HospitalInspections.org

Based on observations and staff interviews, the facility failed to ensure that the patient has the right to have physical personal privacy and prevent the release or disclosure of patient information, including first and last names with their identified medical diagnosis for 4 of 4 observations

The findings include:

1. On 4/6/15 at 9:30 AM, Employee #1, was observed administering medications to Patient #5 in Room #2103, a private room. The patient was on contact isolation precautions. Employee #1 donned personal protection equipment (PPE), including gown, glove, and mask, and entered the patient's room with the medication cart. Employee #1 did not close the door to Room #2103, nor pull the patient's privacy curtain. Employee #1 stood at the head of the patient's bed, on the side of the bed closest to the door. The patient could be seen from the open doorway on the right side of the room lying in his bed. The patient had a hospital gown on. Staff or visitors passed by in the hallway, and could walk freely into the room. Employee #1 asked the patient questions to determine his orientation, such as his birthdate, the year, and whether the patient knew what city he was in. The resident was confused and could not answer the questions correctly. Employee #1 told the patient what the values for his blood pressure and blood sugar were that morning. Employee #1 told the patient that both of his blood pressure medications were being held, because his blood pressure was low. Employee #1 explained to the patient that she was giving him an antibiotic (Cefdinir), with possible side effects of diarrhea and nausea. Employee #1 asked the patient when his last bowel movement was, and discussed use of his stool softener. Employee #1 administered an insulin injection to the patient's left upper arm. Employee #1 administered an antibiotic ointment (Bactroban) ointment to both of the patient's nares. As Employee #1, the surveyor, and designated management staff removed their personal protective equipment (PPE) in the patient's room, Employee #2, Patient Care Tech, entered the room through the open door and talked with Employee #1. The patient's door to the hallway remained wide open during the entire medication pass encounter.

2. On 4/6/15 at 9:55 AM, Employee #1 was observed as she administered medications to Patient #6 in Room #2102. The patient was on contact isolation precautions. Employee #1 donned personal protective equipment (PPE) including gown and gloves, and entered the patient's room with the medication cart. Employee #1 did not close the door to Room #2102, nor pull the patient's privacy curtain closed. Employee #1 stood at the head of the patient's bed, on the side of the bed closest to the window. The patient could be seen from the open doorway on the left side of the room lying in her bed. The patient had on a hospital gown. Staff or visitors passed by in the hallway, and could walk freely into the room. Employee #1 administered an insulin injection in the patient's left upper arm. Employee #1 raised the patient's gown, and administered an injection on the left side of the patient's stomach (Lovenox, to prevent blood clots). Employee #1 administered a medication (Protonix, for stomach acid) through patient's intravenous line in the right arm. Employee #1 administered a medication (Tacrolimus, 3 tablets) that she explained was for the patient's kidney transplant. The patient's door into the hallway remained wide open during the entire medication pass encounter. A nursing student walked freely in and out of the room during the encounter.

3. An observation of a family member was conducted walking around the hallway near a computer workstation, displaying patient information, at which time Employee #3 greeted this surveyor on 4/6/2015 at 10:33 AM in front of the computer workstation that is also observed to have paper- work containing patient information on it (Employee #3 turned the paperwork over), and she stated when asked about her actions, "I turned over the operating room and infusion services special procedure schedule. I always try to remind the staff to privatize". The tracking board for the operating room is observed openly displayed on the computer monitor, which was unattended during this observation; it was confirmed by Employee #4 that the monitor was unattended and that a family member was observed walking in the hall during this observation. Employee #3 was then asked about the person observed in the hallway, and Employee #3 also confirmed that the male is a patient family member who was observed in the hallway, and "Yes, he could have reviewed the patient's confidential information."

4. An observation on the third floor on 4/8/2015 at 9:05 AM was made of paperwork sitting at the side hallway nurses' station containing patient-specific information, which is unattended, face-up and exposed to the general public, including the following information: The patient's room number; the first and last name of the patient; physician; code; age; diagnoses; name of staff attending to the patient care, and the patient's admission status. This document was identified by Employee #4, and she was asked to obtain a copy of the document for this surveyor.

Based on observations, staff interview, and policy/procedures review, the facility failed to ensure that pre-drawn syringes were labeled properly in 1 (#2) operating rooms of 6 operating rooms inspected.

