HospitalInspections.org

A. Based on observation, it was determined that the facility failed to ensure that the adult psychiatric unit had a safe environment for the prevention of suicide.

Findings include:

Reference: Federal Guidelines for Construction and Equipment of Hospital and Medical Facilities, 1996-1997 Edition, section 7.6, states "Psychiatric Nursing Unit...Security and safety devices should not be presented in a manner to attract or challenge tampering by patients."

1. On 5/14/10 in the company of Staff #33 and #34 a tour of the 2nd floor adult psychiatric unit was conducted. Throughout the unit, in the patient rooms the following items were noted that were not suicide proof:

a. Each patient bed had long side rails on each side of the bed that could support a patient's weight in a suicide attempt, and could be removed and used as a weapon.

b. In each room, over the patient beds, there were light fixtures that could support a patient's weight in a suicide attempt.

c. In each room, above the wall closet, there was a metal strip that could support a patient's weight in a suicide attempt, and could be removed and used as a weapon.

d. The sink plumbing fixtures in the patient rooms/bathrooms were not suicide proof.

e. The shower head in the shower rooms (2) across from Room 235 were not suicide proof.




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2. On 5/11/10, at 1:50 PM, with Staff #5, in the child adolescent unit Quiet Room, the window was held in with non tamper-proof screws.

3. On 5/11/10, at 1:55 PM, with Staff #5, in the child adolescent unit 2nd Shower Room, the shower wall was cracked.

4. On 5/11/10, at 1:50 PM, with Staff #5, in the child adolescent unit Room #154, the heating unit plate was held in with non tamper-proof screws.

A. Based on documentation provided for review and staff interview, the facility failed to ensure that medications are administered in accordance with physicians' orders for 3 of the charts reviewed (Patient # 26, #29, #31).

Findings include:

1. On 5/11/10 at 2:55 PM, Patient #26's Post Anesthesia Care Unit (PACU) Standing Orders for analgesic medications were reviewed. The orders written on 5/11/10 included:

a. "Fentanyl 25 micrograms IV (intravenous)q (every) 5 minutes prn (as needed) pain level 4-6 and RR (respiration rate)>10 breaths (per) minute up to a dose of 200 micrograms,

b. Morphine 2 mg IV q 5 minutes prn pain level 4-6 up to total dose of 10 mg (milligrams), and

c. Fentanyl 50 Micrograms IV q 5 minutes prn pain of level 7-10 and RR>10 breaths (per) minute up to total dose of 200 micrograms,

d. Morphine 5 mg IV q 5 minutes prn pain level 7-10 to total dose of 4 10 mg."

2. At 2:47 PM, Patient #26 received 2 mg of Morphine. The surveyor questioned Staff # 23, whether he/she would administer morphine if the patient's RR was less than 10 breaths per minute. The nurse said "no". The orders did not clarify when to administer Morphine versus Fentanyl if the RR is greater than 10 breaths per minute. There was no evidence in the medical record that the nurse had clarified the orders with the physician in order to determine whether to administer Fentanyl or Morphine.

3. On 5/11/10 at 3:00 PM, Patient #29's Post Anesthesia Care Unit (PACU) Standing Orders for analgesic medications were reviewed. The orders written on 5/11/10 included:

a. "Fentanyl 25 micrograms IV (intravenous)q (every) 5 minutes prn pain level 4-6 and RR (respiration rate)>10 breaths (per) minute up to a dose of 200 micrograms,

b. Morphine 2 mg IV q 5 minutes prn pain level 4-6 up to total dose of 10 mg (milligrams),

c. Hydromorphone (Dilaudid) 1 mg IV q 10 minutes prn pain level 4-6 up to 2 mg,

d. Fentanyl 50 Micrograms IV q 5 minutes prn pain of level 7-10 and RR>10 breaths (per) minute up to total dose of 200 micrograms,

e. Morphine 5 mg IV q 5 minutes prn pain level 7-10 to total dose of 10 mg,

f. Morphine 5 mg IV q 5 minutes prn pain level of 7-10 up to total dose of 10 mg, for "Unrelieved Pain, Scale 7-10", and

g. Hydromprphone (Dilaudid) 1 mg IV q 10-15 minutes prn pain level 7-10 up to total dose 4 mg." for "Unrelieved Pain".

