HospitalInspections.org

30170

Based on record review, interview, and policy review, the provider failed to ensure appropriate interventions were implemented on the nursing care plan for one of one sampled patient (39) who had hemodialysis. Findings include:

1. Review of patient 39's complete medical record revealed:
*He had been admitted on 6/5/13.
*He had complained of chest pain during his dialysis at another facility and had been transferred to this provider.
*His diagnoses included:
-Chest pain.
-End-stage renal disease and had hemodialysis secondary to hypertensive nephrosclerosis (kidney disease).
-History of myocardial infarction (heart attack) two times; the most recent had been in January 2012.
*He had a right arm fistula (used for hemodialysis).

Review of patient 39's 6/5/13 nursing care plan revealed there was no record of hemodialysis interventions.

Interview on 6/19/13 at 8:27 a.m. with the vice president of clinical services regarding patient 39 revealed the care plan should have included hemodialysis interventions.

Review of the provider's July 2012 Standards of Nursing Practice and Standards of Patient Care policy revealed the function of that policy was to:
*Assess the patients.
*Manage the information.
*Care for the patients.
*Evaluate the care of the patient.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Edition, St. Louis Mo., 2005, page 327, revealed:
*A nursing care plan was a guide for clinical care. It also served as a document that would communicate a patient's nursing care to all members of the health care team. It would have been made available to the team as a ready reference for nursing care interventions.
*A written care plan was designed to direct clinical care and to decrease the risk of incomplete, incorrect, or inaccurate care. The plan was organized so that any nurse would have been able to quickly identify the patient's nursing diagnoses, goals, and outcomes and nursing interventions that would have been delivered.
*In hospitals and outpatient and community-based settings, the patient would often receive care from more than one nurse, physician, or allied health professional. A written nursing care plan made possible the coordination of nursing care.

Based on observation, interview, and policy review, the provider failed to:
*Properly label opened multiple dose (multi-dose) vials of normal saline (NS) in the nuclear medicine area of the clinic.
*Ensure filter needles or straws were used to draw-up medications from glass ampules during one of one observed patient's (41) surgical procedure.
Findings include:

1. Observation of the nuclear medication area in the clinic and interview on 6/19/13 at 8:40 a.m. with nuclear medicine technician A revealed:
*An opened multi-dose vial of NS 20 milliliter (ml) was presented to the surveyor.
-It had not been labeled with a date or time when it had been first used.
*They had not dated and timed when those vials had been opened because they were used up so quickly.
*They confirmed the requirement was to date and time the opening of any multi-dose vials regardless of how quickly they were used.

Interview on 6/19/13 at 8:45 a.m. with the director of clinical services revealed:
*She was unaware they used multi-dose vials in the clinic.
*She confirmed they should have dated and labeled the multi-dose vials when they were opened regardless of how soon they were used up.

Review of the provider's July 2012 multi-dose vials policy revealed "The container will be labeled with the date opened."



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2. Observation on 6/18/13 from 9:45 a.m. through 12:30 p.m. of patient 41's surgical procedure revealed certified registered nurse anesthetist (CRNA) I had not used a filter needle or straw to draw up medications from glass ampules administered to the patient during his surgery.

Interview on 6/18/13 at 3:45 p.m. with CRNA I revealed she agreed:
*She should have used a filter needle or straw to draw up the medications from glass ampules used during patient 41's surgical procedure.
*Filter needles and straws were used to ensure glass shards were not injected into the patient's vascular system.

Interview on 6/18/13 at 4:15 p.m. with the director of clinical services revealed the provider had no policies that outlined when to use a filter needle or straw. That was a basic standard of nursing practice.

