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Based on interview and policy review, the hospital failed to ensure the policy regarding discussion of Advanced Medical Directives (AMD) took place during the Admission process beginning with the Patient Registration Representative (PRR) as evidenced by the lack of documentation in 1 of 32 sampled patients' medical records that a discussion was held and included the necessary information in order to make an informed decision. (# 9). Findings:


In an interview on 01/04/11 at 1:45 p.m. with S12, Patient Registration Representative (PRR), she stated she asks patients if they have an Advanced Medical Directive. She then gives them the Patient Guide booklet, which provides the information about Advanced Medical Directives. She confirmed she does not explain or discuss the information in order to assist the patients in making informed decisions. S12 added the necessary information was in the Patient Guide booklet, so she did not discuss the information any further. She confirmed she does not require a patient to sign any other forms related to Advanced Medical Directives if the patient states he or she does not have an Advanced Directive.

In an interview on 1/4/11 at 2:00 p.m. with S10, RN, she stated patients were asked if they have AMD during the pre-registration process. She added when patients come to the unit, as part of her assessment, she will ask the patients if they have a Living Will. She stated many patients do not understand what an Advanced Medical Directive is, so she just asks if they have a Living Will. S10, then noted that patient #9 had signed the Consent and Acknowledgement form, which stated under Advanced Directives "I understand that I am not required to have Advance Directives in order to be treated. I have received written information about my rights to formulate Advance Directives."

In an interview on 1/4/11 at 2:10 p.m. with S5, RN, Director of the Critical Care Unit, he confirmed patients are explained about AMD during the pre-registration process. He added if patients wish to change their decision, the Social Worker or the Case Manager will be notified to obtain the necessary forms for AMD. S5 also stated the forms from the Admitting packet related to Advanced Medical Directives were not on the unit; these forms were in the Social Worker's office or in Admitting.

A record review of the entire medical record for Patient #9 revealed no documented evidence that a discussion regarding AMD ' s took place during the admission process as per hospital policy.

Record review of the Admitting booklet titled "Patient Guide" (pg. 5) reads "(Hospital) respects and honors the patient's right to contest how and when medical care is given....This also includes the right of each patient to have enough information in order to make informed decisions."

Record review of the facility's policy titled "Advance Medical Directive, Withdrawal of Life Support" (pg. 11 of 15 pages) #4 Patient Registration Representative (PRR) reads: "During the admission process the admit clerk shall: a. Provide and discuss the admit package which includes AMD information. b. Obtain the required signatures on the Consent and Acknowledgement form. c. Enter appropriate AMD information into the Hospital Information System regarding the existence of an AMD, information provided to the patient regarding AMDs, and the presence of the AMD in the patient's medical record."

Based on observation, interview, and record review, the hospital failed to ensure nursing staff follow physician's orders of providing a cardiac diet for 1 of 32 sampled patients as evidenced by a nursing staff member changing the diet to a full-liquid diet without a physician's order. (#9) Findings:

Patient #9, a 71 year-old with dyspnea on exertion, was admitted to the facility on 01/03/11 for a left and right cardiac catherization. At 1030 (10:30 a.m.), patient #9 was finished with the procedure and transferred back to the Surgical Intensive Care Unit.

Record review of signed physician's Post Angiogram/Intervention Orders dated 01/03/11 and timed at 10:30 a.m. read: "1. Diet: Cardiac. "

An observation of patient #9 on 01/03/11 at 1:30 p.m. revealed he was was sleeping, but arousable. His bedside table was positioned over his waist and contained a full liquid diet (milk, creamy soup, and tea).

During this same time, in an interview with S10, RN, she stated patient #9 was given a full liquid diet because he was nauseated after the removal of the sheath catheter. She added that diets can gradually be increased to a cardiac diet once the patient can tolerate foods without nausea. S10, RN confirmed the physician's orders indicated the patient was to be on a Cardiac diet. She added she had asked dietary to send up a full liquid diet instead of a cardiac diet because patient #9 was nauseated.

