HospitalInspections.org

Based on staff interview and a review of the hospital's orientation training agenda and annual Fundamentals training agenda, the hospital failed to provide staff training on mandated reporting of abuse.

Findings included:

A review of the hospital's orientation training agenda on 8/21/12,indicated that the hospital did not provide any training on mandated reporting of abuse. A review of the hospital's fundamentals annual training program on 8/21/12, revealed that the hospital did provide information on reporting domestic violence but did not provide information on reporting other abuse i.e., in hospital abuse, elder abuse, child abuse.

During interview on 8/21/12 at 11:45 A.M., the Director of Safety and the Director of Human Resources said that training on mandatory reporting of abuse was not provided in the orientation or annual fundamentals training provided by the hospital.

Based on record review and staff interview, the hospital failed to develop, review, and revise the care plan for 2 of 3 restrained, discharged patients reviewed (#47, #48), in a total sample of 33 active patients and 3 discharge patients.
Findings include:

1. Patient #47 had diagnoses of depressive disorder, anxiety, borderline personality disorder and seizure disorder, high cholesterol and osteoporosis.

The patient had a treatment plan dated 6/19/12.

On 6/19/12 at 20:00 P.M., the patient was restrained with a 4-point mechanical restraint for behavior that was a danger to self and others. At 20:40 P.M., the patient was further restrained with a chemical (medication) restraint. The treatment plan was not updated to include the use of restraints.

During interview on 8/22/12 at 11:05 A.M., the Resource Nurse on the psychiatric unit said that the care plan should include the use of restraints.

2. Patient #48 had diagnoses of schizoaffective disorder, diabetes and epilepsy.

The patient had a treatment plan dated 6/19/12.

On 6/19/12 at 15:39 P.M., the patient was restrained with a 5 minute physical hold and then a 4-point mechanical restraint for behavior that was a danger to self and others. At 15:50 P.M., the patient was further restrained with a chemical( medication) restraint. The treatment plan was not updated to include the use of restraints.

During interview on 8/22/12 at 11:05 A.M., the Resource Nurse on the psychiatric unit said that the care plan should include the use of all types of restraints.

Based on record review and staff interview, the hospital failed to obtain a physician's order for a physical hold for 2 of 3 restrained, discharged patients reviewed (#48, #49), in a total sample of 33 active patients and three discharged patients.
Findings include:

1. For Patient #48, the hospital failed to obtain a physician's order for a 5 minute physical hold.

Patient #48 had diagnoses of schizoaffective disorder, diabetes and epilepsy.

The psychiatric unit's policy for restraints indicated the following:

"Physical restraint may include only bodily holding of a patient with no more force than is necessary to limit the patient's movement."

On 6/19/12 at 15:34 P.M., the patient was restrained with a 5 minute physical hold prior to the use of a 4-point mechanical restraint for behavior that was a danger to self and others.

A review of the medical record on 8/22/12, revealed that the hospital did not obtain a physician's order for the physical hold.

During interview on 8/22/12 at 11:30 A.M., the Resource Nurse on the psychiatric unit said that the nursing staff was unaware that a physician's order for a physical hold was required.

2. For Patient #49, the hospital failed to obtain a physician's for a physical hold.

Patient #49 had diagnoses of schizoaffective disorder and alcohol abuse.

On 6/25/12 at 9:09 A.M., the patient was restrained with a physical hold while staff applied 5 point mechanical restraints and while staff administered a chemical restraint (sedating medication) for behaviors that was a danger to self and others.

A review of the medical record on 8/22/12, indicated that the hospital did not obtain a physician's order for the physical hold.

During interview on 8/22/12 at 11:30 A.M., the Director of Psychiatry said that the nursing staff was unaware that a physician's order for a physical hold was required.

Based on record review and staff interview, the hospital failed to ensure that each patient was evaluated within 1 hour after the initiation of the restraint, for 1 of 3 discharged patients reviewed (#48), in a total sample of 33 active patients and 3 discharged patients.

Findings included:
Resident #48 had diagnoses of schizoaffective disorder, diabetes and epilepsy.

On 6/19/12 at 15:34 P.M., the patient was restrained with a 5 minute physical hold prior to the use of a 4-point mechanical restraint for behavior that was a danger to self and others. Also, at 15:50 P.M., the patient was further restrained with a chemical restraint.

A review of the medical record on 8/22/12, revealed that a physician did not write a note indicating that the patient was evaluated within one hour after initiating the restraints.

During interview on 8/22/12 at 11:30 A.M., the Resource Nurse on the psychiatric unit said that sometimes the covering physicians were not always aware of the hospital protocols.

