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Based on record review and interview, the facility failed to ensure that the services performed under a contract are provided in a safe and effective manner, including insuring that every contracted service is evaluated as part of the QAPI plan.

Findings:

Review of four contracts, Anesthesia, Food Services, Pest Control, and Bariatric Service (equipment) reflected that Food Services, Pest Control, and Bariatric Service (equipment) did not document a quality review that was presented to or reviewed by the board of directors.

Interview with the Vice President of Quality on 03/09/2012 at 9:55 a.m. confirmed that the facility did not have evidence that all contracts were review as part of the quality program by the board of directors.

Based on interview and record review, the hospital failed to protect each patients' rights affecting 21 of 38 sampled residents concerning (#8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 36, 37 & 38) and 4 of 12 sampled staff (#TT, UU, VV & WW).

the following:

Findings:

1. Refer to A117 - Based on interview, medical record review and a review of facility documentation, the facility failed to ensure the provision of patient rights in advance of furnishing care for 20 of 38 sampled patients, and failed to ensure the provision of a process in the form of policies and procedures that described how to facilitate the expeditious and non-discriminatory resolution of disputes about whether an individual is an incapacitated patient's representative (#8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 36 & 37).

2. Refer to A154 - Based on record review and interview, the facility failed to ensure staff use appropriate restraints on 1 of 2 sampled patients (#38).

3. Refer to A168 - Based on record review and interview, the facility failed to ensure staff obtain a physician order for the use of restraints on 1 of 2 sampled patients (#38).

4. Refer to A206 - Based on personnel training file, record review and interview, the facility failed to require 1 of 12 sampled staff to have restraint training (#VV); and failed to require 4 of 12 sampled staff to have restraint related first aid training (#TT, UU, VV & WW).

Based on interview, medical record review and a review of facility documentation, the facility failed to ensure the provision of patient rights in advance of furnishing care for 20 of 38 sampled patients, and failed to ensure the provision of a process in the form of policies and procedures that described how to facilitate the expeditious and non-discriminatory resolution of disputes about whether an individual is an incapacitated patient's representative (#8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 36 & 37).

Findings:

During a review of the medical records of patients #8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 36 and 37, no evidence was uncovered which confirmed the provision of patient rights information in advance of care. This was confirmed in during an interview with the Assistant Director of Nursing and Risk Manager at 3:15 PM on 3/08/12.

A review of facility documentation did not reveal any mention of who was to inform patients of their rights in advance of care or how patient rights information was to be provided. This was confirmed during an interview with the Patient Access Director and Risk Manager during an interview on 3/8/12 at approximately 11:37 AM.

A review of facility policies and procedures did not reveal any which described how to facilitate expeditious and non-discriminatory resolution of disputes about whether an individual is an incapacitated patient's representative This was confirmed during an interview with the Risk Manager on 3/08/12 at approximately 11:45 AM.

Based on record review and interview, the facility failed to ensure staff use appropriate restraints on 1 of 2 sampled patients (#38).

Findings included:

During an interview on 03/07/12 at 3 p.m., security officer (staff XX) said he did assist with the application of restraints, does not apply the restraints directly to the patient, but holds the patient so the other staff can put the restraints on. He said he has held patients down and has used handcuffs on patients two times when patients who were Baker Acted, were trying to escape, or hit staff. About 8 months ago, during a situation in the emergency department (ED), the nursing supervisor gave him permission to apply the handcuffs because the patient was trying to hit staff in the face.

During an interview on 03/08/12 at 11:15 a.m., security officer (staff YY) said she is called to units to assist with holding patients for restraint application. She said she does not carry handcuffs, only the armed officers carry handcuffs, but she has observed other officers using handcuffs on patients, about a year ago. On one occasion, one of the other security officers grabbed a patient after the patient eloped, took him down, and put handcuffs on the patient until the police arrived. The police and security escorted the patient back to the ED to get some of the medical devices removed, but the patient became violent and was eventually taken to jail. She said she does consider handcuffs to be a restraint.

Review of the medical records for patient #38 showed he arrived at the Ed on 7/12/2011 at 8:08 p.m. Review of the Security Daily Shift Summary dated 07/13/2011 for the first shift documented the following:
7:00 a.m. - Patient in handcuffs due to request by ED charge nurse, as he had escaped tough cuffs 3 times.
9:00 a.m. - Baker Acted patient in ED 15 was transported to room 369-B. Staff XX assisted to remove cuffs for transfer to bed.
9:15 a.m. - Handcuffs were taken off Baker Acted patient in room 369 and tough cuffs were placed on patient, hospital sitter to watch patient.

