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Based on observation, interview, and record review, the facility failed to provide visual privacy during a respiratory assessment and treatment for 1 of 53 sampled patients (595).

Findings:

During a tour of the 5th floor on 5/10/11 at 10:50 A.M., Patient 595 was observed in bed. A family member was at the bedside. The patient's room was located in an area where two hallways join together in a T, so that anyone walking by in the hallway could see into the room. The privacy curtain and door to the room were open. Staff 514 (a Respiratory Care Practitioner) provided a breathing treatment to the patient. Staff 514 placed a stethoscope on the patient's chest to assess the patient's lungs. Staff 514 then suctioned the patient and said to the patient in a loud voice, "I need you to cough. Cough harder. Cough harder." The patient was not alert and did not participate in the care.

Staff 514 was interviewed on 5/10/11 at 10:55 A.M. She stated that she described the procedure to the patient, prior to the treatment. She conducted the treatment, took vital signs before and after the treatment, assessed the patient's lungs, and then suctioned the patient. She said the patient was confused and unable to participate in the care. She said that as a routine, she does not always close the privacy curtain or the room door when providing a treatment and conducting an assessment.

Patient 595's medical record was reviewed on 5/10/11. According to the licensed nurse's notes, the patient was recently admitted to hospice services for palliative (comfort) care, was comatose and actively dying.

The Family Member was interviewed on 5/10/11 at 11:00 A.M. He said the patient was comatose. He said that if the patient was alert, she would probably be bothered by the lack of visual privacy during the respiratory treatment and assessment.

According to the Patient Rights and Responsibilities, provided to every patient upon admission, "You have the right to:...Have personal privacy respected. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. You have the right to be told the reason for the presence of any individual. You have the right to have visitors leave prior to an examination and when treatment issues are being discussed. Privacy curtains will be used in semi-private rooms."

Based on observation, interview, and record review, the facility failed to ensure that a Registered Nurse (RN 511) was familiar with the plan of care for 1 of 53 sampled patients (594) related to an endoscopy procedure, medication administration for a patient with an order for NPO (nothing by mouth) , and the use of a urinary catheter. The facility failed to assess and document skin breakdown for 1 of 53 patients (596).

Findings:

1a. Patient 594 was observed in bed on 5/10/11 at 8:55 A.M. Signage outside the room indicated the patient was on isolation precautions and was NPO (nothing by mouth).

Registered Nurse 511 was interviewed on 5/10/11 at 9:00 A.M. regarding the plan of care for Patient 594. The RN stated she took over care of the patient at 7:30 A.M. and this was her first time caring for the patient. RN 511 stated the patient was on isolation precautions related to a MRSA (Methicillin Resistant Staphylococcus Aureus - an antibiotic resistant organism) infection from a prior hip surgery. She said the patient did not have MRSA at the present time. The patient was currently admitted for a urinary tract infection (UTI) and confusion. The patient had been NPO since midnight for an endoscopy procedure. RN 511 said she was unsure of the date and time of the procedure or the reason for the procedure. When prompted, RN 511 contacted surgery scheduling at 9:40 A.M. and reported the patient was scheduled for an gastroscopy (scope of the stomach) at 1:00 P.M.

Patient 594 was interviewed on 5/10/11 at 10:00 A.M. She stated she was admitted to the hospital for problems with her memory and because she was not feeling well. She said she had a UTI and received intravenous (IV) antibiotics. Her physician discussed with her the day prior, that she was suppose to have a "scope of my stomach sometime today." She said she had not had anything to eat or drink since midnight and she was hungry. She said she asked her nurse about the procedure, but had not been given any information regarding the time of the procedure.

Patient 594's medical record was reviewed on 5/10/11 at 10:10 A.M. The emergency room labs, dated 5/5/11, indicated the patient was severely anemic and required 2 units of blood. Two stool tests submitted on 5/9/11, indicated the patient had blood in her stool. According to the progress record, the physician discussed the scope procedure with the patient on 5/9/11 at 11:38 A.M.

