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Based on observation and interview with staff for 1 patient (Patient #73), the hospital failed to ensure that care was provided in privacy. The finding includes:

a. A tour of the emergency department (ED) was conducted on 8/23/10 at 10:45 AM. Patient #73 was observed being wheeled on a stretcher from one side of the department to the other. Patient #73 was observed to be laying on a bed pan with his/her buttocks and bed pan uncovered and in view of other patients, visitors, and staff who were in the hallway at that time. The ED Department Head identified that staff were moving Patient #73 to a private area and were unaware that he/she was exposed during the transport.


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Based on observations and interviews with facility personnel, the facility failed to ensure that a patient's privacy was protected.

The findings include:

1. During tour of multiple patient care units from 8/20/10-8/23/10, it was observed that a computerized information board located at the entrance to each surgical unit identified the complete first and last name of patients on the unit including what medical service the patient was admitted to. In addition, these communication boards were accessible to staff and visitors. Interview with the Nursing Director of Surgical Services on 8/21/10 identified that the computerized boards are supposed to have the last name of the patient and the first three letters of the first name to protect the patient's privacy.

2. Patient # 127 was admitted to the hospital on 5/3/10 for a cardiac ablation. Interview and review of the clinical record with the Patient Relations Manager #2 on 9/2/10 identified that anesthesia had called the patient's home for a pre-assessment. Upon notification that the patient was not home, the physician informed the family member to have the patient call regarding an "upcoming procedure". Further interview identified that the hospital had informed the physician that a HIPPA violation had occurred. Review of the hospitals "Patient Rights" policy identified that the patient has the right to confidentiality of private information and clinical records.

Based on clinical record review and interview with staff for 1 patient (Patient #121) who requested a copy of his/her clinical record, the hospital failed to provide the patient with the entire record, as requested. The findings include:

1. Patient #121 received treatment in the emergency department on 4/29/10 and 5/5/10 related to sustaining coyote bites to the left leg. The patient then was admitted for additional treatment from 5/6/10 to 5/7/10. Interview with Medical Records Staff #3 on 8/25/10 at 1:20 PM identified that the Medical Records Department received an official request from Patient #121 for a copy of his/her clinical record on 7/12/10, which was processed and the record was sent to the patient. However, Medical Records Staff #3 identified that on 8/25/10, the medical records department realized that they failed to send a copy of Patient #121's physician's orders, as requested.

Based on clinical record review, observation, interviews with staff, and review of policies for one patient (Patient #75) who was brought to the emergency department in police custody, the hospital failed to ensure that restraints were used only when clinically necessary. The findings include:

1. Patient #75 was brought in to the emergency department on 8/23/10 at 10:45 AM in police custody and wearing handcuffs. The patient was placed on a hospital stretcher, a City police officer removed the handcuffs, and the hospital's protective service personnel were observed placing the patient in hospital issued 4-point restraints, which were termed "custodial restraints." Patient #75 remained in 4-point restraints from 10:55 AM until discharged back into police custody at 1:30 PM (2 hours and 20 minutes), without behaviors that would justify the use of 4-point restraints.
Interviews with the VP of Patient Services, VP of Surgical Services, and Director of Protective Services on 8/24/10 at 9:05 AM identified that when a patient is in police custody, the police hand cuffs are removed and the hospital's protective service personnel place the patient in 4-point hospital restraints.
The hospital assumed the role of providing custodial restraints when applying 4-point restraints for a patient in police custody, rather than following hospital policies regarding the use of restraints for patients who are violent or self-destructive.

Based on review of clinical records, policy review and interviews, for one patient (Patient #79), the facility failed to ensure that the patient's peritoneal dialysis was administered as prescribed and/or daily weights were obtained. The findings include the following:

1. Patient #79 was admitted on 7/28/10, with change of mental status, poor intake and a history of end stage renal disease on peritoneal dialysis. Review of the physician orders directed administration of peritoneal treatments with 1.5% low calcium exchanges with Icodextrin 7.5 % for the last dwell. Review of the cycler flow sheets for the period of 8/1/10 through 8/22/10 failed to identify the amount of fluid utilized, the concentration administered and /or a description of the drainage. Review of the clinical record failed to identify that dialysis was administered on 8/13/10, 8/14/10, 8/15/10. Review of the facility policy indicated that documentation of the flow sheet should include the dialysis solution type, additives, time in/time out, the amount of the exchange and a description of the drainage.

