HospitalInspections.org

Based on document review and interview, it was determined that for 5 of 5 (Pt.#2-Pt.#6) psychiatric patients' clinical records reviewed for Patient Rights, the Hospital failed to ensure that the patients had the right to make informed decisions regarding their care by failing to ensure psychotropic medication consent forms were completed prior to the administration of psychotropic medications.

Findings include:

1. On 8/08/22, the clinical record of Pt. #2 was reviewed. Pt. #2 was admitted to the Hospital's Behavioral Health Unit (BHU) on 8/04/22, with a diagnosis of Major Depressive Disorder. Pt. #2's clinical record included:
- Physician's orders, dated 8/04/22, and included Haloperidol Lactate (Anti-Psychotic Medication) and Trazadone (used to treat anxiety). Pt. #2's MAR (Medication Administration Record) indicated that Pt. #2 received Haloperidol on 8/04/22 at 6:12 PM for agitation and Trazadone on 8/07/22 at 9:00 PM. The "Psychotropic Medication Notice and Consent Form" was reviewed and lacked documentation by the Physician that education was provided about medications. The signed consent form by Pt. #2 did not list any medications and was not dated.

2 On 8/08/22, the clinical record of Pt.#3 was reviewed. Pt.#3 was admitted to the Hospital's BHU on 8/06/22, with a diagnosis of schizoaffective disorder, bipolar type. Pt.#3's clinical record included:
-Physician's orders dated 8/06/22, and included, Haloperidol Lactate, Lithium Carbonate (used to treat manic episodes), and Trazodone. Pt.#3's MAR indicated that Pt.#3 received Haloperidol on 8/06/22 at 2:35 PM, Lithium Carbonate on 8/07/22 at 9:00 AM, and Trazodone on 8/07/22 at 9:00 PM. The "Psychotropic Medication Notice and Consent Form" was reviewed and lacked documentation by the Physician that education was provided about medications. The signed consent form by Pt. #3 did not list any medications.

3 On 8/08/22, the clinical record of Pt.#4 was reviewed. Pt.#4 was admitted to the Hospital's BHU on 8/08/22, with a diagnosis of major depressive disorder. Pt.#4's clinical record included:
-Physician's orders dated 8/08/22 and included Haloperidol Lactate. Pt.#4's MAR indicated that Pt.#4 received Haloperidol on 8/08/22 at 7:23 AM. The "Psychotropic Medication Notice and Consent Form" was reviewed and the signed consent form by Pt. #4 did not list any medications.

4 On 8/08/22, the clinical record of Pt.#5 was reviewed. Pt.#5 was admitted to the Hospital's BHU on 8/07/22, with a diagnosis of schizophrenia. Pt.#5's clinical record included:
-Physician's orders dated 8/08/22 and included Lithium Carbonate, Trazadone, and Haloperidol. Pt.#5's MAR indicated that Pt.#5 received Lithium Carbonate on 8/08/22 at 4:58 PM, and Trazadone on 8/09/22 at 2:39 AM. The "Psychotropic Medication Notice and Consent Form" was reviewed and the signed consent form by Pt. #5 did not list any medications.

5 On 8/08/22, the clinical record of Pt.#6 was reviewed. Pt.#6 was admitted to the Hospital's BHU on 8/04/22, with a diagnosis of major depressive disorder. Pt.#6's clinical record included:
-Physician's orders dated 8/04/22 and included Haloperidol Lactate. Pt.#6's MAR indicated that Pt.#6 received Haloperidol on 8/04/22 at 2:35 PM. The "Psychotropic Medication Notice and Consent Form" was reviewed and lacked documentation by the Physician that education was provided about medications. The signed consent form by Pt. #6 did not list any medications.

6 On 8/08/22 at approximately 11:45 AM, the above findings were discussed with E #10 (Manager of Behavioral Health Unit). E #10 stated that the Psychotropic Medication Notice should be filled out completely and list the medications.

7 On 8/09/22 at approximately 2:30 PM, the Hospital's policy for Psychotropic Medication Consent was requested of the Senior Vice President of Quality and Compliance (E#4). E#4 stated that there is no policy for psychotropic medication consent.

Based on document review and interview, it was determined that the Hospital failed to check the badge meters for radiology workers periodically for amount of radiation exposure, as required. This potentially affected the safety of approximately 26 staff in the radiology department.