Based on observation, interview, manufacturer's instructions, and policy review, the provider failed to ensure:
*Surgical hand antiseptic was used per manufacturer's instructions for one of two observed surgical cases by one of two observed physicians (H).
*Post surgery handwashing was completed by one of two observed physicians (H).
*Supplies in one of one observed arterial line tray were not cross-contaminated by one of one unidentified student certified registered nurse anesthetist (CRNA).
Findings include:

1. Observation on 6/18/13 from 9:45 a.m. through 12:30 p.m. of patient 41's surgical case revealed:
*The unidentified CRNA student inserting the patient's arterial line reached back into the arterial line tray full of supplies used for surgical patients multiple times with blood contaminated gloves.
*Physician H and his unidentified assistant used the provider's surgical hand antiseptic in the following manner:
-They dispensed one pump of the product into the palm of their hands outside the operating room.
-They then immediately entered the operating room while rubbing it into their hands and lower forearms.
-Upon entering the operating room they immediately were gowned and gloved with the product still wet on their hands.
*When physician H completed the surgical procedure he removed his gloves and gown and performed no post operative handwashing prior to leaving the surgical department.

Review of the surgical hand antiseptic bottle instructions used by the provider revealed the following processes should have been followed:
-"Dispense approximately two milliliters into hand, dip fingers of opposite hand into palm working product under nails and into cuticles."
-"Repeat procedure with other hand."
-"With hands still moist spread around the hand and lower 1/3 of the forearm."
-"Reapply the product to the hands, paying particular attention to fingers, cuticles, and interdigital spaces."
-"Following application, rub hands until dry."
-"Hands should remain moist for entire application time, approximately two minutes."

Review of the surgical hand antiseptic manufacturer's instructions review and interview on 6/18/13 at 12:40 p.m. with the surgical services director revealed she agreed:
*Physician H and his unidentified assistant had not performed an appropriate pre-surgical hand scrub according to the product's labeled directions.
*The CRNA student noted above had cross-contaminated the arterial line tray in the operating room that patient 41 was in.
*Physician H had not performed appropriate post-surgical handwashing.

Based on observation, interview, and policy review, the provider failed to obtain physician's orders for respiratory services for one of one sampled patient (28) on a ventilator. Findings include:

1. Observation on 6/18/13 at 4:15 p.m. of patient 28 with registered respiratory therapist (RRT) B and the respiratory therapy director (RTD) revealed:
*He was on a ventilator.
*The ventilator was placed on an assist control (respirations) at a rate of 20.
-Tidal volume (Vt) (amount of air): .450.
-Seventy percent oxygen.
-PEEP (positive end-expirator pressure is a form of therapy applied during mechanical ventilation.) - 8.

Interview at the above time with RRT B and the RTD regarding patient 28 revealed:
*He had been intubated three times since Sunday 6/16/13.
*They had a standing order for the settings on a ventilator.
*The settings for the ventilation had been established by a hospital wide protocol.
*If the protocol was not followed for a patient they would need a physician's order to change the settings.
*They were unable to find the physician's order.
*A review of the following provider's mechanical ventilation protocol at that time revealed the settings the ventilator were set at were not consistent with the protocol.

Review of the provider's September 2012 mechanical ventilation protocol revealed "Patients requiring intubation and mechanical ventilation will be placed on the following mechanical ventilator settings in the absence of more definitive physician orders."

Interview on 6/19/13 at 11:10 a.m. with patient care unit director (PCUD) and the vice president (VP) of clinical services regarding patient 28 revealed:
*PCUD confirmed:
-The order for the ventilator was part of the respiratory therapist's (RT) assessment and treatment order.
-The protocol for ventilators had not been followed.
-If the protocol was not followed the physician would have written an order for the specific settings that would supercede (override) the protocol.
*The VP of clinical services confirmed there was not a physician's order for the ventilator settings.
-The protocol had not addressed the parameters of assist control.

Review of the provider's July 2012 physician's order policy revealed:
*"Physician orders are used to communicate to health care team all medical, nursing, and ancillary treatments, procedures and modalities.
*A provider with available access to CPOM (electronic medical record) must enter orders electronically.
*All orders for medication and treatment shall be in entered in Meditech or may be written during computer down time and must be authenticated by a member of the medical staff."