2. Patient #79 was admitted on 7/28/10, with change of mental status, poor intake and a history of end stage renal disease on peritoneal dialysis. Review of the flow sheets for the period of 8/1/10 through 8/22/10 failed to identify that the patient had been weighed. Interview with staff on 8/23/10 indicated that the patient was on a Clinitron bed not equipped with a scale. Staff further indicated that the nursing unit did not have a hoyer-lift scale that was operable. The policy indicated the patient's daily weight should be documented on the patient flow sheet.







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Based on review of the clinical record, review of facility policies, and interview, the facility failed to ensure that nursing assessments for bladder distention were completed prior to catheterization of one patient, Patient #113, who was catheterized at the end of a surgical procedure. The findings include:

1. Patient #113 was admitted to the facility on 6/16/10 to undergo a left wrist reconstruction. Review of the clinical record identified that Patient #113 received one thousand milliliters (ml.) of intravenous fluids between 7:00 AM and 8:45 AM. The intraoperative report identified that Patient #113 received an additional nine hundred ml. of IV fluid during the four hour procedure. Interview with RN #19 on 8/25/10 at 1:30 PM identified that toward the end of the surgery, he/she was concerned that Patient #113 may have been uncomfortable due to a full bladder. RN #19 stated that although he/she did not provide an assessment of Patient #113's bladder at that time either by palpation and/or bladder scan, that after a discussion and with MD #28 and Certified Registered Nurse Anesthetist #1 (CRNA #1), he/she was given a verbal order to proceed with the catheterization. RN #19 stated that after setting up the equipment for the catheterization, he/she was relieved for lunch by RN #20. Interview with CRNA #1 on 8/31/10 at 11:05 AM identified that he/she believed that he/she was actually the first person to suggest the need to straight catheterize Patient #113. CRNA #1 stated that he/she based her recommendation on the amount of time Patient #113 had been in the OR and the amount of fluid the patient received but stated that she did not physically assess Patient #113's bladder. Interview with RN #20 on 8/25/10 at 2:20 PM identified that upon entering the OR to relieve RN #19 for lunch, she/she was told by that Patient #113 needed to be straight catheterized and that he/she proceeded to catheterize the patient. RN #20 stated that she/she removed four hundred milliliters (ml.) of urine before removing the catheter. RN #20 stated that he/she did not provide an assessment Patient #113's bladder prior to catheterizing the patient. Although the facility lacked a policy that outlined indications for straight catheterizing a patient, facility practice was that the indication for a straight catheterization was guided by the nurse's assessment and review of that assessment with the Licensed Independent Practitioner and/or physician.

Based on clinical record reviews and interviews with facility personnel for one patient (Patient #107), the facility failed to ensure that a comprehensive plan of care was completed.

The findings include:

1. Patient #107 was admitted to the hospital on 8/1/10 with an esopohageal fistula. Review of the fall assessment dated 8/23/10-8/25/10 identified that the patient was identified with a score of 50 (high fall risk). Review of the nursing plan of care dated 8/25/10 failed to identify that the patient risk for falls/injury was identified on the plan of care. Review of hospital policy "Documenting the Nursing Process" identified that the plan of care will include a problem statement, outcomes and interventions appropriate for each problem. Interview with the Nurse Manager on 8/25/10 identified that the fall prevention plan of care was discontinued and did not know why since the patient was a high fall risk.

