HospitalInspections.org

Based on observation and interview, the facility failed to ensure patient privacy by placing the full last names of patients in public view for 24 out of 24 patients on 4B Cardiac and 10 out of 10 patients on 4C Cardiac. The facility census was 345.
Observation on 08/03/10 at 10:39 a.m. of 4B Cardiac floor, showed a chart rack containing 24 patient charts with patients full last names written on the spine. The chart rack is positioned directly behind the nurse station desk. The rack is approximately six feet away from the outside of the nurse desk, and easily readable from the public hallway. This observation was witnessed by Staff C, Nursing Administration Manager.
During an interview on 08/03/10 at 10:39 a.m., Staff QQ, Director of 4B Cardiac, stated he did not realize the visibility of patient last names in public areas violated privacy.
Observation on 08/03/10 at 3:07 p.m. of 4C Cardiac floor, showed a chart rack containing 10 hard charts with patients full last names written on the spine. The chart rack is positioned behind the nurse station desk and easily readable from the public hallway. This observation was witnessed by Staff C, Nursing Administration Manager.

Based on observation and interview the facility failed to follow safe standards of practice within their Dialysis Unit by not visualizing the venous access port location during dialysis and not being able to observe patients during dialysis treatment in rooms 5 and 6 from the nurses' station. It is important to visualize access ports and patients during dialysis treatments in case the needle would become dislodged from the access port. A patient could bleed out (bleed to death due to the dialysis machine pumping the blood out of the patient) in two minutes and may not be able to call for help. The facility also failed to keep hallways clear and open leading to the exit door.
Findings included:
1. Observation on 08/03/10 at 10:20 a.m. in the Dialysis Unit on the 6th floor of the hospital revealed six patients receiving dialysis (medical filtering process: the process of filtering the accumulated waste products of metabolism from the blood of a patient whose kidneys are not functioning properly) treatments and no portal sites could be visualized on any of the patients and were covered with blankets.
2. Observation on 08/03/10 at 10:20 a.m. in the Dialysis Unit revealed patients in rooms 5 and 6 receiving dialysis treatments and were unattended and out of view of the nursing staff.
3. Observation on 08/03/10 at 10:25 a.m. in the dialysis Unit revealed a large clean laundry cart in the hall directly across from room number 5 blocking access to the exit door of the room.
4. Observation on 08/03/10 at 10:25 a.m. revealed storage items stacked up and cluttering the area directly across from the exit door.
5. Observation on 08/03/10 at 10:30 a.m. revealed a hallway next to the nurses ' station that stores large wheel chair scales - leaving approximately two feet of cleared area from the patient rooms to the exit door. This is a large heavy mechanism and could not be moved easily in case of an emergency preventing egress.
6. In an interview with Staff BB, RN, Assistant Nurse Manager of the Dialysis Unit, it was stated that he/she was not aware of the standard requiring patients portal sites to be visualized at all times during dialysis treatments.
7. In an interview on 08/03/10 at 10:34 a.m. with Staff VV, RN, Nursing Administrator, Interdisciplinary Clinical Practice Coordinator (ICPC) verified the isolation of patients in rooms 5 and 6 and inability to view them from the nurses ' station or other areas of the dialysis unit.
8. Observation on 08/04/10 at 1:28 p.m. in the Dialysis Unit revealed 4 patients receiving dialysis treatments - all access sites were uncovered and visible - rooms 5 and 6 were not occupied by patients. The stored clean linen cart had been moved and the stored clutter adjacent to the exit door had been removed allowing egress. The wheel chair weight scale was still in place allowing approximately two feet of walking space.

Based on observation, interview and record review the facility failed to document measurements and describe pressure sores for four of seven patients observed with pressure sores (Patients #9, #26,
#27, and #32); failed to provide treatment as recommended for two of five (Patients #9, and #27); failed to elevate heels off the bed surface for two of five (Patients #9, and #26); and failed to get a dietary consult for one of five patients (Patient #26) with a pressure sore, poor nutritional intake, and laboratory results indicating poor protein levels (can be indicative of poor wound healing ability). The facility identified 18 patients with pressure sores. The facility census was 345.

Findings Include:

1. Review of a facility policy entitled, "Pressure Ulcer Prevention," revised 06/10, revealed the following:

a) Documentation must be done upon identification of skin breakdown.
b) If a pressure ulcer is identified, assessment should be documented which includes:
* Location
* Stage
*Measurement of the pressure ulcer in centimeters (cm), length, width and depth
*Tunneling if present
*Color, Drainage, odor
c) Document skin breakdown when it is identified.

Review of Patient #9's History and Physical (H & P) dated 07/28/10, revealed the patient was admitted on that date with a diagnosis of a left buttocks wound. The patient was, "Very thin and frail"-a risk factor for development of pressure sores.

Review of the nurses' admission skin assessment revealed the patient had a Braden score (a tool used to determine risk of developing pressure sores-a score of 18 or below would indicate higher risk - the lower the score the higher the risk) of "18." The nurses' documentation revealed a skin care consult had been ordered a wound was left open to the air (no dressing or treatment). The admitting nurse failed to measure, stage, and/or describe the wound in the documentation.