RN 511 was again interviewed on 5/10/11 at 10:25 A.M. The medical record was jointly reviewed. She stated she was not aware that Patient 594 required 2 units of blood in the emergency room for a very low blood count. She was not aware the patient had blood in her stool. She was not aware of the reason for the endoscopy and had not notified the patient of the date and time of the procedure. She acknowledged she was not familiar with the patients' plan of care.

1b. Patient 594 was observed in bed on 5/10/11 at 8:55 A.M. Signage outside the room indicated the patient was to have nothing by mouth (NPO).

Patient 594 was interviewed on 5/10/11 at 10:00 A.M. She stated she was suppose to have a "scope of my stomach sometime today." She said she had not had anything to eat or drink since midnight and she was hungry.

Patient 594's medical record was reviewed on 5/10/11. Physician's orders, dated 5/9/11 at 5:21 P.M., indicated the patient was to be, "NPO after midnight." The medication administration record indicated the nurse administered Synthroid (for a thyroid condition) orally (by mouth) at 6:00 A.M.

In addition, the licensed nurse administered the following medications orally at 9:00 A.M.: Liothyronine (for a thyroid condition), Lopressor (for high blood pressure) Remeron (for depression), Ditropan (for an overactive bladder), Protonix (for a stomach condition ), Zoloft (for depression), and Cytomel (for a thyroid condition).

The following medications were scheduled for 9:00 A.M., but were not given: Colace (stool softener), Prednisone (a steroid), and Ferrous Sulfate (iron replacement). The patient's blood pressure was 166/74 at 5:00 A.M. and 159/74 at 8:00 A.M.

RN 511 was interviewed on 5/10/11 at 10:25 A.M. She stated she gave the blood pressure medication, because the patient's blood pressure was elevated. She gave the Remeron, because the patient was depressed. She held the Colace, because the patient had diarrhea. She held the Prednisone, because the medication needed to be given with food and it was ordered only once a day. She stated she did not contact the physician for clarification as to whether the medications were to be administered as ordered or held until after the procedure.

The Nurse Supervisor (RN 512) was interviewed on 5/10/11 at 10:35 A.M. She stated that if the patient was NPO, she would not have administered the medications without first checking with the physician.

The facility policy titled NPO Status of Surgical Patients, effective 3/30/05, indicated the purpose of the NPO status was, "To provide fasting guidelines to reduce the risk of pulmonary aspiration for surgical patients and all endoscopy patients receiving monitored anesthesia." The policy continued, "Endoscopy patients need to call their physicians office for clarification of fasting orders."

1c. Patient 594 was observed on 5/10/11 at 10:00 A.M. with a urinary catheter in place. The urine in the tubing was cloudy and contained sediment. Patient 594 stated she did not have a urinary catheter prior to admission and she was unsure why the catheter was in place. She stated she used a walker at home to ambulate, but was able to move about in her hospital room without the walker.

Patient 594's medical record was reviewed on 5/10/11. According to the emergency room nurse's notes, dated 5/5/11, a Foley (urinary) catheter was inserted while the patient was in the emergency room. Licensed nurse's notes indicated the catheter remained in place from 5/5/11 until the present time. Laboratory studies and physician's orders, dated 5/5/11 through 5/9/11 , indicated the patient had a urinary tract infection, requiring antibiotics for treatment.

RN 511 was interviewed regarding the patient's plan of care on 5/10/11 at 10:25 A.M. The medical record was jointly reviewed. RN 511 said she was unsure why the catheter was in place, but it was probably placed because the patient could not get out of bed. She acknowledged she was not familiar with the patient's plan of care.

2. Patient 596 was observed on 5/11/11 at 9:20 A.M. The patient was sight impaired, but was able to follow simple commands with verbal cues from the RN. The patient became increasingly agitated and kicked off her covers. Patient 596 was observed to have six dried blisters present on the top of the third, fourth, and fifth toes of the left foot. Four dried scabs were present on the top of the left foot. One dried scab was present on the bottom of the left foot. Abrasions and multiple scabs were present on both shins. Bandages covered wounds on the left knee and left elbow. Bruising covered both forearms.