Based on observation and interviews for two sampled patients (Patient#101, #105) the hospital failed to follow standards of practice regarding physician's orders and/or ensure the proper labeling and identification of formula feeding. The findings include:

1. Patient #101 was seen in the Emergency Department on 5/1/10 due to an elevated temperature. A review of the Emergency Department record dated 5/1/10 at 12:20PM identified that Motrin 130 milligrams (mg) was administered at 12:20PM and the patient was catheterized for a urine at 3:15PM. Interview and review of the clinical record with Nurse Manager #11 on 8/26/10 at 9:40AM identified that the record lacked a physician order directing to administer Motrin and/or to obtain a urine specimen via straight catheterization. A review of the Hospital Rules and Regulations identified that all orders for inpatient care shall be placed in the computerized provider order entry or be in writing on designated order form.

2. Observations during a tour of the new born special care nursery on 8/24/10 at 9:20AM identified Patient #105 receiving formula feeding via continuous syringe pump. Physician orders dated 8/24/10 directed to administer Neosure po/pg 33 every three hours. Observation and interview with Registered Nurse #14 at the time identified that the formula feeding is ready to serve, however the feeding syringe lacked identification of the formula that was being utilized. Interview with Nurse Manager #14 on 8/24/10 at 9:30AM identified that although a specific policy regarding the labeling of formula feeding is not in place, the feeding syringe should contain identification of the type of formula that is being administered.

Based on clinical record review, interviews and review of hospital documentation for one of two patients (Patient #101) who was seen in the Pediatric Emergency Department, the hospital failed to ensure that the medical record was complete. The findings include:

1. Patient #101 was seen in the Emergency Department on 5/1/10 for an evaluation of an elevated temperature. Interview and review of the Pediatric Emergency Services record with Nurse Manager #11 on 8/26/10 at 9:15AM identified that Patient #101 was assessed by a resident and an attending physician during his/her visit, however, the clinical record lacked documentation of the time of the assessments. A review of the Hospital rules and regulations identified that the text and signatures contained in all Hospital records shall be legible, dated and timed.

Based on review of the clinical record, review of facility policy, and interview for one patient (Patient #97) who experienced a change of condition the facility failed to ensure that the clinical record contained a physician's note related to the assessment. The finding includes the following:


1. Patient #97 was admitted to the facility on 7/12/10 for a coronary artery bypass graft and mitral valve repair. Review of the clinical record indicated that the patient had three chest tubes placed in the operating room. Interview with MD #32 indicated that on 7/16/10 the patient was noted to have a firm abdomen and a CT scan was completed. Review of the CT scan reflected that the patient had free air in the intraperitoneal space with a surgical consult requested. The patient was subsequently taken to the operating room on 7/16/10 where an exploratory laparotomy was performed. The operative note identified a full thickness perforation, which required a resection of the transverse colon. Review of the clinical record failed to identify a physician's note on 7/16/10 when the patient was identified to have a change in condition and/or a note by the consulting surgeon.

Review of the facility policy indicated that all inpatient consultations are the responsibility of the attending physicians and the findings and recommendations should be documented in the record.

Based on review of the clinical record for one patient (Patient #96) who had surgery the facility failed to ensure that the physician's orders were complete. The finding includes the following:

1. Patient #96 presented to the hospital on 6/2/10 with abdominal pain. On 6/3/10 the patient had a laparoscopic cholecystectomy. Review of the physicians post anesthesia orders dated 6/3/10 identified orders for Fentanyl 25 mcg and Dilaudid 0.2 mg as needed for pain, however the order failed to identify how often the medication could be administered and/or a maximum dosage.

Based on observation and interview, the facility failed to ensure that all medications were secured. The findings include:

During a tour of the South Pavilion preoperative areas on 8/24/10 at 10:15 AM, the door to the medication room was observed to be slightly ajar and able to be opened without use of the keypad lock. No licensed staff members were observed to be in sight of the medication door at the time of the observation. Upon further investigation, the door was re-opened by the surveyor, allowed to close on its own, and found to remain ajar. Interview with Pharmacist #2 on 8/24/10 at 10:45 AM identified that the door was designed to close and lock upon exiting. Pharmacist #2 stated that he/she would expedite the repair of the door's latch to ensure the medication door closed appropriately.

