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Based on observation and interviews, for one of six nursing units, the facility failed to ensure that personal care items and/or activity items were stored to ensure a safe environment. The findings include:
During a tour of the Donnelly One psychiatric unit on 3/7/11 at 10:50 AM, with the Program Director, the following was noted in patient rooms: a container of Elmer's Glue and an abundance of personal care items including shampoo, lotion, Barrier cream and Baza cleanser. Interview with the Director of Nursing on 3/7/11 at 11 AM identified that the facility lacked a specific policy regarding storage of personal items and that it is the responsibility of the staff to monitor items stored in patient rooms to ensure that a safe environment is maintained.

A164

Based on clinical record review, staff interviews, and review of facility policy and procedure for one of three patients (Patient #200), the facility failed to enter comprehensive orders for behavioral restraints. The findings include:

Patient #200 (P#200) was admitted to the Emergency Department (ED) on 6/6/2010 and presented with worsening agitation, combativeness, and confusion. The past medical history included schizoafffective disorder and psychosis. Review of the clinical record with the Nurse Manager #5 indicated a behavioral restraint order was entered on 6/6/2010 at 7:38 PM. The restraint order failed to include the type of restraint to be utilized and the criteria to discontinue restraint use. Review of facility policy and procedured titled Restraint Policy indicated that an individual order for behavioral restraints requires the type of restraint and critieria for discontinuation.

A165

Based on clinical record review, staff interviews, and review of facility policy and procedure for one of three patients (Patient #198), the facility failed to re-evaluate and monitor the care of a restained patient and utilize the least restricitve form or restraint. The findings include:

a. Patient #198 (P#198) was admitted to the Emergency Department (ED) on 1/24/2011 at 9:47 PM for a mental health evaluation. Past medical history included schizoaffective disorder. Review of the clinical record indicated P#198 arrived in handcuffs accompanied by law enforcement, and a behavioral restraint order was first placed on 1/24/2010 at 10:33 PM for the patient to be placed in four point restraints (leather cuff ankle and wrist) due to being combative, threatening staff, kicking, screaming and cursing. Review of the behavioral restraint flowsheets indicated that for the time period of 2:15 AM through 4:59 AM on 1/25/2011, P#198 was described at every 15 minute checks as either sleeping or quiet and cooperative but remained in four point leather restraints. In addition, for the time period of 7:38 PM on 1/25/2011 through 1:30 AM on 1/26/2011, P#198 was described at every 15 minute checks as either sleeping or quiet/cooperative but remained in four point leather restraints. Interview with Nurse Manager #5 on 3/10/2011 indicated that staff is expected to remove or decrease behavioral restraints as soon as patient behavior improves. Review of facility policy and procedure titled Restraint Policy indicated that the continued re-evaluation of restraint need includes: the ongoing need for restraint, the use of less restrictive interventions, or termination of medical/behavioral restraint.

A171

Based on clinical record review, staff interviews, and review of facility policy and procedure for one of three patients (Patient #198), the facility failed to enter or renew orders for behavioral and/or medical restraints. The findings include:

a. Patient #198 (P#198) was admitted to the Emergency Department (ED) on 1/24/2011 at 9:47 PM for a mental health evaluation. Past medical history includes schizoaffective disorder. Review of the clinical record indicated P#198 arrived in handcuffs accompanied by law enforcement, and a behavioral restraint order was placed on 6/24/2010 at 10:33 PM for the patient to be placed in four point restraints (leather cuff ankle and wrist) due to being combative, threatening staff, kicking, screaming and cursing. Review of the behavioral restraint flowsheets indicated that P#198 remained in restraints after 2:45 AM on 6/25/2011, despite the restraint order not being renewed. The restraints were documented to be removed at 4:59 AM. A new order for behavioral restraints was ordered on 1/25/2011 at 10:35 AM. Review of the behavioral restraint flowsheets indicated that P#198 remained in restraints past 3:00 PM despite the restraint order not being renewed. The restraints were documented to be removed at 5:56 PM. A new order for behavioral restraints was ordered on 1/25/2011 at 7:07 PM. Review of the behavioral restraint flowsheets indicated that P#198 remained in restraints after 11:30 PM, despite the restraint order not being renewed. The restraints were documented to be removed on 1/26/2011 at 1:45 AM. Interview with Nurse Manager #5 on 3/10/2011 at 11:50 AM indicated that behavioral restraint orders should be renewed every four hours. Review of facility policy and procedure titled Restraint Policy indicated that individual orders for behavioral restraints are time limited to four hours for ages 18 and older.

A178

Based on clinical record review, staff interviews, and review of facility policy and procedure for one of three patients (Patient #200), the facility failed to provide a face-to-face assessment by qualified staff for a patient in behavioral restraints. The findings include:

a. Patient #200 (P#200) was admitted to the Emergency Department (ED) on 6/6/2010 and presented with worsening agitation, combativeness, and confusion. The past medical history included schizoafffective disorder and psychosis. Review of the clinical record with the Nurse Manager #5 indicated that a behavioral restraint order was entered on 6/6/2010 at 7:38 PM. The clinical record lacked documentation of an assessment of P#200 by a Medical Doctor (MD), LIP, Physician's Assistant (PA), or a behavioral health trained Registered Nurse (RN) within an hour of implementing the behavioral restraint. Review of the facility policy and procedure titiled Restraint Policy indicated that the MD/LIP must see the patient face-to-face within one hour and evaluate the patient's immediate situation, reaction to the intervention, medical and behavioral condition and need to continue or terminate the restraint. In addition, the initial one hour face-to-face assessment may also be conducted by a behavioral health trained RN or PA. If the RN or PA conducts this assessment, he/she must consult the attending MD or other responsible LIP as soon as possible after the completion of the evaluation.

