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Tag No.: C0226
Based on observation and staff interview, it was determined the facility failed to ensure OR humidity was documented. This directly impacted 1 of 1 patient (#27) who was observed in the OR, and had the potiental to impact all patients receiving surgery at the facility. The failure to manage the humidity resulted in the potential for patient health and safety to be compromised. Findings include:
1. The American Society for Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities, Addendum D requires RH in ORs to be maintained between 20 and 60 percent. In addition, this ASHRAE standard has been incorporated into the Facility Guidelines Institute 2010 Guidelines for Design and Construction of Health Care Facilities, and has been approved by the American Society for Healthcare Engineering of the American Hospital Association and the American National Standards Institute.
During a tracing of Patient #27 through the OR on 5/21/14, beginning at 10:30 AM, the surveyor asked the circulating nurse for humidity tracking logs. She stated the facility did not monitor OR humidity.
The Director of Maintenance was interviewed on 5/21/14 at 11:00 AM, and stated, he did not monitor and record humidity in the OR.
The facility failed to monitor and record humidity levels in the OR.
Tag No.: C0227
Based on staff interview and review of CAH safety meeting minutes, it was determined the CAH failed to ensure the staff responded to emergencies including prompt reporting of fires and the evacuation of patients, personnel, and guests. This had the potential to result in the delayed evacuation of persons in response to fire. Findings include:
A dialysis unit was located in the basement of the CAH below the surgery department. Minutes from the CAH's "SAFETY MEETING," dated 1/29/14, stated "Dialysis had a patient late at night; the fire alarm went off during the treatment. When they called the nurses station to find out if they knew where the fire alarm was going off from they were told they do not have time for that."
The Maintenance Director was interviewed on 5/22/14 beginning at 11:00 AM. He stated he was aware of the incident. He stated a fire alarm had sounded. He said a faulty smoke detector had triggered the alarm. He stated he was responsible to maintain the fire alarm system and said he had to come to the CAH to turn off the alarm. He stated the smoke detector had been replaced. He stated he was not aware of any investigation of the incident. He stated he did not have documentation whether the situation had been resolved. He stated he was not aware that any action had been taken to ensure all persons would be notified in the event of an emergency and needed to evacuate the building.
The CAH failed to ensure a plan had been implemented to evacuate all persons in an emergency.
Tag No.: C0270
Based on staff interview and review of medical records and CAH policies, it was determined the CAH failed to ensure 1) policies had been developed to direct medical and nursing staff in the provision of care to patients and 2) POCs addressed the medical needs of neonates. These failures resulted in a lack of direction to staff. Findings include:
1. Refer to C-275 as it relates to the failure of the CAH to ensure a policy had been developed that outlined guidelines for the medical management of health problems that included the conditions requiring medical consultation and/or patient referral.
2. Refer to C-278 as it relates to the failure of the CAH to ensure procedures were implemented to avoid the transmission of infections and communicable diseases.
3. Refer to C-298 as it relates to the failure of the CAH to ensure POCs addressed the medical needs of neonates.
The cumulative effect of these systemic omissions resulted in an increased risk of complications to patients.
Tag No.: C0275
Based on staff interview and review of medical records and CAH policies, it was determined the CAH failed to ensure a policy had been developed that outlined guidelines for the medical management of health problems that included the conditions requiring medical consultation and/or patient referral. This affected the care of 1 of 3 neonates (#4), whose records were reviewed, and had the potential to affect all patients. The lack of a policy had the potential to result in the delay of practitioners seeking advice and guidance for the treatment of patients with complex medical conditions. Findings include:
1. Patient #4's medical record documented a preterm newborn male who was born via caesarean section at the CAH at 1:12 PM on 2/19/14. His gestational age was 36 weeks and 3 days. He was transferred by helicopter to another hospital on 2/22/14 at 12:00 noon. A physician "Progress note," dated 2/21/14 at 7:33 AM, stated Patient #4 was "...born without a heartbeat with Apgars of 0, 6 and 7 at 0, 5, and 10 minutes." The scores indicated the baby did not have a pulse and was not breathing at birth.
