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Based on record review and interview, the facility staff failed to ensure one of 33 sampled patients (Patient 3) had the right to formulate an advance directive. There was no document in Patient 3's medical record regarding advance directive.

Findings:

On December 11, 2012, between 1:50 p.m. and 2:10 p.m., after the initial tour with Staff E in the Post Anesthesia Care Unit in the outpatient ASC (Ambulatory Surgical Unit), a review of the open record revealed Patient 3 was admitted to the facility on December 11, 2012, with diagnosis of breast cancer. The patient underwent right breast augmentation with mastopexy on the admission day.

The "Inpatient/Outpatient Information Record" was reviewed and disclosed no advance directive on file and the patient had not received information (brochure) regarding advance directive.

On December 11, 2012, at 2:35 p.m., during an interview with Staff E, he stated the patient had not received information (brochure) and there was no executive Advance Directive in Patient 3's medical record.

Based on observation, record review and interview, the facility's registered nurses failed to supervise and evaluate the nursing care for 4 of 33 sampled patients (11, 12, 13, and 19).
For Patient 11, Patient 12 and Patient 13, the staff did not follow the Intravenous (IV) Therapy policy and procedure. The staff also failed to document the patient assessment at the end of transfusion in the Blood Bank Transfusion Record upon completion of the blood transfusion and in accordance with the Blood Transfusion Administration policy and prior to starting the next blood transfusion for Patient 11.
For Patient 19, there was no documentation of the patient assessment on the 7 a.m. to 7 p.m., shift on December 10, 2012.

Findings:

1. a. On December 11, 2012 at 10:05 a.m., in the Medical/Surgical Unit Patient 11 was observed in bed, eyes closed, head of bed elevated and side rails up. A unit of packed red blood cells (PRBC) had been transfused and normal saline was infusing via left arm IV (intravenous).

A review of the medical record indicated the patient presented to the emergency room (ER) on December 10, 2012 at 9:46 p.m., with diagnoses of dementia, gastrointestinal bleed, acute urinary tract infection.

The physician order dated December 10, 2012 at 11:40 p.m., indicated to transfuse 3 units of PRBCs, each unit over 4 hours.

The Transfusion Record/Blood Bank Transfusion Record for Patient 11 was reviewed at 11:35 a.m. The completed unit of PRBC observed during the tour was started on December 11, 2012 at 5:35 a.m. However, the end of transfusion section that included the signature of the person completing the transfusion, the patient assessment at end of transfusion, the date and time the transfusion was stopped and amount given were blank.

Further review of the medical record revealed another Transfusion Record/Blood Bank Transfusion Record for the patient. The second Transfusion Record indicated the unit of PRBC was started on December 11, 2012 at 10:35 a.m.

During an interview on December 11, 2012 at 11:40 a.m., RN 1 stated the unit of blood was completed at 10 a.m., she took the vital signs and she started the next unit of blood at 10:35 a.m. RN 1 took the Transfusion Record/Blood Bank Transfusion Record and proceeded to document the patient's vital signs, the date and time the transfusion was stopped and the amount given in the Patient assessment at the end of transfusion section, an hour and 35 minutes after the blood transfusion was stopped.

In another interview at 3 p.m., the same day, RN 1 stated, "I have to complete the form (transfusion record) before starting the next blood transfusion. I was late recording."

A review of the facility policy and procedure titled, Blood Transfusion Administration, last revised in November 2012, indicated under "Completion of blood transfusion: Complete Blood Bank Transfusion Record." Further review of the policy indicated, Documentation: "Insure the completion of the Blood Bank Transfusion Record."

1. b. On December 11, 2012 at 10:05 a.m., Patient 11 was observed with 2 peripheral intravenous sites. The left arm IV site was labeled as 12/10/12 and the left antecubital (AC) site was not labeled.

A review of the facility policy and procedure titled, Peripheral Intravenous Therapy, dated as last reviewed in April 2012, indicated, IV site will be labeled with date, time and initials upon insertion time and with dressing changes.

2. On December 11, 2012 at 10:25 a.m., Patient 12 was observed sitting in the chair. The patient had normal saline intravenous fluid (IVF) infusing at 35 milliliter (ml) per hour via IV infusion pump. The normal saline bag was not labeled and there was approximately 100 to 150 ml in the bag.

During a concurrent interview, Patient 12 stated the IV bag was hung sometime yesterday.

During an interview at 11:55 a.m., Staff I, Director Medical/Surgical Unit, stated the IV bag should be labeled.

