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Based on observation, interview and record review, the facility failed to ensure that one of 34 sampled patients (Patient 14) was informed of the plan of care and updated on her status in a language the patient will understand.

Findings:

On November 6, 2012 when interviewed at about 10:48 a.m., Patient 14 stated she had been admitted a few days ago for chest pain and she did not know what her current status was. According to Patient 14, she only spoke Spanish and neither her physician nor nurse had given a status update on her progress.

On November 6, 2012 when interviewed at approximately 10:37 a.m., Patient 14's nurse (RN 1) stated that the patient was admitted on November 3, 2012, with reports of chest pain. RN 1 stated she was treated with medication, and the plan was for her to transfer to a lower level of care unit. RN 1 stated the patient spoke Spanish.

A review of an admission face sheet indicated Patient 14 was admitted to the facility on November 3, 2012 with the diagnoses that included cardiac arrhythmia. According to the face sheet the patient's language was listed as "Spanish."

A review of an "Adult Clinical Resume" dated November 3, 2012 indicated Patient was Spanish speaking and listed language as a barrier to learning.

A review of the "Patient's Care Plan" indicated a knowledge deficit related to ineffective teaching was initiated on November 6, 2012.

On November 11, 2012 when interviewed at approximately 11:30 a.m., RN 2 stated the staff have the access to the translation phone when translation is needed.

Based on record review and interview, the facility staff failed to document in the medical record whether or not the patient has executed an advance directive during inpatient admission.

Findings:

During a review of closed record revealed Patient 9 was admitted to the facility on August 11, 2012, with diagnosis of pelvic and left hip fracture.

The Self Determination Statement which include whether the patient did or did not have Advance Directive, if patient was offered brochure and if patient would like an assistance in making an advance directive and referred to social work was left blank.
The nursing assessment conducted on admission indicated the patient was alert, oriented to person, event, place and time and had no neurological deficit.
On November 9, 2012, at 9:30 a.m., during an interview with RN 3 while reviewing the clinical record, RN 3 was unable to find written documentation that address the advance directive.

Based on observation, interview, and record review, the facility failed to provide privacy to patients during the triage procedure in the emergency department (ED).

Findings:

On November 6, 2012, during a tour of the ED at approximately 1:30 p.m., the triage area and vital signs measurement area were located in the ED waiting area/lobby. The vital signs machine was located in such a way that the patient and the results displayed on the machine were visible to the public in the ED. The triage procedure (which includes an interview of the patients who were seeking care in the ED) was conducted in a corner of the ED waiting area/lobby. There was a possibility that the conversation may be heard by the public in the waiting area/lobby.

During a concurrent interview with the ED director (RN 4), RN 4 stated due to a lack of space vital signs measurement and triaging occurred in the ED waiting area. According to RN 4, if the reason for seeking care was a sensitive issue, the interview would be conducted in the back.

The facility's practice had the possibility that a patient would not be afforded privacy while receiving care at the ED.

Based on record review and interview, the facility failed to prevent unauthorized access to a patient's medical information. Patient 23's electronic medical record was accessed without authorization by Employee A who is the hospital's physician.
Findings:
According to the facility's letter to the Department dated June 29, 2012, on June 22, 2012 the facility's compliance coordinator was made aware that an employee had inappropriately accessed protected health information of Patient 23 through the facility's electronic medical record system.
A review of the face sheet indicated Patient 23 was admitted to the facility's telemetry unit on June 15, 2012.
During the investigation conducted on November 9, 2012, it was discovered that Employee A accessed the patient' electronic record various times between June 16 - June 23, 2012. A review of the facility's investigation and case notes indicated information accessed by Employee A included laboratory, imaging, microbiology results, vital signs, medications, orders and information about how Patient 23's care was provided during her stay. The facility's investigation indicated Employee A stated he accessed the record because the patient was his wife.
During an interview with Employee B on November 9, 2012 at 9:40 a.m., she stated and confirmed the facility's investigation was complete and accurate.
The facility's policy and procedure titled "Standards of Conduct" dated October 2008 under section Safe guarding Property, Assets and information indicated to ensure that all patient information, in whatever form, was handled in a manner to protect against improper access or use.

Based on observation, interview, and record review, the facility failed to ensure that staff was trained in the monitoring of a patient who is on a psychiatric hold.

Findings:

On November 6, 2012 at approximately 1:30 p.m., a patient care assistant (PCA 1) was seen outside the patient's room in the emergency department.

During a concurrent interview, RN 4 stated the PCA was a sitter (1:1) for a psychiatric patient who was in seclusion.

On November 8, 2012, a review of PCA 1's employee file did not contain evidence that the PCA had met competency criteria for the monitoring of a patient on a psychiatric hold.

On November 8, 2012 when interviewed the director of human resources indicated there was no evidence of training in the monitoring of a person who is on a psychiatric hold.

Based on record review, observation, and interview, the facility failed to ensure patient needs were met for 1 of 34 sampled patients (Patient 19). Patient 19 did not receive screening of MRSA (methicillin-resistant staphylococcus aureus - organism that causes fatal infections) as ordered by a physician.

