HospitalInspections.org

Based on policy review and interview, it was determined the Facility failed to include in their policy and procedure a provision for protection of the patient during an allegation of abuse by an employee. The policy and procedure failed to delineate how the patient will be protected from further potential harm or abuse during the period of investigation. Findings follow:

A. Review of the policy and procedure received from the Director of Quality at 0930 on 05/25/2017 revealed the following under "CODE OF CONDUCT FOR A SAFE AND PRODUCTIVE WORKPLACE," " ... If an investigation confirms that a violation of policy has occurred, Baptist will take corrective action to effectively end the conduct. Depending on the circumstances, such action may include a reprimand, termination of employment or privileges, or other appropriate action."

B. During policy and procedure review and interview with the Director of Quality at 0930 on 05/25/2017 the above finding was verified.

Based on policy and procedure review, clinical record review, and interview, it was determined one (#4) of five (#1-#5) Patients was not restrained in accordance with a Physician's order. Failure to obtain a Physician's order for restraints did not allow the Physician to be knowledgeable regarding the Patient's need for restraints and prohibited the Facility from following its policy. The failed practice affected Patient #4. Findings follow:

A. Review of the policy and procedure received form the Director of Quality at 0830 on 05/24/2017 revealed the following under "RESTRAINT OF THE NON-VIOLENT/NON-SELF DESTRUCTIVE PATIENT," "The use of restraint is in accordance with a Physician order responsible for the care of the patient."

B. Review of Patient #4's clinical record revealed Patient #4 was placed in restraints at 1600 on 4/17/2017 without a Physician's order. The initial order for restraints was placed by the Physician at 0730 on 04/18/2017.

C. During an interview and clinical record review with the Manager of Intensive Care Unit and the Informatics RN at 1100 on 05/26/2017 the above findings in A and B were verified.

Based on clinical record review and interviews, it was determined a Registered Nurse (RN) failed to supervise and evaluate the nursing care in that three of three (#13, #17 and #18) Patient's clinical records did not contain documentation daily weights were performed as ordered; one (#20) of two (#12 and #20) Patient's clinical records did not contain documentation supplements were given as ordered; one (#19) of four (#12, #16, #17 and #19) Patient's clinical records did not contain documentation vital signs were obtained at a frequency as ordered; one of one (#12) Patient clinical record did not contain documentation the patient was turned every two hours as ordered; two of two (#12 and #16) Patient's clinical records did not contain documentation moisture barrier cream was applied as ordered and one (#17) of two (#17 and #19) Patient clinical records did not contain documentation intake and output was obtained and documented as ordered. Failure to obtain daily weights, vital signs and intake and output measurements did not give the physicians the information necessary to make clinical decisions and failure to administer the supplements, turn the patient and apply moisture barrier cream had the potential to allow the patient to have skin breakdown and prolonged hospitalization. The failed practices affected Patients #12, #13, #16, #17, #18, #19 and #20. Findings follow:

A. Review of Patient #13's clinical record revealed a Physician order on 02/07/17 at 1259 for daily weights. Review of Patient #13's clinical record revealed no documentation daily weights were obtained six (02/07/17-02/18/17) of eight (02/07/17-02/14/17) days. The above findings were verified during an interview with the Informatics Registered Nurse (RN) at 1525 on 05/25/17.

B. Review of Patient #17's clinical record revealed a Physician order dated 05/19/17 for daily weights. Review of Patient #17's clinical record revealed no documentation daily weights were obtained three (05/20/17, 05/21/17 and 05/23/17) of seven (05/19/17 - 05/25/17) days. The above findings were verified during an interview with the Informatics RN at 1640 on 05/25/17.

C. Review of Patient #18's clinical record revealed a Physician order dated 05/22/17 for daily weights. Review of Patient #18's clinical record revealed no documentation daily weights were obtained one (05/23/17) of four (05/22/17- 05/25/17) days. The above findings were verified during an interview with the Informatics RN at 1645 on 05/25/17.

D. Review of Patient #20's clinical record revealed a Physician order on 02/17/17 at 0959 for Glucerna with meals. Review of Patient #20's clinical record revealed no documentation the Glucerna was given. The above findings were verified during an interview with the Director of Inpatient Nursing Services at 0848 on 05/26/17.

E. Review of Patient #19's clinical record revealed a Physician order on 05/23/17 at 0439 for vital signs every 30 minutes until stable, then every one hour thereafter. Review of Patient #19's clinical record revealed no documentation the vital signs were checked every one hour from 05/24/17 until 05/26/17 at 0700. The above findings were verified during an interview with the Director of Inpatient Nursing Services at 0924 on 05/26/17.

F. Review of Patient #12's clinical record revealed a Physician order dated 01/31/17 to turn Patient #12 every two hours. Review of Patient #12's clinical record revealed no documentation Patient #12 was turned every two hours for eight (02/01/17, 02/02/17, 02/04/17, 02/06/17, 02/07/17, 02/11/17, 02/12/17, and 02/13/17) of 17 (02/01/17 - 02/17/17) days. The above findings were verified during an interview with the Director of Inpatient Nursing Services at 1201 on 05/26/17.

