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Based on observation, interview, and record review the hospital failed to ensure that a Physician's Order was obtained for the application of soft wrist restraints for 1 of 34 sampled patients (23), in accordance to the hospital's policy. Patient 23's soft wrist restraints were applied during the night shift in order to prevent pulling out medical devices. There was no evidence that a licensed practitioner was notified or evaluated the necessity when the restraints were applied. In addition, there was no written Physician's Order until 12 hours later.

The application of a restraint without the involvement from a licensed practitioner could lead to inappropriate use of physical restraints. Also, the lack of a physician's order made it difficult to determine whether or not the physician actually prescribed the documented medical treatment plan.

Findings:

Patient 23 was admitted to the hospital on 2/2/14 with the diagnoses that included altered level of consciousness (confusion) per the History and Physical, dated 2/2/14.

A joint observation of Patient 23 and interview with Registered Nurse (RN) 21, the Senior Director of Education (SDE), the Performance Improvement Quality Resource (PIQR), the Nursing Director (RN) 10, and the Intensive Care Clinical Manager (ICCM) was conducted on 2/3/14 at 1:50 P.M. Patient 23 rested in the bed with both eyes closed, was connected to a ventilator (machine designed to mechanically move breathable air into and out of the lungs), and had a soft padded device around both wrist with a strap tied to each side of the bed. RN 21 stated that Patient 23 wore bilateral soft wrist restraints to prevent pulling out medical devices.
A joint review of the Nursing Notes and Physician's Orders with the ICCM, RN 10, the SDE, and the PIQR was conducted on 2/4/14 at 8:50 A.M. An RN documented on 2/2/14 on the morning shift, "no need for restraints at this time." On 2/2/14 at 10:00 P.M., the night shift RN documented on the Restraint Observation Record, "Day #1... impulsive, restraints applied." There was no indication that the physician had been notified and had evaluated Patient 23 prior to or shortly after the application of the restraints.
The Medical/Protective Restraint Care Record indicated, "Restraint Day: #1: 2/2/14." The form was signed by the physician on 2/3/14 at 9:00 A.M. and by RN 22 on 2/3/14 at 10:00 A.M. The ICCM stated, she was unable to provide an indication for the time delay in obtaining a Physician's order for the restraint. The ICCM confirmed and acknowledged that the Physician's order for Patient 23's wrist restraints was not written until 12 hours later.
The night shift RN was unavailable for an interview.
A joint review of the hospital's policy titled "Use of Restraints" with the ICCM and RN 10 was conducted on 2/5/14 at 1:50 P.M. The policy indicated, "Initiation of Restraint Orders for use in Medical Surgical Care: If a Licensed Independent Practitioner is not available to issue such an order, a trained RN initiates restraint based on an appropriate assessment of the patient. In that case, a Licensed Independent Practitioner is notified immediately and a verbal or written order is obtained from that practitioner and entered into the patient's medical record. The verbal order shall be read back to the physician." The DICU stated according to the hospital's policy, the physician's order should have been obtained as soon as possible. Both RN 10 and the ICCM stated they were unable to locate the physician's order for the restraint application on 2/2/14 at 10:00 P.M. Both acknowledged that either a telephone or verbal order should have been written or obtained in accordance with the hospital's policy.
A joint interview and review of the hospital's Restraint Policy with the Senior Director of Quality and Risk Management (DQRM) was conducted on 2/6/14 at 10:45 A.M. The DQRM stated a physician's order should be obtained as soon as possible when applying a restraint. The DQRM further stated although the hospital's Restraint Policy referenced Medical Surgical Care Unit, the policy also applied to the ICU.

Based on observation, interview and record review, the hospital failed to ensure that the registered nurses (RNs) had adequate oversight of the nursing care provided for 4 of 34 sampled patients (1, 15, 26, 28) when the RNs did not follow physician's orders and hospital's policy and procedures related to tube feeding and water flush administration. The nursing staff's failure to document the administration of tube feedings and water flushes made it difficult to determine if the patients received their tube feedings and water flushes, in accordance with the physician's orders and the hospital's policy. Lack of documentation pertaining to tube feedings and water flushes made it difficult to assess a patient's nutrition and hydration status.

The hospital failed to ensure that RNs performed blood pressure monitoring, for 1 of 34 sampled patients (2) who was on a Levophed drip, a vasopressor (also known as norepinephrine, a drug that raises blood pressures). The lack of documented blood pressure monitoring made it difficult to determine if the goal listed on the physician's orders was achieved, in an effort to evaluate the effectiveness of the medication administered, and that the physician's orders were implemented as written.

In addition, the hospital failed to clarify medication administration orders for 2 of 34 sampled patients (12, 28). Patient 12's pain medication order was incomplete when there was no clear instruction as to when to start the medication and an indication for use. Patient 28's medications were ordered to be administered by mouth for a patient who was to receive nothing by mouth (NPO) due to swallowing difficulties and had a feeding tube.

Failure to clarify the medication orders and the route of medication administration could cause a medication error or negatively impact the patients medically fragile health status when prescribed medications were unclear and incomplete.

Findings:

1. On 2/3/14 beginning at 4:07 P.M., a tour of the medical-surgical unit in the north wing was conducted with the Chief Operating Officer (COO), the clinical educator (RN 1) and the Nursing Director (RN 10).

On 2/4/14 at 4:00 P.M., Patient 1 was observed sleeping in bed with his tube feeding running at 50 ml/hr (milliters per hour) via a nasogastric tube (NGT - medical process involving the insertion of a plastic tube through the nose, down into the stomach). The bottle of tube feeding had a label that read "Jevity (tube feeding formula) 1.2 cal (calorie)".

A review of Patient 1's medical record was conducted on 2/4/14 at 4:07 P.M. Patient 1 was admitted to the hospital on 1/18/14 with diagnoses that included altered level of consciousness (confusion) and acute hypernatremia (a high level of sodium in the blood possibly due to dehydration or decrease in total body water; normal adult value for sodium 136 - 145 mEq/L [milliequivalent per liter]) per the History and Physical, dated 1/19/14. Per the same H&P, Patient 1's sodium level was 149.

A Physician's order, dated 1/31/14 at 1:23 P.M., indicated that Patient 1 was to be given Jevity 1.2 (fiber) at 30 ml per hour via the feeding tube to a goal rate of 50 ml per hour, hold feedings for residuals greater than 100 mls. Per the same order, it instructed to increase the tube feeding as tolerated by 10 ml every 4 hours.

A review of the hospital's policy titled "Feeding; Via Enteric Tube", dated 3/18/13, was conducted on 2/4/14. The policy indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 32. ...Check gastric residual volume (GRV) every four hours. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A review of Patient 1's Intake and Output (I&O's), dated 1/31/14 - 2/1/14 from 7:00 P.M. to 7:00 A.M., indicated that the total enteral feeding was 470 mls.

A telephone interview with RN 4 was conducted on 2/5/14 at 9:30 P.M. RN 4 stated she recalled caring for Patient 1 on 1/31/14 from 7:00 P.M. to 7:30 A.M. (night shift). She stated that she performed gastric residual checks every 4 hours per hospital policy, and increased Patient 1's tube feedings by 10 ml every 4 hours in accordance with the physician's orders. However, she stated that she reviewed her documentation and acknowledged that there was no documented evidence to demonstrate that she performed the above nursing care and tasks (i.e.. the residual checks and the feeding increases).

An interview with RN 10 was conducted on 2/6/14 at 7:17 A.M. RN 10 confirmed that there was no documented evidence in Patient 1's medical record to demonstrate that RN 1 had performed the gastric residual checks, administered the tube feeding and increased it every 4 hours as tolerated by the patient, in accordance with the physician's orders and hospital policy. RN 10 stated that it was the nursing staff's responsibility to ensure that the documentation in Patient 1's medical record clearly reflected the nursing care rendered, implementation of physician's orders and tasks performed.

2. On 2/3/14 beginning at 4:07 P.M., a tour of the medical-surgical unit in the north wing was conducted with the Chief Operating Officer (COO), the clinical educator (RN 1) and the Nursing Director (RN 10).

On 2/4/14 at 4:00 P.M., Patient 1 was observed sleeping in bed with his tube feeding running at 50 ml/hr (milliters per hour) via a nasogastric tube (NGT - medical process involving the insertion of a plastic tube through the nose, down into the stomach). The bottle of tube feeding had a label that read "Jevity (tube feeding formula) 1.2 cal (calorie)".

A Physician's order, dated 1/31/14 at 1:23 P.M., indicated that Patient 1 was to be given Jevity 1.2 (fiber) at 30 ml per hour via the feeding tube to a goal rate of 50 ml per hour, hold feedings for residuals greater than 100 mls. Per the same order, it instructed to increase the tube feeding as tolerated by 10 ml every 4 hours, and to administer a water flush of 150 ml every 6 hours.

On 2/1/14 at 6:00 P.M., there was a new physician's order that read "Free water 250 ml via NG tube every 6 hours".

A review of Patient 1's Intake and Output (I&O's), dated 1/31/14 - 2/1/14 from 7:00 P.M. to 7:00 A.M., indicated that the NG (nasogastric tube) flush total was 300 mls. Per the I&O's, dated 2/1/14 - 2/2/14 from 7:00 P.M. to 7:00 A.M., it indicated that the NG flush total was 200 mls. The totals did not reflect water flushes that were administered via the feeding tube before and after medication administration and periodically to prevent tube occlusion.

A review of the hospital's policy titled "Feeding; Via Enteric Tube", dated 3/18/13, was conducted on 2/4/14. The policy indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A telephone interview with RN 4 was conducted on 2/5/14 at 9:30 P.M. RN 4 stated she recalled caring for Patient 1 on 1/31/14 from 7:00 P.M. to 7:30 A.M. (night shift). RN 4 stated that she administered water flushes before and after medication administration and periodically to ensure that Patient 1's feeding tube was patent. However, RN 4 stated that she reviewed her documentation and acknowledged that there was no documented evidence to demonstrate the nursing care and tasks performed. She also confirmed that Patient 1's I&O record did not reflect the water flush administration and the patient's actual water intake for the shift per hospital policy.

