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Based on observation, interview and record review, the facility failed to ensure the prompt resolution of patient's concern for missing personal belonging for 1 of 30 sampled patients (Patient 17).

Findings:

On August 26, 2013, at 11 a.m., during the tour of the unit, Patient 17 was observed in bed, and his mother was at the bedside.

The interview was conducted at the time of an observation and the mother stated Patient 17's pair of eye glasses was missing since after the surgery. She stated she took a photograph of the patient while being wheeled to the OR, and the patient was wearing his eye glasses on his way to the operating room. She further stated that she informed the registered nurses who took care of her son about the missing eye glasses and was told they would look into it. She added that she also informed the physician of the missing eye glasses. However, she was concern that the patient will be discharged today and she have not heard from the facility staff regarding the missing eye glasses.

During an interview with RN 5 after leaving the patient room, she stated that she would follow-up the concern as soon as possible.

A review of the Patient Data revealed Patient 17 was admitted to the facility on August 20, 2013, for aortic insufficiency with mitral valve regurgitation. On the same day, the patient underwent mitral valve replacement.

The Pre-Procedure Checklist dated August 20, 2013, revealed eye glasses was included in the checklist. The Nursing In-Patient Notes dated August 21 through 25, 2013 did not have documentation regarding the missing eye glasses. The Social Workers notes was reviewed and there was no documentation that the missing eye glasses was addressed.

A review of the facility policy on Missing Articles indicated to assist the patient/family, the Patient Relations Office will contact Security to determine if their office has made an investigation and/or found the missing articles.

The Grievance Resolution Management indicated grievances stipulated complaints and grievances are addressed in a timely manner and are handled in a way that does not compromise a patient's right to receive respectful and supportive care.

Based on record reviews and interviews, the facility failed to ensure the patient has a properly executed informed consent for 4 of 30 sampled patients (Patient 12, 16, 25, and 26).
a. For Patient 25, the telephone consent was obtained from the patient's parents and the completed consent was not signed at the earliest opportunity by the parents per policy.
b. For Patient 26, the telephone consent was obtained from the patient's parents and the completed consent was not signed at the earliest opportunity by the parents per policy. In addition, a consent the patient's mother signed on July 20, 2013 did not indicate the procedure the mother was consenting for.
c. Patient 12's clinical record did not contain a Condition of Admission document for the patient's August 19, 2013 admission.
d. Patient 16's Outpatient Condition of Admission document was dated, but not timed, as to when it was signed by the parent.

Findings:

a. The clinical record for Patient 25 was reviewed on August 29, 2013, at 8:55 a.m. The "Patient Data" Sheet indicated Patient 25 was admitted to the facility on June 21, 2013 to the Neonatal Intensive Care Unit (NICU) for renal failure.

The "Verification Form for Consent to Surgery or Special Diagnostic or Therapeutic Procedures" dated June 22, 2013, indicated a telephone consent was obtained on June 22, 2013, at 12:20 p.m., for peritoneal dialysis (PD - uses a membrane inside your body (peritoneal membrane) as a filter to clear wastes and extra fluid from your body and to return electrolyte levels to normal) and peritoneal dialysis catheter placement. The section of the form indicating the name, signature, relationship of the signee to the patient, date, and time was left blank.

During the review of the electronic medical record for Patient 25 with Registered Nurse (RN 1) on August 29, 2013, at 11:33 a.m., RN 1 found documentation that Patient 25's mother had visited on June 23, 2013, from 4 p.m. to 7 p.m.; and, on June 24, 2013 from 6 p.m. to 9 p.m.

During the concurrent interview with RN 1, RN 1 stated the opportunity was missed to have Patient 25's mother sign the telephone consent obtained on June 22, 2013 for the peritoneal dialysis and PC catheter placement.

b. The clinical record for Patient 26 was reviewed on August 28, 2013, at 3:12 p.m. The Patient Data Sheet indicated Patient 26 was admitted to the facility on June 7, 2013, for status patent ductus arteriosus (PDA - a congenital disorder in the heart wherein a neonate's ductus arteriosus fails to close after birth).

The Verification Form for Consent to Surgery or Special Diagnostic or Therapeutic Procedures dated June 30, 2013, indicated telephone consent was obtained on June 30, 2013, at 12:55 p.m., for a chest tube placement. The section of the form indicating the name, signature, relationship of the signee to the patient, date, and time was left blank.

The Verification Form for Consent to Surgery or Special Diagnostic or Therapeutic Procedures dated July 20, 2013, indicated Patient 26's mother signed the document on July 20, 2013, at 9:23 a.m. The document was signed by two (2) witnesses. However, there was no documentation of the procedure the physician was obtaining the consent for. The section of the document where the procedure was to be hand-written on was left blank.

