HospitalInspections.org

Based on observation, review of P&P, standards of practice, and staff interview, in 2 of 2 (R and BB) interviews, the hospital failed to have the full 36 vials of dantrolene within the facility to respond to a malignant hyperthermia emergency. This deficiency has the potential to affect all surgical patients at this facility.

Findings include:

Per review of facility policy, on 8/19/2013 in PM, titled "Malignant Hyperthermia (MH)Emergency Protocol" dated 5/11 it states under #3, "if needed send any available personal to the nearest convenience or grocery store for additional ice. If occurrence in the middle of the night may use law enforcement if necessary."

Per interview on 8/16/2013 at 1:50 PM with Pharmacist BB, the policy for MH is a nursing policy and to the best of Pharmacist BB's knowledge it is believed they would utilize the police to transport the rest of the Dantralene. The policy does not address obtaining the additional Dantralene.

On 8/6/2013 at 9:37 AM during a tour of OR 2 Surgical Lead RN R confirmed there are 18 vials of Dantrolene (a medication used to treat an emergent side effect of anesthesia called Malignant Hyperthermia (MH)) in the procedure cart. When asked where the other 18 vials were stored Surgical Lead RN R was unaware of where the other 18 vials stored.

During an interview with Pharmacist BB on 8/7/2013 at 8:30 AM Pharmacist BB confirmed they share a supply of Dantrolene with another hospital which leaves this facility with 18 vials on hand.

Per Frequently Asked Questions from the Malignant Hyperthermia Association of the United States (MHAUS) accessed at the following information was reviewed:

Who Should Stock Dantrolene And How Much?
All facilities, including ambulatory surgery centers and offices, where MH triggering anesthetics (isoflurane, desflurane, enflurane, sevoflurane, methoxyflurane, halothane and succinylcholine) are administered, should stock a minimum of 36 vials of dantrolene, along with the other drugs and devices necessary to treat an MH reaction. If none of these agents are ever in use in the facility, then dantrolene need not be kept at hand.

Where Should Dantrolene Be Kept?
Dantrolene should be kept in or very close to the operating room, so that it is available immediately if MH occurs. Dantrolene may be stored at room temperature. A supply of sterile water for injection USP (without a bacteriostatic agent) should be kept nearby to mix with dantrolene before injection (60 ml/vial); the water for diluting dantrolene should not be stored in a refrigerator; it may be stored in a warming cabinet designed to maintain fluid temperatures between 35-40o? C. All anesthesia and surgical team members should be aware of this location.

Are There Any Advantages In Sharing A Supply of Dantrolene?
No. Minutes count in an MH emergency. The Professional Advisory Council of MHAUS strongly recommends that an adequate supply of dantrolene be available wherever general anesthesia is administered. Responsibility for treatment rests with the facility where the surgery is performed. Sharing is not a good alternative.

Based on tour and observations in 2 of 2 hospital areas (surgical and OR 2), the facility failed to ensure there are intact cleanable wall surfaces. This deficiency potentially affects all Pts treated at the facility.

Findings include:

During a tour of the surgical area with Surgical Lead RN R on 8/6/2013 at 9:40 AM noted deep scrapes in the wall of the dirty linen room which makes the surface non cleanable. Lead Surgical RN R noted the damage at the time of the tour.

During a tour of OR 2 with Surgical Lead RN R on 8/6/2013 at 9:35 AM noted the moulding was damaged/pushed in on the wall that the door is on which makes the surface non cleanable. Lead Surgical RN R noted the damage at the time of the tour.

Based on tour, and interview with staff, in 1 of 1 interview (L and M), the facility failed to ensure all biologicals are secure and not available to patients and visitors. This deficiency potentially affects all outpatients treated at the facility.

Findings include:

Per tour of the Outpatient Clinic attached to the hospital on 8/7/13 at 8:30 AM with Dir L and Mg M, exam room #284 had an unsecured cupboard that contained formalin and cyto prep (for preserving tissue samples). This practice allows patient and visitor access to hazardous substances. This was confirmed during tour with Dir L and Mgr M, adding they have the ability to secure the cupboard.

Based on tours and observations, policy and procedure reviews, CDC guidelines, and interviews with staff (C, N R) the facility failed to ensure a safe and sanitary environment to prevent and control the potential spread of infection. This deficiency potentially affects 22 Inpatients treated at the facility during survey.

Findings include:

Review on 8/7/13 in the AM of facility policy titled Hand Hygiene/Glove Usage, revised 8/07, it states under Procedures "Use alcohol-based hand rub in all recommended situations below unless hands are "visibly soiled": 1. Before and after direct patient contact...3. Before inserting invasive devices...5. After removing gloves. 6. After contact with inanimate objects in the immediate vicinity of the patient."

Review on 8/7/13 in the AM of facility policy titled Venipuncture Procedure, (n.d.) it states under Procedure #5 "Apply tourniquet. Prepare venipuncture site with alcohol preps. DO NOT PALPATE VENIPUNCTURE AREA AFTER CLEANSING unless you clean your gloved finger also with alcohol...."

Review on 8/7/13 in the AM of facility policy titled Laboratory Coat Usage, dated 8/11, it states under Procedure: "1) ...White coats are supposed to be used in the drawing areas-draw rooms in the lab and while drawing patients in any patient care areas (Floors, Nursing Home, Clinic, Oncology, Surgery, Urgent Care and ER (emergency room) When you return to the Lab from drawing, and you collect and receive your specimens, only white lab coats are fine. If you spend ANY TIME -longer than 2-3 minutes in the lab, then you must change out of the white lab coat and put a blue lab coat on."