Based on a review of clinical records and review of facility policy, the facility failed to ensure that physician orders were complete and/or that the physician participated in the interdisciplinary assessment. The findings include the following:

a. Review of Patient #136's hemodialysis orders dated 2/15/11, 2/17/11, 2/19/11, 2/21/11, 2/23/11, 2/25/11, 2/26/11, 2/28/11, 3/2/11, and 3/4/11 directed "UF to dry weight". The order failed to identify the patient's dry weight and/or an amount of fluid to be removed. Review of the hemodialysis standing orders indicated that ultrafiltration should be determined based on the physician's order and that all orders should be placed into CPOE.

b. Review of the clinical record for Patient #185 identified that the patient was on dialysis every other day. The clinical record indicated that the patient received hemodialysis on 2/28/11, however the record failed to contain an order for the hemodialysis.

c. Review of Patient #187's clinical record identified that the patient was receiving dialysis three days a week. The clinical record indicated that the interdisciplinary comprehensive assessment had been completed in 2/11. Review of the comprehensive assessment failed to identify that the physician had participated in the assessment. Review of the facility policy indicated that all disciplines should participate in the comprehensive assessment.

Based on a review of clinical records, policy review, and interview, the facility failed to ensure that the patients level of pain was addressed and/or reassessed after an intervention and/or that medications were administered as ordered. The findings include the following:

a. Review of Patient #115's clinical record indicated that the patient was admitted on 12/23/10 with diarrhea with a history of arthritis, hypertension and renal failure. Review of the record indicated that during the period of 12/26/10 through 12/28/10 that the patient complained of pain on nine occassions. The record failed to identify on seven of these occassions that the patient's pain was addressed.

Review of the facility policy indicated that a patient's pain level should be reassessed at regular intervals. The policy failed to identify when the patients level of pain should be reevaluated and/or staff documentation requirements.

b. Review of Patient #137's clinical record indicated that the patient presented to the ED on 3/4/11 in a sickle cell crisis. The ED record indicated that on 3/4/11 at 10:30 AM the patient received 2 mg of Dilaudid intravenously for a pain level of 9 (scale of 0-10, with 10 being the worst possible pain). The record failed to reflect that the patient's level of pain was reassessed. At 1:30 PM and 5:00 PM, the patient received Dilaudid 2 mg IV. The clinical record failed to identify a pre and/or a post assessment of the patient's level of pain.

c. Patient #137 was subsequently admitted to an inpateint unit. Upon admission to the unit, the patient stated that the level of pain was an 8. The clinical record failed to identify if the pain was treated and/or if the physician was notified of the ongoing pain the patient was experiencing.

d. Patient #185 had a physician's order dated 12/13/10 for "Heparin Protocol (100 units/kg)". Review of the dialysis flow sheets for the period 12/13/10 through 12/17/10 failed to identify that the patient received Heparin, however nursing notes reflected that staff should check with the physician for a heparin bolus. Review of Patient #185's treatment flow sheets dated 12/22/11 to 3/8/11 identified that the patient received a 4,000 unit bolus of heparin at the beginning of each treatment. Interview with the Manager on 3/10/11 at 10:30 AM indicated that the patient should have received heparin based on the physician's order and was unsure why this did not happen. Additionally once the heparin was initiated, the clinical record failed to contain documentation of the order.

Review of the facility policy indicated that medications should be administered based on a physician's order.


20361

Based on clinical record review and interviews for one sampled patient (Patient #116), whose intake and output was being monitored, the clinical record lacked consistent and/or comprehensive documentation of the patient ' s intake and output. The findings include:

a. Patient #116 was admitted on 8/23/10 with diagnoses that included depression, vascular dementia, cerebral vascular accident and diabetes. An initial nutritional screen dated 8/24/10 identified a score of 2 indicating the patient was a low nutritional risk. An interdisciplinary treatment plan dated 11/9/10 identified electrolyte imbalance with interventions that included to review labs, strict intake and output and to provide a low sodium dysphasia diet. Physician orders dated 11/9/09 directed to monitor intake and output, insert a Foley catheter, and to administer D5W at 80 ml (milliliters) per hour intravenously. Interview and review of the nursing graphic sheet from 11/9/09 through 11/11/11 with the Director of Nursing on 3/8/11 at 2:30PM identified that the clinical record lacked consistent documentation of intake during all three shifts, was not consistently inclusive of intravenous fluid intake and that the output was not accurately and/or consistently documented with the use of a Foley catheter.



26703

Based on clinical record review, review of facility documentation and policies and interviews with facility staff for one patient (P #114) who were reviewed for falls, the facility failed to notify appropriate persons and document the incident according to facility policy.

a. P #114 was admitted on 11/30/10 with diagnoses that include a left cerebral artery stroke. Public relations documentation dated 12/8/10 indicated Person #17 had arrived to visit P#114 on 12/8/10 at 10:00 AM and was informed by P#114's roommate that P#114 had fallen at about 3:00 AM on 12/8/10. Public relations documentation dated 12/8/10 indicated when Person #17 informed the 7:00 AM - 3:00 PM licensed staff member assigned to P#114 of what Person #17 had been told, he/she had no knowledge of the fall. A physician progress note dated 12/8/10 at 18:00 (6:00 PM) indicated P#114 had sustained a fall during the night and an x-ray of P#114's right arm, chest and a head CT scan were all negative. The clinical record failed to identify that P#114 had fallen, or that a physical assessment was completed after the fall. Additionally, the clinical record did not identify that the family, physician or supervisory staff were notified of the fall. During a review of the clinical record with the Nursing Informatics representative on 3/10/11 at 11:15 AM, the clinical record lacked documentation that P#114's plan of care had been reviewed and updated pertaining to fall prevention until 12/8/10 at 15:27 (3:27 PM), after the fall. A review of the clinical record indicated P#114 exhibited no signs of injury on 12/8/10 between 3:00 AM and the time the fall was identified (approximately 3:00 PM) to warrent further assessment.

