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Based on observation, medical record review, and interview with staff, the facility failed to ensure medications were administered safely and that a potential medication error was reported as required. The findings were:

According to policy number RM-002, "Occurrence Report-Error Reporting," the facility requires "staff and physicians to report all events with actual or potential (near miss) risk, injury or loss to patients, employees, visitors and medical staff." The facility "utilizes Midas REDI Reporting system to report events electronically."

RN #10 was observed administering medications to patient #37 on 10/25/10 at 4:20 PM. At that time, the patient refused the medication because it was extended release metformin, 1000 milligrams, and the patient explained that his/her medication was metformin, but not extended release. The RN reviewed the computerized medication profile for the patient and told the patient that she would check with the pharmacy. After the RN talked with the pharmacist, she returned the unopened medication to the computerized medication supply system, removed the correct medication and administered it to the patient. Interview on 10/28/10 at 10 AM with the RN showed she did not complete a near miss report regarding this incident. In an interview on 10/28/10 at 11:30 AM, RN #6 stated that according to the hospital policy, the nurse should have completed a near miss report. Interview with the pharmacist on 10/28/10 at 11:45 AM revealed the facility did not have a system for tracking near miss incidents such as this.

Based on medical record review, staff interview, and review of policies and procedures, the facility failed to assure properly executed informed consents were completed for 3 of 26 sample patients who underwent procedures requiring consent. The findings were:

According to the facility's policy and procedure entitled "Informed Consent" with an effective date of 2/2009, in order to be a properly executed consent, the information must include: "2. h. Signature of patient or patient's legal representative and the date and time it is signed by the patient or the patient's legal representative." Further review of the policy and procedure showed: "4. The signature of the patient or the patient's legal representative must be witnessed with a time, date, and signature." Procedures that required informed consent included: "Major or minor surgery involving entry into the body...Transfusions of blood or blood products."
Deficient practice was identified in the following instances:
a. Medical record review showed patient #11 underwent placement of a PICC (peripherally inserted central catheter) line on 10/24/10. Review of the 10/24/10 "Central Line Insertion Safety Checklist" indicated the consent was completed and in the chart. Review of the consent form showed only the patient's unwitnessed signature; the date and time were lacking. On 10/26/10 at 10:10 AM RN #2, a member of the infusion therapy team, stated the consent should have been signed, dated, timed, and witnessed. She also confirmed that the safety checklist form was completed incorrectly.
b. Medical record review showed the documented date on the pre-procedural verification for PICC line placement for sample patient #26 incorrectly showed the procedure was performed on 10/24/10. This incorrect date was also noted on the central line insertion safety checklist. Interview with RN #6 on 10/28/10 at 11:30 AM verified the PICC line was inserted on 10/25/10.
c. Review of the medical record with RN #1 on 10/20/10 at 11:10 AM showed patient #28 was admitted through the emergency department on 10/24/10 and received blood transfusions that day. However, review of the consent form showed the patient did not date and time his/her signature and the witness incorrectly dated it as 10/23/10. Further review of the record revealed this consent was not signed prior to the patient's admission as part of a pre-procedural admission process. RN #1 confirmed the findings at the time of the record review.

18512

Based on staff interview and medical record review, the hospital failed to ensure nursing staff provided comprehensive documentation of events that led to the placement of restraints on 3 of 4 sample patients (#13, #14, #15) who had physical restraints applied. In addition, advance directive information was not included in the medical record for 3 of 29 sample patients (#11, #28, #34), and the dictated history and physical examination was not transcribed for patient #28. The findings were:

1. Review of the medical record for patient #15 showed s/he was in respiratory failure and required intubation and placement on a ventilator on 10/25/10 at 3 PM. Also applied at that time were two soft wrist restraints. Interview with the patient's physician on 10/27/10 at 3 PM revealed this patient was "very anxious" and depressed. He also stated the ventilator setting was at a PEEP (pressure setting) of 15, which was very high and uncomfortable. The physician said the restraints were necessary because he feared the patient would pull at, and possibly pull out, the endotracheal tube (ET) tube. Observations and record review showed the soft wrist restraints remained in place on 10/26, 10/27 and 10/28/10. Review of the nursing notes showed no description of the behaviors exhibited by the patient that indicated the continued need for restraints.

