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Based on interview and record review, the GB failed to ensure the contracted services were evaluated for safety and quality of services provided in the hospital. This failure created the increased risk of substandard services being provided in the hospital.

Findings:

Review of the hospital's FY 2019-Performance Improvement Plan showed in part, "...current framework and philosophy for continuous performance improvement involves- organizing and improving work that emphasizes patient safety, quality standards ..."

Review of the hospital's Medical Staff Bylaws dated 12/5/19, showed in part, "...The Medical staff acknowledges that the Governing Body must act to protect the quality of medical care provided and the competency of the Medical Staff, and to ensure the responsible governance of the hospital ...To assure that all patients admitted to or treated in any of the Hospital's services will receive care of a quality and efficiency that is consistent with generally accepted standards ..."

Review of the hospital's Amended and Restated Bylaws of St. Joseph Hospital of Orange dated 2/28/13, showed in part, "...All binding obligations of the corporation shall be consistent with ethical business practices, accreditation standards, relevant law ..."

On 1/13/20, review of the hospital's contracted services list and the Quality and Safety Committee minutes of the Board and the MEC was conducted. There was no documented evidence of the evaluation of contract services by the GB.

During an interview with Mgr 11 on 1/13/20 at 1100 hours, Mgr 11 stated she would find documentation that the GB evaluated all contracted services. However, the hospital could not provide evidence the GB had reviewed the contracted services for quality and safety for the last 12 months.

Based on interview and record review, the GB failed to ensure the complete list of all contracted services to evaluate all contracted services, creating the increased risk of substandard care and services provided in the hospital.

Findings:

Review of the hospital's Amended and Restated Bylaws of St. Joseph Hospital of Orange dated 2/28/13, showed in part, "...Board of Trustees' Responsibility ...conduct of specific review and evaluation activities to assess, preserve and improve the overall quality ..."

Review of the hospital's FY 2019-Performance Improvement Plan showed in part, " ...The Board...has overall responsibility for the quality and safety of patient care provided and strives to assure that quality ..."

Review of the hospital's P&P titled Contracts and Agreements dated 4/17 showed in part, "...All contracts and agreements are considered part of the daily operations of the hospital and are the direct responsibility of the Chief Executive Officer ... However, he or she is accountable to the Board of Trustees in all matters relative to the daily operations of ...Hospital, including signing or canceling contracts ..."

On 1/13/20, review of the hospital's contract services list showed the clinical contracted services but did not include any other contracted vendors.

On 1/13/20 at 1100 hours, during an interview with Mgr 11, Mgr 11 stated the list contained only the clinical contracted services. She stated the hospital did not have one list of all contracted services.

Based on observation, interview, and record review, the hospital failed to ensure the patient's right to care in a safe setting when the physical environment and equipment were not maintained in a safe, clean, sanitary, and good repair at all times, creating the increased risk to the safety of patients receiving care in the hospital.

Findings:

1. Review of the hospital's P&P titled General Cleaning Procedures dated 8/19 showed the purpose of this policy is to maintain a disinfected environment; to remove dust, lint and soil from items in the hospital environment.

On 1/13/20 at 0806 hours, a tour of Women's Services was conducted with DIR 1 and Mgr 12. The following was observed:

* In the clean storage room, four RF Assure Delivery devices were observed with brown residue that was removed by wiping the area with the disinfecting wipe.

* In a soiled room, the counter tops and bottom panel were broken or had missing laminate.

* In one medication room, the warmer had dust and residue.

* One overhead light in the patient room had a thick layer of dust.

* In the second floor nursery, multiple expired medical supplies were found in the box labeled Code White Cart. One digital thermometer had tape and sticky residue.

* In the Hemorrhage Emergency Cart and in the medication area of the second floor, there were multiple expired venipuncture tubes.

In a concurrent interview, DIR 1 and Mgr 12 acknowledged the findings.

