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Based on record review, medical staff bylaws review, and interview, the provider failed to ensure one of two sampled intensive care patients (17) who had surgery had a readable and comprehensive history and physical (H&P) prior to starting surgery. Findings include:

1. Review of patient 17's medical record revealed:
*She had elective surgery on the morning of 9/23/13.
*She had a post-operative complication of a bronchospasm (spasm of the wind pipe) that had required her to be re-intubated (tube inserted down the wind pipe) to assist her breathing.
*She had a long history of asthma, gastric reflux, cerebral (brain) shunt, and psychological disorders according to the pre-operative anesthesia assessment documentation.
*The hand written pre-surgical H&P from an unknown physician consisted of eight points of un-readable abbreviations.

Interview, H&P review, and medical staff bylaws review on 9/25/13 at 9:45 a.m. with the vice president of nursing and the director of quality revealed:
*The physician who had written the above noted H&P was patient 17's general practitioner.
*They were not able to read the H&P.
*When asked if they believed that was a complete pre-surgical H&P they responded by directing this surveyor to the medical staff bylaws.
*The provider's December 2011 Medical Staff Bylaws stated:
-The H&P "Shall include all pertinent findings resulting from the assessment of all the systems of the body, and a statement of the conclusions or impressions drawn from the admission H&P examination."
-"Surgery is performed only after a history, physical examination, any indicated diagnostic tests, and the preoperative diagnosis have been completed and recorded."
-The provider followed Centers for Medicare and Medicaid regulations related to pre-operative H&Ps.

Interview on 9/26/13 at 8:45 a.m. with the director of emergency services who also served as the director of intensive care revealed she agreed the above noted H&P for patient 17 was not readable or comprehensive.

Based on record review, interview, and policy review, the provider failed to ensure one of one sampled patient (20) had received nursing interventions according to the provider's bowel protocol to prevent constipation. Findings include:

1. Review of patient 20's medical record revealed:
*He had been admitted on 8/31/13.
*He had a diagnosis of nocardiosis (a fungal infection) in his lungs.
*He was not eating well and had lost a significant amount of weight prior to his admission.
*He had received supplemental nutrition through a nasogastric tube (tube placed through the nose into the stomach).
*That supplemental nutrition had started on 9/5/13.
*The supplemental nutrition was held from 9/12/13 through 9/16/13 due to his stomach being distended, and he had increased gas and bloating.

Review of patient 20's bowel movement (BM) history revealed the first documented BM was on 9/5/13. He had subsequent BMs on 9/9/13 and 9/21/13.

Review of patient 20's nurse's notes revealed he had BMs on 9/12/13 and 9/19/13. He did not have a BM recorded for six days.

Review of patient 20's medication administration record revealed he had received:*Docusate sodium 100 milligram (mg) one capsule on 9/9/13 and one capsule on 9/10/13.
*He did not receive that medication again until 9/15/13 when a liquid form was started.
*He had received a bisacodyl suppository on 9/9/13 and 9/19/13.
*He had received Lactulose syrup 20 grams/30 milliliters (ml) on 9/19/13 and 9/20/13.
*He had received a soap suds enema on 9/9/13.
*He also had received narcotic pain medications of hydrocodone, hydromorphone, and fentanyl during his hospitalization. Those medications can cause constipation.

Review of patient 20's plan of care initiated on 8/31/13 revealed no problem, goals, or interventions for bowel management. There was an intervention for an enema on 9/9/13.

Review of the provider's 6/24/10 Bowel Protocol Standing Orders revealed:*Begin with one of the combined stool softener and mild peristaltic stimulants:
-Docusate sodium 100 mg twice daily or docusate calcium 240 mg twice daily.
*If no bowel movement in any forty-eight hour period add one to two of the following:
-Bisacodyl 10 to 15 mg at bedtime, Milk of Magnesia 30 to 60 ml at bedtime, or lactulose 10 grams/15 ml 30 to 45 ml at bedtime.
*If no bowel movement in seventy-two hours, perform a rectal exam to rule out impaction.
*If not impacted try one of the following:
-Bisacodyl suppository, magnesium citrate eight ounces, or a Fleets enema.

Interview on 9/25/13 at 9:00 a.m. with registered nurse manager C revealed:
*The bowel protocol had not been followed for patient 20.
*He agreed six days between BMs was not an acceptable practice.

A. Based on observation, interview, record review, and policy review, the provider failed to ensure one of four sampled intensive care patient (17) had physician's documented orders for the titration (adjustment) of a Fentanyl (narcotic) intravenous drip. Findings include:

1. Observation on 9/24/13 at 3:23 p.m. of patient 17 in her intensive care unit (ICU) room revealed she was on a Fentanyl (narcotic) intravenous drip for pain control and sedation. That drip was set to give her 70 micrograms per hour (mcg/hr) of the medication.