4. Each group of analgesic orders for pain scale 4-6, 7-10, and unrelieved Pain Scale 7-10 stated "Select One". Three (3) medications were ordered by the prescriber for Pain Scale 4-6, 2 medications were ordered for Pain Scale 7-10, and 2 medications were ordered for Unrelieved Pain Scale 7-10.
The orders did not clarify when to administer a specific drug for each Pain Scale category, and there was no documentation in the medical record that the nurse had clarified the orders with the physician.

5. On 5/12/10 at 1:30 PM, Patient #31"s Post Anesthesia Care Unit (PACU) Standing Orders for analgesic medications were reviewed. The orders written on 2/12/10 included:

a. "Fentanyl 25 micrograms IV (intravenous)q (every) 5 minutes prn pain level 4-6 and RR (respiration rate)>10 breaths (per) minute up to a dose of 200 micrograms,

b. Morphine 2 mg IV q 5 minutes prn pain level 4-6 up to total dose of 10 mg (milligrams),

c. Hydromorphone (Dilaudid) 1 mg IV q 10 minutes prn pain level 4-6 up to 2 mg,

d. Morphine 5 mg IV q 5 minutes prn pain level of 7-10 up to total dose of 10 mg, "Unrelieved Pain, Scale 7-10",

e. Hydromorphone (Dilaudid) 1 mg IV q 10-15 minutes prn pain level 7-10 up to total dose 4 mg'' "Unrelieved Pain, Scale 7-10".


6. Each group of analgesic orders for pain scale 4-6, 7-10, and unrelieved Pain Scale 7-10 stated "Select One." Three (3) medications were ordered by the prescriber for Pain Scale 4-6, and 2 medications were ordered for Unrelieved Pain Scale 7-10.
The orders did not clarify when to administer a specific drug for each Pain Scale category, and there was no documentation in the medical record that the nurse has clarified the orders with the physician.

7. Staff #8 told the surveyor that the "Physician's Orders: PACU Only (Standing order Sheet)" was recently revised to clearly state "Select One" order for each analgesic medication in the specific Pain Scale category.

B. Based on observation, documentation provided for review, and staff interview the facility failed to ensure that medications are prepared in accordance with accepted standards of professional practice and recommendations promoted by nationally recognized professional organizations such as the United States Pharmacopeia Chapter 797 (USP 797).

Findings include:

Reference:

USP Chapter 797, when addressing Single- Dose and Multiple-Dose Containers states: Opened or needle-punctured, single-dose containers such as bags, bottles, syringes and vials of sterile products and CSP's shall be used within 1 hour if opened in worse than ISO Class 5 air quality and any remaining contents must be discarded."

1. On 5/11/10 at 2:00 PM in the Post Anesthesia Care Unit, no labels were observed on intravenous (IV) bags of lactated ringer's or normal saline that were infusing into patients. This surveyor asked Staff #22 when the IV bags were spiked for infusion. Staff #22 told the surveyor the IV bags are spiked by the night shift nurses, about 5:00 AM.

2. Upon interview, Staff #8 said the facility does not have a policy/procedure regarding the spiking of IV bags, except that IV tubing must be changed every 96 hours. According to USP Chapter 797, infusion of single dose sterile IV bags, if opened (spiked) in worse than ISO Class 5 air quality, should begin within 1 hour of spiking.

3. On 5/11/10 at 3:20 PM, 2 syringes were observed in Staff #24's pocket. One syringe was labeled "Versed" and the second syringe was labeled "Fentanyl". Staff 24 said he/she removed the Controlled Dangerous Substances (CDS) medications from the Omnicel "around 3:15PM" for Patient #25 and pre-filled the syringes.
According to the CDS Omnicell printout obtained on 5/12/10 from Staff #8, the CDS medications were obtained from the Omnicell at 1:40 PM on 5/11/10, more than 1.5 hours prior to the observation of the syringes in his/her pocket.