Based on record review and interview, the Hospital failed to analyze a patient safety event, involving two patients (#52 and #53), in a total sample of 53, and implement preventive action and mechanisms that include feedback and learning throughout the hospital and establish clear expectations for patient safety. Findings include:

During review of the anesthesia quality/case review minutes of 6/20/12, a case was raised for discussion with the following information: Involved a male patient undergoing an elective surgery for a total hip replacement in the early evening. The patient was intubated, and described as having a very stable intraoperative course. One hour into the case, the attending anesthesiologist was called by staff in the emergency room and asked to assist with the intubation of an adolescent in cardiac arrest. The anesthesiologist was informed it was a life or death situation, the patient was in cardiac arrest and could not be intubated. The surgeon was willing to stop operating and pack the wound. The OR circulating nurse was an experienced intensive care nurse (ICU) who stated she was comfortable watching the patient on the ventilator. The anesthesiologist had a cell phone and could return to the OR within 60 seconds but there were no other anesthesia providers in the OR or hospital. What should the ER be told?

On 8/21/12 at 11:00 A.M., during an interview, the Chief of Anesthesia said the event did occur on 5/21/12, and was discussed at length among the anesthesia providers and was due to be presented at grand rounds at the main affiliated hospital.

Circumstances, according to the interview, were as follows: The chief of Anesthesia was the attending providing anesthesia to patient #53. When the ER staff called, he told them he could not leave as he had a patient under general anesthesia. He was told by the ER staff that they had an adolescent hanging victim that could not be intubated. The anesthesiologist asked to speak with a ER physician. He said someone else got on the phone, not a physician, and said it was a matter of life or death. He stated the OR staff could tell he was torn between his obligation to the patient on the OR table and the potential life he could save in the ER (based on the information he received) and the surgeon said he could stop operating and pack the wound and supported his need to respond to the ER. The circulating nurse said she felt comfortable monitoring the patient while on the ventilator since she had been an ICU nurse and had worked with sedated, vented patients. The anesthesiologist felt comfortable with this, placed the patient on 100% oxygen and increased the inhaled anesthetic gas, desflurane, to 7%, and told the nurse to call him for anything and he would return as this patient was his first priority. The surgeon had packed the surgical wound and stopped operating and remained in the room. The Anesthesiologist went to the ER which was located on the ground floor (the OR was on the fourth floor). He said when he entered the room and assessed Patient #52, he knew immediately the patient was not viable. The ER doctor was attempting a tracheostomy which was not successful. The anesthesiologist attempted twice to intubate the patient without success due to the patient's larynx being crushed. Patient #52 died at 6:02 P.M. of self- inflicted strangulation. The anesthesiologist was gone from the OR from approximately 5:37 until 6:07 P.M. Upon his return, Patient #53 was stable and surgery was resumed.

Further interview with the anesthesiologist indicated that if he had more information about Patient #52's condition, prior to leaving the OR, he would not have left. He said that better communication may have made his decision different. He said he felt he left Patient #53 in qualified hands of the ICU nurse and the surgeon.

Asked if a root cause analysis (RCA) of the events had been done, the Chief of Anesthesia stated not by the Department of Anesthesia.

On 8/23/12 at 8:30 A.M., during an interview, the Chief Medical Officer said she was aware of the incident but was not sure anything was done such as a RCA. The CMO did agree there was room for improvement in communication between the ER and anesthesia.

Review of the Medical Staff Quality Assurance meeting minutes, dated 7/24/12, indicated that the actions of the Chief of Anesthesia were reasonable under the circumstances but failed to identify any patient safety goals or performance improvement opportunities.

Based on medical record review, interviews, and review of hospital credential files, the Hospital failed to ensure that:

(A) The scope of practice and delineation of privileges for three advanced practice Registered Nurses (Nurse Practitioner (NP) #1, Certified Registered Nurse Anesthetist (CRNA) #1 and CRNA #2) were approved by Nursing Administration and/or was in accordance with the Massachusetts Board of Registration in Nursing (BORN) Regulations for Nurses Practicing in an Advanced Practice Role (244 CMR 4.00);

(B) A Registered Nurse (RN) performed a pain Assessments for four patients, (#11, #30, #37, #38 ), in a total sample of 33 active patients who had complaints of pain; and

(C) A Registered Nurse (RN) evaluated two patients (#12, #34), in a total sample of 33 active patients for responses to as needed (prn) medication administration.

