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Based on clinical record reviews, staff interview, and review of policy and procedures, it was determined the Registered Nurse failed to evaluate and supervise the nursing care for 4 (#16, #17, #19, #25) of 34 patients sampled. This practice does not ensure patient's goals are met and may cause a delay in discharge.

Findings include:

1. Review of patient #16's physician order dated 6/3/2011 at 5:05 a.m. revealed the blood glucose to be monitored before meals and at bedtime and to administer insulin according to a low dose sliding scale. Review of the documentation revealed the blood glucose on 6/3/11 at 11:51 a.m. was 184. According to the sliding scale insulin order, the patient should have received two units of insulin. Documentation by the nurse indicated the patient was not eating well and she would recheck the blood glucose. There was no further documentation of the blood glucose results until 4:29 p.m., the regularly scheduled time for blood glucose to be checked. There was no documentation the nurse communicated with the physician regarding not giving the ordered insulin
Blood glucose results on 6/6/11 at 11:50 p.m. revealed the patient's blood glucose was 159. According to sliding scale insulin order, the patient should have received two units of insulin. The nurse documented the patient was not eating and she was going to hold the insulin as a clinical judgment. There was no documentation that the nurse communicated with the physician regarding not giving ordered insulin.

2. A review of the medical record for patient #17 revealed a physician order for a heparin lock dated 6/4/11 at 5:15 p.m. A review of the nursing documentation revealed intravenous (IV) access was initiated on 6/4/11 at 4:00 p.m.

The facility's policy "Peripheral Intravenous Therapy" #PC 344, last reviewed 3/11 required that IV sites are to be monitored with documentation of the condition of the site every two hours.

Documentation of the IV site monitoring was reviewed on 6/6/11 at 11:00 a.m. There had been no documentation of the IV site monitoring since 4:00 a.m. on 6/6/11.

The clinical nurse manager who was present during the record review on 6/6/11 at approximately 11:00 confirmed the finding.


3. Review of physician orders for patient #19 revealed an order for blood glucose monitoring before meals and at night dated 6/3/11 at 9:33 p.m. The physician indicated that insulin was to be administered according to standard dose sliding scale. A review of nursing documentation revealed the blood glucose was 237 at 8:57 a.m. A review of the sliding scale revealed the patient should have received 20 units of insulin. Review of the Medication Administration Record revealed no medication was administered.
The Clinical nurse manager was present during the record review on 6/6/11 at approximately 1:00 p.m. and confirmed the above finding.

4. Review of physician orders for patient #25 revealed an order dated 6/3/11 at 8:45 a.m. for a Patient Controlled Analgesic (PCA) infusion pump with Dilaudid 0.2 milligram (mg). The demand dose was 0.2 mg, initial lockout interval 6 minutes, and 1 hour maximum dose 2 mg. The order indicated to call anesthesia for a systolic blood pressure below 90, pulse below 60, and a respiratory rate below 10. The documentation of vital signs on 6/4/11 at 4:00 a.m. revealed the patient's blood pressure was 88/49. There was no further documentation by the nurse that indicated the physician had been notified and no further patient assessment was found.

Based on record review, policy review and staff interview it was determined the facility failed to ensure appropriate orders were received prior to administration of medications for 2 (#19, #20) of 34 sampled patients. This practice does not ensure safe medication administration.

Findings include:

The facility's policy "Medication Ordering and Transcribing" #RXDNV MM. 4 SR- 1, SR-2, SR - 3, SR-4, last reviewed 6/1/10 required that physician orders are to include the medication name, strength and dosage form and directions for use. It required the signature of the prescriber. It also required that orders that are incomplete are to be clarified with the prescriber prior to administration of the order. In addition it required that titrate orders are to include the minimum and maximum dose, parameters to be used, dosage and time increment used to titrate and the titration medication chart is to be referenced.

1. Review of the medical record for patient #19 revealed that the preprinted sliding scale for administration of Humalog insulin was included with the physician orders. The order sheet was not signed by the physician.

The clinical nurse manger who was present during the record review at 1:00 p.m. on 6/6/11 confirmed that the form was to be signed by the physician.

2. Review of the medical record of patient #20 revealed the physician had ordered Propofol 1000 milligrams per 100 milliliters on the preprinted ventilator order set. The required elements for a titrating medication order were present on the form, but were not selected by the physician. The nurse failed to clarify the order with the physician.

