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Based on record review, policy review, observation and interview, it was determined the facility failed to protect and promote the rights of patients as evidenced by: failure to inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights including by failing to ensure:
(A117) the appeal process outlined in the "Important Message from Medicare;"
(A118) the patient grievance process
(A119) that the governing body assumes responsibility for the grievance process
(A131) the patient receives information need to make informed consents regarding treatment
(A168) patients have orders for restraints when they are applied
(A175) patients in restraints are monitored as required by regulation and facility policy.

During record review of patient ' s #7, #8, #15, #23, and #24 charts on 10/20/10, it was determined that the "Important Message from Medicare " was in the chart, but charted as "patient unable" on the signature line. The signature was never obtained during the rest of the hospitalization for each of the patients.

During review of the policy titled " Distribution of Message from Medicare" on 10/20/10 at 1700, it revealed " In the event the patient is unable to sign....the form will be left at the nursing station and addressed to the patient ' s next of kin. If the form was not taken, it will be mailed to the patient's address " .

The Accreditation Specialist confirmed these findings on 10/20/10 at 1300.



28267

On 10/18/10 at approximately 1200 during the observational tour in the Emergency Department an interview with staff #J regarding the distribution of rights to the patients that are admitted into the Emergency Department and admitted as an inpatient from the Emergency Department, she stated "They (meaning patients) do not receive any information from us, they might get it on the floor".

On 10/18/10 at approximately 1410 during the observational tour on the North 3 unit staff #LL when queried about the distribution of patient rights to patients that are admitted she replied "If they don't get one in the Emergency Department-our Kardex (patient assessment sheet) has to be checked off, then we give it to them" Staff #LL was then asked to supply the documents that are given to the patient to inform them of their rights and Staff #LL was unable to retrieve the documents regarding patient rights.

On 10/18/10 at approximately 1430 during the observational tour on the North 3 unit patient #15 was queried about the distribution of patient rights upon admission and she replied "I didn't receive anything."

On 10/19/10 at 1700 the facility ' s inpatient psychiatric facility on the Hackley campus was toured with the Director if the Behavioral Health (staff FF.) The only posting regarding patient rights was a poster with contact information on how to contact the Recipient Rights Officer. There were no printed materials available to patients on how to file a complaint or grievance. These observations were confirmed by the staff FF.




28267

On 10/18/10 at approximately 1200 during the observational tour in the Emergency Department an interview with staff #J regarding the distribution of rights to the patients that are admitted into the Emergency Department and admitted as an inpatient from the Emergency Department, she stated "They (meaning patients) do not receive any information from us, they might get it on the floor".

On 10/18/10 at approximately 1410 during the observational tour on the North 3 unit staff #LL when queried about the distribution of patient rights to patients that are admitted she replied "If they don't get one in the Emergency Department-our Kardex (patient assessment sheet) has to be checked off, then we give it to them" Staff #LL was then asked to supply the documents that are given to the patient to inform them of their rights and Staff #LL was unable to retrieve the documents regarding patient rights.

Based on interview and record review, the facility failed to ensure that the hospital's governing body either review or delegate the review of patient grievances. Findings include:

On 10/19/10 from 1000-1500 facility policies and board minutes were reviewed. No process for review of grievances by the board or delegation of this task was noted.

On 10/19/10 at 1505 the Director of Service Excellence (staff EE) was asked to explain how the Board of Directors is involved in reviewing grievances. She stated that she did not know whether the Board had delegated review of grievances to another committee.

On 10/20/10 at approximately 1745 the Senior Director of Nursing (staff D) confirmed that a grievance policy delegating review of grievances had not yet been approved by the Board of Directors. A copy of the Board Quality Committee report dated 9/21/10 noted that the patient complaint and Grievance quarterly Report was tabled until November 2010 and the Grievance Policy were sent to the Board of Trustees for approval.

Based on record review and interview, the facility failed to obtain a completed order for restraints for 3 of 6 patients restrained (patient ' s #25, #28, and #50). Findings include:

Record review of patient #25 ' s closed chart revealed that bilateral "soft limb restraints" were initiated on 05/18/10 at 1900. The physician did not authenticate the restraint order until 05/30/10, twelve days later.

