PRINTED: 09/23/2015 FORM APPROVED Indiana State Department of Health STATEMENT.OF DEFICIENCIES | (Xf) PROVIERISUPPUBRCLIA | (02) NULTIFIE CONSTRUCTION (oe) ONE SURVEY [AND PLAN OF CORRECTION entewexrionnumaer — |S sonowe COMPLETED c ‘005084 8G. 02r2ai2015 [NAME OF PROVDER OR SUPPLIER STREET ADDRESS, CITY, STATE, 1P CODE 1701 N SENATE BLVD INDIANA UNIVERSITY HEALTH NDIANAPOUE Beate 20 “SUNARY STATEMENT OF DERCIENGIES 'D FROMDERS PLAN OF CORRECTION ro Prerix | (GACH DEFICIENCY MUST BE PRECEDED BY FULL PRE (EAGNCORRECTIVEAGTION SHOULD HE — | covers TRO. | HECULATORY OR LSC IDENTIFYING NORMATION) Ke CROSSREFERENGED ToTHE APPROPRIATE | “DATE DERCIENCY $000] INITIAL COMMENTS $000 This visit was for the investigation of one (1) State complaint. Complaint Number: IN00161373 Substantiated; State deficiency wp ‘related to allegation cited 3 2 9) Date of survey: 02/28/15 through 02/24/15 58 | Facity umber, 006061 | Surveyor Jennifer Hembree RN Public Heath Nurse Surveyor | | | QA: claughlin 02/26/16 | 5 826 410 IAC 16-1.5-5 NURSING SERVICE S928 | AIO IAC 18-1.5-6 (b)(1) (b) The nursing service shall have the following: (1) Adequate numbers of licensed | registered nurses, licensed practical | nurses, and other ancillary personnel necessary fo the provision of appropriate care to all patients, as needed, to Include the immediate | availablity of a registered nurse. This RULE: is not met aé evidenced by: | Based on document review and interview, the facility filed to ensure adequate numbers of licensed and unlicensed personnel were avaitable 0 meet the needs of patients for 2 of2 patient Units (unit B7 and unit B4) and 8 of 10 patients Indiana Sao Dopartmont of Feath LABORATORY DRECTORS OR PROVIER/SUPPLIER REPRESENTATIVES SIGNATURE me ceoyonte STATE FORT FLU Weaninaalon deat Ta[NAME OF PROVIDER OR SUPPLIER INDIANA UNIVERSITY HEALTH PRINTED: axeo/201s ORM APPROVED OM NO, 0938-0991 [RyDATESURVEY ‘ABUILDING 00 ‘COMPLETED, nw 0212472015 [STREET ADRESS, CY. STATE PCO 1701 N SENATE BLVD INDIANAPOLIS, IN 46202 PRI] MULTIPLE CONSTRUCTION Bay] — SUNOMARY STATEMENT OF DEFIGENCES w aaa wr previ | (EACH DEFICIENCY MUST BE PRECEDED BY FULL prerix | ,gattenmeermexcntabais | COMPLETION, TAG __| REGULATORY OR LSC IDENTEYING INFORMATION) rag _ | SOREN DATE, ‘appropriate care to all patients, as needed, to include the immediate availabilty ofa registered nurse. Based on document review and interview, the facility failed to ensure adequate numbers of licensed and unlicensed personnel were available to ‘meet the needs of patients for 2 of 2 patient units (unit B7 and unit B4) and 8 of 10 patients medical records reviewed (patients #1, 2, 4,6, 7, 8 9 and 10). Findings include: 1, Facility policy titled "PLAN FOR PROVISION OF PATIENT CARE AND SERVICES" with an effective date of 4/13 states on page 7 of 10: "3. Each patient service department maintains a formalized staffing plan which is reviewed at least annually..." The staffing plan for unit B4 calls for an RN (registered murse)-patient ratio of 1:3 and a CPCA (certified patient care associate) of 1:12. The staffing plan for unit B7 calls for an RN:patient ratio of 1:4 and a CPCA:patient ratio of 1:8-12 patients, 2. Facility policy titled "Standard Medication Administration Times" last reviewedirevised 7/13 indicates in appendix A that standard medication administration times for twice daily is 0900 hours and 2100 hours and every 12 8926 | $926 15-1.8-6 Nursing Sorvico | 04/24/2015 Focillyfaied to ensure adequate numbers of iconsed and unlicensed personnel were available to meet the needs of patients. Corrective Action(s): 1U Health Academic Heaith Center Nursing Leadership has Feviowed and by April 24, 2015 ‘wil make revisions to policy ADM 4.85, Plan for Provision of Patient Care and Services, to appropriately reflect scopes of service and staffing parameters. IUH Methodist Nursing Leadership has inated muttipie interventions to respond to nurse slatfing needs, challenged by fluctuating patient consus and increased nursing turnover in calendar year 2014. The budget planning for nursing