Review on 8/7/13 in the AM of facility policy titled Use of Massage in Rehab Services, revised 4/13, it states under Procedure #4 "Apply a small amount of massage cream or mineral oil to hands to warm slightly then rub into patient's/client's skin as a lubricant during massage....Do NOT use contaminated hands (that have touched patient skin) back into massage cream container."

Examples in Rehab department:

Per tour of the Rehab department on 8/5/13 at 2:00 PM with Dir C, the following was observed:

The Hybesis (for electrical stimulation) Charging Station has dust and debris where the units are inserted.

The the top of the crash cart including suction and defibrillator was dusty.

The clean utility room had a small waste basket with dirty laundry.

The above was confirmed with Dir C during the tour, stating in agreement that the equipment should be clean, and moved the laundry from the clean room. During the same tour, there were bottled of ultrasound gel in a warmer next to the ultra sound machine. Per Dir C at approximately 2:15 PM, the bottles are topped off rather than emptied cleaned and refilled, or tossed. This practice allows for potential cross contamination. There are Message Cream containers in each treatment room viewed, 111, 112, 113, and 114. Per Dir C, the staff wash, and use bare hands to obtain cream from the containers, adding they do not "double dip". This practice allows for potential contamination of the product.

Examples in Radiology department:

Per tour of the Radiology department on 8/5/13 at 3:00 PM with Dir D, the Nuclear Med Treatment room had a drawer with a fork and gloves, not clean in a box. Dir D confirmed the presence of the fork and gloves, on 8/5/13 at 3:30 PM, adding the items should not be in the drawer.

Examples in the Kitchen:

The following was observed on 8/6/13 at 12:35 PM:

Per observation of dishwashing, the dish racks were placed directly on the floor after removing clean dishes.

Cook Z did not have a mask covering a goatee.

Cook AA cleaned the tray cart spraying with Mikro-Quat cleaner and immediately began wiping it down. Per the Mikro-Quat manufacturer's instructions, it states under Light-Duty Cleaning and Sanitizing Non-Food Contact Surfaces "...Allow 1 minute contact time.".

Examples in the Outpatient Clinic:

Per tour of the Outpatient Clinic on 8/7/13 at 8:50 AM with Dir L and Mgr M, the following was observed: There are 3 boxes on the floor and lab coats (in wrapping) on the floor of the clean supply room in the specialty area.

Per interview with IP N on 8/7/13 at 8/25 AM there is evidence Ultra Sound gel should not be topped off.


26711

Examples in the Laundry:

According to the U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC) Atlanta, GA 30333, 2003, Guidelines for Environmental Infection Control in Health-Care Facilities, "A laundry facility is usually partitioned into two separate areas - a " dirty " area for receiving and handling the soiled laundry and a " clean " area for processing the washed items to minimize the potential for recontaminating cleaned laundry with aerosolized contaminated lint," and, "After washing, cleaned and dried textiles, fabrics, and clothing are pressed, folded, and packaged for transport, distribution, and storage by methods that ensure their cleanliness until use."

A tour of the EVS laundry area was conducted on 8/5/2013 at 1:30 p.m. accompanied by EVS Mgr B. This facility outsources most of their laundry, however they continue to wash their own mop heads, kitchen towels and surgical scrubs. After drying, the scrubs are taken to the EVS Mgr's office to be folded and then are transported in the laundry's wheeled basket to the surgery locker rooms.

There is a common door for dirty linen to go in and clean linen to go out of the laundry area and the transport basket is not covered when wheeled through the hallways to its destination point.

This was confirmed by EVS Mgr B at the time of discovery.

Example of respiratory treatment observation:

An observation of RT F providing a hand held nebulizer (HHN-device that delivers medication to the lungs upon inhalation) to Pt. #19, who was on droplet precautions for pneumonia, was conducted on 8/5/2013 at 3:55 p.m.
According to the CDC, droplet precautions should include the following PPE: "Wear a facemask, such as a procedure or surgical mask, for close contact with the patient; the facemask should be donned upon entering the exam room. If substantial spraying of respiratory fluids is anticipated, gloves and gown as well as goggles (or face shield in place of goggles) should be worn. Perform hand hygiene before and after touching the patient and after contact with respiratory secretions and contaminated objects/materials."
RT F entered Pt. #19's room, bringing the computer on wheels along, and put on a mask and then gloves without washing hands. With gloved hands RT F assembled the HHN, listened to Pt. #19's lungs twice, assisted Pt. #1 to turn, turned off and on light switches in the room, handled the privacy curtain, disassembled the HHN equipment rinsing it in the sink and storing it back in the cabinet, handled Pt. #1's incentive spirometer (apparatus to exercise the lungs), and left the room with the computer on wheels. Once outside the room in the hall, RT F removed one glove and the mask. With the un-gloved hand RT F wiped off the top of the computer cart with a sani-wipe, then removed the other glove. RT F did not wash hands or change gloves throughout the procedure thereby contaminating all items touched after touching Pt. #1.
These findings were discussed on 8/6/2013 at 4:15 p.m. with Dir Q and IP N, and Quality Mgr A present.

