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Based on interview and record review, the hospital failed to ensure an appropriate plan of care was developed and implemented, in accordance with its policy, for one of 32 sampled patient (Patient 2).

Patient 2 had a critically low hemoglobin (part of the blood that carries oxygen to the tissues and muscles) of 5.7 (normal range is 12.2 to 15.3). Staff failed to notify the physician when blood was available for transfusion and failed to ask for an order to give the blood. This resulted in a delay of over five hours after the blood was ready but before the blood transfusion was started and had the potential to result in a significant deterioration of the patient's condition.

Findings:

The facility policy, "Standards of Care," last revised 6/4/16, for the Emergency Department was reviewed. Under Intervention, it read: Emergency nurses should implement a plan of care based on assessment data, nursing diagnosis and medical diagnosis. Emergency nurses should function independently within the parameters established for professional nursing practice. Emergency nurses should function collaboratively with other health care providers to implement the prescribed regimen within the scope of professional nursing.

A review of Patient 2's record disclosed she was a 48 year old who presented to the Emergency Department (ED) on 1/5/17 at 12:55 pm with a complaint of shortness of breath, headache, and vaginal bleeding for one and a half months. Lab tests were done which showed Patient 2 had a critically low hemoglobin of 5.7. The facility's lab report designated the result of the hemoglobin as a "critical" result because it was less than 7. An order to type and crossmatch (to ensure the patient's blood is compatible with the donor's blood) four units of blood was given by the physician on 1/15/17 at 2:32 pm. The transfusion record indicated the blood was ready at 4:09 pm. There was a physician's order at 9:16 pm to transfuse four units of blood and on this order, it was noted to be a medical emergency. Patient 2 left the ED at 9:16 pm and was transferred to a medical-surgical unit where the first of four units of blood was started at 10:05 pm. Patient 2 had a surgical procedure to treat the cause of the bleeding the following day and was discharged from the hospital in good condition on 1/9/17.

During a concurrent record review and interview on 1/24/17 at 3 pm, Senior Clinical Lab Scientist (SCLS), confirmed the blood was available and ready for use on 1/15/17 at 4:09 pm and ED staff was notified of this at 4:13 pm on 1/5/17. SCLS confirmed it was their practice to call the nursing unit to notify them when blood was ready for any patient and provided a copy of the Blood Bank Product Call List which indicated the lab called a staff member in the ED at 4:13 pm on 1/5/17.

During a concurrent record review and interview on 1/24/17 at 3:15 pm, the ED Nursing Coordinator (EDC) identified the person the lab spoke to as an ED secretary and agreed the secretary should have told the nurse the blood was ready. EDC stated she did not see anything in the record that indicated the physician was told the blood was ready. EDC was asked if it was acceptable for a patient with a hemoglobin of 5.7 to go that long (more than five hours in the ED) without receiving blood and EDC stated, "no".

During an interview on 1/25/17 at 3:25 pm, the ED secretary confirmed she received a call from the lab to say the blood was ready for Patient 2. She stated she told Registered Nurse (RN) A who was caring for Patient 2.

During a phone interview on 1/25/17 at 2:30 pm, Nurse Practitioner (NP) stated Patient 2 was not originally her patient since she came on duty at 6 pm on 1/5/17. NP stated Patient 2 would have already been seen by another provider who would have decided upon the disposition of the patient and usually blood transfusion would have already been ordered with the type and crossmatch. NP stated she could not recall being told by the nurse that the blood was ready and did not know why the blood was delayed for so long.

During a concurrent record review and interview on 1/25/17 at 1:45 pm, the ED Medical Director (ED MD 1) stated Patient 2's vital signs were normal and she appeared stable. He stated ideally the blood should have been started sooner but it depended on how much she was bleeding, "which you can't tell from the record".

