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Based on review of the clinical record, interview and review of the facility policy, the facility failed to ensure that the physician orders were complete and prescriptive. The findings include the following:

1. Patient #44 had a physician's order dated 3/3/10 for hemodialysis treatment utilizing a 2 potassium / 2.5 calcium bath and blood flow as tolerated. Review of the flow sheets for the period of 3/6/10 through 3/15/10 indicated that the patient received a 3 potassium bath for part of the treatment dated 3/8/10 and for the treatment dated 3/10/10. The medical record failed to contain a physician's order for the three potassium bath and for an exact blood flow rate.

2. Review of Patient #44's flow sheets during the period of 3/6/10 through 3/15/10 failed to indicate that the patient had been weighed before and after each treatment. Interview with the Nursing Director on 3/17/10 at 1:30 PM indicated that the treatment is based on the CRIT line monitoring not on the patient's weight. Review of the facility policy failed to identify parameters and/or guidelines for the use of the CRIT line for fluid volume.

3. Patient #44 had a physician's order dated 3/3/10 for Heparin 3,000 units per treatment. The treatment flow sheets dated 3/6/10 identified that no Heparin had been administered and on 3/8/10 and 3/10/10, 2,000 Units of heparin had been administered. Interview with the Director indicated that the Heparin dose was held post-operatively and decreased on 3/8/10 and 3/10/10 due to bloody urine. Review of the facility policy indicated that the RN may change the Heparin rated based on the needs of the treatment. The policy failed to identify parameters and/or guidelines for the change of Heparin dose. The policy further indicated that the RN could alter the blood flow depending on the condition of the access, increase dialysis time if weights gains are in excess of those prescribed by the unit, and give supplements of normal saline or albumin if the patient is hypotensive. The policy failed to provide parameters and/or guidelines for the RN to make these changes in the absence of a physicians order.

On 3/22/10, the Department requested a corrective action plan from the facility to ensure the care being provided would be based on physician's orders. The plan identified that the aforementioned policy would be put on hold and all hemodialysis treatments would based on physician's orders and Interview with the QA Coordinator on 3/22/10 indicated that he was not aware of the dialysis policy and/or that the policy failed to have identified parameters to guide to nursing care. The QA Coordinator indicated that the policy was previously approved for use by the Medical Director of the unit, the Nursing Director covering the area and the Hemodialysis Nurse.

Based on clinical record review, interviews and review of facility documentation for two of five patients (Patient #s 42 and 43) with a history of wounds, the clinical record lacked a physician's order for treatment of the wound. The findings include:

Patient # 42 was admitted to hospital on 12/8/09. Diagnoses included right foot cellulites and abscess, diabetes mellitus, coronary artery disease and anemia. A History and Physical dated 12/8/09 identified that the patient was alert and oriented. Review of physician notes dated 12/10/10 identified that a wound on the dorsum of the right foot was incised and packed. Review of nurse notes dated 12/10/09 to 12/13/09 identified that dressing changes with normal saline irrigations were done two to three times daily.
Interview and review of the clinical record with Nurse Manager # 6 on 3/18/10 at 2:10 PM failed to provide evidence that a physician order was obtained prior to the initiation of treatment.



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Patient #43 was admitted on 3/7/10 with diagnoses which included congestive heart failure and chronic obstructive pulmonary disease. A nursing assessment dated 3/7/10 identified the presence of a stage 1 pressure ulcer on the right buttock measuring 4 centimeters (cm) x 2 cm and a stage 2 pressure ulcer on the right buttock measuring 4millimeters(mm) x 2mm with Allevyn foam in place. A care plan dated 3/8/10 identified skin breakdown with interventions that included turn every two hours, Accumax mattress with motor and encourage nutrition. Interview and review of the clinical record with Registered Nurse (RN) #4 on 3/16/10 at 1:55PM identified that the clinical record lacked a physician order for the treatment of the stage 2 pressure ulcer. Interview with the Wound Care Consultant on 3/17/10 at 9AM identified that although an order is not required to use an Allevyn foam dressing for protection, a physicians order is required to utilize Allevyn foam for the treatment of a stage 2 pressure ulcer.