Examples in Decontamination area:
A tour of the Decontamination area (Disinfection and Sterilization Department) was conducted on 8/6/2013 at 8:56 a.m. accompanied by, lead CSR T, Surgical Lead RN R and CNO P.
CSR T performs instrument cleaning for sterilization and high level disinfection.
The initial step in instrument cleaning is to pre-soak for a specified amount of time, according to the manufacturer, in an enzymatic cleaner to relieve the instruments of bio-burden (tissue/blood/stool that gets on the instruments during use).
The sink used to pre-soak is a stainless-steel sink that is not marked for water levels. The directions on the container of enzymatic cleaner state the pre-soak is to be 2-4 minutes.
When asked about the manufacturer's directions for the enzymatic cleaner and water concentration, CSR T replied that it is 4 gallons of water and 4 pumps of enzymatic cleaner and for the endoscopes (used for colonoscopies and upper endoscopies) CSR T leaves them in, "About 45 seconds maybe, long enough to run the endoflush." The endoflush is an automated device used to help clean endoscopes.
CSR T was unable to state how T knows the water level used is 4 gallons if the sink is not marked. CSR T was unsure how long the sink has been unmarked as T had just noticed it was not marked during this tour.
During the tour of the Decontamination area it was also discussed that this facility, as part of the surgical services, performs eye surgeries such as cataract removals and lens implants. The MDs bring their own instruments which are sterilized in the "immediate use" manner (previously known as flash sterilization) prior to use and inbetween cases. There are two sets of eye instruments that are brought in and on days that the MD does surgery there can be up to 10 or more surgeries. CSR T states that immediate use sterilization is done with these eye instruments because there is not enough equipment to do a full cycle of steam sterilization with only two kits. The facility/MDs lack the equipment.
Regarding immediate use sterilization techniques, the CDC, in 2008 stated, "Flash sterilization should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time."
These findings were confirmed at the time of discovery with CNO P and Lead RN R present.


32670

Example of OR tour:

During a tour of the surgical area on 8/6/2013 at 9:40 AM with Surgical Lead RN R, noted 4 opened and used lip balms in the anesthesia cart in OR 1 and 3 open and used lip balms in the anesthesia cart in OR 2. Surgical Lead RN R stated at the time of the tour that these lip balms are used for multiple patients.

Based on tour, review of P&P, and interview with staff (G), in 3 of 3 tours of kitchen/kitchenettes, the facility failed to ensure food temperatures are maintained prior to delivery to Pts, and all nutritional items are labeled and not expired beyond use date. This deficiency potentially affects all Inpatients treated at the facility during survey.

Findings include:

Review on 8/7/13 in the AM of facility policy titled Food Preparation, dated 2009, it states under Preparation Procedures #2 "Temperatures of food are maintained by use of effective equipment and monitoring of food with temperature checks. During serving time, temperature of each hot food item are taken and documented on a temperature check sheet. Temperatures of hot and cold food at various phases of delivery may also be taken."

On 8/6/13 at 7:30 AM the breakfast tray line was observed, with Mgr G. Mgr G stated in interview at 7:30 AM, Mgr G has not done test tray temperatures to determine the food maintains the correct temperature during transit to the Pt floor and at time of delivery. A test tray was requested to determine temperatures. The cart with Pt trays was delivered to the Pt Unit at 7:50 AM, the first tray was delivered at 8:05 AM. At 8:10 AM, Mgr G took temps of the test tray food, with the following results: Milk was 51 degrees, coffee-138, hot cereal-119, orange juice-56. Per temperature records from 8/6/13 for breakfast the hot cereal was recorded at 193-200 degrees. Per interview with Mgr G at 8:10 AM, the test try temperatures should have been: Milk-40, coffee-140, hot cereal 120- and orange juice-40.

Per tour of the Kitchen on 8/6/13 at 8:30 AM there are unlabeled bags of food product, identified as french fries by Mgr G; and an unlabeled tray of individual bags of cooked food, identified as taco meat by Mgr G. Mgr G confirmed there are no dates or labels.

Per tour of the Birthing Department on 8/6/13 at 1:00 PM there are 4-8 packs of Gerber Good Start formula expired 8/3/13.


32670

During a tour of the surgical department on 8/6/13 at 9:40 AM noted an opened and undated loaf of bread in the refrigerator in PACU nutrition room. Surgical Lead RN R noted the undated bread at the time of the tour.

Based on MR review, and interview with staff (K, O, A and S), in 11 of 11 MR requiring nursing CPs out of a total of 22 MR reviewed (#8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19 and 20), the facility failed to develop and individualize CP. This deficiency potentially affects all 22 inpatients treated at the facility during survey.

Findings include:

Per interview with Mgr A on 8/7/13 at approximately 1:00 PM, there is no P&P related to developing CPs.

In an interview with RN K during the MR review, K stated that individualization of CP is possible. This issue has been recognized as a problem with the electronic records and a plan is being developed to address the lack of CP individualization. RN K admits that the care plans are not very individualized.

A MR review for Pt #16 was conducted on 8/6/2013 at 3:01 p.m. accompanied by Charge RN K. Pt. #16 was admitted on 7/30/2013 for the Swing Bed program after multiple fractures. A computerized CP for pain was initiated which is standardized for all patients with this problem and is not individualized to reflect the the unique needs of Pt. #16.

A MR review for Pt #17 was conducted on 8/7/2013 at 11:15 a.m. accompanied by MR Clerk O. Pt #17 was admitted on 7/28/2013 and discharged on 8/5/2013 for the Swing Bed program after a right total knee. A computerized CP for pain and mobility was initiated. They are standardized for all patients with this problem and are not individualized to reflect the the unique needs of Pt #17.

