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Based on record review, document review and staff interview it was determined the facility failed to provide patient rights information to 2 (#4, #5) of 10 sampled patients.

Findings included:

1. The review of Patient #4's medical record revealed the patient was admitted on 07/20/2106. There was no evidence Patient #4 was provided with patient rights information.

2. The review of Patient #5's medical record revealed the patient was admitted on 07/20/2106. There was no evidence Patient #5 was provided with patient rights information.

3. The review of the document "Patient Agreement and Consent for Facility Services" revealed an area designated for the patient or the patient's representative to acknowledge receipt of patient rights information. The facility was unable to produce the documents at the time of the survey due to a computer software problem.

A telephone interview on 07/27/2016 with the Quality Manager following the review of the faxed documents confirmed the facility was unable to produce the "Patient Agreement and Consent for Facility Services" for Patients #4 and #5 and had no evidence of providing Patients #4 and #5 with patient rights information.

Based on record review, policy review and staff interview it was determined the facility failed to ensure the nursing staff could consistently honor patients advance directives.

Findings included:

1. The review of the Visit History for Patient #6 included documentation the patient had been admitted to the facility from 1/20/16 through 2/4/16 (admission #1) and from 3/18/16 - 3/30/16 (admission #2).

The review of the record for admission #1 revealed an advance directive signed by Patient #6 dated 1/26/16 indicating the patient did not want cardiopulmonary resuscitation or mechanical ventilation in the event a cardiac arrest or was unable to breathe on her own.

The review of the record for Admission #2 revealed the Admission Data Base dated 3/18/16 and signed by the Registered Nurse (RN) indicated Patient #6 did not have an advanced directive. The section of the form indicating the source of the information regarding advanced directives was left blank.

The review of the document titled "Advance Directive Documentation" revised 1/22/2014 revealed instructions on how to document in the electronic medical record if the patient did not have an advance directive, did not want one or wanted additional information. If the patient had an advance directive, the location of the document was documented or if the patient did not bring a copy were to document.

An interview was conducted with the Quality Manager on 7/21/16 at approximately 4:00 p.m. She confirmed the finding the RN completing the Admission Data Base for Patient #6 on 3/18/16 had failed to accurately identify that Patient #6 had an advanced directive.

2. An interview with Staff Nurse #A (RN A) was conducted on 7/21/16 at the time of the tour of the Street 2 nursing unit. RN A indicated if she walked into a patient's room and the patient was not breathing she would immediately start resuscitative measures. In response to questions related to the manner in which she would determine if the patient was a DNR (Do Not Resuscitate) status, she pointed to the fields on her computer screen that indicated if her assigned patients had an advanced directive or not. When asked if she would leave the patient's bedside to check her computer screen before initiating resuscitation, she indicated she would not.

3. An interview was conducted with the RN Charge Nurse on 7/21/16 at the time of the tour of the Street 2 nursing unit. She indicated each patient that had a DNR status had a colored wrist band applied. It indicated the patient had an advanced directive or a physician order to withhold cardiopulmonary resuscitation. In response to questions regarding the color of the DNR wristband, she was unable to respond without consulting an information sheet that indicated the DNR wristband was purple. She explained the facility had recently implemented new wristband colors throughout the hospital. Prior to 7/12/16 a patient with an DNR status would have a yellow wristband. Now a yellow wristband indicated a patient was a fall risk and a purple wristband indicated DNR status.

4. RN A was re-interviewed on 7/21/16 following the discussion with the Charge Nurse. She was unable to answer the question "what color wristband would indicated a patient had a DNR status"? Two staff members near by who heard the question indicated they could help. They responded the wristband color would be yellow for a DNR patient.

5. In an interview conducted on 7/21/16 at approximately 6:00 p.m. the Quality Manager confirmed the patients were at risk of either being resuscitated when they were a DNR or not resuscitated when they should be as a result of the staff lack of knowledge regarding the change in wristband colors.