Record review of patient #28 ' s closed chart revealed that bilateral "soft limb restraints" were initiated on 06/10/10. The physician did not authenticate the restraint order until 06/16/10, six days later.

Record review of patient #50 ' s closed chart revealed that bilateral soft wrist restraints were initiated on 04/06/10 at 1430. The physician did not authenticate the restraint order until 04/19/10, thirteen days later.

These findings were confirmed during an interview with the Accreditation Specialist on 10/20/10 at 1430.





28267

On 10/18/10 at approximately 1230 during the observational tour in the Emergency Department an interview with Staff # H revealed that patients that are intubated and placed on a ventilator will have soft restraints applied to both wrists. When queried if that is considered restraints Staff #H replied "We put on the soft wrist restraints when they are on the vent. We don't get an order because it is for a medical reason, it's for precautions, so they don't pull out the tube."

On 10/18/10 at approximately 1500 during an observational tour of the North 3 unit review of patient #17's medical record revealed a form titled "Restraint Order Sheet" with a telephone order from a registered nurse taken on 10/18/10 at 0322 for soft restraints to both wrists and ankles. An interview with Staff #LL revealed that the particular physician had been on the floor for patient rounds at 1330 and at 1500 the telephone restraint order was still not authenticated. This finding was confirmed by Staff #LL.

On 10/18/10 at approximately 1630 upon review of the facility's policy titled "Restraint Use" it is written "The physician shall perform a face-to-face assessment of the patient within 24 hours of the initiation of the restraint, at which time he or she shall either discontinue or write an order for continuation of the restraint." In addition, "The physician shall perform an in-person assessment of the restrained patient at least once every calendar day, at which time restraint shall be either re-ordered or discontinued as indicated."


27065

The facility failed to obtain a physician's order for restraint of one of two patients (#63) reviewed on the inpatient behavioral unit. Findings include:

On 10/21/10 at approximately 1100, patient #68's closed medical record and facility restraint documentation of restraint use was reviewed with the the Behavioral Unit Manager. On 8/8/10 patient #68 was restrained at 0915. A signed physician's order was not noted until 1500. There was no documentation of a face-to-face assessment by the physician until 1500. Documentation indicates that the restraints were removed at 0955 and 1330, without new orders being obtained. These findings were confirmed by the Manager of the Behavioral Health Unit on 10/21/10 at 1210.

Facility policy #7080006, outlines procedures for the use of restraints for the Hackley Behavioral Health Center. The policy states that the RN will: "obtain and document a physician's verbal order with required information by phone no later than 30 minutes following initiation of the procedures." It states that the physician will "see and evaluate the patient and document the need for restraint or seclusion within one hour after initiation of this intervention. If the patient is released prior to the one hour, face-to-face evaluation is still required."

Based on interview and record review the facility failed to ensure the monitoring of restrained patients by trained staff per hospital policy for 4 of 8 (#7, #17, #23, #25) patients. Findings include:

On 10/18/10 at approximately 1440 during an observational tour of the North 3 unit review of patient #17's medical record revealed that on both wrists and ankles soft restraints were applied at 0322 with an initial assessment, the patient was then reassessed according to documentation at 0530 and the next reassessment documented was timed at 0843. This finding was confirmed by Staff #LL.

On 10/18/10 at approximately 1630 upon review of the facility's policy and procedure titled "Restraint Use" it is written "Other monitoring activities shall be performed at least every two hours or more frequently if indicated by the condition or behavior of the patient......"

Based on record review and interview, the facility failed to ensure that all patient medical record entries were completed with the correct date and time, by the person responsible for providing the service, in 12 out of 14 clinical records reviewed Patient ' s # 1, # 2, #3, # 4, #5, #6, #13, #23, #27, #30, # 31, and #45 .

Findings include:

During review of patient #23's chart it was noted that the physician orders were not completed on 06/03/10 at 0230, 1730, and 2130; 06/04/10 at 0258, 0649, 0930, 0935, 1102, 1826, 1845, 2010, and 2011, 06/05/10 at 0829.

