HospitalInspections.org

Based on review of facility policy, medical records (MR) and staff (EMP) interviews, it was determined the facility failed to ensure staff followed established policies and procedures for providing care in a safe setting by by not providing direct visualization and allowing prohibited items in a patient room as ordered in two of two medical records (MR17 and MR43).

Findings include:

Review on October 8, 2019, of facility policy "Suicide/Self-harm Precautions", last approved by the facility on May 8, 2019, revealed "...Definitions: When used in this policy these terms have the following meaning...1:1 Direct Visual Observation: The provision of a member of the hospital's staff to be in constant attendance and in close proximity to the patient, even during bathroom use (patient will be accompanied by appropriate clinical staff). The staff member must have a clear and unobstructed view of the patient at all times...Emergency Department Procedure...Upon completion of the suicide evaluation indicating ideation with intent (high risk): 1. The 1:1 direct visual observation will be provided to observe the patient throughout the hospital stay or until the patient is medically cleared, admitted/transferred to a Psychiatric unit, or an evaluation by Psychiatry and an order is placed to discontinue the 1:1...3...All objects that pose a risk for self-harm that can be removed without adversely affecting the ability to deliver medical care should be removed...4. The direct visual observation will be provided even if the patient's family members or visitors are present...8. All patients presenting to the ED for evaluation of emotional/behavioral disorders and/or suicide attempt will be changed into paper scrubs...9. Their belongings will be secured until evaluated by a physician."

Observation during a tour of the Emergency Department (ED) on October 8, 2019, at approximately 1430, revealed MR17 was sitting on a stretcher in a cloth hospital gown in Room 4. MR17's personal belongings were observed on the floor beside the stretcher. Two visitors were observed in the room with MR17. EMP9 assigned to provide 1:1 observation was observed turning their back to the patient and walking into the nurses' station.

Review of MR17 on October 9, 2019, confirmed MR17 arrived at 1411 and was identified at triage to be at risk for self-harm.

Interview with EMP2 on October 8, 2019, at approximately 1430, confirmed MR17 should not be in a hospital gown and MR17's personal belongings should have been secured in the nurses' station. EMP2 also confirmed EMP9 did not provide 1:1 observation when they turned their back to the patient and walked into the nurses' station.

Observation during a tour of the Emergency Department (ED) on October 11, 2019, at approximately 0930, revealed MR48 lying on a stretcher in Room 4 covered with a blanket. Signage in/near Room 4 indicated that pillows and blankets were not permitted in the room.

Review of MR48 on October 11, 2019, at approximately 0935, revealed no provider order for the use of a blanket.

Interview with EMP5 on October 11, 2019, at approximately 0935, revealed patients in Room 4 are not permitted to have a blanket unless ordered by a provider. EMP5 confirmed MR48 did not have a provider order for use of a blanket.

Based on review of facility policy, observation and staff (EMP) interview, it was determined the facility failed to ensure a medical physical examination was completed prior to a procedure requiring anesthesia in the Surgical Short Procedure Unit (SPU) for one of one patient observed (MR56).

Finding include:

Review on October 11, 2019, of facility policy, "Patient Preparation, Guidelines for completion," last reviewed February 18, 2019, revealed "Purpose: The purpose of this policy is to correctly outline the steps for patient preparation the day of surgery ... Patient Preparation: ... 9. A history and physical [H&P], including evaluation of heart and lungs must be completed within 30 days and updated the day of surgery. ... 10. H&P update must be done day of surgery. ..."

Review on October 11, 2019, of facility policy, "Patient Assessment Prior to Induction of Anesthesia," last reviewed April 4, 2019, revealed "Purpose: To provide optimum patient care through a comprehensive pre-anesthesia evaluation, ensuring that the patient is hemo-dynamically [blood flow through the vessels provides a steady supply of oxygen to all tissues and organs in the body] stable to receive the administration of anesthetic agents. Policy: The policy of the Anesthesia Department is to assess all patients prior to delivery of anesthetic agents. This assessment is to be completed before the patient is transported to the Operating Room except in the case of a life and death emergency. All patients will have a pre-anesthesia evaluation prior to a surgical and/or invasive procedure in those instances where anesthesia services are requested. Procedure: ... the patient will be evaluated by an individual qualified to administer anesthesia. Individuals qualified to perform the pre-anesthesia evaluation include: a qualified anesthesiologist, a doctor or [sic] medicine or osteopathic medicine (other than an anesthesiologist) ... with the results of the evaluation documented ... The pre-anesthetic evaluation will include: ... examination of the patient ... All patients requiring anesthetic agents will be evaluated immediately prior to being transported the Operating Room, ..."

