HospitalInspections.org

The Hospital reported a census of twelve patients with 33 clinical records reviewed. Based on document review and staff interview, the Hospital failed to assure 10 of 33 patients with clinical records reviewed were informed of their patient's rights (patient #'s 4, 6, 14, 15,16, 17, 21, 25, 26 and 28).

Findings include:

The Hospital's policy, titled "Rights and Responsibilities", reviewed on 4/4/12 at 2:00pm, revealed "Patient and/or family are informed of their rights at the time of admission".

- Patient #4's clinical record, reviewed on 4/3/12 at 8:30am, revealed an admission date of 1/26/12 to the Emergency Department (ED) with a suicide attempt. The clinical record lacked evidence the Hospital informed the patient (or their representative) of their patient's rights.

- Patient #6's clinical record, reviewed on 4/3/12 at 10:30am, revealed an admission date of 2/19/12 to the ED with substance abuse. The clinical record lacked evidence the Hospital informed the patient (or their representative) of their patient's rights.

- Patient #21's clinical record, reviewed on 4/2/12 at 3:00pm, revealed an admission date of 3/26/12 with diagnoses including cancer, heart failure and diabetes. The clinical record lacked evidence the Hospital informed the patient (or their representative) of their patient's rights.

- Staff H, interviewed on 4/3/12 at 2:50pm confirmed the Hospital failed to assure patients are notified of their patient's rights.


The Hospital's failure to inform patients (or their representative) of their patient's right also affected patient #'s 14, 15,16, 21, 25, 26 and 28.

The hospital reported a census of twelve patients with 33 clinical records reviewed. Based on policy review, clinical record review and staff interview nursing staff failed to follow hospital policy for blood administration for one of two sampled patients that received blood (#32).

Findings include:

- The hospital's policy for Blood and Blood Derivatives Administration reviewed on 4/3/12 at 12:15pm, directed "...Begin the blood transfusion slowly; recommend an initial rate of 120ml(milliliters)/hour; monitor patient closely, after the first 15 minutes ...if patient's condition is satisfactory, the rate of the infusion can be increased to 200ml/hour if appropriate for the patient ' s condition...".

- Patient #32's clinical record reviewed on 4/3/12 at 1:00pm revealed an outpatient admission date of 3/27/12 with diagnoses of Anemia and Malignancy. The patient had low hemoglobin on 3/26/12 and the physician ordered a transfusion of two units of packed red blood cells. Patient #32's clinical record review revealed nursing documentation of the first unit of packed red blood cell began on 3/27/12 at 10:10am. The clinical record lacked documentation of the rate of administration for the first unit of packed red blood cells. Nursing documentation for the second unit of packed red blood cells indicated a start time of 3/27/12 at 12:30pm. The clinical record lacked documentation of the rate of administration for the second unit of packed red blood cells. The clinical record lacked evidence the Registered Nurse (RN) followed the hospital's policy for the rate of infusion of the blood.

Administrative staff A interviewed on 4/3/12 at 4:40pm acknowledged patient #32's clinical record lacked evidence of the rate of infusion for two units of packed red blood cells and lacked evidence the RN followed the hospital's policy for the rate of infusion of the blood.

The Hospital reported a census of twelve patients with 33 records reviewed. Based on medical record review and staff interview the Hospital failed to obtain properly executed informed consent forms for procedures and treatments for 10 of 33 sampled patients who received patient care (patient #'s 4, 6, 14, 15, 16, 17, 21, 25, 26 and 28).

Findings include:

- Patient #14's clinical record reviewed on 4/2/12 at 2:00pm revealed an admission date of 3/31/12 following birth. The clinical record lacked evidence the hospital obtained properly executed informed consent by the patient and/or representative prior to giving care to the patient.

- Patient #15's clinical record reviewed on 4/2/12 at 2:40pm revealed an admission date of 4/1/12 following birth. The clinical record lacked evidence the hospital obtained properly executed informed consent by the patient and/or representative prior to giving care to the patient.

- Patient #25's clinical record review on 4/2/12 at 1:40pm revealed an admission date of 3/21/12 with a diagnosis of Pancreatitis. The clinical record lacked evidence the hospital obtained properly executed informed consent by the patient and/or representative prior to giving care to the patient.

- Staff J interviewed on 4/3/12 at 11:00am acknowledged the medical records for patient #'s 14, 15, and 16 lacked evidence the hospital obtained properly executed informed consent prior to giving care to the patient.

The Hospital's failure to obtain informed consent from the patient and/or their representative also affected patient #'s 4, 6, 16, 17, 21, 26 and 28.