During review of patient #27's chart it was noted that the " Anesthesiology Post-Operative Assessment Notes " lacked the time and date of the completion of the post op assessment.

During review of patient #31's chart it was noted that the physician orders were not completed on 08/15/10 at 0090, and 1010. The Adult Sub Q Order Set signed by the registered nurse on 08/15/10 at 1010 did not contain the physician's signature.

During review of patient #45's chart it was noted that the "Anesthesiology Post-Operative Assessment Notes" lacked the patients name, medical record number, and the time and date of the completion of the post op assessment.

The Accreditation Specialist confirmed on 10/20/10 at 1600 that the patient care orders were not completed according to hospital policies and procedures.


28267

On 10/18/10 at approximately 1200 during the observational tour in the Emergency Department review of three (#1, #2, #3) patient open medical records the following was found:

Patient #1: The form titled Emergency Record was absent of a time after the physician's signature.
Patient #2: The form titled Emergency Record was absent of a time after the physician's signature.
The form titled Adult Self Harm Screening For Determining Level of Suicidality was absent a time after the nurse's signature.
Patient #3: The form titled Emergency Record was absent of a time after the physician's signature.

The above findings were confirmed by Staff #B.

On 10/18/10 at approximately 1630 upon review of the facility's Medical Staff Rules and Regulations it is written "Medical Record Entries and Authorization: All entries made into the medical record shall be dated, timed and authenticated by the originator."

On 10/18/10 at approximately 1445 during the observational tour of North 3 a review of patient #52's medical record revealed a form titled "ED Home Medications List" that documented "QD" for the route of medication for 4 of 6 medications listed. This finding was confirmed by Staff #LL.

On 10/18/10 at approximately 1630 review of the facility's policy and procedure titled "Policy for Abbreviations used in Medical Records" it is written "Abbreviations on the 'Trinity Dangerous Abbreviations' list should not be used." Review of the Trinity Dangerous Abbreviations list indicates that QD is not to be used and the approved abbreviation is "daily".


29313

On 10/18/10 at approximately 1100 during record review it was observed that the following patient's charts had incomplete medical records:
A)Patient # 4 document titled "Emergency Record" had no time following the physician's signature. The document titled "Emergency Nursing Record" was without pre and post medication pain ratings.
B)Patient #5 document titled "Emergency Record" had no time following the physician's signature. The document titled "ED Home Medications List" had no date following the physician's signature and no time following the registered nurses signature. The document titled "Adult Self Harm Screening for Determining Level of Suicidality" had no time following registered nurses signature.
C)Patient #6 document titled "Emergency Record" had no time following the physician's signature. The document titled "ED Home Medications List" had no physician signature, date or time.
D)Patient #13 document titled "Emergency Record" had no time following the physician's signature. The document titled "ED Home Medications List" had no time following physician's signature and had no registered nurse signature, date or time.

Based on record review and staff interview, the facility failed to authenticate verbal orders within the designated time frame of 48 hours in 7 of 13 charts. Patient's #13, #14, #16, #19, #23, #26, and #30. Findings include:

Clinical record revealed that physician's failed to authenticate verbal orders within the 48 hour time frame. This was observed on survey date of 10/18, 19, 20, and 21 of 2010.

Interview with the Accreditation Specialist on 10/20/10 confirmed that the policy was for 48 hours authentication.

During review of the policy titled "Verbal Orders", it was revealed that the orders were to be signed within 48 hours.


28267

On 10/18/10 at approximately 1440 during an observational tour of the North 3 unit review of patient #16's medical record revealed on the form titled "Physician Order Sheet" a telephone order received and dated 10/15/10 at 1453 and is absent of a physician's signature for authentication.

On 10/18/10 at approximately 1630 upon review of the facility's medical staff rules and regulations it is written "Verbal Orders: .....Such orders are authenticated (signed, timed and dated) by the practitioner responsible for the patient at the time of the next visit or within forty-eight (48) hours."


