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Based on policy, review of records and interview, it was determined the facility failed to reassess pain after pain relieving medication administration according to policy in that five (#2, #4, #5, #7 and #8) of eight (#2-#5, #7-#10) patient records reviewed had evidence pain medication was administered and pain was not re-assessed according to policy (within one hour after each intervention). By not following policy, the facility could not assure the patient's needs were being assessed and met. The failed practice had the potential to affect the average daily census of 22 patients. Findings follow:
A. Review of policy titled "Pain Management and Assessment" stated "Pain is assessed before and reassessed within one hour after each intervention."
B. Review of patient records revealed the follow samples:
1) Patient #2 received Lortab 10 mg (milligram) on 03/25/13 at 2139 for a pain level of 8. The record revealed the patient was not reassessed until 2300.
2) Patient #4 received Lortab 10 mg on 03/23/13 at 0751 for a pain level of 8. The record revealed the patient was not reassessed until 1002.
3) Patient #4 received Lortab 10 mg on 03/26/13 at 2121 for a pain level of 8. The record revealed the patient was not reassessed until 2305.
4) Patient #5 received Morphine 2 mg at 1318 for a pain level of 5. The record revealed the patient was not reassessed until 1456.
5) Patient #7 received Morphine 2 mg on 03/25/13 at 2129 for a pain level of 9. The record revealed the patient was not reassessed until 03/26/13 at 0137.
6) Patient #8 received Acetaminophen 325 mg on 03/26/13 at 0847 for a pain level of 9. The record revealed the patient was not reassessed until 1050.
C. Findings were verified, through interview, at the time of record review on 03/28/13 with the RN Clinical Information Technologist.

Based on policy, review of clinical records and interview, it was determined the facility failed to follow physician orders in that three (# 2, #5, #7) of eight (#2-#5, #7-#10) patient records reviewed had medications administered outside the medication administration times, or doses missed. By not following the physician ' s orders the facility could not assure the patient achieved the intended therapeutic effect for the best possible outcome. The failed practice had the potential to affect the average daily census of 22 patients. Findings follow:
A. Review of policy titled "Medication Administration/Timing" stated "Non-time critical scheduled medications: are those where early or delayed administration of maintenance doses one hour before or after the scheduled dose should not cause harm or result in substantial sub-optimal therapy or pharmacological effect. This includes medications ordered to be administered at intervals of four hours or greater." Routine medication administration times shall be assigned as follows (unless otherwise designated by departmental standards):
Daily 0900
Q6H (Every 6 hours) 0600-1200-1800-2400
Q8H (Every 8 hours) 0600-1400-2200
Q12H (Every 12 hours) 0900-2100
B. Review of patient medical records revealed the following samples of non-compliance with medication administration times:
1) Patient #2's physician ordered Zosyn 3.375 Grams Q6H starting 03/20/13:
a) On 03/21/13 the 1200 dose was administered at 1308, and the 2400 dose was never administered.
b) On 03/23/13 the 1200 dose was administered at 1355.
c) On 03/24/13 the 0600 dose was not administered.
d) On 03/25/13 the 0600 dose was administered at 0711.
2) Patient #5's physician ordered Clindamycin 900 mg (milligram) Q8H starting 03/25/13:
a) On 03/2713 the 1400 dose was given at 1710.
b) On 03/27/13 the 2200 dose was given at 2315.
3) Patient #7's physician ordered Carvedilol 25 mg one tablet Q12H starting 03/24/13:
a) On 03/25/13 the 0900 dose was given at 1326.
b) On 03/26/13 the 2100 dose was given at 2206.
C. Findings were verified, through interview, at the time of the clinical record review on 03/28/13 with Registered Nurse (RN) Clinical Information Technologist.

Based on policy, review of clinical records, and interview, it was determined the facility failed to follow a doctor's order in that one (#4) of eight (#2-#5,#7-#10) patient records reviewed had evidence medication was administered while the patient was on "NPO (nothing per mouth) order". By not following the physician order and administering medication orally during that time, the facility could not assure the patient's safety and best possible outcome of treatment plans. The failed practice had the potential to affect the average daily census of 22 patients. Findings follow:
A. Review of policy titled "Medication Administration and Documentation" stated "Identify those patients scheduled for procedures or surgery requiring the patient to be NPO to ensure medications are given as indicated by the NPO status. (Example: NPO vs. NPO except for medications.) Note: NPO is strictly "nothing by mouth" unless otherwise specified by written order. Example: Nothing by mouth except medications."
B. Review of Patient #4's clinical record revealed a physician order on 03/26/13 at 1013 for "NPO after midnight, No Exceptions", started 03/27/13 at 0001.
C. Review of Patient #4's medication administration record revealed the following medications were administered while NPO on 03/27/13:
1) Gabapentin 600 mg (milligram) by mouth at 1400;
2) Metoprolol 25 mg by mouth at 1137;
3) Roflumilast 500 mcg (micrograms) by mouth at 1137; and
4) Lortab 10 by mouth at 1400.
D. Findings were verified, through interview, at the time of Patient #4's clinical record review on 03/28/13 with the RN Clinical Information Technologist.

