HospitalInspections.org

Based on a review of clinical records, interview and policy review, the facility failed to obtain informed consent for two of two Patients' (#90 and #91) prior to the initiation of hemodialysis. The findings include the following:

a. Patient #90 was admitted to the hospital on 6/1/15. On 6/11/15 the patient was observed in the acute dialysis unit receiving hemodialysis. Review of the clinical record failed to reflect that consent was obtained for hemodialysis.

b. Patient #91 was admitted to the hospital on 6/9/15 with right foot gangrene and required hemodialysis. On 6/11/15 the patient was observed in the acute dialysis unit receiving hemodialysis. Review of the clinical record failed to reflect that consent was obtained for hemodialysis.
Interview with the Charge Nurse on 6/11/15 at 11:00 AM indicated that all patients not affiliated with the chronic unit require consents prior to the initiation of hemodialysis and the consents may be located in the inpatient records. Review of the inpatient records with the Director of Nurses on 6/11/15 reflected that consents were not completed for Patient #90 and 91. Review of the hemodialysis documentation policy indicated that informed consent should be obtained prior to the starting of hemodialysis.

Based on review of clinical records, hospital documentation and hospital policies for 1 (P#30) of 4 patients reviewed for patient rights the hospital failed to treat the patient in a dignified manner. The findings include:

P#30 was admitted to the hospital for labor and delivery (L&D) services. His/her medical record identified additional diagnoses included bipolar disorder and anxiety According to the medical record on December 9, 2014 P#30 delivered P#31 via cesarean section. According to the intraoperative record Person #1 and an additional visitor were present during the delivery. Documentation indicated following P#31's delivery, while in the L&D operating room, offensive comments were made by certified Surgical Technician (CST) #1 about P#31 in which Medical Doctor (MD) #1 intervened. The documentation indicated following the comments made by CST#1 P#30 began to cry and became visibly upset.

During an interview with Medical Doctor (MD) #1 on 6/16/15 at 1:55 PM MD#1 indicated he/she had overheard CST#1 make several comments in reference to P#31 and MD#1 had motioned to CST#1 to stop. MD#1 indicated he/she did not feel the comments were malicious however were inappropriate. MD#1 indicated P#30 and Person #1 were upset relative to the comments made and MD#1 apologized for the actions of CST#1.

The hospital Patient Rights and Responsibilities policy indicated patients have the right to receive considerate, respectful care in a safe setting, be treated with dignity, receive treatment from compassionate, skilled, qualified healthcare professionals and be free from all forms of abuse and harassment.

According to hospital documentation on 12/12/14 CST#1's employment at the hospital was terminated.

Based on medical record reviews, review of facility policies, and interviews for one of six patients reviewed for intravenous (IV) administration (Patient #56), the facility failed to ensure that the confidentiality of personal patient information, and failed to ensure the confidentiality of patient information by ensuring it could not be observed by visitors, staff and patients who were in the cardiac catherization lab. The finding includes:

a. Patient #56 was admitted to the hospital on 4/13/14. Physician orders dated 4/16/15 through 4/21/15 directed Sodium Chloride 0.9% 250 milliliter (ml) at 10ml/hour intravenously (IV). The Medication Administration Record (MAR) identified that the patient received the Sodium Chloride as ordered.

Patient #50 was admitted to the hospital on 4/6/15 with diagnoses that included hypoxia and sepsis versus pulmonary embolism. Physician orders dated 4/6/15 through 4/26/15 directed the antibiotic Ertapenem IV daily. The MAR dated 4/16/15 identified that Patient #50 received the antibiotic as ordered at 3:00 PM. Patient #50's nursing narratives dated 4/16/15 at 6:10 PM noted that RN #15 accidentally placed the identification label of another patient (Patient #56) on Patient #50's bag of Sodium Chloride that would be used as a flush following the administration of Patient #50's antibiotics.

Facility documentation dated 4/16/15 indicated that Patient #56's information was exposed to Patient #50 and Patient #50's family member and that Patient #50 received the correct medication.

The facility IV labels indicated that the patient's identification label be placed on the IV label and then to the IV bag. Review of patient identification labels identified that the patient's first and last name, date of birth, admission date, sex, and medical record number were printed on the label.

Review of Patient #56's medical record with Nurse Manager #6 on 6/11/15 at 11:20 AM noted that Patient #56's record did not document the breech in patient confidentiality and/or that Patient #56 had been made aware of the incident.

The facility policy for reporting privacy violations identified that members of hospital are required to report privacy incidents to the Office of Compliance, Audit, and Privacy. The policy further indicated that the Hospital will respond in writing and in a timely manner to allegations- either oral or written- of potential violations of patients' privacy and security rights due to inappropriate access, use and/or disclosure of protected health information.


b. During a tour of the cardiac catherization lab on 6/9/15, a daily scheduling board was observed in the hallway, which had full names of patients listed who were having procedures that day in the cardiac catherization lab. Further observation identified that patients were being wheeled through this hallway to go to the procedure room for their procedure. Review of hospital policy identified that all patients have the right to personnel privacy and confidentiality. Interview with Nurse Manager on 6/9/15 identified that the scheduling board has been listing full names of patients for a long time and would have to change the practice to maintain patient confidentiality.




19907

Based on a review of clinical records, interview and policy, for one of three patients reviewed for restraints (#312), the facilty failed to ensure that leather wrist restraints were applied based on a physician's order. The finding includes the following:


Patient #312 presented to the ED on 6/2/15 with changes in mental status. The ED notes indicated that the patient was agitated and bilateral wrist restraints were applied at 8:45 PM. Review of the physicians' order dated 6/2/15 at 8:55 PM directed the use of bilateral wrist holders. The restraint flow sheet dated 6/2/15 at 9:00 PM revealed that the patient was in bilateral leather restraints for agitation. Interview with the ED Director of the psychiatric unit on 6/8/15 at 10:30 AM stated that the physicians order should include the type of restraint to be utilized and was unsure what a wrist holder was but assumed it was when a patients wrist had to held for a line insertion.

