HospitalInspections.org

Based on observation and the interview, the facility failed to maintain a safe environment in one of ten of Emergency Department (ED) rooms observed.

The findings included:

Observation with the ED Manager on 3/7/16 at 2:25 PM, in ED room #6, revealed a pair of orthopedic scissors and a pair of bandage scissors was stored in an unsecured drawer.
Interview with the ED Manager on 3/7/16 at 2:25 PM, in ED room #6, confirmed the scissors should not be stored unsecured.

Based on review of facility policy, review of the Medical Staff Bylaws, review of The Joint Commission (TJC) standards, medical record review, observation, and interview, the facility failed to provide physician's services in accordance with the facility bylaws for 1 patient (#43) of 3 surgical patients selected for observation.

The findings included:

Review of facility policy "Physician's Wellness Program" last revised 11/15, revealed "...to provide guidelines regarding aiding a physician in retaining or regaining optimal functioning consistent with protection of patients and to ensure quality patient care by promoting a safe, cooperative and professional health care environment and to prevent or eliminate to the extent possible, conduct which: has the potential to cause harm...disrupts the operation of the organization...affects the ability of health care workers to carry out their jobs...creates a hostile work environment for health care workers...interferes with an individual's ability to practice competently...and adversely affects the community's confidence in the organization's ability to provide care...definition: disruptive conduct - any conduct or behavior that interferes with the ability of an individual to function effectively within the hospital environment. Since disruptive behavior cannot be narrowly defined and is somewhat a function of specific acts and circumstances, the following is a non-exclusive list of examples of behaviors that may be considered disruptive conduct: [1] abusive behavior of any kind, including both verbal and non-verbal actions...[3] verbal statements directed at individuals that are personal, or go beyond the bounds of professional comment..." Further review revealed "...procedure: documentation of disruptive conduct is critical since it is ordinarily a pattern of conduct, rather than one incident..."

Review of the Medical Staff Bylaws last amended 11/17/15 revealed "...requirements for service: the medical staff must require that the services provided meet the Joint Commission requirements and CMS [Centers for Medicaid and Medicare Services]..."

Review of TJC standard LD.03.01.01, date 1/1/16 revealed, "...Behavior that intimidates others and affects morale or staff turnover undermines a culture of safety and can be harmful to patient care. Leaders must address such behavior in individuals working at all levels of the hospital, including management, clinical and administrative staff, licensed independent practitioners, and governing body members..."

Medical record review revealed Patient #43 was admitted to the Emergency Department (ED) on 3/9/16 at 7:34 AM with a chief complaint of right hip pain. The patient's x-ray of the right hip revealed a nontraumatic posterior dislocation of the right hip. Further review revealed a Closed Hip Reduction under anesthesia was to be performed in the ED. The surveyor and the escort went to the ED to observe the case in the ED on 3/9/16.

Observation on 3/9/16 at 9:00 AM, in the ED, revealed the patient was in the ED Trauma Room and was alert and oriented to time and place. Verbal permission was obtained from the patient by the Director of Infection Control and the surveyor for the surveyor to observe the procedure. Facility staff introduced the patient and the surveyor and again verified the verbal permission for observation of the procedure.

Medical record review of the Anesthesia Record dated 3/9/16 at 9:15 AM revealed the patient received the following medications: Fentanyl 2 mg [milligrams] IV [intravenous]; Diprivan [anesthesia medication] 100 mg IV; Zemuron [anesthesia medication] 5 mg IV and Succinylcholine [anesthesia medication] 100 mg IV by anesthesia. Further review revealed the patient was on a cardiac monitor and had oxygen by nasal cannula in place.

Observation of 3/9/16 at 9:23 AM, in the ED Trauma Room, revealed the orthopedic physician who was to perform the procedure, walked into the trauma room after anesthesia was administered to the patient and very loudly stated "...I will not do the procedure unless the patient has signed a written release for the state to be in the room...I will not do anything without that form signed..." Continued observation revealed "...if I have to sign a consent to treat the patient then they have to sign a consent to observe the case..." Further observation revealed the Director of Infection Control informed the physician the patient had given verbal permission to the Director of Infection Control and the surveyor prior to the anesthesia medications being given. Further observation revealed the physician turned to walk out of the room and stated "...I am not going to do the procedure without written consent..." The physician then walked out of the room and out of the ED.

Observation on 3/9/16 at 9:30 AM, in the ED, revealed the physician returned to the ED, entered the trauma room where the patient was located, and slammed the door.

Interview with the Director of Infection Control on 3/9/16 at 9:30 AM, in the ED hallway, confirmed the Director of Infection Control had obtained verbal permission from the patient. Further interview revealed "...I tried to tell him but he wanted a written consent...he should have not acted that way..."

Medical record review of an Operative Procedure note dated 3/9/16 at 9:40 AM, revealed "...periprosthetic right hip posterior dislocation...procedure: closed reduction in ER [Emergency Room]...anesthesia: general..." (without the surveyor observing).

