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Based on observations and staff interviews, the facility failed to ensure the patients' right to personal privacy was protected in regard to electronic monitors with patient names and room numbers located throughout the facility. These monitors were located on the fourth floor at the nurses' stations. The patient census was 168 patients.

Findings include:

During a tour on 03/28/12, of the 4th floor north and south wings, between 8:45 AM and 11:20 AM, electronic monitors were observed hanging on the wall inside the nurses' stations. These monitors were located at the top of the wall, in the corner, with patient names and room numbers listed. At 8:50 AM, Staff W was interviewed regarding the purpose of these monitors. Staff W stated the monitors were used by staff to see if the rooms were empty or whether they had been cleaned, and were ready for use. Staff W verified the patients' names and room numbers were able to be viewed by visitors when standing at the nurses' station.

Based on interview, policy review, review of meeting minutes, and observation, the facility continued to not meet the Condition of Participation at CFR482.23 by failure to follow the hospital's policy regarding patient intravenous access, failure to ensure physician was notified of patient's abnormal laboratory values prior to administering a potassium lowering medication (A395), failed to ensure nursing care plans addressed the psychological needs of two patients (Patient #13 and #15) (A396), failed to construct a policy and a framework for nursing to differentiate between which medications are time-critical involving Patient #18 and failed to ensure Patient #34 received an anesthetic at a drip rate as ordered by the physician (A 405), and failed to implement measures to ensure compliance. This affected six (Patients #35, #16 , #17, #15, #13, and #34) of the 36 patients reviewed. The patient census was 168.

Findings:
The facility failed to ensure nursing consulted the physician to obtain an order to check the blood glucose level on a patient with a history of hyperglycemia, failed to ensure the hospital's own policy was followed regarding a patient's intravenous access, and failed to ensure a patient's abnormal laboratory values were communicated to the physician prior to administering a potassium lowering medication. Refer to A 395.
The facility failed to include nursing care plans that addressed two patients' psychosocial needs. Refer to A 396.
The facility failed to construct a policy and a framework for nursing to differentiate between which medications are time-critical involving Patient #18 and failed to ensure Patient #34 received an anesthetic at a drip rate as ordered by the physician. Refer to A 405.

Based on interview, clinical record review, observation, and policy review, the facility failed to ensure nursing consulted the physician to obtain a blood glucose level on Patient #35 who had a complaint of weakness and a history of severe hyperglycemia, failed to ensure its own policy was followed regarding Patient #16's intravenous access in her/his lower extremity for nearly eight days, and failed to ensure Patient #17's abnormal laboratory values were communicated to the physician prior to administering a potassium lowering medication. This affected three (#35, #16 #17) patients from the total of 36 patients reviewed. The total census was 168.

Findings include:

The clinical record review in its electronic form for Patient #35 was completed on 03/28/12. The review revealed a history and physical dated 10/01/11 that stated the 44 year old patient was treated in the emergency department on 10/01/11. The history and physical stated the patient was brought to the department with a blood sugar of 1299 milligrams/deciliter. The history and physical listed as a diagnosis hyperglycemic non-ketosis state and hypovolemic shock.
The clinical record revealed the patient came to the emergency department on 03/27/12 via emergency medical services at 1:33 PM with a chief complaint of weakness. The clinical record revealed a physician assessment identified the patient was a diabetic and was taking 15 units of long acting insulin a day at breakfast, and two units of fast acting insulin three times a day with meals.
The clinical record lacked documentation nursing had consulted with the physician regarding performing a blood glucose test (i.e., an accucheck). The clinical record lacked documentation a blood glucose test was performed. The clinical record revealed the patient was discharged to home at 3:35 PM.
The clinical record revealed the patient returned to the hospital emergency department on 03/27/12 at 9:14 PM with a complaint that he/she slumped out of her/his chair and hit her/his right eye.
The clinical record revealed the patient's blood glucose/sugar was tested at 03/28/12 at 1:30 AM, and was found to be 438 milligrams/deciliter. The clinical record revealed a physician decision- making note which stated he/she had a blood sugar in the 500 range consistent with diabetic ketoacidosis. The clinical record revealed the patient was placed on an insulin drip to regulate the blood sugar.
On 03/28/12 at 11:20 AM, during an interview, Staff A and Staff O confirmed a blood sugar test was not performed during the patient's first emergency department visit of 03/28/12 at 1:33 PM.