Findings included:

(A) Massachusetts Board of Registration in Nursing (BORN) Regulations for Nurses Practicing in an Advanced Practice Role (244 CMR 4.00), state the following:

According to 244 CMR 4.22(1): "All nurses practicing in an expanded role shall practice in accordance with written guidelines developed in collaboration with and mutually acceptable to the nurse and to:
(b) the appropriate medical staff and nursing administration staff of the institution employing the nurse."

According to 244 CMR 4.22(4)(a)(b): "A nurse practicing in an institution may not practice in an expanded role until:

(a) The governing body, including the medical staff and nursing administration staff of the institution, formally reviews and approves of the guidelines under which (the nurse) proposes to practice; and
(b) a Physician is designated who shall provide such medical direction as is customarily accepted in the specialty area."

"In addition to the requirements of 244 CMR 4.22(2), the guidelines pertaining to prescriptive practice shall:
(a) include a defined mechanism to monitor prescribing practices, including documentation of review with a supervising physician at least every three months;
(b) include protocols for the initiation of intravenous therapies and Scheduled II drugs;
(c) specify the frequency of review of initial prescription of controlled substances; the initial prescription of Scheduled II drugs must be reviewed within 96 hours; and
(d) conform to M.G.L. c. 94C, the regulations of the Department of Public Health at 105 CMR 700.000 et seq.., and M.G.L. c. 122, sections 80 E or 80 G, as applicable."

1. NP #1 was employed primarily in the Employee Health Unit and also conducted History and Physical Examinations on the Behavioral Health Unit. Review of the credential file of NP #1, on 8/22/12, indicated that the scope of practice and delineation of privileges for the Nurse Practitioner lacked the following:

(1) A defined mechanism to monitor prescribing practices, including documentation of review with a supervising physician at least every three months;
(2) Protocols for the initiation of intravenous therapies and Schedule II drugs;
(3) The frequency of review of initial prescription of controlled substances and the initial prescription of Scheduled II drugs, reviewed within 96 hours; and
(4) Documentation of protocol approval from Nursing Administration, although required.

3. Review of the credentialing files for CRNA #1 and CRNA #2 indicated there was no scope of practice approved by the nursing administration and the delineation of privileges was also not approved by the nursing administration as required.

During an interview with the Chief Nursing Officer (CNO), at 10:00 A.M., on 8/23/12, the CNO said that she was not aware that she or nursing administration needed to approve the Nurse Practitioner or advance practice nurse's scope of practice protocols.

(B) A Registered Nurse (RN) failed to perform a pain assessment for Patients #11, #30, #37 and #38.

1. For Patient #11, medical record review on 8/20/12, indicated that the patient presented to the Emergency Department (ED) with complaints of chest pain. The ED record indicated that the Pain Assessment portion of the record was not completed. The triage nurse did not indicate that the patient had pain, nor did she indicate the level of pain based on a scale of 1 to 10, with 1 indicating no pain and 10 indicating the most pain, as per the Hospital's pain assessment policy.

During interview with the Director of Emergency Services on 8/21/12 at 11:00 A.M., the Director said that the patient should have been assessed for pain, and that staff's compliance with ED documentation was an issue.

The Triage Nurse failed to evaluate the patient's pain, as required by facility policy.

2. For Patient #30, medical record review on 8/20/12, indicated the patient presented to the ED with chest pain. The Pain Assessment portion of the ED record was incomplete. The record lacked identification of the severity of the patient's pain level, based on a scale of 1 to 10.

3. For Patient #37, medical record review indicated that the patient presented to the ED with complaints of bilateral ear pain. During a telephone interview at approximately 11:00 A.M., on 8/21/12, the patient's significant other said that the patient went to the ED for treatment of excruciating pain in both ears, after dental surgery. The ED record lacked any pain assessment.

4. For Patient #38, medical record review on 8/21/12, indicated that the patient presented to the ED with head pain after a fall. The Pain Assessment portion of the ED record was incomplete. The record lacked identification of the severity of the patient's pain level, based on a scale of 1 to 10.

(C) An RN failed to evaluate patients' for responses to prn (as needed) medications: for Patients #12 and #34.

1. For Patient #12, medical record review on 8/20/12, indicated that the patient presented to the ED with complaints of abdominal pain. Review of physician orders indicated that the patient had a doctor's order for Morphine (pain medication) 4 milligrams (mg), intravenously (IV), prn for pain. Review of the ED medication administration record (MAR) indicated that the patient was given Morphine, 4 mg, IV at 6:42 AM and 8:10 A.M.

The medical record lacked a post medication pain evaluation to determine the effects of the pain medication, as required by Hospital policy.