Review of ostomy nurse (nurses trained to do wound care) documentation dated 07/29/10 revealed the patient had a Stage II (partial thickness skin loss presenting as a shallow crater or blister) pressure sore, on the left lateral coccyx (tailbone) measuring 0.6 centimeters (cm) by 1.7 cm. The patient also had reddened heels, that blanched very slowly (can indicate potential further breakdown). The ostomy nurse recommended the following:

a) Cleanse with wound cleanser, gently pat dry, apply hydrocolloid (a slightly spongy hydrating type dressing)-small oval size- change every three days and as necessary.
b) Float heels when in bed (keep off mattress).

Observation on 08/02/10 at 9:25 a.m. revealed the following:

a) Patient #9's heels were on the mattress.
b) Patient #9 had an oval shaped Stage II pressure sore on the left buttocks/coccyx that measured approximately 4 cm by 1.5 cm.
c) Registered Nurse (RN) Staff member G failed to use wound cleanser. RN G put a piece of white foam (not the hydrocolloid dressing) over the pressure sore and taped it in place.

Review of the patient's care plan revealed a problem of skin integrity, with a goal of wound healing. Interventions included turn every two hours, use foam dressing (incorrect), and a barrier cream.

During an interview on 08/02/10 at 9:38 a.m., RN H said nurses don't stage pressure sores. RN H also said the patient's pressure sore should have described in the admission nurses' assessment or in another note. RN H confirmed RN G should have used the hydrocolloid dressing recommended by the ostomy nurse.

2. Review of Patient #26's admission nursing assessment revealed he/she was admitted on 08/02/10 with a reddened buttocks which was cleansed. The patient's Braden score was "15." The admitting nurse failed to describe the buttocks further.

Review of a dietary note dated 07/30/10 (before the patient was transferred to the current unit) revealed the patient had a poor intake and it needed to increase.

Review of physician's orders dated 08/02/10 revealed an order for Ensure (a liquid nutritional supplement) to be delivered with each meal. As of review on 08/04/10 at 10:45 a.m., staff failed to document the consumption of the Ensure six of seven opportunities.

Review of laboratory results dated 08/04/10 revealed the patient's albumin level was 2.6 g/dL (normal = 3.5-5.0), and total protein level was 5.8 g/dL (normal = 6.3-8.2).

Review of the entire record on 08/04/10 revealed no evidence the Registered Dietitian had assessed the patient since 07/30/10.

Review of an ostomy nurse note dated 08/03/10 revealed the patient had a Stage II pressure sore on the left heel, measuring 1.0 cm by 2 cm, and a skin tear to the right buttock measuring 0.3 cm by 0.3 cm.

Observation on 08/04/10 at 10:52 a.m. revealed the patient's heels were on the mattress (causing pressure to an already existing pressure sore). The buttock was covered with a white cream. Staff failed to initially identify the heel pressure sore in the documentation.

Review of the patient's care plan revealed a problem of Infection, Risk/Actual, a goal was to prevent/manage skin breakdown, with interventions to turn/reposition, log roll, use turn sheet, trapeze bar and transfer board. Staff failed to address actual skin breakdown with more specific interventions individualized to this patient's needs.

3. Review of Patient #27's H & P dated 07/20/10 revealed the patient was transferred to the 3A unit on 07/30/10 after a stay on another unit in the hospital, with a diagnosis of pancreatitis (inflammation in the pancreas). The H & P revealed the patient had no skin lesions or rashes.

Review of the patient's skin assessment documentation dated 07/21/10 revealed the patient developed a Stage II pressure sore on the coccyx area. The most current documented measurement, dated 07/30/10 and timed 1:40 p.m., prior to transfer to 3A, was 3.0 cm by 1.0 cm.

Review of the admission nursing assessment, dated 07/30/10 and timed 5:25 p.m., revealed the patient's skin was dry reddened, with slough (dead tissue). The skin was cleansed and a barrier applied. The patient's Braden score was "14." The admitting nurse failed to stage, put location or measure and describe the area further.

Review of an ostomy nurse's documentation, later on 07/30/10, revealed a recommendation to use a hydrocolloid dressing, changing every three days.

Observation and interview, on 08/04/10 at 1:55 p.m., revealed the patient had a Stage II pressure sore in the coccyx split measuring approximately 4.0 cm by 1.0 cm. The Ostomy nurse failed to follow the previous recommendations for treatment. The Ostomy nurse used a product called Hydrogel, even though Ostomy nurse YY said he/she thought the current recommendations were to use a barrier called extra protective cream (EPC).




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4. Open record review on 08/03/10 at 3:00 p.m. revealed no measurements for a stage one decubitus ulcer for Patients #32, and inpatient on unit 6C, Stroke Center.
During an interview with Staff DD, RN, NM, on 08/03/10 at 3:00 p.m., it was stated that decubitus ulcers are not referred to the wound care nurse until the decubitus is a stage 2.

Based on interview and record review facility staff failed to ensure six current patients (Patients #11, #12, #26, #27, #32 and #33) had a current plan of care, directing interventions, measurable goals and objectives. The facility census was 345.

Findings included:

1. Record review of current Patient #11's admission history and physical revealed staff admitted the patient on 07/30/10 with chief complaints of abdominal pain, constipation nausea, difficulty urinating and with past diagnoses including diabetes. Further review of an addition, dated 07/31/10, to the admission history and physical revealed the physician assessed a cystic mass in the pelvis and anticipated surgical intervention.

