HospitalInspections.org

Based on medical record review, document review, video surveillance review, and staff interviews, in one (1) of 16 medical records reviewed, the facility did not ensure that a patient received care in a safe environment. Specifically,
(a) the facility staff did not take appropriate actions to prevent a patient elopement; (b) the facility did not develop and implement effective policy and procedure on elopement.

This failure resulted in patient harm and placed other patients at risk for potential harm.


Findings include.


The medical record review of Patient #1 identified a 72-year old male admitted on 1/18/17 to the Telemetry Unit for evaluation of abnormal cardiac rhythm.

Cardiology Consult dated 1/20/17 at 11:44 AM, documented patient was status post cardiac catheterization with findings that included three-vessel disease with deficient ejection fraction, and was considered for a Coronary Artery Bypass Graft (CABG).


Physician's Note dated 1/20/17 at 8:00 PM documented that the physician saw the patient earlier at 5:00 PM and updated him on the plan for Coronary Artery Bypass Graft (CABG) with family in the room. The physician noted that the patient was in good spirits, comfortable, and oriented. The patient eloped from the unit and was found outside the hospital building in cardiopulmonary arrest. The patient was coded with return of spontaneous circulation. Subsequently, the patient was admitted to the Cardiac Care Unit for comprehensive management.


On 4/6/17 at 3:30 PM, Staff C, Telemetry Technician (for 8 NORTH) was interviewed. Staff C stated recollection of Patient #1. Staff C explained that she observed the patient's leads were off on the telemetry monitor. Staff C stated that she paged and communicated to the secretary that the patient was off leads. Staff C stated that the secretary responded right away indicating that the patient was off the floor.
Staff C indicated that Staff D, RN called back and reported that Patient #1 was not in the room and patient was off the floor.


On 4/7/17 at 12:53 PM, Staff D, RN who responded to the telemetry alert, was interviewed. Staff D stated that he was not assigned to the patient. Staff D stated that he answered the phone call from the telemetry staff who reported that the patient was off leads. Staff D explained that he went to the room and found that the patient was not in the room. Staff D stated that he reported to the telemetry technician that the patient was not in the room.
Staff D stated that he was called to attend immediately to another patient and could not remember how long he was with the other patient. Staff D stated that he did not have recollection as to what happened to the patient's telemetry box.


Review of the video recording dated 1/20/17 showed the following:

At 6:53 PM, the camera at Tenbroeck Entrance showed hospital Security Officer walking away from post toward the inside hallway of the hospital.

At 7:05 PM, the camera at Bank #1 Elevator Second Floor showed Patient #1 standing in front of the elevator and in few seconds, he was off camera.

At 7:07 PM, a camera at the Second Floor hallway toward Tenbroeck Hallway showed Patient #1 ambulatory, wearing patient hospital gown and black shorts, with black shoes and white socks on, and an ID band.

At 7:07:33 PM, a video showed Patient #1 walked past the sliding door of Tenbroeck Entrance/Exit to the street exit/driveway.

At 7:10 PM, the camera at Tenbroeck Entrance/Exit showed a female staff in a black jacket running in, and after few seconds, running back out. The video showed other staff running out from hallway going toward the street exit.


There was a three minute time lapse noted from the time the patient exited the facility until the time staff were observed running in that entrance/exit for assistance.


From approximately 7:10 PM through 7:14 PM, camera showed staff running in and out of the Tenbroeck Exit.


At 7:26 PM, patient was brought back in by clinical team, via stretcher, and ambu-bagging was in progress.



Review of the facility's policy and procedure titled "Elopement of Patients" last reviewed/revised May 2014 documented the following: "Patients who leaves a patient care area unexpectedly or without informing staff is considered an elopement ... (a) Once the patient is identified as not being in his/her room, an immediate search of the unit is done and the nurse in charge is informed as well as the responsible clinical provider; (b) If the patient is not found on the unit, security is immediately notified."


There was no indication that the staff validated the patient's whereabouts, when the patient was found missing from his room. There was no evidence that an immediate search of the unit was conducted, and that security was immediately notified in accordance with the facility's policy.


The policy and procedure did not indicate what actions should be taken by staff when any patient is observed wandering unescorted from a hospital patient care area to the outside exit.


On 4/7/17 at 2:00 PM, Staff G, the Security Manager and Staff H, the Assistant Director Security, were interviewed. Staff H stated that the Security Officer assigned to the Tenbroeck Exit was called for an emergency few minutes before the event. Staff H explained that the post is assigned to a Security Officer 24/7 who could respond to emergencies when needed.


The policy for "Elopement of Patients" did not indicate coverage for the Security Post 24/7 when an officer is called away for an emergency.