4. On 5/11/10 at 2:55 PM a morphine sulfate 10 milligram (mg) Carpuject syringe was observed on Patient #26's over-bed table in the PACU. According to Patient #26's medical record, 2 mg of morphine was administered to the patient at 12:47 PM. Upon interview, Staff #23 told the surveyor that he/she "saved the remaining 8 mg of morphine in case I have to give more."
Staff #8 told the surveyor that the remaining 8 mg of morphine in the syringe should have been wasted and witnessed, according to hospital procedures, not saved for future administration.

Based on document review, and review of 6 of 6 Medical Records (#'s 3, 4, 5, 6, 8, and 9), it was determined that the facility failed to ensure that verbal orders were authenticated within 48 hours.

Findings include:

Reference: The facility's policy titled, "Verbal orders," stated, "IV. Procedure--A. Each Discipline determines designated staff that may take verbal orders according to their Licensure governing body. These should be limited to telephone orders. Credentialed Medical Staff Personnel dictates verbal order via telephone and co-signs the order within 48 hours with signature, date and time (except 24 hours for narcotics and restraints)."

1. On 5/11/10 review of the six (6) medical records revealed the following:

a. Medical Record #3 had two (2) verbal order dated 5/2/10 that were signed but not dated or timed. It could not be determined if the orders were signed within 48 hours.

b. Medical Record #4 had four (4) verbal orders dated 5/6/10 and one (1) dated 5/7/10 that were signed but not dated or timed. It could not be determined if the orders were signed within 48 hours.

c. Medical Record #5 had two (2) verbal orders dated 2/10/10 and one (1) dated 2/21/10 that were signed but not dated or timed. It could not be determined if the orders were signed within 48 hours.

d. Medical Record #6 had one (1) verbal order dated 3/7/10 and one(1) dated 3/8/10 that were signed but not dated or timed. It could not be determined if the orders were signed within 48 hours.

e. Medical Record #8 had one (1) verbal order dated 3/13/10 that was signed but not dated or timed. It could not be determined if the order was signed within 48 hours.

f. Medical Record #9 had one (1) verbal order dated 2/20/10 that was signed but not dated or timed. It could not be determined if the order was signed within 48 hours.

A. Based on staff interview and a lack of available documentation, the facility failed to obtain a Drug Enforcement Administration (DEA) registration and a Controlled Dangerous Substance (CDS) registration, as required by New Jersey regulation, in the name of a practitioner at the address of the Satellite Emergency Department (SED) and the Psychiatric Units, located at 333 Irving Avenue, Bridgeton, NJ, to allow for the distribution, dispensing and/or storage of controlled substances at this location.

Findings include:

Reference:

CDS Regulations
N.J.A.C. 8:64-1.1 to 8:65-1.7
8:65-1.2 Registration requirements ...
(f) A separate application shall be made and a separate registration obtained for each place of business or professional practice, where the applicant manufacturers, distributes or dispenses controlled dangerous substances. A separate application shall be made and a separate registration obtained for each separate and distinct business entity doing business at one location under more than one business name or trade name may obtain a single registration provided that all such business names or trade names are stated in the application.

Drug Enforcement Administration Regulations
Code of Federal Regulations, Title 21, Food and Drugs Volume 9
21CFR1301.12

(a) A separate registration is required for each principal place of business or professional practice at one general physical location where controlled substances are manufactured, distributed, imported, exported, or dispensed by a person.

(b) The following locations shall be deemed not to be places where controlled substances are manufactured, distributed, or dispensed: ...

(3) An office used by a practitioner (who is registered at another location) where controlled substances are prescribed but neither administered nor otherwise dispensed as a regular part of the professional practice of the practitioner at such office, and where no supplies of controlled substances are maintained.