Record review of the patient's care plan dated 07/31/10 revealed nursing staff addressed two problems; infection and hysterectomy and failed to address surgical wound healing for a diabetic patient.

Record review of the physician's progress notes revealed the following:
-Dated 08/01/10 the physician assessed the patient with ileus (decrease in the gastrointestinal tract's ability to push contents through) and third spacing of fluids (body fluid collected in spaces in the body that do not normally contain fluids).
-Dated 08/02/10 the physician assessed the patient with slow improvement of ileus and peritonitis (inflammation of the lining of the abdominal cavity) and planned to provide a rectal suppository and discontinue a urinary catheter.
-Dated 08/03/10 at 9:39 AM the physician assessed the patient's intake and output records did not coincide with body weight, the complete blood count showed a white blood cell count (blood cells that fight infection) of thirty three thousand (high), the creatinine (indicator of kidney function) was elevated and the bowel sounds were hypoactive
(sounds made by the movement of the intestines contents were diminished).

Record review of the patient's care plan (reviewed on-line) on 08/03/10 at 10:35 a.m.revealed staff maintained the same two problems of infection and hysterectomy and failed to plan for care and interventions for the patient's problems of ileus, constipation, fluid balance, diabetes and healing of a surgical wound.

During an interview on 08/03/10 at approximately 2:00 p.m., Nursing Administration Manager, Staff K reviewed the patient's care plan and stated staff failed to provide care planning for patient problems including diabetes and surgical wound healing.

2. Record review of current Patient #12's admission history and physical revealed staff admitted the patient on 07/29/10 with chief complaints of weakness, chills, fever, diagnoses of urinary tract infection and sepsis (infection in the blood) and past medical history including high blood pressure, anxiety associated with depression, urinary tract infection, and sepsis.

Record review of the patient's physician's progress notes dated 08/02/10 revealed the physician assessed the patient had pain in the left hip and pelvis, was tearful, concerned about blood pressure, was anxious and depressed. Further, the physician recorded the patient's spouse had died on the floor (nursing unit the patient was on) and that was a problem for the patient.

Record review of the patient's psychologist's progress notes dated 08/02/10 revealed the psychologist assessed the patient with the following stressors:
-Spouse died twelve to fifteen months prior to admission.
-Loss of a house.
-Had two children and a grandchild living in the home.
-Financial pressures.
-Retired from a housekeeping department job five to six months ago due to medical problems.

Record review of the patient's care plan (reviewed on-line) on 08/03/10 at 10:38 a.m. revealed staff identified three problems and interventions including:
-Pain.
-Trauma/injury risk with an intervention of manage the environment.
-Infection with a goal of prevent/manage nutritional deficiency.
-Staff failed to identify care plans and interventions for anxiety with depression.

During an interview on 08/03/10 at approximately 2:30 p.m, Nursing Administration Manager, Staff K reviewed the patient's care plan and stated staff failed to provide care planning for patient problems including depression.


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3. Review of Patient #26's admission nursing assessment revealed he/she was admitted on 08/02/10 with a reddened buttocks which was cleansed. The patient's Braden score was "15" (a score of 18 or below indicates high risk for development of pressure sores). The admitting nurse failed to describe the buttocks further.

Review of an ostomy nurse note dated 08/03/10 revealed the patient had a Stage II pressure sore on the left heel, measuring 1.0 cm by 2 cm, and a skin tear to the right buttock measuring 0.3 cm by 0.3 cm.

Observation on 08/04/10 at 10:52 a.m. revealed the patient's heels were on the mattress (causing pressure to an already existing pressure sore). The buttock was covered with a white cream.

Review of the patient's care plan revealed a problem of Infection, Risk/Actual, a goal was to prevent/manage skin breakdown, with interventions to turn/reposition, log roll, use turn sheet, trapeze bar and transfer board. Staff failed to address actual skin breakdown with more specific interventions individualized to this patient's treatment/needs, and failed to use an applicable/measurable goal since the patient already had existing breakdown.

4. Review of Patient #27's H & P dated 07/20/10 revealed the patient was transferred to the 3A unit on 07/30/10 after a stay on another unit in the hospital, with a diagnosis of pancreatitis (inflammation in the pancreas).

Review of the patient's skin assessment documentation dated 07/21/10 revealed the patient developed a Stage II pressure sore on the coccyx area. The most current documented measurement, dated 07/30/10 and timed 1:40 p.m., prior to transfer to 3A, was 3.0 cm by 1.0 cm.

Review of the admission nursing assessment, dated 07/30/10 and timed 5:25 p.m., revealed the patient's skin was dry reddened, with slough (dead tissue). The skin was cleansed and a barrier applied. The patient's Braden score was "14."

Review of an ostomy nurse's documentation, later on 07/30/10, revealed a recommendation to use a hydrocolloid dressing, changing every three days.

Observation and interview, on 08/04/10 at 1:55 p.m., revealed the patient had a Stage II pressure sore in the coccyx split measuring approximately 4.0 cm by 1.0 cm. The Ostomy nurse failed to follow the previous recommendations for treatment. The Ostomy nurse used a product called Hydrogel, even though Ostomy nurse YY said he/she thought the current recommendations were to use a barrier called extra protective cream (EPC).