for 2015 was led by the CNO. Benchmarks were set athe 26th percentile for lke facilities in the Action Ol Database. A complete review of other facilities included in the financial comparison group was conducted to ensure their scopes of care and services were comparable to Methodist Hospital. Those who did not mirror the scope of service for Methodist units were exclucied. This resulted in an increase in Hours per Patient Day (HPPD) and FTE increases in the following areas: Perioperative Services, Progressive Care Units, State Form Bret ID: PILUI1 Frei. 005054 comimutin sheet Page 2 of 15DEPARTMENT OF HEALIIL AND IKUMAN SERVICES ‘CENTERS FOR MEDICARE. MEDICAID SERVICES. ‘STATEMENT OF DEEICIENCIES [Ty PROVIDERSUPFIEOCT ANDPLANOF CORRECTION [WDENTICATION NUMBER: 150058 Bw NAMEOF PROVIDER OR SUPPLIER INDIANA UNIVERSITY HEALTH HOTTIPCE CONSTRUCTION ALBUILDING 00 Rover oszwanis PORMAPPROVED ‘Onm 0. 0938-0391 ‘STREET ADDRESS, CITY, STATIN 1701 N SENATE BLVD INDIANAPOLIS, IN 46202 POY DATE SURVEY ‘COMPLIETED 92/24/2015 Ga}ID | SUMMARY STATEMENT OF DEFICIENCIES ® Sea ae aaa oy prprix | (RACH DEFICIENCY MUST BE PRECEDED BY FULL prem | gaSlelmaictacar age | coMPLETION TAG _| REGULATORY OR LSC IDENTIFYING INFORMATION) TAG. SRE ea erro DATE hour medications are administered at 0900 hours and 2100 hours. 3. Facility policy titled "DOCUMENTATION STANDARDS: INPATIENT" with an effective date of 10/12 states on page 3 of 15: "4. Vital Signs a, Record temperature, heart rate, respiratory rate, and blood pressure." Page 6 of 15 states: "C. DAILY ASSESSMENT AND CARE STANDARDS 1. Vital Signs- measure and records as ordered..." Page I of 15 states: "18. Narrative Notes A narrative note is used whenever the electronic or paper forms do not support the level documentation required to accurately and adequately capture a patient event, situation or care episode. There are two main types of narratives, Significant Events and Clinical Notes.....Clinieal Notes: wu... Verbal and telephone communication with physician related to patient's care. r Inability to perform routine nursing ate...” Page 14 of 15 states "Daily Assessment and Care Standards Timeline 1. Vital Signs, as ordered,...4. Pt position if one of following conditions is ‘met (patient is immobile, on bed rest, has a specific position ordered or a specific order for change of positions): every 2 hours." ‘and Intensive Care Units, and select Medical-Surgical Units. These exceptions were approved by the IU Health Board of Directors. Additionally, year to date 2015, careful assessment of necessary staffing levels has been ongoing and the following tactics have been deployed to maintain adequate staffing levels ‘Additional Bedside RN Positions (1/1/18 ~ 2/28/15): 85, filled, with active recruitment of 73 ‘open positions, Increase in number of orientation offerings each month to increase orientation times available, The Resource Center (nursing float pool), is in the process of hiring 30 additional full time Positions to help meet increased ‘demands throughout the hospital Premium pay: Shift bonuses (implemented in late 2014) Continue for staff in direct care areas who voluntarily sign up for overtime. Triage of facility transfers: The Administrative Associate, in conjunction with the Chief ‘Medical Officer (CMO), assesses ‘on a dally basis the available beds and staffing levels, Requested transfers from other ‘aciliies are delayed when necessary to ensure nurse staffing levele are adequate to support the needs of patients being transferred. Diversion of admissions to Beat: PILUI Stale Form scltyD 005081 ‘contain steet Page 3 of 15DEPARTMENT OF HEALTH AND HUMAN SERVICES (CENTERS FOR NORDICANE & MEDICAID SERVICES PRITED: osr20/2018 FORM APPROVED OME NO. 0938-0391 STATERERT OF DEICIENCIES” [Ty PEOVIDEROSUPPUERRTI [Oy MULTIPLE CONSTRUCTION PSVDNTESURVEY JANDPLAWOF CORRECTION IDENTIFICATION NUR A.BUILDING 00. CConPLETED 450056 3. WING 2124/2015 Sano eee ae STREET ADDIS, CTY, STAT POOL 41701 N SENATE BLVD INDIANA UNIVERSITY HEALTH INDIANAPOLIS, IN 48202 CID] SUnARARY SHA TENENT