HospitalInspections.org

Based on observation, record review and staff interview, it has been determined that the hospital failed to adhere to the policies and procedures of the hospital regarding providing adequate supervision of all nursing personnel for 1 of 2 staff members reviewed for performance of safety checks of patients on an inpatient psychiatric unit for Certified Nursing Assistant (CNA) Staff C, and 2 of 2 Registered Nurses (RN) reviewed for recertification of cardiopulmonary resuscitation (CPR)/Basic Life Support (BLS), Staff A and B.

Findings are as follows:

1.) Review of the hospital policy titled, "Observation of Patients on Inpatient Psychiatric Units Chapter: Behavioral Health", reads in part:

"...The inpatient psychiatric units provide a highly supervised and regulated environment that affords protection to patients and staff while providing for patient choice and responsibility.

To delineate standards of care for patients admitted for inpatient treatment. Frequent observations are necessary to maintain patient safety, to intervene prior to a crisis, and to account for all patients on the unit...

Definitions ...

Five-Minute Safety Checks: A staff member will be assigned to monitor and observe the patient every five minutes and will document on the Q5-minutes check observation forms. Five minute safety checks should be noted on the Q5 minute observation sheet when implemented...

The Patient Monitor/Observer: This is a staff member who has been assigned the function of maintaining the appropriate observation level in accordance with the observation order. This includes conducting safety checks according to ordered level of observation (safety checks) ....

2. The Registered Nurse Role ...

b.The RN's are responsible for ensuring that the nursing assignment sheet is accurate as it relates to the assignment of safety checks ....

3.The Patient Monitor/Observer Role...

a.The qualified staff member conducting checks will remain in the milieu during his/her assignment to safety checks.
b. During his/her assignment to safety checks, the qualified staff member will not undertake other assignments.
c. During his/her assignment to safety checks, the qualified staff member will actively round throughout the unit, visualize each patient at 15-minute intervals or as ordered by the patient's Physician/designee, determine the patient's safety, and confirm the presence of life signs.
d. If the patient cannot be visualized because s/he is engaged in bathing or elimination activities, the qualified staff member will knock on the bathroom door and inform the patient that the qualified staff member will be opening the door to conduct patient safety checks. The qualified staff member will then open the door and visualize the patient and ensure that the patient is safe ..."

1. Surveyor observations of the West-3 Unit (The Geriatric Psychiatric Unit) on 03/29/2021 from approximately 9:25 AM - 9:40 AM revealed Staff C sitting in the T.V. room while Patient ID#'s 3 and 4 were in their rooms lying on their beds.

Review of the medical record for Patient ID #3 revealed that s/he presented to the ED from home on 03/21/2021 with reports of feeling suicidal and had a past medical history significant for a potential overdose. S/he was admitted to the West-3 Unit of the hospital, and was placed on 5-minute safety checks.

Review of the medical record for Patient ID #4 revealed that s/he presented to the ED from a skilled nursing facility on 12/07/2020 with reports of assaulting another resident of that facility. S/he was admitted to the West-3 Unit and was placed on 5-minute safety checks.

During an interview with the West-3 Unit Registered Nurse (RN), Staff D on 03/29/2021 she revealed that because of its population type (geriatric psychiatric), all the patients on the West-3 Unit are on 5-minute safety checks.

Observation of Staff C on 03/29/2021 at approximately 9:46 AM revealed she was sitting in the West-3 Unit's T.V. room with 4 patients, there was also another patient noted to be in the hallway outside of this room in a recliner chair. Staff C was noted to be documenting in the Patient Observations five (5) minute safety checks book.

Immediately following this observation, the surveyor reviewed the Patient Observations five (5) minute safety checks book which revealed Patient ID# 3 was last checked at 9:30 AM and ID# 4 was last checked at 9:35 AM, despite the patients not being observed by Staff C.

Immediately following this observation, Staff C was interviewed and revealed that she does not leave the T.V. room as she was responsible for the monitoring of patients in that room. Staff C indicated that she was unable to perform the safety checks in a timely manner because she had to assist her coworker.

Additionally, she revealed that she had not visualized Patient ID#s 3 and 4 as they were in their beds in their individual rooms, which could not be observed from the T.V. room. She then indicated that she relied on her co-workers to inform her of their whereabouts although acknowledged at the time of this interview her coworkers were in the shower room with a patient and she was unsure of the safety of Patient ID#s 3 and 4.

2.) Review of the hospital's policy/requirements for the "Job Title: Registered Nurse" reveals in part, "...Licensure: Maintain a current ...BLS certification."