During an interview with the Director of Performance Improvement (PI) at approximately 11:00 A.M., on 8/20/12, the Director of Performance Improvement (PI) said that staff were required to evaluate the effects of pain medication approximately 30 minutes to one hour after patient administration.


2. For Patient #34, medical record review on 8/21/12, indicated that the patient presented to the ED with complaints of ankle pain after a hockey injury. Review of physician orders indicated that the patient had a doctor's order for Morphine 2 milligrams (mg), intravenously (IV), at 2:00 P.M. and 3:00 P.M.

Review of the ED medication administration record (MAR) indicated that the patient was given Morphine, 2 mg, IV at 2:10 P.M. and 2:55 P.M.

The medical record lacked a post medication pain evaluation to determine the effects of the pain medication, as required by Hospital policy.

5. For Patient #19, the hospital failed to develop a care plan for back pain and an ear ache.

Patient #19 was admitted to the psychiatric unit, on 8/14/12 with diagnoses of depressive disorder, borderline personality disorder, back pain and scoliosis.

A review of the medical record on 8/21/12, indicated that the patient complained of excruciating back pain on 8/16/12. Also, the H & P dated 8/19/12 indicated that the patient was having a large amount of yellow drainage from the right ear and tenderness.

Following interview with the Psychiatric Resource Nurse, on 8/20/12 at 3:00 P.M., when treatment planning of medical issues was discussed , the Resource Nurse updated the treatment plan to include medical issues and dated it 8/21/12. She did not include the patient's problem with ear drainage and pain which the nurse practitioner was treating.

On 8/21/12 at 2:30 P.M., the Resource Nurse stated she updated the care plan on that day to be proactive in including medical issues on the treatment plan.



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10. For Patient #5, admitted post surgery on 8/20/12, the care plan lacked any interventions for identified problems.

Patient #5 had diagnoses of status post right total knee replacement, diabetes, hypertension and had a right femoral nerve block catheter in place post operatively for pain management.

Review of the Plan of Care, dated 8/20/12, listed only problems and goals but no interventions. For example; for pain, the goal was pain L3: for decreased mobility the goal was to ambulate with rolling walker 25 feet with assist of one and for post operative knee the goal was patient to be infection free vital signs will be stable with no temperature, incision will be clean and dry and will be free from falls. There was no interventions to meet these goals.

11. For Patient #4 was admitted 8/19/12 with diagnosis of Pulmonary Embolism,sacral decubiti, hypertension and anemia.

According to the emergency room records, the patient 9 out of 10 flank pain upon presentation to the ER that had been present for the last week. The patient was medicated in the ER for pain.

Although the nursing assessment done on admission to the unit indicated the patient had no pain at that time, nursing did not complete the assessment to obtain the history of pain and failed to develop a care plan for pain.

12. For Patient #3, the Hospital failed to develop a care plan for constipation, failed to monitor for constipation and failed to monitor effects of medication administered for bowels.

Patient #3, admitted 6/26/12, had admitting diagnosis of constipation and dehydration.

The admitting physician progress note, dated 6/27/12, said the patient had a large amount of stool bulging from the rectum and had to be disimpacted for "approximately 5 pounds worth of dry hard stool."

Review of the initial nursing assessment identified constipation as a problem but the Plan of Care did not identify constipation as a problem or plan any interventions to monitor or prevent further episodes. No care plan was initiated until 8/16/12, when a care plan goal for constipation was documented, that stated patient will have a Bowel movement (BM) following Miralax and Senna administration, on morning of 8/17/12.

Review of the medication administration record indicated the patient received Miralax 17 grams each day and received an as needed dose (PRN) of Senna 8.6 milligrams one tab on 8/16/12.

Review of the daily bowel book, indicated the patient had no BM on 8/14, 8/15, 8/16, 8/17 and 8/18.

Review of nursing notes on 8/19/12, indicated the patient complained of being worried about constipation and was given Milk of Magnesia 30 cc's. Patient did have a BM on 8/20/12.

13. During an interview with Director of Education, on 8/22/12, at approximately 13:00 P.M., the Director said the care plans were an issue that needed to be addressed and agreed interventions were lacking. For Pateint #3, the Director said the staff failed to do adequate monitoring of the patient's bowel activity.















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8. For Patient # 6, the hospital failed to develop a care plan that included interventions related to a diagnosis of clostridium difficile that addressed infection control issues.

Patient # 6 was admitted to the hospital on 8/10/12 with a diagnosis of pneumonia and question of clostridium difficile. A review of the Care Plan for Patient # 6 showed no evidence of specific interventions or specific goals for infection control.