Review of the patient's care plan revealed a goal of prevent/manage skin breakdown with interventions of sensation impairment protection and skin membrane protection. Staff failed to address actual skin breakdown with more specific interventions individualized to this patient's treatment/needs, and failed to use an applicable/measurable goal since the patient already had existing breakdown.


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5. Open record review on 08/03/10 at 3:00 p.m. revealed no care plans for Patients #32 and #33. Patients #32 and #33 are inpatients on unit 6C, Stroke Center, and both patients have stage 1 decubitus ulcers. The medical records showed that one patient ' s decubitus was measured and documented the other patient ' s decubitus were not measured and documented making assessment of a worsening condition improbable.
During an interview with Staff DD, RN, NM, it was stated that decubitus ulcers are not referred to the wound care nurse until the decubitus is a stage 2.
During an interview with Staff UU, RN, it was stated that neither Patient #32 nor Patient #33 had a care plan pertaining to skin.
6. Record review of the Policy and Procedure effective 09/24/09 and revised 09/24/09 for Procedure No: 230, INTERDISCIPLINARY CARE PLANNING, states, in part:
Purpose:
The Interdisciplinary Care Plan (ICP) is developed and updated based upon the admission assessment and an changes in condition

Policy:
1. The Care Plan is initiated by an RN within 12 hours of admission ...
5. Progress toward goals is updated at least every 24 hours and with any changes in condition.
1. If a patient has an unexpected change of condition or response to treatment, the LPN must consult and RN. The RN will review the situation and update the plan of care.



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During an interview on 08/04/10 at 10:30 a.m. Staff C, Nursing Administration Manager stated nursing care plans should be reviewed every shift, at minimum two times per day.

Record review of Patient #58 printed Care Plan printed on 08/03/10 at 2:32 p.m. showed a goal for Pain as "prevent/manage skin breakdown". The documentation of nursing staff showed the care plan was not addressed for greater than 24 hours for the following dates and times:
-07/03/10 12:53 a.m. until 07/04/10 3:35 a.m.;
-07/04/10 3:35 a.m. until 07/06/10 2:27 a.m.;
-07/08/10 5:18 a.m. until 07/09/10 6:57 p.m.;
-07/09/10 6:57 p.m. until 07/11/10 7:16 a.m.;
-07/28/10 5:11 a.m. until 07/30/10 4:38 a.m.

Based on observation, interview, and record review, the facility failed to ensure scheduled medications were administered according to policy for 12 patients (#12, #16, #40, #43, #44, #46, #47, #48, #49, #50, #52, and #53) of 27 charts reviewed. This can lead to increased or decreased effectiveness of medications, affecting patient outcomes. The facility census was 345.

Findings Included:

1. Review of Policy #0806 titled "Medication Administration and Documentation", with a revision date of 6/10 stated:
Policy #1:
-Licensed nursing personnel ...will administer medications as prescribed by practitioner (page 1);
Procedure: Medication Administration #3(b).
-Correct time falls within 30 minutes before prescribed time and 30 minutes after prescribed time (page 3).
Standard Medication Times #8.

2. Record review at 08/03/10 at 9:00 a.m., Patient #52 medication administration record showed Protonix (a medication used to treat problems caused by excessive stomach acid) was due to be administered at 7:00 a.m. The record shows the medication was not administered.
During an interview on 08/03/10 at 9:02 a.m., Staff OO, Registered Nurse (RN), stated the Protonix which was due at 7:00 a.m. had not been administered to Patient #52 because he/she had been having excruciating chest pain at the time of medication administration. Staff OO stated he/she would document the medication had not been administered and notify the physician.
3. Review of Patient #40's medical record, printed 08/03/10 at 2:40 p.m. revealed the following medications administered outside of the 30 minute time window allowed for scheduled medications:
-levothyroxine 75 milligrams (mg) daily, due 05/27/10 at 9:00 a.m. was administered at 9:32 a.m.;
-hydrochlorothiazide 25 mg daily, due 05/27/10 at 9:00 a.m. was administered at 9:32 a.m.;
-multivitamin 1 tablet daily, due 5/27/10 at 9:00 a.m. was administered at 9:32 a.m.;
-famotidine 20 mg two times daily, due 05/25/10 at 9:00 p.m. was administered at 9:39 p.m.;
-famotidine 20 mg two times daily, due 05/26/10 at 9:00 p.m. was administered at 8:24 p.m.;
-famotidine 20 mg two times daily, due 05/27/10 at 9:00 a.m. was administered at 9:31 a.m.;
-famotidine 20 mg two times daily, due 05/27/10 at 9:00 p.m. was administered at 9:35 p.m.

4. Review of Patient #43's medical record, printed 08/03/10 at 3:22 p.m. revealed the following medications administered outside of the 30 minute time window allowed for scheduled medications:
-fluticasone-salmeterol 250-50 micrograms (mcg) twice daily, due 08/02/10 at 9:00 p.m. was administered at 9:41 p.m.;
-mupirocin 2% nasal ointment two times daily, due 08/02/10 at 9:00 p.m. was administered at 9:41 p.m.;
-cefazolin 2000 mg every eight hours, due 08/03/10 at 8:00 a.m. was administered at 9:03 a.m.;
-amiodarone 200 mg two times daily, due 08/03/10 at 9:00 p.m. was administered at 8:24 p.m.;
-insulin glargine 18 units daily, due 08/03/10 at 9:00 a.m. was administered at 9:33 a.m.;
-amiodarone 200 mg two times daily, due 08/04/10 at 9:00 a.m. was administered at 8:23 a.m.