29313

On 10/18/10 at approximately 1440 during an observational tour of the North 3 unit review of patient #13's medical record revealed on the form titled "Physician Order Sheet" a telephone order received and dated 10/11/10 at 0910 and a telephone order received and dated 10/11/10 at 1045 are absent of a physician's signature for authentication.

Based on staff interview, and record review, it was determined the facility failed to ensure that all discharged inpatient's clinical records were complete, including an authenticated signature from the attending physician. Findings include:

During an interview, and record review with the Director of Health Information on 10-20-10 at 1510, it was identified there were 965 incomplete inpatient clinical records that were awaiting signatures from the physician 30 days following the patient's discharge from the hospital.
During review of the Medical Staff By-Laws on 10-20-10 at 1630 (pg 7) revealed that " Delinquent Records: All patient medical records shall be completed within thirty (30) days after the date of discharge of the patient " .

On 10/18/10 between the hours of 1030 and 1230 during an observational tour of the Emergency Department the following medications were found to be accessible for patient use:

Medication Room
A)On the counter a vial of Lidocaine 1% 50 ml bottle was open and not dated.
B)On the counter a vial of Labetalol 20 cc was open and dated.
C)In an open dental box kit two bottles of Benzocaine topical anesthetic gel 34 grams were noted to be open and not dated. A topical bacteriocidal agent 1 fluid ounce was found with an expiration date of 2/10.
D)In the medication refrigerator a vial of Novolin R insulin was found open and not dated.


29313

On 10/18/10 between the hours of 1030 and 1230 during an observational tour of the Emergency Department the following medications were found to be accessible for patient use:
Emergency Department-Medication Room
In the cabinet above the sink a vial of bupivacaine multi dose was discovered with and expiration date of 10/13/10.


29314

Based on observation, interview and policy review the facility failed to ensure that all medications were labeled with an open date to ensure that open medications were discarded within 28 days of opening. Findings include:

During a tour of the pharmacy on 10-18-10 at approximately 1500 it was observed that multiple dose medications were open and not dated for approximately 20 bottles of medication on the shelf.

The interview with staff member M on 10-18-10 at approximately 1500 it was stated that "We don't date any multiuse medications with open dates, we never have."

During policy review of the policy titled "Multiple Dose Medication Vials/Containers/Intravenous Solutions" it was stated "A Beyond use date (written as month/date/year) will be placed on multiple dose containers by the person opening the medication. This beyond use date will be 28 days from the date opened."

Based on observation, policy review and interview the facility failed to label open medications that were available for patient use according to policy and regulation. Findings include:

While touring the surgical area on 10/19/10 at approximately 1515 in operating room 6 the following was discovered:
One vial of Dexamethasone 20mg opened without an open date.

During policy review of the policy titled "Multiple Dose Medication Vials/Containers/Intravenous Solutions" it was revealed that "A beyond use date (written as month/day/year) will be placed on multiple dose containers by the person opening the medication."

The Director of Surgical Services confirmed the above supplies were not labeled with open dates.

The facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the Life Safety Code deficiencies identified. See A-710.

Base on observation, the facility failed to provide an environment that ensures the safety and well being of patients. Findings include:

During the facility tour with the Director of Plant Operations and the Facility Manager the following plumbing hazards were discovered.
-On 10/18/2010 at approximately 1:00 PM in Respiratory Therapy processing room 3212, it was observed that the potable water supply to the instrument washer was not properly protected by a reduced pressure principle backflow assembly (RPZ).
-On 10/18/2010 at approximately 1:30 PM in soiled utility room 2345 serving OB C-Section it was observed that there was a spray valve on the bed pan washer downstream of the atmospheric vacuum breaker (AVB). This causes the AVB to be under continuos pressure which can cause the AVB to get stuck open and prematurely fail.
-On 10/19/2010 at approximately 9:30 AM, it was observed that the the potable water supply to the scope cleaners in Endoscopy are protected by atmospheric vacuum breakers. Due to the hazard, the potable water supply to the scope cleaners must be protected by RPZ's.

Without the correct backflow protection at these locations, there is an increased potential of contaminating the potable water system.

