P 66, R 16, T 98.5 F - Transfusion rate increased to 100 mL/hr 3:11 pm - Documented "Found on room air, [again] SpO2 was 86, placed on 2 [liters per minute]", SpO2 94% after O2 3:12 pm - Diminished breath sounds documented on left and right side 3:41 pm - VS documented BP 130/71, P 59, R 14, T 97.9 F, SpO2 99% 4:18 pm - VS documented BP 132/64, P 57, R 20, T 97.9 F, SpO2 98% 4:55 pm - VS documented BP 133/68, P 57, R 14, T 98.0 F, SpO2 99% -- Transfusion rate increased to 130 mL/hr 5:15 pm - Transfusion rate increased to 200 mL/hr - No VS documented 5:33 pm - VS documented 136/70, P 64, R 14, T 98.1 F, SpO2 99% 5:52 pm - Transfusion stopped, documented no suspected reaction 6:31 pm - 1st set of VS documented after transfusion (38 minutes later) BP 122/71, P 67, R 14, T 98.1 F, SpO2 97% 7:58 pm - SpO2 97%, lowered O2 to 1 liter per minute 7:59 pm - Breath sounds diminished on left side, crackles on left upper lung Review of Patient #18's nurse's note, dated 1/2/18 at 7:19 pm, written by LN #7, revealed no documentation of need for oxygen, low SpO2 rate, or diminished breath sounds during blood transfusion. During an interview on 8/30/18 at 2:46 pm, a Quality Staff #1 stated blood transfusions and the corresponding documentation are monitored monthly during Quality Assurance and Performance Improvement (QAPI) meetings. He/she stated a lack of VS monitoring and documentation had been identified as deficient in accuracy throughout the 2018 year, 89% accurate as of the second quarter of 2018. He/she further stated that no plan of correction has been implemented to correct this deficiency. During an interview on 8/30/18 at 3:10 pm, LN #3 stated the standard interval of taking VS during a blood transfusion were: 30 minutes before blood administration, 5 minutes after blood infusion had begun, then at 15 minutes post initial transfusion, every 30 minutes during blood transfusion, and within 30 minutes after transfusion had completed. He/she further stated if VS are not done or missed, the patient's health could be at risk. LN #3 stated transfusion reaction signs and symptoms are: tachycardia (increased heart rate), feel flushed, fever, BP spike or change from norm, tachypnea (breathing that is abnormally rapid and shallow). He/she further stated the LN is to report to the supervisor or charge nurse and the physician if a reaction occurs. During an interview on 8/30/18 at 3:25 pm, LN #2 stated he/she does consider blood transfusions a high risk intervention. He/she stated VS should be obtained 10 to 15 minutes prior to blood being given and 15 minutes after blood starts. He/she further stated VS should be taken every 15 minutes for the first hour of the blood transfusion, then every 30 minutes. In addition, LN # 2 stated a set of VS should be obtained once transfusions stops. He/she stated if VS are missed, the patient could receive an injury from the transfusion. LN # 2 stated transfusion reaction signs and symptoms are: BP will decreased dramatically, shortness of breath, tachypnea, and increased pulse. If these are observed, LN # 2 stated the transfusion should stop and be reported to the house supervisor, pharmacy, and blood bank. An incident report would then be completed. He/she reiterated that abnormal VS are reportable to the supervisor. During an interview on 8/30/18 at 3:45 pm, the Medical Director stated blood transfusions are high risk interventions to the patients. He further stated that following protocol of taking VS is important because nurses could miss a severe reaction and result in harm for the patient. He stated that doctors should be called if there is a change in VS during a transfusion. He further stated that policies are in place to assure continuity of care for all patients. During an interview on 8/30/18 at 4:28 pm, the Risk Manager stated there have been no blood transfusion reactions reported by nurses this year. He further stated there have been no investigations in regards to blood transfusions this year. Review of the facility policy "Transfusion of Blood and Blood Components," last reviewed January 2018, revealed the following: - G. Pre-Administration: "Take patient's vital signs within 30 minutes before initiating the transfusion and document in the [medical record software] ...Include Temperature, Heart rate, Blood Pressure, and Respiration." - J. During Administration: "4. Begin transfusion slowly for first 15 minutes. [Registered Nurse] or Provider remains with the patient during this time. 5. Monitor patient status for signs or symptoms which may indicate a transfusion reaction (Breathing effort/quality ...significant change from baseline vitals), retake vital signs 5 minutes and 15 minutes after initiation of transfusion and every 30 minutes during transfusion and document in the medical record. 6. All vital signs, interventions, notifications, etc. Related to the administration of the blood/component are to be documented in the [medical record software] ...signs of volume overload may include the following new symptoms and would require Provider notification: Shortness of breath ... [high blood pressure ... [high heart rate]." - K. No Transfusion Reaction: "2. Vital signs will continue to be taken every 30 minutes during transfusion. Vital signs will be obtained 30 minutes after the transfusion has completed." - L Transfusion Reaction - Apparent/Potential: "1. Symptoms of a transfusion reaction may include the following: chills, fever, rash, itching, dyspnea, hypotension ... 2. Stop transfusion immediately if significant change in patient condition or vital signs is noted ... 4. Notify Provider [immediately] of symptoms of transfusion reaction, vitals, and discontinuance of blood/component." - M Post Administration: "3. If no concern regarding transfusion reaction, take vital signs within 30 minutes after transfusion is complete and do a brief exam including breath sounds (which could indicate fluid overload) ...5. If not stable via exam or vital signs, notify Provider STAT and implement orders - assume patient is having a transfusion reaction and follow policy above related to Transfusion Reaction ...10. An Incident Report is required if: There is an apparent or suspected transfusion reaction ..." Additional facility policy review revealed a quick reference guides Licensed Nurse's (LN's) use during their shift entitled, "Transfusion of Blood and Components Update: Changes to Blood Administration within [medical record software]," no date, which reads: "Vital Signs - All vital signs must be documented as follows. - Up to 30 minutes pre-transfusion - 5 minutes post start of transfusion - 15 minutes post start of transfusion - 30 minutes post start of transfusion - Every 30 minutes thereafter during transfusion - 30 minutes after end of transfusion Review of the CDC protocol, "National Healthcare Safety Network Biovigilance Component Hemovigilance Module Surveillance Protocol," dated April 2018, revealed the following complications can occur with blood transfusions: Hypotension Transfusion Reaction: occurs during or within 1 hour after cessation of transfusion. Drop in systolic BP of greater than or equal to 30 mmHg and systolic BP less than or equal to 80 mmHg. Febrile Non-Hemolytic Transfusion Reaction (FNHTR): occurs during or within 4 hours of cessation of transfusion AND EITHER fever (greater than or equal to 100.4F) and a change of at least 1.8 F from pre-transfusion value. Shock: A drop in blood pressure accompanied by a drop in cardiac output including rapid heart rate (increase to 100 beats per minute or more) and rapid breathing. | |||||||||
