HospitalInspections.org

Based on staff interview and record review, the CAH failed to ensure all patients received vulnerable adult screenings in accordance with state law for 14 of 24 patients (P8, P9, P10, P11, P12, P13, P7, P14, P1, P2, P3, P4, P5, P6) reviewed. Findings includes:

Vulnerable adult assessment screenings were not completed on all patients admitted to the CAH.

The emergency department's (ED) "Nursing" notes included a screening section that stated, "Do you feel unsafe in any of your personal relationships with your spouse/partner/ family member, or other individuals?" An area of either "Yes" or "No" was to be completed during staff interview with the patient.

P8 was admitted to the CAH from the ED on 1/18/10.
P9 was admitted to the CAH from the ED on 1/31/10.
P10, a male patient, was admitted to the CAH from the ED on 1/30/10.
P11 was admitted to the CAH from the ED on 11/8/09.
P12 was admitted to the CAH From the ED on 12/19/09.
P13, a male patient, was admitted to the CAH From the ED on 1/27/10.

However, none of the "Nursing" note VA screen questions were completed for these patients.


P7 was admitted directly to the CAH from the clinic on 12/1/09.
P14 was admitted directly to the CAH from the clinic on 10/26/09.

However, the "Admission Nursing Assessment" dated 10/26/09 lacked any VA screening for P7 and P14.


On 2/11/10, at 10:50 a.m. the assistant director of nursing verified the patients lacked VA screenings. She stated the staff had been directed to only complete the VA screening on females. She added the CAH lacked a system to ensure VA screenings were completed on patients admitted directly from transfers or the clinic and not through the ED.


12831


Additionally, P1, P2, P3, P4, P5, and P6 were all admitted to the CAH from the ED. The patients' ED "Nursing" note VA screen questions were not completed.


The emergency/hospital charge nurse was unsure about the vulnerable/abuse question on the ED's "Nursing" note when asked at 9:00 a.m. on 2/11/10. However, she indicated she thought it should be answered as it was highlighted in yellow.

Interview with the assistant director of nursing at 10:00 a.m. on 2/11/10, indicated they only assessed women that came through the emergency room for abuse. They did not ask women, men or children that were admitted directly to the hospital, nor did they assess children, or men that came through the ED. She further indicated they did not have a policy or procedure on how the assessment for vulnerability or abuse should be completed.

Based on observation and interview, the CAH failed to ensure that expired medications were not available for patient use. Findings includes:

The emergency department's (ED) crash cart and medication refrigerator had outdated medications available for patient use.

During the tour of the ED at 2:05 p.m. on 2/9/10 with the ED charge nurse, three outdated medications were found. These medications included two vials of Vecuronium 10 mg (a muscle relaxant) dated with an expiration of January 2010, in the ED crash cart. Two more expired vials of Vecuronium were found in the respiratory intubation kit with expiration dates of January 2010. Two vials of Cefazolin 1 gm (an antibiotic) dated as expired January 2010, were found in the crash cart. Diastat diazepam rectal gel 2/5 mg (a sedative used for seizures) was found in the ED refrigerator with an expiration date of January 2010.

The current pharmacy's policy revised April 2007 indicated the pharmacy tech would check the crash carts in the emergency department (ED) cabinets, critical care bucket, and refrigerator once a month for outdated medications.

Interview with pharmacy tech-A at 2:25 p.m. on 2/9/10, confirmed two of the three expired medications were missed when the pharmacy staff had checked for outdates. She indicated the third medication was on back order and was unsure of what their policy was regarding medications they were unable to replace.

Based on observation, staff interview, and record review, the CAH failed to maintain an adequate system to identify and implement appropriate interventions to prevent the spread of infection for 1 of 1 patient (P16) with wound care and for 1 of 1 patient (P17) who received blood glucose testing by the use of a glucometer. Findings include:


Staff failed to perform adequate infection control interventions according to the CAH's policy during wound care for P16 on 2/10/10.

P16 had been admitted on 2/8/10, for post surgical care of a right total knee arthroplasty. P16 was oberved to receive a dressing change and wound care on 2/10/10, at 1:10 p.m. RN-A was observed to remove P16's dressing with gloved hands. The RN was heard to tell the patient there was "just a little bit" of yellow drainage on the dressing. RN-A then disposed of the soiled dressing, but was not observed to change her gloves, wash or sanitize her hands. Next RN-A cleansed the patient's incision with saline and guaze with the same gloved hands. Following this, RN-A apply a new dressing on the incision and a mesh gauze covering. The RN then removed her gloves.

