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Based on review of facility policy, medical record review, and interview, the facility failed to ensure physician's orders for the use of a physical restraint were consistent with facility policy for two patients (#16, #35) of four restraint records reviewed.

The findings included:

Building A

Review of facility policy titled "Restraints" dated February 7, 2011, revealed,"...To provide guidelines to ensure that the use of restraint...is safe and limited to those situations with adequate, appropriate clinical justification...Before implementing a restraint intervention...a physician's order...must be obtained...The order for restraint must include the type of restraint used, duration of the restraint, and specific behavior that led to the use of restraint..."

Patient #16 was admitted to the facility on December 20, 2012, with diagnoses including Respiratory Failure.

Medical record review of a Restraint Order dated December 23, 2011, revealed no documentation regarding the duration and type of release used. Medical record review of a Restraint Order dated December 24, 2011, revealed no documentation regarding the type of restraint. Medical record review of a Restraint Order dated December 25, 2011, revealed no documentation regarding the duration and type of restraint used.

Interview with Registered Nurse (RN #7) on January 10, 2012, at 10:00 a.m., confirmed the facility failed to implement the facility's Restraint Policy for Patient #16.


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Building C

Patient #35 was admitted to the facility on December 22, 2011 with diagnoses to include Myocardial Infarction, Respiratory Failure, and Acute Renal Failure.

Medical record review of a Physician's Order, dated January 3, 2012, at 1:00 a.m., revealed the patient was to be in wrist restraints for pulling out tubes and catheters. Continued review revealed no documentation regarding the time limit for use of the restraint.

Interview with the Chief Nursing Officer at the 300 hall nursing station on January 9, 2012, at 3:00 p.m., confirmed the facility failed to implement the facility's Restraint Policy for Patient #35.

Based on observation, policy review, standards review, and interview, the facility failed to provide dialysis treatments in compliance with facility policy and industry standards.

The findings included:

Building A.

Observation, on January 10, 2012, at 1:45 p.m., of the Dialysis Unit's water treatment system, on the second floor of Building A, revealed the system consisted of a source of city water, two carbon filter tanks, a water softener, and a reverse osmosis (RO) unit.

Review of the facility's policy titled, "Water Treatment: Maintenance and Use of Central RO and Water Treatment System", last revised April 28, 2011, revealed, "The water quality...will be according to the AAMI (American Association of Medical Instrumentation) standards". Further review of the policy revealed, "Test the water for chlorine/chloramines at valve #T2 (access port between the first and second carbon filter tanks), after the first set of carbon filters".

Review of AAMI standard RD52:2004 revealed, "Two carbon beds shall be installed with a sample port following the first bed" and "performance is monitored by measuring free chlorine and/or chloramines concentrations in the water exiting the first carbon bed of a series connected pair."

Interview with Registered Nurse #1 (RN#1) on January 10, 2012, at 1:45 p.m., in the water treatment room, revealed RN#2 had tested the water for chlorine that morning prior to starting dialysis. RN#1 stated that, "had rechecked the chlorine level again four hours later, as the water is tested prior to beginning dialysis and every four hours while dialysis is being provided." RN#2 demonstrated how the water was tested for chlorine by obtaining product water from a port on the RO unit. Further interview with RN#2 confirmed this nurse always obtained the test sample from the RO unit and never tested water from the port between the carbon tanks.

Interview with RN#8, in the Dialysis Unit, on January 11, 2012, at 9:00 a.m., confirmed it was facility policy to obtain the water specimen from the port between the first and second carbon tanks, for chlorine testing.

Building A

Based on review of facility policy, review of medical records, and interview, the facility failed to ensure a medical record was completed consistent with hospital policy for one patient (#1) of fifty sampled patients.

The findings included:

Building A

Review of facility policy "Physicians Orders" dated July 25, 2011, revealed,"...Physician orders will be managed according to the following protocols"...Required elements: All medication orders...must be complete, accurate, and must include:...Dose and dosage form...Strength...Route of Administration...Dosage regimen (frequency)...Orders that are...incomplete will be clarified with the prescriber...Preprinted Orders: If a physician...adopts 'routine orders', a copy of the orders should be timed, dated and signed by the physician...Standing Orders: these orders are developed for use...for a procedure or process..."

Patient #1 was admitted to the facility on January 1, 2012. Medical record review of a Physician's Orders form dated January 2, 2012, at 3:50 p.m., revealed nine of thirty-two orders preceded with a blackened check box, and included, "...Lactated ringers 1000 ml (milliliters) or (and a blank line)..." Continued review revealed no documentation regarding the route or dose regimen. Continued review revealed twenty-three possible orders preceded by a blank check box, with no indication whether the orders were to be implemeneted or deleted.