Review of the policy "Patient Restraints" dated as effective 01/10/2012, read, "The use of handcuffs and other restrictive devices used by law enforcement who are not employed or contracted by the facility for custody, detention or other public safety reasons, and not for the provision of healthcare, is not governed by these standards. However, the use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients."

Review of the job description for the Armed and Unarmed Security Officers, dated effective 05/2010 showed the following essential function - Knows and follows hospital policies and able to put into action all codes and emergency plans as it relates to security function, and - Provide security function in ensuring a safe, secure, functional and effective environment for patients, staff members and other individuals in the hospital.

During an interview on 03/08/2012 at 2:30 p.m., the director of plant operations and safety and security said handcuffs are a restraint and not appropriate for restraining a patient. He said he received a daily report from officers and was not aware of any handcuff use by his officers.

Based on record review and interview, the facility failed to ensure staff obtain a physician order for the use of restraints on 1 of 2 sampled patients (#38).

Findings:

Medical record review for patient #38, age 22, presented to the emergency department (ED) on 7/12/2011 at 8:08 p.m. with a diagnosis of possible psychosis. Review of the restraint documentation for 7/12/11 at 10:45 p.m. showed 4 point soft restraints applied, but no physician order for the restraints. Review of the restraint documentation for 7/13/11 at 7 a.m. 10:45 p.m. showed handcuffs restraints applied, but no physician order for the restraints. During an interview on 03/09/2012 at 11:10 a.m., the Vice President of Quality confirmed the nurse notified the physician, but this would not be a physician's order.

Review of the policy-Patient Restraints, dated as effective 01/10/2012, read, "An order for restraint must be obtained from a LIP(licensed independent practitioner)/physician who is responsible for the care of the patient prior to the application of restraint . . . . [and] The use of handcuffs and other restrictive devices used by law enforcement who are not employed or contracted by the facility for custody, detention or other public safety reasons, and not for the provision of healthcare, is not governed by these standards. However, the use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients.

Based on personnel training file, record review and interview, the facility failed to require 1 of 12 sampled staff to have restraint training (#VV); and failed to require 4 of 12 sampled staff to have restraint related first aid training (#TT, UU, VV & WW).

Findings included:

1. Review of the personnel training file for registered nurse (RN) #VV showed he is a contracted nurse in the dialysis unit working since 8/21/08. The file did not contain documentation of training related to restraint application or first aid related to restraint application.

2. Review of the personnel training file for RN #TT, hired 12/16/09, did not contain documentation of training related to restraint application or first aid related to restraint application.

3. Review of the personnel training file for RN #VV, hired 3/08/12, did not contain documentation of training related to restraint application or first aid related to restraint application.

4. Review of the personnel training file for RN #WW, hired 10/05/11, did not contain documentation of training related to restraint application or first aid related to restraint application.

Review of the policy-Restraint Policy 900A825, dated as reviewed 01/06/2012, read:
"First Aid-Staff will be trained and able to demonstrate competency in first aid techniques for patients in restraint or seclusion who are in distress or injured. The patient populations will be assessed to identify potential scenarios and develop training to address those scenarios . . . . Staff will be trained and certified in the use of cardiopulmonary resuscitation and periodically recertified.

During an interview on 03/09/12 at 9:30 a.m., the Vice President of Quality confirmed staff receives cardiopulmonary resuscitation recertification, but the personnel files do not document the first aid training.

Based on observation, record review and interview, the facility failed to assure a registered nurse (RN) assessed the care for each patient upon admission and when appropriate on an ongoing basis for 5 of 37 sampled patient (#1, 9, 10, 29 & 30).

Findings:

1. An observation on 03/06/12 at 11:45 a.m. found patient #10 in bed at rest with her daughter at the bed side. The daughter wore gloves but did not wear a gown to protect her clothing. A sign on the door at the entrance to the room indicated the patient was on contact precautions. The sign read, "Gloves and Gown - wear gloves and gown when entering room or cubicle. Remove gown and gloves before leaving the patient's room and ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transmission of microorganisms."

