HospitalInspections.org

Based on Medical Record review, document review, and interview, the facility did not ensure compliance with the hospital's Policy for the use of restraints. Specifically: (a) Nursing Staff maintained a patient on restraints without a Physician's Order in one (1) of six (6) Medical Records, and (b) Physicians and Mid- Level Practitioners (MLPs) did not complete an assessment or examination of restrained patients prior to reordering restraints, in six (6) of six (6) Medical Records. (Patient #4, #9, #23, #24, #25, #26).


Findings include:

(A) The facility's Policy and Procedure titled "Restraints" last reviewed 05/16 stated "...The use of restraint must be ordered by a Physician or a LIP who is responsible for the care of the patient."

Review of Medical Record for Patient #23 identified that on 03/12/17 at 11:13PM, Mitten Restraints were ordered, then discontinued on 03/13/17 at 11:12PM. Mitten Restraints were again reordered on 03/14/17 at 12:50PM. The Nursing Restraint Flow Sheet dated 03/14/17 stated "Restraints maintained" from 2:00AM to 6:00AM. Patient #23 was restrained for four (4) hours without a Physician or LIP Order.

This observation was made in the presence of Staff Members AA (Nurse Administrator),
Staff Z (Clinical Director) and Staff R (Performance Improvement Specialist) who acknowledged the findings.

During interview of Staff AA (Nurse Administrator) on 03/17/17 at 3:05PM, Staff AA acknowledged that the patient should not have been restrained from 2:00AM to 6:00AM on 03/14/17 without a Physician or LIP Order.


(B) The facility's Policy and Procedure titled "Restraints," last reviewed 05/16 stated, "...If restraint for non-behavioral health purposes is continued beyond 24 [twenty-four] hours, its use is ordered once each calendar day by a Licensed Independent Practitioner [LIP], based on his or her examination of the patient. After 24 [twenty-four] hours, before writing a new order for the use of restraint, the LIP who is responsible for the care of the patient must see and assess the patient."

Review of Medical Record for Patient #24 identified that from 02/09/17 to 02/25/17,
Patient 2#4 had orders for Mitten Restraints. On 02/17/17 at 9:07AM Mitten Restraints were reordered by Staff HH (Physician).
There was no documentation of an assessment or examination of Patient #24 by Staff HH prior to the reorder of the restraint.

On 02/24/17 at 10:09AM, Mitten Restraints were reordered by Staff LL (Physician) on
Patient #24. There was no documentation of an assessment or examination of Patient #24 by Staff LL prior to the reorder of the restraint.

The same lack of documentation of Physician assessments or examinations for restraint reorders was found in the Medical Records for Patients #4, 9, 23, 25 and 26.

These observations were made in the presence of Staff G (Performance Improvement Specialist) who acknowledged the findings.

These findings were discussed with Staff I (Chief Medical Officer) on 03/17/17 at 7:00PM and on 03/22/17 at 4:00PM. When asked about Physician or LIP documentation of the assessment or examination of restrained patients prior to restraint reordering, Staff I stated "Patients get examined daily by an Attending [physician], but not necessarily by the Physician reordering the restraints."

Based on observation, medical record review, and interview, in three (3) of three (3) observations, nursing staff failed to utilize two (2) patient identifiers while performing blood glucose testing (BGT) in accordance with hospital policy and procedure (Patients #5, #6 and #7).

Findings include:

During observation of Staff D (RN) on 03/17/17 at 11:45AM, Staff D did not utilize two (2) patient identifiers to identify Patients #5, #6 and #7, prior to performing blood glucose testing (BGT). Staff D stated the patient's last name and informed them their blood sugar would be tested, but did not ask for verbal confirmation.

On 03/17/17 at 12:00PM Staff D was observed administering Insulin injections to Patients #5 and #6. Staff D did not ask for verbal confirmation. When asked how patients are identified prior to BGT or medication administration, Staff D stated "I should have asked for name and DOB," and acknowledged she had failed to do so.

These observations were made in the presence of Staff Members C (Assistant Nurse Manager) and Staff F (Clinical Director), who confirmed that both full name and DOB should have been confirmed with each patient.

The facility Policy and Procedure titled "POCT Accu-Chek Inform II Blood Glucose Testing," last reviewed 08/2016, directed staff to "Identify the patient by checking the identification band and by verbal confirmation from the patient or staff member. Use 2 [two] patient unique identifiers (1) Patient name (2) MR# and if third ID required, use Date of Birth [DOB]."
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Based on observation, document review, and interview, the Pharmacy Staff did not ensure outdated or otherwise unusable drugs and biologicals were not available for patient use.


Findings include:

During an observation of the Pediatric Unit on 03/22/17 at 11:20AM, four (4) Intravenous (IV) Piggy Back medications were found in the Medication Room refrigerator with expiration dates of 03/21/17. This observation was made in the presence of Staff O.

During interview of Staff O (Nurse Manager) at the time of observation, Staff O stated "Expired medications are sometimes put in a bin and are picked up by Pharmacy daily."

Per interview of Staff P (Director of Pharmacy) on 03/22/17 at 1:50PM, Staff P stated "The Nursing Staff puts the expired medications in a blue bin to be picked up by Pharmacy daily." Staff P reported that Pharmacy Staff also inspect and remove expired medications daily from the Medication Rooms and restock by 8:00AM and 9:00AM. Staff P stated "those IV piggy backs may have been missed." Staff P also stated "no policy exists for the daily removal of expired medications."

