HospitalInspections.org

Based on observation and staff interview, the facility failed to protect and provide personal health information confidentiality for the inpatient population served at the facility.

The findings include:
On 02/02/2010 at the Pineridge campus at 4:25 p.m. a tour of the second floor was conducted. The tour included 3 state surveyors, the Chief Nursing Officer (CNO) and the Director of Environment. Observation revealed a Wallaroo (This is a rectangle box like device located in the hallway on the wall between patient rooms. The door opens and allows the staff to place a computer or papers for documenting in the medical record. This provides a desktop for staff. This device has a spring for automatic closing of the door.) According to the CNO the Wallaroo is also used by the staff to house the clip board which holds the current day medical information for patients. On arriving on the second floor it was observed that the Wallaroo outside room 204 was open with an Accu-check machine (this is equipment used to determine blood glucose levels). The Accu-check machine, Wallaroo and clip board was visible to anyone in the hallway. The Wallaroo door was held open by the weight of the Accu-check machine. The clip board was not appropriately covered and the medical record exposed personal health information. This was witnessed by the 3 state surveyors and 2 facility staff members. The CNO stated, "The records on the clip board usually have a blue paper or a manila colored file folder covering the personal health information on the clip board." The CNO continued by stating, "I have not seen this practice since I have worked here and I started in October." The CNO then proceeded to speak to the staff nurse regarding the Accu-check machine and the exposed patient medical record. The staff nurse was observed to cover the medical record information and remove the Accu-check machine from the Wallaroo and the Wallaroo door was then closed.
At 4:36 p.m. the tour was continued on the third floor. As the surveyors were walking out the door of the elevator on to the third floor, one staff member was observed removing a meal tray from a Wallaroo and was turning over the clip board to hide the exposed personal health information. Facility staff was also observed checking the cover status of the medical records. The surveyor asked the CNO if there was a policy regarding the use of Wallaroo's and the personal health information contained in the Wallaroo. The CNO stated, "We do not have a policy."

Based on interview and record review, the facility failed to ensure a registered nurse supervise and evaluate patients health status and response to interventions for 2 (Patients #18 and #3) of 41 patients reviewed.

The findings include:

1. Review of the clinical record at the Pine Ridge Facility for Patient #18 on 2/3/10 at 09:45 a.m. revealed on 1/29/10 the patient was initiate post operatively a patient controlled analgesia (PCA) containing morphine. The patient was changed to Dilaudid at 1825 p.m. (6:25 p.m.). Review of the PCA Pain Management Flowsheet reveals the patient was assessed for pain on 1/29/10 at 1425 (2:25 p.m.). The next assessment was completed at 2045 p.m. (8:45 p.m.) by a Licensed Practical Nurse. The next assessment was completed on 1/30/10 at 8:57 a.m. 12 hours later. Further review of the PCA Pain Management Flowsheet revealed an assessment documented on 1/31/10 at 1700 p.m. (5:00 p.m.) with the next assessment being documented 2/1/10 at 0001 a.m. 7 hours between assessments. The next assessment documented on 2/1/10 at 06:00 a.m. 6 hours later. On 2/2/10 an assessment was documented at 08:15 a.m. with the following assessment at 1810 p.m. (6:10 p.m.) 10 hours between assessments.

Review of the facility's policy on acute pain management states a patient on a PCA/PCAE, as indicated, utilizing the (PCA/Epidural Pain Management Flow Sheet): to record vital signs, level of sedation and pain assessment every 4 hours.

Interview with the Quality Services Specialist on 2/3/10 at 11:08 a.m. confirmed pain assessment on this patient were not completed as per facility policy.