91 | 022001 | ST ELIAS SPECIALTY HOSPITAL | 4800 CORDOVA STREET | ANCHORAGE | AK | 99503 | 08/31/2018 | Complaint Investigation | 1 | A0843 | Reassessment Of Discharge Planning Process | 482.43(e) | Standard of Participation | 10/31/2018 | Y | Joint Commission | 33393 . Based on record review and interview, the facility failed to demonstrate a mechanism for ongoing reassessment of its discharge planning process to identify preventable re-admissions. This failed practice had the potential to reduce the quality of communication and dialogue about discharge planning which could lead to negative outcomes for patients. Findings: Record review on 8/30-31/18 of the facility's Quality Assurance/Performance Improvement (QAPI) plan lacked data and/or information about discharge process review for quality purposes. During an interview on 8/31/18 at 1:20 pm, the facility Risk Manager stated the facility did not perform assessments of readmissions to evaluate whether readmissions were due to discharge planning process failure. During an interview on 8/31/18 at 1:30 pm, Registered Nurse Case Manager #1 stated the facility made follow up phone calls to discharged patients but there was no formal process for evaluation of effectiveness of the discharge plan process. During an interview on 8/31/18 at 1:40 pm Medical Records Manager revealed that there was no data tracking or trending on readmissions. During an interview on 8/31/18 at 2:00 pm, Quality Assurance member #1 (QA1) stated that readmission rates were not tracked. The QAPI further stated QAPI team does not review readmission issues to determine if re-admissions are preventable. When asked where the information could be found, the QA1 stated Medical Executive Committee may discuss readmission data. During an interview on 8/31/18 at 3:50 pm, the Medical Director (MD) stated the Medical Executive committee talked about discharges to acute facilities and percentage of discharge locations. The MD further stated readmission rates were kept by the MRM. A review of Medical Executive Committee notes from July 2017 through April 2018, revealed no discussion of readmissions or discharge plan issues that may have prevented readmission. . | |||||||||
92 | 024002 | ALASKA PSYCHIATRIC INSTITUTE | 3700 PIPER STREET | ANCHORAGE | AK | 99508 | 07/19/2018 | Complaint Investigation | 1 | 0 | Initial Comments | Memo Tag | Y | Joint Commission | 27425 The following deficiencies were noted during an unannounced Hospital Validation and complaint survey (AK #s 3501, 3463, and 3512) survey conducted 7/16-19/18. The sample included 31 patients; 16 active and 15 closed records. State of Alaska Department of Health and Social Services Division of Health Care Services Health Facilities Licensing and Certification 4501 Business Park Blvd, Ste 24, Bldg L Anchorage, Alaska 99503 . 07765 An unannounced Recertification survey was conducted by two (2) Federal surveyors on July 16-July 18, 2018. The census on the first day was 57; the sample of active patients was nine (9). | |||||||||||
93 | 024002 | ALASKA PSYCHIATRIC INSTITUTE | 3700 PIPER STREET | ANCHORAGE | AK | 99508 | 07/19/2018 | Complaint Investigation | 2 | 0 | Initial Comments | Memo Tag | Y | Joint Commission | 27425 33393 . An unannounced survey was conducted at Alaska Psychiatric Institute (API) on 7/16-19/18. The survey found API was not in substantial compliance with Center for Medicare and Medicaid Services (CMS) requirements for hospitals. During a revisit survey conducted at Alaska Psychiatric Institute (API) on 11/27-30/18 and 12/5-7/18. The survey found API was not in substantial compliance with Center for Medicare and Medicaid Services (CMS) requirements for hospitals. The following deficiencies were noted during an unannounced revisit survey conducted on 11/27-30/18 and 12/5-7/18. The sample included 20 patients. State of Alaska Department of Health and Social Services Division of Health Care Services Health Facilities Licensing and Certification 4501 Business Park Blvd, Ste 24, Bldg L Anchorage, Alaska 99503 . 07765 07814 An unannounced Recertification (follow-up) survey was conducted by Federal consulting surveyors from November 27, 2018 to November 29, 2018. The census at the time of survey was 57; the sample of active patients was eight (8). Alaska Psychiatric Institute is in compliance with 42 CFR 482.61 Condition of participation: Special Medical Record Requirements for Psychiatric Hospitals and 42 CFR 482.62 Condition of participation: Special Staff Requirements for Psychiatric Hospitals. | |||||||||||
94 | 024002 | ALASKA PSYCHIATRIC INSTITUTE | 3700 PIPER STREET | ANCHORAGE | AK | 99508 | 07/19/2018 | Complaint Investigation | 1 | A0049 | Medical Staff - Accountability | 482.12(a)(5) | Standard of Participation | 12/07/2018 | Y | Joint Commission | 27425 . Based on record review and interview the facility failed to ensure medical staff followed the medical staff bylaws in the area of peer review. This failed practice denied the facility the ability to identify opportunities for improvement. In addition, this failed practice placed all patients residing in the facility at risk for substandard quality of care (based on a census of 57) . Findings; Review of the Licensed Independent Practitioner (LIP) files on 7/18-19/18 revealed: LIP #7 had references for competency completed by registered nurses. There were no references from peers or evidence of peer review activity in the provider binder. LIP #2 had no references for competency by peers in his/her record. There was no evidence of peer review activity. LIP #3 had 2 references for competency by peers in his her record. There was no evidence of peer review activity. The remaining 4 LIP files reviewed did not contain evidence of peer