Based on clinical record reviews, interviews with satff, and review of policies for one of 3 patients (Patient #11), the hospital failed to ensure that a history and physical were performed within 30 day of surgery/procedure. The findings include:

Patient #11 was admitted on 3/15/10 and underwent a panendoscopy. Review of the clinical record on 3/15/10 at 11:30 AM with the Nurse Manager identified that the initial history and physical was not signed or dated, as the hospital policy directed..

Based on observation and interviews with staff, the hospital failed to ensure that drugs were stored appropriately. The findings include:

A tour of the hospital's endoscopy procedure rooms and main operating suite were conducted on 3/15/10 at 11:15 AM and 1 PM respectively, with the Nurse Manager. In each area, an anesthesia cart that contained injectable medications including paralytics were found unlocked and unattended. In addition, the anesthesia cart in the endoscopy procedure room contained two syringes that were filled with medications that were not labeled with the name of the medication, and/or did not indicate the date and time they were prepared, per hospital policy.

Based on observation, review of the facility policy, and interview the facility failed to ensure that medications were properly stored and/or that practice was based on facility policy. The findings include the following:

1. Tour of the OB operating room 3/16/10 identified three vials of Succinylcholine in the anesthesia cart that were dated 1/18/10, 2/8/10 and 2/17/10. Review of the facility policy indicated that medications that come from the refrigerator will be dated and that once dated, Succinylcholine is good for fourteen (14) days regardless if the vial was opened or not opened. Interview with the Director of Pharmacy on 3/17/10 at approximately 10:00 AM indicated that the guidelines utilized and posted in pharmacy are that Succinylcholine is good for thirty (30) days if not opened and twenty-eight days if opened. The facility failed to ensure that the policy and practice were consistent.

In addition the Pharmacy policy indicated that the anesthesia trays will be swapped out on a daily basis and that the used trays will be returned to pharmacy to be replenished and double-checked. The policy does not address how the unused trays will be monitored to ensure the medications are discarded once the appropriate time frame had been exceeded.

On March 23, 2010, as part of the periodic Federal Survey inspection, the Nuclear Medicine, and Radiology Departments of Middlesex Hospital were inspected for compliance with Sections 19-24-1 through 19-24-14 of the Connecticut Administrative Regulations.

The inspection consisted of a review of records, procedures, equipment and facilities, including the following: (a) in-house physics reports and follow-up corrective actions; (b) personnel dosimetry records; records of receipt of radioactive materials; (d) quarterly inventories; (e) records of area surveys; (f) records of calibration of available radiation detection instrumentation; (g) calibration of the dose calibrator, including linearity, and constancy determinations; and (h) leak test records.

In the Radiology Department, no items of non-compliance were identified within the scope of the inspection. In the Nuclear Medicine Department, one item of non-compliance was identified.

1) Sec. 19-24-7 (2) Surveys- " Each owner of an installation or mobile source shall make or cause to be made such surveys as may be necessary for him to comply with the provisions of sections 19-24-1 to 19-24-14, inclusive " .

Contrary to the above, an out of calibration survey meter was used to perform contamination surveys.

Based on observation and interview the facility failed to ensure that dialysis supplies were appropriately maintained. The findings include the following:

1. Tour of the dialysis unit on 3/17/10 area identified that two jugs of 3 calcium dialysate had expired in January of 2010 and two jugs had expired in February of 2010. Interview with the Dialysis Nurse on 3/17/10 at 9:00 AM indicated that she was unaware the dialysate had expired.

Based on observation and review of policies for one patient (Patient #25) who was placed on contact precautions, the hospital failed to ensure that staff followed established infection control procedures. The findings include:

A tour of the out-patient post anesthesia care unit was conducted on 3/15/10 at 1:30 PM with the Nurse Manager. A sign on Patient #25's door identified that contact precautions were to be followed when entering the patient's room. RN #4 was observed in Patient #25's room starting an IV wearing gloves, but no gown. The posted sign and hospital policy directed anyone entering the room to wear gloves and a gown.