During an interview with the daughter on 03/06/12 at 11:50 a.m., the daughter said she did not remember staff telling her she should wear a gown when in her mother's room. She also said her mother had C-Diff (Clostridium Difficile, a bloody diarrhea) and she knew all about that because she caught the C-Diff from her mother last year.

Review of the medical record showed the patient #10 as admitted on 03/03/12 for weakness and abdominal pain. Review of the lab work showed the urine culture dated 03/04/12 positive for pseudomonas; toxin screen dated 03/04/12 positive for C-Diff; and urine culture dated 03/04/12 for Vancomycin Resistant Enterococcus.

During the record review, the nurse manager confirmed the medical record showed the patient was incontinent of stool on 03/05/12 and confirmed the nursing standard of care would include a care plan related to infection control problems and the patient did not have one. She also said the nursing staff have the option in the computerized system to select infection control as a care plan problem.

2. Review of facility policy 900A615.1 "Medication Administration: Patient Controlled Analgesia Administration (PCA)" read, "Document....administration and assessment of analgesia and sedation levels on the PCA/Epidural flow sheet q(every)15 minutes x4, q1h(hour) x4, then q4h until the PCA is discontinued . . . . Co-signatures are required on the PCA/Epidural flow sheet."

Review of facility policy 900A615, Pain Management states "5. Documentation A patient's pain is documented...When the patient is medicated for pain...and will include severity of pain, location, duration . . . . After 30-60 minutes from the time an analgesic is given, the nurse records the effect of the medication."

Review of patient #1's record reflected the patient received a Lortab-5, Vicodin tablet on 03/02/12 at 4:15 p.m. The assessment of the patient at the time of administration failed to document the intensity, location or duration of the pain. The record failed to reflect a reassessment within 60 minutes of administration.

3. Review of patient #29's record reflected the patient received a Lortab-5, Vicodin Tablet on 12/10/11 at 7:59 p.m. The assessment at the time of administration failed to document the location, or duration of the pain. Interview on 03/07/12 at 3 p.m. confirmed the records were as documented and that the policies were current.

4. Review of patient #30's record documented that Hydromorphone 10 mg.(milligrams)/50ml. (millimeter) was started on 12/08/11 at 8:52 a.m. The record failed to document assessments following the initiation of the PCA per the policy. Interview on 03/07/2012 at 3 p.m. with the Chief Nursing Officer confirmed the lack of a PCA/Epidural Flow Sheet in the documentation system, the lack of documentation on patient #30's record and that the system requires documentation on more than one screen in the current documentation system.


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5. Review of the medical record for patient #9, admitted on 03/03/12 with a diagnosis of pelvic abscess following a C-section (baby deliver by surgical incision in the abdomen) on 02/2012 showed the patient had an exploratory laparotomy, incision and drainage of the abscess, with adhesions on 03/04/2012. Wound culture dated 03/04/12 and urine culture dated 03/03/12 showed E-coli. During an interview on 03/06/12 at 12:05 p.m., the nurse manager confirmed the standard of care would include a care plan related to infection control related problems and the patient did not have one.

Based on observation, record review and interview, the facility failed to assure drugs and biologicals were administered in accordance with the approved medical staff policies and procedures for 2 of 37 sampled patients (#28 & 30).

Findings:

1. Review of facility policy 900A615.1 "Medication Administration: Patient Controlled Analgesia Administration" read, "Document....administration and assessment of analgesia and sedation levels on the PCA/Epidural flow sheet q (every)15 minutes x4, q1h (hour) x4, then q4h until the PCA is discontinued . . . . Co-signatures are required on the PCA/Epidural flow sheet."

Review of patient #28's record documented that Hydromorphone 10 mg. (milligrams)/50 ml. (milliliters) was started on 03/07/12 at 12:14 p.m. in the Post Anesthesia Care Unit (PACU). The documentation failed to reveal a PCA/Epidural flow sheet. The documentation required the co-signatures on the mediation administration screen and the assessments on the PCA evaluation screen.

2. Review of patient #30's record documented that Hydromorphone 10 mg./50 ml. was started on 12/08/11 at 8:52 a.m. The documentation failed to reveal a PCA/Epidural flow sheet. The documentation required the co-signatures on the mediation administration screen. The record failed to document assessments following the initiation of the PCA per the policy.

Interview on 03/07/2012 at 3 p.m. with the Chief Nursing Officer confirmed the lack of a PCA/Epidural Flow Sheet in the documentation system, the lack of documentation on patient #30's record and that the system requires documentation on more than one screen in the current documentation system.

