HospitalInspections.org

Based on facility policy review, medical record review, and interview, the facility failed to ensure an advanced directive status was accurate for one Patient (#3) of 36 patients reviewed.

The findings included:

Review of a facility policy, Advance Directives, last revised 4/18/13 revealed "...documents in each adult individual's medical record whether or not the individual has executed an Advance Directive...When the patient has designated through an Advanced Directive that he/she does not desire extraordinary life support measures or resuscitative measures such as cardiopulmonary resuscitation...Advance Directives may be any of the following...POST form (Physician Order for Scope of Treatment)..."

Medical record review revealed Patient #3 was admitted to the facility from an Assisted Living Facility on 9/16/16 with a diagnosis of Altered Mental State and Urinary Tract Infection.

Medical record review of a "Record of Admission" [patient admission demographic form] dated 9/16/16 revealed the advance directive status was marked "No" [patient did not have an advance directive]. Further review revealed the patient's medical record contained a copy of a completed POST form dated 8/13/13, which indicated the patient was a "...Do Not Attempt Resuscitate (DNR)...Comfort Measures..."

Interview with the Chief Compliance Officer on 9/19/16 at 9:30 AM, at the Medical Surgical (M/S) Nursing Station, confirmed the record of admission indicated the patient did not have an advance directive.

Interview with Registered Nurse #1 on 9/19/16 at 9:37 AM at the M/S Nursing Station revealed Patient #3 is a "full code."

Interview with the Admitting Supervisor on 9/21/16 at 8:50 AM, in the conference room, confirmed the patient was a DNR and the advance directive status was incorrect.

Based on review of facility policy, review of Position (Job) Descriptions, review of personnel files, and interviews, the facility failed to maintain qualified nurses in 1 (#3) of 5 personnel files reviewed.

The findings included:

Review of the Position Description for Emergency Department (ED) Registered Nurse (RN), effective date 4/1/08, revealed "...Regulatory Requirements...PALS [Pediatric Advance Life Support]..."

Review of RN #3's personnel file revealed she was hired in 2005, and worked in the ED. Further review of the personnel file revealed RN #3's PALS certification expired "...08-06-2016..." and there was no current PALS certification in the personnel file.

Interview with the Nursing Coordinator on 9/21/16, at 11:30 AM, in the conference room, confirmed ED nurses are required to be PALS certified and RN #3 was not currently certified in PALS.


36450

Based on review of facility policy, medical record review, and interview, the facility failed to ensure telephone orders were authenticated by the physician for 2 patients (#23, #24) of 36 medical records reviewed.

The findings included:

Review of facility policy Medication Prescribing-Verbal Orders/Telephone Orders, last revised 6/2011, revealed "...all orders dictated over the telephone shall be signed...the verbal order shall be authenticated at the time of chart completion and not later than thirty days post discharge..."

Medical record review revealed Patient #23 was admitted to the facility on 3/13/16 with diagnoses including Near Syncope, Dehydration, and Urinary Tract Infection (UTI). Further review revealed the patient was transferred to an another acute care facility on 3/14/16.

Medical record review of a Physicians Order sheet dated 3/14/16 at 9:00 PM revealed "...transfer pt. [patient] to [named acute care facility] via [by] [named aeromedical service]..." Continued review revealed the physician had not signed the telephone order.



36003

Medical record review revealed Patient #24 was admitted to the facility on 3/3/16 with diagnoses including Acute Chronic Obstructive Pulmonary Disease Exacerbation, Congestive Heart Failure, and Shortness of Breath. Continued review revealed the patient was transferred to another acute care hospital on 3/5/16.

Review of a Physician's Order revealed a telephone order dated 3/5/16 at 8:30 AM "...Transfer to [named acute care hospital] via ALS [Advanced Life Support] Emergency Traffic Ambulance..." Continued review revealed the physician had not signed the telephone order.

Interview with the Chief Compliance Officer (CCO) on 9/20/16 at 4:15 PM, in the CCO's office, confirmed the facility failed to ensure telephone orders were authenticated by the physician and failed to follow facility policy.

Based on facility policy review, medical record review, and interview, the facility failed to complete a transfer consent form for 1 patient (#25) of 3 patients reviewed for transfers and failed to document physician notification of a death for 1 patient (#33) of 2 death records reviewed.

