HospitalInspections.org

Based on interview, record review, and observation the facility failed to ensure all patients were notified of their rights when receiving services at the facility. This failed practice placed patients at risk for not receiving notification of what their rights were and reduced their ability to exercise their rights. Findings:

During an interview on 12/14/15 at 9:40 am, when asked how and when patient rights were discussed with patients, Charge Nurse #1 stated patients' rights were done in the emergency room before the patient would get to the inpatient unit.

During an interview on 12/15/15 at 10:00 am, when asked if the facility had explained his rights as a patient and who to contact if she/he wanted to file a complaint, Patient #19 said, "No, that wasn't explained to me. "

During an interview on 12/15/15 at 9:15 am, when asked if the facility had explained patient rights to him or provided information on how to file a complaint, Patient #20 (who was admitted through the emergency department) stated, "No". The Patient said the facility had only provided information about the right to privacy of medical information, but no other rights were discussed.

During an interview on 12/15/15 at 10:20 am, when asked how patients were given information on patient rights and how to file a grievance, Charge Nurse #2 stated the information was located in a folder in the patients' rooms. Observations of Patient #s 19 and 20's rooms revealed no folders containing the information in their rooms.

Review of Patient #s 19 and 20's medical records revealed there was no documentation that the patients had received their patient rights.

During an interview on 12/17/15 at 8:00 am, the Chief of Staff confirmed patients who used the back entrance of the emergency department would not have an opportunity to read the patient rights information that was posted out front.
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Based on observation and interview the facility failed to ensure 3 patients (#s2, 19, and 20) were notified of their right to file a complaint or grievance with the State agency if they wished. This failed practice denied patients the information needed to contact the State agency. Findings:

Observation of the signage "Your Rights [and] Responsibilities" posted in the admission area and waiting room of the emergency department revealed "If, after discussion [with the facility staff], an issue remains unresolved, we request that you complete a Patient Comment Form which will be forwarded to the Customer Relations Department for investigation. You also have the right to contact the following agencies." The State agency phone number was listed. The signage was only available to patients who came into the facility through admissions and were in the waiting room in the emergency department.

During an observation of the emergency department back entrance, on 12/17/15 at 8:00 am, where the ambulance bay was located, revealed patient rights information was not posted. Observation of the emergency department revealed the patient rights information was not posted in any of the patient rooms.

During an interview on 12/15/15 at 9:15 am, when asked if the facility had explained patient rights to him or provided information on how to file a complaint, Patient #20 (who was admitted through the emergency department) stated, "No". The Patient said the facility had only provided information about the right to privacy of medical information, but no other rights were discussed.

During an interview on 12/15/15 at 10:00 am, when asked if the facility had explained his rights as a patient and who to contact if she/he wanted to file a complaint, Patient #19 said, "No, that wasn't explained to me."

During an interview on 12/15/15 at 2:25 pm, Patient #2's Parent was asked if he received information, written or verbally, how to file a complaint or grievance. He stated he had signed a consent to treat and for advanced directives in the emergency room but received no information on who to talk to, at the hospital or at the State of Alaska, if he had a complaint.

During an interview on 12/15/15 at 10:20 am, when asked how patients were given information on patient rights and how to file a grievance, Charge Nurse #2 stated the information was located in a folder in the patients' rooms. Observations of Patient #s 19 and 20's rooms revealed no information in their rooms regarding how to file a grievance.

Review of a folder on 12/15/15 provided by Charge Nurse #2, which she said would be identical to the ones found in the patients' rooms, revealed information about patient rights and responsibilities but no information on how to contact the State agency if the patient wished to file a complaint or grievance with the State agency.

During an interview on 12/17/15 at 8:00 am the Chief of Staff confirmed patients using the back entrance of the emergency department would not have an opportunity to read the patient rights information posted out front.

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Based on record review, interview, and policy review the facility failed to ensure 3 staff who provided direct patient services had evidence of a current background check. The failure to provide screening of staff placed patients at risk for abuse and/or neglect. Findings:

Review of employee records on 12/16/15 at 1:00 pm revealed Staff #s 1 and 2 did not have any evidence of a back ground check. Staff # 3's back ground check had expired 9/22/15 and needed to be repeated. All three staff worked in clinical positions at the facility and had unsupervised access to patients.

During an interview on 12/16/15 at 1:30 pm, the Vice President of Workforce Development confirmed the 2 background checks had not been completed and Staff #3's background check had expired.

