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Based on review of facility policy, medical record review, observation, and interview, the facility failed to follow the policy for contracted Dialysis services to obtain a weight before and after administering a hemodialysis (HD) treatment for one patient (#24) of three HD patients reviewed.

The findings included:

Review of the policy, Patient Evaluation Pre Treatment in (Named Dialysis Service) Inpatient Services revealed, "...Step 1-Obtain the patient's weight prior to treatment..."

Review of the policy, Evaluating the Patient Post Treatment in (Named Dialysis Service) Inpatient Services revealed, "...Step 9-Weigh the patient and compare to pre treatment weight...purpose is to evaluate if the patient obtained the calculated volume removal goal..."

Patient #24 was admitted to the facility on May 1, 2014, with diagnoses including Atrial Fibrillation, Bradycardia, and End Stage Renal Disease.

Observation of the patient on May 5, 2014, at 10:45 a.m., in the Acute HD Unit, during hemodialysis treatment, revealed the treatment was programmed to remove 5300 milliliters (or 5.3 kilograms/11.6 pounds of weight).

Interview with registered nurse (RN #1) in charge of the HD treatment, on May 5, 2014, at 10:45 a.m., in the Acute HD Unit, revealed the patient had dialysis in the unit on May 2, 2014. Further interview revealed an inpatient would be expected to gain no more than 3 to 3.5 kilograms from May 2 through May 5, 2014, and the RN was unable to provide an answer for the patient's weight gain (the 5.3 kilograms being removed during the May 5 treatment).

Medical record review of the "Hospital Program Hemodialysis" treatment sheet dated May 2, 2014, revealed the patient had not been weighed pre or post HD treatment.

Interview with the Nurse Manager, on May 5, 2014, at 11:15 a.m., in the break room of the acute HD unit, confirmed patients treated in the acute HD unit were to be weighed pre and post dialysis. Interview confirmed patient #24's post dialysis weight was not obtained on May 2, 2014, and it could not be determined how much weight the patient had gained between May 2, 2014, and the start of the May 5, 2014, treatment. Interview confirmed the policy to obtain pre and post weights was a critical step in acute HD treatments.

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Based on medical record review, review of facility policy, and interview, the facility failed to follow policy for reassessment of pain for one patient (#41) of sixty patients reviewed.

The findings included:

Patient #41 was admitted to the facility on May 2, 2014, with diagnoses including Wound Debridement and Colostomy Closure.

Medical record review of the nursing flowsheets and Medication Administration Record (MAR) revealed the nurse administered pain medication on May 4, 2014, at 8:07 p.m., for a pain scale of 10 (pain scale is 1-10 with 10 being the worst). Continued review revealed no re-assessment of the patient's pain or medication effectiveness was documented until May 4, at 11:45 p.m., when the patient's pain was assessed at level 6 and patient #41 was again medicated for pain.

Medical record review of nursing flowsheets and the MAR revealed the patient was medicated for pain scale of 7 on May 5, 2014, at 4:10 a.m., without a reassessment of pain or effectiveness of the medication documented following the medication administration.

Medical record review of nursing flowsheets and the MAR revealed pain medication was given on May 5, 2014, at 4:05 p.m., for a pain scale of 7 and no reassessment of the patient's pain or of the effectiveness of pain medication documented. Continued review revealed at 8:05 p.m., the patient again received pain medication for a pain scale of 9 and there was no reassessment of pain or effectiveness of the medication documented.

Medical record review of nursing flowsheets and the MAR revealed a pain assessment of 5 was documented on May 6, 2014, at 12:00 a.m., and no reassessment was documented. On May 6, 2014, at 4:15 a.m., a pain scale of 7 was documented and pain medication was given, no reassessment was documented.

Review of the facility policy "Subject: Pain Management" revised date 4/13 (April 2013), revealed "...documentation of pain score will be done...prior to each pain intervention. Pain reassessment will be done and documented..."

Interview with the Director of Critical Care and the IMCU (Intermediate Care Unit) Nurse Manager on May 5, 2014, at 10:45 a.m., at the nursing station, confirmed the pain reassessments were not documented.

Based on medical record review, policy review, and interview, the facility failed to follow facility policy for blood transfusions for one patient (#43) of sixty patients reviewed.

The findings included:

Patient #44 was admitted to the facility on February 26, 2014, with diagnoses including Dehydration and Urinary Tract Infection.

Medical record review of physician's orders dated March 25, 2014, revealed an order for two units of packed red blood cells to be transfused (blood given through a needle into a vein) that day.

Medical record review of a transfusion record dated March 25, 2014, revealed the transfusion for the first unit of packed red blood cells was started at 6:35 p.m., and was completed at 9:15 p.m. Further review of the transfusion record revealed the transfusionist (person administering the blood transfusion) and the witness (second staff person who confirms the blood product was correct) had not signed the transfusion record.