The unit director confirmed the above findings during record review on 6/7/11 at approximately 9:00 a.m.

Based on record review and staff interview it was determined the facility failed to ensure all parts of the medical record were accessible for 1 (#20) of 34 sampled patients. This practice does not ensure all information is available to the interdisciplinary team caring for the patient.

Findings include:

Review of the medical record for patient #20 revealed that he had been in wrist restraints to prevent pulling on tubes from midnight on 6/6/11 until 2:00 p.m. An order written at 8:00 a.m. on 6/6/11 was present in the record. No order for the restraint initiated at midnight could be found.

The Director of he Intensive Care Unit was interviewed on 6/7/11 at approximately 9:00 a.m. She stated she had presented the order to the physician to authenticate the order on 6/6/11. She stated she had completed the daily quality review of the restraint and had documented on the data gathering form that an order had been taken from the physician via phone call at midnight. She could not explain what had happened to the order.

Based on interview and record review the hospital failed to ensure that the food service director was granted authority and delegated responsibility by the hospital's governing body and medical staff for the operation of the dietary services. The facility failed to maintain the food service director's documentation of education and experience when hired. This practice does not ensure safe management of the dietary department.


Findings include:


Review of the food service director's personnel file with a hospital human resources staff on 06/08/11 at appropriately 3:45 p.m. revealed that there was no documentation that the hospital's governing body and medical staff granted authority and delegated responsibility to the food service director for the operation of dietary services. Additionally, the human resources staff person could not find any documentation of the food service director's culinary arts degree in the file. The human resources staff person asked if this documentation should be in the file. The food service director was hired by the hospital about 8 years ago. The food service director recently earned the credential of a certified dietary manager on 05/31/11.

Based on observation, interviews and record reviews it was determined the facility failed to ensure the therapeutic diet manual was available to all medical, nursing and food service personnel. This practice does not ensure dietary information is accessible.


Findings include:


On 06/08/11 at 11:15 a.m., the food service director, Registered Dietitian (RD) and diet clerk were interviewed about the hospital diet manual. There was a print version of the 2002 Florida Dietetic Association Diet Manual observed on a shelf in the dietary office. The RD stated that there was a current 2011 on-line version of the Manual of Medical Nutrition Therapy by the Florida Dietetic Association. The diet clerk was asked to demonstrate how she would access the on-line diet manual on the computer and she said could not and added that she uses the print diet manual. The Food Service Director also stated at that time that he did not have access to the current on-line diet manual. The RD said that she could access it but need the pass code to do this.

At 12:45 p.m. on 06/08/11, a mental health technician on the second floor Behavioral Health Unit was asked to demonstrate how she would access the on-line diet manual. She was unable to do this. She did not know how to access a diet manual in the hospital.

At approximately 4:00 p.m., the food service director provided instructions with a pass code to access the online diet manual. He stated there were 2 printed 2009 Manuals of Medical Nutrition Therapy by the Florida Dietetic Association on the third floor and not in the Behavioral Health Unit or critical care units. Only designated staff had access to the on-line version of the current diet manual and was not available to all medical, nursing and food service personnel.

Based on observation and staff interview, the hospital failed to maintain enough non-perishable food supply for emergency and/or disaster situations according to State law. This practice does not ensure patient safety.


Finding include:


The hospital's policy included a disaster menu for 5 days, instead of one week. There was not enough non-perishable food supply for one week on hand during the survey.

During a tour of the hospital kitchen and dry food storage area on 06/08/11 at 10:35 a.m., there did not appear to be a one week supply of non-perishable food on hand to serve the hospital's current census of 86 patients. There was very little non-perishable foods representing the milk group. The food service director stated at that time that he thought he only need food available for 96 hours.

The hospital's Food and Nutrition Services written policy, titled "Disaster Preparedness Menu", effective September 2003 was reviewed. This policy included a disaster menu for 5 days and to maintain a supply for 5 days rather than a week.

Based on observation, staff interview, and record review, the infection control officer failed to identify, report, and investigate infection control activity to ensure a sanitary kitchen environment and proper food handling practices to prevent potential foodborne illness.