During a concurrent record review and interview on 1/25/17 at 3:55 pm, Registered Nurse (RN) A stated he vaguely recalled Patient 2. He stated the ED secretary told him the blood was ready but he did not have an order to give blood. RN A stated if a patient has a critically low hemoglobin and blood was ready in the lab but there was no order to give the blood, he would talk to the patient's physician to get an order. RN A did not recall talking to the physician about Patient 2.

Based on interview and record review, the hospital failed to ensure all medication refrigerators included daily temperature checks, as described in the hospital's policy and procedure. This had the potential to result in changes in medication potency (strenght and effectiveness).

Findings:

During the initial tour of the Emergency Department (ED) at 9:05 am and the second floor medical surgical unit at 10:15 am, on 1/24/17, it was noted each of these units had one medication refrigerator with a temperature log that was incomplete for the month of 1/2017. The ED refrigerator temperature log was missing three days for 1/2017 and the second floor medical surgical unit refrigerator temperature log was missing one day for 1/2017. This was confirmed in a concurrent interview by the Director of Risk and Accreditation who was also present during the tour.

The hospital policy titled, "Security and Inspection of Medication Storage Areas," last revised 10/15/14, was reviewed. It read, refrigerator logs are to be used to monitor non-vaccine refrigerator storage requirements. Nursing was required to check and record medication refrigerator temperatures daily.

Based on observation, and interview, the hospital failed to ensure drugs were secure when an unlocked, unattended, anesthesia cart, (contained medication and supplies), was located in a hallway accessible to patients and visitors. This had the potential for unauthorized users to access the unlocked cart.

Findings:

The facility's policy titled "Security and Inspection of Medication Storage Areas", dated 2014, indicated all medications were to be kept locked in a secured area that was not accessible to unauthorized individuals. The policy indicated medications were to be identified with the contents and date.

On 1/23/17 at 9:45 am, during an initial tour of the facility's labor and delivery unit, an "epidural cart" (used for spinal anesthesia) was observed in the hallway and contained seven vials of Lidocaine (medication used for spinal anesthesia). The cart contained an unlabeled 10 cc syringe that was filled. During a concurrent interview, the Registered Nurse Manager for Labor and Delivery (OBM) confirmed pre-drawn medications were required to be labeled to document the date and the name of medication. The OBM confirmed the facility's policy and procedure required the cart be securely locked if unattended and in an accessible area.

Based on observation, interview, and policy review, the hospital failed to follow their policies to prevent the transmission of infections when:

1. Isolation precautions were not followed for patients identified on contact and droplet isolation status (require specific procedures using personal protective equipment (PPE) to prevent the spread of infection, typically of multi-drug resistant organisms).

2. Infection control monitoring did not include assessment of the integrity of patient bed mattresses. Multiple mattresses were found to have discoloration and stains.

These failures had the potential for patients to acquired healthcare associated infections which could further compromise their health status.

Findings:

The facility's policy titled, "Protocol for Preventing the Spread of Infection including Multidrug Resistant Organisms", dated 2016, included specific direction for transmission-based precautions (used for patients with highly transmissible diseases).

The policy indicated "contact precautions" (requires use of gloves and gown during patient care) was the most significant mode of transmission of infectious agents. Transmission "can occur by directly touching the patient, through contact with the patient's environment, or by using contaminated gloves or equipment ... Healthcare workers caring for patients in contact precautions must ... remove and discard gloves and gown and clean hands before leaving the patient's room ..."

The policy included direction for "droplet precautions, in addition to gloves and gown, a mask must be worn and discarded and hands cleaned before leaving the patient's room.

1 . On 1/25/17 at 2:10 pm, Room 343 was observed to have signage indicating droplet precautions were in place for the single resident room. A Respiratory Therapist (RT) was observed in the room with appropriate PPE (wearing a gown, mask and gloves) and administering a respiratory treatment to the patient. The RT was then observed returning to the mobile workstation located in the hallway just outside the room. The RT removed her gloves and set them on the workstation, and pulled her mask down under her chin, then used the keyboard. The RT was then observed to re-glove and reenter the patient care area. Upon return to the workstation the RT was observed to remove one glove and while holding the glove with the opposite gloved hand, used the computers keyboard. The RT was observed touching multiple surfaces of the workstation with her hands and also with her gowned arms and elbows. During a concurrent interview on 1/25/17 at 2:20 pm, the RT explained the droplet precautions per direction on the doorof Room 343, but was unsure whether it was ok to touch the workstation (located outside the room) prior to removing her PPE and performing appropriate hand hygiene.