The findings Included:

Review of the facility policy, Death Determination & Pronouncement by a Registered Nurse, dated 7/1/15 revealed "...the RN [Registered Nurse] ensures...documentation in a progress note...RN writes...patient has no spontaneous pulse...no spontaneous respiration AND...the patient was declared dead by the RN...RN contacts the attending physician...notify him/her...patient is deceased and obtains a telephone order from the physician...to transfer the body to the funeral home...in the physician order...RN also includes the date and time that the patient was pronounced deceased..."

Medical record review revealed Patient #25 was admitted to the facility on 4/13/16 with diagnoses including Unstable Angina, Chest Pain, and Elevated Cardiac Enzymes.

Medical record review of a progress note dated 4/13/16 revealed "...pale...diaphoretic...pt [patient] c/o [complain of] chest pressure...nitro [medication to prevent episodes of chest pain] given x [times] 3...MD [medical doctor] called...c/o pain...prepaing [preparing] pt for transfer...picked up by [helicopter emergency medical services]..."

Medical record review revealed the record did not contain a transfer consent form.

Interview with the Chief Nursing Officer on 9/20/16 at 3:12 PM, in the conference room, confirmed the facility failed to complete a transfer consent form.

Medical record review revealed Patient #33 was admitted to the facility on 5/17/16 with diagnoses including Pneumonia, Hypernatremia, Acute Renal Failure, Alzheimer's Disease, and Dementia.

Medical record review of a Physicians Progress Note dated 5/20/16 revealed "...comfort measures...d/w [discussed with] family..."

Medical record review of a Patient Progress Note dated 5/21/16 at 3:21 AM revealed "...Pt (patient) lying in bed resting. No needs at this time..." Continued review of a progress note at 3:30 AM revealed "...vital signs...temperature...101...axillary..."

Medical record review of the Death Record Form (completed by an RN) dated 5/21/16 revealed "...Pronounced...4:57 [AM]..." Further medical record review revealed no documentation of a physician order for the RN to determine and pronounce the death of Patient #33 and the physician had not been notified upon the patient's death. Continued review revealed no documentation of the patient having no spontaneous pulse and respirations. Further review revealed an order had not been obtained to release Patient #33's body to the funeral home.

Interview with the Chief Nursing Officer on 9/20/16 at 3:08 PM, in the conference room, confirmed the facility failed to document MD notification of a death, failed to document the patient's pulse and respirations, failed to obtain an order to release the patient's body, and failed follow facility policy.

30553

Based on facility policy review, medical record review, and interview, the facility failed to ensure a discharge summary was complete within 30 days for 5 patients (#28, #34, #29, #27, and #31) of 23 records reviewed.

The findings included:

Review of a facility policy, Incomplete Medical Records, last revised 5/23/16 revealed "...Medical records shall be completed promptly and authenticated...within 30 days following a patient's discharge..."

Medical record review revealed Patient #28 was admitted to the facility on 3/5/16 with diagnoses of Acute Abdominal Pain, Nausea, Gastroenteritis and Colitis, Pneumonia, and Dehydration. Further review revealed the patient was discharged on 3/7/16. Continued review revealed the discharge summary was electronically signed by the Advanced Practice Nurse (APN) on 4/27/16 and the physician on 4/27/16 (51 days after discharge).

Medical record review revealed Patient #34 was admitted to the facility on 3/23/16 with diagnoses of Jaundice, Hepatic Failure, Acute Cholecystitis, Viral Hepatitis C, and Dehydration. Continued review revealed the patient was discharged 3/26/16. Further review revealed the discharge summary was electronically signed by the APN on 5/14/16 (50 days after discharge).

Medical record review revealed Patient #29 was admitted to the facility on 5/1/16 with diagnoses of Abdominal Pain, Nausea, Diabetes Mellitus Type 2, and Delusions. Continued review revealed the patient was discharged on 5/2/16. Further review revealed the discharge summary was electronically signed by the Phsyician on 6/26/16 (55 days after discharge).

Medical record revealed Patient #27 was admitted to the facility on 5/30/16 with diagnoses of Weakness and Dehydration. Further review revealed the patient was transferred to another acute care facility on 5/30/16. Continued review revealed the discharge summary was electronically signed by the Nurse Practitioner (NP) on 7/14/16 at 2:34 PM (45 days after discharge).