Interview and record review on 9/24/13 at 3:35 p.m. with registered nurse (RN) D and the director of emergency services who also served as ICU director regarding patient 17's Fentanyl drip revealed:
*The only recorded physician's order for Fentanyl was from 9/23/13 at 9:45 a.m. That order had called for the Fentanyl drip to have been set at 25 mcg/hr.
*The Fentanyl drip had been titrated multiple times during 9/23/13 and 9/24/13 to a total of 70 mcg/hr without any documented physician's order for those changes.
*RN D believed the patient's pulmonary (lung) physician had verbally ordered to change the Fentanyl, but those orders had not been entered by nursing staff or the pulmonary physician.

Interview and policy review on 9/25/13 at 8:35 a.m. with the director of emergency services revealed she agreed physician's orders for the titration of patient 17's Fentanyl drip had not been documented according to the provider's September 2012 Physician's Orders policy by the patient's pulmonary physician and nursing staff.



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B. Based on observation, interview, and policy review, the provider failed to ensure:
*Medication samples dispensed in one of one urology clinic were documented in accordance with acceptable standards of practice.
*A physician's order was obtained for one of six sampled surgical patients (34) medication review.
Findings include:

1. Review of the urology clinic's December 2012 through September 2013 medication Sample Log Intake sheets revealed the following information had been documented:
*Drug representative/company.
*Drug name.
*Drug dose.
*Quantity.
*Lot/Expiration date.
*Date/Initials of the staff member that had documented medication receipt from a drug representative/company.
*The date and initials of the staff member who had documented receipt of sample medications had not been done consistently.
*The medication expiration date at times had been documented in the column for date and initials of the staff member documenting medication receipt.
*Each medication received had not been documented on a separate log sheet. The medications had been documented in a continuous fashion on the intake sheets. It was difficult to determine an exact count for each medication that might have been available for dispensing.

Interview and review on 9/25/13 at 8:30 a.m. and at 11:40 a.m. of the urology clinic's Sample Log Intake sheets with RN E revealed:
*The Sample Log Intake sheets had been documented as described above.
*Information on which medication a patient had been dispensed would be located in the patient's medical record.
*You would have to review urology patients' medical records to determine which medication samples a patient had received.
*There was no central log for documenting which patients had been dispensed sample medications, the amount, and dosage.

Interview and review on 9/26/13 at 10:34 a.m. of the urology clinic's Sample Log Intake sheets with the director of pharmacy revealed:
*The urology clinic had not followed hospital policy for documenting sample medication dispensing.
*The Sample Log Intake sheets did not identify which patient had been provided medication samples, the dosage, or the amount dispensed.
*The urology clinic should have followed the hospital's Pharmaceutical Samples policy for documenting dispensing of sample medications.

Review of the provider's March 2010 Pharmaceutical Samples policy revealed the following information should have been documented in a log when medication samples had been dispensed:
*Date.
*Patient name.
*Medication name and strength.
*Quantity dispensed.
*Lot number and expiration date.

2. Interview and review on 9/26/13 at 9:00 a.m. with nurse manager C regarding patient 34's medication administration record revealed:
*Tramadol 50 milligrams (mg) had been administered on 9/24/13 at 8:03 a.m. and at 11:48 a.m. A review of the patient's electronic medical record did not reveal a physician's order for Tramadol.
*Ondansetron (anti-nausea medication) had been administered on 9/19/13 at 8:56 a.m. A review of the patient's electronic medical record did not reveal a physician's order for ondansetron.
*He was not sure if there would have been a standing order or a verbal order for the medications.
*He would continue to review the medical record for the missing orders.
*No additional information regarding the missing physician's orders had been provided to this surveyor at the time of the exit conference.

Review of the provider's September 2012 Physician's Orders policy revealed:
*"All orders for treatment shall be entered into the EMR (electronic medical record) electronically by the physician. Verbal communication of orders should be limited to urgent situations where immediate electronic communication is not feasible and may be entered in the EMR by any licensed provider (RN, PT, RT, ect)."
*Verbal orders must be signed by the ordering physician within 48 hours.
*"Verbal/telephone orders are entered in the EMR by the person receiving the order and is done so by specifying the ordering physician's name or the name of the physician's agent communicating the order, along with the source of how the order was obtained."

Based on record review, interview, and policy review, the provider failed to ensure blood products were always verified by two registered nurses prior to administration for four of four sampled patients (3, 7, 20, and 23). Findings include:

1. Review of patient 3's blood transfusion records revealed he:
*Had received two units of fresh frozen plasma and two units of packed red blood cells on 9/19/13.
*Had received two units of packed red blood cells on 9/20/13.
*There was no record two registered nurses had verified the blood products prior to administration.

2. Review of patient 7's blood transfusion record revealed she had received one unit of packed red blood cells on 9/12/13. There was no record two registered nurses had verified the blood product prior to administration.