Review of the restraint policy indicated that the individual order by the licensed independent practitioner should identify the type of restraint.

a. Based on medical record reviews, review of facility documentation, review of medical staffing documentation, and interview, the facility failed to ensure that one of three patients who required consultative services (Patient #51), received the required service. The finding includes:

Patient #51 was admitted to the hospital on 3/5/15 with a diagnosis of Myasthenia Gravis crisis. Neurology progress notes dated 3/17/15 identified that the patient had a right upper extremity redness with plaques and bilateral lower extremity redness and cellulitis. Neurology progress notes dated 3/18/15 identified that the patient had a rash and a dermatology consult would be called. The note also indicated that dermatology was not available for a consultation. Interview with the Director of Regulatory Readiness on 6/12/15 at 12:50 PM indicated that the Chief Medical Officer had instructed that medical staff call him/her when a dermatology consultation was needed and that he/she would then contact a dermatologist on the medical staff. Review of Medical Staff Office documentation identified that 14 active dermatologists and one courtesy dermatologist were credentialed to the hospital medical staff.

The email entitled Dermatology Interim Plan sent to medical staff on 7/24/14 identified that the hospital did not have in- house dermatology coverage however, were working on establishing a trigger- based consult for only emergent issues. The email further noted that all consults for dermatology were to be filtered through two physicians one of which was/is the Chief of Medicine.




19952

b. Based on review of the clinical record, review of hospital policy, review of hospital documentation and interviews with hospital personnel for one surgical patient (Patient #303), documentation and interviews failed to reflect that the patient received adequate postoperative pain management. The findings include:

Patient #303 was admitted to the hospital's ED on 3/7/15 at 8:56 PM complaining of upper abdominal pain, status post (s/p) hysteroscopic fibroid removal and ablation on 3/6/15. Review of the clinical record identified that the patient was diagnosed with peritonitis from uterine perforation and small bowel perforation secondary to endometrial ablation. The patient underwent an exploratory laparotomy with small bowel resection and supracervical hysterectomy on 3/8/15 at 6:59 AM. Review of the clinical record identified that the patient complained of severe pain, 8-10/10 (0-10, 10 worst pain) for over 12 hours postoperatively. During that time, Patient #303 received Dilaudid Patient Controlled Anesthesia (PCA) intravenously (IV), Toradol IV, Valium IV, Tylenol per rectum (PR). The patient's pain decreased to 6/10 on 3/9/15 at 2:00 AM after Morphine PCA IV was ordered and administered. Review of the record and interview with the supervising surgeon, MD #9 identified that the first year surgical resident (PGY 1), MD #11 was concerned about converting the Dilaudid to Morphine. MD #11 was not available for interview at the time of the investigation. A pain consultation was ordered 2 days postoperatively, on 3/10/15 at 7:02 AM. Review of hospital documentation identified that a pain consult service was available to inpatients to optimize the pharmacological management of pain, Monday-Friday, 8 AM- 4:30 PM. Documentation and interviews failed to reflect that the patient received adequate postoperative pain management.




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c. Based on review of the clinical record, hospital documentation and interviews for 1 (P#29) of 4 patients who underwent obstetrical procedures the hospital failed to identify a retained piece of instrument used during the procedure. The findings include:


According to facility documentation on 11/12/14 P#29 underwent placement of an intrauterine device (IUD) post vaginal delivery. On 12/26/14 P#29 complained of rectal pain and upon examination a fragmented part of the IUD was visualized in the rectum. P#29 was taken to the operating room (OR) for repair of a vaginal rectal perforation. The IUD and fragmented applicator were removed from P#29's rectum. Upon exam the uterine cavity was noted to be intact. During an interview with Medical Doctor (MD) #5 on 6/12/15 at 9:20 AM MD#5 indicated after placement of the IUD the applicator was removed, visualized and appeared intact. According to MD#5 he/she was not aware the applicator had an attached outer sheath on the applicator tip and therefore did not note the outer sheath was missing. MD#5 indicated the cause of the vaginal/rectal perforation was the fragmented applicator.

1. Based on review of the procedural record, review of hospital policy and interview, for one patient of three patient records reviewed who received moderate sedation (#41), the hospital failed to ensure that the patient's oxygen saturation was monitored, post removal of oxygen, prior to being discharged home. The finding includes:
Review of the procedural record for Patient #41, who underwent a colonoscopy on 6/9/15 and was recovered in the post procedural area, identified that the patient was admitted to the recovery area at 9:45 AM on six (6) liters of oxygen (O2) via face mask. Review of the recovery area documentation identified that the patient's oxygen saturation was measured at 99% on six liters of O2 at 9:45 am and 9:50 AM. Nursing narratives reflected that the oxygen was removed at 10:00 AM, however, the record lacked documentation that the oxygen saturation was measured on room air following removal until the time the patient was discharged at 10:45 AM. According to post recovery guidelines, oxygen saturation should be monitored q (every) 15 minutes times two, and then every 30 miniutes.
During an interview on 6/9/15 at approximately 11:40 AM, the Manager of the area stated that the nurse should have read the patient's oxygen saturation on room air prior to discharging the patient.