9. For Patient # 9, the hospital failed to develop a care plan that included interventions to address pain management.

Patient # 9 was admitted to the hospital on 8/16/12 and underwent abdominal surgery ; exploratory laparoscopy.

A review of the Care Plan for Patient # 9 did not include any specific interventions to address pain management.



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Based on record review and staff interview the hospital failed to ensure that patients' Care Plans included all assessed active medical problems for 17 of 33 active patients( #3, #4, #5, #6, #9, #13, #14, #15, #19, #21, #22, #23, #24, #25, #26, #27, #28 ). Findings include:

1. Patient #13 was admitted to psychiatric unit on 8/19/12 with multiple medical and psychiatric diagnoses, to include asthma, melanoma, anemia and seizures ,along with the multiple psychiatric diagnoses of depression, psychosis and substance abuse.

Record review and interview with staff indicated that the care plan did not contain any interventions for active medical diagnoses, such as seizure disorder, asthma and anemia.

2. For Patient #14 , was admitted with to the psychiatric unit with diagnoses of alcohol dependence and depression as well as cataracts, gout, diabetes on 8/18/12. Record review and interview with staff indicated that the care plan did not contain any interventions for active medical diagnoses.

3. For Patient #15, was admitted to the psychiatric unit on 8/18/12 with multiple medical diagnoses to include, seizures, back pain, otitis externa and finger pain. Record review and interview with staff indicated that the care plan did not contain any interventions for active medical diagnoses.
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4. During an interview,on 8/23/12 at approximately 10:30 A.M.,, the Unit Coordinator said this was a Psychiatric Unit and they did care plan for Medical Diagnoses but after discussion with surveyor they would start to add medical issues to the care plan.



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6. Review of the Intensive Care Unit (ICU) care plans for 5 Patients (#21, 22, 25, 26, and 27) indicated the care plans were inadequate. Although the document was titled a "Care Plan," there were no identified patient problems with corresponding interventions.

During an interview with the Director of ICU on 8/20/12 at 4:10 P.M., the Surveyor asked her to specify the patient problems with the corresponding interventions. She stated that the whole sheet (referring to a form labeled care plan) is the the care plan. When the Surveyor stated that this care plan document only lists goals with no corresponding problems and interventions, the Director of ICU stated, "it does not look like there are any listed problems or interventions."



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7. For Patients #23, #24, and #28, the hospital failed to develop a care plan that included interventions related to ventilator use and pneumonia.

According to the medical records reviewed on 8/20/12, three of three patients required ventilator support. These patients also had a diagnosis of possible pneumonia. A review of the Care Plans for each of the three patients sampled revealed that neither interventions, nor specific goals were present for ventilator support or pneumonia.

Based on record review and interview, the Hospital failed to ensure that medication orders were consistent with accepted basic safe standards of practices for medication administration for 3 patients ( #5, #7 and #9 ) in a total active sample of 33, that requires the following to be confirmed before administration: the correct dose, to ensure that the dosage of the medication matches the prescribed dose and that the prescription itself does not reflect an unsafe dosage level. Findings include:

1. The Hospital has a range order policy which allows for a medication order in which the dosing interval varies over a prescribed range depending on the situation or patient's status. According to the procedure, range should not be used for time frequencies and should contain all aspects of a medication order (patient name, medication, dose, frequency, route). Dose ranges are allowed and should never exceed a factor of four. For example an acceptable order is Morphine 2-8 milligrams (mgs) every 4 hours as needed (prn) pain. Interpretation of a new range order will start at the lowest does if the patient's condition is mild to moderate in nature. If the patient's condition is severe in nature, interpretation of a new range order would start at the highest dose until the patient's condition is adequately controlled.

2. For Patient #5, the Hospital staff did not have safe narcotic administration orders for narcotic pain relievers.

Patient #5 had a total knee replacement on 8/20/12.

The post operative pain management orders, dated 8/20/12, at 16:30 P.M., read: Oxycontin 10 mg every twelve hours for 48 hours, Colecoxib 200 mg every twelve hours for 48 hours , Tylenol 650 mg every 12 hours for 48 hours and Neurontin 100 mg every 12 hours for 48 hours. May have Oxycodone 5 mg -15 mg orally every three hours for breakthrough pain. There was no pain scale written with the doses of Oxycodone to guide the nurse with which dose of Oxycodone to give. For example, if pain 1-4 out of 10, give 5 mg.