The findings include:

During a tour of the Surgical Department on 4/7/2015 at 8:52 AM, Operating Room #2 was observed as staff prepared the room for a surgical case. The patient was not in the room at the time; a circulating nurse and surgical technologist were opening up the sterile field. An inspection of the Care Fusion Pyxis anesthesia system was conducted and the security of the device was tested by this surveyor and Employee #4 for being in a locked status. When the door on the medication storage and dispensing machine was pulled on, the door easily opened and it was identified that in the second drawer, there was a 60 milliliter syringe with 'Propofol' marked on the syringe with a pre-printed sticker; a white liquid in the 60 milliliter syringe was confirmed by Employee #5 on 4/7/2015 at 9:04 AM and a 12 milliliter syringe of Zemuron was pulled out, marked with a similarly pre-printed sticker; but no date or initials can be identified.

The pre-drawn syringes, (6) in total, were identifed in the second and third drawer of the anesthesia cart, which identifed that there are 4 additional medications drawn up and in syringes: (3) 5 milliliter syringes with clear liquid and (1) 12 milliliter syringe with white liquid (Propofol) were drawn up.

An interview with the head of the Anesthesia Department on 4/7/2015 at 9:10 AM was conducted and he stated, "There are (5) elements that are supposed to be on the syringes, including the employee's initials who pulled the medication up, the date that the medication was opened and drawn; and the strength of the medication along with the medication in the syringe."

It was confirmed by observation with Employee #5 and Employee #4 that each of the 6 syringes inspected in drawer #2 and drawer #3 had only the pre-printed label identifying the medication, and did not have any additional markings.

A review of the policy and procedures titled 'Handling and Labeling of Medication On and Off the Sterile Field' documents it is intended for the peri-operative and other procedural settings, both on and off the sterile field. Section III under I tem A. documents, "Labeling occurs when any medication or solution is transferred from the original packaging to another container". Item B. documents, "Medication and solution labels include the following:

1. Medication or solution name.
2. Strength.
3. Amount of the medication or solution containing medication (if not apparent from the container).
4. Diluent and volume (If not apparent from the container).
5. Expiration date when not used within 24 hours.
6. Expiration time when expiration occurs in less than 24 hours.

Based on observations, staff interviews, and facility policy review, the facility failed to securely store drugs used in the peri-operative setting in 1(#2) of 6 Operating Rooms.

The findings include:

During a tour of the Surgical Department on 4/7/2015 at 8:52 AM, Operating Room #2 was observed for a case that staff were preparing to participate in. The patient was not in the room at the time; a circulating nurse and surgical technologist were opening up the sterile field. An inspection of the Care Fusion Pyxis Anesthesia system was conducted and the security of the device was tested by this surveyor and Employee #4, as being in a locked status. When the door on the medication storage and dispensing machine was pulled on, the door easily opened and it was identified that in the second drawer was a 60 milliliter syringe with 'Propofol' marked on the syringe with a pre-printed sticker; white liquid in the 60 milliliter syringe was confirmed by Employee #5 on 4/7/2015 at 9:04 AM and a 12 milliliter syringe of Zemuron was pulled out of the drawer.

All medication drawers on the Care Fusion Pyxis system and all of the medication contained therein, were easily accessed by Employee #4, Employee #5, and this surveyor, including syringes of Propofol and Zemuron.

These medications were all in the second drawer and the third drawer down, and has 4 additional medications drawn up and in syringes as follows: (3) 5 milliliter syringes with clear liquid and (1) 12 milliliter syringe with white liquid (Propofol) were also identified. Among the drawers were numerous vials of anesthetic agents, which are easily accessed.

An interview with the head of the Anesthesia Department on 4/7/2015 at 9:10 AM was conducted and he stated: "The Certified Registered Nurse Anesthetist (CRNA) is supposed to take his finger and touch the corner of the screen where the 'X' is, and the machine will lock. The CRNA did not do this; when we sign out of the machine, it will automatically lock the drawers and you can hear a noise cascading from top to bottom as the doors locked; they know that they are supposed to sign out when they are not with the cart."

A review of the facility's Policy Number (MED 012) Medication Adminstration; Patient Care/Medication Management, was conducted and documents on Page 3 of 3 at line number N. the following: After dispensing from the Pyxis, medications are not to be left unattended and are to be stored in an approved, secure manner prior to adminstration.

