HospitalInspections.org

Based on record review and interview the facility failed to follow protocol for testing and adjusting 1 of 20 patient's (#18) medications.
Findings:

Patient #18 had a Partial Thromboplastin Time (PTT) test with a result of 53 on 8/11/2010 at 8:37 PM and the protocol indicates that the next PTT should be completed in 6 hours and adjustment of the heparin dosage should be completed at that time. The next documented PTT is on 8/12/2010 at 06:45 AM and the adjustment in drip rate and the ordered bolus injection of heparin were not completed until 6:45 AM

Interview with the pharmacist on 11/09/2010 at 2:00 PM reveals that she agrees that the PTT was not completed when ordered and the next required change in heparin was not completed on time.

Based on record review and interview the facility failed to ensure that all verbal orders were authenticated within 48 hours for 1 of 20 (#19) records reviewed.

Findings:

Review of the record for patient # 19 reveals that a telephone order written on 10/15/2010 at 7:50 PM was not signed by the provider until 11/10/2010.

Review of the record for patient #19 reveals that a telephone order written on 10/15/2010 at 8:40 PM was not signed by the provider until 11/10/2010.

Review of the heparin protocol for patient #19 ordered on 10/15/2010 at 7:50 PM reveals that it is not signed by the provider until 11/10/2010.

Interview with the pharmacist on 11/09/2010 at 2:00 PM reveals that she agrees the orders are not signed by the provider.

Based on observation, interview and record review the facility failed to ensure the control of infections and the spread of infections by failing to have 2 medication (med)carts properly decontaminated prior to leaving a patient's room and failed to maintain a sanitary environment during the imaging department process.

Findings:

1) Observation of 2 med nurses administering meds on the second floor and interview with the Chief Nursing Officer at 10 AM on 11/8/10, revealed that the medication carts are taken into the patients' rooms for the scanning of the patients and the medicines. When asked about cleaning of the carts after being in the room, he responded that the staff nurses clean off the cart before they leave the room.

Observation of Registered Nurse #1, on 11/8/10 at 10:20 AM, was asked when she came out of the patient room #204, if she had cleaned the cart off before she came out of the patient's room, she replied, "No". When she was asked if she knew what the policy was, she replied to wipe the cart down when they remove the medication cart from the patient room and to clean between patients.

Observation of Registered Nurse #2, on 11/8/10 at 10:35 AM, revealed her coming out of room 207 with the medication cart. When asked if she had cleaned the medication cart prior to coming out of the patient room, she replied, "No". When asked if she knew what the policy was, she replied, "No".

Review of the facility's policy revealed that under, "Policy Statement", number 2-"Patient equipment will be cleaned between EACH PATIENT use and more frequently as needed." The definition of equipment included medication carts.

Interview with Infection Control Nurse on 11/9/10 at 11:15 Am, revealed that she is aware of the incident above and is going to look at the process.



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2.) During an Imaging Department observation with the Imaging Department Director, on 11/8/10 at 1:00 PM the RF1 room imaging table had a dried liquid mark approximately 8 inches in length on the table. It was located at the position where the head is placed on the table. The imaging table located in RF2 room had debris located on the side of the table, dried liquid substance mark approximately 3 inches long, black marks on the white, hanging lead filled protection covers on the side of the table. The white, hanging protection covers had adhesive marks with various debris and substances left on them from past items taped to the vinyl covers. There were pointed, used, medical scissors left in 2 unattended rooms.

An interview with the Director of the Imaging Department on 11/8/10 at approximately 1:30 PM revealed she trains her staff to clean each table between each patient. She confirmed the tables in RF1 and RF2 rooms were not cleaned. She confirmed one of the tables had not been used that day yet so the substances were from a previous day. The other she described as a frequently used and older machine which requires a lot of care. She immediately tried to clean the white, hanging protection covers, but noted the adhesive substances would require alcohol to remove.