HospitalInspections.org

Based on observation, staff interview and review of facility policy and procedure, it was determined that the facility failed to ensure that patients personal information is kept confidential.

Findings include:

Reference: Faciliy policy titled, "Notice of Privacy Practices" states: "...OUR PLEDGE REGARDING MEDICAL INFORMATION... The law requires us to: -Make sure that medical information that identifies you is kept private....."

1. A tour of the Emergency Department (ED) was conducted on 9/8/20 from 10:47 AM to 11:45 AM in the presence of Staff #4. The following was identified:

a. The nurse's station was observed to be located in the middle of the main ED. There were no barriers between the nurse's desks, the patient bays and ED corridor. Six (6) computers were facing patient bays #4 through #7. Four (4) of the six (6) computers had a patient list on the screen that included identifiers such as the patient's full name, room number, complaint, age and gender. The computer screens were visible to visitors and staff members in the ED.

(i) At 11:26 AM, a staff member moved from in front of the computer screen to go to a different area in the ED, then returned to the computer at 11:28 AM. The ED patient list was in full view of visitors and staff members in the ED. An interview with Staff #4 at 11:30 AM confirmed the findings and identified that the staff member should have logged off the computer before getting up and leaving the area.

A. Based on observations of the Emergency Department and the unit 5E, and interview with staff, it was determined that the facility failed to provide patient care in a clean environment.

Findings include:

1. On 9/8/20 from 10:47 AM to 11:45 AM, a tour of the Emergency Department (ED) was conducted in the presence of Staff #4. The following was observed:

a. In Bay #10, the mattress on the stretcher had multiple tears, exposing foam-like material which is an uncleanable surface. The wall had multiple areas with peeled paint.

b. The linen cart, in the hallway, was partially uncovered with a clear plastic material, exposing clean supplies to contaminants.

c. In the Quiet Room, the floor had dark marks and dents. The doorframe had peeled paint.

d. In Bay #9, the floor had heavy dirt built up and the bottom edges of the sliding double doors had dirt built up. A patient stretcher in the room had a build up of dirt and debris on the wheels and undercarriage.

e. In the bathroom for patients and visitors, the wall vent was dusty.

f. Throughout the main ED, the floor edges had dirt built up.

2. The above findings were confirmed by Staff #4 at the times of discovery.

3. A tour of the 5E, Behavioral Unit, was conducted from 1:16 PM to 2:00 PM on 9/8/2020 in the presence of Staff #2 and Staff #9. The following was observed:

a. In the two (2) Patient Shower Rooms across from Room ES5, the vents had areas of rust colored substance.

b. In one patient lavatory located off the main hallway, the ceiling had noted areas of mildew and moisture.

c. In Room #528, the ceiling vent had areas of rust colored substance.

d. In Room #530, the radiator vent under the window had brown spots.

4. The above findings were confirmed by the Staff #2 and Staff #9 at the times of discovery.



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B. Based on observation and staff interview, it was determined that the facility failed to ensure that needles and syringes are kept in locked storage areas.

Findings include:

1. A tour of the Emergency Department (ED) was conducted on 9/8/20 from 10:47 AM to 11:45 AM in the presence of Staff #4. The following was identified:

a. A procedural cart was located in the fast track area of the ED. The cart was unlocked and did not have staff members attending to the cart. The cart contained needles and syringes.

(i) An interview at 10:59 AM with Staff #5, a nurse in the fast track area, stated that the cart "stays unlocked all day."

(ii) An interview at 11:08 AM with Staff #4 indicated that the cart should be kept locked due to its contents.

b. Cabinets located above the sink in the fast track area were unlocked and one door was left open. The cabinets contained IV (intravenous) insertion needles and butterfly catheter needles for drawing blood. The cabinets were unattended at the time of discovery.

(i) The opened door could not be closed due to a blue container blocking the closure. The blue container was wider than the shelf and therefore the door could not be closed and locked.

(ii) An interview at 10:59 AM with Staff #5 noted that the cabinet does not get locked, despite containing needles.