15482

2. Based on a review of clinical records, interview and policy review, for three of five patients (#46, #90, and #91) receiving acute hemodialysis, the facility failed to conduct comprehensive pre and/or post assessments including weights in accordance with facility policy. The findings include the following:

a. Review of Patient #46's clinical record indicated that the patient required acute hemodialysis. The hemodialysis flow sheet dated 6/6/15 failed to reflect that a post-treatment weight and/or the total amount of fluid removed had been documented. The reverse side of the patient treatment flowsheet was blank. This included pre and/or post treatment assessment data including the patient's respiratory, cardiac, neurological, GI, skin, activity, psychosocial status, and pain assessments. The patient outcome section was also blank. This included assessment of the patient ' s fluid status, signs and symptoms of infection present, hemodynamic stability, access complications and discharge disposition.

b. Review of Patient #90's treatment sheets dated 6/2/15 and 6/6/15 indicated that the patient's pre-treatment weight was obtained however failed to reflect post-treatment weights.

c. Review of Patient #91's hemodialysis flow sheet dated 6/9/15 failed to reflect that a post-treatment weight was obtained.

Review of the assessment policy directed that vital signs and pre/post treatment weights should be obtained and that all areas of the flowsheet are to be completed with no areas left blank.



3. Based on observation, interview, and policy review, the facility failed to ensure that vascular access sites were visible at all times for two of six patients (#92 and #94) observed on hemodialysis. The findings include the following:

a. On 6/11/15 at 10:33 AM, Patient #92 was observed receiving hemodialysis. The patient's central venous access site was noted to be covered rendering an inability to view the site at all times in accordance with facility policy.

b. On 6/11/15 at 10:35 AM, Patient #94 was observed receiving hemodialysis. The patient's AVF was noted to be covered rendering an inability to view the site at all times in accordance with facility policy. Subsequent to surveyor inquiry the access sites were uncovered by a staff member.

Interview with the Charge nurse on 6/11/15 at 11:00 AM indicated that all sites should be uncovered at all times especially arms and that if patients cover them they should be uncovered. Review of the facility policy indicated that all needle sites and connections must be visible at all times.

4. Based on a review of clinical records, interview, and policy review, for four of six patients' reviewed for complaints of pain (#9, 47, 48, and 303) the facility failed to address pain in a timely manner and/or reassess the patients' pain following administration of pain medication. The findings include the following:

a. Patient #9 presented to the ED on 6/8/15 at 4:45 AM with complaints of abdominal pain. The record indicated that the patient rated pain as a 10 on a scale of 0-10, with 10 being the worst possible pain, at 4:48 AM. The pain assessment obtained at 5:03 AM noted the patient's pain was a 10. Review of the clinical record failed to reflect interventions provided to address the patient's pain until 6:51 AM when Toradol 30 mg was administered by mouth.

In addition, review of Patient #9's clinical record indicated that on 6/8/15 at 7:30 AM the patient was given 1 mg of Dilaudid IV absent a pain assessment prior to administration and/or following administration to determine the efficacy of the intervention.

b. Patient #47 was admitted on 6/4/15 with alcohol abuse. Review of the clinical record with the Nurse Manager on 6/9/15 indicated that the patient received Tylenol on 6/8/15 at 6:00 PM and 10:00 PM absent pain assessments prior to the administration of the Tylenol and/or reassessments after the intervention to determine the efficacy of the medication. Interview with the RN caring for the patient on 6/9/15 at 11:00 AM stated the patient had chronic knee pain.

c. Patient #48 was admitted on 6/3/15 with pancreatitis. A nurse's note dated 6/3/15 at 6:00 PM identified that the patient had increased pain, rated as a 6 on a scale 0-10, with notation that the patient had one more hour before he/she could receive additional pain medication. The note on 6/3/15 at 7:00 PM indicated that the patient's level of pain was still a 6 and was medicated with Dilaudid 1 mg. The subsequent pain assessment at 8:00 PM noted the patient rated pain as a 5. The facility failed to ensure that the physician was notified of the pain level when medication could not be offered and/or that alternative measures to relieve pain were documented.

d. Patient #303 was admitted to the hospital's ED on 3/7/15 at 8:56 PM with complaints of upper abdominal pain, status post (s/p) hysteroscopic fibroid removal and ablation on 3/6/15. Review of the pain scale flowsheet dated 3/7/15 at 9:01 PM noted that the patient rated pain as a 10 (worst possible pain), however, the assessment failed to reflect the body region, orientation, and body part where the pain was presenting and/or non-verbal indicators, pain quality, and duration of the pain. The triage note dated 3/7/15 at 9:04 PM reflected that the patient was "very uncomfortable and tearful". A reassessment of the patient's pain at 9:19 PM noted that the pain level remained a 10. A nurse's note dated 3/7/15 at 9:27 PM noted that the patient's abdomen was distended, painful to palpation with hypoactive bowel sounds, and the patient was tearful and observed to be holding the painful area. The physician was notified of the patient's pain level with a plan to see the patient. At 9:57 PM, the mid-level practitioner directed the administration of 1 milligram of Dilaudid IV push (IVP) now. The record identified that the medication was administered at 10:26 PM. The clinical record lacked evidence that the patient's pain was addressed in a timely manner and/or that alternative measures to relieve pain were documented.


e. Review of the clinical record dated 3/7/15 indicated that Patient #303 received Dilaudid 1 mg IVP at 11:02 PM with a post assessment at 11:51 PM that noted the patient rated pain as a 7/10. Although the patient's pain level was not an acceptable level, according to the patient during interview on 6/17/15, documentation failed to reflect that other alternatives were implemented to address the pain. According to the medication administration record dated 3/8/15, Dilaudid 1 mg IVP was administered at 1:29 AM.


f. Review of Patient #303's clinical record during the period of 3/8/15 at 1:30 AM through 5:45 AM identified that the patient had complaints of abdominal pain and received Toradol 30 mg IVP at 1:47 AM, Dilaudid 1 mg IVP at 3:39 AM, and Fentanyl 75 mcg IVP at 3:59 AM, the clinical record lacked evidence that comprehensive assessments of the patient's pain were documented.


