HospitalInspections.org

Based on observation, review of manufacturer's labels, and staff interview, the facility failed to ensure expired medications in 1 of 2 anesthesia carts were removed and not available for use. The findings were:

1. Observation with CRNA #1 on 11/3/15 at 10:20 AM revealed expired medications in anesthesia cart #1 were available for use. Review of the manufacturer's label on the expired medications revealed the following concerns:
a. Vials containing Metoprolol (anti-hypertensive), Hydralazine (anti-hypertensive), Zofran (antiemetic), and Benadryl (antihistamine) expired in 2014.
b. One vial of Esmolol (beta blocker) expired in 2013.
c. One vial of Solumedrol (glucocorticosteriod) expired in February 2015.
d. A container of Halothane (an inhalation general anesthetic) expired in 2005.

2. Interview with CRNA #1 during the observation revealed the medications should not have been available for use, but should have been discarded on the date of expiration.

Based on observation, review of policies and procedures and manufacturer's instructions, and staff interview, the facility failed to ensure acceptable infection control practices were implemented with regard to OR cleaning and OR attire. In addition, the facility failed to ensure test strips to ensure adequate high level disinfection of surgical instruments/scopes were used within timeframes established by the manufacturer. The findings were:

Related to OR attire:
1. Observation on 11/3/15 from 10:35 AM until 11:06 AM revealed housekeeper #1 cleaned OR #2 after the last scheduled case (a colonoscopy) of the day. The housekeeper wore a gown over street clothing (jeans), in addition to shoe covers and a cover for her hair. The gown hit below the knees, exposing some of the jeans. During the observation, the housekeeper got on her hands and knees on the floor to wipe some equipment, touching the jeans on the un-mopped floor. During an interview on 11/3/15 at 11:01 AM, the housekeeper stated she normally wore jeans with a gown to clean the OR. She further stated she could help out with cleaning anywhere in the hospital.

2. On 11/3/15 at 11:02 AM an outside vendor was observed going to into OR #1 wearing a gown over street clothing; the gown did not cover all of his clothing.

3. Review of the facility's policy "Operating Room Attire" (number 2150-24, reviewed 2015) revealed "All personnel entering the semi-restricted areas of the surgical suite, as defined in the policy for traffic patterns in the surgical suite, should be in OR attire...All persons should be attired in a pant suit or one piece suit and shoe covers..." However, review of the facility's policy "Procedures for Cleaning the Surgical Area" (number 3240-34, reviewed 2015) showed "Housekeeping personnel will wear cap, gown and shoe covers when cleaning in the OR area."

4. During an interview on 11/3/15 at 2:40 PM the infection control coordinator confirmed the facility's policies conflicted each other related to OR attire. She stated she had never thought about the housekeepers not wearing proper OR attire because they had always done it that way. On 11/3/15 at 3:40 PM the infection control coordinator showed the surveyor an AORN reference book and stated the facility used that for standards to follow in the OR. Review of "Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings", 2013 edition, AORN, revealed on page 92 "...Perioperative personnel entering the OR or invasive procedure room for any reason (eg, stocking supplies, bringing procedural supplies and equipment into clean rooms) should wear clean scrub attire...Surgical attire helps contain bacterial shedding and promotes environmental cleanliness." In addition, on page 121, "...Persons entering the semi-restricted or restricted areas of the surgical suite for a brief time for a specific purpose (eg, law enforcement officers, parents, biomedical engineers) should cover all head and facial hair and may don either freshly laundered surgical attire or a single-use coverall suit (eg, jumpsuit) designed to totally cover outside apparel."

Related to OR cleaning:
1. Observation on 11/3/15 from 10:35 AM until 11:06 AM revealed housekeeper #1 cleaned OR #2 after a colonoscopy. During the observation, she returned the mop into the solution in the bucket twice after using the mop on the floor. During an interview on 11/3/15 at 11:06 AM the housekeeper confirmed she returned the used mop to the solution in the bucket. She stated she had never been taught to do anything different. Review of facility policies showed no specific policy that addressed that issue. During an interview on 11/3/15 at 3:40 PM the infection control coordinator stated the facility followed AORN standards, which stated the mop should not go back into the solution after being used.