The hospital reported a census of twelve patients with 33 records reviewed. Based on observation, policy review, and staff interview the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices for one of one observed cleaning of a discharged patient room, one of one observed procedure room, one of two observed operating rooms, eight of eight observed emergency rooms, one of one glucometer test observation, four of four observed post operative cleaning of patient equipment, and observed breeches in hand hygiene for five of five sampled patients (#'s 11, 12, 13, 22 and 26).

Findings include:

- The Hospital's policy titled " Hand Washing " reviewed on 4/4/12 at 4:30pm directed "staff will maintain clean hands before, during, and after patient care".

- Patient #13 clinical record reviewed on 4/2/12 at 3:15pm revealed an admission date of 4/2/12 with diagnosis of caesarean section (the uterus is surgically opened) delivery of an infant. Observation of care on 4/2/12 at 2:40pm revealed Staff I obtaining intravenous medication (medicine that goes in the vein) from the medication cart, taken to the patient room, given to Patient #13 and then exiting from the patient room without hand hygiene performed.

- Patient #11 clinical record reviewed on 4/2/12 at 2:00pm revealed an admission date of 3/31/12 with diagnosis of vaginal delivery of an infant. Observation of care on 4/2/12 at 3:05pm revealed Staff J pushing the vital sign machine down hall and placed the machine in the dirty holding closet. Staff J then went to medication cart, obtained oral medication, went to patient #11's room, adminstered the medication to Patient #11 and exited the patient's room without hand hygiene performed.

- Patient #12's clincial record reviewed on 4/2/12 at 2:40pm revealed an admission date of 3/31/12 with diagnosis of vaginal delivery of an infant. Observation of care on 4/2/12 at 3:25pm revealed Staff J obtaining oral medication from the medication cart, taken to the patient room, given to Patient #12 without hand hygiene performed.

- Patient #22's clinical record reviewed on 4/2/12 at 3:25pm revealed an admission date of 3/30/12 with a diagnosis of Cellulitis (a skin infection) of the right lower leg. Observation of care on 4/3/12 at 9:40am revealed, staff K removed medications from the medication cart and entered the patient #22's room without performing hand hygiene.

The hospital failed to follow their policy to maintain clean hands before, during, and after patient care.


- Patient #26's clinical record reviewed on 4/2/12 at 3:30pm revealed an admission date of 3/31/12 with diagnoses of Altered Mental State and Hyperglycemisa. Observation of care on 4/3/12 at 12:00pm of staff L performing a blood sugar check on patient #26 revealed staff L entered patient #26's room without performing hand hygiene. Staff L placed the glucometer (a machine used to test blood sugar) and blue box with supplies needed to test the patient ' s blood sugar on the over bed table. Staff L applied gloves and completed the blood sugar test. Staff L removed their gloves, performed hand hygiene, and picked up the glucometer and blue box from the patient ' s over bed table. Staff L returned the blue box containing testing supplies and the glucometer to a counter at the nurse ' s station without cleaning the blue box or glucometer, available for use on other patients.- The manufacturer ' s guidelines for cleaning the " Accu-Check " glucometer reviewed on 4/5/12 at 10:15am directs " How to Clean the System ...use a dampened cloth or pre-moistened wipe with one of the following: water, soap, 70% (or less) isopropyl alcohol, 1:10 dilution of sodium hypochloride, ammonium (quaternary ammonium compounds) ...gently wipe exposed surfaces of the meter and base unit " .

- Observation in the procedure room of the surgical suite one on 4/3/12 at 9:45am revealed one open Yankauer suction tip (a rigid hollow tube made of disposable plastic with a curve at the distal end used to remove thick secretions during oral pharyngeal suctioning) ready for use. The package on the Yankauer suction tip directed sterile unless opened or damaged.

- Observation in the surgical suite of room one on 4/3/12 at 10:10am revealed one open endotracheal tubes (a plastic tube used to assist a patient in breathing during surgery) ready for use and one open Yankauer suction tip ready for use. The package on the endotracheal tube and Yankauer suction tip directed sterile unless opened or damaged.

- Administrative Staff B interviewed on 4/3/12 between 9:45am and 10:10am acknowledged the open endotracheal tubes and Yankauer suction tip in the surgical suite.

- Observation in the Emergency Department (ED) on 4/2/12 at 2:30pm revealed open Yankauer suction tips in ED treatment bays 1, 2, 3, 4, 5, 6, 7 and 8.

- Staff H, interviewed on 4/2/12 at 2:30pm confirmed the open Yankauer suction tips in the ED.

- Review of the manufacturer's guidelines for the use of the "Virex Tb" disinfectant cleaner on 4/4/11 at 2:15pm directed, "...Spray area until it is covered with the solution. Allow product to penetrate and remain wet three minutes for all bacteria...".