1. On 5/11/10 at 9:50 AM ,interview with Staff #1 confirmed that the Satellite Emergency Department (SED) and the Psychiatric Units, all located at the same address, 333 Irving Avenue, Bridgeton, NJ do not have a DEA (Drug Enforcement Administration) and a CDS for this location.

2. Staff #1 also said that the facility was unable to negotiate an arrangement with a practitioner to obtain a DEA and CDS registration in his/her name at the address of the SED and Psychiatric Units.

B. Based on documentation provided for review and staff interview, the facility failed to ensure that the Controlled Dangerous Substance (CDS) Registration, and the New Jersey Board of Pharmacy license are issued to the same named entity as the Drug Enforcement Administration Registration (DEA).

Findings include:

1. On 5/11/10, review of the DEA and CDS registrations, and the Pharmacy permit, revealed that the DEA registration is issued to " South Jersey Healthcare Regional Medical " and the CDS registration and Pharmacy license are issued to "South Jersey Hosp (hospital) Newcomb Phcy (pharmacy) " .

2. Staff #8 said that when Newcomb Hospital closed and the Reginal Medical Center opened, the Board of Pharmacy said to apply for a name and location change. The address on the CDS registration and Pharmacy license were changed to 1501 W. Sherman Avenue, the new location, however, the name was not updated.

3. Staff #8 was unable to provide any additional documentation regarding the name and location change.

A. Based on document review and staff interview, it was determined that the food service director failed to provide daily supervision of the food services department including the implementation of all policies and procedure, as written in the "Director, Food And Nutrition Manager" position description, Reference 1.

Findings include:

Reference 1: The "Director, Food And Nutrition Manager" position description
states that the "Major Function: Plans, directs, organizes, coordinates all food services and clinical nutritional services at all South Jersey Hospitals." Some of the the "Essential job responsibilities" identified are:
a. "Develops and Implements Policies and Procedures that Guide and Support Provision of Services."
b. "Continuously Assesses and Improves Department's Performance"...."Ensures that important processes and activities are measured, assessed and improved systematically using accepted performance improvement techniques."

Reference 2: The "Inpatient Nutritional Counseling and Visitation Policy # Diet.85" states "Inpatients on all diets routinely receive nutrition assessments, visitations and counseling as indicated after screening on admission or according to level of Nutrition Risk."

Reference 3: The "Nutritional Education Policy # Diet.86" states "The Clinical Nutrition Staff will assess, evaluate patients and provide necessary Nutritional Education...," "A plan will be designed, taking into consideration the patients age and level of comprehension..." and "The Clinical Nutrition Staff will be available on a consultative basis to handle daily questions regarding diet and disease as they arise."

Reference 4: The "Discharge Rounds - Dietary Participation Policy # Diet.89" states "The inpatient clinical dietitians are members of the Interdepartmental Care Management Teams. Food and Nutrition participation on these teams is required. Attendance will include a physician, a nurse from each floor, the dietitian, and members of other departments....It will be the responsibility of each clinical dietitian to attend the rounds for his/her floor assignments."

Reference 5: The "Nutritional Consults Policy # Diet.300" states "The Clinical Nutrition Staff will complete nutrition consults for inpatients within 24-48 hours of notification."

Reference 6: The "Mental Health Unit - Nutrition Care coverage - Bridgeton Policy # Diet.127" states "It will be the responsibility of the Clinical Nutrition Team to complete consults, assessments, and education sessions within appropriate timelines for care for each patient..." "A Clinical Nutrition Team member will respond to a consult within 48 hour time line for completion of consults. This may mean a special visit by the team member, aside from the regular scheduled visit days."

Reference 7: The "Care Plans, Interdisciplinary Policy # MHS.31" states "Every patient admitted/transferred to the Mental Health Unit will have an interdisciplinary care plan formulated within 72 hours of admission/transfer...," "An initial plan of care is begun by each discipline upon completion of their assessments. The data collected is discussed, integrated and becomes the basis for the patient's comprehensive plan of care..." which includes "...identification of problems...., The interdisciplinary team will identify both short term and long term goals for each problem listed..."

