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Based on record review, interview, and policy review, the provider failed to ensure all sampled medical record entries from different patient service areas were authenticated with either a signature, date, or times. A sample of twenty seven patients' medical record entries (1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 23, 24, 25, 32, and 33) revealed twenty seven instances where either the signature or time of the entry was not recorded. Findings include:

1. Review patients 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 23, 24, 25, 32, and 33's medical records revealed the history/anesthesia evaluation forms were not timed.

2. Review of patients 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 23, 24, 25, 32, and 33's medical records revealed the anesthesia consent forms were not timed.

3. Review of patient 9's blood transfusion form revealed that form had not been timed.

4. Review of seven patients' postoperative reports (11, 12, 13, 14, 15, 16, and 19) revealed a time had not been documented when the physicians had signed those seven forms.

Interview on 4/27/10 4:10 p.m. with the director of nursing confirmed the time when the above patients or the physicians signed the above forms was not documented.

Review of the provider's Consent policy dated 10/12/07 revealed the consent needed to include the time of signing.

Review of Maintaining a Legally Sound Health Record: Paper and Electronic, American Health Information Management Association (http://library.ahima.org) revealed "Every entry in the health record must include a complete date (including month, day, and year) and a time.

Based on observation, interview, and policy review, the provider failed to store medications in a secure manner at three of three areas (the nurses station, storage room, and recovery room). Findings include:

1. Observation on 4/26/10 at 3:20 p.m. behind the nurses station were three unlocked cupboards. Inside the cupboards were:
*Medications that were either oral or injectable.
*Individual plastic bins with patient names on the outside of the medication bottle that contained each patient's current home medications.
*Intravenous medications and intravenous solution bags.
*Medications that would require a physician's order to obtain such as pain medications, muscle relaxant, antibiotics, anti-emetics, and anti-inflammatory.
*Over-the-counter medications included stool softners, iron supplements, antacids, and vitamins.

The above three unlocked cupboards remained unlocked on 4/26/10 from 3:20 p.m. to 4:45 p.m. Observation during that time revealed one of the cupboard doors was left open to the publics view for approximately ten minutes. At that time there were no staff members located at the nurses station. Observation on 4/27/10 from 7:15 a.m. to 8:55 a.m. revealed the same three cupboards remained unlocked.

Interview and observation on 4/27/10 at 11:30 a.m. with the pharmacist revealed:
*The medication cupboards located behind the nurse's station were not locked, and the medications should be kept secured.
*The intravenous solutions were kept in the unlocked storage room located next to the nurses station. Observation of the storage room revealed a large amount of intravenous solutions.
*Medications were stored in a cart in the recovery room. Observation of that cart revealed it was not locked. Observation revealed the staff members working in the recovery room were assisting a patient behind the privacy curtains which would have made the cart out of sight.
*The intravenous solutions in the storage room and the medications stored in the cart in the recovery room were not kept secured from unauthorized individuals.

Review of the provider's Location of Floor Stock Medications policy dated 3/7/05 revealed all medications storage areas would be secured and locked to make inaccessible to visitors, patients, and unauthorized staff.

Based on observation and interview, the provider failed to store clean housekeeping cloths and paper towels in a sanitary manner in one randomly observed room (soiled utility room). Findings include:

1. Observation at 4:30 p.m. on 4/26/10 in the soiled utility room by the new addition revealed:
*New, clean paper towels were stored unprotected on the shelves of the soiled utility room.
*Clean housekeeping cloths were stored on the shelves of the soiled utility room.

Interview with the head of housekeeping at that time revealed he had not considered the items listed above clean items. He stated should not have been stored in a soiled area. He agreed the items listed above should have been stored in a clean area protected from contamination and not in a soiled utility room.

A. Based on record review, interview, and policy review, the provider failed to fully document investigation, analysis, and interventions related to postoperative infections for:
*Six of ten patients (34, 35, 36, 37, 38, and 39) that developed staphylococcus infections between January 2009 and March 2009.
*Four of ten patient infections (the patient names were requested but not provided by staff) that occurred between April 2009 and September 2009.
Findings include:

1. Review of the provider's quality improvement meeting minutes dated 12/10/09 revealed:
*Ten postoperative infections had occurred from January 2009 through September 2009.
*From January 2009 to March 2009 six of the ten patients (34, 35, 36, 37, 38, and 39) had staphylococcus identified as the causative organism.
*From April 2009 to September 2009 four postoperative infections were identified.
-One of the four patients (the patient name was requested but not provided by staff) had been listed twice. That patient had been identified with a postoperative infection at two different times. The causative organism was not listed. The circumstances of how the infections occurred had not been documented.
-One patient acquired an infection after being placed in the whirlpool bath at the nursing home. No preventative measures had been documented.
-One of the ten patients (the patient name was requested but not provided by staff) had contacted cellulitis. The reason for cellulitis had not been documented.

