HospitalInspections.org

Based on medical record review, document review and staff interview, the facility failed to periodically measure the effectiveness of its medication administration timing policies (Patient #s 2, 23, 25, 28 and 31).

Findings include:

Review of Medication Administration Records for five (5) of five patients revealed that nurses consistently documented the scheduled times and not the actual time medications were administered.

Review of the facility's 2017/2018 Quality Assurance and Performance Improvement Data, shows that data has not been collected and analyzed to measure the effectiveness of staff adherence to medication administration timing policies.

On 11/2/2018 at 10:45 AM, during interview with Staff E, Chief Nursing Officer, she confirmed that staff adherence to Medication Administration Timing policies has not been measured and acknowledged that due to the current documentation practice, adherence to the policy could not be determined.

Based on medical record review, document review and staff interview, in two (2) of four (4) transfusion orders reviewed, nursing staff failed to implement physician orders. Specifically, the duration of blood transfusion was not implemented (Patient #s 2 and 31).

Findings include:

Review of facility policy and procedure titled "BB004 Administration of Blood and Blood products" last reviewed 08/21 2018, indicated that blood should be infused within four hours of leaving the blood bank as per physician order.

Review of medical record for Patient #31 noted an order on 10/19/2018 at 7:30 AM for one (1) unit of Packed Red Blood Cells (PRBC) to be infused for two (2) hours. Nurse note revealed Blood transfusion start time: 8:02 AM and end time: 11:00 AM.

The PRBC was not transfused in two hours as prescribed by the physician. There was no documented evidence of the rationale for not implementing the physician order.

On 10/31/2018 at 11:30 PM, Staff A, Registered Nurse, acknowledged that the order was for the PRBC to be transfused in two hours but that she implemented the Blood Transfusion Policy, which indicates that blood and blood products should be transfused within four hours.

Similar finding was noted for Patient #2, who on 10/26/2018 at 08:14, had a physician order to receive one unit of PRBC with a transfusion rate of 2 hours per unit. The nurse documented 9:55 AM and 12:30 PM as the start and end times respectively.

There was no documented evidence that the blood transfusion order was implemented as prescribed by the physician.

Based on medical record review, document review and staff interview, the facility failed to ensure that:
(1) Nutrition screen is conducted on admission for patients to identify their nutrition risk. This finding was noted in four (4) of seven (7) medical records reviewed (Patient #s 37, 38, 39 and 40);
(2) Therapeutic menus are evaluated for nutritional adequacy. This finding was evident in 11 of 11 menus reviewed;
(3) Physician prescribed diet includes specific restrictions that meets identified nutritional needs of patients.

Findings include:

1) Review of medical record for Patient #37 revealed that the nutrition screen on admission (10/29/18) was incomplete after three days of admission.

Review of medical record for Patient #38 noted that the patient was admitted on 10/30/18.
There was no documented evidence of a nutrition screen two days after admission.

Similar findings were noted for Patient #s 39 and 40 who both had incomplete nutrition screen during their admission assessment.

On 11/1/18 at approximately 1:00 PM, Staff B, RN acknowledged findings.


2) Review of facility's therapeutic menus and their corresponding caloric content, revealed that menus did not specify measurements and describe restrictions,

The nutritional adequacy of each menu was not determined as there was no documented evidence that a nutritional analysis had been conducted.

During interview on 10/31/18 at approximately 1:30 AM, Staff D, Clinical Nurse Manager, acknowledge findings.


3) Review of Diet Formularies used by physicians for diet orders shows that it did not specify the restrictions for each therapeutic diet. In addition, the prescribed orders for diet did not match the facility approved menus.

For example, a "Low fat -low cholesterol "diet order did not include the amount of fat allowed in the food.
An order for "renal diet" did not include restrictions for protein, potassium and other restrictions required for the diet.

Similar findings were noted for "consistent carbohydrate meal plan" and other diets listed on the hospital diet formulary.

On 10/31/18 at 2:00 PM, Staff D acknowledged findings.

Based on observation and staff interview, the facility failed to ensure that the environment of the Outpatient Operating Room was constructed and maintained in such a manner that the safety and well-being of patients are assured.

This failure may result in infection control and safety hazard to patients.

Findings include:

During the tour of the 4 th Floor Ambulatory Surgery procedure rooms on 10/31/2018 at approximately 2:00PM, it was observed that five (5) of the seven (7) procedure rooms (Room #s A, B, C, D and E), used to perform minor surgeries under sedation, had tiled floors and had voids between the coved base and the flooring.

The flooring surfaces were not easily cleanable due to the collection of dust and moisture in between the tiles. This flooring also did not allow ease of ambulation for patients using canes/walkers, due to the possibility of equipment getting stuck in the joints between the tiles.

Procedure rooms must have a monolithic and joint free floor with integral coved base.

On 10/30/18 at approximately 2:30 PM, Staff H, Director of Operation-Engineering acknowledged findings.
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