2. Review of the hospital's P&P titled Lockout/Tagout dated 2/17 showed this policy establishes the minimum requirements for the lockout/tagout of electrical devices or unsafe equipment. Lockout is the process of installing a locking device on an electrical device to ensure the equipment/machinery cannot be operated until the lockout is removed. Tagout is the process for attaching a prominent warning device (tag, sign) to isolating device (electrical equipment) to warn others not to restore energy to the device in which the tag has been attached. Lockout/Tagout procedures will be employed upon discovering equipment which are found to be malfunctioning or unsafe to use. The Lockout For Safety Tag must be signed and dated by the person initiating the tagout. The equipment must be locked out using the lockout device.

On 1/16/20 at 0808 hours, a tour of the Women's Services Triage Unit was conducted with DIR 1 and Mgr 12.
In the storage room, one Panda Warmer was observed with a hand written note on the paper towel showing "Do not use system error - Biomed." The patient care equipment that was out of services due to malfunctioning or unsafe to use was not labeled as per the hospital's P&P.

In a concurrent interview, DIR 1 and Mgr 12 acknowledged the finding.

Based on observation, interview, and record review, the hospital failed to ensure the nursing services were provided to two of seven sampled patients (Patients 2 and 3) as evidenced by:

1. Failure to ensure Patient 2's BP was monitored when receiving the labetalol (antihypertensive medication) as per the protocol.

2. Failure to ensure the medications were removed for two discharged patients (Patients 2 and 3).

These failures created the increased risk of poor health outcomes to the patient receiving services in the hospital.

Findings:

1. On 1/14/20 at 1355 hours, an interview and concurrent review of Patient 2's medical record review was conducted with RN 23.

Patient 2's medical record showed the patient was admitted to the Mother-Baby Unit on 1/9/20, after the cesarean delivery.

Review of the Postpartum Progress Note dated 1/11/20 at 1401 hours, showed Patient 2 had preeclampsia and chronic HTN, and was on the labetalol medication.

Review of the physician's order showed labetalol injection to be started on 1/8/20 at 1345 hours. The protocol section showed to administer labetalol IVP if SBP was greater than 160 mmHg or DBP was greater than 110 mmHg; when SPB was less than 160 mmHg and DBP was less than 110 mmHg, repeat BP measurements every 10 minutes for one hour, then every 15 minutes for one hour, then every 30 minutes for one hour, and then every hour for four hours.

Review of the Medication Administration showed 40 mg of labetalol were administered IVP to Patient 2 on 1/11/20 at 1823 hours, for the BP of 161/83 mmHg.

Review of the Vital Signs record dated 1/11/20, showed the following:

* For the first hour (from 1823 to 1923 hours) after the labetalol was administered to Patient 2, the patient's BP was taken at 1838 hours (or 15 minutes later), 1848 hours, 1859 hours (or 11 minutes later), 1915 hours (or 16 minutes later), and 1950 hours (or 35 minutes later), instead of every 10 minutes as per the protocol.

* For the second hour (from 1923 hours to 2023 hours), the patient's BPs were taken at 1950 hours, 2006 hours (or 16 minutes later), 2015 hours, and 2050 hours (or 35 minutes later), instead of every 15 minutes as per protocol.

In a concurrent interview, RN 3 acknowledged the findings.

2. Review of the hospital's P&P titled Unused Patient Medication Dispensed from the Pharmacy revised 9/17 showed when a medication is discontinued or the patient is discharged, all unused portions of medications (not removed from unit dose packaging) is returned to the Pharmacy unless there is a prescription for the patient to have bulk medication administered in the hospital relabeled for home use.

a. On 1/13/20 at 0848 hours, a tour of the L&D Unit was conducted with DIR 1 and Mgr 12. The medication refrigerator was observed to have three bags of gentamicin (antibiotic medication) for Patient 3 who had been discharged.

In a concurrent interview, DIR 1 and Mgr 12 acknowledged the finding and confirmed Patient 3 had been discharged from the L&D Unit on 12/30/19.

b. On 1/13/20 at 1440 hours, a tour of the Mother Baby Unit was conducted with DIR 1 and Mgr 12. The medication cassette was observed to have multiple medications that had been prescribed for Patient 2 who had been discharged.

In a concurrent interview, DIR 1 and Mgr 12 acknowledged the finding and confirmed Patient 2 had been discharged home on 1/9/20. DIR 1 and Mgr 12 stated the pharmacy staff should have removed the medications and returned them to the pharmacy.