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Based on observation, interview, record review and policy review, the facility failed to:
- Ensure patients with suicidal thoughts and/or attempts to self-harm were provided an environment free of suffocation, looping/ligature hazards and free of hazardous contraband for nine of nine patients reviewed on suicide precautions (A-144);
- Establish a process that correctly distinguished between complaints and grievances by requiring a multi- step process to file a grievance. This requirement could cause a delay in investigation of patient issues (A-118);
- Ensure each patient and/or patient's representative in the Emergency Departments (ED) and the outpatient departments (Northeast and Northwest) were asked to determine if the patient had an established Advance Directive or offered the opportunity to establish an Advance Directive. Facility also failed to protect the patients' right to have Advance Directive by having a policy that stated Advance Directives are suspended while patients are in outpatient care settings (A-132);

Due to the severity and cumulative effect of the systemic practices resulted in the facility being out of compliance with 42 CFR 482.13 - Condition of Participation: Patient's Rights and resulted in the facility's failure to provide a safe environment for patients. Subsequently the situation constituted a condition of Immediate Jeopardy (IJ). The hospital administration was notified of the IJ on 04/27/11 at 2:55 PM. At the time of the exit conference on 05/03/11 at 3:00 PM, the facility had implemented actions to abate this Immediate Jeopardy situation.

The facility census was 267.

Based on record review and interview, the facility failed to establish a process that correctly distinguished between complaints and grievances by requiring a multi-step process to file a grievance. This requirement could cause a delay in investigation of patient issues. The facility census was 267.

Findings included:

1. Record review of the facility's policy AIM#322, titled, "Complaint Management, Service Recovery and Grievance" revised December 28, 2009 showed:
- Christian Hospital has a two stage process for handling patient complaints (policy describes 3 stages)
- Stage 1 involves a limited number of decision makers in the review of the complaint.
- A concern shall be defined as an issue that does not require significant investigation; which can be immediately resolved by the receiver; no closure letter is required. Concerns that cannot be resolved by the recipient must be elevated to the appropriate person within one business day.
-A complaint shall be defined as an issue which requires some substantive investigation and does not have a readily identifiable solution, closure letter is required.

Stage 2: Service Recovery: Sequence of behaviors
-If the complainant is not satisfied with the resolution obtained through the complaint management process, then they will be informed verbally and in writing of their right to file a grievance. This will include an explanation of the hospital grievance process and an explanation of how to file a grievance with State Department of Health and/or The Joint Commission.

Stage 3: Grievance Process:
-Grievances can be filed by letter, phone, or in person by contacting the Manager, Service Excellence and the Manager, Patient Safely/Regulatory Compliance who will provide written information regarding the process for filing a grievance. (See attached Grievance Form)
-Christian Hospital Grievance Form states: If you feel your concern has not been resolved to your satisfaction, you may complete this form and return it to (hospital address). If you do wish to file a formal grievance please complete the form below to facilitate our ability to provide you with a satisfactory resolution to your concerns.

2. Record review of response letter to discharged Patient #34, dated March 6, 2011, stated that: "I went through a whole lot, so I don't want others to experience that. I have something to say. I want something put in writing. I want to file a grievance. I'm not stopping until I know something is in writing and I will go to the top" (patient quote). The response letter continues: "We have a Complaint Management Process at Christian Hospital, which states that we have 14 business days to investigate complaints. The Complaint process involves the documentation of the experience, conference (in person or by phone) discussion with the manager of the department; then follow up via written correspondence. If you feel we have not addressed your issues to your satisfaction (after receipt of this letter), please know that you may request a Grievance Hearing by calling the Manager of Patient Safety."

3. During an interview on 04/29/11 at 11:00 AM Staff NN, Manager Service Excellence, stated that:
-Concerns are usually verbal and the issue can be handled immediately;
-Complaints require investigation and a closure letter is sent to the patient as resolution. The letter advises the patient that if they are not satisfied with the response they can contact us to file a grievance. Staff NN stated that hospital staff will assist the patient in completing the grievance form if necessary;
-Patient issues that are received in writing (by letter or email) automatically are considered a grievance. Otherwise it is considered a complaint and if the patient is not happy with response they would call and we can send them the grievance form or complete it with them on the phone. (According to regulation, a complaint becomes a "grievance" when the complaint can not be resolved at the time of the complaint by the staff who are present. The facility failed to identify grievances and required multiple steps to be taken by the patient and/or representative in order to be a grievance).

Based on interview, record review and policy review, the facility failed to ensure each patient and/or patient's representative in the Emergency Departments (ED) and the outpatient departments (Northeast and Northwest) were asked to determine if the patient had an established Advance Directive or offered the opportunity to establish an Advance Directive. Facility also failed to protect the patients' right to have Advance Directive by having a policy that stated Advance Directives are suspended while patients are in outpatient care settings. This had the potential to affect all patients seen in the ED's and outpatient areas. The facility census was 267.

Findings included:

1. Record review of the facility's policy #145 titled, "Advance Directives", revised February, 2011 showed the following:
- Outpatient settings: Formal advance directives are documents that state patients' choices for health care. Advance directives allow patients to make known their wishes regarding the medical care they do or do not want to receive if they become too sick to speak for themselves. In an outpatient care setting, if a patient should suffer a cardiac or respiratory arrest or other life threatening situation, their signed consent implies consent for resuscitation and transfer to a higher level of care. Therefore Advanced Directives are suspended while patients are in our outpatient care settings.
- Review of Policy #145 showed:
No definition of outpatient settings;
No direction to staff on obtaining any information about advanced directives in outpatient area or emergency departments;
No direction to staff on how to advise patients of the suspension of this right.

