HospitalInspections.org

Based on policy review, medical record reviews and staff interview, the patient care staff failed to comply with the Advance Directives for 1 of 14 sampled patients (Patient #7).

The finding include:

Review on 02/09/2017 of the facility's policy, "Advance Directives/Advance Directive Acknowledgement" revised 01/2016 revealed, "...The purpose of the Act is to protect each adult inpatient's right to participate in health care decision making to the maximum extent of his/her ability and to prevent discrimination based on whether the patient has executed an advance directive for health...It is the policy of {hospital name} that staff will provide information, at the time of admission and in same day surgery preop, to each adult individual, describing: ...b. Health care Power of Attorney; ...Furthermore, staff members will respond to patient requests for information regarding advance directives, and will document such requests and the steps taken to fulfill such requests. ..."

Closed medical record review on 02/07/2017 revealed on 12/05/2016 at 1223, Patient #5, a 75 year-old female patient presented to the hospital and received an admitting diagnosis of Acute Respiratory Distress, low of the oxygen levels and Pneumonia (Klebsiella-bacteria). Advanced Directive review revealed the patient's {HCPOA-Healthcare Power of Attorney} was a family member. Review revealed on 12/13/2016, Physician Progress Note revealed the {HCPOA} requested the patient care staff not to discuss any decisions with other family members. Medical record review of the 12/05/2016 admit revealed Patient #5 plan of care was possibly discussed with unauthorized person(s).

Telephone interview with Nurse #4 on 02/07/2017 at 1525 revealed this nurse provided patient care to Patient #5 in nusring care area #6. Interview revealed the {HCPOA} desired to have the patient moved to the intensive care area for monitoring purposes. Interview revealed Physician #4 was notified, presented to the patient's bedside, evaluated Patient #5 and determined the patient was stable and did not require transfer to the intensive care area. Interview revealed during the medical evaluation of the patient, the {HCPOA} was not at the bedside and the patient's code status was discussed with the patient's {child} and the {child} was not the {HCPOA}. Interview revealed Patient's #5 plan of care was discussed with an unauthorized person.

Based on policy and procedure review, medical record review and staff interview, the nursing staff failed to fully execute an informed consent for a blood transfusion in 1 of 3 blood transfusion records reviewed. (Patient # 1)

The findings included:

Review on 02/09/2017 of the Policy and Procedure "Blood and Blood Product Administration" (revised 12/2013) revealed "Informed consent is obtained prior to administration of blood products, including whole blood, ..."

Closed medical record review on 02/09/2017 of Patient #1 revealed he was a 66 year old male patient admitted to the facility on 07/08/2016 with a chief complaint of weakness, fatigue and low hemoglobin (blood oxygen carrying protein in the blood). Review of "Physician Orders" revealed an order for a blood transfusion of two units of PRBCs (packed red blood cells). Further review revealed a consent for the blood transfusion was obtained. Review of the consent revealed three signature lines, the first line was for the Patient's signature. The second line was for the Witness' signature, date and time, and the third line was for the physician's signature, date and time. Further review revealed the second lined contained the signature of the RN (registered nurse), the date "7/8/16" and no time indicated. Continued review revealed Patient #1 recieved a blood transfusion on 07/08/2016 from 2040 through 2215. The third line contained a stamp with "Authenticated by [physician name] On 08/03/2016 07:15:16 AM." The review revealed the consent did not have the time of the day when it was executed.

An interview on 02/08/2017 at 1615 with RN #1 revealed the consent should include the date and time to assure informed consent was recieved prior to the initiation of the blood transfusion.

Based on Policy and procedure review, observation and staff interview, nursing staff failed to label food brought in from the outside, with patient's names and date and the facility staff failed to prevent the transmission of infectious disease by storing the personal food of a patient identified with an infectious disease in a refrigerator with food for the general patient population on one of two medical surgical units toured (Patient #14).

The findings included:

Review on 02/09/2017 of the Policy and Procedure "Food from outside Sources" (revised 01/2016) revealed, "... 1. Perishable food brought in from the outside that requires storage in patient refrigerators will be covered/wrapped 2. All patient food stored in patient refrigerators will be labeled with the patient name and room number. 3. All patient food stored in patient refrigerators is to be dated. 4. Any food found past date or not dated, and/or unlabeled of patient identification and /or uncovered will be discarded immediately. ..."

Observation on 02/07/2017 at 1430 of the patient nourishment refrigerator on the 4th floor, revealed a cup with "Cookout" on it in the freezer with frozen contents inside. Observation revealed the cup had a room number written on it, but, no patient name or date. Continued observation revealed an orange Popsicle wrapped in a transparent blue grocery bag labeled with a room number, but, no patient name or date. Further observation of food contents in the refrigerator revealed a container of "Honey Nut Spread" with a room number, but, no patient name or date. Observation of the contents inside of the container of "Honey Nut Spread" revealed knife marks indicating previous use and/or consumption. Observation revealed the patient nourishment refrigerator and freezer contained perishable food items that were not labeled per policy.

An interview with on 02/07/2017 with RN # 2 at 1440 revealed the food items were brought in on 02/07/2017. Continued interview revealed the room numbers were placed on the food package but the date it was brought in and the patient's name were missing. Further interview revealed the food items would be labeled with the patient's name and the date.

An interview on 02/07/2017 at 1445 with PCT #4 (patient care technician) revealed the "Honey Nut Spread" belonged to Patient #14. Continued interview revealed the patient was admitted on 02/07/2017 and was placed on isolation for VRE (vancomycin resistant enterococcus).

An interview on 02/09/2017 at 1105 with AS (Administrative Staff) #11 revealed, because of the infection control concern identified during the surveyor's unit tour, the policy was revised on 02/09/2017 to include ,"no isolation patient food products are to be allowed in the patient refrigerator; it is a single use item and will be thrown away."