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Based on interview and record review, the facility failed to obtain consent for treatment for 2(Patient #4 and Patient #5) of 21 patients reviewed for patient rights, from a total sample of 21 patients, resulting in the potential for patients to be uninformed of their rights and not having given consent for treatment received.

Findings:
Review of Patient #4's medical record on 5/3/16 at 1215 revealed she was admitted to the facility on 1/29/16 through the Emergency Department. The medical record was reviewed with the Emergency Room Director (Staff I) and Admitting Supervisor (Staff T), who were unable to locate a signed consent for treatment.

Review of Patient #5's medical record on 5/3/16 at 1430 revealed she was admitted to the facility on 1/19/16 through the Emergency Department. The medical record was reviewed with Staff I and Staff T, who were unable to locate a signed consent for treatment.

In an interview on 5/3/16 1220, Staff T stated normally staff would make every attempt to approach a patient once they are admitted to obtain a signed consent for treatment, but these must have been missed.

Review of the facility Consents policy on 5/4/16 at 1400 revealed, "Patient Registration will obtain the patient's or parental consent if the patient is a minor."

Based on observation, interview and record review, the facility failed to ensure nursing staff labeled and dated Intravenous (IV) tubing when hung, and failed to discard expired IV tubing according to accepted standards of practice for 1 (#3) of seven patients reviewed for nursing services resulting in the potential for the reuse of expired tubing during IV medication administration.

Findings include:

On 05/03/16 at 1130 during the initial tour of the critical care unit patient #3 was observed awake in bed. The patient was agreeable to an interview. When asked if he was receiving Intravenous (IV) medication he lifted up his arms from under his blanket and explained that he was holding too much water. His bilateral upper arms were swollen and bruised. He stated, "Yes, I'm getting some medicine through the IV. They disconnected it earlier." A peripheral IV heplock access site was observed on the patient's left lower arm.

An IV pole was observed near the patient. There were 2 empty 100 milliliter (ml) antibiotic bags observed. The tubing on an empty 100 ml IV bag labeled Tobramycin (antibiotic) was dated 4/29.
A 1000 ml bag containing 800 ml of half normal saline was observed with no date on the bag or tubing that reflected when the bag was spiked (accessed).

On 5/3/16 at 1135 during an interview the Chief Nursing Officer (CNO) was asked how often IV tubing was changed and if IV tubing and or solutions were required to be labeled and dated when hung. She explained IV tubing was changed every 72 hours and IV tubing should be dated when the bag was spiked. At 1140 while accompanied by the CNO she confirmed the tubing dated dated 4/29 should have been discarded on 5/2, 72 hours after usage and she confirmed the nurse should have labeled and dated the IV tubing for the 1000 ml bag of IV solution.

On 5/4/16 at 1030 a review of the facility's undated "Intravenous Therapy" policy ", last reviewed on 6/2015 documented: "...8. The IV administration ser (tubing) must be tagged with the date the tubing was hung or the date it is to be changed.

Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in substantial compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated May 4, 2016.
K-0015
K-0029
K-0047
K-0064
K-0076
K-0147

Based on observation and interview the facility failed to ensure supplies and equipment in use met requirements and were maintained resulting in the potential for adverse patient outcomes. Findings include:

1. On 05/03/2016 at approximately 1110 during a tour of the psychiatric department, it was noted the typical central shower room, tub room, and the shower serving the seclusion room's showers are equipped with the standard type of grab bar (Non-psychiatric approved) while the grab bars serving the typical toilet room are in compliance. The use of the open (standard) grab bar in the psychiatric department is a potential hazard for patient to harm him/herself. Finding confirmed by accompanying staff E at approximately 1115.

2. On 05/03/2016 at approximately 1530 during a tour of the kitchen, found the installed ceiling tiles are of the standard type in lieu of the required smooth surface and cleanable type (vinyl faced). Standard ceiling tiles are porous and are not cleanable. Finding confirmed by both accompanying staff members E & G on 05/03/2016 at approximately 1535.