During an interview with RN#20 on 3/11/11 at 8:25 AM, RN#20 indicated that on the morning that P#114 fell, RN#20 was caring for a patient who was trying to get out of bed and was notified by the Patient Care Assistant (PCA) that P#114 had fallen. RN#20 indicated when he/she arrived in the room RN#18 was assisting P#114 back to bed. Upon surveyor inquiry he/she indicated that he/she, as well as, RN#18 had assessed P#114 after the fall, but had forgotten to document the assessment. RN#20 identified that once P#114 was assessed to be without injury, RN#20 returned to check on the patient he/she had been caring for prior to being notified of P#114's fall. During the interview RN#20 indicated that he/she had not notified the family and physician about the fall and RN#20 further indicated he/she had forgotten to notify the next shift nurse about the incident.

Facility Fall Prevention and Management Policy indicated that when a patient falls the physician, family and Nursing Coordinator, manager or educator will be notified. The policy further indicated to document the fall on the post fall documentation progress note and review and revise the patient's plan of care.



29051

Based on clinical record review, staff interviews, and review of facility policy and procedures for one patient (Patient #113), the facility failed to ensure timely notification to the patient's family of a change in condition.

a. Patient #113 (P#113) was admitted to the Emergency Department (ED) on 4/21/2010 at 9:27 AM presenting with hypotension, decreased urine output, respiratory distress and decreased mental status. Past medical history included chronic respiratory failure, aspiration pneumonia, chronic obstructive pulmonary disease, congestive heart failure, gastrointesinal bleed, aortic stenosis and dementia. P#113's treatment plan for Comfort Measures Only was implemented at 4:45 PM. Review of the nursing assessment forms indicated that while awaiting transport to a palliative care bed, RN#106 found the P#113 to be in asystole and apneic at 5:32PM and that MD#25 was paged. Review of the Death Notice form indicated the time of death to be 5:32 PM on 4/21/2010, however the Death Notice lacked documentation of relative notification. During the morning of 4/22/2010, MD#26, a cardiologist with a history of caring for the patient, was made aware of P#113's death and telephoned Person #18 to extend his/her condolensces At that time MD#26 realized the family had yet to be notified of the patient's death. Interview on 3/10/2011 at 12:45 PM with MD#25, the physician on-call at the time of death, indicated that at the time of P#113's death, he/she did not receive notification, and was not aware of the patient's death until the following day. Interview with the Medical Director on 3/10/2011 at 9:00 AM indicated that a review of page logs confirmed that MD#25 did not receive a page from nursing staff that the patient had expired. MD#26 indicated that the procedure normally followed is that if staff receives no response from a physician after numerous pages, the next step would be to notify the group in which the physician belongs which was not done in this case.

Based on clinical record review and staff interview for two of seven patients reviewed on the inpatient psychiatric unit, the facility failed to ensure that the clinical record contained an Interdisciplinary Treatment Plan (ITP) and/or failed to ensure that the ITP was complete/accurate. The findings include:

a. Patient # 210 was admitted to the inpatient psychiatric unit on 2/26/11. Review of the clinical record progress notes on 3/7/11 identified that the patient was tentatively scheduled for discharge. Review of the clinical record and interview with the unit Program Manager identified that the record lacked an ITP. Further interview with the Program Manager indicated that the ITP could not be located on the unit.

b. Patient # 212 was admitted to the inpatient psychiatric unit on 2/27/11 with psychosis, NOS and a history of asthma. Review of the ITP identified asthma listed as a problem with goals that included compliance with the treatment plan and medications. Further review of the ITP and interview with the Director of Nurses identified that although the patient had not currently required use of an inhaler, the ITP failed to identify any interventions related to the problem of asthma.

The hospital policy "Interdisciplinary Treatment" requires a formal interdisciplinary pocess of treatment plan preparation and documentation, which assures that all information available on the patient is considered and includes substantiated diagnoses, short and long-term goals, specific treatment modalities and the responsibilities of team members.


15482

Based on review of the clinical record, review of facility policy, and interviews with staff for four patients (Patients #138, #131, #151, and #114) the facility failed to ensure that a comprehensive care plan had been completed. The findings include the following:

a. Patient #138 was admitted on 2/19/11 with chronic obstructive pulmonary disease (COPD) and a myocardial infarction. The patient's admission weight was 145.5 pounds (lbs). Review of the Dietician's assessment identified that the patient had a highly compromised nutrition status. Review of the clinical record indicated that the patient was NPO and on tube feedings until 3/5/11 then made NPO again on 3/7/11 for a potential GI bleed. The patient's weight on 3/8/11 was 138.9 lbs. The clinical record failed to identify that the patients nutritional issues had been identified on the care plan.

Review of the hospital policy "Clinical Documentation Guidelines" identified that an individualized plan of care will be documented for each patient and serve as a communication tool from provider to provider to assure continuity of care.


19907

b. Patient # 131 was admitted to the hospital on 2/25/11 with a diagnosis of recurrent ovarian cancer who presented with complaints of nausea and vomiting. Patient # 131 was treated with intravenous fluids and total parenteral nutrition. Imaging was completed and revealed a small bowel obstruction. A bowel resection and ileocolic bypass with colostomy was performed on 3/3/11. Interview and review of the clinical record with Nurse Manager # 10 on 3/7/11 at 10:45 AM failed to identify that that a comprehensive care plan was completed with interventions that were individualized for Patient # 131. Review of the hospital policy " Clinical Documentation Guidelines " identified that an individualized plan of care will be documented for each patient and serve as a communication tool from provider to provider to assure continuity of care. Subsequent to surveyor inquiry on 3/7/11 at 12:19 PM the patient ' s care plan was updated with interventions on the patient ' s Hospital Education Outcome Record.
c. Patient # 151 was admitted to the hospital on 2/26/11 with a twin pregnancy of twenty- five weeks gestation. Diagnosis included premature rupture of membranes, preterm labor, and oligohydramnios. Medications were used to prevent premature birth and respiratory distress syndrome in the preterm infants. Interview and review of the clinical record with Nurse Manager #11 on 3/7/11 at 1:30 PM failed to identify that a comprehensive care plan was completed with interventions that were individualized for Patient # 151. Review of the hospital policy " Clinical Documentation Guidelines " identified that an individualized plan of care will be documented for each patient and serve as a communication tool from provider to provider to assure continuity of care.