Review on October 11, 2019, of facility policy "Documentation and the Anesthesia Medical Record," last reviewed April 4, 2019, revealed "Policy: Each patient who receives care from a member of the Division of Anesthesiology will have a Geisinger [name] Anesthesia Record completed. Procedure: ... The anesthesia provider performing a procedure is responsible for completion of all relevant documentation. ..."

Observation of MR59 in the Surgical SPU, on October 10, 2019, at 10:00 AM noted OTH2 performing a medical history and physical on MR59. OTH2 did not listen to MR59's heart or lungs during this exam.

Interview with EMP8 on October 10, 2019, at 10:00 AM, confirmed OTH2 should listen to MR59's heart and lungs during the medical history and physical examination prior to a procedure requiring anesthesia.

Observation of MR59 in the Surgical SPU, on October 10, 2019, at 10:45 AM noted OTH3 performing a medical history and physical on MR59. OTH3 did not listen to MR59's heart or lungs during this exam.

Interview with EMP8 on October 10, 2019, at 10:00 AM confirmed OTH3 should listen to MR59's heart and lungs during the medical history and physical examination prior to a procedure requiring anesthesia.

Based on review of facility policy and medical records (MR) and staff (EMP) interviews, it was determined the facility failed to ensure staff followed established policies and procedures regarding pain evaluation and reassessment for three of three medical records (MR4, MR36 and MR43) and failed to administer medication as ordered in one of one MR (MR36).

Findings include:

Review on October 9, 2019, of the facility's "Pain Evaluation and Management" policy, last approved by the facility April 4, 2019, revealed..."Responsibilities: Licensed staff are required to:...1. Obtain the patient's pain history. 2. Evaluate the patient for pain...3. Implement interventions as ordered. 4. Evaluate effectiveness of interventions. The degree of pain relief should be determined after each pain reducing intervention, after sufficient time has elapsed for treatment to reach peak effect or within 60 minutes after intervention. Documentation should reflect the time of the evaluation...Procedure:...4...a. Pain interventions 1. Pharmacologic interventions must correlate to the appropriate analgesia ordered for the identified numeric pain score-mild, moderate, or severe...Pain Evaluation Tools Self-reporting tools;[sic]...Geisinger Adult Pain Scale...Score of 1-3 indicates mild pain Scores of 4-5 indicates[sic] moderate pain Scores of 6-10 indicate severe pain..."

1) Review on October 9, 2019, revealed MR4 was administered Fentanyl (pain medication) intravenously (IV) at 1225 on October 9, 2019. There was no documentation of a pain reassessment following the medication. Further review of MR4 revealed an additional dose of Fentanyl was administered IV at 1317. There was no documentation of a pain evaluation prior to the pain medication administration or a pain reassessment following the administration of the Fentanyl.

Interview with EMP3 on October 9, 2019, at approximated 1415, confirmed no documentation was present in MR4 of pain reassessment following pain medication administration at 1225. EMP3 confirmed no documentation was present of pain evaluation prior to the administration of pain medication at 1317 or pain reassessment following that medication administration.

Review on October 11, 2019, of MR36 revealed MR36 was administered Oxycontin (narcotic) for pain on October 10, 2019, at 2223. There was no documentation of a pain evaluation prior to the administration of the Oxycontin.

Interview with EMP5 on October 11, 2019, at approximately 1100, confirmed there was no documentation in MR36 of a pain evaluation prior to the administration of pain medication on October 10, 2019, at 2223.

Review on October 11, 2019, of MR43 revealed the administration of pain medication on July 10, 2019, at 1542. There was no documentation of a pain reassessment within 60 minutes following the administration of the medication.