An interview with RN 10 was conducted on 2/6/14 at 7:17 A.M. RN 10 confirmed that there was no documented evidence in Patient 1's medical record to demonstrate that the nursing staff had administered the water flushes in accordance with the physician's orders and hospital policy. RN 10 stated that it was the nursing staff's responsibility to ensure that the documentation in Patient 1's medical record clearly reflected the NG flush intake values and calculation per shift.

3. On 2/3/14 beginning at 4:07 P.M., a tour of the medical-surgical unit in the north wing was conducted with the Chief Operating Officer (COO), the clinical educator (RN 1) and the Nursing Director (RN 10).

A review of Patient 2's medical record was conducted on 2/4/14 at 2:11 P.M. Patient 2 was admitted to the hospital's Emergency Department (ED) on 2/2/14 with diagnoses that included fever and respiratory distress per the History and Physical, dated 2/2/14. According to Nurse's Notes, dated 2/2/14 at 7:46 P.M., Patient 2's blood pressure readings were hypotensive (abnormally low blood pressures), the physician was notified and the nursing staff continued to monitor blood pressures until an intervention was ordered by the physician.

A telephone Physician's Order, dated 2/2/14 at 8:00 P.M., indicated to start a Levophed drip and titrate to keep systolic blood pressure above 100.

A review of the hospital's protocol form titled "IV Drip Critical Care Medication Titration Orders - Vasopressors" was conducted on 2/4/14. There was a section for Norepinephrine Drip (Levophed) with a clinical response goal that read systolic blood pressure greater than or equal to 90 mmHg (millimeters of mercury - a unit of pressure measurement) or other with a blank (to list other specifications). Per the same form, the Standardized Titration Order indicated that a Levophed drip was to start at 1 mcg/min (micrograms per minute); titrate 1 mcg/min every 10 minutes until the clinical response was achieved. The maximum dose was 30 mcg/min, and to notify the physician if clinical response was not achieved for further orders.

According to Patient 2's electronic medical record, dated 2/2/14 at 9:20 P.M., indicated that the patient continued to be on a Levophed drip, administered at 8:15 P.M. Per the same record, Patient 2's blood pressure was 99/56 and the Levophed drip was running at 2 mcg/min. There was no documented evidence in the medical record to demonstrate that RNs performed blood pressure monitoring on Patient 2 when the patient was placed on a Levophed drip and titrations had been made, in accordance with the physician's orders and hospital's protocol.

An interview with RN 3 was conducted on 2/6/14 at 7:39 A.M. RN 3 stated that she recalled caring for Patient 2 on 2/2/14 and initiating the administration of the patient's Levophed drip as ordered. She stated that she had acknowledged the physician's order related to the initiation of the drip, obtained the hospital's IV drip protocol, started Patient 2's Levophed drip at 1 mcg/min as indicated in the hospital's protocol, and continued to monitor the patient's blood pressures every 5-10 minutes. She did confirm that at some point, she increased Patient 2's Levophed drip up to 2 mcg/min for not achieving the desired systolic blood pressure however, her documentation did not demonstrate the blood pressure monitoring that was performed on Patient 2 during the Levophed drip administration.

A review of the hospital's policy titled "Titrating Medications", dated 8/22/12, was conducted on 2/6/14. The policy indicated that "Orders for medications that require titration must include the desired state the prescriber desires for the patient ...." Per the same policy, "Useful dosage adjustment increments must be known before titrating medication to allow clinical staff to determine how much to increase or decrease the medication as attempts are made to achieve the [ordered state] for the patient."

An interview with the Nursing Director of Emergency Services (NDES) was conducted on 2/6/14 at 8:08 A.M. The NDES stated that the nurses were expected to obtain the hospital's IV drip protocol when a physician's order was obtained to start a Levophed drip and systolic blood pressure parameters were listed. He stated that Patient 2's medical record should have contained documented evidence to demonstrate that the nursing staff were monitoring the patient's blood pressures during the administration of the Levophed drip, and during the required titrations based on blood pressure readings every 10 minutes per hospital protocol and physician's orders.





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4. A review of patient 12's medical record was conducted on 2/3/14 at 3:10 P.M. Patient 12 was admitted to the hospital on 2/3/14 with a diagnosis of osteoarthrosis (arthritis) right knee and underwent a right knee surgical procedure on 2/4/14.

A review of the Recovery Room (PACU - Post Anesthesia Care Unit) Post-OP Orders, dated 2/3/14, indicated that an order for Dilaudid (narcotic pain medication) 0.5 milligrams (mg) intravenous (IV) every 15 minutes total of 2.0 mg. Patient 12's pain medication order was incomplete when there was no clear instruction as to when to start the medication and an indication for use.

A review of Patient 12's pain assessment documentation was conducted on 2/3/14 at 4:00 P.M. The pain assessment documentation indicated that on 2/3/14 at 3:10 P.M., Patient 12's right knee pain level was a 4 (moderate pain). There was no indication that the patient declined a pharmacological intervention, or that an intervention or pain medication was administered. On 2/3/14 at 3:25 P.M., 3:40 P.M., and 3:55 P.M., Patient 12's right knee pain level was a 4. Under the comment section, Patient 12 had declined pain medications offered at 3:25 P.M., 3:40 P.M., and 3:55 P.M.

An interview with registered nurse (RN 11) was conducted on 2/3/14 at 4:20 P.M. She stated that she had not administered any pain mediation, and that if the pain level was a 4 at the next assessment, she would administer the Dilaudid. She acknowledged that she had not contacted the physician to clarify the medication order.

A review of the hospital's policy entitled "Medication Orders, Resolving Questionable Physician" was conducted on 2/3/14. The policy indicated that "clarification of orders with the physician occurs when there may legibility, dosing or an incomplete order issue".

An interview with the charge nurse (RN 12) was conducted on 2/3/14 at 4:22 P.M. He stated that the Dilaudid medication order was unclear and did not specify an indication for use. He stated the RN should have clarified the order with the physician.

5. A review of Patient 15's medical record was conducted on 2/4/14 at 8:49 A.M. Patient 15 was admitted to the hospital on 1/30/14 with a diagnosis of altered mental status (confusion) per the Facesheet.

A Physician's order, dated 2/2/14 at 3:27 A.M., indicated tube feeding of Jevity (tube feeding formula) 1.2 (fiber) with a start rate of 30 ml/hr (milliliters per hour) and to increase by 10 mls every 4 hours. The max rate of the tube feeding was 50 ml/hr. Per the same order, it instructed to administer 200 mls of water flush every 6 hours.

A review of Patient 15's Intake and Output Detail Report indicated that only 80 ml of free water was documented on 2/3/14 at 10:00 P.M. There was no further documentation to demonstrate that water flush administration had been performed.

A review of the hospital's policy entitled "Feeding, Via enteric Tube" was conducted on 2/4/14. The policy indicated "check order for correct feeding times, amount and liquid nourishment."

An concurrent interview with the Nursing Director (RN 10) and ICU clinical manager (ICCM) was conducted on 2/4/14 at 9:00 A.M. They both acknowledged that the free water (flush) documented on the intake and output report was not consistent with the written physician's order and that the free water (flush) should have been documented as given per the written order in accordance with the hospital's policy.











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6a. Patient 26 was admitted to the hospital on 1/29/14 with the diagnoses that included congested heart failure (when the heart is unable to provide sufficient pump action to maintain blood flow to meet the needs of the body) per the History and Physical, dated 1/27/14.

A joint observation of Patient 26 and interview with Registered Nurse (RN) 23, the Senior Director of Education (SDE), the Performance Improvement Quality Resource (PIQR), and the Medical Surgical Clinical Manager (MSCM) was conducted on 2/4/14 at 10:40 A.M. Patient 26 rested in the bed with the head of the bed elevated, a tube feeding Jevity 1.2 infused at 50 milliliters (ml) per hour (hr). Patient 26 stated everything was good. RN 23 stated that Patient 28 was disoriented and received nothing by mouth (NPO) because of the tube feeding administration thru the G-tube (gastrostomy tube - surgically inserted feeding tube into the stomach).

A joint review of the Physician's Progress Notes, Physician's order, and Intake and Output Detail Report with the MSCM, SDE, and PIQR was conducted on 2/4/14 at 11:20 A.M. According to the Physician's Progress Notes, Patient 26's G-tube was inserted on 1/31/14. The Physician's order, dated 1/31/14, indicated that on 2/1/14 start Jevity 1.2 infuse at 20 ml/hr, increase 10 ml every four hours to reach the goal rate of 50 ml/hr with a water flush of 200 ml every six hours.

The following was documented on the Intake and Output Detail Report:
2/1/14 from 7:00 A.M. - 7:00 P.M.: 200 ml tube feeding, water flush blank
2/1/14 from 7:00 P.M. - 7:00 A.M.: Nothing by mouth (NPO); no documentation of tube feeding or water flush
2/2/14 from 7:00 A.M. - 7:00 P.M.: 600 ml tube feeding, water flush blank
2/2/14 from 7:00 P.M. - 7:00 A.M.: 600 ml tube feeding, 360 cubic centimeter (cc) water
2/3/14 from 7:00 A.M. - 7:00 P.M.: 1200 ml tube feeding, water flush blank
2/3/14 from 7:00 P.M. - 7:00 A.M.: tube feeding 0, water flush blank

The MSCM confirmed that the calculated intake contained inconsistent data. The MSCM acknowledged that the inconsistent data made it difficult to ascertain the actual nutritional and hydration status of the tube feeding administration.