Patient 596's medical record was reviewed on 5/11/11. The emergency room nursing assessment indicated the patient entered the emergency room on 5/9/11 at 5:15 P.M. The patient was assessed with excoriation to the rectal area and a photograph was taken on 5/9/11 at 8:40 PM. Two additional photographs were taken on 5/9/11 (no time) and labeled left knee and left arm. There was no description of the lesions on the left foot documented on the emergency room nurse's notes.

The physician's admission history and physical, dated 5/9/11, indicated the patient had ecchymosis (bruising) to the upper extremities (arms), left anterior/lateral knee erythema (redness) with unstageable wound, skin tears, and perianal excoriation (redness). On 5/9/11, the physician made a request for the Wound Care Nurse Specialist to see the patient.

On 5/9/11 at 9:45 P.M. the skin assessment indicated the patient had redness/excoriation to the left arm and left leg, described as dry and ecchymotic. In addition, the skin assessment indicated the patient had abrasions on the left arm and left leg, described as dry and ecchymotic.

The Adult Admission Assessment, dated 5/9/11 at 9:45 P.M. indicated the patient had excoriation on the coccyx, a left knee wound that was dry with intact skin, an abrasion to the left arm, redness/excoriation to the rectal area, and dry ecchymotic areas on the left arm and left leg. The assessment did not contain documentation related to the patient's skin breakdown on the legs and feet or a description of the dried blisters and abrasions on the patient's toes, foot, and shins.

According to the Nursing Narrative, the Wound Care Nurse Consultant conducted and documented an assessment on Patient 596 on 5/10/11 at 10:19 A.M. The assessment identified the patient with a pressure ulcer on the left knee with soft eschar (black dead tissue covering the pressure ulcer) and a wound above the elbow that was not a pressure ulcer. The assessment indicated there was not a wound on the coccyx, instead the patient had "denuded skin" around the anus. There was no mention of the blisters on the left foot or the abrasions and scabbed areas on the lower legs. Wound care orders listed treatment for the left elbow wound, the left knee pressure ulcer, and the perianal area.

The Adult Ongoing Assessments for 5/10/11 at 8:00 A.M. and 8:15 P.M. were reviewed. There was no documented assessment related to the skin breakdown on the patients left foot and lower legs.

RN 526 was interviewed on 5/11/11 at 10:10 A.M. She stated she was notified of the skin breakdown during shift report. She acknowledged there was no documented assessment related to the dried blisters, scabbed areas, and abrasions since the patient's admission two days prior.

The Wound Care Nurse Consultant was interviewed and the medical records for Patient 596 were jointly reviewed on 5/11/11 at 2:15 P.M. She stated she was asked to evaluate the wounds on the patient's left knee, left elbow, and buttocks. She said she noticed the wounds on the patient's left foot and lower legs, but did not include those areas in her assessment. She said the licensed nurses should have assessed and documented all wounds that were present during the initial skin assessment and with each subsequent assessment.

The Standards of Patient Care for the Adult Inpatient indicated that skin assessments should include the skin color, description, temperature, integrity, turgor, pressure ulcer, surrounding tissue, any other type of wound, and skin integrity risk score (Braden). The section titled Documentation included, "Document initial assessment with measurements on Integumentary portion of Adult Admission Assessment. Document shift assessment on Integumentary portion of Adult Ongoing Assessment."

Based on observation, interview, and record review, the facility failed to ensure medications were administered according to physician's orders for 1 of 53 sampled patients (597).

Findings:

Licensed Nurse (LN) 525 was observed during the medication pass on 5/11/11 at 8:40 A.M. LN 525 administered five medications, including Famotidine (Pepcid), to Patient 597. The physician's orders were reconciled with the medications administered. According to the admission physician's orders, dated 5/9/11, the patient was prescribed Ranitidine (Zantac), not Pepcid.

LN 525 stated the licensed nurse's were required to check the physician's orders against the Medication Administration Records (MAR) every 12 hours to prevent medication errors. She reviewed the physician's orders and validated that every 12 hours since the patient's admission, a licensed nurse documented "24 hour chart check," which meant the physician's orders were compared with the MAR and determined to be accurate.