Interview with Vice President of Quality on January 9, 2012, at 10:33 a.m., in a 3 Central work space, revealed the "Physician's Orders" form was a "standing orders" form. Interview with the Vice President of Quality on January 11, 2012, at 10:30 a.m., in the the Chief Nursing Officer's (CNO) conference room, confirmed the physician's order for Lactated Ringers was incomplete.

Interview with the Director of Pharmacy on January 11, 2012, at 10:43 a.m., in the CNO's conference room, revealed pharmacy reviewed orders daily and followed up the prescriber when an issue was identified. Continued interview revealed the Physician's Orders dated January 1, 2012, required clarification, and confirmed the facility failed to ensure the orders dated January 1, 2012, were completed consistent with hospital policy.

Based on medical record review, observation, review of facility policy, and interview, the facility failed to ensure physician's orders were authenticated, dated, and timed for two patients (#7 and #8) of fifty patients reviewed.

The findings included:

Building A

Patient #7 was admitted to the facility on January 9, 2012, for a Discectomy.

Medical record review of the pre-printed physician's orders Pre-Op Laminectomy/Fusion revealed "CBC" (Complete Blood Count) and "PT/PTT" (Prothrombin Time and Partial Thromboplastin Time) had been circled to indicate the labwork was to be completed prior to surgery. Continued review of the pre-printed physician's order sheet revealed the orders had not been signed, dated, or timed by the physician. Further medical record review revealed the labwork had been obtained on December 28, 2011.

Patient #8 was admitted to the facility on January 9, 2012, for an ACD&F (Anterior Cervical Discectomy and Fusion).

Medical record review of the pre-printed physician's orders Pre-Op Laminectomy/Fusion revealed orders for labwork, and preoperative antibiotics of Cefazolin 2 grams. Continued review of the pre-printed physician's order sheet revealed the orders had not been signed, dated, or timed by the physician. Further medical record review revealed the labwork was obtained and resulted in the chart and the antibiotic was administered on January 9, 2012, at 12:28 p.m.

Observation on January 9, 2012, at 3:10 p.m., revealed the patient was in bed in the recovery room, with a cervical collar present, and was answering the recovery room nurse's questions regarding post-operative pain.

Review of the facility's policy Physicians Orders, no policy number, revised July 25, 2011, revealed, "...Preprinted Orders: If a physician or group of physicians adopts 'routine orders', a copy of the orders should be timed, dated and signed by the physician and included in the patient's record..."

Interview with the Manager of ODS/PACU (One Day Surgery/Post Anesthesia Care Unit) on January 9, 2012, at 2:50 p.m., in the ODS pre-operative area, and at 3:30 p.m., in Phase I PACU, confirmed the orders had not been authenticated, timed, or dated by the physicians for patient #7 or patient #8.

Based on medical record review, observation, review of facility policy, and interview, the facility failed to obtain informed consent for one patient (#2) of fifty patients reviewed.

The findings included:

Building A

Patient #2 was admitted to the facility on January 8, 2012, with diagnoses including Respiratory Failure, Congestive Heart Failure, and Osteomyelitis.

Medical record review of the physician's orders and an Operative Summary dated January 8, 2012, revealed a central line (catheter placed in a major vessel for administration of medications) was placed in the left subclavian vein (major vessel) on January 8, 2012.

Observation of the patient on January 9, 2012, at 11:00 a.m., revealed the patient in bed in the Intensive Care Unit (ICU), with a dressing present over the left subclavian area (chest area) dated January 8, 2012.

Review of the facility's policy Central Venous Catheters - Regional, no policy number, revised April 7, 2011, revealed, "...An informed consent must be obtained prior to insertion..."

Interview with Registered Nurse (RN) #1 and the Chief Nursing Officer on January 9, 2012, at 10:55 a.m., at the ICU nursing station, and with RN #1 at 11:00 a.m., in the patient's room, confirmed the patient had a central line placed; the patient was unable to consent to treatments; and no family had been present in the facility. Continued interview confirmed there was no documentation of attempts to contact the family and consent for the central line placement had not been obtained.

Based on observation, interview and review of facility policy, the facility failed to secure medications for one of two Operating Rooms (OR) observed.

The findings included:

Building A

Observation on January 9, 2012, at 2:05 p.m., in Operating Room #16, revealed an anesthesia box in the unlocked anesthesia cart containing the following medications: Albuterol inhaler, Phenylephrine, Levophed, Epinephrine, Naloxone, Hydralazine, Ephedrine, Famotidine, Diphenhydramine,Decadron, and Lasix, which may be used during surgery and anesthesia.

