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Based on record review and interview, the provider failed to inform outpatients at the Cancer Center of their patient's rights. Findings include:

1. Review of documents presented to new outpatients at the provider's Cancer Center revealed they did not offer information patients of their right to file a grievance or who to contact to file a grievance. The information offered to patients did not include any contact telephone numbers for the state Quality Improvement Organization or the state regulatory agency.

Interview on 1/6/10 at 2:00 p.m. with the director of the Cancer Center revealed the Cancer Center:
*Informed new patients of their rights under the Health Insurance Portability and Accountability Act of 1996.
*Had a social worker on staff who provided patients with information about durable power of attorney and advanced directives.
*Provided new patients an admission packet that discussed health issues related to treatments.
*Did not provide new patients the same admission packet as provided by the hospital for inpatients.
*Did not provide new patients or discuss with them any patient's rights or grievance procedures.

Review of the Cancer Center policy for admitting the new patient reviewed on July 2002 revealed new patients seeking treatment would be admitted by the receptionist/secretary. The secretary was to assign a medical record number, secure signed admission consent forms, and provide the patient with advanced directive literature along with patient rights information.

Based on record review and interview, the provider failed to ensure:
*There was accurate documentation for administration of medication for one of three patients (6) reviewed for medication administration.
*Allergies were checked prior to administration of a medication for 1 of 34 patient records (34) reviewed.
Findings include:

1. Review of the medication record for patient 6 revealed:
*A Flovent inhaler was to be administered two times daily. The record for 1/3/10 documented the Flovent was administered only one time.
*One tablet of senna-s was to be administered two times daily. The record for 1/2/10 documented the senna-s was administered only one time and was refused at that time. The record for 1/3/10 documented the senna-s was administered only one time and was refused at that time.

Interview on 1/6/10 at 3:00 p.m. with the patient support service quality risk manager (PSQRM) revealed she was not sure if the provider had a policy stating what documentation was required for administration of medications. The PSQRM added it was a professional expectation for all doses of medication (administered or refused) to have been documented on the medication record.

Interview on 1/6/10 at 3:10 p.m. with a registered nurse (RN) working on the floor where patient 6 was located revealed:
*All administration or refusals of medication should have been documented.
*The electronic record system could have been utilized by nurses during their shift to determine if there was documentation for administration of all doses of prescribed medication during that shift.




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2. Review of patient 34's closed record revealed she had been admitted to the hospital on 7/8/09 and was discharged on 7/15/09. Review of her admission history and physical revealed an allergy to Vicodin was listed in bold letters. Review of her 7/13/09 physician's orders revealed an order for Vicodin 5/325 one or two tablets every four to six hours as needed for pain. That order was noted by a nurse. No documentation was found within the record to indicate the physician had been questioned regarding the Vicodin allergy.

Review of patient 34's medication administration record revealed she had received Vicodin three times prior to discharge. Review of her 7/15/09 discharge orders revealed an order for Vicodin to be taken for pain at home.

Review of patient 34's electronic medical record revealed an allergy to Vicodin or Co-gesic was listed on each form. Review of Todd Semla et al, Lexi-Comp's Drug Reference Handbook, 12th edition, page 744, revealed they were both brand names for the same generic formula of hydrocodone and acetaminophen.

Interview with the PSQRM at 2:30 p.m. on 1/6/09 revealed it would have been her expectation the nurse noting the original order should have clarified that order with the physician. She further stated the nurses who administered the medication should have also been aware of that patient's allergy prior to administration.

Review of the provider's revised February 2009 medication administration policy revealed allergies should have been checked prior to administration of a new medication.

Based on record review, interview, and policy review, the provider failed to ensure documentation was complete and accurate at the time of death for one of three patient's (17) closed death records reviewed. Findings include:

1. Review of patient 17's closed record revealed she had been admitted on 9/29/09 and passed away on 10/1/09. Review of her 10/1/09 patient progress notes revealed:
*4:17 p.m. She had very loose sounding respirations. She was administered a medication to help control upper airway secretions.
*4:29 p.m. Her vital signs were temperature 100.7, respirations 38, and pulse 106. Tylenol was given to bring the temperature down and alleviate pain.
*6:37 p.m. Her family was at her bedside, and her color was dusky.
*6:55 p.m. There was a note to see the patient death record. Review of that death record revealed the time of death was 6:55 p.m. Further review indicated a phone call was made to the physician, and the funeral home was notified. No documentation was found to indicate an assessment was completed or vital signs were noted at the time of death.