A review of the medical record for Patient 12 disclosed a physician order for NS at 100 cubic centimeter per hour (cc/hr) on December 7, 2012. Another order dated December 9, 2012, indicated to decrease the IV fluid at 75 cc/hr.

During an interview at 12:05 p.m., RN 2 stated he decreased the rate to 35 ml/hr.

In another interview at 3:10 p.m., RN 2 stated, "It was 75 ml/hr when I came in...To stop the noise (from the alarm), I decreased the rate to 35 ml/hr." RN 2 stated also that he had to get another IV solution and he did not want air bubbles to get in the tubing. When informed about the lack of label on the IV bag, RN 2 stated that all IV bags are supposed to be labeled.

A review of the facility policy and procedure titled, Peripheral Intravenous Therapy, dated as last reviewed in April 2012, indicated the following: Solutions will be changed every 24 hours. IV site will be labeled with date, time and initials at insertion time and with dressing changes.

3. On December 11, 2012 at 11 a.m., Patient 13 was observed in bed with 1 liter of normal saline infusing via infusion pump. The IV solution bag was not labeled. The PICC line was labeled 12/10.

During an interview at 11:55 a.m., Staff I, Director Medical/Surgical Unit, stated the IV bag should be labeled.

4. On December 12, 2012 at 11:20 a.m., in the Post Critical Care Unit (PCCU) Patient 19 was observed awake and in bed.

During a concurrent interview, Patient 19 stated she had been in the hospital since December 5, 2012, because of a (blood) "clot" in her lungs.

The medical record for Patient 19 was reviewed at 11:35 a.m., with Staff J, Director of Critical Care/PCCU. The Assessment Flow Sheet dated December 10, 2012 for 7 a.m. to 7 p.m. (0700 - 1900) was blank. There was no entry in the assessment grid which included neurologic, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, psychosocial and discomfort/pain.

During a concurrent interview, Staff J acknowledged the blank assessment grid and stated, "I can't explain why. She (the nurse) did the narrative but not the grid." Staff J stated the assessment is done at the beginning of the shift, every twelve hours.

A review of the facility policy and procedure titled, "Patient Assessment" dated June 2012, indicated the following: "Initial Assessment, Nursing: Upon admission to a patient unit a registered nurse will assess each patient to determine immediate needs and to collect assessment data. Reassessment will occur...When there is a significant change...A minimum of every twelve hours for nursing."

Based on observation, interview and record review, the facility nursing staff failed to develop, and keep current, a nursing care plan for 2 of 33 sampled patients (Patient 23 and 24).

Findings:

On December 11, 2012, at 10:45 a.m. during the tour of the unit, the following was observed:

1. Patient 24, who had 1:1 sitter by her side, was lying in bed.

A review of the medical record revealed the patient was admitted to the facility on December 9, 2012, for multiple suicide attempts. There was an interdisciplinary Plan of Care that addressed actual psychosocial compromise related to potential suicidal or homicidal ideation. The care plan failed to show written documentation of the date/time the care plan was developed. Also the intervention for 1:1 sitter was not included in the plan of care intervention.

2. Patient 23 was sitting on a chair with indwelling catheter in place. The indwelling catheter was draining 280 cc of light tea colored urine. The record indicated the catheter was inserted on December 9, 2012. There was an intravenous access (Heplock) on his right hand labeled December 10, 2012.

The record indicated the patient had a laparoscopic resection of retroperitoneal mass done on December 7, 2012 on his mid-abdomen and had a Jackson-Pratt suction to collection surgical wound drainage.

A review of the interdisciplinary Plan of Care indicated no documented evidence the plan of care was developed to address indwelling catheter, IV access site (Heplock), mid-abdomen surgical site and Jackson - Pratt.

Further review of the facility's policy number 200.28 Provision of Care, Treatment Services Care Planning stipulated once patient's needs have been identified and prioritized, members of the health care team develop a plan of care, document in the patient's medical record and interventions to address and meet the care goals.

During a concurrent interview with Staff K while reviewing the clinical record, Staff K stated the record failed to show written documentation of plan of care developed to address the care needs of the patients.

Based on observations, interviews and record reviews, the facility's staff failed to implement its policy and procedure for PCA (Patient Control Anesthesia) when administering narcotic analgesia to 1 of 33 sampled patients (Patient 7). The facility's staff failed to assess Patient 7 for pain and vital signs while receiving narcotic analgesia via PCA in accordance with the facility's policy and procedure.