reviews. During an interview on 7/19/18 at 2:00 pm, Office Assistant (OA) #1, stated he/she was responsible for maintaining the credentialing files as well as other duties. The OA stated he/she had wanted to become credentialed but had never found the time. When asked about the peer review for LIP #7 AO stated because LIP was an advanced nurse practitioner, nurses had provided the reviews. When asked how a nurse could evaluate the clinical judgement of LIP #7, the AO stated stated they could not. The LIP stated the non-clinician reviews were not a review of LIP clinical performance. Further review of the providers binder revealed LIP #7 had been provided with an extension for credentialing. Review of the Medical Staff Bylaws, effective 7/1/14, revealed "Membership Responsibilities...Participate in quality/ performance improvement and peer review activities." Review of "Ongoing Professional Practice Evaluation (OPPE)" revealed "The Medical Staff will engage in OPPE to identify professional practice trends that affect quality of care and patient safety. Information from this evaluation process will be factored into the decision to allow LIPs to maintain existing privileges ...prior to or at the time of reappointment. Review of the "Medical Staff Meeting", dated 1/9/18, revealed "Peer review feedback...review at future meeting." There was no information about the peer reviews in the "Med Exec Team" meeting minutes from 5/22/18; 5/29/18; Review of the facility policy, "Peer Review", dated 11/1/14, revealed "At least quarterly 5% of the cases performed by a medical staff member will be randomly selected for peer review." During the interview on 7/19/18 the OA stated the facility had completed an independent peer review by an outside agency 9 months ago. The independent peer review was not provided to the survey team at the time of exit. . | |||||||||
95 | 024002 | ALASKA PSYCHIATRIC INSTITUTE | 3700 PIPER STREET | ANCHORAGE | AK | 99508 | 07/19/2018 | Complaint Investigation | 1 | A0115 | Patient Rights | 482.13 | Condition of Participation | Y | Joint Commission | 27425 . Based on record review and interviews the facility failed to ensure the hospital protected and promoted each patients' rights according to the Condition of Participation: CFR 482.13 Patient's Rights. findings: The facility failed to: Ensure patients in 4 of 4 nursing care units were provided care in a safe setting free of ligature risk, inadequate supervision and hazardous items. Reference at tag A 144 Ensure allegations and/or of potential abuse and/or maltreatment of patients were investigated in a timely manner. Reference at tag A 145 Ensure 1 patient (#22), out of 30 sampled patients, was free from unnecessary restraint and/or seclusion. Reference at tag A 154 Ensure 2 patients (#10 and #24), were free from unnecessary seclusion. Reference at tag A 162 Ensure sufficient opportunities at least restrictive interventions were attempted prior to a restraint and/or seclusion initiated for 1 patient (#22). Reference at tag A 164 Ensure the type or technique of restraint or seclusion used was the least restrictive intervention for 2 patients (#10 and #24). Reference at A 165 Ensure seclusions were discontinued at the earliest possible time for 2 patients (#10 and #24) Reference at tag A 174 Ensure ongoing assessment and monitoring of 1 patient's (#10) condition while in seclusion. Reference at tag A 175 Ensure the patient's medical record contained a description of warranted conditions or symptoms to place 2 patients (#10 and #24) in seclusion. Reference at tag A 187 The facility was out of compliance with the Condition during the investigation. . | ||||||||||
96 | 024002 | ALASKA PSYCHIATRIC INSTITUTE | 3700 PIPER STREET | ANCHORAGE | AK | 99508 | 07/19/2018 | Complaint Investigation | 2 | A0115 | Patient Rights | 482.13 | Condition of Participation | Y | Joint Commission | 27425 . Based on record review and interviews the facility failed to ensure the hospital met the Condition of Participation for Patient Rights. The hospital failed to assure patients rights were protected and promoted. Findings: 1) 1 patient (#9) was free from physical abuse; 2) 1 patient (#19) was free from sexual abuse and neglect; and 3) 2 patients (#'s 1 and 2) with allegations of abuse and/or neglect were reported to State Agencies in an appropriate time frame. (Reference at tag A-0145); 2) 1 patient (#16), out of 6 sampled patients who experienced a restraint or seclusion, was free from unnecessary seclusion imposed as a means of coercion, discipline, convenience, or retaliation by staff. (Referenced at tag A-0154); 3) 1 patient (#1) out of 6 sampled patients who experienced a seclusion or restraint, was free from unnecessary seclusion (Referenced at tag A-0162); 4) The least restrictive interventions were attempted and determined to be ineffective prior to a seclusion for 2 patients (#1 and 16), out of 6 sampled patients. (Referenced at tag A-0164); 5) Safe application of NAPPI (Non-Abusive Psychological and Physical Intervention - behavior assessment, de-escalation, and defusing skills for humane and effective response to violent and/or unsafe patient behavior) restraint techniques for 1 patient (#9), out of 6 sampled patients who experienced a seclusion or restraint. (Reference at tag A-0167); 6) Seclusions were discontinued at the earliest possible time for 2 patients (#1 and #16) out of 6 sampled patients who experienced a seclusion or restraint. (Reference at tag A-0174); 7) Ongoing, line of sight monitoring and assessment of 2 patients (#'s 15 & 17) while in restraint, out of 6 sampled patients who experienced seclusion and/or restraint. (Reference at tag A-0175); and 8) Documentation reflected the immediate condition or symptom(s) that warranted the use of seclusion for 2 patients (#1 and 16), out of 6 sampled patients who experienced a seclusion or restraint. Reference at tag A-0187; The failure to ensure policies and procedures were followed placed patients (#1; 2; 9; 15; 16; and 17) out of 6 patients reviewed for restraint and/or seclusion at risk for injury and/or further trauma. . | ||||||||||