Based on record review and interview, the facility failed to ensure medications on all units where keep are checked for expiration on a monthly basis.

Findings included:

Review of the pharmacy inventory checklist document provided by the pharmacy showed multiple areas including the Endoscopy area, ICU, 2 West, RX code cart, ER fast tract, and cardio-pulmonary rehab areas were not checked for medication expiration dates for the months of November 2011, December 2011, January 2012 and February 2012.

Review of the policy "Medication Area Inspections" dated as revised 12/01/09 read, "Unannounced inspections of all preparation and dispensing areas shall be made by the pharmacy technician assigned to the area each month." The policy requires monthly checking.

The Vice President (VP) of Quality provided the following correspondence from the pharmacy director, "Nursing Unit Inspections (undated) [read] our previous structure was to have routine unit assignments to individuals. Due to employee turnover, several areas were not reassigned and therefore went without routine inspection."

During an interview on 03/09/12 at 9 a.m. the VP of Quality confirmed the blank areas of the pharmacy inventory check off list and the pharmacy director's awareness of the problem.

Based on observation, interview and a review of facility documentation, the facility failed to ensure the implementation of policies governing infections in the form of policies addressing expired sterile items such as those in the Cardio-Vascular Intensive Care Unit supply room.

Findings:

During an inspection of the Supply Room for the Cardio-Vascular Intensive Care Unit on 3/06/12 at 11:20 AM, the following expired sterile items were discovered:
3 Twin Cath 18/20 Multiple Lumen Peripheral Catheters with the respective expiration dates of October 2009; November 2011; and November 2005;
12 BBL Culture Swab(s) Plus with the respective expiration dates of February 2012; January 2010; June 2009 (two each); February 2009 (three each); January 2010; November 2010 (two each); September 2010; and October 2008.

The preceding was confirmed during interviews with the Director of Cardio Vascular Services, Risk Manager and Assistant Director of Nursing at the above stated time.

A review of facility policy "Managing Non-Moving, Obsolete and Expired Items" revealed the following: "All items that have expired, are obsolete, or are non moving are to be removed from the facility in a timely manner and accounted for appropriately" [and] "If an expired product is identified, the following process is followed . . . Upon discovery of expired product, the merchandise is to be removed from stock."

During an interview of the Assistant Director of Nursing on 3/09/12 at 10:18 AM, she confirmed that the findings in the above observation were in violation of the above stated policy.

Based on observation, interview and record review, the facility failed to ensure staff followed facility policy related to contact isolation and visitors.

Findings included:

During an observation on 03/06/12 at 11:45 p.m., patient #10 was found in bed at rest with her daughter at the bed side. The daughter had on gloves but was not wearing a gown to protect her clothing. There was a sign on the door at the entrance to the room indicating the patient was on contact precautions. The sign read, "Wear gloves and gown when entering room or cubicle. Remove gown and gloves before leaving the patient's room and ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transmission of microorganisms."

During an interview with the daughter on 03/06/12 at 11:50 a.m., the daughter said she did not remember the staff telling her she should wear a gown when in her mother's room. She also said her mother had C-diff (Clostridium Difficile) and she knew all about that because she caught the C-diff from her mother last year.

Review of the medical record showed the patient #10 was admitted on 03/03/12 for weakness and abdominal pain. Review of the lab work showed the urine culture dated 03/04/12 positive for pseudomonas; toxin screen dated 03/04/12 positive for Clostridium Difficile; and urine culture dated 03/04/12 positive for Vancomycin Resistant Enterococcus (VRE).

During the record review on 3/06/12 at approximately 12:30 p.m., the nurse manager confirmed the medical record showed the patient was incontinent of stool on 03/05/12 and confirmed the visitor should have been wearing a gown and gloves as the sign stated.

Review of the facility policy "Clostridium Difficile (undated) read, "Adhere to complete gowning and gloves to be worn when entering the room. Individuals with C-Difficile associated disease shed spores in the stool that can be spread from person to person. Spores can survive up to 70 days in the environment and can be transported on the hands of healthcare personnel who have direct contact with infected patients or with environmental surfaces contaminated with C-Difficile [and] Visitors are to don gown and gloves upon entering the room. Visitors are to be instructed on proper hand hygiene by healthcare workers. Only adult and adolescent visitors are permitted to visit patient."