- Staff M, observed in the post-op area of the ambulatory surgery area of the hospital on 4/4/12 at 8:20am, cleaned a patient stretcher with "Virex Tb" disinfection solution. The surfaces on the stretcher remained wet approximately one minutes, not the required three minute for total disinfection.

- Staff M, observed in the post-op area of the ambulatory surgery area of the hospital on 4/4/12 at 8:53am, cleaned a patient recliner with "Virex Tb" disinfection solution. The surfaces on the recliner remained wet approximately one minutes, not the required three minute for total disinfection.

- Staff M, observed in the post-op area of the ambulatory surgery area of the hospital on 4/4/12 at 8:59am, cleaned a patient stretcher with "Virex Tb" disinfection solution. The surfaces on the stretcher remained wet approximately one minutes, not the required three minute for total disinfection.

- Staff M, observed in the post-op area of the ambulatory surgery area of the hospital on 4/4/12 at 11:00am, cleaned a patient stretcher with "Virex Tb" disinfection solution. The surfaces on the stretcher remained wet approximately one minutes, not the required three minute for total disinfection.

- Administrative staff B interviewed on 4/4/12 at 11:01am acknowledged the patient stretcher remained wet for one minute not the required amount of wet time by the manufacturer's guidelines.

- The manufacturer ' s guidelines for " Virex One-Step Disinfectant Cleaner and Deodorant " reviewed on 4/3/12 at 4:10pm directed, " To disinfect hard, non-porous surfaces, treated surfaces must remain wet for 10 minutes " .

- The manufacturer's guidelines for " Crew Non-Acid Bowl and Bathroom Disinfectant Cleaner " reviewed on 4/3/12 at 4:10pm directed, " ...remove water from bowl ...apply 1 ounce of Crew cleaner to swab applicator ...swab entire surface. " " Treated surfaces must remain wet for ten minutes. "

- Observation on 4/3/12 at 9:50am of the terminal cleaning of a discharged patient room, revealed staff D, using " Virex II " cleaning solution wet wiped the mattress, bed frame, pillows, bedside stand, over bed table and fixtures in the room. The surfaces remained wet for a contact time of one to six minutes. While cleaning the sink with the " Virex II solution staff D wet wiped the mirror and immediately dried it with a dry paper towel. The cleaned surfaces did not remain wet for the required ten minutes for disinfection.
Staff D demonstrated they cleaned the inside of the toilet bowel with "Crew" disinfectant by squirting an unmeasured amount of the "Crew" solution in the toilet bowel, swabbed the toilet bowel with a brush and flushed the toilet. Staff D failed to follow the manufacturer ' s guidelines to achieve disinfection.

Staff D interviewed on 4/3/12 at 10:35am acknowledged the surfaces failed to remain wet for the required ten minutes as directed by the manufacturer.

The Hospital reported a census of twelve patients with 33 clinical records chosen for review. Based on policy review, clinical record review and staff interview the Hospital failed to provide an ongoing program of activities for three of three sampled swing bed patients (patient #'s 17, 18, and 19).

Findings include:

- The Hospital policy titled "Activities and Recreation" reviewed on 4/4/12 at 2:16pm directed, "Activities will be available seven days a week with nursing personnel assisting with activities. It will be nursing's responsibility to see that the activities for which they are responsible are carried out and appropriately documented." "Activities assessments will be conducted upon admission, weekly, at the request of a member of the multidisciplinary team and whenever the patient elects not to participate in the current activity plan."

- Patient #17's closed clinical record reviewed on 4/3/12 at 1:00pm revealed an admission date of 1/2/12 with diagnoses of Congestive Heart Failure (CHF), and Type II Diabetes and a discharged date of 1/4/12. Patient #17's clinical record lacked evidence of an activity assessment and documentation of any activities provided for the patient.

- Patient #18's closed clinical record reviewed on 4/3/12 at 1:35pm revealed an admission date of 11/13/11 with a diagnosis of Pneumonitis and a discharged date of 11/21/11. Patient #18's clinical record lacked evidence of an activity assessment and documentation of any activities provided for the patient.

Patient #19's closed clinical record reviewed on 4/3/12 at 2:10pm revealed an admission date of 11/1/11 with diagnosis of Post Left Knee Replacement and a discharged date of 11/14/11. Patient #19's clinical record lacked documentation of any activities provided for the patient based on the completed activity assessment.

Staff C interviewed on 4/4/12 at 10:30am acknowledged the the Hospital failed to provide an ongoing activity program for swing bed patients #'s 17, 18, and 19.