A MR review for Pt #18 was conducted on 8/6/2013 at 2:15 p.m. accompanied by RN K. Pt #18 was admitted on 8/6/2013 around 5:30 a.m. with Congested Heart Failure. A computerized CP for decreased cardiac output was initiated which is standardized for all patients with this problem and is not individualized to reflect the the unique needs of Pt. #18.

A MR review for Pt. #19 was conducted on 8/6/2013 at 2:27 p.m. accompanied by RN K. Pt #19 was admitted on 8/4/2013 with pneumonia. Pt #19 also has had a history of strokes with partial paralysis and needs a walker for ambulation, as well as having a history of falls. A computerized CP for impaired gas exchange was initiated which is standardized for all patients with pneumonia and is not individualized to reflect the the unique needs of Pt #19. There is no CP plan for safety or falls, which RN K states Pt #19 should have had.

A MR review for P. #20 was conducted on 8/6/2013 at 2:46 p.m. accompanied by RN K. Pt #20 was admitted on 8/2/2013 with shortness of breath. A computerized CP for impaired gas exchange and pain was initiated which is standardized for all patients with these problems and is not individualized to reflect the the unique needs of Pt #20. Pt #20 is a fall risk and does not have a falls CP initiated.

The findings in these MRs were confirmed at the time of the MR reviews with RN K.


32670

A MR review was conducted on Pt # 9's closed newborn record on 8/6/2013 at 2:45 PM accompanied by Informatics RN S who confirmed Pt #9 did not have a CP on record.

A MR review was conducted on Pt #8's closed record on 8/6/2013 at 2:10 PM accompanied by Informatics RN S who confirmed Pt # 8 did not have a CP on record.

A MR review was conducted on Pt #11's closed labor and delivery record on 8/6/2013 at 3:30 PM accompanied by Informatics RN S who confirmed the only problem listed on the computerized CP for Pt #11 is "Alteration in Comfort" which is a standardized CP and is not individualized to reflect the unique needs of Pt #11.

A MR review was conducted on Pt # 12's Newborn record on 8/6/2013 at 3:50 PM accompanied by Informatics RN S who confirmed the only problem listed on the computerized CP for Pt #12 is "Potential Alteration in Elimination" which is a standardized CP and is not individualized to reflect the unique needs of Pt #12.


18816

Pt #10's MR review on 8/7/13 at 11:00 AM revealed Pt #10 was admitted for hip surgery on 5/21/13,. Pt #10 was discharged on 5/25/13. The RN CP developed on 5/21/13 lists a problem as Alteration in Comfort, with three goals "Verbalize pain relief or ability to cope with incomplete relief of pain, Pt will report changes in comfort level and Pt will verbalize understanding of pain modalities available" The are no other problem lists that would pertain to a surgical Pt including, but not limited to mobility, wound care, self care, and skin integrity. This is confirmed in interview with RN S on 8/7/13 at 11:00 AM, stating there should be more to the CP, and not unique to the Pt.

Pt #14's MR review on 8/7/13 at 12:15 PM revealed Pt #14 was admitted for knee surgery on 4/24/13,. Pt #14 was discharged on 4/27/13. The RN CP developed on 4/24/13 lists a problem as Alteration in Comfort, with three goals "Verbalize pain relief or ability to cope with incomplete relief of pain, Pt will report changes in comfort level and Pt will verbalize understanding of pain modalities available" The are no other problem lists that would pertain to a surgical Pt including, but not limited to mobility, wound care, self care, and skin integrity. This is confirmed in interview with RN S on 8/7/13 at 12:15 PM, stating there should be more to the CP and not unique to Pt.

Based on MR review and interview with staff (S), in 4 of 11 MR requiring discharge instructions (21 and 22), and in 2 of 2 ED MRs where Pts are transferred (3 and 5) out of a total 22 MRs reviewed, the facility failed to ensure all documentation is complete including content dates, times, and risks of transfer. This deficiency potentially affects all pts treated at the facility.

Findings include:

A MR review was conducted on Pt. #21's closed same day surgical record on 8/7/2013 at 12:10 p.m. accompanied by MR Clerk O, who confirmed the findings. Pt. #21 has discharge instructions on the MR that were not signed by the discharging RN.

A MR review was conducted on Pt. #22's closed surgical record on 8/7/2013 at 12:32 p.m. accompanied by MR Clerk O. Pt. #22's MR did not contain documentation of hand-off communication from the intraoperative RN to the PACU RN. Quality Mgr A, who assisted MR Clerk O to find this documentation, stated, "It should be here but it is not."


18816

Pt #3's MR review on 8/7/13 10:25 AM revealed Pt #3 was transferred to another facility from the ED due to Chest Pain. The facility Transfer Form dated 1/29/13 lists preprinted risks as "Injury to Driver, Suicide, Death, and Loss of Anxiety". Each risk was checked as applicable to Pt #3. These risks are general and not unique to Pt#3's condition. This is confirmed in interview with RN S on 8/7/13 at 10:25 AM, agreeing they are preprinted and not unique.

Pt #5's MR review on 8/7/13 at 10:40 AM revealed Pt #5 was transferred to another facility from the ED due to potential hydrocephalus (swelling of the brain). The facility Transfer Form dated 6/24/13 lists preprinted risks as "Injury to Driver and Death" These risks are general and not unique to Pt # 5's condition. This is confirmed in interview with RN S on 8/7/13 at 10:40 AM, agreeing they are preprinted and not unique.