During the facility tour with the Director of Plant Operations and the Facility Manager on 10/18/2010 & 10/19/2010 it was observed that all of the janitors closets were not locked. There were poisonous chemicals stored in the janitors closets that patients could gain access to since the janitors closets were not locked. The Director of Plant Operations agreed that the Janitors closets should be locked.

During the facility tour with the Director of Plant Operations and the Facility Manager on 10/18/2010 at approximately 12:45 PM it was noticed that the Oxygen and Vacuum Zone Cut Out Valves serving the patient exam rooms 3rd floor central was located within the locked pharmacy. Since these valves are within the locked pharmacy, they are not easily accessible and can not be turned off quickly during an emergency.

During the facility tour with the Director of Plant Operations and the Facility Manager on 10/18/2010 at approximately 2:45 PM it was noticed that the sink was clogged in the nourishment room on 2nd floor in the OB Department. There was about 4 inches of standing water in the sink basin.

During the facility tour with the Director of Plant Operations and the Facility Manager on 10/18/2010 at approximately 3:00 PM, it was noticed that there was not a handwash sink in Nuclear Medicine Room 1118 for staff to use to wash their hand in-between patients.

During the facility tour with the Director of Plant Operations and the Facility Manager on 10/18/2010 at approximately 3:15 PM it was observed that the drywall was damaged in Operating Room 1 and that the corner guards were not installed in the corridor that leads to recovery. These exposed areas of drywall present an area that can not be easily cleaned.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on October 19-20, 2010, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated October 20, 2010, for Life Safety Code.

Based on observation and interview the facility failed to ensure that all supplies, and equipment were maintained to ensure an acceptable level of safety and quality. Findings include:





29313


On 10/18/10 at approximately 1100 during the initial observational tour of the Emergency Department it was observed in room #8 and and Trauma room #2 that the yonkers (a hard, long plastic tube used for suctioning) attached to the suction unit on the wall were uncovered.
On 10/18/10 at approximately 1100 these findings were confirmed by staff # B and #H.

Based on observation the facility failed to provide proper ventilation in a janitors closet and a respiratory storage room. Findings include:

During the facility tour with the Director of Plant Operations and the Facility Manager on Monday October 18, 2010 at approximately 11:30 am it was noticed that the exhaust grill was missing in the janitors closet across from room 426 which is causing the odors from the room to be properly exhausted to the outside.

During the facility tour with the Director of Plant Operations and the Facility Manager on Monday October 18, 2010 at approximately 12:00 PM the respiratory storage room on 4th floor did not have any ventilation. This room shall have supply air with four air changes an hour and the room must be under positive pressure per the Minimum Design Standards for Healthcare Facilities in Michigan.

Based on observation, interview, and record review the facility failed to provide a sanitary environment to avoid sources and transmission of infection by not contolling methods for prevention (A-0749).


22182

The facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. Findings include:

During the facility tour with the Director of Plant Operations and the Facility Manager it was observed that the facility was storing janitors cart and supplies in storage rooms designated for other functions. Specific examples include a janitors cart and equipment were being stored in the sitz bath on 4th floor (10/18/10 at 11:35 AM), janitors cleaning supplies stored with general storage items (decorations) in a storage room next to room 4336 (10/18/10 at 11:40 AM), and a janitors cart and cleaning supplies being stored in the 4th floor Rehabilitation Laundry. This practice increases the chance for cross-contamination.

During the facility tour with the Director of Plant Operations and the Facility Manager on 10/18/10 it was notice that the handwash sinks in a alcove in the corridor that served the patient room were blocked. The handwash sink on 4th floor North was blocked by a soiled linen cart (11:30 AM) and the handwash sink on 3rd floor North was blocked by a blood pressure machine (1:10 PM). Staff do not have access to a handwash sink so that they can wash their hands between patients.

During the facility tour with the Director of Plant Operations and the Facility Manager on 10/19/10 at 8:45 AM, clean linen was observed to be stored on top of the blanket warmer and the clean linen cart was left uncovered in the Endoscopy prep/recovery area. This increases the chance of cross-contaminating the clean linen.