Review of Registered Nurse, Staff A and Registered Nurse, Staff B's employee files on 3/26/2021 failed to reveal evidence of current certification in CPR or BLS.

During an interview with the Risk Management Coordinator on 3/29/2021 she revealed that both Staff A and B lacked current certification of BLS or CPR. Additionally, she acknowledged that per policy, this was a requirement to work as a Registered Nurse in the hospital.

Based on surveyor observation, policy review and staff interview, it has been determined that the hospital failed to follow its own policy relative to infection control and Personal Protective Equipment (PPE) for 2 of 3 staff observed providing care to patients on transmission based precautions, and for 1 of 6 Units observed relative to physical distancing of patients and staff, on the West-3 Unit.
.
Findings are as follows:

Review of the Hospital's policy/procedure "COVID IC 001" last revised on 02/04/2021, states in part, " ...Roger Williams Medical Center adopts the attached Centers for Disease Control (CDC) and Prevention Guidance entitled, 'Interim infection prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic.' ..."

Review of the CDC's document entitled, "Interim infection prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated on 12/14/2020, states in part:
" ...1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic ...
Encourage Physical Distancing ...
Arrange seating in waiting rooms so patients can sit at least 6 feet apart ...
Modifying in-person group healthcare activities (e.g., group therapy, recreational activities) by ...having patients sit at least 6 feet apart ...
2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection ...
HCP [Health Care Professional] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N-95 or equivalent or higher-level respirator ...gown, gloves and eye protection ...
Elastomeric respirators, such as half facepiece or full facepiece tight-fitting respirators ..."

Review of the CDC's document titled, "Elastomeric Respirators: Strategies During Conventional and Surge Demand Situations Conventional, Contingency, and Crisis Strategies" updated October 13, 2020 reads in part, " ...Effective Elastomeric Respirator Use:
When properly fitted and worn, minimal leakage occurs around the edges of the tight-fitting respirator where it seals to the user's face ..."

1. Record review of Patient ID #10 revealed s/he was admitted to the hospital on 03/26/2021 with a diagnosis of COVID 19 pneumonia.
Surveyor observation of the signage at the entrance of Patient ID #10's room, on the Intensive Care Unit (ICU), on 03/29/2021 at 10:21 AM, revealed Patient ID #10 was on airborne contact precautions. The sign stated all staff entering the room were to wear a gown, gloves, eye protection and either a PARP [A powered air purifying respirator] or Fit tested N95 mask.

A subsequent observation of Patient ID# 10's room revealed Staff E, a registered nurse (RN), providing care to the patient with a surgical mask underneath her half facepiece respirator and her gown untied and draped around her elbows.
At the time of this observation the ICU Clinical Manager acknowledged that Staff E was incorrectly wearing her gown and that the surgical mask was impeding the ability of her respirator to make a seal with her face.

2. Record review of Patient ID #11 revealed s/he was admitted to the hospital on 02/08/2021 with a history of SARS-CoV-2 pneumonia resulting in Acute Respiratory Failure. Currently the patient has a diagnosis of Carbapenem-Resistant Enterobacteriaceae (CRE), a bacteria that is difficult to treat because it is resistant to multiple antibiotics. Patient ID #11 is in the ICU for ongoing care.

Review of the hospital's policy titled, "Carbapenem-Resistant Enterobacteriaceae (CRE) " states that a patient who has a current infection ...or history of CRE will be placed in isolation, on contact precautions.

Surveyor observation of the entrance to Patient ID #11's room revealed signage indicating that s/he was on contact precautions. The sign further indicated that those entering the room were required to wear a gown, gloves and clean hands with alcohol-based hand sanitizer or wash hands with soap and water for 20 seconds when entering, and then to wash with soap and water only when leaving the room."

On 03/29/2021 at 10:08 AM surveyor observation of RN, Staff F, revealed she was exiting the patient's room without a gown or gloves on, and then obtained gloves and a gown from a supply cart in the hallway. She then returned to Patient ID #11's room and donned the gown and the gloves inside the room.

Immediately after this observation the Clinical Manager of the ICU acknowledged that Staff F was not wearing the proper PPE when she was in the room providing care to the patient, and that she did not wash her hands prior to leaving the room. She also acknowledged that Staff F re-entered the room without first having donned the gown and gloves, and that she did not perform hand hygiene upon entering the room.

3. Surveyor observation of the West-3 Unit, on 3/29/2021 at approximately 9:25 AM, revealed 5 patients and one staff member sitting in the unit's television room. The observation further revealed a certified nursing assistant, Staff C, sitting in the corner of the room with a patient sitting in a wheelchair less than 1 foot in front of her.
Additionally, two patients were observed sitting in chairs next to one another to Staff C's left, without spacing between the three seats.
At the time of the observation the Risk Manager acknowledged that Staff C and patients in the room were not physically distanced in accordance with guidance provided by the CDC.