26703


d. P #114 was admitted on 11/30/10 with diagnoses that include a left cerebral artery stroke. Public relations documentation dated 12/8/10 indicated Person # 17 had arrived to visit P#114 on 12/8/10 at 10:00 AM and was informed by P#114's roommate that P#114 had fallen at about 3:00 AM on 12/8/10. A relations documentation dated 12/8/10 indicated when Person #17 informed the 7:00 AM - 3:00 PM licensed staff member assigned to P#114 of what Person #17 had been told, the he/she had no knowledge of the fall. A physician progress note dated 12/8/10 at 18:00 (6:00 PM) indicated P#114 had sustained a fall during the night and an x-ray of P#114 ' s right arm, chest and a head CT scan were all negative. The clinical record failed to identify that P#114 had fallen, or that a physical assessment was completed after the fall. Additionally, the clinical record did not identify that the family, physician or supervisory staff were notified of the fall. During a review of the clinical record with the Nursing Informatics representative on 3/10/11 at 11:15 AM, the clinical record lacked documentation that P#114's plan of care had been reviewed and updated pertaining to fall prevention until 12/8/10 at 15:27 (3:27 PM), after the fall. A review of the clinical record indicated P#114 exhibited no signs of injury on 12/8/10 between 3:00 AM and the time the fall was identified (approximately 3:00 PM) to warrent further assessment.

During an interview with RN#20 on 3/11/11 at 8:25 AM, RN#20 indicated that on the morning that P#114 fell, RN#20 was caring for a patient who was trying to get out of bed and was notified by the Patient Care Assistant (PCA) that P#114 had fallen. RN#20 indicated when he/she arrived in the room RN#18 was assisting P#114 back to bed. Upon surveyor inquiry he/she indicated that he/she, as well as, RN#18 had assessed P#114 after the fall, but had forgotten to document the assessment. RN#20 identified that once P#114 was assessed to be without injury, RN#20 returned to check on the patient he/she had been caring for prior to being notified of P#114's fall. During the interview RN#20 indicated that he/she had not notified the family and physician about the fall and RN#20 further indicated he/she had forgotten to notify the next shift nurse about the incident.

Facility Fall Prevention and Management Policy indicated that when a patient falls the physician, family and Nursing Coordinator, manager or educator will be notified. The policy further indicated to document the fall on the post fall documentation progress note and review and revise the patient ' s plan of care.

Based on clinical record review, staff interviews and review of policies and procedures for one of seven inpatient psychiatric patients, the facility failed to ensure that the clinical record was complete and accurate. The findings include:

a. Patient # 212 was admitted to the inpatient psychiatric unit on 2/27/11 with psychosis and and a history of asthma. Review of the clinica record identified that a current history and physical (H&P) was lacking for the current admission. Review of clinical documentation and interview with the patient's psychiatrist identified that a history and physical examination was performed on 1/29/11 during a prior admission, which was not incorporated into the patient's current clinical record. Further review of the 1/29/11 H&P also failed to identify the patient's history of asthma. Review of the facility's policy "Psychiatric Intake and Evaluation" on 3/7/11 identified that if a history and physical examination has been performed within 30 days of admission, a durable, legible copy of the report may be placed in the medical record provided any changes are noted in the record at the time of admission.

Based on observations and interview with staff, the Hospital failed to ensure that a patient's clinical record was kept confidential. The findings include:

a. A tour of CB2 was conducted on 3/7/11 at 10:20 AM with the Unit Manager. Multiple computer work stations were located in the hallways throughout the unit. Practitioner #200 was observed accessing Patient #121's clinical record. The content of the patient's clinical record was visible from all areas of the hallway where other patients and visitors had access.

Based on clinical record review and interviews with staff for one patient (Patient #194) who had a surgical procedure, the clinical record failed to reflect that medications were administered to the correct site. The findings include:

a. Patient #194 was admitted on 3/8/11 for a left cataract removal. Review of the clinical record identified that pre-operative medications were administered to the patient's right eye. Interview with the Nurse Manager on 3/8/11 at 9:45 AM identifed that the medication was correctly administered in the left eye (as ordered), and that the documentation in the clinical record was incorrect.

Based on observation and interviews, for one of six nursing units, the facility failed to ensure that medications were stored in accordance with accepted professional principles. The findings include:

a. Observations during a tour of the Donnelly One North Intravenous Supply Room on 3/7/11 at 11AM identified seven cases (25 bottles/per case)of Sodium Chloride (10 ml) bottles for injection with an expiration of January 2011. Interview with the director of Nursing at the time identified that it is the responsibility of the 11-7 nursing staff to monitor the supplies and return expired items to the pharmacy for replacement.

