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Based on observation, staff interview, and review of nationally recognized infection control standards, the provider failed to ensure staff followed accepted procedures for hand hygiene after using gloves to complete personal care for 1 of 11 sample patients (#6). The findings were:

Observation in the intensive care unit (ICU) on 7/13/10 at 8:20 AM showed RN #3 donned gloves and assisted patient #6 with perineal care. After completing care and without removing the gloves, the RN then handled her personal stethoscope, the telemetry equipment, the intravenous equipment, and the patient's gown, bedding, and walker before removing the gloves and washing her hands. During an interview on 7/13/10 at 10 AM, the infection control practitioner confirmed failure to immediately remove the gloves and perform hand hygiene before touching anything else was not acceptable practice. Review of information from the Centers for Disease Control & Prevention, October 25, 2002, Guideline for Hand Hygiene in Health-Care Settings, Recommendations of the Healthcare Infection Control Practices Advisory Committee and the ICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force revealed "...Decontaminate hands after contact with body fluids or excretions...If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands...Alternatively, wash hands with an antimicrobial soap and water..."

Based on observation and staff interview, the provider failed to ensure expired medications were not available for patient use on 2 of 3 crash carts located in the emergency department. The findings were:

During a tour of the emergency department with the clinical manager on 7/13/10 at 10:50 AM, observation revealed the crash cart in room 2-2 contained two locked medication trays, each labeled to indicate the contents included one or more medications that expired on 6/30/10. When Pharmacist #4 arrived, he opened the trays and confirmed one contained expired Vasopressor and the other contained expired Procainamide.
Immediately after removal of the trays, observation of the crash cart in room 2-3 revealed it contained another tray labeled as containing expired medications. That tray was not opened so the outdated contents were not identified. However, both the clinical manager and the pharmacist verified the expiration date on the label.

Based on medical record review and patient and staff interviews, the provider failed to ensure care plans were updated to reflect the current status for 2 of 2 sample patients (#2, #3) who had significant changes in their care. In addition, the care plans for 20 of 20 sample inpatients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20) whose records were reviewed failed to include specific interventions for various problem areas that were identified by the facility. The findings were:

1. Review of the medical record for patient #2 showed s/he was admitted on 7/8/10. The patient was healing from a left hip surgery. On this date, a care plan was developed, and showed skin integrity was identified as a problem area. The interventions to be used were not specifically listed, instead the care plan showed "protocol: 1L WOUND." Further review of the medical record showed a nurses' note dated 7/12/10 at 2:28 PM that revealed the patient developed a "small open area on the right buttock." Interview with the patient on 7/13/10 at 8:45 AM revealed s/he was able to move and re-position in bed without assistance. The patient stated staff regularly reminded her to turn and use the call bell for assistance to get up and move more; however, the patient stated s/he usually did not call them because s/he felt it took too long for staff to respond. In an interview with RN #6 on 7/14/10 at 6 PM, she revealed the protocol included a number of various interventions that the nursing staff could use. However, the care plan document failed to include a way to know which interventions were planned from the protocol, or which ones were expected to be used. Since development of the patient's new open area, staff received orders to apply xenaderm ointment. Interview with RN #2 on 7/15/10 at 12:40 PM revealed the care plan should have been updated to address all interventions and the fact that a new skin problem was identified.

2. Review of the medical record for patient #3 showed a nurses' note written on 7/11/10 at 1 PM that revealed the patient was noted to have a black bruise on his/her left great toe. The note showed that when the patient was questioned, the responses indicated abuse by one of the patient's family members. The nurse noted that this information was taken to her supervisor. Interview with the interim director of patient care services on 7/12/10 at 6:15 PM revealed they called the police and adult protective services who were conducting an investigation. The patient was moved across from the nurses' station and was put on 15 minute checks for increased supervision. The family member allegedly involved in the abuse of the patient was allowed to continue visits with supervision. Although the provider took appropriate action, there was no update made to the patient's care plan related to the increased supervision.

3. Review of the care plans for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20 revealed they were developed using an electronic record system. Based on the diagnosis, the care plans identified the problem areas for the patients and referred to various protocols. The protocols listed all interventions, whether appropriate or not, which could possibly be implemented, but there was no way to determine which were actually appropriate for the individual, which were actually being used, and which were effective. Interview with RN #6 on 7/14/10 at 6 PM, revealed the protocols consisted of a variety of interventions that could be used. The RN stated there was no way to know what interventions were planned or tried based on the format of the care plan and the lack of corroborating documentation in the nurses' notes.

