HospitalInspections.org

Based on observation and record review, the facility failed to ensure 1 patient (#22) of 34 current patients, privacy was maintained. Findings:

During an observation on 4/30/13 from 12:30-12:35 pm, Patient #22 was observed, from the hallway, in his room standing by the side of his bed with his back to the hallway. While an employee stood in front of him, the Patients hospital gown was open in the back and his buttocks and upper legs were exposed to anyone who passed by.

During an interview at 4/30/13 at 4:00 pm, the Chief Executive Officer and the Chief Medical Director confirmed that the patient being exposed was not appropriate.

Review of the most current Patient Handbook, dated 1/2013, revealed "Patient Rights and Responsibilities...You can expect full consideration of your privacy..."

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Based on record review and interview, the facility failed to ensure staff immediately notified 2 patients (#s 5 and 7) physician of a critical change in the patient's condition. Specifically, both patients had experienced a significant change in vital signs (measurements of blood pressure, heart, respiratory rate, and temperature, used to assess body function) that required clinical interventions. The facility's failure to ensure emergency interventions were implemented in a timely fashion placed patients at risk for injury or death. Findings:

Patient #5

Record review on 4/29-5/2/13 revealed Patient #5 was admitted to the facility on 12/14/12 with a primary diagnosis of respiratory failure. The Patient required a ventilator to assist with breathing and was a full code (resuscitated in the event of a cardiac arrest).

Review of the nursing assessments, dated 4/14-30/13, revealed the following dates when the Patient had vital signs (VS) and assessments that indicated concerns where the Patient's physician should have been contacted. On 4/14/13 at 4:00 pm, the Patient's BP (blood pressure) was 170/114 and P (pulse) was 110; at 5:00 pm, the BP was 167/113 and P was 103; and at 8:00 pm the BP was 161/104 and P was 122. On 4/15/13 at 12:00 am, the Patient's VS were, BP 163/104 and P 103, at 4:15 am, the Patient's HR (heart rate) was elevated at 100-120, and at 5:15 am the HR was 110 and above.

According to "Human Anatomy & Physiology", by Elaine Mariab, 5th edition, "In normal adults at rest, systolic blood pressure varies between 110 and 140 mm hg, and diastolic pressure between 75-80 mm Hg."

The nursing pain assessments, dated 4/14-15/13 at 4:00 pm and 5:30 am revealed the Patient was in pain (grinding teeth; having loose stools; blinking eyes to indicate "yes" when asked if in pain).

Review of the nurses notes, dated 4/27-28/13, revealed that at 8:10 pm, Patient's BP was 155/109 and his P rate was115; at 9:00 pm, BP 182/105 and P 127; and at 10:00 pm, BP 188/119 and P 112.

The nursing pain assessments, dated 4/27/13, between the hours of 8:10 pm and 10:50 pm revealed the Patient was in pain (grinding teeth, loose stools; blinking eyes to indicate "yes" when asked if in pain).

Review of the nursing narrative notes, dated 4/14-15/13 and 4/27/-28/13, revealed nursing did not contact the Patient's physician when the Patients vital signs fell outside of the acceptable parameters.

Review of the physician's narrative progress note, dated 4/27/13, at 11:30 pm revealed "[Patient #5] was tremoring, flushed, markedly hypertensive with BP 210/125 & HR 123 ...grinding [Patient #5] teeth; + bowel movement during event...stats [oxygen saturation levels in the blood] were in [the] 80s with copious purulent secretions ...presentation [consistent with] pain crisis & evolving [right lower lobe pneumonia]..."

During an interview on 5/1/13 at 9:00 am, the Patient's Physician was asked if he would have wanted to be contacted by nursing on 4/27/13 when the Patient first started having out-of-range vital signs and consistent uncontrollable pain. The physician confirmed nursing should have contacted him about the Patient's condition earlier.

Patient #7

Record review on 4/29-5/2/13 revealed the Patient was admitted to the facility on 4/22/13 with diagnoses that included acute and respiratory failure. The Patient required a ventilator to assist with breathing and was a full code.