Based on observations, record reviews, and policy/procedures review, the facility failed to ensure infection control practices were maintained to prevent the potential for infection and cross contamination in 3 different areas of the hospital.
The findings include:
1. On 4/6/15 at 9:30 AM, Employee #1, Registered Nurse, was observed during Medication Pass for Patient #5 in Room #2103, a private room. A sign posted on the door alerted staff that the patient was on contact isolation precautions. At the time of the observation, Employee #1 stated that the patient had MRSA (Methicillin-resistant Staphylococcus aureus, a drug resistant bacteria). Employee #1 donned personal protection equipment (PPE) including gown, glove, and mask. Employee #1 entered the patient's room with the medication cart. Employee #1 did not close the door to the patient's room. Employee #1 administered oral, nasal, and injectable medications to the patient, and discussed his care. As Employee #1 finished the patient encounter, Employee #2, Patient Care Tech, entered the patient's room through the open door, walked to the patient's bedside, and began talking to Employee #1. Employee #2 continued to talk as Employee #1 removed her PPE and washed her hands. Employee #2 picked up a glove off of the floor with her ungloved hand, and threw it in the trash in the patient's room. Employee #2 did not wash her hands, and then followed Employee #1 out of the patient's room, still talking. At the threshold to the door, Employee #1 interrupted Employee #2 and pointed to the sign posted on the patient's door. Employee #1 informed Employee #2 that the patient was on isolation now. Employee #2 said she "didn't know" about it.
Review of Patient #5's medical record revealed that a nasal culture collected on 3/31/15 was reported positive for multi-drug resistant organism (MDRO) on 4/1/15. Review of physician's orders for Patient #5 revealed that contact isolation was ordered for the patient on 4/1/15.
Review of the facility policy titled 'Multi-drug Resistant Organism Control and Prevention', last revision 2/2015, revealed that multi-drug resistant organisms include MRSA. The electronic chart is flagged when a positive lab result is identified to ensure proper isolation precautions will be practiced. Quickly identify specific organisms that require isolation precautions to be initiated immediately to prevent the spread of infections. Prevention, containment and eradication measures, including use of contact precautions, are indicated to prevent the spread of resistant micro-organisms that have been identified within the facility. Best practice: use contact precautions for all patients identified as colonized or infected with an MDRO. Process when MRSA is identified in a patient: A transmission-based precaution sign is placed outside the patient's room by the nursing staff. The hospital will comply with the CDC hand hygiene recommendations utilizing soap and water and alcohol based hand hygiene products.
According to CDC guidelines for MRSA infections at cdc.gov, MRSA is a bacteria resistant to many antibiotics. In a healthcare setting, such as a hospital or nursing home, MRSA can cause severe problems such as bloodstream infections, pneumonia and surgical site infections. MRSA is usually spread by direct contact with an infected wound or from contaminated hands, usually those of healthcare providers. Adherence to infection control measures is critical to preventing MRSA outbreaks. People who have MRSA germs on their skin or who are infected with MRSA may be able to spread the germ to other people. MRSA can be passed on to bed linens, bed rails, bathroom fixtures, and medical equipment. It can spread to other people on contaminated equipment and on the hands of doctors, nurses, other healthcare providers and visitors. Use Contact Precautions when caring for patients with MRSA. Contact Precautions mean:
o Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with MRSA.
o When leaving the room, hospital providers and visitors remove their gown and gloves and clean their hands.

2. An observation of ostomy (a surgical opening from inside the body to the outside) care with the Wound Care Nurse was conducted on 4/6/15 at 10:40 AM. The nurse cleaned around Patient #1's new stoma (opening) with normal saline and gauze. She removed her soiled gloves and donned new gloves without washing her hands or using hand sanitizer. The nurse proceeded to apply skin prep around the stoma and complete the application of the appliance.
Review of the facility Hand Hygiene Policy revealed hand hygiene is expected but not limited to:
1. Upon entering and exiting a patient room
2. Before and after any patient contact
3. After contact with patient surroundings
4. Before putting on personal protective equipment (PPE)
5. After removing PPE
6. After contact with blood, body fluids, or contaminated surfaces, even if gloves are worn
7. Before invasive procedures
3. During initial tour of the facility on 4/6/2015 at 10:50 AM in the pre-operative holding area, Room #12 used a spinal needle with visible blood on the hub, which was observed, lying in the groove on top of the lid to a wall-mounted Sharps container designated for needle disposal. The needle was not secured, and anyone reaching for the lid could come into contact with it. The loose needle could also fall off of the Sharps container. A patient's family member was observed sitting on a chair in the room at the time of the observation, with free access to the used needle. (Photographic evidence of Sharps container and needle obtained).
The Nurse Manager and Process Improvement Coordinator both confirmed in an interview at the time of the observation on 4/6/2015 at 10:55 AM that the spinal needle was loose on top of the lid to the Sharps container, and not secured. They both stated, "Oh, look at that, we are in the process of getting a new system; we don't like this one."