Based on observation, interview, and review of documents, in one (1) of 16 medical records reviewed, it was determined the facility failed to ensure that infection control practices were implemented to prevent the transmission of infections and communicable diseases as follows:

(a) Failure to ensure that a Hepatitis B surface Antigen positive (HBsAg-positive) patient on hemodialysis treatment at the bedside was separated from other susceptible patients.

(b) Failure to ensure that effluent (water waste obtained during hemodialysis treatment) from a HBsAg-positive patient was not drained into a handwashing center sink to avoid sources and transmission of infections and communicable diseases.

(c) Failure to develop, and implement Infection Control policies and procedures in accordance with nationally recognized infection control practices and guidelines, as well as, applicable regulations and other Federal and State agencies.

The facility did not adhere to CDC guidelines for dialysis of HBsAg positive chronic hemodialysis patients. Specific reference is made to : CDC MMWR (Morbidity and Mortality Weekly Report) April 27, 2001/ 50 (RR05); 1-43
"...While hospitalized, HBsAg-positive chronic hemodialysis patients should undergo dialysis in a separate room and use separate machines, equipment, instruments, supplies, and medications designated only for HBsAg-positive patients (see Prevention and Management of HBV Infection). While HBsAg-positive patients are receiving dialysis, staff members who are caring for them should not care for susceptible patients."


These breaches in infection control practices placed other patients and staff at risk for hospital acquired infections and communicable diseases.


Findings include:


During an initial unit inspection of 7 South on 4/5/17 at 11:45 AM, a Fresenius 20082K Hemodialysis (HD) machine was observed placed in room 710B adjacent to Patient #2. The HD machine was labeled Hepatitis B + (positive). The HD machine was placed in a position that obstructed the entrance to the only shared bathroom for patient care.
Two (2) salad bowls, containing the nurse's lunch, were observed atop the HD machine.
Patient #3 was observed in bed across from Patient #2.


The facility did not provide hemodialysis in an area that will safely allow patient care, and
needs of other patients to be met.

The facility did not ensure that hemodialysis treatment for HBsAg-positive patient was provided in a separate area as required by CDC Guidelines.


On 4/5/17 at 12:00 PM, Staff J, Hemodialysis nurse was interviewed. Staff J stated that she temporarily placed her salads atop the dialysis machine since there was no available refrigerator in the employees' lunchroom.


On 4/5/17 at 12:30 PM, Staff K, Nurse Manager of 7 SOUTH was interviewed.
Staff K was asked how the patient in bed A (Patient #3) would be accommodated for personal hygiene needs. Staff K explained that the patient in bed A could go to another room for morning care, and if needed the nurses' aide would assist the patient to another room for toileting purposes.
Staff K stated that as far as she knew, there was no reason to separate the patient in bed A from the patient in bed B. Staff K stated, "Standard Universal Precautions are used for all patients on the unit."


On 4/6/17 at 12 PM, Staff L, Director of Infection Prevention (Infection Control Officer) and Staff M, Registered Nurse (RN) Infection Control Nurse were interviewed. Staff L stated, "The Hospital uses Standard Precautions on all patients. We do not isolate for Hepatitis B antigen positive patients because we use universal precautions and barrier precautions. It is acceptable for both antigen negative and antigen positive patients to share the same room. We have no reports of any seroconversion for any patient."


Staff N, Nurse Manager for the Dialysis Unit was interviewed on 4/6/17 at 12:30 PM.
Staff N explained that there is one dedicated Hepatitis B machine for Hepatitis B positive patients. Staff N stated that these Hepatitis B positive patients are dialyzed at bedside, in the Hospital, because the acute unit does not have an antigen positive station."


A follow-up observation of Patient #2 was conducted on 4/7/17 at 3:00 PM. The patient was observed with a hemodialysis treatment at bedside. The HD machine was on, and fluid was observed draining from the two (2) plastic tubes into the handwashing sink. The tubes were tied to the base of the faucet with a blue plastic material. The HD machine was observed blocking entrance to the shared bathroom.
During the observation, the hemodialysis nurse was observed washing her hands twice in the same handwashing sink where the HD effluent was draining.
Another new patient was observed in 710A, Patient #4.


Staff O, Hospital Epidemiologist was interviewed on 4/7/17 at 1:11 PM. Staff O stated that the facility had no policy for isolating HB positive patients on hemodialysis treatment. Staff O stated that Hepatitis B patients share rooms with other patients, and that universal precautions are followed. Staff O indicated that the facility had a hemodialysis machine that is designated for Hepatitis B positive patients.