Findings:

The clinical record was reviewed on November 6, 2012. The face sheet indicated Patient 19 was admitted to the facility on November 3, 2012 with diagnosis of deep vein thrombosis (DVT).

During an observation on November 6, 2012 at 9:55 a.m., Patient 19 was noted in his room receiving intravenous antibiotics and oxygen via nasal canula.

A review of the physician's admitting orders dated November 3, 2012 indicated Patient 19 was to receive MRSA nasal swab.

During an interview and review of the clinical record with the nurse manager (RN 5) on November 6, 2012 at 10:20 a.m., she stated the MRSA screening would be under microbiology and that she did not see it completed for Patient 19. RN 5 stated it should have been done upon admission based on the physician order. RN 5 also stated the registered nurse did not sign off on the physician order for November 3, 2012.

A review of the facility's MRSA rate dashboard, year to date for 2012 indicated a key action plan was to improve compliance with MRSA screening and accurate and timely identification of MRSA positive patients.

During an interview with the infection control specialist on November 8, 2012 at 11:10 a.m., she stated the MRSA rates for the facility were increasing.

The facility policy and procedure titled Chart Checks - Inpatient dated March 2012 indicated the purpose was to prevent errors, ensure patient safety, avoid missed orders and ensure that all noted orders have been correctly implemented in an appropriate timeframe. The policy indicated every patient's chart with physician orders was reviewed by the off going registered nurse with the oncoming registered nurse, during report to verify all orders had been initiated and implemented.

Based on record review and interview, the facility's nursing staff failed to develop, keep current a nursing care plan for 2 of 34 patients (Patient 20 and 22). The nursing care plan for Patient 20 and 22 indicated the patients were assessed with multiple problems, however there were no nursing interventions in response to those problems in the care plan.

Findings:

1. Patient 20's clinical record was reviewed on November 7, 2012. The face sheet indicated Patient 20 was a nine year old female, admitted to the facility on November 4, 2012 with diagnosis of femur fracture.

A review of the clinical record (Nurse Desktop) indicated the "PEDS Care Plan" was started on November 4, 2012.
1.a. The care plan identified a problem of "Pain" with the long term out (LO) of "Report pain at or below FPG". There was no nursing intervention in response to this problem.
1.b. The care plan identified a problem of "Impaired Gas Exchange" with the LO of "Maintain optimal gas exchange and maintain a patent airway". There was no nursing intervention in response to this problem.
1.c. The care plan identified "Impaired Functional Mobility (PT/OT/SP) with the LO of "Improve functional mobility and participate in discharge planning. There was no nursing intervention in response to this problem.

The facility policy and procedure titled Interdisciplinary Plan of Care dated September 2012, indicated the care plan was a communication tool that identified and prioritized treatment needs, including outcomes and interventions.

During an interview with registered nurse (RN 6) on November 7, 2012 at 11:05 a.m., when asked about Patient 20's care plan interventions for the impaired functional mobility, she stated the interventions were, "just the activity record."

A review of the activity record for Patient 20 dated every four hours, from November 4, 2012 at 4 p.m. - November 7, 2012 at 8 a.m., indicated the same documentation each time. Patient activity was bedrest, activity tolerance was good or fair, gait pattern was unable and assistive devices was crutches. This indicated there were no interventions the facility staff could implement and that the care plan interventions were not individualized. In addition, this indicated the care plan was not in collaboration with an interdisciplinary team (i.e., physical therapy), as the care plan did not indicate documentation of specialized services.

During an interview with the charge nurse (RN 7) on November 7, 2012 at 11:15 a.m., she stated Patient 20 was able to ambulate with crutches (however, the care plan indicated gait unable) and the options for gait pattern for Patient 20 were steady or unsteady, as the patient was able in gait pattern. This indicated a discrepancy in the nursing assessment.

The facility policy and procedure titled Interdisciplinary Plan of Care dated September 2012, indicated the nursing care plan was kept current by ongoing assessments of the patient's needs and the patient's response to interventions, and updating or revising the patient's nursing care plan in response to those assessments.

According to Saunders and Mosby Elsevierhealth.com 2012, impaired physical mobility care plan included ongoing therapeutic interventions of facilitate early ambulation and transfer training of dangling or sitting in chair, maintain limbs in functional alignment, perform passive or active range of motion exercises, promote resistance training, turning patient routinely and use of prophylactic antipressure devices as needed.

2. Patient 22's clinical record was reviewed on November 7, 2012. The face sheet indicated Patient 22 was admitted to the facility on November 3, 2012, with diagnoses which included atrial fibrillation and rapid ventricular response.

A review of the clinical record (Nurse Desktop) indicated the "DOU Care Plan" was started on November 3, 2012.
2.a. The care plan identified a problem of "Altered Tissue Perfusion" with the long term out (LO) of "Exhibit optimal tissue perfusion". There was no nursing intervention in response to this problem.
2.b. The care plan identified a problem of "Decreased cardiac output" with outcome of "maintain adequate cardiac output". There was no nursing intervention in response to this problem.
2.c. The care plan identified a problem of "Actual dysrhythmia" with outcome "experience reduced cardiac dysrhythmias". There was no nursing intervention in response to this problem.

