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Based on observation, interview and record review, the facility failed to ensure nursing staff developed comprehensive care plans that addressed altered respiratory status and altered nutritional status for 3 patients (#'s 12, 13 and 24) of 22 patients reviewed for care plans out of a total of 24 sampled patients resulting in the potential for less than optimal outcomes. Findings include:

A review of the medical record for patient #24 was conducted with the Director of Clinical Education (Staff F) on 11/14/17 at approximately 1315. Per record review patient #24 was a 64 year old female admitted to the facility on 11/10/17 with diagnoses that included acute hypoxic respiratory failure, chronic obstructive pulmonary disease and generalized weakness.

A review of the patient's (#24) history and physical dated 11/10/17 documented the patient had a past medical history of dysphagia (difficulty swallowing) with a percutaneous esophageal gastrostomy tube (peg).

A review of the patient's nursing admission assessment dated 11/10/17 at 0231 documented the patient was alert and had a peg tube on admission.

A review of the registered dietician evaluation assessment dated 11/10/17 at 1459 documented:
"Patient states usually good appetite and no complaints of nausea or vomiting. Per husband, patient confused and may be questionable historian. Husband states he feeds her through PEG at night and by mouth during the day. States she needs 'hydrated'. Patient doesn't like PEG tube due to tube coming out and leaking."

A review of physicians orders dated 11/10/17 documented the following:
1. 2 Cal HN (enteral feeding) 42 milliliters (ml) per hour daily to be infused at 1900-0700 via peg tube (504 ml/day).
2. 200 ml water flush via peg tube every 6 hours (800 ml/day).

A review of the patient's 24 hour Intake and Output record flow sheets dated 11/10/17 through 11/14/17 revealed the following:
On 11/10/17 there were no water flushes documented for the day via the patient's peg.
On 11/11/17 the patient received 400 ml of water via peg.
On 11/12/17 there were no water flushes documented for the day via the patient's peg.
On 11/13/17 the patient received 200 ml of water via peg.
On 11/14/17 the patient received 250 ml of water via peg.


Further review of the medical record revealed there was no care plan for the patient's altered nutritional status or peg tube.

On 11/14/17 Staff F was asked to explain why there was no care plan that addressed the enteral feeding, peg tube or water flushes for the patient's altered nutritional status. Staff F explained a care plan should have been at least started upon the patient's admission to the facility on 11/10/17.




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On 11/13/17 from approximately 1030 to 1215 a tour of the three hospital intensive care units (ICU) were conducted. Observations of patient #12 revealed she was on a ventilator (an appliance used to provide artificial respiration). An interview with patient #12's son, who was visiting at the time of the observation, stated patient #12 was placed on a ventilator in October following a surgical complication. He stated she was recently taken off the ventilator for a short time and then had to be placed back on the ventilator.

On 11/13/17 at approximately 1330 with the ICU clinical manager, Staff A, the electronic clinical record for patient #12 was reviewed and revealed an admission on 10/9/17 with a diagnosis of inguinal hernia and an admission to ICU on 10/11/17 when she was placed on a ventilator. Further review of the clinical record revealed no care plan to address respiratory status had been initiated. When Staff A was asked if a care plan to address patient #12's ventilator dependence for respiration should have been initiated, Staff A nodded yes and stated "I would expected it would have."

On 11/15/17 at 0930 Staff B, Director of Nursing Services provided copies of the problem list and care plans for patient #12. Patient #12's problem list and care plans were initiated to address patient problems/concerns on admission for surgery and when admitted to ICU, however, care plans to address respiratory needs were not initiated until 11/14/17 at 1442 and 1443 respectively, titled "Airway Clearance, Ineffective (Actual)" and "Breathing Pattern, Ineffective (Actual)." Staff B confirmed the care plans to address respiratory status were initiated on 11/14/17 the day after the surveyor reviewed and inquired about patient #12's care plans.

During the tour of the ICU observations and record review for patient #13 revealed patient #13 was admitted to the ICU on 11/11/17 with diagnoses that included acute DKA (life threatening diabetic complication) and NSTEMI (heart attack) among other diagnoses. Patient #13 was on a ventilator for respirations. Review of the clinical record for patient #13 with Staff A and Registered Nurse, Staff J, revealed no care plan to address respiratory status had been initiated. Staff A and J were asked if a care plan for respiratory assistance via ventilator should have been initiated and nodded yes.

A copy of the facility policy for development and initiation of patient care plans was requested from Staff A at the time of the above noted observations.

On 11/15/17 at 0945 Staff B, Director of Nursing Services provided copies of the problem list and care plans for patient #13. Patient #13's problem list and care plans were initiated to address patient problems/concerns when admitted to ICU, however, care plans to address respiratory needs were not initiated until 11/14/17 at 0456, titled "Breathing Pattern, Ineffective (Actual)." Staff B confirmed the care plan to address respiratory status was initiated on 11/14/17 the day after the surveyor reviewed and inquired about patient #13's care plans.

On 11/15/17 at 0855 Staff F, the Director of Clinical Education stated "Care Planning is an area we have been working on with the nursing staff. We have been pushing for the nurses to develop care plans based on why the patient is here, not just on the admitting diagnoses. When patients come in the nurses take the medical and surgical history and then review and coordinate with the physicians to develop care plans based on the patients problems. Staff F, stated she would expect to see a respiratory care plan for patients on ventilators."

