HospitalInspections.org

Based on record review and staff interview this facility failed to ensure that surgical outpatients were asked about Advanced Directives (AD) or that this was documented in the surgical EMR in three of three surgical outpatients reviewed out of a total of 20 EMRs (Pt. #5, 6, and 7). Failure to inquire and/or document about ADs has the potential to affect all surgical outpatients at this facility.

Findings include:

The facility's policy titled, "Advanced Directives," dated September 1, 2013, was reviewed on 3/26/2014 at 2:37 p.m. The policy states in part, "C. 2. During the hospital admission, the admitting nursing staff will: a. Ask the patient/family if the patient has a Living Will, Power of Attorney for Healthcare or any document that communicate their healthcare wishes. b. If the patient does have one of the above, ask him/her if they have ever given a copy to someone at [the facility]. If the patient's does have one but has not given a copy to anyone at the [facility's] campus ask him/her to have a copy brought to the hospital and give it to his/her nurse. c. Give the advance directive brochure to every patient."

The policy indicates that its Distribution is "Hospitalwide" and does not specify between inpatients and outpatients in the above quoted section.

EMR reviews were conducted on 3/26/2014 between 8:30 a.m. and 11:45 a.m. accompanied by HIM Coord J. It was noted that during the review of surgical outpatients EMRs (Pt.s #5, 6, and 7) there was no documentation regarding ADs in the pre-operative history section.

In an interview with Coord J during the EMR reviews, J stated that J was unaware if patients were asked about ADs as an outpatient.

RN P, who was in the room during the EMR reviews stated that OR staff does not document ADs and does not ask about them.

In an interview with OR RN Q on 3/26/2014 at 1:03 p.m. regarding ADs, RN Q agreed with RN Ps statement. Surgical Outpatients are not asked about ADs and it is not a part of the pre-surgical phone call or the pre-surgical history to document about ADs.

Based on the tour of the facility from March 24th to the 26th, 2014 with the Director of Facilities and the Maintenance Supervisor; this surveryor observed that the hospital failed to be constructed, arranged, or maintained the buildling to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

42 CFR 485.623: Condition of Participation: Physical Plant is NOT MET.

K-tags cited were as follows:
K-15: Finish materials in a room at least Class C rating
K-17: Corridors smoke-tight
K-18: Positive latching corridor doors
K-22: Exit signs
K-25: Smoke compartments built as one-hour
K-29: Hazardous areas built as one-hour
K-34: Exit with minimum clearance height
K-56: Sprinkler system installed per NFPA 13
K-144: Generator load bank annually if not 30% loaded
K-147: Electrical equipment installed per NFPA 70

These deficiencies were confirmed at the time of discovery by a concurrent observation, record review and interview with staff B and staff G. Please refer to the individual K-tags for the full description of each deficient practice.

Based on observations and staff interview this facility failed to ensure the environment is well maintained and safe for all patients and staff in two of nine departments visited (OR and kitchen). Failure to ensure a well maintained environment that is safe has the potential to affect all patients (one patient was scheduled for surgery during the course of the survey) and staff who enter these departments.

Findings include:

A tour of the Surgical suite was completed on 3/24/2014 from 1:50 p.m.-2:15 p.m. accompanied by Surgery Coord F. It was noted that an area of approximately 10 inches by 2 inches was gouged out of the drywall along one wall in OR 1, exposing a porous surface that is not cleanable. Non-cleanable surfaces in the OR can pose a risk to patients and staff. Coord F acknowledged this finding at the time of discovery.



05409


During the kitchen tour accompanied by Dietary Manager M and Dietary Supervisor N beginning at 11:00 a.m. on 3/26/14, when the dry storage room was toured at 11:16 a.m. the outside cement wall by the ceiling edge was noted to have deep cracks along most of the top portion of the wall making the surface porous and not cleanable. In an interview with Manager M during the tour, M said, "Oh, yes I see. It's just that outside wall."

Based on the tour of the facility from March 24th to the 26th, 2014 with the Director of Facilities and the Maintenance Supervisor; this surveryor observed that the hospital failed to be constructed, arranged, or maintained the buildling to ensure the safety of the patients. The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients. The Existing Health Care Occupancy chapter of the Life Safety Code (2000 Edition) [NFPA 101] was used for this survey.