Based on a tour of the pharmacy department, review of hospital policies and interviews, the pharmacist failed to ensure dosage accuracy for intravenous admixtures that had been prepared by the pharmacy technician prior to dispensing. The findings include:

a. A tour of the pharmacy department was conducted on 3/8/11 with the Director of Pharmacy. Observation on 3/8/11 at 2 PM identified that the pharmacy technician drew up the chemotherapeutic agents into syringes, the pharmacist verified the accuracy of the medications and dosages and the medications were then injected into the IV solution by the pharmacy technician. Observation of another pharmacy IV preparation room noted the pharmacy technician injected medication into the IV solution prior to pharmacist accuracy verification. Interview with the Lead Pharmacy Technician on 3/8/11 at 2 PM identified that the pharmacy technician prepared IV antibiotic admixtures from multi dose vials of Tobramycin and Gentamycin and injected the medication into the IV solution prior to accuracy verification by a pharmacist. H/she further noted that the pharmacist later confirmed the accuracy of the dosage by visualizing an air- filled syringe next to the multi dose vial of medication that had the plunger pulled back to depict the amount of medication that had been injected. The pharmacist could not verify with complete certainty the amount of medication that had originally been drawn into the syringe from the multi dose vial and injected into the IV solution. Interview with the Director of Pharmacy on 3/8/11 noted that, beginning 3/29/11, verification of IV admixtures would be done using a system that will take pictures of all vials and medication- filled syringes. The system would require the pharmacist's computerized verification of accuracy prior to the printing of the sticker that signified readiness for dispensing. The pharmacy policy for IV admixtures identified that a pharmacist will check to insure the proper drug and dosage has been prepared as well as the proper solution, volume of solution and correct labeling.

Based on observation, interviews and review of facility policies and procedures, the facility failed to ensure medications in the medication storage unit (Pyxis) had not expired. The findings include:

a. During a tour of Unit North 9 on 3/7/11 at 10:30 AM, with Nurse Manager #6 and the North 9 Nurse Educator, a random sample observation of medications in the medication storage unit (Pyxis) was made for expiration date accuracy. During the observation it was identified that two of three vials of Atropine Sulfate had expired on 2/2011.
During an interview with the Pharmacy Systems Coordinator on 3/7/11 at 10:50 AM, he/she indicated a print out of medications contained in the Pyxis, including the expiration date, are printed out daily. and identify the expiration dates of the medications. The Pharmacy Systems Coordinator further identified that this is the responsibility of the pharmacy Technition. Upon conclusion of the interview the Pharmacy Systems Coordinator removed the expired Atropine Sulfate from the Pyxis inventory. During an interview on 3/9/11 at 1:35 PM with the Pharmacy Operations Manager, he/she indicated Atropine Sulfate was a medication in which the expiration date function in Pyxis was activated and he/she could not identify how the expired medication had remained in the Pyxis inventory.

Based on observation, review of facility documentation, and staff interviews the hospital failed to ensure that the physical environment of the hospital was maintained in a safe manner. Please refer to A 0701 and A 724

1. Based on observation of the facility operating rooms and support areas the facility did not ensure that electrical power was provided to facility patient care equipment in compliance with NFPA 70 " National Electrical Code " and NFPA 99 " Health Care Facilities " regarding the use of temporary power.

a. On 03/09/11 at 09:30 AM and at other times throughout the survey, the surveyors along with the Facility Fire Marshal, and the Director of Biomedical Engineering observed that the facility was utilizing extension cords that were not hospital grade and /or approved for use in wet locations throughout the Core Building, Bliss building, High Building and Jefferson Building Operating rooms and support areas.
2. The Hospital failed to ensure that the physical environment was designed and constructed to maintain the safety of patients with suicidal tendencies and/or tendencies to cause harm to themselves or others. The Hospital failed to implement immediate safety interventions to correct the environmental safety issues. The finding includes the following:

a. On 03/09/11during tours of the Donnelly building from 9:00 AM and 11:55 AM and from 1:15 PM and 3:00 PM, the surveyor accompanied by the Director of Engineering, Administrative Staff and Fire Safety Officer observed the following:

b. Throughout Three (3) North, Three (3) South, Two (2) North, Two (2) South and One (1) North units patient adjustable electric beds had electrical cords in excess of three (3) feet long and not secured and/or removed to prevent a patient from utilizing them as a means of hanging;

c. Throughout Three (3) North, Three (3) South, Two (2) North, Two (2) South and One (1) North units patient bedroom call bell cords in excess of four (4) feet long and not secured to prevent a patient from utilizing them as a means of hanging;

d. Contrary to Hospital policy to remove hand held shower hoses when not in use by patients who are accompanied by staff; a hand held shower hose attached to the shower wall in excess of four (4) feet long was observed at the Two (2) South handicap patient room #36. Subsequently the shower hose was removed by staff and secured at the nursing station;

e. Patient rooms on Two (2) North were provided with pendant type sprinkler heads with concealment covers at the ceiling level and not with instuitional sprinkler heads that prevent a patient from utilizing them as a means of hanging.

3. Based on observation, tour, interview and review of facility documentation the facility failed to ensure an acceptable level of safety and quality and/or that supplies were maintained in an appropriate manner. The findings include the following:

a. On 03/09/11 at 1:00 PM, the surveyors along with the Facility Fire Safety Inspector observed that the facility was utilizing an outside loading dock as the storage area for the 55 Gallon Drums of acid solution on pallets not protected from temperature extremes as required by manufactures labeling i.e. protect from high temperatures and freezing. Subsequent staff interview with the Dialysis Technician identfied that the facility had been storing them outside throughout the entire winter and summer seasons.
b. On 03/09/11 at 1:00 PM, the surveyors along with the Facility Fire Safety Inspector observed that the facility bicarbonate and acid tank room in the Jefferson Building basement was debris laden and had bicarbonate buildup on all pumps, piping, and floors. The storage tank vent filters were marked as having been last changed in 10/1997. Subsequent interview with the dialysis center staff identfied that they had no record of the vent filters being changed and no policy on the changing of the filters. Subsequent to these observations the filters were changed and all debris and bicarbonate buildup was removed.