Medical record review revealed Patient #31 was admitted to the facility on 7/25/16 with a diagnosis of Acute Gastroenteritis. Continued review revealed the patient was discharged on 7/26/16. Further review revealed the discharge summary was electronically signed by the APN on 9/20/16 and the physician on 9/20/16 (56 days after discharge).

Interview with the Director of Medical Records on 9/20/16 at 2:07 PM, in the conference room, confirmed the facility failed to ensure discharge summaries were completed and authenticated within 30 days of a patient's discharge and the facility failed to follow facility policy.




36003

During the recertification survey completed September 19-21, 2016, the facility was found not to be in compliance with requirement 482.42, Condition of Participation for Infection Control.

Please refer to A-0749.





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30553

Based on review of facility policy, review of manufacturers recommendations, observation, and interview, the facility failed to ensure a sanitary environment was maintained in 5 of 12 facility units observed.

The findings included:

Review of facility policy, Basic Cleaning Responsibility, last revised 10/2015, revealed "...Non-patient Room Cleaning responsibilities: check daily and clean as needed: [a] Clean door knobs [b] spot wash walls..."

Review of facility policy, Emergency Crash Cart Supplies, last revised 7/2015, revealed "...the entire contents of the crash cart are checked monthly..."

Review of a facility policy, IV (Intravenous) Admixture Preparation, dated 4/1/08, revealed "...Prepare label fully with patient name, date/time..."

Review of a facility policy Medication Distribution-Intravenous Admixture Service last revised 7/15 revealed "...written on the label...indicating a 24-hour expiration time from the time of preparation..."

Review of a facility policy, IV's-Site, Tubing, Bag-Change and Care, last reviewed 8/15/15, revealed "...change continuous peripheral...and secondary administration sets every 72 hours...if the secondary set remains connected to the primary set, it can also be changed every 72 hours. But, if the secondary set is disconnected after each use [from the patient] and then reconnected, it should be managed as an intermittent set, which means it would be changed every 24 hours...Change intravenous bag every 24 hours, at a minimum...ensure the date and time of insertion, size of the cannula, and the initials of the nurse who inserted the IV is on the dressing label..."

Review of the facility's policy, CS HIGH LEVEL DISINFECTION, dated 7/1/15, revealed, "...A chemical Hydrogen Peroxide 2.0% will be used for high-level disinfection...Remove device from the solution and rinse thoroughly by immersing completely in a large volume of fresh rinse water..."

Review of manufacturers label directions for intravenous (IV) fluids, not dated, revealed, "...Do not remove from overwrap until ready for use..."

Observation and interview with the Chief Compliance Officer (CCO) on 9/19/16 at 12:45 PM, in Emergency Department (ED) Bay 6, revealed red colored dried debris splattered on the wall. Interview with the CCO confirmed the dried red debris on the wall was blood.

Observation and interview with the Infection Control Coordinator on 9/19/16 at 1:05 PM, in the Laboratory, revealed 46 unpackaged butterfly blood draw needles attached to vacutainer holders and ready for use, 3 opened packages of 10 ml (milliliter) syringes in a blood draw tray, and a drawer of unpackaged butterfly blood draw needles, all tangled together and too numerous to count (due to the possibility of a needle stick). Interview with the Infection Control Coordinator confirmed the supplies were not maintained in their protective packages and the facility failed to follow infection control guidelines.

Observation and interview with the Infection Control Coordinator on 9/19/16, at 2:00 PM, in the Stress Test Laboratory, revealed the emergency cart contained four 100 ml bags of 5% dextrose in water (a solution given to patients intravenously) with the protective overwrap removed. Interview confirmed 4 bags of IV solution had their protective overwraps removed and the facility failed to follow infection control guidelines.

Observation on 9/20/16 at 8:50 AM, in Patient #37's room, revealed a 1000 ml IV fluid bag of Normal Saline with IV tubing attached and labeled "Change Tuesday," but was not dated or timed. Further observation revealed a secondary bag of Arthromycin (antibiotic) with the IV tubing labeled "Change Wednesday", but was not dated or timed. Continued observation revealed both IV tubings hung freely and were not attached to the patient.

Observation on 9/20/16 at 9:00 AM, in Patient #39's room, revealed a 1000 ml IV fluid bag of NS with IV tubing attached and labeled "Change Thursday," but was not dated or timed. Further observation revealed the IV tubing hung freely and was not attached to the patient. Continued observation revealed Patient #39 had an IV site in the right arm, which was undated.

