HospitalInspections.org

Based on record review and interview the facility failed to provide patient or the patient's representative of a phone number and address for filing a grievance with the State agency for all patients being admitted to the facility. This failed practice increases the likelihood of patients not being able to report grievances.

The findings are:

A. Record review of facility Patient Admission Packet dated November 2021 has several phone numbers noted for Department of Health. The correct phone number is noted under section labeled, "Abuse, Neglect and Misuse of Personal Property", there are several other numbers that are listed in the packet that are incorrect contact numbers for Department of Health.

B. On 03/09/22 at 3:20 pm during interview with S (Staff) 2, Admitting Manager who confirmed, "The information in the Patient Notebook is from a print on November 2021 that was received in February 2022. This print has the wrong phone number listed for Department of Health. This may be a non-updated booklet. The facility may need to order more with the correct information. The Outpatient Booklet has the correct phone number. In the consent packet under Abuse, Neglect and Misuse of Personal Property the correct number is noted but not under Complaints/Grievances.

Based on interview and record review the facility failed to meet the Condition of Participation (COP) for nursing services by failing to comply with the requirements as evidenced by the following:

A. The facility failed to ensure a registered nurse monitored oximetry (measure the oxygen saturation) with central monitoring technicians. See tag 395.

Based on record review and interview the facility failed to:
1. Ensure a Registered Nurse monitored oximetry (measure the oxygen saturation)
2. Ensure Central Monitoring Technicians remote telemetry monitoring (analysis of cardiac rhythm) were monitoring 1(P6) of 10 (P1-P10) sampled. This deficient practice is likely to result in interventions not being implemented in case of a patient emergency.

The findings are:

A. Record review of P6 Medical Chart reveled: 51 year old male admitted for COVID-19, positive with difficulty breathing. P6 was on high flow oxygen 60 liters per minute with 100% FIO2 (fraction of inspired oxygen or concentration of oxygen of the gas mixture).

B. Record review of P6 physician orders dated 12/05/21 until specified revealed "pulse oximetry department SFMC 21 (room on progressive care unit) Patient Care: notify physician if oxygen saturation < (Less than) 90%."

C. Record review of P6 Medical Chart revealed Telemetry Monitoring showing active oximetry monitoring was occurring (by CMT) on 12/21/21 [day before P6 expired] at 8:36 pm telemetry notified (P6) assigned nurse of a "condition update SpO2 (measurement of oxygen saturation or amount of oxygen your blood is carrying as a percentage) 75% (standard above 90%)." Telemetry notified the assigned nurse of low oxygen level when it was observed to go below 90% on 12/21/21.

D. Record review of (P6) Medical Chart Nurse's note dated 12/22/21 at 9:07 pm revealed, patient connection to oximetry monitoring Staff (S14) "pulse oximeter probe site changed (placed on a different finger)."

E. Record review of (P6) Medical Chart nurse (S14) note dated 12/23/21 at 12:23 am (retroactive charted) "patient was found with both oxygen devices removed and pulse ox removed. Pulses were thready (weak pulse that feels thread like) at the carotids (arteries in neck) and radial (arteries in wrist). Hospitalist (Physician who is employed by the hospital to care for patients) called and was at bedside along with RT (Respiratory Therapist) and Charge Nurse (head nurse responsible for nurse area). Patient was declared to have cardiac death (loss of heart function) at 10:50 pm."

F. Record review of (P6) Medical Chart physician discharge summary dated 12/22/21 at 11:23 pm (retroactive) revealed: "patient had a long hospital stay for COVID-19 pneumonia (lung infection caused by Corona Virus) and he was using high flow oxygen. This evening when the nurse checked on the patient he was off oxygen and did not have spontaneous (occurring without apparent external cause) breathing. Telemetry showed no rhythm (repeated beating of heart). She (he) [sic] was put back on oxygen and his blood pressure was in the 50s. He had very diminished pause (pulse) [sic]. He (it) [sic] was on clear (unclear) [sic] how long patient was off oxygen. I checked on the patient and there was no breathing or heartbeat. I declared the death at 2250 (10:50 pm). Patient's family was given the update and the condolences."

G. Record review of P6 Medical Chart revealed an order for "continuous pulse oximetry was discontinued at discharge by patient expiration (death) by facility's own computer system by Batch, Prod (productions) 12/23/21 02:31 am [patient discharge]."