2. Record review of the facility's brochure titled, "Outpatient Guide to Services," showed Advance Directives are encouraged however, not applicable in outpatient areas.

3. During an interview on 04/25/11 at 2:30 PM, Staff E, Director of Patient Care Services at Northeast ED, stated that ED staff do not ask patients or their representatives if they have an Advance Directive. Staff E stated that if the patient is going to be admitted as an inpatient the "Admit Nurse" will ask about Advance Directive.

4. During an interview on 04/28/11 at 9:30 AM, Staff JJ, Manager at Northwest ED, stated that ED staff do not ask patients or their representatives if they have an Advance Directive. Staff E stated that if the patient is going to be admitted they will obtain that information after transfer to admitting facility.

5. During an interview on 04/28/11 at 10:35 AM, Staff OO, Lead Patient Access Representative, stated that he/she registers patients at the Northwest location for the Breast Center, Sleep Center, Radiology Services and the ED. Staff OO stated that registration staff do not ask about Advance Directives during their registration process.

6. During an interview on 04/29/11 at 11:25 AM, Staff I, Manager of Patient Safety/Regulatory Compliance, stated that if a patient is coming for treatment in an outpatient area, they are asking for care and we will provide care to the fullest degree.

Based on observation, interview and record review, the facility failed to ensure patients with suicidal thoughts and/or attempts to self-harm were provided an environment free of suffocation, looping/ligature hazards and free of hazardous contraband for nine (#25, #49, #50, #51, #52, #17, #18, #19, and #48) of nine patients reviewed on suicide precautions. The facility census was 267.

Findings included:

1. Observation on 04/27/11 at 9:15 AM through 10:25 AM of 3 South (Adult/Adolescent Psych) unit showed five patients on suicidal precautions (of 15 total patients on unit) with the following environmental concerns:
3 South: 10 patient rooms (301 through 314-each equipped with a private bathroom)
-Long stemmed handles on hand wash sinks in each patient room created a ligature/looping risk; (Rooms 301-310 had handles two and three quarters inches long on valve stems, one and one half inch above the sink top, and Rooms 311-314, had handles three inches long on valve stems, two and one eighth inches above the sink top).
-Heavyweight vinyl shower curtains in each private bathroom (10 rooms), presented as a potential suffocation risk.
-Television in day room 306 with a TV cable and an electrical cord that each measured 35 inches long, accessible to patients and presented as a ligature/looping risk.

2. Observation on 04/27/11 at 9:15 AM of Room 301-2 showed a butane cigarette lighter sitting on the window sill next to Patient #25's bed.

Review of Patient # 25's (Room 301-2) medical record on 04/26/11 showed the patient presented to the emergency with complaints of suicidal thoughts with a plan of overdosing on medication and stated he/she wrote a suicide note. The patient has a history of suicidal ideation, self mutilation including cutting him/her. The patient was admitted to inpatient psychiatric services with depression on 04/25/11.

During an interview on 04/28/11 at 11:00 AM, Staff UU, Behavioral Health Manager, stated that all patients being admitted to the Behavioral Health unit are searched and their personal items are screened by security. Staff UU stated that valuables are secured in a vault in Administration, contraband items such as lighters, matches, and knives are inventoried and locked up by Security until patient is discharged. Staff UU stated they were not sure where the cigarette lighter came from, but felt certain it came in from the outside, and that the patient did not smoke. Staff UU stated that the rooms are checked twice daily by Mental Health Techs between 8:00 AM to 9:00 AM, and between 8:00 PM to 9:00 PM. Staff UU stated the last rounding on the morning of 04/27/11 would have occurred between 8:00 AM and 9:00 AM. The facility failed to provide documented evidence of this rounding log sheet.

3. Review of Patient #49's medical record showed the patient was admitted for observation and stabilization, with suicidal ideations, suicidal attempts and depression. Patient #49's room (Room 302-1) was one of 10 patient rooms on 3 South where long stemmed handles on a sink fixture in the room presented a ligature/looping hazard and the shower curtain for the private shower presented a potential suffocation risk. Based on their suicidal thoughts, the patient needed closer supervision and more frequent monitoring than other patients, to protect them from self-harm. The environmental risks provided a greater opportunity for self-harm.

4. Review of Patient #50's medical record showed the patient was admitted with suicidal thoughts, attempts and ideations, and for hearing voices telling him/her to self harm. Patient #50's room (Room 303-2) was one of 10 patient rooms on 3 South where long stemmed handles on a sink fixture in the room presented a ligature/looping hazard and the shower curtain for the private shower presented a potential suffocation risk. Based on their suicidal thoughts, the patient needed closer supervision and more frequent monitoring than other patients, to protect them from self-harm. The environmental risks provided a greater opportunity for self-harm.

5. Review of Patient #51's medical record showed the patient was admitted with suicidal thoughts, and hearing voices telling him/her to self harm and for depression. Patient #51's room (Room 304-1) was one of 10 patient rooms on 3 South where long stemmed handles on a sink fixture in the room presented a ligature/looping hazard and the shower curtain for the private shower presented a potential suffocation risk. Based on their suicidal thoughts, the patient needed closer supervision and more frequent monitoring than other patients, to protect them from self-harm. The environmental risks provided a greater opportunity for self-harm.

6. Review of Patient #52's medical record showed the patient was admitted with Psychosis (Psychosis is a loss of contact with reality, usually including false beliefs about what is taking place or who one is [delusions] and seeing or hearing things that aren't there [hallucinations]), depression and suicidal thoughts. Patient #52's room (Room 310-2) was one of 10 patient rooms on 3 South where long stemmed handles on a sink fixture in the room presented a ligature/looping hazard and the shower curtain for the private shower presented a potential suffocation risk. Based on their suicidal thoughts, the patient needed closer supervision and more frequent monitoring than other patients, to protect them from self-harm. The environmental risks provided a greater opportunity for self-harm.