The facility's Policy and Procedure titled "Removal of Pharmaceuticals from Stock," last reviewed on 03/2015 stated, "As part of the monthly medication storage inspections, Pharmacy Staff shall inspect and restock expired and otherwise unusable medications in all drug preparation, dispensing and storage areas of the Medical Center..."

The facility's Policy and Procedure titled "Inspection of Medication Storage Areas" last reviewed on 11/2015 stated, "Outdated or otherwise unusable drugs are identified and removed from stock."
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Based on observation, document review, and interview, the facility did not ensure acceptable standards of practice for Infection Control were followed when providing patient care. Specifically, (a) Nursing Staff did not clean or sanitize point of care testing glucometers between patient use in one (1) of four (4) observations; (b) staff did not perform hand hygiene in three (3) of thirteen (13) observations; (c) staff did not implement the facility policy for the labeling of multi-dose medication vials; and (d) staff did not utilize aseptic technique when administering blood products. (Patient #5, #6, #7, #8, #21).


Findings include:

(A) During observation of Staff D (RN) on 03/17/17 at 11:45AM, Staff D was observed performing BGT (Blood Glucose Testing) on Patient #5, in Room 352, then exiting the room without cleaning or sanitizing the glucometer. Next, Staff D entered Room 353, performed BGT on Patient #6 twice but was unsuccessful. Staff D exited Room 353 with the glucometer, failed to clean / sanitize it, and returned with another glucometer to attempt a third BGT from Patient #6. Staff D then proceeded to Room 354 without cleaning / sanitizing the glucometer, and performed BGT on Patient #7, who was on Contact Precautions for MRSA (Methicillin Resistant Staphylococcus Aureus) of the left first toe. Again, without cleaning / sanitizing the glucometer, Staff D approached Patient #8 in the same room. Staff D was asked to stop by Staff C (Assistant Nurse Manager), and instructed to clean / sanitize the glucometer with sanitizing wipes before performing BGT on Patient #8.

These observations were made in presence of Staff Members C and F (Clinical Director) who confirmed that the glucometer(s) should have been cleaned / sanitized between each patient use.

The facility Policy and Procedure titled "POCT Accu-Chek Inform II Blood Glucose Testing," last reviewed 08/2016, directed staff to clean and/or disinfect the glucometer immediately after each patient use.


(B) Observation of the facility's 5W Unit during a tour on 03/17/17 between 9:45AM and 12:05PM identified the following:

Staff M (RN) was observed reconstituting IV push medication on the patient's bedside table. Staff M removed the dirty glove from the right hand and, without performing hand hygiene, opened the medication cart and retrieved a Saline flush and alcohol pads from the cart. Staff M was then observed removing, with contaminated gloves, a Saline flush and alcohol pads from the staff's pockets, prior to flushing a patient's peripheral IV lock. Staff M then removed the contaminated gloves, applied Alcohol Based Sanitizer (ABS) and, without allowing the ABS to completely evaporate, retrieved clean gloves from a box and donned them.

During the same tour, Staff N (RN) was observed retrieving, with contaminated gloves, Sani-Cloths [disinfecting wipes] from a dispenser after performing BGT.

These observations were both made in the presence of Staff Members Q (Director of Nursing) and Staff Z (Clinical Director), who acknowledged the findings.

Observation of the facility's Emergency Department during a tour on 03/22/17 at 9:50AM identified the following:

Staff U (RN) was observed retrieving a Saline flush and alcohol pads from their pockets with contaminated gloves on. Staff U was then observed retrieving a new pair of gloves from a box, without having removed the contaminated gloves first. After glove removal, Staff U washed their hands for less than the required fifteen (15) seconds, and applied ABS without allowing it to completely evaporate prior to donning clean gloves.

This observation was made in the presence of Staff R (Performance Improvement Specialist), who confirmed the findings.

The facility's Policy and Procedure titled "Hand Hygiene" last revised 10/15 stated the following: "Circumstances when decontamination of hands is recommended: Before and after patient contact ... after touching patient care equipment or environmental surfaces ... after donning gloves ... after removing gloves..." For Alcohol Based Sanitizer (ABS) "apply enough product to the palm of one (1) hand and vigorously rub hands together ... allow alcohol to thoroughly evaporate." "For soap and water, apply soap vigorously, rub hands together at least 15 seconds."


(C) During an observation in the 5 North Medication Room on 03/16/17 at 1:00PM, a multi-dose vial of Lantus Insulin was found in the refrigerator with a date open label dated 03/13/17 and no discard date.

This observation was made in the presence of Staff Members Q (Director of Nursing) and Z (Clinical Director). Staff Q stated "the medication should only have the date that it was opened."

The facility Policy and Procedure titled "Single Dose / Multiple Dose Vials: Appropriate Use," last reviewed on 06/14 stated, "Once a multiple-dose vial is punctured, it should be assigned a "beyond-use" date."


(D) During blood transfusion observation of Staff U (RN) at 10:40AM on 03/22/17, Staff U disconnected blood tubing from Patient #21 and without placing a cap on the end of the tubing, exposed the uncapped tubing to air and her non-sterile gloved hand.

After medication administration, Staff U then cleansed the peripheral Intravenous (IV) access with an alcohol pad, and used the same contaminated alcohol pad to wipe the end of the IV tubing, before reconnecting the tubing to the patient.

This was observed in the presence of Staff R (Performance Improvement Specialist) who confirmed the finding.

During interview of Staff Members S (Director) and Staff R at the time of the observation, both acknowledged Staff U did not utilize aseptic technique or placed a cap at the end of the tubing after disconnecting it from the patient.


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