Interview with the chief nursing officer (CNO) at 3:15 p.m. on 1/5/09 revealed the provider did not have a policy regarding documentation at the time of death. She further revealed it would have been her expectation at a minimum vital signs should have been recorded at the time of death. She further stated the nurse should have documented her entire assessment at the time of death.

Interview with the CNO at the above time revealed the provider used a 2004 Lippincott, Williams, and Wilkins nursing text as their standard for care. Review of that nursing text revealed documentation at the time of death should include changes in the patient's vital signs, intake and output, and consciousness level. The times of cardiac arrest and end of respirations should have been noted.

Based on record review, interview, and policy review, the provider failed to ensure all sampled medical record entries from different patient service areas were authenticated with signatures, dates, or times. A sample of 300 medical record entries revealed 191 instances where either the signature, date, or time of the entry was not recorded. Findings include:

1. Review of 109 written physicians' orders during review of medical records on all patient care areas revealed 2 were not signed, 19 were not dated, and 55 were not timed.

2. Review of 48 telephone physicians' orders during review of medical records on all patient care areas revealed 10 were not dated and 21 were not timed.

3. Review of 70 physicians' progress notes during review of medical records on all patient care areas revealed 3 were not signed, 1 was not dated, and 12 were not timed.

4. Review of 73 miscellaneous forms regarding physician contact with the patient during review of medical records on all patient care areas revealed 28 were not dated and 40 were not timed.

Interview with the director of nursing and the patient support service quality risk manager at random times during the review of medical records revealed they were aware all entries should have been signed, dated, and timed.

Review of the provider's medical staff rules and regulations reviewed November 2008 revealed all entries in the medical record should have been dated and authenticated. The rules did not include a requirement for the above entries to be timed.

Based on record review and interview, the provider failed to ensure medication was not administered to a patient (34) with a known allergy to that medication. Findings include:

1. Review of patient 34's closed record revealed she had been admitted to the hospital on 7/8/09 and was discharged on 7/15/09. Review of her admission history and physical revealed an allergy to Vicodin was listed in bold letters. Review of her 7/13/09 physician's orders revealed an order for Vicodin 5/325 one or two tablets every four to six hours as needed for pain.

Review of patient 34's medication administration record revealed she had received Vicodin three times prior to discharge. Review of her 7/15/09 discharge orders revealed an order for Vicodin to have been taken for pain at home.

Review of patient 34's electronic medical record revealed an allergy to Vicodin or Co-gesic was listed on each form. Review of Todd Semla et al, Lexi-Comp's Drug Reference Handbook, 12th edition, page 744, revealed they were both brand names for the same generic formula of hydrocodone and acetaminophen.

Interview with the patient support service quality risk manger at 2:30 p.m. on 1/6/09 revealed it would have been her expectation the pharmacist should have noted that allergy prior to sending that medication to the floor to be administered to the patient. She further stated the electronic medical record should have triggered an alert regarding that medication. She stated the pharmacy did not have a policy regarding medication allergies.

Based on observation, interview, and policy review, the provider failed to ensure:
*Medication refrigerator keys were securely stored and not available to unauthorized individuals at four of four nursing stations 3rd floor West, 3rd floor East, 3rd floor North, and 2nd floor East.)
*Intravenous fluids maintained in three of three storage rooms (300 west hallway, 200 east nursing sub-station, and obstetrics unit) were secured from unauthorized access.
*The post acute care unit (PACU) medication cart was unaccessible to unauthorized individuals.
Findings include:

1. Observation on 1/4/10 revealed the medication refrigerator key was stored in an unsecured drawer at the nurses station:
*3rd West nurses station at 4:20 p.m. - The medication refrigerator was locked. The registered nurse (RN) removed the key from an unlocked drawer at the nurses station. Interview at that time with the RN revealed the key for the medication refrigerator was maintained there at all times. Further interview with the RN revealed staff were not always at the nurses station.
*3rd East nurses station at 4:30 p.m. - This surveyor asked the RN where the key to the medication refrigerator was stored. The RN removed the medication refrigerator key from an unlocked drawer at the nurses station. The RN agreed when staff were not available at the nurses station the key would be available to unauthorized individuals.
*3rd North nurses station at 4:50 p.m. - There were no staff available at the nurses station, and the medication refrigerator was unlocked. The RN accompanying this surveyor removed the key from an unlocked drawer at the nurses station.

Interview with the patient support service quality risk manger (PSQRM) at the time of the above observations confirmed the medication refrigerator keys were maintained in unsecured drawers at the nurses stations. The PSQRM agreed unauthorized individuals would have access to medications in the refrigerators when the staff were not available.

Review of the provider's Medication Distribution policy dated July 2009 revealed "Refrigerators will be locked and keys securely stored."




