HospitalInspections.org

25745

Based on observation, staff interview, review of facility policies and procedures, review of manufacturers' recommendations, and review of recommendations from the Centers for Disease Control, the facility failed to ensure staff followed appropriate infection control practices during random observations. The findings were:

Deficient practice related to lack of hand hygiene:
1. Observation on 7/27/10 from 8:20 AM to 9:45 AM revealed the following deficient practices related to lack of hand hygiene:
a. At 8:20 AM RN #4 was comparing medication cards with individual file cards. After completing this, she placed the cards in slots on a medication tray and began to set up medications for patients #7, #24, #25, #26 and #27. During this process, the RN was unable to open two of the unit-dose blister packs, so she reached into her pocket and pulled out her scissors. Without cleaning the scissors, the RN cut both blister packs, removed the tablets with her fingers, and placed them into the medication cups. She then placed the scissors back into her pocket. The RN next removed a set of keys from her pocket and unlocked and opened a second cabinet containing injectable medications. The RN removed Lovenox from this cabinet, relocked the cabinet, returned the keys to her pocket, prepared the Lovenox for injection, and then went back to setting up the remaining medications.
b. At 8:35 AM the RN administered the two oral tablets she had handled with her bare hands to patient #26. She also administered the injectable Lovenox without wearing gloves.
c. The RN administered three oral medications to patient #7 at 8:38 AM.
d. At 8:44 and 8:47 AM, the RN was observed as she administered two inhaled medications for patient #24. However, the RN dropped the capsule for the Foradil inhaler on the bedside table and picked it up with her bare hands before placing it in the inhaler. The patient rinsed his/her mouth after these medications and spit the fluid into an emesis basin. The RN donned gloves to handle and empty the basin, removed the gloves, and, without further hand hygiene, handed the patient the two oral medications at 8:50 AM.
e. After administering these medications, the RN returned to the nurses' station and signed out for each patient's medications on the medication administration records.
f. At 8:55 AM the RN set up medications for patient #27, but left them on the medication tray as the patient was not in his/her room.
g. At 9 AM the RN checked on patient #25. Since the patient was a diabetic, the RN returned to the nurses' station, obtained the glucometer and, without cleaning or disinfecting it, checked the patient's blood sugar level at 9:02 AM. As the patient's blood sugar was high, she called the physician, then returned the glucometer to the case without ever cleaning and disinfecting it. When the physician arrived, he ordered an additional dose of Lantus insulin, which the RN prepared and administered at 9:17 AM, again, without wearing gloves.
Observations ceased at 9:45 AM. Despite performing many tasks requiring hand hygiene, during the hour and 25 minute period from 8:20 AM to 9:45 AM, the RN never washed her hands or used a hand sanitizer. During an interview on 9/27/10 at 10 AM, the DON defined her expectation for performing hand hygiene as "...all the time...in and out of patient rooms...between patients...before and after glove use." Review of the facility's policy and procedure entitled "Hand Hygiene At Johnson County Healthcare Center" procedure number IC-064.1, last reviewed 1/2006, supported the DON's expectation. The policy specified that handwashing or alcohol-based hand rubs should be used "...b. Before and after procedures...c. Before and after applying gloves...d. After touching excretions (...or materials soiled with them)...before touching any patient/resident again...i. Before and after preparation of medication.."

Deficient practice related to failure to clean and disinfect the glucometer:
1. Observation on 7/27/10 at 4:30 PM showed RN #8 used a glucometer to perform a glucose test on patient #4. The observation showed she did not clean or disinfect the glucometer before or after use. Immediately after the observation, RN #8 brought the glucometer to RN #4 in CCU. Observation showed RN #4 then performed a glucose test on patient #25, again without cleaning or disinfecting the glucometer prior to or after use.
2. Refer to #1. g. under "Deficient pratice related to hand hygiene."
3. Interview with the DON on 7/29/10 at 9:40 AM revealed staff were to clean glucometers after each use. She further stated the facility did not have a policy and procedure for cleaning glucometers. Review of the manufacturer's recommendation for glucometer cleaning showed, "Follow your facility's policies and procedures for infection control...."
4. According to the Centers for Disease Control recommendations, "Glucometers should be assigned to individual patients. If a glucometer that has been used for one patient must be reused for another patient, the device must be cleaned and disinfected." Recommended infection-control and safe injection practices to prevent patient-to-patient transmission of bloodborne pathogens. Centers for Disease Control website. 2005. Available at: www.cdc.gov/hepatitis/Resources/OrderPubs/HealthProf/PrevP-to-PTransHandout_Eng.pdf. Accessed May 10, 2010.