A review of the physician's order dated November 3, 2012 at 12:55 p.m., indicated Heparin per pharmacy, Heparin 2800 units intravenous push one time and Heparin 600 units per hour (15ml/hr). At 5 p.m., the physician order indicated to continue Heparin per pharmacy until further notice.

According to Nurse's Drug Guide 2009, indicated Heparin was an anticoagulant (alters the bloods ability to clot) used to treat thrombosis and embolisms with a life threatening adverse effect of spontaneous bleeding.

A review of the Thrombosis Risk Assessment dated November 3, 2012 indicated Patient 22 had three or more risk factors for deep vein thrombosis and was on prophylaxis treatment (leg/ft squeezers, heparin, lovenox or coumadin).

A review of Patient 22's Patient Education form dated November 5, 2012 indicated lovenox was discussed and first dose given.

During an interview with the registered nurse (RN 8) on November 7, 2012 at 10:05 a.m., she stated the care plan for Patient 22's atrial fibrillation and the use of anticoagulants was actual dysrhythmia with the outcome as experience reduced cardiac dysrhythmias. When RN 8 was asked about the care plan interventions for actual dysrhythmia, she stated the interventions were the telemetry records and the shift assessments.

A review of the telemetry records dated November 6, 2012 at 7:44 p.m., November 7 at midnight, 4 a.m., and 7:45 a.m., indicated Patient 22's electrocardiogram rhythm was atrial fibrillation, that there was no ectopy and the heart rate. This indicated there were no interventions the facility staff could implement and/or evaluate the outcome of those interventions. In addition, the care plan interventions were not individualized, as any patient with a care plan problem of actual dysrhythmia would have a telemetry record documenting rhythm, ectopy and heart rate and every patient would have shift assessments.

A review of the shift assessment dated November 6, 2012 at 8:18 p.m., indicated Patient 22 received a neurological assessment, respiratory assessment, skin assessment and fall prevention strategies. The shift assessment indicated a cardiovascular exam comment of atrial fibrillation, heart rate 80 - 100, S1S2 heard, distant heart sounds, irregular. The shift assessment also indicated under Education, the plan of care was reinforced for the shift.

This indicated the care plan interventions did not indicate prevention of pulmonary embolism or deep vein thrombosis, no monitoring of signs and symptoms of stroke and no assessment of risk for bleeding or bruising.

During an interview with RN 9 on November 9, 2012 at 10:30 a.m., she stated Patient 22's care plan did not indicate any type of documentation regarding prevention of deep vein thrombosis or risk of bleeding.

According to National Center for Biotechnology Information 2012 (a service of the National Institutes of Health), indicated the nursing care plans and health information technologies were intended to facilitate information flow and the care planning process was a framework for coordinating communication that would result in safe and effective care. When the care planning process was computerized, there appeared to be substantial system problems resulting from lack of nursing input, which contributed to questionable patient outcomes.

The facility policy and procedure titled Interdisciplinary Plan of Care titled September 2012, indicated each patient would receive care based on an individualized plan of care initiated by the registered nurse in collaboration with the interdisciplinary team. The policy indicated the care planning process included: implement actions or interventions required to meet the outcome, evaluate outcome attainment and effectiveness of interventions and to revise the care plan as needed. The policy indicated the care needs that were emergent or life threatening shall be prioritized.

Based on observation, record review and interview, the facility staff failed to ensure that telephone orders were dated, timed and authenticated by the ordering physician and/or another practitioner who was responsible for the care for 4 of 34 sampled patients (1, 6, 7 and 9).

Findings:

1. On November 6, 2012, at 10:05 a.m., Patient 1 was observed sitting on a wheelchair being pushed by the physical therapist assistant to the neuro-gym for his rehabilitation exercises.

A review of the Patient Care Worksheet revealed Patient 1 admitted to the facility on October 29, 2012, with diagnoses that included left basal ganglia hemorrhage, left hemiparesis, history of hypertension, renal insufficieny and poly-substance abuse.

On October 31, 2012, at 11 a.m., there was a telephone order for Dysphagia Evaluation which was signed by the physician but not dated and timed.

On November 1, 2012, at 12:30 p.m., there was a telephone order for Baclofen 5 mg by mouth, every four hours as needed for mild spasm and Baclofen 10 mg by mouth, every four hours as needed for moderate spasm. This order was signed by the physician but not dated and timed.

On November 1, 2012, at 10:20 a.m., there was telephone order to discontinue saline lock and post void residual which was signed by the physician but not dated and timed.

2. On November 8, 2012, during review of closed record of Patient 7 revealed he was admitted to the facility on June 7, 2012, with diagnosis of urinary tract infection.

On June 5, 2012, at 4:35 p.m., there was a telephone order to hold Xarelto (oral anticoagulant medication) which was not signed by the physician.

On June 6, 2012, at 7:25 a.m., there was a telephone order for CT Urogram (computerized tomography Urogram) however, the order was not signed by the physician.