The clinical record review, in its electronic form, for Patient #16 was completed on 03/28/12. The clinical record revealed the 46 year old patient was admitted to the facility on 03/19/12. The clinical record revealed a history and physical dated, 03/19/12, that stated the patient presented with complaints of chest pain and arm pain. The history and physical stated the patient has multiple clotting disorders.
On 03/27/12 at 1:45 PM a tour of the Intensive Telemetry Unit was conducted, and Patient #16 was observed to have an intravenous access to her/his foot. The clinical record lacked a physician's order for the intravenous access in the foot, and did reveal it was placed on 03/19/12 at 4:31 PM, almost eight days prior to the observation..
A review of the hospital policy number PCS 402, effective March, 2012, entitled "Intravenous Therapy", was completed on 03/28/12. The policy revealed a physician's order was necessary if a lower extremity was used for intravenous therapy, all peripheral sites were to be changed every 96 hours (four days), and may be continued for an additional 48 hours with a physician's order, for a total of six days.
The clinical record lacked a physician's order to continue the intravenous site in the foot for an additional 48 hours after the first 96 hours.
On 03/27/12 at 3:30 PM, during an interview, Staff A confirmed there was not a physician's order for the intravenous access to be continued for additional time in the foot after the first 96 hours. Following surveyor intervention Staff A did present a physician's order for the intravenous access to the foot, dated 03/27/12 at 1:53 PM after surveyor intervention.


The clinical record review, in its electronic form, for Patient #17, was completed on 03/28/12. The clinical record revealed a history and physical dated 03/23/12 at 6:57 PM that stated the patient had a chief complaint of cardiac arrhythmia, nausea, vomiting, and confusion.
On 03/27/11 at 9:10 AM, the surveyor observed Staff P administer to the patient 20 grams of Lactulose--a laxative that has the side effect of lowering potassium levels (low potassium levels can be life threatening and lead to cardiac arrhythmia)s. The history and physical assessment also identified severe left ventricular systolic dysfunction.
The clinical record revealed the patient had a potassium level of 3.2 milliequivalents per liter on 03/27/12 at 5:23 AM. In addition, the patient had a potassium level of 3.3 milliequivalents per liter on 03/26/12 at 6:19 PM and had been given 20 grams of Lactulose on 03/26/12 at 9:24 PM.
On 03/27/12 at 11:15 A.M. during an interview, Staff Q said although he/she did not know what the critical value was for potassium, Patient #17's physician should have been called before the Lactulose was given.

Based on staff interview, clinical record review, and review of a facility form, the facility failed to ensure nursing care plans addressed the psychological needs of two (Patients #15, and #13 ) of 34 sampled patients. The total census was 168.
Findings include:
The clinical record review for Patient #15 was completed on 03/28/12. The clinical record revealed the 57-year-old patient was admitted to the facility on 03/26/12. The patient had a history and physical dated 03/26/12 that stated the patient had a chief complaint of left arm weakness and right leg pain. The patient had a history of emphysema, alcoholism, tobacco addiction, and paranoid schizophrenia. The history and physical stated the patient had a non-displaced fracture of the right ankle.
The patient's nursing care plans lacked interventions to address his/her psychosocial needs related to his/her paranoid schizophrenia.
On 03/27/12 at 3:06 P.M. during an interview, Staff A confirmed the care plans did not address the patient's paranoid schizophrenia. Staff A explained the appropriate interventions for patients with paranoid schizophrenia are contained in a care plan for a patient when admitted to behavioral health, and the appropriate interventions for Patient #15's plan of care were not activated.

The clinical record review for Patient #13 was completed on 03/28/12. The clinical record revealed a history and physical dated 03/25/12. The 54-year-old patient had a chief complaint of seizure and was brought to the facility by her/his spouse who reported he/she had an episode of seizure activity. The history and physical stated the patient had acute encephalopathy/delirium that was likely metabolic/drug induced as the patient's urine drug screen tested positive for barbiturates.
The clinical record revealed the patient had a sitter. A sitter is a clinician that continuously and constantly views the patient to maintain's the patient's safety.
The clinical record lacked a care plan that addressed the use of a sitter for the patient, explaining why one was needed, and when one could be discontinued.
On 12/27/12, during an interview, Staff A stated a request form for sitters is used to determine whether a patient needs a sitter. Staff A said the form is not a part of the permanent record, and a completed request form for a sitter was not available for the agency to present for surveyor review.
A review of a " Low Bed vs. Sitter Request Form " (no other identifier found) was completed on 03/28/12. The form revealed a list of behaviors and situations, e.g. pulling at lines, recent inpatient fall, family unable to be at bedside, etc., that had points assigned to each. If the total number of points was 16 or greater, the form indicated a need for a sitter.