Interview with EMP3 on October 11, 2019, at approximately 1145, confirmed there was no documentation in MR43 of a pain reassessment within 60 minutes following the administration of pain medication.

2) Review on October 11, 2019, of MR36 revealed at 2030 on October 9, 2019, MR36's self-reported pain score was nine (severe pain). MR36 was administered Toradol ordered for moderate pain at 2041. Further review of MR 36 revealed the administration of Oxycontin (narcotic) for pain on October 10, 2019, at 2223. There was no documentation of a pain evaluation prior to the administration of the Oxycontin.

Interview with EMP5 on October 11, 2019, at approximately 1100, confirmed MR36 was given a medication for a moderate pain score for a complaint of severe pain on October 9, 2019. EMP5 also confirmed there was no documentation in MR36 of a pain evaluation prior to the administration of pain medication on October 10, 2019, at 2223.

Based on review of facility policy, observation and staff (EMP) interview, it was determined the facility failed to ensure acceptable supplies were available for immediate use for six of six sexual assault kits and failed to ensure documentation of daily checks of emergency equipment was completed in the Obstetrics and Nursery areas.

Findings include:

1) Review on October 9, 2019, of facility policy, "SAFE Program-Sexual Assault Policy," last reviewed May 10, 2019, revealed "Purpose To provide immediate medical and emotional care to the victim of reported sexual assault and to provide professional and timely collection of evidence. Ensure medical examinations and laboratory or diagnostic tests are completed to ensure the health, safety and welfare of the sexual assault victim. ... Policy This policy is intended to ensure compassionate care of the patient and to guide the collection and handling of medical forensic evidence in reported sexual assault cases. Additionally, this policy is to make certain that appropriate specimens are collected, and that medical forensic evidence is maintained in an unbroken chain of custody. ..."

Observation on the Obstetrics Unit on October 9, 2019, at 1:10 PM, revealed the Sane Room (used for exam of sexual assault victims) with four sexual assault kits with an expiration date of October 31, 2018 and one sexual assault kit with an expiration date of November 30, 2018. Further observation revealed no acceptable sexual assault kits in the room.

Interview with EMP2 on October 9, 2019, at 1:10 PM, confirmed the Sane Room had four sexual assault kits with an expiration date of October 31, 2018 and one sexual assault kit with an expiration date of November 30, 2018. Further interview confirmed the Sane Room had no acceptable sexual assault kits for immediate use.

Observation in the Emergency Department on October 9, 2019, at 1:22 PM, revealed the room used for sexual assault victims with one sexual assault kit with an expiration date of October 31, 2018 and one sexual assault kit with an expiration date of November 30, 2018.

Interview with EMP2 on October 9, 2019, at 1:22 PM, confirmed the room used for sexual assault victims in the Emergency Department had one sexual assault kit with an expiration date of October 31, 2018 and one sexual assault kit with an expiration date of November 30, 2018. Further interview confirmed the room had no acceptable sexual assault kits for immediate use for sexual assault exams and for collection of appropriate specimens.

2) Review on October 9, 2019, of facility policy "Code Cart Checklist," last reviewed January 18, 2019, revealed Purpose: The purpose of this policy [sic] to provide a list of all items located within the code cart. Policy: It is the policy of [name] and GBH (Geisinger Bloomsburg Hospital) to have properly stocked and standardized code carts. ..."

Review on October 9, 2019, of facility policy "Daily Emergency Equip. Checking Instructions Code Cart/Intubation Boxes," last reviewed May 15, 2019, revealed "Purpose: The purpose of this policy is to standardize the process of checking the intubation box and code cart daily. ..."

Review of "Daily Emergency Equipment Checksheets" on October 8, 2019, revealed
documentation of the equipment checks for the Obstetrics and Nursery areas were missing for four days in March 2018, seven days in May 2018, two days in June 2018, seven days in July 2018, three days in September 2018, eight days in October 2018, three days in November 2018, six days in December 2018, one day in January 2019, four days in March 2019, seven days in April 2019, one day in May 2019, three days in June 2019 and six days in July 2019.