Findings Include:


1. The hospital's dishwashing machine was not working properly to ensure dishes were properly washed and sanitized. During a tour of the kitchen on 06/09/11 at 9:55 a.m., the dishwasher was in use. The dishwasher was equipped with 3 temperatures gauges for the wash, rinse and final rinse temperatures. During the dishwashing cycle, the wash temperature was 138 ?F, the rinse temperature was 144 ?F, and the final rinse was 192 ?F. The data plate on the dishwasher indicated that the minimum wash, rinse and final rinse temperatures were 140 ?F, 164 ?F, and 180 ?F, respectively. The dishwasher was run again and the temperatures for the wash, rinse and final rinse were 142 ?F, 150 ?F, and 182 ?F. The water flow pressure gauge was 2 PSI, rather than a minimum of 20 PSI, according to the machine specifications. The food service director was informed of this at the time and stated that he was not aware that the machine water flow pressure was regulated. He used heat sensitive labels or "paper thermometers" to check the sanitizing temperature and the labels did not change color for 160 ?F. Then he used a maximum registering thermometer which he ran through the dishwasher twice and this measured the maximum temperature at 158 ?F and 160 ?F. Several plates that were being washed in the dishwasher were observed to have food particles on the food contact surface after being washed.

The dishwasher temperature log was reviewed for the month of June 2011. The log had only the final rinse temperatures recorded three times daily, which were all 180 ?F . There was no monitoring of the wash temperature for the dishwasher. The food service director stated he would call the service technician to check the machine. He was asked what actions should be taken when the dish machine was not working properly. He directed the employee operating the dishwasher to use disposables.

At 11:25 a.m. on 06/08/11 the service technician informed the food service director and the surveyor that the water flow pressure gauge was broken and the spray jets were clogged. He stated that he needed to get a part to fix the dishwasher.

2. Food service equipment was not properly cleaned. During a tour of the kitchen on 06/08/11 at 9:45 a.m., there were multiple metal sheet pans throughout the kitchen that were encrusted with food residue and/or had excessive carbon/grease build-up. In the "overnight" reach-in refrigerator unit, there several cans of sodas, cartons of soy milk and a container with individual margarine packets stored on a metal sheet pan with encrusted food residue. The exterior of the bulk flour and sugar bins had food spillage and residue. A large inverted clear plastic rectangular food container, which was clean and stored on a shelf with other clean equipment, was observed with brown colored dried liquid food spill around the rim. Additionally, there was clean cylinder-shaped clear plastic container with a degraded adhesive label on the the exterior and a clean rectangular-shaped black food container that had a degraded adhesive label on the exterior surface.

At 10:18 a.m., there were 3 spatulas hanging above a cook's prep table. The food contact surface of these 3 spatulas was very stained with an amber color (the original color was white). There was a metal suspension cart on which food was stored that had dried food residue it. One of the manual can opener had a nick in the blade with scant metal shavings around the gear. The top of the slotted knife holder had an accumulation of food residue. At 10:55 a.m., the dome lid storage dollie had an accumulation of dried food particles in the bottom of it. The sandwich press had an accumulation of carbon/grease build up on the exterior.
At 10:07 a.m., the sprayer nozzle for the three compartment sink was encrusted with food soil.

3. A kitchen worker did not handle dishes properly to prevent cross contamination.
On 06/08/11 at 10:07 a.m., a kitchen worker was observed to load soiled dishes in the dishwasher and then went to unload clean dishes. He was wearing gloves and did not change gloves between handling the soiled and clean dishes. The food service director was informed of this at the time.

At 10:18 a.m., the same kitchen worker removed an empty container of dishwasher spot rinse from the dispenser and replaced this with a full container, loaded soiled dishes and did not change gloves after these tasks before preceding to touch clean trays. The food service director intervened at that point and told the kitchen worker to change his gloves.

Based on record review and staff interview the facility failed to conduct a case manager's admission review for 4 (#12, #14, #15, #17) of 34 medical records reviewed according to the facility's guidelines. This practice may lead to a prolonged hospital stay.

Findings include:

The electronic record reviews were conducted with the Director of Case Management that revealed the following:
1. Patient #12 was admitted to the facility on 6/3/11. The patient did not have an admission review conducted by case management within 24 hours of admission with documentation.

2. Patient #14 was admitted to the facility on 6/3/11. The patient did not have an admission review conducted by case management within 24 hours of admission with documentation.

3. Patient #15 was admitted on 6/4/11. The medical record revealed that the patient did not have an admission review conducted by case management within 24 hours of admission with documentation.