H. On 03/14/22 at 11:20 am during interview S4 (Quality Manager) stated following the adverse event with nurse S14 (Nurse) he stated that "he doesn't know why telemetry never called (to notify nurse of P6 O2 levels dropping)." S4 confirmed telemetry should have notified nurse of O2 level dropping. When asked to provide the telemetry report for P6 she stated that the records are not kept past 30 days and could not provide the documentation regarding telemetry monitoring for this patient.

I. On 03/15/22 at 11:30 pm during a phone interview with (S18) (Telemetry Manager), S18 stated, telemetry monitors oximetry as long as there is an order and if a person is off their telemetry typically, they (telemetry) will contact the floor nurse if they are off longer than the time it takes to change a battery or about a minute. They typically call if it is longer than a battery change. They (telemetry staff) must chart a call under clinician notification in the flow sheet and what the update was for the condition, it is part of the patient's chart. It is in the nurse flow sheet as well. This is done for any alarm or change. When asked, Did anyone speak to you or your staff about an incident on December 22, 2021, regarding a (P6), (S18) stated "From what I recall, I did review with quality, but I did not speak with staff because there was not an order to monitor oximetry. If there is not an alarm going off there is no need to intervene. If the alarm is going off, they would notify the nurse of what was going on." (S18) further stated "He (P6) only had an order for oxygen monitoring in the ED (Emergency Department). He did not have an order on the unit. They would not have him hooked up to monitor him. If there is no order, they would not be monitoring him."

J. On 03/15/22 at 12:45 pm during interview with (S20) (Charge Nurse), S20 confirmed, when discontinuing telemetry and oximetry orders (S20) states "It (order) would need to say discontinue cardiac monitoring and you would need a second order to discontinue oximetry." (S20) stated "Telemetry refers to cardiac monitoring, but you have to have separate orders for both to start and stop monitoring." (S20) further stated, you cannot have them just in the room only for vital signs. If they are hooked up in the room it goes to [name of city] (telemetry command center) even if there is not an order for it, but then they would call you. When asked how long you would be on the monitor before they call you about the monitoring S20 replied "They (telemetry command center) pretty much call you right away within a minute or so. They will tell you either take them off (remove telemetry or oximetry) or get an order for it." S20 stated "If they are plugged in, they monitor it." When asking S20 if telemetry will call the nurse if they don't have an order for oximetry and a patient is connected? "Yeah, telemetry will call if they don't have an order right away." When asked how difficult it would be for a patient to turn off the monitor she reveals "like for standby, it is not entirely impossible, but they would really need to be paying attention to how staff does it. It takes several steps, and they don't get to really see everything we do. I don't think I've ever had one do it. We educate them a lot on not touching the monitors and stuff like that."


K. On 03/15/22 at 08:50 am during phone interview with (S12) (Secretary/Tech) (last staff member with P6 prior to nurse finding P6 unresponsive) surveyor asked "I saw in his record that you went into his room and changed his linens. Did anyone help you?" (S12 responded) "Just me, the nurse came in and out briefly. (S12) reported when she was finished changing the linens, "he (P6) was hooked up with his mask on." (S12) did not remember if he was hooked up to oxygen monitoring. (S12) stated, I was by myself already. I had been on my own for about one week maybe (prior to patients death)."

L. Record review of staffing schedule revealed S12 was on orientation the week prior, week of, and a couple days following this event (12/22/21).

M. Record review of remote telemetry monitoring (analysis of cardiac rhythm) reference number PC.PDS.249 dated 02/25/22, #2 & 3. Revealed Cardiac Telemetry Monitor Technicians (CMT) are responsible for:

a. "2.3 continuously monitoring patients with telemetry and oximetry orders."

b. "2.3.1 When the CMT is unable to see and/or interpret cardiac rhythm oximetry pleth (plethysmograph-the pleth waveform corresponds to blood flow. A well-defined pleth suggests a strong pulse and good perfusion at the probe site) secondary to loss of signal, artifact, or if the telemetry equipment needs a battery change, CMT:"

c. "2.3.1.1 CMT immediately notifies the assigned patient nurse via Vocer [facility name] phone/ messaging system) system."

d. "2.3.1.2 CMT documents the fact and the reason of notification the EMR (Electronic Medical Record)."