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2. Observation on 1/4/10 at 10:30 a.m. at the end of the 300 west hall revealed an unlocked storage room. Items in the storage room included bags of lactated ringers solution, dextrose solution, dextrose 5% and 0.45% normal saline solution, D5 normal saline solution, normal saline solution, and sodium chloride solution. The storage room also contained patient supplies such as shampoo and bandaids. The storage room was located near the 300 west nurse's station.

Interview on 1/4/10 at 10:35 a.m. with the chief nursing officer confirmed the room was secured but was not kept locked.

3. Observation on 1/6/10 at 8:10 a.m. of the PACU revealed an unlocked cart that contained medical supplies and medications.

Interview on 1/6/10 at 10:35 a.m. with the surgical services director revealed the PACU was under the supervision of a nurse when patients were present. She stated there were times when the cleaning staff arrived in the PACU prior to the nursing staff arrival. She confirmed the medications should have been kept locked up when nursing staff were not present.




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4. Observation on 1/6/10 at 8:30 a.m. in the clean utility room (door frame 1290) revealed an unlocked storage room. Items in the storage room included bags of lactated ringers solution, dextrose solution, heparin sodium solution, and sodium chloride solution. The clean utility room also contained other patient supplies. The storage room was located in a hallway by itself away from supervision.

Interview on 1/6/10 at 8:35 a.m. with the housekeeping supervisor confirmed the room was not kept locked.




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5. Observation on 1/4/10 at 4:10 p.m. of the 2nd floor east nurses sub-station revealed a locked medication refrigerator. Additional observation of the sub-station revealed a key was located in a cabinet drawer. The key was used by the surveyor to unlock the medication refrigerator. There were no authorized personnel present in the sub-station at the above time.

6. Observation on 1/4/10 at 4:10 p.m. revealed a storage room was located behind the 2nd floor east nurses sub-station. The door to the room was unlocked and propped open. The room contained both patient supplies and intravenous solutions. There were no authorized personnel present in the nurses sub-station or the storage room at the above time.

7. Observation on 1/5/10 at 1:25 p.m. revealed an unlocked storage room on the obstetrics unit. The room contained both patient supplies and intravenous solutions.

8. Review of the provider's policy for medication storage and security revised August 2009 revealed:
*The purpose of the policy was to provide for the safe, secure, and appropriate storage of all drug supplies stocked outside of the pharmacy department.
*Accessibility to medication was limited to authorized personnel.
*Personnel were authorized to access medications in their assigned areas.

A. Based on observation and interview, the provider failed to maintain cleanable surfaces on walls in six areas in patient rooms 230, 305, 317, 322, 326, and a clean utility room with a door frame number 2138. Findings include:

1. Observation throughout the survey on January 5 and 6, 2010 revealed several areas in the hospital were the walls in patient areas where damaged. The following rooms had holes and/or gouges in the gypsum board walls: patient rooms 230, 305, 317, 322 (photo 2 and 3), patient room 326 (photo 6), and a clean utility room with a door frame number 2138. Interview with the housekeeping supervisor at the time of the observations confirmed those findings. He stated the damage had been done by the patient recliner chairs present in the rooms. Those areas needed repairs to maintain a cleanable surface.

B. Based on observation and interview, the provider failed to maintain cleanable surfaces on wooden surfaces of two visitor chairs in patient room 306. Findings include:

1. Observation at 9:45 p.m. on 1/5/10 revealed two chairs with a wooden frame were located in patient room 306. The four arms of the two chairs had large areas were the varnish had been worn off exposing the raw wood surfaces (photo 5). Interview with the housekeeping supervisor at the time of the finding revealed the chairs were old, and years of cleaning the chairs also contributed to the vanish being removed.

C. Based on observation and interview, the provider failed to keep microwaves and refrigerators clean in patient nourishment areas of the 4th floor dialysis and the 3rd floor at door frame 3090. Findings include:

1. Observation throughout the survey on 1/5/10 revealed:
* The 4th floor dialysis area microwave had food splatter on it (photo 1).
* The 3rd floor nourishment room (door frame number 3090) microwave had food splatter on it and the refrigerator/freezer was dirty and had food spilled inside (photo 4).

Interview at the time of the above findings with the housekeeping supervisor and the people in charge of the above areas revealed no policy was in place for the cleaning of the nourishment area appliances by any hospital department.




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D. Based on observation, interview, and testing, the provider failed to develop and implement a policy or protocol for monitoring two of two patient blanket warming cabinets located on patient care units 2nd floor clean utility room and the 3rd floor clean utility room. Findings include:

1. Observation on 1/4/10 at 3:45 p.m. in the 3rd floor clean utility room revealed a tabletop blanket warmer. At the time of the observation the digital temperature reading was 142 degrees Fahrenheit (F).