On 10/19/10 at approximately 1035, an off-site clinic, the MHP Lakes Urgent Care Center, was toured with the Director of Inpatient nursing Services and Director of surgery Services. In exam room #6 a Bayonet forceps was observed lying on the counter. The Supervisor of the Urgent Care stated that the room was cleaned except for the forceps which he planned to carry down the hall, without a container or bag, and place it in a sink for further cleaning. The facility policy titled: "Infection Prevention and Control," dated 6/14/10, states: "Contaminated items shall be placed in puncture-proof sealable containers labeled biohazard during transport to cleaning areas."

In the central nursing station area, a long countertop contained both clean and dirty items. To the right of the sink two bags of soiled equipment, to be autoclaved, were stored touching boxes of clean gloves and tissues. The facility policy titled: "Infection Prevention and Control," dated 6/14/10, states: "Soiled equipment/instruments must be physically separated from clean and sterile items in order to prevent cross-contamination."


28267

Based on observation, interview, and record review the facility failed to identify and control infections of patients and personnel. Findings include:

On 10/18/10 between the hours of 1030 and 1530 during an observational tour of the Emergency Department and unit North 3 the following was observed:

Emergency Department
1)In room 12 oxygen extension tubing was observed connected to the oxygen wall unit. At approximately 1125 staff #I was queried regarding the disposal of the extension tubing when cleaning the room after a patient has been discharged and staff #I stated "No I don't throw it away, I wrap it up and hang it on the wall when I clean the room." This finding was confirmed by Staff #B and Staff #H.

Unit North 3:
1)In patient room N314 the intravenous tubing that runs from the bag of medication to the patient's insertion site was observed laying on the floor between the intravenous line pole and the patient.
This finding was confirmed by Staff #B.

2)Patient room N307 was observed to be marked as contact isolation and when staff #LL was queried for reason she stated "She has C-Diff". At approximately 1515 a patient care assistant was seen in the patient's room with gloves on and no gown. She was at the patient's bedside taking vital signs and her clothes and arms were observed touching the patient and the patient's bed. Staff #T was asked to make the observation and was queried if the absence of the gown was acceptable and she replied "No, the patient care assistant should be wearing a gown." This finding was confirmed by Staff #B, Staff #T, and Staff #LL.

On 10/21/2010 at approximately 0830 upon review of the facility's policy and procedure titled "Isolation Precautions" it is written "Isolation Precautions procedures will be practiced by all associates." The isolation precautions are referred to in the policy to a program on the facility's intranet which describes exactly what precautions to take and the appropriate personal protective equipment that is to be donned prior to entering a patient's room that is in isolation according to Staff #Y. Staff #Y also indicated that all patient care staff have been trained in isolation precautions in their particular mandatory skills fairs that took place earlier this year of 2010.


29313

On 10/18/10 between the hours of 1030 and 1530 during an observational tour of the Emergency Department and unit North 3 the following was observed:

Emergency Department
1)In room # 3, #4, #6, #7, #8, #10, and Trauma room #1 the single use oxygen extension tubing device was observed connected to the oxygen wall unit. This finding was confirmed by Staff #B and Staff #H.

Unit North 3:
1)In patient room N324 the intravenous tubing that runs from the bag of medication to the patient's insertion site was observed laying on the floor between the intravaneous line pole and the patient. The leg pumps were also observed on the side of the patient's bed on the floor. This finding was confirmed by Staff #B.

Based on record review, Medical Staff General Rules and Regulation review and interview, the facility failed to ensure that a post-anesthesia evaluation was completed within 48 hours on 11 out of 15 O.R. procedures (Patient #8 , #18, #19, #27, #34, #35, #40, #44, #46, #47, #48).
Findings include:

During record review of the surgical patient charts it was revealed that post operative anesthesia evaluation was not completed according to the facility's policy.

The facility's Medical Staff General Rules and Regulations titled Rule 002: Medical Records states " post anesthetic visit shall be recorded after the patient leaves the OR/Procedure room or Recovery Room."

Interview with Medical Director of Quality on 10-20-10 at approximately 1320 confirmed these findings.