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Based on observation, interview, and record review, the hospital failed to update the nursing plan of care for one of 19 sampled patients (Patient 6) when Patient 6 was physically restrained, both wrists and hands, and the nursing plan of care did not reflect this. This failure had the potential to result in patient injury and the use of unnecessary restraints.

Findings:

On 8/11/14 at 12:04 pm, Patient 6 was observed in the intensive care unit (ICU). Patient 6 was intubated (a plastic tube passed through the mouth or nose into the windpipe to assist with breathing for the patient), had multiple intravenous (IVs) lines for medications and fluids, a urinary catheter (a flexible tube inserted into the bladder to drain urine), two large abdominal dressings which covered surgical incisions, three tubes coming from the incisions to drain fluid from the previous surgical sites and a nasal gastric tube (a plastic tube inserted into the nose into the stomach).

Patient 6's record was reviewed on 8/11/14. Patient 6 was admitted to the hospital on 8/5/14, and underwent extensive abdominal surgery to remove cancer of the pancreas (an organ in the abdomen). On 8/9/14, Patient 6 required a repeat surgery. The record revealed Patient 6 continued to be intubated after the second surgery, was restless, and attempted to pull at the tubes connected to her body.

On 8/9/14, the physician ordered restraints for Patient 6's hands and wrists. The order instructed soft wrist restraints and hand mitts to be released every two hours. The record indicated the restraints were applied to prevent Patient 6 from pulling at the tubes, IVs and dressings necessary to support her condition. Patient 6's pain medication was also increased to manage her pain, provide sedation, and decrease her restlessness.

On 8/11/14 at 12:10 pm, Registered Nurse E stated Patient 6 was restrained because she would become very restless and confused, and pull at her tubes, IVs and dressings.

On 8/11/14 at 2:27 pm, Patient 6's record was reviewed concurrently with Administrative (Admin) Nurse C. Patient 6's plan of care did not reflect that Patient 6 required both wrists and hands to be restrained, the goal in the use of the restraints, or a plan when restraint reduction could be initiated. Admin Nurse C acknowledged the above finding and stated the nurses' plan of care was based on the patient's assessment which was performed multiple times daily by the nurse. She stated the nurses' plan of care was the tool the nurses used to document patient care, and Patient 6's plan of care needed to be updated.

A hospital policy, dated 8/2013, titled, Use of Restraints, instructed on page four, "Any changes in the patient's behavior or clinical condition are documented. Potential for physical injury is initiated on the Multidisciplinary Plan of Care and updated at least every 24 hours on all restrained patients. Patient/family teaching is documented ... "

A 12 page undated document titled, "Intensive Care Unit Patient Documentation Guidelines (Adult)" instructed, the "Interdisciplinary Plan of Care is reviewed every shift: Update and individualized daily. All restraint patients MUST have a plan of care."

Based on interview and record review, the hospital failed to administer medication as ordered by the physician for two of 19 sampled patients (Patients 2 and 13). This had the potential for medications to be ineffective and result in a decline in the patients' conditions.

Findings:

1. Patient 2's record was reviewed on 8/12/14. Patient 2 was admitted to the hospital on 8/5/14, with diagnoses that included chest pain, heart disease, and lung cancer.

Patient 2's record contained a physician's order dated, 8/6/14, which instructed to give, morphine (a narcotic pain medication) two to six mg (milligrams) IV (intravenous, given through a small tube directly into the vein) every one hour as needed for pain. The order instructed to give 2 mg of morphine for mild pain as indicated by a 1 to 3 rating on a 0 to 10 pain scale (where 0 indicates no pain and 10 indicates a maximum level of pain). Give 4 mg for moderate pain as indicated by a 4 to 7 rating. Give 6 mg for severe pain as indicated by a rating of 8 to 10.

Patient 2's Medication Administration Record (MAR) indicated the following:

a. On 8/6/14 at 2:04 pm, morphine 2 mg was given for a reported pain score of 5.

b. On 8/8/14 at 2:41 am, morphine 2 mg was given for a reported pain score of 6.