The Nursing Supervisor (LN 510) was interviewed on 5/11/11 at 9:00 A.M. She stated the pharmacy does not supply Zantac and substitutes the medication with Pepcid. She stated the pharmacy usually writes an order and faxes the new order to the unit. The physician's orders were jointly reviewed. She was unable to locate a physician's order or a fax from the pharmacy for Pepcid.

The Pharmacist (Staff 529) was interviewed on 5/11/11 at 11:55 A.M. She stated that therapeutic medication substitutions for medications in the same classification were approved by the Pharmacy and Therapeutics Committee. She stated that Pepcid was one of the approved substitutions for Zantac. When the pharmacy received an order for Zantac, the pharmacy would automatically substitute the medication with Pepcid. The order for Pepcid would be entered on the MAR and a fax would be sent to the unit with the new orders. She acknowledged the fax for the medication substitution for the Pepcid was not on the patient's medical record, yet the nursing staff administered the medication without a physician's order.

Based on record review, 2 of 53 sampled patients (102, 103) closed post-surgical records reviewed contained multiple physician's orders that did not have a time of the physician's signature. This resulted in an inability to properly construct the sequence of events when the chart is reviewed for Quality Assurance purposes.

Findings:

1. Four closed surgical records were reviewed on 5/9/11 at 10:50 A.M. Record 102 contained multiple orders that were not timed. Examples of written orders not timed or dated in record 102 include preprinted orders for Pre-Operative Tests ordered for 3/22/11 that were signed but not dated or timed. Post-Op orders for the same date lacked a time of the provider's signature.

Examples of verbal orders in record 102 that were not properly authenticated include a Medication Reconciliation form signed and dated by the doctor on 3/22/11 but not timed. Also, a verbal order on 3/23/11 for Buspar and other medications was not signed by the physician.

2. Examples of verbal orders in record 103 without proper authentication by the provider include a telephone order for discharge that was not signed by the provider. A verbal order for medications dated 3/02/11 (amicar and calcium) was not signed by the physician.

Based on observation, interview and record review, the hospital failed to ensure that all potentially hazardous foods were cooled down safely.

Findings:

On 5/9/11 at 10:16 A.M., there was a pan of pasta was in the walk-in refrigerator. The Executive Chef stated the pan size was 4" deep and approximately 18" long, and the pasta was "cooked here yesterday" for the cafe. The Executive Chef stated that the pasta was not cooled down because "we do not cool down a food that is not a high risk item."

The Food Service Director was present during the interview and acknowledged that pasta for the cafe was not incorporated into their food service systems to be cooled down safely. The Registered Dietitian (RD 1) stated that the pasta was used for the cafe, and could be provided to patients as a "Substitute Menu Selection" option. The "Substitute Menu Selections" included items such as macaroni and cheese and pasta with marinara.

On 5/10/11 at 9:15 A.M., the System Director over food service operations stated that "absolutely, the pasta should have been cooled down."

According to the hospital's policy and procedure entitled Cooling Log for Potentially Hazardous Foods indicated, "Potentially hazardous foods must be kept at 41 degrees Fahrenheit or below or 135 degrees Fahrenheit or above. In order to be properly cooled, the food must reach 41 degrees Fahrenheit within 6 hours. Process: *135 degrees to 70 degrees within 2 hours; * 70 degrees Fahrenheit to 41 degrees within an additional 4 hours; *total cooling time of 6 hours."

A potentially hazardous food that is allowed to remain in the temperature danger zone enough for the bacteria to produce toxins will become unsafe to eat. Most toxins are not destroyed by high temperatures which could cause a food borne illness. (FDA Food Code 2009)

Based on interview and record review, the hospital failed to ensure there was documentation to indicate 2 of 53 sampled patients (200, 403) received a nutrition supplement in accordance with physician's order.

Findings:

1. On 5/9/11 at 1:53 P.M., Patient 200's clinical record had a physician's order, dated 5/6/11, that indicated, "Beneprotein (a protein powder) three scoops daily while on propofol...". A nutrition assessment for Patient 200 was completed the same day by a registered dietitian (RD) with recommendations, "Beneprotein 3 scoops daily while on propofol" to benefit the patient's nutritional status.