Review of the clinical record identified that the patient required surgical intervention for a diagnosis of peritonitis from uterine perforation and small bowel perforation secondary to the endometrial ablation performed on 3/6/15.


Review of the Patient Rights Regarding Pain Management Policy identified patients are taught that pain management is part of their treatment. Patient self-report is the most reliable indication of the presence of pain and staff will respond to a patient's report of unrelieved pain, as all staff are responsible for the patient's pain control. Patients have the right to appropriate assessment and management of pain. If pain is identified as a problem, a comprehensive pain assessment will be performed. Pain will be re-assessed after a sufficient amount of time had elapsed for the intervention to reach peak effect but no longer than two hours. If the patient's pain intensity is unacceptable to the patient, there will be an intervention to reduce the pain. Complementary and non-pharmacological therapies will be available and offered when appropriate.



5. Based on a review of clinical records, interview and policy review, the facility failed to ensure that 1 of 2 patients (#47) were monitored in accordance with the CIWA (Clinical Institute Withdrawal Assessment) protocol. The finding includes the following:

Patient #47 was admitted on 6/4/15 with alcohol abuse, nausea, vomiting, depression and diarrhea. Review of the clinical record and interview with the RN indicated the patient was high risk for alcohol withdrawal on admission and was initiated on the CIWA protocol that directed every four hour monitoring. Review of the record indicated that on arrival to the floor on 6/5/15 at 8:00 AM, the patient was a "5" (without withdrawal). The record failed to reflect that the patient was assessed four hours later at 12:00 PM. An assessment at 4:00 PM indicated that the patient scored an "8" (mild withdrawal).


Review of the CIWA monitoring completed on 6/6/15 reflected that the patient was assessed at 3:00 PM, however, the next assessment was not completed until 10:00 PM, seven hours later.















29049

6. Based on a review of the clinical record, staff interviews and a review of the hospital's policies and procedures for one of two mother infant couplets reviewed in labor and delivery (Patient #70 and #71), the facility failed to administer Oxytocin in accordance with the hospital policy and/or failed to monitor Patient #70's vital signs to ascertain fetal well-being. The findings included:


a. Review of the clinical record identified Patient #70 was admitted to the hospital on 5/28/13 at 11:19 AM at thirty nine weeks gestation for an induction of labor secondary to polyhydramnios. A category I (normal), fetal tracing was identified on admission. a Physician's order dated 5/28/13 at 11:40 AM directed the initiation of the Oxytocin Protocol for an induction of labor. At 2:00 PM Oxytocin was administered at one (1) mulliunit/minute intravenously. Oxytocin was increased per protocol to achieve cervical dilation, effacement, descent of the presenting part, and a vaginal delivery. On 5/29/13 at 12:57 AM the fetal tracing revealed a bradycardic episode that was five minutes in duration. Interview and review of the clinical record with RN #17 on 6/16/15 at 9:30 AM indicated she discontinued the Oxytocin infusion at that time which was running at seventeen (17) milliunits/minute. Further interview with RN #17 identified she restarted the Oxytocin infusion at 1:15 AM at seventeen (17) milliunits/minute. Review of the hospital policy entitled, Oxytocin Administration for Induction of Labor, directed in part if the oxytocin infusion is stopped as a result of fetal distress, patient status must be assessed by a provider and the decision to restart the infusion would be made by the provider. The policy further directed if the infusion was discontinued for less than thirty minutes; restart the infusion at one half the dose when the infusion was turned off. Further interview with RN #17 indicated she was not aware the policy directed to decrease the dose in half within a thirty minute time frame. Further interview and review of the clinical record with RN #17 identified Oxytocin was decreased to eight (8) milliunit/minute at 1:55 AM per the direction of the resident who was at the bedside and reviewed the fetal tracing.


b. Further review of Patient #70's clinical record identified on 5/29/13 at 4:36 AM deep variables were occurring with a loss of a fetal heart tracing. At 4:42 AM during a position change the internal fetal electrode became disconnected and the fetal heart rate was not monitored. Several attempts were made to replace the internal fetal scalp electrode with continued loss of fetal activity on the monitor. Further review of the fetal tracing indicated an external monitor was placed and a fetal heart rate of 130 beats/minute was identified for less than ten seconds at 4:48 AM with subsequent loss of a fetal heart rate. Review of the progress note indicated at 4:51 AM an ultrasound was requested to assess fetal cardiac activity. At 4:57 AM an ultrasound was conducted that identified absent fetal cardiac activity. Upon entry into the operating room at 4:58 AM an external monitor was placed and an audible heart rate of 130 beats/minute was heard for approximately ten seconds at 4:59 AM. An additional ultrasound was conducted at 5:00 AM that identified no cardiac activity. Interview with RN #17 on 6/16/15 at 9:30 AM indicated at 4:42 AM when Patient #70 was changing position the pulse oximeter which was used to monitor the maternal heart rate fell off and was not replaced. RN #17 identified she did not obtain a maternal heart rate, pulse or replace the oximeter. Review of the clinical record indicated maternal vital signs were not monitored for eighteen (18) minutes until Patient #70 entered the operating room. Interview and review of the clinical record with MD #4 on 6/12/15 at 11:00 AM indicated although an external monitor identified a fetal heart rate of 130 beats/minute at 4:59 AM it was unclear if the heart rate was maternal or fetal. Interview with RN #18 on 6/16/15 at 4:45 PM who was the nurse educator for the labor and delivery area identified when a loss of fetal tracing occurred the expectation would be to take the mothers pulse and/or heartrate to differentiate maternal/fetal cardiac activity so that subsequent interventions could be conducted timely.