Review of facility policy Storage, with last revision dated June 24, 2009, revealed "...when not in use, nursing medication carts, anesthesia carts or other medication carts containing drugs or biologicals must be locked or stored in a locked storage room...all drugs and biologicals must be secure..."

Interview with the OR manager revealed OR #16 had not been used since the previous weekend. Further interview with Operating Room (OR) Manager and the Director of Surgery, at 2:05 p.m., in OR room #16, confirmed the anesthesia box, with medications, was unsecured in the anesthesia cart and the cart was not locked. Further interview with the OR manager revealed OR #16 had not been used since the previous weekend.

Based on observation, policy review, and interview, the facility failed to remove expired drugs from patient use.

The findings included:

Building B

Observations, on January 9, 2012, at 1:00 p.m., of Building B's Intensive Care Unit (ICU) Medication Room, revealed three 250 milliliters (ml) bags of Intravenous (IV) Dextrose 5% with Water (D5W), with expiration date of October 2011.

Review of facility policy titled, "Storage:General", last revised June 24, 2009, revealed, "Medications shall be stored under proper conditions of sanitation..."

Interview with the Clinical Leader, on January 9, 2012, at 1:00 p.m., in the medication room, confirmed the three IV bags were expired and available for patient use.


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Based on observation and interview, the facility failed to ensure supplies were not avaliable beyond the expiration date in the Interventional Radiology department.

The findings included:

Building A

Observation on January 10, 2012, at 2:35 p.m., in the Interventional Radiology Department, revealed twenty tongue depressors with an expiration date of June, 2009 and four #11 Scalpel Blades with an expiration date of May, 2006, in an emesis basin in the cabinet.

Interview with Radiology Technician (RT) #1, on January 10, 2012, at 2:35 p.m., in the Interventional Radiology Department, confirmed twenty tongue depressors with an expiration date of June, 2009 and four #11 Scalpel Blades with an expiration date of May, 2006 in the cabinet and were expired.

Interview with the Chief Nursing Officer (CNO), at 2:40 p.m., in the conference room, confirmed the tongue depressors and scalpel blades were expired and available for patient use.

Based on observation, policy review, and interview, the facility failed to ensure single use patient care items were not used for more than one patient in the Interventional Radiology Department of building A; failed to ensure unclean linens were properly handled in two medical surgical units (3 central and 1 central) in building A; failed to ensure the cleanliness of clothing items provided by the facility for newborn infants in the nursery of building A; failed to ensure the facility hand washing policy was followed while preparing medications by one nurse in the emergency room of building A; failed to ensure the facility hand washing policy was followed while administering medications by one nurse on the 200 hall medical surgical unit of building C; failed to ensure the continuation of Neutropenic Precautions (reverse isolation precautions are generally indicated to prevent exposure of a patient to infections for a patient with a low blood neutrophil count which is the most common type of white blood cell that fights infections) on the 300 hall medical surgical unit of building C; and failed to ensure items recommended for single patient use were not cleaned and used on multiple patients in the outpatient surgery center's pre-operative area of building C.

The findings included:

Building A

Observation on January 10, 2012, at 2:35 p.m, in the Interventional Radiology Department, revealed one multi-dose vial of Heparin (10,000 unit per 1 milliters) with a connector device and one three ml syringe in the locked cabinet.

Interview with Radiology Technician (RT) #1, at 2:35 p.m., in the Interventional Radiology Department hallway, confirmed the 3milliliter (ml) syringe was reused multiple times to withdraw the Heparin from the multi-dose vial and then add 1ml into 1000ml's of Normal Saline for a Heparin drip.

Review of facility policy Safe Injection Practices, with original date June 1, 2011, revealed "...needles, cannulae, and syringes are sterile, single-use items...needles, cannulae and syringes will not be used for another patient nor to access a medication or solution that might be used for subsequent patient...if multi-dose vials must be used, both the needle or cannula and syringe used to access the multi-dose vial must be sterile..."

Interview with the Chief Nursing Officer (CNO) on January 10, 2012, at 2:40p.m., in the conference room, confirmed the reuse of a 3ml syringe did not follow facility policy.

Review of facility policy titled "Linen Utilization - Regional" dated July 30, 2010, revealed, "...Torn, stained, or otherwise unusable linen should be placed in a designated receptacle...Standard Precautions will be used when handling all linen..."

Medical record review revealed Patient #1 was admitted to the facility on January 1, 2012, with diagnoses including Methicillin Resistant Staph Aureus (MRSA, an infectious organism resistant to treatment by most antibiotics).