97 | 024002 | ALASKA PSYCHIATRIC INSTITUTE | 3700 PIPER STREET | ANCHORAGE | AK | 99508 | 07/19/2018 | Complaint Investigation | 1 | A0144 | Patient Rights: Care In Safe Setting | 482.13(c)(2) | Standard of Participation | 12/07/2018 | Y | Joint Commission | 33393 . Based on observation, interview and document review the facility failed to ensure patients in 4 of 4 nursing care units were provided care in a safe setting free of ligature risk, inadequate supervision and hazardous items. This failed practiced placed patients, on 4 of 4 unitsbeing utilized, at risk for injury from self harming behaviors. Findings: Taku Unit: Coat Closet Hall Ligature Risk: During an observation on 7/16/18 at 2:35 pm, of the Taku unit, revealed 5 different ligature point opportunities within the coat closet hall leading from the unit corridor to the courtyard: - 3 office doors with ligature handles; - 1 entry door from corridor to coat closet hall with ligature handle; and - 1 exit door, leading from coat closet hall to the courtyard, with a ligature-risk horizontal cross bar. During the same observation on 7/16/18, the coat closet hall door was observed to be propped open. The design of the door revealed the door swung into the coat closet hall resulting in the ligature risk handle to be out of view of cameras and staff at the central nurse's station. In addition, there were no staff present in or near the area for observation of any patients that may be in the coat closet hallway alone. During an interview on 7/16/18 at 2:35 pm, Psychiatric Nursing Assistant (PNA) #1, stated the coat closet hall door from the unit hallway always stays open while patients are outside. Half-Wall Ligature Risk: Additional observation of Taku unit on 7/16/18 revealed a closed-in alcove, with half-wall and a window at the end of hallway near bedrooms T5 and T6, with no camera monitoring within the visually obstructed space. There was a hand rail system within the alcove that is not anti-ligature designed. The interior of the alcove is not viewable from the front desk of the unit. During an interview on 7/16/18 at 2:36 pm PNA #2 stated he/she was assigned to sit at the central nursing station and observe the unit's corridors. When asked if he/she could observe the area behind the half-wall, the PNA stated he/she was unable to view the ligature-risk handrails behind the half-wall from the desk and there was no camera to observe the concealed area. PNA #2 further stated that suicidal patients may be housed in rooms T5 and T6. Medication Room Door Ligature Risk: Further observation on 7/16/18 revealed an entrance door, with ligature-risk handle, to the medication room located in a recessed alcove. Further observation of the area revealed a half-dome safety mirror mounted opposite of the alcove at the ceiling level. When seated at the central nursing station, only one side of the dome is visible and drastically skewed the reflected image making it difficult to visualize the alcove. Additionally, when seated at the central nursing station the door's ligature-risk handle was not visible to the staff member. During an interview on 7/17/18 at 10:10 pm, PNA #3 stated patients do sit within the medication room alcove and cannot be seen from the front desk or subsequent hallway space in between. The PNA further stated the coat closet hall door (from hallway of unit) remained open while patients are outside. When asked where do staff sit while patients are outside, PNA #3 stated the staff would sit anywhere within the courtyard and/or follow patients around. The PNA was then asked if the courtyard entrance door (leading from the unit) could be seen at all times while other staff followed patients outside, he/she stated no. During an interview on 7/16/18 at 3:37 pm the Safety Officer stated no ligature risk assessment had been conducted on the unit's corridor areas. Susitna Unit: Plastic Bag Risk: During an observation on 7/16/18 at 10:10 am of the courtyard on Susitna Unit, three plastic garbage bags full of leaves were sitting on the ground amongst the bushes within the courtyard unsecured. Coat Closet Ligature Risk: Observation of the Susitna Unit on 7/16/18 at 1:42 pm revealed the two ligature points in the coat closet hall leading from the unit corridor to the courtyard: - 1 entry door from corridor to coat closet hall with ligature handle; and - 1 exit door, leading from coat closet hall to the courtyard, with a ligature-risk horizontal cross bar. Further observation revealed no cameras were located in this area. In addition, the coat closet hall was not viewable from the center nursing desk. Medication Room Door Ligature Risk: Further observation on 7/16/18 revealed an entrance door, with ligature-risk handle, to the medication room located in a recessed alcove. Further observation of the area revealed a half-dome safety mirror mounted opposite of the alcove at the ceiling level. When seated at the central nursing station, only one side of the dome is visible and drastically skewed the reflected image making it difficult to visualize the alcove. Additionally, when seated at the central nursing station the door's ligature-risk handle was not visible to the staff member. During an interview on 7/16/18 at 3:37 pm the Safety Officer stated no ligature risk assessment had been conducted on the unit's corridor areas. During an interview on 7/17/18 at 9:50 pm PNA #4 stated when he/she sits at the central nursing station, during the night time shift, the medication room alcove is hard to see via the half-dome safety mirror due to the dim lighting and skewed reflection. During an observation on 7/17/18 at 9:50 pm the Surveyor stood in the blind spot of the medication room alcove. The Nursing Supervisor #1 stated it was difficult to see the surveyor due to dim lighting and skewed reflection from the side of the half-dome safety mirror. Chilkat Unit: Coat Closet Hall Ligature Risk: Observation of the Chilkat Unit on 7/16/18 at 10:20 am revealed the two ligature points in the coat closet hall leading from the unit corridor to the courtyard: - 1 entry door from corridor to coat closet hall with ligature handle; and - 1 exit door, leading from coat closet hall to the courtyard, with a ligature-risk horizontal cross bar. During an interview on 7/16/18 PNA #5 stated when patients are in the courtyard. The door leading from the unit corridor to the coat closet hall stays open. Further observation revealed no cameras were located in this area. In addition, the coat closet hall was not viewable from the center nursing desk. During an observation on 7/17/18 at 9:10 pm PNA #6 stated when patients are in the courtyard, the door leading from the unit corridor to the coat closet hall stays open. During an observation on 7/17/18 at 9:11 pm PNA #7 stated when patients are in the courtyard staff will sit facing the courtyard with backs to the courtyard entrance door (coat closet hall) and/or follow patients around. Propane Gas Tank Risk: Observation of the Chilkat Unit courtyard on 7/16/18 at 10:28 am revealed a propane grill. Further observation revealed the compartment harboring the propane tank was easily accessible. The tank was in the on position. Fuel lines leading form the