3. Review of patient 20's blood transfusion record revealed he had received one unit of packed red blood cells on 9/2/13. There was no record two registered nurses had verified the blood product prior to administration.




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4. Review of patient 23's blood transfusion record revealed she had received two units of packed red blood cells on 5/21/13. There was no record two registered nurses had verified the blood product prior to administration.

Surveyor: 26632
5. Interview on 9/24/13 at 2:00 p.m. with the laboratory director revealed:
*Two RNs would have checked the blood product prior to administration.
*A blood product issue form was signed by the two RNs and then sent back to the laboratory.
*The laboratory only kept that form for a few days, and then it was discarded.
*She agreed there was no record two RNs had verified the blood product prior to administration.

Review of the provider's revised October 2011 Guideline for Completion of Patient Identification Slip revealed:
*Once the blood or blood product was received all criteria as indicated in the product administration procedure should have been verified with a second RN.
*Obtain that RN's signature on the second line of the identification slip.
*That slip must be returned to the laboratory within ten minutes of receiving the blood product.

A. Based on observation and interview, the provider failed to ensure nursing staff:
*Disinfected patient care equipment between patient care for two of two observed patients (4 and 6).
*Completed appropriate hand hygiene prior to administering intravenous (IV) medication for two of two sampled patients (4 and 6).
*Completed appropriate disinfection of an IV port prior to administering IV medication for two of two sampled patients (4 and 6).
Findings include:

1. Observation on 9/24/13 at 9:00 a.m. revealed registered nurse (RN) A entered patient 6's room with a stethoscope around her neck and carried a portable pulse oximeter on a clipboard with patient papers and a prefilled syringe of morphine sulfate (MS) (narcotic pain medication) 4 milligrams. Upon entering patient 6's room she:*Did not wash or sanitize her hands.
*Used the computer key board to review patient 6's electronic medication administration record (EMAR).
*Retrieved an alcohol wipe from her pocket,and cleansed the IV port with the alcohol wipe for less than three seconds.
*Administered the MS through the IV port.
*Disposed of the used syringe in the sharps container and without washing or sanitizing her hands she put on gloves and administered a subcutaneous injection of Enoxaparin (blood thinner) into patient 6's abdomen.
*Removed her gloves and did not wash or sanitize her hands.
*Documented those medications using the computer keyboard.
*Obtained patient 6's oxygen saturation level with the pulse oximeter.
*Listened to patient 6's lungs and abdomen with the stethoscope.
*Loosened the tape around the dressing to patient 6's right upper thigh.
*Retrieved an oral swab from the patient care supply closet in the room.
*Put on gloves.
*Filled a glass with water and swabbed patient 6's lips and mouth.
*Removed her gloves, used hand sanitizer, gathered the clipboard and pulse oximeter, and went into patient 4's room.

2. Observation on 9/24/13 at 9:17 a.m. revealed RN A entered patient 4's room with a stethoscope around her neck and carried a portable pulse oximeter on a clipboard with patient papers. She then:
*Placed the clipboard and pulse oximeter on the counter by the sink.
*Used hand sanitizer.
*Used the computer key board to review patient 4's EMAR.
*Retrieved the oral medication of Diovan and potassium chloride from the patient's medication medication drawer.
*Gave the medications to patient 4.
*Documented those medications in the EMAR using the computer keyboard.
*Obtained patient 4's oxygen saturation level with the pulse oximeter.
*Listened to patient 4's lungs and abdomen with the stethoscope.
*Retrieved a saline flush syringe from the patient's medication drawer.
*Wiped the IV port with an alcohol pad for less than two seconds.
*Left the room and retrieved a medication from the Pyxis medication machine.
*Used hand sanitizer when she returned to the room.
*Administered that medication to patient 6 and documented that medication using the computer keyboard in the EMAR.
*Retrieved a specimen container from patient 6's overbed table. That container had sputum inside.
*Tightened the cover and placed the specimen in a biohazard bag.
*Left the room with the stethoscope around her neck, the pulse oximeter on the clipboard, and carried the biohazard bag to the nurse's station.

3. Interview on 9/24/13 at 9:30 a.m. with RN A revealed she:
*Did not include sanitizing her stethoscope or the pulse oximeter between patients as part of her normal routine.
*Was not aware an IV port should have been cleansed for at least fifteen seconds before access.
*Was not aware she had not consistently washed or sanitized her hands during patient care.

Interview on 9/24/13 at 9:45 a.m. with RN nurse manager C revealed:
*He agreed patient use equipment should have been sanitized or disinfected between patients.
*He was aware an IV port should have been cleansed for at least fifteen seconds before access.