Review of the medical record (MR) for Patient #2, documented this 70 year old male patient was admitted on 4/3/17 with diagnoses including End Stage Renal Disease (ESRD), and Hepatitis B positive. This patient was placed on hemodialysis treatment.
Review of the Hepatitis B Surface Antigen laboratory reports dated 4/5/17 documented Hepatitis B Surface Antigen Reactive (Reference Range: Non-reactive).


Review of MR for Patient #3, documented a 60 year old male was admitted on 3/17/17 for hematemesis and rectal bleeding. His past medical history included cirrhosis of the liver, and portal hypertension.
MR review for Patient #3 did not document Hepatitis B status. Hepatitis B status was unknown.


Similar concern was identified for Patient #4. Review of MR for Patient #4 documented no immunity status for Hepatitis B. Hepatitis B status was unknown.


Review of the facility's policy and procedure on "Isolation and Handling of Patient with Hepatitis B and Hepatitis B Seroconversion," Reviewed: 2/14 documented, "Hepatitis B surface antigen (HBsAg) positive patients will be dialyzed at the bedside and assigned to the designated hemodialysis machine."


This written protocol did not comply with the Centers for Disease Control (CDC) Guidelines
for placement of HBsAg-positive patients on hemodialysis while hospitalized.


REFERENCE: CDC MMWR (Morbidity and Mortality Weekly Report) April 27, 2001/ 50 (RR05); 1-43
"...While hospitalized, HBsAg-positive chronic hemodialysis patients should undergo dialysis in a separate room and use separate machines, equipment, instruments, supplies, and medications designated only for HBsAg-positive patients (see Prevention and Management of HBV Infection). While HBsAg-positive patients are receiving dialysis, staff members who are caring for them should not care for susceptible patients."


The facility's written protocol lacked reference to a nationally recognized infection control practices and guidelines, as well as applicable regulations, and other Federal and State
agencies.

Based on observation, interview, and review of document, in one (1) of 16 medical records reviewed, it was determined the facility failed to:

(a) develop and implement policies to ensure separation of Hepatitis B surface Antigen (HBsAg) positive patients receiving hemodialysis while hospitalized;


(b) develop and implement policies to ensure that effluent (water waste obtained during hemodialysis treatment) from a HBsAg-positive patient was not drained into a handwashing center sink to avoid transmission of bloodborne infections.


(c) provide a sanitary environment to avoid sources and transmissions of infectious and communicable diseases in the Operating Room (OR) hallways, and Post Anesthesia Care Unit (PACU).


Findings include:


Review of the facility's policy and procedure on "Isolation and Handling of Patient with Hepatitis B and Hepatitis B Seroconversion," Reviewed: 2/14 documented, "Hepatitis B surface antigen (HBsAg) positive patients will be dialyzed at the bedside and assigned to the designated hemodialysis machine."

The protocol did not comply with the CDC Guidelines for the placement of HBsAg-positive patients on hemodialysis while hospitalized.

The facility's written protocol lacked reference to a nationally recognized infection control practices and guidelines, as well as applicable regulations, and other Federal and State
agencies.



During the OR unit inspection on 4/10/17 at approximately 12:00 Noon, with the OR and PACU staff, the following observations were made:

The areas under the OR handwashing centers outside OR #s 2 and 3; OR #s 3 and 4; and OR #s 5 and 6 were dusty, stained, and with multiple plastic caps and debris.

A portable microscope was observed with drape hanging and touching the floor. This microscope was adjacent a janitor's cart with cleaning equipment including mops, wipes, buckets, and sweepers;

Two (2) Porters' Closet in the OR hallway were inspected. These closets contained both clean supplies and dirty cleaning equipment, and had open dusty drain holes on the floor.

A green bin labeled hazardous (for endo-mechanical devices) was observed in the OR hallway across OR #3.



During the unit inspection of PACU on 4/10/17 at 2:00 PM, with the OR and PACU staff, the following observations were made:

The Dirty/Soiled Utility Room was cluttered and crowded with hampers, buckets, brooms, mops, a large biohazard red container, and a large red bag filled with trash. These items were blocking access to the only sink in the room.

The Handwashing Center across the Nursing Station was observed with two (2) filled bins. One bin was filled with used pulse oximeters. The second bin was filled with used batteries. This Handwashing Center was contiguous to a Pyxis machine for controlled medications and had no barrier/splash guard to prevent cross contamination during handwashing.

A cart in an unoccupied patient cubicle Room 2-D had clean linens, gowns, and towels that were uncovered.

A blue covered cart with clean linens, gowns, and towels was found in an unoccupied Isolation Room N-307.


These environmental findings in the OR and PACU were acknowledged by the OR and PACU Staff.