Medical record review of a transfusion record dated March 26, 2014, revealed the transfusion for the second unit of packed red blood cells was started on March 25, 2014, at 10:00 p.m. and was completed at 12:30 a.m., on March 26, 2014. Further review of the transfusion record revealed the transfusionist and the witness had not signed the transfusion record.

Review of the facility's policy titled, Blood Transfusion, last review date April 2012, revealed, "...Verify patient identification at the bedside with two licensed individuals...After verifying...the transfusionist and witness will sign the Blood Product Record at the bedside..."

Interview with the Blood Bank Director and the Nurse Manager on May 6, 2014, at 10:50 a.m., in the Three North Chart Room, confirmed the Blood Product Record for patient #44's two transfusions administered on March 25, 2014, were not signed by the transfusionist and witness. Further interview confirmed the Blood Product Record must be signed immediately by both the transfusionist and witness while at the patient's bedside prior to starting the transfusion.

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18603

Based on medical record review and interview, the facility failed to ensure the patient's record contained essential information pertinent to the patient's status for two (#6 and #13) of sixty patient records reviewed.

The findings included:

Patient #6 was admitted to the facility on December 26, 2013, following Rupture of a Cerebral Aneurysm and subsequent Subarachnoid Hemorrhage.

Medical record review of physician's notes revealed patient #6 underwent coil occlusion of the aneurysm, and developed increased intracranial pressure requiring removal of bone flap and insertion of a ventricular drain. Further medical record review revealed the patient continued to deteriorate and expired on December 27, 2013.

Medical record review of physician's notes dated December 27, 2013, revealed no documentation the patient expired, no documentation of events leading up to the declaration of death, and no documentation of pronouncement of death.

Patient #13 was admitted to the facility on April 7, 2014, with diagnoses including End Stage Renal Disease, Insulin Dependent Diabetes Mellitus, and Hypertension.

Medical record review of physician's notes dated April 8, 2014, revealed the patient suffered a cardiorespiratory arrest and suffered anoxic encephalopathy (brain injury due to lack of oxygen). Continued review of physician's notes dated April 12, 2014, revealed the patient was extubated (breathing tube removed); all medications were discontinued; comfort care was instituted; and the patient expired on April 13, 2014.

Medical record review of physician's notes dated April 13, 2014, revealed no documentation the patient expired and no documentation of pronouncement of death.

Interview with the Quality Assurance Director on May 7, 2014, at 12:10 p.m., in the Medical Record Department, confirmed there was no documentation of death by the physician.

Based on medical record review, review of medical staff rules and regulations, and interview, the facility failed to ensure discharge summaries were completed for two (#6, #13) of sixty patient records reviewed.

The findings included:

Patient #6 was admitted to the facility on December 26, 2013, following Rupture of a Cerebral Aneurysm and subsequent Subarachnoid Hemorrhage.

Medical record review of physician's notes dated December 26, 2013, revealed patient #6 underwent coil occlusion of the aneurysm, and developed increased intracranial pressure requiring removal of bone flap and insertion of a ventricular drain. Further medical record review revealed the patient continued to deteriorate and expired on December 27, 2013.

Medical record review of physician's notes dated December 27, 2013, revealed no discharge summary describing the patient's hospital course and eventual expiration.

Patient #13 was admitted to the facility on April 7, 2014, with diagnoses including End Stage Renal Disease, Insulin Dependent Diabetes Mellitus, and Hypertension.

Medical record review of physician's notes dated April 10, 2014, revealed the patient suffered a cardiorespiratory arrest and suffered anoxic encephalopathy (brain injury due to lack of oxygen). Continued review of physician's notes dated April 12, 2014, revealed the patient was extubated (breathing tube removed); all medications were discontinued; comfort care was instituted; and the patient expired on April 13, 2014.

Medical record review of physician's notes dated April 13, 2014, revealed no discharge summary describing the patient's hospital course and eventual expiration.

Review of the rules and regulations of the medical staff revealed, "...a discharge summary shall be written or dictated on all hospital medical records within 30 days after discharge of the patient..."

Interview with the Quality Assurance Director on May 7, 2014, at 12:10 p.m., in the Medical Record Department, confirmed there was no discharge summary in the medical records of patients #6 and #13.

30553

Based on observation and interview, the facility failed to ensure expired Intravenous (IV) Fluids were not available for patient use in one of thirty-one bays in the Emergency Department (ED).

The findings included:

Observation on May 5, 2014, at 10:15 a.m., in room #2 in the ED, revealed one 250ml (milliliter) bag of Normal Saline, in the cabinet where IV fluids were stored, with an expiration date of March 1, 2014.

Interview with the Nurse Manager on May 5, 2014, at 10:16 a.m., in room #2, confirmed the IV fluids were expired and were available for patient use.