Based on observation, the facility failed to ensure that supplies had not expired. The findings include the following:

a. Tour of the dialysis unit on 3/9/11 identified outdated blood tubes. A package of red top blood collection tubes expired in 2/11 and blue tops expired in 12/10.

b. Tour of the isolation area identified Dexamethasone that had expired in 2/11 and three bottles of hardness test strips that had expired on 7/05, 2/07 and 3/07 respectivley. Additionally in the storage room off the isolation room there were expired pharesis kits dated 5/10 and 9/10.

c. Tour of the dialysis mixing room identified conductivity solution that had expired in 12/10.

d. Tour of the peritoneal dialysis area identified Stay Safe catheter caps in all three training rooms that had expired in 8/10 and 2/11 and blue top blood collection tubes that had expired in 2/11.



17921

Based on tour of the facility and review of facility documentation the facility did not ensure that patient care electrical devices in patient areas were being inspected and/or maintained as required in NFPA 99 ' Health Care Facilities' .

a. On 03/07/11 at 10:50 AM and at other times throughout the day, the surveyor, while accompanied by the Director of Engineering & Facilities Development and the Facility Fire Prevention Officer, observed that the air pumps for the resident air mattresses and resident beds throughout Conklin 6,5,4, & 2 and High 10 &9, lacked, current, non-expired preventive maintenance stickers and the facility failed to provide documentation on the days of survey that all patient electrical devices for in-patient areas are inspected as required in NFPA 99, Section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facility's preventive maintenance program; i.e. all of the air pumps and most of the beds were past due next inspection dates according to the pm tags affixed to them.

b. On 03/07/11 at 1:30 PM and at other times throughout the day, the surveyor, while accompanied by the Facility Fire Marshal and the Engineering Technician observed that the IV /infusion pumps throughout Conklin 6,5,4, & 2 and High 10 &9, failed to have preventive maintenance stickers that were dated as inspected within the intervals required and the facility failed to provide documentation that longer preventative maintenance intervals are warranted as required in NFPA 99, Section 7-5 and as part of the facility's preventive maintenance program; i.e. facility is using 1onger pm dates without demonstrating histories with the equipment.

c. On 03/09/11 at 1:00 PM, the surveyor, while accompanied by the Director of Engineering & Facilities Development and the Facility Fire Prevention Officer, observed that the breast pump located in the Emergency Department's Behavioral Suite (Purple Pod)-Soiled Utility Room lacked a current, non-expired preventive maintenance sticker and the facility failed to provide documentation that all patient electrical devices in-patient areas are inspected as required in NFPA 99, Section 7-5.1.3, 7-5.2.2.1 and 7-6.2.1.2 and as part of the facility's preventive maintenance program; i.e. sticker on device indicated last service done on 07/14/09 and due in 06/10.

d. On 03/07/11 at 11:15 AM and at other times throughout the day, the surveyor while accompanied by the Facility Fire Marshal and Director of Biomedical Engineering observed that the all bipap machines for the sleep lab on Center 11 had expired preventive maintenance stickers i.e. stickers on device #' s 39546, 39547, 39548, 39550 and two bipap machines lacked asset tags. The PM tags for all bipap machines indicated service was due in 06/10.
e. On 03/07/11 at 11:15 AM, the surveyor while accompanied by the Facility Fire Marshal and Director of Biomedical Engineering observed that the emergency code cart for the sleep lab on Center 11 had expired defibrillator pads. " Expired 10/27/02 & 08/17/03 ".

f. On 03/09/11 at 11:15 AM, the surveyor while accompanied by the Facility Fire Marshal and Director of Biomedical Engineering observed that the emergency code cart for by JB 419 had expired defibrillator pads expired 03/10 & 07/10.




19907

Based on observations and interviews with facility personnel, the facility failed to ensure that emergency equipment was maintained to ensure a level of safety.

The findings include:

a. During tour of the C-Section rooms on 3/7/11, it was identified that on the code cart, the Zoll pads were expired on 1/24/11 and the defibrillator pads were expired on 12/09. Interview with the Nurse Manager # 11 identified that the pads were expired and would have them replaced. Further interview identified that the code cart and contents are checked on a daily basis.

Based on medical record reviews, review of hospital policies, observations and interviews the hospital failed to ensure infection control practices were followed. The findings include:

a. A tour of the cardiac catheterization department was conducted with the Vice President (VP) of Support Services on 3/7/11. Observations on 3/7/11 at 1:25 PM identified that one scrub sink area serviced procedure rooms B, C, and D and procedure room A had a separate scrub sink area. Both scrub sink areas contained Avagard antiseptic hand scrub and an iodine scrub. Although a clock was observed on the wall near procedure room A, the scrub area near rooms B, C, and D did not have a clock that could be visualized from the scrub area. Interview with the VP of Cardiology Services on 3/7/11 at 1: 25 PM indicated that staff utilized either scrub by prior to a procedure and the iodine scrub required scrubbing for two to three minutes for effectiveness. Subsequently, interview with the VP of Nursing on 3/9/11 at 3:10 PM indicated that a clock was placed near the B, C, D scrub room area as well as three additional clocks in other areas of the hospital. The hospital policy for surgical scrub procedure directed a total scrub time of five minutes to include a one-minute preliminary scrub followed by a two-minute hand scrub and a two-minute arm scrub.

b. A tour of the interventional radiology department was conducted on 3/8/11 with the Manager of Interventional radiology. Observation on 3/8/11 at 2:35 PM, during Patient #143's procedure, identified that the physician and the scrub technician were donned in masks, sterile gowns, gloves and surgical caps. Although the scrub technician managed the sterile instruments and was positioned close to the patient to assist the physician, the scrub technician's surgical cap did not cover the front of his/her head and allowed his/her hair to hang freely. Interview with the Manager of Interventional Radiology on 3/8/11 at 2:35 PM indicated that the scrub technician had prepped the patient's surgical site at the beginning of the procedure and followed the same surgical dress code as operating room (OR) staff. The scrub technician's hair was subsequently contained in the surgical cap with the assistance of another staff member. The radiology dress code policy for Radiology OR staff directed that surgical hats and masks be worn while setting up sterile tables, during all procedures and all hair must be covered.