Based on medical record reviews, review of facility documentation, review of facility policies, and interviews for three of six patient reviewed for intravenous therapy (IV) administration (Patients #34, #35, and #50), the facility failed to ensure that the IV fluids were appropriately labeled. The finding includes:

1. Patient #34 was admitted to the hospital on 6/3/15 with diagnoses of End Stage Renal Disease and a kidney transplant. The physician's order dated 6/8/15 directed the antibiotic, Cefazolin, IV every eight hours. Observation on 6/9/15 at 9:06 AM noted that an empty IV bag of Cefazolin hanging on the patient's IV pole and the medication bag did not include a patient identification label. The Medication Administration Record identified that the Cefazolin was last administered at 1:00 AM on 6/9/15.

2. Patient #35 was admitted to the hospital on 6/7/15 with a diagnosis of syncope bradycardia. Physician orders dated 6/8/15 at 5:31 PM noted to discontinue the Sodium Chloride 0.9% 1000 millilters (ml) IV solution. Observation on 6/9/15 at 9:06 AM identified a 1000 ml bag of Sodium Chloride 0.9% IV solution on the patient's IV pole that had been discontinued. The IV bag lacked a patient label.

3. Patient #50 was admitted to the hospital on 4/6/15 with diagnoses that included hypoxia and sepsis versus pulmonary embolism. Physician orders dated 4/6/15 through 4/26/15 directed the antibiotic Ertapenem IV daily. The MAR dated 4/16/15 identified that Patient #50 received the antibiotic as ordered at 3:00 PM. Patient #50's nursing narratives dated 4/16/15 at 6:10 PM noted that RN #15 accidentally placed the identification label of another patient (Patient #56) on Patient #50's bag of Sodium Chloride that would be used as a flush following the administration of Patient #50's antibiotics.

Interview with RN #2 on 6/9/15 at 9:08 PM indicated that IVs/IV antibiotics are delivered to the automated dispensing system by pharmacy and nursing staff needed to place a patient identification label onto the bag prior to hanging/administering.

Based on a review of clinical records, hospital documentation, interviews and policy review, the facility failed to ensure that two of 7 patients (#303 and #67) records were accurate and/or complete. The findings include the following:


a. Patient #303 was admitted to the hospital's ED on 3/7/15 at 8:56 PM with complaints of upper abdominal pain, status post (s/p) hysteroscopic fibroid removal and ablation on 3/6/15. Review of the pain scale flowsheet dated 3/7/15 at 9:01 and 9:19 PM noted that the patient rated pain as a 10 (worst possible pain). The record reflected an order to administer 1 milligram of Dilaudid IV push (IVP) now, by the mid-level practitioner at 9:57 PM and the medication was administered at 10:26 PM. Review of the clinical record with the ED Director on 6/10/15 indicated that the patient's IV was established at 10:55 PM, 29 minutes after the medication was administered. Interview with the RN who administered the medication on 6/10/15 at 11:30 AM stated she documented the IV insertion time later therefore not reflective of the actual time it was established.



29049


b. Review of the clinical record identified Patient #67 was admitted to the hospital on 7/30/14 at 7:29 AM with spontaneous rupture of membranes at thirty-six weeks gestation. The infant was delivered on 7/30/14 at 2:15 PM via a spontaneous vaginal delivery with apgar scores of seven and nine. The mother infant couplet was transferred to the postpartum unit in stable condition. Review of the physician's progress note dated 7/31/14 at 6:30 AM identified Patient #67 requested to be discharged on 7/31/14. Further review of the clinical record dated 7/31/14 at 9:10 AM indicated Patient #67 also requested the infant's discharge at twenty four hours post-delivery. Review of the pediatric examination conducted on 7/31/14 recommended that the infant remain hospitalized until 8/1/14. Interview with MD #3 on 6/10/15 at 3:30 PM identified she was the patient's attending physician and after a review of the clinical record there was no documentation regarding the decision to discharge Patient #67 on 7/31/14. MD #3 indicated Patient #67 could have likely been discharged on 7/31/13 despite the infant's need to remain hospitalized. Further interview with MD #3 identified she should have documented a rationale as to why Patient #67 could or could not be discharged twenty four hours post-delivery and did not.

Based on medical record reviews, review of facility policies, and interviews for one of nine patients reviewed for medication administration (Patient #50), the facility failed to ensure that the medication was prepared and/or administered as ordered. The finding includes:

Patient #51 was admitted to the hospital on 3/5/15 with a diagnosis of Myasthenia Gravis crisis. Physician orders dated 3/13/15 directed Azathioprine (Imuran) suspension 50 mg via feeding tube twice a day. The MAR identified that the patient did not receive the 9:00 AM doses of the medication on 3/17/15 and 3/19/15 because the medication was unavailable (received 9:00 PM doses 3/17/15 and 3/19/15). Interview with the Director of Pharmacy on 6/12/15 at 11:15 AM noted that the pharmacy made an Imuran suspension 100 milligram (mg) on 3/13/15. He/she further indicated that the evening of 3/16/15, two Imuran medication syringes were delivered to the refrigerator of the automated medication dispenser to be administered by nursing. He/she noted that although the syringes were not delivered the evening of 3/18/15, a syringe dose was sent to the unit the morning of 3/19/15. The Director of Pharmacy identified that it was not clear if the medication was actually delivered or if nursing did not realize that the medication was located in the refrigerator.