tank supply were accessible. During an interview on 7/16/18 at 10:28 am Protective Services Specialist stated the tank needed to be secured immediately as it may pose a safety risk. Corridor Handrail Ligature Risk: Observation, from a seated position where staff sit at the center nursing desk, on 7/16/18 at 1:59 pm revealed the middle hall of Chilkat Unit was partial obstructed from view on the left side of the hallway. Further observation revealed approximately 27 feet of ligature risk hand rails were out of view from the monitoring staff person that sat at the central nursing station. During an interview on 7/16/18 at 1:59 pm PNA #8 stated, when seated, he/she could view all three hallways and if needed could review the camera monitor at the central nursing desk. When asked if all three hallways on the unit were visible by camera, the PNA stated yes. Observation of the camera monitor during this interview revealed the camera (C21) was not functioning for the middle hallway. Continuous observation on 7/16/18 from 2:01 pm to 2:07 pm revealed no staff was continuously present at the center nursing station. During an interview on 7/16/18 at 3:35 pm the Quality Manager stated staff should not use the camera as a primary method for observing patients location and activity. Review of the facility's policy "Video Surveillance/Closed Circuit Television (CCTV) System," dated 12/22/11, revealed "The CCTV system shall not be used as a primary method for observation and monitoring of patient." Medication Room Door Ligature Risk: Further observation on 7/16/18 revealed an entrance door, with ligature-risk handle, to the medication room located in a recessed alcove. Further observation of the area revealed a half-dome safety mirror mounted opposite of the alcove at the ceiling level. When seated at the central nursing station, only one side of the dome is visible and drastically skewed the reflected image making it difficult to visualize the alcove. Additionally, when seated at the central nursing station the door's ligature-risk handle was not visible to the staff member. During an interview on 7/16/18 at 3:37 pm the Safety Officer stated no ligature risk assessment had been conducted on the unit's corridor areas. Katmai Unit: Coat Closet Hall Ligature Risk: Observation of the Katmai Unit on 7/16/18 at 2:24 pm revealed the two ligature points in the coat closet hall leading from the unit corridor to the courtyard: - 1 entry door from corridor to coat closet hall with ligature handle and - 1 exit door, leading from coat closet hall to the courtyard, with a ligature-risk horizontal cross bar. During an interview on 7/16/18 at 2:24 pm PNA #9 stated when patients are in the courtyard, the door leading from the unit corridor to the coat closet hall stays open. Medication Room Door Ligature Risk: Further observation on 7/16/18 revealed an entrance door, with ligature-risk handle, to the medication room located in a recessed alcove. Further observation of the area revealed a half-dome safety mirror mounted opposite of the alcove at the ceiling level. When seated at the central nursing station, only one side of the dome is visible and drastically skewed the reflected image making it difficult to visualize the alcove. Additionally, when seated at the central nursing station the door's ligature-risk handle was not visible to the staff member. During an interview on 7/16/18 at 3:37 pm the Safety Officer stated no ligature risk assessment had been conducted on the unit's corridor areas. Review of the facility's policy "Searches, Contraband & Restricted Items, including Weapons," dated 4/15/18, revealed: "Definitions: Restricted Items ...potential for being hazardous to patient safety ...plastic bags ..." "Procedure: Section I: Staff Responsibility for contraband & restricted items: A. All staff will continuously observe the environment for contraband, restricted items, and other safety hazards." . | |||||||||
98 | 024002 | ALASKA PSYCHIATRIC INSTITUTE | 3700 PIPER STREET | ANCHORAGE | AK | 99508 | 07/19/2018 | Complaint Investigation | 1 | A0145 | Patient Rights: Free From Abuse/Harassment | 482.13(c)(3) | Standard of Participation | Y | Joint Commission | 27425 . Based on record review and interview the facility failed to ensure allegations and/or of potential abuse and/or maltreatment of patients were investigated in a timely manner for 2 patients (#22 and 25) out of 30 sampled patients. This failed practice created a risk for further abuse and/or harassment for all patients residing in the hospital. Findings: Record review on 7/17-18/18 of Patient #22's record revealed an event on 6/18/18 of the Patient jumping on the furniture. When the Patient refused to get down the Patient was approached by WEKA (contracted security support staff). After the Patient struck out at the WEKA staff, the Patient was placed in a manual hold, strapped to a gurney, and placed in seclusion. Review of Patient #25's medical record revealed there was an event of the Patient stashing 3 pills and a bobby pin (considered contraband). On 6/24/18 the Patient was placed into a safety vest (a thick garment that doesn't tear) and physically had his/her underwear removed by staff after refusing to completely disrobe. The event was assigned for process review on on 6/28/18. Review of the investigations revealed the process reviews of both events had not been completed by nursing administration and none of the involved staff had been interviewed and/or educated on possible patient maltreatment. Review of the "Process Review Update", updated 6/26/18, revealed events were patients had been possibly maltreated or denied their rights from 1/2018 until 6/13/18, totaling 16 cases, had not been reviewed by administrative staff. During an interview on 7/19/18 at 8:40 am, when asked about the incomplete reviews of incidents involving potential patient abuse and/or harassment, the Quality Manager (QM) stated they had not been getting completed. The QM stated they were reassigned to the current interim Director of Nursing (DON) and the facility was planning on hiring a contractor to help finish them. During an interview on 7/19/18 at 10:05 am, the Safety Officer stated process reviews assigned to nursing administration for review were not getting completed, in addition, the review done by nursing administration were not completed objectively. Review of the policy "Conduct Involving Patients" dated 10/13/17, revealed "the Senior Manager Department Head of the identified staff person, their designee or the RSS will: 1. Investigate the allegation of abuse, neglect, or serious misconduct using the Process Review from and 2. Complete the investigation, and 3. Document the findings and recommendations on the Process Review form within (5) business days of the original notice." . | ||||||||||