7. Observation on 04/27/11 at 10:25 AM through 11:00 AM of 3 North (Geriatric Psych) unit showed four geriatric patients on suicide precautions (of eight total patients on unit) with the following environmental concerns:
3 North: 10 patient rooms (315 through 327-each equipped with a private bathroom).
-Long stemmed handles on hand wash sinks in each patient room created a ligature/looping risk; (Rooms 319-327 had handles two and three quarters inches long on valve stems, one and one half inch above the sink top, and Rooms 315-318, had handles three inches long on valve stems, two and one eighth inches above the sink top).
-Heavyweight vinyl shower curtains in each private bathroom (10 rooms) presented as a potential suffocation risk.
-Room 315 had three steel ceiling access covers with one sixteenth inch gap between the locked panel and recessed frame. (A cord or cloth could be placed through the opening and create a ligature/looping risk).
-Rooms 317, 318, 319, and 324 had one box bed and one electro-mechanical bed with a electrical cord measuring 32-38 inches in length, that presented as a ligature/looping risk.
-Room 323 had one manual bed with removable cranks and one electro-mechanical bed. Both beds had side rails. Patient #18's oxygen concentrator had an 85 inch electrical cord. Both patients in room 323 were on suicide precautions. The facility assigned a sitter for Patient #19, however, the sitter and Patient #19 were not always in the room placing Patient #18 at risk for strangulation from this 85 inch cord.
-Television in day room 320 had an exposed TV cable and electrical cord, both measured 66 inches long. These cords were accessible to patients and posed a ligature/looping risk.
-Television in Group Room 322 had a TV with a 48½ inch electrical cord, and an 84 inch cable, both were accessible to patients and posed a ligature/looping risk.
-Electronic scale in Group Room 322 with a 71 inch cord accessible to patients and posed a ligature/looping risk.

8. Review of Patient #17's medical record showed the patient was admitted for an overdose, depression and suicidal thoughts.

Observation on 04/27/11 at 4:19 PM of Patient #17's room (Room 319-1) showed an electric hospital bed with a 32-inch electrical cord. The bed also had side rails on both sides. With the bed in high position and side rails up the bed measured as follows: Floor to the top side rail measured 45.5 inches; floor to the middle side rail measured 37 inches; and floor to the bottom side rail measured 30.5 inches. The bed frame and base of the footboard measured 26.25 inches from the floor to the frame and 39.5 inches from the floor to the top of the footboard. The electric cord, side rails, and footboard presented a looping/ligature hazard.

9. Review of Patient #18's medical record showed the patient was admitted for mood instability, suicidal thoughts and psychosis (a loss of contact with reality).

Observation on 04/27/11 at 4:21 PM of Patient #18's room (Room 323-1) showed an electric hospital bed with an approximate 32-inch electrical cord. The electric cord on the bed presented a looping hazard. The bed also had side rails on both sides. An exposed 85-inch electrical cord on an oxygen concentrator presented an additional looping/ligature hazard.

10. Review of Patient #19's medical record showed the patient was admitted for high anxiety level, suicidal thoughts with a plan for overdosing on medication and hearing voices to self-harm.

Observation on 04/27/11 at 4:22 PM of Patient #19's room (Room 323-2) showed an electric hospital bed with an approximate 32-inch electrical cord. The bed also had side rails on both sides. With the bed in high position and side rails up the bed measured as follows: Floor to the top side rail measured 43 inches; floor to the middle side rail measured 38.5 inches; and floor to the bottom side rail measured 34 inches. The footboard rail measured 32.5 inches from the floor while in high position. The electric cord, side rails, and footboard presented a looping/ligature hazard.

11. Review of Patient #48's medical record showed the patient was admitted for suicidal thoughts, mild mental retardation and depression.

Observation on 04/27/11 at 4:25 PM of Patient #48's room (Room 324-1) showed an electric hospital bed with an approximate 32-inch electrical cord. The bed also had side rails on both sides. With the bed in high position and side rails up the bed measured as follows: Floor to the top side rail measured 42.5 inches; floor to the middle side rail measured 38.5 inches; and, floor to the bottom side rail measured 33.5 inches. The footboard measured 34 inches from the floor in high position. The electric cord, side rails, and footboard presented a looping/ligature hazard.

Based on observation, interview and record review the facility failed to develop a specific care plan, with a specific goal and interventions to address the use of wrist restraints for one of two patients reviewed with restraints (Patient #5). The facility census was 267.

Findings Included:

1. Review of a facility policy titled, "Care Planning and Care Practice Guidelines," dated June 2010, directed staff to develop an individualized care plan and update it every 24-hours, and as appropriate, to the patient's condition and ongoing health needs.

2. Review of Patient #5's History and Physical, dated 04/23/11, showed the patient was admitted to the intensive care unit (ICU) on 04/22/11 with a diagnosis of a brain bleed, resulting in left-sided weakness.

Observation and interview on 04/26/11 at 1:44 PM showed patient #5 lie in bed with a wrist restraint on the right wrist. Registered Nurse (RN), Staff N, stated the patient had the restraint because he/she had been pulling at medically necessary lines/tubes.

Review of physician's orders showed the restraint(s) began (at times both wrists) on 04/22/11 and continued through this date, 04/26/11.

Review of the patient's current plan of care, on 04/26/11, showed the facility identified a problem of safety. The goal, "The patient will remain free from injury by identifying risks, using two patient identifiers, and universal precautions, and consistent communication." Interventions included, restraint in place, restraint removed as soon as possible. Facility staff failed to identify restraints as a problem, what type of restraint was being used, where it was applied, why it was being used, and how they intended to achieve removal at the earliest opportunity. Facility staff also failed to develop a goal specific to the restraint.