On 1/25/17 at 2:30 pm, Room 338 was observed to have signage indicating contact isolation precautions were in place for the single resident room. Registered Nurse B (RN B) was observed inside the room, speaking to the patient. RN B was then observed returning to the workstation located in the hallway just outside the patient's room, and touching th keyboard with her gloved hand and setting down a scanner (used to identify resident and medications given) on the surface of the workstation. RN B was observed taking off her PPE and performing hand hygiene prior to exiting the room. RN B was then observed to clean the scanner after which she set the scanner back down without cleaning the surface under the scanner. RN B was observed to move the workstation towards another resident room without cleaning the keyboard. At 2:40 pm during a concurrent interview, RN B confirmed the details as described above. RN B stated she always cleaned the keyboard in the morning before starting her shift, but did not always clean the keyboard between patients.

On 1/25/17 at 2:45 pm, RN C was observed standing in front of the workstation on wheels (WOW) and using the keyboard, in the hallway just outside Room 346, with gown and gloves on. During a concurrent interview, RN C stated his gloves were clean, but confirmed isolation procedures required that PPE was not to be worn outside the patient's room even if clean.

On 1/25/17 at 2:40 pm, a Nurse Technician (NT) was observed coming out of an isolation room (after removing PPE and washing her hands per procedure), near Room 342, and carrying something held with a tissue, through the nursing unit and to the soiled utility room. NT was observed placing a pulse oximeter probe into a white bucket in the utility room. During a concurrent interview, the NT confirmed she had just come out of an isolation room. NT explained she had removed the pulse oximeter probe from the patient's toe, and placed it in the bucket to be recycled.

On 1/26/17 at 11:15 am, during an interview, Infection Control Nurses 1 and 2 (ICN 1 and ICN 2), stated pulse oximeter probes that were used for a patient on isolation precautions should be thrown away after use. ICN 1 stated carrying the item through the nursing unit and placing it in the recycle bin was in violation of isolation precaution standards. ICN 1 and ICN 2 confirmed that the details described above represented a breakdown in the isolation precaution procedures and had the potential for avoidable spread of antibiotic resistant infectious pathogens (bacteria or other disease causing organisms) to other patients.

2. On 1/24/17 at 10:45 am, during an initial tour of the facility, Environmental Services Staff was observed transporting a bed to the "to be cleaned" holding area. During a concurrent observation and interview, the Inpatient Care Services RN (ICS), confirmed there were multiple stains and discoloration throughout the mattress.

On 1/26/17 at 10:40 am, during an interview and concurrent observation of the storage areas for clean and dirty mattresses, the Environmental Services Manager (EVSM) stated he thought the discoloration was caused during the cleaning process with a strong bleach solution. EVSM stated the process to monitor the integrity of mattresses included removing any mattress that had a tear. EVSM stated there was not a process to evaluate the integrity of a mattress that did not have a tear.

On 1/26/17 at 11:15 am, during an interview, ICN 1 and ICN 2 confirmed there was not a process in place, to monitor the integrity of mattresses, in the infection control auditing process. ICN 1 and 2 were shown a photo of the stained mattress observed during the initial tour. ICN 1 and 2 confirmed the integrity of the mattress could have been compromised by the bleach solution and should be removed from service.