Observation on 9/20/16 at 9:10 AM, in the Patient #40's room, revealed a 250 ml IV fluid bag of NS with IV tubing attached and labeled "Change Friday," but was not dated or timed. Continued observation revealed a secondary 100 ml bag labeled Phenergan (nausea medication) and tubing labeled "Change Wednesday, but was not dated or timed." Further observation revealed the IV tubings hung freely and was not connected to the patient. Further observation revealed Patient #40 had an IV site in the right arm, which was undated.

Interview with Registered Nurse #2 on 9/20/16 at 9:10 AM, at the nursing station, confirmed IV tubing was to be labeled with the date and time and the secondary tubing was to be changed every 24 hours (if used intermittently). Further interview confirmed the facility failed to follow facility policy.

Observations and interview with the Operating Room (OR) Director on 9/20/16 at 9:30 AM, in OR #2, revealed 7 unwrapped syringes in the anesthesia cart. Further observations of the anesthesia cart revealed 13 endotracheal tubes (tubes placed through the throat and into the patient's lungs to provide a safe airway during anesthesia) with the wrapper/package opened and stored in the drawer of the anesthesia cart. Interview with the OR Director confirmed the 7 unwrapped syringes and 13 unwrapped endotracheal tubes should have been used immediately after opened or discarded.

Observations and interview with the OR Director on 9/20/16 at 9:40 AM, in OR #2 revealed a large amount of dust and lint on the surgical light over the operating table. Interview with the OR Director confirmed there was a large amount of dust and lint on the surgical light and the light should be cleaned each morning before surgical cases begun.

Observations and interview with the OR Director on 9/20/16, at 9:47 AM, of OR #1 revealed a large amount of dust and lint on the surgical light over the operating table. Interview with the OR Director confirmed there was a large amount of dust and lint on the surgical light and the light should be cleaned each morning before surgical cases begun.

Observations of the endoscopy processing room, on 9/20/16, at 10:00 AM, revealed there was only one sink in the processing room. Further observation revealed the Certified Scrub Technician (CST) #1 washed the used/soiled colonoscope in the single sink and throughout the wash process water and detergent leaked from the sink. Continued observation revealed the CST had to refill the sink with water and enzymatic three times because the water leaked out of the sink through the drain faster than the scope could be cleaned. Further observation revealed CST #1 placed the cleaned scope in the container of "Revital-Ox" disinfectant, to soak for 10 minutes. Further observations of the processing room revealed no clean sink available for the CST to rinse the disinfected scope in after the disinfection process was completed.

Interview with CST #1 in the endoscopy processing room on 9/20/16 at 10:15 AM confirmed after the scope finished the disinfection process she would rinse the disinfected colonoscope in the same sink she used to wash it prior to disinfection. Further interview with CST #1 confirmed the water leaked made it difficult to keep the endoscope submerged in water and enzymatic detergent during the cleaning process.

Interview with the OR Director and the Chief Nursing Officer (CNO) on 9/20/16, at 10:15 AM, in the endoscopy processing room, confirmed there was only one sink in the processing room and it was used to wash the dirty scopes in and after disinfection the same sink was used to rinse the disinfected scopes.

Observation and interview with the Infection Control Coordinator on 9/20/16 at 10:30 AM, of the Emergency Cart located in the main ED, revealed dried red debris on the top of the emergency cart and on the front drawers of the cart. Interview confirmed the dried red debris was blood and the cart had not been cleaned.

Observation of the ED Emergency Cart on 9/20/16 at 10:40 AM, in the main ED, revealed 2 Gel Defibrillation packages with expirations dates of 4/2014 and 8/2016. Interview with the Infection Control Coordinator confirmed the Defibrillation pads were expired and were available for patient use.

Observation and interview with the CCO on 9/20/16 at 3:30 PM, in Patient #40's room, revealed a IV bag of Pipercillin (antibiotic) with IV tubing attached and labeled "Change Tuesday," but not dated or timed and the tubing hung freely and was not attached to the patient.

Interview with the CCO on 9/20/16 at 3:30 PM, at the nursing station, confirmed IV tubings were not labeled with date and the time and the facility failed to follow facility policy.