Duing an interview on 04/27/11 at 9:07 AM, the Clinical Process Leader, RN Staff S, confirmed the facility needed to add specific outcome indicators for restraints.

Based on interview, record review and policy review the facility failed to have documentation that showed the training requirements for physicians in the use of restraint or seclusion had been completed in a timely manner. This failure had the potential to affect all patients placed in restraints. The facility census was 267.

Findings included:

1. Record review of the facility policy HO.PC.13 titled, "Use of restraints," revised 4/11, showed directive that physicians and other LIP s (Licensed Independent Practitioners) who order restraints or seclusion shall be trained in the requirements of this policy.

2. Record review of a statement provided by the facility showed a copy of the Restraint policy was sent to physicians in 2010 with a requirement to sign and return an attestation statement indicating they had read and were responsible for following the policy. Current compliance (in returning the signed attestation statement) was at 77%.

3. During an interview on 04/29/11 at 10:45 AM Staff KK, Supervisor Medical Staff Office, stated that:
-The plan to obtain 100% compliance required physicians to sign an attestation statement as part of the re-credentialing process. Physicians are re-credentialed every two years;
-This process would take a while to complete;
-Staff failed to verify that physicians who regularly wrote restraint orders had signed the attestation statement.

Based on observation, interview and record review, the facility failed to prevent pain during a dressing change for one of three patients reviewed with wounds (Patient #6). The facility also failed to follow-up on dietary recommendations to change a tube feeding formula and vitamins for one of two patients reviewed with nutritional problems (Patient #1). The facility census was 267.

Findings included:

1. Review of a facility policy titled, "Pain Management," dated April 2010, directed staff to do the following:
-Observe the patient for non-verbal evidence of discomfort such as restlessness or facial expressions such as grimacing;
-Utilize the pain scale (1-10, with 10 being worst pain) to select dose of pain medication;
-Encourage use of pain medication before physical activity;
-Confer with appropriate discipline to identify appropriate pain management.

Review of a documented staff meeting presentation, dated 04/11, directed staff to pre-medicate per physician's order for all painful procedures, dressing changes, therapies and activities.

2. Review of Patient #6's History and Physical (H & P) dated 04/25/11 showed the patient was admitted on 04/24/11 with a diagnosis of diabetes and a foul smelling left foot ulcer, ultimately osteomyelitis (infection of the bone), and cellulitis (infection at the cellular level). The patient' s white blood cell count was 11.2/liter (indicative of infectious processes, normal = 5-10/liter). The physician ordered intravenous (IV) antibiotics, wound care, diabetes and infectious disease consults.

Review of the patient's care plan dated 04/26/11 showed comfort as a problem with a goal of, "Patient will achieve optimal level of comfort and well-being during hospitalization." An intervention included, "Scheduling of pain medication for optimal management," and "pain scale and interventions to keep patient comfortable."

Review of a wound culture report dated 04/25/11 showed the patient had moderate growth of Beta Hemolytic Streptococcus.

Review of nursing pain assessments from admission through 04/27/11 showed the patient complained of pain in the left foot on the following dates:

-04/24/11 at 11:15 AM, rating of 8-10 (severe pain);
-04/24/11 at 12:18 AM, rating of 8-10 (severe pain);
-04/24/11 at 5:44 PM, rating of 6-10 (moderate to severe aching pain);
-04/25/11 at 3:10 PM, and again on 04/26/11 at 6:55 PM, rating of 6 (moderate pain).

Review of the physician's orders, dated 04/24/11, showed an order for Morphine (narcotic pain medication) 4 mg (milligrams) every 4 hours PRN (as needed) IV push (administer through a small catheter inserted into the patient's vein) for pain.

Review of information provided by the pharmacy showed that even though the patient complained of pain at the above times, staff failed to administer pain medication except on 04/25 at 5:31 PM, and again on 04/26 at 3:01 PM.

Review of wound treatment orders for the patient's left foot showed an order dated 04/26/11 to cleanse with normal saline, paint entire surface with Betadine (an antiseptic), loosely pack 2 x 2 gauze in wound bed, cover with six 4 x 4 ' s and wrap with Kerlix (a gauze wrap), twice daily.

Observation and interview on 04/26/11 at 2:50 PM showed the following:

-The patient had a half-dollar sized open, deep wound under/near the little toe on the left foot that extended clear through to the top of the foot where it was dime-sized;
-There was a strong and foul odor when entering the patient's room;
-The Skin, Wound, and Treatment (SWAT) nurse cleansed the openings with normal saline and manipulated a loose piece of tissue. The patient displayed restlessnes with his hands/arms and grimaced in pain while the SWAT nurse did this;
-The patient told the manager of the unit, Registered Nurse (RN) Staff M, that there was always pain during the dressing change and rated it currently at, "4-5";
-The SWAT nurse continued with the treatment, packing the wound and wrapping it, all causing further pain, with the patient continuing to grimace and was restless, squirming, moving his/her hands and arms around;
-When the treatment was nearly finished, the RN responsible for the patient, Staff VV stated, "We should probably pre-medicate prior to the dressing change," and administered Morphine (at 3:01 PM).

Staff failed to thoroughly identify when the patient was in pain, and prevent this pain by pre-medication.

3. Record review of the facility's policy titled, "Nutrition Recommendations by Clinical Staff," dated 02/10, showed the following direction:

- Nutritional recommendations by the clinical nutrition staff to the physician will be documented in the patient's medical record.
- If the recommendation does not produce a change in the nutritional care of the patient and/or a response from the physician, following will be done during the next follow-up:
Contacting the physician to discuss the recommendations, or
Patient's care team nurse, charge nurse of the unit, or case manager will be informed of the recommendations to patient's physician when they discuss the patient's care.
Document all the results of the discussion in the medical record.