Based on MR review, review of R&R and interview with staff (S), in 3 of 8 MR requiring DS (10, 13, and 14) out of a total 22 MRs reviewed, the facility failed to ensure DS and MRs are complete with in 30 days of Pt discharge per facility R&R. This deficiency potentially affects all 22 Inpatients treated at the facility during survey.

Findings include:

Review on 8/7/13 in the PM of Medical Staff R&R revealed under Discharge Summaries "Record of discharged patient shall be completed within thirty (30) days following the patient's discharge, or shall be deemed delinquent and the subject to automatic suspension as outlined within the Medical Staff Bylaws."

Pt #10's MR review on 8/7/13 at 11:00 AM revealed Pt #10 was discharged on 5/25/13, a progress note dictated on 5/24/13 is authenticated on 7/4/13 and the DS dictated on 5/25/13 is not authenticated with a date and time, greater than 30 days from discharge. This is confirmed in interview with RN S on 8/7/13 at 11:00 AM, stating the authentications should be dated and timed and within 30 days.

Pt #13's MR review on 8/7/13 at 12:00 PM revealed Pt #13 was discharged on 6/26/13, the OP dictated on 6/26/13 is not authenticated by the MD with a date and time, greater than 30 days from discharge. This is confirmed in interview with RN S on 8/7/13 at 12:00 PM, stating the authentication should be dated and timed.

Pt #14's MR review on 8/7/13 at 12:15 PM revealed Pt #14 was discharged from Acute care on 4/29/13, the OP dictated on 4/24/13 is not authenticated by the MD with a date and time, greater than 30 days from discharge. This is confirmed in interview with RN S on 8/7/13 at 12:15 PM, stating the authentication should be dated and timed.

Based on staff interview (O and A), P&P review and MR review, in 3 of 18 MRs requiring an H&P (#15, 17 and 21) out of a total 22 MRs reviewed, the hospital failed to ensure timely completion of the H&P on admissions and prior to surgery. This deficiency has the potential to affect all 22 inpatients at the time of this survey.

Findings include:

Review of Medical Staff R&R on 8/7/13 in the PM revealed under History and Physical it states "A complete history and physical examination, assessment and plan of treatment shall be recorded no more than 30-days before or twenty-four (24) hours after admission and for all high-risk elective or emergency procedures or low-risk procedure done in the operating suite on high-risk patients prior to procedures. If a complete history has been recorded and a physical examination performed within thirty (30) days prior to a patient's admission, a legible copy of such a report may be used in the patient's hospital medical records in lieu of the admission or pre-procedure history and physical examination. In such instances, an interval note that includes any change in health status or medication, as well as a brief physical exam documenting any changes shall be recorded."

A MR review was conducted on Pt. #15's closed Surgery MR on 8/7/2013 at 12:00 PM. accompanied by Quality Manager A who confirmed in interview the following findings during the MR review: There is a form titled "Surgical History and Physical Update" on file which reads "I have reviewed the History and Physical that is dated:" but the date was left blank on the form. The form was signed on 1/15/2013 by the MD. There is no H&P on file to be reviewed.


26711

A MR review was conducted on Pt. #17's closed Swing Bed MR on 8/7/2013 at 11:15 a.m. accompanied by MR Clerk O who confirmed the following findings during the MR review: There is no H&P on file for this Swing Bed admission.

A MR review was conducted on Pt. #21's closed same day surgery MR on 8/7/2013 at 12:10 p.m. accompanied by MR Clerk O who confirmed the following findings during the MR review: Pt. #21 had hernia surgery on 3/7/2013. The H&P on file is dated 1/25/2013. This exceeds the 30 day requirement for completion of H&Ps prior to surgery.

Based on review of MR, review of R&R, review of P&P, and interview with staff (S), in 2 of 2 SA MRs reviewed (1 and 2), out of a total 22 MRs reviewed, the facility failed to ensure there are orders corresponding with medications administered to SA Pts.

Findings include:

Review of R&R dated 3/17/2010, on 8/7/13 in the PM, revealed under Routine Orders/Standing Orders it states "...Pre-printed orders require approval by the Medical Staff through the medical records function and must be signed off by the physician each time they are used. Standing orders will be in writing and will be followed insofar as proper treatment of the patient will allow and when the attending physician does not write specific orders, the routine orders will constitute the orders for treatment."

Review on 8/7/13 in the AM of the facility's Medication Policy and Standing Orders (n.d.) there is a list of medications that may be given prophylatically for treatment of sexual transmitted disease or prevent pregnancy resulting from a SA. This policy is signed 3/8/11 by the facility medical director and director of the contracted agency for SANEs.

Pt #1's MR review on 8/6/13 at 3:25 PM revealed there are no orders in the MR for the antibiotic Ceftiraxone administered in the ED on 2/26/13. There is no copy of the policy/orders signed by the RN or MD on duty at the time of the Pt's visit. This is confirmed in interview with RN S on 8/6/13 at 3:25 PM, agreeing the orders should be in the MR.

Pt #2's MR review on 8/7/13 at 9:50 AM revealed there is a SO in the MR for the antibiotics Zithoromax and Rocephin, and emergency contraception Levonorgesteryl administered in the ED on 4/5/13. There is no MD authentication to this This is confirmed in interview with RN S on 8/6/13 at 9:50 AM, agreeing the orders should in the the MR.