On 11/15/17 at 0855 facility Staff F provided policy 1-201 for care planning, titled "Assessment of Patient" dated revised 12/2015 which documented the following: "1. Purpose 1.1 To provide guidelines for patient assessment to determine the care, treatment, and services that will meet the patient's initial and continuing needs. 2. Scope 2.1 Physician, Registered Nurse (RN), other practitioners. 4. Policy 4.1 Each patient will be assessed for the following: . . .4.1.5. An identification of problems, needs, admitting diagnoses 4.1.6 An initial plan of care to address key elements from the problem list. . .4.1.15. Physician/Nursing assessment and reassessment of the patient will occur at a minimum of; 4.1.15.1 Upon admission 4.1.15.2 Whenever there is a change in condition . . .4.1.17 An RN will complete the Nursing Admission Assessment upon admission as an inpatient and determine the patient's needs for nursing care. . . 4.1.19 The physicians and the multidisciplinary clinical personnel involved in the initial patient assessment will inform the patient or significant other about diagnosis and care. This shall include objectives, goal setting, and a planned step-by step approach with documentation on treatments, medication, safety, physical limitations, and requirements depending on the patients diagnosis."

Based on observation and interview the facility failed to ensure the physical environment was developed and maintained to ensure the safety of the patient resulting in the potential for harm to all patients served by the facility. Findings include:
See specific tags:

A-0701 - Failure to ensure the physical environment of the hospital was maintained to assure the safety and well-being of patients

A-0710 - Failure to comply with applicable provisions of the 2012 edition of the Life Safety Code

A-0724 - Failure to maintain the facility and its equipment and supplies to ensure an acceptable level of safety and quality

A-0726 - Failure to maintain the required hot water temperature for the eyewash station located in the blood bank area to provide working staff a safe and functional environment

Based upon observation and interview, the facility failed to maintain the facility and its equipment and supplies to ensure an acceptable level of safety and quality resulting in the potential for harm to all occupants. Findings include:

On 11/13/2017 between the hours of 900 and 1630 the following observations were made:

The typical clean utility/linen room on each floor of both south and west towers were noticed with full and empty oxygen cylinders being stored in each of these rooms. The oxygen cylinders are subject to fire and the clean utility/linen room walls are not rated for such storage (safe oxygen storage). In case of fire everyone staff and patients will be subjected to harms way on each of these floors and towers

Above findings were confirmed by accompanying staff C & D at time of observation.

Based upon observation and interview the facility did not meet the provisions of the 2012 edition of the NFPA 101 Life Safety Code and failed to provide a safe environment which could result in the potential for harm from fire for all patients. Findings include:

See the individually and below cited K-tags dated 11/16/17.

Building I
K-0211
K-0225
K-0321
K-0353
K-0372
K-0912

Building II
K-0363
K-0372
K-0923

Based upon observation and interview, the facility failed to maintain the facility and its equipment and supplies to ensure an acceptable level of safety and quality resulting in the potential for harm to all patients. Findings include:

On 11/13/2017 between the hours of 900 and 1630 the following observations were made:

1. One ripped staff chair in use inside the pharmacy serving the surgery department allowing for dust and dirt to accumulate and preventing the surface from a being cleaned;

2. Typical patient room's shower curtain is touching the shower floor allowing for the cross contamination and improper cleaning and sanitation;

3. High dusting is a typical issue throughout the facility including all surgical light mast arms, wall cabinets, clean linen carts, pyxis and refrigerator in medication rooms, and refrigerator (omni cell) serving the pharmacy;

4. Dirty floor at clean supply room serving the 3rd floor south tower across from patient room 318;

5. Wall damage and opening in wall near floor in OR #9 allowing for rodents to roam the area and preventing the area from being properly cleaned and sanitized;

6. Strong odor in soiled room serving the 3rd floor west tower an indication the exhaust fan is not working. A test was run to see if the exhaust fan is in operation, it failed the test and the fan was determined to be down and not operational at the time of the survey. Proper exhaust fan operation is required in this room to prevent the potential for cross contamination and the spread of the odor to the adjacent areas;

7. Broken handrail in corridor of the 4th floor south tower across from patient rooms 429 and 431; and

8. The x-ray hand control for both x-ray rooms A and E is unrestrained (free) with long loose cable allowing the staff to carry the hand control and accidently expose his/herself to radiation if inside the x-ray room while instructing the patient. The typical hand control must be fastened to the console to prevent any possible accident from occurring.

Above findings were confirmed by accompanying staff C & D at time of observation.

Based upon observation and interview, the facility failed to maintain the required hot water temperature for the eyewash station located in the blood bank area to provide working staff a safe and functional environment resulting in the potential for harm to all working staff in the blood bank area at the facility. Findings include

On 11/13/2017 between the hours of 900 and 1630 the following observations were made:

The available eyewash station serving the blood bank of the lab area at the facility did not meet the requirement of ANSI Z258.1-2004. Hands free type with tepid water eyewash station is required in all areas where staff and/or patients are subjected to blood pathogens, handling of cleaning products including chemicals and corrosive materials. It was discovered during the survey that only cold water is provided to this non-compliant eyewash station (hand held type) subjecting all working staff in this lab area to potential harm when an eye injury occurs. The typical eyewash station shall be provided to be hands free type with tepid water and readily accessible for use and to comply with applicable code. Areas where subjected to handling of blood and cleaning and handling of bleach and other corrosive materials are used to conduct daily services at this facility must have a fully compliant eyewash station(s) per OSHA/ANSI (Occupational Safety and Health Administration/American National Standards Institute) requirements ANSI Z358.1 - 2004.

Above findings were confirmed by accompanying staff C & D at time of observation.