3. On November 8, 2012, during review of closed record Patient 9 revealed she was admitted to the facility on August 11, 2012, with pelvic and left hip fracture.

On August 4, 2012, at 5 p.m., there was a telephone order to discontinue Foley catheter in the morning however, the order was not signed.

4. On November 8, 2012, at 8:30 a.m., Patient 6 was observed sitting on the bed getting ready to have her morning bath. During an interview, the patient was alert, oriented and verbalized the reason of her hospital admission.

During review of Patient 6's medical record revealed she was admitted to the facility on November 2, 2012, with diagnosis of erosion of adjustable gastric band.

On November 2, 2012, at 11:55 p.m., there was telephone order to discontinue Compazine due to unavailability, and change to Zofran, every four hours as needed for nausea and Phenergan 12.5 mg intravenously (IV) every four hours as needed for nausea. The order was not signed by the physician.

A review of the facility's policy number: 8740.121 titled "Physician Order for Patient Care" stipulated all orders for patient care must be legibly dated, timed and signed by the admitting /attending physician, AHP and/or House Staff with accompanying identification number.

During a concurrent interview with the RN 10, she stated that medical orders need to be signed, dated and timed.

Based on observation, interview, and record review, the facility failed to ensure that safe injection standards of practice were implemented.

Findings:

1. On November 6, 2012 during a tour of the Pediatric ECMO room at approximately 11:07 a.m., a bag of normal saline and a bag of Heparin (anticoagulant) flush was hung on the wall of the station. The normal saline bag was dated November 5, 2012 at 10 a.m. the date and time its was first used.

During a concurrent interview, RN 3 stated the bags were used to fill syringes for flushing of the patient's lines. According to RN 3, the bags were good for 24 hours.

The Centers for Disease Control and Prevention's (CDC) "Safe Injection Practices to Prevent Transmission of Infections to Patients" recommended to not use bags or bottles of intravenous solution as a common source of supply for multiple patients.

2. On November 6, 2012, during a tour of the Pediatric Critical Care unit, an inspection of the unit's clean utility room was conducted. In the utility room there was an unlabeled syringe with a clear liquid attached to an IV tubing. The set was found in direct contact with the handle of the IV insertion tray.

The practice of placing the IV tubing in direct contact with a high touch surface has the potential to cross contaminate the IV tubing. In addition, the practice of not labeling a syringe has the potential for confusion of the syringes content.

A review of the facility's policy and procedure titled "Peripheral IV" dated September 2012 stipulated that strict aseptic technique and standard precautions would be practiced through the procedure.

Based on observation and interview, the facility failed to ensure that two unlicensed Pharmacy staff had access to the facility's narcotic room which contained controlled (narcotic) drugs. The facility also failed to develop a written policy and procedure on who could have access to controlled (narcotic) drugs and the facility's narcotic room.

Findings:

Inspection of the facility's narcotic room revealed that on the outside door of this room was a magnetic reader locking mechanism, which licensed Pharmacy staff used to open the door of the narcotic room. Interview with the facility's Director of Pharmacy on 11/6/12 at 11:30 am revealed that two of the Pharmacy's buyers (which are unlicensed staff) had access to this narcotic room by the use of the employee's identification badges (which contained an electronic magnetic strip). Both of the Pharmacy buyers could access the narcotic room, (which contained unsecure controlled drugs once inside the room), without requiring a Pharmacist to be present. Further interview with the facility's Director of Pharmacy revealed that the facility's policy and procedure was to not allow unlicensed Pharmacy staff to access this narcotic room, without a licensed Pharmacist being in the narcotic room as a result of the scheduled narcotics which were contained inside of this room. The facility's Director of Pharmacy also indicated that a licensed Pharmacist may not always present in the room when the buyer accesses the narcotic room.

When the Director of Pharmacy was asked on 11/6/12 at 4:00 p.m., if the facility had developed a written policy and procedure for who could have access to the controlled (narcotic) drugs or the Pharmacy narcotic room, the Director of Pharmacy indicated that the facility had not developed a formal written policy and procedure to address who should have access to the controlled drugs or the Pharmacy narcotic room.

Based on observation, interview and record review, the facility failed to maintain the hospital environment to assure the safety and well-being of patients.

Findings:

a. During a tour of the kitchen on November 6, 2012, from 10 a.m.-10:55 a.m., the following was observed:
1. The faucet at the food preparation sink was leaking.
2. In the front cookline, one vent was dusty and one vent had stains.
3. In the three compartment sink area, there were janitorial items (broom, dust pan) along the wall next to the paper towel dispenser.
At the same time, during an interview, the food services director could not explain why the janitorial items were left in the area.
4. The seal on top of the three compartment sink had thick black deposits.
5. In the three compartment sink area, the handwash sink water temperature was 87 degrees Fahrenheit.
6. Above the cookline, the light covers had stains.
7. The rubber gasket at the bottom of refrigeration unit #15 was detached.
8. In the colds production preparation area, 6 ceiling vents were dusty.
9. The electrical cords plugged in from the ceiling electrical sockets were dusty.
10. Above the steam table area, two ceiling light covers had stains.
11. In the dry goods storage/delivery area, the ceiling was dusty above the fan guards. The air curtain was dusty.
12. The rubber gasket of refrigeration unit #34 was taped on the side.
13. Five storage racks had shelves with food and debris.
At the same time, during an interview, the food services director could not explain why the shelves were not clean when the shelves were removable and easy to clean.
14. In the ingredient room (cold preparation), there were stains in the ceiling. The section of the ceiling around the vent was dusty.
15. Inside refrigeration #34, the fan guards were dusty.