Based on the hospital's inability to provide surveyors access to the radiology department and/or program documentation requested, the scope of radiological services was unable to be assessed. The findings include:


On June 23, 2015 at approximately 9 AM the survey team from the Department of Energy and Environmental Protection (DEEP) announced themselves and requested access to the radiology department and/or documentation related to radiological services. Between 9:00 AM and 12:00 PM the survey team was not provided sufficient documentation to assess radiological services. At 12:00 PM the survey team terminated its federal survey due to the hospital being deemed not inspection ready. Following the termination of the survey, arrangements were made with management to resume the inspection on June 24, 2015 allowing the hospital additional time to gather survey documents. On June 24, 2015, the inspection team resumed its review for compliance with federal and state regulations and acceptable standards of practice.

Based on observation and review of radiological documentation, the department of radiology failed to ensure that hazardous areas were adequately identified and failed to ensure that the bi-monthly radiation safety committee met as established. The findings include:

a. On June 24 and July 3, 2015, the survey team conducted inspections/tours of the radiology department to assess compliance with federal and state regulations and acceptable standards of practice. R.C.S.A 19-24-8 (5)(C) requires in part that each area or room in which sources of ionizing radiation other than radioactive materials are used shall be conspicuously posted with the sign or signs bearing the radiation caution symbol and appropriate wording to designate the nature of the source.

Contrary to the above, the hospital did not have conspicuously posted radiation signs in the hallway of the interventional suites.


b. Interviews with the RSO established that radiation safety committee meetings are held bi-monthly.

Contrary to the above, the hospital did not hold bi-monthly radiation safety committee meetings. Specifically, meetings were not held from September, 2014 through December 2014. Additionally, two of the meeting reports for the months of June and February, 2015 were substantially the same.

Based on review of documentation, the hospital failed to ensure that radiological safety documentation was in place for review. The findings include:

On June 24 and July 3, 2015 the radiology department was inspection and documents were reviewed. R.C.S.A 19-24-7 and 19-25a-4 requires in part that an evaluation of the radiation hazards incident to the use of radiation sources under a specific set of conditions. The adequacy of surveys shall be subject to review by the department's representatives.

Contrary to the above, the hospital was unable to produce a shielding design or shielding surveys for their x-ray operatories in "CORE 9."

Based on policy review and interview with radiological staff, the hospital failed to ensure that policies were in place and/or readily available in regards to adverse reaction to diagnostic agents. The findings include:

On June 24 and July 3, 2015 the radiology department was inspected for compliance with federal and state regulations and acceptable standards of practice related to emergency care of patients who experience an adverse reaction to diagnostic agents in the radiology service.

Contrary to the above, a review of hospital policies revealed adverse reactions are not adequately addressed in their policies. Specifically, during interviews with CT technologist #1, when asked about the adverse reaction to diagnostic agent's policy, three different answers were given and one technologist couldn't find the online electronic policy. Additionally, a policy from a non-hospital facility was provided to the inspector.

Based on observation and interviews of the Blueback Square, A Woman's Life building, the facility failed to ensure that 3 of 3 fire extinguishers were maintained. The finding includes:

A tour of the Blueback Square, A Woman's Life building on 6/10/15 at 9:10 AM identified that 3 of 3 fire extinguishers had not been checked monthly for function by hospital staff or yearly by the professional vendor since 2009. In an interview with the Woman's Life Director, there was no documentation that could be provided relative to ensuring the required testing of the fire extinguishers. At that time, the Quality Coordinator called Hartford Hospital Fire Safety staff and replacement fire extinguishers were delivered to the Woman's Life building approximately 1/2 hour later.

Based on observation and interview, the hospital failed to ensure that the vaporizing canisters located on the anesthesia machines were labeled with the date of calibration and/or that equipment was kept in good condition when utilized throughout the operating suite. The finding includes:
a. Observation of the anesthesia machines located throughout the operating suite on 6/8/15, identified that the Sevoflurane canisters failed to be identified with stickers identifying the date the canister was calibrated/cleaned etc. as such canisters are portable and may be moved from machine to machine.
b. A tour throughout the operating suite identified that the vinyl fabric on chairs in numerous rooms were nicked and torn, preventing effective cleaning of the chair between cases. During interview with the Quality Coordinator during tour on 6/18/15 at approximately 10:30 AM, identified that many chairs had been recently replaced due to the ripping of the vinyl fabric.
c. Observation of several gel positioning devices identified tears, rips and perforations of the clear surface covering rendering the piece of equipment unusable in the OR due to inability to clean. The Quality Coordinator removed each damaged piece of equipment.
d. Observation of the walls in the Jefferson Building Ambulatory Surgery Department identified many gouges of the wallpaper and plastic throughout the hallway secondary to stretcher parking. During interview on 6/8/15 at approximately 11:30 AM, the Quality Coordinator stated that the repair and resurfacing of the wall marring was already being addressed.

Based on observation and interviews of the Duncaster Primary Care Clinic, the facility failed to ensure 3 of 6 empty portable oxygen tanks were securely fastened in accordance with the referenced Life Safety Code. The finding includes:

An observation on 6/9/15 at 1:30 PM identified that portable 3 empty oxygen cylinders were stored leaning against each other and against the wall and were not secured in holders. Additionally, there were 2 full portable tanks and 3 empty portable tanks that were stored in holders in the same area, the phlebotomy room. An interview with the Duncater Primary Care Clinic at this time identified that up until the prior day, the portable oxgen cylinders were being stored in the supply room and she knew they didn't belong there so they were moved to the phlebotomy room. She further indicated they came from various vendors and as of the day prior had started to locate the vendors to have them removed and wasn't clear on how long they had been empty or why they were there.