Record review indicated that on 8/20/12 at 17:30 P.M., the patient complained of 10/10 pain and received 10 milligrams of Oxycodone with a decrease in pain to 4/10. On 8/21/12 at 7:54 A.M., the patient complained of 6/10 pain and again received 10 mg of Oxycodone with a decrease in pain to 2/10.

Record review also indicated the patient had a Percocet order that read Percocet 1-2 tablets every 4-6 hours as needed. This order is against the policy for time frequencies and does not indicate which dose to administer to the patient when (one tablet for what type of pain).



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3. Patient #7 was admitted to the Hospital on 8/16/12 and underwent a Total Left Knee Replacement on that day. Post-op orders included: (8/16) Oxycodone IR , 5-15 mg. po q 3 hrs prn pain. There was no written indication for dosing based on pain level; i.e.. moderate, severe or other pain scale.

4. Patient #9 was admitted to the Hospital on 8/16/12 and underwent an exploratory laparoscopy on that day. Post-op orders dated 8/20/12 included: MS (Morphine Sulfate) 2-4 mg. IV q 2 hours prn pain. There was no written indication for dosing based on pain level; i.e., moderate, severe or other pain scale.

Based on record review and staff interview the Hospital failed to ensure that the Patient's medical records were properly filed, retained and accessible for one patient (#22) out of a total sample of 33 active patients. Findings included:

Review of the Patient #22's medical record indicated this patient had a Endoscopic Retrograde Cholangiopancreatography (ERCP) on 8/19/12, but there was no signed surgical consent in the medical record.

During an interview with RN #11 on 8/20/12 at 15:55 P.M., she stated that she signed the Surgical consent as a witness for the ERCP for Patient #22. Although RN #11 conveyed that a surgical consent was signed for Patient #22, the consent was not filed in this patient's medical record.

Based on record review and staff interview, the facility failed to ensure that the medical history and physical exam (H & P) was completed and documented within 24 hours of admission for 5 patients ( #15, #16, #17, #19 and #49) in a total sample of 33 active patients, and 3 discharged patients.

Findings included:

1. For Patient #16, the hospital failed to complete a H & P within 24 hours of admission.

Patient #16 was admitted on 8/6/12, with diagnoses of bipolar disorder and post traumatic stress disorder. The H & P was attempted on 8/11/12 and the patient refused.

2. For Patient #17, the hospital failed to complete a H & P within 24 hours of admission.

Patient #17 was admitted on 8/15/12, with diagnoses of schizoaffective disorder, delusional, asthma, diabetes and hypertension. The H & P was not completed until 8/19/12.

3. For Patient #19, the hospital failed to complete a H & P within 24 hours of admission.

Patient #19 was admitted on 8/14/12, with diagnoses of depressive disorder, borderline personality disorder, chronic back pain and scoliosis. The H & P was not completed until 8/19/12.

4. For Patient #49, the hospital failed to complete a H & P within 24 hours of admission.

Patient #49 was admitted on 6/25/12 and was discharged on 7/2/12. The patient had diagnoses of schizoaffective disorder and alcohol abuse. The H & P was not completed until 6/27/12.

5. During interview on 8/22/12 at 11:00 A.M., the Resource Nurse on the psychiatric unit stated that nurse practitioners (NP) usually did the H & P's. She stated that the summer schedule with NP's on vacation was the reason that the H & P's were not done in a timely manner.



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6. Patient # 15 was admitted on 8/07/12 with Seizures. Depression, Multiple Suicide Attempts, Neck and back pain and Otitis Externa. The History and Physical was done 08/11/12 and signed by the Psychiatrist on 8/12/12.

Based on medical record review and interviews, the Hospital failed to ensure that all patients' medical records contained complete nursing notes, patient assessments, and correct triage indexes for 4 Patients (#11, #12, #30, #36) of 33 active patients. Findings included;

1. For Patient #11, medical record review on 8/20/12, indicated that the patient was admitted for chest pain with a history of a heart attack in 2009, cardiac stents x 2, and a vein bypass in the right leg. Review of the Emergency Department medical record indicated the patient was assigned an ESI, (emergency services index which indicated the severity of condition), of 3. An ESI of 3 indicated that the patient was stable and could wait to be seen by the ED physician.

During an interview with the Director of Performance Improvement (PI) at approximately 10:00 A.M. on 8/20/12, the Director of PI said that the patient should have been assigned an ESI of 2, indicating that the patient was unstable and needed to be seen by the ED physician in a minimum of 10 minutes.

