HospitalInspections.org

Based on hospital policy and procedure review, open medical record reviews and staff interviews the Registered Nurse (RN) failed to administer and document hemodialysis treatments per physician's orders and per hospital policy in 2 of 2 patients receiving hemodialysis treatments (#19, #20).

The findings include:

Review of hospital policy,"Safety Checks During Inpatient Treatment FMS-CS-IS-I-501-050A" revealed "Monitoring of the patient will be performed every 15-30 minutes at a minimum." Review of hospital policy, "Safety Checks During Inpatient Treatment FMS-CS-IS-I-501-050C," revealed "2. Check dialysate flow to ensure setting is correct and the prescribed flow is being delivered...Document safety checks on the patient treatment record."

1. Medical record review of Patient #19 revealed a 46 year-old admitted on 06/02/2010 with a diagnosis of pericardial rub and end stage renal disease requiring hemodialysis. Medical record review revealed physician's order for hemodialysis with a dialysate flow rate (DFR) of 500 on 06/02/2010. The medical record review of the "HEMODIALYSIS UNIT TREATMENT RECORD" revealed hemodialysis was initiated at 0830 on 06/02/2010 and ended at 1230. The record revealed the patient's blood pressure was 181/130 at 0830 and 125/94 at 1130. The record revealed the patient's blood pressure dropped to 97/56 at 1145. The record revealed the patient was administered a 250 cc bolus of normal saline at 1145. The record revealed no documentation of a physician's order for normal saline boluses. Record review revealed no documentation of the DFR with the 30 minute safety checks. Record review revealed no documentation of a physician's order for the bath to be administered during the hemodialysis treatment on 06/02/2010

Observation of patient #19 on 06/03/2010 at 0845 revealed the dialysis nurse monitoring the patient at the bedside during the hemodialysis treatment.

Interview on 06/03/2010 at 0900 with the dialysis nurse revealed there was no documentation available of a physician's order for the bath to be used and usage for normal saline for boluses for the hemodialysis treatment conducted on 06/02/2010. The interview revealed the nurse initiated the hemodialysis treatment on 6/2/2010 with a bath based on past medical history and previous hospitalization. The interview revealed the physician should have been notified and an order of the bath should have been obtained prior to the start of the hemodialysis treatment. The interview revealed the nurse had administered a 250 cc normal saline bolus to the patient during the hemodialysis treatment on 6/02/2010. The interview revealed there was not a physician's order available to administer saline boluses.
Interview revealed there was no documentation of the DFR with each safety check.

2. Medical record review of Patient #20 revealed a 49 year-old admitted with chest pain on 05/25/2010 . Medical record review revealed physician's orders for hemodialysis on 05/27, 05/28, and 05/31/2010 with DFRs ordered at 300, 400, and 500, respectively. Medical record review of the "HEMODIALYSIS UNIT TREATMENT RECORD" revealed no documentation of DFRs on 05/27, 05/28, and 5/31/2010 during 30 minute safety checks.
Record review revealed no documentation of the DFRs during hemodialysis on 05/27, 05/28, and 5/31/2010.

Interview on 06/03/2010 at 1030 with administrative staff revealed there was no available documentation of DFRs on 05/27, 05/28, and 05/31/2010.

Based on observations as referenced in the Life Safety Report of survey completed 06/02/2010, observation during tours and policy review, the hospital failed to develop and maintain the facilities in a manner to ensure the safety of patients.

The findings include:

The hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

~Cross-refer to 482.41(b) Physical Environment Standard Tag A-0710.

Based on observations as referenced in the Life Safety Report of survey completed 06/02/2010, the hospital failed to ensure the safety and well-being of patients by failing to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA).

The findings include:

Observations of Building 1 on 06/01/2010 - 06/02/2010 revealed the following:

1. Based on observation, on June 2, 2010 at approximately 0500 onward, there are gaps greater than one eight of an inch between the meeting edges of exit access doors serving the recovery suite (located in the maternity center).

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0018.

2. Based on observation, on June 2, 2010 at approximately 0500 onward, there are deadbolt latches on exit access doors in the third floor storage rooms - located in circular tower section.

Note: Additional latching devices were removed during survey - doors did not require greater than a single hand motion.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0038.

3. Based on observation, on June 2, 2010 at approximately 0500 onward, the fire safety policies and procedures are incomplete due to the following:

a. there are no posted evacuation signs for the means of egress serving operating rooms 1 - 4.

b. fire safety procedures did not address the location and use of air handler emergency shutdown switches during fire emergencies.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0048.

4. Based on observation, on June 2, 2010 at approximately 0500 onward, there is no sprinkler system coverage in the following areas:

a. manager's closet - located in PACU/ICU.

b. shower stall in men's dressing room - OR Suite.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0056.

5. Based on observation, on June 2, 2010 at approximately 0500 onward, the following sprinkler system components were noncompliant:

a. heat box containing main sprinkler valves and backflow preventer - heater and emergency receptacle did not function during initial test. Heater circuit in emergency electrical panelboard was not identified as required by the National Electrical Code. Note: Heater and receptacle were corrected prior to completion of survey.

b. gauges located in fire pump main are not listed for fire protection service.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0062.

6. Based on observation, on June 2, 2010 at approximately 0500 onward, the following mechanical system components are incomplete:

a. air handler system shutdown switches are located greater than forty-eight inches above the finished floor (third floor nurse's station located in circular floor section).

b. lack of emergency shutdown switch at a supervised station - air handling unit serving operating rooms 1 - 4.

c. emergency shutdown switch for the air handler, located in medical records, is not located at a supervised station.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0067.

7. Based on observation, on June 1, 2010 at approximately 1430 onward, the means of egress is obstructed due to the following: doors to clean linen storage closet protrude greater than seven inches into the required corridor width in the fully open position (fifth floor cylindrical tower section).

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0072.

8. Based on observation, on June 2, 2010 at approximately 0500 onward, location of medical gas system zone valves could not be verified for operating room suite containing rooms #1 - #4. Engineered drawings failed to provide correct location of valves. Alarm signals could not be verified for a pressure differential of plus or minus twenty percent of operating pressure.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0077.

9. Based on observation, on June 2, 2010 at approximately 0500 onward, the following electrical system components are noncompliant:

a. broken lamp test switch for generator annunciator panel serving generators #1, and #2.

Note: Switch was immediately corrected by facilities management during survey.

b. delayed egress locks serving maternity center did not release during loss of power - located near manager's office.

Note: Improperly labeled circuit breaker was corrected during survey - lock was verified to release with loss of power.

~ cross-refer to Life Safety Code Standard - NFPA 101, Tag K0147.