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Based on clinical record reviews, interview and medical staff regulations for three of five (Patients #84, 85, 87 ) post anesthesia physician orders reviewed, the facility failed to ensure the orders were comprehensive. The findings include the following:

a. Patient #84 was admitted to the GI lab on 3/11/13 for a colonoscopy. Review of the preprinted post-operative anesthesia orders directed Compazine IV or IM and Morphine every 5 minutes with a maximum dose of 10 mg, however the physicians orders failed to identify a dosage for either medication. The clinical record indicated that the orders were signed off and staff failed to call for clarification.

b. Patient #85 was admitted on 3/11/13 for a colonoscopy. Review of the preprinted post-operative anesthesia orders directed Phenergan IV or IM and Morphine every 5 minutes with a maximum dose of 10 mg, however the physicians orders failed to identify a dosage for either medication. The clinical record indicated that the orders were signed off and staff failed to call for clarification.

c. Patient #87 was admitted on 3/11/13 for chronic otitis media. Review of the preprinted post-operative anesthesia orders directed Zofran IV times 1, Reglan IV times 1 and Tylenol by mouth times 1, however the physicians orders failed to identify a dosage for the medications. The clinical record indicated that the orders were signed off and staff failed to call for clarification.

Review of the Medical Staff Regulations identified that the physician is responsible for orders.

Based on clinical record reviews and policy for one of two patients (Patient #70) receiving conscious sedation, the facility failed to ensure that the patients RASS score was monitored and/or for one of one patients (Patient #83) requiring CIWA the facility failed to ensure the patient was monitored per policy and/or for one of one patient's (Patient #83) with pain the facility failed to ensure the patients pain was addressed and/or reassessed following administration of pain medication. The findings include the following:

a. Review of Patient #70's clinical record identified that the patient was admitted on 3/4/13 for removal of a right thumb mass under moderate sedation. The record indicated that the patient received a total of 100 mg of Fentanyl, and 7 mg of Versed. Review of the clinical record failed to identify that the patient's level of consciousness was assessed during the procedure. Review of the Moderate Sedation policy indicated that during the procedure the patient's level of consciousness should be monitored at least every ten minutes utilizing the Ramsey sedation scale (RASS).

b. Patient #83 was admitted on 3/9/13 after being found on the ground. The patient was identified as having alcohol intoxication with the CIWA protocol initiated. The CIWA assessments completed at 5:00 AM and 9:07 AM were incomplete and failed to identify the patient's total score. The CIWA completed at 4:00 PM identified that the patient was assessed as a "4".

Review of the policy indicated that the frequency of CIWA assessments will be based on the patients score. For patients with a score less then 5 the CIWA assessments should be completed every four hours and discontinued if a patient remains less than 5 for twenty four hours.

c. Patient #83 was admitted on 3/9/13 after being found on the ground and was diagnosed with a fractured orbital bone. A physician's order dated 3/9/13 directed Dilaudid 1 milligram (mg) as needed for pain. Review of the flow sheet dated 3/9/13 at 4:37 PM identfied the patient rated pain as a 7 on a scale of 1-10 (10 being the worst possible pain). The record failed to reflect an intervention to address the patient's pain. A pain assessment on 3/9/13 at 7:29 PM identified that the patient rated pain as a 6 with Dilaudid 1 mg administered. The flow sheet dated 3/10/13 at 8:00 AM identfied the patient rated pain as an 8 with Dilaudid 1 mg administered. The record failed to reflect that the patient was reassessed to determine the efficacy of the pain medication. The flow sheet dated 3/10/13 at 6:00 PM identfied that the patient rated pain as a 6 with Dilaudid 1 mg administered. The record failed to reflect that the patient was reassessed to determine the efficacy of the pain medication.

Review of the policy indicated that all patients have a right to be assessed for pain, appropriate interventions and pain management, and reassessments done based on interventions.

Based on observation, review of facility safety guidelines for side rail use, and interviews related to 10 of 18 beds on the in-patient psychiatric unit, the facility failed to ensure safe side rail usage. The findings include:

Tour of the 18 bed in-patient psychiatric unit and interview with Unit Manager #7 on 03/11/13 from 9:45 AM through 10:45 AM identified that 10 of the 18 patient beds were equipped with four, one quarter (1/4) side rails. Each quarter side rail was constructed with 3 apertures (open space within the perimeter of the rail) that measured 9 inches (in) by 7.5 in, 7.5 in by 7.5 in, and 9 in by 7.5 in, respectively.