25745


Based on medical record review, review of an internal memo, staff interview, and review of facility policies and procedures, the facility failed to assess nutritional needs for 1 of 1 sample acute care patient (#1) who was identified as being "at nutritional risk." The findings were:

Review of the nursing admission assessment dated 7/25/10 for patient #1 showed staff documented s/he was "at nutritional risk." Further review showed a nutritional assessment was not in the record. Review of a memo provided by the certified dietary manager (CDM) entitled "RAPID IMPROVEMENTS" and dated January 2010 showed key changes included "List of diagnoses that would trigger dietary consult" and "Nursing asked to alert dietary by writing "Deb consult" on either dietary requisition or night dietary sheet for listed dx."
During an interview with the CDM and registered dietitian (RD) on 7/28/10 at 1 PM, each said they were unaware that the patient had been determined to be "at nutritional risk" and acknowledged the RD had not assessed the patient.
Review of the facility's policy and procedure showed, "All patients identified as being at Moderate or Severe Nutritional Risk, will have a comprehensive RD assessment..."

Based on review of policies and procedures and staff interview, the facility failed to ensure the policies for the pharmacy department were reviewed annually. The findings were:

Review of the policies for the pharmacy department showed they were kept in three separate binders. Those in the first binder had been reviewed and revised. However, the second binder contained several policies last reviewed in 2009, and the third contained policies primarily reviewed or revised in 2003. In the absence of the pharmacist, interview with the pharmacy technician on 7/27/10 at 1 PM revealed that revising the policies was a "work in progress." She confirmed that about one third of the policies had not been reviewed or revised for six and a half to seven years.

Based on observation, staff interview, medical record review, and review of policies and procedures, the facility failed to ensure expired medications were not available for patient use in 2 of 5 areas where medications were administered. Furthermore, medications were unsecured in the critical care unit (CCU). In addition, the facility failed to ensure medications were administered as ordered for 3 of 19 sample inpatients (#14, #15, #20). Finally, the facility failed to ensure verbal and telephone orders were signed by the physician in a timely manner for 2 of 20 sample inpatients (#5, #14). The findings were:

Deficient practice related to expired medications:

1. Observation in the emergency department with the DON on 7/29/10 at 10:35 AM revealed individual doses of stock medications were stored in zip-lock bags or in larger containers. The following expired medications were available for patient use:
a. Clonidine 0.1 mg, expired 10/1/09
b. Diphenhydramine (Benadryl) 25 mg, two capsules, expired 3/1/2010
c. One tube of L-M-X4 (Lidocaine 4%), expired 3/2010
d. One bottle of Genabs (acetaminophen) 325 mg, expired 5/2010
e. One jar containing several Glycerine suppositories, expired 5/2010
f. One tube of Lidocaine, expired 6/2010
In addition, two tablets of omeprazole 20 mg had no expiration date listed on the label. During the observation, the DON confirmed the omeprazole lacked an expiration date and that expired medications were available for patient use.

2. During an observation in the CCU on 7/29/10 at 12:25 PM, one opened vial of Novolin R insulin was dated as first used on 4/21/10. An interview with RN #2 during the observation verified the medication had been used and was available for future use; however, it was outdated, as opened injectable insulin was only good for 30 days.

3. According to the facility's policy and procedure, "Unusable Medications and Devices," procedure number 0260-30A, last revised 2003: "Expired (outdated) medications will be removed from stock..."