Review of the physician progress note, dated 4/27/13 at 11:10 pm, revealed, "I was returning to the hospital to follow up on patients for routine check-in. Prior conversations with nursing had discussed stable vitals [vital signs]...As I entered [and] was working on chart. RN [Registered Nurse] informed me that [Patient #7] was actually hypotensive with SPB [systolic blood pressure] in the 60's..."

Further review of the medical record, dated 4/27/13, revealed the first hypotensive episode was charted at 10:13 pm when the Patient had a blood pressure of 69/37. The patient's code status was changed to " Attempt at Cardiopulmonary Resuscitation..." 4/27/13 at 10:50 pm.

During an interview on 4/29/13 at 10:00 am, when asked if he was immediately notified of the Patient's dropping blood pressures, the Patient's Physician responded that he had found the Patient to be hypotensive when he came in the facility.

During an interview, on 5/1/13 at 9:22 am, when asked how soon the physician was notified after the hypotension episode was identified; the Assistant Director of Nursing stated it was difficult to tell from the nursing documentation.

Review of "Report Abnormal Vital Signs to MD" information card attached to the back of Registered Nurse (RN) #2's name badge revealed "Systolic BP greater that 180 or less than 90", "Diastolic BP greater than 110", and "Pulse greater than 130 or less than 50". According to the RN, all nursing staff had the information cards attached to their name badge.

Review of a sign observed in the nurses stations 4/30/13 revealed "MD MUST BE NOTIFIED WITH ALL OCCURANCES & DOCUMENTED IE: FALLS, MEDICATION ERRORS, CHANGE IN PATIENT STATUS"

Review of the facility "Notice to Patients", dated 10/1/07, revealed, "Although a Physician is available on an 'on-call' basis 24 hours per day, the facility does not necessarily have a Physician 'in-house' 24 hours per day."

As a result, on call physicians were not immediately notified of significant changes in patient's clinical presentation as presented by abnormal vital signs. Failing to ensure on-call physicians were notified immediately placed patients at risk from the delay in treatment and services.
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Based on record review, policy review and interview the facility failed to ensure medications and treatments were administered and documented on the Medication Administration Record (MAR) according to physician's orders for patient (#6) of 9 active patient records reviewed and for patient (#s 12, 14, and 16) of 12 closed patient records reviewed. As a result, it was unknown as to whether or not these patients received their ordered medications and treatments. Findings:

Patient #6

Record review on 5/1/13 revealed Patient #6 was admitted to the facility on 10/14/12 with a primary diagnosis of acute and chronic respiratory failure.

Further record review revealed the Patient was prescribed the following medications that were not consistently documented as administered on the MAR:

Nystatin powder (used to treat fungal infections), to be applied 2 times a day, was not signed as given on 4/6/13 at 9:00 am.

Combivent (bronchodilator that relaxes the smooth muscles in the respiratory tract) MDI (meter dose inhaler) to be given 4 times a day, was not signed as given on 4/6/13 at 8:00 am, 12:00 pm, and 4:00 pm, below the initials "RT" (Respiratory Therapy) were written.

Symbicort INH (inhaler used to reduce and prevent respiratory tract inflammation) to be given 2 times daily, was not signed as given at 9:00 am. Written below were the initials "RT".

Combivent MDI, to be given 4 times daily, was not signed as given on 4/7/13 at 8:00 pm; the initials "RT" was written below.

Combivent MDI, to be given 4 times daily, was not signed as given on 4/9/13 at 8:00 am, 12:00 pm, and 4:00 pm. The initials "RT" were written below.

Cavalon barrier cream (a protective barrier cream used to prevent rashes), to be applied 2 times daily, was not signed as given 4/14/13 at 9:00 am.

Bacitracin zinc (antibacterial ointment), to be applied 2 times a day, was not signed as given on 4/15/13 at 9:00 pm.

