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A. Based on review of Hospital policy, observation, clinical record review, and staff interview, it was determined that for 2 of 2 clinical records reviewed (Pts. 22 & 23) for patients in restraints in the Emergency Department (ED), the Hospital failed to ensure physicians' orders for restraints were complete.

Findings include:

1. Hospital policy No. HP-P-17, titled, "Protective Devices" was reviewed on 1/4/11 at 12:45 PM. The policy required, "Application of restraints for protective purposes and behavioral management: 1... The use of a restraint must be in accordance with the order of a physician. 2... The order includes the type of restraint and the duration for the device being used..."

2. On 1/4/11 at 1:15 PM, an observational tour was conducted in the North Emergency Department (ED). Pt. #22 was in full leather restraints in Room 14.

3. On 1/4/11 at 1:30 PM, an observational tour was conducted in the South ED. Pt. #23 was in full leather restraints in Room N.

4. On 1/4/10 at 1:20 PM, the clinical record of Pt. #22 was reviewed. Pt. #22 was a 51 year old male, treated in the ED on 1/4/11, with a complaint of Altered Mental Status. A Physician's order (E #8) for restraint was signed and dated, but lacked: time, type of restraint to use, duration for restraint, and criteria for release of restraint.

5. On 1/4/10 at 1:35 PM, the clinical record of Pt. #23 was reviewed. Pt. #23 was a 47 year old male, treated in the ED on 1/4/11, with a complaint of Shortness of Breath. A Physician's order (E #9) for restraint was signed, but lacked date, time, and duration for restraint.

6. These findings were confirmed by the Emergency Department Director during an interview on 1/4/11 at 1:40 PM.
Surveyor 19843

A. Based on review of Hospital policy, observation, clinical record review, and staff interview, it was determined, that for 1 of 2 clinical records reviewed (Pt. # 22) for patients in restraints in the Emergency Department (ED), the Hospital failed to ensure restrained patients were monitored and reassessed.

Findings include:

1. Hospital policy No. HP-P-17, titled, "Protective Devices" was reviewed on 1/4/11 at 12:45 PM. The policy required, "Use of Restraints for Behavioral Purpose... 3. The patient will be reassessed every 15 minutes and documentation will be done on the 24 hour restraint flow record."

2. On 1/4/11 at 1:15 PM, an observational tour was conducted in the North Emergency Department (ED). Pt. #22 was in full leather restraints in Room 14.

3. On 1/4/10 at 1:20 PM, the clinical record of Pt. #22 was reviewed. Pt. #22 was a 51 year old male, treated in the ED on 1/4/11, with a complaint of Altered Mental Status. Pt. #22 was transported to the ED by ambulance, arrived in triage at 11:06 AM, and was transported into room 14 at 11:08 AM. A physician's order for behavioral restraints was dated 1/4/11. The record lacked documentation of the time Pt. #22 was placed in restraints.

The Surveyor requested to review Pt. #22's behavior restraint care sheet at 1:15 PM. Approximately 1 minute later a Registered Nurse (E #7) was found completing the form, but had only written a time (11:30 AM) and checked 2 boxes for observations/ reassessment. The surveyor again requested that the form be copied, without further alteration. Therefore, 15 minute reassessments were not documented for 1 1/2 hours (11:30 AM to 1:15 PM).

4. These findings were confirmed by the Emergency Department Director during an interview on 1/4/11 at 1:20 PM.

A. Based on review of Hospital policy, clinical record review, staff interview and stated Hospital practice, it was determined that for 2 of 5 (Pt. #4 & 5) clinical records reviewed on 5 Telemetry, the Hospital failed to ensure hourly rounding was completed as required by policy and stated practice.

Findings include:

1. The Hospital policy titled, "Patient Care" was reviewed on 1/3/11 at approximately 1:00 PM. The policy required, "All patients admitted to ... Hospital are at level 1 Risk. Intervention... Hourly rounds...."

2. The clinical record of Pt. #4 was reviewed on 1/3/11, at approximately 10:05 AM. Pt. #4 was a 75 year old male admitted on 12/30/10 a with diagnosis of Pneumonia. The nursing admission assessment dated 12/30/10 indicated Pt. #4 was at level 2 fall risk. The hourly rounding sheet dated 1/3/11 lacked documentation of rounding at 7:00 AM, 8:00 AM and 9:00 AM.

