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Based on observation, review of clinical records, hospital policies and procedures, and interviews for one of three patients in the in-patient, adult, Behavioral Health Unit who utilized one full side rail and/or had a history of suicidal ideation or attempt, Patient #51, the hospital failed to ensure that the patient was free of risk for use of a ligature. The findings include:
Tour of the adult in patient Behavioral Health Unit on 05/06/13, 05/08/13, and 05/09/13 identified that multiple beds were equipped with bilateral, full-length, side rails. Each rail was divided by one horizontal rail, leaving a space of 4 and ¾ inches between top and middle rail and middle and bottom rail. Residents #49, #50, and #51 were observed with 1 full side rail elevated.
Patient #51 was admitted to the hospital on 04/08/13 with diagnoses that included depression with overdose attempt and history of Bipolar disorder. The patient presented to the Emergency Department (ED) after a suicide attempt and stated that he/she did not want to live anymore. A Behavioral Health Shift Assessment dated 04/08/13 identified that P #51 had a safety concern for potential violence however, currently denied suicidal thoughts and demonstrated safe behavior.
Review of a restraint order dated 04/28/13 identified that he/she presented as violent, danger to self, aggressive, and a danger to others as evidenced by hitting his/her head and hands, threatening, unable to follow directions and swearing and was placed in 4 point restraints for 3 hours.
Review of a restraint order dated 05/04/13 identified that R #51 was violent, aggressive, threatening to harm staff and throwing things. The patient was placed in seclusion for 1.5 hours. Following discontinuation of seclusion, RN #3 documented that the patient was unable to express reasonable insight related to triggers, behavioral control, and personal responsibilities to respect others.
On 05/09/13 at 10:45 AM Patient #51 was observed to be on every 15 minute checks with 1 full side rail up. Interview with Registered Nurse (RN) #2, assigned to the patient at 10:45 AM identified that Patient #51utilized 1 side rail up a personal choice to assist in getting in and out of bed. RN #2 identified that the Patient had fleeting suicidal ideation but had promised to remain safe and not to harm him/herself. RN #2 identified that he/she did not know whether or not the side rail presented a hazard risk for use of a ligature.

1. Based on clinical record reviews and interviews with facility personnel for one of five sampled patients (Patient #1), the facility failed to complete assessments and/or that reassessments were completed per hospital policy. The findings include:

Patient #1 was admitted to the Emergency Department (ED) on 12/3/11 with a sudden onset of left hip/thigh pain and unable to bear weight. Review of the pain assessment dated 12/3/11 at 10:39 AM identified that the patient's pain level was a 10/10 (severe pain). Patient #1 received Decadron 8 milligrams (mg) IV at 12:34 PM. Further review failed to identify that the patient was reassessed for pain until he/she was transferred to another hospital at 2:24 PM. Review of hospital policy identified that if a patient receives medication, the assessment, documentation of intervention and reassessment is done with the Comfort/Pain/Anxiety Management Intervention. Interview with the Quality Manager on 5/9/13 identified that pain reassessent should be completed within one hour of an intervention.


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2. Based on clinical record review and staff interviews for 1 (P#3) of 5 patients reviewed for appropriate medication administration, the facility failed to administer a medication according to the physician's order. The findings include:

P#9 was brought to the Emergency Department (ED) by emergency personnel for intoxication and epigastric pain. On admission P#9 was irritable, agitated and combative. P#9 had a blood alcohol level of 387 milligrams/deciliter (mg/dL. (Normal value 0 to 100 mg/dL).

Nurse's notes dated 1/13/13 indicated P#9 was initially noncompliant with attempts at placement of an intravenous (IV) catheter. Medical Doctor (MD) #3 and security staff were at the bedside. P#9 became more cooperative and an IV was placed. A physician progress note by MD #3 dated 1/14/13 indicated P#9 was uncooperative, swearing, trying to get out of bed and refusing intravenous (IV) catheter insertion. The progress note further indicated the the patient would need some sedation to facilitate medical workup and treatment. A physicians order by MD#3 dated 1/14/13 at 1:20 PM indicated P#9 was to receive Haldol Lactate 10mg one time IM. Subsequent notation by RN#1 indicated the Haldol had been administered to P#9 via the IV and not IM as ordered. A nurse's note dated 1/14/13 at 1:40 AM indicated the physician entered P#3's room and found him/her blue in color and not breathing. Cardiopulmonary resuscitation (CPR) was started immediately. P#9 had a breathing tube placed and his/her pulse was noted to have spontaneous rhythm on the cardiac monitor. P#9 was transferred to the intensive care unit. A history and physical dated 1/14/13 indicated P#9 had experienced cardiac arrest and was status post resuscitation with the most likely being a respiratory problem in the setting of sedation and alcohol intoxication. On 2/5/13 P#9 was discharged to a rehabilitation facility to build his/her endurance and strength.