In an interview with S13, Registered Dietitian on 01/03/11 at 3:20 p.m., she stated surgical patients were usually started on clear liquids. She confirmed that nursing staff can make adjustments to patients' diets without an order as long as the nursing staff were not progressing the patient's diet upward without an order. S13, Registered Dietitian confirmed she had no policy, which outlined how a nurse was supposed to gradually progress a patient's diet. She added that Registered Dietitians and RN's cannot progress a diet, such as a full liquid to a regular diet, without a physician's orders.

A record review of Physician's Orders dated 01/03/11 and timed at 1400 (2:00 p.m.) read: "Please order full liquid diet for patient lunch and start cardiac diet at dinner." This telephone read back order was written by S10, RN and later signed by the physician (no documented time of signature).

A record review of the Daily Focus Assessment Report (electronic nurse's note) dated 01/03/11 and timed at 1400 (2:00 p.m.) revealed missing documentation of the type of lunch the patient was served.

In an interview on 01/04/11 at 9:00 a.m. with S4, DON, she stated that nursing services did not have a policy which addressed nurse's making decisions regarding a patient's diet without a physician's order. She stated it was an appropriate nursing action to request a full liquid diet instead of a cardiac diet for a patient who was nauseated.

Based on record review and interview, the hospital failed to ensure medications were administered according to acceptable standards of practice as evidenced by failing to ensure that Diltiazem (Cardizem) was administered by the registered nurse in accordance with the hospital approved policy/procedure titled "Diltiazem Administration". This was noted for 1 of 1 patient (Patient #6) on a Cardizem drip out of a total sample of 32 patients. Findings:

Patient #6: Review of Patient #6's medical record revealed the patient was admitted to the hospital on 1/03/10. Review of the ED (Emergency Department) record revealed an order dated 1/03/10 at 5:28 a.m. for Cardizem 5mg/hour to be administered. Review of the ED record revealed that Patient #6 was transferred from the ED to the SICU (Surgical Intensive Care Unit) with atrial fibrillation and rapid ventricular rate on 1/03/10 at 9:05 a.m. SICU functioned as an overflow unit to the CICU (Cardiac Intensive Care Unit). Review of the inpatient admission orders revealed orders dated 1/03/10 at 8:18 a.m. for "Cardizem drip. Titrate to HR (heart rate) 90 - 100". Review of the record revealed the following documentation in regards to Patient #6's heart rate on 1/03/10 and the Cardizem drip administration dosage:
-11:46 a.m. - heart rate average of 78 beats per minute (Cardizem drip at 7mg per hour)
-12:00 noon - heart rate average of 106 beats per minute (Cardizem drip at 7mg per hour)
-12:16 p.m. - heart rate average of 155 beats per minute (Cardizem drip at 7mg per hour)
-12:31 p.m. - heart rate average of 83 beats per minute (Cardizem drip at 7mg per hour)

The hospital approved policy/procedure titled "Diltiazem Administration" also known as "Cardizem Protocol" was reviewed. The policy/procedure documents the procedure as "Diltiazem Administration Protocol". The policy/procedure documents the protocol for continuous IV infusion of Cardizem as "If Heart Rate (greater than or equal to) 100 beats per minute, infuse at 10mg per hour", "If Heart Rate 61 to 99 beats per minute, infuse at 5mg per hour", "Contact MD if SBP (less than or equal to) 90 mmHg or HR (less than or equal to) 60 bpm, or HR (greater than or equal to) 130 bpm with diltiazem therapy".

There was no documentation in the medical record of Patient #6 to indicate that the Cardizem drip was titrated according to the patient's heart rate as indicated in the administration protocol as the dose remained at 7 mg per hour from 11:46 a.m. through 12:31 p.m. when the patient's heart rate averaged between 78 beats per minute and 155 beats per minute. In addition, there was no documentation in the medical record to indicate that the physician was notified of the patient's heart rate of 155 beats per minute as documented to be the average heart rate at 12:16 p.m.