Based on MR review, review of R&R and interview with staff (S), in 3 of 22 MRs reviewed (10, 13, and 14) the facility failed to ensure all signatures are authenticated with a date and time. This deficiency potentially affects all 22 Inpatients treated at the facility.

Findings include:

Review on 8/7/13 in the PM of Medical Staff R&R, dated 3/17/10, is states under Authentication of Medical Records it states "All clinical entries in the patient's medical record shall be legible, accurately dated, timed, and authenticated".

Pt #10's MR review on 8/7/13 at 11:00 AM revealed a Progress note dictated on 5/24/13 was not authenticated until 7/4/13 and the DS dictated on 5/25/13 is not authenticated with a date and time. This is confirmed in interview with RN S on 8/7/13 at 11:00 AM, stating the authentications should be dated and timed and within 30 days.

Pt #13's MR review on 8/7/13 at 12:00 PM revealed the OP dictated on 6/26/13 is not authenticated by the MD with a date and time. This is confirmed in interview with RN S on 8/7/13 at 12:00 PM, stating the authentication should be dated and timed.

Pt #14's MR review on 8/7/13 at 12:15 PM revealed the OP dictated on 4/24/13 is not authenticated by the MD with a date and time. This is confirmed in interview with RN S on 8/7/13 at 12:15 PM, stating the authentication should be dated and timed.

Based on MR review, review of P&P and interview with staff (A, O and S), in 5 of 6 OR MRs reviewed (#10, 14, 15, 21 and 22), out of a total 22 MRs reviewed, the facility failed to ensure documentation oc the alcohol based skin preparation is dry prior to draping.

Based on 6 of 7 MRs where Pts had anesthesia (#8, 10, 13, 14, 21 and 22) out of a total 22 MRs reviewed, the facility failed to ensure the pre-anesthesia evaluation is documented and the post-anesthetic evaluation is comprehensive including cardiopulmonary status, level of consciousness, follow-up care, observations and complications. See tag 322.

The cumulative effect of these deficiencies potentially affects all surgical patients treated at the facility.

Findings include:

Facility policy titled "Patient Fire Safety in Operating Room Oxygen Enriched Environment" dated November 2012 states: The circulating nurse will inform the team if an alcohol based prep solution was used and announce that 3 minutes was allowed for drying, and the prepped area was tested for dryness, prior to draping.

During interview with Quality Manager A on 8/7/2013 at 8:30 AM when asked where skin prep dry times are recorded, Quality Manager A stated "at this time we don't document dry times".

Per interview with Surgery Lead RN R at time of tour of surgical area on 8/7/2013 at 9:40 AM the skin prep would be applied once the surgeon enters the surgical suite and begins donning sterile gown and gloves. When asked when the drape would be applied, Surgery Lead RN R stated "immediately after the skin prep."


18816

Pt #10's MR review on 8/7/13 at 11:00 AM revealed Pt #10 had hip surgery on 5/21/13. The IND included documentation the alcohol based skin prep ChloraPrep was used. There is no documentation the prep was dry prior to draping for surgery. This is confirmed in interview with RN S on 8/7/13 at 11:00 AM, agreeing the documentation is not present in the MR.

Pt #14's MR review on 8/7/13 at 12:15 PM revealed Pt #14 had a total knee arthroscopy on 4/24/13. The IND included documentation the alcohol based skin prep ChloraPrep was used. There is no documentation the prep was dry prior to draping for surgery. This is confirmed in interview with RN S on 8/7/13 at 12:15 PM, agreeing the documentation is not present in the MR.

A MR review was conducted on Pt. #15's closed surgical record on 8/7/2013 at 12:00 PM accompanied by Quality Manager A, who confirmed the following findings: Pt. #15 had gynecological surgery on 1/15/2013 where Chloraprep, an alcohol based skin prep, was used. There is no evidence in the MR that the skin prep was dry prior to applying the surgical drape.


26711

A MR review was conducted on Pt. #21's closed same day surgical record on 8/7/2013 at 12:10 p.m. accompanied by MR Clerk O, who confirmed the following findings: Pt. #21 had hernia surgery on 3/7/2013 and Chloraprep, an ABSP, was used. There is no evidence in the MR that the skin prep was dry prior to applying the surgical drape.

A MR review was conducted on Pt. #22's closed surgical record on 8/7/2013 at 12:32 p.m. accompanied by MR Clerk O who confirmed the following findings: Pt. #22 had appendix surgery on 2/12/2013 and Chloraprep was used. There is no evidence in the MR that the skin prep was dry prior to applying the surgical drape.

Based on MR review, review of R&R, review of P&P and interview with staff (A, O and S), in 6 of 7 MRs where Pts had anesthesia (#8, 10, 13, 14, 21 and 22) out of a total 22 MRs reviewed, the facility failed to ensure the pre-anesthesia evaluation is documented and the post-anesthetic evaluation is comprehensive including cardiopulmonary status, level of consciousness, follow-up care, observations and complications. This deficiency potentially affects all surgery patients treated at the facility.

Findings include:

Review on 8/7/13 in the PM of Medical Staff R&R, dated 3/17/10, it states under Anesthesia Records "The anesthetist shall maintain a complete anesthesia record to include evidence of pre-anesthetic evaluation and post-anesthetic follow-up documenting the patient's condition including date and time and presence or absence of anesthesia related complications."