Deficient practice related to unsecured medications:

Observation revealed the CCU was located on one side of a corridor. It consisted of a long narrow room; one side was divided into three separate, glassed patient cubicles which were curtained for privacy. The nurses' station was across from all three cubicles with walking space separating it from the patient areas. A counter with cabinets fastened above was against the wall behind the nurses' station, again with walking space separating the two areas. Doors at either end of the unit were always open, and there was no limitation on who could enter the unit. Throughout the survey, staff were not consistently present in the CCU as they also cared for patients in rooms on the other side of the corridor.
Observation on 7/27/10 from 8:35 AM to 9:45 AM and on 7/28/10 at 9:30 AM showed medications were placed in medication cups and left on an unsecured tray placed on the counter in the CCU. Numerous employees and visitors were present on both sides of the nurses' station at various times during these observations when the RN was not present. In addition, observation on 7/27/10 showed the cabinet containing stock medications was left unlocked from 8:30 AM until 8:55 AM. Interview with the DON on 7/27/10 at 10 AM revealed that setting the medication tray containing medications out on the counter was the usual staff practice. The DON confirmed the CCU was open and that staff and visitors had unlimited access to that area. The DON also confirmed that medications should be secured after they were set up. According to the facility's policy and procedure, for "Medication Dispensing," procedure number 1600-2 (A), effective 11/03, medications "...will be locked at all times..."

Deficient practice related to lack of evidence of medication administration:

1. Medical record review showed patient #14 had physician orders dated 3/21/10 for Pantoprazole (proton pump inhibitor) 40 milligrams (mg) daily, Levothyroxine (thyroid product) 75 micrograms daily, and Escitalopram (antidepressant) 20 mg daily. Review of the patient's medication administration record (MAR) for March 2010 showed that on 3/22/10, it was not initialed by the nurse to indicate she had administered each of the identified medications. Interview with the DON on 7/29/10 at 9:40 AM revealed she could not determine if the medication was given because the MAR was not initialed.

2. Medical record review revealed patient #15 underwent surgery on 9/18/09. Upon the patient's return from surgery, the physician ordered the narcotic, Morphine Sulfate, intravenously for pain control. According to Turkoski, Lance, and Tomsik in Drug Information Handbook for Nursing, 11th Edition, 2010: "constipation" is a side effect of Morphine Sulfate. The physician discontinued the Morphine on 9/19/09 and ordered two tablets of the laxative, Senokot-S twice daily until the patient had a bowel movement. Review of the MARs dated 9/19/09 showed no evidence the patient received the evening dose of Senokot-S, even though s/he had not had a bowel movement. Interview with the DON on 7/29/10 at 8:44 AM confirmed the space for Senokot-S was not initialed as administered. The DON verified there was no evidence the medication was given as ordered.

3. According to the medical record, patient #20 was admitted on 4/8/10. Review of physician orders and the April 2010 MARs showed the patient was to receive Prednisone 5 mg and Colace 100 mg at 9 PM and Glyburide 10 mg at 5 PM. Further review of the MAR showed no evidence these medications were administered at the specified times on 4/12/10. On 7/29/10 at 9:37 AM the DON verified the medications were not initialed as administered; therefore, there was no evidence they were given.

Deficient practice related to unsigned verbal and/or telephone orders:

1. Review of the medical record for patient #14 showed one verbal order and one telephone order, dated 3/22/10. Further review showed each order was not signed by the physician until 4/29/10 (38 days later).

2. Medical record review showed two verbal/telephone orders had been written for patient #5 on 7/22/10, and one was written on 7/23/10. Neither of the three had been signed as of 7/27/10 at 4:30 PM.

3. Although a time line was not specified in facility policies and procedures or in the "Medical Staff Rules and Regulations," the director of health information management stated in an interview on 7/27/10 at 2:35 PM that verbal and/or telephone orders should be signed by a physician within 48 hours.