Based on observation, policy review, clinical record review, review of a clinical manager's agenda, and review of the chief nursing officer's work group retreat minutes, the facility failed to construct a policy and a framework for nursing to differentiate between which medications are time-critical and which ones are not, (Patient #18), and failed to ensure Patient #34 received an anesthetic at a drip rate as ordered by the physician. This affected two (Patients #18,and #34) of the 36 patients reviewed. This has the potential to affect all patients in the facility. The patient census was 168.
Findings include:
On 03/27/12 at 8:45 AM the surveyor observed the administration of medication to Patient #18. The surveyor observed the patient receiving Dilantin, Cardizem, Digoxin, Amiodarone, a magnesium supplement, and a potassium supplement all at the same time.
The clinical record review for Patient #18, was completed on 03/28/12. The clinical record revealed a history and physical dated 03/26/12 at midnight that stated the patient had a chief complaint of palpitations and shortness of breath.
A review of the patient's medication administration record did not reveal where the medications were differentiated between those that are considered time-critical, and those that are considered non-time-critical.
On 03/27/12 at 11:23 AM in an interview, staff A confirmed the facility was using the " 30 minute rule. "
A review of minutes from a Chief Nursing Officer Work Group, dated 03/05/12, was completed on 03/28/12. The review revealed,although there was a " discussion " related to new medication standards developed from Centers for Medicare and Medicaid Services, the minutes did not identify the topic of the discussion, what steps were going to be implemented to meet the new standards, and the deadline for the implementations.
A review of a clinical manager's agenda, for meeting to take place in 04/10/12, revealed the " 30 minute rule " is to be discussed, but, again, does not provide any further details.
On 03/28/12 at 2:30 PM in an interview, s















Staff R stated there was a lot of work still to be done to meet Centers for Medicare and Medicaid Services' new medication standards. He/she said on 04/10/12 a plan would be devised, and then later presented to the nursing department for approval. He/she did not say when it would be presented to the medical staff for their approval. He/she also stated the facility's software vendor said they would have issues building the new medication standards into the software used by the facility to document medication administration.
The clinical record review, for Patient #34 was completed on 03/28/12. The review revealed a history and physical dated 03/19/12, stated the patient came to the hospital with a chief complaint of left hip pain after a fall. The history and physical stated he/she had a history of heart attack, coronary bypass surgery, stroke, and blood clots in the leg and lungs. The history and physical stated he/she was letting his/her cat into the house when he/she slipped on a step. The history and physical stated he/she was found to have a fracture of the left femoral neck.
On 03/28/12 at 2:30 P.M. on the third floor intensive care unit, the surveyor observed Patient #34 receiving intravenously, a Diprovan drip. (Diprovan is used for anesthesia.)
The clinical record revealed a physician's order dated 03/25/12 at 6:30 PM. The order directed five to 50 micrograms/kilogram/minute to be given. The clinical record revealed a titration scale that directed the nurse to start the drip at 5 micrograms/kilogram/minute, and titrate in 5 to 10 micrograms/kilogram/minute intervals to a three to four on a sedation scale of one to seven, with one being unarousable and seven being dangerously agitated.
The clinical record revealed a medication administration record that identified the drip was started at 15 micrograms/kilogram/minute on 03/25/12 at 7:14 P.M. (and not 5 milligrams/kilogram/minute as ordered), then stopped at 7:56 P.M. (and not titrated down in 5 to 10 micrograms/kilogram/minute intervals as ordered), then restarted at 5 micrograms/kilogram/minute at 7:59 PM.
The clinical record lacked documentation the patient's baseline level of sedation was assessed using the sedation scale assessment form at the start of the drip at 7:14 PM. The clinical record revealed, on 03/25/12 at 8:00 PM (46 minutes after the drip started), the patient was assessed as a two on the sedation scale.
From 03/26/12 at 4:00 P.M. to 03/27/12 at 9:23 A.M., while the patient was receiving the Diprovan drip, the clinical record lacked documentation an assessment was conducted using the sedation scale assessment form.
A review of the facility's policy, "Mechanical ventilation, management of analgesia, sedation, paralysis, and delirium," effective February 2012, stated the staff were to assess the patient's level of sedation prior to administering sedating medications, and every five minutes times two after the administration of sedation has begun. The policy also stated once the desired level of sedation was reached, an assessment was to be conducted every four hours using the sedation scale assessment form.
On 03/28/12 at 2:30 P.M. during an interview, Staff A confirmed the above findings.