Interview with the Chief Operating Officer (COO) on 3/9/16 at 9:40 AM, in the ED hallway, revealed "...I am not sure why he acted that way...he is employed by the facility...he would be expected to follow the same guidelines as anyone else..." Further interview confirmed the physician refused to do the procedure while with surveyor was in the room after verbal permission was obtained from the patient. Further interview confirmed the physician's behavior was not within the acceptable behaviors as expected by facility employees.

Interview with the Chief of Staff on 3/9/16 at 10:35 AM, in the conference room, confirmed the medical staff were expected to comply with the medical staff bylaws of the facility.

Based on observation and interview, the facility failed to ensure supplies were not available for patient use beyond the expiration date for one of six operating rooms.

The findings included:

Observation with the Director of Surgical Services on 3/8/16 at 11:34 AM, in OR #4, revealed 6 packages of sutures stored in a suture cabinet with an expiration date of 1/2016.
Interview with the Director of Surgical Services on 3/8/16 at 11:34 AM, in OR #4, confirmed the sutures were expired and were available for patient use.

Based on facility policy review, medical record review, observation, and the interview, the facility failed to follow infection control guidelines for hand washing for one (#7) of six patient procedures observed; failed to follow facility policy for labeling intravenous administration tubing for 2 (#16, #25) of 20 inpatients; and failed to ensure a patient's medical record remained free of contamination for one (#38) of one oupatient observations.

The findings included:

Review of facility policy, Hand Hygiene, last revised on 11/2015, revealed "...Health Care Workers (HCWs) may come in contact with microorganisms when...touching a contaminated object or surface such as...trash cans
...examples of times alcohol hand antiseptic should be used...after having contact with inanimate objects in the vicinity of the patient...before donning sterile gloves...after glove removal..."

Medical record review revealed Patient #7 was admitted to the facility on 2/24/16 for diagnoses including Congestive Heart Failure and Shortness of Breath.

Medical record review of a physician's order dated 2/29/16 revealed an order to place a peripherally inserted central catheter (PICC) line.

Observation with Registered Nurse (RN) #1 on 3/7/16 at 1:45 PM, in the patient's room, revealed RN #1 washed her hands and applied protective gloves; she removed the existing dressing from the patient's PICC line; removed her gloves; applied sterile gloves without sanitizing her hands; cleaned the PICC line site with antiseptic swabs; removed her gloves; applied sterile gloves without sanitizing her hands; secured the PICC line with a transparent dressing; removed her gloves, and then sanitized her hands.

Interview with RN #1 on 3/7/16 at 2:10 PM, outside the patient's room, confirmed the RN did not sanitize the hands after removing soiled gloves and before application of sterile gloves.

Review of facility policy, IV (Intravenous) Therapy, last reviewed 12/2015, revealed "...IV tubing changes are made every 72 hours...IV tubing is changed every 72 hours with site change, labeling, and documentation in Nursing Notes..."

Interview with RN #3 on 3/7/16 at 1:00 PM, on the Mother/Baby unit, confirmed "...we get IV's out as soon as possible...IV policy says 72 hours for tubing change...if we have one that stays that long we label it..."

Observation of Patient #16 on 3/7/16 at 2:00 PM, in the patient's room, revealed the patient in bed with a ¾ full 1000 ml (milliliter) bag of Normal Saline (NS) hanging without the IV administration tubing being labeled with the date or time the tubing was changed.

Interview with RN #4 and RN #2 on 3/7/16 at 2:05 PM, at the nursing station, confirmed the IV tubing was not labeled and the facility failed to follow facility policy.

Observation of Patient #25 on 3/8/16 at 11:08 AM, in the patient's room, revealed the patient had a partially filled 1000 ml bag of IV fluid hanging and the tubing was unlabeled.

Interview with RN #6 on 3/8/16 at 11:08 AM, in the patient's room, confirmed "...supposed to label...hung this morning..."

Interview with RN #4 on 3/8/16 at 11:12 AM, in the patient's room, confirmed the IV tubing was not labeled and the facility failed to follow facility policy.

Interview with the Director of Infection Prevention on 3/9/16 at 10:25 AM, in the hallway outside the conference room, confirmed the facility failed to follow facility policy.

Observation with Certified Registered Nurse Anesthetist (CRNA) #1 on 3/8/16 at 9:36 AM, in the preoperative area, revealed the CRNA laid Patient #38's chart on the open trash can, sanitized the hands, picked the chart up from the trash can, and laid the chart on the bedside table. Further observation revealed the surgery nurse opened the chart to get out paperwork. Continued observation revealed the CRNA interviewed Patient #38, touched the patient's neck, and auscultated the patient's heart and lung sounds. Further observation revealed CRNA touched the patient's bed railing and handed the chart to the patient.

Interview with the Director of Infection Control on 3/8/16 at 10:05 AM, outside the preoperative area in the hall way, confirmed the CRNA failed to ensure infection control was maintained during the preoperative assessment and the facility's infection control policy was not followed.