5. Review of Patient #44's medical record, printed 08/03/10 at 2:09 p.m. revealed the following medications administered outside of the 30 minute time window allowed for scheduled medications:
-atenolol 100 mg daily, due 08/03/10 at 9:00 a.m. was administered at 8:16 a.m.;
-bisacodyl 10 mg daily, due 08/03/10 at 9:00 a.m. was not administered because the nurse, Staff SS stated this should be a prn medication and she used her nursing judgment to determine whether or not to administer this medication.;
-clonazepam 0.5 mg two times daily, due 08/03/10 at 9:00 a.m. was administered at 8:17 a.m.;
-ferrous sulfate 325 mg daily, due 08/03/10 at 9:00 a.m. was administered at 8:17 a.m.;
-furosemide 20 mg daily, due 08/03/10 at 9:00 a.m. was administered at 8:17 a.m.;
-haloperidol 1 mg every 6 hours, due 08/03/10 at 12:00 p.m. was administered at 2:03 p.m.;
-pantoprazole 40 mg two times daily, due 08/03/10 at 9:00 a.m. was administered at 8:16 a.m.

During an interview on 08/03/10 at 2:43 p.m., Staff SS, 4B Cardiac Charge Nurse and Staff RR, RN, stated medications are ordered by the physician as routine (medications scheduled to be given on at specific time(s) during the day), when they should be ordered prn (as needed). Staff RR stated patients who come from nursing homes have stool softeners and laxatives ordered as scheduled medications. Staff RR stated he/she uses nursing judgment, based on assessment and knowledge, to determine whether certain medications should be given. Staff SS stated that nursing staff should contact the physician for order clarification instead of the nurse determining whether to give the medication. Staff RR then stated she should have contacted the physician and documented why she held the medication, but she didn ' t.

6. Review of Patient #46's medical record, printed 08/03/10 at 2:29 p.m. revealed the following medications administered outside of the 30 minute time window allowed for scheduled medications:
-caffeine citrated 14 mg daily, due 06/19/10 at 9:00 a.m. was administered at 9:33 a.m.

7. Review of Patient #47's medical record, printed 08/03/10 at 2:38 p.m. revealed the following medications administered outside of the 30 minute time window allowed for scheduled medications:
-ranitidine 20 mg every 12 hours, due 03/26/10 at 9:00 a.m. was administered at 10:16 a.m.;
-sodium chloride flush 1 milliliter, due 03/26/10 at 9:00 a.m. was administered at 10:16 a.m.

8. Review of Patient #49's medical record, printed 08/03/10 at 10:25 a.m. revealed the following medications administered outside of the 30 minute time window allowed for scheduled medications:
-aspirin 325 mg daily, due 07/30/10 at 9:00 a.m. was administered at 10:06 a.m.;
-atorvastatin 10 mg daily, due 07/30/10 at 9:00 a.m. was administered at 10:06 a.m.;
-diltiazem 60 mg every 12 hours, due 07/30/10 at 9:00 a.m. was administered at 10:06 a.m.;
-diltiazem 60 mg every 12 hours, due 07/30/10 at 9:00 p.m. was administered at 10:41 p.m.;
-enoxaparin 70 mg every 12 hours, due 07/30/10 at 9:00 a.m. was administered at 10:07 a.m.;
-enoxaparin 70 mg every 12 hours, due 07/30/10 at 9:00 p.m. was administered at 10:41 p.m.;
-lisinopril 10 mg two times daily, due 07/30/10 at 9:00 a.m. was administered at 10:06 a.m.;
-lisinopril 10 mg two times daily, due 07/30/10 at 9:00 p.m. was administered at 10:36 p.m.;
-atorvastatin 10 mg daily, due 07/31/10 at 9:00 a.m. was administered at 9:33 a.m.;
-diltiazem 60 mg every 12 hours, due 07/31/10 at 9:00 a.m. was administered at 9:33 a.m.;
-enoxaparin 70 mg every 12 hours, due 07/31/10 at 9:00 a.m. was administered at 9:33 a.m.;
-lisinopril 10 mg two times daily, due 07/31/10 at 9:00 a.m. was administered at 9:33 a.m.

9. Review of Patient #50's medical record, printed 08/03/10 at 10:11 a.m. revealed the following medications administered outside of the 30 minute time window allowed for scheduled medications:
-aspirin 81 mg daily, due 07/27/10 at 9:00 a.m. was administered at 8:25 a.m.;
-olmesartan 5 mg daily, due 07/27/10 at 9:00 a.m. was administered at 8:25 a.m.;
-rosuvastatin 20 mg daily, due 07/27/10 at 9:00 a.m. was administered at 8:25 a.m.;
-tiotropuim 18 micrograms (mcg) daily, due 07/27/10 at 9:00 a.m. was administered at 8:25 a.m.;
-varenicline 1 mg two times daily, due 07/27/10 at 9:00 a.m. was administered at 8:25 a.m.;
-varenicline 1 mg two times daily, due 07/27/10 at 9:00 p.m. was administered at 8:22 p.m.;
-aspirin 81 mg daily, due 07/28/10 at 9:00 a.m. was administered at 9:33 a.m.;
-olmesartan 5 mg daily, due 07/28/10 at 9:00 a.m. was administered at 9:33 a.m.;
-rosuvastatin 20 mg daily, due 07/28/10 at 9:00 a.m. was administered at 9:33 a.m.;
-tiotropuim 18 micrograms (mcg) daily, due 07/28/10 at 9:00 a.m. was administered at 9:32 a.m.;
-varenicline 1 mg two times daily, due 07/28/10 at 9:00 a.m. was administered at 9:33 a.m.