During the review of the electronic medical record for Patient 26 with RN 1 on August 29, 2013, at 10:23 a.m., RN 1 found documentation that Patient 26's mother had visited on July 1, 2013 from 11 a.m. to 1 p.m., 5 p.m. to 7 p.m., and again from 8 p.m. to midnight on July 2, 2013.

During the concurrent interview with RN 1, RN 1 stated the opportunity was missed to have Patient 26's mother sign the telephone consent obtained on July 30, 2013, for the chest tube placement. In addition, RN 1 stated the surgeon was supposed to write the procedure to be performed that he/she was obtaining the consent for, on the consent form.

The facility policy titled "Informed Consent" effective March 17, 2010, indicated the consent form should provide the information regarding the proposed procedure. The consent must be obtained and documented in the patient's medical record before the procedure is performed. If the consent was obtained via telephone, the patient/patient's legal representative will sign a completed consent form at the earliest opportunity.



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c. A review of Patient 12's Data Sheet, conducted on August 29, 2013, indicated the patient was admitted to the Neurosurgical Unit on August 19, 2013, with diagnosis of chronic draining of left posterior thigh wound and wound closure with local flap advanced.

A review of the clinical record failed to indicate a Consent for Admission (COA- explains basic rules of hospital and responsibilities of hospital staff and the patient, provides explanation of consent for medical and/or surgical procedures, explains financial responsibilities of the parent and/or guardian, and explains assignment of insurance benefits).

On August 29, 2013 at 2 p.m., during an interview and review of the clinical record with the Quality Improvement Manager, she stated she was unable to locate a COA for the patient's current admission, and that there should be one in the patient's record.

A review of the facility's policy titled, "Admission Process: Forms Requiring Signature in Admitting", dated April 2012, indicated it was the responsibility of the Admitting Department to obtain the required parent signatures at pre-admission, admission, or as soon after as possible.


d. A review of Patient 16's Data Sheet indicated the patient was admitted to the facility on August 26, 2013, with a diagnosis of pancreatitis (inflammation of the pancreas).

A review of the clinical record indicated an outpatient COA, dated August 26, 2013. However, the consent was not timed.

During interview and record review with the Manager of Quality Improvement, on August 29, 2013 at 4 p.m., she stated the consent should be both dated and timed when the consent was signed by the parent.

Based on observation, interview and record review, the facility failed to ensure 1 of 30 sampled patients (Patient 19) was able to make known if he had advance directives or was provided written information on advance directives.

Findings:

On August 26, 2013, at 2:30 p.m., Patient 19 was observed in the room playing card with her mother. The patient was alert and oriented and able to make her needs known. The patient stated she had blood transfusion twice and consent was signed prior to receiving the blood and blood products.

A review of the Conditions of Admission (COA) dated August 25, 2012, indicated the patient signed the COA; however, section #12, Advance Directive, failed to show the answers for the following questions:
a. The patient has received written information on advance directive.
b. The patient has an advance directive.
c. If the answer to yes to "b", a copy of the patient's advance directive has been placed in the medical record.

During an interview with RN 4 while reviewing the clinical record of Patient 19, she concurred that since the patient 19 is 19 years old, she can sign her COA, and the Advance Directive portion should have been completed.

According to the facility policy Patient Self-Determination Act indicated to provide each competent adult (18 years of age or older and emancipated minors) with written information describing (i) an individual's right under California statutes and court decisions to accept or refuse medical or surgical treatment and to formulate Advance Directive, and (ii) the Hospital's policies regarding these rights to make health care decisions and to formulate Advance Directives, and regarding the way such decisions and directives will be implemented in the hospital and inquire whether or not the patient has executed an Advance Directive.

Based on record review and interview, the facility failed to obtain a physician order for a wrist restraint, in a timely manner, for one of 30 sampled patients (14). Patient 14 had a right wrist restraint applied on August 12, 2013. However, a physician order was not obtained for the restraint until August 14, 2013.

Findings:

The electronic medical record for Patient 14 was reviewed with RN 2 on August 29 at 9 a.m. The Patient Data sheet indicated Patient 14's birth date was May 13, 2013. On May 16, 2013, the patient underwent surgical repair for left hypoplastic heart syndrome (congenital heart defect in which all of the structures on the left side of the heart are severely underdeveloped). Following the surgery, the patient was admitted to the Chest/Thoracic ICU. The patient was intubated (breathing tube inserted into the lungs for purposes of airway management), dependent on a ventilator machine for breathing, and was receiving intravenous (IV) medication for pain and sedation.

