HospitalInspections.org

Facility A:

Based on policy and procedure review and observation, it was determined the facility (Facility A) failed to ensure patients received care in a safe environment in that one of one Patient (Pt # 32) observed for phlebotomy blood draw was not identified by Phlebotomist #1 prior to performing venipuncture for blood cultures. The failed practice did not ensure that the blood being drawn for blood cultures was performed on the correct patient and had the potential to affect any patient requiring venipuncture by Phlebotomist #1.

Findings:

A. Review of policy and procedure titled Patient Identification Policy received on 06/05/19 at 10:47 AM showed Phlebotomy is considered a high risk procedure and all patients undergoing this procedure will first be asked to state their name and birth date. This information will be compared with two sources, i.e. armband, physician order, requisition or other written documentation.

B. Observation on 06/05/19 at 10:15 AM showed Phlebotomist #1 did not ask Pt. #32 his name or birthdate and he did not ask to see Pt. #32's armband prior to performing venipuncture for blood cultures.

C. The above findings in A and B were verified with the Director of Quality on 06/05/19 at 10:30 AM.

Facility A:

Based on review of policy, list of medication errors for June 4, 2018 through June 4, 2019, review of clinical records and interview, it was determined the facility failed to maintain accurate records in that two (#2 and #5) of five (#1-#5) incidents of a medication error were not documented in the chart of the patient that received the medication in error. By not documenting the medication errors, the facility was not keeping an accurate record of the patient's course of treatment and care. The failed practice had the potential to affect all patients that were treated at the facility. Findings follow:


A. Review of the facility's policy titled, "Medication Administration," dated 08/2016, showed the nurse was to enter the medication, as administered, in the medical record.

B. Review of medication errors given showed the following:

1) Incident #2 showed Patient #34 received a dose of Metformin and Lisinopril at 8:00 AM in error; and

2) Incident #5 showed Patient #37 received a dose of Heparin at 12:35 PM in error.


C. Review of clinical record showed the following:

1) Review of Patient #34's clinical record showed no evidence the medication error was documented anywhere

2) Review of Patient #37's clinical record showed no evidence the medication error was documented anywhere.


D. During an interview on 06/05/19 at 9:41 AM, the Director of Quality verified the findings at B and C.

Facility C:

Based on observation and interview, it was determined that the facility failed to ensure the condition of the hospital environment was maintained in a manner that provides a level of safety and well-being of patients. This was evident in that risk of electrical shock existed in Room #33 on the 1st floor of Facility C as follows: a freestanding bathing tub was installed adjacent to two standard-grade electrical outlets, one of which was powering a portable refrigerator and massage chair located next to the tub. The hazardous environment had the potential to affect 10 patients previously treated in room #33, and any new patients admitted to the room. Findings follow:

A. Observations of Room #33 on 06/04/19 from 1:56 PM to 2:30 PM showed there was a freestanding bathing tub installed adjacent to two standard-grade electrical outlets, one of which was powering a portable refrigerator and massage chair located next to the tub.

B. The above finding in A was verified 06/04/19 at 2:30 PM with the Director of Maintenance.

C. Interview with the Director of Maintenance on 06/04/19 at 2:30 PM stated that the bathing tub installation was completed six months prior.


On 06/04/19 at 4:00 PM the Director of Maintenance was informed there was an Immediate Jeopardy to patient health and safety in the facility in that risk of electric shock was present in Room #33 on the 1st floor of Facility C as follows: a freestanding bathing tub was installed adjacent to two standard-grade electrical outlets, one of which was powering a portable refrigerator and massage chair located next to the tub. The hazardous environment had the potential to affect 10 patients previously treated in Room #33 and any new patients admitted to the room.


The Immediate Jeopardy was lifted at 09:00 AM on 06/05/19 with the following plan of action:

1. Facility C's Low Intervention Suite Room #33 was taken out of clinical service in order to prevent risk of patient harm.

2. A certified electrician removed three electrical receptacles, replaced one of the electrical receptacles with an approved hospital-grade GFCI (Ground Fault Circuit Interrupter) located greater than five feet from the water source.

3. The massage chair and refrigerator were removed from the Low Intervention Birthing Suite.

4. The Risk Manager/Patient Safety Officer performed a patient safety risk assessment on the Low Intervention Birthing Suite to assess all areas of possible risk for patient safety.

Facility C:

Based on observation and interview, it was determined the facility failed to ensure the condition of the hospital environment was maintained in a manner that provides a level of safety and well-being of patients. This was evident in that risk of electrical shock existed in Room #33 on the 1st floor of Facility C as follows: a freestanding bathing tub was installed adjacent to two standard-grade electrical outlets, one of which was powering a portable refrigerator and massage chair located next to the tub. The hazardous environment had the potential to affect 10 patients previously treated in Room #33, and any new patients admitted to the room.

Findings:

A. Observations of Room #33 on 06/04/19 from 1:56 PM to 2:30 PM showed there was a freestanding bathing tub installed adjacent to two standard-grade electrical outlets, one of which was powering a portable refrigerator and massage chair located next to the tub.

B. The above finding in A was verified 06/04/19 at 2:30 PM with the Director of Maintenance.

C. Interview with the Director of Maintenance on 06/04/19 at 2:30 PM stated that the bathing tub installation was completed six months prior.

Based on observation, clinical record review, policy and procedure review and interview, it was determined the facility failed to follow established policies and procedures for ventilator humidification in that the humidification provided to one of one (#31) tracheostomy patient was provided by a heat/moisture exchanger (HME) device and not heated humidification. The failed practice placed the patient at risk of complications from thickened respiratory secretions. The failed practice had the potential to affect all patients on which an HME was used.


Findings:

A. Record review of the facility's policy titled, "Heat and Humidity During Mechanical Ventilation Policy," with a revision date of 02/21/13 showed humidification was provided to all patients requiring mechanical ventilation via an artificial airway. Conditions of inspired gases should be instituted with an HME or a heated humidifier. HMEs may be used for short term use less than or equal to 96 hours and during transport. Heated humidifiers would be used for patients requiring long term mechanical ventilation greater than 96 hours or for patients who exhibit contraindications for HME use. Use of an HME was contraindicated for patients with thick, copious or bloody secretions. HMEs would be replaced with heated humidifiers after 96 hours of use or 48 hours after a new tracheotomy. HMEs would be replaced with heated humidifiers if any of the hazards/complications of HMEs were observed.

B. The findings of A were confirmed in an interview with the Director of Respiratory Therapy on 06/14/19 at 1:35 PM.

C. Observation on 06/04/19 at 1:20 PM showed Patient #31 had an HME in use. Patient #31 had a tracheostomy as an airway for ventilation.

D. Review of Patient #31's clinical record on 06/04/19 showed the following:

1) Surgical Documentation dated 05/30/19 showed a tracheostomy was performed.

2) Ventilator check documentation showed the patient was provided humidification via an HME and had thick sputum (respiratory secretions) from 06/01/19 at 2:18 PM to 06/04/19 at 12:21 PM. There was no evidence the patient was placed on a heated humidifier.

E. The findings of C and D were confirmed in an interview with the Director of Respiratory Therapy on 06/04/19 at 1:35 PM. He confirmed the patient was not placed on a heated humidifier. He stated the facility's policy did not conform to the current standards and the facility's practice did not conform to the established policy.