Findings:

On December 12, 2012, at approximately 9:40 a.m., during tour of Oncology Unit, with Staff G, Patient 7 was observed lying in bed receiving medication via PCA.

A review of the Flowsheet-Patient Control Anesthesia dated 12/11/12 disclosed the first dose was given to the patient at 5:45 p.m., with assessment of pain scores and sedation. The 2nd dose was given to the patient at 8:15 p.m., with assessment of pain scores and sedation. The 3rd dose was given to the patient at 11:45 p.m., with assessment of pain scores and sedation.

However, there was no documentation that Patient 7's pain scores and sedation were assessed at 6:45 p.m., 7:45 p.m. and 8:45 p.m., which was "Q (every) 1 hour x 2".

During a concurrent interview with Staff G at 11 a.m. on 12/11/12, she admitted the pain and sedation had not been assessed.

According to the facility's policy and procedure for PCA:
" V. Patient Assessment
A. Initial and ongoing assessment will include the following every hour x2 hours, then every 4 hours for duration until PCA pump is discontinued (repeating this sequence with each dosage increase)."

Based on record review and interview, the facility failed to ensure verbal orders were authenticated within 48 hours for 2 of 33 sampled patients (Patient 13 and 14).

Findings:

1. On December 12, 2012, the medical record for Patient 14 was reviewed with Staff J. The physician orders were reviewed and revealed nine physician telephone orders dated December 5 and 6, 2012 were not authenticated. For example: On December 5, 2012 at 10:20 p.m., a telephone order indicated start IV Propofol drip (gtt) titrate per guidelines to maintain. On December 6, 2012 at 6:10 a.m., a telephone order indicated, Lasix 20 milligrams (mg) IV (intravenous) now. On December 6, 2012 at 8 a.m., a telephone order indicated Lasix 80 mg IV.

During a concurrent interview, Staff J stated verbal orders are to be signed within 48 hours.

2. On December 11, 2012, the medical record for Patient 13 was reviewed. The physician telephone order dated December 5, 2012 at 9:01 a.m., to admit to Med/Surg (Medical/Surgical), diagnosis osteomyelitis, lt (left) 3 toes confirmed by MRI was not authenticated.

During an interview at 2:45 p.m., the same day, RN 3 stated verbal orders must be signed by the physician within 48 hours.

A review of the facility's ByLaws, Rules and Regulations of the Medical Staff disclosed "The prescribing member, a covering or attending member, or another responsible for the care of the patient, even if the order did not originate with the countersigning member, shall countersign, date and time such orders within forty-eight (48) hours."

Based on record review and staff interview, the facility failed to ensure the 2 of 33 sampled patients (Patient 9 and 33) had discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care that completed within 14 days after discharge, per facility's policy.

Findings:

1. A review of the closed record revealed Patient 33 was admitted to the facility on November 13, 2012. The patient was discharged on November 16, 2012.

Further review of the medical record revealed the discharged summary was completed on December 3, 2012, which was 17 days after the discharge.

On December 13, 2012, at 1:35 p.m., during an interview with Staff B while reviewing the medical record , she stated the discharge summary should be completed 14 within days after discharge.

According to the facility's policy for "Suspension of Privileges", All patient will have timely dictation and documentation in the medical records by the physicians within fourteen (14) days after discharge or the physician privileges will be suspended until the medical records have been completed."Discharge summary with outcome of hospitalization, disposition of care and provisions for follow-up care.



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2. A review of the clinical record disclosed Patient 9 was admitted to the facility on November 11, 2012. The patient was discharged on November 16, 2012.

Further review of the record disclosed the discharge summary was completed on December 5, 2012, which was 19 day after the discharge.

During an interview with Staff B on December 13, 2012 at 2 p.m., she stated the discharge summary for Patient 9 was not completed within 14 days of discharge.

Based on observation, interview, and document review, the facility failed to control medications by failing to ensure monthly nursing unit inspection conducted consistently.

Findings:

On 12/12/2012, at 11:10 a.m., during an inspection of the "injection room" of the Nuclear Medicine department, there was a box inside a locked medication cart containing emergency medications. The content list taped to the outside of the box indicated there was item in the box that would have expired on "9/17/12". Another content list of the box was written with items that would be expiring on "12/12".

At 3 p.m., during a review of the facility's pharmacy record of inspection, the director of pharmacy acknowledged that unit inspections were not performed consistently; at least, for the radiology/nuclear medicine department, there was no record that inspection was performed in November 2012.