Review of the clinical record conducted on August 29 at 8:20 a.m., with RN 2, indicated that a soft restraint was applied on Patient 14's right wrist on August 12, 2013 at 7 p.m., for care management.

During the concurrent interview with RN 2, she was unable to locate documentation of a physician order for August 12, 2013 at 7 p.m. According to the section of the clinical record, "Activity/Restraints", the first restraint order was dated May 16, 2013. Then next documented restraint order was dated August 14, 2013 at 12:04 a.m.

On August 29 at 11:35 a.m., during an interview with the Vice President for Quality Improvement and Patient Safety, he stated he had spoken with the Care Management team. The team was unable to explain why there was no documented physician order for the restraint.

The facility policy titled, "Use of Restraint and Seclusion", revised July 15, 2009, stipulates that the RN must notify the Licensed Independent Practitioner (LIP) or designee within 12 hours to obtain an order for restraint. An initial telephone order is acceptable for care management restraints

Based on observation, record review, and interview, the facility staff failed to reassess the patients' pain level prior to the administration of pain medication and within one hour after the medication administration for five of 30 sampled patients (17, 19, 20, 22, and 23).

Findings:

a. On August 26, 2013, at 2:30 p.m., Patient 19 was observed in the room playing card with her mother. The patient was alert, oriented and able to make her needs known.

According to Patient Data, Patient 19 was admitted to the facility on August 25, 2013 with diagnoses of swollen lip and rectal bleeding.

A review of the In Patient Nursing Notes dated August 27, 2013, at 8 a.m., indicated the patient's level of pain was assessed as 8/10 (0 for no pain, and 10 for the most severe pain), throbbing, buttocks/hemorrhoids and 2 tablets of Dilaudid was administered. The patient's pain level was reassessed at 10 a.m. (two hours later), and it was 3/10.

The facility policy on "Pain Management and Assessment of Pain in Infants, Children, Adolescents and Young Adults" indicated that within an hour of any intervention, reassess the patient.

b. On August 28, 2013, at 7:15 a.m., Patient 17 was observed lying in bed, and the mother was at the bedside.

According to the Patient Data, Patient 17 was admitted to the facility on August 20, 2013, with diagnoses of aortic insufficiency and mitral valve regurgitation.

A review of the In Patient Nursing Notes dated August 23, 2013, at 6:45 a.m., the patient's pain level was assessed as 3/10 and acetaminophen hydrocodone (Norco) one tablet was administered. At 11 a.m., the patient was administered Norco, however there was no documentation the pain was assessed prior to the medication administration.

c. According to Patient Data, Patient 20 was admitted to the facility on August 11, 2013, with diagnosis of trauma.

A review of the In Patient Nursing Notes dated August 11, 2013, at 8 p.m., indicated the patient's level of pain was assessed as 6/10 ( at 6 scale is moderate pain) and acetaminophen 80 milligrams (mg) was administered. The patient's pain level was reassessed at 10 p.m., (2 hours later) as 0/10 (no pain).

A review of the physician order dated August 11, 2013, indicated acetaminophen, 80 mg, PO (oral), suspension PRN (as needed) routine. for mild pain. The FLACC pain scale use indicated 0 for no pain, 1- 3 for mild pain, 4- 6 moderate pain and 7 - 10 for severe. The physician order did not include how much medication is to be given at what level of pain.

d. According to Patient Data, Patient 22 was admitted to the facility on August 15, 2013, with diagnosis of pneumothorax.

On August 26, 2013, at 12:40 a.m., during the tour of the unit, Patient 22 was observed in bed. The patient had gastrostomy tube and tracheostomy.

A review of the In Patient Nursing Notes dated August 23, 2013, at 9 p.m., indicated the patient's level of pain was assessed as 10/10 (severe) in the neck, abdomen and midline, and 2 mg of morphine was administered. An again at 9:55 p.m., 2 mg of morphine was administered. However, there was no documentation of pain level for the pain in the neck and abdomen.

A review of the In Patient Nursing Notes dated August 24, 2013, at 1:15 a.m., indicated the patient's level of pain was assessed as 7/10 (severe) in the neck and midline, and 4 mg of morphine was administered. At 4:15 a.m. (3 hours later), the patient's level of pain was 6/10 (moderate) and 4 mg of morphine was administered.

e. According to Patient Data, Patient 23 was admitted to the facility on August 23, 2013, with diagnosis of germ cell tumor and has a portacath on the right chest.