(iii) An interview at 11:08 AM with Staff #4 confirmed that the blue container was blocking the closure of the cabinet, and that the needles were left unsecured.

c. In Bay #5 of the main ED, a vacutainer Saf-T holder device was identified on the shelf behind the patient stretcher. The vacutainer contains a needle. Staff #4 confirmed that the vacutainer should not have been left out and unsecured.

d. A cabinet at the nurse's station identified as "IV trays set up 1" was unlocked and contained one (1) box of #18 gauge IV insertion angiocatheters, two (2) boxes of #22 gauge IV insertion angiocatheters, and one (1) box of #24 gauge IV insertion angiocatheters. The nurse's station is located in the middle of the main ED without any barriers between the nurse's desks and cabinets and the patient bays and ED corridor. The cabinet was unattended at the time of observation. An interview at 11:30 AM with Staff #4 confirmed that the cabinet should have been kept locked due to its contents.

e. Outside Bay #7, the airway trauma/cardiac cart contained several spinal needles and IV needles that were unsecured. An interview at 11:40 AM with Staff #4 confirmed that the cart should have been locked due to its contents.

2. A tour of the 1 West Intensive Care Unit was conducted on 9/8/20 from 11:47 AM to 12:40 PM in the presence of Staff #2. An unlabeled room was identified on the tour and the door to the room was propped open with a small triangular wedge under the door. The room contained a procedural cart that was unlocked and contained central line insertion kits that contained needles, sutures with needles, and syringes. An interview with Staff #2 at 11:54 AM confirmed that the cart should have been locked due to its contents.

3. Upon request on 9/8/20 at 3:15 PM to Staff #1 and Staff #2 and on 9/9/20 at 12:56 PM to Staff #1 and Staff #2, the facility was unable to provide a policy regarding the securing of needles and syringes.

Based on observation, policy review, staff interview, and review of the medical records of three (3) out of three (3) patients observed in mitts restraints (#7, #8, #9), it was determined that the facility failed to ensure that patients in restraints have a valid physician order.

Findings include:

Reference: Facility policy titled "Restraint And Seclusion" states: "... Policy: ... 5. Restraints are initiated using the least restrictive type of restraint that will be effective to protect the patient ... Types of Restraints used. [sic] a) Hand mitt ... 6. The use of restraints is based upon the time limited order of a physician or LIP [licensed independent practitioner]. If the physician or LIP is not available to issue such an order, the RN may initiate restraint use, in an emergency situation, based upon an appropriate assessment of the patient. The physician or LIP must be notified of the emergency application of restraint or seclusion immediately and respond within 1 hour to evaluate the patient via a face to face assessment. ..."

1. On 9/8/20 from 11:47 AM to 12:40 PM, a tour of the Intensive Care Unit (ICU) was conducted in the presence of Staff #2. The following was identified:

a. Patients #7, #8 and #9 were observed to have mitts on their hands bilaterally.

b. At 12:00 PM, Patient #7 was observed to be sedated and intubated. This observation was confirmed at the time of the observation in an interview with Staff #6, a nurse.

(i) Upon interview at 12:00 PM, Staff #6 stated that Patient #7 had been in restraints since his/her shift began at 7:00 AM. Upon request to Staff #6 at 12:09 PM for a physician order for mitt restraints, Staff #6 indicated that an order was not needed. He/she stated it was a nursing judgement to apply mitts since the patient could potentially pull at the ventilator tubes.

(ii) A review of the medical record for Patient #7 was conducted immediately following the interview with Staff #7 and the medical record lacked evidence of a physician order for the application of mitt restraints.

c. At 12:27 PM, Patient #9 was observed to be sedated and intubated. This observation was confirmed per interview with Staff #8 at the time of the observation.

(i) Upon interview at 12:27 PM, Staff #8 stated that an order is needed for the application of mitts. Staff #8 stated that Patient #9 had mitts off and on based on nursing judgement, and that the mitts were placed back on at 11:30 AM.

(ii) Upon review of the medical record immediately following the interview with Staff #8, the "Restraint Assessment and Orders for Safety" flowsheet indicated that an order for one mitten (right) was obtained on 9/8/20 at 12:15 PM.

Based on a review of policy and procedure and review of one (1) medical record (#4) of a patient who was placed in restraints for the management of violent or self-destructive behavior, it was determined that monitoring of the patient was not performed in accordance with hospital policy.

Findings include:

Reference: Facility policy titled, "Restraints and Seclusion" states: "... IX. Monitoring/Care of the Patient While in Restraint: ... 2. The clinical condition of the patient will be evaluated by the RN [registered nurse] and documented at least once every hour. This evaluation includes: ... d) Vital signs ..."

1. On 9/9/20, the medical record of Patient #4, included an order placed on 8/5/20 starting at 1300 (1:00 PM) and ending at 1700 (5:00 PM) for 4-point locked restraints. The vital signs section of the "Restraint/Seclusion Assessment And Order For Violent/Self Destructive Behavior" lacked evidence that vital signs were obtained between 14:00 (2:00 PM) and 16:00 (4:00 PM). The patient was out of restraints at 1700 (5:00 PM).

