HospitalInspections.org

30172


Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services by failing to ensure the patient's environment was free of ligature risks and safety hazards.
Findings:
Main Campus:
An observation on 07/30/15 from 10:15 a.m. to 11:00 a.m. of the main campus (locked in-patient psychiatric unit) with SF1ADM revealed the following observations:
1) The psychiatric unit had 4 (four) bedroom units with 4 (four) beds to each unit. There were 2 (two) beds on each side of the unit and the 2 (two) beds on each side were separated by a wall. The main entrance to each unit was through a single door from the main hallway and there was 1 (one) bathroom inside each unit for the 4 beds. The bathroom doors inside each unit were not able to be seen from the main hallway. There were also 2 (two) single occupancy bedrooms each with their own bathroom. The bathroom doors in those rooms were also not able to be seen from the main hallway (4 units, 18 beds). The doors to all the patient room's bathroom doors were observed to have door hinges set apart widely enough to allow for potential ligature risks,
2) Each bedroom unit had an air conditioner unit in the window that was encased by a metal slatted encasement that could be potential ligature points,
3) The psychiatric unit had 4 beds with attached head and foot boards- the 4 points of attachment (2 on the headboard and 2 on the footboard) that were not flush to the bed frame facilitating a potential ligature risk. One of the 4 beds was noted to have 3 hand cranks located on the foot of bed facilitating a potential ligature risk.
Off-site Campus

Observations on 7/30/15 at 9:30 a.m. of the off-site locked in-patient psychiatric unit, revealed the inside bathroom doors in patient rooms 213 and 214 had door hinges set apart widely enough to allow for potential ligature risks.
In an interview with S5RN/PD during the observations, S5RN/PD indicated that in order to alleviate the potential ligature risks of the inside bathroom doors, the tops of the doors were cut at a slant. S5RN/PD further added she was not aware the hinges on the doors posed a ligature risk.
In an interview on 7/30/15 at 11:15 a.m. with SF1ADM and SF2DON/IC/QA, the observations referenced above were reviewed. They agreed that the widely spaced door hinges, the attachment points of the head/foot boards, the slatted metal encasements around the air conditioning units, and the bed hand cranks were potential ligature points and posed a safety risk for the psychiatric patients receiving treatment on the unit. SF2DON/IC/QA further indicated that she thought that the environment modifications had addressed all the potential ligature risks/points. She indicated that they did not perform a Risk Assessment to identify/address any further potential ligature risks/points after the environment modifications were performed.



30984

30984


Based on record reviews and interviews, the hospital failed to ensure drug administration errors were identified, reported immediately to the attending physician and documented in the patient's medical record for 2 of 2 (#F1, #F2) sampled patients with medication variances reviewed out of a total patient sample of 6 (#F1-#F6).

Findings:

Review of the hospital policy titled, "Pharm-107: Medication Administration Error, effective date of January 2006", revealed in part the following: When medication is administered improperly or a drug reaction occurs, the following procedure is used: Notify physician, Director of Nursing or Designee. Record incident in nurse's notes and on Incident Report form. (Do not document on nurse's notes that an incident form was completed.)

Patient #F1
Review of the medical record for Patient #F1 revealed the patient was a 55 year old male admitted to the hospital's main campus on 07/27/15 with a diagnosis of recurrent Major Depression with Psychotic Behavior. The patient's diagnoses also included Insulin Dependent Diabetes Mellitus and Hypertension.

Review of Patient #F1 ' s admission orders, dated 7/27/15 at 17:30 (5:30 p. m.), revealed the patient ' s vital signs were ordered as routine for the unit. (SF2DON/IC/QA indicated routine vital signs for the unit were once a shift).

Review Patient #F1 ' s physician standing orders, dated 7/27/15, revealed the following: PRN (as needed) order: If either diastolic or systolic (blood pressure) is greater than 160/90, give Clonidine 0.1 mg (milligrams) p.o. (by mouth) Q (every) 1 hr (hour) x (times) 3 doses, then call physician.

Review of Patient #F1 ' s graphic (vital sign) record, dated 7/27/15, 1st vital sign entry documented after admission at 17:30 (5:30 p. m.), revealed a blood pressure reading of 172/92.