42 CFR 485.623 (d)(1) Standard: Life Safety from Fire is NOT MET

K-tags cited were as follows:
K-15: Finish materials in a room at least Class C rating
K-17: Corridors smoke-tight
K-18: Positive latching corridor doors
K-22: Exit signs
K-25: Smoke compartments built as one-hour
K-29: Hazardous areas built as one-hour
K-34: Exit with minimum clearance height
K-56: Sprinkler system installed per NFPA 13
K-144: Generator load bank annually if not 30% loaded
K-147: Electrical equipment installed per NFPA 70

These deficiencies were confirmed at the time of discovery by a concurrent observation, record review and interview with staff B and staff G. Please refer to the individual K-tags for the full description of each deficient practice.

Based on observation, P/P review, and Staff interview, this facility failed to 1. Ensure the integrity of the contents of one of three emergency carts that contain medications, needles, and syringes in one of three rooms in the ED; 2. Ensure that no expired medications are available for patient use in one of one medication refrigerators in the ED, and 3. Clearly mark expired solutions not for patient use in one of one medication refrigerators on the Medical/Surgical floor. Failure to secure medications to maintain their integrity and remove expired medications has the potential to affect all patients coming to the ED (there were none during the tour). Failure to clearly mark expired solutions has the potential to affect all patients on the Medical/Surgical unit (eight during the course of the survey).

Findings include:

The facility's policy titled, "Expiration Dates on Medications," dated September 2013, was reviewed on 3/26/2014 at 7:37 a.m. The policy states in part, "1. Everyone in the Pharmacy is responsible for watching for expired or soon to expire medications. 2. One Pharmacy Technician will be responsible for providing all hospital departments and the clinic with in-date medications and removing soon to expire medications."

The facility's policy titled, "Crash Cart Drugs," dated October 2001, was reviewed on 3/26/2014 at 2:29 p.m. The policy does not address the double locking system that 2 out of 3 emergency carts in the ED have.

A tour of the ED was conducted on 3/25/2014 at 10:20 a.m. accompanied by ED Coord D and Dir of Patient Care Services C.

It was noted that the emergency cart in Bay 1, secured only by a breakaway lock that removed with very little effort, was placed in an area of the room not visible from the nurses station and therefore tampering with medications and/or access to needles/syringes is possible. This cart does not have the double locking system that the other 2 emergency carts in the ED that were observed did have.

In an interview with Coord D during the tour, regarding cart security and if patients could be left in this Bay without staff being present at all times, Coord D stated that it is possible patients could be in the Bay without staff.

During this same ED tour, at 10:40 a.m. the medication refrigerator was found to contain an open vial of Regular insulin which was dated to have expired on 3/8/2014. In an interview with Dir C at the time of discovery regarding expired medications, Dir C stated pharmacy should have removed the insulin when going through the refrigerator.


05409


At 4:51 p.m. on 3/24/14 accompanied by RN H and Director C, the refrigerator in the clean utility room in the medical/surgical unit was examined and found to have 3 jugs of Sodium Chloride irrigation solution with the expiration date of 10-2011. One of the 3 jugs was 1/2 full and the other two were full. When shown to Director C, C said,"I'm sorry for the findings, I witnessed it."

At 8:25 am on 3/25/14 per interview with Director C, C said that C had spoken to pharmacy who said the jugs were in the clean utility refrigerator to maintain the temperature, but added "Should not be available for staff to use and should be appropriately labeled." There were no labels on the 3 jugs other than the manufacture label to indicate that staff were not to use the contents.

Based on kitchen tour observations and staff interviews, the hospital failed to ensure that dishwashing and cooler/freezer temperatures were monitored each shift daily for two of three months reviewed (February and March). By not monitoring the safety of sanitization during dish washing, and by not monitoring the cooler/freezer temperatures to ensure safe food temperatures are maintained, this poses a risk to affect all employees and pts. who eat meals in the hospital, including the eight patients present during the course of the survey.

Findings include:


During tour of the kitchen accompanied by Dietary Manager M and Dietary Supervisor N beginning at 11:00 a.m. on 3/26/14, N was asked to provide dish washing and cooler/freezer temperature logs from January 2014 to present.

Per review of the dish washing temperature log for March 2014, it was noted that there were no temperatures recorded for the lunch meals on 3/4/14 and 3/7/14; no breakfast temperatures for the breakfast meals on 3/15/14 and 3/16/14, and none for the lunch and supper meals on 3/23/14.