An interview and joint review of the Intake and Output (I&O) Detail Report with RN 24, the MSCM, the SDE, and the PIQR was conducted on 2/4/14 at 11:25 A.M. RN 24 confirmed the inconsistent total volume documented for Patient 26. RN 24 stated he had documented the incorrect total amount for Patient 26's intake volume on 2/3/14. RN 24 stated documentation should be correct in order to track fluid balance. RN 24 acknowledged that the calculated total intake volume was inconsistent with the physician's order.

The hospital policy titled "Feeding; Via Enteric Tube" indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A joint meeting with the Quality Assessment and Performance Improvement (QAPI) committee was conducted on 2/6/14 at 10:00 A.M. The Senior Director of Quality and Risk Management (DQRM) acknowledged that the hospital was aware of the nursing staff's inconsistent I&O documentation. The DQRM stated that the hospital was currently working on a process in order to streamline the documentation for the intake and output.

6b. Patient 28 was admitted to the hospital on 1/26/14 with the diagnoses that included dysphagia (difficult to swallow) post G-tube (gastrostomy tube - surgically inserted feeding tube into the stomach) placement per the History and Physical, dated 1/26/14.

A joint observation of Patient 28 and interview with Registered Nurse (RN) 23, the Senior Director of Education (SDE), the Performance Improvement Quality Resource (PIQR), and the Medical Surgical Clinical Manager (MSCM) was conducted on 2/4/14 at 10:30 A.M. Patient 28 rested in the bed with the head of the bed elevated, a tube feeding Glucerna 1.2 infused at 50 milliliters (ml) per hour (hr). RN 23 stated that Patient 28 received nothing by mouth (NPO) because of the tube feeding administration thru the G-tube.

A joint review of the Physician's Progress Note, the Physician's order, and the Intake and Output (I&O) Detail Report with the MSCM, SDE, and PIQR was conducted on 2/4/14 at 2:30 P.M. According to the Physician's Progress Notes, Patient 28's G-tube was inserted on 1/31/14.

The Physician's order, dated 2/2/14, indicated Glucerna 1.2 infused at 50 ml/hr, with a free water (flush) of 200 ml every six hours per the G-tube.

The following was the documented on the Intake and Output Detail Report:
2/1/14 from 7:00 A.M. - 7:00 P.M.: 165 ml tube feeding, 400 cubic centimeter (cc) water flush
2/1/14 from 7:00 P.M. - 7:00 A.M.: Blank
2/2/14 from 7:00 A.M. - 7:00 P.M.: 550 ml tube feeding, 1200 cc water flush
2/2/14 from 7:00 P.M. - 7:00 A.M.: 500 ml tube feeding, 400 cubic centimeter (cc) water
2/3/14 from 7:00 A.M. - 7:00 P.M.: Blank
2/3/14 from 7:00 P.M. - 7:00 A.M.: Blank
2/4/14 from 7:00 A.M. - 12:00 P.M.: Flush 380 cc
2/4/14 from 7:00 P.M. - 7:00 A.M.: Blank

The MSCM confirmed that the calculated intake contained inconsistent data. The MSCM acknowledged that the inconsistent data made it difficult to ascertain the actual nutritional and hydration status of the tube feeding administration.

An interview and joint review of the Intake and Output Detail Report with RN 25, the MSCM, the SDE, and the PIQR was conducted on 2/6/14 at 8:20 A.M. RN 25 stated that on 2/2/14 she believed that Patient 28's tube feeding had been on hold due to complications. She stated that the water flush order was 200 ml every six hours. According to the 1200 ml calculation documented in the I&O on 2/2/14 from 7:00 A.M. to 7:00 P.M., the total included 30cc water flushes with medications, and a 60 cc flush because the tube was bloody. RN 25 stated accurate intake was important for cardiac patients. RN 25 acknowledged that the calculated total intake volume was inconsistent with the physician's order.

The hospital policy titled "Feeding; Via Enteric Tube" indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A joint meeting with the Quality Assessment and Performance Improvement (QAPI) committee was conducted on 2/6/14 at 10:00 A.M. The Senior Director of Quality and Risk Management (DQRM) acknowledged that the hospital was aware of the nursing staff's inconsistent I&O documentation. The DQRM stated that the hospital was currently working on a process in order to streamline the documentation for the intake and output.

7. Patient 28 was admitted to the hospital on 1/26/14 with the diagnoses that included dysphagia (difficult to swallow) post G-tube (gastrostomy tube - surgically inserted feeding tube into the stomach) placement per the History and Physical, dated 1/26/14. Per the same H&P, Patient 28 will be fed through the feeding tube.

A joint observation of Patient 28 and interview with Registered Nurse (RN) 23, the Senior Director of Education (SDE), the Performance Improvement Quality Resource (PIQR), and the Medical Surgical Clinical Manager (MSCM) was conducted on 2/4/14 at 10:30 A.M. Patient 28 rested in the bed with the head of the bed elevated, a tube feeding Glucerna 1.2 infuse at 50 milliliters (ml) per hour (hr). RN 23 stated that Patient 28 received nothing by mouth (NPO) because of the tube feeding administration thru the G-tube.

A joint review of the Physician's Progress Note with the MSCM, SDE, and PIQR was conducted on 2/4/14 at 2:30 P.M. According to the Physician's Progress Notes, Patient 28's G-tube was inserted on 1/31/14.

A joint review of the Physician's orders with the MSCM, SDE, and PIQR was conducted on 2/6/14 at 8:05 A.M. The Physician's orders, dated 1/27/14, indicated Colace (stool softener) liquid 10 milliliter (ml) oral twice a day; Flomax (improve urination) .04 milligram (mg) 1 capsule oral at bedtime; Avodart (improve urinary flow) 0.5 mg 1 capsule oral at bedtime; Lasix (water pill) 40 mg 1 tablet orally every morning; and Reglan (treat heartburn) 5 ml orally every six hours. There was no specifications documented to administer the medications via the G-tube.

The MSCM stated it was the expectation that the RN's clarify the physician's orders to have the exact designated route for medication administration. The MSCM acknowledged that the incorrect route for the medication administration could lead to a medication error or cause a medical complication.

The hospital policy titled "Feeding; Via Enteric Tube" indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

An interview with the Senior Director of Quality and Risk Management (DQRM) was conducted on 2/6/14 at 10:45 A.M. The DQRM stated there should be a clarification for the designated route of medication administration if the ordered route was by mouth when a patient was on a NPO status and had a feeding tube, to prevent complications related to dysphagia or a medication error.

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Based on observation, interview and record review, the hospital failed to ensure that Registered Nurses (RNs) developed nursing care plans for 2 of 34 sampled patients (26, 28) with an gastrostomy tube (G-tube-surgical inserted tube into the stomach for nutrition and medication administration). Both Patient 26 and 28 received nutrition thru the G-tube; however, there was no documented evidence to show that a nursing care plan had been developed related to the monitoring of their nutritional and hydration status. Failure to develop a care plan related to a patient's nutritional need (a tube feeding requirement), impeded the hospital's goal of ensuring that the nursing staff were providing nursing care to meet the needs of the patient and that was reflective of current standards of nursing practice.

Findings:

1a. Patient 26 was admitted to the hospital on 1/29/14 with the diagnoses that included congested heart failure (unable to provide sufficient pump action to maintain blood flow to meet the needs of the body) per the History and Physical, dated 1/27/14.
A joint observation of Patient 26 and interview with Registered Nurse (RN) 23, the Senior Director of Education (SDE), the Performance Improvement Quality Resource (PIQR), and the Medical Surgical Clinical Manager (MSCM) was conducted on 2/4/14 at 10:40 A.M. Patient 26 rested in the bed with the head of the bed elevated, a tube feeding Jevity 1.2 was infusing at 50 milliliters (ml) per hour (hr). Patient 26 stated everything was good. RN 23 stated that Patient 28 was disoriented and received nothing by mouth (NPO) because of the tube feeding administration thru the G-tube.

A joint review of the Physician's Progress Notes and Care Plan section with the MSCM, SDE, and PIQR was conducted on 2/4/14 at 11:20 A.M. According to the Physician's Progress Notes, Patient 26's G-tube was inserted on 1/31/14. There was no care plan developed to address and monitor the nutritional and hydration status for Patient 26's G-tube. The MSCM confirmed that a care plan was not developed. The MSCM acknowledged that no care plan had been developed to monitor the nutritional and hydration status of the tube feeding administration.

A joint meeting with the Quality Assessment and Performance Improvement (QAPI) committee was conducted on 2/6/14 at 10:00 A.M. The Senior Director of Quality and Risk Management (DQRM) stated it was the expectation that a care plan be developed for patient's with a tube feeding to monitor their nutritional and hydration status.

1b. Patient 28 was admitted to the hospital on 1/26/14 with the diagnoses that included dysphagia (difficult to swallow) post G-tube placement per the History and Physical, dated 1/26/14.

A joint observation of Patient 28 and interview with Registered Nurse (RN) 23, the Senior Director of Education (SDE), the Performance Improvement Quality Resource (PIQR), and the Medical Surgical Clinical Manager (MSCM) was conducted on 2/4/14 at 10:30 A.M. Patient 28 rested in the bed with the head of the bed elevated, a tube feeding Glucerna 1.2 was infusing at 50 milliliters (ml) per hour (hr). RN 23 stated that Patient 28 received nothing by mouth (NPO) because of the tube feeding administration thru the G-tube.

A joint review of the Physician's Progress Notes and Care Plan section with the MSCM, SDE, and PIQR was conducted on 2/4/14 at 2:30 P.M. According to the Physician's Progress Notes, Patient 28's G-tube was inserted on 1/31/14. There was no care plan developed to address and monitor the nutritional and hydration status for Patient 28's G-tube. The MSCM confirmed that a care plan was not developed. The MSCM acknowledged that no care plan had been developed to monitor the nutritional and hydration status of the tube feeding administration.

