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Based on record review and interview, the facility staff failed to ensure two (2) patients (Patient 3 and 10) had the right to formulate advance directive. There was no documented evidence found in the clinical records regarding advance directives information for Patient 3 and Patient 10 during their hospitalization stay.

Findings:

1. On November 27, 2012, between 2:20 p.m. and 2:50 p.m., after the initial tour with Staff A and Staff C in the Med/Surg Unit, a review of the open record for Patient 3 revealed the patient was admitted to the facility on November 26, 2012, with diagnoses of chronic obstructed pulmonary disease and bronchitis.

The "Advanced Dicrective Acknowledgement" dated November 26, 2012, indicated there was no documentation whether or not the patient have executed an advance directive or if the patient received a brochure and the patient would like to speak to someone about advance directive.
The Initial Nursing Assessment & Screening dated November 26, 2012, indicated the patient was assessed as being confused.

2. A review of the closed record revealed Patient 10 was admitted to the facility on October 16, 2012, with diagnosis of revision of total left knee replacement.

The "Advanced Dicrective Acknowledgement" dated October 16, 2012,
indicated there was no documentation whether or not the patient have executed an advance directive or if the patient received brochure and the patient would like to speak to someone about advance directive.
The Initial Nursing Assessment & Screening dated October 16, 2012 indicated the patient was assessed as being alert and oriented.
On November 27, 2012, at 2:40 p.m., during an interview with Staff C, he stated he was unable to find written documentation that addressed the advance directives for Patient 3 and Patient 10.

Based on observation, interview, and record review, the facility failed to ensure that the staff was trained in the monitoring of a patient who was on a psychiatric watch (monitoring of psychiatric behavior).

Findings:

On November 27, 2012, at approximately 11 a.m., a patient and a security guard (SG 1) were seen at the foot of the patient's bed just outside the emergency department bay.

During a concurrent interview, a registered nurse stated the patient was on a "watch" due to her expressing auditory hallucinations and she was unable to remain seated. The patient was going to be assessed by a psychiatric evaluation team and SG 1 was there for her safety.

On November 29, 2012, a review of SG 1's employee file did not contain evidence that he had met a competency criteria for the monitoring of a patient on a psychiatric watch. SG 1 had training in the management of workplace violence; however, the training did not include psychiatric behavior monitoring.

On November 29, 2012, when interviewed, Staff E stated there was no evidence of training in the monitoring of a person who was on a psychiatric watch.

Based on observation, interview, and record review, the facility failed to ensure a monitor technician was competent to operate heart monitor and its software.

Findings:

On November 27, 2012, during a tour of the facility's DOU (definitive observation unit) at 10:30 a.m., a monitor technician was seen operating the heart monitor central computer. The monitor technician (MT 1) was asked to view the arrythmia alarm settings; however, the monitor technician did not appear to be knowledgeable with the system. The monitor technician was then assisted by another monitor technician (MT 2) who was able to navigate the system and find the arrythmia alarm settings.

During a concurrent interview, MT 1 stated she had been working as a MT for "about one year" and the heart monitoring software had changed and they were new machines.

A review of MT 1's employee file indicated there was no evidence of MT 1's training for the use of the heart monitoring computer and its software.

On November 29, 2012, when interviewed at 11 a.m., Staff E reviewed the employee's file and could not produce evidence of MT 1's training for the use of the heart monitoring computer and its software.

A review of the facility's policy and procedure titled, "Patient Clinical Alarms" dated December 2005 stipulated the facility staff would be able to check alarm settings to ensure the alarms are appropriate.

Based on observation, interview, and record review, the facility nursing staff failed to develop a care plan to include appropriate nursing interventions in response to the patients' needs for 1 patients (Patient 3).


Findings:

1. On November 27, 2012, at approximately 1:50 p.m., during the tour of the Med/Surg Unit, with Staff A and Staff C, Patient 3 was observed lying in bed with a "contact isolation" sign posted by the door. There was no "Safe" sign posted on the door frame. The patient was not wearing yellow socks for the feet.

