HospitalInspections.org

Based on clinical record review, staff interview and review of policy and procedure it was determined the Registered Nurse failed to supervise and evaluate care related to assessments for 3 (#3, #4, #5) of 30 sampled records. This practice does not ensure patient goals are met.

Findings include:

1. Patient #3's nursing assessments revealed the patient was not assessed on the evening shift (7:00 p.m. to 7:00 a.m.) on 9/18/11, 9/19/11 and 9/20/11. The patient was not assessed for either the day (7:00 a.m. to 7:00 p.m.) or evening shift on 9/21/11. Further review of the clinical record showed the patient had not been turned on 9/19/11 from 2:32 a.m. to 7:18 a.m. for a total of approximately 5 hours.

2. Patient #4's nursing assessment revealed the patient was not assessed on 9/16/11, day or evening shift. The patient was not assessed on the evening shift on 9/18/11, 9/19/11, 9/20/11, and 9/21/11.

3. Patient #5's nursing assessment revealed the patient had been assessed by a registered nurse on 9/18/11 at 7:00 a.m. The next registered nurse assessment was not until 9/20/11 at 8:00 p.m., approximately 2 days

A review of the facility's policy, " Assessment/Reassessment", policy # H-PC 04-009, revised 11/2010, page 3 of 10, section Nursing Department revealed (5) patients are reassessed at a minimum every shift, based on level of care and needs by a licensed nurse. An RN reassesses the patient every 24 hours.

An interview was conducted on 9/23/11 at approximately 3:00 p.m. with the Director of Education. After review of the above records the findings were confirmed.

Based on observation, staff interviews, and review of nursing competency checklist and Moderate Sedation policy it was determined the facility did not ensure the Registered Nurse administer conscious sedation within their scope of practice and consistent with facility policy. This practice does not ensure safe administration of medications for conscious sedation.

Findings include:

1. Interview of the Operating Room (OR) Procedure Nurse on 9/21/11 at 1:05 p.m. revealed that all procedures are performed in the patient's room and that the operative area was not used. There are no Anesthesiologist or CRNA(Certified Registered Nurse Anesthetist) that participate in the procedures. The nurse stated that the conscious sedation was performed by her or one of the trained Registered Nurses. She stated that conscious sedation usually involved IV (intravenous) Versed and Demerol administration. The surveyor asked if Propofol was used based on the types of scope procedures conducted. The nurse stated that Propofol was used and the physician administers it IV push.

A review of the "Endoscopy Procedure Log" was conducted for September 2011. The log revealed surgical procedures included EGD (esophagogastroduedenoscopy), Broncoscopy, Tracheostomy, and Colonoscopy.

A review of the training file for the OR Procedure Nurse contained a SKILL: Moderate Sedation, Clinical Staff Competency Assessment Validation, dated 12/3/10, as "Done". Goals: ICU/RNs/Nursing Supervisors will demonstrate appropriate and competent skills in administering and or monitoring patients receiving moderate sedation. Listed in #3, performance criteria: Versed, Morphine, Amidate(physician use only) Propofol and Demerol.

The policy and procedure for Moderate and Deep Sedation was reviewed and noted the Nursing Services section contained IV sedation drugs as Versed, Morphine, and Amidate.

Interview was conducted with the Clinical Director regarding the the skills competency and the policy. She stated that nurses only give IV drip Propofol for ventilated patients. They do not give IV push Propofol for conscious sedation. She agreed that the policy and the nurses skills competency needed clarification.

Based on clinical record review, staff interview, policy and education review it was determined that nursing did not follow the facility's policy' and competency training for blood transfusions. This practice does not ensure safe administration of blood and or blood products.

Findings include:

1. Patient #5's clinical record revealed on 9/22/11 at 4:15 a.m. the patient received a blood transfusion. A review of the blood transfusion record did not reveal a Registered Nurses (RN) signature on the form as required by policy.

2. Review of facility reports revealed a unit of blood was discard/wasted due to the patient's elevated temperature. The documentation was filed by a Licensed Practical Nurse (LPN). Further review of the blood transfusion record dated 5/20/11 did not reveal a RN signature, as the transfuser or witness.

A review of the "Blood Transfusion Competency", revised 7/05, no document number, revealed on page 2, section 5, Bedside procedure, "Checks blood component with another licensed nurse (one of which must be an RN).
A review of the facility's policy "Transfusion Therapy", policy # H-PC 08-072, revised 11/2010, revealed" Prior to transfusion, a second clinician or caregiver will validate the patient's name, identification number, date of birth, Donor Number or platelet unit number, ABO group and Rh type, and expiration date. After verification, the two staff members performing the identification must sign transfusion record and form."

An interview was conducted on 9/23/11 at approximately 3:00 p.m. with the Director of Education. After review of the above records, she confirmed the findings. The Director stated it is the policy of the facility for at least 1 RN to be on the record.

Based on observations conducted on the three days of the survey it was determined the physical environment was not maintained for cracked, wet or missing ceiling tiles. This practice does not provide for a sanitary and safe environment.

Findings Include:

Observations conducted during tour on 9/21/11 revealed brownish wet appearing ceiling tiles in the janitor closet in the back hall of the kitchen. Observations conducted on 9/21/11 and 9/22/11 of the Surgery Department and Recovery Room revealed cracked and peeling ceiling tiles. On 9/22/11 and 9/23/11 observations made in a janitor closet near the conference room revealed wet and missing tiles.