1. Review of Medical Record #37 revealed that the Mental Health Services Progress notes dated 5/6/10 to 5/13/10, indicated that the patient has poor appetite, refuses protein foods, and continues to avoid food. The medical record lacked the following:

2. On 5/13/10 at 11:40 AM, Staff #10 and Staff #31 confirmed that one of one dietary consults ordered was not completed within 24 -48 hours as required according to the facility policy and procedures, Reference 5 and 6.

a. On 5/13/10 at 11:40 AM, in the Adult Behavioral Health Unit, Medical Record #37 contained a written order for a "Dietary Consult re poor appetite," that was signed and dated 5/10/10 at 3:40 PM. The requested dietary consult was not yet completed at time of the visit on 5/13 and was 20 hours overdue.

b. Staff #10 confirmed that the dietitian is scheduled to visit the Behavioral Health units twice a week and was not available on a daily basis for special visits and consultations to handle questions regarding diet and disease, as written in the facility policy and procedures, Reference 3 and 6.

2. On 5/13/10 at 11:55 AM, Staff #10 and Staff #31 confirmed that the dietitian does not participate in the mental health unit interdisciplinary care plan treatment team meetings for patients at nutritional risk and in need of diet education.

a. On 5/13/10 at 11:55 AM, in the Adult Behavioral Health Unit, Medical Record #37 contained a written "Medical Nutrition Therapy Initial Assessment," that was signed and dated on 5/6/10 by the dietitian. Staff #10 and Staff #31 confirmed that the "Medical Nutrition Therapy Initial Assessment" did not contain short and long term nutrition goals and interventions established by the dietitian.

i. On 5/13/10 at 11:55 AM, in the Adult Behavioral Health Unit, Medical Record #37 contained a written "Multidisciplinary Treatment Plan (MTP)," that identified "weight loss" as a problem on 5/7/10.

ii. The "Multidisciplinary Treatment Plan," was signed and dated on 5/7/10 by the physician, registered nurse, social worker, occupational therapist and patient care manager. The MTP was not signed by the dietitian.

iii. Staff #10 and Staff #31 confirmed that the dietitian failed to participate as a member of the Multidisciplinary Treatment Team to review, assess, develop interventions and goals for the identified nutrient intake and weight loss problem.

iv. Staff #10 and Staff #31 confirmed that the dietitian failed to implement policies as stated in References: 2, 3, 4, 6 and 7.

b. On 5/13/10 at 11:55 AM, in the Adult Behavioral Health Unit, Medical Record #38 contained a written "Diet ADA 1800 calories" signed and dated by the physician on 4/27/10. The History and Physical dated 4/27/10 included a new diabetic diagnosis.

i. The "Medical Nutrition Therapy Initial Assessment" that was signed and dated on 4/29/10 by the dietitian was observed to be incomplete. The diagnosis section had written "DX: Crisis pt transfer RMC," The Diet Order section had "NA" written and the section for "Previous Nutritional/Medical Issues:" has written "new DM." Staff #10 and Staff #31 confirmed that the "Medical Nutrition Therapy Initial Assessment" failed to contain an evaluation of the patient's "new Diabetes" diagnosis, the "ADA 1800 calories" diet order, learning needs, interventions and short and long term nutrition goals established by the dietitian.

ii. On 5/13/10 at 11:55 AM, in the Adult Behavioral Health Unit, Medical Record #38 contained a written "Multidisciplinary Treatment Plan" that identified "diabetes" as a problem, with the doctor and nurse responsible for the interventions on 4/27/10 and 5/5/10.

iii. The "Multidisciplinary Treatment Plan" was signed and dated on 4/27/10 and 5/5/10 by the physician, registered nurse, social worker, occupational therapist and patient care manager. The MTP was not signed by the dietitian.

iv. Staff #10 and Staff #31 confirmed that the dietitian failed to participate as a member of the Multidisciplinary Treatment Team to review, evaluate, develop interventions and goals for the identified new onset diabetes diagnosis and diabetic diet order.

v. Staff #10 and Staff #31 confirmed that the dietitian failed to implement policies as stated in References: 2, 3, 4, 6 and 7.