During an interview and concurrent record review on 8/12/14 at 10:30 am, Administrative (Admin) Nurse B confirmed that the morphine had been given to Patient 2 outside of the ordered parameters. Admin Nurse B acknowledged that according to Patient 2's report of pain, she should have received morphine 4 mg and not 2 mg. Admin Nurse B verified that there was no documentation indicating why the physician's order had not been followed.

The hospital's policy titled, "Pain Management," dated 4/2014, indicated that the single most reliable indicator of the existence and intensity of pain is the patient's self report. The hospital respects the patient's right to pain management.


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2. Patient 13 was admitted to the hospital with diagnoses which included acute transverse myelitis (a condition affecting the spinal cord). She was unable to walk when first admitted.

Review of Patient 13's record revealed a physician's order, dated 7/31/14, for Lovenox (a medication used to prevent blood clots) 40 milligrams every day by subcutaneous injection (given by a needle into the skin).

According to the Medication Administration Record, Patient 13 refused every daily dose of Lovenox from 7/31 through 8/12/14. Nurse's notes showed that a physician was notified of the missed doses on 8/2 and 8/10/14.

During an interview on 8/12/14 at 9:45 am, Registered Nurse G stated that the physician should have initially been notified sooner than the third day of the patient's refusal to accept the Lovenox.

According to the hospital's policy for Refusal of Medications, Treatments, Tests (MTT), "When a patient refuses to accept an MTT, the prescribing physician must be notified...the nurse/respiratory therapist will notify the physician once a day for the same medication that the patient refuses."

Based on staff interview, document and clinical record review, the hospital failed to ensure that the records of six of 19 sampled patients (Patients 9, 16, 17, 18, 19, 20) contained sufficient information to monitor the nutritional progress of the patients. This had the potential for the patients not to receive appropriate care.

Findings:

1. Patient 16 was admitted on 8/6/14 with diagnoses including multi-system blunt trauma, clavicle (collar bone), rib, and pelvic fractures (breaks). The physician ordered a consistent carbohydrate diet dated 8/8/14.

A review of Patient 16's clinical record showed that the meal percentage intakes (amount of food consumed by the patient for each meal) dated 8/10/14 was only documented for the breakfast meal and 8/11/14 for the breakfast and lunch meal only. There was no documented intakes recorded for the other dates or meals.

2. Patient 17 was admitted on 8/6/14 with diagnoses including clot retention. The physician ordered a regular diet dated 8/7/14. The physician ordered the patient to be NPO (nothing by mouth) after midnight on 8/7/14 then the regular diet resumed on 8/8/14 at 3:59 pm.

A review of Patient 17's clinical record showed that the meal percentage intakes dated 8/7/14 was only documented for the breakfast meal, 8/9/14 for the breakfast meal, 8/10/14 for breakfast and lunch only. There was no documented intakes recorded for the other dates or meals.

3. Patient 18 was admitted on 8/7/14 with diagnoses including altered mental status, confusion and fever. The physician ordered a regular diet dated 8/7/14. The physician ordered the patient to be NPO after midnight dated 8/11/14.

A review of Patient 18's clinical record showed that the meal percentage intakes dated 8/8/14 was only documented for the dinner meal, 8/9/14 for the breakfast meal and dinner meal, 8/10/14 for the dinner meal. There was no documented intakes recorded for the other dates or meals.

4. Patient 19 was admitted on 8/4/14 with a chief complaint of progressive weight loss, weakness, and persistent chest pain. Physician orders dated 8/4/14 indicated a clear liquid diet, a regular diet was ordered 8/6/14, NPO ordered 8/7/14, and on 8/8/14 a regular diet was ordered.

A review of Patient 19's clinical record showed that the meal percentage intakes dated 8/6/14 was only documented for the lunch meal, dated 8/7/14 for the breakfast and lunch meal only, dated 8/10/14 for the breakfast and lunch meal, dated 8/11/14 for the breakfast meal only. There was no documented intakes recorded for the other dates or meals.

5. Patient 20 was admitted on 8/6/14 with diagnoses including mixed metabolic drug induced encephalophathy (disorder or disease of the brain). Physician orders dated 8/8/14 indicated a cardiac diet, orders dated 8/12/14, a regular diet.