A policy and procedure entitled Vent Cleaning was provided by the facility. However, the facility had no schedule for frequency of vent cleaning.

b. During a tour of the facility on November 7, 2012, from 7:40 a.m.-11:32 a.m., the following was observed:
WEST TOWER
16. In the clean utility room, the zipper of the linen cart cover was not closed and clean linens were sticking out from the shelf.
17. In room 575, a room occupied by a patient on contact isolation, the trash receptacle was overflowing.
18. In the hallway outside room 573, the front of the linen cart was facing the wall. There was no cover and the clean linens on the shelves were the wall.
19. In the clean utility room, the linen cart cover was approximately two inches short exposing the clean linens on the bottom shelf. On the bottom shelf there were 18 bath covers. The bath covers were overstacked pushing the linen cart cover outward.
20. In the hallway outside room 564, the front of the linen cart was facing the wall.
21. In room 562, a room occupied by a patient on contact isolation, the trash receptacle was overflowing.
22. In room, 551, there was a urinal on top of the overbed table next to the breakfast tray.

2 WEST
23. The clean linen cart had a torn velcro cover. The clean linens in the bottom shelf were exposed.

4WEST
24. In the hallway outside room 487, the clean linen cart had no cover and the front of the clean linen cart was facing the wall.
25. In the environmental services closet, the disinfectant solution dispensing tube was inside the service sink. The service sink had a thick brownish deposit throughout the service sink floor.
26. In the clean utility room, the clean linen cart had a torn velcro cover.
27. Inside room 464, a room occupied by a patient on contact isolation, the trash receptacle was overflowing. There was a soiled glove on the floor next to the trash receptacle.
28. In the hallway outside room 456, the clean linen cart had no cover. The front of the cart was facing the wall.
29. In room 453, the trash receptacle was overflowing. This was observed at 9:57 a.m.

At the same time, during an interview, the unit manager stated there was one housekeeping staff assigned to clean the patient rooms.

30. In room 452, the trash receptacle was overflowing.
31. In the clean utility room, the clean linen cart cover was short approximately two inches short and not covering the cart fully.

6 EAST-Module 1
32. In the clean utility room, the clean linen cart cover had stains.

6 EAST- Module 2
33. In the clean utility room, the clean linen cart cover had stains.

6 EAST-Module 3
34. In the clean utility room, the clean linen cart cover had stains.

5 EAST-Module 2
35. In the clean utility room, the the clean linen cart cover could not be closed.

During a tour of the facility on November 8, 2012, from 7:35 a.m.- 10:40 a.m., the following was observed:

ICU WEST
36. In the hallway outside room 4, the linen the clean linen cart the clean linens in the bottom shelf was exposed.
37. In room 5, the trash receptacle was overflowing.
38. In room 8, the trash receptacle was overflowing.
At the same time, during an interview, the unit manager stated trash was collected every 2-3 hours.
Each room had 1-3 trash receptacles.

ICU EAST
39. In room 27, a room occupied by a patient on contact isolation precautions, 2 trash receptacles were overflowing.
40. In room 25, the trash receptacle was overflowing.
41. In room 22, the trash receptacle was overflowing.
42. In the clean utility room, the blanket warmer was indicating a temperature of 134 degrees Fahrenheit.
At the same time, the safety director stated the temperature should be 130 degrees Fahrenheit.
A review of the policy and procedure entitled Warming Cabinets Temperature dated October 18, 2010 indicated the temperature of warming cabinets for blankets should not exceed 130 degrees Fahrenheit. Warming cabinet temperatures should be set and monitored by the department owning the cabinet. If the temperature can not be maintained by the department adjusting the warming cabinet controls, the Clinical Technology Department should be contacted for repairs.

EMERGENCY DEPARTMENT
43. The clean linen cart in the hallway had a torn cover.
44. In PEDS 4, the clean linens stored in a cabinet had a missing cover exposing the clean linens.

A review of the facility's policy and procedure titled "Storage, Collection and Transportation of Linen" indicated all linens will be stored in a manner that prevents the transmission of microorganisms to other patients and areas.

TEMPERATURE/HUMIDITY MONITORING FOR SENSITIVE AREAS
45. A review of the facility's temperature monitoring records for sensitive areas revealed the following ranges (degrees Fahrenheit):
Cath lab - 68-73
NICU - 68-73
Recovery - 68-73
ICU - 68-73
Operating Room - 68-73
There was no documentation provided of temperature monitoring in the delivery room and newborn nursery.