3. On 5/13/10 at 2:00 PM, Staff # 10 and 19 confirmed that the "Dietary" Department "2009 Performance Report" failed to include dietary department data collected at Bridgeton.

i. Staff #10 and Staff #31 confirmed that the Bridgeton dietary Performance improvement data is collected and filed at the Bridgeton facility. It is not reviewed and evaluated for possible process improvements as stated in Reference: 1.

Based on observations, interviews and document review, it was determined that the physicians failed to prescribe diets for patients.

Findings include:

Reference 1: The "Diet Orders, Transmission of Diet Orders and Diet Changes" policy # DIET.88 states that "One verbal order from Nursing will be accepted for one meal. Any food tray after this will need a physicians order written into the medical records and then placed into the computer system."

1. On 5/12/10, Staff #2 and Staff #28 confirmed that the medical record for patient #35 had an order dated 5/10/10 for clear liquid.

a. Staff # 2 and Staff #28 confirmed that the medical record had documentation that patient #35 received a regular breakfast on 5/12/10, not clear liquids.

b. Staff #2 and Staff #28 confirmed that patient #35 was observed with a regular lunch on 5/12/10, not clear liquids.

c. Staff #2 and Staff #28 confirmed that the medical record for patient #35 did not have a written regular diet order, as required per Reference #1.

Based on observations, interviews and document reviews it was determined that the patients' nutritional needs were not met in accordance with the diet ordered by the physician.

Findings include:

1. On 5/12/10, Staff #2 and Staff #28 confirmed that patient #35 had an order written on 5/10/10 for clear liquid diet.

a. Staff #2 and Staff #28 confirmed that patient #35 received a regular breakfast on 5/12/10, not clear liquids as was ordered.

b. Staff #2 and Staff #28 confirmed that patient #35 was observed with a regular lunch on 5/12/10, not clear liquids as was ordered.

Based on document review, it was determined that the facility failed to ensure that respiratory treatments were administered in accordance with physician order.
Findings include:
Reference: The facility's policy titled, "Automatic Stop Order," stated, "Procedure: A. An automatic three-day stop order tag will be placed on the Physician Order Sheet."
1. On 5/11/10, Medical Record #3 indicated a physician order dated 5/2/10 at 10:20 for Xopenex 1.25 mg. Neb (nebulizer) Rx (treatment) q (every) 6h (hour) & D/C (discontinue) Duoneb once it is given. On 5/8/10 at 0035 the order read, "May substitute Albuteral 2.5 mg. for Xopenex until pt's family brings in her own Xopenex from home. "
a. Review of the Cardiopulmonary Department Care Plan/Assessment/ Evaluation Sheet revealed that Xopenex was administered every six hours from 5/2/10 at 1400 until 5/8/10 at 0030.
b. There was no evidence that Xopenex was reordered every 3 days as per policy. There was no reorder tag in the medical record. Staff administered respiratory treatment without physician orders.
c. The above was confirmed with Staff #32.
2. Medical Record # 4 indicated a physician order dated " 5/5/2010 at 9 PM " for " Ventolin 2.5 mg. + Atrovent 0.5 mg. neb q6h. "
a. The Cardiopulmonary Department Care Plan/Assessment/Evaluation Sheet revealed that the patient was administered the first respiratory treatment at 5/6/10 at 1045. This respiratory order was obtained via phone as a "now order."
b. There was no evidence that the prescribed Ventolin and Atrovent respiratory treatment was administered every six hours, as prescribed, from the initial order until the now order.
c. The above was confirmed with Staff #32.