Based on observation, interview, and policy review, the facility failed to ensure staff performed hand hygiene and/or implemented contact precautions in accordance with facility policy which created the potential to result in exposure to potentially contaminated medical equipment, infectious substances and transmission of infectious diseases to other patients and staff. The findings include the following:

a. On 6/8/15 during the period of 2:15 PM and 2:45 PM sinks designated as hand washing sinks were observed to have dirty IV bags in the sinks rendering the sink contaminated.

b. On 6/8/15 at 2:20 PM, RN #100 was observed to touch the patient at station #2 with ungloved hands and without the benefit of hand hygiene, proceeded to station #1 (clean machine) to obtain the B/P cuff, and returned to station #2 to take the patient's B/P.

c. On 6/8/15 at approximately 2:25 PM, RN #100 was observed to obtain a patient's temperature utilizing the portable thermometer and returned the thermometer to the counter without the benefit of disinfection.

d. On 6/11/15 at 9:55 AM, Patient #93 was observed lying in bed at station 1 receiving hemodialysis. A contact precautions sign was noted on the patient's table that directed to clean hands upon entering and leaving room or area, and that gloves and gown (PPE) were required. At 10:10 AM, RN #201 was observed to place a funnel in the dialysate bottle on the bottom of the patient's hemodialysis machine to add more dialysate to the existing bottle, discarded the funnel and returned the dialysate bottle to the main supply area. RN #201 failed to don gloves/gown when entering the area and failed to perform hand hygiene before proceeding to the common area. At 10:15 AM, RN #201 was observed to obtain the dialysate bottle from the common area and with a funnel, poured the dialysate into the dialysate bottle at station 4 then returned the bottle to the storage area. RN #201 proceeded to the Pyxis machine without performing hand hygiene.

e. On 6/11/15 at 10:00 AM, RN #510 was observed touching the machine at station #4 without the benefit of gloves. RN #510 then proceeded to don a gown, reset the machine then documented in the patient's chart without the benefit of hand hygiene. Interview with RN #510 at 10:02 AM stated she didn't wear gloves because she washed her hands.

f. On 6/11/15 at 10:20 AM, RN #201 was observed with gloves on to draw up medication and administer the medication to Patient #93. The RN failed to don a gown before entering the patient area in accordance with the posted instructions for isolation precautions. Interview with RN #201 on 6/11/15 at 10:25 AM stated he did not understand why he needed to don a gown as the patient was not in an isolation room. Subsequent to the observation, the Nurse Director educated the nurse that the patient's station was considered the area that required precautions. Review of the Transmission-Based Isolation policy directed that all staff entering the room must wear appropriate PPE as indicated on the sign posted.

g. On 6/11/15 at 10:45, CCHT #201 was observed to remove the covers from Patient 93's access site while wearing a gown and gloves. The CCHT removed his gloves and without the benefit of hand hygiene, donned gloves. CCHT #201 proceeded to clean the machine at station #4 without the benefit of removing the gown used for isolation Patient #93.

h. On 6/11/15 at 10:55 AM, RN #201 was observed to remove his isolation gown and with the gown rolled up in one hand, obtained hand gel with the other hand and attempted to perform hand hygiene while holding the gown.

The above observations were reviewed with the Nurse Director on 6/11/15 at 11:00 AM and subsequently, the Infection Preventionist was called to the unit to review appropriate infection control procedures with staff. Review of the infection control policy indicated that hand hygiene should be completed before and after direct patient contact, after completing a task at one station and before moving to another station, and after contact with a patients vascular access.

1. Based on observation, policy review and interview, the hospital failed to ensure that operating rooms were clear of paperwork and clutter. The finding includes:
During tour of the operating rooms on 6/8/11 with the Quality Coordinator for the Operating Room (OR) identified that some rooms had pieces of paper, unsheathed in plastic fastened to walls, with additional books stacked on a desk area within a corner of the OR. The substerile room located between the cardiac rooms desk area was stacked with manuals on the desk rather than the enclosed shelving provided. Anesthesia forms were identified to be stacked on the side of the anesthesia medication cart, rather than in an enclosure. All of the above hindering the ability to clean furniture, equipment and walls as stipulated in the hospital policy for cleaning of the operating/procedure rooms according to hospital policy, on a regular basis.




14528

2. Based on a tour of the dietary department, review of facility policies, observations, and interviews the hospital failed to ensure appropriate hair coverage was donned and/or that gloves were changed after becoming soiled. The finding includes:

A tour of the dietary department was conducted on 6/10/15 with the Director of Food Services. Observation noted that the dietary aide serving soup had a bouffant- type hair covering with holes throughout the cap that had been intentionally made. A non- hospital employee was observed to enter the kitchen and walked within one foot of a food preparation area and without hair coverage. The cook was observed preparing food, was donned with a chef's hat, and approximately 2 inches of hair at the sides of the cap, and approximately 5 inches of hair at the back of the head was exposed. The dietary aide during salad preparation was observed with a hair net and the net did not cover the front and sides of the aide ' s hair. Observation at 11:16 AM on 6/10/15 identified a dietary aide (in training) on the tray line with plastic gloves over heat resistant gloves. The dietary aide left the tray line, wiped his/her mouth with a paper towel, crumpled the paper towel, placed the towel in his/her pocket and returned to the tray line without changing his/her outer gloves. The dietary aide left the tray line and returned with a tray of hot food. Subsequently, the dietary aide changed his/her outer gloves following instructions from the Director of Food Services. Interview with the Director of Food Services on 6/10/15 at 11:30 AM identified that the dietary aide serving soup had been instructed in the past not to place holes in his/her bouffant cap. He/she indicated that all hair must be covered beneath the cap that was worn. The Director of Food Services noted that the non- hospital employee was picking up food for the community and was aware he/she was not supposed to enter food preparation areas of the kitchen.

The facility dietary dress code policy identified that all employees in production, serving, and plating areas The policy further identified that hair must be completely covered shall wear clean gloves after washing hands. Although the policy directed that delivery personnel must completely cover hair, the policy did not direct hair coverage for community delivery personnel that enter the dietary department.