A joint meeting with the Quality Assessment and Performance Improvement (QAPI) committee was conducted on 2/6/14 at 10:00 A.M. The Senior Director of Quality and Risk Management (DQRM) stated it was the expectation that a care plan be developed for patient's with a tube feeding to monitor their nutritional and hydration status.

Based on observation, interview and record review, the hospital failed to ensure that a Levophed (also known as norepinephrine, a drug used to raise blood pressures) drip was administered by Registered Nurses (RNs) in accordance with the physician's orders and the hospital's protocol, for 1 of 34 sampled patients (2). There was no documented evidence to demonstrate that the start dose and titration (the act of increasing or decreasing of a medication) of the Levophed drip was administered to Patient 2, as ordered by the physician and in accordance with the hospital's protocol. The hospital's form titled "IV (intravenous) Drip Critical Care Medication Titration Orders - Vasopressors" was not found in Patient 2's medical record, in accordance with the hospital's protocol. The failure of RNs to implement medication policies and procedures and physician's orders increased the potential for patient harm.

Findings:

1. On 2/3/14 beginning at 4:07 P.M., a tour of the medical-surgical unit in the north wing was conducted with the Chief Operating Officer (COO), the clinical educator (RN 1) and the Nursing Director (RN 10).

On 2/4/14 at 11:35 A.M., a concurrent observation and interview was conducted with RN 2. Patient 2 was laying in bed watching television. Patient 2 stated that he had no problem to report with regards to his care and hospital stay.

A review of Patient 2's medical record was conducted on 2/4/14 at 2:11 P.M. Patient 2 was admitted to the hospital's Emergency Department (ED) on 2/2/14 with diagnoses that included fever and respiratory distress per the History and Physical, dated 2/2/14. According to Nurse's Notes, dated 2/2/14 at 7:46 P.M, Patient 2's blood pressure readings were hypotensive (abnormally low blood pressures), the physician was notified and the nursing staff continued to monitor blood pressures until an intervention was ordered by the physician.

A telephone Physician's Order, dated 2/2/14 at 8:00 P.M., indicated to start a Levophed drip and titrate to keep systolic blood pressure above 100.

A review of the hospital's form titled "IV Drip Critical Care Medication Titration Orders - Vasopressors" was conducted on 2/4/14. The form contained 3 columns that read: IV drip, Standardized Titration Order and Optional Physician's Orders. Each column contained sections that had boxes to mark and blanks to complete. There was a section for Norepinephrine Drip (Levophed) with a clinical response goal that read systolic blood pressure greater than or equal to 90 mmHg (millimeters of mercury - a unit of pressure measurement) or other with a blank (to list other specifications). Per the same form, the Standardized Titration Order indicated that a Levophed drip was to start at 1 mcg/min (microgram per minute); titrate 1 mcg/min every 10 minutes until the clinical response was achieved. The maximum dose was 30 mcg/min, and to notify the physician if clinical response was not achieved for further orders.

According to Patient 2's Nurse's Notes, dated 2/2/14 at 9:20 P.M., the notes indicated that the patient continued to be on a Levophed drip, which was administered at 8:15 P.M. Per the notes, Patient 2's blood pressure was 99/56 and the Levophed drip was running at 2 mcg/min. There was no documented evidence in the medical record to demonstrate that the Levophed drip had been started at 1 mcg/min per the hospital's protocol. Patient 2's medical record did not contain documented evidence to demonstrate that the hospital's protocol was implemented related to the initiation and titration of a Levophed drip.

An interview with RN 3 was conducted on 2/6/14 at 7:39 A.M. RN 3 stated that she recalled caring for Patient 2 on 2/2/14 and initiating the administration of the patient's Levophed drip as ordered. She stated that she had acknowledged the physician's order related to the initiation of the drip, obtained the hospital's IV drip protocol and started Patient 2's Levophed drip at 1 mcg/min as indicated in the hospital's protocol. However, she acknowledged that there was no documented evidence to demonstrate that she administered the initial dose and titrated the Levophed in accordance with the physician's orders and hospital's policy. She acknowledged the importance of documentation and stated that "if it's not documented, it was not done."

A review of the hospital's policy entitled "High Risk/High Alert Medications", dated 8/22/12, was conducted. The policy indicated that "Medications that have the highest risk of causing injury when misused are known as high-alert medications." Levophed was listed as high risk/high alert medication.

A review of the hospital's policy titled "Titrating Medications", dated 8/22/12, was conducted on 2/6/14. The policy indicated that "Orders for medications that require titration must include the desired state the prescriber desires for the patient ...." Per the same policy, "Useful dosage adjustment increments must be known before titrating medication to allow clinical staff to determine how much to increase or decrease the medication as attempts are made to achieve the [ordered state] for the patient."

An interview with the Nursing Director of Emergency Services (NDES) was conducted on 2/6/14 at 8:08 A.M. The NDES stated that the nurses were expected to obtain the hospital's IV drip protocol when a physician's order instructed to start a Levophed drip and systolic blood pressure parameters were listed. He stated that Patient 2's medical record should have documented evidence to demonstrate that RN 1 started the Levophed drip and titrated the drip in accordance with the physician's orders and hospital protocol.

2. A review of Patient 2's medical record was conducted on 2/4/14 at 2:11 P.M. Patient 2 was admitted to the hospital's Emergency Department (ED) on 2/2/14 with diagnoses that included fever and respiratory distress per the History and Physical, dated 2/2/14. According to Nurse's Notes, dated 2/2/14 at 7:46 P.M, Patient 2's blood pressure readings were hypotensive (abnormally low blood pressures), the physician was notified and the nursing staff continued to monitor blood pressures until an intervention was ordered by the physician.

A telephone Physician's Order, dated 2/2/14 at 8:00 P.M., indicated to start a Levophed drip and titrate to keep systolic blood pressure above 100.

A review of the hospital's form titled "IV (intravenous) Drip Critical Care Medication Titration Orders - Vasopressors" was conducted on 2/4/14. The form contained 3 columns that read: IV drip, Standardized Titration Order and Optional Physician's Orders. Each column contained sections that had boxes to mark and blanks to complete. There was a section for Norepinephrine Drip (Levophed) with a clinical response goal that read systolic blood pressure greater than or equal to 90 mmHg (millimeters of mercury - a unit of pressure measurement) or other with a blank (to list other specifications). Per the same form, the Standardized Titration Order indicated that a Levophed drip was to start at 1 mcg/min (micrograms per minute); titrate 1 mcg/min every 10 minutes until the clinical response was achieved. The maximum dose was 30 mcg/min, and to notify the physician if clinical response was not achieved for further orders.

According to Patient 2's Nurse's Notes, dated 2/2/14 at 9:20 P.M., the notes indicated that the patient continued to be on a Levophed drip, which was administered at 8:15 P.M. Per the Notes, Patient 2's blood pressure was 99/56 and the Levophed drip was running at 2 mcg/min. There was no documented evidence in the medical record to demonstrate how the Levophed drip was to be administered, initial/start dose and titration instructions per hospital protocol.

An interview with RN 3 was conducted on 2/6/14 at 7:39 A.M. RN 3 stated that she recalled caring for Patient 2 on 2/2/14 and initiating the administration of the patient's Levophed drip as ordered. She stated that she had acknowledged the physician's order related to the initiation of the drip, obtained the hospital's IV drip protocol and started Patient 2's Levophed drip at 1 mcg/min as indicated in the hospital's protocol. However, she acknowledged that there was no documented evidence to demonstrate that she administered the initial dose and titrated the Levophed in accordance with the physician's orders and hospital's policy. She acknowledged the importance of documentation and stated that "if it's not documented, it was not done." She also acknowledged that the hospital's form titled "IV Drip Critical Care Medication Titration Orders - Vasopressors" was not completed and placed in Patient 2's medical record. She explained this was the hospital's Standardized Titration Order which provided clear instruction to the nursing staff on how to start the drip and titrate in accordance with the physician's orders.

A review of the hospital's policy entitled "High Risk/High Alert Medications", dated 8/22/12, was conducted. The policy indicated that "Medications that have the highest risk of causing injury when misused are known as high-alert medications." Levophed was listed as high risk/high alert medication.

A review of the hospital's policy titled "Titrating Medications", dated 8/22/12, was conducted on 2/6/14. The policy indicated that "Orders for medications that require titration must include the desired state the prescriber desires for the patient ...." Per the same policy, "Useful dosage adjustment increments must be known before titrating medication to allow clinical staff to determine how much to increase or decrease the medication as attempts are made to achieve the [ordered state] for the patient."

An interview with the Nursing Director of Emergency Services (NDES) was conducted on 2/6/14 at 8:08 A.M. The NDES stated that the nurses were expected to obtain the hospital's IV drip protocol when a physician's order instructed to start a Levophed drip and systolic blood pressure parameters were listed. He stated that Patient 2's medical record should have documented evidence to demonstrate that RN 1 started the Levophed drip and titrated the drip in accordance with the physician's orders and hospital policy. He also stated that the hospital's form titled "IV Drip Critical Care Medication Titration Orders - Vasopressors" should have been in Patient 2's medical record.





26660

Based on observation, interview and record review, the hospital failed to ensure that Registered Nurses (RNs) accurately and completely documented in Intake and Output (I&O) Records, for 3 of 34 sampled patients (1, 26, 28). The RNs' documentation related to tube feeding and water flush administration were inconsistent, inaccurate and incomplete. The lack of consistent, accurate and complete I&O data made it difficult to ascertain the actual nutritional and hydration status of medically fragile patients who required tube feedings and water flush administration.

Findings:

1. On 2/3/14 beginning at 4:07 P.M., a tour of the medical-surgical unit in the north wing was conducted with the Chief Operating Officer (COO), the clinical educator (RN 1) and the Nursing Director (RN 10).

On 2/4/14 at 4:00 P.M., Patient 1 was observed sleeping in bed with his tube feeding running at 50 ml/hr (milliliters per hour) via a nasogastric tube (NGT - medical process involving the insertion of a plastic tube through the nose, down into the stomach). The bottle of tube feeding had a label that read "Jevity (tube feeding formula) 1.2 cal (calorie)".