OF DIRICENCIES D Same wy REM | (EACH DEFICIENCY MUSTIE PRECEDED BY FULL rec | exccamereacnsasate | commstion ‘t4G _| REGULATORY OR1SC IDENTIFYING INFORMATION tac ERR! DATE 4, Review of staffing for unit B7 for ‘other facities: The 12/7/14 through 12/20/14 and 2/15/15 eee through 2/23/15 indicated thatthe unit Spey seaeea cinete rougt actively assesses admissions ‘was not staffed according to the staffing requested from the ED for plan. The staffing numbers included the movement to other IU Health charge nurse. On 12/7/14 the census was cee enon et. a bat 24 patients and the unit was short one (1) fades eee eevee RN on night shift. On 12/8/15 the census ‘Closure of beds: Nursing was 23 patients and the unit was short 1 leadership wil close beds in order RN and two (2) techs (there were no eee are techs working) on night shift. On “Travel nurse contracts: Travel 12/9/14 the census was 22 patients and nurse contracts are utilized in the unit was short 1 RN and | tech on units with increased vacancy or night shift. On 12/10/14 the census was ay orrecutice ar eeanialst 24 patients and the unit was short 1 RN Sf bedside stall. Currently, there ‘on night shift. On 12/11/14 the census 28 60 approved travel contracts ‘was 24 patients and the unit was short 1 at Methodist Hospital. Extensions tech on day shift and 1 RN and 1 tech on eee night shift On 12/12/14 the census was ee 24 patients and the unit was short 1 RN ‘These tactics will alleviate the ‘on night shift. On 12/14/14 the census curren sting challenges and ‘was 24 patients and the unit was short 1 will allow for re-opening of alt : closed beds by the end of July, RN on night shift, On 12/15/14 the 3018. Ona daly basis, the census was 24 patients and the unit was following actions are being short 1 RN on night shift. On 12/16/14 utilized fo continually adjust the census was 24 patients and the unit oe ieee RID GEnaTES was short | RN and I tech on night shift establishes projected sating On 12/17/14 the census was 24 patients needs for the next 24 hours, and the unit was short 1 RN and 1 tech Resource Center proactively ‘on night shift. On 12/18/14 the census works to miigate any shortages ‘was 22 patients and the unit was short 1 ice daranaeaetea tech on night shift. On 12/20/14 the shared resources internal to local census was 22 patients and the unit was U Health facilites. short | RN on night shift. On 2/15/15 the ‘Shift staffing, every four hours ste Form ent: PILUTT FesiyD: 005051 eontinnonster Page 4 of 15DEPAIREOIENT OF HEALTIE AND HUMAN SERVICES (CENTERS FOR MEDICARE. & MEDICAID SERVICES PRINTED: o52N?015 FORM APPROVED OMB NO. W938.0891, ‘STATERERT OF DERUCIENCIES [XT PROVIDERS PVT ERACTIA™ FR RIULTIPCE CONSTRUCTION PeTDATESORVEY ANDPLAN OF CORRECTION —fORNTTFICATION NUMBER ‘A.BULDING 00. comeL.enED 150056 B.wiNG o2r24i2015 ee STREETADDUESS COTY, STATE POO 4701 N SENATE BLVD INDIANA UNIVERSITY HEALTH INDIANAPOLIS, IN 46202 ‘GENT ] — SOAR STATENTENT OF DEFICIENCIES i Paces aaa or prerc | @ACHDEFICIENCY MUST BE PRECEDED BY FULL wrcmix | euSletRRanieACaSttiosts || comptznion ‘TAG _| REGULATORY OR LSC IDENTIFYING INFORMATION as itkaanct DATE ‘census was 23 patients and the unit was ‘and eight hours at night, short 1 tech on day shift and 1 RN and 1 Tanctcrenand paesed tech on night shif.. On 2/16/15 the heeds versus staff on hand and ‘census was 23 patients and the unit was ‘with submission of data tothe short 1 RIN on day shift and 2 techs on central Resource Center. night shift (there were no techs working), Managers and the house On 2/17/15 the census was 24 patients Seem 524 patients participate in a staffing call to and the unit was short 1 RN on night collectively determine the shift, On 2/21/15 the census was 18 ditto of resources ina patients and the unit was short L tech on manner that supports safe care and manages patient throughput night shift. On 2/22/15 the census was “Sthe Associate Administator 21 patients and the unit was short | tech escalates staffing concems when on night shift. On 2/23/15 the census necessary and a conference