4. Review of Patient #1's H & P dated 04/14/11 showed the patient was admitted on that date with a diagnosis of end-stage renal disease.

Review of a dietary progress note dated 04/22/11, timed 10:00 AM, showed the patient was on hemodialysis (a filtering of the poisons from the blood) so the Registered Dietitian (RD) recommended addition of renal restriction to the diet. The patient had been receiving a tube feeding formula called Jevity, and the RD wanted the formula changed to Nepro (specifically designed for those in renal failure), plus also felt the patient may benefit from Vitamin B and C versus a multivitamin.

Review of the patient's record (along with accompanying staff), on 04/25/11 at 3:00 PM, showed facility staff failed to follow-up on the RD's recommendation.

During an interview on 04/25/11 at 3:10 PM, the manager of the unit, RN staff A, stated there was no evidence of physician notification or change in the patient's diet.

During an interview on 04/26/11 at 10:18 AM, RN educator, staff PP stated according to one of the RD's (staff member QQ), the RDs' rely on the physicians to read the RD's recommendations and if not responded to within five days, they call the physician.

Staff failed to communicate a change in nutritional care, and vitamins for patient #1 as of 04/26/11, or four days after the RD recommended these changes.




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During an interview on 04/26/11 at 2:30 PM, Staff T, Chief Clinical Registered Dietitian Manager, stated if she/he recommended a diet change for a patient, she/he would fill out an "Oral/Enteral Nutrition Medical Therapy Protocol" form and place it in front patient's chart for the physician to see. He/she would also make a note of the recommendation in the physician's progress notes and in the Registered Dietitian's assessment of the patient's medical record. Staff T stated if the physician do not concurr or sign off on his/her recommendation within two to three days, she/he would pick up the phone and call the physician.

Staff XX, the RD making the recommendation, failed to complete the Oral/Enteral Nutrition Medical Therapy Protocol and place it in front of the patient's chart. Staff XX also failed to contact the physician when the physician failed to sign-off on the recommendation within two to three days (four days had passed).

Based on observation and interview, the facility failed to ensure the contract dialysis (using a machine to filter the blood and remove harmful wastes and fluid) staff maintained the patient, vascular access site and bloodline connections (connections to remove the patient's blood and return it to the patient after filtration) in constant view throughout the dialysis treatment for one (#9) of five patients observed during dialysis. Constant view is important due to the potential for the dialysis patient to loose blood rapidly. The facility census was 267.

Findings included:

1. Record review of the contracted company's policy titled, "Monitoring Inpatients During Treatment" dated 08/25/08, showed the following direction:
- All patients must be under continual visual observation by (contract company) Inpatient Service staff.
- The (contract company) Inpatient Service staff is not to leave the patient unattended during the treatment.
- All patient connections are secure and visible AT ALL TIMES due to serious risk of exsanguinations (rapid loss of blood) that could go undetected if the access was covered.

2. Observation on 04/26/11 at 1:10 PM showed Staff P, Registered Nurse (contracted dialysis nurse) administer dialysis to Patient #9. The vascular access site and bloodline connections were covered with a white paper towel. The white paper towel was the same color as the patient's bed linen. Staff P left the patient's room, leaving the patient without a trained dialysis nurse to observe the patient.

During an interview on 04/26/11 at 1:10 PM, Staff P stated that the vascular access site and bloodline connections were covered as a "flag" to others not to move or bother it.

During an interview on 04/26/11 at 3:35 PM, Staff R, Acute Coordinator for the dialysis contract company, stated that the vascular access site and bloodline connections should not be covered. Staff R stated that the nurse could leave the room if he/she can still hear the alarms.

Based on interview, record review, and the facility's Medical Staff Rules and Regulations, the facility failed to ensure physician orders included the time and date to show when written for one (#27) of 28 current patients' medical records reviewed This failure has the potential to affect all patients in having orders implemented timely. The facility census was 267.

Findings included:

1. Record review of the facility's document titled, "2011 Medical Staff Rules & Regulations", showed the following direction in regards to written orders, verbal orders and telephone orders:
- All orders for treatment/medication shall be in writing, dated, timed and authenticated;

2. Review of Patient #27's medical record showed the following telephone orders not dated and timed:
- A telephone order written (no date nor time) for the patient to receive NPO (nothing by mouth) and Suplena tubefeeding - bolus (a method of feeding through a tube) fed 1 can 5x/da (5 times per day).

During an interview on 04/27/11 at 3:41 PM, Staff DD (Director of Health Information Management) stated he/she concurred that the facility's physicians needed to improve on timing orders.

Based on record review, interview, and the facility's Medical Staff Rules and Regulations, the facility failed to ensure verbal and/or telephone orders were signed, dated, and timed by the physician within 48 hours for three (#3, #10, and #31) of 28 current patients' medical records reviewed. This failure has the potential to affect all patients in having verbal and telephone orders reviewed timely and confirmed by the ordering physician. The facility census was 267.

Findings included:

1. Record review of the facility's document titled, "2011 Medical Staff Rules & Regulations", showed the following direction in regards to verbal orders and telephone orders:
- The ordering practitioner or another physician responsible for the care of the patient shall authenticate/sign, date and time all telephone orders within 48 hours.