e. "2.3.1.3. If no action taken by RN (Registered Nurse), CMT escalates to the charge nurse within a reasonable timeframe."

f. "2.4.5.4. Numerical value of the pulse oximerty."

g. "3. The primary registered nurse (RN) is responsible for:

3.3.1 Saving, printing and filing a telemetry strip into patients medical record to be scanned into the EMR.

3.3.1.4 When there is a change in patient's condition."

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary (hygienic) environment to avoid sources and transmission (spreading) of infection and ensure items utilized for direct patient care are furnished appropriately by not using items past expiration dates and not identified as being under an extended use authorization by the United States Food and Drug Administration. Certain expired items are at risk of bacterial growth leading to more serious illnesses and antibiotic resistance. This failed practice is likely to lead to increased risk of infection, cross-contamination, or product failure for patients while in the facility and can lead to a serious infections or death.

The findings are:

For expired items:

A. On 03/09/22 at 02:15 pm record review of "Standard Precautions for Infection Control effective 05/11/21 states 2. Standard Precautions are practices to reduce healthcare-associated infections and are used with all people (patients, employees, and visitors), regardless of diagnosis or isolation status, and apply to interacting with blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes. The required elements include: 2.2 Disinfecting surfaces and equipment between patients uses;"

B. On 03/09/22 at 1:45 pm during observation of the clean supply room on progressive care unit (PCU) unit, the following supplies were found to be expired:

a. 2 pressure injectable Multi-Lumen CVC (Product Name) expiration date 02/28/22

b. 8 Duoderm CGF 6x7 (Product Name) expiration date 12/2020

c. 9 Duoderm CGF 4x5 (Product Name) expiration date 10/2021

d. 5 Devon skin marker (Product Name) expiration date 12/31/21

e. 10 Biatain Silicone Lite 2x2 (Product Name) expiration date 10/09/21

B. On 03/09/22 at 2:00 pm interview with Staff (S5) (Nurse Manager) acknowledged expiration date on supplies and took expired supplies to be disposed of in central supply services.


D. On 03/11/22 at 11:45 am during observation of the respiratory therapy clean supply room located on the 2nd floor, the following supplies were found to be expired:

a. 1 EZ Pap (Product Name) expired 02/01/22

b. 2 Halyard 1500 heat and moisture exchanger (Product Name) expired 11/2020

c. Glide Rite single-use stylet small 3.0-4.0 mm (Product Name) expired 05/14/21

d. 2 Ambu King mask size 1 disposable anesthesia face mask (pediatric) (Product Name) expired 05/2021

e. 22 3M Tegaderm film 1 ¾ inch x 1 ¾ inch expired 12/29/21

f. 5 3M Tegaderm film 1 ¾ inch x 1 ¾ inch expired 11/29/21

E. On 03/11/22 at 12:15 pm during interview with (S1) (Chief Nursing Executive) in the Respiratory supply room, surveyor showed the expired supplies to (S1) who acknowledged each set of items were expired for the shown date. (S1) thanked the surveyor and took all the expired items with her to be disposed of stating "I'm not happy about it, but I'm glad you found them, and we look to do better in the future."

F. On 03/15/22 at 02:15 pm during record review of supply chain services Expiration check process, weekly supervisor quality log, and last two previous month audits (January 2022 and February 2022) expiration employee check list reveals the Standard SOP (standards of practice) Worksheet- Expiration Check Process revised 03/05/19 2- check for expired items and remove them from the cart. 3- Remove products that have expiration dates that fall in current month of audit.

G. On 03/15/22 at 02:15 pm record review of Expiration: Employee Checklist January 2022 PCU/ ICU (intensive care unit) notes are dated and initialed as follows: NE (North East) supply room 01/21/22, NW (North West) supply room 01/28/22, SE (South East) supply room 01/19/22, and SW (South West) supply room 01/13/22.

H. On 03/15/22 at 02:15 pm record review of Expiration: Employee Checklist February 2022 PCU/ ICU notes are dated and initialed as follows: NE supply room 02/10, NW supply room 02/21, SE supply room 02/21, and SW supply room 02/25.

For unsanitary oxygen regulators and adapters:

I. On 03/09/22 at 01:13 pm during observation of clean ICU room 225. There are two oxygen adapters referred to as "Christmas tree" on oxygen regulators. One Christmas tree is hanging on a chain connected to the oxygen regulator that is connected to wall access. The other Christmas tree is connected to the regulator that is laying on the counter next to the head of the bed.