c. A tour of the Central Sterile Supply (CSS) department was conducted with the CSS Manager on Tuesday 3/8/11. Observation of the clean side of the department on 3/8/11 at 10:45 AM identified an accumulation of dust and debris on floors beneath metal tables/ and shelving, attached to the front undersides of five steam sterilizers and on storage shelves. The observation also noted multiple collections of dust swirled into the air as the incubation table was moved away from the wall. Interview with the CSS Manager on 3/8/11 at 11:10 AM indicated that the CSS department had a designated housekeeper that cleaned the department Monday through Friday to include mopping, sweeping and dusting.


15482


d. On 3/10/10, a staff member was observed taking a patient's temperature then returned the thermometer to the nurse's station without the benefit of disinfection.

e. On 3/10/11 at 10:35 AM, a staff person was observed without gloved hands to place "dirty" blue clamps in the designated bin to be cleaned then proceeded to the nurse's station to obtain clean supplies without the benefit of handwashing.

f. Tour of the surgical center on 3/8/11 identified two cabinets in the procedure room that contained scopes for colonoscopies and endoscopies. The end of the scopes were observed to touch the base of the cabinet which had a clean towel in place.

g. During a tour of the CB2 unit on 3/7/11 at 10:20 AM, clean and sterile supplies were observed to be stored on top of a hand washing sink in the medication room.


19907


h. During tour of the Labor & Delivery Unit on 3/7/11, it was observed that misc. clean items were being stored in the soiled utility room. Interview with Nurse Manager #11 identified that the items would be removed immediately and should not have been stored in a dirty area.

Based on a review of clinical records, hospital policy, and interviews with facility personnel for two sampled patients (Patient #131 and #115), the facility failed to ensure that the initial discharge evaluation was completed in a timely manner. The findings include:
a. Patient # 131 was admitted to the hospital on 2/25/11 with a diagnosis of recurrent ovarian cancer who presented with complaints of nausea and vomiting. Patient # 131 was treated with intravenous fluids and total parenteral nutrition. Imaging was completed and revealed a small bowel obstruction. A bowel resection and ileocolic bypass with colostomy was performed on 3/3/11. Interview and review of the clinical record on 3/7/11 at 11:35 AM with Discharge Coordinator # 1 failed to reflect that an initial evaluation by case management was made. Discharge Coordinator # 1 indicated that a patient's medical insurance directs when a case coordinator initially evaluates the patient. On 3/10/11 at 11:35 AM Clinical Director # 4 for the Department of Case Coordination identified that case coordinators should be evaluating all patients within twenty four hours of admission, regardless of insurance type. Review of the hospital policy on Discharge Planning directs the case coordinator to complete an initial assessment with twenty four hours of admission. This shall include the review of the patient's diagnosis, treatment plan and potential discharge needs.
b. Patient #115 was admitted to the stepdown unit on 12/23/10 with diarrhea. Review of the clinical record identified that the patient was alert, oriented, and conversant. On 12/27/10, the patient was transferred out of the stepdown unit. The record indicated that on 12/30/10, the Care Manager met with the patient to review potential discharge plans. Follow-up visits were made to Patient #115 on 12/30/10 in the afternoon and on 1/3/11. Interview with Care Management Manager stated that a Care Coordinator should complete an initial assessment of all patients in the first 24-48 hours, however, some exceptions include patients in the ICU or stepdown unit if they are unable to talk with the Care Manager.

Based on clinical record reviews and interviews with facility personnel for three sampled patients (Patient's #131, #155, and #189), the facility failed to ensure that surgical patients had a complete post anesthesia evalution that was performed after the patient was sufficiently recovered to participate in the evaluation.

The findings include:

a. Patient #131 was admitted to the hospital on 3/3/11 for a Exploratory Laparotomy. Review of the intraoperative record identified that the patient had a dressing applied at 4:10pm, and sent to the PACU at 4:36pm. Further review identified that the post anesthesia evaluation was completed at 4:36pm and identified that the patient was sedated, stable with no complications.

b. Patient #155 was admitted to the hospital on 2/24/11 with a Right hip fracture repair. Review of the intraoperative record identified that the patient had a dressing applied 4:59pm and sent to the PACU at 5:24pm. Further review identified that the post anesthesia evaluation was completed at 5:30pm and identified that the patient was sedated, stable and no complications.


c. Patient #189 was admitted to the hospital on 3/4/11 for a right colectomy and exploratory laparotomy. Review of the intraoperative record identified that the patient had a dressing applied at 9:29pm and sent to the PACU at 12:50am on 3/5/11. Further review identified that although a post-anesthesia evaluation was conducted on 3/5/11, the clinical record failed to identify the time the evaluation was completed. Review of a note on the anesthesia record by a registered nurse dated 3/7/11 identified that the patient was out of ICU, hypotensive in PACU and started on Levophed , transferred to ICU and had been confused.

In addition, review of the post operative anesthesia evaluation sheets identified that registered nurses (not qualified to administer anesthesia) were seeing the patients post operatively to document the patient's current status. Further review failed to identify any other post operative assessment was conducted by anesthesia personnel. Interview with the Associate Chief of Anesthesia on 3/10/11 identified that registered nurses in the department of anesthesia were performing visits to all post operative patients for the purpose of quality assurance.