Medical record review of a physician's progress note dated January 5, 2012, revealed, "...MRSA facial abcess."

Observation with the Vice President of Quality on medical surgical hall 3 central, on January 9, 2012, at 9:56 a.m., revealed the patient in bed, a dressing on the left wrist/hand, and unclean linen on the floor beside a red storage receptacle.

Interview with the Vice President of Quality on January 9, 2012, at 9:56 a.m., confirmed the facility failed to store the unclean linen in a manner to prevent the spread of infection.

Medical record review revealed Patient #15 was admitted to the facility on January 5, 2012, with diagnoses including Altered Mental Status.
Observation on January 9, 2012, at 2:32 p.m., revealed the patient in a bed and unclean linen in a chair in the room. Continued observation revealed a Certified Nursing Assistant (CNA #1) picked up the linen with ungloved hands and the linen made contact with the CNA's uniform.

Interview with CNA #1 on medical surgical hall 1 central, on January 9, 2012, at approximately 2:34 p.m., outside the patient's room, revealed the CNA is to wear gloves when handling unclean linen.

Interview with Registered Nurse (RN #6) on January 9, 2012, at 2:35 p.m., outside the patient's room, confirmed the facility failed to handle the linen in a manner to prevent the spread of infection.

Observation of the newborn nursery of building A with the Manager of the Women's Center and the Clinical Leader of the Women's Center of building A, on January 10, 2012, at 2:00 p.m., revealed several drawers contained homemade hand crocheted infant hats and blankets.

Interview with the Manager of the Women's Center and the Clinical Leader of the Women's Center of building A, on January 10, 2012, at 2:00 p.m., confirmed the cleanliness of the homemade items provided by the facility to the newborns could not be ascertained.

Observation of Registered Nurse (RN) # 4 in the Emergency Department (ED) of building A with the Manager of the ED on January 11, 2012, at 9:30 a.m., revealed RN #4 standing at the ED nursing station with the hands tucked down into the waist band of the scrub pants RN #4 was wearing. Continued observation revealed RN #4, without washing or sanitizing the hands, entered the medication area and entered information on the keyboard on the medication storage cabinet. RN #4 opened the medication storage cabinet; opened a medication drawer; extracted two containers of medication; obtained a disposable drinking cup; filled the cup with ice and water; and proceeded down the hall with the medication.

Interview in the medication area of the ED of building A with RN #4 and the ED Manager on January 11, 2012, at 9:30 a.m., confirmed the RN did not wash or sanitize the hands prior to obtaining and preparing patient fluids and medications.

Review of the facility policy, Hand Hygiene, no number, dated revised September 21, 2010, revealed "...to reduce, as low as possible, the number of viable microorganisms on the hands in order to prevent transmission of pathogens from one patient to another...use anti-microbial soap...or alcohol based hand rub...before contact with intact patient skin..."

Building C

Observation on the 200 hall of the medical surgical unit of building C with the Chief Nursing Officer (CNO) on January 9, 2012, at 2:20 p.m., revealed RN #3 exited the medication room and without washing or sanitizing the hands. The RN entered the room of a patient; handled the wrist area of the patient's left arm then walked to the right side of the bed and handled the tubing for the patient's IV (intravenous) line. The RN reached into the pocket of the scrubs withdrawing a syringe; injected the medication in the syringe into the port on the IV tubing then reached into the pocket of the scrubs again, and injected another syringe of medication into the port of the patient's IV line.

Interview in the medication room of the 200 hall medical surgical unit of building C on January 9, 2012, at 2:25 p.m., with RN #3 and the Chief Nursing Officer confirmed the hands had not been washed or sanitized prior to entering the patient's room and injecting medications into the patient's IV port. Continued interview confirmed the facility policy called for the hands to be washed or sanitized prior to entering a patient's room and administering IV medications.

Patient #34 was admitted to the facility on January 5, 2012 with diagnoses to include Neutropenia. Review of the Physician's Admit Orders, dated January 5, 2012, at 5:30 p.m., revealed "...Neutropenic Precautions..."

Observation of the doorway to patient #34's room with the CNO on January 9, 2012, at 3:30 p.m., revealed no signage to indicate patient #34 was on Neutropenic Precautions and no isolation equipment outside the patient's door.

Interview at the nursing station of the 300 hall of the medical surgical unit of building C on January 9, 2012, at 3:30 p.m., with RN #5 revealed RN #5 had received information in the morning report the Neutropenic Precautions had been discontinued.