A review of Patient 1's medical record was conducted on 2/4/14 at 4:07 P.M. Patient 1 was admitted to the hospital on 1/18/14 with diagnoses that included altered level of consciousness (confusion) and acute hypernatremia (a high level of sodium in the blood possibly due to dehydration or decrease in total body water; normal adult value for sodium 136 - 145 mEq/L [milliequivalent per liter]) per the History and Physical, dated 1/19/14. Per the same H&P, Patient 1's sodium level was 149.

A Physician's order, dated 1/31/14 at 1:23 P.M., indicated that Patient 1 was to be given Jevity 1.2 (fiber) at 30 ml per hour via the feeding tube to a goal rate of 50 ml per hour, hold feedings for residuals greater than 100 mls. Per the same order, it instructed to increase the tube feeding as tolerated by 10 ml every 4 hours.

A review of the hospital's policy titled "Feeding; Via Enteric Tube", dated 3/18/13, was conducted on 2/4/14. The policy indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A review of Patient 1's Intake and Output (I&O's), dated 1/31/14 - 2/1/14 from 7:00 P.M. to 7:00 A.M., indicated that the total enteral feeding was 470 mls. Per the same I&O, dated 2/1/14 at 3:00 A.M., Patient 2 was given 470 mls of enteral feeding.

A telephone interview with RN 4 was conducted on 2/5/14 at 9:30 P.M. RN 4 stated she recalled caring for Patient 1 on 1/31/14 from 7:00 P.M. to 7:30 A.M. (night shift). She stated that she increased Patient 1's tube feedings by 10 ml every 4 hours in accordance with the physician's orders. However, she stated that she reviewed her documentation and acknowledged that on 2/1/14 at 3:00 A.M., her documentation indicated that Patient 1 had been given a bolus, 470 mls of enteral feeding. She explained that Patient 1 through the course of her shift received a total of 470 mls of enteral feeding which was not evidenced by her I&O documentation.

An interview with RN 10 was conducted on 2/6/14 at 7:17 A.M. RN 10 acknowledged that Patient 1's I&O Record was inconsistent, inaccurate and incomplete related to the tube feeding administration. RN 10 stated that the hospital had identified problems with the nursing staff's documentation of I&Os and were in the process of correcting the problem.

2. On 2/3/14 beginning at 4:07 P.M., a tour of the medical-surgical unit in the north wing was conducted with the Chief Operating Officer (COO), the clinical educator (RN 1) and the Nursing Director (RN 10).

On 2/4/14 at 4:00 P.M., Patient 1 was observed sleeping in bed with his tube feeding running at 50 ml/hr (milliters per hour) via a nasogastric tube (NGT - medical process involving the insertion of a plastic tube through the nose, down into the stomach). The bottle of tube feeding had a label that read "Jevity (tube feeding formula) 1.2 cal (calorie)".

A Physician's order, dated 1/31/14 at 1:23 P.M., indicated that Patient 1 was to be given Jevity 1.2 (fiber) at 30 ml per hour via the feeding tube to a goal rate of 50 ml per hour, hold feedings for residuals greater than 100 mls. Per the same order, it instructed to increase the tube feeding as tolerated by 10 ml every 4 hours, and to administer a water flush of 150 ml every 6 hours.

On 2/1/14 at 6:00 P.M., there was a new physician's order that read "Free water 250 ml via NG tube every 6 hours".

A review of Patient 1's Intake and Output (I&O's), dated 1/31/14 - 2/1/14 from 7:00 P.M. to 7:00 A.M., indicated that the NG (nasogastric tube) flush total was 300 mls. Per the I&O's, dated 2/1/14 - 2/2/14 from 7:00 P.M. to 7:00 A.M., it indicated that the NG flush total was 200 mls. The totals did not reflect water flushes that were administered via the feeding tube before and after medication administration and periodically to prevent tube occlusion.

A review of the hospital's policy titled "Feeding; Via Enteric Tube", dated 3/18/13, was conducted on 2/4/14. The policy indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A telephone interview with RN 4 was conducted on 2/5/14 at 9:30 P.M. RN 4 stated she recalled caring for Patient 1 on 1/31/14 from 7:00 P.M. to 7:30 A.M. (night shift). RN 4 stated that she administered water flushes before and after medication administration and periodically to ensure that Patient 1's feeding tube was patent. However, RN 4 stated that she reviewed her documentation and acknowledged that Patient 1's I&O Record did not reflect the water flush administration and the patient's actual water intake for the shift per hospital policy.

An interview with RN 10 was conducted on 2/6/14 at 7:17 A.M. RN 10 acknowledged that Patient 1's I&O Record was inconsistent, inaccurate and incomplete related to the water flush administration to include water flushes given before and after medication administrations. She stated that it was the nursing staff's responsibility to ensure that the documentation in Patient 1's medical record clearly and accurately reflected the NG flush intake values and calculation per shift. RN 10 stated that the hospital had identified problems with the nursing staff's documentation of I&Os and were in the process of correcting the problem.







25321

3a. Patient 26 was admitted to the hospital on 1/29/14 with the diagnoses that included congested heart failure (unable to provide sufficient pump action to maintain blood flow to meet the needs of the body) per the History and Physical, dated 1/27/14.

A joint observation of Patient 26 and interview with Registered Nurse (RN) 23, the Senior Director of Education (SDE), the Performance Improvement Quality Resource (PIQR), and the Medical Surgical Clinical Manager (MSCM) was conducted on 2/4/14 at 10:40 A.M. Patient 26 rested in the bed with the head of the bed elevated, a tube feeding Jevity 1.2 was infusing at 50 milliliters (ml) per hour (hr). Patient 26 stated everything was good. RN 23 stated that Patient 26 was disoriented and received nothing by mouth (NPO) because of the tube feeding administration thru the G-tube (gastrostomy tube - surgically inserted feeding tube into the stomach).

A joint review of the Physician's Progress Notes, Physician's order, and Intake and Output Detail Report with the MSCM, SDE, and PIQR was conducted on 2/4/14 at 11:20 A.M. According to the Physician's Progress Notes, Patient 26's G-tube was inserted on 1/31/14. The Physician's order, dated 1/31/14, indicated that on 2/1/14 start Jevity 1.2 infuse at 20 ml/hr, increase 10 ml every four hours to reach the goal rate of 50 ml/hr with a water flush of 200 ml every six hours.

The following was documented on the Intake and Output Detail Report:

2/1/14 from 7:00 A.M. - 7:00 P.M.: 200 ml tube feeding, water flush blank
2/1/14 from 7:00 P.M. - 7:00 A.M.: Nothing by mouth (NPO); no documentation of tube feeding or water flush
2/2/14 from 7:00 A.M. - 7:00 P.M.: 600 ml tube feeding, water flush blank
2/2/14 from 7:00 P.M. - 7:00 A.M.: 600 ml tube feeding, 360 cubic centimeter (cc) water
2/3/14 from 7:00 A.M. - 7:00 P.M.: 1200 ml tube feeding, water flush blank
2/3/14 from 7:00 P.M. - 7:00 A.M.: tube feeding 0, water flush blank

The MSCM confirmed that the calculated intake contained inconsistent data. The MSCM acknowledged that the inconsistent data made it difficult to ascertain the actual nutritional and hydration status of the tube feeding administration.

An interview and joint review of the Intake and Output (I&O) Detail Report with RN 24, the MSCM, the SDE, and the PIQR was conducted on 2/4/14 at 11:25 A.M. RN 24 confirmed the inconsistent total volume documented for Patient 26. RN 24 stated he had documented the incorrect total amount for Patient 26's intake volume on 2/3/14. RN 24 stated documentation should be correct in order to track fluid balance. RN 24 acknowledged that the calculated total intake volume was inconsistent with the physician's order.

The hospital policy titled "Feeding; Via Enteric Tube" indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A joint meeting with the Quality Assessment and Performance Improvement (QAPI) committee was conducted on 2/6/14 at 10:00 A.M. The Senior Director of Quality and Risk Management (DQRM) acknowledged that the hospital was aware of the nursing staff's inconsistent I&O documentation. The DQRM stated that the hospital was currently working on a process in order to streamline the documentation for the intake and output.

3b. Patient 28 was admitted to the hospital on 1/26/14 with the diagnoses that included dysphagia (difficult to swallow) post G-tube (gastrostomy tube - surgically inserted feeding tube into the stomach) placement per the History and Physical, dated 1/26/14.

A joint observation of Patient 28 and interview with Registered Nurse (RN) 23, the Senior Director of Education (SDE), the Performance Improvement Quality Resource (PIQR), and the Medical Surgical Clinical Manager (MSCM) was conducted on 2/4/14 at 10:30 A.M. Patient 28 rested in the bed with the head of the bed elevated, a tube feeding of Glucerna 1.2 was infusing at 50 milliliters (ml) per hour (hr). RN 23 stated that Patient 28 received nothing by mouth (NPO) because of the tube feeding administration thru the G-tube.

A joint review of the Physician's Progress Note, the Physician's order, and the Intake and Output (I&O) Detail Report with the MSCM, SDE, and PIQR was conducted on 2/4/14 at 2:30 P.M. According to the Physician's Progress Notes, Patient 28's G-tube was inserted on 1/31/14.

The Physician's order, dated 2/2/14, indicated Glucerna 1.2 infused at 50 ml/hr, with a free water (flush) of 200 ml every six hours per the G-tube.