2. Review of the facility's copy of "Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings," 2015 edition, AORN, showed on page 244 "...used cleaning mops or cloths should not be returned to the cleaning solution container."

Related to test strips for high level disinfection:
1. Observation on 11/3/15 at 9:50 AM showed sterile processing tech #1 used a test strip in the solution in the Olympus OER-PRO (used for high level disinfection of scopes). Review of the opened container of Aldechek test strips for Glutaraldehyde solution showed no date when the container was opened. Review of the instructions on the container showed the test strips should not be used after 90 days of opening.

2. Observation on 11/3/15 at 8:52 AM revealed sterile processing tech #1 put an item from a scope (used in a colonoscopy) into a container of Cidex OPA (for high level disinfection). Review of the opened container of test strips for the Cidex OPA solution showed no date when the container was opened. Review of the instructions on the container showed the test strips were good for 90 days after opening.

3. During an interview on 11/3/15 at 9:55 AM sterile processing tech #1 confirmed neither container of test strips was labeled with the date opened.

Based on staff interview, medical record review, and review of policies and procedures, the facility failed to ensure staff provided the necessary assessments, monitoring, and nursing measures to ensure adequate pain management for 2 (#7, #10) of 4 sample patients who had pain. The findings were:

1. Review of the physician's history and physical for patient #10 showed the patient had surgery on 9/30/15 and was admitted for post operative care. Review of the 9/30/15 physician's orders revealed orders for pain management included intravenous scheduled Tylenol, Toradol 30 mg every 6 hours as needed (PRN), and Morphine 2 mg every hour PRN. Review of the care plan, dated 9/30/15 to 10/4/15, showed staff were directed to reassess the patient's pain level 1 hour following interventions. Review of the 9/30/15 to 10/4/15 patient progress notes, medication record, and problem activity document revealed the following concerns:
a. On 9/30/15 at 7:24 PM Morphine was administered for aching, chronic, intermittent back pain and the assessed pain level was 5 (pain level on a scale of 0 to 10 with 10 being the worst). No additional assessments were completed until more than 2 hours later at 10 PM.
b. On 10/1/15 at 12:14 AM a pain assessment was not done prior to administering Toradol; nor was it done within an hour after the medication was administered.
c. On 10/1/15 at 8:48 PM the patient's assessed pain level was 5, Toradol was administered. However an additional pain assessment to determine the effectiveness of the medication was not done.

2. Review of the physician's history and physical for patient #7 showed the patient was admitted on 8/4/15 due to injuries sustained during a fall. Review of the physician's progress notes, dated 8/4/15, showed the patient had right knee pain related to suspected internal derangement and left shoulder pain due to long standing degenerative arthritic changes. Review of the physician's orders showed intramuscular injections of Dilaudid (medication for pain) 4 mg was ordered on 8/4/15 to be administered for pain every three to four hours PRN. Further review showed oxycodone (medication for pain) 1 tablet was ordered on 8/5/15 to be administered every 4 hours PRN. Interview with the DON on 11/5/15 at 9:45 AM revealed she expected staff to use the 0 to 10 pain scale to assess the patient's pain before and within an hour after administering PRN pain medications. She further stated the nurses were expected to document this information in the patient's medical record. Review of the 8/4/15 to 8/6/15 patient progress notes, medication record, and problem activity document revealed the following concerns:
a. Pain was identified as problem in the care plan, but individualized interventions, specific non-pharmacological interventions, measurable goals, and a system for evaluating the effectiveness of the pain interventions were lacking.
b. From 8/4/15 to 8/6/15 repositioning and ice packs were applied periodically to address the patient's pain, but the effectiveness of these non-pharmacological approaches was not assessed.
c. On 8/5/15 at 2 AM Dilaudid 4 mg was administered for pain. A pain assessment was not completed within an hour after the medication was administered.
d. On 8/5/15 a pain assessment was not completed before or after Dilaudid 4 mg was administration at 4:52 AM.
e. On 8/5/15 at 7:58 AM Dilaudid 4 mg was administered for pain. This medication was assessed as ineffective at 8:30 AM and again at 10 AM. According to additional pain assessments the patient did not have effective pain relief until after receiving Dilaudid 4 mg at 11 AM.
f. On 8/5/15 at 9:09 PM Oxycodone was administered for pain. A pain assessment was not completed within an hour after the medication was administered.
g. On 8/6/15 at 6:30 AM, the patient requested and received Oxycodone. However, a pain assessment was not completed before or after the medication was administered.
h. On 8/6/15 Oxycodone was administered at 8:51 AM and again at 10:54 AM for acute stabbing pain and pain level of 9. A pain assessment was not completed after the medication was administration at 8:51 AM or 10:54 AM.