Based on a tour of the YNPH and Winchester wings of the hospital with the Facilities Systems Coordinator, the facility failed to ensure that the psychiatric care sleeping rooms and units were maintained in such a manner as to promote the safety and well being of patients.

1. On 08/30/10 at 10:00 AM and various times throughout the day, while touring the adult psychiatric units with the Facilities Systems Coordinator services the following was observed:

a. The faucet and shower controls, sprinkler heads, door lock handles, door hinges and wardrobe hanger rails privacy curtains, posed a potential hanging hazard and were not designed to a psychiatric/ institutional standard;

b. The Intensive Observation Unit had doors that had multiple locking means i.e slide bolt locks that dog into the door frame and dead bolt door locks, and also had drop in ceiling tiles posing a potential hanging hazard off piping above and or framing;

c. The Winchester wing and the YNPH wing had non institutional lighting that provided gaps which could be potential hanging hazard and sporadic areas contained screws used to secure switches lighting and ancillary equipment that were not tamper proof.

Based on observation and interview, the facility failed to ensure a safe environment. The findings include:

1. An observation was made of two bureaus with drawer knobs attached with screws located in Room 318 during tour of the WS3 Adult Psychiatric Unit on 8/24/10. Interview with the Director of Psychiatric Nursing Services on 8/24/10 identified that the drawer knobs should not be present on the bureaus.

2. Tour of the Cardiology Department of the Shoreline Medical Center identified that the cardiac defibrillator and the suction machine were past due for periodic maintenance. The defibrillator maintenance sticker indicated that the service was due March 2010 and the suction machine maintenance sticker indicated that the service was due October 2009.

Based on observation and interview the facility failed to ensure that appropriate infection control measures had been utilized. The findings include the following:

1. Observation on 8/25/10 identified a patient being transported via bed into the hemodialysis unit. The bed was labeled with a contact isolation sign and was being pushed by a staff person wearing gloves only. Review of the facility policy indicated that when patients on contact isolation are transported via the bed, staff are required to wear gloves and a gown. Interview with the Infection Control practitioner on 8/25/10 indentified that staff should wear gown and gloves when transporting an isolation patient via a bed.



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Based on observation, review of manufacturer's directions, and interview, the facility failed to ensure that all surfaces in the operating room were appropriately cleaned. The findings include:

1. During an observation of the turnover of one operating room in the East Pavilion surgical area on 8/25/10 at 10:45 AM, Operating Room Technician #1 (OR Tech #1) was observed to wipe down surfaces of various equipment that included the Mayo stand, a metal cart, and the OR table utilizing a disposable Cavi wipe. OR Tech #1 was observed to quickly wipe the surfaces in a circular motion causing the centers of each surface to be untouched by the Cavi wipe. The centers of each surface were observed to remain dry while the surrounding surface wiped by OR Tech #1 were visibly wet. Interview with OR Tech #1 immediately following the observation identified that his/her training had included to wipe all surfaces with the Cavi wipe in a back and forth motion over the entire surface until visibly wet to ensure the area was clean. Review of the Cavi Wipes manufacturer's directions identified that when using the Cavi wipes, the entire surface would be wiped with the disposable cloth and remain visibly wet to ensure the cleaning process was complete.


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Based on observation and interview the facility failed to ensure that appropriate infection control measures had been utilized. The findings include the following:

1. An observation was made of clean linen bags on the floor of the storage closet during tour of the WS3 Adult Psychiatric Unit on 8/24/10. Interview with the Director of Psychiatric Nursing Services on 8/24/10 identified that the bags were to be hung on the door rack.

2. Tour of the Shoreline Radiology Department on 8/26/10 identified that the vaginal ultrasound probes were disinfected utilizing Cidex OPA solution. Review of the High Level Disinfection Policy identified that when opening a new bottle of Cidex OPA solution, first check the manufacturer's expiration date to be sure that the solution had at least 75 days of remaining shelf life and to record the date opened and expiration date on the bottle. Observation of the opened Cidex OPA solution bottle and interview with the Radiology Manager failed to reflect that the open/expiration dates were documented on the bottle as per policy.