Based on observation and interview, the facility dietary department failed to maintain a sanitary dietary environment, failed to store foods in a sanitary manner, and failed to maintain clean dietary food production equipment.

The findings included:

Observation and interview with the Food Service Director, Patient Service Manager, and Systems Chef, on May 5, 2014, beginning at 3:25 p.m., in dietary department confirmed the following:
1. The dish machine was in operation. One wall mounted fan was in operation on the dirty side of the dish machine and blowing directly on all dishes and other items in the area. A second wall mounted fan was in operation and blowing directly on the clean side of the dish machine, on all cleaned items coming out of the machine, and all clean items in storage units. Both wall mounted fans had a very heavy accumulation of dust and blackened colored debris on the grates blowing directly onto all contents in the dish room, potentially contaminating the cleaned items.
2. Three walk-in refrigerators had painted concrete floors. The paint was peeling or totally off the floor in the main traffic areas. The exposed concrete created an environment for potential contamination.
3. In walk-in refrigerator #2, the floor area by the back wall, under the elevated rack storing multiple cases of milk, and the interior perimeter of the refrigeration unit had a very heavy accumulation of blackened debris.
4. The three compartment sink was in operation with all sinks filled with water. The dietary staff member working at the three compartment sink dipped a plastic sheet pan, a half pan, and a utensil into and out of the sanitizer solution. The dietary staff member placed all items onto a drying station to air dry. The dietary staff member failed to totally submerge the items in the sanitizer solution per the manufacturer's recommended one to three minutes.
5. The ice machine lid, by the Tea Freezer, was closed. Inside the ice machine was an ice scoop in direct contact with the ice potentially contaminating the ice.
6. Three pans/containers in the walk-in freezer, containing Canadian Bacon, burritos, and blueberries, had a plastic wrap cover that was not secured to the pan/container therefore exposing the contents to potential contamination.

Observation and interview with the Food Service Director, Patient Service Manager, and the Systems Chef, on May 6, 2014, beginning at 10:40 a.m., in dietary department confirmed the following:
1. The two spill pans under the range top had a heavy accumulation of food debris on the top of the foil liner. Further observation revealed an accumulation of debris under the foil liner.
2. The exterior sides of the grill had a very heavy accumulation of blackened greasy debris. The left side of the grill was next to the Bain Marie containing food, in storage for warming, for meal service.
3. The large steam jacketed kettle base, next to the bank of small steam jacketed kettles, had a discoloration of debris.
4. The Cooks Cooler (reach-in refrigerator) floor had food debris and discoloration present with two stacked cardboard corrugated egg containers, and various containers of food in direct contact with the floor of the refrigeration unit.
5. The hot food production area can opener base and slot had a sticky blackened accumulation of debris.
6. The hot food production area floor mixer legs, bowl arms, and base had dried brown and white splattered debris and an accumulation of dried debris. The leg area, from the floor to the top of the curve of the leg, had a heavy accumulation of blackened debris.
7. The exterior side of the lid of the tilt skillet had an accumulation of dusty debris. Further observation revealed three stacks of inverted pans in direct contact with the dusty debris on the tilt skillet lid.
8. Filters in the hood over the grill, range top, and fryers had an accumulation of debris. Interview with the Systems Chef revealed the filters were cleaned "every two weeks."
9. The shelf over the range top/grill had an accumulation of dusty debris.

30553

Based on medical record review, observation, review of facility policy, and interview, the facility failed to follow standard infection control practices for three patients (#22, #43, and #53) of sixty patients reviewed.

The findings included:

Patient #22 was admitted to the Operating Room on May 5, 2014, for surgery with diagnoses including Right Hip Complex Wound, Exposed Right Trochanteric Femur.

Observation on May 5, 2014, at 3:40 p.m., in Operating Room (OR) #2, revealed patient #22 was being prepared for a right hip incision debridement, proximal femoral resection, and a Girdlestone (removing part of the ball or head of the thigh bone). Further observation revealed the surgery team was positioning the patient on the surgery table and sterile drapes were in place. Continued observation revealed the surgeon (physician #1) at the bedside and positioning the patient. Further observation revealed (physician #2) entered OR #2 without sanitizing the hands upon entering the room or wearing gloves. Further observation revealed physician #2 touched the open wound on the right hip, without wearing gloves, and then exited OR #2, without sanitizing the hands after touching the wound or upon exiting the room.

Review of facility policy, Isolation Policy, last revised on May 2013, revealed, "...Purpose...(named facility) has a responsibility for protecting patients and personnel from undue exposure to contagious infections in the hospital...the hospital relies upon the knowledge and sound judgment of the members of the medical staff and other health care workers to fulfill this responsibility...these individuals should be able to identify situations in which transmission of disease-causing agents is likely to occur and to carry out appropriate infection control procedures as indicated..." Further review revealed "...Standard Precautions...(C)...(1) gloves should be worn when touching fluids or areas such as non-intact skin or mucous membranes..."