A review of Patient 20's clinical record showed that the meal percentage intakes dated 8/8/14 was documented for the breakfast and lunch meal, dated 8/9/14 for the breakfast and dinner meal and evening snack, dated 8/11/14 for the breakfast meal. There was no documented intakes recorded for the other dates or meals.

On 8/12/14 at 10:40 a.m. an interview was conducted with Registered Nurse (RN) F regarding recording meal percentage intakes. RN F stated either the nurse or the tech charted the intakes in the record. RN F stated they should document the meals for the shift in the clinical record during their shift.

On 8/12/14 at 2:00 p.m. an interview was conducted with the Clinical Nutrition Manager (CNM). The CNM stated it was not uncommon for them to see incomplete documentation regarding the meal percentage intakes. She stated sometimes the nurse caring for the patient the day the dietitian comes to assess or reassess the patient is the first day they have had them so they only know how the patient is doing that day. She stated they usually have to ask the patient how they have been eating and hope it is accurate.

Review of the documentation guidelines for the medical surgical patient indicated that all intake, output, and percentage of meals consumed shall be documented at a minimum of every shift.

On 8/13/14 at 1:20 p.m. an interview was conducted with the Chief Nursing Executive (CNE). The CNE stated they published the packet with the documentation guidelines on 8/1/14 and this is something that is still in process with monitoring the nursing staff.






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6. Patient 9 was admitted to the hospital on 8/9/14, with diagnoses of acute pyelonephritis (severe kidney infection). The physician ordered intake and output (a measurement of the amount a patient takes in and puts out), and a regular diet.

A review of the Patient 9's record revealed, the amount or percentage of lunch and dinner percentage consumed by Patient 9 on 8/10/14 was not recorded on the meal percentage record or documented in the nurses notes.

On 8/12/14 at 2:50 pm, RN B confirmed the above findings and stated the meal intake of all patients was required to be recorded in the patient's record.



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Based on observation, interview and document review, the hospital failed to conduct active surveillance and obtain infection control data for all areas of the facility. This had the potential to result in an ineffective infection control program and expose patients to infectious organisms.

Findings:

1. During an interview with Infection Control Practitioner (ICP) and ICPB on 8/13/2014 at 10:00 a.m., both confirmed consistent formal or informal documentation (rounding tools, surveillance tracking tools) of infection control surveillance were not available. Both ICP and ICPB acknowledged that Central Supply does not supply information to the ICP nor does the ICP conduct active surveillance in that area.

During an interview on 8/13/2014 at 2:10 p.m., Infection Control Medical Doctor (ICMD) and ICP, specified that the facility policy required regular environmental surveillance rounds to all areas by ICP.

2. On 8/13/2014 at 3 pm, a record review of Infection Control policies and procedures indicated that three out of four polices did not have signature approvals and four out of four were missing the reference to the national recognized standard relied on when developing the policy and procedure.

In an interview on 8/13/2014 at 11 am, ICP verified, per facility policy, that policy and procedures are to be reviewed and updated every two years by the appropriate committees. Some policy and procedures had not been reviewed since 2011.

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Based on observation, interview and document review the hospital failed to provide a functional and sanitary environment when:

The facility failed to ensure that potentially hazardous food (phf-foods that can spoil and cause food bourne illness) were not maintained at proper temperatures and ice machines were not maintained under sanitary conditions. This had the potential to cause food bourne illness and the spread of disease and infection.

The facility failed to ensure a hand washing station and hand sanitizer were available for staff use in the clean utility supply room located in the postpartum unit. This had the potential to contaminate "clean" patient care supplies and cause the spread of infection.

The facility failed to ensure surgical instruments were sterilized, packaged, and stored in accordance with Association of PeriOperative Registered Nurse (AORN) Standards. AORN (National Recognized Standards the hospital identified as the standard they followed). This had the potential to result in a facility wide ineffective infection control program and expose patients to infectious organisms.

Findings:

1. On 8/11/14 at 11:50 a.m. a tour of the cafeteria was conducted. The reach-in refrigerator (True Refrigerator) did not contain a thermometer. The unit did not feel cold when opened. There was sliced cheese in the refrigerator dated with an expiration date of 8/26. The temperature was taken by the surveyor which indicated the cheese was 46.6 degrees Fahrenheit (F).