Interview with EMP6 on October 8, 2019, at approximately 12:40 PM, confirmed the Daily Emergency Equipment Checksheets for the Obstetrics and Nursery areas had documentation missing for four days in March 2018, seven days in May 2018, two days in June 2018, seven days in July 2018, three days in September 2018, eight days in October 2018, three days in November 2018, six days in December 2018, one day in January 2019, four days in March 2019, seven days in April 2019, one day in May 2019, three days in June 2019 and six days in July 2019. EMP6 confirmed the Emergency Equipment Checksheets are to be noted daily when the Code Carts are checked.

Interview with EMP5 on October 8, 2019, at 1:20 PM, confirmed the Daily Emergency Equipment Checksheets for the Obstetrics and Nursery areas had documentation missing for four days in March 2018, seven days in May 2018, two days in June 2018, seven days in July 2018, three days in September 2018, eight days in October 2018, three days in November 2018, six days in December 2018, one day in January 2019, four days in March 2019, seven days in April 2019, one day in May 2019, three days in June 2019 and six days in July 2019. EMP6 confirmed the Emergency Equipment Checksheets are to be noted daily when the Code Carts are checked.

Based on review of facility documents and staff (EMP) interview it was determined the facility failed to complete a periodic review between the Organ Procurement Organization (OPO) and the hospital death records during the time frame of July 1, 2018 through June 30, 2019.

Findings include:

Review on October 11, 2019, of the facility's "Organ, Tissue and Eye Donation" policy, last approved October 5, 2018, revealed "... I. Principles A. It is an essential objective of this policy that the interest in procuring organs and tissues does not interfere with optimal patient care by health care professionals. B. Decisions concerning the treatment and management of the patient (including but not limited to the decision to withdraw life support) must be made independently by the responsible attending physician and separately from discussions of organ donation. C. Upon determination of non-recoverable illness or injury at the first signs of neurologic devastation and/or other progressive, terminal system failure, referral to [name] will be made by the attending physician (or designee), charge nurse, bedside nurse, nursing supervisor, or social Worker. The referral to [name] should occur prior to termination of life sustaining measures. The timing of referral should allow sufficient time for [name] to arrive prior to withdraw of support whenever possible. ..."

Review on October 9, 2019, of the [name] and facility reconciliation revealed the facility reconciled the January 1, 2019 - June 30, 2019 data in response to the Department's request on October 8, 2019. The facility reconciliation revealed no documentation of notification to the OPO of MR19's death on June 1, 2019. Further review of the reconciliation revealed no documentation of notification to the OPO of MR20's death on June 4, 2019.

Interview with EMP1 on October 9, 2019, at 2:40 PM, confirmed the facility reconciled January 1, 2019 - June 30, 2019 in response to the Department's request on October 8, 2019. EMP2 confirmed the reconciliation revealed the OPO was not notified of the death of MR19 on June 1, 2019 or the death of MR20 on June 4, 2019. Further interview with EMP2 confirmed facility policies do not address the OPO and facility reconciliation process.

Based on review of facility policy, observation and staff (EMP) interview, it was determined the facility failed to ensure proper attire in the Operating Room during a procedure.

Findings include:

Review on October 10, 2019 of facility policy, "Surgical Suite Attire Policy," last reviewed February 21, 2019, revealed "Purpose: The Infection Control Surgical Attire Policy establishes guidelines to reduce the risk of healthcare associated infections for patients and personnel in the surgical suite. Persons Affected: All Geisinger personnel working in a surgical suite. ... Procedure: 1. General Regulations: ... f. ... I. Restricted Zone - requires complete scrub attire, including: ... 4) Head covers. Personnel entering the restricted areas should cover their head, hair, and facial hair. ... k. ... II. Head covers: 1) Personnel entering the restricted and or semi-restricted areas should cover the head and hair. ... III. Beard covers: Disposable beard covers must be worn for all staff with facial hair. ..."

Observation of a procedure on MR59 in an Operating Room, on October 10, 2019, at 11:45 AM, noted the Surgical Tech (OTH1) with facial hair uncovered, approximately two inches by two inches, on each side of their face.

Interview with EMP7 on October 10, 2019, at 11:45 AM, confirmed OTH1 with facial hair uncovered, approximately two inches by two inches, on each side of face. EMP7 confirmed all facial hair is to be covered. EMP7 confirmed the facility has beard covers.