Interview with the Director of Surgery on May 5, 2014, at 3:45 p.m., in the OR at the time of the observation, confirmed the physician was not wearing gloves in the surgical suite and touched the open right hip wound without wearing gloves.

Interview with the OR Nurse Manager on May 5, 2014, at 3:40 p.m., in the OR hallway, confirmed, "...I was in the room and saw the physician touch the wound without wearing gloves...the physician should have had gloves on..."

Interview with the Infection Control Nurse on May 7, 2014, at 2:40 p.m., in the Infection Control office, confirmed, "...any health care professional who is touching a wound should wear personal protective equipment and follow standard infection control practice..."

Patient #43 was admitted to the facility's Ambulatory Infusion Center on May 6, 2014, for administration of intravenous (IV, infusion of medications into a vein) medications.

Observations of Patient #43, in the infusion center, on May 6, 2014, at 11:20 a.m., revealed Registered Nurse (RN) #3 was inserting an IV needle into the patient's left arm, while wearing gloves with the right index finger of the glove removed, exposing the nurse's finger.

Interview with the Nurse Manager, on May 6, 2014, at 11:20 a.m., in the infusion center, confirmed RN #3's glove was missing the right index finger, and the nurse was starting an IV with the right index finger exposed. The Nurse Manager confirmed complete gloves must be worn by staff when starting an IV.

Interview with RN #3 in the infusion center, on May 6, 2014, at 11:21 a.m., confirmed the nurse routinely removed the index fingers of gloves when performing difficult needle sticks.

Patient #53 ws admitted to the facility on April 24, 2014, with a diagnosis of Congestive Heart Failure.

Observation of patient #53 on May 7, 2014, at 9:50 a.m., in the patient's room, revealed the patient had a PIV INT (peripheral intravenous line, intermittent needle therapy) in the right wrist covered by a clear occlusive dressing. The PIV INT was not labeled with the date or the identification of the person who inserted the PIV INT.

Review of the medical record revealed the PIV INT had been inserted on May 5, 2014, at 6:01 a.m.

Review of the facility policy number PC.NU.051 revised date 1/14 (January 2014), revealed "...The PIV site shall be labeled with the date, size of cannula and initials of person performing the insertion...dressing shall be dated and initialed..."

Interview with the Director of Clinical Services on May 7, 2014, at 9:50 a.m., confirmed the PIV INT was not labeled as per policy.

Based on medical record review, observation, review of facility protocols, and interview, the facility failed to follow the facility Chest Pain Protocol for two patients (#18, #60) of seven Emergency Department (ED) patients reviewed.

The findings included:

Patient #18 was admitted to the ED on May 5, 2014, at 10:35 a.m., with a chief complaint of chest pain. Medical record review revealed the patient was started on the chest pain protocol (specific interventions to be initiated) while in the ED.

Observation on May 5, 2014, at 11:05 a.m., in room #3 in the ED, revealed the patient was in the room lying on the stretcher and was not connected to the cardiac monitor.

Review of the facility's Chest Pain protocol, dated December 2012, revealed, "...chest pain...continuous cardiac monitor..."

Interview with the Nurse Manager on May 5, 2014, at 11:05 a.m., in the ED hallway, confirmed, "...any patient who is admitted and started on the Chest Pain protocol should be on the cardiac monitor..."

Interview with Registered Nurse (RN) #1, who was exiting the patient's room on May 5, 2014, at 11:10 a.m., revealed, "...I connected the patient to the monitor...the patient did not have electrodes on the chest and I placed the electrodes on the patient..." Further interview confirmed the patient was not on the cardiac monitor and the physician had ordered the chest pain protocol for the patient.

Patient #60 was admitted to the ED on May 6, 2014, at 8:12 a.m., with a chief complaint of chest pain. Medical record review revealed the patient was started on the chest pain protocol while in the ED.

Observation on May 6, 2014, at 11:15 a.m., in the ED nurses station, revealed patient #60 was on the tracking board (electronic patient flow board) with a chief complaint of chest pain. Further observation revealed the patient's cardiac monitor was not viewable on the nurse's station telemetry monitor (for remote monitoring). Continued observation in the patient's room (room #3) revealed the patient was connected to the cardiac monitor and the patient telemetry was viewable in the room but not at the nurse's station.

Interview with the Nurse Manager on May 6, 2014, at 11:20 a.m., in the ED nurse's station, confirmed the telemetry for patient #60 was not viewable at the nurse's station. Further interview revealed, "...not sure why that happened...the patient's rhythm should show up at the nurse's station when they are connected to the monitor in the room..." Further interview revealed, "...if the patient experienced a cardiac dysrhythmia it would sound in the room but not sure if the nursing staff would hear the alarm at the nurse's station..."