During an interview with the Medical Director of Emergency Services at approximately 10:00 A.M. on 8/20/12, the Director said that improper ESI assignment was an issue and she had multiple conversations with ED staff concerning the need for correct ESI assignments. The Medical Director said the ESI number was important because the ED physicians prioritize which patients they see first, according to ESI classification. Essentially, timely patient care could be delayed to patients with serious conditions, because of wrong ESI assignments.

2. For Patients #12, a patient with abdominal pain, Patient #30, a patient with chest pain, and Patient #34, a patient with an ankle injury, medical record review on 8/20/12 and 8/21/12, indicated the patients lacked any ESI assignments.

Based on record review and interview the Hospital failed to provide an environment for storing dirty urine collection containers for measuring urinary output, for 3 of 9 Patients (#3, #21 and #27) in the Intensive Care Unit (ICU). In addition, the Hospital failed to maintain a handwashing sink in a sanitary manner in the Central Sterile Department. Findings included:

1. Observation in the ICU on 8/20/12 at 12:24 P.M., in the Room of Patient #3, there was a dirty urine collection container for measuring urine, stored on the handwashing sink counter top (considered a clean area).

Observation in the ICU on 8/20/12 at 12:25 P.M., in the Room of Patient #21, there was a dirty urine collection container for measuring urine, stored on the handwashing sink counter top. Next to this dirty urinal was an unopened sterile package of sponges.

During an interview with RN #9 on 8/20/12 at 12:3:0 P.M., the Surveyor asked if there was a place in these patient rooms to store clean and also dirty items. She stated that there was not an area in the patient rooms to store the urine container, nor the clean supplies other than the sink counter.

2. Observation in the ICU on 8/20/12 at 16:10 P.M., in the Room of Patient #27 there was a dirty urine collection container for measuring urine stored on the handwashing sink counter top.

During an interview with RN #10 on 8/20/12 at 4:10 P.M., she stated that there were no shelves or areas to store the urine container in this Patient's Room.



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3. The hospital failed to consistently maintain a handwash/clean sink in a sanitary manner.
Findings include:

Observation in the Central Sterile Department clean area on 8/21/2012 at approximately 7:30 A.M. revealed a dehumidifying unit installed adjacent to the sink. The dehumidifier was fitted with a tube, and piped into the clean sink where condensation would drain from the dehumidifier unit. The fluid dripping into the sink did not ensure the sink could readily be sanitized.

Based on observations, interviews, and review of the Hospital's policies/procedures, logs, and employee health records, the Hospital failed to consistently ensure an acceptable level of infection prevention practice.

A. The Hospital failed to ensure that a high level disinfection (HLD) process (a cleaning process that should destroy all microorganisms, except for bacterial spores) was consistently used to reprocess semi-critical items (items that contact mucous membranes or non-intact skin) in the Imaging Departments.

The following step in the disinfection process was not performed in accordance with manufacturer's instructions:

1. Observation in the Soiled Utility Room of the Imaging Department on 8/21/12, at approximately 11:00 A.M., revealed manual high-level disinfection using an OPA product (ortho-phthalaldehyde) product was used to reprocess vaginal probes and transesophageal probe (TEE) (an instrument that is inserted through the mouth and passed into the esophagus and used to image of the heart). According to the Ultrasound and the Echocardiac Technicians, after the disinfection process, the probes were not totally immersed in a large volume of fresh water for at least one minute, and repeated immersions in fresh water for a total of three separate rinses to ensure removal of chemical residue, in accordance with manufacturer's instructions. According to the Ultrasound Technician, the probes were rinsed under running water and not immersed, as required.
Also, according to the Ultrasound Technician at the completion of the procedure, the sheaths covering the vaginal probes were discarded, and the probes were rinsed in the procedure room. However, the probes were being rinsed in the handwash sink instead of in the clinical utility sink.

Based on record review and interview the Hospital failed to have an adequate Organ & Tissue Donation Policy. This Policy did not specify the time frame of 1 hour or less for informing the Organ Procurement Organization (OPO) of a patient's death, in an effort for obtaining viable tissue/organ donations. Findings include:

Review of the OPO's agreement with the Hospital, it states under, j. "Timely referral... In case of potential donation, a timely referral is as soon as possible (with a target of within 1 hour) of asystolic death."

Review of the Hospital's policy on Cadaveric Organ and Tissue Donation, effective 6/22/12, page 2, under 3, it states, "The Attending Physician or his/her designee is responsible for timely notification to the OPO of all patients who die (tissue donation) or whose death is imminent (organ donation)."