A review of the clinical record revealed Patient 3 was admitted to the facility on November 26, 2012, with diagnoses of chronic obstructed pulmonary disease and bronchitis. The Initial Nursing Assessment & Screening conducted on admission indicated the patient was assessed as being confused.

A review of the Initial Morse Fall Risk Screening dated November 27, 2012, disclosed the patient had been assessed as high risk for fall. However, there was no documentation that the Interdisciplinary Plan of Care for Fall was developed. There was no documentation that the Interdisciplinary Plan of Care for infection had been developed.

During a concurrent interview with Staff C, he stated the Interdisciplinary Plan of Care for fall and infection had not been developed.

According to the policy and procedure for "Fall Prevention Management" revised on October 2012 indicated the following:

For Low Risk Category Interventions, update the Interdisciplinary Plan of Care for falls and place "SAFE" magnet on the frame of the door outside the patient room. The high risk patient is to wear yellow non skid socks to alert staff the patient is a high risk for fall risk.

According to the policy and procedure for "Care Planning," the procedures included once the needs have been identified and prioritized, members of the health care team should develop a plan of care for that patient. This plan is documented in the patient's medical record in several ways by documenting on the care plan or diagnosis specific care guides or in the progress notes."

Based on record reviews and interview, the facility failed to ensure Patient 11 was assessed for pain and sedation while receiving narcotic analgesia via PCA (Patient Control Anesthesia), in accordance with the facility's policy and procedure for PCA.


Findings:

A review of the closed record disclosed Patient 11 was admitted to the facility on October 24, 2012 with diagnosis of degenerated arthritis. The patient was discharged on October 29, 2012.

The operative report dictated on October 24, 2012 at 9:14 a.m. indicated the patient had undergone a surgical procedure, revision of right total knee arthroplasty.

The PCA Physician's Orders dated October 25, 2012 at 1 a.m.disclosed the physician had prescribed "Hydromorphine" as the patient's PCA.

A review of the electronic Patient Progress Notes disclosed the patient's PCA was initially assessed and documented on October 25, 2012 at 5:44 a.m., with vital signs, pain level and sedation level. The patient's PCA was assessed and documented on October 26, 2012 at 6 a.m., on October 27, 2012 at 6:38 a.m., and on October 28, 2012 at 5:10 a.m. with vital signs, pain level and sedation level.

The vital signs were electronically documented in the Patient Progress Notes at 8 a.m., 2 p.m. and 7:55 p.m. on October 25, 2012, at 2 a.m., 5:37 a..m., 8:32 a.m., 2:45 p.m., 3 p.m. 5:45 p.m. and 10:09 p.m. on October 26, 2012, at 2 a.m., 8:38 a.m., 2:09 p.m., and 8 p.m. on October 27, 2012; at 2 a.m., 8:15 a.m., 1:49 a.m. and 8 p.m. on October 28, 2012. However, there was no documentation that Patient 11's pain level and sedation level were monitored and documented between 5:44 a.m. on October 25, 2012 and 6 a.m. on October 26, 2012, between 6 a.m. on October 26, 2012 and 6:38 a.m. on October 27, 2012, between 6:38 a.m. on October 27, 2012 and 5:10 a.m. on October 28, 2012. Vital signs and pain scores were assessed at 3 p.m., and 4 p.m., which was "Q (every) 1 hour x 2."

During a concurrent interview with Staff A at 10:20 a.m. on November 29, 2012, she stated the pain and sedation level had not been assessed for Patient 11, based on the policy and procedure for the PCA.

According to the facility's policy and procedure for PCA, under assessment/documentation, upon initiating PCA, the following must be monitored and documented every 2 hours times 3, then every 4 hours thereafter: Vitals signs, pain level, sedation level, and oxygen saturation (included in preprinted orders).

Based on interview with staff and record review, the facility failed to ensure that timely completion of medical records within 30 days of patient discharge by the medical staff in compliance with State law and Medical Staff bylaws.

Findings:

During an interview with Staff G on November 28, 2012 at 2:30 PM, disclosed the facility recognized that they tracked and trended on a monthly basis with incomplete medical record rates varying from 43% to 52% beyond the date of discharge of the patient in 2011 and the first half of 2012. At the time of the survey, there was no evidence provided regarding processes to improve this deficient trend had been developed.