Review of the facility's policy "Background and Character Checks", dated 6/18/12, revealed "Yukon-Kuskokwim Health Corporation (YKHC) will permit only those individuals who, upon successful completion of a criminal background check, meet its standards of character to perform job responsibilities and/or work in any capacity that gives them access to: regular contact with, or regular control over children, dependent adults, and other vulnerable persons."
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Based on record review, interview, and policy review the facility failed to document ongoing assessment and monitor 1 patient (#26) while in physical restraints and failed to document the type of restraints initiated. Failure to assess and monitor the patient had the potential to cause harm and/or death of the patient. Findings:

Record review on 12/16-17/15 revealed Patient #26 presented to the emergency department on 6/20/15 for treatment. Further review of the medical record revealed "...agitated and uncooperative. [Patient #26] is spitting at the staff and refuses to cooperate. While trying to maintain [Patient #26] safety, [Patient #26] bit [Patient #26's] nurse."

Review of the physician's order, dated 6/20/15 at "16:19 [4:19 pm]", revealed "Restraint Monitoring Violent...Document restraint monitoring every 15 minutes." The physician's order did not specify the type of physical restraint to be used.

Review of the nursing notes, dated 6/20/15 at "16:20 [4:20 pm], "revealed "Pt [Patient #26] combative/assaulting staff. Spitting on staff. Secured pt [Patient #26] to bed w/ [with] restraints and spit hood. Airway patent. Good circulation." The nurses note did not indicate the type of physical restraints that were used.

Review of the nursing notes, dated 6/20/15 at 4:45 pm, revealed "Pt [Patient #26] bit staff [staff's name] on left wrist. Restraints maintained."

The next documented nursing note, on 6/20/15 at 7:05 pm, revealed restraint documentation for behavior; episode activity; nutrition/hydration; elimination; reality orientation; and criteria for release of restraints.

Review of the nursing note, dated 6/20/15 at 7:12 pm revealed "...plan discussed w [with] pt was at 1920 [7:20 pm] trial removal of restraint ..."

Review of the nursing note, dated 6/20/15 at 7:25 pm, revealed "all restraints removed (2 wrist and 2 ankle)". Meaning all extremities were tied down.

Review of all the documentation revealed Patient #26 was in continuous restraints from 4:20 pm - 7:25 pm, 3 hours 5 minutes, with only 1 nursing note that addressed the assessment and the monitoring of the restraints, even though the physician ordered "Document restraint monitoring every 15 minutes."

During an interview on 12/16/15 at 3:10 pm with the Interim Chief Nursing Executive and the Emergency Room Manager they both confirmed there was only 1 documented nursing note that assessed and monitored the restraints of Patient #26 and the restraint monitoring was not done every 15 minutes.

Review of the facility policy "Restraint and Seclusion Policy", dated 5/6/2015, revealed "...The patient is continually monitored and documentation of continuous monitoring will occur every 15 minutes."
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Based on record review, interview, and policy review the facility failed to ensure there was a face-to-face provider evaluation within 1 hour after initiation of restraints for 1 patient (#26) who was in physical. This failed practice placed the patient, who was in physical restraints, potentially at risk for injury and/or death. Findings:

The following record review was from 12/16-17/15:

Patient #26 presented to the emergency department 6/20/15 being "...agitated and uncooperative. [Patient #26] is spitting at the staff and refuses to cooperate. While trying to maintain [Patient #26] safety, [Patient #26] bit [Patient #26's] nurse."

Review of the physician's "Physical Examination" note, dated 6/20/15, revealed "...Mood and affect: Hostile, Behavior: Uncooperative, belligerent..."

Review of the physician's order, dated 6/20/15 at "16:19 [4:19 pm]", revealed "Restraint Initiate..." Further review revealed the Patient was placed in 4 point restraints (each limb was tied) at 4:20 pm.

Review of the physician's note, dated 6/20/15, revealed a reexamination/reevaluation note electronically signed at 7:28 pm, over 3 hours after the patient was placed in the physical restraints. There was no documentation of when the physician had examined the patient.

During an interview on 12/17/15 at 11:50 am, when questioned about the face-to-face examination by the physician the Chief of Staff stated it "Varies by provider. I do go back to see the patient when they are ready to come out of restraints." When questioned about the physician's note, the Chief of Staff stated "He doesn't say when he saw the patient."

Review of the facility "Restraint and Seclusion Policy", dated 5/6/2015, revealed "When applying restraint for behavior management the physician, nurse practitioner, or physician assistant must see the patient face to face and evaluate the need for restraint/seclusion within one hour after initiation of the intervention."
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Based on record review and interview the facility failed to provide evidence 2 clinical nursing staff had completed job specific orientation and 2 clinical nursing staff had evidence of cardiopulmonary resuscitation training (CPR). This failed practice placed patients at risk for not receiving necessary care and services from qualified nurses. Findings:

Review of Registered Nurse (RN) #2's orientation information revealed no job specific orientation in the employee file nor was information provided by the facility.