When reviewing the forms labeled "Storage Area Temperature Monitoring Form" for February and March 2014, the following was noted: 2/5/14 the snack cooler temperature was not checked on the daily schedule as required at 5:30 a.m.; the required 12:30 p.m. temperature check of the vegetable freezer was not done on 2/19/14; the required 12:30 p.m. checks of the walk-in cooler, walk-in freezer, upright cooler/freezer, storeroom cooler, sandwich cooler, and snack cooler were not done on 3/9/14; the required 5:30 a.m. and 12:30 p.m. temperature checks were not done for the vegetable freezer and storeroom cooler on 3/16/14. When Supervisor N was show the blanks for temperatures on the forms for freezers/coolers and asked if noted the temperatures were missing, N said, "Yes."


Per interview with Manager M, M said that the missing temperatures may be due to new staff on the
weekends.

Based on EMR review, Medical Staff Rules and Regs, and staff interview, this facility failed to ensure that telephone/verbal (TO/VO) orders are properly authenticated with signature, date, and time within a 24-hour period of being written in two of three outpatient surgical patients (Pt. #5 and 6) and four out of nine inpatient records (Pt.s #14, 15, 17, and 19) out of a total of 20 EMRs reviewed. Failure to have properly authenticated TO/VO has the potential to affect all patients receiving care in this facility, including the eight patients present during the course of the survey, and the three patients scheduled for outpatient procedures on 3/25/2014.

Findings include:

The Medical Staff Rules and Regs, dated August 2013, were reviewed on 3/26/2014 at 2:20 p.m. On page 4 the Rules and Regs state in part, "Orders dictated over the telephone or given verbally shall be taken by the Registered Nurse...The attending physician shall sign and date such orders within twenty-four (24) hours."

The EMR review of Pt. #5 was conducted on 3/26/2014 at 9:59 a.m. accompanied by HIM Coord J who confirmed the following during the EMR review:
Pt. #5 had a VO written on 1/23/2014 and the MD did not include a date and time for the signature.

The EMR review of Pt. #6 was conducted on 3/26/2014 at 10:10 a.m. accompanied by HIM Coord J who confirmed the following during the EMR review:
Pt. #6 had a VO written on 3/12/2014 and the MD did not include a date and time for the signature.


05409

Per paper medical record review of Pt. #14 at 2:26 p.m. with RN L on 3/26/14, it was noted that the order written by pharmacy at 2:15 p.m. on 3/22/14 was not signed by the physician. When shown to RN L, L said "yes, it's not signed." The verbal order recorded at 8:00 p.m. on 3/23/14 was not signed by the physician. When shown to RN L, L said, "yes, it's not signed."

Per EMR of Pt. #15 at 10:50 a.m. on 3/26/14 during review of physician orders with RN L, it was noted that the verbal order written at 11:00 p.m. on 1/1/14 was not signed by the physician. Per interview when discussed that the order was not signed, L said, "yes."

During paper medical record review of physician orders for Pt. #17 beginning at 2:25 p.m. it was noted that the telephone order written at 8:26 p.m. on 3/21/14 was not dated and timed when the physician signed it. When shown to RN L at this time, L said, "I don't see it."

During the EMR review of Pt. #19 with Quality Assessment and Improvement Coordinator at K at 1:05 p.m. on 3/26/14, review of physician orders revealed the the verbal /telephone orders written at the following times on 12/30/13 were not dated or timed when signed by the physician: 1:15 a.m.; at 5:50 a.m.; at 6:35 a.m.; 9:55 a.m.; 11:18 a.m.; 11:40 a.m.; and 11:50 a.m. When these 12/30/13 oral orders were show to K, per interview, K said, "It's not there."

Based on record review and staff interview this facility failed to ensure that prior to surgical procedures the provider/MD is ensuring, through documentation, that patient's are informed of the risks and benefits of the procedure in two of three surgical EMRs reviewed (Pt. #6 and 7). Failure to document that patients have been informed of the risks and benefits of the surgical procedure has the potential to affect all patients receiving surgery in this facility.

Findings include:

The facility's policy titled, "Informed Consent," dated September 1, 2013, was reviewed on 3/26/2014 at 2:35 p.m. On page one the policy states in part, "The concept of consent to treatment requires a physician to obtain the patient's authorization before treatment."