Based on record review and interview, the facility failed to ensure the verbal orders were authenticated within 48 hours for 2 patients (Patient 7 and 10).

Findings:

1. On November 27, 2012 at 10 a.m., a review of the open record for Patient 7 disclosed the patient was admitted to the facility on November 24, 2012, with diagnosis of full term pregnancy. The patient underwent a cesarian section surgical procedure.

The physician orders disclosed the verbal orders dated on November 24, 2012 at 5:30 p.m. and November 25, 2012 at 12:10 a.m. were not authenicated as of November 27, 2012 at 10 a.m.

During an interview with the chief nursing officer (CNO) on November 28, 2012 at 10:09 a.m., she stated the verbal orders dated on November 24, 2012 at 5:30 p.m. and November 25, 2012 at 12:10 a.m. were not authenicated as of November 27, 2012 at 10 a.m.

2. On November 29, 2012 at 10 a.m., a review of the closed clinical record disclosed Patient 10 was admitted to the facility on October 16, 2012 with diagnosis of total knee replacement on the left knee.

The physician orders disclosed the verbal orders dated on October 23, 2012 at 12:30 p.m. was not authenicated as of November 29, 2012 at 10 a.m.

During an interview with Staff A on November 29, 2012 at 10:05 a.m., she stated the verbal orders, dated on October 23, 2012 at 12:30 p.m. was not authenicated as of November 29, 2012 at 10 a.m.

According to the facility's Medical Staff, General Staff Rules and Regulations" dated June 2012, page 14, "All telephone orders need to have times and dates and sign within 48 hours, when signed by physician."

Based on interview, document review, and policy review, the facility failed to ensure that accountability procedures were in place to control the use of all controlled substances (CS), and to readily identify loss or diversion of all CS by not completing and resolving the CS audit and not having the policy and procedure to guide the process.

Findings:

On November 27, 2012 at 2:30 PM, during a discussion of CS use monitoring in the ED (Emergency Department) and Recovery Units that had automatic dispensing cabinets (ADC) called OmniCells that were non-profiled, it was observed that in the DOP's office, the daily CS use reports for November 2012 and October 2012 were stacked about one foot high in two piles on the table.

During a concurrent interview, Rx 3 explained the report was reviewed daily to ensure there were physician orders for the CS used from the OmniCell in the ED and Recovery Units.

Review of the daily use report in the ED and recovery units indicated that the review was not consistently completed and resolved on a daily basis.

During a concurrent interview, Rx 2 and Rx 3 acknowledged that there were not enough personnel to be able to complete the audit daily and agreed that there needed to be a significant process improvement in the CS monitoring of use in the ED and Recovery Units by the Pharmacy. They also both acknowledged that there could be potential discrepancies and drug diversions left not investigated and resolved for unnecessary amount of time.

The facility was not able to provide written policy and procedure pertaining to the current process of monitoring the use of CS in ED and Recovery Units.

Review of the facility's policy and procedure titled, "Medication - Automated Dispensing System (OMNICELL)" indicated the following:

Controlled Medications
Pharmacy will generate a hard copy of the Transaction by Date Report on a weekly basis to serve as a permanent record of controlled substances transactions, as well as electronically archiving all data generated in the system on a daily basis.

Based on observation, interview, and document review, the facility failed to control medications by failing to:

1. Ensure the Pharmacy clarified physician orders to prevent potential therapy duplication and for completeness of the order.
2. Ensure monthly nursing unit inspection conducted consistently.
3. Ensure the anesthesia controlled substance boxes or trays were retrieved and reconciled on a daily basis.


Findings:

1. During a review of Patient 23's medical record on November 29, 2012 at 10:30 AM, it was noted that on November 27, 2012, on the physician completed Post-Operative Physicians Orders, the following orders were ordered as indicated by the checked boxes:

PCA: See order.
Norco 5/325 mg one tablet by mouth every 4 hours as needed for moderate pain (pain scale 3-6).
Percocet 5/325 mg two tablets by mouth every 4 hours as needed for severe pain (pain scale 7-10).