3. The clinical record of Pt. #5 was reviewed on 1/3/11, at approximately 10:55 AM. Pt. #5 was an 82 year old male admitted on 12/27/10 with a diagnosis of Profound Anemia. The nursing admission assessment dated 12/27/10 indicated Pt. #5 was at level 1 fall risk. The hourly rounding sheet dated 12/29/10 lacked documentation of rounding at 5:00 AM, and 6:00 AM. The hourly rounding sheet dated 1/1/11 lacked documentation of rounding at 8:00 AM, 11:00 AM and 12:00 - 6:00 PM.

4. The Telemetry Nurse Manager was interviewed on 1/3/11 at approximately 11:15 AM. The Manager stated that it is Hospital practice to round and document on all patients hourly. The above findings were confirmed with the Nurse Manager during the interview.

A. Based on review of Hospital policy, review of clinical records, and staff interview, it was determined that for 5 of 12 clinical records reviewed (Pt's. #1, 4 , 5, 10 and 11), the Hospital failed to ensure a nursing care plan was initiated and/or updated in a timely manner.

Findings include:

1. Hospital policy No. HP-D-8 titled, "Documentation of Patient Care" policy was reviewed on 1/3/11 at 12:55 PM. The policy required, "... A Plan of Care will be initiated within 8 hours of a patient's admission to the hospital. The Plan will be reviewed every day and revised, as necessary."

2. On 1/3/11 at 10:30 AM, Pt. #1's clinical record was reviewed. Pt. #1 was a 28 year old female, admitted on 1/2/11, with diagnoses of Term Pregnancy and Repeat Caesarian Section. Pt. #1 was admitted to the Family Birthing Unit on 1/2/11 at 1:50 AM. A nursing care plan had not been initiated at the time of the review, more than 32 hours after admission.

3. The above finding was confirmed by the Director of the Family Birth Center during an interview on 1/3/11 at 10:50 AM.


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This was found on the 5th Floor Unit.

4. The clinical record of Pt. #4 was reviewed on 1/3/11 at approximately 10:05 AM. Pt. #4 was a 75 year old male admitted on 12/30/10 with a diagnosis of Pneumonia. The care plan, initiated on 12/30/10, lacked documentation of review on 1/2/11.

5. The clinical record of Pt. #5 was reviewed on 1/3/11 at approximately 10:55 AM. Pt. #5 was an 82 year old male admitted on 12/27/10 with a diagnosis of Profound Anemia. The care plan was not initiated until 12/30/10, and lacked documentation of review and/or update on 1/1/11.

6. The clinical record of Pt. #10 was reviewed on 1/3/11 at approximately 1:45 PM. Pt. #10 was a 44 year old female admitted on 12/22/10 with a diagnosis of Sepsis. The physician's order dated 12/23/10 at 11:00 AM included: "dialysis MWF" The care plan initiated on 12/22/10, lacked an update to include the Hemodialysis treatments.

7. The clinical record of Pt. #11 was reviewed on 1/3/11 at approximately 2:45 PM. Pt. #11 was a 65 year old female admitted on 12/26/10 with a diagnosis of Sepsis. The physician's orders on 12/28/10 at 11:25 AM and 12/30/10 at 1:30 PM included: "Hemodialysis in AM....." The care plan initiated on 12/26/10 lacked an update to include the Hemodialysis treatments.

8. The above findings were confirmed with the 5th Floor Nurse Manager during an interview, on 1/3/11, at approximately 3:00 PM.

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 5 (Pt #3) clinical records reviewed of patients that had received blood component transfusions, the Hospital failed to ensure blood was transfused as ordered.

Findings include:

1. Hospital policy entitled, "Blood Transfusion Procedure," reviewed on survey date 1/3/11 at approximately 12:30 PM required, "..V. Request for Blood/Blood Components: 1. Request for transfusion are made by physician order. 2. A blood Transfusion Transfusion Requisition is completed for each unit of blood...IX. Administration /Transfusion Documentation. 1. The transfusionists will obtain the recipient's pre-transfusion vital signs...3. The transfusionists will obtain the recipient's vital signs 15 minutes after the transfusion was started..4. Upon completion of the unit, the transfusionists will record the completed by, date, and time portion of the Transfusion Record...5. The transfusionists will obtain the recipient's vital signs after the transfusion is completed and record..6. The remainder of the Transfusion Record on the requisition must be completed as follows" a. amount..b. Transfusion reaction.."