28042

During the tour of the Emergency Department with Facility Emergency Director (Staff I), on 5/3/16 at 11400, three (3) different patient rooms were observed to have crash carts. Each crash cart was observed to have a clip board with a "crash cart checklist" to be completed each day of the month, which included medications, supplies and operation of equipment. Review of all three (3) checklists for the months of February 2016, March 2016, and April 2016 revealed multiple weekend dates to be blank and multiple week days to be blank.

In an interview with Staff I on 5/3/16 at 1410, he stated it was his expectation that all crash carts be checked once daily.

Review of the facility Crash Cart and Defibrillator policy (dated 11/15) on 5/4/16 at 1300 revealed, "Crash cart checking and defibrillator/monitor testing shall be performed and documented every 24 hours."



28775


On 05/03/16 at approximately 1100 a tour of the Critical Care Unit was conducted with the Chief Nursing Officer (CNO). A crash cart was observed. The flow sheet dated May 2016 was reviewed with the (CNO). There were no entries documented on the flow sheet for 5/1/16 or 5/2/16. There was only 1 entry recorded that read 5/3/16. When asked who was responsible for checking the crash cart to ensure the defibrillator was monitored and operable she stated, "The midnight nurses are responsible". No further explanation was offered at that time to explain way no one had documented on the flow sheet that the defibrillator had been checked and was operable on those dates.

During observational tour of the facility the following observations were noted:
1. On 05/03/2016 at 1050 during tour of the Pharmacy with the maintenance supervisor (staff E) an accumulation of dust on the top shelves where pharmacy product was kept was noted.
2. On 05/03/2016 at 1120 an accumulation of lint, dust, and debris was observed on the nuclear machine and the table for the machine where the patient will lay down.
3. On 05/03/2015 at approximately 1330 during a tour of the emergency department, trauma room #1, the boom for the task light exhibited accumulation of dust.
4. On 05/03/2015 at approximately 1410 during a tour of the surgical department, in operating rooms 2 and 3 an accumulation of high dust on flat-topped surfaces of task lights and booms was noted.

5. On 05/03/2016 at approximately 1505 during a tour of the lab - blood draw area, the ceiling tile directly above the patient chair exhibited lint and dust accumulation.

All above items/findings were confirmed by accompanying staff E during the tour of the facility on 05/05/2016.


27408

Based on observation and interview the facility failed provide and maintain a clean environment resulting in the potential for the spread of infectious disease. Findings include:

On 05/03/16 at approximately 1100 during the initial tour of the Critical Care Unit (CCU) it was determined that there was an accumulation of dust noted on top of the CCU Crash Cart, defibrillator, and the three computer monitor screens located at the CCU nurses's station charting area.
On 05/03/16 at approximately 1100 the Director of Nursing (Staff C) confirmed these findings. Staff C stated, "Housekeeping was responsible to keep the area clean."

Based on record review, interview, and policy review, the facility failed to complete 2 of 6 post anesthesia assessments for Patient #1 and Patient #2, with a potential for poor patient outcomes for any future surgical patients. Findings include:

On 05/03/16 at approximately 1200 during record review for Patient #1, it was determined that the document titled "Anesthesia Record" dated 04/22/16, did not have the completed "Post Anesthesia" portion of the record, filled in by the appropriate personnel within the "post anesthesia recovery" per facility policy.

On 05/03/16 at approximately 1215 during record review for Patient #2, it was determined that the document titled "Anesthesia Record" dated 04/29/16 did not have the completed "Post Anesthesia" portion of the record, filled in by the appropriate personnel within the "post anesthesia recovery" per facility policy.

On 05/03/16 at approximately 1220, Staff C stated that the "follow up (post anesthesia assessment) might have been written in the progress notes." Staff C was not able to provide the surveyors with the post anesthesia assessment by the end of the survey date.

On 05/05/16 at approximately 0930 during review of the policy titled "Post Anesthesia Assessment" dated 03/24/16, it was stated "1. All inpatients will have a documented assessment by an anesthesia provider within 24 hours of the patient's procedure." Patient #1 and Patient #2 did not receive a follow up assessment by an anesthesia provider.