Based on interview and a review of facility documentation, the facility failed to ensure that a list of Home Health Agencies and Skilled Nursing Facilities were available in discharge documentation to patients participating in the Medicare program.

Findings:

A review of facility documentation revealed a list of Home Health Agencies and Skilled Nursing facilities in the facility's geographic area which were available to patients upon discharge. However, there was no indication on the list which indicated whether or not any or all these agencies and facilities participated in the Medicare program. The preceding was confirmed during an interview with the Assistant Director of Nursing on 3/09/12 at 10 AM.

Based on observation, record review and interview, the facility failed to assure a registered nurse (RN) assessed the care for each patient upon admission and when appropriate on an ongoing basis for 5 of 37 sampled patient (#1, 9, 10, 29 & 30).

Findings:

1. An observation on 03/06/12 at 11:45 a.m. found patient #10 in bed at rest with her daughter at the bed side. The daughter wore gloves but did not wear a gown to protect her clothing. A sign on the door at the entrance to the room indicated the patient was on contact precautions. The sign read, "Gloves and Gown - wear gloves and gown when entering room or cubicle. Remove gown and gloves before leaving the patient's room and ensure that clothing and skin do not contact potentially contaminated environmental surfaces that could result in possible transmission of microorganisms."

During an interview with the daughter on 03/06/12 at 11:50 a.m., the daughter said she did not remember staff telling her she should wear a gown when in her mother's room. She also said her mother had C-Diff (Clostridium Difficile, a bloody diarrhea) and she knew all about that because she caught the C-Diff from her mother last year.

Review of the medical record showed the patient #10 as admitted on 03/03/12 for weakness and abdominal pain. Review of the lab work showed the urine culture dated 03/04/12 positive for pseudomonas; toxin screen dated 03/04/12 positive for C-Diff; and urine culture dated 03/04/12 for Vancomycin Resistant Enterococcus.

During the record review, the nurse manager confirmed the medical record showed the patient was incontinent of stool on 03/05/12 and confirmed the nursing standard of care would include a care plan related to infection control problems and the patient did not have one. She also said the nursing staff have the option in the computerized system to select infection control as a care plan problem.

2. Review of facility policy 900A615.1 "Medication Administration: Patient Controlled Analgesia Administration (PCA)" read, "Document....administration and assessment of analgesia and sedation levels on the PCA/Epidural flow sheet q(every)15 minutes x4, q1h(hour) x4, then q4h until the PCA is discontinued . . . . Co-signatures are required on the PCA/Epidural flow sheet."

Review of facility policy 900A615, Pain Management states "5. Documentation A patient's pain is documented...When the patient is medicated for pain...and will include severity of pain, location, duration . . . . After 30-60 minutes from the time an analgesic is given, the nurse records the effect of the medication."

Review of patient #1's record reflected the patient received a Lortab-5, Vicodin tablet on 03/02/12 at 4:15 p.m. The assessment of the patient at the time of administration failed to document the intensity, location or duration of the pain. The record failed to reflect a reassessment within 60 minutes of administration.

3. Review of patient #29's record reflected the patient received a Lortab-5, Vicodin Tablet on 12/10/11 at 7:59 p.m. The assessment at the time of administration failed to document the location, or duration of the pain. Interview on 03/07/12 at 3 p.m. confirmed the records were as documented and that the policies were current.

4. Review of patient #30's record documented that Hydromorphone 10 mg.(milligrams)/50ml. (millimeter) was started on 12/08/11 at 8:52 a.m. The record failed to document assessments following the initiation of the PCA per the policy. Interview on 03/07/2012 at 3 p.m. with the Chief Nursing Officer confirmed the lack of a PCA/Epidural Flow Sheet in the documentation system, the lack of documentation on patient #30's record and that the system requires documentation on more than one screen in the current documentation system.


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5. Review of the medical record for patient #9, admitted on 03/03/12 with a diagnosis of pelvic abscess following a C-section (baby deliver by surgical incision in the abdomen) on 02/2012 showed the patient had an exploratory laparotomy, incision and drainage of the abscess, with adhesions on 03/04/2012. Wound culture dated 03/04/12 and urine culture dated 03/03/12 showed E-coli. During an interview on 03/06/12 at 12:05 p.m., the nurse manager confirmed the standard of care would include a care plan related to infection control related problems and the patient did not have one.