Review of Patient #F1 ' s MAR (medication administration record) revealed no documented evidence that the PRN Clonidine, 0.1 mg p.o. had been administered, as ordered, for a blood pressure reading of greater than 160/90.

Review of Patient #F1 ' s nurse's notes, dated 7/27/15-7/29/15, revealed no documented evidence of administration of the PRN dose of Clonidine 0.1 mg p.o. (ordered for blood pressure greater than 160/90) as treatment for a blood pressure reading of 172/92 on 7/27/15 at 17:30 p.m. Further review revealed no documented evidence that the patient ' s physician had been notified of the missed PRN dose of Clonidine. Additional review revealed the missed dose of Clonidine had not been documented as an identified medication error.

Review of the medication variance reports presented as current by SF2DON/IC/QA revealed no documented evidence of identification of the missed dose of Clonidine, referenced above, as a medication error.

Patient #F2
Review of the medical record for Patient #F2 revealed the patient was a 23 year old male admitted to the hospital's main campus on 07/26/15 with a diagnosis of Depression and Substance Abuse (history of marijuana use and a positive urine drug screen for cocaine).

Review Patient #F2 ' s physician standing orders, dated 7/26/15 at 11:15 a.m., revealed the following PRN order: If either diastolic or systolic (blood pressure) is greater than 160/90, give Clonidine 0.1 mg p.o. Q 1 hr x 3 doses, then call physician.

Review of Patient #F2 ' s graphic record, dated 7/27/15, revealed a documented blood pressure reading of 163/94.

Review of Patient #F2 ' s MAR revealed no documented evidence that the PRN Clonidine, 0.1 mg p.o., had been administered, as ordered, for a blood pressure reading of greater than 160/90.

Review of Patient #F2 ' s nurse's notes, dated 7/27/15-7/29/15, revealed no documented evidence of administration of the PRN dose of Clonidine 0.1 mg p.o. (ordered for blood pressure greater than 160/90) as treatment for a blood pressure reading of 163/94 on 7/27/15. Further review revealed no documented evidence that the patient ' s physician had been notified of the missed PRN dose of Clonidine. Additional review revealed the missed dose of Clonidine had not been documented as an identified medication error.

Review of the medication variance reports, presented as current by SF2DON/IC/QA, revealed no documented evidence of identification of the missed dose of Clonidine, referenced above, as a medication error.

In an interview on 7/29/15 at 3:45 p.m. with SF2DON/IC/QA, she indicated the PRN Clonidine dose should have been administered, as ordered, to both Patient #F1 and Patient #F2, when their blood pressure had fallen outside of the 160/90 range. She also indicated the missed doses of Clonidine, referenced above, should have been identified and documented as medication variances. SF2DON/IC/QA confirmed the missed doses should have been documented in the patient's records. She also confirmed the above referenced missed Clonidine doses had not been captured in the medication variance reports presented to the survey team as current.

In an interview on 7/29/15 at 4:16 p.m., with SF10LPN, she confirmed she had taken care of Patient #F1 and #F2 on 7/27/15. She also confirmed that the patients should have received the PRN Clonidine as ordered (0.1 mg p.o. x 3 for blood pressure readings greater than 160/90). She verified Patient #F1 and #F2 had not received the PRN Clonidine doses as ordered. She also verified the missed doses were medication errors.

Based on observations, interviews, and record reviews, the hospital failed to ensure the infection control officer maintained an effective system for identifying, reporting, investigating, and controlling of infections and communicable diseases of patients and personnel, as evidenced by: failing to ensure environmental cleaning of patient rooms followed acceptable infection control practices, failing to ensure that glucometer disinfecting followed hospital policy, and failing to ensure that staff followed hospital policy when preparing patient injections.