On 5/9/11 at 2:15 P.M., Clinical RD 201 reviewed Patient 200's clinical record and was unable to find documentation that Beneprotein was provided to Patient 200 in accordance with physician's order.

On 5/9/11 at 2:30 P.M., Licensed Nurse (LN) 202 reviewed Patient 200's medical record via paper chart and the electronic medical record, medication administration record (MAR), and flowsheet for 5/8/11, and verified that there was no documentation that Patient 200 received 3 scoops of the protein powder as ordered by the physician.

LN 202 stated that if Beneprotein was provided to Patient 200 then it should have been documented under the intake section of the flow sheet as that was part of a patient's permanent medical record. LN 202 stated that the MAR is discarded after use.

2. On 5/10/11 at 9:28 A.M., Patient 403's clinical record had a physician's order, dated 4/25/11 at 1:10 P.M. that indicated, "...Beneprotein 4 scoops TID (three times a day)." A nutrition assessment for Patient 403 was completed the same day by a registered dietitian with recommendations for "Beneprotein 4 scoops TID" to benefit the patient's nutritional status. There was another physician's order, dated 4/28/11, that indicated, "...stop Beneprotein."

On 5/10/11 at 9:50 A.M., Clinical RD 204 reviewed Patient 403's paper clinical record, electronic medical record (including nursing narrative, and nursing form) and flowsheet for the time period of 4/25/11 - 4/28/11 and was unable to locate any documentation that the Beneprotein had been provided to Patient 403 in accordance with physician's orders.

On 5/10/11 at 10:12 A.M., LN 203 stated that nursing staff was trained to document Beneprotein on the flowsheet under the intake section. LN 203 verified that there was no documentation that Beneprotein had been given to Patient 403 between 4/25/11 - 4/28/11 in accordance with physician's orders.

Based on observation, interview, and record review, the facility failed to ensure 4 staff members utilized gloves appropriately and used appropriate hand hygiene after handling items soiled with body fluids and during the medication pass. The facility failed to ensure blood glucometer's were cleaned with the appropriate cleaning agents after exposure to clostridium difficile (a bacteria that causes severe diarrhea). The infection control officer failed to identify and address breaches in infection control practices occurring at the hospital's Ambulatory Surgery Center. This resulted in chemical cleaners not being used per manufacturers recommendations.

Findings:

1. On 5/10/11 at 10:51 A.M., Staff 513 (a Certified Nursing Assistant) was observed entering the hallway from a patient room. She was carrying a washcloth in her bare hands. The washcloth was soiled with a brownish substance. She approached the door to the soiled utility room and attempted to enter a code several times before she was able to gain access to the room. She stated the washcloth was soiled with vomit. She stated that she knew she was suppose to wear gloves when she handled items soiled with body fluids.

After placing the washcloth in the dirty utility room, Staff 513 exited the dirty utility room without washing her hands or using hand gel. She then went to the nurse's station and had a discussion with a licensed nurse. As she was speaking to the nurse, she touched the nurse on the arm. Staff 513 and the licensed nurse went to another patient's room. After entering the patient's room, Staff 513 utilized the hand gel on her hands.

According to the Infection Control Standard Precautions policy and procedure, effective 9/9/10, hand hygiene with soap and water is required when "hands are visibly soiled." Gloves are to worn "when touching sources of microorganisms (blood or other potentially infectious materials, mucous membranes, and nonintact skin."

According to the Patient Safety flyers, posted throughout the facility, "Alcohol based hand sanitizers are used except during during the following instances: when hands are visibly soiled, after using the restroom, before meals."

2. The laboratory was inspected on 5/10/11 at 1:05 P.M. Staff 518 was the only staff member in the laboratory, during the tour, that was not wearing gloves. In the blood bank, Staff 518 opened a cabinet and removed blood products. He demonstrated the procedure for signing out blood products, as he held the blood products in his ungloved hands. When asked why he was not wearing gloves as all the other staff, he replied, "I'm not working."