Observation on 1/6/10 at 3:15 p.m. of the 3rd floor warming cabinet revealed the digital temperature reading was 143 degrees F. This surveyor tested the blanket warmer temperature and obtained a reading of 141.6 degrees F.

Observation on 1/6/10 at 3:25 p.m. of the 2nd floor blanket warming cabinet revealed a thermostat set at "blanket warming setting." There was no numerical reading for that temperature setting. This surveyor tested the blanket warmer temperature and obtained a reading of 127.7 degrees F. Review of the manufacturer's label on the inside of the warming cabinet revealed the temperature should not exceed 120.0 degrees F.

Interview on 1/6/10 at 3:15 p.m. and at 3:25 p.m. with the chief nursing officer (CNO) confirmed the above temperature findings. Continued interview with the CNO revealed she was not aware of a policy or protocol for the blanket warmers used on the 2nd and 3rd floor. The CNO stated the temperatures of both warming cabinets were not monitored by staff.

Review of the Association of periOperative Registered Nurses (AORN), Connections Perioperative News Update pamphlet dated August 2009 revealed blanket warming cabinet temperatures should not exceed 130 degrees F.

Review of the AORN, Perioperative Standards and Recommended Practices, 2008 Edition, revealed:
*A warming cabinet temperature should have been checked at regular intervals according to the provider's policy.
*The temperature should have been documented on a temperature log or recorded on a record provided by an electronic recording system.
*Blankets should have been rotated on a first-in, first-out basis.
*Cabinet temperatures above the safe range should have been reported to the clinical engineering for maintenance.

Based on record review and interview, the provider failed to ensure a patient plan of care was developed and implemented for two of five sampled swing bed patients (27 and 28). Findings include:

1. Review of the electronic medical record for patients 27 and 28 revealed:
*Patient 27's admitting diagnosis was left knee osteoarthritis. He was admitted on 10/2/09 and discharged on 10/5/09.
*Patient 28's admitting diagnosis was septicemia. He was admitted on 11/20/09 and discharged on 11/26/09.
*There were no care plans in the medical records for patients 27 and 28.

Interview on 1/5/10 at 3:10 p.m. with the chief nursing officer (CNO) confirmed patients 27 and 28 did not have a plan of care documented within their medical records. The CNO revealed the standard care plan for safety, comfort, and education had not been identified in patient 27 and 28's medical records. She stated the plan of care should have been initiated by the nurse upon the patients admission.

Review of the provider's Plan of Care policy dated May 2008 revealed evidence of implementation of an individualized plan of care was contained within the patient's record. The Patient Care Team developed an individualized plan of care to meet the patient care goals for:
*Implementing and maintaining the medical treatment plan.
*Keeping the patient safe during the hospital stay.
*Keeping the patient comfortable during the hospital stay.
*Patient education.

Based on record review and interview, the provider failed to ensure:
*A comprehensive activity assessment had been completed for one of five sampled swing bed patients (10).
*An effective activity care plan had been developed for two of five (10 and 27) sampled swing bed patients.
Findings include:

1. Review of patient 10's medical record revealed her admission date was 12/30/09. An activity assessment could not be located in the patient's medical record.

Interview on 1/6/10 at 3:10 p.m. with the chief nursing officer (CNO) confirmed there was no activity assessment and no activity care plan in patient 10's medical record. Continued interview with the CNO revealed she had contacted the occupational therapist (OT) responsible for completing patient 10's activity assessment. The OT had informed her the activity assessment had been completed but had not been documented in the patient's medical record.

2. Review of patient 27's activity assessment dated 10/5/09 revealed:
*The patient had been admitted into swing bed on 10/5/09.
*His mobility was slow due to Parkinson disease.
*He enjoyed music and reading "newspaper and/or magazines, and local."

Review of patient 27's activities plan outlined in the 10/5/09 activity assessment revealed "No further needs. Patient (PTS) spouse here during day. Watches a little TV, walks in hall, information (info) provided on lounge area."

Interview on 1/6/10 at 3:10 p.m. with the CNO revealed the activity plan did not indicate what activities the nursing staff should have been offering. The patient enjoyed music and reading, but the type of music and which newspapers and magazines had not been identified.

Review of the provider's Activities Program policy dated June 2006 revealed:
*The activity coordinator or designee was responsible for identifying appropriate activities to meet the patient needs.
*The activity assessment should have been completed within 24 hours of the patients admission.
*An individualized activity plan would be developed for each swing bed patient.
*The patient's medical record would reflect the social activity related goals and interventions that should have been completed.