2. Review of the medical record for patient #13 showed s/he required the application of two soft wrist restraints on 10/25/10 at 8:30 AM. Review of the non-violent restraint form showed the patient was intubated, was restless, and was considered at high risk of trying to remove the ET tube. Review of the restraint records and observation showed the patient continued to have the restraints on through 1 PM on 10/26/10. Review of the nursing notes showed no description of the behaviors exhibited by the patient that required continued need for restraints. Interview with the physician on 10/27/10 at 3 PM, however, revealed the continued utilization of restraints was medically necessary.

3. Review of the medical record for patient #14 showed s/he was intubated at 5 PM on 10/25/10. Review of the non-violent restraint form showed two soft wrist restraints were applied after insertion of the ET tube because the patient was considered to be at risk of removing the ET tube due to restlessness and agitation. Observation and review of the restraint records showed the patient's restraints were not removed until 11:45 PM on 10/25/10. Interview with the physician on 10/27/10 at 3 PM revealed the continued use of the restraints was medically necessary. However, review of the nursing notes showed staff failed to describe the behaviors that necessitated continued use of restraints.

4. Review of medical records for patients #11, #28, and #34 revealed all three patients indicated they had advance directives. Staff requested each patient or family member bring the information to the hospital, but evidence was lacking that anyone followed up to assure this was done. Lack of these directives potentially allowed for errors related to each patient's desire for resuscitation.
a. The 10/21/10 admission information for patient #34 indicated his/her family was asked to bring a copy of the advance directive to the hospital. However, it was never brought to the facility, and the patient was listed per the physician's order as a full code. On 10/27/10 a code was initiated at 1:13 PM. On 10/28/10 at 9:45 AM, manager #4 stated that since the physician visited with the patient, the family was not asked again to provide a copy of the directive.
b. Patient #11 was admitted on 10/23/10, and the initial information on advance directives indicated s/he had a living will on file with another hospital. Staff requested that a family member bring a copy to the current facility, but there was no directive in the medical record as of 10/27/10 at 10:55 AM. At that time case manager #5 stated the issue had not been referred to her, and she did not know if anyone had contacted the family member to follow up on the concern.
c. Medical record review showed patient #28 was admitted on 10/24/10. The space for advance directive information indicated a copy was requested from medical records, but the directive was not on the patient's record. On 10/27/10 at 4:10 PM a copy of the advance directive was requested from medical records. The provided document turned out to be a power of attorney that was unrelated to an advance directive. At that time, RN #6 acknowledged that staff were not following through on obtaining the directives.

3. According to the face sheet, patient #28 was admitted on 10/24/10.
Further review showed the dictated history and physical (H&P) examination was not included in the medical record. On 10/28/10 at 7:55 AM RN #6 checked with health information management; the RN reported they were unable to locate the dictated H&P, therefore it had not been transcribed.

21849

Based on observation, staff interview, and review of policies and procedures for isolation and precautions, the facility failed to ensure staff followed appropriate practices for 2 of 2 observations of patient rooms posted with infection control precautions. The facility further failed to ensure work practices in the clean linen room prevented recontamination of sheets. The findings were:

1. Regarding infection control precautions:

Observation on 10/26/10 from 8:40 AM to 10:05 AM (85 minutes) showed rooms 440 and 442 were posted with contact precautions signage. The medical unit nurse manager, RN #4 stated in interview on 10/26/10 at 9:30 AM both patients were diagnosed with Clostridium difficile (C. diff) infections. The nurse manager stated staff were required to obey the precautions listed on the signage, which included donning a disposable gown and gloves when entering the room and removing these items before exiting. A trash container was located in the room to contain the potentially contaminated gowns and gloves removed by staff. A rack hung from the door on each of the posted rooms and held gowns and gloves for staff use.
Continued observations of these two posted rooms revealed dietary aide #9 entered room #440 without using either the disposable gowns or gloves located on the isolation rack. The aide went about 5 feet into the room and recorded information about the patient's meal on a wall-mounted clipboard. This same clipboard had been handled earlier by CNA #3 when she recorded patient information; the CNA handled the clipboard with the same gloves she had just used to reposition the patient and move bed linens.
At 8:50 CNA #3 was observed to don a gown and gloves before providing perineal care for bowel incontinence. After completing care, the CNA picked up the plate cover and touched the patient's empty dishes and meal tray before removing the contaminated gloves and washing her hands. The tray was then passed to the dietary aide who placed it on a delivery cart. The dietary aide was observed to move items on the patient's tray with her bare hands and then reentered room 440 to make additional notes on the clipboard.
The dietary aide next received a food tray from CNA #3 removed from room 442. The aide had not washed her hands since leaving room 440. The CNA removed the gloves she had used in room 442 and placed them on the food tray as it was removed from the room. The dietary aide was again observed to move items on the food tray with her bare hands, enter room 442 to add information to a wall-mounted clipboard, and exit the room without the use of gown, gloves, or any hand hygiene.
CNA #3 stated in interview on 10/26/10 at 9:25 AM that she placed her gloves on the food tray to identify for the kitchen staff that the tray came from a room with infection control precautions. The dietary aide acknowledge the gloves were to alert kitchen staff to "...be careful..." When asked by the surveyor about her practices of touching the used food trays, entering the rooms without any personal protective equipment (PPE), and not washing her hands, the dietary aide used an alcohol-based hand rub on her hands and put on gloves. She did not verbalize a comment.
Interview with the director of nutrition services on 10/27/10 at 1:15 PM revealed there was not an expectation that gloves would be placed on trays and sent to the dish room. She stated all trays including those coming out of isolation rooms were treated the same way. All carts that held dirty trays were cleaned each day after being emptied, using a quaternary ammonia sanitizer solution. The director further stated dietary staff were instructed not to enter isolation rooms.
Interview with the infection control officer on 10/27/10 at 2:20 PM revealed all staff must use PPE when entering any room posted with infection control precautions and, further, all PPE must be removed before leaving the room. She further acknowledged the facility did not have any procedures that required used gloves be placed on food carts and moved to the kitchen.
Review of a computer-based training program required for all facility employees stated "...alcohol gel does not kill C. diff bacteria - hands must be washed with soap and water..." The training program was titled "February 2010 Education: National Patient Safety Goal 7 - Multi-drug resistant organisms (MDRO)."

2. Regarding recontamination of linen

Observation during a tour of the facility on 10/28/10 at 9:48 AM showed a laundry worker standing at a folding machine removing clean "fitted" sheets from a large hamper. The worker repeatedly (approximately 6 times) allowed the clean sheets to drag on the floor while she folded them. Facility policy #7014 titled "Storage, Collection and Transportation of Linen" stated "All linen will be stored, handled, transported and processed in a manner that prevents the transmission of microorganisms." The operations manager stated at the time of the observation that the worker should not allow the sheets to touch the floor while folding them.

Based on observation, staff interview, and review of temperature print-outs and manufacturer's label information, the facility failed to ensure 1 of 1 packages of temperature-sensitive reagents and controls were maintained in appropriate conditions. The findings were:

While touring the respiratory services department on 10/27/10 at 10:20 AM, 2 semi-automated blood gas analyzers were observed in room 3E248. The room also housed a small, undercounter refrigerator in which a package of reagents and control materials for the analyzer systems were stored. These materials were labeled by the manufacturer with storage requirements of 2-9 degrees Celsius (equivalent to 35.6-48.2 degrees Fahrenheit). A note was taped to the refrigerator door stating the internal temperature was monitored by a computer system under control of the facility maintenance services.

Respiratory technician #8 was present on the tour and confirmed temperatures were monitored remotely (via a computer-based system) and she did not maintain any temperature logs or manual checks. The technician further stated if temperatures were out-of-range, either too low or too high, an alarm would automatically notify the maintenance staff.

A computer printout provided by facility maintenance on 10/27/10 at 10:35 AM showed the storage temperature inside the refrigerator for the period 8/10/10 through 9/23/10 taken at 2 hour intervals. These data revealed that of 179 temperature sampling intervals, 58 (32%, range 49.3 to 56.8) were out-of-range high (exceeding the manufacturer's allowable temperature). There was no evidence to show an alarm was activated by these unacceptable storage temperatures.

The laboratory manager acknowledged in interview on 10/27/10 at 10:50 AM that, based on information from the maintenance staff, the remote alarm system was not triggered by the out-of-range temperatures noted on the print-out. She attributed the problem to incorrectly set alarm temperatures in the monitoring application on the maintenance computer system.