2. The clinical record of Pt #3 was reviewed on survey date 1/3/11 at approximately 10:00 AM. Pt #3 was an 85 year old male admitted on 12/17/10 with a diagnosis of Altered Mental Status. The clinical record contained a physician's order dated 12/17/10 at 10:00 PM that required Pt #3 to be type and cross matched for 2 units of packed red blood cells and transfused at a 2 hour rate. The clinical record lacked documentation that Pt #2 had received the ordered blood and/or a physician's order discontinuing the blood transfusion.

The clinical record also contained a physician's order dated 12/18/10 at 2:30 PM that required Pt #3 be type and cross matched for 2 units of packed red blood cells and transfuse one on 12/18/10 and the other unit in the morning of 12/19/10. The clinical record contained documentation that Pt #3 received one unit of blood products on 12/18/10. However, the unit that was ordered on 12/19/10 was documented as cancelled. The clinical record lacked a physician's order to cancel the second unit of blood product.

The blood transfusion record for packed cells # W0397 10349606 was reviewed on survey date 1/3/11 at approximately 10:00 AM. The record lacked the date of completion, time of completion, the recipient's vital signs after the transfusion was completed, the amount transfused and presence or absence of transfusion reaction.

3. The above findings were confirmed by the Vice President of Patient Care Services and Nurse Manager of the Intensive Care Units during an interview on survey date 1/3/11 at approximately 10:30 AM.

A. Based on a review of the Hospital's Medical Staff Rules and Regulations, a review of an attestation letter from the Medical Record's Department, and staff interview, it was determined that the Hospital failed to ensure completion of all medical records within 30 days post discharge.

Findings include:

1. The Hospital's Medical Staff Rules and Regulations were reviewed on 1/4/11 at 7:30 A.M. The Rules and Regulations included, " The patient's medical record shall be complete at time of discharge...Where this is not possible...the patient's chart will be available in a stated place in the Medical Record Department for 30 days after discharge."

2. The attestation letter from the Director, Health Information Management was reviewed on 1/5/11 at 1:30 PM. The letter included that as of survey date 1/5/11, there were 345 medical records incomplete (delinquent) greater than 30 days post discharge.

3. The above finding was confirmed with the Director, Health Information Management during an interview on 1/5/11 at 1:30 PM.

A. Based on review of Hospital policy, observation and staff interview, it was determined that in 1 of 1 crash cart in the Coronary Intensive Care Unit (CICU), the Hospital failed to ensure all outdated drugs were not available for patient usage.

Findings include:

1. Hospital Pharmacy policy entitled, "Inventory Control-Security of Medication Storage Areas," reviewed on survey date 1/3/11 at approximately 11:30 AM required, "Procedure:..4. Department personnel shall check the integrity of the lock and expiration daily..."

2. Hospital policy entitled, "Code Blue," required, "...Crash Cart Monitoring:.2. If drugs/supplies have expired or cart is compromised, the cart should be exchanged."

3. On survey date 1/3/11 at approximately 9:15 AM the CICU was toured. During the tour the unit crash cart was opened and the following observations made: one (1) 30 ml vial of Normal Saline expired on 12/1/10 and two (2) vials of Adenocard 6 mg/2 ml expired on 11/1/10.

4. The above findings were confirmed by the Vice President of Patient Care Services and Nurse Manager of the Intensive Care Units during an interview on survey date 1/3/11 at approximately 9:30 AM.

A. Based on review of Hospital policy and staff interview, it was determined that for 1 of 1 policy related to automatic stop orders, the Hospital failed to ensure a time was established for all drugs to be automatically stopped when the physician's order did not specifically prescribe the time limit or number of doses.