2. The above was confirmed by Staff #2 on 9/9/20 at 11:00 AM.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that Neurological (Neuro) Checks were performed in accordance with physician's orders in one (1) out of two (2) medical records of patient's requiring Neuro Checks.

Findings include:

1. On the afternoon of 9/8/20, review of Medical Record #7 revealed the following:

a. A physician order dated 9/7/20 at 23:55 (11:55 PM) stated, "Neuro Check Q1 [every hour]."

b. Nursing documentation for neuro check were as follows: 9/8/20 at 1:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM and 12:00 PM.

c. Neuro checks were not performed every hour as ordered by the physician.

2. The above was confirmed by Staff #27 at 2:25 PM.

A. Based on observation and staff interview, it was determined that the facility failed to ensure that equipment for patient use is maintained to prevent the transmission of infection.

Findings include:

1. On 9/8/20 from 10:47 AM to 11:45 AM, a tour of the Emergency Department (ED) was conducted in the presence of Staff #4. Outside of Bay #7, an airway trauma/cardiac cart was identified. The airway trauma/cardiac cart contained supplies in one of the drawers that were overstocked and unorganized; this caused compression of the supplies which can compromise the integrity of the packaging. In the same drawer, catheters were folded in half with a rubber band which can compromise the integrity of the packaging.

2. The above finding was confirmed by Staff #4 at the time of discovery.

B. Based on 5 of 5 observations in the Emergency Department, staff interview, and review of policy and procedure, it was determined that that facility failed to ensure single use medications are discarded after opening.

Findings include:

Reference: Facility policy titled, "Medication Safe Storage Handling and Beyond Use Dating of Multidose Vials" states: "...Whenever possible, single dose vials will be used... Single dose vials are to be used for a single patient only, not for multiple patients....."

1. A tour of the Emergency Department (ED) was conducted on 9/8/20 from 10:47 AM to 11:45 AM in the presence of Staff #4. The following was identified:

a. A procedural cart was located in the fast track area of the ED. An opened bottle of Benzoin Tincture was identified on the shelf of the cart and available for patient use.

(i) The warning on the bottle stated: "Do not use if tamper evident seal is broken or missing....."

(ii) An interview at 11:04 AM with Staff #5 noted that Staff #5 was unsure when the bottle was opened, and if the bottle could be used for multiple patients. Staff #4 removed the bottle of Benzoin Tincture, and confirmed that the seal was broken and that the Benzoin Tincture should have been discarded after opening.

b. Bay #4 of the main ED contained two (2) opened four (4) ounce bottles of Hydrox, Solution of Hydrogen Peroxide 3% USP (United States Pharmacopeia). One bottle had a green circular label on it that noted it was opened on 8/26/20, and the second bottle was not labeled.

(i) Both bottles had the following statement on the manufacturer's label: "Sealed For Your Protection [sic] If Seal Is Broken Or Missing Do Not Use."

(ii) Staff #4 removed the two bottles of Hydrox upon discovery and confirmed that both the bottles' seals were broken and both bottles of Hydrox should have been discarded after opening. Staff #4 confirmed at the time of discovery that the one bottle of Hydrox should not have been labeled and available for multiple patient use.

c. Bay #5 of the main ED contained two (2) opened bottles of Scrub Care 10%. One bottle had a green circular label on it that noted it was opened on 8/14/20 and the second bottle had a green circular label on it that noted it was opened on 8/12/20.

(i) Both bottles had the statement: "For Single Use Only" located on the original manufacturer's label.

(ii) Staff #4 removed the two bottles of Scrub Care and confirmed that the bottles should have been discarded after opening and not labeled and available for multiple patient use.

d. Bay #7 of the main ED contained an opened bottle of Scrub Care 10%. The bottle had a green circular label on it that noted the bottle was opened on 8/4/20.

(i) The bottle had the statement: "For Single Use Only" located on the original manufacturer's label.

(ii) Staff #4 removed the bottle of Scrub Care and confirmed that the bottle should have been discarded after opening and not labeled and available for multiple patient use.

e. A cabinet at the nurse's identified as: "IV trays set up 2" was unlocked and contained one (1) opened bottle on Benzoin Compound Tincture.

(i) The warning on the bottle stated: "Do not use if tamper evident seal is broken or missing....."

(ii) At 11:36 AM, Staff #4 discarded the bottled of Benzoin Compound Tincture and confirmed that the Benzoin Compound Tincture's seal was broken and that the bottle should have been discarded after opening and made available for multiple patient use.