Review of the ER [Emergency Room] Nurse Manager's orientation information provided by the facility. Revealed the "Performance Criteria and Evaluation", undated, was not filled out. Review of the "Department Orientation Check List", dated 8/15/15, revealed the ER Nurse Manager had completed the department orientation but had no orientation specific to her role.

RN #2 and RN #3 did not have evidence of current CPR education in their employee files.

During an interview on 12/16/15 at 2:00 pm, the Vice President of Workforce Development confirmed there was no specific orientation for RN #2 or for the ER Nurse Manager and confirmed RN #2 and #3 did not have evidence of a current CPR.

No further information was provided prior to exit.

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Based on observation, interview and record review the facility failed to ensure the safe storage of medications. Failure to adhere to best practices for medication storage places all patients at risk for receiving expired medication or medication that was potentially ineffective. Findings:

Observations on 12/14/15 at 9:30 am in the anesthesia medication cart revealed 2 pre-filled syringes labeled atropine and 1 pre-filled syringe labeled robinul. The labels on the syringes did not have the date, time, strength, or initials of the staff.

In addition, a 500 ml bag of IV (intravenous-in to the vein) fluid that had been pre-spiked was in a drawer. The fluids had neo-synephrine written on the IV bag. The labeling did not have the date, time, strength, or initials of the staff.

During an interview on 12/14/15 at 9:30 am during the medication cart observation the CRNA (nurse anesthetist) confirmed the medication was not properly labeled.

Observation on 12/16/15 at 8:00 am revealed a spiked 500 ml bag of IV fluids hanging on the IV pole in operating room #1 while the room was being terminally cleaned.

During an interview on 12/16/15 at 8:00 am Pharmacist #1 confirmed medication labels should be complete and staff should adhere to the facility policy. In addition, the Pharmacist confirmed IV fluids should be spiked at the time of use, should be labeled appropriately, and discarded at the time of patient discharge.

Record review from 12/14-17/15 of the facility policy "Medication Labeling" dated 10/1/08, revealed "All medications removed from their original package/container and transferred to another container must be labeled with the following information: drug name, drug strength ...date and time prepared, initials, and ...expiration time."


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Based on observation, interview, and policy review the facility failed to ensure emergency medications on the inpatient adult crash cart were not outdated. This failed practice placed patients at risk for receiving expired and ineffective medications and/or biologicals. Findings:

During an observation on 12/14/15 at 10:45 am of the inpatient adult crash cart revealed:

4 - Epinephrine 1 mg vials, expired 12/1/15; and
2 - 50% Dextrose 25 gram vials, expired 12/1/15.

During an interview on 12/14/15 at 10:45 am, Pharmacist #2 confirmed the crash cart medications were outdated. Pharmacist #2 also stated pharmacy was responsible for ensuring the crash cart medications were not outdated.

During an interview on 12/16/15 at 9:15 am, the Pharmacy Director confirmed the pharmacy was responsible for checking medication outdates on the crash carts.

Review of the facility policy "Emergency Medications", dated "7/05", revealed "...The pharmacist or a designee will inspect the drug supply monthly as part of a monthly unit inspection."
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Based on observation and interview the facility failed to ensure patient supplies were not outdated in the following areas: 1) Inpatient pediatric supply closet; 2) Adult and pediatric inpatient crash carts; 3) Dental clinic; and 4) Obstetrics. This failed practice put all patients at potential risk for using supplies with an unacceptable level of safety and quality. Findings:

Inpatient Pediatric Supply Closet

During an observation on 12/14/15 at 10:00 am the following supplies, located in the inpatient pediatric supply closet, were found to be outdated:
1 - Similac Sensitive Infant Formula With Iron 2 oz bottle, expired 12/1/15;
29 - Nutren Liquid Nutrition 250 ml, expired 12/11/15; and
1 - Gerber Graduates Meatstick jar, expired 12/2/15.

During an interview on 12/14/15 at 10:30 am, the inpatient Charge Nurse confirmed the items in the pediatric supply closet were outdated.

During an interview on 12/17/15 at 8:22 am, the Surgical Services Director stated the inpatient clinical staff was responsible for checking the supplies for outdates in the pediatric supply closet.

Inpatient Crash Carts

During an observation on 12/14/15 at 10:15 am revealed the inpatient pediatric crash cart had 1 opened undated package of electrodes on the top of the cart. During the same observation the inpatient adult crash cart had 1 opened undated package of electrodes on its cart.

During an interview on 12/17/15 at 8:22 am, the Surgical Services Director stated the inpatient clinical staff was responsible for checking supplies for outdates on the crash carts.