Based on record review and staff interview it has been determined that the hospital failed to provide a service which is well organized and provided in accordance with acceptable standards of practice relative to implementation of appropriate count procedures for 1 of 1 sampled patients who underwent a surgical procedure and was found to have retained a surgical item, Patient ID # 1.

Findings are as follows:

Review of Surgeon 1's, Operative Report dated March, 2021 reads in part, "Patient who underwent a massive operation...had unexpected amount of bilious secretions coming out of the NG tube [nasal gastric tube, a flexible tube of rubber or plastic used to drain contents of the stomach]...I obtained a KUB [an x-ray of the abdomen]. As an incidental finding of the KUB a surgical ribbon indicative of an operative device ...was identified ..."

During an interview with Circulating Registered Nurse (RN) Staff A on 3/25/2021 at approximately 1:31 PM, she indicated that she was in the OR (operating room) on 3/19/2021 to observe Circulating RN Staff B as needed, because Staff B was new to oncology cases. Additionally, she states she was not directly involved in any of the counts (procedure of counting the exact number of sponges, instruments, and other materials before, during, and after an operation in order to reduce the likelihood of leaving an object inside a body cavity) because staff B was the main circulating nurse for this procedure. Staff A stated that the type of sponge that Patient ID# 1 had removed from his/her abdominal cavity was a laparotomy sponge (approximately 18 inches by 18 inches in size), and approximately 70 of these sponges were used during this procedure.

An interview was conducted with Circulating RN Staff B, on 3/25/2021 at approximately 2:48 PM, in which she stated at the conclusion of Patient ID# 1's surgery there were no indications that a laparotomy sponge had been left in Patient ID# 1's abdominal cavity. She revealed that these sponges come in packs of 5 and when each pack was opened 5 sponges would be added to the white board to keep a running tally of how many sponges are used during the entire procedure. Additionally, she indicated that a count of the tools and sponges was performed three times, twice with Surgical Tech (ST) Staff G, once prior to the start of surgery and again at the end of surgery and a final post-surgical count with ST Staff H. According to Staff B, all counts were correct.

During an interview with ST Staff G on 3/25/2021 at approximately 1:05 PM she revealed that she was that primary ST during Patient ID#1's surgery, indicating she and Staff B prepared for the procedure with 15 laparotomy sponges counted. She also revealed she was present for the first post-surgical count with Staff B and that count was correct. She left the OR for her lunch break and was relieved by ST Staff H.

During an interview with ST Staff H on 3/29/2021 at approximately 2:06 PM she indicated that when she entered the OR on 3/19/2021, ST Staff G and Staff B were in the process of performing the first post-surgical count. She then revealed at this point Staff A and Staff G left the OR for their lunch breaks. She took over for ST Staff G and began the 2nd post-surgical count with Staff B, which again was reported as correct. She also revealed that although laparotomy sponges normally come in packages of 5, she has seen laparotomy sponges come packaged irregularly from time to time with 4 or 6 sponges in a package.

During a surveyor interview with Surgeon 1, on 3/25/2021 at approximately 2:02 PM he acknowledged that there was a laparotomy sponge retained in Patient ID#1's abdominal cavity from his/her surgery on 03/19/2021.

Based on record review and staff interview, it has been determined that the hospital failed to ensure that an operative report describing techniques, findings, and tissues removed or altered was written or dictated immediately following surgery and signed by surgeon 2, for 1 of 6 sampled patients ID# 2

Findings are as follows:

Review of the, "Medical Staff Bylaws and Rules and Regulations" last revised in December of 2019, under section 15.0 "Medical Records" subpart 15.5 states in part, "Operative reports shall be completed immediately after surgery, authenticated by the surgeon 2, and filed in the medical record immediately after surgery ...Any surgeon having un-dictated operative reports 24 hours following the day of surgery shall be automatically suspended from all operative privileges ..."

A review of Patient ID# 2 record revealed the patient had undergone a surgical procedure on 03/18/2021, Review of the patient's draft Operative Report was not dictated until 03/22/2021, approximately 4 days post-operative. Additional review of the draft Operative Report failed to reveal a signature by the surgeon 2.

During an interview with the Risk Manager on 03/26/2021 at approximately 1:24 PM she acknowledged that the Operative Report for this patient was not written or dictated within 24 hours of surgery per the Medical Staff Bylaws, nor was it signed.