HospitalInspections.org

Based on medical record review and interview, the facility failed to the ensure the nursing staff re-assessed the vital signs for one patient (#16) of twenty-one records reviewed.

The findings included:

Patient #16 was admitted to the facility on May 3, 2012, with diagnoses to include a two day duration of Nausea, Vomiting and liquid red-brown Diarrhea.

Medical record review of the Physician order, dated May 4, 2012, at 9:00 a.m., revealed the patient had been prescribed Lisinopril (anti-hypertensive) 10 mg (milligrams) daily.

Review of the vital sign record dated May 5, 2012, at 2:00 a.m., revealed the patient had a blood pressure of 83/39 (normal range 120/80). Continued review revealed the next vital sign was recorded on May 5, 2012 at 6:00 a.m., four hours later.

Interview at the third floor nursing station with the Director of Accreditation and Chief Nursing Officer on May 8, 2012, at 10:40 a.m., confirmed nursing would be expected to re-assess the blood pressure prior to four hours after the low blood pressure was recorded on May 5, 2012, at 2:00 a.m.

Based on medical record review, observation, and interview, the facility failed to ensure the care plan reflected the needs of one patient (#13) of twenty-one records reviewed.

The findings included:

Patient #13 was admitted to the facility on May 5, 2012, with diagnoses to include Cerebral Vascular Accident with Right Side Hemi-paresis, Dementia, and Non-verbal.

Observation of patient #13 on May 7, 2012, at 4:45 p.m., revealed the patient in bed with an indwelling urinary catheter and unable to answer any questions.

Medical record review of the Care Plan, dated May 7, 2012, revealed no documentation of the patient's needs related to the indwelling urinary catheter, Dementia, or speech deficit.

Interview with the Chief Nursing Officer and the Accreditation Director on May 7, 2012, at 4:45 p.m., confirmed the Care Plan did not address the indwelling urinary catheter, Dementia, or the patient's inability to communicate.

Based on medical record review, facility policy review, and interview, the facility failed to ensure vital sign were documented prior to the administration of blood for two patients (#12 and #14) of three blood transfusion records reviewed.

The findings included:

Patient #12 was admitted to the facility on April 30, 2012, with diagnoses to include Ascities, Chronic Alcohol Abuse, and Increased Liver Enzymes.

Medical record review of the physician's order, dated May 1, 2012, at 11:00 a.m., revealed the patient was to receive a unit of packed red blood cells.

Medical record review of the blood transfusion record revealed the patient's blood transfusion was started on May 1, 2012, at 3:20 p.m.

Medical record review of the vital signs graphic record revealed the patient's vital signs were obtained on May 1, 2012, at 2:00 p.m. and 3:20 p.m.

Patient #14 was admitted to the facility on April 30, 2012, with diagnoses to include Acute Gastrointestinal Bleed.

Medical record review of the physician's order, dated May 1, 2012, at 1:03 p.m., revealed the patient was to receive two units of packed red blood cells.

Medical record review of the blood transfusion record revealed the patient's blood transfusion was started on May 1, 2012, at 7:55 p.m.

Medical record review of the vital signs graphic record revealed the patient's vital signs were obtained on May 1, 2012, at 7:00 p.m. and 7:55 p.m.

Review of the facility policy "Blood and Blood Product Transfusion", no number, dated February 3, 2012, revealed "...Obtain baseline vital signs prior to the administration of blood (temperature, blood pressure, pulse, respirations)..."

Interview with the Chief Nursing Officer and the Accreditation Director on May 7, 2012, at 3:15 p.m., at the Intensive Care Unit nursing station and at the 300 hall nursing station on May 7, 2012, at 4:20 p.m., confirmed the pre-administration vital signs for blood would be expected to be done at least 15 minutes prior to the administration of blood; confirmed the facility policy was not followed for pre administration vital signs; and confirmed the pre-transfusion vital signs were not recorded for patient #12 and patient #14.

Based on medical record review, facility policy review, and interview, the facility failed to ensure a physician's order for medication was clarified prior to administration for one patient (#12) of twenty-one patient records reviewed.

The findings included:

Patient #12 was admitted to the facility on April 30, 2012, with diagnoses to include Ascities, Chronic Alcohol Abuse, and Increased Live Enzymes.

Medical record review of the physician's order, dated May 1, 2012, at 11:00 a.m., revealed the patient was to receive Lasix (diuretic) 40 mg (milligrams) IVP (intravenous push) between units of blood. Continued review revealed the order for the blood transfusion was for the patient to receive one unit of blood.

Medical record review revealed the patient received Lasix 40 mg IVP on May 1, 2012, at 6:23 p.m., after the blood transfusion.

Review of the facility policy "Ordering and Transcribing", no number, dated December 23, 2011, revealed "...Medication orders are clear and accurate..."

Interview with the Chief Nursing Officer and the Accreditation Director on May 7, 2012, at 3:15 p.m., at the Intensive Care Unit nursing station confirmed the order would require clarification as order for medications was to be "between units (of blood)"; the order for the blood was for one unit; the order was not clear; and the facility policy was not followed.

Based on medical record review, medical staff bylaws review, and interview, the facility failed to ensure a discharge summary was completed for one (#4) of twenty-one records reviewed.

The findings included:

Medical record review revealed patient #4 was admitted to the facility on March 13, 2012, to undergo a Right Thyroidectomy. Continued medical record review revealed the patient was discharged on March 14, 2012.