3. Review of the hospital policy on pain management, Procedure #3010-7, effective 2000, showed the following: "All patients will be assessed for presence, absence, and history of pain... "This will include such factors as description, intensity (0 -10 scale), location, aggravating and alleviating factors, signs and symptoms, impact on function ability, pain management in the past and patients goal for pain relief (0 - 10 scale)." ..."Pain intensity and pain relief will be assessed and documented" after pain management intervention once a sufficient time has elapsed for treatment to reach peak effect.

4. Interview with the DON on 11/5/15 at 8:50 AM revealed the policy and procedure did not include an initial assessment of the patient's acceptable pain level.

Based on review of policies and procedures and staff interview, the facility failed to develop policies and procedures for timing of medication administration, missed or late administration of medication, and assessment and monitoring of patients receiving medications. The findings were:

1. Review of policies and procedures revealed none had been developed that addressed acceptable standards of nursing practice for medication administration in the following areas:
a. Timing of medication administration, based on the nature of the medication and its clinical application, to ensure safe and timely administration.
b. Actions to be taken when medications eligible for scheduled dosing times are not administered within their permitted window of time.
c. Identified parameters within which nursing staff are allowed to use their own judgement regarding the rescheduling of missed or late doses and when notification of the practitioner responsible for the care of the patient is required prior to doing so.
d. Manner and frequency of monitoring, considering patient and drug risk factors, are determined and the information to be communicated at shift changes, including the facility's requirements for the method(s) of communication.
e. Monitoring and treatment for fluid and electrolyte imbalances that may occur with blood transfusions and intravenous medications.

2. During interviews with the pharmacist on 11/4/15 at 10:30 AM and the DON on 11/4/15 at 10:45 AM, both verified the lack of the above required policies and procedures.

Based on medical record review and staff interview, the hospital failed to ensure care plans were individualized, complete with measurable goals, and periodically evaluated for 1 of 20 sample patients (#7). The findings were:

1. Review of the 8/4/15 physician's note for patient #7 showed the patient had an acute fall injury resulting in shoulder and knee pain. Review of the 8/4/15 to 8/6/15 physician's orders showed Oxycodone and Dilaudid were ordered as needed for pain. Review of 8/4/15 - 8/6/15 the nursing notes showed the patient received pain medication 15 times and various non-pharmacological interventions during that time. Further review revealed inconsistent pain assessments and documentation regarding the effectiveness of medications and non-pharmacological interventions. Review of the care plan showed pain was identified as a problem. However, further review revealed the lack of individualized interventions, identified non-pharmacological interventions, measurable goals, and a system for evaluating the effectiveness of the nursing interventions for pain. During an interview on 11/5/15 at 10 AM the DON acknowledge the care plan was not individualized and should have included the above elements.
2. Review of Smith, Duell, and Martin, "Clinical Nursing Skills," Seventh Edition, 2012, Chapter 3, "Managing Client Care" showed, "...care plans are an integral part of providing nursing care. Without them, quality and consistency of client care may not be obtained."