The following was the documented on the Intake and Output Detail Report:

2/1/14 from 7:00 A.M. - 7:00 P.M.: 165 ml tube feeding, 400 cubic centimeter (cc) water flush
2/1/14 from 7:00 P.M. - 7:00 A.M.: Blank
2/2/14 from 7:00 A.M. - 7:00 P.M.: 550 ml tube feeding, 1200 cc water flush
2/2/14 from 7:00 P.M. - 7:00 A.M.: 500 ml tube feeding, 400 cubic centimeter (cc) water
2/3/14 from 7:00 A.M. - 7:00 P.M.: Blank
2/3/14 from 7:00 P.M. - 7:00 A.M.: Blank
2/4/14 from 7:00 A.M. - 12:00 P.M.: Flush 380 cc
2/4/14 from 7:00 P.M. - 7:00 A.M.: Blank

The MSCM confirmed that the calculated intake contained inconsistent data. The MSCM acknowledged that the inconsistent data made it difficult to ascertain the actual nutritional and hydration status of the tube feeding administration.

An interview and joint review of the Intake and Output (I&O) Detail Report with RN 25, the MSCM, the SDE, and the PIQR was conducted on 2/6/14 at 8:20 A.M. RN 25 stated that on 2/2/14 she believed that Patient 28's tube feeding had been on hold due to complications. She stated that the water flush order was 200 ml every six hours. According to the 1200 ml calculation documented in the I&O on 2/2/14 from 7:00 A.M. to 7:00 P.M., the total included 30cc water flushes with medications, and a 60 cc flush because the tube was bloody. RN 25 stated accurate intake was important for cardiac patients. RN 25 acknowledged that the calculated total intake volume was inconsistent with the physician's order.

The hospital policy titled "Feeding; Via Enteric Tube" indicated to "10. Check the order for correct feeding times, amount, and liquid nourishment. 37. ...If administering a continuous feeding, flush the feeding tube with at least 30 ml of water before and after every medication administration and periodically to prevent tube occlusion. 56. Record procedure, type and amount of formula, intake and output."

A joint meeting with the Quality Assessment and Performance Improvement (QAPI) committee was conducted on 2/6/14 at 10:00 A.M. The Senior Director of Quality and Risk Management (DQRM) acknowledged that the hospital was aware of the nursing staff's inconsistent I&O documentation. The DQRM stated that the hospital was currently working on a process in order to streamline the documentation for the intake and output.

Based on observation, interview and document review, the hospital did not ensure that emergency battery lighting was provided in 2 out of 2 labor and delivery (L&D) operating rooms (OR's) to ensure uninterrupted lighting during surgical procedures in the event of a power loss and a delay in the initiation of generator power. In addition, the hospital did not ensure that testing of the emergency battery lighting was conducted in accordance with manufacturer's specification in 5 out of 5 OR's.

Findings:

1. A tour of the two L&D operating rooms was conducted on 2/4/14 at 1:05 P.M., there were no battery operated lighting units observed in either of the two OR's. Functioning flashlights were produced by the OR staff for each L&D OR.

An interview with L&D OR technician was conducted on 2/4/14 at 8:55 A.M. She stated that when the power had gone out in the past that there was a brief period of darkness before the generator power came on.

An interview with the Director of Maternal Child Services was conducted on 2/4/14 at 1:10 P.M. She acknowledged that the L&D OR's did not have battery operated lighting units installed.

2. A tour of operating room 1, 2, 4 and 5 was conducted on 2/4/14 at 2:30 P.M. The emergency battery lighting was tested by pressing the test buttons in each OR which indicated that the battery lighting failed testing in OR's 1, 2, 4 and 5. OR 3's battery lighting test button was tested on 2/4/14 at 5:45 P.M. which also failed testing.

A review of the hospital's life safety code inspection form was conducted on 2/4/14 at 3:51 P.M. The form indicated that the emergency battery lighting had been tested and passed every month for the past year.

A review of the manufacture's specifications for the fluorescent emergency lighting system was conducted on 2/4/14 at 6 P.M. The specifications indicated that "test switch provides manual activation of 30 second diagnostic testing for on demand usual inspection".

An interview was conducted with the Director of Facilities on 2/5/14 at 8:30 A.M. He stated that upon inspection of the emergency lighting that the test buttons had not been "wired" and that is why they failed to illuminate the battery lighting when tested. He stated that facilities staff had tested the emergency battery lighting by turning off the lights and not by using the test buttons. He further stated that was why the life safety log indicated that the emergency lighting passed testing each month. He acknowledged that the lighting should be tested using the test buttons as indicated by the manufacturer.

K3 BUILDING:01
K6 PLAN APPROVAL: 1949
K7 SURVEY UNDER: EXISTING
STRUCTURE TYPE : 2 STORIES , TYPE 11(111), FULLY SPRINKLERED

The following reflects the findings of the California Department of Public Health, Life Safety Code Unit, during a revisit focus survey. The findings are in accordance with 42 CFR (Code of Federal Regulations) 482.41 and NFPA (National Fire Protection Association) 101, Life Safety Code 2000 Edition, Existing codes.

Representing the California Department of Public Health: 29626 and 29566

Census: 73

K 12

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in walls and ceilings. This affected 1 of 2 floors. This could result in the spread of smoke and fire throughout the facility and the increased risk of injury to patients and staffs, due to smoke and fire.

Building construction type and height meets one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

Findings:

During a facility tour with the Construction Manager (Manager 41), the walls and ceiling were observed.

1. On 2/4/14, at 11:10 A.M., there were 2 unsealed penetrations measured approximately 1/2 inch circular with 5/8 depth in the separation wall of Environmental Services Clean linen room.

2. On 2/4/14 at 2:28 P.M., there was a 2 by 6 inch penetration in the hard ceiling in the Administration office server room. The penetration was around multiple pipes/conduits for the computer server exposing the attic space above.

3. On 2/5/14 at 9:47 A.M., there were two unsealed pipes running through the exterior wall of the building by the Housekeeping laundry area.

K 18

Based on observation, the facility failed to maintain their doors. This was evidenced by corridors doors obstructed from closing or latching. This affected 1 of 2 floors. This could result in the spread of smoke and fire throughout the facility and the increased risk of injury to patients and staffs due to smoke and fire.

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1? inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3

Findings:

During facility tour with the Construction Manager (Manager 41) on 2/3 to 4/14, the corridor doors were observed.

1. On 2/3/14, at 4:18 P.M., the door to the housekeeping closet by the Physician Room failed to latch. The door was equipped with a self-closing device.

2. On 2/4/14 at 9:09 A.M., the corridor door to Labor and Delivery entrance failed to latch. The door was equipped with a self-closing device.

3. On 2/4/14, at 10: 29 A.M., the dish washer room door failed to latch. The door was equipped with a self-closing device.

4. On 2/4/14, at 2:05 P.M., room 24 door was obstructed from closing by a trash can.

K 25

Based on observation, the facility failed to maintain the integrity of the smoke barrier construction. This was evidenced by an unsealed penetration in smoke barriers wall and corridor walls. This affected affecting 1 of 2 floors. This finding could result in the spread of smoke and fire and increase the risk of injury to patients and staff, in the event of a fire.

Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4

Findings:

During the facility tour with the Construction Manager (Manager 41), the smoke barriers walls were observed.

1. On 2/4/14, at 9:51 A.M., there was an unsealed pipe, measured approximately 3 inches, in the smoke barrier wall by the Medical Records room.

2. On 2/4/14, at 10:42 A.M., there was a 2 feet by 4 feet unsealed penetration in the smoke barrier wall by the dishwasher room seismic separation wall.

K 51
Based on observation, the facility failed to ensure that the fire alarm notification system was maintained in reliable operating condition. This was evidenced by audio device that failed to activate and the room where the fire alarm control unit was located did not have a smoke detector. This affected 1 of 2 floors. This could result in delay in notification of fire to staff and visitors and patients.
NFPA 72.1999 Edition- 1-5.6* Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.
4-3.2.2* To ensure that audible public mode signals are clearly heard, they shall have a sound level at least 15 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m)above the floor in the occupiable area.
Exception No 1: Audible alarm notification appliances installed in elevator cars shall be permitted to use the audibility criteria for private mode appliances detailed in 4-3.3.2.
Exception No 2: If approved by the authority having jurisdiction, audible alarm notification appliances installed in restrooms shall be permitted to use the audibility criteria for private mode appliances detailed in 4-3.3.2
Exception No 3: If permitted by the authority having jurisdiction a fire alarm system arranged to stop or reduce ambient noise shall be permitted to produce a sound level at lest 15 dBA above the reduced average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds after reduction of the ambient noise level, which ever is greater measured 5 ft(1.5 m) above the floor in the occupiable area. Visible notification appliances shall be installed in the affected areas in accordance with Sections 4-4 or 4-5, Relays, circuits, or interfaces necessary to stop or reduced ambient noise shall meet the requirements of Chapters 1 and 3.
Findings:
During tour of the facility with the Construction Manager (Manager 41), the fire alarm notification devices and the fire alarm control unit were observed.
1. On 2/4/14, at 9:46 A.M., in the house Supervisor room on the south wing, a sub-fire alarm panel was located in the locked room. The room was not equipped with a smoke detector.
2. On 2/5/14, at 1:46 A.M., in the Mechanical/Maintenance Room, off the south Corridor, the audio device of the fire alarm system could not be heard during the activation of the fire alarm.

The Construction Manager (Manager 41) and Central Staffing Manager (Manager 42) concurred with these findings at the time and during exit conference on 2/6/14.

K 61

Based on observation and interview, the facility failed to maintain their sprinkler system supervisory valves. This was evidenced by a Supervisory Valve audio alarms that failed to activate. This affected 1 of 2 floors. This could result in a delay in notification of a problem with the sprinkler system and potential harm to patients and staff, in the event of a fire emergency because staff is unaware of any problems with the sprinkler system.

NFPA 72 Fire Alarm Code 1999 Edition, 1-5.4.4 Distinctive Signals. Fire Alarms, Supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

NFPA 101. Life Safety Code , 2000 Edition 9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

4.6.12.2* Existing life safety features obvious to the public if not required by the Code, shall be either maintained or removed.

Findings:

During tour of facility with Construction Manager (Manager 41), the sprinkler system was observed and tested.