According to the facility's policy and procedure, titled "unit inspections and emergency drugs", dated "08/27/12", "Pharmacy staff shall be assigned to check all areas storing drugs outside the pharmacy every 30 days.

Based on observation, interview and record review, the facility staff failed to ensure that all drugs and biologicals were kept in a secure area when appropriate.

Findings:

1. On December 11, 2012, at 10 a.m., during the initial tour of the unit , the following was observed:

a. In Room 2106, there were two (2) 10 cc pre-filled syringes with 0.9% sodium chloride left unattended on top of the intravenous pump.

When RN 4 was summoned in the room for question, he stated the syringe should have not been left unattended. He then later disposed the pre-filled syringe in a regular trash can in the room. When he was asked, he stated the syringe with its content can be thrown in a regular trash can.

A review of the NPSG #3 Use Medication Safely indicated on Medication Wastage to drain NS (normal Saline) and D5 down the drain.

b. In Room 2132, there was a 10 cc syringe, three (3) needles, 4 packets of Povidone Iodine swab, a 250 ml of 0.9% sodium chloride intravenous bag and a suture removal kit which contained scissor, scalpel, etc. by the sink.

During a concurrent interview with RN 5 she stated the above mentioned items should not be left unattended by the sink for safety reason. She further stated she should have gathered all the supplies and put it back it the room when the physician is ready to do his suture removal for the patient.

c. In room 2144, there was a 10 cc pre-filled syringe with 0.9 % sodium chloride by the sink.

2. On December 12, 2012, at 8:45 a.m., during the tour of the Post-Partum Unit, two (2) bottles of pre-natal vitamins were observed in Patient 26's bedside table.

During a concurrent interview with the patient, she stated the medications belong to her, she takes it and her husband brought it to the hospital.

During a concurrent interview with the RN 6, she stated she saw the patient in the morning but was not aware of the medications. She further stated that if the patient brought her own medications, the medications should be verified by the pharmacy. The physician would be notified and obtain an order.

Review of the clinical record revealed there was no order for pre-natal vitamins or to keep the medication at the bedside.

Review of the facility's Pharmacy Facility number 6.10-2D Use of Patients Own Medications stipulated the following:
(1). The physician should indicate as a chart order"Patient may use own meds" including the name of the drug, strength and dosage regimen.
(2). The nurse should forward patient's own medications to the Pharmacy for verification of identity.



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3. On December 11, 2012 at 10:05 a.m. to 11:30 a.m., during tour of the Medical/Surgical Unit pre-filled 10 cc syringes were observed on top of the intravenous infusion pump in rooms 2156 and 2184. The syringes were pre-filled with clear solution with no needles.

During an interview at 11:55 a.m., Staff I, Director of Medical/ Surgical Unit stated the staff should not leave the syringes in the patient's room. Staff I further stated she had been educating the staff not to put the syringes in their pockets.

Based on observation, interview, and document review, the facility failed to control medications by failing to ensure monthly nursing unit inspection conducted consistently.

Findings:

1. On December 11, 2012 during a tour of the Operation Room #7 at approximately 11:20 a.m., a 20 ml (milliliter) vial of labetatol Hydrochloride [100 mg (milligram)/20 ml] in the anesthesia cart was observed opened but not dated.

During a concurrent interview, Staff D stated the vial should be dated when opened.

According to the facility's policy for "Medication Administration":
XII. Medication Storage
B. ---Multi-dose vials are dated, when opened and are discarded within 28 days, or earlier if indicated."



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2. During a tour of the Pharmacy on December 11, 2012 at 10:35 a.m., three medications were discovered in the pharmacy department to be expired:
a. An ear drop, Hydrocortisone and Acetic Acid Otic Solution 10 milliliters with an expiration date of October, 2012.
b. A tube of an antibiotic eye ointment, Ciloxan 0.3% Ophthalmic Ointment 3.5 grams, not in a box, with an expiration date of March, 2012
c. Located in the IV (Intravenous) Room one vial of Furosemide 100mg (10 milligrams per 1 milliliter) 10 milliliters vial, with an expiration date of November, 2012

During an interview on December 11, 2012 at 11 a.m., Director of Pharmacy (DOP) stated that the medications had expired and should have been pulled prior to December, 2012.

During a concurrent interview, the Pharmacy Technician (PT 501) stated that each full time Pharmacy Technician has an assigned area to check each month for expired medications.