During an interview with MD #3 on 5/9/13 at 10:30 AM, MD#3 ordered the Haldol to be administered to P# 9 in order to conduct a medical workup. MD#3 indicated he/she could not imagine ordering the Haldol IV but did not remember specifically the route of administration he/she had ordered.

During an interview with RN #1 on 5/9/13 at 1:00 PM, RN#1 indicated he/she was in the room with P#9, MD#3, security and other staff members. At the time P#9 was combative and would not let RN#1 place the cardiac monitor on or start an IV line. The room was chaotic as P#9 was attempting to get off the bed and was striking out at staff. When P#9 was calm enough, the IV line was inserted. RN#1 indicated as he/she was leaving the room when MD#3 gave a verbal order for P#9 to receive Haldol. Upon surveyor inquiry RN#1 did not recall specifically whether MD#3 ordered the medication IM or IV. RN#1 administered the Haldol to P#9 via the IV. RN#3 then left the room to chart the administration of the medication and that was when he/she realized the order was for IM not IV. In the meantime MD#3 entered the room and found P#9 unresponsive several minutes after the Haldol was administered.

Based on clinical record review and staff interviews for 1 (P#9) of 5 patients reviewed for appropriate medication administration, the facility failed to administer a medication by the appropriate route. The findings include:

P#9 was brought to the Emergency Department (ED) by emergency personnel for intoxication and epigastric pain. On admission P#9 was irritable, agitated and combative. P#9 had a blood alcohol level of 387 milligrams/deciliter (mg/dL. (Normal value 0 to 100 mg/dL).

Nurse's notes dated 1/13/13 indicated P#9 was initially noncompliant with attempts at placement of an intravenous (IV) catheter. Medical Doctor (MD) #3 and security staff were at the bedside. P#9 became more cooperative and an IV was placed. A physician progress note by MD #3 dated 1/14/13 indicated P#9 was uncooperative, swearing, trying to get out of bed and refusing intravenous (IV) catheter insertion. The progress note further indicated the the patient would need some sedation to facilitate medical workup and treatment. A physicians order by MD#3 dated 1/14/13 at 1:20 PM indicated P#9 was to receive Haldol Lactate 10mg one time IM. Subsequent notation by RN#1 indicated the Haldol had been administered to P#9 via the IV and not IM as ordered. A nurse's note dated 1/14/13 at 1:40 AM indicated the physician entered P#3's room and found him/her blue in color and not breathing. Cardiopulmonary resuscitation (CPR) was started immediately. P#9 had a breathing tube placed and his/her pulse was noted to have spontaneous rhythm on the cardiac monitor. P#9 was transferred to the intensive care unit. A history and physical dated 1/14/13 indicated P#9 had experienced cardiac arrest and was status post resuscitation with the most likely being a respiratory problem in the setting of sedation and alcohol intoxication. On 2/5/13 P#9 was discharged to a rehabilitation facility to build his/her endurance and strength.

During an interview with MD #3 on 5/9/13 at 10:30 AM, MD#3 ordered the Haldol to be administered to P# 9 in order to conduct a medical workup. MD#3 indicated he/she could not imagine ordering the Haldol IV but did not remember specifically the route of administration he/she had ordered.

During an interview with RN #1 on 5/9/13 at 1:00 PM, RN#1 indicated he/she was in the room with P#9, MD#3, security and other staff members. At the time P#9 was combative and would not let RN#1 place the cardiac monitor on or start an IV line. The room was chaotic as P#9 was attempting to get off the bed and was striking out at staff. When P#9 was calm enough, the IV line was inserted. RN#1 indicated as he/she was leaving the room when MD#3 gave a verbal order for P#9 to receive Haldol. Upon surveyor inquiry RN#1 did not recall specifically whether MD#3 ordered the medication IM or IV. RN#1 administered the Haldol to P#9 via the IV. RN#3 then left the room to chart the administration of the medication and that was when he/she realized the order was for IM not IV. In the meantime MD#3 entered the room and found P#9 unresponsive several minutes after the Haldol was administered.

§482.27 (b) Standard: - Potentially Infectious Blood and Blood Components

Based on record review and staff interview with the Blood Bank Supervisor and Laboratory Administrator on 05/06/2013 it was determined that the Blood Bank Laboratory ' s procedure manual is not up-to-date to meet the Federal regulations and guidelines.

The findings include:
1. Review of the current procedure " A.004 Investigation of possible recipient transfusion-transmitted infections-Product Recalls/Market Withdrawal/Look-Backs " revealed that the last procedural revision was September 2004 and does not reflect the current federal revision Rev. 37 that was issued on October 17, 2008.