Medical record review of patient #34 revealed the White Blood Cell (WBC) count on January 5 - 1.8 MM3; January 6 -1.9 MM3; January 7 - 1.9 MM3; January 8 - 2.3 MM3; and January 9 - 2.0 MM3 (normal ranges: WBC - 3.7 - 10.7 MM3) - (MM3 is, in brief, the measurement by micrometers according to the National Institution of Health).

Continued medical record review revealed no order to discontinue the Neutropenic Precautions.

Interview at the nursing station of the 300 hall of the medical surgical unit of building C on January 9, 2012, at 3:30 p.m., with RN #5 revealed, the physician wanted to continue the Neutropenic Precautions.

Interview at the nursing station of the 300 hall of the medical surgical unit of building C on January 9, 2012, at 3:30 p.m., with the CNO confirmed the Neutropenic Precautions had been discontinued without a written physician's order.

Observation in the outpatient surgery center of building C with the Chief Nursing Officer (CNO) on January 9, 2012, at 1:10 p.m., revealed the pre-operative area contained 10 patient beds. Continued observation revealed each bed area had a rolling nurse's work area with a work space of three feet by one and one half feet and an attachment hanging from the side with storage spaces. Continued observation revealed each nurse's work area contained an emesis basin (disposable pink plastic kidney shaped container manufactured for containment of vomitus) with "DO NOT DISCARD" written in permanent marker on each emesis basin.

Interview in the pre-operative area with the CNO and Charge Nurse of the pre-operative area on January 9, 2012, at 1:10 p.m., confirmed the emesis basins were cleaned after each patient and utilized to hold such things as the IV (intravenous) catheters and discarded IV items utilized after starting an IV. Continued interview revealed the manufacturer had not provided instructions indicating the emesis basins could be cleaned; could not be used on more than one patient; and were single patient use items.



30553

Based on observation, interview, and review of manufacturer's recommendations, the facility failed to follow manufacturer's recommendations for processing (high level disinfection and/or sterilization) and storage of endoscopes for one of two operating rooms observed in the surgery department.

The findings included:

Building A

Observation of Operating Room (OR) #13 on January 9, 2012, at 1:10 p.m., revealed a cabinet contained five closed rigid containers with endoscopes, cameras, light cords, and instrumentation, with visible moisture on the inside of the containers. Observation of the containers revealed cardboard cards set on top of the containers with dates and times of January 9, 2012, 9:00 a.m., and 9:10 a.m., (four hours earlier) on two trays.

Interview with Scrub Tech #1 on January 9, 2012, at 1:10 p.m., in OR #13, revealed the scopes were processed in the rigid trays using an automatic processor in the mornings and then stored in the rigid containers, stacked in the cabinet, for use during "clean" procedures (not sterile surgeries) scheduled during the day.

Interviews with the Director and the Manager of the OR on January 9, 2012, at 1:20 p.m., in OR #13, and at 1:50 p.m., in the substerile room, confirmed staff process the endoscopes in the mornings, and store the scopes in the rigid containers, without drying the scopes or instrumentation, for use throughout the day and within 24 hours.

Review of the automatic processor manufacturer's recommendations revealed, "...Devices are sterilized, rinsed, and ready for immediate use upon the successful completion of the sterile processing cycle...The processing chamber and the processing containers/trays are also sterilized during the cycle to provide a sterile environment for the devices during the brief time between the completion of sterilization and the removal of the devices for use. The use of devices sterile processed in a SYSTEM 1 Processor should be in a manner consistent with 'Just In Time' processing and delivery. Devices, properly processed in SYSTEM 1 are sterile and ready for immediate use in patient procedures. Neither the Processor nor the processing containers/trays are intended for storage of devices. Storage of medical devices post-processing should be conducted per the user facility's procedures. (Organizations such as AORN [Association of periOperative Nurses] and SGNA [Society of Gastroenterology Nurses and Associates] offer post-processing guidelines.) Devices stored overnight, for extended periods of time, or otherwise not properly removed and transported to the sterile field for immediate use (JIT) must be re-sterilized prior to use in patient procedures..."

Interviews with the Director and the Manager of the OR on January 9, 2012, at 1:50 p.m., in the substerile room and outside OR #13, and with the Director of Sterile Processing on January 9, 2012, at 2:35 p.m., in the Sterile Processing Department, confirmed the facility had not reviewed manufacturer's recommendations for the automatic processor or the endoscopes, before implementing the process of storing the endoscopes in the rigid containers during the day. Further interviews confirmed the endoscopes were only used in "clean" procedures requiring high level disinfection of the scopes and instrumentation, and not procedures where sterile cavities were entered and sterile instrumentation was required. Further interviews confirmed manufacturer's recommendations and society standards were not followed in processing and storing the endoscopes.