Findings include:

1. On 8/9/2022, the Hospital's policy titled, "Radiation TLD Badges for Controlled Personnel" (reviewed by the Hospital in 2021) was reviewed and required, " ... Procedure ... The hospital radiation safety officer or his/her designate are the individuals responsible for assuring that all controlled personnel within the Department of Radiology are properly monitored by radiation exposure badges ... 3 ... The monthly ... badge reports ... will be evaluated by the radiation safety officer ..."

2. On 8/9/2022, the Monthly Radiation Dosimeter (Badge) Reports from February 2022 through July 2022 were reviewed. The report lacked monthly radiation badge reports for May, June, and July 2022.

3. On 8/10/2022, findings were discussed with E #21 (Director of Radiology Department). E #21 stated that there were approximately 26 staff (e.g., physicians, X-ray technicians, CT/Computerized Tomography technicians, etc.) who work in close proximity to radiation in the Radiology Department. E #21 could not provide documentation and review of the monthly badge reports from May through July 2022.

Based on document review and interview, it was determined that the Hospital failed to manage dietary services in compliance with diatetic policies to ensure food was safe for consumption. This failure potentially affected an average monthly admission of 450 patients receiving meals from the dietary department. As a result, the Condition of Participation CFR 482.28 Food and Dietetic Services was not in compliance.

Findings include:

1. The Hospital failed to measure and record food temperatures to ensure food is being served at safe temperatures. See deficiency at A-620 A.

A. Based on observation, document review, and interview it was determined that the Hospital failed to manage dietary services by not measuring and recording food temperatures to ensure food is being served at safe temperatures. This failure potentially affected an average monthly admission of 450 patients receiving meals from the dietary department.

Findings include:

1. On 8/9/2022 between approximately 10:50 AM through 11:45 AM, an observational tour of the dietary service area was conducted. According to E #14 (Executive Director for Food and Nutrition), the Hospital's trayline service hours are at 7:00 AM (breakfast), 11:00 AM (lunch), and 3:30 PM (dinner). During the tour, E #15 (Cook/Server) was observed distributing the food in the trayline. E #15 was not observed taking the temperatures of the hot food items (pork chops, rice, spinach, chili, and vegetable soup). The trayline temperature log for the hot food items was also requested from E # 14. There was no log available for review.

2. On 8/9/2022, the Hospital's policy titled, "Food Production, Service and Distribution Standards" (reviewed by the Hospital on 2021) was reviewed and included, "...Procedure... 4. Food Service and Distribution: 4.1. Food is held at the proper temperature during service... 4.4. Temperatures of hot food is taken in serving line and recorded on trayline temperature log sheet..."

3. On 8/9/2022 at approximately 11:30 AM, an interview was conducted with E #15. E #15 stated that he takes the temperature of the food once but does not record on the log sheet.

4. On 8/9/2022 at approximately 11:30 AM and on 8/10/2022 at approximately 11:20 AM, findings were discussed with E #14. E #14 could not provide the log sheet for monitoring the temperature of hot food items. E #14 stated that there is no documentation available to ensure that the hot food items are within the range. E #14 stated that it is important to monitor the food temperatures to ensure that it is safe for consumption.

B. Based on observation, document review and interview, it was determined that for 2 of 2 cold storage areas (Cold Storage #1 and Cold Storage #3), the Hospital failed to manage the dietary services by ensuring that food items beyond used by date were not available for consumption. This could potentially affect approximately 105 patients receiving meals from the dietary on 8/9/2022.

Findings include:

1. On 8/9/2022 between approximately 10:50 AM through 11:45 AM, an observational tour of the dietary service area was conducted. The following were observed:

- In cold storage #1, there were containers of guacamole with used by date of 8/8/2022, salsa with used by date of 8/2/2022, and chopped tomato with used by date of 8/2/2022.

- In cold storage #3, there was a tray of 19 boiled eggs with a used by date of 8/8/2022.

2. On 8/10/2022, the Hospital's policy titled, "Food Storage" (revised on 8/2021) was reviewed and required, " ... Procedure ... 10. Perishable food ... shall be refrigerated until needed for preparation or service ..."