Nystatin powder, to be applied 2 times a day, was not signed as given on 4/27/13 at 8:00 pm.

Patient #12

Record review on 5/1/2013 revealed Patient #12 was admitted to the facility on 9/29/12 with a primary diagnosis of respiratory failure.

Further record review revealed the Patient was prescribed the following medications that were not consistently documented as administered on the MAR:

Combivent inhaler, ordered to be administered every 6 hours was not documented as given 2 times at 3:00 am between 10/10-19/12;

Novolin R (insulin), ordered to be administered every 6 hours was not documented as given 4 times at 6:00 am and 1 time each at 12:00 pm; and 6:00 pm between 10/10-19/12;

Flovent HFA inhaler (for the treatment of asthma or asthma like symptoms), ordered to be administered 2 times a day was not documented as given 1 time at 9:00 pm between 10/18-19/12;

Prosource (nutritional supplement), ordered to be administered 3 times a day was not given 2 times at 12:00 pm between 10/14-15/12; and

Saline flush (used to keep intravenous lines patent), ordered to be administered every 12 hours was not documented as given 2 times at 9:00 am between 10/10-19/2012.

Patient #14

Record review on 5/1/13 revealed Patient # 14 was admitted to the facility on 4/18/13 with a primary diagnosis of postoperative infection.

Further record review revealed the Patient was prescribed the following medication that was not consistently documented as administered on the MAR:

Peperacillin SOD-Tazobactam (a combination antibiotic), ordered to be administered every 6 hours but was not documented as given 2 times at 12:00 pm; 2 times at 6:00 pm; 2 times at 12:00 am and 2 times at 6:00 pm between 4/18-20/13.

Patient #16

Record review on 5/1/13 revealed Patient #16 was admitted to the facility on 4/3/13 with a primary diagnosis of septicemia (infection of blood).

Further record review revealed the Patient was prescribed the following medications that were not consistently documented as administered on the MAR:

Bupivacine HCL (local anesthetic), ordered to be instilled into VAC Dressing and allow to dwell 20-30 minutes prior to dressing changes, was not documented as administered at 8:00 am on 4/19/13.

Metoprolol Succinate ER (high blood pressure medication), ordered 1 time a day at 9:00 pm was not documented as given on 4/19/13.

Saline Flush (Intravenous saline flush), ordered to be administered 2 times a day at 9:00 am and 9:00 pm was not given at 9:00 pm on 4/19/13.

Senna Plus (a laxative), ordered to be administered 2 times a day at 9:00 am and 9:00 pm was not documented as given at 9 pm on 4/19/13.

Crestor (an anti-lipid), ordered to be administered each day at 9:00 pm was not documented as given at 9:00 pm on 4/19/13.

Juven (nutritional supplement), ordered to be administered 2 times a day at 9:00 am and 9:00 pm was not documented as given 1 time at 9:00 am and 2 times at 9:00 pm between 4/11-20/13.

During an interview on 5/2/13 at 1:00 pm Quality Assessment and Performance Improvement Program (QAPI) the Chief Medical Director, the Director of Pharmacy, and the Director of Quality Assurance, disclosed it was the facility's policy to have medications and treatments signed off by staff on the MAR. They stated if the medication or treatment was given then nursing and/or respiratory staff were to sign their initials next to the time it was given. If the medication or treatment was not given, for whatever reason, it was to be circled and initialed by nursing and/or respiratory staff.

Review of the facility's policy "General Principles of Medication Administration", last reviewed on 1/13, revealed "The medication is charted by time on the appropriate line by shift, date, and drug description, and the Nurse's initials are written beside the time. If the medication is omitted, the medication time is circled..."

Additional facility policy review for "Metered Dose Inhaler (MDI) Administration", dated 1/13, revealed "...The Respiratory Therapist will sign the Medication Administration Record (MAR) after each MDI administration performed or observed."