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B. Based on observation, interview, and policy review, the provider failed to ensure:
*Staff members wore appropriate personal protective equipment (PPE) and performed hand hygiene during two of two observed patients (53) and 55) invasive procedures in the post-anesthesia recovery unit (PACU).
*Staff members completed hand hygiene for one of one observed patient's (56) surgical procedure in the cardiac catheterization department.
*Staff members disinfected vial septums and IV ports prior to withdrawal and administration of medication for one of one observed patient's (56) surgical procedure in the cardiac catheterization department.
*The surgical mask was worn appropriately for two of two observations of cardiac catheterization technician (H).
*A paper towel dispenser had been mounted in one of one urology clinic laboratory.
Findings include:

1.a. Observation on 9/25/13 at 9:20 a.m. of patient 56's surgical procedure in the cardiac catherization department revealed:
*At 9:43 a.m. and at 9:49 a.m. RN I withdrew medications from vials into syringes and administered those medication to the patient. She had not disinfected the vial septum or the IV port with an alcohol wipe prior to withdrawal and administration of those medications.
*At the conclusion of the patient's surgical procedure:
-Physician J removed his contaminated PPE, removed his lead apron, and exited the operating room. He had not performed hand hygiene prior to or after exiting the operating room and went to the control desk computers.
-Cardiac catherization technician K removed her contaminated PPE, exited the operating room, removed her lead apron, and hung the apron on a rack. She had not performed hand hygiene prior to exiting the operating room or before hanging the lead apron on the rack.
-RN I while wearing gloves assisted the patient from the operating room table into her wheelchair, removed her gloves, exited the operating room, and went to the control desk. She had not performed hand hygiene after removal of her gloves. Upon reentering the operating room she sanitized her hands with hand gel.

Review of the provider's July 2013 Medication Administration policy revealed:
*Prior to withdrawing medications from an ampule or a multidose vial the stem of the ampule and the rubber top (septum) of the vial should have been cleansed with an alcohol wipe.
*Cleansing the rubber top of single-use vials had not been addressed.

Review of the provider's June 2012 Flushing Peripheral Intermittent Intravenous Catheters policy revealed staff members should have swabbed the injection port with alcohol prior to medication administration via IV ports.

b. Observation on 9/25/13 at 10:30 a.m. in the cardiac catheterization department revealed cardiac catherization technician H in the hallway talking on the phone. His mask was pulled down and resting on his chin.

Observation on 9/25/13 at 9/25/13 at 11:30 a.m. in the cafeteria revealed cardiac catherization technician H eating lunch. His mask was pulled down and resting under his chin.

Interview on 9/26/13 at 9:30 a.m. with infection coordinator N revealed cardiac catherization technician H should not have worn his mask on his chin. Once a mask had been used it became contaminated and should have been discarded. If a mask was needed at a later time a new mask should have been put on.

Review of the provider's April 2012 Standard Precautions policy revealed "Masks/Goggles/Shield Masks - except for instances of reuse of N95 masks, all masks are considered one-time use."

2. Observation on 9/25/13 at 12:58 p.m. in outpatient services revealed RN L washed her hands, turned the faucet off with her wet hands, and then dried her hands with a paper towel.

Interview at the time of the observation with infection control coordinator M confirmed RN L had recontaminated her hands when she turned the faucet off with her wet hands. To prevent her hands from contamination she should have used a paper towel to turn off the faucet.

Review of the provider's April 2012 Hand Hygiene policy revealed hand hygiene should have been performed:
*"Before direct patient contact.
*After contact with patient's intact skin.
*After removing gloves.
*After contact with objects (including equipment) located in the patient's environment."

3.a. Observation on 9/25/13 at 1:00 p.m. in the PACU of patient 55's bone marrow biopsy procedure revealed:
*Prior to the procedure RN O washed her hands and turned off the faucet with her wet hands.
*Certified nurse practitioner (CNP) P performed hand hygiene and had contaminated his hands when he had opened the bone marrow procedure tray. He had not performed hand hygiene with hand gel prior to putting on his sterile gloves. He had assisted the physician with the procedure by handing him items off the sterile procedure tray.
*Physician Q performed the procedure without wearing sterile PPE or eye protection.
*Physician Q at the conclusion of the procedure removed his contaminated gloves, washed his hands, and contaminated his hands by turning the faucet off with his wet hands. He then charted on the patient's medical record.

b. Observation on 9/25/13 at 1:30 p.m. in the PACU of patient's 53's intrathecal (spinal) chemotherapy infusion revealed:
*Physician Q had put on an unsterile disposable cover gown, sterile gloves, but had not worn eye protection to perform the procedure.
*CNP P put on an unsterile disposal cover gown and sterile gloves but had not worn eye protection.

c. Interview on 9/25/13 at 2:00 p.m. with infection control coordinators M and N revealed:
*Physician Q should have worn a sterile gown and eye protection when he had performed patient 55's bone marrow biopsy. There was a potential for splatter from the operative site and skin shedding onto the surgical site from the physician.
*CNP P at a minimum should have used hand gel prior to donning sterile gloves to assist physician Q with patient 55's bone marrow procedure.
*Physician Q should have worn a sterile gown and eye protection when he had performed patient 53's intrathecal chemotherapy infusion.