According to "The 2010 California Mechanical Code" requirements for temperature in sensitive areas indicated:
Operating room - 68-75
Cath lab - 70-75
Delivery room - 68-75
Post-Anesthesia Care Unit 70-75
Newborn nursery - 72-78
Newborn Intensive Care Unit (NICU) - 70-75
Intensive Care (ICU) 70-75


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The following was observed during a tour of the Emergency Department.
46. The medication room had a large accumulation of dust and debris on the floor.

47. A biohazard trash can was in direct contact with a privacy curtain.

48. A blood specimen tube (with dark red fluid) was seen in the medication disposal bin.

On November 6, 2012 at approximately 1:45 p.m., RN 4 stated the tube should have been disposed of in the biohazardous waste bin.

49. On November 7, 2012 at 10:15 a.m., during a tour of the pre-procedure area for patients undergoing cardiac catheterization in the catheterization laboratory (Cath Lab), the call light alert system had paper folded in such a manner as to block the chime speaker of the call light alert system.

During a concurrent interview the Cath Lab manager stated the speaker was too loud and folded paper was placed to reduce lower the speaker's volume.

The facility's practice had the potential to delay treatment/intervention to patients if the call light alert system was not heard by a staff member.

50. On November 7, 2012, a tour of the endoscope reprocessing and storage area was conducted at 10:30 a.m. the clean endoscopes were stored in a room on a rack fastened to the wall. The walls where the upper endoscopy scopes were hung had discolorations, cracks, and debris.

When interviewed on November 7, 2012 at 10:32 a.m., the manager stated there was not a schedule developed for routine cleaning of the walls.

The proximity of the scopes to the walls was such that there was a high potential to cross contaminate the clean scopes if they were to make contact with the debris found on the walls.

Based on observation, interview, and record review, the facility failed to maintain the environment in such a way to prevent the spread of infection.

Findings:

1. On November 6, 2012, at 10:05 a.m., Patient 1 was observed in a wheelchair being wheeled by the physical therapist assistant (PTA) to the neuro-gym. The PTA wore the same pair of gloves from the time she wheeled the patient to the elevator, pushed the button on the elevator and assisted the patient from standing up from his wheelchair to start performing and finishing his exercises.

At 11:45 a.m., during an interview with the PTA, she stated she was wearing the same glove because she considered it one session with the patient from beginning to end.

A review of the facility policy number : 746 on Standard Precautions stipulated hand hygiene within healthcare setting and encourages the use of alcohol based hand sanitizers when appropriate such as before contact with patient, after contact with patient and after contact with the patient's environment.

2. On November 7, 2012, at 8:30 a.m., Patient 3 was observed during treatment of multiple avulsions between her legs and buttocks. The patient was on contact isolation. RN 2 was assisted by PCA 1 , both were wearing yellow gown and gloves. RN 11 initially cleansed the avulsions by applying foaming gel on the affected areas and wiped it off. The RN then took a container of a barrier cream, squeezed the content on her gloved hand and applied it to the avulsions between her legs. RN 11 was not changing her gloves during this procedure.

On November 9, 2012, at 10:10 a.m., during an interview with Certified Infection Control Nurse (CICN), she stated the RN should have changed gloves when she completed doing the dirty task and before going to the clean task during treatment procedure.

A review of the facility's policy number : 746 Standard Precaution stipulated gloves must be changed when moving from a dirty to a clean procedure on the same patient.

3. On November 7 and 8, 2012, at various times during the tour of the units, the following was observed:

a. In room W687, there was an oxygen tubing exposed and wrapped around the flowmeter. Also, there was an exposed nasal/mouth piece from a bipap machine that was on top of the machine.

During a concurrent interview with the patient, he indicated that he only used the oxygen tubing on his first two days of admission on November 1 and 2, 2012. He further stated he didn't use the bipap nasal/mouth piece because he couldn't sleep with it.

During a concurrent interview with RN 12, she stated that when oxygen tubing was not in use, it should be placed in a bag.

b. In room E510, there was an exposed oxygen tubing hanging on the flowmeter.

c. In room E547, there was an exposed oxygen tubing found on the floor.

On November 9, 2012, at 10:10 a.m., during an interview with CICN, she stated the oxygen tubing should be discarded after it's use because it's disposable.



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4. During an observation on November 7, 2012, at 8:24 a.m., the pillow used by the patients had a label indicating the the material as polyester fiber. Another label indicated for disinfection 1:10 dilution of household bleach may be used as recommended by the Centers of Disease Control.

During an interview on November 7, 2012, at 8:26 a.m., a housekeeping staff stated the disinfectant used for the pillows was Quick fill Stat III TB. A review of the directions for use revealed polyester material was not included among the fabrics where this disinfectant could be used.

During an interview on November 8, 2012, at 11:30 a.m., the infection control specialist stated that after reviewing the label of the disinfectant, it did not appear that the germicidal detergent was appropriate for the polyester fiber.

A review of the Product Specification Document of Stat III TB revealed this product is for the use on vinyl and plastic upholstery.