In interview on 1/03/10 at 1:25 p.m., the SICU Charge Nurse (S8) reviewed the medical record of Patient #6 and reported that she was the registered nurse providing care to Patient #6. S8 confirmed that the rate of the Cardizem drip remained at 7mg per hour from 11:46 a.m. through 12:31 p.m. and was not titrated as indicated in the hospital approved policy/procedure. In addition, S8 was unable to provide documentation in the medical record to indicate that the physician had been notified of the average heart rate of 155 beats per minute as documented in the medical record at 12:16 p.m.

Based on observation, interview, and policy review, the facility failed to ensure all foods were stored, prepared, distributed, and served under sanitary conditions as evidenced by
(1) 1 of 3 refrigerators measuring temperatures below, 41-F and;
(2) food was left uncovered in a warming tray. Findings:

1) On 1/5/11 at 9:00 a.m. an observation of 3 refrigerators in the kitchen area revealed 1 (one) large walk-in refrigerator had a temperature reading of 45-F. At this time, in an interview with S7, Dietary Manager, he stated his evening supervisor had notified him the large walk-in refrigerator failed to register 41-F or lower on the outside temperature gauge. S7, added the evening supervisor notified maintenance approximately 6:00 p.m. about the temperature readings being too high to store foods. S7 stated maintenance did not check the refrigerator until 6:00 a.m. on 1/5/11. The reading on the outside thermometer registered 44-F. S7, Dietary Manager confirmed the food in this refrigerator, which included both bottled milk and cartons of milk, stayed in the refrigerator at a temperature of 44-F for approximately 12 hours.

On 1/5/11 at 9:05 a.m., an observation of a second refrigerator revealed a crate of 4 bottles of milk. S7, Dietary Manager stated that this crate of 4 bottles of milk had been moved from the large walk-in refrigerator, at 6:00 a.m. once the morning dietary supervisor realized that the large walk-in refrigerator was not keeping the correct temperature, to the second refrigerator. The cartons of milk used for patients were placed in a refrigerated holding container next to the serving line.

On 1/5/11 at 11:30 a.m. a test tray, which contained a carton of milk, was brought to the Rehab unit. S7, Dietary Manager checked the temperature on the hot food and the carton of milk. The carton of milk was observed to register 45-F on the temperature gauge. S7, Dietary Manager confirmed this temperature and acknowledge that the cold food was to be served at a temperature of 41-F or below.

A record review of the facility's policy titled "HACCP/Food Safety Program" under C. Handling Food During Preparation, Cooking, Holding, Cooling, Reheating, and Serving" (pg 8 of 11) revealed that cold foods: "are held at 40F or below."

2) On 1/5/11 at 9:30 a.m., an observation of 2 warming bins revealed 1 warming bin with the monitor gauge not working. One of the warming bins, which had 2 compartments, an upper compartment and a lower compartment. The upper compartment contained a tray of sliced toast uncovered, 1 container of scrambled eggs with the plastic wrap uncovered and a serving spoon in the container, and 1 covered plastic wrap of covered grits. The monitor gauge, which measured the temperature on the upper compartment was not registering. S27, Assistant Dietary Manager confirmed the gauge outside the upper compartment was not working. The bottom compartment was empty of food and registered 192-F temperature.

In an interview with S27, Assistant Dietary Manager, she stated the dietary staff record the holding temperatures of foods stored in these warming bins every 2 hours. She added that the food in the upper compartment was kept for patients who may need a late breakfast.

Record review of the HACCP Critical Control Points Daily Temperature Log dated 1/5/11 revealed the holding temperature at 7:20 a.m. registered 175-F for the scrambled eggs. The next time on the daily temperature log was 8:00 a.m. A line was drawn down through the column. S27, Assistant Dietary Manager confirmed that the line drawn down through the column indicated the temperature of the food in the upper compartment of the warming bin had not been measured.