Review of the provider's April 2002 Bone Marrow Aspiration and Biopsy policy did not address PPE usage for the procedure.

Review of the provider's April 2012 Standard Precaution policy revealed:
*PPE "Must be utilized unless the employee temporarily and briefly declines to use it under rare and extraordinary circumstances where its use would prevent the delivery of healthcare or would pose an increased safety hazard to the worker OR to the patient/resident."
*The policy did not address the wearing of a sterile gown when performing sterile invasive procedures.

4. Observation and interview on 9/25/13 at 10:55 a.m. in the urology clinic with RN E revealed the paper towels were in a bundle on the handwashing sink. Interview at the time of the observation confirmed a paper towel dispenser had not been mounted to protect the paper towels from contamination.




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C. Based on observation, label review, interview, and policy review, the provider failed to ensure:
*The cleanliness of all patient floor housekeeping carts.
*The cleanability of all patient floor housekeeping cart mop wringer handles.
*Clean linen was kept covered in three randomly observed storage rooms (fourth floor, intensive care unit (ICU), and isolation room in the ICU).
*Positioning wedges in two of three (1 and 3) x-ray rooms were cleanable or covered with a cleanable surface.
*Alcohol based hand rubs (ABHR) were not kept beyond the expiration date in two of two randomly observed areas (cardiac catheter laboratory [lab] and the main lab).
Findings include:

1. Observation on 9/24/13 from 8:45 a.m. to 4:00 p.m. revealed:
*The housekeeping carts used on the patient care floors had a build-up of dirt, debris, and grime next to the mop buckets. Interview with the housekeeping manager at the time of the random observation confirmed those findings. He stated he did not have a scheduled cleaning for the housekeeping carts. He stated staff would wipe down the shelves and other surfaces where paper products and chemicals were stored. But apparently had not cleaned the lower level where the mop buckets were stored.
*The housekeeping cart mop bucket wringer handles used on the patient care floors had pieces of foam rubber wound with duct tape or clear tape. That foam rubber and tape had darkened from hand contact when the wringer had been used. Interview with the housekeeping manager at the time of the random observation confirmed those findings. He stated the housekeepers had placed that foam rubber on the handles to ease their grip when using the wringer on the mop bucket. He stated he had considered the foam handles an infection control issue but had not implemented an alternative for the staff.
*Three randomly observed storage rooms on the fourth floor, in the intensive care unit (ICU), and in the isolation room in the ICU revealed clean linen had been left uncovered. Appropriate covers were in place on the laundry carts, but the flap of the cover was tucked under the clean linen on the top shelf or flipped over the top exposing the clean linen. Interview with the housekeeping manager at the time of the random observation confirmed those findings. He stated staff were aware the clean linen must be kept covered when in storage.
*Review of the provider's October 2011 dated Guidelines for Infection Control in Linen and Laundry policy revealed:
-"4. Linens will be covered (or wrapped) for transport. This will be accomplished by cart covers or other methods to safeguard clean linens from contamination in patient care areas, during distribution of linens to departments.
-5. When personnel distribute linens to patient care rooms or areas, small linen distribution carts will be covered."
*Randomly observed positioning wedges in x-ray rooms one and three had torn and ripped vinyl covers. One wedge had no cleanable cover, and the foam rubber was completely exposed. Interview with the radiology manager at the time of the observation confirmed those findings. He stated he was not aware the postioning wedges needed to be recovered or repaired. He stated the staff used a pillow case to cover the foam rubber wedge, but he was unaware the wedge itself must be encased in a cleanable material.
*Two of four ABHR in the catheter lab were outdated with March 2012 and May 2013 expiration dates. Interview with the housekeeping manager at the time of the observation confirmed those findings. He stated his housekeeping staff were responsible for checking the expiration dates on the ABHR. Twelve of twelve ABHR (six in-use and six on reserve) in the main lab were outdated with January 2012 and May 2013 expiration dates. Interview with the lab manager at the time of the observations confirmed those findings. She stated the housekeeping staff were responsible to check the expiration dates of those ABHR.

Based on observation, interview, record review, and policy review the provider failed to ensure a physician's order was documented for one of one sampled intensive care unit (ICU) patient (17) who was on a ventilator (machine to assist with breathing). Findings include:

1. Observation on 9/24/13 at 3:20 p.m. of patient 17 in her ICU room revealed she was:
*Intubated with an endotracheal tube (tube in her windpipe to help her breath).
*On a ventilator.
*Heavily sedated with intravenous medications.

