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Based on clinical record reviews and interviews with facility personnel for two sampled patients (Patient #134, Patient #126), the facility failed to ensure that assessments and reassessments were completed after medication administration.

The findings include:

1. Patient #134 was admitted to the hospital on 6/30/10. Review of the physician orders dated 7/10/10 identified that the patient was to receive Propofol IV 100ml/1,000mg, titrate to sedation score (SAS) of 4 and critical care dosing guidelines. Review of the nursing flowsheets dated 7/11/10 identified that the IV medication was started at 8:00am however a SAS was not assessed on initial administration and not until 4pm (8 hours later). Review of hospital policy identified that a sedation score is completed upon initiation of the medication and every four hours. Interview with the ICU Nurse Manager on 7/12/10 identified that the sedation score was not completed per hospital policy.

2. Patient # 126 was admitted to the hospital on 7/14/10 for infusion therapy. Review of the physician orders dated 7/14/10 identified that the patient was to receive
Zometa 4mg IV infusion. Review of nursing documentation dated 7/14/10 identified that although vital signs were completed, the clinical record failed to identify that an pre/post assessment was completed. Patient #126 was discharged to home. Review of hospital infusion therapy flowsheet identified that assessments are completed before and after IV therapy. Interview with the Infusion Center Nurse manager on 7/14/10 identified that they were short staffed and the pre/post assessment was not documentated prior to the patient being discharged.

Based on review of hospital policy and interviews with facility personnel, the facility failed to ensure that hospital policy was reviewed to maintain person's authorized to administer medications.

The findings include:

1. Review of the hospital's administration of medication policy identified that medications may be administered only by person's authorized by their respective licensing agency within the State of CT. Further review included that patient care technicians (under the supervision of a nurse) may administer medications. Interview with the Director of Patient Safety on 7/26/10 identified that the patient care technicians were not allowed to administer medications and the policy needed to be updated.

Based on review of clinical records, interviews and review of hospital policy and procedure for two of four patients (Patients #101 and 110) that were provided care and services, the hospital failed to ensure that the treatment for consent document was completed in a timely manner and/or was accurate and/or complete. The findings include:

1. Patient #101 arrived at the hospital on 7/7/10 in labor and was admitted. Review of the clinical record identified that a person other than Patient #101 signed the "Authorization for Treatment" on 7/10/10. This documentation did not reflect that the patient was not able to sign and/or the relationship of the person to Patient #101 and/or the printed name of the witness, admission staff #1 and/or the time signed. Interview with the Manager of Admissions, on 7/12/10, identified that the admissions department staff do not to go the Labor and Delivery Unit to have the patient sign the "Authorization for Treatment" form and he/she monitors the unsigned authorization forms throughout the hospital. Interview with the Director of Admissions, on 7/12/10, identified that it is the responsibility of the admission department staff to have the patient sign the "Authorization for Treatment" form when the patient is admitted to the hospital. Interview with Admission Staff #1, on 7/12/10, identified that he/she did not document that the patient was not capable to sign the form, the husband of Patient #101 signed the "Authorization for Treatment" form and he/she did not identify the relationship to the patient and did not write his/her name.

2. Patient #110 was admitted on 7/9/10. Review of the clinical record identified an "Authorization for Treatment" form and the form was not complete, including the printed name of the witness and/or the person signing the document.

Review of the hospital policy and procedure, titled Consent for Treatment and Diagnosis, identified that the hospital obtains written consent from each patient at the time of admission and if the patient is not capable of signing the documentation, it must be identified. The witness completes the form and the form is dated and timed.

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Based on observations and interviews with facility personnel, the facility failed to ensure that infection control practices were followed.

The findings include:

1. During tour of the dialysis storage room on 7/12/10, it was identified that multiple items were being stored for patient use and that the room was cluttered. In addition, this room was also being utilized for cleaning of dialysis machines. Review of hospital policy identified that clean and dirty equipment is stored in separate areas. Interview with the Infection Control Nurse on 7/14/10 identified that dirty items should not be stored or cleaned with clean items.

2. During tour of the respiratory instrumentation room on 7/13/10, it was observed that multiple items were being stored in the room for patient use. In addition, this room was also being utilized for cleaning of ventilators. Review of hospital policy identified that clean and dirty equipment is stored in separate areas. Interview with the Infection Control Nurse on 7/14/10 identified that dirty items should not be stored or cleaned with clean items.

3. During tour of the ICU on 7/12/10, it was identified that commodes were placed outside of the soiled utility room. Further review failed to identify if these items were clean or dirty. In addition, it was observed that multiple fans were on the floor of the dirty utility room. Review of hospital policy identified that clean and dirty equipment is stored in separate areas. Interview with the ICU nurse manager on 7/12/10 identified that she was unsure if the commode was cleaned by staff.

4. During tour of the Sleep Center on 7/14/10, it was observed that an open bin in the hallway contained clean masks and tubing. Further observation identified that a container of santi-wipes was placed on top of the clean masks and tubings. Review of hospital policy identified that clean and dirty equipment is stored in separate areas. Interview with the Infection Control Nurse on 7/14/10 identified that clean items should not be stored with dirty items.