Record review of the Daily Taste Panel Guidelines found on the HACCP Critical Control Points Daily Temperature Log dated 1/5/11 (3,4) Holding Temperature Requirements reads "Hot foods: Hold at 140-F or above. Product temperature must be recorded on this log at two (2) hour intervals during holding and serving."

Record review of the policy titled "HACCP/Food Safety Program" (pg 11 of 11) reads: "On Self-service stations not monitored: All hot food left over may be reused if all HACCP and food safety requirements are adhered to at all times. This includes monitoring and recording HACCP temperatures during refrigeration storage, production, cooking, holding, serving, cooling, and reheating."

Based on observation and interview, the hospital failed to ensure that all facilities, supplies, and equipment was maintained in a manner to ensure an acceptable level of safety and quality. Findings:

1. Observations in the ED (Emergency Department) on 1/03/11 between 10:30 a.m. and 11:30 a.m. revealed the following:
-Two (2) ED stretcher pads were noted to have rips/tears in the vinyl covering with exposed foam cushioning. This resulted in the hospital's inability to ensure for disinfection of the stretcher pads as the surface area being wiped with a disinfectant was not intact.
-Examination table immediately behind the registration section of the ED was noted to have a section of brownish/reddish droplet stains on the side of the table. The brownish/reddish droplet stains were removed with a damp sanicloth.
-One (1) cabinet in the ED triage room was noted to have four (4) brownish/reddish droplet stains near the handle of the cabinet door. The brownish/reddish droplet stains were removed with a damp sanicloth.
- One (1) wheelchair in the ED was noted to be in disrepair as the arm pad on the right side was missing from the wheelchair.
- Observation of the soiled utility room in the ED revealed a brown substance on the floor next to the wall that was dried and brown streaks on the wall above the substance on the floor.

The Director of Emergency Services (S6) was present during the above documented observations and confirmed the findings.

Record review of the facility's policy titled "Procedure #603: Patient Support Areas" (pg 1 of 2) under List of Areas: #2 Clean and soiled utility rooms. Under Daily cleaning: "Dust mop and damp mop floor (including corners, edges, behind doors, and baseboards) using a germicidal solution or vacuum."

2. Observations in the Surgical Services Area on 1/04/11 between 10:20 a.m. and 11:15 a.m. revealed the following:
-Rips/tears were noted in the vinyl covering of the pad on the surgical table in Operating Room #6
-Lint debris was noted in the grooves of the floor mats in the sterile corridor near the surgical scrub sinks.
-Sections of peeling and flaking paint were noted on the door frames in the surgical services area including the operating rooms.

The Director of Surgical Services (S23) was present during the above documented observations and confirmed the findings.

3. Observations in the Radiological Services Area on 1/04/11 between 2:30 p.m. and 3:15 p.m. revealed the following:
-Nuclear Medicine procedure room was noted to have a section of flooring that was in disrepair resulting in a potential fall hazard to patients and/or staff. A section of the floor measuring approximately 12 inches in length by 4 inches in width was noted to be bubbling up approximately 1 inch from the base of the floor.

The Director of Radiological Services (S24) was present during the above documented observations and confirmed the findings.

4. Observations in the Kitchen on 1/05/11 between 9:50 a.m. and 10:45 a.m. revealed the following:
-Sections of peeling/flaking paint were noted on the warmer oven in the kitchen.
-Test strips used to test the quality of the sanitizer used in the three compartment sink was noted to be outdated. The expiration date on the bottle of test strips being used was June of 2006.

The Director of Nutritional Services (S7) was present during the above documented observations and confirmed the findings.

5. Observations in the Infusion Therapy Unit on 01/03/11 revealed the following:
-Observation of the infusion pumps on the unit revealed 1 of 5 of the infusion pumps had several white streaks across the outside of the infusion pump door.