Findings include:

1. On 1/5/11 at 9:15 AM, policy #: VII-F, titled, "Medication Preparation and Distribution - Automatic Stop Orders" was reviewed. The policy required, "1. The need for specified automatic stop orders is determined by the Pharmacy and Therapeutics Committee... 3. Physicians are alerted of an expiring medication order via the Medication Profile printed daily and placed in the patient's chart..." The policy included drug time limits for controlled substances, intravenous infusion with Potassium, and Total Parenteral Nutrition, but lacked time limits for other medications.

2. On 1/5/11, between 9:00 AM and 9:20 AM, an interview was conducted with the Director of Pharmacy. The Director was asked if there was an automatic stop order for all medication. The Director stated that there was an automatic stop order for Controlled Substances and Antibiotics, but not for other medications, and confirmed the findings.

A. Based on an observational tour, staff interview and Hospital policy review, it was determined that for 6 of 10 rooms inspected (rooms 402, 403, 404, 406, 407 and 412), the Facility failed to ensure rooms were hygienically cleaned in accordance with policy.

Findings include:

1. On 1/03/11 an observational tour was conducted on the 4th floor medical/surgical unit from approximately 9:20 AM until 11:45 AM. The following rooms, identified by staff as clean and ready for a patient admissions, contained the following:

* The bed frame in 402-1 (unoccupied) was dusty.

* The bed frame in room 403-1 (unoccupied) was dusty, the side rail and the privacy curtain contained brown stains. A mattress was stored directly on the floor.

* Occupied room 403-2 contained a bedside commode with a brown substance inside.

* The bed frame in room 404 (unoccupied) was dusty.

*The curtain in room 406-1 (unoccupied) contained brown stains.

*The bed frame in room 407-1 (unoccupied) was dusty.

* The bed frame in 412-2 (unoccupied) was dusty. The side rail of the bed frame contained a brown substance that was easily removed by the surveyor with the hospital's approved "all purpose cleaner."

2. The Nurse Manager was interviewed on 1/03/11 at approximately 10:20 AM. The Manager stated the unoccupied rooms were cleaned on 1/2/11 by housekeeping. The above findings were verified by the Nurse Manager.

3. Policy #CP-3 titled, "Patient Room Terminal Cleaning" was reviewed on 1/03/11 at approximately 1:30 PM. The policy included, "...The purpose of this policy is to ensure that patient rooms are hygienically cleaned...before another patient is admitted. Procedure: Wash entire bed and side rails."

B. Based on an observational tour, clinical record review, staff interview and Hospital policy review, it was determined that for 1 of 3 patients (Pt. #9) observed with Foley drainage bags on the 4th floor Medical/Surgical unit, the Facility failed to ensure the drainage bags were not directly touching the floor.

Findings include:

1. On 1/03/11 at approximately 10:00 AM, the patient in room 406-2 (Pt. #9) had a Foley catheter connected to a closed drainage bag. The drainage bag was observed directly on the floor causing the potential for infection.

2. On 1/03/11 at approximately 10:30 AM, the clinical record for Pt. #9 was reviewed. Pt. # 9 was admitted to the 4th floor on 1/1/11 with a diagnosis of Sepsis.

3. The above findings were verified by the Nurse Manager during an interview on 1/3/11 at approximately 10:00 AM.

4. On 1/3/11 at approximately 3:00 PM, Facility policy 2-F titled "Transportation of a Patient with a Foley Catheter" was reviewed. The policy included, " ...In order to prevent infection, do not allow urinary drainage bag to touch the floor.


19843


C. Based on observation and staff interview, it was determined, that for 1 of 1 steam sterilizer in OR and 2 of 2 Ethylene Oxide (EO) sterilizers in the Central Service/ Sterilization Department, the Hospital failed to ensure sterilizers were free of rust, to reduce the potential for contamination of instrument packages during sterilization.

Findings include:

1. On 1/4/11 from 7:45 AM through 9:15 AM, an observational tour was conducted in the Operating Room Area and Central Service/ Sterilization Department. The following sterilizers contained a significant amount of rust:

- OR steam sterilizer - sides contained rust

- Central Service Area - 2 of 2 EO sterilizers bottoms contained rust

2. The findings related to the OR steam sterilizer were confirmed by the OR Charge Nurse/ Team Leader on 1/4/11 at 8:00 AM, during an interview. The findings related to the Central Service Area were confirmed by the Central Service Department Supervisor on 1/4/11 at 8:45 AM, during an interview.