2. At the Collier Campus on 02/02/2010 at 11:00 a.m. a chart review for Patient #3 was conducted in the postpartum (after delivery) unit of the Woman's Center. This chart review was conducted with the Director of the Woman's Center. At 11:10 a.m. during the review of Patient #3's medical record the Labor and Delivery (L&D) Admit orders and the Vaginal Delivery orders were reviewed. The following medications did not contain a frequency (how often or when these medications were to be administered. For example: Every 4 hours as needed or apply after each bowel movement, not to exceed 6 doses in 24 hours) of administration. The admit orders read: (including but not limited to) * Bicitra 30 mL (milliliter) by mouth as needed for constipation /heartburn.* Lidocaine 1% subcutaneous (administered by injection or infusion just into the subcutaneous layer of the skin) as needed for perineal (area of the genitalia) repair/infiltration.
* Cytotec 400 mcg (micrograms) rectally as needed for vaginal bleeding following delivery.
* Methergine 0.2 mg (milligrams) IM or IV (Intramuscular or Intravenously) as needed for vaginal bleeding following delivery.*Hemabate 250 mcg IM as needed for vaginal bleeding following delivery.
The Vaginal Delivery Orders dated 02/01/2010 and signed by the physician at 2:35 p.m. read: (including but not limited to)* Hydrocortisone Cream USP 1% 30 GM (gram) to perineum/hemorrhoids as needed for discomfort.* Apply Tucks pads to perineum/hemorrhoids as needed for discomfort.An interview with the Director of the Woman Center was conducted at 11:10 a.m. The Director stated, "These orders are specifically written this way. This allows the nurse access to these medications after delivery to stop the bleeding. This avoids an over-ride of the Accu-Dose (Medication dispensing system)." The Director continued by explaining if the order was designated a specific time parameter for a dose and the patient needed another dose of the medication, the system would not allow access to the medication if the time frame of administration was not in that specifically ordered time frame. This would require either pharmacy or supervisory intervention to gain access to additional medications. Also explained was the delivery component of the Woman Center is a 24 hours a day and 7 days a week. On nights and weekends the supervisor of the clinical areas of the hospital is needed to physically open the Accu-dose system for medication access. The Director explained the Lidocaine, Cytotec, Methergine and the Hemabate are considered emergent (emergency drugs) drugs and a delay in administration may cause harm to the patient.
At 11:45 a.m., the Director of the Woman's Center accompanied the surveyor to Pharmacy. The Director of Pharmacy verbalized the "over-ride" of the Accu-dose system and the emergent drugs are a direct order from the physician at that moment of assessment. The Pharmacy Director also commented, "Once the baby is delivered and postpartum orders are received all previous medications are automatically discontinued due to a change in level of care." According to the interview with the Director of the Woman Center and the Director of Pharmacy the physician or practitioner must physically reorder each new medication for the current level of care. The Director of Pharmacy explained, "If the physician wants to continue a previously ordered medication, the medication reconciliation sheet must contain a check next to the medication and must be signed by the physician or practitioner."

Based on observation, staff interview, and medical record review, the facility failed to provide a process ensuring drugs and biological components are ordered for the patient care using accepted standards of practice for those patients receiving services in the Women Care Center (Collier). Additional findings include the application of the Nurse Practice Act. The Nurse Practice Act states the following:
Professional Standard of Care is defined in Chapter 766.102 as, "the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers."

The Florida Nurse Practice Act, Chapter 464.003 defines the "practice of professional nursing" as "the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments and the "practice of practical nursing" as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist."

The findings include:

On 02/02/2010 at 11:00 a.m. a chart review for Patient #3 was conducted in the Postpartum (after delivery) Unit of the Woman's Center. This chart review was conducted with the Director of the Woman's Center. At 11:10 a.m. during the review of Patient #3's medical record the Labor and Delivery (L&D) Admit orders and the Vaginal Delivery orders were reviewed. The following medications did not contain a frequency (how often or when these medications were to be administered. For example: Every 4 hours as needed or apply after each bowel movement, not to exceed 6 doses in 24 hours) of administration. The admit orders read: (including but not limited to) * Bicitra 30 mL (milliliter) by mouth as needed for constipation /heartburn.* Lidocaine 1% subcutaneous (administered by injection or infusion just into the subcutaneous layer of the skin) as needed for perineal (area of the genitalia) repair/infiltration.
* Cytotec 400 mcg (micrograms) rectally as needed for vaginal bleeding following delivery.
* Methergine 0.2 mg (milligrams) IM or IV (Intramuscular or Intravenously) as needed for vaginal bleeding following delivery.*Hemabate 250 mcg IM as needed for vaginal bleeding following delivery.
The Vaginal Delivery Orders dated 02/01/2010 and signed by the physician at 2:35 p.m. read: (including but not limited to)* Hydrocortisone Cream USP 1% 30 GM (gram) to perineum/hemorrhoids as needed for discomfort.* Apply Tucks pads to perineum/hemorrhoids as needed for discomfort.An interview with the Director of the Woman Center was conducted at 11:10 a.m. The Director stated, "These orders are specifically written this way. This allows the nurse access to these medications after delivery to stop the bleeding. This avoids an over-ride of the Accu-Dose (Medication dispensing system)." The Director continued by explaining if the order was designated a specific time parameter for a dose and the patient needed another dose of the medication, the system would not allow access to the medication if the time frame of administration was not in that specifically ordered time frame. This would require either pharmacy or supervisory intervention to gain access to additional medications. Also explained was the delivery component of the Woman Center is a 24 hours a day and 7 days a week. On nights and weekends the supervisor of the clinical areas of the hospital is needed to physically open the Accu-dose system for medication access. The Director explained the Lidocaine, Cytotec, Methergine and the Hemabate are considered emergent (emergency drugs) drugs and a delay in administration may cause harm to the patient.
At 11:45 a.m., the Director of the Woman's Center accompanied the surveyor to Pharmacy. The Director of Pharmacy verbalized the "over-ride" of the Accu-dose system and that the emergent drugs are a direct order from the physician at that moment of assessment. The Pharmacy Director also commented, "Once the baby is delivered and postpartum orders are received all previous medications are automatically discontinued due to a change in level of care." According to the interview with the Director of the Woman Center and the Director of Pharmacy the physician or practitioner must physically reorder each new medication for the current level of care. The Director of Pharmacy explained, "If the physician wants to continue a previously ordered medication, the medication reconciliation sheet must contain a check next to the medication and must be signed by the physician or practitioner."

The Medication Administration Record (MAR) review dated 02/01/2010-02/02/2010 at 15:11 (3:11 p.m. print time) indicates a discontinuation of the previous medications ordered for admission. Additional MAR's for Patient #3 indicates the Hydrocortisone Cream 1% Topical as needed remains as an order without specific parameters for frequency of administration.
During the continued interview with the Director of Pharmacy it was reported to the surveyor the fixed physician order sheets which have no indication of frequency are evaluated by the forms committee. The Pharmacy Director confirmed: "You are correct there is no frequency for the Bicitra and the Hydrocortisone and yes there should be." An interview with the Pine Ridge Pharmacy Director was conducted on 02/03/2010 at 10:00 a.m. This interview included a review of the MAR and the physician order sheets for Patient #3. After review of the physician orders including the Bicitra and Hydrocortisone orders the Pine Ridge Pharmacy Director stated, "I agree these need additional instruction."

The facility failed to provide clear physician/practitioner orders for the accurate provision of care and services including the care provided by the nursing staff in the administration of medications in accordance with acceptable standards of practice.

Based on observation and interview, the facility failed to ensure all drugs are stored under proper conditions of security and segregation to promote patient safety and proper utilization in the Surgical Services Department.

The findings include:

Observation during the tour of the surgical suites at Pineridge campus in the presence of the Unit Director and the Clinical Coordinator on 2/2/10 at 11:45 a.m. revealed Operating Room #2 to be unoccupied with no staff present. Immediately after entering Operating Room #2 in clear view, unsecured on a desk by a computer were two vials of medication. One was labeled as "Sensorcaine with Epinephrine 1:200,000 30ml single dose vial" and the other labeled as "Ketorolac Tromethamine 30mg 1cc vial." Also in clear view on the desk were 2 boxes of medication labeled as "Topical Thrombin 5,000 IU."