§482.27 (c) Standard: - General blood safety issues.

Based on record review and staff interview with the Blood Bank Supervisor and Laboratory Administrator on 05/06/2013 it was determined that the Blood Bank Laboratory ' s procedure manual is not up-to-date to meet the Federal regulations and guidelines.

The findings include:
1. Review of the current procedure " A.004 revealed that the last procedural revision was September 2004 and does not reflect the current federal revision Rev. 37 that was issued on October 17, 2008.

Based on multiple kitchen observations, review of hospital policies, and interviews, the hospital failed to ensure the maintenance of sanitary conditions and/or maintenance of equipment and environment. The findings include:
Tour of the kitchen on 05/07/13 from 3:00 PM through 4:15 PM with the Food Service Manager identified the following:
a. A large labeled, plastic, covered, bulk flour bin, ¾ filled with flour was stored beneath a counter on casters. The exterior was coated with a yellow greasy substance with debris that was loosely adhered to the surface. The Food Service Manager identified that the surface of the bin should be routinely cleaned.
b. The soap dispenser and paper towel dispenser above the hand washing sink in the food prep area had darkened surface areas consistent with contact with soiled hands.
c. The wall above and behind large garbage cans in the food prep area were streaked and appeared greasy. Debris was visible on the tile base between the wall and the floor.
d. Garbage cans lacked covers in all areas of the kitchen.
e. A square metal grate set into the tile floor behind a garbage can, stored under a counter was displaced and exposed an accumulation of unidentifiable debris.
f. Six metal pitchers, stored below a stainless steel counter were identified as clean. On direct observation, brown stains were visible in the bottom of each pitcher.
g. An offensive odor was detected in the dish room and mop heads were observed to be stored in buckets of discolored water.
h. A large plastic, portable garbage transport device used to transport bags of garbage from the kitchen area, through the service corridor, down the service elevator and to the trash compactor on the loading dock was observed in the dish room without benefit of a cover.
i. Observation of the pot washing procedure on 05/08/13 at 10:08 AM identified that all pots and pans were washed, rinsed manually, and placed in the Pot Washing Machine. The Food Services Manager identified that the pot washing function had ceased to function long ago. The corresponding gauge was covered with plastic tape. The Food Services Manager identified that the Pot Washing Sink was used for sanitizing only and achieved a temperature of 190-193 degrees Fahrenheit (F) for a period of approximately 1 minute. There was no written procedure for the use of the pot sanitizer and/or heat test strips available to verify the temperature. Manufacturer ' s recommendations were not available for review.
j. Observation of the dishwashing area and procedure on 05/08/13 at 10:25 AM with the Food Services Manager and Dietary Aide #1 identified approximately 2 inches of standing water in the corner of the dish room, behind the dish machine, where dishes were loaded into the machine. Water was observed to be dripping from a faucet and from an open pipe that was identified as a pressure release valve. There was an offensive odor in the area. A floor tile was observed to be crushed into multiple pieces and floating in water. The pre wash temperature was 140 degrees (F), less than the required 150 degrees F.
Interview with the Director of Food and Nutrition on 05/09/13 at 1:30 PM identified that the Job Flow documentation describes each staff member ' s role in maintaining sanitary conditions in the kitchen. Environmental Services is responsible for nightly cleaning of the kitchen floor. The problem of cleanliness was identified a few months ago and a plan was developed with the Environmental Services shift supervisor.
Review of the Job Flow descriptions for all kitchen staff failed to identify responsibility for cleaning walls and/or vertical surfaces as well as equipment.
Review of a Hospital Policy entitled Infection Control Policy for Food Service Department identified, in part, that all floors in the dietary food preparation area will be cleaned daily. All Pots and pans are washed with hot water and detergent until debris is off and placed in a pot washer for 1 cycle with a wash temperature of 150 degrees F and a rinse cycle of 180 degrees F. Each run of the dishwasher should include the entire cycle with pre-rinse at 150 degrees F; Pre-Wash at 150 degrees F, rinse at 150 degrees F, and final rinse at 180 degrees F. Pumps are inspected for leakage weekly. Regarding garbage disposal, garbage is placed in garbage cans with plastic liners which are kept covered, are emptied frequently, and the contents taken, sealed, to the disposal area near the loading dock. Spills are cleaned up immediately and floors are washed daily.