10. Observation on 08/03/10 at 9:30 a.m. of #53's medication pass showed the following medication administered outside of the 30 minute time window allowed for scheduled medications:
-L-Mfolate-B6 Phos-Methyl-B12 3-35-2 mg daily, due 08/03/10 at 9:00 a.m. was administered after 10:30 a.m.
During an interview on 08/03/10 at 9:30 a.m. with Staff PP, RN, the pharmacy failed to have the above medication available for Patient #53's daily pass. The medication was a scheduled medication which was started on 07/20/10. Staff PP contacted the pharmacy and received the medication from the pharmacy at 10:30 a.m. This was witnessed by Staff C, Nursing Administration Manager.
11. Review of Patient #48's medical record, printed 08/03/10 at 3:34 p.m. revealed the following medications administered outside of the 30 minute time window allowed for scheduled medications:
-escitalopram 10 mg two times daily, due 08/02/10 at 9:00 p.m. was administered at 8:28 p.m.;
-metoclopramide 10 mg every six hours, due 08/02/10 at 6:00 a.m. was administered at 5:03 a.m.



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12. Record review of Patient #12's admission history and physical revealed staff admitted the patient with diagnoses including high blood pressure, anxiety associated with depression, urinary tract infection and sepsis (infection in the blood).
Record review of the patients Medication Administration Record (MAR) revealed the physician directed staff to administer medications including the following:
-Clonazepam (anti-anxiety medication), one milligram tablet two times a day and staff administered the medication on 07/31/10 at 9:41 PM, on 08/01/10 at 9:56 PM and on 08/03/10 at 9:43 PM and failed to provide the medication at 9:00 PM as directed by facility policy.
-Hydrocodone-acetaminophen (pain relieving medication) seven point five-three hundred twenty five milligram tablet, one tablet every six hours and staff administered the medication on 07/30/10 at 4:42 AM and failed to provide the medication at 6:00 AM as directed by facility policy.
-Lisinopril (blood pressure medication) twenty milligram tablet daily and staff administered the medication on 08/02/10 at 9:55 AM and on 08/03/10 at 9:43 AM and failed to provide the medication at 9:00 AM as directed by facility policy.
-Lovastatin (cholesterol lowering medication) twenty milligram tablet daily and staff administered the medication on 07/31/10 at 8:16 AM, on 08/01/10 at 9:56 AM, and on 08/03/10 at 9:43 AM and failed to provide the medication at 9:00 AM as directed by facility policy.
-Pantoprazole (stomach acid reducing medication) forty milligram tablet daily and staff administered the medication on 07/31/10 at 8:16 AM, 08/01/10 at 9:56 AM and 08/03/10 at 9:42 AM and failed to provide the medication at 9:00 AM as directed by facility policy.

13. Record review of the facility policy #0806, titled Medication Administration and Documentation dated 06/10 directed, in part, the following:
-Medications ordered as provided daily would be administered at 9:00 AM.
-Medication ordered two times daily would be provided at 9:00 AM and 9:00 PM.
-Medications ordered to be provided three times a day would be administered at 9:00 AM, 1:00 PM and 6:00 PM.
-Medications ordered to be provided every six hours would be administered at 6:00 AM, 12:00 noon, and 6:00 PM and at 12:00 midnight.



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14. Record review of Patient #16's History and Physical dated 07/26/10 revealed the patient was admitted on that date to the orthopedic unit after a surgical procedure on the left knee. The patient had an infection in the surgical wound requiring an antibiotic called Imipenem.

Review of medication administration records for the patient revealed the Imipenem was due to be administered at midnight on 08/02/10. However, staff administered it at 11:28 p.m., outside the 30-minute prior to due time regulatory guidance.

Based on observation and interview, the facility failed to remove unusable medications from patient care areas to prevent medication administration errors. The facility census was 345.

1. Observation and interview (in the medication room on the Rehab unit) on 08/02/10 at 2:23 p.m. revealed the following:
a) A four-ounce bottle of Hydrogen Peroxide, opened and used, sat on a computer top.
b) The peroxide did not have a date, time, or the staff ' s initials that opened it.
c) Registered Nurse Staff member A said these bottles are usually disposed of after use on a single patient. If not disposed of, it should be labeled with the patient ' s name, date, and nurse ' s initials.



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2. Observation on 08/02/10 at 3:10 p.m. on the 6th Floor in the clean supply area in an unlocked drawer was an open and used (approximately ? inch below the neck) bottle of Bacteriostatic Water. The vial was not dated, timed, or initialed and could not be verified that it was within the 28-day expiry date and should not be used for another patient.