4. Patient #17 was admitted to the facility on 6/4/11 with the diagnosis of abdominal pain. Review of the medical record revealed that the initial social services evaluation was not performed until 6/6/11.

The Director of Case Management ( CM) was interviewed at approximately 11:00 a.m. on 6/6/11 and confirmed that as per the facility's Utilization Management Plan (UM), the case managers will follow the hospital UM plan and perform an admission review within twenty-four hours of admission, with documentation in the CM Decision Point system.

A review of the facility's Utilization Management Plan 2011 revealed on page 11: The Initial Case Management Assessment and discharge plan will be initiated within twenty-four hours of admission.
A job description for case manager's position was provided by the Risk Manager on 6/6/11 at approximately 9:30 a.m. Under the heading, Utilization Management it read: Performs admission review within twenty-four hours of admission, with documentation in the CM Decision Point System.

Based on record review and staff interview it was determined that the facility failed to ensure medications were administered according to physician orders for three (#17, #18, #20) of 34 sampled patients. This practice does not ensure safe and effective medication therapy.


Findings include:


1. Patient #17 physician's order dated 6/4/11 at 5:15 p.m. instructed for Lovenox 40 milligrams to be administered subcutaneously daily. Review of the Medication Administration Record (MAR) revealed the medication was not administered as ordered on 6/4/11 and 6/5/11.

The clinical nurse manager who was present during the record review on 6/6/11 at approximately 11:00 a.m. confirmed the findings.


2. Patient #18's physician order dated 6/1/11 at 6:00 p.m. indicated solumedrol 40 milligrams was to be administered intravenously (IV) every 8 hours. On 6/3/11 at 1:00 p.m. the order was changed to solumedrol 40 milligrams IV every 12 hours. Review of the MAR revealed the patient received 40 milligrams at 1:13 p.m. on 6/3/11. The next dose was administered at 9:50 p.m., which was 8.5 hours later, 3.5 hours too early.

On 6/2/11 at 8:25 a.m. the physician wrote an order for Levaquin 250 milligrams IV every morning. Review of the MAR revealed no Levaquin was administered on 6/3/11.

The clinical nurse manger who was present during the record review on 6/6/11 at approximately 12:00 p.m. confirmed the above findings.


3. Patient #20 was admitted to the facility on 6/4/11. Review of the medication reconciliation order form, which was signed by the physician, revealed the patient was to received 8 milligrams of perphenazine three times daily. Review of the MAR revealed the medication was not added to the MAR and was not administered.

The unit director who was present during the record review on 6/7/11 at approximately 9:00 a.m. confirmed the finding.

The physician wrote an order for Ciprofloxacin 400 milligrams IV every 12 hours on 6/5/11 at 10:00 p.m. The first dose was administered at 12:52 a.m. on 6/6/11. The next dose was administered 9 hours later at 10:00 a.m. The next dose was administered at 8:00 p.m., which was 10 hours later.

The unit director also confirmed the above finding.

Based on observation, record review and interviews the facility failed to prevent altering of a medical record for one patient (#14) by a staff member. This practice does not ensure the medical is accurate.

Findings include:

On 6/6/2011 at approximately 10:00 a.m. an open medical record review was conducted for patient #14. Record review revealed that the patient had been admitted to the facility on 6/3/11. The patient's general consent for treatment was noted to be undated and incomplete. These findings were brought to the attention of the information systems educator who at the time was assisting with the medical record review. An electronic record review was conducted by the information systems educator (IS Educator). She reviewed each section of the electronic medical record thoroughly for any consent forms for the patient and was unable to locate a scanned consent form.

The Director of Respiratory Therapy was also present during the electronic record review and confirmed the missing information on the patient's admission summary and acknowledgment form that was in the medical record. He made a copy of this consent form for the surveyor at approximately 10:45 a.m.

A second consent form was provided to the surveyor at approximately noon by corporate staff. She stated that this was scanned from the computer. However, this form was filled out differently than the original copy that had been provided earlier. It was noted that the information that was missing on the original consent form had been altered as follows:
1. On page #1 under the heading; IV. Advance Directive, questions #2, #3 and #4 had been marked with an "x" as "No"
2. On page two the date of 6/3/11 had been inserted.
This concern was shared with administration and corporate staff. They confirmed the alteration of the record by the "In Patient Account Representative".