D. Based on observation and staff interview, it was determined, that for 5 of 5 ceiling vents in the OR and Central Service/ Sterilization Department, the Hospital failed to ensure ceiling vents were free of dust, to reduce the potential for contamination of instruments and instrument packages.

Findings include:

1. On 1/4/11 from 7:45 AM through 9:15 AM, an observational tour was conducted in the Operating Room Area and Central Service/ Sterilization Department. The following ceiling vents contained a thick layer of dust:

- OR decontamination room - 1 of 1 ceiling vent

- Central Service Area (where steam sterilizers # 1 & 3 are housed) - 2 of 2 ceiling vents

- Central Service Area, sterile supply room - 2 of 2 ceiling vents

2. The findings related to the OR decontamination room were confirmed by the OR Charge Nurse/ Team Leader on 1/4/11 at 8:00 AM, during an interview. The findings related to the Central Service Area and Sterile supply room were confirmed by the Central Service Department Supervisor on 1/4/11 at 8:45 AM, during an interview.


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E. Based on observation and staff interview it was determined that for 4 of 4 portable Reverse Osmosis (RO) machines (#s 1-4), the Hospital failed to maintain equipment in a sanitary manner.

Findings include:

1 An observational tour of the Hemodialysis treatment area was conducted on 1/4/11 at approximately 9:00 AM. The following was observed:

* 4 of 4 portable Reverse Osmosis (RO) machines carts contained rusted free weights lying at the base of the cart, rolls of fluid soaked tape, and fluid soaked 2 x 3 inch taped wrapped boxes.
*1 of 4 (#1) portable RO machines was taped at the top seam of the RO, preventing proper cleaning of the machine.
* 4 of 4 RO machine water lines (2 each RO) were capped with purple gloves at the opening of the water lines, a potential for contamination.

2. The above findings were confirmed with the 5 th floor Nurse Manager on 1/4/11 at approximately 9:00 AM, during an interview.


F. Based on review of Hospital policy, observation and staff interview, it was determined that for 2 of 2 (E #10 & 11) Hemodialysis staff, the Hospital failed to ensure hand hygiene was performed as required by policy.

Findings include:

1. The Hospital policy titled "Infection Control Guidelines- Hemodialysis" was reviewed on 1/5/11 at approximately 11:00 AM. The policy required, "Disposable gloves are worn by dialysis personnel for protection when handling dialysis equipment and accessories.... Gloves should be removed after completion of task and hand washed immediately...."

2. During an observational tour of the Hemodialysis treatment area on 1/5/11 at approximately 11:15 AM the following were observed.

- E #10 touched a blood transfusion line (during transfusion of a patient), the hemodialysis blood lines, and the dialysis machine screen without wearing gloves; and proceeded to document observations without hand washing between each task.
- E #11 held a 1 pint blood container during verification with E #10, without wearing gloves. E #11 did not perform hand washing after touching blood lines and dialysis lines.

3. The above findings were confirmed with the 5 th floor Nurse Manager during an interview on 1/5/11 at approximately 11:40 AM.

A. Based on observation, staff interview and Facility policy review, it was determined that for 4 of 5 staff members (E#s 2, 4, 5 and 6) observed in operating room (OR) D, the Facility failed to ensure staff adherence to the surgical dress attire.

Findings include:

1. On 1/04/11 observations were conducted in OR- D from 7:30 AM until approximately 8:10 AM. Employees #2, 4 and 5 entered OR- D with approximately 1-2 inches of hair exposed beneath their surgical caps.

2. The circulating nurse (E#6) was observed wearing a warm up jacket while in OR- D that was not buttoned. The warm up jacket was not removed prior to performing the surgical skin prep, on 1/4/11 at approximately 8:05 AM, in accordance with policy.

3. The above findings were discussed with the OR Manager during an interview at approximately 9:00 AM.

4. On 1/04/11 at approximately 10:10 AM, Facility Policy # OR-D-9 title, "Surgical Services" was reviewed. The policy included, "All hair on the head must be covered...Circulating RN's may wear warm up jackets. Warm up jackets must be kept buttoned/snapped when worn, and must be removed ...before performing skin prep."