3. On 8/9/2022 at approximately 11:30 AM, findings were discussed with E #14 (Executive Director for Food and Nutrition). E #14 stated that the food items should have been removed from the refrigerator based on the used by date.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted August 8 & 9, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of the Full Survey Due to a Complaint conducted August 8 & 9, 2022, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on observation, document review, and interview, it was determined that for 1 of 3 (Pt. #19) patients reviewed for isolation, the Hospital failed to ensure that the infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital by ensuring contact isolation precautions were fully implemented.

Findings include:

1. The Hospital's policy titled, "Transmission - Based Precautions (Isolation Precautions)" dated September 2019 was reviewed. The policy required, " ...Contact Precautions ...Patients who require Contact Precautions shall be placed in a single-patient room when available."

2. On 8/8/2022 at approximately 9:58 AM, an observational tour of the Intensive Care Unit (ICU) was conducted. There were 8 beds (6 in a large room with no walls separating and 2 isolation rooms separated by walls and a door). There were 3 patients in the ICU. There was one patient (not on isolation precautions) in 1 of the 2 isolation rooms. The 2nd isolation room was unoccupied. There was 1 patient (Pt. #19) on contact isolation. There was an isolation sign above Pt. #19's bed, an isolation cart near the foot of the bed, and the curtain was open (not drawn). Pt. #19 was not placed in the available isolation room.

3. On 8/8/2022, Pt. #19's clinical record was reviewed. Pt. #19 was admitted on 7/26/2022, with a diagnosis of altered mental status. Pt. #19 also has the diagnoses of severe sepsis and severe dehydration. Pt. #19's nasal swab culture collected on 7/26/2022, was reported on 7/30/2022, with positive Methicillin Resistant Staphylococcus Aureus (MRSA) results. Pt. #19's physician order dated 7/30/2022, included, an order for contact isolation.

4. On 8/8/2022 at approximately 10:01 AM, an interview was conducted with a Registered Nurse (E #3). E #3 stated that Pt. #19 is on isolation for positive MRSA in the nares. E#3 stated that Pt. #19 is not in an isolation room, but is separated from the other patients.

5. On 8/10/2022 at approximately 10:15 AM, an interview was conducted with the Interim Vice President of Patient Services (E #2). E #2 stated that patients on contact isolation should be placed in separate room when available.

A. Based on document review, observation, and interview, it was determined that for 1 of 2 disinfectant solution bottles in the out-patient rehabilitation unit, the Hospital failed to ensure a sanitary environment was provided to avoid transmission of infection, potentially affecting approximately 115 rehab patient each month.

1. On 8/9/2022, a policy for solution labeling and dating was requested. On 8/11/2022 at 9:02 AM, the Vice President of Financial and Ancillary Services (E #25) stated that there is no policy for the labeling and dating of solutions.

2. On 8/9/2022 at 10:30 AM, an observational tour was conducted in the out-patient rehabilitation unit. There was a plastic spray bottle, approximately 1/3 full of a clear fluid, lacking the name of the contents, and dated 12/1/15. There were cleaning cloths next to the bottle.

3. On 8/9/2022 at 10:35 AM, an interview was conducted with the Director of Physical Medicine and Rehab (E #11). E #11 stated that the clear solution was for disinfection of surfaces and equipment. E #11 stated that the solution was the same as in another bottle (Virex). However, the Virex solution was a light purple color, not clear. E #11 did not know why the date, 12/1/15, was on the bottle. E #11 stated that the disinfection solution is sprayed on the surface and then wiped off.

B. Based on document review, observation, and interview, it was determined for 2 of 2 staff (E #13 and an unidentified ED staff member) in the perioperative (OR) decontamination area, the Hospital failed to ensure that a sanitary environment was provided by wearing proper attire, to avoid transmission of infection, potentially affecting approximately 45 surgical patient each month..

1. On 8/10/2022, the Hospital's policy titled, "Dress Standards for Central Service Technician," not dated, was reviewed. The policy included, "Personnel working in the decontamination area will wear the following attire: Clean scrub attire... head covering, shoe covers..."