On 03/11/13 at 1:15 PM, Unit Manager #7 identified that side rails were used as a nursing measure, based upon a standard of nursing care, for patients who were determined to be at risk to fall and/or had a seizure disorder. Side rail usage did not require a physician's order and/or addition to the patient's plan of care. Fall risk factors included use of Benzodiazepine, antipsychotic, and antidepressant medications, as well as diagnoses that included anxiety, post traumatic stress disorder (PTSD), impaired judgment, and/or hallucinations.

Additionally, the facility lacked a policy and/or procedure regarding side rail usage that would include, in part, invidualized patient assessments for safe siderail use.

Interview with the Facilities Operations Manager and facility maintenance personnel on 03/14/13 at 10:30 AM identified that, based upon a report from an Evidence-Based Practice Center which identified side rail entrapment risks published in 2008, the facility determined that the side rails used on the in-patient psychiatric unit were unsafe and they were removed from the beds at that time (2008). In December of 2011, Unit Manager #7 requested that the side rails be placed back on the beds due to an increase in patient falls. The maintenance personnel identified that, following discussion with Manager #7 and the Director of Safety/Risk Management, he/she was directed to place the original side rails on 10 of the 18 beds.

The Evidenced-Based Practice Center (ECRI Institute) identified that, based upon the Hospital Bed Safety Workgroup (HBSW) whose goal is to reduce the risk of entrapment in hospital beds; side rail gaps should not be greater than 4.75 inches.

Subsequent to surveyor inquiry on 03/14/13 at 10:30 AM, the non-compliant side rails were removed.

Based on tour, observation and interview the facility failed to ensure that supplies were not expired and/or supplies were maintained at an acceptable temperature. The findings include the following:
a. Tour of the Pequot ED on 3/12/13 identified Hemacult cards located throughout the fast track area with expiration dates of 2011 and 2012.
b. Tour of the operating room on 3/11/13 identified a malignant hypothermia cart in the hallway with a small refrigerator that contained medications and fluids. The temperature reading within the refrigerator was 66 degrees Fahrenheit. Interview with the Manager on 3/11/13 at 11:00 AM indicated that the temperature was monitored by engineering and reported to the department if there was an issue. Interview with the QA coordinator on 3/14/13 at 1:00 PM identified that the refrigerator thermometer on the malignant hypothermia cart failed to be connected to the engineering department, therefore was not being monitored. Subsequently all medications and fluids were removed and discarded.

Based on clinical record review, interview and policy review for one of five surgical patients reviewed (Patient #85) the facility failed to ensure that a current consent was obtained prior to surgery. The finding includes the following:

a. Review of Patient #85's clinical record with the Manager on 3/11/13 indicated that the patient was admitted on 3/11/13 for a colonoscopy. Review of the consent for the procedure identified that the patient signed and dated the consent on 10/22/12. Review of the policy indicated that a written consent is good for sixty days.

Based on review of clinical records, review of hospital policies and interviews with hospital personnel for 2 of 3 ventilator-dependent patients (Patients #74 & #75), documentation and interviews failed to reflect physician orders for ventilator management as per hospital policy. The findings include:

1. Patient #74 was admitted to the Intensive Care Unit (ICU) on 3/9/13 with the diagnosis of subdural hematoma. Review of physician orders dated 3/9/13 directed the following ventilator settings: Mode: Volume Control plus; Tidal Volume: 450cc; Rate: 14; FiO2: 85%; PEEP: 5 cm. During a tour of the ICU on 3/11/13 at 10:55 AM and subsequent review of the computerized ventilator/airway flowsheet identified that the ventilator parameters were set as follows: Mode: Assist Control; Tidal Volume: 450ml; Rate: 18; FiO2: 55%; PEEP: 0.
2. Patient #75 was admitted to the ICU on 3/1/13 with the diagnosis of cerebral vascular accident. Review of physician orders dated 3/5/13 directedthe following ventilator settings: Mode: Volume Control plus; Tidal Volume: 450cc; Rate: 12; FiO2: 50%; PEEP: 0. During a tour of the ICU on 3/11/13 at 10:55 AM and subsequent review of the computerized ventilator/airway flowsheet identified that the ventilator parameters were set as follows: Mode: Assist Control; Tidal Volume: 450ml; Rate: 12; FiO2: 40%; PEEP: 3cm.
Review of documentation and interview with the Director of Respiratory Therapy on 3/11/13 at 11:35 AM failed to reflect physician orders that directed the changes made to the ventilator settings for Patients #74 and # 75.
Review of the hospital policies for Mechanical Ventilation and Ventilator Setting Changes identified that the Respiratory Therapist was authorized to change all life support settings based on orders from a physician with ventilator privileges.