Based on staff interview and observation, the facility failed to ensure drugs were safely distributed to its automated medication dispensing machines. This affected two patient care areas; 2A and the emergency department. The total census was 168.
Findings include:
On 03/27/12 at 9:00 AM., a visual examination of the automated medication dispensing machine in the 2A telemetry medication room was completed with Staff A and Staff N. The surveyor observed the automated medication dispensing machine direct the nurse to find atropine and epinephrine in drawers three and four. The surveyor observed atropine in one area of a shelf, and epinephrine immediately behind the atropine. Neither medication were in a labeled container.
On 03/27/12 at 10:20 AM a visual examination of the automated medication dispensing machine in the main emergency department was completed with Staff A and Staff N.
The following inconsistencies were observed:
The refrigerator revealed a 300 milligrams suppository laying on a shelf, the automated medication dispensing machine listed it in pocket #10, two 200 milligrams vials of Succiynlcholine (a paralytic agent) with expiration dates of 03/24/12, three vials of 10 milligrams of Pavulon (a muscle relaxant used in emergent anesthesia) laying on the top shelf, the automated medication dispensing machine listed it in drawer #3, and two vials of 10 milligrams of Rocuronium (a muscle relaxant used in emergent anesthesia) lying on the third shelf from the top in the refrigerator, the automated medication dispensing machine listing it in pocket #38.
On 03/27/12 at 10:20 AM during an interview, Staff A and Staff N confirmed the inconsistencies listed above were observed.

On 03/27/12 at 10:45 AM an observation of the automated medication dispensing machine in the observation unit of the emergency department revealed 12 650 milligrams of acetaminophen suppositories in pocket 43 that the machine had listed in pocket 21.
On 03/27/12 at 10:45 AM in an interview, Staff A and Staff N confirmed the inconsistency listed above was observed.

On 03/27/12 at 10:50 AM an observation of the refrigerated section of the automated medication dispensing machine in the trauma area of the emergency department was completed. The observation revealed one 10 milligrams vial of Rocuronium (a muscle relaxant used in emergent anesthesia) on the shelf, one on the shelf below, and two more on the second shelf from the top. These two vials of Rocuronium were lying next to two 200 milligrams vials of Succiynlcholine (a paralytic agent). The machine listed the Rocuronium in pocket #2, and the Succiynlcholine in pocket #1.
On 03/27/12 at 10:50 A.M. during an interview, Staff A and Staff N confirmed the inconsistencies listed above were observed.

¿Based on observations, and staff interviews this Condition of Participation was not met related to fire safety in regard to smoke detector placement, sprinkler installation, sprinkler system maintenance, trash and linen chutes locations, storage of oxygen tanks, lack of emergency lighting in areas which use general anesthesia, smoke detector location, testing of fire alarm and smoke detector system, and sprinkler system testing. This could affect all patients in the facility. The total census during this visit was 168 patients.

Findings include:

During this visit, from 03/26/12 through 03/29/12, a tour was conducted in the facility with
Staff S. Observations were conducted in the main building and three offsite locations.

In the main building:
The facility failed to ensure smoke detectors were located greater than 36 inches from air diffusers.

The facility was observed without sprinkler heads throughout all areas of the building.

The facility failed to maintain sprinkler heads as dirty sprinkler heads were observed throughout the facility.

Trash and linen chutes were observed not in a one hour fire resistant rated protected area.

The facility failed to maintain less than twelve E-tanks of oxygen in a smoke compartment.

Three cardiac catheterization laboratories, an endoscopy room, a cystoscopy room, and a bronchoscopy procedure room, in which general anesthesia was used, lacked emergency lights.