On 2/5/14, at 2:52 P.M., the supervisory valve audio alarm of Node 2 fire alarm panel by Administration failed to activate upon testing of the sprinkler system. The panel was equipped with a light labeled audio alarm.

K 62

Based on observation, the facility failed to maintain their automatic sprinkler in accordance with NFPA 25, 1998 edition. This was evidenced by stored materials blocking sprinkler heads, debris on sprinkler heads, and weight on sprinkler pipes. This affected 1 of 2 floors and could result in ineffective function of the sprinklers.

Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Findings:

During the tour of the facility with the Construction Manager (Manager 41), the sprinkler heads were observed.

1. On 2/4/14, at 10:24 A.M., the sprinkler head in the walk in refrigerator had a built up of debris on the deflector.

2. On 2/4/14, at 10:35 A.M., in the dishwasher room, a hose was wrapped around the inspector test valve pipe and parts of the hose was in between the pipe and the room wall.

3. On 2/4/14 at 10:50 A.M., the sprinkler in the Pharmacy was obstructed by a refrigerator unit positioned 16 inches directly below the sprinkler deflector.

4. On 2/4/14, at 1:41 P.M., the sprinkler in the Storage Room by Room 26 was obstructed by supplies positioned, on a shelf, directly below the sprinkler deflector.

5. On 2/4/14 at 1:57 P.M., the sprinkler head in the Janitor Closet, North Wing, had a built up of debris on the deflector.

6. On 2/4/14, at 2:06 P.M., the sprinkler in the Storage Room across from Room 34, was obstructed by supplies positioned, approximately 12 inches directly below the sprinkler deflector.

K 135

Based on observation, the facility failed to ensure that fire safety was maintained around heat producing equipment. This was evidenced by flammable liquid stored in the same room as their chillers in the Central Plant Room. This affected 1 of 2 floors. This finding could result in a hazardous condition and increase the risk of fire and possible harm to patients, staff and visitors.

NFPA 101, Life Safety Code, 2000 Edition 9.2.2 Ventilating or Heat-Producing Equipment. Ventilating or heat producing equipment shall be in accordance with NFPA 91, Standard for Exhaust System for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids; NFPA 211, Standard for Chimneys, Fireplaces, Vents, and Solid Fuel Burning Appliances; NFPA 31, Standard for the Installation of Oil-Burning Equipment; NFPA 54, National Fuel Gas Code; or NFPA 70, National Electrical Code, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 54, National Fuel Gas Code, 1999 Edition
5.2.2 Clearance to Combustible Materials. Gas utilization equipment and their vent connectors shall be installed with clearances from combustible material so their operation will not create a hazard to persons or property. Minimum clearances between combustible walls and the back and sides of various conventional types of equipment and their vent connectors are specified in Chapters 6 and 7 (Reference can also be made to NFPA 211, Standard for Chimneys, Fireplaces and Solid Fuel-Burning Appliances).

6.29.3 Clearance
(a) The clearance shall not be such as to interfere with combustion air, draft hood clearance and relief, and accessibility for servicing listed water heaters shall be installed in accordance with their listing and the manufactures' instructions.

Findings:

During a tour of the facility with the Construction Manager (Manager 41), the Central Plant was observed.

On 2/4/14, at 2:37 P.M., there were approximately 30 gallons of flammable liquid stored besides chiller and other combustible items in the central plant room.


29626


K27

Based on observation, the facility failed to maintain their fire doors to prevent the passage of smoke or fire. This was evidenced by cross corridor fire doors that failed to close and positive latch, doors constructed with non-fire rated material, and gaps between doors. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 2 of 2 floors.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

Findings:

During a tour of the facility with the Maintenance Mechanic Lead (Staff 53) and the Quality Coordinator (RN 52) from 2/3/14 through 2/6/14, the fire doors were observed.

First Floor:

1. On 2/5/14, at 1:32 P.M., 1 of 2 cross corridor fire doors by the Dietary Department failed to close and positive latch upon activation of the fire alarm system. The doors were observed to be equipped with automatic closing and latching mechanisms.

During the facility tour with the Construction Manager (Manager 41), the fire alarm system was tested and smoke barrier doors were observed.

2. On 2/4/14, at 11:11 A.M., in the Environmental Services clean linen room, the access panel door to the smoke barrier attic was constructed of non-fire rated material.

3. On 2/5/14 at 1:39 P.M., smoke barrier double doors by Pediatric corridor were held open with electronic automatic-closing devices. The left door failed to latch and left a gap at the bottom of the door, upon activation of the fire alarm system.

4. On 2/5/14, at 1:42 P.M., smoke barrier double doors by Environmental Services were held open with electronic automatic-closing devices. One of the doors failed to latch upon activation of the fire alarm system.

5. On 2/5/14, at 2:07 P.M., the smoke barrier door by Emergency Room to Medical Surgical unit, there was a gap between the doors panels greater 1/8 inch.

6. On 2/5/14, at 2:11 P.M., the Emergency Room smoke barrier double doors (ambulance Entrance) was held open with electronic automatic-closing devices. The left door failed to latch upon activation of the fire alarm system.

7. On 2/5/14, at 2:23 P.M., double doors by Room 217 (East to West, second floor) was held open with electronic automatic-closing devices. The left door failed to latch upon activation of the fire alarm system.

8. On 2/5/14 at 2:32 P.M., the South smoke barrier door on the 2nd floor, central station, had the smoke barrier gasket sealed was loose from the door frame. As a result, the door failed to latch upon activation of the fire alarm system.

K46

Based on observation and interview, the facility failed to maintain the emergency lights per manufactures requirements. This was evidenced by emergency lights that failed to illuminate when tested with the light fixtures test buttons. This could result in injury during an emergency evacuation and in the event of a power outage. This affected 5 of 5 Operating Rooms.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a tour of the facility with the Maintenance Mechanic Lead (Staff 53) and the Quality Coordinator (RN 52) from 2/3/14 through 2/6/14, the emergency lights were observed.

First Floor:
1. On 2/4/14, at 2:31 P.M., the two battery powered emergency lighting units in Operating Room 1 failed to illuminate when pushing down on the "emergency light push to test" buttons.

2. On 2/4/14, at 2:35 P.M., the two battery powered emergency lighting units in Operating Room 2 failed to illuminate when pushing down on the "emergency light push to test" buttons.

3. On 2/4/14, at 2:37 P.M., the two battery powered emergency lighting units in Operating Room 4 failed to illuminate when pushing down on the "emergency light push to test" buttons.

4. On 2/4/14, at 2:38 P.M., the two battery powered emergency lighting units in Operating Room 5 failed to illuminate when pushing down on the "emergency light push to test" buttons.

5. On 2/4/14, at 5:43 P.M., the two battery powered emergency lighting units in Operating Room 3 failed to illuminate when pushing down on the "emergency light push to test" buttons.

6. On 2/5/14, at 9:08 A.M., the Director of Facility Services (DIR 51) was interviewed and he stated that upon further investigation, the "emergency light push to test" buttons were not wired.

K47

Based on observation, the facility failed to maintain exit signs to continuously illuminate. This was evidenced by exit signs that were not illuminating when observed. This could potentially delay evacuation in the event of a power outage and an emergency evacuation. This affected the Rooftop Heliport and 1 of 2 floors.

NFPA 101, Life Safety Code, 2000 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

Findings:

During a tour of the facility with the Maintenance Mechanic Lead (Staff 53) and the Quality Coordinator (RN 52) from 2/3/14 through 2/6/14, the exit signs were observed.

First Floor:
1. On 2/3/14, at 2:43 P.M., the exit sign (labeled #114) installed in the corridor by the Laboratory Department, failed to illuminate when observed.

2. On 2/3/14, at 2:44 P.M., the exit sign (labeled #115) installed in the corridor by the Emergency Department, failed to illuminate when observed.

3. On 2/3/14, at 3:11 P.M., the exit sign installed in the Emergency Department Supertrack, failed to illuminate when observed. The exit sign was a radioactive type with the installation and replacement dates not displayed.

Rooftop Heliport:
4. On 2/3/14, at 4:21 P.M., the exit sign installed on the rooftop heliport by exit door # 3X005, failed to illuminate when observed. The exit sign was a radioactive type with the installation and replacement dates not displayed.

During tour of facility with the Construction Manager (Manager 41), the exit signs were observed.

5. On 2/4/14, at 11:25 A.M., the nuclear exit sign above the door of Central Sterilize Dispensary room had an expiration date of 6/1990. Staff was unclear if it was the expiration date or insulation date due to the label was unclear.

6. On 2/4/14, at 2:40 P.M., the exit signs above the door of the Central Plant failed to illuminate when observed, and failed to illuminate when staff pressed on the test button.

K52

Based on observation, the facility failed to ensure that the fire alarm system was properly maintained in accordance with NFPA 101, 2000 edition. This was evidenced by the fire alarm not heard throughout all occupied spaces and obstructed fire alarm devices. This had the potential for occupants to not be notified of a fire in the building, increasing the risk for injury. This affected 1 of 2 floors.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Findings:

During a tour of the facility with the Maintenance Mechanic Lead (Staff 53) and the Quality Coordinator (RN 52) from 2/3/14 through 2/6/14, the fire alarm system was tested and observed.

First Floor:

1. On 2/5/14, at 1:46 P.M., the fire alarm audible/visual (A/V) notification device installed by the Nurses Station in the Women's Center, failed to function upon activation of the smoke detector in Patient Room 107. The A/V notification device was labeled as "patient room smoke detector."

During the facility tour with the Construction Manager (Manager 41), fire alarm system devices were observed.

2. On 2/3/14, at 4:01 P.M., a water cooler unit blocked access to the manual pull station in the Doctor's lounge on OB wing.

3. On 2/4/14, at 9:46 A.M., three chairs blocked access to the fire alarm panel in house supervisor room on the South wing.