Based on observation and staff interview, it was determined the facility failed to protect medical records from unauthorized access in medical record storage areas (C308). This system failure resulted in the inability of the hospital to meet the necessary requirements for the Medical Records Condition of Participation.

Based on observation and staff interview, the facility failed to ensure medical records were protected from unauthorized access in 6 of 6 rooms where medical records were stored. One room was unlocked and the other rooms were accessible to staff that did not have a need to access medical records (maintenance staff). The findings were:

1. Observation of the radiology department with the manager on 11/3/15 at 4 PM revealed one room in the department was used to store radiology personal health information files and reports. Further observation revealed non-employees and ancillary department employees could walk through the reception desk area to access the unlocked file storage room when staff were not at the reception desk. Interview with the manager on 11/5/15 at 8 AM verified this accessibility. At that time he stated the door to the room containing the files was never locked; and access to the room was not limited. He further stated approximately 4500 files and reports, ranging from 5 to 18 years old, were stored in the room.

During an interview on 11/4/15 at 1:50 PM the medical records manager stated radiology films and reports were considered confidential medical record information and should be locked up. She stated she was not aware that the radiology department had medical record information in an unlocked room.

2. Observations on 11/4/15 at 1:50 PM with the medical records manager and on 11/5/15 at 8:25 AM with the maintenance director revealed the following areas where medical records were stored:
a. The medical records storage room in the medical records office contained 23 cabinets with 6 shelves each. The door to the room had a key pad to enter a code.
b. A storage room with a total of 17 shelves on the main level of the hospital contained medical records. The door was locked and required a key to open.
c. There was a room in the basement that required a key to unlock. Inside the room there was over 20 boxes of medical record information. In addition, within the room there were two interior doors that required another key to unlock; both rooms contained medical record information.

During an interview on 11/4/15 at 1:50 PM the medical records manager stated that in addition to medical records staff and some nursing staff, she believed the maintenance director also had a "master key" to access all of the rooms where medical records were stored.

On 11/5/15 at 8:25 AM the maintenance supervisor took the surveyor to each medical records storage room and was able to unlock the door with a key. Interview with him at that time revealed he had a key to each room because he needed access to the fire alarm system components.

Based on review of employee files, staff interviews, and review of policies and procedures, the facility failed to ensure the nurse aide registry was checked prior to hire for 8 of 8 certified nurse aides (CNAs) reviewed (#1 through #8). The findings were:

CNAs #1 through #8 employee files were reviewed on 11/4/15 at 10:55 AM. Of the 8 files reviewed, all lacked evidence to show the facility had checked the nurse aide registry prior to hiring the individuals. Interview with the Human Resources Director during review of the files revealed the nurse aide registry check had not been done for any of the CNAs currently employed and the facility did not have a policy and procedure that addressed this process. At that time she further stated she had not known this was a regulatory requirement for swing-bed facilities.

Based on medical record review and staff interview, the facility failed to ensure care was provided in accordance with the written plan of care for 1 of 2 swing bed patients (#23). The findings were:

Review of the care plan for swing bed patient #23 revealed staff were instructed to administer analgesic medication as scheduled and to "reassess pain level 1 hour following interventions." Review of the medical record on 11/5/15 at 9:16 AM with IT (information technology) staff #1 revealed the following examples of when pain was not reassessed within an hour after administration of PRN (as needed) pain medication:
a. On 9/19/15 at 12:58 PM the patient was given 1 tab of Hydrocodone/acetaminophen 5/325 milligrams (mg). There lacked a reassessment of pain to determine the effectiveness of the medication.
b. On 10/23/15 at 4:40 AM the patient was given a 1/2 tab of Hydrocodone/acetaminophen 5/325 mg for pain at a level "7" (on a scale of 0 to 10). There was no reassessment of pain in one hour. At 6:50 AM the patient's pain was still a "7" so staff administered 500 mg of Tylenol.

During an interview on 11/5/15 at 9:16 AM IT staff #1 confirmed that the care plan was not followed with regard to reassessing pain after administering PRN pain medications.