In the Women's Clinic off-site building:
There was no evidence of an annual fire/smoke detector test.
Smoke detectors were located less than 36 inches from air diffusers.

In the Maternal Child Health Clinic:
The facility failed to conduct quarterly sprinkler tests, failed to conduct an annual test of the fire, smoke detection system and had no evidence of monthly or annual testing of the battery backup lighting system.

In the Outpatient Therapy Building, located in the YMCA on campus:
The facility failed to conduct an annual ninety minute test of the battery operated emergency lights, and had not conducted quarterly sprinkler tests.

Refer to A0709.

Based on observations, review of floor plans, and staff interviews, the facility failed to meet the provisions of the Life Safety Code related to smoke detector placement, sprinkler installation, sprinkler system maintenance, trash and linen chutes locations, storage of oxygen tanks, lack of emergency lighting in areas which use general anesthesia, smoke detector location, testing of fire alarm and smoke detector system, and sprinkler system testing. This could affect all patients in the facility. The total census during this visit was 168 patients.

Findings include:

During this visit, from 03/26/12 through 03/29/12, tour was conducted in the facility with Staff S. Observations were conducted in the main building and three offsite locations.

In the main building:
Smoke detectors were located less than 36 inches from air diffusers. Refer to A0710.

The facility was observed without sprinkler heads throughout all areas of the building. Refer to A0710.

The facility failed to maintain sprinkler heads as dirty sprinkler heads were observed throughout the facility. Refer to A0710.

Trash and linen chutes were observed not in a one hour fire resistant rated protected area. Refer to A0710.

The facility failed to maintain less than twelve E-tanks of oxygen in a smoke compartment. Refer to A0710.

Three cardiac catheterization laboratories, an endoscopy room, a cystoscopy room, and a bronchoscopy procedure room, in which general anesthesia was used, lacked emergency lights. Refer to A0710.

In the Women's Clinic off-site building:
There was no evidence of an annual fire/smoke detector test. Refer to A0710.

In the Maternal Child Health Clinic:
The facility failed to conduct quarterly sprinkler tests, failed to conduct an annual test of the fire, smoke detection system and had no evidence of monthly or annual testing of the battery backup lighting system. Refer to A0710.

In the Outpatient Therapy Building, located in the YMCA on campus:
The facility failed to conduct an annual ninety minute test of the battery operated emergency lights, and had not conducted quarterly sprinkler tests.

Refer to A0710.

Based on observations, review of floor plans, and staff interviews, the facility failed to meet the provisions of the Life Safety Code, National Fire Protection Association related to sprinkler system location, sprinkler maintenance, trash and linen chutes locations, storage of oxygen tanks, lack of emergency lighting in areas which use general anesthesia, smoke detector location, testing of fire alarm and smoke detector system, and sprinkler system testing. This could affect all patients in the facility. The total census during this visit was 168 patients.

Findings include:

During this visit, from 03/26/12 through 03/29/12, tour was conducted in the facility with Staff S. Observations were conducted in the main building and three offsite locations.

In the main building:
The facility failed to ensure smoke detectors were located greater than 36 inches from air diffusers. Refer to K52.

The facility was observed without sprinkler heads throughout all areas of the building. Refer to K56.

The facility failed to maintain sprinkler heads as dirty sprinkler heads were observed throughout the facility. Refer to K62.

Trash and linen chutes were observed not in a one hour fire resistant rated protected area. Refer to K71.

The facility failed to maintain less than twelve E-tanks of oxygen in a smoke compartment. Refer to K76.

Three cardiac catheterization laboratories, an endoscopy room, a cystoscopy room, and a bronchoscopy procedure room, in which general anesthesia was used, lacked emergency lights. Refer to K78.

In the Women's Clinic off-site building:
There was no evidence of an annual fire/smoke detector test. Refer to K130.

Smoke detectors were located less than 36 inches from air diffusers. Refer to K130.

In the Maternal Child Health Clinic:
The facility failed to conduct quarterly sprinkler tests, failed to conduct an annual test of the fire, smoke detection system and had no evidence of monthly or annual testing of the battery backup lighting system. Refer to K130.

In the Outpatient Therapy Building, located in the YMCA on campus:
The facility failed to conduct an annual ninety minute test of the battery operated emergency lights, and had not conducted quarterly sprinkler tests.
Refer to K130.