At 11:05 a.m. a record review with the DOP and PT 501 of the facility's log sheet titled, "Expiration Date Monitoring and Pharmacy Responsibility Area" , listed seventeen pharmacy staff names indicating their assigned areas to check for expired medications for November and December 2012. However, on the November 2012 log sheet, there was one initial, indicating one out of seventeen areas was inspected. The DOP and PT 501 could not confirm that pharmacy staff had performed the expired medication inspection for areas that had not been initialed. Sixteen out of Seventeen areas had not been inspected for 42 days.

During an interview on December 12, 2012 at 3:30 p.m., PT 502 stated each pharmacy technician has their own area of responsibility to inspect for expired medications and is given the entire month to complete.

Review of the facility's policy and procedure titled, "Unit Inspections and Emergency Drugs", dated August 8, 2012 indicated the following:
"Expired medications shall be removed from stock in the designated areas. Pharmacy staff shall be assigned to check all areas storing drugs outside the Pharmacy every 30 days."

Review of the facility's policy and procedure titled, " Storage of Pharmaceuticals" , dated April 2, 2012 indicated the following:
"Stock shall be rotated so that the current stock is distributed first. Outdated drugs shall be removed from use and retained in a designated area of the storeroom or vault for appropriate disposal."

Based on observation and review of hospital menus and staff interviews, the hospital failed to ensure that menu developed for patients on pureed diets had variety. Lack of variety could result in elimination of a food group by a patient causing nutritional inadequacies.

Findings:

During dinner meal observation on 12/12/12 at approximately 5 p.m., mashed potato was observed on the plate of every patient who is on pureed diet. Review of the menu for patients on pureed diets revealed that every day for lunch and dinner on the seven day menu cycle, mashed potato is the only starch offered.

In addition, the hospital utilizes preformed meats and vegetables. Beef and Chicken are the only meats offered. Since the preformed are bought already prepared, patients on the pureed diet have only two choices of the same tasting meats throughout their stay in the hospital. According to the food service director, the hospital does not routinely puree entrees offered other patients on regular diets.

Based on review of clinical records, staff interviews and hospital documents, the hospital failed to ensure that the therapeutic diets for two patients (Patients N1 and N2) were ordered by the physician responsible for the care of these patients.

Findings:

1. Patient N1 was admitted to the hospital on 11/24/12 with diagnoses including acute cholecystitis (sudden inflammation of the gall bladder that causes severe abdominal pain) and intractable nausea and vomiting. She was initially placed on NPO (nothing by mouth) in preparation for surgery. On 11/27/12 she was placed on a clear liquid diet and on 11/28/12, the diet order was upgraded to a regular diet.

On 12/3/12, the nutrition services department received an order to provide a low fat diet for Patient N1. The low fat diet was provided from 12/3/12 to 12/6/12. The patient continued to have abdominal pain and refusing meals, on 12/6/12, she was placed on TPN. Review of clinical records did not reveal that the low fat diet was ordered by the physician.

An interview was conducted on 12/13/12 at approximately 2:30 p.m. with RN10, who stated that she had taken care of the patient on 12/3/12 and had ordered the diet. She further explained that the patient and daughter had requested the diet and so she placed the order. In response to a question about a need to get a physician's order prior to placing the order, she indicated she did not believe an order was necessary and as a nurse since she "can downgrade" the diet, implying her action was appropriate.

2. Patient N2 was admitted on 12/11/12 for surgery for Cushing's Disease, a disease associated with inappropriately high levels of the hormone cortisol, sometimes caused by tumors. After surgery, she was admitted to the intensive care unit with the preprinted orders form titled "Neurosurgery Admit Orders for Transsphenoidal (a surgery performed through the nose to remove tumors) patients". Included in the order was a category titled "Diet", the box "advance to regular as tolerated" was checked.

On 12/13/12 at approximately 3:00 pm, in an interview with the director of the CCU (Critical Care Unit), the unit where Patient N2 was admitted; she stated that nurses are trained on advancing diets. She stated that patient could start out with clear liquid or full liquid diets before advancing to regular diet. She shared other scenario leaving the nurse to base the decision on what diet to start with on his or her judgment. The director was not able to show any facility policy on criteria necessary to proceed to the next diet. The physicians order was not specific on diet to serve the patient. It was the only order that was non-specific that was left to the discretion of the nurse. There was no documented evidence that nursing staff clarified the order requesting the physician to be specific or give parameters as when to advance to the regular diet.

Based on observation, interview, and record review, the facility failed to ensure the patient's nutritional needs were met in accordance with recognized dietary practices.