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Based on observation, record review, and interview, the facility failed to consistently document outputs for 4 patients (#s 4, 7, 9, and 12) and failed to document assessments of pain when analgesics were administered for 1 patient (#7) out of 21 sampled patients. Findings:

An observation, on 4/30/13 at 9:00 am at the 2 South nurse's station, revealed "I & O: They're not just numbers!" posting. "....ALL drains such as...wound vacs...are the nurse's responsibility to mark and record output...This is part of the ongoing assessment of the patient."

Patient #4

Record review on 4/29-5/2/13 revealed Patient #4 was admitted to the facility on 4/16/13 with diagnoses that included infection of post right hip replacement, which included wound therapy. Further review revealed the Patient had a wound vacuum (vac) system that collected fluid and drainage off the wound.

Review of the nursing flow sheets, dated 4/23; 4/24; 4/25; and 4/26/13, revealed no output documentation for Patient #4's bowel movements from 7:00 pm until 6:00 am the following day.

Review of the nursing flow sheet, dated 4/22/13 revealed no output documentation for Patient #4's wound vac from 7:00 am until 6:00 pm, and the nursing flow sheets dated 4/22 and 4/23/13 revealed no output documentation for the wound vac from 7:00 pm until 6:00 am the following day.

Patient #7

Record review on 4/29-5/1/13 revealed the Patient was admitted to the facility 4/22/13 with a diagnosis that included acute and chronic respiratory failure. The Patient was on a ventilator, to assist with breathing, and had an indwelling urinary catheter to drain the bladder.

Review of the nursing flow sheet, dated 4/23/13, revealed the Patient's weight was not documented.

Review of the nursing flow sheet, dated 4/25/13, revealed the Patient had 1600 ml of urine output from 7:00 am until 7:00 pm. Review of the total on the 24 hour total revealed only 1100 ml output was documented for the shift.

Review of the nursing flow sheet, dated 4/28/13 from 7:00 pm to 6:00 am (4/29/13), revealed no documented total output in the graphics; the 174 ml output was documented below in the shift total.

Review of the nursing flow sheet, dated 4/29/13 from 7:00 pm until 6:00 am (4/30/13), revealed the Patient's pain level was not assessed prior to receiving pain medication. Review of the additional nurses notes, dated 4/30/13 at 2:00 am revealed "Medicated for pain. Sleeping soon after"

Review of the Medication Administration Record (MAR) revealed the Patient had received Morphine (a narcotic analgesic) on 4/30/13 at 2:45 am. There was no information that indicated what the Patient's pain level was before receiving the pain medication.

During an interview on 4/30/13 at 9:00 am, the Assistant Director of Nursing (ADON) confirmed the nurses should assess the pain when administering pain medication and should assess for pain every shift. When asked about the inconsistency of the Intake and Output documentation, with some staff totaling at the end of the graphic and some staff totaling at the bottom, the ADON confirmed nursing should have more "conformity" with their totals.

Patient #9

Patient #9 was admitted to the facility 4/22/13 with a diagnosis which included wound vacuum for his abdominal wound.

Review of the nursing flow sheet, dated 4/22/13, revealed no output documentation from the wound vac, from 7:00 pm until 6:00 am (4/23/12).

Patient #12

Patient #12 was admitted to the facility 9/29/12 with a diagnosis which included a right quadrant ostomy (a surgical procedure creating an opening in the body for discharge of body wastes).

Review of the nursing flow sheets, dated 11/3-5/12, revealed no output documentation for the patients bowel movements documented from 7:00 am until 6:00 pm, and from 7:00 pm until 6:00 am (11/4/12). Review of the 11/4/12 nursing assessments revealed no bowel movement documentation from 7:00 pm until 6:00 am (11/5/12).

During an interview on 4/30/13 at 9:10 am, Registered Nurse (RN) #2 was asked how patients input and outputs were documented on the nursing flow sheet. RN #2 said the nurses should document at least once a shift on the nursing flow sheets.