2. Review of current Patient #3's medical record on 04/26/11 showed the following telephone orders not signed by the physician within 48 hours:
- A telephone order written on 04/17/11 at 10:40 AM for "Alendronate (used to treat and prevent thinning of bones) 70 mg (milligrams) po (by mouth) q (every) Friday" and "Ergocalciferol (a form of vitamin D) 50,000 units po q Sunday". This telephone order was signed by the physician on 04/20/11 at 11:00 AM (62 hours after written).
- A telephone order written on 04/22/11 at 8:50 AM for "NPO (nothing to eat or drink) after breakfast" and "UGI (upper gastrointestinal) upper endoscopy (test to look at the upper gastrointestinal tract)". This order had not been signed by the physician (four days since the order was written).
- A telephone order written on 04/22/11 at 1:50 PM for "PICC (peripherally inserted central catheter) line today". This order was signed by the physician but was not dated and timed to show when it was signed.

During a concurrent interview, Staff D, Registered Nurse Manager, confirmed the above telephone orders were not authenticated appropriately and stated that the physician is to sign verbal/telephone orders within 48 hours.

3. Review of current Patient #10's medical record on 04/26/11 showed the following telephone orders not signed by the physician within 48 hours:
- A telephone order written on 04/23/11 for "Coumadin (blood thinner) 5 mg po daily". This order was signed by the physician but was not dated and timed to show when it was signed.

4. Review of current Patient #31's medical record on 04/28/11 showed the following telephone orders not signed by the physician within 48 hours:
- A telephone order written on 04/25/11 for "DC (discontinue) Morphine (narcotic pain medicine)" and "Dilaudid (narcotic pain medicine) 2 mg IVP (intravenous push - through a small catheter inserted into the patient's vein) q 4 hr (hours) prn (as needed) pain". This order was signed by the physician but was not dated and timed to show when it was signed.

Based on interview, record review and policy review, the facility failed to ensure staff obtained a properly executed informed consent without the use of abbreviations for five (#10, #3, #31, #32, and #16) patients and failed to complete the consent with appropriate information and signatures for one (#10) of eight records reviewed for informed consent. Use of abbreviations on a consent form potentially leads to different interpretations of the procedure to be performed. The facility failed to properly complete the consents. The facility census was 267.

Findings included:

1. Record review of the facility's policy titled, "Informed Consent Policy", dated April 2010, showed the following direction:
- Who is to obtain consent
Surgical Consent - The medical staff surgeon is responsible for placing the patient's informed consent in the preoperative record.
Anesthesia Consent - The anesthesiologist is responsible for placing the patient's informed consent in the patient's preoperative record.

Record review of the facility's policy titled, "Medical Abbreviations" dated 09/08/2010, showed the following direction:
- Abbreviations are not allowed on procedural consent documents.

2. Review of current Patient #10's medical record showed the following:
- Facility's form titled, "Consent to Surgery or other Procedure", showed staff hand wrote the surgical procedure for "Exploratory laparotomy (surgically explore the abdomen), colectomy (removal of the large colon), possible ileostomy (connect the small intestine to an opening in the abdomen)". The anesthesia provider failed to sign the consent.
- Facility's form titled, "Consent to Surgery or other Procedure" showed staff hand wrote the procedure for "Transesogeal (sic) Echocardiogram (ultrasound of the heart done by a probe placed in the esophagus)". The physician failed to sign the consent.
- Facility's form titled, "Consent to Surgery or other Procedure" showed staff hand wrote the surgical procedure for "Permanent Pacemaker Placement". The anesthesia provider failed to sign the consent.
- Facility's form titled, "Consent to Surgery or other Procedure" showed staff hand wrote the procedure for "placement of new H.D. (abbreviation) cath (abbreviation) and removal of old H.D. cath". The part of the consent where it stated, "This operation is to be performed by Dr." did not have the physician's name of who was to perform the procedure.

3. Review of current Patient #3's medical record showed the facility's form titled, "Consent to Surgery or other Procedure" showed staff hand wrote the surgical procedure for "IVC (abbreviation) filter". A second form titled, "Consent to Surgery or other Procedure" showed staff hand wrote the surgical procedure for "PICC (abbreviation)".

4. Review of current Patient #31's medical record showed the facility's form titled, "Consent to Surgery or other Procedure" showed staff hand wrote the surgical procedure for, "Drainage/Debridement of abd (abbreviation) abscess".

5. Review of current Patient #32's medical record showed the facility's form titled, "Consent to Surgery or other Procedure" showed staff hand wrote the surgical procedure for, "D&I (abbreviation) Right leg wound".

6. Review of current Patient #16's medical record showed the facility's form titled, "Consent to Surgery or other Procedure" showed staff hand wrote the surgical procedure for, "EUA (abbreviation), possible hemorrhoidectomy (removal of hemorrhoids), proctoscopy (use of a scope to examine the rectum)".

During an interview on 04/28/11 at approximately 9:15 AM, Staff U, Registered Nurse Manager, and Staff C, Director of Patient Care stated that they did not know what "EUA" abbreviation meant.

Based on observation, interview and policy review the facility failed to ensure expired patient care and diagnostic supplies were not available for patient use. Staff failed to date items when opened and, therefore, it could not be determined when they expired. This had the potential to affect all patients treated in the Emergency Department. The Northeast and Northwest Emergency Departments treat about 270 patients per day. The facility census was 267.

Findings included:

1. Record review of facility policy titled, "Medication Administration", dated July 2010 showed direction for facility staff to label multi use containers with a 28 day expiration date from the date of opening and that irrigating solutions should be used within 1 hour of opening (single use).

2. Observation in the Northeast Emergency Department trauma room B on 04/25/11 at 3:05 PM showed:
-2 opened, undated bottles of Povidine solution (used to clean skin/wounds);
-2 opened, undated bottles of Peroxide solution (used to clean skin/wounds);
-1 opened, undated bottle of normal saline irrigating solution (used to clean wounds/lacerations).

During an interview on 04/25/11 at 3:10 PM Staff E, Director of Patient Care Services, stated that the Povidine and peroxide were good for 30 days after opening and the saline was good for 24 hours after opening. Staff E confirmed that these solutions should be dated when opened and staff failed to record the expiration dates.