Findings:

Patient N3 was admitted on 12/13/12 with diagnoses including acute renal failure, diabetes. She was placed on a 60 gram protein, 2 gram potassium, 2 gram sodium diet, carbohydrate controlled 1200 cc fluid restricted diet.

On 12/13/12 at approximately 4:00 pm, a tray cards with leftover food from lunch was observed on the table next to her bed. Review of the tray card showed that she was offered the following items: seasonal mixed green salad, braised pork with cranberry glaze and diet gelatin. There were colored stickers on the tray card. One of the colored stickers, yellow in color was titled fluid restriction, in red ink "7 oz" was hand written. The bright pink colored sticker written in large bold letters was the word "DIABETIC" and hand written in red ink was "1800".

The amount of food on the tray did not appear to be appropriate for the diet as ordered. Registered dietitian (RD) 1 who was present during the observation explained that the 1800 implied 1800 calories. She stated that when a specific caloric level is not specified in the diet order, the hospital policy is to offer 1800 calories. RD 1 stated that the tray slips are marked by the diet clerks to determine the amount and type of food a patient can receive on their trays.

Review of the Basic Diabetic Meal Pattern showed the 1800 calorie diet meal pattern had more food than the lunch that was served to Patient N3. According to RD1, the serving of diet gelatin was equivalent to four ounces of fluid, leaving three ounces not provided.

The dietary employee, diet clerk 1(DC 1) who marked the tray card was interviewed at approximately 10:00 am on 12/14/12. She indicated that she had not offered the patient more food as was allowed on the diet because of the restrictions on protein. She explained that if she had offered more food the amount of protein would have exceeded the 60 grams ordered by the physician. She had no explanation as to why the correct amount of fluid was not provided. She had no explanation for why the registered dietitians were not consulted when she realized that the diet order was complicated.

The hospital did not have a system in place to validate the accuracy of the tray cards marked by the diet clerks. The RDs do not cross check the tray slips prior to meals being served or during meal service. It is unclear how often errors like this are made resulting in inadequate calories or nutrients.

Patient N3 was served less food than was prescribed by the physician.

Based on observation, interview, and record review, the facility staff failed to maintain physical plant in such a manner that the safety and well-being of patients are assured.

Findings:

During a tour of the facility on December 11, 2012, from 10 a.m. - 11:02 a.m. and from 1:30 p.m. - 2:45 p.m., the following was observed:
RADIATION/ONCOLOGY
1. In the hallway, near the waiting area, the water fountain had green deposits in the nozzles.
2. In the skin therapy room, the knee wedge had torn covering.
3. In the mold room, there was a hole in the ceiling measuring approximately 2 inches in diameter covered with tape.
At the same time, the director of plant operations who accompanied the evaluator during the tour could not explain why there was a hole in the ceiling. He stated the hole should be sealed.
CLEAN LINEN ROOM
4. In the hallway outside the clean linen room, there were three carts with the name Bellwood Linen Company with clean linens that were outside the plastic containers. There was a linen cart in the hallway with a delivery date of December 9, 2012 with a bundle of baby blankets not inside the plastic container. There was no staff attending to the linens.