The facility's policy titled, "Anesthesia Scope of Practice," dated 2/96, was reviewed on 8/7/2013 in the a.m. The policy outlines anesthesia's responsibilities for a pre-anesthesia evaluation as, "All patients who receive general anesthesia or major block anesthesia must have a complete preoperative evaluation which includes a written history and physical examination as well as laboratory determinations established by department policy unless the emergency nature of the case precludes waiting for the results of these tests."

There is no criteria listed for anesthesia's responsibility for post-anesthesia evaluations.

In an interview with Quality Mgr A on 8/7/2013 at 9:00 a.m. Mgr A stated that this facility does not have a policy for post-anesthesia evaluations.

A MR review was conducted on Pt. #8's closed vaginal birth record on 8/6/2013 at p.m. accompanied by RN Informatics S, who confirmed the following findings: Pt. #8 had an epidural catheter placed for pain control on 8/6/2013. There is not a pre-anesthesia evaluation or a post-anesthesia evaluation on file. There is no documentation on file as to when the epidural was removed.

Pt #10's MR review on 8/7/13 at 11:00 AM revealed Pt #10 had hip surgery on 5/21/13. The surgery ended at 2:50 PM, the Post-op evaluation by the CRNA at 3:36 PM states under Regional Block: Motor Block Recovery "Incomplete" and Sensory Block Recovery "Incomplete". There is no follow up evaluation to determine full recovery of Motor Block or Sensory Block. This is confirmed in interview with RN S on 8/7/13 at 11:00 AM, agreeing there should be further assessment.

Pt #13's MR review on 8/7/13 at 12:00 PM revealed Pt #13 had a fractured ankle repair, under general anesthesia, on 8/26/13. There is no Pre-op or Post-op evaluation by anesthesia staff for the surgery. This is confirmed in interview with RN S on 8/7/13 at 12:00 PM, agreeing there should be both a pre and post-op anesthesia assessment.

Pt #14's MR review on 8/7/13 at 12:15 PM revealed Pt #14 had a total knee arthroscopy on 4/24/13. The surgery ended at 12:05 PM, the Post-op evaluation by the CRNA at 12:30 PM on 4/24/13 states under Regional Block: Motor Block Recovery "Incomplete" and Sensory Block Recovery "Incomplete". There is no follow up evaluation to determine full recovery of Motor Block or Sensory Block. This is confirmed in interview with RN S on 8/7/13 at 12:15 PM, agreeing there should be further assessment.


26711

A MR review was conducted on Pt. #21's closed same day surgical record on 8/7/2013 at 12:10 p.m. accompanied by MR Clerk O, who confirmed the following findings: Pt. #21 had hernia surgery on 3/7/2013. The post-anesthesia evaluation indicates that Pt. #21's vital signs were stable but does not state what they are.

A MR review was conducted on Pt. #22's closed surgical record on 8/7/2013 at 12:32 p.m. accompanied by MR Clerk O who confirmed the following findings: Pt. #22 had appendix surgery on 2/12/2013. The post-anesthesia evaluation indicates that Pt. #21's vital signs were stable but does not state what they are.

Based on review of Quality program data and interviews with 3 of 3 staff (Staff A, R,W), this facility failed to include all services affecting patient care are evaluated and included in the overall Quality plan for the facility. Failure to evaluate all services for quality of care has the potential to affect all patients receiving care in this facility including the 22 patients present during the course of the survey.

Findings include:

A review of the 2013 Quality Improvement Plan was conducted on 8/7/2013 in the a.m. The plan outlines the responsibilities of the organization and departments with a mission of, "Improving the health of our community with the caring staff driven by shared values."

One of the Clinical Quality Goals is to, "Evaluate and improve the quality of patient care and services provided in the hospital and outpatient services through improvement in the processes utilized in delivery of care an services."

In an interview with Surgical Lead RN R on 8/7/2013 at 8:30 a.m., there are currently no projects pending for the Post Anesthesia Care Unit.

In an interview with CRNA W on 8/6/2013 at 9:20 a.m., CRNA W stated that W is unaware of any current projects being reported to the quality program.

In an interview with Quality Mgr A on 8/7/2013 at 8:30 a.m., Mgr A stated that along with monitoring quality data for the national indicators that require data collection (falls, burns, medication errors) A has met with the department heads within the facility and they are to be working on a quality project that will improve the quality of patient care and safety.

Quality Mgr A admits that to date not all departments have quality projects and that some of the departments need more direction and intervention, which is in the plan for the upcoming year.

Mgr A also stated that contracted services have not been included in the overall quality plan for the hospital and the services have not been officially evaluated for quality of care and patient safety. Anesthesia services provided to this facility is one of these contracted services.

Based on review of P&P and interview with staff (P and S), in 1 of 2 death MRs (7) out of a total of 22 MRs reviewed, the facility failed to ensure staff followed P&P in reporting to the OPO and the P&P reflected the practice per interview. This deficiency potentially affects all potential organ donors and their families.

Findings include:

Review on 8/6/13 in the PM titled Preparation for Tissue Donation, dated 7/88, states under #2 "RN who has completed the Requestor Training Program is to discuss tissue donation with family and document consent or refusal on appropriate forms. Written consent is always obtained from next of kin - even if there is a signed donor card....", under #5 it states "...Due to the fact that we do not have a morgue with a cooling system, there is a time limit of 6-12 hours uncooled time ...", and under
#6 "After tissue procurement has been completed, arrange for patient to be transported to the funeral home of family's choice.""

Per interview with CNO P on 8/6/13 at 11:15 AM, the facility contracts with the OPO to be the requestor contacting the family of deceased. CNO P stated there are no trained requestors at the facility.