Based on observation, review of pharmacy policy, review of manufacturer's information on Quelicin (Succinylcholine Chloride) and interview, the facility failed to store Quelicin according to manufacturer's guidelines in that three of three (Operating Room #4, Operating Room #3 and Anesthesia work room) areas toured in Surgical Services had Quelicin stored at room temperature for periods of time that exceeded manufacturer's recommendation (14 days). The potential existed for Quelicin to have had a reduction in potency upon administration to patients. The practice had the potential to affect all patients that received Quelicin that was stored at room temperature longer than recommended. Findings follow:

A. A tour of the Surgical Services on 03/25/13 between 1330 and 1420 revealed the following:
1) Operating Room #4 had one Quelicin 20 milligram (mg)/milliliter (ml)/ 20 ml vial in the anesthesia tray, stored at room temperature not dated in order to determine the 14 day limit.
2) Operating Room #3 had one Quelicin 20 mg/ml/ 20 ml vial in the anesthesia tray, stored at room temperature dated "05/09/13."
3) Anesthesia work room had 10 vials of Quelicin 20 mg/ml/ 20 ml vials, stored at room temperature in anesthesia trays, with the following dates of expiration which was beyond the 14 day limit: 05/27/13, 05/07/13, 05/02/13, 05/30/13, 06/09/13 x three vials, 06/02/13, 06/03/13, and 06/10/13.
B. Review of pharmacy policy titled "Anesthesia Trays" stated "Pharmacy will be responsible to see that all trays contain no expired pharmaceuticals and for maintaining the expiration dates for any drugs pulled from their normal refrigerated condition. Manufacturer's guidelines will be used for all expiration dating."
C. Review of the medication package insert on 03/26/13 reflected Quelicin should be stored in refrigerator, and may be stored at room temperature for 14 days without significant loss of potency.
D. Findings were verified, through interview, with Pharmacist #1 on 03/27/13 at 0840.

Based on observation and interview it was determined the hospital did not meet requirements related to the fire rated construction separating the hospital from the adjacent ambulatory health care occupancy. The failed practice had the potential to affect all patients, staff, and visitors because they were not protected from fire and smoke originating from the adjacent ambulatory surgery center for a minimum of 2 hours as required by NFPA 101, Section 19.1.2.3 (2000 edition). The facility had a census of 15 patients on 03/25/13. See K130.

Based on observation and interview, it was determined the facility failed to ensure three of three (kitchen, 3rd floor nourishment room, and cardiac unit nourishment room) microwaves were free of stains and residue. The failed practice created the potential for food items to become contaminated and could affect any patient receiving food that had been in the microwave. Findings follow.

A. During a tour on 03/26/13 at 1315, the microwave in the kitchen, 3rd floor nourishment room, and cardiac unit nourishment room were observed to contain stains, food splatters, and food residue.
B. When asked whose responsibility it was to clean the nourishment room microwaves the Senior Area General Manager stated "nursing." The surveyor was not supplied with any sort of cleaning schedule indicating who or when the microwaves were to be cleaned.
C. Findings were confirmed by the Senior Area General Manager on 03/26/13 at 1400.

Based on clinical record review and interview, it was determined seven (#12, #16-#21) of eight (#2, #12, #16-#21) clinical records of patients who underwent operative procedures contained operative reports that did not contain the time of surgery Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow:

A. Review of operative reports revealed the time of surgery was not documented for Patient #12 and #16-#21.
B. Patients' #17-#21 findings were confirmed by the Clinical Informaticist on 03/28/13 at the following times:
1) Patient #17 at 1348;.
2) Patient #18 at 1320;
3) Patient # 19 at 1305;
4) Patient #20 at 1250; and
5) Patient #21 at 0917.
C. Patients #12 and #16 were confirmed by the Director of Nursing on 03/28/13 at 1530.