Findings:
A review of the hospital's policy titled, "Cleaning and Disinfection Patient Rooms" provided by SF2DON/IC/QA as the most current policy dated January 2013, revealed no documentation of when housekeeping staff should change their gloves when going from one patient bedroom area to another patient bedroom area and no documentation of the "contact" (kill time) when using the hospital's approved EPA registered disinfectant wipes.
A review of the directions on the EPA disinfectant wipes approved by the hospital for disinfectant use revealed in part: effectively kills the listed micro organisms within a 2 (two) minute contact time when used as directed by the item remaining wet for the appropriate time.
An observation of the main campus psychiatric hospital revealed the psychiatric hospital had 4 (four) bedroom units with 4 (four) beds to each unit. There were 2 (two) beds on each side of the unit and the 2 (two) beds on each side were separated by a wall. The main entrance to each unit was through a single door from the main hallway and there was 1 (one) bathroom inside each unit for the 4 beds.
On 7/30/15 from 9:00 a.m. to 9:30 a.m. an observation was made of SF12Hk cleaning a patient unit containing 4 separate bedroom areas. Observations revealed the following: SF12Hk went from cleaning one patient bedroom area and furnishings to cleaning the next patient's bedroom area and furnishings without changing her gloves between each individual patient's designated bedroom area. SF12Hk was not observed always waiting the 2 minutes "contact" time when cleaning room items.
In an interview on 7/30/15 at 9:30 a.m. with SF12Hk she was asked about the cleaning practices in cleaning patient rooms in relation to changing her gloves and the "contact" time (kill time) of the EPA disinfectant. SF12Hk indicated that she was inserviced on infection control practices for the cleaning of patient rooms by SF2DON/IC/QA and SF3ADON. SF12Hk indicated that in the in-service she was instructed to change gloves between each unit. SF12Hk further indicated that she was not aware of the "contact" time (kill time) of the EPA disinfectant and she did not remember that being discussed in the in-service.
In an interview on 7/29/15 at 4 :00 p.m. with SF3ADON, she indicated that she and SF2DON/IC/QA gave the infection control in-services to the nurses and to the housekeeping staff. SF3ADON was made aware of the above infection control breaches. The in-service content was reviewed by SF3ADON and she indicated that they did not address in the in-service that housekeepers were to change their gloves and perform hand hygiene after each patient designated bedroom area. SF3ADON further indicated that the hospital's EPA disinfectant's "contact " (kill time) was not addressed in the in-services. SF3ADON indicated that the in-services should be repeated with more specific information.
A review of the hospital policy titled, "Cleaning, Disinfection, and Sterilization- IC -300", provided by SF2DON/IC/QA as the most current with a revised date of July 2015, revealed in part: Outer surface of non-immersible equipment will be wiped with a cloth dampened in a cleaning solution such as an EPA approved disinfectant. Accu-Check and Glucometer - Disinfect according to IC-301- Methods of Sterilization and Disinfection. A review of IC-301 revealed in part: All nurse will be in-serviced on cleaning and disinfection of non critical patient care items. Clean medical devices as soon as practical after use, at the point of use.
A review of the hospital policy titled, "Glucose Testing by Finger Stick", provided by SF2DON/IC/QA as the most current with a revised date of July 2015, revealed in part: Disinfect glucometer according to IC-300 and IC-301.
A review of the hospital policy titled, "Hypodermic/SQ Medication Administration", provided by SF2DON/IC/QA as the most current and dated January 2006, revealed in part: Care of Equipment- Discard disposable syringe in a sharps container. Do not re-cap needles.
A review of the QA (Quality Assurance) indicators, provided by SF2DON/IC/QA as the revised QA indicators, dated July 2015, revealed in part: Infection Control- To ensure cleaning of the glucometer in accordance with policy, a cleaning log will be maintained and 1(one) observation of each licensed nurse will be made per quarter.
A review of the QA (Quality Assurance) indicators, provided by SF2DON/IC/QA as the revised QA indicators, dated July 2015, revealed in part: Nursing Services- Nursing staff will complete glucose testing by finger stick according to policy and 2 (two) glucose testings will be observed each month.
A review of the QA (Quality Assurance) indicators, provided by SF2DON/IC/QA as the revised QA indicators, dated July 2015, revealed in part: Nursing Services- Nursing staff will administer subcutaneous injections in accordance with approved policy and procedure and 2 (two) subcutaneous injections will be observed each month.