Pt #7's MR review on 8/7/13 at 10:55 AM revealed Pt #7 died on 2/16/13. The MR Death Record is dated 2/16/13, indicating Pt #7's body was removed from the facility on 2/16/13 (there is no time documented), the OPO contact date as 4/1/13. This is confirmed in interview with RN S on 8/7/13 at 10:55 AM, agreeing the contact date was too late to retrieve any tissue or organs.

Based on review of facility documents and in two of two staff interviews (Staff P and X), this facility does not inform Swing Bed patients about the ability to work or refuse to work while in the Swing Bed program. By not informing Pt's of this right the facility is prohibiting Pt's from making an informed decision. This affects the 2 Swing Bed patients present during the time of the survey.

Findings include:

Facility documents titled, "Swing Bed Unit Bill of Rights," "Patient Rights," and "Swing Bed Unit Admission Agreement," were reviewed on 8/6/2013 in the afternoon. These documents do not include information about the right of Swing Bed Pt's to decline or agree to work as a part of their plan of care while a Pt. in the program.

In an interview on 8/7/2013 at 8:00 a.m. with CNO P and SW X, both confirm that they do not include information about "Work" in the rights/responsibilities for Swing Bed Patients and were not aware of the requirement.

Based on review of facility documents and in two of two staff interviews (Staff P and X), this facility fails to inform patients of their right to share a room with their marital partner if both partners were in the Swing Bed program at the same time. By not informing Pt's of this right the facility is prohibiting Pt's from making an informed decision. This affects the 2 Swing Bed patients present during the time of the survey.

Findings include:

Facility documents titled, "Swing Bed Unit Bill of Rights," "Patient Rights," and "Swing Bed Unit Admission Agreement," were reviewed on 8/6/2013 in the afternoon. These documents do not include information about the right of Swing Bed Pt couples to share a room with their marital partner if both partners were in the Swing Bed program at the same time and they were both agreeable to the arrangement.

In an interview on 8/7/2013 at 8:00 a.m. with CNO P and SW X, both confirm that they do not include information about "Married Couples" in the rights/responsibilities for Swing Bed Patients.

Based on staff interview (X), Pt interview (#16) and MR review, the facility failed to provide an ongoing activities program for 2 of 2 swing bed patients (#16 and #17) with a total universe of 22. This has the potential to affect all swing bed patient including the 2 swing bed patient present during this survey.

Findings include:

Per interview with Pt #16 on 8/7/2013 at 7:40 AM Pt #16 denied being given the option to attend any planned activities but was offered books and magazines.

Per interview with SW X on 8/6/2013 at 8:00 AM swing bed patients are offered books, puzzles and games for activities. Per SW X there is not an ongoing activities calendar or schedule at this time.


26711

A MR review was conducted on Pt. #16's open Swing Bed MR on 8/6/2013 at 3:01 p.m. accompanied by RN K who confirmed the following findings during the MR review: Pt. #16 was admitted to the Swing Bed program on 7/30/2013. There is no ongoing documentation in the MR that Pt. #16 was offered diversional activities or participated in an organized activity program.

In an interview with RN K during the MR review on 8/6/2013, K stated that there is no set activity program. RN K stated, "The MD can write a pass for the day but other than that there is not much."

A MR review was conducted on Pt. #17's closed Swing Bed MR on 8/7/2013 at 11:15 a.m. accompanied by MR Clerk O who confirmed the following findings during the MR review: Pt. #17 was in the Swing Bed program from 7/28/2013-8/5/2013. There is no ongoing documentation in the MR that Pt. #17 was offered diversional activities or participated in an organized activity program.

Based on review of facility documents and in two of two staff interviews (Staff P and X), this facility does not ensure that 24-hour emergency dental care could be provided for swing bed patients. By not informing Pt's of this right the facility is prohibiting Pt's from making an informed decision. This affects the 2 Swing Bed patients present during the time of the survey.

Findings include:

Facility documents titled, "Swing Bed Unit Bill of Rights," "Patient Rights," and "Swing Bed Unit Admission Agreement," were reviewed on 8/6/2013 in the afternoon. These documents do not include an agreement or contract with a dentist to provide 24-hour emergency dental care to swing bed patients.

In an interview on 8/7/2013 at 8:00 a.m. with CNO P and SW X, both confirm that they do not have a contract/agreement with a dental provider for the Swing Bed program.

Based on review of P/P and interview with staff, in 1 of 1 interview (A) the facility failed to ensure there is a visitor policy that includes the Pt rights for visitors. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Per interview on 8/6/13 at 7:05 AM with Quality Mgr A, there is no policy that delineates visitation hours and/or restrictions.

Based on interview with staff, in 1 of 1 interview (A) the facility failed to ensure there is a visitor policy that includes the Pt rights for visitors. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Per interview on 8/6/13 at 7:05 AM with Quality Mgr A, there is no policy that delineates visitation rights including potential restrictions, but not denied due to same sex partner, family members or friends.

Based on interview with staff, in 1 of 1 interview (A) the facility failed to ensure there is a visitor policy that includes ensures all Pts may choose visitor without discrimination and said visitors have equal visitation rights. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Per interview on 8/6/13 at 7:05 AM with Quality Mgr A, there is no policy that includes information that all Pts may have visitors as they choose, and they will not be discriminated against based on sex, gender identity, race, color, national origin, religion, sexual orientation or disability; and all visitors are treated equally.