On August 27, 2013, at 7:30 a.m., during the tour of the unit, Patient 23 was observed in bed. The patient's mother was at the bedside.

A review of the In Patient Nursing Notes dated August 25, 2013, at 10:30 a.m., indicated the patient's pain level was assessed as 10/10 (severe), in the abdomen and midline, and the physician was notified. At 12 p.m. ( an hour and half later), the patient's pain level was reassessed as 0/10 (no pain), however, 20 mg of acetaminophen was administered.

A review of the physician order dated August 25, 2013, indicated acetaminophen (Tylenol) 240 mg, every 4 hours (Q4H) , as needed (PRN) for pain and routine.

During an interview with RN 4 while reviewing the above patients clinical records (both hard copy and e-record), RN 4 concurred there was no assessment and/or re-assessments within an hour after the administration of the pain medication, and there was no dosage medication order for moderate pain.

Based on observations, record reviews, and interviews, the facility failed to ensure the nursing staff develops, and keeps a current individualized nursing care plan for four of 30 sampled patients (Patient 15, 22, 23, and 28).

Findings:

a. During the tour of the Pediatric Intensive Care Unit on August 26, 2013, at 12:45 p.m., Patient 28 was observed in bed asleep. The patient was receiving a continuous Insulin infusion via intravenous catheter. According to the registered nurse who was at Patient 28's bedside, the blood glucose level checks are performed on Patient 28 every hour.

The electronic medical record and the paper medical record for Patient 28 were reviewed with Registered Nurse (RN 1) on August 29, at 10:35 a.m. The "Patient Data" sheet indicated Patient 28 was admitted to the facility on August 26, 2013 with an admitting diagnosis of diabetic ketoacidosis (life-threatening problem that affects people with diabetes. It occurs when the body cannot use sugar as a fuel source because there is no insulin or not enough insulin. Fat is used for fuel instead. When fat breaks down, waste products called ketones build up in the body).

During the concurrent interview with RN 1, RN 1 stated she was unable to find documented care plan addressing Patient 28's diabetes problem.

The facility policy titled "Multidisciplinary Plan of Care (MPC)" revised February 1, 2012 indicated "Multidisciplinary Plan of Care Plan which Identify current problems related to the hospitalization of the patient. Interventions should be patient specific as to how care should be provided considering the age/ developmental level of the patient. Describe the care needed to resolve the identified problem ..."



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b. A review of Patient 15's Data Sheet indicated the patient was admitted to the facility on August 26, 2013, with a diagnosis of abscess of the jaw. The patient was being admitted for incision and drainage of the abscess, and underwent the procedure on August 27.
A review of the care plans failed to indicate a plan of care with interventions specific to how manage the patient's pain and what is the care for pre and post procedure.
On August 29, 2013 at 2:30 p.m., during interview and record review with RN 3, she stated there should be a plan of care for pain management, but did not see one in the patient's record.



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c. On August 26, 2013, at 12:40 a.m., during the tour of the unit, Patient 22 was observed in bed. The patient had gastrostomy and tracheostomy tubes. There were dried blood noted around the tracheostomy insertion site.

A review of the patient's clinical record revealed the patient was admitted to the facility on August 15, 2013, for pneumothorax. On August 23, 2013, a new tracheostomy was inserted. The Inpatient Notes revealed the following:

On August 23, 2013, at 12 a.m., the documentation indicated there was bleeding in the tracheostomy.

On August 24, 2013, at 6 p.m., the documentation indicated tracheostomy was clean, dry and intact and site was cleaned with Betadine. There was no documentation that the tracheostomy care was provided. At 12 a.m., the documentation indicated tracheostomy insertion site was clean, dry and intact and trach care was done with 1/2 strength hydrogen peroxide.

On August 25, 2013, at 4 a.m., the documentation indicated tracheostomy was clean, dry, intact and small amount of bloody drainage. There was no documentation that the tracheostomy care was done.

On August 26, 2013, at 8 a.m., the documentation indicated the tracheostomy insertion site was clean, dry, intact and tracheostomy care was done with 1/2 strength hydrogen peroxide. At 12 p.m., the documentation indicated tracheostomy was clean, dry, intact and tracheostomy care was done with 1/2 strength of hydrogen peroxide.

A review of the Care Plan (Problems/Outcomes List) #5 - New Tracheostomy Care dated August 29, 2013, indicated under interventions was to clean with 1/2 strength peroxide twice a day and as needed for 10-14 days post-op.