G. Review of Patient #12's clinical record revealed an order dated 01/31/17 for Moisture Barrier Cream to be applied to the buttocks and coccyx daily. Review of Patient #12's clinical record revealed no documentation the Moisture Barrier Cream was applied for nine (02/01/17, 02/02/17, 02/03/17, 02/04/17, 02/05/17, 02/07/17, 02/10/17, 02/11/17 and 02/15/17) of 17 (02/01/17 - 02/17/17) days. The above findings were verified during an interview with the Director of Inpatient Nursing Services at 1159 on 05/26/17.

H. Review of Patient #16's clinical record revealed an order on 05/22/17 at 1833 for Moisture Barrier Cream to be applied to the buttocks every shift. Review of Patient #16's clinical record revealed no documentation the Moisture Barrier Cream was applied every shift for two (05/23/17 and 05/24/17) of four (05/22/17 - 05/25/17) days. The above findings were verified during an interview with the Director of Inpatient Nursing Services at 1310 on 05/26/17.

I. Review of Patient #17's clinical record revealed an order on 05/19/17 at 1724 for intake and output every three hours and notify Physician if urine output was less than 40 cc (cubic centimeters) per hour for 12 hours. On 05/22/17 at 0822 a new order was written for strict intake and output measurements every shift. Review of Patient #17's clinical record revealed no documentation the intake and output was measured and recorded from 1730 on 05/19/17 through 1650 on 05/20/17, 1650 on 05/20/17 through 0900 on 05/21/17 and 0415 on 05/22/17 through 2203 on 05/22/17. The above findings were verified during an interview with the Informatics RN at 1625 on 05/25/17.

Based on clinical record review and interview, it was determined the Facility failed to ensure a current and comprehensive Nursing Care Plan was developed and implemented for one (#13) of three (#13, #17 and #20) isolation patients. Failure to develop and maintain a current and comprehensive plan of care did not ensure the patients, families and other care givers were educated on the potential spread of a highly communicable disease and methods of protecting themselves and the community. The failed practice affected Patient #13.
Findings follow:

A. Review of Patient #13's clinical record revealed a diagnosis of Tuberculosis as of 2153 on 02/04/17. Review of Patient #13's clinical record revealed no care planning and no education of the patient and family for Airborne Isolation.
B. The above findings were verified in an interview with the Informatics Registered Nurse at 1505 on 05/25/17.

Based on observations, policy and procedure review and interviews, it was determined staff failed to follow policy and procedure in that surgical masks were observed dangling around the necks of operating room (OR) employees. Failure to ensure surgical masks were not dangling around the neck had the potential to allow cross contamination between staff and patients as well as not ensuring surgical masks were changed as appropriate. The failed practice was likely to affect any patient undergoing a surgical procedure in the operating suite. Findings follow:

A. Observations in the operating suite on 05/25/17 from 0725 through 0815 revealed the following employees with surgical masks dangling around their necks: Registered Nurse (RN) #2 at 0725; Certified Registered Nurse Anesthetist (CRNA) #1 at 0730; Physician #4 at 0735; Surgical Technologist #1 at 0740; Surgical Technologist #2 at 0744; Surgical Technologist #3 at 0748; Physician #3 at 0750; CRNA #2 at 0755; and RN #3 at 0812. The above findings were verified by the OR Manager at 0815 on 05/25/17.

B. Review of the policy and procedure titled "Departmental Dress Code" received from the Director of Quality at 0830 on 05/24/17 revealed the following under "POLICY: ...4. Masks are worn in restricted areas of the operating room suite. To prevent venting, masks are secured in a manner so that the mouth and nose are completely covered. Masks are changed frequently, especially if they have become damp, and are not worn dangling around the neck. Masks are removed by touching only the strings ....".

C. During an interview with the Director of Quality at 0935 on 05/25/17 she stated the Facility adheres to AORN (Association of Operating Room Nurses) and AST (Association Surgical Technicians).

D. Review of the AORN "Guidelines for Perioperative Practice, 2015 Edition" revealed the following on page 106, I.h.3." ...A fresh surgical mask should be donned before the health care worker performs or assists with each new procedure ..." and I.h.4. " ...Surgical masks should not be worn dangling around the neck ..."

E. During an interview with the Director of Quality at 0935 on 05/25/17, the findings in B and C were verified.


Based on observation and interview it was determined the Facility was receiving and parking clean linen carts on the same positive pressure hallway the Facility was removing soiled linen and trash. The Facility failed to provide maintenance of a sanitary physical environment by using a positive pressure hallway for linen receiving and a negative pressure hallway for soiled linen and trash removal. This failure provided for an opportunity for clean linen to be contaminated with soiled linen or waste and placed patients at risk for potential infections and communicable diseases. Findings follow.

A. An Environmental Service Worker was observed at 0910 on 05/25/2017 bringing trash by the clean linen carts in the positive pressure hallway and out the same door utilized for clean linen delivery.

B. During an interview with the Director of Environmental Services at 0920 on 05/25/2017 and observation, the above findings in A were verified.