Review of hospital policy "post anesthesia evaluations" identified that the post-anesthesia follow-up report must be written within 48 hours after the inpatient surgery. The follow-up report must be written by the individual who administered the anesthesia or an MD/DO may delegate the post anesthesia assessment to a practitioner who is qualified to administer anesthesia in accordance with state law and hospital policy.

Based on review of clinical records, interviews and review of hospital policy and procedure for four patients (Patients #156, 158, 159 and 160) that required mechanical ventilation, the hospital failed to ensure that the patients received respiratory care and services in accordance with the physician orders. The findings include:
a. Patient #156 was admitted to the hospital on 1/5/11 for decompensated heart failure with a past medical history that included Chronic Obstructive Pulmonary Disease, hypertension, Hepatitis C, status post Cerebral Vascular Accident with right sided weakness. On 2/22/11, he/she had left ventricular assistive device (LVAD) implant surgery. Review of the physician orders, dated 3/4/11 at 12:31 A.M., directed the staff to maintain Patient #156 on non-invasive ventilation with a rate of 10 breaths per minute, IPAP of 14 and EPAP of 6. Review of the respiratory flow sheet, dated 3/4/11 at 3:30 A.M., identified that the patient was maintained on non-invasive ventilation at a rate of 12 breaths per minute and an IPAP of 16, which was not in accordance with the physician ' s orders. Review of the clinical record, dated 3/4/11 at 4:45 A.M., identified that the patient was not stable and he/she required intubation and invasive mechanical ventilation.
Review of the physician orders, dated 3/4/11 at 5:32 A.M., directed the staff to maintain the patient on mechanical ventilation settings of pressure control, mode: SIMV, rate: 16 breaths per minute and PEEP of 8 and pressure support of 8. Review of the respiratory flow sheet, dated 3/4/11 at 6:30 A.M., identified that the patient was maintained on volume control, mode SIMV, rate of 10 breaths per minute and a pressure support of 10, which was not in accordance with the physician ' s orders. In addition, review of the respiratory flow sheet, dated 3/4/11 at 9:00 A.M., identified that the patient was maintained on volume control, mode SIMV, rate of 10 breaths per minute and a pressure support of 10, which was not in accordance with the physician ' s orders.
The physician orders, dated 3/4/11 at 11:59 A.M. directed the staff to maintain Patient #156 on the mechanical ventilator setting of volume control, mode: SIMV, tidal volume of 420, rate 10, PEEP of 8 and pressure support of 10. Review of the respiratory flow sheet, dated 3/7/11 at 1:40 A.M., identified that the patient was maintained on volume control, mode AC which was not in accordance with the physician ' s orders.
Interview with Respiratory Therapist (RT) #1, on 3/7/11 at 2:10 P.M., identified that any changes for invasive and/or non-invasive ventilation must be ordered by a physician.

b. Patient #158 was admitted to the hospital on 3/6/11, from a long term care facility, with the complaint of difficulty breathing with a past medical history that included Chronic Obstructive Pulmonary Disease, asthma, bipolar disorder, atrial fibrillation and obesity. Review of the physician ' s orders, dated 3/6/11 at 9:05 P.M., directed the staff to maintain the patient on non-invasive ventilation with the rate of 14 breaths per minute, IPAP of 26 and EPAP of 10 and review of the respiratory flow sheet, dated 3/6/11 at 11:40 P.M., identified that the patient was maintained on non-invasive ventilation at a rate of 12 breaths per minute and an IPAP of 30, which was not in accordance with the physician ' s orders.

c. Patient #159 was admitted to the hospital on 3/2/11 with shortness of breath with a past medical history that included Congestive Heart Failure, atrial fibrillation, Diabetes Mellitus, hypertension, depression and status post breast cancer and deep vein thrombosis. Review of the physician ' s orders, dated 3/2/11 at 7:00 P.M., directed the staff to maintain the patient on non-invasive ventilation with settings that included IPAP of 12 and EPAP of 5. Review of the respiratory flow sheets, dated from 3/3/11 at 6:45 A.M. to 3/7/11 at 1:10 A.M., identified that the patient was maintained on non-invasive ventilation with IPAP of 18 and EPAP between 8 to 12, which was not in accordance with the physician ' s orders.
Interview with RT #2, on 3/7/11 at 10:15 A.M., identified that a physician ' s order is required for any non-invasive ventilator changes.
d. Patient #160 was admitted to the hospital on 3/4/11 with pneumonia and a past medical history that included Chronic Obstructive Pulmonary Disease and asthma. Review of the physician orders, dated 3/5/11 at 1:35 P.M., directed the staff to maintain the patient on mechanical ventilation settings including volume control with a mode of AC/CMV, tidal volume of 450, rateof 12 breaths per minute and PEEP of 5. Review of the respiratory flow sheets, dated from 3/5/11 at 6:00 P.M. to 3/7/11 at 12:20 A.M., identified that the patient was maintained on a rate between 14 to 18 breaths per minute, which was not in accordance with the physician ' s orders.

Review of the hospital policy and procedure, titled Mechanical Ventilator Adjustment Policy, identified that any change to mechanical ventilators are ordered by the physician.
Interview and review of documentation with the Clinical Director and the Education Coordinator of the Respiratory Care Department, on 3/8/11 at 9:00 A.M., identified that on 3/7/11 at 3:55 p.m., the hospital informed the Respiratory Care Department that reviews of selected patients receiving invasive and non-invasive ventilation identified that current settings were not according to physician/practitioner orders. In addition, for every patient that is ordered to receive invasive and non-invasive ventilation, audits will be completed to ensure that the settings are in accordance with physician orders and 100% compliance was achieved. Interview with the Chief Medical Information Officer and the Vice President of Patient Care Services, on 3/10/11 at 11:40 A.M., identified that on 3/9/11 he/she informed medical staff and mid-level licensed practitioners that for all mechanical ventilation changes a physician/practitioner order is required, except in an emergency.