Interview and record review on 9/24/13 at 3:37 p.m. with registered nurse D regarding patient 17's ventilator revealed:
*No physician's orders were present for the noted settings of the ventilator.
*The ventilator settings had been changed several times since 9/23/13 when she had been intubated according to respiratory therapy documentation.
*The physician handling the patient's pulmonary care (lung care) would frequently go into the patient's room and adjust the ventilator. She was unsure if he would notify respiratory therapy or write an order when he did that.
*The initial ventilator order was blank.

Interview, record review, and policy review on 9/24/13 at 4:30 p.m. with the respiratory therapy supervisor and an unidentified respiratory therapist revealed:
*They agreed patient 17 should have had a physician's order for the settings of the ventilator.
*Respiratory therapy should have sought an order for the ventilator settings.
*They agreed when they noted the ventilator settings had been changed as noted above they should have contacted the physician and nurse to confirm those setting changes had been ordered.
*They agreed the provider's 1/14/13 Mechanical Ventilation policy had not been followed for attaining a physician's orders for mechanical ventilation.

A. Based on observation, interview, record review, and policy review, the provider failed to ensure one of four sampled intensive care patient (17) had physician's documented orders for the titration (adjustment) of a Fentanyl (narcotic) intravenous drip. Findings include:

1. Observation on 9/24/13 at 3:23 p.m. of patient 17 in her intensive care unit (ICU) room revealed she was on a Fentanyl (narcotic) intravenous drip for pain control and sedation. That drip was set to give her 70 micrograms per hour (mcg/hr) of the medication.

Interview and record review on 9/24/13 at 3:35 p.m. with registered nurse (RN) D and the director of emergency services who also served as ICU director regarding patient 17's Fentanyl drip revealed:
*The only recorded physician's order for Fentanyl was from 9/23/13 at 9:45 a.m. That order had called for the Fentanyl drip to have been set at 25 mcg/hr.
*The Fentanyl drip had been titrated multiple times during 9/23/13 and 9/24/13 to a total of 70 mcg/hr without any documented physician's order for those changes.
*RN D believed the patient's pulmonary (lung) physician had verbally ordered to change the Fentanyl, but those orders had not been entered by nursing staff or the pulmonary physician.

Interview and policy review on 9/25/13 at 8:35 a.m. with the director of emergency services revealed she agreed physician's orders for the titration of patient 17's Fentanyl drip had not been documented according to the provider's September 2012 Physician's Orders policy by the patient's pulmonary physician and nursing staff.



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B. Based on observation, interview, and policy review, the provider failed to ensure:
*Medication samples dispensed in one of one urology clinic were documented in accordance with acceptable standards of practice.
*A physician's order was obtained for one of six sampled surgical patients (34) medication review.
Findings include:

1. Review of the urology clinic's December 2012 through September 2013 medication Sample Log Intake sheets revealed the following information had been documented:
*Drug representative/company.
*Drug name.
*Drug dose.
*Quantity.
*Lot/Expiration date.
*Date/Initials of the staff member that had documented medication receipt from a drug representative/company.
*The date and initials of the staff member who had documented receipt of sample medications had not been done consistently.
*The medication expiration date at times had been documented in the column for date and initials of the staff member documenting medication receipt.
*Each medication received had not been documented on a separate log sheet. The medications had been documented in a continuous fashion on the intake sheets. It was difficult to determine an exact count for each medication that might have been available for dispensing.

Interview and review on 9/25/13 at 8:30 a.m. and at 11:40 a.m. of the urology clinic's Sample Log Intake sheets with RN E revealed:
*The Sample Log Intake sheets had been documented as described above.
*Information on which medication a patient had been dispensed would be located in the patient's medical record.
*You would have to review urology patients' medical records to determine which medication samples a patient had received.
*There was no central log for documenting which patients had been dispensed sample medications, the amount, and dosage.

Interview and review on 9/26/13 at 10:34 a.m. of the urology clinic's Sample Log Intake sheets with the director of pharmacy revealed:
*The urology clinic had not followed hospital policy for documenting sample medication dispensing.
*The Sample Log Intake sheets did not identify which patient had been provided medication samples, the dosage, or the amount dispensed.
*The urology clinic should have followed the hospital's Pharmaceutical Samples policy for documenting dispensing of sample medications.

Review of the provider's March 2010 Pharmaceutical Samples policy revealed the following information should have been documented in a log when medication samples had been dispensed:
*Date.
*Patient name.
*Medication name and strength.
*Quantity dispensed.
*Lot number and expiration date.

2. Interview and review on 9/26/13 at 9:00 a.m. with nurse manager C regarding patient 34's medication administration record revealed:
*Tramadol 50 milligrams (mg) had been administered on 9/24/13 at 8:03 a.m. and at 11:48 a.m. A review of the patient's electronic medical record did not reveal a physician's order for Tramadol.
*Ondansetron (anti-nausea medication) had been administered on 9/19/13 at 8:56 a.m. A review of the patient's electronic medical record did not reveal a physician's order for ondansetron.
*He was not sure if there would have been a standing order or a verbal order for the medications.
*He would continue to review the medical record for the missing orders.
*No additional information regarding the missing physician's orders had been provided to this surveyor at the time of the exit conference.