5. During a tour of 5 WEST on November 7, 2012, at 8:40 a.m., room 587 was being cleaned.

At the same time, during an interview, the unit manager stated the patient was discharged the night before. The patient was on contact precautions.

A review of the discharge record revealed the patient in room 587 was discharged on November 6, 2012 at 9 p.m.

During an interview on November 9, 2012, at 10:22 a.m., the director of risk management stated the patient's room is cleaned right away after the patient is discharged including late evening discharges.

During an interview on November 9, 2012, at 12:53 p.m., the director of environmental services stated on November 6, 2012, during the third shift, there were only 9 housekeeping staff for the whole hospital. The usual number is 15-20. There was not enough housekeeping staff.

A review of the facility's bed tracking/bed history dated 11/6/12 to 11/7/12 revealed a cleaning request was made for room 587 on 11/6/12 at 10:19 p.m. The cleaning for room 587 was in progress on 11/7/12 at 9:46 a.m. and finished at 11:15 a.m.

A review of the facility's policy and procedure entitled Cleaning Patient Room-Discharge/Transfer indicated all patient rooms will be cleaned when a patient has been discharged or transferred. The patient care unit will notify the Environmental Services Department when the patient has left the premises. The Environmental Services Department will clean the room as soon as possible.

6. During a tour of 2 WEST on November 7, 2012, at 9:28 a.m., room 251 was occupied by a patient on contact precautions. The label on the wall outside the room read "Contact Precautions, to prevent the spread of infection, anyone entering this room must wear gloves and gown." There was a Spanish translation on the label. There were two family members inside the room wearing street clothes.

At the same time, during an interview, the licensed nurse stated the family had been taught. However, at the time of the observation, the licensed nurse did not remind the family of the need to wear gloves and gown.

7. During a tour of 6 EAST on November 7, 2012, at 11:25 a.m., room 636 was occupied by a patient on contact precautions. There was a family member inside the room wearing gloves but not gown.

When the unit manager talked to the family member, she stated that she was told that wearing a gown was optional.



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8. During a tour of the Emergency Department unit 2 on November 6, 2012 at about 2 p.m., the treatment rooms did not have biohazardous waste bins to dispose of biohazardous waste. One small biohazardous bin was located in a clean/dirty utility area away from the treatment rooms.

During a concurrent interview, RN 4 stated the facility does not keep biohazardous bins because they do not have biohazardous waste in the unit.

A review of an undated document produced by the facility titled "Know Your Biohazardous Waste" indicated that isolation waste which contains discarded materials contaminated with excretions or secretions by patients who are isolated for infection control should be discarded in a biohazardous waste bin.

On November 9, 2012 during an interview at 8:38 a.m., RN 4 stated that the ED unit 2 sometimes takes patients that present with fever and are potentially infectious.

9. During a tour of the Emergency Department unit 2 on November 6, 2012 at about 2 p.m., a room designated a clean/dirty utility room where clean patient care items were stored also had a large toilet where excretions were disposed of. The toilet was in close proximity to patient care items. The proximity had the potential for cross contamination of the clean items from potential splashing from excretions.

During a concurrent interview RN 4 stated that excretions were disposed of in toilet and recognized the potential for cross contamination.

10. On November 7, 2012 during a tour of the telemetry unit at about 8:45 a.m. Patient Room 3208 (Patient 15's room ) had a sign out side the room's bathroom that indicated stool samples were to be collected for possible clostridium difficile infection (C. diff). In addition, there was neither an isolation sign nor isolation cart which alerted staff to implement contact isolation procedures.

During a concurrent interview with the telemetry unit manager (RN 12), RN 12 stated if stool is being collected for clostridium difficile infection the patient should be placed in contact isolation.

A review of an admission facesheet indicated Patient 15 was admitted to the facility on November 4, 2012 with the diagnosis that included chest pain.

A review of a Bowel Movement tracking record revealed the patient had had seven bowel movements from November 5, 2012 8:31 a.m. and November 6, 2012 5:44 a.m.

A review of a Physician's Order dated November 6, 2012 at 8:30 a.m., indicated to collect and send stool sample to the laboratory for C. diff analysis.

On November 7, 2012 when interviewed at approximately 9:30 a.m., Patient 15 stated she has had several episodes of diarrhea the past day.

On November 7, 2012 when interviewed at approximately 9:20 a.m., RN 2 stated that according to the facility's policy, patients with active diarrhea should be placed in contact isolation when screened for C. diff infection.

11. a. On November 6, 2012 during a tour of the Pediatric Intensive Care Unit (Peds ICU) there were light fixtures with fluorescent light tubes located in the hallway that were exposed in such a manner that if the tubes were to burst or break the glass could potentially cause injury to the patient.

11.b. On November 8, 2012 during a wound care observation in Patient Room W283 at approximately 1:20 p.m., a light fixture with fluorescent light tubes located directly above the patient's head of bead was exposed in such a manner that if the tubes were to burst or break the glass could potentially cause injury.