cal was 7 ; ss with clinical directors is convene nee tobest determine the allocation of and I tech on night shift. rosa eet Currently, incidents of patient fall 5. Review of staffing for unit Bd for are communicated immediately to 12/21/14 through 12/27/14 and 2/15/15 Seer ene. through 2/23/15 indicated the unit was ee OR ea eta ein not staffed according to the staffing plan. with the patient's caregivers to On 12/21/14 the census was 24 patients discuss circumstances of the fall and the unit was short | RN on day shift ered ee oa ee and I RN and 1 tech on night shift. On Semana Eis be aise 12/22/14 the census was 24 patients and the patient's medical record, an the unit was short I RN on day shift. On incident report is fled and 12/23/14 the census was 24 patients and eae aoe ie the unit was short 1 RN on day shift and Methodist B4’and B7 Unit Clinical 2RN's and 1 tech on night shift. On Managers will emphasize nursing 12/24/14 the census was 16 patients and Unit standards of care end the unit was short J tech on night shift. Ciccarelli On 12/25/14 the census was 16 patients Kelleners and the unit was short 1 tech on night posiioning, bathing, vital signs, shift. On 12/26/14 the census was 19 ‘neurological checks, appropriate patients and the unit was short { tech on ‘documentation of cinical variance sto Form Bet: PILU1 FeliyID: 006051 eontinnon shed Page § of 15YRIerED: as/2072015 DEPARTMENT OF HEALTILAND HUMAN SERVICES voRM APPROVED ‘CENTERS FOR MEDICARE & MEDICAMD SERVICES Ov NO. 0938-0391 STATEMENT OF DERTCRENCTES” Ty PROVIDERS CPACTERICTIA 0 RIOLTIPLE CONSTRUCTION POHDRTESURVEY JANDPLANOF CORRECTION fDBNTIFICATION NUMBER: ACDUILDING 00 comet 180056 awine o2na2o15 STREETADDNENS, TY STATE PO ‘NAME OF PROVIDER OR St - (MOF PROVIDER OR SUPPLIER Tih Sout INDIANA UNIVERSITY HEALTH INDIANAPOLIS, IN 46202 ‘Bai SUMMARY STATENENT OF DEFICHNCIES oy we neni | GACH DEFICIENCY MUST BI PRECEDED BY TULL REET ‘COMPLETION AG _] REGULATORY OR LSC IDENTIFYING INFORMATION) 1G DATE day shift and night shift. On 12/27/14 the ‘and nolicafion to physicians of census was 24 patients and the unit was {hat variance, e.g, blood pressure : call orders. The IUH Methodist short I RN and I tech on night shift, On Ginical Diector ofthe Medical 2/15/15 the census was 24 patients and Division will convene and chair a the unit was short 2 RNs on day shift and ‘group of staff on Be and B7 to 2. RNs and 1 tech on night shift. On itetesed sede dace 2NGNS the census was 23 patients and Monnorlig’ Te eras the unit was short | RN on dayshift and 1 compliance, beginning April 2015, RN and | tech on night shift. On 2/17/15 Methodist Clinical Managers on the census was 20 patients and the unit 4 and B7 will inate a monthly was short | fech on night shift. On ee ee : ee records. The audit will include 2/19/15 the census was 18 patients and ‘monitoring of documentation the unit was short 1 RN on day shift and related to medication 1 tech on night shift. On 2/20/15 the administration, positioning, census was 19 patients and the unit was tee eee eee short 2 techs on night shift (there were no documentation of clinical variance techs working). On 2/22/15 the census and notification to physicians of ‘was 22 patients and the unit was short 1 lace a camnctgens RN on day shift. On 2/23/15 the census Saab tame ‘was 21 patients and the unit was short 2 vith the staff on an individual techs on night shift (there were no techs basis for perfomance working) improvement. This aueit will completed for three months, with : : expectations for 90% compiance 6. Review of patient #1 medical record Orpreater, this tveshold is indicated the following: achieved, then the auditing {A) An order was written at 1641 hours Poodle a a Maumee on 12/7/14 for Heparin 5,000 units enced dhestald ietetnier subcutaneous every 12 hours. Per then consistent auciting will medication administration policy, continu until such ime that data administration times would be 0900 Se eee 7 period reflects achievernent of hours and 2100 hours for an every 12 rer titssiGLRacun cr abiee hour