Review of the provider's September 2012 Physician's Orders policy revealed:
*"All orders for treatment shall be entered into the EMR (electronic medical record) electronically by the physician. Verbal communication of orders should be limited to urgent situations where immediate electronic communication is not feasible and may be entered in the EMR by any licensed provider (RN, PT, RT, ect)."
*Verbal orders must be signed by the ordering physician within 48 hours.
*"Verbal/telephone orders are entered in the EMR by the person receiving the order and is done so by specifying the ordering physician's name or the name of the physician's agent communicating the order, along with the source of how the order was obtained."

Based on record review, interview, and policy review, the provider failed to ensure blood products were always verified by two registered nurses prior to administration for four of four sampled patients (3, 7, 20, and 23). Findings include:

1. Review of patient 3's blood transfusion records revealed he:
*Had received two units of fresh frozen plasma and two units of packed red blood cells on 9/19/13.
*Had received two units of packed red blood cells on 9/20/13.
*There was no record two registered nurses had verified the blood products prior to administration.

2. Review of patient 7's blood transfusion record revealed she had received one unit of packed red blood cells on 9/12/13. There was no record two registered nurses had verified the blood product prior to administration.

3. Review of patient 20's blood transfusion record revealed he had received one unit of packed red blood cells on 9/2/13. There was no record two registered nurses had verified the blood product prior to administration.




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4. Review of patient 23's blood transfusion record revealed she had received two units of packed red blood cells on 5/21/13. There was no record two registered nurses had verified the blood product prior to administration.

Surveyor: 26632
5. Interview on 9/24/13 at 2:00 p.m. with the laboratory director revealed:
*Two RNs would have checked the blood product prior to administration.
*A blood product issue form was signed by the two RNs and then sent back to the laboratory.
*The laboratory only kept that form for a few days, and then it was discarded.
*She agreed there was no record two RNs had verified the blood product prior to administration.

Review of the provider's revised October 2011 Guideline for Completion of Patient Identification Slip revealed:
*Once the blood or blood product was received all criteria as indicated in the product administration procedure should have been verified with a second RN.
*Obtain that RN's signature on the second line of the identification slip.
*That slip must be returned to the laboratory within ten minutes of receiving the blood product.

A. Based on observation and interview, the provider failed to ensure nursing staff:
*Disinfected patient care equipment between patient care for two of two observed patients (4 and 6).
*Completed appropriate hand hygiene prior to administering intravenous (IV) medication for two of two sampled patients (4 and 6).
*Completed appropriate disinfection of an IV port prior to administering IV medication for two of two sampled patients (4 and 6).
Findings include:

1. Observation on 9/24/13 at 9:00 a.m. revealed registered nurse (RN) A entered patient 6's room with a stethoscope around her neck and carried a portable pulse oximeter on a clipboard with patient papers and a prefilled syringe of morphine sulfate (MS) (narcotic pain medication) 4 milligrams. Upon entering patient 6's room she:*Did not wash or sanitize her hands.
*Used the computer key board to review patient 6's electronic medication administration record (EMAR).
*Retrieved an alcohol wipe from her pocket,and cleansed the IV port with the alcohol wipe for less than three seconds.
*Administered the MS through the IV port.
*Disposed of the used syringe in the sharps container and without washing or sanitizing her hands she put on gloves and administered a subcutaneous injection of Enoxaparin (blood thinner) into patient 6's abdomen.
*Removed her gloves and did not wash or sanitize her hands.
*Documented those medications using the computer keyboard.
*Obtained patient 6's oxygen saturation level with the pulse oximeter.
*Listened to patient 6's lungs and abdomen with the stethoscope.
*Loosened the tape around the dressing to patient 6's right upper thigh.
*Retrieved an oral swab from the patient care supply closet in the room.
*Put on gloves.
*Filled a glass with water and swabbed patient 6's lips and mouth.
*Removed her gloves, used hand sanitizer, gathered the clipboard and pulse oximeter, and went into patient 4's room.