The CAH's policy "Hand Hygiene" dated as revised 12/2007, directed: "Hands are to be washed before and after:....touching blood, body fluids, secretions, excretions, or handling any contaminated items such as dressings (even if gloves are used).

On 2/10/10, at 1:20 p.m. RN-A verified she had not changed her gloves after removing the patient's soiled dresssing and stated she should have done that.

On 2/11/10, at 10:40 a.m. the assistant director of nursing (ADON) verified gloves should be changed after soiled dressings are touched during wound care.



The CAH failed to ensure adequate disinfection of glucometers used for multiple patients.


On 2/10/10, at 4:00 p.m. RN-C was observed to complete a blood glucose test with a glucometer for P17. Following this, RN-C was observed to take the glucometer placed on the top of the glucometer storage case out of the patient's room and to a counter behind the nursing station. RN-C was observed to cleanse all of the outer surface of the glucometer with a 70% alcohol wipe and replace it inside the glucometer case.

At this time, RN-C stated the glucometer was used for all the inpatients in the CAH.

On 2/11/2010, at 8:40 a.m. RN-B verified the nurses use the same glucometer for all the CAH's inpatients. She also verified staff clean the glucometer with 70% alcohol wipes after each patient use.



20012


At 4: 27 p.m. on 2/10/10, the ADON provided a policy dated 11/08 entitled "Precision Xceed Pro Whole Blood Glucose Testing System." The policy stated: "The monitor needs to be cleaned only with a damp cloth or sponge. It is suggested that the monitor be turned off while it is being cleaned. Do NOT spray any cleansers on the monitor. Do NOT use bleach or hydrogen peroxide based cleaners." The ADON verified at that time that the hospital had 2 Precision Glucometers, one for the emergency room, and one for the hospital to be used for multiple patients.


The CAH's policy "Safe Infection, Infusion and Medication Vial Practices" with the revision date of September 2009, stated, "Assign glucometer to individual patients. Clean and disinfect glucometer if they must be reused between patients."


At 10:30 a.m. on 2/11/10, the infection control officer (ICO) and ADON were interviewed regarding the "Safe Infection,Infusion and Medication vial practices" policy. The ADON indicated the policy was an "Error" and must be "2 years old." Both the ADON and ICO indicated they did not expect staff to disinfect the glucometers between patient use.

Based on staff interview, record review, and review of Quality Assurance (QA) minutes and action plans, the CAH did not have a effective quality assurance program in all areas/departments of the facility. Findings include:

The Radiology (Medical Imaging) and Laboratory departments did not have effective quality assurance (QA) programs to evaluate their services.


Although the Radiology (Medical Imaging) department was monitoring equipment, an effective quality assurance program to evaluate treatment outcomes was lacking.

On 2/9/10, at 3:30 p.m. the Medical Imaging manager indicated the current QA was to increase the number of emergency room physician's recording diagnosis of medical imaging exams ordered in the emergency department. To do this, the physicians were to fill out the Emergency Room Patient Radiology Interpretation Forms. The Medical Imaging manager indicated they had been using this form for a couple of years. He added he has been tracking the percentage of forms with no readings completed since at least January of 2009, and reporting it to the medical staff every three months.

During January though March of 2009, the forms with no readings were identified at 29.7 %. From April through June 2009, the forms with no imaging readings were identified at 36.1 %. From October through December 2009, the forms with no imaging readings were identified at 36 %. The forms noted the information would be given to the medical staff. However, review of the QA meeting minutes and the QA reports for 2009, indicated no action plans had been developed to improve the outcomes.

Interview with the Medical Imaging manager at 4:20 p.m. on 2/9/10, indicated the information had been reported to the medical staff. The manager also confirmed the recording of the ED imaging readings by the physicians had not improved in 2009. He also confirmed he had not implemented other interventions and did not have an action plan to improve performance and outcomes. He also verified Medical Imaging had no other QA projects that included action plans.


Although the Laboratory department was monitoring equipment and patient records, an effective quality assurance program to evaluate treatment outcomes was lacking.

Review of the Laboratory QA indicated an action plan to improve services for the patients was lacking.

At 11:45 a.m. on 2/9/10, review of the QA with the assistance laboratory manager indicated they were auditing patient charts every month. She stated the Laboratory department has been doing this on a regular basis for many years. She indicated they had received new machines in the lab to improve processes; however, they had not identified treatment outcomes to improve services that involved the use of an action plan in 2009.