According to the Infection Control Standard Precautions policy and procedure, effective 9/9/10, gloves are to worn "when touching sources of microorganisms (blood or other potentially infectious materials, mucous membranes, and nonintact skin."

3. During a tour of the 5th floor, on 5/10/11 at 11:40 A.M. a Licensed Nurse (Staff 515) was asked about infection control practices regarding blood glucometer's. She stated the glucometer's were cleaned after each use with a sanitizing agent. She pointed to a purple top container and stated, "That's what I use." She stated she would use the same sanitizing agent to clean the glucometer after caring for a patient with clostridium difficile, a bacterial infection that causes severe diarrhea.

The Nurse Supervisor (Staff 512) was interviewed on 5/10/11 at 11:50 A.M. She stated that when the glucometer was used on a patient that had clostridium difficile, the glucometer was cleaned with a sanitizing agent that contains bleach. She pointed to a white top container, located next to the purple top sanitizing agent, and said, "We use this one for c. diff."




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5a. The Ambulatory Surgery Center was toured on May 10, 2011 at 9:50 A.M. Two of four operating rooms (ORs) were inspected. The head cushion on the OR table in room 3 was frayed in multiple places and had multiple tears to the point that the foam filling was exposed. The cushion could not be effectively sanitized.

5b. The instrument processing area was inspected. The surgical technologist (Staff 117) was asked to demonstrate how she would mix the enzymatic cleaner for the soak and hand wash of surgical instruments. She presented a basin and stated she would put water in the basin and then add 3 pumps (1 oz per pump) to the water. The amount of the water in the basin was measured and was approximately 1 gallon. Per the manufacturers recommendations for the product (Asepti-Zyme Multi), the correct concentration was 1 to 2 ounces per gallon. The concentration actually being used was 3 ounces per gallon.

5c. Housekeeping Staff 118 was in OR 2 when it was inspected. She was asked about the product she used to clean between cases. She presented a spray bottle labeled Santimaster 4 spray disinfectant. The Supervisor stated that this spray was automatically mixed by a dispensing device in the Central Processing Department. The housekeeper stated that she would spray the product on a surface and allow it to dry approximately 2 minutes. The product instructions were reviewed. Per the manufacturers recommendations, the contact time for some organisms was 5 minutes, but to adequately sanitize against all the organisms for which the product was approved would require a contact time of 10 minutes. The Infection Control Manager was interviewed about this after the tour and stated that the contact time should be 5-10 minutes.





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4. During the morning Medication Pass on 5/10/11 at 9:27 A.M., Staff 308 (a Registered Nurse) entered a patient's room and put on gloves. Staff 308 gave the patient his medications via a gastrostomy tube (a tube that is placed directly into the stomach for long term administration of food, fluids, and medications), removed her gloves, left the patient's room, and went to the nurse's station to obtain a syringe from the supply cart. She did not wash her hands or use hand sanitizer before entering the room or after removing her gloves.

At 9:45 A.M., Staff 308 re-entered the patient's room, put on gloves, and flushed the patient's gastrostomy tube. She then primed an intravenous medication tubing, removed her gloves, and left the room to obtain an alcohol swab from the supply cart in the nurse's station. Staff 308 did not wash her hands or use hand sanitizer before re-entering the patient's room or after removing her gloves.

At 9:50 A.M., Staff 308 re-entered the patient's room, put on gloves, and assisted the patient to the bathroom and then back to his bed. She changed her gloves then connected the intravenous medication tubing to the patient's saline lock (an intermittent device for the administration of medications through the vein). Staff 308 did not wash her hands or use hand sanitizer prior to re-entering the patient's room or before changing her gloves.

Per the Infection Control Standard Precautions policy and procedure for hand hygiene dated 9/9/10, if hands are not visibly soiled, alcohol gel should be used "routinely for decontaminating hands before having direct contact with patients and after removing gloves."

When interviewed on 5/10/11 at 10:17 A.M., Staff 308 stated the policy was to use hand sanitizer when going into a patient's room and when leaving a patient's room if hands are not visibly soiled. She stated she did not use hand sanitizer when she entered or left the patient's room or after removing her gloves and before putting on new gloves because she was caring for the "same" patient.