Review of the Hospital's policy on Organ Donation after Cardiac Death, effective 6/22/12, page 2, under 3, it states. "The Attending physician or his/her designee is responsible for timely notification of the OPO of all patients who are mechanically ventilated and in whom death is imminent."

During an interview with Director of Quality on 8/22/12 at 11:00 A.M., she stated that there is no specific time frame in the OPO policies for notification of the OPO.

Based on record review and interview the Hospital failed to follow their agreement with an Organ Procurement Organization OPO) for notifying the OPO in a timely manner,of patients who have died in the hospital for 3 of 5 patient death records (#43, #45 and #52). Findings included:

1. Review of the OPO's agreement with the Hospital, it states under, j. "Timely referral... In cases of potential organ donation, a timely referral is as soon as it is anticipated that the patient may meet the criteria for imminent death as defined herein and prior to the withdrawal of any life sustaining therapies. In case of potential donation, a timely referral is as soon as possible (with a target of within 1 hour) of asystolic death."

2. Review of the discharge record of Patient #43 indicated that the Nurse's Note of 2/15/12 at 16:33 P.M, stated, "Dr. (name of the Doctor) called pt's (patients) daughter to discuss pt's worsening condition, daughter decide to make pt. CMO (comfort care). Morphine drip started, 12:30 expired."

Review of the OPO documentation indicated the OPO was notified of this Patient's death on 2/15/12 at 13:44 P.M. (1 hour and 14 minutes after this Patient's death).

3. Review of the discharged record of Patient #45 indicated the Nurses Note of 4/7/12 at 17:30 P.M. stated, "Pt (patient) CMO (comfort care) expired at 17:30 (5:30 P.M..) Dr (name of the Doctor) to speak with family."

Review of the OPO documentation indicated the OPO was notified of this Patient's death on 4/7/12 at 19:10 P.M. (1 hour and 40 minutes after this Patient's death).

4. Review of the discharge record of Patient #52 indicated the Emergency Department Report of 5/21/12 at 17:30 P.M., stated, "(This Patient was) asystolic times 30 minutes (the time of imminent death 17:00 P.M.) by ALS (advance life support)."

Review of the OPO documentation indicated the OPO was notified of this Patient's death on 5/21/12 at 18:31 P.M. (1 hour and 31 minutes after this Patient's death).

During an interview with the Director of Quality on 8/22/12 at 4:10 P.M., she verified that the OPO agreement for the 1 hour time frame notification of imminent death of the Patient was not followed.

Based on observations, record review and interview, the operating staff failed to implement policies for maintenance of the sterile surgical field for one of three operating rooms in use. Findings include:

On 8/21/12 between 8:00 A.M. and 10:30 A.M., the surveyor was observing the operating room (OR) environment with the OR resource nurse. There were four OR suites of which only three were in use.

At approximately 9:00 A.M., the surveyor looking in OR 1 and observed that the sterile field had been opened and no one was in the room. Upon entering the room with the OR resource nurse, Scrub Technician (ST) #1 entered also.

During interview, ST #1 said she had opened and set up the sterile field in anticipation of upcoming large plastic surgery. The surveyor inquired what was the hospital OR policy on leaving a sterile field unattended and the ST said someone outside the room was watching the room. The OR resource nurse said the STs are not to leave the room once the sterile field is open, in accordance with OR policy and Association of Operating Room Nursing (AORN) standards of practice which they follow.

Based on record review and interview, the Hospital failed to ensure that for two of five surgical patients (#7) and Surgical Day Care (SDC) #1), a History and Physical was updated, to include any changes in the patient's condition and is documented within 24 hours after admission or registration when the medical history and physical examination was completed within 30 days before admission or registration. Findings include:

1. For Patient # 7, the hospital failed to ensure that a History and Physical that was completed on 8/10/12 was reviewed and that the patient was examined within 24 hours prior to surgery on 8/16/12, as required .

Patient # 7 was admitted to the hospital on 8/16/12 and underwent a total left knee replacement that day, under general anesthesia.

Review of the medical record revealed that the History and Physical that was completed on 8/16/12 was not reviewed for changes prior to the patient's surgery, as required.


2. For Surgical Day Care Patient (SDC) #1, record review indicated the patient underwent a removal of a right axilla mass under general anesthesia on 8/20/12. Review of the record indicated the patient had a pre-surgical history and physical done by the surgeon on 8/12/12.

Further review indicated the H and P was not reviewed for changes, as required, within 24 hours prior to surgery.

During an interview on 8/20/12 at 11:00 A.M., the Director of Education, who accompanied the surveyor said the H and P was not done.