It was also noted that there was a separate PCA order by the same physician for hydromorphone 0.2 mg/ml with 0.5 mg to be given as a loading dose and patient controlled dose of 0.2 mg no sooner than every 15 minutes but the boxes next to the order was left unchecked.

PCA, Patient Controlled Analgesia, is a device that can be programmed to give the patient the control to safely manage the pain often after surgery.

Norco, Percocet, and hydromorphone are narcotic controlled substances used for pain management.

Review of the patient's MAR (Medication Administration Record) indicated that all of the above orders was entered and verified by the pharmacist.

During a concurrent interview, Staff F stated that the patient was currently receiving PCA hydromorphone and stated that for breakthrough pain, the pain medications were usually given by IV (intravenously).

During a concurrent interview, MD 1 stated that the oral as-needed pain medications were ordered with the PCA so that the patient could transition to the as-needed pain medications after PCA was discontinued.

During an interview on November 29, 2012 at 11 AM, Rx 2 acknowledged that there was a duplicate pain medication that were not necessary and that the verifying pharmacist should not have entered the oral pain medications with the PCA order without clarifying the PCA order.

Review of the Patient Controlled Analgesia PCA Physician Orders form indicated the following:

"PCA Orders:
All previous analgesic orders will be automatically discontinued once PCA order is activated. All orders below must be checked and completed to activate PCA order."

2. During review of the facility's monthly Nursing Unit Inspection Log on November 28, 2012 at 1 PM, it was noted that there was indication that monthly inspections were not performed by the pharmacy staff on January, February, March, April, May, June and September of 2012.

During a concurrent interview, Rx 2 acknowledged that the inspection was not done citing scheduling issues.

Review of the facility's policy and procedure titled, "Medication Area Inspections" indicated the following:

"The Pharmacy Department makes monthly inspections of all hospital nursing stations and ancillary area where medications are dispensed, administered or stored."

3. On November 27, 2012 at 10:40 AM, during a discussion of the narcotic controlled substances inventory control and audit, Rx 3 stated the anesthesiologists would check out anesthesia boxes (locked boxes containing narcotics for use during surgery) and those boxes would be returned to the pharmacy department daily for audit and refilling.

A review of an anesthesia box controlled substances record, control number "0031398" , indicated the content of the box had been used in eight patient cases; eight yellow copies of those anesthesia documentation records were attached. The dates on those anesthesia documentation records indicated this anesthesia box had been in used in surgeries dated between October 5, 2012 to October 9, 2012. The anesthesia box record audit also indicated this anesthesia box was audited on October 10, 2012.

A review of another anesthesia box controlled substances record, control number "0031542" , indicated the content of the box had been used in ten patients' surgeries occurred between November 21, 2012 to November 28, 2012 before the box was retrieved and audited.

According to the facility's policy and procedure, titled "Anesthesia Trays - Distribution and Administration of Controlled Substances," dated Marchl 2010, "...the pharmacist or technician will daily remove all used anesthesia trays ... from the O.R./L&D narcotic cabinet."

Based on observation, interview, and document review, the facility failed to ensure the unusable medication was not available for patient use.

Findings:

During a tour of the Pharmacy on November 27, 2012 at 10:50 AM, in the medication refrigerator located in the IV (Intravenous) Room, there were one reconstituted vial of 1 gram Vancomycin and one opened 10-ml vial of Multitrace elements without a visible open date on the vial.

During a concurrent interview, Rx 4 acknowledged that it would not be possible to determine when the vials were opened and agreed that they should not be used beyond the 28 days in accordance with the facility's policy and procedure.

Review of the facility's policy and procedure titled, "Multi-Dose Vials" indicated the following:

"Multiple dose vials should be used if single use vials are not available or practical. Despite the presence of preservative to ensure prevention of bacterial contamination, certain criteria must be met...Vials should be discarded regardless of remaining content within 28 days."

Based on observation, interview, and record review, the facility failed to ensure the recommendations made of a registered dietician (RD) were acknowledged by a physician in a timely manner.