2. Observation on 9/24/13 at 9:17 a.m. revealed RN A entered patient 4's room with a stethoscope around her neck and carried a portable pulse oximeter on a clipboard with patient papers. She then:
*Placed the clipboard and pulse oximeter on the counter by the sink.
*Used hand sanitizer.
*Used the computer key board to review patient 4's EMAR.
*Retrieved the oral medication of Diovan and potassium chloride from the patient's medication medication drawer.
*Gave the medications to patient 4.
*Documented those medications in the EMAR using the computer keyboard.
*Obtained patient 4's oxygen saturation level with the pulse oximeter.
*Listened to patient 4's lungs and abdomen with the stethoscope.
*Retrieved a saline flush syringe from the patient's medication drawer.
*Wiped the IV port with an alcohol pad for less than two seconds.
*Left the room and retrieved a medication from the Pyxis medication machine.
*Used hand sanitizer when she returned to the room.
*Administered that medication to patient 6 and documented that medication using the computer keyboard in the EMAR.
*Retrieved a specimen container from patient 6's overbed table. That container had sputum inside.
*Tightened the cover and placed the specimen in a biohazard bag.
*Left the room with the stethoscope around her neck, the pulse oximeter on the clipboard, and carried the biohazard bag to the nurse's station.

3. Interview on 9/24/13 at 9:30 a.m. with RN A revealed she:
*Did not include sanitizing her stethoscope or the pulse oximeter between patients as part of her normal routine.
*Was not aware an IV port should have been cleansed for at least fifteen seconds before access.
*Was not aware she had not consistently washed or sanitized her hands during patient care.

Interview on 9/24/13 at 9:45 a.m. with RN nurse manager C revealed:
*He agreed patient use equipment should have been sanitized or disinfected between patients.
*He was aware an IV port should have been cleansed for at least fifteen seconds before access.




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B. Based on observation, interview, and policy review, the provider failed to ensure:
*Staff members wore appropriate personal protective equipment (PPE) and performed hand hygiene during two of two observed patients (53) and 55) invasive procedures in the post-anesthesia recovery unit (PACU).
*Staff members completed hand hygiene for one of one observed patient's (56) surgical procedure in the cardiac catheterization department.
*Staff members disinfected vial septums and IV ports prior to withdrawal and administration of medication for one of one observed patient's (56) surgical procedure in the cardiac catheterization department.
*The surgical mask was worn appropriately for two of two observations of cardiac catheterization technician (H).
*A paper towel dispenser had been mounted in one of one urology clinic laboratory.
Findings include:

1.a. Observation on 9/25/13 at 9:20 a.m. of patient 56's surgical procedure in the cardiac catherization department revealed:
*At 9:43 a.m. and at 9:49 a.m. RN I withdrew medications from vials into syringes and administered those medication to the patient. She had not disinfected the vial septum or the IV port with an alcohol wipe prior to withdrawal and administration of those medications.
*At the conclusion of the patient's surgical procedure:
-Physician J removed his contaminated PPE, removed his lead apron, and exited the operating room. He had not performed hand hygiene prior to or after exiting the operating room and went to the control desk computers.
-Cardiac catherization technician K removed her contaminated PPE, exited the operating room, removed her lead apron, and hung the apron on a rack. She had not performed hand hygiene prior to exiting the operating room or before hanging the lead apron on the rack.
-RN I while wearing gloves assisted the patient from the operating room table into her wheelchair, removed her gloves, exited the operating room, and went to the control desk. She had not performed hand hygiene after removal of her gloves. Upon reentering the operating room she sanitized her hands with hand gel.

Review of the provider's July 2013 Medication Administration policy revealed:
*Prior to withdrawing medications from an ampule or a multidose vial the stem of the ampule and the rubber top (septum) of the vial should have been cleansed with an alcohol wipe.
*Cleansing the rubber top of single-use vials had not been addressed.

Review of the provider's June 2012 Flushing Peripheral Intermittent Intravenous Catheters policy revealed staff members should have swabbed the injection port with alcohol prior to medication administration via IV ports.

b. Observation on 9/25/13 at 10:30 a.m. in the cardiac catheterization department revealed cardiac catherization technician H in the hallway talking on the phone. His mask was pulled down and resting on his chin.

Observation on 9/25/13 at 9/25/13 at 11:30 a.m. in the cafeteria revealed cardiac catherization technician H eating lunch. His mask was pulled down and resting under his chin.

Interview on 9/26/13 at 9:30 a.m. with infection coordinator N revealed cardiac catherization technician H should not have worn his mask on his chin. Once a mask had been used it became contaminated and should have been discarded. If a mask was needed at a later time a new mask should have been put on.

Review of the provider's April 2012 Standard Precautions policy revealed "Masks/Goggles/Shield Masks - except for instances of reuse of N95 masks, all masks are considered one-time use."

2. Observation on 9/25/13 at 12:58 p.m. in outpatient services revealed RN L washed her hands, turned the faucet off with her wet hands, and then dried her hands with a paper towel.

Interview at the time of the observation with infection control coordinator M confirmed RN L had recontaminated her hands when she turned the faucet off with her wet hands. To prevent her hands from contamination she should have used a paper towel to turn off the faucet.

Review of the provider's April 2012 Hand Hygiene policy revealed hand hygiene should have been performed:
*"Before direct patient contact.
*After contact with patient's intact skin.
*After removing gloves.
*After contact with