Patient #4's "Discharge Summary," dated 2/22/14 at 8:42 AM, stated "Positive pressure ventilation was performed as well as about 20-30 seconds of chest compressions before a heart rate above 100 [beats per minute] was noted. Patient initially required 1/4 liter of oxygen [per nasal cannula]." The "Discharge Summary" stated his initial blood glucose level was below 20. (A physician progress note, dated 2/20/14, stated the laboratory analyzer could not measure blood glucose levels below 20.) Laboratory reports listed normal blood glucose levels between 51 and 96. The "Discharge Summary" stated Patient #4 received IVs with dextrose. The IVs were not effective at raising the baby's blood glucose levels.
Cumulative laboratory values on a document titled "Laboratory--Comparative Report," dated 2/23/14 at 4:00 PM, listed the following blood glucose levels:
2/19/14: 2:27 PM <20, 3:01 PM <20, 4:41 PM 24, 5:29 PM 21, 6:06 PM 23, 8:06 PM 33, 10:08 PM 27
2/20/14: 12:13 AM 27, 2:14 AM 30, 4:13 AM 33, 7:59 AM 44, 10:33 AM 39, 12:20 PM 53, 5:01 61, 11:04 PM 50
2/21/14: 7:21 AM 38, 12:34 PM 42, 6:34 PM 42
2/22/14: 12:11 AM 38, 7:47 AM 40
According to the "Medline Plus" website, a service of the National Institutes of Health, accessed 5/27/14, "Severe or persistent low blood sugar levels may affect the baby's mental function. In rare cases, heart failure or seizures may occur."
Patient #4's "Discharge Summary" also stated the baby was diagnosed with jaundice and hyperbilirubinemia (high bilirubin levels in the blood resulting in jaundice). The note stated his condition was serious and he was transferred to a NICU in a neighboring state.
Patient #4's medical record documented a neonatal bilirubin level, drawn at 6:37 AM on 2/22/14, was 15.3. Normal bilirubin levels were listed as 0-13.2.
Patient #4's "Discharge Summary," dated 2/22/14 at 8:42 AM, stated the case was discussed with the attending physician on the NICU at the receiving hospital. No documentation was present in physician progress notes stating that a neonatologist was consulted about the case prior to 2/22/14 at 8:42 AM.
Patient #4 was cared for by a family practice physician. The physician was interviewed on 5/29/14 beginning at 12:05 PM. He confirmed Patient #4's condition and laboratory values. He stated, after Patient #4's birth, he did speak with a neonatologist at another hospital about Patient #4's care. However, he said he did not document this. He stated the hospital did not have a policy requiring physicians to consult regarding patient care. He stated he considered a policy that would require physicians to consult to be "...completely inappropriate."
The physician Chief of Staff for the CAH was interviewed on 5/23/14 beginning at 8:10 AM. He stated the CAH had no policy that addressed conditions requiring medical consultation.
The CAH had not developed a policy which established guidelines for the medical management of health problems that included the conditions requiring medical consultation.
Tag No.: C0278
Based on staff interview, observation of patient care, and review of hospital policies, it was determined the facility failed to ensure the implementation of procedures to avoid potential transmission of infections and communicable diseases. This directly affected the care of 1 of 1 patient (#27) who was observed in the OR and had the potential to impact all patients. Failure to follow policies and standard precautions had the potential to allow for transmission of infections and foodborne illnesses. Findings include:
1. During a tour of the hospital's kitchen on 5/20/14, beginning at 1:30 PM with the Food Service Manager, the following sanitation concerns were noted:
a. An undated policy, titled "Sanitation of Dietary Department", stated, "The dietary staff shall maintain the sanitation of the dietary department through compliance with a written, comprehensive cleaning schedule."
The kitchen freezer had food spillage and food waste on the floor.
The Food Service Manager stated the freezer is to be cleaned daily and as needed. There was no written cleaning schedule.
b. The ice machine had a sticker with "February" documented as the last date cleaned. A specific date was not mentioned.
The Food Service Manager stated, the "ice machine is cleaned monthly," and confirmed the last cleaning date was February 2014. The ice machine had not been cleaned for 3 months.
c. A policy titled "Dietary Infection Control", undated, stated "... foods that are refrigerated are stored at or below 40 degrees F."