On the left side of Operating Room #2, an Accudose automated medication dispensing system was housed on a metal cart with drawers. The drawers were not locked. One of the drawers contained 2 capped syringes, one labeled "Ephedrine 10mg/ml, 5ml" and the other was labeled "Phenylephrine 0.1mg/ml 10ml." Other medications observed in the unlocked drawer were: Neostigmine methylsulfate 1mg/ml, 10ml vial; Glycopyrolate 1mg/5ml, 5ml vial; Atropine 1mg/ml, 1ml vial; and two 1ml vials of Dexamethasone 4mg/ml.

Located next to the Accudose automated medication system cart was the anesthesia machine. At the base of the machine were unlocked drawers. In one of the drawers, two bottles of "Suprane liquid" for inhalation 240ml and one bottle of "Sevoflourane inhalation anesthetic" 250ml was observed. The bottles contained varying amounts of liquid.

During an interview with the Unit Director at the time of the observation, she acknowledged the medications should have been locked in the drawers.

During the tour, it was observed unlicensed staff members have access to unoccupied operating rooms.

Based on record review and interview, the hospital failed to ensure required medical and surgical notes and reports are completed for patients after surgery requiring anesthesia. A post-anesthesia evaluation was not completed and documented by an individual qualified to administer anesthesia for 1 (Patient #37) of 41 records reviewed.

Practice Guidelines for Postanesthetic Care (Anesthesiology, Vol 96, No 3, March, 2002) recommends postanesthetic assessment and monitoring of respiratory and cardiovascular function, neuromuscular function, mental status, temperature, pain, nausea and vomiting, drainage and bleeding, and urine output.

The findings include:

On 2/2/2010, review of clinical records for Patient #37 revealed the patient was admitted to the Collier Boulevard campus on 1/25/2010. The patient had a surgical repair of a hernia on 1/26/2010. Records documented that the patient received general anesthesia. On the Anesthesia Record for Patient #37, the Post Op Note section contained a checked box for "no anesthesia complications" and the Anesthesiologist's initials. Further review failed to find a post-anesthesia assessment of respiratory, cardiovascular, and neuromuscular function, mental status, temperature, pain, nausea and vomiting, drainage and bleeding, and urine output by the Anesthesiologist or CRNA (Certified Registered Nurse Anesthetist).

In an interview on 2/2/2010 at 3:25 p.m., the Director of Surgical Services said the Anesthesia Record provides the post-anesthesia evaluation. She pointed out the section entitled Post Op Note.

In an interview on 2/3/2010 at 10:12 a.m. at the Pine Ridge campus, the Chief of Anesthesiology said "the post-anesthesia evaluation is done in the PACU (Post-Anesthesia Care Unit). They assess and note on the Anesthesia Record." He explained the evaluation consists of "vital signs, mental status, and anesthesia complications; it's not detailed."

Based on observation and interview, the facility failed to ensure that respiratory care service equipment is periodically inspected and maintained in the Emergency Department.

The findings include:

During the tour of the Collier campus Emergency Department (ED) in the presence of the Unit Director on 2/1/10 at 3:45 p.m. a room prepared for gynecologic examinations was observed. An infant incubator was present in the room. Three infant respiratory resuscitation kits were bagged and attached to the incubator. On further examination of the equipment, it was revealed that all 3 kits contained equipment that expired in 2007. The expired respiratory resuscitation equipment was noted as: C02 (carbon dioxide) indicator, expiration date 4/2007; infant manual resuscitator with oxygen reservoir tube, expiration date 10/2007; pressure manometer, expiration date 9/2007; and disposable pressure manometer, expiration date 1/2007.

A separately packaged bag valve mask was also attached to the infant incubator. It did not contain an expiration date. The infant face seal on the mask attachment was observed to be yellowed and deflated.

During an interview with the Unit Director during the tour, she acknowledged the infant respiratory resuscitation equipment was outdated and the face mask attachment on the undated bag valve mask needed to be replaced.