A review of the Staff Meeting/In-Service and Attendance Sheet dated 6/30/15, facilitated by SF2DON/IC/QA and SF3ADON, revealed in part: Topics discussed - updated policies, IC-300, IC-301, IC-302. The Attendance Sheet revealed attendees included, SF7RN, SF8RN, SF9LPN, SF10LPN.
In an interview on 7/29/15 at 2:10 p.m. with SF7RN (morning shift nurse), she indicated that she was in-serviced by the hospital on the revised infection control policies. SF7RN was asked about the cleaning of the glucometer after each patient use. SF7RN indicated that the glucometer can be wiped with an alcohol wipe.
In an interview on 7/29/15 at 2:30 p.m. with SF8RN (evening shift nurse) she indicated that she was in-serviced by the hospital on the revised infection control policies. SF8RN was asked about the cleaning of the glucometer after each patient use. SF8RN indicated that she thinks the glucometer can be wiped with an alcohol wipe.
In an interview on 7/29/15 at 2:20 p.m. with SF9LPN (morning shift nurse), she indicated that she was in-serviced by the hospital on the revised infection control policies. SF9LPN was asked about the cleaning of the glucometer after each patient use. SF9LPN indicated that the glucometer should be disinfected with the hospital's EPA disinfectant. SF9LPN was asked about the "contact" time (kill time) for the EPA disinfectant. SF9LPN indicated that she was not sure of the "contact" time (kill time) for the EPA disinfectant.
In an interview on 7/29/15 at 2:30 p.m. with SF10LPN (evening shift nurse), she indicated that she was in-serviced by the hospital on the revised infection control policies. SF10LPN was asked about the cleaning of the glucometer after each patient use. SF10LPN indicated that the glucometer should be disinfected with the hospital's EPA disinfectant. SF10LPN was asked about the "contact" time (kill time) for the EPA disinfectant. SF10LPN indicated that she was not sure of the "contact" time (kill time) for the EPA disinfectant.
On 7/29/15 at 4:30 p.m. an observation (Main Campus) was made of SF10LPN performing an accu-check with a multiple patient use hand held glucometer on Patient F2 and an observation was made of SF10LPN preparing an insulin injection for Patient F2.. Observations revealed: SF10LPN did not change her soiled gloves (after performing the accu-check) and don clean gloves before returning all the clean glucometer supplies back into the accu-check supply cart. SF10LPN did not disinfect the glucometer immediately after use on Patient F2 and placed the glucometer device onto the medication cart. SF10LPN obtained the insulin from the refrigerator and prepared the insulin injection for Patient F2 all with the same gloves and was not observed changing her gloves. After the injection was given to Patient F2, SF10LPN was observed re-capping the needle before placing it into the sharps container. SF10LPN was then observed disinfecting the glucometer with the same gloves. SF10LPN was not observed waiting the 2 (two) minutes "contact" time after disinfecting the glucometer before returning it to its case. SF10LPN then removed the gloves that she used during the entire observations and washed her hands.
In an interview on 7/29/15 at 4:50 p.m. with SF3ADON, she indicated that she assisted SF2DON/IC/QA, the infection control nurse, with preparing and giving the infection control in-services that was presented to all the nursing staff in June 2015 and July 2015 on the revised infection control policies. SF3ADON was made aware of the above infection control breaches. SF3ADON indicated that the in-services reviewed acceptable infection practices and that those observations were not acceptable infection control practices. SF3ADON indicated that the in-services did not include return demonstrations. SF3ADON was asked if any monitoring of staff, according to the hospital's QA indicators, had been preformed after the in-services on the revised infection control policies. SF3ADON indicated that she had only performed 1(one) monitoring observation of a staff member. SF3ADON indicated that the revised QA indicators were only going to require 2 (two) glucose testings to be observed each month, 2 (two) subcutaneous injections to be observed each month, and 1(one) observation of each licensed nurse to be made per quarter for glucometer cleaning. SF3ADON indicated that a glucometer cleaning log was being maintained, but it was only documenting that the nurse cleaned the glucometer between patient use and not the process of how the glucometer was being cleaned or if the glucometer was being cleaned according to the infection control policy. SF3ADON further indicated that the in-services should be repeated with return demonstrations and that the QA indicators monitoring of the observations should be increased until compliance can be maintained.