Based on medical record review and staff interview, the provider failed to ensure medical records contained all pertinent information related to the health status and care needs for 4 of 23 sample patients (#1, #6, #16, #17). Advanced directives were not obtained and placed in current medical records for all 4 patients. In addition, copies of the durable power of attorney (DPOA) were unavailable for patients #16 and #17. Finally, an informed consent for blood administration was not completed properly for patient #1. The findings were:

1. Review of medical records revealed advanced directive information was lacking in each of the following records:
a. Patient #1 was admitted on 7/1/10 and the documentation indicated a family member was to bring in his/her advanced directive. The physician did discuss the patient's desires with his/her spouse, but the advanced directive was not on the record as of 7/13/10 at 9:15 AM when RN#3 reviewed the record and verified it was missing. b. Review of the admission documentation revealed staff documented that it was unknown whether patient #6 had a living will or wanted information about advanced directives. The documentation indicated the patient was not given the Wyoming Advanced Directives Pamphlet. On 7/14/10 at 1:35 PM, RN #6 confirmed the directive was not included.
c. Review of the medical records for patients #16 and #17 showed each patient had answered "yes" for having advanced directives. Further review showed there was no copy in either patient record, and the physician had not documented either patient's wishes concerning advanced directives. No explanation was documented as to why the facility failed to obtain a copy of either patient's directives. During an interview on 7/15/10 at 8:50 AM, the special projects director confirmed staff failed to obtain copies of the advanced directives for either patient or document why this failure occurred.
During the interview on 7/14/10 at 1:35 PM, RN #6 acknowledged that it looked as if staff "dropped" the issue after asking the questions related to advanced directives. She confirmed the facility needed to follow up and obtain a copy of each patient's directive.

2. Review of the medical records for patients #16 and #17 showed each patient had a DPOA. Neither record contained a copy of that information, and the physician had not documented either patient's wishes concerning advanced directives. No explanation was documented as to why the facility failed to obtain copies of the directives. During an interview on 7/15/10 at 8:50 AM, RN #6 confirmed staff failed to obtain copies of either DPOA or document why this failure occurred.

3. Medical record review showed patient #1 received a transfusion of packed red blood cells (PRBCs) on 7/8/10. Review of the consent form showed the type of blood (PRBCs, whole blood, plasma, etc.) the patient was to receive was not indicated. Furthermore, the time the consent was signed was not documented. After reviewing the consent on 7/13/10 at 9:15 AM, RN #3 confirmed it was incomplete. She stated the type of blood to be administered should have been indicated, and she confirmed that, without documenting the time the consent was signed, there was no way to know if it was signed before the blood was administered.




25745

Based on observation and staff interview, the facility failed to ensure clinical records were safeguarded against damage in 2 of 4 record storage areas. The findings were:

Observation of the clinical record storage areas on 7/14/10 at 2:30 PM revealed two storage areas where cardboard boxes filled with clinical records were stored directly on the floor. One area, referred to by the clinical records staff as the "top of the ramp" storage area, contained 57 boxes of clinical records that were directly in contact with the floor. These boxes were then stacked with additional boxes 3 to 4 rows high. During the observation, interview with the clinical records director and a clinical records technician revealed the records were stored on the floor due to a lack of space on the shelves. The second area was downstairs where there were multiple locked storage cages. In the locked area labeled "patient financial services, urgent care" there were at least 50 boxes stored directly on the floor that contained patient clinical and financial records. At that time the clinical records director confirmed that storing the records directly on the floor increased the likelihood they would be damaged.

Based on medical record review and staff interview, the facility failed to ensure comprehensive assessments for 2 of 2 swing bed patients (#8, #9) included an assessment related to activity pursuit. The findings were:

Review of the medical records for swing bed patients #8 and #9 showed they were admitted to swing bed status on 4/13/10 and 1/29/10, respectively. Review of the comprehensive assessments revealed they did not cover activity pursuits. Interview with the swing bed director on 7/14/10 at 8:30 AM confirmed the assessment conducted for swing bed patients failed to include the area of activities.

Based on medical record review and patient and staff interviews, the facility failed to develop care plans that included clear interventions to meet the needs of 2 of 2 swing bed patients (#8, #9). The findings were:

Review of the care plans for the two swing bed patients (#8 and #9) revealed the care plans lacked specific interventions to be used for the problem areas identified. Refer to C298 for further information.