In interview on 01/03/11 at 3:15 p.m., S11, RN, indicated that commercial strength Spic and Span is used to clean the infusion pumps. S11 further indicated the Spic and Span is sprayed on the outside of the infusion pump, leaves it on for 5 minutes, and then wipes it with a clean rag. S11, RN could not identify what these white streaks were. He confirmed he had not cleaned the infusion pump yet at the end of the day.

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Based on record reviews, review of the Centers for Disease Control (CDC) Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005, and interviews, the hospital failed to: 1) develop a system to ensure all physicians were free of tuberculosis (TB) upon appointment and annually thereafter for 8 of 8 physicians' files reviewed for TB screening (S14, S15, S16, S17, S18, S19, S20, S21, S22) and 2) ensure that complete and accurate data was obtained and reported relating to the hospital's surgical site infection rate. This was evidenced by the hospital reporting surgical site infection rates prior to ensuring compliance regarding the reporting of data relating to surgical site infections from all physicians who had performed surgical procedures in the hospital.

Findings:

1) Physician files:
Review of the credentialing files for Physicians S14, S15, S16, S17, S18, S19, S20, S21, and S22 revealed no documented evidence of TB screening.

S22, Medical Staff Coordinator was interviewed on 01/04/11 at 1:00pm. S22 indicated the hospital did not require physicians to have TB screenings.

Review of Centers for Disease Control Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 revealed in part, "...HCWs (Health Care Workers) refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs. All HCWs who have duties that involve face to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. The following are HCWs who should be included in a TB screening program: ... Dental staff ... Physicians (assistant, attending, fellow, resident, or intern), including anesthesiologists, pathologists, psychiatrists, psychologists...".


2) Surgical Site Infection Rates

The Infection Prevention Coordinator (S9) was interviewed on 1/05/11 at 1:00 p.m. When asked about the system used by the hospital to monitor post surgical site infections, S9 reported that a form is sent out monthly to each physician who performs a surgical procedure in the hospital with information informing the physician that the form is used by the hospital to monitor infections for patients who are 30 days post op. S9 indicated that the form contains the name of each patient that the physician performed a surgical procedure on during the month. S9 reported that there is a section for the physician to check to indicate if the patient developed a post operative surgical site infection. S9 reported that the physicians are to complete the form by checking off either yes there was an infection or no there was not an infection. S9 reported that the data from these forms is used to track and trend post operative surgical site infections for patients who do not return to the hospital after their surgical procedure. When asked for the reports for the month of September of 2010, S9 indicated that approximately 30% of the physicians who perform surgical procedures in the hospital failed to complete the forms for the month of September of 2010.

A request was made for the names of the physicians who failed to complete the post operative surgical site infection reports for surgeries done in September of 2010. Review of the infection control reports revealed (in part) that S17 (General Surgeon) performed a total of 44 surgical procedures in September of 2010 and has not completed and returned the infection control reports to the infection control department as instructed so that accurate data relating to post operative infections could be monitored; S25 (Urologist) performed a total of 6 surgical procedures in September of 2010 and has not completed and returned the infection control reports to the infection control department as instructed so that accurate data relating to post operative infections could be monitored; S26 (General Surgeon) performed a total of 33 surgical procedures in September of 2010 and has not completed and returned the infection control reports to the infection control department as instructed so that accurate data relating to post operative infections could be monitored. When asked what actions were being taken by the hospital to ensure compliance with the completion of the post operative surgical site infection report, S9 indicated that no action has been taken by the hospital to ensure physician compliance. When asked how many surgical procedures had been performed by S17, S25, and S26 in the hospital after failing to meet the deadline for completing and returning the post operative surgical site infection reports, S9 reported that S17 has performed 36 surgical procedures, S25 has performed 8 surgical procedures, and S26 has performed 10 surgical procedures since failing to meet the deadline for completing and returning the post operative surgical site infection reports for surgical procedures performed in September of 2010.