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5. Review of the Daily Scope Washer Checklist during tour of the GI Endoscopy Department on 7/13/10 identified that the water temperature was to be between 110-120 degrees Farenheit and that some temperatures were not within range. Review of the Manufacturer's documentation for the System 83 Plus Washer-Disinfector indicated that the temperature of the detergent solution was determined by the water temperature, which was required to be 105-115 degrees Farenheit (not 110-120). The Checklist identified that for 21 days between April 2010- July 2010 temperatures were out of range (below 105 degrees Farenheit).

6. Review of the Daily Inspection Log and interviews with hospital staff during tour of the Wound Care and Hyperbaric Medicine Center on 7/14/10 identified that the Hyperbaric Chambers were cleaned. Interview with the Director of the Hyperbaric Center indicated that the gurney, stretcher and mattress were cleaned with Hi-Tor Plus between patient use and that the chamber's acrylic cylinder was cleaned once per week. Review of the Daily Chamber Inspection and Quality Control Check for Hyperbaric Operation Policy indicated that all chambers must be cleaned between patients or as needed. The Cleaning of Hyperbaric Chambers Policy identified that Hi-Tor Plus was used to clean the chamber mattress, the acrylic and any contaminated materials after each patient treatment. However, review of the Manufacturer's documentation indicated that the chamber acrylic cylinder would be cleaned with mild detergent solution and that the chamber would be disinfected according to the type of cases being treated and as directed by medical staff. Review of documentation and interview with the Infection Control Director identified discrepancies existed between the Hyperbaric chamber cleaning policies, the manufacturer's documentation and practice (for between patient use).





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7. Observations during a tour of the dietary department on 7/14/10 at 11:05AM with the Director of Nutrition Services identified:

a. At 11:25AM a receiving room clerk walked from the dietary supply room through the kitchen to deliver mail to the dietary office without the benefit of hair covering. Interview with the Director of Nutrition Services identified that the Receiving Room Clerk should have waited for dietary staff to meet him in the supply room to deliver the mail or walked around the kitchen to deliver the mail to the kitchen entrance.
b. a. At 11:40AM during observation of the tray line a utility worker was noted to wipe down the steam table of excessive moisture with a paper towel then discard the paper towel and latex gloves. The utility worker then proceeded to don a clean pair of latex gloves without the benefit of hand washing until the Director of Nutrition Services intervened and directed him/her to remove gloves and wash hands prior to returning to food distribution at the steam table.
c. The utility worker returned to the steam table and began food distribution when he/she picked up a dirty item off of the floor, discarded it and proceeded to obtain an item from the refrigerator and place it in the microwave without the benefit of changing gloves and/or washing hands. A review of the nutrition services hand washing policy and procedure identified that all employees associated with the handling of food shall wash hands before putting on gloves and after handling garbage. Interview with the Infection Control Coordinator on 7/14/10 at 1:00PM identified that non-dietary staff should not be in the dietary department without the benefit of hair covering and the basic hand hygiene policy should be followed in the dietary department.

8. Based on observation and interviews with staff, the hospital failed to ensure that patient supplies were stored in a sanitary manner. A tour of the Emergency Department was conducted on 7/14/10 with the Interim Director of Emergency Operations. IV tubing and a 500cc bag of IV solution was noted stored on the edge of a hand-washing sink. The IV supplies were splattered with hand-washing soap and droplets of water, compromising the integrity of the items.

Based on clinical record reviews and interviews with staff, the hospital failed to ensure that for 1 of 4 patients (Patient #104) who underwent a surgical procedure, the hospital failed to ensure that a post-operative note was written or dictated immediate following the procedure. The findings include:

Patient #104 was admitted to the surgical suite on 7/12/10 and underwent a pain injection at the 4-5 lumbar regions. Review of the clinical record with the Nurse Manager on 7/12/10 at 10:06 AM identified that the patient had the injection and had already been discharged home. The clinical record lacked a brief operative note written or dictated by the physician immediately following the procedure. Interview with the Anesthesiologist on 7/12/10 at 11:00 AM identified that there should have been a note immediately following the procedure.

Based on review of hospital documentation and interviews with facility personnel, the facility failed to ensure that policies for moderate sedation, including the administration of medication, were complete and included rescue protocols for oversedation.

The findings include:

1. During review of the respiratory therapy department on 7/15/10, it was identified that respiratory therapists (RTs) assist pulmonologists with bronchoscopies during which moderate sedation is used for the patient. Review of the moderate sedation policy on 7/15/10 failed to identify that the policy was reviewed and/or approved by the hospital's medical executive committee. Further review failed to identify who may administer sedating medication, and who would be monitoring the sedated patient. Interview with the Chief of Anesthesiology on 7/14/10 identified that he is not involved with bronchoscopies. Interview with the Vice President of Patient Care Services on 7/19/10 identified that the hospital policy was not specific regarding medication adminstration and that the policy failed to contain a rescue protocol.

Based on review of hospital documentation and interviews with facility personnel, the facility failed to ensure that respiratory therapists operate within their scope of practice as defined in Connecticut General Statutes Section 20-162n (b).

The findings include:

1. During tour of the respiratory department on 7/12/10, it was identified that respiratory therapists were inserting arterial lines, Although hospital policies identify that respiratory therapists were able to insert arterial lines, such practice was inconsistent with state scope of practice statutes. Interview with the Chief of Anesthesiology on 7/14/10 identified that respiratory therapists were trained to insert arterial lines since they are able to draw arterial blood gases from arterial lines. Further interview with the Chief of Anesthesiology identified that he was unaware that it was not within their scope of practice.