The hospital provided the Operations and Maintenance Manual for the hospital's mattresses. The manual's direction for cleaning included a warning section which indicated "... Always inspect support surface covers (outer covering of the mattress) for tears, punctures, excessive wear, and misaligned zippers each time the covers are cleaned. If compromised immediately remove the support surface from service and replace the covers to prevent cross-contamination; ... Always perform preventative maintenance (described below) more frequently based on usage level of the product...; ... If you do not properly rinse and dry the product, a corrosive residue may be left on the surface of the product that could cause premature degradation of critical components...." The manual included preventative maintenance instructions as follows: "At a minimum, check all items listed during annual preventive maintenance ... you may need to perform preventive maintenance checks more frequently based on your level of product usage. Note: Clean and disinfect te exterior of the support surface before inspection. Inspect the following items: Zipper and covers (top and bottom) are free of tears, cuts, holes, or other openings; Internal components for signs of staining from fluid ingress or contamination by fully unzipping the covers; Labels for legibility, proper adherence, and integrity; Handles are free of rips or cracks and stitching is intact; Cover straps are free from rips, cracks, or tears; Straps properly secure the support surface to the crib assembly; Foam and other components have not degraded or come apart; Compression set of the foam is less than 1.25 inches; Optional fire barrier for rips, cracks, or other visible signs of damage (If excessive wear of the fire barrier is observed, replacement is recommended)."

Based on interview, and record review, the hospital failed to ensure a properly executed informed consent for one of 32 sampled patients (Patient 23). This resulted in a lumbar puncture procedure for Patient 23 without proper consent.

Findings:

The hospital's policy titled, "consent procedures", dated 4/15/11, and indicated "all procedures related to consents shall be based upon the current California Hospital Association Consent Manual." The manual's list of procedures that required completion of the informed consent form included an X-ray Lumbar Puncture under Fluoroscopic Guidance. The hospital provided a "procedural checklist" which included direction for the documentation of an informed consent.

Review of Patient 23's record indicated he was admitted to the hospital on 1/15/17 with diagnoses that included acute paresis (slight or incomplete paralysis) of the lower extremity (leg). The record indicated an X-ray Lumbar Puncture under Fluoroscopic Guidance" was performed on 1/20/17.

The record included an undated form titled, "Authorization for and Consent to Surgery or Special Diagnostic or Therapeutic Procedures". The form included Resident 23's name, and indicated the procedure to be performed was an "X-ray Lumbar Puncture under Fluoroscopic Guidance". The "Name of the practitioner who is performing the procedure or administering the medical treatment" was left blank. The area of the form to indicate understanding of the procedure including risks, benefits and alternatives, and consent for the performance of the procedure and anesthesia included Patient 23's signature, but the date, time, and witness signature were all left blank.

On 1/25/17 at 4 pm, during an interview and concurrent record review, the registered nurse Quality Manager (QIM) confirmed the findings described above did not meet the requirements for an informed consent.

Based on interview and record review, the hospital failed to ensure Emergency Department (ED)services were integrated with Obstetrical (OB, pregnancy and childbirth) services when one of 10 sampled OB patients (Patient 3) who presented to the ED was not transferred to the Women and Infants Pavilion (WIP) according to facility policy. As a result, Patient 3's unborn child (fetus) was not monitored according to facility policy and the care provided to Patient 3 and her unborn child in the ED was not consistent with the care she would have received in the OB unit. This had the potential to result in a decline in the health of the fetus which would have gone unrecognized and untreated.

Findings:

The hospital policy from the Labor and Delivery (L&D) Policy/Procedure Manual titled, "Common Nomenclature (system of names) and Fetal Heart Rate Monitoring," last revised 7/29/16, was reviewed. It read, All pregnant patients who have reached 20 weeks or more gestation (pregnancy) and are admitted to the L&D (Labor and Delivery) or Antepartum (before birth), as well as those being observed in Triage (waiting to be assigned a level of urgency), will have continuous electronic fetal monitoring (EFM, continuously monitors the baby's heartbeat to ensure there are no medical complications) unless the physician provides an order for intermittent fetal heart rate monitoring (may be ordered per shift or per day for antepartum patients)".