99 | 024002 | ALASKA PSYCHIATRIC INSTITUTE | 3700 PIPER STREET | ANCHORAGE | AK | 99508 | 07/19/2018 | Complaint Investigation | 2 | A0145 | Patient Rights: Free From Abuse/Harassment | 482.13(c)(3) | Standard of Participation | Y | Joint Commission | 27425 . Based on record review and interview the facility failed to ensure: 1) 1 patient (#9) was free from physical abuse; 2) 1 patient (#19) was free from sexual abuse and neglect; and 3) 2 patients (#'s 1 and 2) with allegations of abuse and/or neglect were reported to the State agency per facility policy. This failed practice resulted in 2 patients enduring abuse and/or neglect and 2 patients at risk for prolonged exposure to an unsafe environment. Findings: Patient #9 - Physical Abuse Record review on 11/27-30/18 and 12/5-6/18 revealed Patient #9 was admitted to the facility with diagnoses that included major depression and post-traumatic stress disorder (PTSD - anxiety and flashbacks triggered by a traumatic event). Further review revealed the Patient had a history of physical abuse. Review of Patient #9's medical record revealed a Brief Manual Restraint (BMR - a method where one or more staff physically hold a patient to immobilize or reduce the ability of a patient to move his/her arms, legs, body, or head freely) occurred on 11/23/18 at 9:38 pm and 5- point restraint (a method of using a mechanical device that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. 5-point restraint - 2 wrist restraint, 2 ankle restraints, and one restraint across the Patient's chest while the Patient is lying on his/her back) occurred at 10:12 pm. Camera review on 12/5/18 at 1:15 pm, of the 11/23/18 incident revealed the following non-approved NAPPI techniques used by Psychiatric Nursing Assistants (PNAs) and WEKA support staff (contract security staff hired within the facility to help with escalated situations who must comply with facility approved NAPPI hold techniques): - 9:38:00 pm - Patient #9 kissed a peer. To stop the behavior, PNA #4 placed his/her hand on Patient's forehead and pushed his/her head away from the peer. This caused the Patient to become assaultive. - 9:38:09 pm - As Patient #9 stood up, PNA #4 grabbed the Patient from behind, over his/her arms, and the PNA locked his/her arms together in front of Patient's body (hugging him/her tightly from behind). - 9:38:14 pm - Due to head butting behavior, PNA #5 was observed to grab the back of Patient #9's neck and place his/her other hand on Patient's forehead. - 9:38:27 pm - Staff attempted to walk Patient #9 to the Oak Room (a separate room in the facility for seclusion or restraint) however the Patient was able to struggle free. At 9:38:29 pm, WEKA staff #1 and PNA #5 placed Patient #9 in another BMR by placing the Patient's chest against the wall. - 9:38:31 pm - The audible comment "get [him/her] off the wall" can be heard (unknown who spoke). - 9:38:32 pm - WEKA Staff #2 grabbed Patient #9's legs as the Patient was against the wall. -9:38:36 pm - WEKA Staff #1, #2, and PNA #5 took Patient #9 to the floor in a controlled manner. Staff restrained the Patient on the floor for 6 minutes, patient positioned on his/her back and with staff on all limbs. Patient #9 walked to the Oak Room at 9:44:13 pm after other staff arrived. - 10:04:43 pm - Patient #9 became assaultive in the Oak Room, BMR on the restraint bed initiated (Patient placed on his/her back). WEKA Staff #2 was observed to place his/her right knee on Patient #9's right arm (the arm was raised, bent at 90 degrees, back of hand lying flat on the restraint bed), at the elbow and upper arm junction. The WEKA Staff #2 apply pressure with his/her knee to keep arm stationary. WEKA Staff #2 restrained the arm in this manner for 2 minutes and 15 seconds. - 10:10:54 pm - A release from the BMR was attempted, to lock Patient #9 in seclusion, however he/she became assaultive again. As BMR was re-initiated (Patient was standing), WEKA Staff #2 was observed to put his/her right hand on Patient's left facial cheek and grab the back of Patient #9's neck with his/her left hand. WEKA Staff #2 pushed the Patient's head down onto the restraint bed, forcing Patient #9 to bend over, face to bed. - 10:12:16 pm - As restraints were being placed (Patient laying on back on restraint bed), it was observed that WEKA Staff #2 leaned his/her left elbow onto Patient #9's chest and pushed down with his/her body weight to restrain Patient's shoulder and chest. During an interview on 12/5/18 at 1:30 pm, NAPPI Instructors #1 and #2 stated these non-approved techniques are not safe and should not have been used: - It is never authorized to push a Patient's head away with staff's hands, this could injure the Patient's neck. - Placing a Patient in a hug from behind could impede the Patient's breathing. - Neck holds, as seen multiple times in the camera review, are extremely dangerous and could injure the neck. - A Patient cannot be held against a wall or hard surface, as this can impede breathing. - WEKA Staff #2 increased the risk to Patient #9, as well as WEKA #1 and PNA #5 when he/she immobilized the Patient's legs as the Patient was held against the wall. This could have caused the group to trip and fall, which could have potentially caused injury. - WEKA Staff #2 increased the risk of injury to Patient #9's arm by restraining it with his/her knee. - WEKA Staff #2 increased the risk of breathing difficulty when he/she leaned onto Patient #9's chest. In addition, NAPPI Instructor #1 stated he/she completed the audit of this video on 12/2/18 at 6:30 pm and sent the report, which included the inappropriate NAPPI hold techniques, to the Chief Nursing Officer (CNO). Review of the WEKA staff work schedule, from 12/2/18 to 12/7/18, revealed the facility could not provide an account of WEKA staff #1's and #2's hours worked within the facility after the inappropriate NAPPI techniques were identified and reported. Review of the facility's policy "Seclusion and or Restraint," dated 6/1/18, revealed: "Those who apply the restraints ...and those who monitor patients while restrained ...will receive the training, and demonstrate the safe use of all approved restraint types, including physical hold techniques ..." Further review revealed: "Only NAPPI approved techniques for physical intervention will be used ...High risk considerations for ...physical or mechanical restraint(s) include ...Restraint in supine position (laying down, face up) may result in aspiration. Restraint against a wall or other vertical surface is not