Inside the linen room, there were five storage racks containing clean linens with the covers on top of the rack exposing the clean linens.
At the same time, the administrator for the clean linens stated that staff was filling up the shelves. However, the evaluator did not observe any staff inside the room.
There was a backpack on top of one of the shelves touching clean scrubs. At the same time, during an interview, the administrator stated the backpack should not be placed on the shelf next to clean scrubs.
There was a shirt and a jacket hang on the pole of the storage rack for clean linens.
BASEMENT
5. In the chute room for the soiled linen, the floor had dust and debris.
6. In the chute room for the trash, the floor had dust and debris.
LABORATORY
7. In the histology room, the door under the sink failed to stay closed. Folded paper was used to keep the door closet. The two eye wash faucets had thick green deposits.
8. Four chair used by the staff had white deposits at the back and base of the chairs.
9. In the microbacterial room, the floor was dirty.
10. In the blood bank area, the faucet was leaking.
11. In the hematology area, under the counter containing the microscope, the base coving was detached and there was a stain along the wall.
12. In the coagulation area, under the counter containing the computer, there was a brown stain on the floor.
13. In the staff lounge, there was a cracked ceiling tile.
MORGUE
14. There was dust and debris on the floor.
CSS 1A
15. In the biohazard room, the ceiling vent screen had brown stains.
16. In room 2134, the trash receptacle was overflowing. The room was occupied by a patient on isolation precautions.
CSS 1D
17. In the restroom of room 2154, the faucet was leaking.
18. In room 2158, there was soiled towel on the floor.
During a tour of the facility on December 12, 2012, from 7:35 a.m. - 10:40 a.m., the following was observed:
SECOND FLOOR - POST CRITICAL CARE
19. In the common area shower room next to room 2292, there was a soiled face towel, bandage with brown stain, EKG leads and empty bottles of head to toe wash on top of the shower chair seat. On top of the chair, there was a soiled gown, a soiled towel, a soiled cloth shower cover. There were three soiled towels on the floor. There were two thermometers on stands stored in the shower room. The shower room was very dry, an indication that the shower room had not been used recently.
20. In the common area shower next to the Information Services Room, the ceiling vent had an accumulation of dust. There was an empty bottle of head to toe wash on the floor.
21. In the janitor closet, the floor and the service sink was dirty.
ICU 2A
22. In room 2236, the trash receptacle was overflowing. There was a pile of clean towels and 3 blankets stored in the room.
At the same time, during an interview, the licensed nurse stated that clean linens were not usually stored in the patient ' s room. The licensed nurse further stated the patient had a bath at 4 a.m. and that the patient was going to have a CT scan.
23. In room 2218, the trash receptacle was overflowing.
A review of the facility's policy and procedure entitled Bed Making Policy indicated hoarding or having excessive linen in the patient rooms is not permitted. Only linen additionally necessary for immediate use may be placed in the room.

Based on observation, interview and record review, the facility staff failed to implement its policy on infection control to prevent the potential spread of infections and communicable diseases.

Findings:

1. On December 11, 2012, at 10 a.m., during the initial tour of the facility with RN 7, the following was observed:

a. In Room 2122, RN 8 was observed providing care to Patient 23 who was sitting on the chair beside the bed. The patient had an indwelling catheter in place, was receiving 3 liter of oxygen via nasal cannula and had a peripheral IV access on the right wrist which was dated 12/10/12.
The RN was noted wearing a pair of gloves and touching the indwelling catheter bag to check the content for amount and color of the urine. Without removing the gloves, the RN used the telephone and gathered the unused syringe and paperworks.

During a concurrent interview with the RN, she acknowledged that she failed to perform hand hygiene and not changing gloves, washing hands and putting on a new pair of gloves when needed.

A review of the facility's policy number 322 Hand Decontamination: Handwashing and Hand Antiseptics stipulated decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

b. There was an intravenous bag of 0.9% sodium chloride and tubings hanging which were unlabeled and undated in the following rooms 2102, 2106, 2120 and 2132.

A review of the facility's policy number 200.101 Peripheral Intravenous Therapy stipulated solutions would be changed every 24 hours and replaced administration sets, including secondary sets and add-on devices every 96 hours unless catheter-related infection is suspected or documented.

c. The patients with peripheral IV access and/or PICC (peripherally inserted central lines) did not have labels on their access site dressing which indicated the date/time the access sites were placed in the following rooms: 2102, 2104, 2106, 2108, 2112, 2120, 2124, 2130, 2134, 2140, 2142, 2144 and 2148.

During a concurrent interview with RN 7, she stated the IV site dressing should be noted with the date and time when it was initially inserted.

A review of the facility's policy number:200.101 Peripheral Intravenous Therapy stipulated the IV site will be labeled with date, time, and initials at insertion time and with every dressing changes.

d. There were oxygen tubing, IV tubing and sequential compression device machine and connecting hose on the floor in rooms 2104, 2106, 2128, 2144 and 2148.

During an interview with Staff L on December 13, 2012, at 10 a.m., she concurred the above mentioned items should not be on the floor. The facility's policy number 342 Infection Prevention and Control stipulated contaminated disposable (single use) patient care equipment is handled and disposed of in a manner that reduces the risk of transmission of microorganisms and decreases environmental contamination in the hospital.

Based on record review and interview, the facility failed to ensure the medical history and physical examination was completed and documented before the procedure was started for 1 of 33 sampled patients (Patient 6).

Findings:

On December 12, 2012, between 8:52 a.m. and 10:35 a.m., a tour and open record review were conducted in the Orthopedic Unit with Staff F.

A review of the face sheet disclosed Patient 6 was admitted to the facility on December 11, 2012. The "Post Operative Procedure Notes for Inpatient" dated at 12:45 p.m. on 12/11/12 was reviewed and disclosed the patient had undergone a surgical procedure, revision intralaminar and subarticular decompression for lumbar 2 to lumbar 3, on 12/11/12.