Interview on 4/30/10 at 8:30 a.m. with the infection control coordinator revealed:
*Ten infections had been listed for the year 2009, and of six of those infections staphylococcus had been cultured.
*A review of those six patients revealed common factors were lengthy surgery times and obesity. It was discussed the preoperative antibiotic dose might not have been a sufficient enough dose when the patients' weights were taken into consideration. It was determined to continue monitoring was the best course of action.
*Documentation of that discussion and a plan for preventative action had not been documented.
*One patient had been listed twice, because that patient had developed an infection at two different times. The causative organism, an analysis of the incident, and no preventative measures had been documented.
*One patient had been diagnosed with cellulitis. No further analysis for cause or interventions had been documented.
*The infection control data was incorporated into the quality improvement minutes. There were no infection control minutes.

Review of the provider's infection control program policy revealed the goals of the infection control program were to:
*Decrease the risk of infections to the patient and personnel.
*Monitor the occurrence of infections and implement appropriate control measures.
*Identify and correct problems related to infection control practices.

B. Based on interview, record review, and policy review, the provider failed to ensure the infection control program incorporated a system for monitoring, reporting, and investigating potential communicable disease for all employees. Findings include:

1. Interview on 4/28/10 at 8:30 a.m. with the infection control coordinator revealed:
*She was not aware the infection control program should have included employees at risk for infections and communicable diseases.
*An infection control log was maintained to track and review patients at risk for infections and communicable diseases.
*There was no log or program that tracked employees at risk for infections and communicable diseases after they had been hired. If an employee called in sick that was handled by each department manager. It was a small facility, and she would know when an employee called in sick.
*Employees that were out of work for three consecutive days were required to have a physician's medical clearance before returning to duty.

Review of the provider's quality improvement meeting minutes from January 2009 through April 2010 revealed no data collection for employee illnesses.

Review of the provider's infection control program policy revealed:
*"The Infection control program is comprehensive in that it addresses detection, prevention, and control of infections and communicable diseases among patients and personnel."
*Surveillance of infections included monitoring infections among patients and personnel and documentation of infections that occurred.
*Control measures included employee work restrictions for illness.
*Prevention included education and employee immunization to decrease preventable infectious diseases.

Review of Centers for Medicare and Medicaid State Operations Manual, Appendix A, Survey Protocol, Regulations and Interpretive Guidelines for Hospitals, A749, revealed "Development and implementation of infection control measures related to hospital personnel; hospital staff, for infection control purposes, includes all hospital staff, contract workers (e.g., agency nurses, housekeeping staff, etc), and volunteers."

C. Based on observation, interview, and policy review, the provider failed to ensure a safe and sanitary environment within one of three operating rooms (2). Findings include:

1. Random observation of operating room (OR) 2 on 4/27/10 from 9:30 a.m. until 11:00 a.m. revealed the following incidents occurred:

a. A registered nurse (RN) exited OR 2 toward the end of the surgical procedure carrying a suction container filled with reddish liquid, entered the decontamination room, and emptied the liquid into the hopper. The RN did not put a protective apron over her scrub attire prior to emptying the suction container. She returned to OR 2 and resumed circulating duties. Observation of that RN revealed she wore protective eyewear and gloves, and there were several small stains on the front of her scrub jacket. The scrub jacket was not changed prior to returning to OR 2.

Review of the provider's bloodborne pathogens and airborne pathogens standard policy dated 8/28/08 revealed:
*According to the concept of universal precautions all human blood and certain human body fluids were treated as if known to be infectious.
*All procedures involving blood or other potentially infectious materials were performed in a manner to minimize splashing, spraying, spattering, and generation of droplets.
*Personal protective equipment (PPE) was worn by healthcare workers to protect themselves from direct exposure to infectious materials. PPE included wearing of protective eyewear, gloves, and aprons. Fluid-resistant aprons were available in different sizes, readily available, and worn to protect the healthcare worker.

b. Wearing gloves RN 1 gathered numerous bloody instruments in her hand, exited OR 2, and walked a short distance down the hall to the decontamination room.