3. Tour of the Shoreline Radiation Oncology Department on 8/26/10 identified that medical equipment was disinfected utilizing Cidex OPA solution. Review of the High Level Disinfection Policy identified that the Cidex OPA solution test strips had a 90 day expiration and that when opening a new bottle one would record the "Date Opened" and "Do Not Use After" date in the space provided on the bottle of test strips. Observation of the Cidex OPA solution test strips failed to reflect the dates as per policy.

Based on review of the clinical record and interviews with facility staff for one patient who received anesthesia, documentation and interviews failed to reflect an accurate anesthesia record. The findings inlcude:

1. Patient #122 underwent an upper endoscopy on 8/25/10 in the Temple Ambulatory Services Department. Review of the Anesthesia Record identified that the patient initially received Propfol 30 mg intravenously and then a Propofol drip. Review of the record and interview with the Anesthesia Medical Director failed to reflect the total amount of Propofol that was administered.

Based on clinical record review, interviews with staff, and review of policies for 1 patient (Patient #125) who was escorted out of the emergency department (ED), the hospital failed to ensure that the patient was assessed for potential medical or psychiatric problems prior to escorting the patient out. The findings include:

1. Patient #125 was referred to the emergency department (ED) on 3/22/10, by a primary care physician, for evaluation of back pain (after declining to contact a pain management clinic). Patient #125's clinical record identified that the patient arrived in the ED at 10:57 AM with a complaint of back pain with a pain level of 10 out of 10. The patient was triaged as a level IV (appropriate for the urgent care/fast track area), however, this was changed by PA #3 to a triage level of III (higher level of care due to multiple complex health problems), which required that the patient be evaluated in the main ED. The next entry in the clinical record was dated 3/24/10 and identified that the patient left without being seen.

Interview with Patient Relations staff member #2 on 8/25/10 at 11:10 AM identified that he/she received a call from a staff member in Administration on 3/22/10 stating that Patient #125 called the hospital and identified that he/she had just been refused treatment in the ED. Patient Relations staff member #2 identified that he/she interviewed RN #16 who stated that Patient #125 threatened the safety of staff and their families and threw his/her self to the floor. Security and City Police were called, and the patient was escorted out of the ED. Patient #125 came back later that day, apologized for his/her earlier behaviors, and agreed to wait to be seen in the main ED.

Interview with RN #16 on 9/1/10 at 1:45 PM identified that he/she performed a rapid assessment of Patient #125 on 3/22/10 at 10:57 AM. The patient complained of back pain, vital signs were obtained, and the patient was identified as hemodynamically stable. RN #16 identified that the patient could be seen in the urgent care area, however, PA #3 identified that the patient required a higher level of care. RN #16 apprised Patient #125 of the need to be seen in the main ED, and that the patient would have to wait to be seen. RN #16 identified that Patient #125 became belligerent, threatening the safety of staff, and threw his/her self to the ground. RN #16 asked the patient to stand up and the patient did. Patient #125 continued to threaten the safety of RN #16 and his/her family. RN #16 identified that the ED charge nurse took over and he/she did not see Patient #125 leave the ED area.

Interview with RN #18, (ED charge nurse 3/22/10) on 8/9/10 at 11:20 AM identified that he/she was not involved in the care or treatment of Patient #125 on 3/22/10.

Interview with PA #3 on 8/26/10 at 9:50 AM identified that patients who have complex medical problems that include unrelieved pack pain are not appropriate for fast track and need to be seen in the main ED. PA #3 identified that he/she did not see Patient #125 on 3/22/10.

Patient #125's clinical record was reviewed with RN #18 and Legal Counsel #2 on 8/9/10 at 11:20 AM. The record lacked an assessment of Patient #125 following the patient throwing his/her self to the ground, and lacked a medical screen of Patient #125 for the potential need for medical and/or psychiatric care (by a member of the medical staff), prior to escorting the patient out of the ED. Review of Patient #125's return visit to the ED on 3/22/10 at 3:20 PM identified that the "patient was signed into the ED several hours ago" and "was not evaluated at that time."