Findings:

A review of Patient 16's medical record revealed an admission face sheet that indicated the patient was admitted to the facility on November 26, 2012, with diagnoses of pneumonia and congestive heart failure.

A review of Comprehensive Nutritional Assessment dated November 27, 2012, conducted by an RD indicated a recommendation for Boost Plus (nutritional supplement) one can three times a day because the "patient usually drinks 2-3 cans per son."

On November 28, 2012, when interviewed at 2:20 p.m., the definitive observation care unit (DOCU) clinical manager (CM 1) reviewed the patient's medical record and could not produce evidence that the RD's recommendation was acknowledged by a physician or that the recommendation was implemented. According to CM 1, the RD was responsible to forward the recommendation to the physician.

2. A review of Patient 17's medical record revealed an admission face sheet that indicated the patient was admitted to the facility on November 23, 2012, with diagnoses of pleural effusion and acute renal failure.

A review of an Admission Order dated November 23, 2012, the diet order was an 1800 kcal (kilocalories) ADA (Amedican Diabetic Association) 2 gram sodium diet.

A review of a Comprehensive Nutritional Assessment conducted by an RD dated November 27, 2012, indicated a recommendation to adjust the patient's diet order to a 2000 kcal ADA 2 gram sodium diet.

On November 28, 2012 at approximately 2:20 p.m., CM 1 reviewed the patient's medical record and could not produce evidence that the RD's recommendation was acknowledged by the physician. CM 1 stated the diet recommendation should have been followed up.

A review of the facility's policy and procedure titled, "Registered Dietician Recommendation to Physicians" dated September 2011 stipulated the RD recommendations to physicians would be communicated in a clear and timely manner.

Based on observation, interview, and record review, the facility failed to ensure the bottles of liquid nutrition were stored in the ICU (intensive care unit) beyonds its expiration date.

Findings:

1. On November 27, 2012, during a tour of the ICU at 9:40 a.m., two bottles of liquid nutrition Diabetisource were stored in a cabinet and had an expiration date of November 20, 2012 and November 26, 2012. The bottles were expired.

During a concurrent interview, the charge nurse verified and confirmed the nutrition bottles were expired. The charge nurse stated the bottles should be thrown out if they are expired.

A review of the facility's policy and procedure titled, "Tube Feedings" dated September 2012 indicated the tube feeding (liquid nutrition) would be provided in accordance to proper sanitation procedures. The practice of storing expired tube feeding nutrition has the potential to be used and may potentially cause a foodborne illness.

2. On November 27, 2012 during a tour of the ICU at 9:40 a.m., a red sanitation pail was seen directly adjacent to the clean drinking cups.

During a concurrent interview, the nutrition services director stated the red pail is used for cleaning purposes and should not be stored with the cups.

Based on observation and interview, the facility failed to ensure that the dietary department was maintained in optimal and sanitary conditions at all time.

Finding:

On November 27, 2012, the evaluator conducted an inspection of the facility dietary department. The evaluator observed the following:
1. In the garbage disposal area, the walls were damaged with blackened substance in the cracks and crevices/seams.

2. There was a barrel of spent cooking oil located outside the back door. The barrel was caked with dirty oil, the oil was trailing out into a sewer drain.

3. In the walk-in refrigerator #4, the door sealant was damaged and there was an electrical junction box hanging from the ceiling.

4. The two-compartment sinks had lettuce heads draining in a plastic container/colander. The two-compartment sinks did not have an indirect connection.

According to the 2010 California Plumbing Code, Chapter 8 Indirect Wastes, 801.2.3, Food-preparation sinks, steam kettles, potato peelers, ice cream dipper wells, and similar equipment shall be indirectly connected to the drainage system by means of an airgap. Bins, sinks, and other equipment having drainage connections and used for the storage of unpackaged ice used for human ingestion, or used in direct contact with ready-to-eat food, shall be indirectly connected to the drainage system by means of an airgap. Each indirect waste pipe from food-handling fixtures or equipment shall be separately piped to the indirect waste receptor and shall not combine with other indirect waste pipes. The piping from the equipment to the receptor shall be not less than the drain on the unit, and in no case less than one-half (1/2) of an inch (15 mm).