Further review of the medical record revealed no discharge summary or no addendum to the History and Physical Examination related to the patient's condition at time of discharge, final diagnosis, and medications.

Review of Medical Staff Bylaws for 2012 revealed "...The Discharge Summary shall be completed within 15 days on all medical records. This may be combined with the History and Physical if hospitalized less than 48 hours. The content of the medical record shall be sufficient to justify the diagnosis and warrant the treatment and end results...".

During interview with a nurse from Clinical Informatics on May 7, 2012, at 4:00 p.m., in the conference room, revealed there was no discharge summary in the record, and a discharge note was not combined with the History and Physical.

Based on observation and interview, the facility failed to ensure a sanitary environment was maintained in the Intensive Care Unit (ICU); Medical Surgical (Med-Surg) area; Nursery area; Obstetrical/Gynecology (OB/GYN) area; Emergency Department (ED); and the Operating Room (OR) area of the facility.

The findings included:

Observation of the ICU clean utility area on May 7, 2012, at 2:30 p.m., revealed a peg board hanging above a cart containing coffee supplies and condiments available for staff use. Continued observation revealed the peg board had numerous 50 ml (milliliter) bags of intravenous fluids containing antibiotics intended for patient use. Continued observation revealed the items on the cart were less than six inches from the intravenous fluids with antibiotics. Continued observation revealed two dozen chlora-prep wipes, utilized for cleansing a patient's skin, were dated as expired March 2012.

Interview in the clean utility room with the Chief Nursing Officer and Director of Accreditation on May 7, 2012, at 2:30 p.m., confirmed the intravenous fluids with antibiotics were intended for patient use and were in direct proximity to the coffee and condiments. Continued interview confirmed the intravenous fluids with antibiotics were not to be located in direct proximity to the coffee and condiments. Continued interview confirmed the chlora-prep wipes had expired and were available for patient use.

Observation of the Med/Surg unit on May 7, 2012, between 3:30 p.m. and 4:10 p.m., revealed the clean utility room had a hand held hair dryer with a dusty filter located on a shelf in a cabinet with patient shower caps, patient gowns, and a 24 hour urine specimen container. Continued observation revealed room 310 had a sign on the door indicating the patient in the room was on contact precautions. Continued observation revealed soiled linens were on the floor of the bathroom of room 310.

Interview on the Med/Surg unit on May 7, 2012, between 3:30 p.m. and 4:10 p.m., with the Chief Nursing Officer and Director of Accreditation, confirmed the hand held hair dryer was not clean and was located on a shelf with patient use items which were clean. Continued interview confirmed soiled linens were not to be placed on the floor.

Observation of the Nursery area on May 8, 2012, between 8:30 a.m. and 9:00 a.m., revealed a laundry basket filled with hand knitted baby caps. Continued observation revealed a spray bottle of environmental sanitizer located on a counter next to infant disposable diapers and wipes. Continued observation revealed a cabinet containing linens, re-usable bed pads, pamphlets, manuals, decorations, and an iron.

Interview in the Nursery area on May 8, 2012, at 8:45 a.m., with Registered Nurse #1, revealed the hand knitted baby caps had been made by volunteers and delivered to the hospital. Continued interview confirmed the caps had not been washed by the facility and their cleanliness could not be determined.

Interview in the Nursery area on May 8, 2012, between 8:30 a.m. and 9:00 a.m., with the Director of Accreditation confirmed the cleanliness of the caps could not be determined; the environmental sanitizer was not to be located with patient use items; and patient use items were not to be stored with unclean items.

Observation of the OB/GYN area on May 8, 2012, between 9:10 a.m. and 9:30 a.m., revealed located in the storage room cabinets were stuffed toys, oxygen equipment, suction equipment, towels, sterile vaginal speculums, sterile gloves, sterile urinary catheters, a used printer, and loose office supplies. Observation of the clean utility room revealed a disposable cup with lipstick on the lip of the cup, a personal tote bag, geriatric sleeve protectors, and loose office supplies located in the cabinets.

Interview in the OB/GYN area on May 8, 2012, between 9:10 a.m. and 9:30 a.m., with the Director of Accreditation confirmed the storage room was not to contain unclean items stored with patient use items; and the clean utility room was not to contain staff's personal items or drinks; and clean patient supplies were not to be stored with unclean items.

Observation of the ED on May 8, 2012, between 12:45 p.m. and 1:35 p.m., revealed a cabinet located at the nursing station contained sutures, patient use supplies, office supplies, manuals, and a spray can of oven cleaner. Continued observation revealed a box of umbilical tape dated as expired July 2011. Continued observation revealed a cabinet in ED room #9 had four 1000 ml (milliliter) sealed, sterile glass bottles utilized for the evacuation of abdominal fluids dated as expired March 2011.

Interview in the ED with the ED Manager and the Director of Accreditation, on May 8, 2012, between 12:45 p.m. and 1:35 p.m., confirmed the patient use items were not to be stored in the cabinet with unclean items or chemicals; and the evacuation bottles had expired and were available for patient use.

Observation of the OR Biological Hazard Waste room outside of the OR corridor revealed the room and outside of the room did not have a sink for the washing of the hands or hand sanitizer available. Continued observation revealed the access to the closest sink or hand sanitizer would require the staff to enter the OR's semi-sterile core to clean the hands after the handling of bio-hazardous waste.

Interview with the Manager of the OR and the Accreditation Director on May 9, 2012, at 10:25 a.m., in the OR corridor, confirmed there were no facilities or materials to wash or sanitize the hands after handling bio-hazardous waste.