The reach-in refrigerator (Refer 5) was 42 degrees F. There was a deli area on top of the unit that contained sliced ham and sliced cheese. The temperatures were 45.5 degrees F and 50.9 degrees F, respectively.

A concurrent interview was conducted with the Area Director of Nutrition Services (ADNS) who stated the True refrigerator had some maintenance problems a couple weeks ago but was now okay. She stated she had thought all refrigerators in the kitchen and cafe had Temp Track (electronic temperature monitoring system) and was surprised the true refrigerator did not have one. The ADNS stated they would throw away all of the food items. The ADNS stated they did not have any documentation to show the temperature of the reach-in refrigerators and the food items.

Review of the hospital policy and procedure titled Food Storage dated 1/07, indicated refrigerated foods shall be maintained at 40 degrees F.

2.a. On 8/12/14 at 10:55 a.m., in nourishment room in 1 East, a joint observation was made of the ice-machine with the Clinical Nutrition Manager (CNM), in which the chute (area where ice is dispensed from the ice machine) of the ice-machine had a large amount of a white colored substance. The CNM acknowledged the white substance on the ice machine.

b. On 8/12/14 at 11:30 a.m., in the soiled utility room on 2 East, a joint observation was made of the ice machine with the CNM, in which the chute of the ice machine had a white colored substance throughout the chute in which the ice were dispensed from. The CNM verified the white substance on the ice machine.


On 8/13/14 at 10:05 a.m. an interview was conducted with the DPO regarding cleaning and sanitizing of the ice machines. The DPO stated each of the ice machines are cleaned and sanitized per the manufacturer's directions and they do this every three months. The DPO stated they did an external deep clean about a month ago which was something new that they have done. The DPO stated they monitor the ice machines monthly with a visual check and they report this to Infection Control.


Review of the Ice Machine work order for 1 East indicated it was last cleaned and sanitized on 7/4/14 and for 2 East on 7/6/14.


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3. On 8/11/14 at 12:10 pm, the clean utility supply room on the postpartum (a unit where mothers are provided care after birth) unit was observed concurrently with Administrative (Admin) Nurses C and D. There was clean supplies on a cart and shelving. The clean utility supply room did not have a hand washing station or hand sanitizer available for staff use before obtaining supplies from the clean utility room.

Admin Nurses C and D confirmed the above finding and stated a hand sanitizer unit needed to be place near the door and available for use before staff obtained supplies for patient care.


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4. On 8/13/2014 at 2:00 p.m., an observation of bins and shelves containing stored processed sterile surgical instruments and supplies revealed the instruments and supplies were not maintained in a manner consistent with the facility's policy titled, "storage and handling of sterile supplies."

A subsequent interview with Admin Nurse E and ICP acknowledged, the supplies were incorrectly stored according to the policy presented.

A concurrent observation conducted of sterile Instruments and supplies revealed the shelves and bins are located in an uncontrolled traffic area. Several large bins 1 ft by 2 ft stored on selves contained tightly packed sterile surgical instruments and sterile supplies. The packages were not stored in a vertical manner as required by policy and National Standards.. Admin Nurse E acknowledged the uncontrolled traffic conditions and excess handling contributed to the worn peel packs.

5. On 8/13/2014 at 2:25 p.m. an observation and interview was conducted with STA, Admin Nurse E, and ICP. A stringer (typically, approximately a foot long 3 rod type device to assist with the positioning of instruments for sterilizing) was noted to be packed with, Twenty-three (23) sterile hinged instruments packed in a tight group. Ten out of twenty three (23) hinged instruments had blades closed and tips layered on the bottom of the tray with tips closed.

On 8/13/2014 at 2:30 p.m. an observation of hinged instruments packed incorrectly utilizing a 3M tip protector card (a card that is made to hold hinged instruments tips open with the most exposure to steam as possible.

In a concurrent interview, ICP, Admin Nurse E and STA acknowledge they are not aware of the facilities policy and procedure or national recognized standards for packing surgical instruments with the requirement to have tips open to ensure sterilization.