3. Observation in the Northwest Emergency Department medication room on 04/28/11 at 9:15 AM showed:
-1 opened, undated bottle of Gastroview liquid (liquid is reconstituted and patient drinks prior to radiology studies to enhance view for radiologists reading).

During an interview on 04/28/11 at 9:20 AM Staff JJ, Manager Northwest Emergency Department, stated that staff failed to document the expiration date on the bottle.

Based on observation, interview, record review and facility policy, the facility failed to:
- Ensure the operating room crash cart (mobile cart with emergency medications, supplies, and equipment used during life-threatening events) was checked for emergency readiness on eight of 27 days of the current month. This had the potential to impact the emergency response to all patients in the operating rooms on those days;
- Perform test to verify sterilizers were running correctly on two (04/27/11 and 04/28/11) of four days reviewed. Failure to perform this safety check could potentially lead to equipment being improperly sterilized before use in surgery.
The facility census was 267.

Findings included:

1. Record review of the facility's policy titled, "Emergency Crash Carts," dated April 2010 showed the following direction:
- Nursing will verify specified items once within 24 hour day.

2. Observation on 04/28/11 at approximately 2:30 PM showed one crash cart utilized for 16 operating rooms.

Record review of the facility's document titled, "Monthly Crash Cart Tracking Log," for April, 2011 showed staff failed to check the crash cart on 04/09/11, 04/10/11, 04/16/11, 04/17/11, 04/22/11, 04/23/11, or 04/27/11. The crash cart check was incomplete on 04/13/11. Information provided by the facility showed the number of surgical cases completed on the following dates:
- 04/09/11, two surgeries;
- 04/10/11, two surgeries;
- 04/13/11, 22 surgeries;
- 04/16/11, four surgeries;
- 04/17/11, two surgeries;
- 04/22/11, 21 surgeries;
- 04/23/11, two surgeries;
- 04/27/11, 27 surgeries.

During an interview on 04/28/11 at approximately 2:30 PM, Staff CC, Manager of Perioperative (Operating Rooms) Services, and Staff FF, Perioperative Educator, stated that there was only one crash cart for all of the operating rooms and confirmed staff failed to complete the checks.

3. Observation on 04/28/11 at approximately 2:40 PM showed seven sterilizers designated for flash sterilization (sterilizing equipment for immediate use) outside of the operating rooms.

During an interview on 04/28/11 at approximately 2:40 PM, Staff FF, Perioperative Educator, stated that each sterilizer has an Attest (test to verify sterilizer is running correctly) done daily in the morning by nursing staff. Staff FF stated that each sterilizer has a log for recording the Attest and equipment that is flash sterilized.

Record review of the facility's form titled, "Attest Daily Autoclave Log" on 04/28/11 showed staff failed to perform any Attest for all seven sterilizers on 04/27/11 or 04/28/11. Information provided by the facility showed the following number of surgical cases completed on those dates:
- 04/27/11, 27 surgeries;
- 04/28/11, (facility did not provide number of surgeries).

Record review of the facility's form titled, "Sterilizer/Steris Log 2011," for sterilizer unit #4 showed six surgical items that were flash sterilized. The column for, "Sterilizer/Steris Parameters met (indicator changed): Y (yes)/N (no)," showed staff failed to document if the sterilization parameters were met for three of the six items sterilized.

Based on interview, record review and facility policy, the facility failed to ensure daily temperature and humidity checks were performed in the operating rooms. Temperature and humidity control help provide an electrically safe environment and could impact any patient having surgery on the days that the checks were not completed. The facility census was 267.

Findings included:

1. Record review of the facility's policy titled, "Environmental Controls", dated May 2010, showed the following direction:
- Temperature and humidity are controlled to provide an environment which is electrically safe and comfortable.
- A nurse on duty will monitor and record temperature and humidity daily.

2. Review of the facility's document titled, "CHNE (Christian Hospital Northeast) OR (Operating Room) Temperature and Humidity Log - 2011" for April showed no temperature or humidity checks done on 04/02/11 (Saturday), 04/03/11 (Sunday) 04/09/11 (Saturday), 04/10/11 (Sunday), 04/13/11 (Wednesday), 04/16/11 (Saturday), 04/17/11 (Sunday), 04/23/11 (Saturday), 04/24/11 (Sunday).

3. Review of information provided by the facility showed the following numbers of surgical cases were completed on those dates:
- 04/09/11, two surgeries;
- 04/10/11, two surgeries;
- 04/13/11, 22 surgeries;
- 04/16/11, four surgeries;
- 04/17/11, two surgeries;
- 04/23/11, two surgeries;

4. During an interview on 04/29/11 at 7:50 AM, Staff CC, Manager of Perioperative (Operating Rooms) Services, and Staff EE, Operating Room Supervisor, stated that temperature and humidity checks were done Monday through Friday and they were not sure if those checks were done on weekends.

Based on observation, interview, and policy review, the facility failed to:
-Ensure food plates served in the Emergency Department (ED) were heated to a safe temperature. This failure potentially exposed patients in the emergency department to unsafe food consumption;
-Utilize sterile technique when doing a sterile dressing change on one of seven patients (Patient #4) observed for appropriate use of personal protective equipment (gloves);
-Maintain walls and floors in a condition that presents a clean and safe environment in multiple areas of the facility;
-Maintain the integrity of mattresses in the Nuclear Medicine department;
-Maintain the integrity of dialysis equipment preventing appropriate cleaning and disinfecting between patients;
- Ensure old tape was removed from one patient's (#9) side rail, which prevented appropriate cleaning and disinfecting of the bed;
- Clean a portable fan, which would prevent blowing dust directly on Patient (#16);
-Prepare and serve foods in a sanitary and safe manner for all patients in the facility.
The facility census was 267.