order, Per the medication and falls moritoring will be administration record (MAR), the included in unit quality display ‘Heparin was not administered until 2334 boards and communicated Sate Form Brea: PILUT1 FelisyID: QO5051 __‘Meontinntionskeet_ Page 6 of 15.PRIVTED: o52872015 DRPARTMENE OW HEALTH AND IUMAN SERVICES. FORM APPROVED ‘CENTERS FOR MEDICARE & MEDICAID SERVICES (0 NO. 0958-0591 ‘STATEMENT OF DEFICIENCIES [XT PROVIDTRESUPPLITRICLIA [RAF MUTUAL CONSTRUCTION ANDPLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUIDING 00 150056 NAME OF PROVIDER OR SUPPLIER INDIANA UNIVERSITY HEALTH INDIANAPOLIS, IN 46202 BVI] SORIREARY STATEMENT OF DEFICIENCIES D aay causes oo rari | (BACH DEFICIENCY MUST!BE PRECEDED BY FULL reenx | _eatleinieivencnsemedite | compuction TAG _| REGULATORY OR LSC IDENIIEVING INFORMATION) tae. ee Date hours on 12/7/14. Thvough the unit Professional Praclice Councils. Responsible 7. Review of patient #2.medical record Coan n cnanieea is indicated the following: Offiors, Statewide Regulatory (A) An order was written at 1700 hours Afairs Accreditation Specialist on 12/11/14 for Torsemide (diuretic) 80 one Direeor of Hecrediston and mg twice daily. The MAR lacked paris io ag spi documentation that the medication was implementation of changes to given on evening shift 12/12/14 ‘ADM Policy 1.85. 1U Health (B) An order was written at 0059 hours ae Clinical eee a the on 12/12/14 for Troponin (lab test) every Clinical Managers of 84 and 87 8 hours x 2 which was not drawn, Per willbe responsible for ensuring nurses notes, the error was discovered on that staf has a clear 12/13/14 at 0409 am. and the Troponin Understanding of stafing and ‘was drawn at 0627 on 12/13/14 with sete Waren ti aoteency ie resultof .05 (normal range <.03). Corrected and wil not recur. (©) The patient was transferred to unit B4 on 12/21/14 and an order was written to do neurochecks every 2 hours. Per nursing flowsheet review, the neurochecks were not performed per order. ‘The neurochecks were not conducted from 12:00-1600 hours on 12/21/14, from 1600 hours to 2000 hours, and from 2000 hours to midnight on 12/21/14, ‘The neurochecks were not conducted from 0400 hours to 12:30 pan. on 12/22/14, not conducted from 1342 houts to 1648 hours on 12/22/14, and not from 2000 hours until midnight on 12/22/14. "The neurochecks were not conducted from 0400 hours to 0800 hours on 12/23/14, and from 0800 hours to 12:00 noon on 12/23/14, and from State Form ew 1 PALUIT Faliyi: 005051 __‘evntinatien shes Page 7 of 15ranren: 437202015 DEPARTMENT OF HEALTH AND HUMANSERVICES. FORM APPROVED CENTERS FOR MEDICARE & MEDICATD SERVICES, OM NO. 0958-0391 ERTEMENT OF DEFICIENCIES” [X1) PROVIDERSUPPUTERICLIN JO} HULTIPI CONSTRUCTION POY DATESURVEY JAND PLAN OF CORRECTION. DENTIFICATION NUMBER, ‘A.BUILDING 00) ‘COMPLETED 4150056 od 212412015 STREET ADDRESS CITT 1701 N SENATE BLVD INDIANAPOLIS, IN 45202 PATE IP CODI [NAMEOF PROVIDER OX SUL INDIANA UNIVERSITY HEALTH R ‘GayIO | SUMMARY STATEMENT OF DEFICENCES B Sa gaat we PREFDC | (RACH DEFICIENCY MUST BE PRECEDED BY FULL preex | qactinnme ive scrapie | COMPLETION Ta _ | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG ‘Sec DATE, 12:00 noon fo 1825 hours on 12/23/14, 8. Review of patient #4 medical record indicated the following: (A) An order was written at 2229 hours on 2/22/15 for neurochecks every 4 hours and vital signs every 4 hours. (B) An order was written at 2233 on 2N2N15 for bedrest. (©) The medical record lacked documentation that the neurochecks were conducted per order. Per flowsheet documentation, the neurochecks were not conducted from 0900 hours-1700 hours on 2/23/15 and from 0100 hours-0700 hours on 2/24/15. (D) The medical record lacked documentation that the vital signs were obtained per order. Per flowsheet documentation, the vital signs were not taken from 0200 hours to 0742 hours on 2/23/15, were not taken from 0742 hours to 1107 hours on 2/23/15 and were not taken from 1107 hours to 1700 hours on 223/15, (B) The medical record lacked documentation that the patient was turned every 2 hours per poliey. Per nursing flowsheets, the patient was not turned from 2300 hours until 0300 hours on 22/15-223/15, was not tumed from 0300 hours until 0700 hours on 2/23/15, was not tumed from 1100 hours until 1500 hours on 2/23/15, was not turned ‘State For Bent: PALU11 FacliyID: 005051 eontimntionsheet Page 8 of 15DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED; asza/2015 ORM APPROVED ‘OM NO. O938.0301 STATEMENT OF DEFICIENCIES [1 PROVIDER SUPTTIETI ANDPLANOE CORRECTION DENTWICATION NUMBER. 