19907

3. Based on observations, review of hospital policies and procedures and interviews with facility personnel, the facility failed to ensure that infection control practices were followed. The findings include:

During tour of the cardiac catherization lab on 6/9/15, it was observed on the terminal cleaning logs that all 4 procedure rooms were not terminally cleaned on 6/5/15 and 6/8/15. Review of hospital policy identified that it is the responsibility of all staff to decontaminate procedure rooms that have been in contact witt the patient during a procedure. Interview with the Director of Environmental Services on 6/9/15 identified that all procedure rooms are to be terminally cleaned daily on the evening shift and it was not documented as being completed.

Based on observation and interview, the hospital failed to ensure policy and compliance with the preset-up of the perfusion lines. The finding includes:
During tour of the Operative Suite (OR) on 6/8/15 with the Quality Coordinator for the OR, identified two cardiac bypass machines (one located in an operating room and a second machine in the sub-sterile area between cardiac rooms) were identified as set-up for the "next case" with tubing lines, transducers and syringes (no fluids). The machine set-ups lacked an identification date as to when the set-up was initiated and/or for what period of time the set-up was considered sterile. The machine failed to be covered in any way as protection against foot traffic in the near location and/or terminal cleaning activities.
During interview on 6/8/15 at approximately 10:40 AM, the Chief Perfusionist stated that no policy directed a time limit for the set-up. He
stated that usually the set-up perfusionist would initial the date of the tubing sterility, which in this case was 1/31/17. The set-up lacked any identifying markers as to who set it up or when the set-up expired.



19907

1. Based on review of hospital policies, observation and interview, the hospital failed to ensure that hair coverage/wearing of exposed jewelry met acceptable standards within the restricted and semi-restricted areas of the surgical suite. The findings include:
a. During tour of the operating suites on 6/8/15 with quality personnel, it was observed that some operating room staff members failed to keep head and facial hair contained within the borders of the head covering/masks that were worn. Although hoods were utilized for some men, either the hood was turned back and thus exposed the hair at the neckline or the hood, although worn correctly, failed to cover the sides of the face, exposing the beard between the hood and the mask.
b. Observation on 6/8/15 at approximately 10:00 AM, identified a surgical procedure in progress with a scrub tech at the surgical site who wore drop earrings outside the head covering. Review of the hospital policy for Dress Code within Perioperative Services, identified that the selected head covering must be disposable and cover all head hair, including long sideburns, long neckline hair and beards. All jewelry, if worn, must be contained within scrub attire to prevent contamination of the wound or sterile field.



26703

2. Based on review of documentation interview and a review of hospital policies and procedures for an incident of a retained object the hospital failed to follow the pathology policy and procedure for retained objects. The findings include.

According to facility documentation on 11/12/14 P#29 underwent placement of an intrauterine device (IUD) post vaginal delivery. On 12/26/14 P#29 complained of rectal pain and upon examination part of the IUD was visualized in the rectum. P#29 was taken to the operating room (OR) for repair of a vaginal rectal perforation. The IUD and applicator fragment was removed however according to facility documentation and interview with the Director of Risk Management and Patient Safety on 6/10/15 at 1:00 PM the applicator fragment was not sequestered and/or sent to Pathology for processing when removed. During an interview with the Quality Improvement (QI) Coordinator on 6/11/15 at 2:30 PM he/she indicated after review of the hospital policy the retained piece of applicator should have been sent to pathology. Hospital OR Pathology and Laboratory Medicine Procedure identified surgical specimens including foreign bodies are to be processed using the identified standard procedure for the proper handling of, transporting and documentation of specimens and foreign objects.

Based on review of the surgical record, review of hospital policy and interview, the hospital failed to ensure that for three of three records for patients (#41, #42, #43) who underwent gastrointestinal procedures, were legible and correct. The findings include.
1. Review of the procedural record for Patient #41 who underwent a colonoscopy on 6/9/15, identified that the anesthesia record failed to clearly identify how much Propofol the patient received during the procedure. Although the record identified "35", the record failed to clearly delineate the unit of measurement.
2. Review of the procedural record for Patient #42, who underwent an EGD (endogastroduodenoscopy) on 6/9/15, identified that the anesthesia record recorded 100 of Propofol delivered to the patient, however, the documentation failed to identify the unit of measurement.
3. Review of the procedural record for Patient #43 who underwent an EGD/colonoscopy on 6/9/15 identified that the anesthesia record failed to document the amount of Propofol delivered to the patient during the procedures. During interview on 6/11/15 at 2:30 PM, the Chief of Anesthesia reviewed the documentation and stated that the handwriting/omission was not acceptable.
Review of the hospital policy governing documentation within the anesthesia record identified that the current standard of care stipulates that the name, dosage, route and time of administration of all drugs and anesthesia agents needs to be documented.

Based on clinical record review, interviews and a review of hospital policies for 1 of 4 patients reviewed who underwent surgical procedures, the hospital failed to complete a post anesthesia assessment. The findings include:
On 6/5/15 Patient (P) #57 underwent an exploratory laparotomy, hernia repair, right colectomy, and removal of an ileoconduit, requiring anesthesia. A review of the medical record on 6/9/15 at 1:40 PM with Director #2 and Nurse Manager #5 identified that the medical record lacked documentation of a post anesthesia evaluation following the surgical procedure on 6/5/15. A subsequent interview on 6/10/15 at 10:45 AM with the Director of Regulatory Readiness and Nursing Operations identified the medical record had again been reviewed and the medical record lacked a post anesthesia evaluation for the 6/5/15 surgery. Facility policy for post anesthesia evaluation and documentation indicated a post anesthesia evaluation must be completed and documented by an individual qualified to administer anesthesia no later than 48 hours after surgery or a procedure requiring anesthesia services.