Findings included:

1. Observation on 04/25/11 at 3:30 PM of the refrigerator in the nourishment area of the ED showed five food plates with meat, gravy, mashed potatoes and broccoli covered with a blue, hard plastic top.

During an interview on 04/25/11 at 3:36 PM Staff E, Director of Patient Care Services, stated that staff heat the food and serve patients. Staff E stated that a lot of food was served to patients. Staff E stated that he/she was not sure how staff knew if food had been heated to a safe temperature.

During an interview on 04/27/11 at 2:45 PM Staff L, Director Food and Nutrition Services, stated that he/she did not realize the ED served food that required heating. Staff L stated that there was no mechanism for staff in the ED to know how long to heat the food to ensure safety. Staff L stated that he/she understood the problem.


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2. Record review of the facility's policy titled, "Central Venous Catheter Management," dated April 2010, showed the following direction when changing a dressing on a peripherally inserted central catheter (PICC - a type of intravenous line):
-Remove the old dressing with non-sterile gloves, and discard;
-Remove non-sterile gloves, perform hand hygiene, and DON sterile gloves;
-Continue with dressing change.

Review of Patient #4's History and Physical (H&P), dated 04/12/11, showed the patient was admitted that day with a diagnosis of bladder cancer.

Observation on 04/26/11 at 10:50 AM showed Staff RR, Registered Nurse (RN), donned non-sterile gloves to remove most of an old PICC dressing (a clear, occlusive, adherent dressing). Staff RR donned sterile gloves over the non-sterile gloves and handled the dirty dressing again, removing it completely. Staff RR failed to perform hand hygiene and proceeded with the sterile dressing change with the contaminated gloves.


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3. Observations from 04/25/11 through 05/03/11 showed the following concerns regarding a clean and safe environment:
-Dialysis clinic floors (white tile) had blackened areas around the base of door frames and corners of the rooms;
-Dried spill, approximately four feet in length and two inches wide, of unknown substance in the corridor near patient rooms 817 and 818;
-Acronyl (protective opaque polymer) covering the lower half of door to patient room 728 was blackened with dark scuff marks;
-Yellow stain, approximately 36 inches wide and 8 inches high, on the wall, cove base and floor behind the double doors in the corridor between patient rooms 520 and 521;
-Dirt and dust particles extended along the edge where the cove base and floor meet, around the base of door frames and in the corners behind the entrance door to patient room 510;
-Dirt and dust particles extended along the edge where the cove base and floor meet, on both sides of the corridor outside of patient rooms 428 and 429.

4. Observation on 04/28/11 at 5:00 PM showed chips of surface material missing in several places on the sides, top surface and seams of mattresses in Nuclear Medicine rooms 3 and 4, which exposed the inner core of the mattress pad. This created a potential repository for infections to be transmitted from patient to patient. Tape and tape residue were also noted on the head and upper torso perimeter of the metal table in room 3.

5. During an interview on 04/28/11 at 5:00 PM, Staff TT, Nuclear Medicine staff, confirmed the damaged mattress and tape residue.

6. During an interview on 05/03/11at 10:55 AM, Staff GG, Environmental Services Manager, stated that they do miss things once in awhile.


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7. Observation on 04/26/11 at approximately 1:15 PM showed Patient #9 receiving dialysis (using a machine to filter the blood and remove harmful wastes and fluid). The front of the dialysis machine had two areas of chipped paint around the side and top of the heparin (blood thinner) pump. The chipped paint area to the side of the heparin pump measured approximately 5 inches wide by 4.5 inches high. The chipped paint area above the heparin pump measured approximately 6 inches wide by 1.5 inches high. These areas prevented appropriate cleaning and disinfecting of the equipment between patients.

During a concurrent interview, Staff C, Director of Patient Care, and Staff P, RN, confirmed the paint was chipped from the front of the dialysis machine.

8. Observation on 04/26/11 at approximately 1:15 PM showed Patient #9's bed with old, blackened tape adhered to the left side rail. The adhesive and tape surface prevented appropriate cleaning and disinfecting of the surface between patients.

During a concurrent interview, Staff C confirmed the tape appeared old and dirty and should have been removed.

9. Observation on 04/28/11 at 11:15 AM showed Patient #16 with a portable, floor fan blowing air directly on the patient. The fan was covered with a thick layer of dust.

During an interview on 04/29/11 at 9:30 AM, Staff GG, Manager of Environmental Services, stated that he/she would expect the fan to be cleaned.


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10. Record review of the Food and Drug Administration (FDA) 2005 Food Code, Chapter 2-4, Hygiene Practices, Subpart 2-402.11 (A) - Hair Restraints Effectiveness showed the following:
-(A) Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipments, utensils, and linens; and unwrapped single-service and single-use articles.

(The Food Code is considered a nationally-accepted standard of practice for the food industry).

Observation on 04/26/11 at 10:11 AM until 11:30 AM, showed staff failed to prepare and serve patients' foods in a sanitary manner, to include the following:
-Staff J (Cook) prepared patients' foods and failed to wear a facial hair restraint over his beard. Staff J's beard measured approximately one-eighth inch long.
-Staff K (Sanitation Worker) placed entrée, starch and vegetable items on patients' plates as the trays went down the tray line; he failed to wear a hair restraint over his moustache while serving patients' foods. Staff K's facial hair measured approximately one-fourth inch long.

During an interview on 04/27/11 at 10:03 AM, Staff L, Director of Nutrition Services, stated he/she thought they were in compliance of the regulations. Staff L stated that he/she thought facial hair measuring ¼ inch or shorter was acceptable.