Based on observations, interviews, and record review the facility failed to: 1) ensure foods were stored in a manner to prevent potential contamination; 2) ensure kitchen dishwasher temperature reach 180 degrees during the rinse cycle; 3) ensure staff perform proper hand hygiene and equipment disinfecting while providing patient care; 4) ensure expired hand sanitizer was not in use; and 5) ensure outside shipping boxes were not kept in patients' rooms. As a result, these failed practices created a potential for food borne illness and the spread of disease from contaminated hands, equipment and outside shipping boxes; based on census of 34. Findings:

Potentially Contaminated Foods

Observations on 4/29/13 at 8:00 am during the initial tour of the hospital's kitchen revealed:

1-opened box of semi-sweet chocolate chips;
1-opened box of white chocolate chips;
1-box of opened biscuit mix; and
1-box of opened corn muffin mix loosely closed sitting in side a bag.

During an interview on 4/29/13 at 8:52 am Dietary staff (DS) #1 confirmed once dry goods were opened they should be tightly re-closed.

Observations on 5/1/13 at 6:50 am revealed a bucket of sanitizing solution with multiple dishcloths in it sitting on top of the food prep counter next to 3 freshly baked trays of chocolate chips cookies. During the observation DS #2, reached in the bucket, pulled out a sanitizing cloth and began wiping a kitchen counter. The DS then returned the cloth to the sanitizing bucket.

During an interview on 5/1/13 at 6:55 am Cook #1 disclosed the bucket of sanitizing solution was normally kept on top of the food prep counter. When asked if the food could become contaminated from the cleaning solution being in such close proximity to it, the Cook agreed it could.

Review on 5/2/13 of the facility's policy and procedure "Food Storage", dated 1/13, revealed the purpose of the policy was "To hold food products in a safe and efficient manner."

Kitchen Dishwasher Temperature log

Record review on 5/1/13 at 7:30 am of the dishwasher temperature daily log for the month of 4/13, revealed there were only 2 times the dishwasher's rinse cycle reached the required 180 degree temperature.

During an interview on 5/1/13 at 7:40 am the Dietary Manager confirmed the temperature log was correct and further stated when the dishwasher rinse cycle did not reach the 180 degree temperature the kitchen staffs were to run the dishes through the rinse cycle until the 180 degree temperature was met. The Dietary Manager agreed confirmed that the temperature logs showed the 180 degree temperatures, had not been met.

Review on 5/2/13 of the facility's policy and procedure "Temperature log", dated 1/13, revealed the purpose of the policy was "To ensure that the equipment is working properly and prevent potential food-borne illnesses."

Contaminated Equipment and Outside Shipping Box

Clipboard and Stethoscope

On 4/29/13 at 1:00 pm, the Respiratory Therapist (RT) #1 was observed providing respiratory care to patients. The RT first entered Patient #2s room carrying a plastic clipboard. After setting the clipboard on the Patient's bedside table, the RT proceeded to change the dressing on the Patient's tracheostomy (a surgical hole in the trachea).

After completing the dressing change the RT picked up the clipboard, and without cleaning it carried it out of the Patient's room who was on contact precautions and into Patient # 23s room.

The RT then placed the clipboard on the medication cart located in the room. After administering the Patient's inhalers, the RT pulled a stethoscope out of his pocket, used it to listen to the Patient's chest and then draped, the now contaminated stethoscope, around his neck. The RT then carried the clipboard out of the room and, without first cleaning it, placed it on an isolation supply cart located outside another patient's room.


During an interview on 4/29/13 at 1:40 pm, the RT stated, "[Patient #23] used to have MRSA [Methicillin Resistant Staphylococcus Aureus -a bacteria responsible for several difficult to treat infections] but not anymore."


Record review on 4/29/13 revealed Patient #2 was on contact precautions due to a history of MRSA in the nares.


During a second interview on 4/29/13 at 1:45 pm, when asked how often the clipboard needed to be cleaned, the RT replied he cleaned his clipboard before and after each shift, when asked about the stethoscope, the RT stated he cleaned it between patients.