2. On 8/9/2022 at 11:30 AM, an observational tour was conducted in the OR decontamination area. A maintenance employee (E #13), not wearing OR attire, hair cover, or shoe covers, was cleaning lights and sprinkler heads on the ceiling. An unidentified female employee rang the decontamination door bell and was let in by a Sterile Processing Technician (E #12). The unidentified female was not wearing a hair cover or shoe covers. The female staff member walked into the decontamination room, spoke with E #12, and then left.

3. On 8/9/2022 at 11:50 AM, an interview was conducted with the Sterile Processing Technician (E #12). E. #12 stated that outside staff are supposed to put on a bunny suite before entering the sterile processing/ decontamination area. E #12 stated that he did not know who the female employee was, but did know she was from the Emergency Department and was trying to obtain a "suture lining," E #12 did not know what a suture lining was.

C. Based on document review, observation, and interview, it was determined for 1 of 1 Sterile Processing Technician (E #12) in the perioperative (OR) decontamination area, the Hospital failed to ensure a sanitary environment was provided by properly mixing disinfectant, to avoid transmission of infection, potentially affecting approximately 45 surgical patients each month..

1. On 8/9/2022, a policy for measuring disinfectant solution was requested. On 8/11/2022 at 9:02 AM, the Vice President of Financial and Ancillary Services (E #25) stated that there is no policy for measuring disinfectant solution.

2. On 8/9/2022 at 11:30 AM, an observational tour was conducted in the OR decontamination area. A Sterile Processing Technician (E #12), discussed the procedure for cleaning surgical instruments. E #12 stated that precleaning is done using 2 gallons of water and a "cap" of either "Renuzyme Plus" or "Neutrawash". The instructions on the "Renuzyme Plus" bottle recommended the use of 1 - 2 ounces per gallon of water. The instructions on the "Neutrawash" bottle recommended the use of 0.2 - 1.0 ounces per gallon of water. There was not measuring device for measuring disinfectant or water. There was no labeled sink mark for water measurement.

3. On 8/9/2022 at 11:50 AM, an interview was conducted with the Sterile Processing Technician (E #12). E. #12 stated the germicidal solutions were very strong and only a "cap" of solution was needed for 2 gallons of water. E #12 stated he knew how much water to fill the sink to reach 2 gallons.

D. Based on document review, observation, and interview, it was determined that for 2 of 2 Pharmaceutical Compounding Machines, the Hospital failed to ensure a sanitary environment was provided to avoid transmission of infection, potentially affecting approximately 450 patients admitted to the Hospital each month..

1. On 8/10/2022, the Hospital's policy titled, "Admixture Guidelines," reviewed 3/20/2022, was reviewed. The policy lacked guidance on the pharmaceutical compounding room environment.

2. On 8/10/2022, the 2019 USP (United States Pharmacopoeia) General Chapter (797) Pharmaceutical Compounding - Sterile Preparations, was reviewed. The Standards required, "4.3 Creating Areas to Achieve Easily Cleanable Conditions: Cleanroom Suits: The surfaces of ceiling, walls, floors, doors, door frames, fixtures, shelving, work surfaces, counters, and cabinets in the classified area must be smooth, impervious, free from cracks and crevices, and non-shedding so they can be cleaned and disinfected and to minimize spaces in which microorganisms and other contaminants can accumulated... minimize dust-collecting..."

3. On 8/9/2022 at 1:00 PM, an observational tour was conducted in the Pharmacy. In the medication compounding room, there were 2 medication mixing machines, providing a sterile environment for pharmaceutical compounding. However, the room contained dusty floors, shelves and surfaces. Medications were also stored in the clean room.

4.. On 8/10/2022 at 11:00 AM, an interview was conducted with the Interim Director of Pharmacy (E #20). E. #20 stated that the compounding room was very dusty and would receive a thorough cleaning.

A. Based on document review, observation, and interview, it was determined that the Hospital failed to adhere to a surgical care policy to ensure that the Surgical Department contained readily available supplies, medications, or equipment required for a malignant hyperthermia emergency (severe reaction from anesthesia drugs).

Findings include:

1. The Hospital's policy titled, "Malignant Hyperthermia Box" (dated 6/2018) was reviewed on 8/11/2022, and included, "The Hospital will maintain a treatment box for cases of Malignant Hyperthermia at all times in the Hospital."