On August 29, 2013, 9 a.m., during an interview with RN 4 while reviewing the e-record and the chart, RN 4 stated the plan of care for the tracheostomy care was not followed.

d. According to Patient Data, Patient 23 was admitted to the facility on August 23, 2013, with diagnosis of germ cell tumor and the patient has a portacath on the right chest.

On August 29, 2013, 9 a.m., during an interview with RN 4 while reviewing the e-record and the chart of Patient 23, RN 4 stated there was no care plan found in the clinical record to address the specific care that should be provided Patient 23's portacath.

Based on record reviews and interviews, the facility failed to ensure the blood transfusion procedures were followed in accordance to the approved policy and procedures for 3 of 30 sampled patients (Patient 17, 26, and 27). For Patient 17, Patient 26 and Patient 27, the blood transfusion slips were not completed per policy.

Findings:

The facility policy titled "Transfusion of Blood Products and Plasma-Derived Pharmaceutical Products" revised on August 1, 2009 indicated two (2) staff members (Registered Nurse, Physician, intravenous-certified Licensed Vocational Nurse, Physician's Assistant, and Certified Cardio Pulmonary Perfusionist) must sign their names on the transfusion slip verifying that the blood and blood products were checked at the bedside. The Blood Bank transfusion slip must be checked against the labels of the blood product for the patient's name, medical record number, blood donor number, expiration date, product desired, and blood type compatibility. Record the date and time the transfusion is begun on the transfusion slip. The transfusion slip must be completed and filed in the patient's medical record.

a. The clinical record for Patient 26 was reviewed on August 28, 2013, at 3:12 p.m. The "Product Identification Tag (Transfusion Slip)" dated July 11, 2013 indicated the fresh frozen plasma (FFP) was administered to Patient 26 at 4 p.m. However, there was no documentation in the transfusion slip of the total amount transfused to Patient 26, and if Patient 26 had a reaction to the transfusion.

b. The clinical record for Patient 27 was reviewed on August 28, 2013, at 1:50 p.m. The following Product Identification Tags (Transfusion Slips) indicated the missing information:

1. On May 16, 2013, around 11 a.m., there was no documented transfusion start time for the cryoprecipitate (a blood component). In the box for transfusion start date and time, a hand-written "11:30" was documented. The stop time documented was 11:10 a.m. There was no signature of the person who started the transfusion. The box titled " Transfusionist " was left blank.
2. On May 16, 2013, at 11:48, there was no documentation of the amount of red blood cells given and if Patient 27 experienced transfusion reaction. There was no transfusion stop time documented.
3. On May 16, 2013, red blood cells were transfused. However, there was no documentation of the transfusion start and end time, amount transfused and if the patient had a transfusion reaction.
4. On May 21, 2013, at 9:08 a.m., there was no documentation of the amount of red blood cells transfused and if Patient 27 had a transfusion reaction.
5. On July 17, 2013, at 5:05 p.m., there was no documentation of the transfusion stop time of the red blood cells, no documentation of the amount of blood transfused, and if the patient had a reaction to the transfusion.
6. A Transfusion Slip with a Blood Bank Technician generated form dated July 18, 2013, at 10:23 p.m., did not have the date and start time, date and end time of the red blood cell transfusion.
7. On July 22, 2013, at 9:25 a.m., there was no documentation of the transfusion stop time of the red blood cells, no documentation of the amount of blood transfused, and if the patient had a reaction to the transfusion.
8. On July 22, 2013, at 9:52 a.m., there was no documentation of the transfusion stop time of the red blood cells, no documentation of the amount of blood transfused, and if the patient had a reaction to the transfusion.
9. On July 22, 2013, at 9:54 a.m., there was no documentation of the transfusion stop time of the fresh frozen plasma (a blood component), no documentation of the amount of blood transfused, and if the patient had a reaction to the transfusion.

During the interview with Registered Nurse (RN 1) on August 29, 2013, at 11:23 p.m., RN 1 stated the blood transfusion slip must be completed. RN 1 stated the nurse who administered the blood transfusion failed to filling out the form completely.



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c. On August 28, 2013, at 7:15 a.m., Patient 17's clinical record was reviewed. The "Product Identification Tag (Transfusion Slip) dated August 21, 2013 indicated a blood product was administered at 5 a.m., to the patient. However, there was no documentation to indicate the stopping time, the amount, and the patient's reaction to the blood transfusion. At 10:14 a.m., another unit of blood product was administered; however, the stopping time was not documented.

During the interview with Registered Nurse (RN 1) on August 29, 2013, at 11:23 p.m., RN 1 stated the blood transfusion slip must be completed. RN 1 stated the nurse who administered the blood transfusion failed to filling out the form completely.