HospitalInspections.org

Based on Hospital documents and interview, it was determined that the Hospital failed to submit a request for a approval of a modification of a health care institution when planning to make a change in the building where a health care institution is located when moving the Materials Management office and storage to another building on the campus which is an unlicensed space. This deficient practice poses a risk to supply integrity and sterility when having to transport items from a non-contiguous building to the hospital.

Hospital document titled "Facility Campus Plan" revealed 2 small sheds located on the facility campus established in 12/2022 that house the Materials Management Department.

Observation conducted on 08/22/2023 revealed 2 temperature-controlled sheds located on the facility campus that house the Materials Management Office and the facility's main source of supplies.

Employee #16 confirmed during an interview conducted on 08/24/2023 that the Materials Management Department was moved to the 2 sheds located on the facility campus in 12/2022. Employee #16 confirmed that there was no in-hospital materials storage area.

Based on facility records and interviews it was determined that the hospital failed to ensure that policies and procedures were followed when labeling and replacing fluids in the warming cabinet. This deficient practice poses a risk of the fluids losing their stability.

Policy titled "Unit Inspections" Reviewed 07/2022, revealed: " ...2.0 PROCEDURE. 2.5. IV Fluids kept in the Emergency Department warmer will be replaced every 28 days and labeled with Beyond Use Dates ...."

Hospital document titled "Bradford Teaching Hospitals NHS Foundation. Guidelines for the Warming of IV Fluids and Irrigation Fluids" revealed: " ...5. Storage of IV fluids in a Warming Cabinet. Irrigation fluids should be marked with a permanent marker to identify the date (and time for Baxter Plastic Pour Bottles) they were put into the cabinet, and when they need to be removed ...."

Observation conducted on 08/22/2023, of the Emergency Room Warming Cabinet revealed the stock of 1000 ml bags of IV Fluids were dated 09/29.

Employee # 14 confirmed during an interview conducted on 08/22/2023 that the IV fluids in the warming cabinet were dated with a removal date of 09/29. The facility policy states IV fluids are to be removed from the warmer after 28 days.

Based on record reviews and staff interviews, it was determined the hospital failed to obtain consent for treatment from the patient or patient's representative before or at the time of admission. This deficient practice poses the risk of the patient receiving treatment without giving consent.

Findings include:

Policy titled, "Consent - Informed and Implied", revealed: " ...A written informed consent form will be completed and entered into the medical record when the patient seeks care from the hospital system (general consent for care) ...."

Document titled, "Conditions of Treatment", revealed: " ...1. Medical and Surgical Consent: The undersigned consents to customary nursing, x-ray examinations, technical services, therapy services, laboratory services ...The undersigned also consents to observation and/or demonstration of the patient during administration of medical treatment, or diagnostic procedures for the purpose of education of physicians, medical students, student nurses and any other proper student or technician ...."

Review of hospital medical records revealed 1 of 21 patient charts (Patient #63) treatment was provided without consent.

Employee #6 confirmed during an interview conducted on 08/22/2023 that Patient #63 was treated without consent. S/he further confirmed vital signs were taken on 05/22/2023 at 18:58 and the physician assessment was performed at 19:17.

Employee #17 confirmed during an interview conducted on 08/22/2023 that consent for treatment is not obtained until after the nursing staff and physician have seen the patients in the ED.