Based on observation, interview, and record review, the facility failed to ensure the combustible liquids were stored in a manner that would prevent possible combustion of the flammable liquid.

Findings:

On November 27, 2012 during a tour of the Emergency Room (ER) at 11:05 a.m., three bottles of rubbing alcohol (flammable liquid) were seen on a counter directly adjacent to electrical equipment (heat source).

During a concurrent interview, the ER charge nurse could not explain why the rubbing alcohol bottles were stored where it was found. The charge nurse understood the potential risk of fire.

Based on observation, interview, and record review, the facility failed to ensure that trash receptacles were maintained in a sanitary manner.

Findings:

On November 27, 2012, during an tour of the DOU at 10 a.m., there was strong foul odor in the dirty utility room. Further inspection revealed a large trash cart that was used to transport trash outside, had an accumulation of debris and liquid at the base of the cart. The cart emitted a malodorous scent.

On November 27, 2012, when interviewed the environmental services director stated the carts were cleaned once a week on Fridays. In addition, he stated the trash bags leak and that is why they are dirty.

Based on observation and interview, the facility failed to ensure that the staff or patients' equipment were properly maintained and stored. The facility also failed to ensure the defibrillators were checked on a daily basis to ensure its quality.

Finding:

1. On November 29, 2012, at 2:00 p.m., the evaluator conducted an inspection of the facility and observed the following:
a. In the Emergency Room, a refrigerator for patient use was stored in a staff locker room.
b. In the basement recovery room, the staff refrigerator was rusted around the ice dispenser and was stored in the ceramic sluice sink. The refrigerator was blocking access to the sink. A sluice sink is used to dispose of human waste.

An interview was held with the Building Supervisor and he stated that the two refrigerators would be removed as soon as possible.


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2. On November 27, 2012, during an inspection of the ICU ( intensive care unit) at 9:30 a.m., the quality check log book for the defibrillators was reviewed. According to the defibrillator daily check log book, the transport defibrillator had missing entries indicating the equipment was not checked by staff. In addition, the main defibrillator also had missing entries.

During a concurrent interview with the ICU charge nurse (RN 10), she stated the defibrillators should be checked once a day and night shift staff were responsible for checking the machine; however, there was no designated person who was responsible for checking the defibrillator.

A review of the facility's policy and procedure titled, "Code Blue, Code White, Adult and Pediatric/Neonatal Crash Cart Responsibilities" dated June 2012 stipulated the defibrillators would be checked every 24 hours by a clinical manager and documented on the log.

Based on interview and record review, the facility failed to ensure single-dose injectable medications were used in one dose on one patient.

Findings:

On November 28, 2012 at 2:30 p.m., in the operation rooms (O.R.), during a discussion about the usage of the fentanyl (a narcotic analgesic and anesthetic agent) 250 microgram (mcg) per 5 milliliter (ml) ampules, Physician 500 stated that sometime he would split the content of one ampule for use in two different patients.

On November 29, 2012 at 11:30 a.m., Staff G confirmed that anesthesiologists sometime would draw up multiple syringes for multiple patients from one 5-ml size ampule of fentanyl. Staff G further stated anesthesiologists would store those syringes in the narcotic cabinet at the OR department between surgeries.

A review of the fentanyl package insert, obtained from Pharmacist 511, indicated the ampule "contains no bacteriostat, antimicrobial agent ... and is intended only for use as a single-dose injection. When smaller doses are required, the unused portion should be discarded ... "

At 1:30 p.m., during an interview, the director of infection prevention stated single-dose vial should only be single use. The director further stated anesthesiologists should not be splitting the single use vial for multiple doses.

A review of the facility's policy and procedure, titled, "Single Dose Vials" dated Mrach 2008 indicated "in patient care areas single dose vials should be properly discarded after one use."

Based on observation, interview, and record review, the facility failed to ensure the patient care equipment was maintained in a manner that would prevent infections.