J. On 03/09/22 at 01:15 pm during interview with (S5) (Nurse Manager) how does the staff know if the oxygen Christmas tree adapter is clean? (S5) replied "they will be disconnected and hanging to dry after being cleaned." Surveyor asked (S5) what happens when a staff member goes into a clean room, and it is still connected? (S5) stated "the staff should assume it is dirty because it may have been missed by housekeeping and they should clean it before they use it."

K. On 03/09/22 at 01:30 pm during observation of clean room 214, the Christmas tree oxygen adapter is screwed onto oxygen regulator which is connected to wall access.

L. On 03/09/22 at 01:37 pm during observation of clean room 224, the Christmas tree oxygen adapter is hanging from the chain connected to the oxygen regulator connected to the wall access.

M. On 3/10/2022 at 1:40 pm, during interview with (S5), surveyor asked, can you confirm these rooms 214 & 224 were cleaned? (S5) confirmed that both rooms were cleaned.

N. On 03/15/22 at 10:43 am during observation, a housekeeping cart in front of room 213 was being wheeled away. Surveyor was in the doorway of room 213 noting that the floor has been recently moped and appears wet. Surveyor additionally observed the wall behind the bed and noted that 2 (two) oxygen regulators are connected to the wall. One Christmas tree adapter is hanging by a chain to the regulator. The other Christmas tree adapter is screwed to the regulator.

O. On 03/15/22 at 10:45 am during interview with (S5) surveyor asked, was this room cleaned from a discharged patient? (S5) replied "yes."

P. On 03/11/22 at 8:30 am during interview (S3) (Registered Nurse/ Charge Nurse) when asked how do you know if oxygen regulator or adapter is clean? (S3) stated "I believe it is housekeeping that does it and I assume it is clean for next patient."

Q. On 03/15/22 12:10 pm during an interview with (S20) (Manager of Environmental Services) revealed, when discussing cleaning oxygen adapters "Well, I try to train everyone to disconnect the adapter wipe it down and leave it on the counter. We are trying to train everyone to do it the same way, but some still disconnect it and leave it hanging." When Surveyor asked "If it's on the wall and connected does this mean it has not been cleaned?" (S20) replied "Yes."






















46172

Based on record review and interviews, the facility failed to follow respiratory policies of their own facility to monitor and chart every six hours in accordance with medical staff directives for high flow oxygen for 1 (P6) of 10 (P1-P10) patients sampled. This failed practice is likely to adversely affect patient's oxygen levels which can lead to death.

The findings are:

A. During record review of [facility] clinical procedure titled high flow cannula (thin tubing) reference number PUL.PDS.409 effective date 04/01/17, reveals "procedure 10.1 of required observation and documentation states oxygen therapy is documented in Epic (The electric charting system) a minimum of Q6 (every 6 hours) and should include type of device, duration, flow and/or FIO2, temperature, and any clinical observations as appropriate. Consider increasing patient checks and documentation with the use of higher flows."

B. During record review of (P6) medical chart dated 12/22/21 at 11:15 am revealed that Staff (S24) (Registered Respiratory Therapist, RRT) charted "SPO2 (oxygen saturation or amount of oxygen being carried by the blood) 92% O2 (oxygen) Device high flow nasal cannula (oxygen delivery placed in nose), O2 Flow Rate (amount of oxygen) 60L/ min (liters per minute), FIO2 (the percentage of oxygen a person inhales) 100%."

C. During record review of (P6) medical chart dated 12/22/21, (S13) (RRT) charted "SPO2 95% O2 Device high flow nasal cannula, O2 Flow Rate 60L/ min, FIO2 100%" at 2020 [10:20 pm] (9 hours later).

D. On 03/11/22 at 10:20 am during interview (S16) RRT (Registered Respiratory Therapist) confirmed high flow checks are done every 4 hours.

E. On 03/11/22 at 11:22 am during interview (S17) RRT confirmed high flow checks are done every 6 hours.

F. On 03/15/22 at 09:05 am during interview (S13) RRT confirmed high flow patients are checked every 3 hours, and "I chart on those in the adult PCS (patient care system). I put in o2 sat, FIO2, breath sounds (lung sounds), and how much oxygen they are on."


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