Based on policy review, observation and staff interview it was determined the facility failed to ensure equipment and supplies were maintained in compliance with manufacturer's recommendations.

Findings included:

1. The facility policy "Code Team Procedure and Code Cart Maintenance" (no policy number) revision date 7/14 indicated the daily nursing responsibilities for Code Cart Maintenance included "6. Unplug defibrillator and check-charge and discharge per manufacturer's recommendations. Document successful discharge by placing checkmark on the Code Cart Daily Maintenance Log". The review of the policy failed to reveal any documentation related to an unsuccessful check of the defibrillator.

Observations of the Code Cart (emergency equipment) were conducted on 07/21/2016 at 11:20 a.m. on Street 1 Medical/Surgical/Neuro unit. The defibrillator located on top of the cart was observed to have a long continuous monitor strip attached.

The review of the monitor strip revealed the continuous strips were dated separately 7/8/16, 7/9/16, 7/12/16 and daily for 7/13/16 through 7/21/16. Each of the dates included computer generated documentation "Self-test did not complete-Perform manual test". There was no evidence manual checks were performed per the manufacturer's recommendations.

The review of the Code Cart Daily Maintenance Log revealed a checkmark indicating the defibrillator had successfully passed. The daily check was signed by an RN.

The Quality Manager and Unit Nurse Manager were present at the time of the observations. The Unit Manager was unable to clarify the discrepancy between the monitor strips generated by the defibrillator computer indicating the defibrillator checks were unsuccessful and the nursing documentation indicating the checks were successful. She confirmed the finding the defibrillator was not checked appropriately to ensure it was functioning properly.


2. The facility policy titled "BISC Obsolete Stock Review and Removal" (MM017) revision date 06/23/2015 indicated inventory should be reviewed monthly for obsolescence and removed from inventory.

On 07/21/2016 at 11:10 a.m. a tour of the Street 1 Medical/Surgical/Neuro Unit revealed 12 of 12 supplies were past the manufacturer's date for use as follows:
Central Line dressing kit Lot #23F14J052 expiration date 06/2016
Epidural Catheterization Kit Lot #23F13M1001 expiration date 04/2016
Epidural Catheterization Kit Lot #23F13M1001 expiration date 04/2016
Surgical Gowns Lot #10MLK045 expiration date 12/2015
Surgical Gowns Lot #10MLK019 expiration date 12/2015
Surgical Gowns Lot #10HLK080 expiration date 08/2015
Swab Culture Lot #032045 expiration 01/2016
4 Swab Culture Lot #0320C03LX19G02 expiration 04/2016
1 Box (#100) Vacutainers Lot #5336522 expiration date 06/2016

An interview on 07/21/2016 during the tour with the Quality Manager and Unit Nurse Manager confirmed the above findings.


3. The policy titled "Planned Maintenance Inspections" number CES-03 revision date 01/2015 indicated planned maintenance (PM) inspections were scheduled procedures performed on clinical devices that are in the Clinical Engineering Services (CES) Medical Equipment Management Program. All Planned Maintenance inspections required updating the Planned Maintenance Inspection label, which will include inspector's initials and the next PM due date (Month/Year).

On 07/21/2016 at 11:20 a.m. during the tour of the Street 1 Medical/Surgical/Neuro Unit revealed the following equipment PM inspections were expired:
Sage CHG warmer expiration date 04/01/2016 Ready bath warmer expiration date of 04/01/2016

An interview on 07/21/2016 during the tour with the Quality Manager and Unit Nurse Manager confirmed the above findings.

On 07/21/2016 at 1:50 p.m. during the tour of the Street 4 Oncology Unit revealed the following equipment PM inspections were expired:
Sage CHG warmer expiration date 04/01/2016 Ready bath warmer expiration date of 04/01/2016
2 Kangaroo Feeding Pumps expiration date 05/2016
1 Kangaroo Feeding Pump expiration date 05/2015

An interview on 07/21/2016 during the tour with the Quality Manager confirmed the above findings.