Dental Clinic

Observations on 12/15/15 at 9:00 am during a walk-through of the Dental Clinic revealed the following outdated supplies:

3 - SNOOP Caries Detecting Dye, 1 expired 9/2015; 1 expired 4/2014; 1 expired 11/2011;

1 - Smear Clear Cleaning Solution, expired 3/2015;

4 - Ketac Conditioner, expired 7/2015; and

1 - Cavicide Surface Disinfectant Decontaminant Cleanser Spray expired 12/2014.

In the Dental crash cart the following supplies were outdated:

2 boxes - Freestyle Blood Glucose Test Strips, expired 4/2013;

1 box - Freestyle Lancets, expired 8/2015;

1 - Pediatric PAK Battery and Electrodes (for AED-automated external defibrillator), "Use until: July 2015"; and

1 - Adult Pad-Pak battery & defibrillation pads (for AED), "Use until: August 2015".

During an interview on 12/14/15 at 11:40 am the Dental Director stated the pharmacy maintains the crash cart.

Obstetrics

Observation on the Obstetric Unit on 12/14/15 at 11:45 am revealed multiple lab tubes that expired 11/15/15 in the pediatric code cart and the intravenous supply cart.

During an interview on 12/16/15 at 3:10 pm the Interim Chief Nursing Executive stated the registered nurses were responsible for restocking the supplies on carts and checking for outdates.

During an interview on 12/17/15 at 2:35 pm, the Clinical Services Director stated there was no facility policy regarding outdated supplies.

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Based on observation, interview and record review the facility failed to ensure: 1) the OR (operating room) was free from dust and 2) supplies in the Dental Clinic were not stored under the sinks. Failure to adhere to cleaning practices placed patients at risk for infection transmission. Findings:

OR

Observations in the OR on 12/14/15 between 9:00 am - 11:00 am revealed a layer of dust on the top of the cupboard in OR 1.

Observations in the OR on 12/15/15 between 9:20 am and 11:10 am revealed a layer of dust on the anesthesia medication cart and the computer brought into OR 2.

Dental Clinic

Observations of the Dental Clinic dirty sterilization room, on 12/15/15 at 9:00 am, revealed the following items were found under sinks:
1 - gallon of Liqui-Jet Ultrasonic Cleaner;
1 - Sklar Instrument Polish;
Bio medical/maintenance parts;
Open garbage bags;
1 - plastic pitcher;
1 - enzymatic cleaner;
3 - ½ gallons Surgical Milk; and
1 - container used to clean out the suction hoses.

During an interview on 12/17/15 at 4:10 pm, the Interim Chief Nurse Executive was asked for a policy on the storage of supplies under the sink. No policy was provided by the time of exit.

Review of the facility policy "Cleaning the Surgery Department" dated 4/22/13, revealed "Between case cleaning ...clean the ...counters, and furniture ...Terminal cleaning ...Furniture is thoroughly scrubbed ...all wall mounted equipment ...are cleaned with a detergent ..."

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Based on record review and interview the facility failed to ensure coordination with the receiving facility was documented for 1 Patient's (#23) discharge. This failed practice placed the Patient at risk for not receiving necessary care and services due to the receiving facility's lack of knowledge regarding the patient's care. Findings:

Record review on 12/17/15 revealed Patient #23 was admitted to the facility on 12/2/15 with diagnoses that included schizoaffective disorder ( a condition in which a person experiences a combination of schizophrenia symptoms-hallucinations and/or delusions) and early onset dementia (decline in cognitive ability).

Review of a social service note, dated 12/3/15 at 5:02 pm, revealed "PT [patient] has been accepted for admission to [name of assisted living facility in Anchorage]...As this LCSW [Licensed Clinical Social Worker] will be gone starting tomorrow afternoon (12/5/15) thru 12/15/15, it will be necessary for BH [behavioral health] to coordinate with [owners name] and arrange for pts actual move to Anchorage next week."

Further review of the medical record revealed the Patient was discharged to the Anchorage ALF(assisted living facility) 12/8/15. Review of the physician's progress note, dated 12/8/15, revealed "Discharged today see d/c [discharge] summary for details."

Review of the discharge summary revealed "Discharge instructions: given to patient. Discharge disposition: discharge to skilled nursing facility [ALF]. Prescriptions: continue same medications."

During an interview on 12/17/15 at 11:00 am, the LCSW stated Patient #23 had been a complex discharge due to the Patient's behaviors and previously failed discharges. The LCSW stated the discharge had been set up with the ALF prior to her leave of absence on 12/5/15.

Further review of the medical record revealed discharge instructions and a medication list was sent to the ALF with the Patient and her escort on 12/8/15. The medical record contained no information about report being given to the ALF. In addition, there was no information about other medical information being given to the ALF so the patient could continue with the physicians order plan of care.
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