Findings:

1. On November 2, 2012 during a tour of the definitive observation care unit (DOCU) at 10:15 a.m., Patient 16 was seen in bed with a family member at her bedside. Patient 16 had an indwelling urinary catheter and the drainage bag was seen in direct contact with the bed's wheel. The finding had the potential of cross contamination of the indwelling catheter.

A review of an admission face sheet indicated Patient 16 was admitted to the facility on November 26, 2012 with diagnoses that included pneumonia and congestive heart failure.

During a concurrent interview with the infection prevention professional, she stated the drainage bag should not be touching the bed's wheel.

According to the CDC, 2009 Guidelines for Preventing Catheter Associated Urinary Tract Infections indicated to implement standards precautions with the collection system and do not rest the collection bag on the floor.

2. On November 28, 2012, during a tour of the Pediatric unit at 10 a.m., a registered nurse was observed to use a soiled linen cart as a desk to write notes on a document. Using the same gloves, she continued to provide care to a newborn patient. The practice of touching potentially contaminated items had the potential to cross contaminate potentially clean patient items.

During a concurrent interview, the director of infection prevention stated that the soiled linen cart should not have been used as a desk.

According to the CDC, appropriate use of patient care items should be implemented to prevent cross contamination of patient care items and to prevent infections.

3. On November 28, 2012, during a tour of the ICU (intensive care unit) at 10:15 a.m., a registered nurse was interviewed. The registered nurse stated that the glucometer is cleaned with either alcohol swaps or bleach wipes. According to the registered nurse, it's a choice between use of the bleach wipes or alcohol wipes.

On November 28, 2012 when interviewed at approximately 10:30 a.m., the director of infection prevention stated the bleach wipes should be used to clean the glucometer after use.

A review of an undated glucometer disinfection reminder furnished by the facility indicated that glucometer should be cleaned with bleach wipes after use.

Based on interview and record review, the facility failed to ensure that a plan to improve the timely referral of potential donors was initiated.

Findings:

On November 29, 2012 when interviewed at approximately 1:30 p.m., the director of the organ procurement program (ADMN 1) stated the organ procurement organization (OPO) tracks the rates of referrals and their timeliness. According to ADMN 1, their target for timely referral of a death was 100 percent.

A review of the facility's policy and procedure titled, "Organ and Tissue Donation" dated January 2012 stipulated that referrals would be made within one hour of meeting a trigger (death; trauma; brain death).

A review of of the OPO's Tissue Donation Dashboard which documents the facility's timeliness of referrals indicated that the facility's rate of timely referral was on average 71 percent for the months of January-August 2012.

A review of the Referral Activity Summary for October 2012 indicated that 61 percent of referral were done in a timely manner.

According to ADMN 1, the timely referral rates are low and staff inservices have been conducted; however, the rates remain low. ADMN 1 stated there was no process for the evaluation of the staff's compliance to the OPO referral policy.

The practice of not evaluating an intervention has the potential of failing to recognize that an intervention is not effective and a different approach to the problem may be delayed.

Based on record review and interview, the facility failed to ensure the physician updated examination of the patient, including any changes in the patient's condition, was completed and documented before the procedure was started for 2 patients (Patient 1 and 6).

Findings:

1. A review of the face sheet disclosed Patient 1 was admitted to the facility on November 25, 2012. The "Post Operative Procedure Notes for Inpatient " dated November 27, 2012 at 10:30 p.m. disclosed the patient had undergone a surgical procedure, left hip hemiarthroplasty.

A review of the medical record disclosed "History and Physical" was dictated and transcribed on November 26, 2012. The "History and Physical" was not reviewed and electronically signed by the physician.

During an interview with Staff A on November 27, 2012 at 11:20 a.m., she stated the "History and Physical" had not been reviewed and authenticated by the physician for completion.

2. A review of the face sheet disclosed Patient 6 was admitted to the facility on November 27, 2012. The "Post Operative Procedure Notes for Inpatient " dated November 27, 2012 was reviewed and disclosed the patient had undergone a surgical procedure, Ceasarian Section. However, there was no documentation that the history and physical had been completed.