On November 6, 2012 at approximately 10 a.m., RN 3 stated the light tubes were not shatterproof and did not have protective sheaths.

Based on record review and interview, the facility failed to assess the patient's discharge plan and begin discharge planning as soon as possible after admission for 1 of 34 sampled patients (Patient 20). Patient 20's discharge planning began on the day of discharge, which resulted in an increased risk of decline in patient outcomes and level of functioning.

Findings:

The clinical record was reviewed on November 7, 2012. The face sheet indicated Patient 20 was a nine year old female, admitted to the facility on November 4, 2012 with diagnosis of femur fracture.

During an interview and record review with the clinical nurse specialist (RN 14) on November 9, 2012 at approximately 8:40 a.m., she stated the discharge planning for Patient 20 was not initiated until November 7, 2012 at 1 p.m.

During an interview and record review with the clinical informatics analyst (RN 9) on November 9, 2012 at approximately 8:50 a.m., she stated Patient 20 had been educated but there was no discharge teaching until November 7, 2012, (three days later) the day of discharge.

The facility policy and procedure titled Discharge Planning dated October 2012 indicated the purpose was to provide a comprehensive, multidisciplinary, discharge planning process that optimizes patient outcomes. The policy indicated discharge planning process began at the time of registration or admission to the hospital.

Based on record review and interview, the facility failed to ensure the physician updated examination of the patient, including any changes in the patient's condition, was completed and documented before the procedure was started for Patient 33.

Findings:

A review of the "Confidential Document" (face sheet)disclosed Patient 33 was admitted to the facility on November 6, 2012. The "Immediate Post Operative Notes" dated at 1:30 p.m. on 11/6/12 was reviewed and disclosed the patient had undergone a surgical procedure, fat grafting on the bilateral breast from bilateral thighs and bilateral nipple reconstruction, on the admission day.

However, the case record (intra-operative nursing record) was reviewed and disclosed the procedure was started at 11:07 a.m. and was ended at 12:56 p.m. on 11/6/12,

A review of the medical record disclosed "Presurgical History & Physical" was completed on 10/26/12. The "History and Physical" in the "Progress Record" was updated by the physician at 1:30 p.m. on 11/6/12, which was 2 hours and 27 minutes after the procedure was started.

During an interview with the Manager of Post-Anesthesia Care Unit on 11/6/12 at 2:15 p.m., she stated the updated examination of the patient, including any changes in the patient's condition, had not been completed and documented before the procedure was started.

According to the facility's Medical Staff, General Staff Rules and Regulations" dated September 2012, page 33, "The H&P must be completed in advance, but no more than 30 days before the planned admission or procedure. If the H&P has been performed within 30 days before admission, a copy of this report must be used as the H&P provided that any changes are recorded in the medical record at the time of admission (i.e. an interval notes)"

Based on record review and interview, the facility failed to ensure a properly executed informed consent form for the operations was in the patient's chart before surgery for 2 of 34 sampled patients (Patient 33 and 34).

Findings:

1. A review of the "Confidential Document" (face sheet) disclosed Patient 33 was admitted to the facility on November 6, 2012. The "Immediate Post Operative Notes" dated at 1:30 p.m. on 11/6/12 was reviewed. The patient had undergone a surgical procedure, fat grafting on the bilateral breast from bilateral thighs and bilateral nipple reconstruction, on the admission day.

The "Authorization for and Consent to Surgery, Care, Treatment, Special Diagnostic or Therapeutic Procedures" and "Progress Notes" dated 11/6/12 were reviewed. There was no documentation that the material risks including risks with a high degree of likelihood but a low degree of severity, as well as those with a very low degree of likelihood but high degree of severity and benefits for the patient related to the surgery and anesthesia, including the likelihood of each, based on the available clinical evidence, had been informed by the responsible practitioner.

2. A review of the "Confidential Document" (face sheet) disclosed Patient 34 was admitted to the facility on November 6, 2012. The "Immediate Post Operative Notes" dated at 1:30 p.m. on 11/6/12 was reviewed. The patient had undergone a surgical procedure, right breast reconstruction with tissue expander and alloderm on the admission day.

The "Authorization for and Consent to Surgery, Care, Treatment, Special Diagnostic or Therapeutic Procedures" dated 11/1/12 and and "Progress Notes" dated 11/6/12 were reviewed and disclosed there was no documentation that the material risks including risks with a high degree of likelihood but a low degree of severity, as well as those with a very low degree of likelihood but high degree of severity and benefits for the patient related to the surgery and anesthesia, including the likelihood of each, based on the available clinical evidence, had been informed by the responsible practitioner.

During an interview with the Manager of Post-Anesthesia Care Unit on 11/6/12 at 2:15 p.m., she agreed there were no properly executed informed consent form for both Patient 1 and 2's operations.

According to the facility's Medical Staff, General Staff Rules and Regulations" dated September 2012, page 15, "Material information is defined as:

The nature of the procedure or treatment
The risks, complications and expected benefits or effect of the procedure including potential problems related to recuperation
Any alternatives to the treatment and their risks and benefits
Likelihood of achieving treatment or care goals---"