The kitchen walk-in refrigerator log for May 2014 recorded, improper temperatures as follows: 44 F 5/05/14 at 6:00 AM, 48 F 5/06/14 at 7:00 PM, no temperature recorded 5/07/14 at 6:00 AM, 44 F 5/07/14 at 7:00 PM, 46 F 5/08/14 at 6:00 AM, 46 F 5/08/14 at 7:00 PM, 46 F 5/09/14 at 6:00 AM, 46 F 5/09/14 at 7:00 PM, 42 F 5/10/14 at 6:00 AM, 44 F 5/10/14 at 7:00 PM, 44 F 5/12/14 at 7:00 PM, 46 F 5/13/14 at 7:00 PM, 42 F 5/14/14 at 6:00 Am, 44 F 5/14/14 at 7:00 PM, 42 F 5/15/14 at 6:00 AM, 46 F 5/15/14 at 7:00 PM, 44 F 5/16/14 at 6:00 AM, 58 F 5/16/14 at 7:00 PM, 44 F 5/17/14 at 6:00 AM, 44 F 5/17/14 at 7:00 PM, 44 F 5/18/14 at 6:00 AM, no temperature recorded 5/19/14 at 6:00 AM, 46 F 5/19/14 at 7:00 PM, 48 F 5/20/14 at 6:00 AM, 46 F 5/20/14 at 7:00 PM, 46 F 5/21/14 at 7:00 PM, 42 F 5/22/14 at 6:00 AM, and 44 F 5/22/14 at 7:00 PM.
The Food Service Manager confirmed the kitchen walk-in refrigerator was not maintained at acceptable temperatures.
The hospital failed to ensure policies were followed to prevent food borne illness.
2. A policy titled "Infection Control Nursery & Postpartum", undated, stated, "Upon discharge and as needed, housekeeping will clean the nursery and post-partum units."
A tour of the hospital's nursery was conducted with the DON on 5/20/14 beginning at 8:15 AM. A used blanket was observed in the baby warmer. Linen used by the last occupant was on a rocking chair and supplies were in disarray on a counter area.
The DON stated a newborn patient had been admitted to the nursery on 5/19/14 and then discharged to the mother's room that same day. She stated the nursery had not been cleaned after the baby was discharged to the mother's room.
The Infection Control Officer was interviewed on 5/21/14 at 1:35 PM. She stated the nursery should have been cleaned after the baby was discharged.
The hospital failed to ensure infection control policies were followed in the nursery.
3. A policy titled "Dress Code in the Operating Room," undated, stated, "Suitable attire must be worn by all O.R. staff and surgeons before entering O.R...Masks should be changed between cases."
An observation of a shoulder surgery on Patient #27 was conducted on 5/21/14 beginning at 10:30 AM. The surgeon had made his first incision, then 1 staff member and 1 student observer entered the OR without masks for approximately 15-20 seconds. The CNRA notified them to leave and don masks before returning.
The Infection Control Officer was interviewed on 5/21/14 at 1:35 PM. She stated an incident report had been completed and the event would be investigated. The Infection Control Officer confirmed, masks were required before entering the OR.
The hospital policy requiring the use of masks in the OR was not followed.
Tag No.: C0298
Based on staff interview and review of medical records and CAH policies, it was determined the CAH failed to ensure a nursing POC was developed for 2 of 3 neonates (#4 and #28), whose records were reviewed. This resulted in a lack of direction to staff and had the potential to interfere with the consistency of care. Findings include:
1. Patient #4's medical record documented a preterm newborn male who was born via caesarean section at the CAH at 1:12 PM on 2/19/14. His gestational age was 36 weeks and 3 days. He was transferred by helicopter to another hospital on 2/22/14 at 12:00 noon.
A physician "Progress note," dated 2/21/14 at 7:33 AM, stated Patient #4 was "...born without a heartbeat with Apgars of 0, 6 and 7 at 0, 5, and 10 minutes." The scores indicated the baby did not have a pulse and was not breathing at birth.
Patient #4's "Discharge Summary," dated 2/22/14 at 8:42 AM, stated the baby was revived and was placed on oxygen. The "Discharge Summary" stated the baby had an IV throughout his stay.