Based on medical record review, staff interview, and review of the plan of correction for the 4/2/10 complaint survey, the facility failed to develop care plans for 3 of 6 sample, acute care patients (#1, #3, #12) to address identified concerns within timelines established by the facility. The findings were:

According to the plan of correction for the 4/2/10 complaint survey, the facility would ensure care plans were developed for acute care patients within twelve hours of admission. The date of compliance for this plan to become effective was 5/17/10. Review of medical records of patients admitted to acute care since that date revealed the following deficient practice:
a. An initial nursing assessment for patient #1 was completed on 7/25/10. The assessment also showed the patient was "at nutritional risk." Review of the patient's care plan showed the facility failed to address nutrition as a need. Review of the facility policy and procedure showed, "All patients identified as being at Moderate or Severe Nutritional Risk, will have a comprehensive RD assessment with a care plan being developed in cooperation with other health care team members as needed." Interview with the certified dietary manager and registered dietitian on 7/28/10 at 1 PM confirmed a care plan had not been developed.
b. Review of the medical record showed patient #3 was admitted on 7/26/10 at 2:09 PM. Review of the record again on 7/27/10 at 5 PM (27 hours after admission) revealed no evidence a care plan had been developed.
c. Patient #12 was admitted on 7/22/10 at 8:10 AM and delivered a premature infant that day. Review of the care plan revealed it was pre-printed and had not been individualized. The only identified concern for this patient was "post partum bleeding." During an interview on 7/28/10 at 9:45 AM, the DON acknowledged the care plan was inadequate. She confirmed many other care issues were also of concern and should have been addressed on the care plan.

Based on medical record review, staff interview, and review of policies and procedures, the facility failed to ensure medical records for 8 of 20 sample patients (#1, #2, #5, #12, #15, #16, #22, #23) contained necessary, accurate, and complete information. The findings were:

1. Medical record review identified deficient practice related to advance directives for the following sample patients:
a. Review of the medical record for patients #1 and #16 showed the area for advance directives on each STATEMENT OF ACKNOWLEDGEMENT form was blank. Further review showed no advance directives in either medical record.
Review of the medical record for patient #22 showed s/he had no STATEMENT OF ACKNOWLEDGEMENT form or advance directive in the medical record. Further review showed no evidence the patient ever received patient rights information.
Interview with the DON on 7/29/10 at 9:40 AM verified there was no information on advance directives in the medical record for patients #1, #16, and #22. In addition, the DON stated there was no acknowledgement in the medical record that patient #22 ever received patient rights information.
b. Patient #2 was admitted on 7/25/10. Further review showed that areas addressing advance directives on the "Statement of Acknowledgment" and the nursing admission assessment were blank. Detailed review of the entire medical record showed advance directives were not included. The DON confirmed this lack on 7/26/10 at 3:23 PM
c. Patient #5 was admitted to acute care on 7/21/10 and transferred to swing bed status on 7/24/10. According to the 7/21/10 nursing admission assessment, the patient had advance directives; however, they were not included in the acute care record. On 7/28/10 at 2:23 PM the DON stated that instead of copying the information for the patient's swingbed record, staff removed the directives from the acute care record.
d. Patient #15 was admitted on 9/17/09 for an elective induction. Review showed the "Statement of Acknowledgment" was signed, but the area for advance directives was blank. Review of the entire record showed advance directives were not addressed in any other portion of the facility's labor and delivery chart. The DON reviewed the record on 7/29/10 at 8:44 AM and confirmed the lack of advance directives.
e. Patient #23 was admitted to the critical care unit on 7/27/10, but advance directives were not indicated. Further, the area for advance directives on the "Statement of Acknowledgment" form was blank.