1450056 NAME OF PROVIDER OR SUPHLIER. INDIANA UNIVERSITY HEALTH OTE SURVEY ‘coMPLisTED o2m4i2015 PRO) MULTIPLE CONSTRUCTION A.BUILDING — 90. 8. WING THEET ADDRESS, CTTW STAT 1701 N SENATE BLVD INDIANAPOLIS, IN 45202 TCO ‘SUMMARY STATEMENT OF DEFICIENCIES (EACH DERICENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Bom RE TAG oy PREF TAG or ‘COMPLETION DATE, nee fiom 1900 hours until 2300 hours on 2/23/15. (B) The medical record lacked documentation that the patient was bathed on 2/23/15. 9. Review of patient #6 medical record icated the following: (A) An order was written at 1612 hours ‘on 2/17/15 for vital signs every 4 hours. ‘The medical record lacked documentation that the vital signs were taken per order. Per nursing flowsheets, the vital signs were not taken from 1200 noon to 1700 hours on 2/18/15, vitals ‘were not taken from 1700 hours to 2203, on 2/18/15, and vitals were not taken, from 2203 hours to 0326 hours on 2/18/15-2/19/15 and the vitals signs were not taken from 0326 to 0844 hours on 2/19/15. 10. Review of patient #7 medical record indicated the followin; (A) An order was written at 0744 hours on 2/19/15 to call M.D. with systolic blood pressure (SBP) > 160 or < 90. (order still current on unit B7) (B) An order was written at 0816 hours ‘on 2/21/15 for Labetalol 10 mg. LV. every 4 hours pm for SBP > 180. This order was discontinued on 2/23/15 and an order written at 1334 on 2/23/15 for Labetol 10 mg LV. for SBP > 170 ot ute Form Brew: PHLUIT FactyID: 005051 __‘Teamtinmionsheet_ Page 9 of 15DEPARTMENT OF HEALTH AND HUMAN SERVICES. CENTERS FOR PRINTED: e37202015 FORM APPROVED. M15 NO. 0936.0391 ‘STATEMENT OF DEFICIENCIES” [XT] PROVIDEUSUPPUFRICLN AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER INDIANA UNIVERSITY HEALTH bavinicaTiON NUMBER 150056 OY UT TTETE CONSTRUCTION ‘A. BUILDING: BL WING 00. SET ADDRESS CY, STATE PCO 1701 N SENATE BLVD INDIANAPOLIS, IN 46202 [SY DATESORVEY ‘COMPLETED 02/24/2015 TD | _ SUNGART STATEMENT OF DUMCTNCES B aoa i) proc } (GACH DEHICIENCY MUST PRECEDED BY FULL vee | ones | coxeeiON 7AG _| REGULATORY OR LSC IDENTIFVING INFORMATION) AG SACI DATE diastolic blood pressure (DBP) > 110. Per nursing flowsheets, the patient's blood pressure was 201/123 at 0830 hours on 2/21/15, 166/110 at 2120 hours on 2/21/15, 169/110 at 0300 hours on 2/2/15, 171/100 at 0742 hours on 2/22/15, 173/100 at 2300 hours on 2/22/15, 176114 at 0200 hours on 2/23/15, 166/103 at 0755 hours on 2/23/15, and 175/110 at 0313 hours on 2MANIS. Per record review, the increased blood pressures were not reported to the physician per order. Additionally, the blood pressure of 175/110 at 0313 hours on 2/24/15 was not treated with prn (as needed) Labetalol per order. 1. Review of patient #8 medical record indicated the following: (A) An order was written at 1549 on 2/19/15 for vital signs every 4 hours. Per flowsheet review, the patients vitals were not taken from. 0300 hours to 0850 hours ‘on 2/20/15, were not taken from 1500 hours to 2000 hours on. 2/20/15, were not taken from 2000 hours to 0408 hours on 2/20/15-2/21/15, were not taken from 0200 hours to 0819 hours on 2/23/15, and were not taken from 0200 hours to 11:00 am, on 2/24/15. 