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3. Observation on 08/03/10 at 10:00 a.m. of the 4A Cardiac Floor medication room, showed the following unusable drugs:
-Lovenox (a medication used to prevent blood clots) syringe, dated 07/27/10 for Patient #50, who was discharged on 07/29/10;
-two Lovenox syringes dated 07/31/10 for Patient #49, who was discharge on 07/31/10 at 12:43 p.m.
4. Observation on 8/3/10 at 3:09 p.m. of the 4D Post Surgical Cardiothoracic Stepdown floor medication room, showed the following unusable drugs:
-Vancomycin (antibiotic) dated 07/31/10 for Patient #55, who was discharged on 07/30/10;
-Vancomycin dated 07/31/10 for Patient #56, who was discharged on 08/01/10;
-two doses of Lovenox, dated 07/29/10 and 07/30/10 for Patient #57, who was discharged on 07/29/10.

5. During an interview on 08/3/10 at 3:30 p.m., Staff TT, Assistant Nursing Director 4D, stated medications which are not used when a patient is discharge should be placed in the pharmacy "out box" and returned to the pharmacy when the patient is discharged.

Based on observation, interview and record review facility staff failed to ensure equipment on the Pediatric Unit emergency code cart was checked by trained staff and according to facility protocol to ensure equipment was in good working order. The Pediatric Unit census was 9 patients and the facility census was 345.

Findings included:

1. Record review of the facility policy titled External Defibrillator Check Protocol (Battery); last reviewed 04/08 directed, in part, the following:
-The purpose of the policy was stated as regular checking of defibrillators helps assure the device was operable and also helps the infrequent user stay familiar with the device, which reduces the possibility for error.
-A nurse is responsible for checking the function of the unit's defibrillator and therapy cable daily according to the items on the Operator's Shift Protocol as outlined below.
-Manual Defibrillators-Operator's Shift Protocol outlined specifics including:
-Check patient cable and cable connection for damage. Inspect for broken wires, for units with paddles make sure paddles are clean and not pitted.
-Check stock of supplies. Keep on hand one set of defibrillation pads or pacing/defibrillation (Combo) pads, electrodes and two replacement supplies of ECG paper {electrocardiogram, a test measuring electrical activity of the heart}. Check defibrillation pads and electrodes for package integrity, to prevent drying out of the pads and expiration dates.
-Defibrillators with attached battery chargers must be unplugged prior to testing and plugged-in after the test is completed.
-For units with removable batteries, rotate daily. Verify charger is plugged in and spare batteries are charging if applicable.
-Check that all displays are functional (i.e., power-on, self test, battery charging, pacer operation if applicable.)
-Test fire using a test load per manufacturer's procedure.
-Leave unit with energy selector to appropriate setting for charge/readiness. (Note: Power should be off.)

2. Record review of the Pediatric Unit Quality Control-Risk Management log dated 07/10 revealed on thirty of thirty one days a Patient Care Assistant (PCA) and not a nurse initialed they checked the code cart and the defibrillator per protocol. Further review revealed the initials, signatures and credentials of PCA, Staff II; PCA, Staff JJ; PCA, Staff KK; and PCA, Staff LL were documented at the bottom of that page of the log.

3. Observation on 08/03/10 at approximately 10:20 a.m. on the Pediatric Unit in an alcove behind the nurse's desk revealed staff stored an emergency code cart with a defibrillator, a suctioning device and a clip board on top of the cart.

Record review of the documents on the clip board revealed a log page titled Quality Control-Risk Management dated 08/10 with initials, signatures and corresponding
credentials on the bottom of the page including registered nurses (RNs), and a patient care assistant (PCA, Staff KK). Further review revealed the initials, signature and credentials of PCA, Staff KK was documented as the staff who checked the emergency code cart on at least one day out of four for the month.

During an interview on 08/03/10 at approximately 10:20 a.m. the Pediatric Unit Manager, Staff O stated nurses and patient care assistants who were also assigned to be Unit Secretaries were assigned to check the emergency code cart including equipment on the cart.

4. During an interview on 08/04/10 at 8:20 a.m. the Director of Quality, Risk Management and Accreditation, Staff Q, provided a copy of the facility protocol for defibrillator checks and stated the facility protocol directed nurses to check the defibrillators and not PCAs.

5. During a telephone interview on 08/04/10 at approximately 11:30 a.m. PCA, Staff LL stated the following:
-He/she had been a PCA on the Pediatric Unit since 12/09.
-He/she was not a certified nurse aide.
-He/she had been assigned to check the code cart and the equipment on the code cart as part of routinely assigned duties.
-Completion of the code cart checks encompassed unplugging the equipment from the wall, hit the button, go to options and select user tests.
-Completion of the code cart checks also encompassed checking the number on the tag (plastic tamper tags-if broken indicate cart medication and supplies drawers may have been opened).
-Completion of the code cart checks encompassed "running a strip" but, PCA, Staff LL did not routinely save the strip.
-Completion of the code cart checks also encompassed recording the check in the QC book.
-Completion of the code cart check did not include checking the suction pump.
-He/she was taught how to complete the code cart checks by the current Unit Secretary, PCA, Staff KK.
-Code cart check were not supervised or results reviewed by the registered nurse on the shift.