permitted under any circumstances. Pressure placed on the neck may result in an obstructed airway, and is prohibited. Weight placed on the back, abdomen, or chest may result in asphyxiation." Additional review of the policy revealed: "Intentional misuse of a restraint technique or any handling of a patient with more force than reasonable for a patient's proper control, treatment or management will be reported as abuse per the [Alaska Psychiatric Institute] Conduct Involving Patients policy (see P&P LD-020-13 "Conduct Involving Patient") ..." Patient #2 and Patient #19 - Sexual Assault/Abuse Record review of the Patient #2's medical record, dated 11/14/18 at 7:17 am, revealed Patient #2 self-reported inappropriate and non-consented sexual act toward Patient #19. Record review of Patient #19's medical record, dated 11/14/18 at 4:52 pm, revealed Patient #19 stated that Patient #2 did conduct an inappropriate sexual act in October 2018 after taking a nap right after lunch. During an interview on 12/5/18 at 12:33 pm Registered Nurse (RN) #13 stated the night nurse working 11/13-14/18 reported the allegation to him/her the morning of 11/14/18 that Patient #2 self-reported unsolicited sexual act toward another patient. RN #13 stated he/she interviewed both patients and substantiated the accusation by both patients' accounts. Patient #19 stated he/she didn't feel safe. RN #13 stated he/she was surprised nothing was done to separate the two patients or protect Patient #19 when reported to the night shift nurse. The RN further stated Patient #2 had a history of sexual assault in the community, as well as, diagnoses such as Schizophrenia, antisocial personality disorder and mild intellectual disability. Record review of a facility provided document entitled "Alaska Psychiatric Institute - Unusual Occurrence Report (UOR)," dated 11/14/18 at 1:30 pm, and supported documents revealed Patient #2 stated that he/she conducted an inappropriate and non-consented sexual act toward Patient #19 sometime in October 2018. This was allegedly reported to the RN #12 sometime during his/her shift from 11/13/18-11/14/18. The document indicated the facility was to call the local police (note dated 11/14/18 at 2:00 pm). Furthermore, the documented revealed on 11/14/18 at 6:00 pm, the local police arrived that day at 4:50 pm, and interviewed both patients. As a result, both patients remained in the facility. Review of Patient #2's medical record revealed the Patient was placed on 1 to 1 supervision at 5:47 pm on 11/14/18. This occurred approximately 11 hours after allegation was reported from the night nurse to the day nurse. Further review revealed the patient was moved to a different unit on 11/16/18, 2 days after the facility was aware of the allegation. Review of the facility provided policy "Patient Sexual Activity," dated 4/4/11, revealed inappropriate sexual activity included any touching of a patient in a sexual manner, with or without the patient's permission. The policy further revealed patients are not allowed to engage in sexual activity with other because patients must be protected from exploitation by others. Hospital staff members will response to every incident of reported or suspected sexual activity in order to ensure every patient is protected. Review of the facility provided policy "Response to Assaults," dated 6/1/15, revealed assaults include sexually aggressive act. In addition, when a patient to patient assault occurs the supervisor is to be notified and will immediately arrange for the continued monitoring and safety of the alleged assailant, victim, and milieu. Reporting of Allegations: Patient #1 Record review of Patient #1's medical record dated 11/11/18 revealed the Patient was experiencing multiple daily episodes of vomiting that resulted in the Patient being transferred to a local medical hospital. Further review revealed a nursing note dated 11/12/18 that stated a nurse from the medical hospital informed RN #10 that Resident #1 self-reported consuming hand sanitizer while in the exercise room over the past few days. During an interview on 11/29/18 at 12:24 pm, Patient #1 stated staff would open the door to the area off to the side of the gym so the patient could have some alone time. The patient further stated he/she would be in the room for up to 5 minutes unsupervised. When asked how many times he/she would go into the area and drink hand sanitizer, he/she stated approximately five times over the 1-2 weeks prior to his/her transfer to the medical hospital. During an interview on 11/29/18 at 1:38 pm, the Chief Nursing Officer (CNO) stated a root-cause analysis (RCA) was given to Physician #1 on 11/20/18. The CNO stated a RCA should have been conducted sooner. This alleged event was not reported to the State Agency until 11/21/18, 9 days after the facility became aware of the allegation. Patient #2 Record review of the Patient #2's medical record, dated 11/14/18 at 7:17 am, revealed Patient #2 self-reported inappropriate and non-consented sexual act toward Patient #19. Record review of Patient #19's medical record, dated 11/14/18 at 4:52 pm, revealed Patient #19 stated that Patient #2 did conduct an inappropriate sexual act in October 2018 after taking a nap right after lunch. This alleged event of unwanted sexually behavior was not reported to the State Agency until 11/16/18, 2-3 days after the facility became aware of the allegation. During an interview on 11/27/18 at 12:16 am the Chief of Operations (COO) stated the facility's Executive Team would receive UORs for review each morning. When asked how reporting of alleged abuse, neglect and malpractice occurred on the nights and weekends, the COO stated the current process of reviewing allegations is problematic on the nights and weekends. During second interview on 11/29/18 at 11:27 am the COO stated the facility could improve the review process of allegations and understood the facility was not compliant with reporting requirements. Review of the facility policy, Abuse and Neglect Prevention Policy, dated 10/31/18, revealed "If the employee making the report to the CEO, Safety Officer (SO), Nursing Shift Supervisor (NSS) or designee is a mandatory reported per Reporting requirements for Vulnerable Adults-A.S. 47.24.010 & Mandatory Reporter for Child Abuse and Neglect A.S. 47.17.020 the staff member will comply with the applicable statutes." AS 47.24.010 states: (a) Except as provided in (e) and (f) of this section, the following persons who, in the performance of their professional duties, have reasonable cause to believe that a vulnerable adult suffers from abandonment, exploitation, abuse, neglect, or self-neglect