12. Review of patient #9 medical record indicated the followin; (A) An order was written at 1338 hours ‘tte Farm Even ID: PALUI Filiy ID: 005051 onimation eet Page 10 of 15DEPARTMENT OF HEALTH AND HUMANSERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. PRINTED: osa02015 FORM APPROVED OM NO. 0938-0301 ‘STATEMENT OF DERCTNGIES AND PLAN OF CORRECTION I PROVDERSUPPLERCOR foe ruricATION NUMER: 150056, 'NAMEOF PROVIDER OR SUPPLIER INDIANA UNIVERSITY HEALTH TT UC TIPLE CONSTRUCTION A. BULLDING B.WING 00, 1701 N SENATE Bl OV DATESURVE' COMPLETED 02/24/2015 LV TPO: INDIANAPOLIS, IN 45202 oa PREEIX TAG. ‘SUWMARY STATEMENT OF DEFICIENCIES (EACH DEBICIENCY MUST IIE PRECEDED BY FULL REGULATORY OR SC IDENTIFYING INFORMATION) OF ‘COMPLETION DATE. Iiceneay ‘on 2/20/15 to report SBP > 180 or DBP > 100 or < 50. (B) An order was written at 12:49 p.m, ‘on 2/20/15 for vital signs every 2 hours. ‘The vital signs were not taken per order, Per nursing flowsheet, the vital signs ‘were not taken from 0400 hours to 0800 hours on 2/21/15 and not taken from (0400 hours to 0805 hours on 2/24/15. Additionally, the patients blood pressure ‘was 136/105 at 0800 hours on 2/22/15 and the medical record lacked documentation that the physician was notified per order: 13, Review of patient #10 medical record indicated the following: (A) An order was written at 12:09 p.m. on 2/20/15 for vital signs every 2 hours and an order was written at 12:1] p.m. on same date to call the M.D. if DBP <50. Per flowsheet review, the vital signs were not taken per order. The vital signs were not taken from 1600 hours to 2000 hours on 2/21/15 and were not taken from 1600 hours to 2200 hours on 2/22/15. ‘Additionally, the patient's blood pressure of 117/48 at 0200 hours on 2/21/15, 118/48 at midnight 2/21/15, 125/48 at 1500 hours on 2/22/15, and 110/45 at 2200 hours on 2/21/15 were not reported to the physician pet order. 14, Staff member #4 (Clinical State Form Brew ID: PILUTY FoeyD: 005081 eonimationsheet Page 11 of 16PRINTED: oz072015 DEPARTMENT OF HEALTH AND HUMAN SERVICES, ORM APPROVED ‘CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 938.0391 STATERENT OF DEFICIENCIES” [RT PROVIDEROSUPPLIERICLIR—] RIV MUILTTPLE CONSTRUCTION POS DATESURVET [AND PLANOF CORRECTION |iDENTHFICATION NUMBER: A.BUILDING 00 ‘COMPLETED 450056, 2. WING 92/24/2015 STREET ADDUESS, CHV, STATE, IPCODE™ 1701 N SENATE BLVD INDIANAPOLIS, IN 46202 [NAME OF PROVIDER OR SUPPLIER INDIANA UNIVERSITY HEALTH CAD] SOMIARY STATIATINT OF DEFICENCIES D URE Oy prerD¢ | (EACH DEFICIENCY MUST DB PRECEDED BY FULL rece | gaSiUBeASRSPRR | commnetion ‘TAG _| REGULATORY OR LSC IDENTIFYING INFORMATION) tag | TSR amMeye Sener DATE Tnformaties) assisted with and verified the medical record information beginning at 1:00 p.m, on 223/15. 15, Staff member #f1 (Accreditation Regulatory Specialist) verified in interview beginning at 11:40 a.m. on 2/23/15 that the staffing plans presented were the current staffing plans. 16. Staff member #5 (Clinical Manager of B7) indicated in interview beginning at 9:15 a.m, on 2/24/15 that ideally the charge nurse would not have a patient assignment. He/she indicated that the unit has remained full for the last 2 years. He/she verified the staffing sheets completed were correct and that the staffing was fess than the staffing pattern calls for. 17. Staff member #7 (RN unit B7) indicated in interview beginning at 9:50 am. on 2/24/15 that the unit is typically short staffed with both licensed and unlicensed staff and feels the staffing levels has contributed to an increase in falls. He/she indicated the unit has heavy care patients with lots of medications and patients that are total care. He/she indicated that at times medications are administered late due to staffing issues. 18. Staff member #10 (RN unit B7) sue For Bont ID: PALUI1 FeiityID: 005051 —_—_fcotinanionsteet_ Page 12 of 15DEPARTMENT OF (CENTERS FOR [ STATEMENT OF DEFICIENCIES [XT FRO AND PLAN OF CORRECTION [NAME OF PROVIDER OR SUPPLIER INDIANA UNIVERSITY HEALTH HAND HOMAN SERVICES, ICARE & MEDICAID SERVICES PRINTED: eaw01s FORM APPROVED OM NO. 0938-0991 DERISUPPUUERRCTA hneartircaTION NUMBER 180058 ‘A. AUIL Bo wiNG NG PROF MOTTTPLE CONSTR TIREET ADD 4701 N SENATE BLVD INDIANAPOLIS, IN 48202 PO) DATESURVE ‘coMPLETED 02/24/2015 00 SW sTaT opi PREEIX TAG SUMMARY STATEMENT OF DEACENGTES @ (GACH DEFICIENCY MUSTRE PRECEDED BY FULL PREFDC [REGULATORY