During an interview with Staff A on November 28, 2012 at 9:50 a.m., she stated the "History and Physical" had not been completed.

According to the facility's Medical Staff, General Staff Rules and Regulations" dated June 2012, page 10, "A H&P (History and Physical) must be completed no more than 30 days prior to admission for surgery/invasive procedure. H&Ps done within 30 days prior to admission or prior to a surgery or invasive procedure, whichever comes first. Without a current or updated H&P, no surgery/invasive procedure will be performed."

Based on record review and interview with staff, the facility failed to ensure the operative reports were electronically signed for completion by the surgeon immediately following surgery for 3 patients (Patient 6, 7, and 11). The facility also failed to ensure an operative report describing findings was written by the surgeon immediately following surgery for Patient 5.

Findings:

1. On November 27, 2012, a review of the clinical record disclosed Patient 5 was admitted to the facility on November 25, 2012 with diagnosis of appendicitis.

The "Post Operative Procedure Notes for Inpatient" dated at 7:20 p.m. dated November 25, 2012 disclosed the patient had undergone a surgical procedure, laparoscopic appendectomy. However, there was no documentation that the "Finding" had been decribed in the notes.

During an interview with the chief nursing officer (CNO) on November 27, 2012 at 3:20 p.m., she stated there was no documentation that the "Finding" had been decribed in the notes.

2. On November 28, 2012, a review of the clinical record disclosed Patient 6 was admitted to the facility on November 27, 2012.

The "Intraoperative Record" dated November 27, 2012 at 9:23 p.m. disclosed the patient had undergone a surgical procedure, Cesarean Section.

During an interview with CNO on November 28, 2012 at 9:50 a.m., she stated there was no documentation that an operative report had been completed.

3. On November 28, 2012, a review of the clinical record disclosed Patient 7 was admitted to the facility with diagnoses of intrauterine preganacy at term plus and failure to progress on November 26, 2012.

The "Operative Report" transcribed on November 26, 2012 at 10:25 p.m. disclosed the patient had undergone a surgical procedure, Cesarean Section. However, there was no documentation that the physician had electronically signed the operative report for completion.

During an interview with Staff A on November 28, 2012 at 10:09 a.m., she stated the physician had not electronically signed the operative report for completion.

4. On November 29, 2012, a review of the clinical record disclosed Patient 11 was admitted to the facility with diagnosis of degenerative arthritis on October 24, 2012.

The "Operative Report" transcribed at 9:20 a.m. on November 13, 2012 disclosed the patient had undergone a surgical procedure, revision right total knee arthroplasty. However, there was no documentation that the physician had electronically signed the operative report for completion.

During an interview with Staff A on November 29, 2012 at 10:20 a.m., she stated the physician had not electronically signed the operative report for completion.

According to the facility's Medical Staff, General Staff Rules and Regulations" dated June 2012, page 12, "8. Cinincal Entries-Date and Authenicated: All clinical entries in the patient's medical record shall be accurately dated, timed, and authenicated. Authenication means to establish authorship by written signature. Under page 11, "Operative reports ahall include a detailed account of the finding at surgery as well as the details of the surgical technique."

Based on observation, interview, and record review, the facility failed to ensure that the respiratory care was delivered according to the physician's order.

Findings:

On November 27, 2012, during an observation at 9:20 a.m., Patient 14 was observed in bed intubated and on a ventilator. The patient's ventilator settings included a fraction of inspired oxygen of 40 percent.

A review of an admission face sheet indicated the patient was admitted to the facility on November 23, 2012, with diagnoses that included rectal bleeding.

A review of a Physician's Order dated November 27, 2012 indicated to administer a fraction of inspired oxygen of 50 percent. The Physician's Order did not include titration parameters; however, the fraction of inspired oxygen was decreased to 40 percent.

When interviewed, a respiratory care practitioner (RCP) stated in order to change the ventilator settings the RCP should get a Physician's Order for such changes.

A review of the facility's policy and procedure titled, "Respiratory Therapy" dated August 2003 stipulated that the Physician's Order for ventilator settings would include fraction of inspired oxygen.