Laboratory reports listed normal blood glucose levels between 51 and 96. Laboratory reports documented Patient #4's initial blood glucose level was below 20.
Cumulative laboratory values on a document titled "Laboratory--Comparative Report," dated 2/23/14 at 4:00 PM, listed the following blood glucose levels:
2/19/14: 2:27 PM <20, 3:01 PM <20, 4:41 PM 24, 5:29 PM 21, 6:06 PM 23, 8:06 PM 33, 10:08 PM 27
2/20/14: 12:13 AM 27, 2:14 AM 30, 4:13 AM 33, 7:59 AM 44, 10:33 AM 39, 12:20 PM 53, 5:01 61, 11:04 PM 50
2/21/14: 7:21 AM 38, 12:34 PM 42, 6:34 PM 42
2/22/14: 12:11 AM 38, 7:47 AM 40
Patient #4's medical record, dated 2/20/14 at 8:58 AM, contained a section titled "PROBLEM ACTIVITY." It was written by an RN. It stated "PROBLEM: Altered Health Maintenance...Patient/family will discuss measures to increase/maintain functional ability. Patient/family will discuss measures to prevent disease. Patient/family will participate in discharge plan." The section did not provide direction to nursing staff in caring for Patient #4. It did not address respiratory problems, blood glucose problems, or his IV.
The DON was interviewed on 5/29/14 beginning at 11:00 AM. She stated the section "PROBLEM/ACTIVITY" was Patient #4's nursing POC. She confirmed it did not provide direction to nursing staff.
Patient #4 did not have a nursing POC that directed staff how to care for him.
2. Patient #28's medical record documented a newborn female who was born via caesarean section on 2/27/14 at 7:30 PM. Her "HISTORY AND PHYSICAL,"dated 2/27/14, stated she had Apgar scores of 0 at 1 minute and 7 at 5 minutes of age. The scores indicated the baby did not have a pulse and was not breathing at 1 minute of age. She was discharged home on 3/02/14.
Laboratory reports documented Patient #28's initial blood glucose level was below 20 on 2/27/14 at 8:19 PM. Two other blood glucose levels were documented. These included 26 at 11:41 PM on 2/27/14 and 43 on 2/28/14 at 7:30 AM. No further blood glucose levels were documented. No blood glucose readings in the normal range of 51 to 96 (based on the acceptable range listed in the laboratory reports) were documented.
Patient #28's medical record contained a section titled "PROBLEM ACTIVITY," dated 2/28/14 at 10:00 PM. It was written by an RN. It included problems of "Parental Role Conflict" and "Altered Parent/Child Attachment and Altered Health Maintenance." The section stated "Patient/family will discuss measures to increase/maintain functional ability. Patient/family will discuss measures to prevent disease. Patient/family will participate in discharge plan." The section did not provide direction to nursing staff in physically caring for Patient #28. It did not address blood glucose problems or monitoring her blood glucose levels.
The DON was interviewed on 5/28/14 beginning at 3:55 PM. She stated the section "PROBLEM/ACTIVITY" was Patient #28's nursing POC. She confirmed it did not provide direction to nursing staff regarding her physical care.
Patient #4 did not have a nursing POC that directed nursing staff in caring for her.
Tag No.: C0302
Based on staff interview and review of medical records, the hospital failed to ensure documentation was complete and/or accurate for 4 of 38 patients (#3, #4, #24, and #28) whose records were reviewed. This resulted in incomplete or inaccurate medical records. It had the potential to interfere with clarity of information related to the course to treatment and completeness of the medical record. Findings include:
1. Patient #24's medical record documented a 75 year old female who was admitted to the CAH on 4/02/14 for an outpatient colonoscopy procedure.
Patient #24 signed a consent for anesthesia services, untimed, dated 4/02/14. The consent was not signed by the CRNA to indicate anesthesia risks were reviewed.
The Assistant DON reviewed the record on 5/23/14 beginning at 8:00 AM. She reviewed the consent for anesthesia services and confirmed Patient #24's consent for anesthesia services was not signed by the CRNA.
Patient #24's consent for anesthesia services was not signed by the CRNA.