Based on observation, interview, and record review, the facility failed to have documented surveillance and monitoring related to urinary catheter care and failed to observe contact isolation protocol for one patient (Patient #35) on 6C, Stroke Center. The facility also failed to ensure staff consistantly follow the hand washing policy, and failed to institute a policy for cleaning staff phones used in patient care areas. The facility census was 345.
Findings included:
1. Observation on 08/03/10 at 9:40 a.m. revealed Staff YY, RN (registered nurse), and Staff ZZ, RN, performing urinary catheter (any tube system placed in the body to drain and collect urine from the bladder) care for Patient #55. The nurses performed hand hygiene and glove wearing but cleaned the perineum (the small area between the anus and the vulva in the female or between the anus and the scrotum in a male) area of the patient from back to front with visible feces on the cloths thereby contaminating the catheter area and putting the patient at risk for infection.
2. During an interview on 08/03/10 at 9:50 a.m. Staff VV, RN, Nursing Administrator, Interdisciplinary Clinical Practice Coordinator (ICPC), verified the observation.
3. Observation on 08/03/10 at 2:25 p.m. revealed Staff FF, PCA (Patient Care Assistant) enter the contact isolation room of Patient #35 without gowning and gloving per contact isolation protocol. Staff FF, PCA entered the room on three different occasions to bring in equipment and supplies for the patient. Staff FF, PCA, did not acknowledge the contact isolation sign posted outside the patient ' s door.
4. Observation on 08/03/10 at 2:25 p.m. revealed Staff VV, RN, ICPC, Staff DD, RN, Nurse Manager, and Staff AAA, PCA, watched outside the room as Staff FF, PCA, repeatedly failed to follow contact isolation protocol.
5. During an interview on 08/04/10 at 9:08 a.m. with Staff R, RN, Director, Infection Prevention, acknowledged that cleaning the perineum area back to front would put the patient at risk for infection. Staff R, RN, also stated that contact isolation precaution protocol should be followed no matter what the pathogen of infection.
6. Record review of the INFECTION CONTROL POLICY dated 09/1983 and reviewed 06/2008 showed, in part:
SUBJECT: Types of Isolation Precautions (ISOL2)
CONTACT PRECAUTIONS
In addition to Standard Precautions, use Contact Precautions for patients known or suspected to be infected or colonized with infectious organisms that are transmitted by direct patient contact (hand or skin-to-skin contact) or indirect contact (touching) with environmental surfaces or patient-care items. I.E., MRSA, VRE, C difficile.
B. Gloves and Hand Hygiene
Perform Hand hygiene before putting on gloves
Wear gloves (clean, non-sterile gloves are adequate) every time you enter the patient's room.
Change gloves after having contact with infective material.
Remove gloves before leaving the patient's environment and decontaminate hands immediately.
C. Gown
Wear a gown every time you enter the patient's room.



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7. Record review of policy Hand Hygeine IC-5, with a revision date of Dec. 2009, showed staff are to perform hand hygeine: -before and after each patient contact; -before putting on gloves; -after removal of gloves. Gloves are not a substitute for good hand hygiene.
8. Observation on 08/02/10 at 3:27 p.m. in the Emergency Trauma Center (ETC) showed Staff F, Emergency Department Physician (EDP), failed to wash his hands prior to entering patient room #16. The physician was observed touching the patient while examining the patient in the room. Staff F exited the room without hand washing, picked up and answered a zone phone (a portable telephone used in patient care areas by hospital staff to communicate), typed on the desktop computer, and picked up a desk phone to make a phone call without washing his hands. This observation was verified by Staff C, Nursing Administration Manager.
During an interview on 08/02/10 at 3:45 p.m. Staff D, Assistant Nursing Director of the ETC stated she did not know how often the zone phones were cleaned or if there was a policy stating how often they are to be cleaned.
9. Observation on 08/02/10 at 3:42 p.m. in the ETC showed Staff XX, ETC technician, wearing gloves while pushing a dirty linen cart through the ETC. Staff XX enters patient room #13 with gloves on, picks up the patients phone, hands the phone to the patient, and pulls the patient cart over to the wall phone by the bed rail. Staff XX then removes gloves and washes hands prior to exiting.
During an interview on 08/02/10 at 3:44 p.m. Staff XX stated the linen cart was dirty and the gloves should have been removed and hands washed prior to entering the patient's room and touching items that may come in contact with the patient.
Observation on 08/02/10 at 3:45 showed Staff E, Registered Nurse (RN) ETC, assisting with a splint application in patient room #9 in the ETC, touching the patient's right arm. Staff E removes gloves and exits the patient's room without hand washing. Staff E opens several drawers in a supply cart in the main ETC hallway, and then returns to patient room #9 without washing hands. This observation was verified by Staff C, Nursing Administration Manager.
10. Observation on 08/03/10 at 9:30 a.m. showed Staff PP, RN, while administering medications to Patient #53, picked up a zone phone from the medication cart, return the zone phone to the med cart, and continues administering medications to Patient #53 without washing hands. This observation was verified by Staff C, Nursing Administration Manager.
11. During an interview on 08/03/10 at 9:30 a.m., Staff C, Nursing Administration Manager, stated there is no policy for cleaning the zone phones.
During an interview on 08/04/10 at 9:08 a.m. Staff R, Director of Infection Prevention stated there is no policy regarding cleaning the zone phones, "but I would certainly want the phone to be clean". Staff R also stated staff should take precautions every time they enter the room with good hand washing and proper attire for contact precautions, just in case the patient asks to be handed something or needs help toileting.