On page 2 of this same policy it states in part, "The attending physician or the specialist, who is most familiar with the risks and benefits of the proposed course of treatment, should obtain the patient's informed consent. Although hospital employees can be utilized to provide such information to the patient, the physician performing the procedure remains responsible for ensuring that the patient has been adequately informed of the risks and benefits of treatment."

The Medical Staff Rules and Regs, dated August 2013, were reviewed on 3/26/2014 at 2:20 p.m. On page 14 the Rules and Regs state in part, "3. The surgeon must properly explain an informed consent."

EMR reviews were conducted on 3/26/2014 between 8:30 a.m. and 11:45 a.m. accompanied by HIM Coord J. It was noted that the surgical consents for Pt.s #6, and 7 did not contain surgeon authentication but indicate that risks and benefits of the procedure had been satisfactorily explained by the physician. In an interview with Coord J during the EMR reviews, J stated that the physicians were not signing the consent.

In an interview with Dir of Organizational Integrity A on 3/26/2014 at 1:00 p.m. regarding these findings, A thought this may be documented in the H&Ps of these patients.

At 1:50 p.m. on 3/26/2014 Dir A presented the H&Ps for Pt.s #6, and 7. The H&Ps for Pt. #6 and 7 do not indicate the physician discussed risks and benefits.

Based on EMR review, Medical Staff Rules and Regs and Staff interview, this facility failed to ensure that MD orders are properly authenticated and complete for two of three surgical outpatients (Pt. #5 and 6) out of a total of 20 EMRs reviewed. Failure to have complete and authenticated orders has the potential to affect all patients receiving care in the facility, including the eight inpatients and three outpatients during the course of the survey.

Findings include:

The Medical Staff Rules and Regs, dated August 2013, were reviewed on 3/26/2014 at 2:20 p.m. On page 9, under "Clinical Entries" the Rules and Regs state in part, "All clinical entries in the patient's medical record shall be legible, accurately dated, timed, and authenticated....Timing and dating entries are necessary for patient safety and quality of care. Timing and dating of entries establishes a baseline for future actions or assessments and establishes a timeline of events."

On page 13 of the Rules and Regs it states in part, "There must be a a discharge order for all patients."


The EMR review of Pt. #5 was conducted on 3/26/2014 at 9:59 a.m. accompanied by HIM Coord J who confirmed the following during the EMR review:
Pt. #5 does not have a discharge order from outpatient surgery. There are discharge instructions but not an order. In an interview with Coord J during the EMR review, J stated, "You are right, there is no order there."

The EMR review of Pt. #6 was conducted on 3/26/2014 at 10:10 a.m. accompanied by HIM Coord J who confirmed the following during the EMR review:
Pt. #6 has a MD order that does not include the time the order was written. In an interview with Coord J during the EMR review, J stated, "My people (HIM staff) should have caught that."

Based on record review and staff interview, this facility failed to follow it's protocol for the OPO to approach family members regarding organ donation in one of four EMRs of patients who passed away (Pt. #9). This failure has the potential to affect all patients who pass away at this facility.

Findings include:

In an interview with Dir of Patient Care Services C on 3/25/2014 at 9:10 a.m. regarding the OPO program at the facility, C explained that the facility has an "assisted approach" to approaching families regarding donation. Nursing staff are responsible for contacting the OPO liaison and informing families that the OPO will be contacted.' The facility no longer has designated requestors that are used for such purposes. Dir C states that two staff are still trained as requestors for informative purposes only and that the OPO is usually responsible for approaching families.

The facility's policy titled, "Organ and Tissue Donation," dated 10/2013 was reviewed on 3/26/2014 at 2:48 p.m. The policy states in part, "Nursing staff are trained in the assisted approach process and [name of organization who is the liaison between the facility and the OPO] staff assumes responsibility for making the request, obtaining consent, and coordinating donation services."

The EMR review of Pt. #9 was conducted on 3/26/2014 at 10:55 a.m. accompanied by HIM Coord J who confirmed the following during the EMR review:
Pt. #9 came into the ED on 1/2/2014 and life saving measures were attempted but did not succeed. ED RN R documents that R spoke to Pt. #9's family regarding organ procurement and autopsy and then called the OPO. This practice is not supported by the facility's policy.

In a follow up interview with Dir C on 3/26/2014 at 1:00 regarding these findings, Dir C stated this was an error on the nurse's part and OPO has identified the error with the facility. Dir C identified that RN R is not one of the staff members who are trained as a requestor.