Based on record review and interview, the hospital failed to ensure the effective implementation of the hospital approved policy/procedure titled "Quality Control for Diagnostic Studies in the Emergency Department" for 1 of 1 patient (Patient #32) whose medical record was reviewed for radiological discrepancies/overreads out of a total sample of 32 patients. Findings:

The Director of Emergency Services (S6) was interviewed on 1/04/11 at 2:20 p.m. When asked about the hospital's process for radiology discrepancies and/or overreads, S6 explained the process as the Radiologist will notify the ED physician of the discrepancy who will then notify the patient of the discrepancy. S6 was asked to present information relating to the most recent radiology discrepancy. S6 reported that the most recent discrepancy occurred on 8/30/10 and involved Patient #32. S6 presented the hospital approved policy/procedure titled "Quality Control for Diagnostic Studies in the Emergency Department" which is the policy/procedure for personnel to follow in regards to radiology discrepancies and/or overreads.

Patient #32: Medical record review revealed the patient presented to the ED (Emergency Department) on 8/30/10 at 5:16 p.m. Review of the ED record revealed that Patient #32's Chief Complaint was "I can't breathe" and the onset/duration was documented as "3 weeks". Review of the ED record revealed that the ED physician wrote discharge orders for the patient to be discharged from the ED to home in improved and stable condition on 8/30/10 at 1905 (7:05 p.m.) The clinical impression was documented as anxiety, bronchitis, and smoking cessation. Review of the radiology report (chest x-ray) revealed a report electronically signed on 8/31/10 at 3:57 p.m. which documented the impression as "1. A 4MM NODULAR DENSITY PROJECTING IN LEFT UPPER LOBE. FURTHER EVALUATION WITH CT THORAX IS RECOMMENDED TO EXCLUDE ANY POSSIBILITY OF PULMONARY NODULE/NEOPLASM, ALTHOUGH THIS MAY WELL BE ARTIFACTURAL IN NATURE". Review of the radiology report (Chest with contrast CT) revealed the impression as "A 5MM LEFT LOWER LOBE NODULAR DENSITY. IF PATIENT IS AT HIGH RISK FOR DEVELOPMENT OF PULMONARY MALIGNANCY, FOLLOW UP CT WITHIN 6-12 MONTHS RECOMMENDED TO DIFFERENTIATE BENIGN AND MALIGNANT ETIOLOGIES, OTHERWISE, FOLLOW UP CT IS RECOMMENDED AT 12 MONTHS". There was no documentation in the medical record to indicate that the findings or recommendations for follow up studies were discussed with the patient.

The hospital approved policy/procedure titled "Quality Control for Diagnostic Studies in the Emergency Department" was reviewed. The policy/procedure documents "The Emergency Physician (or designee) should compare the diagnosis made in the Emergency Department to the diagnostic findings." and "If it is determined that there is a discrepancy between the patient's diagnosis and the report, the Emergency Physician should attempt to contact the patient by phone. The Cardiology Department contacts patients for EKG discrepancies". The policy/procedure also documents "All discrepancies and patient contacts should be documented by the Emergency Department Physician of the discrepancy and of any appropriate treatment that may be indicated". The policy/procedure further documents "If the physician is unsuccessful in reaching the patient by telephone, a certified letter is sent to the patient, notifying him/her of the discrepancy and of any appropriate treatment that may be indicated. The certified letter receipt and copy of the letter is attached to the Emergency Department medical record".

Review of Patient #32's medical record revealed no documentation to indicate that the ED physician had contacted the patient by telephone or attempted to contact the patient by telephone to inform them of the radiologists findings. In an interview on 1/04/11 at 2:30 p.m., the Director of Emergency Services (S6) confirmed that there was no documentation in the medical record of Patient #32 to indicate that the ED physician had contacted the patient by telephone or attempted to contact the patient by telephone to inform them of the radiologists findings.

Review of hospital documentation revealed that a certified letter was delivered to Patient #32 on 12/12/10 which was greater than 3 months after the discrepancy was initially identified.