A review of the medical record disclosed there was no documentation to indicate the time that the "History and Physical" was performed on 12/11/12.

During an interview with Staff F on 11/27/12 at 10:30 a.m., she stated the "History and Physical" had not been timed to indicate it was performed prior to the elective surgical procedure.

According to the facility's Medical Staff, General Staff Rules and Regulations" dated June 2012, page 145, "For elective procedure, the history and physical examination must be recorded and transmitted to the Health Center at least two (2) business days prior to the schedule date of the planned procedures."

Based on record review and interview, the facility failed to ensure a properly executed informed consent form for the operation was in the patient's chart before surgery for 1 of 33 sampled patients (Patient 10).

Findings:

A review of the "Information Record" disclosed Patient 10 was admitted to the facility on November 14, 2012. The "Operative Report" dated at 11:17 a.m. on 11/14/12 was reviewed. The patient had undergone a surgical procedure, right total hip arthroplasty on the admission day.

The "Verification of Informed Consent" dated 11/14/12 and "Pre-Operative History & Physical Examination" dated 11/13/12 were reviewed. There was no documentation that an alternative methods of treatment (if any) and their associated risks and benefits had been discussed or informed to the patient by the surgeon prior to the surgical procedure.

During an interview with Staff B on 12/13/12 at 2 p.m., she agreed there were no properly executed informed consent form for Patient 10's operation.

According to the facility's Medical Staff, General Staff Rules and Regulations" dated September 2012, page 147:

"6. d. Informed consent from the patient or authorized health care surrogate. The informed consent discussion between the member and the patient or surrogate should be sufficient to assure that the patient or surrogate receives known, relevant, applicable information necessary to make informed decisions about the contemplated care such as:

i. health status, diagnosis and progress;
ii. The nature and purpose of the proposed procedure, anesthesia to be used (if applicable), short and long-term risk and consequences and the probability that the proposed procedures will be successful;
iii. An explanation of alternative methods of treatment (if any) and their associated risks and benefits;
iv. An explanation of the risks and prognosis if no treatment is rendered; and
v. An explanation of who will actually perform the procedure, who will administer the anesthesia (if applicable), and which other practitioners will perform important parts of the surgical procedures."

Based on records review and interview with staffs, the facility failed to ensure an operative report describing findings was written by the surgeons immediately following surgery for 3 of 33 sampled patients (Patient 1, 4, and 5).

Findings:

1. On December 11, 2012, between 11:05 a.m. and 10:35 a.m., a tour and open record review were conducted in the Post Anesthesia Care Unit with Staff D.

A review of the clinical record disclosed Patient 1 was admitted to the facility on December 11, 2012.

The "Post-Operative Physician Progress Record" dated on 12/17/12 was reviewed and disclosed the patient had undergone a surgical procedure, bilateral ,lumbar 3 to lumbar 5 decompression. However, there was no documentation that the "Findings" had been described in the notes.

During an interview with Staff D on 12/11/12 at 11:35 a.m., she stated there was no documentation that the "Findings" had been described in the notes.

2. On December 12, 2012, between 8:52 a.m. and 10:35 a.m., a tour and open record review were conducted in the Orthopedic Unit with Staff F.

A review of the clinical record disclosed Patient 4 was admitted to the facility on December 10, 2012.

The "Post-Operative Physician Progress Record " dated on 12/10/12 was reviewed and disclosed the patient had undergone a surgical procedure, decompression lumbar 4 to lumbar 5, lumbar 5 to sacral 1. However, there was no documentation that the "Findings" had been described in the notes.

3. A review of the clinical record disclosed Patient 5 was admitted to the facility on December 10, 2012.

The "Post-Operative Physician Progress Record " dated on 12/10/12 was reviewed and disclosed the patient had undergone a surgical procedure, decompression spine lumbar 4 to lumbar 5. However, there was no documentation that the "Finding" had been described in the notes.

During an interview with Staff F on 12/11/12 at 10:30 a.m., she stated there was no documentation that the "Finding" had been described in the notes for both Patient 4 and 5.

According to the facility's Medical Staff, General Staff Rules and Regulations" dated June 2012, page 148:

The operative procedure report and the progress note must contain at least (7 elements):
(1) the name (s) of the primary surgeon(s) and assistants
(2) the name of the procedure(s) performed
(3) a description of each procedure and
(4) findings
(5) estimated blood loss
(6) specimens removed
(7) the post-operative diagnosis