00023
2. Patient #4's medical record documented a preterm newborn male who was born via caesarean section at the CAH at 1:12 PM on 2/19/14. He was transferred by helicopter to another hospital on 2/22/14.
a. A physician "Progress note," dated 2/21/14 at 7:33 AM, stated Patient #4 was "...born without a heartbeat with Apgars of 0, 6 and 7 at 0, 5, and 10 minutes." An Apgar score is traditionally taken at 1 minute of age, not at 0 minutes of age. Patient #3 was Patient #4's mother. Patient #3's "OPERATIVE NOTE," dated 2/19/14 at 2:19 PM, stated Patient #4's Apgar scores were listed as "0, 6 and 7 at 1, 5, and 10 minutes, respectively." The Apgar scores from the 2 records did not match.
The RN who participated in the resuscitation of Patient #4 was interviewed on 5/22/14 beginning at 4:20 PM. She stated the Patient #4's Apgar score of 0 was measured at 1 minute of life.
b. Patient #4's "Discharge Summary," dated 2/22/14 at 8:42 AM, stated "Positive pressure ventilation was performed as well as about 20-30 seconds of chest compressions before a heart rate above 100 [beats per minute] was noted. Patient initially required 1/4 liter of oxygen [per nasal cannula]." The "Discharge Summary" stated his initial blood glucose level was below 20. (A physician progress note, dated 2/20/14, stated the laboratory analyzer could not measure blood glucose levels below 20.) Laboratory reports listed normal blood glucose levels between 51 and 96. The "Discharge Summary" stated Patient #4 received IVs with dextrose. The IVs were not effective at raising the baby's blood glucose levels. The "Discharge Summary" indicated Patient #4 was transferred to the another hospital for stabilization of his blood glucose.
No documentation was present in the medical record stating the physician consulted with a neonatologist regarding Patient #4's care.
Patient #4's physician was interviewed on 5/29/14 beginning at 12:05 PM. He stated he contacted a neonatologist at an acute care hospital on 2/20/14 regarding Patient #4's care. He stated he did not document this.
Patient #4's medical record did not contain complete documentation.
3. Patient #28's medical record documented a newborn female who was born via caesarean section on 2/27/14 at 7:30 PM. She was discharged home on 3/02/14.
Patient #28's "HISTORY AND PHYSICAL" by the physician, dated 2/27/14 at 8:42 PM, stated her Apgar score was 0 out of 10 at 1 minute of life, indicating the newborn had no pulse and no respirations. The document stated the Apgar score had risen to 7 at 5 minutes.
Patient #28's "Labor and delivery Summary," written by an RN but not dated or timed, stated the neonate's Apgar scores were 5 at 1 minute and 7 at 5 minutes of age.
Patient #28's medical record was reviewed by the obstetrical nurse on duty on 5/23/14 beginning at 9:15 AM. She confirmed the discrepancy between physician and nursing documentation regarding Patient #28's Apgar scores.
Patient #28's medical record contained conflicting documentation.
Tag No.: C0322
Based on observation and interview, it was determined the facility failed to ensure that, prior to receiving anesthesia, patients were examined to evaluate the potential risks. This impacted 1 of 1 patient (#27) whose surgery was observed. This had the potential to result in negative patient outcome. Findings include:
Patient #27 was a 43 year old male admitted to the facility on 5/21/14 for same day surgery on his right shoulder.
On 5/21/14, beginning at 9:00 AM, Patient #27 was observed in his room as an RN was preparing him for surgery. At appoximately 9:30 AM, the CRNA was observed to introduce himself to Patient #27. He asked Patient #27 if he had any prior issues with anesthesia, when he had last had anything by mouth, and about his health history. Patient #27 was then transferred to the recovery room where the CRNA prepared to administer a nerve block to his right shoulder. After the nerve block was placed, Patient #27 was taken to the OR. The CRNA did not listen to Patient #27's heart and lungs with a stethoscope before taken to the OR.
The CRNA was interviewed on 5/23/14 at 10:45 AM. He confirmed that he should have completed a physical examination of Patient #27.
Patient #27 did not receive a pre-anesthesia evaluation.