Oi LSCIDENTIFYING INFORMATION) TAG oy COMPLETION DATE indicated in interview beginning at 10:00 a.m, on 2/24/15 that they try to schedule the unit according to the pattem, however staff members get floated to other units ‘There has been an increase in falls toward the end of 2014 and beginning of 2015 and he/she feels that staffing levels has made a difference in the fall rates. He/she indicated that medications are given late due to staffing and feels staffing is an issue on the unit. He/she {eels that charting is pushed to the side and is not as good. 19, Staff member #9 (PCA [patient care assistant] unit B7) indicated in interview beginning at 10:30 am. on 2/24/15 that the unit frequently has total care patients. He/she indicated that at times if there are only 2 techs on the unit and patients are a heavy load that itis difficult to clean patients and turn patients and there are times when patients can't get turned every 2 hours and bathed because there are only 2 techs, 20. Staff’ member #8 (RN unit B7) indicated in interview beginning at 10:45 a.m, on 2/24/15 that approximately 50% of the time he/she has a patient assignment when he/she is charge murse. He/she indicated that when he/she has had 5 patients, "things that have to be done are done” and sometimes talking to State Form Bea ID: PALUIA FeoiliyID. 005054 Ieonimaten sheet Page 13 of 18DEPAREMENE OF HI (CHNTYRS FOR MEDICARE & MEDICA IHL AND HUMAN SERVICES SERVICES, ‘STATERINT OF DEFICIENCIES AND PLAN OF CORRECTION [WANE OF PROVE INDIANA UNIVERSITY HEALTH RU PROVIDERSUPPERCT lmrrmicaTioN NuMBER 150056 ROR SUPPLIER STREET ADDRESS CHV. STATE, AP CODE 1701 N SENATE BLVD INDIANAPOLIS, IN 46202 RnvrED: asz0201s FORM APPROVED, ‘OMB NO. 0938-0391 ROVDATESURVEY CONPLSTED 02/24/2015 oD PREFIX TAG. ‘GORRARY STATEMENT OF DEFICIENCTES (EACH DEFICIENCY MUST BE PRECEDED BY FULL. [REGULATORY OR LSC IDENTIFYING INFORMATION) D PREAIX TAG Oy ‘comLTION DATE patients or teaching is rushed 21. Staff member #11 (RN unit B7) indicated in interview beginning at 11:00 am, on 2/24/15 that he/she has 5 patients today and this is typical on this unit. He/she indicated that the work gets done but is not timely. He/she indicated that the patients on this unit are heavy care patients with lots of medications ete. 22. Staff member #12 (PCA unit B7) icated in interview beginning at 11:15 aim, on 2/24/15 that usually there are 2 PCAs working on the unit and ‘occasionally there are 3. He/she is responsible for the care of twelve (12) patients today. He/she indicated that at times helshe is not able to get baths completed or patients turned and repositioned. He/she indicated that incontinent patients take priority for geiting baths. 23. Staff member #17 (interim Manager of B4) indicated in interview beginning at 2:50 p.m. on 2/24/15 that currently there are six (6) nursing vacancies on the unit. Additionally, the unit needs 3 PCAs. Has had vacancies since December. 24. Staff member #14 indicated in interview beginning at 4:00 p.m. on 2/24/15 that the unit usually has 1-3 techs sia Form BwetID: PALUIT FasltyID: 005081 Ifeontimation sheet Page 14 of 15DEPAEMENT OF HEALTH AND HUMAN SERVICES CENTERS VOR MEDICARE & MEDICAID SERVICES riven: osrana01s FORM APPROVED own NO. o938-0301, ‘STRTRMENT OF DanICTERCIES [XT PROVIDERISUPPIERICTI AND PLAN OF CORRECTION ON NUMBER: ‘NAME O¥ PROVIDER OK SUPPLIFR. INDIANA UNIVERSITY HEALTH pay A.BUILDING 00 B.WING TALE TONSTRUCTION PE DATESURVEY ‘COMPLETED 02/24/2015 STREET DOMES, CT STATE 4701. N SENATE BLVD INDIANAPOLIS, IN 46202 CHD] SONMARY STATEMENT OF DERICIENGIES D Saar ae PREFIX | (BACH DEFICIENCY MUST BE PRECEDED BY FULL rer | aE RUSNSRRS | commusrion TAG__| REGULATORY OR LSC IDENTIFYING INFORMATION) "AG ‘sane nom bare on duty. He/she indicated that medications are given but may not be on 25, Staff member #16 (Vice President (VP) and Chief Nursing Officer (CNO) verified in interview beginning at 4:15 pam, on 2/24/15 that helshe is aware of the staffing issues. Ste Form Bveat ID: PALUI1 FaciityID: 005051 _Ifeentinntionsheet_ Page 15 of 15