shall, not later than 24 hours after first having cause for the belief, report the belief to the department's central information and referral service for vulnerable adults: (1) a physician or other licensed health care provider; (2) a mental health professional as defined in AS 47.30.915 (11) and including a marital and family therapist licensed under AS 08.63; (3) a pharmacist; (4) an administrator of a nursing home, residential care or health care facility; (5) a guardian or conservator; (6) a police officer; (7) a village public safety officer; (8) a village health aide; (9) a social worker; (10) a member of the clergy; (11) a staff employee of a project funded by the Department of Administration for the provision of services to older Alaskans, the Department of Health and Social Services, or the Council on Domestic Violence and Sexual Assault; (12) an employee of a personal care or home health aide program; (13) an emergency medical technician or a mobile intensive care paramedic; (14) a caregiver of the vulnerable adult; (15) a certified nurse aide. (b) A report made under this section may include the name and address of the reporting person and must include (1) the name and address of the vulnerable adult; (2) information relating to the nature and extent of the abandonment, exploitation, abuse, neglect, or self-neglect; (3) other information that the reporting person believes might be helpful in an investigation of the case or in providing protection for the vulnerable adult. AS 47.17.010 states: To protect children whose health and well-being may be adversely affected through the infliction, by other than accidental means, of harm through physical injury or neglect, mental injury, sexual abuse, sexual exploitation, or maltreatment, the legislature requires the reporting of these cases by practitioners of the healing arts and others to the department. It is not the intent of the legislature that persons required to report suspected child abuse or neglect under this chapter investigate the suspected child abuse or neglect before they make the required report to the department. Reports must be made when there is a reasonable cause to suspect child abuse or neglect in order to make state investigative and social services available in a wider range of cases at an earlier point in time, to make sure that investigations regarding child abuse and neglect are conducted by trained investigators, and to avoid subjecting a child to duplicative interviews about the abuse or neglect. It is the intent of the legislature that, as a result of these reports, protective services will be made available in an effort to: (1) prevent further harm to the child; (2) safeguard and enhance the general well-being of children in this state; and (3) preserve family life unless that effort is likely to result in physical or emotional damage to the child. . | ||||||||||
100 | 024002 | ALASKA PSYCHIATRIC INSTITUTE | 3700 PIPER STREET | ANCHORAGE | AK | 99508 | 07/19/2018 | Complaint Investigation | 1 | A0154 | Use Of Restraint Or Seclusion | 482.13(e) | Standard of Participation | Y | Joint Commission | 40259 . Based on record review and interview, the facility failed to ensure 1 patient (#22), out of 30 sampled patients, was free from unnecessary restraint and/or seclusion. This failed practice violated the patient's right to be free from restraint and seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. This had the potential to effect the patient's response to treatment and increase potential risk for injury. Findings: Patient #22 Record review on 7/16-19/18 revealed Patient #22 was admitted to the facility on 6/15/18 with a diagnosis of Oppositional Defiant Disorders (a disorder in a child marked by defiant and disobedient behavior to authority figures). Record review of Patient #22's medical record on 7/17/18 at 11:45 am revealed a Brief Manual Restraint (BMR) (any manual method that immobilizes or reduces the ability of a patient to move his/her arms, legs, body, or head freely) took place on 6/18/18 at 2:26 pm. Indication for BMR was: "[Patient] on unit refocus program. [Patient] exited room and was not redirectable back to [his/her] room. [Patient] informed staff that [he/she] was afraid of [his/her] room. Staff offered the family room as an alternative refocus area. [Patient] refused. [Patient] asked to walk to the Oak Rook to work on [his/her] refocus. [Patient] refused. [Patient] placed in a BMR to assist [him/her] to Gurney and then to Oak Room. [Patient] became very elevated and fought staff throughout the BMR-Gurney-Oak Room process..." Further review revealed this BMR incident escalated patient to the point of requiring a seclusion (the act prohibiting a patient from leaving an area) for safety. During this seclusion, Patient #22 attempted to tie a sweatshirt around his/her neck. A second attempt was made with his/her pants. This prompted an increased restriction, the use of mechanical restraints (use of straps to secure patient's wrists, ankles, and chest to a bed), for safety. Review of the order for BMR, dated 6/18/18 at 2:26 pm, Licensed Individual Practitioner #1 revealed the clinical justification for the BMR was "[Patient] not redirectable from the staff hallway, [Patient] refused to walk to a safe area." During an interview on 7/19/189 at 10:25 am, Registered Nurse (RN) # #1 stated he would initiate a BMR, retraint, or seclusion if a patient was "a danger to self, danger to others, or disruptive behavior to point of creating an unsafe environment." When asked about Patient #22's BMR and subsequent seclusion and restraint, he stated it may have been "rushed." RN #1 could not state the behavior Patient #22 was exhibiting that justified the start of the restrictive measures taken by staff except to say he/she felt it was "unsafe" having Patient #22 in a unit hallway that contained some staff offices. RN #1 further stated that a patient has the right to refuse refocus. Review of the facility policy "Management of Patient Behavior", effective date 6/1/2018, revealed: "API will provide least restrictive and non-violent therapeutic environment for the care of its patients, will treat all patients with dignity and respect, and well ensure the safety and well-being of all patients, staff and visitors." The policy further revealed: "Definitions: Management of Patient Behavior: ...These procedures include de-escalation of a patient through the progression of non-verbal, verbal, and physical interventions necessary to safely and therapeutically manage a patient's behavior. As a last resort, the interventions may include seclusion, physical holds/restraint, and mechanical restraint ..." . |