4. On 2/5/14, at 3:05 P.M., an industrial copier blocked access to the fire alarm panel in Private Branch Exchange (PBX). Construction Manager (Manager 41) had to maneuver around the copier to access the panel due to the copier positioned less than 3 feet of clearance around the panel.

5. On 2/5/14, at 3:10 P.M., also admitting clerk desk and chair blocked access to the fire alarm panel in PBX.

K72

Based on observation, the facility failed to ensure that all means of egress were continuously maintained free of obstructions to full instant use in the case of fire or other emergency. This was evidenced by medication dispensing units that were not properly secured and by furniture and items stored in corridor. This could result in a delay in evacuation in the event of a fire, or other emergency. This affected 1 of 2 floors.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.2.2 There shall be no obstructions by railings, barriers, or gates that divide the open space into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment.

Findings:

During a tour of the facility with the Maintenance Mechanic Lead (Staff 53) and the Quality Coordinator (RN 52) from 2/3/14 through 2/6/14, the egress paths were observed.

First Floor:
1. On 2/3/14, at 2:08 P.M., there was 1 of 2 medication dispensing units in the corridor by Operating Room 1 that was not anchored to prevent it from tipping over. The height of the unsecured medication dispensing units was approximately 6-feet.
During the facility tour with the Construction Manager (Manager 41), the egress corridor were observed.
2. On 2/3/14, at 1:50 P.M., there were 5 chairs stored in the Emergency lobby entrance by the exit doors.
3. On 2/4/14, at 9:18 A.M., there was standing patient scale stored in the egress corridor by the smoke barrier doors in the Pediatric wing.
4. On 2/4/14, at 10:31 A.M., there were 5 dietary carts stored in the corridor by kitchen. At 10:32 A.M., during an interview with Dietary staff 44, she stated the dietary carts are stored in the corridor between meal times.
5. On 2/4/14, at 2:31 P.M., there were 6 utility carts and boxes stored in the egress corridor in the direct path of Exit door of the Pharmacy corridor.
6. On 2/4/14, at 3:50 P.M., during an interview with the Director of Facility Services (DIR 51), he stated he is claiming a categorical waiver for all wheeled equipment to be stored in the corridors. The claim for categorical waiver did not meet the categorical waiver criteria set by the authority having jurisdiction.

K144

Based on record review and interview, the facility failed to maintain their Emergency Power System (EPS). This was evidenced by failing to properly record weekly checks on all EPS and failing to provide battery-powered emergency lighting units for 2 of 4 generator areas . This could result in failure of the generator during the loss of power and not able to troubleshoot the generator during the loss of power.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition.
5-3 Lighting.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established. (see figure Figure A-6-3.1(a) in NFPA 110 for suggested maintenance schedule)

6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer

6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

Findings:

During a tour of the facility with the Maintenance Mechanic Lead (Staff 53) and the Quality Coordinator (RN 52) from 2/3/14 through 2/6/14, the generators were observed and documents were reviewed.

1. On 2/4/14, at 9:45 A.M., the area where the 350 Kilowatt generator was located did not have a battery-powered emergency lighting unit.

2. On 2/4/14, at 9:46 A.M., the area where the 750 Kilowatt generator was located did not have a battery-powered emergency lighting unit.

3. On 2/5/14, at 5:09 P.M., there was no written record showing that the generator was visually inspected at least weekly for the following: coolant level, lubricant level, battery electrolyte levels, exhaust system check, and general inspection of the area for any leaks. The Director of Facility Services (DIR 51) was interviewed on 2/6/14, at 8:20 A.M. and he acknowledged that he had no written record that showed that the generator had been inspected for the above items at least once a week.


K147

Based on observation, the facility failed to maintain electrical safety. This was evidenced by broken receptacle outlet covers, broken metal conductors left inside ground ports, by failing to distinctly identify electrical receptacles that are supplied by the emergency power system (EPS), and by the use of multi-outlet power strips as a substitute for fixed wall outlets. This had the potential for increasing the risk of electrical fire and electrical shock that may result in the injury to patients, visitors, and staff. This affected 1 of 2 floors

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.
380-9. Provisions for Snap Switch Faceplates. (a) Position. Snap switches mounted in boxes shall have faceplates installed so as to completely cover the opening and seat against the finished surface.
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

NFPA 99, Health Care Facilities, 1999 Edition
3-4.2.2.4 Wiring Requirements (b) Receptacles 2. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.

Findings:

During a tour of the facility with the Maintenance Mechanic Lead (Staff 53) and the Quality Coordinator (RN 52) from 2/3/14 through 2/6/14, the electrical equipments and devices were observed.

First Floor:
1. On 2/3/14, at 3:03 P.M., the electrical receptacle wall outlet in the Emergency Department Supertrack by Chair 1, had a broken cover plate.

2. On 2/3/14, at 3:04 P.M., the electrical receptacle wall outlet in the Emergency Department Supertrack by Chair 3, had a broken cover plate.

3. On 2/3/14, at 3:05 P.M., the electrical receptacle wall outlet in the Emergency Department Supertrack by the Bed, had a broken cover plate.

4. On 2/3/14, at 3:06 P.M., the electrical receptacle wall outlet in the Emergency Department Supertrack by the Bed, had a broken metal piece stuck in the ground port.

5. On 2/3/14, at 3:07 P.M., the electrical receptacle wall outlet in the Emergency Department Supertrack by Chair 4, had a broken metal piece stuck in the ground port.

6. On 2/5/14, at 8:57 A.M., the quad receptacle wall outlets in the Labor and Delivery Operating Rooms 1 and 2 had white colored cover plates. The Electrician (Staff 56) confirmed that the outlets were supplied by the EPS and most EPS supplied outlets in the facility had red colored cover plates to distinctively identify them from other outlets not supplied by emergency power.

During a tour of the facility with the Construction Manager (Manager 41), hospital's receptacle outlets were observed.

7. On 2/3/14 at 4:02 P.M., there was microwave, a coffee-pot, water-cooler and fan plugged into a multi-plug, power-strip in the doctor lounge of Obstetrics Wing (OB wing).

8. On 2/3/14, at 4:05 P.M., there was a lamp plugged into an extension cord in the doctor lounge of the OB wing.

9. On 2/3/14, at 4:25 P.M., there was a refrigerator and air condition unit plugged into multi-plug power-strip, in the employee lounge of OB wing.

10. On 2/4/14, at 2:17 P.M., the electrical panel, labeled LA in the cashier office, was not equipped with a panel schedule (label).

25321

Based on observation, interviews, and record reviews, the hospital failed to ensure that infection control practices were maintained regarding the storage of bi-level positive airway pressure machine (BiPap-a breathing apparatus that helps its user get more air into the lungs) masks in accordance to the hospital's policy. Two Bipap masks were not stored in a sanitary manner. In addition, three expired specimen collection kits were stored for use.

Failure to maintain infection control practices could potentially lead to the transmission of infections, a false culture result, and the increase incidence of hospital acquired infections throughout the entire hospital.

Findings:

1a. During the initial tour of the Medical Surgical Unit with the Registered Nurse (RN) 23, the Medical Surgical Clinical Manager (MSCM), the Senior Director of Education (SDE), and the Quality Performance Improvement Resource (QPIR) on 2/4/14 at 10:30 A.M., a Bipap mask was observed stored across the top of the machine uncovered in two occupied patient rooms. RN 23 stated the storage of the Bipap mask was maintained by the Respiratory Department and it was the normal practice to store the mask uncovered.

An interview with the Director of Cardio-Pulmonary (DCP) was conducted on 2/4/14 at 11:00 A.M. The DCP stated it was the hospital's policy to store any unused respiratory devices such as a Bipap mask in a plastic bag. The DCP stated by storing the used Bipap mask in a plastic bag was to maintain a sanitary environment with emphasis on infection control.

An interview with the Infection Control Coordinator (ICC) and the Infection Control Nurse (ICN) was conducted on 2/5/14 at 2:05 P.M. The ICC stated respiratory supplies such as a Bipap mask should be stored in a plastic bag to prevent the potential spread of infection.

The hospital policy titled "Cardiopulmonary equipment cleaning," dated 4/23/13 indicated under, "Disposable Single Patient Use Items: ...In use patient items such as Non-invasive Ventilation Tubing or Masks, ... will be stored at the patient bedside in a plastic set up bag labeled with the patient's name."

An interview with the Senior Director of Quality and Risk Management (DQRM) was conducted on 2/6/14 at 10:45 A.M. The DQRM stated the storage of Bipap masks when not in use should be in a plastic bag to decrease the spread of infection.

1b. During the initial tour of the Medical Surgical Unit with the Registered Nurse (RN) 23, the Medical Surgical Clinical Manager (MSCM), the Senior Director of Education (SDE), and the Quality Performance Improvement Resource (QPIR) on 2/4/14 at 10:30 A.M., three expired specimen collection kits were stored in a drawer inside the East wing medication room.

The following items were found:
1 urethral (connects to the urinary bladder to the genitals for males) specimen collection kit had an expiration date of 6/30/13.
1 urine specimen collection kit had an expiration date of 6/30/13.
1 endocervical (located near the mouth and in the canal of the cervix leading into the uterus) specimen collection kit had an expiration date of 8/31/13.

The MSCM confirmed that the above items were expired and stated if they were stored in the medication room it would have been used. The MSCM further stated it was the responsibility of the Charge Nurse to check the medication room for any expired items. The MSCM acknowledged that the expired items were stored for use and should have been removed upon the expiration date.

An interview with the Infection Control Coordinator (ICC) and the Infection Control Nurse (ICN) was conducted on 2/5/14 at 2:05 P.M. The ICC stated expired medical supplies should not be stored for use and should be discarded upon the expiration date.

An interview with the Senior Director of Quality and Risk Management (DQRM) was conducted on 2/6/14 at 10:45 A.M. The DQRM stated expired items should not be stored for use and should be removed on the expiration date.