Interview on 4/27/10 at 10:00 a.m. with RN 1 revealed carrying contaminated instruments through the hallway in her hands might not be the best practice. A basin or covered container might have worked better.

c. While in OR 2 the physician and a member of the operating team removed the protective paper outer hood from the orthopedic helmets worn during the procedure and discarded the hoods in the trash. The physician and the staff member exited OR 2, removed the helmets, and placed the helmets on a community used shelf. On that shelf were additional orthopedic helmets. The helmets were not cleaned prior to being placed on that shelf.

d. At the end of the orthopedic case in OR 2 the patient was transferred by bed to recovery by the anesthesia provider and the nurse. Observation of the staff remaining revealed the room was disinfected for the next procedure. The staff did not clean or disinfect the anesthesia work area, the EKG leads, or the blood pressure cuff. The blood pressure cuff was observed dangling and touching the floor. Those items were not disinfected by anesthesia provider prior to leaving the room. The anesthesia provider was observed walking another patient into OR 2, positioning the patient on the table, connecting the patient to the contaminated EKG leads, and applying the contaminated blood pressure cuff.

Interview on 4/27/10 at 10:00 a.m. with the OR director revealed anesthesia personnel were responsible for cleaning their area after procedures.

Review of the provider's bloodborne pathogens and airborne pathogens standard policy dated 8/28/08 revealed:
*Contaminated meant the presence or reasonably anticipated presence of blood or other potentially infections materials on the item or surface.
*Decontamination meant the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point they were no longer capable of transmitting infectious particles, and the item was rendered safe for handling, use, or disposal.

Review of the provider's OR environmental sanitation policy dated 8/28/08 revealed to provide a safe, clean environment for the surgical patient and personnel after each procedure all items that came in contact with the patient/and/or the sterile field should have been considered contaminated and disposed of, terminally sterilized, or disinfected.

Based on observation, record review, and interview, the provider failed to administer medications according to acceptable standards of practice for three of three observations. Findings include:

1. Observation on 4/26/10 at 3:40 p.m. revealed registered nurse (RN) 4 removed from the medication cupboard two different antibiotics, Ancef and clindamycin, and two saline intravenous bags. Without comparing the antibiotics to a medication administration record (MAR) the RN prepared the two antibiotics. She placed a label on each bag with patients 2 and 5's names and the medication. RN 4 then administered the intravenous antibiotics to each patient.

2. Observation on 4/26/10 at 4:10 p.m. revealed RN 5 removed from the medication cupboard two cefazolin antibiotics and two saline intravenous bags. Without comparing the medication to the MAR the RN prepared the medications for patients 1 and 4. The RN placed a label on each bag with the patient's name and the medication. RN 5 then administered the intravenous antibiotics to each patient.

3. Observation on 4/27/10 at 7:15 a.m. revealed RN 4 removed from the medication cupboard clindamycin and Ancef and two saline intravenous bags. Without comparing the medication to the MAR the RN prepared the medications for patients 2 and 5. The RN placed a label on each bag with the patients name and the medication. The RN then administered the intravenous antibiotics to each patient.

Interview with RN 4 after she had administered the antibiotics to patients 2 and 5 revealed she had not compared the medications listed on the patients individual MARs. Further interview revealed she had given the patients the same medications the day before and knew what medications they were to receive.

Interview on 4/27/10 at 9:00 a.m. with the quality assurance performance improvement coordinator and the director of nursing revealed:
*The nurses were to follow the five rights when preparing and administering medications.
*The MAR should have been used when preparing the medications.
*The method RN 4 and 5 had used to prepare the antibiotics was not an acceptable practice.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Edition, St. Louis, Mo., 2005, page 841, revealed:
*"Standards are those actions that ensure safe nursing practice. To ensure safe medication administration the nurse should be aware of a nursing standard called the six rights of medication administration. All medication errors can be linked, in some way, to an inconsistency in adhering to the six rights of medication administration."
*"The six rights of medication administration include the following:
1. The right medication.
2. The right dose.
3. The right client.
4. The right route.
5. The right time.
6. The right documentation."