The facility policy from the Emergency Department Policy/Procedure Manual titled, "Triage," last revised 6/14/15, was reviewed. It read:

"I. Any patient known to be pregnant over 20 weeks gestation with symptoms that appear to be pregnancy related is evaluated by the ED MD (physician) and determined if stable to transfer to the WIP by on-campus transportation with an ED RN (Registered Nurse). If the patient is unstable the patient will be transferred to the WIP unit with a RN that has completed a competency-based orientation in high risk obstetrical care and any additional personnel required, when the benefits to the patient exceed the risks of the transfer.

1. Symptoms which should be considered referable and potentially aggravating to the pregnancy include but are not necessarily limited to: abdominal, back or flank pain, vaginal bleeding, decreased or absent fetal movement, leaking vaginal fluid.

2. Symptoms of pregnancy induced hypertension presenting in a combination include: Blood pressure (BP) greater than 140 systolic (top number indicating maximum pressure in arteries) or 90 diastolic (bottom number indicating minimum pressure in arteries), proteinuria (protein in the urine), visual changes (blurred or double vision), epigastric pain, generalized edema, hyperreflexic (overactive) DTRs (deep tendon reflexes), and headaches.

A review of Patient 3's record indicated she presented to the ED on 1/10/17 at 9:21 am, with a chief complaint of blurred vision. She was 24 weeks pregnant. Her vital signs were checked upon admission at 9:21 am and BP was high at 167/113 (normal 120/80), pulse 115 (normal 60 to 100), respirations 20. The ED MD evaluated Patient 3 at 10:32 am and noted her complaint of blurred vision while driving and "room spinning," no abdominal contractions, and no vaginal bleeding or leaking. An EKG, labs and MRI (magnetic resonance imaging to produce detailed pictures of inside the body) were ordered and were within normal limits. Patient was discharged at 3:23 pm, at which time her BP was 137/92 and pulse 93. Fetal heart tones (FHTs) were obtained once with a doppler (handheld device used to hear the heartbeat) during this six hour period, at 11:03 am, and were 150 (normal 120-160).

During a concurrent interview and record review on 1/25/17 at 8:50 am, Inpatient Care Services Director (ICS) confirmed there was only one set of FHTs taken during Patient 3's ED visit. She called the Perinatal Services Director (PSD) who stated if a patient who is greater than 20 weeks pregnant presents to the ED instead of the WIP, the ER MD should get an OB consult. ICS could not find anything in Patient 3's record to indicate this had been done.

During an interview on 1/25/17 at 9:40 am, PSD stated a patient who is greater than 20 weeks pregnant with blurred vision could be having a problem with the pregnancy and an OB MD consult should be obtained. PSD stated the facility has an OB MD that can see patients who have no OB MD or whose MD is unable to come in to see them. PSD also stated anyone who comes to triage greater than 20 weeks pregnant should be placed on electronic fetal monitoring (EFM).

During an interview on 1/25/17 at 9:45 am, OB RN Manager (OBM) stated, depending on the maternal size, it takes at least 20 to 30 minutes of EFM to adequately assess the well being of the fetus. OBM stated if the EFM was ordered continuous it would not be taken off until the patient was discharged and if not continuous, the fetal heartrate would be checked again prior to the patient's discharge.

OBM stated if a patient who was 24 weeks pregnant presented to the WIP with a complaint of blurred vision, BP 167/113 and pulse of 115, as Patient 3 did to the ED, this could be signs of pre-eclampsia (a potentially dangerous pregnancy complication characterized by high blood pressure)and the patient would be placed on EFM, BPs checked every 15 to 20 minutes, and MD notified right away.

During a concurrent interview and record review, on 1/25/17 at 2 pm, ED MD 1 (the medical director of the ED) stated the work up done for Patient 3 was "great" except he did not see a call to the OB consult. ED MD 1 stated the L&D policy did not apply to the ED. He then reviewed the ED policy and confirmed according to their policy, although Patient 3 should have been transferred to the WIP, this was not done.