2. Deficient practice related to inaccurate or incomplete information was identified for the following sample patients:
a. Medical record review showed patient #12 delivered a premature infant on 7/22/10. Review of the "Obstetric Discharge Summary" showed the physician checked "Term Pregnancy-Delivered" instead of documenting in the area for preterm delivery. In addition, the forms entitled "Obstetric Admitting Record," "Labor and Delivery Summary," and "Labor Progress Chart" were incomplete. On 7/28/10 at 9:45 AM the DON confirmed the inaccurate and incomplete information.
b. Documentation on the "Obstetric Admitting Record" dated 9/17/09 and a consultation report dictated on 9/22/09 indicated patient #15 was pregnant with a second child. However, the history and physical (H&P) documented that this was the patient's first pregnancy. In addition to these discrepancies, the forms labeled "Obstetric Admitting Record," "Labor and Delivery Summary," and "P.A.C.U. Record" were incomplete. Furthermore, prenatal information was not included in the record.
Review of the facility's policy and procedure entitled "Medical Record Content" procedure number 4009, last revised 4/2010, revealed that "...obstetrical records will include all prenatal information..." The DON confirmed the inconsistent documentation, the incomplete forms, and the lack of prenatal information on 7/29/10 at 8:44 AM.


























25745

Based on medical record review, staff interview, review of policies and procedures, and review of the "Medical Staff Rules & Regulations," the facility failed to ensure the history and physical (H&P) examination was completed, and a consultation dictated, in a timely fashion for 1 of 20 sample patients (#15). The findings were:

According to the medical record, patient #15 was admitted on 9/17/09. However, the H&P was not dictated until 10/16/09, almost a month after the patient's admission. A consultation conducted on 9/18/09 was not dictated until 9/22/09 after the patient had been discharged. On 7/29/10 at 8:44 AM, the DON confirmed the documented reports were not completed in a timely fashion. Review of the facility's policy and procedure entitled "Medical Record Content" procedure number 4009, last revised 4/2010, showed the H&P was to be "recorded in the medical record at the time of the patient's admission." Review of the "Medical Staff Rules & Regulations," last revised 1/31/07, showed a complete H&P "...shall be written or dictated within 24 hours after admission of the patient."

Based on medical record review and staff interview, the facility failed to ensure required orders for surgery were on the medical record for 1 of 3 sample patients (#15) who underwent a surgical procedure. The findings were:

According to a consultative report, the operative report, and the discharge summary, patient #15 underwent surgery on 9/18/09. Review of the physician's orders showed none addressed the type of surgery, the surgical preparations, or the medication changes that were documented in the consultation report as occurring prior to surgery. On 7/29/10 at 8:44 AM the DON confirmed these orders were not recorded in the record.

Based on observation, staff interview, and review of policies and procedures, the facility failed to ensure medical records were secured from unauthorized access in 2 of 3 storage areas. The findings were:

During an interview on 7/27/10 at 2:35 PM, the director of health information management (HIM) stated current medical records were stored on the main level of the hospital with older records stored in the basement. The director and the administrator stated that, in order to obtain records after hours, the RN in the emergency department had a key to the record room. However, they also stated that housekeeping had a key and would clean after hours. In addition the administrator stated that he and maintenance had master keys to the building.
Observation with the director on 7/27/10 at 3 PM revealed the basement storage area consisted of two inner rooms off an entrance room from the corridor. The entrance room was used for storage by the billing office, and they had a key to that area. Further observation showed the doorknob was missing from one of the medical record storage rooms so the room was unsecured, thus allowing anyone with access to the front area to have access to the records. During the observation, the director of HIM stated the doorknob had been off about a month.
According to the facility's 4/2010 policy and procedure, "Secure Filing of Medical Records," medical records shall "...be kept in secure areas at all times...shall not be left unattended in areas accessible to unauthorized individuals...accessed only by Health Information Management personnel or their designees."

Based on medical record review, staff interview, review of policies and procedures, and review of the "Medical Staff Rules and Regulations," the facility failed to conduct surgery in a safe manner for 1 of 3 sample patients (#15). The findings were:

Review of the medical record showed patient #15 was admitted on 9/17/09 and underwent a Caesarean section (C-section) on 9/18/09. Detailed review of the entire medical record revealed the history and physical (H&P) was not on the record at the time of surgery, nor was there a note indicating that a delay of the procedure would be detrimental to the patient. Further review revealed the "Obstetrical Admitting Record" was incomplete and did not contain the information required for an H&P. On 7/28/10 at 4:05 PM the administrator called the clinic and verified that an H&P had not been done as part of prenatal care. After searching for the H&P, the DON produced a copy on 7/29/10 at 10:20 AM and stated it was the only information she could locate. The copy was the same as the original which had not been dictated until 10/16/09, almost one month after the patient's surgical procedure.
According to the "Medical Staff Rules & Regulation" revised 1/31/07, "...except in severe emergencies...", patients must be assessed prior to any surgical procedure. This assessment should include a history and physical examination..." which must be "...recorded on the patient's medical record prior to any surgical procedure." If not recorded, the operation "...shall be canceled unless the attending surgeon states in writing that such delay would be detrimental to the patient..."
Review of the 4/2010 policy and procedure, "Medical Record Content" procedure number 4009 revealed the following information for an H&P included, but was not limited to, "...Chief complaint...History of present illness...Relevant past medical history, family and social history...Review of systems, including a minimum review of the cardiovascular, respiratory, genitourinary and gastrointestinal systems...Obstetrical records will include all prenatal information, which may be a copy from the physician's office."
On 8/3/10 at 9:17 AM, the administrator verified the facility was unable to locate any other information related to an H&P done prior to before the patient's surgical procedure.

Based on medical record review, review of the facility's policies and procedures, and staff interview, the facility failed to ensure that the designated organ procurement organization (OPO) was notified concerning the death of 1 of 2 sample patients (#9) whose records were reviewed for organ procurement. The findings were:

Review of the medical record for patient #9 showed s/he was admitted to the emergency department on 6/1/10 at 5:50 PM with an original diagnosis of altered mental status. Further review showed the patient's condition deteriorated, which resulted in cardiac arrest and death on 6/1/10 at 10:39 PM. The record review showed the facility did not contact the OPO at any time. During an interview on 7/28/10 at 1 PM, the DON confirmed the OPO had not been notified as required.
According to the facility's policy and procedure for organ procurement, "Any patient meeting the following criteria will be considered as a possible organ and/or tissue donor. These criteria apply to patients of all ages, including newborns. Criteria include, 'Cardiac Death: Cessation of cardiac function (asystole)'."

Based on medical record review, review of an internal memo, review of policies and procedures, and staff interview, the facility failed to complete a nutritional assessment for 1 of 1 sample swing bed patient (#6) with an identified nutritional risk. The findings were:

Review of the medical record for patient #6 showed an initial nursing assessment was completed on 7/21/10. Further review showed the patient was assessed as being "at nutritional risk." Review of a January 2010 memo provided by the certified dietary manager (CDM) titled "RAPID IMPROVEMENTS" revealed the process devised to request a dietary consult included, "List of diagnoses that would trigger dietary consult" and "Nursing asked to alert dietary by writing "Deb consult" on either dietary requisition or night dietary sheet for listed dx." Interview with the CDM and registered dietitian (RD) on 7/28/10 at 1 PM showed they were unaware the patient required a comprehensive nutritional assessment by the RD.
Review of the facility's policy and procedure showed, "All patients identified as being at Moderate or Severe Nutritional Risk, will have a comprehensive RD assessment..."

Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan for 1 of 5 sample swing bed patients (#20) that addressed all identified concerns. The findings were:

Review of the medical record showed patient #20 was admitted to swing bed status on 4/8/10 for rehabilitation after spinal surgery. The patient was assessed as having significant pain and as smoking half a pack of cigarettes a day. Review of the care plan showed neither of these issues was addressed. The DON confirmed this failure on 7/29/10 at 9:37 AM.

Based on medical record review and staff interview the facility failed to develop a post-discharge plan of care or complete a discharge summary that included a recapitulation (recap) of stay for 1 of 1 swing bed patients (#20) reviewed who required those services. The findings were:

Medical record review showed patient #20 was admitted to swing bed status on 4/8/10 and discharged on 4/13/10. Further review showed neither a post-discharge plan of care nor a discharge summary containing a recap of stay was included in the record. The demographics were completed on the discharge plan, but the area for problems, goals, and interventions was blank. On 7/29/10 at 9:37 AM the DON confirmed the post-discharge plan of care and the recap of stay were not completed.