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1. Based on observation during tour of the Operating Suite and Central Sterile, interview and review of hospital policy, the hospital failed to ensure maintenance of a sanitary hospital environment. The findings include:
a. During tour of the Operating and GI Suites on 5/6 and 5/7/13, respectively, cloth chairs were observed to be utilized in the semi-restricted area of the OR hallway and in the procedure room in GI. The chairs failed to be of fluid resistant fabric and therefore would not have been able to be cleaned according to the terminal cleaning policy.
b. During tour of OR #6 on 5/6/13 with the Director and Manager of Peri-operative Services, observation was made of the wall/ceiling mounted microscope that was covered with a layer of dust. On the arm of the microscope hung a blue cloth cover, which failed to either cover the microscope or be constructed of such a material that was wipe-able during cleaning between cases and/or terminal cleaning. Review of the policy for surgical suite infection control directs that all horizontal surfaces should be damp dusted with phenolic disinfectant before the first procedure of the day and on a daily cleaning basis all over the table light fixtures and shelves, in part, should be cleaned with the disinfectant.
c. During tour of the OR Suite, all ORs were observed to have a periphery of clutter that included, in part, paper files in plastic wall mounted holders, fiberboard clipboards, as well as a supply (multiple packages) of suction tubing clustered along the edges of each operating room, which remained in place from case to case and day to day.
According to AORN 2010 guidelines, a visual inspection of the OR for cleanliness should be completed prior to introducing all soft supplies and instrumentation into the OR.
Review of the hospital policy for surgical suite infection control directs that prior to the first procedure of the day all horizontal surfaces should be damp with additional cleaning on a daily basis.
d. Observation of several anesthesia cart surfaces (top) identified multiple pieces of tape and adhesive substance along the edges of the cart, rendering the surface unable to be cleaned in an effective manner.
e. Observation of OR #10 during surgery, identified that the surgeon ' s head covering failed to cover the hair at the sides and back of the head. Review of hospital policy for OR attire directs that head coverings in the restricted and semi-restricted areas of the operating suite should cover all hair at the sides and back of the head.


2. Based on review of the hospital documentation, interview and review of hospital policy, the Central Sterile Processing failed to ensure that biological testing documentation was complete. The finding includes the following:
a. Review of the biological testing log for the Sterrad sterilizer for the period of 4/8/13 through 5/6/13, identified that testing documentation, for some dates, failed to reflect what date the load was sterilized. Additionally, on 4/26/13 and 4/29/13, the documentation failed to reflect the date that the test was planted and retrieved, according to manufacturer ' s directions to achieve an accurate test reading.
During interview on 5/6/13 at approximately 2:10 PM, the Manager of Central Sterile stated that s/he would expect that all documentation would be in place, especially the date the load was sterilized.
Review of the hospital policy for the Sterrad biological monitoring, while identifying the actual test, failed to direct staff to document the date the test load is done in the log book and when the test is planted and/or retrieved should reflect the date, time and initials of the person logging and/or reading the test.



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3. Based on observations and interviews with facility personnel, the facility failed to ensure that infection control practices were followed. The findings include:
During tour of the Emergency Department, ICU and SDU on 5/6/13-5/7/13, it was observed that housekeeping supplies, clean vases, waffle mattresses and supplies utilized for patient care were being stored in the soiled utility rooms. Interview with the Quality Manager on 5/7/13 identified that the facility practice is that clean supplies and equipment are not to be stored in the soiled utility room.








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Based on observation, review of hospital policies and procedures, and interviews related to the cleanliness of the kitchen and maintenance of kitchen equipment, the hospital failed to ensure that priorities for performance improvement included the kitchen. The findings included:
Observation of the kitchen on all days of survey identified multiple issues with lack of cleanliness and maintenance of equipment.
Interview with the Food Service Manager on 05/07/13 at 03:15 PM identified that cleaning was to be completed at the end of each staff member's shift and did not include the use of a check list.
Interview with the Director of Environmental Services on 05/09/13 at 9:20 AM identified that the walls, floors, and tile floor base, were Food Service staff 's responsibility.
Interview with the Chief of Human Resources on 05/09/13 at 9:30 AM identified that quality measures included monitoring the cleanliness of the kitchen floors and environmental services was directed to submit an action plan, additionally the vendor has not been able to fix the dish machine and the hospital is seeking quotes for repair as well as consideration of a leasing agreement.
Interviews with Infection Control (IC) Managers #7 and #8 on 05/09/13 at 10:00 AM identified that they conducted annual Infection Control rounds in the kitchen with the Director of Food and Nutrition and the Executive Chef multiple concerns were identified that included, in part, waste receptacles required emptying and dish room soaking sinks were leaking.
Interview with the Director of Food and Nutrition on 05/09/13 at 1:30 PM identified that problems with cleanliness were identified a few months ago and he/she developed a plan to address the problem in collaboration with the Environmental Shift Supervisor.
Review of Quality Improvement Minutes from 08/2011 through 12/2012 failed to identify issues regarding the kitchen sanitation and/or equipment maintenance.