2. The Hospital's policy titled, "Malignant Hyperthermia" (dated 4/2021), was reviewed on 8/11/2022, and included, "Purpose: To provide guidelines for treatment of malignant hyperthermia to ensure patient safety...Protocol will be utilized for treatment of malignant hyperthermia..." The Hospital's policy details the procedure required in the event of an emergency and included the required medications and supplies needed.

3. On 8/9/2022 at 11:20 AM, an observational tour of the Surgical Department was conducted. During the tour, it was noted that the department lacked a malignant hyperthermia cart/box, or the required supplies, medications, or equipment readily available in case of an emergency. The Operating Room Director (E #23) was present and acknowledged that there wasn't a malignant hyperthermia cart/box readily available at the time of the tour. E #23 stated that the malignant hyperthermia box was in the Pharmacy. E #23 stated that the malignant hyperthermia box should be in the OR.

4. On 8/9/2022 at 11:25 AM, an interview was conducted with E #23. E #23 stated that a malignant hyperthermia box should be available in case of an emergency.

B. Based on document review, observation, and interview, it was determined that the Hospital failed to adhere to a surgical care policy to monitor the Operating Room's humidity, to ensure that the recordings were within the required range.

Findings include:

1. The Hospital's policy titled, "Temperature and Humidity Requirements" (revision date 8/9/2022), was reviewed on 8/10/2022, and required, "To assure safe and physical comfort for patients and staff...Operating Room (OR): Room Humidity: 50-60 %..."

2. The Hospital's Operating Room Temperature Log (dated 7/5/2022-8/9/022), was reviewed on 8/9/2022. The log included recorded OR room temperatures and room humidity. The following room humidity recordings were outside of the required range of 50-60 % (in OR Room 1):
- 7/5/2022: 70 %
- 7/11/2022: 66 %
- 7/18/2022: 70 %
- 7/20/2022: 73 %
- 7/27/2022: 77 %
- 8/2/2022: 70 %
- 8/4/2022: 70 %
- 8/5/2022: 69 %
- 8/8/2022: 75 %
- 8/9/2022: 66 %
The OR room's temperature logs did not include any notification to the clinical manager or maintenance department indicating that the room humidity was out of range.

3. On 8/10/2022 at 10:15 AM, an interview was conducted with the Interim Vice President of Patient Care (E #2). E # 2 stated that it is important that the OR's temperature and humidity are within range in case the room needs to be used for a procedure, because if not, organisms can grow, increasing risks of infection.

Based on document review and interview, it was determined that for 2 of 2 patients' (Pt. #20 and Pt. #23) clinical records reviewed who were receiving breathing treatments, the Hospital failed to document respiratory assessments, as required, to ensure services were delivered in accordance with the medical directives.

Findings include:

1. On 8/9/2022, the clinical record for Pt. #20 was reviewed. Pt. #20 was admitted to the Hospital with a diagnosis of pneumonia. The clinical record included a physician's order for a breathing treatment with Xopenex/Ipatropium (bronchodilator) every four hours on 7/30/2022. Pt. #20 was given breathing treatments by a respiratory therapist on 8/7/2022 at 7:00 PM and on 8/8/2022 at 12:00 MN and at 4:00 AM. Respiratory assessments were not conducted on the said dates.

2. On 8/9/2022, the clinical record for Pt. #23 was reviewed. Pt. #23 was admitted with a diagnosis of chronic obstructive pulmonary disease. The clinical record included a physician's order for a breathing treatment with Albuterol and Atrovent every six hours on 8/8/2022. Pt. #23 was given a breathing treatment by a respiratory therapist on 8/8/2022 at 4:00 PM. Respiratory assessment was not conducted on the said date.

3. On 8/10/2022, the Hospital's policy titled, "Respiratory Care Assessment Recommendations" (reviewed by the Hospital on 11/2020) was reviewed and required, " ... IV. Procedures ... 4 ... Assessment of outcome is performed by monitoring the physiological parameters ... of all patients treated with bronchodilator therapy ..."

4. On 8/9/2022, findings were discussed with E #19 (Directory, Respiratory Department) at approximately 1:45 PM. E #19 stated that the respiratory therapist should perform an assessment (e.g., lung sounds and response to treatment) whenever a patient is given a breathing treatment. E #19 confirmed that there were no respiratory assessments for Pt. #20 and Pt. #23 on the dates/times in question.