Shipping Box


An observation on 5/1/13 at 2:30 pm revealed Certified Nursing Assistant (CNA) #1 completing a terminal cleaning of room #107 of non-sampled Patient #24 who had died that morning Record review revealed the Patient had a primary diagnosis of "non-healing surgical wounds" which required the Patient to be on isolation and contact precautions.


During the cleaning process CNA #1 brought a large opened shipping box out of the room 107 into the hospital hallway and asked the Assistant Director of Nursing (ADON) what to do with the box that contained a wound vac. The ADON told the CNA to sit it down at the nurse's station where the physicians dictated. After the opened shipping box had sat at the nurse's station for 7 minutes housekeeping staff came and put the large box into a clear plastic bag and took it out of the area.


Interview during the Infection Control (IC) meeting on 5/2/13 at 11:30 am, the IC Manager confirmed outside shipping boxes were not to be brought into patients' rooms. The IC Manager also confirmed reusable equipment that was in rooms of patients on isolation/contact precautions should not have been brought out of the room and left in public areas without being properly covered.


Hand Hygiene Issues

During an observation on 4/29/13 at 1:20 pm, the Staff RT #1 prepared to change the dressing around Patient #2s tracheostomy stoma. After sanitizing both hands, the RT put on a pair of clean gloves, removed the soiled dressing from around the tracheostomy tube, placed the sterile drape around the site. The RT then walked over to the cart where the dressings were stored, removed an opened dressing package and used a pair of scissors from it to cut a sponge to fit around the tracheostomy tube. The RT removed the gloves and without performing hand hygiene, put on a pair of sterile gloves, then using the right hand the RT cleaned the area around the tracheostomy tube and placed the clean sponge sound the tube.


During an interview on 4/29/13 at 1:20 pm, when asked if this was considered a sterile procedure, the RT responded it was considered an aseptic (without germs) dressing change.


During an interview on 5/1/13 at 1:00 pm, when asked if the procedure was clean or aseptic, the RT Manager responded that cleaning around the outside of the tracheostomy cannula was a "clean procedure". The RT Manager further stated staffs were expected to use hand sanitizer or wash their hands between dirty to clean tasks.


Hand Sanitizer

During an observation on 4/29/13 at 8:00 am at the hospital's front reception desk revealed a bottle of hand sanitizer with an expiration date of 1/13 sitting on the counter for public use. A sign was located near the bottle of hand sanitizer encouraging visitors to use the hand sanitizer.


During an observation of the nursing unit on 4/29/13 at 2:20 pm, an undated, unlabeled bottle that had a flower hand drawn on it containing a green gel was observed sitting on the nurse's station next the Unit Secretary (US).



During an interview on 4/29/13 at 2:20 pm, when asked what was in the bottle, the US #1 and the Assistant Director of Nursing confirmed it was a bottle of hand sanitizer.


During random observations on 4/29-5/1/13, the unlabeled, undated hand sanitizer remained at the nurse's station.



Observation on 5/1/13 at 7:30 am in the Pharmacy Department revealed 1 Avagard bottle with an expiration date of November 2012. The Director of Pharmacy confirmed the Avagard was expired and that staff were using the Avagard.



Review of the facility's policy and procedure for "Standard & Transmission Based Precautions (Isolation)", dated 6/2009, revealed "...Gloves; "a. Wash hands before donning gloves. b. Wear gloves (clean, non-sterile gloves) when touching mucous membranes and non-intact skin, blood, body fluids, secretions, excretions, and/or contaminated items... c. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms d. Remove gloves promptly after use. Before touching non-contaminated items and environmental surfaces, and before going to another patient, wash hands immediately to avoid transfer of microorganism to the other patients or environment." And "Supplies and Equipment: a) Supplies which have had the package integrity compromised should be discarded... c) All patient equipment that is reusable should be cleaned with vapor cleaner or disinfectant ..." "Handle used patient-care equipment soiled with blood, body fluids, secretions, and/or excretions in a manner that prevent skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other patients and environment."