HospitalInspections.org

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Based on observations, record review and staff interview, it was determined that the facility did not comply with the Condition of Participation for Patient Rights. This was evidenced by the facility's non-compliance with the standard to protect the safety of children and newborn infants.

Findings:

See Tag A 144.
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Based on staff interview, document review (interoffice email) and the facility's Policy, it was determined that the facility failed to ensure timely responses to patients' / patients' representatives' Grievances. This was evident in one (1) of five (5) Grievances reviewed (Patient #16).

Findings:

Patient #16 was admitted to the Emergency Department on 07/02/14 at 10:07AM with a complaint of dizziness and blurred vision.

Review of the facility's interoffice email revealed that on 07/03/14, a complaint was lodged with the Patient Care Representative regarding care issues and poor treatment in the Emergency Department which included that the intravenous was not dripping and the patient did not receive anything to eat or drink.

Further review of these emails revealed that on 07/09/14 Nursing was aware of the complainant's grievances.

Review of the facility files revealed there was no documented evidence that a letter acknowledging receipt of the complaint was sent to the complainant or that a complete investigation was conducted and a resolution achieved.

An interview conducted with Staff #19 on 08/15/14 at 2:05PM confirmed these findings.

Review of the facility's Policy titled "Patient / Family Complaint Management" dated 12/2013 documented in Section (1.0) that the patient or complainant who wishes to lodge a complaint on behalf of the patient has the opportunity to speak with the Patient Care Representative who will document the complaint and/or grievance and forward it to the appropriate Nurse Manager, Physician and/or Director of Service for investigation and follow up with their staff. The Policy further documents that within five (5) business days an acknowledgement letter will be sent to the complainant and a response letter addressing the resolution of the grievance will be sent to the complainant within thirty (30) days.
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Based on observation, staff interview and review of procedures, it was determined the facility failed to ensure a safe environment for infants and young children. Specifically, the facilityfailed to have a system in place for the protection of infants and young children in order to minimize the potential risk for harm or abduction.

Findings include:

During the tour on the 18th Floor of the Pediatric Unit the morning of 08/11/14, it was stated by Staff #21 that an electronic tag system used to augment safety and tracking of newborn infants and Pediatric patients from ages 0-6 (zero to six) years on Unit 18 and the 3rd Floor of the DCB Building.

During observation on 8/11/14 it was noted that these Units are accessed via employee swipe cards only but the exit doors are unlocked for anyone who tries to depart the Unit. Interview with Staff Members #21 and #22 on 08/11/14 determined that anyone who arrives to the Unit must be buzzed in by staff and have Visitor Passes. Interview with Nursing staff on 08/11/14 at 2:30PM revealed that it is the Nurse's responsibility to verify the identity of Visitors and that the RN will perform hourly checks on the patients.

It was also reported on interview on 8/11/14 with Staff #21 that this system operates when an electronic transponder tag is attached to an umbilical clamp or to a band placed around the ankle or wrist of all children placed under the monitoring system. However, if the umbilical cord falls off or is not available due to the acuity of the patient, the tag is placed on the wrist or ankle of the patient. This device is linked electronically to a computer tracking system which activates a visual and audible electronic alarm if the doors to the Unit lock when the infant wearing the device approaches approximately four (4) feet proximity of the exit doors to the Unit. There are two (2) components of the system: the first involves the activation of locking the exit doors from the Unit when a tagged infant is located close in proximity to the exit doors, and the second is a visual alarm component that posts the last known location of the device on the Unit displayed on an computer in the Nursing Stations.

During the tour on 8/11/14 of Pediatric Unit 18 DCB, it was noted by Surveyors and confirmed by staff interviews that the layout of the Pediatric Unit is in a manner that does not permit accessible viewing of all persons entering or exiting the Unit. There are multiple Patient Rooms located proximal to the points of egress which are not readily visible by Nurses or other staff. It was stated by Staff #22 that there are cameras installed in the stairwells on every other floor which are visible at the Security Command Center. There was no monitoring device in the Elevator Lobby or at the Entrance / Exit Door from the 18th Floor Pediatric Unit.

Inspection of the facility's electronic infant security was conducted on the Pediatric and Neonatal Units located on the 18th and 3rd Floors respectively on 08/11/14 between 11:00AM and 3:00PM. Two (2) Surveyors and five (5) facility staff were present during these testing sessions (Staff Members #21, #22, #23, #24 and #25).

All three (3) of the three (3) tests performed found that the system failed to activate the alarms when the band was cut off.

The first simulation test inspection was conducted on the 18th Floor Pediatric Unit of the DCB Building at 11:30AM. Staff #22 wore the bracelet over his finger during which it was observed that the auditory alarm failed to activate when the band was cut.

A second simulation test was then performed at 11:45AM on the 18th Floor of the DCB Building. The door for Exit Stair #2 was propped open in an attempt to simulate an abduction where the door would be manipulated to remain ajar. When the band was cut off, it was observed that it was possible to remove the infant from the Unit with no alarm activation. In addition, there was no alarm activation when the door was propped open. It was also noted that Stairway #2 exited directly to the street, therefore posing a high risk of infant abduction through it without adequate monitoring systems.

A third simulation test was conducted between 2:00PM and 3:00PM on the Entrance Doors and Stair #3, where it was determined that the auditory alarms activated within one (1) second after the band approached the proximity of these Exit Doors, but failed to activate when the band was cut or when the doors were propped open.

It was confirmed on interview that the electronic device system is not linked to the elevator system so that if an abductor bypasses the lock feature of the double doors at the entrance of the Pediatric Unit, the elevators would not be deactivated.

In addition, while the alarm activation occurs in the particular Unit, it is not audible at the First Floor Security Greeting Desk located at the entry to the facility.

The Nursing staff of these Units and Staff #22 were not aware of the requirement for alarm activation upon the band being tampered with. An interview with Staff #22 at approximately 2:00PM revealed that the "McRobert Monitoring System" did not have this particular feature.

Review of the written Policy titled "Policy for My Child Security Transmitters" on 08/11/14 details procedures for application of the transmitter. However, this procedure did not describe the specific details and the procedure involved in the testing of the system and did not include potential contingencies, including instances where the door is manipulated to remain open or when the band is cut off.

Finally, the facility did not consistently implement effective procedures for the prevention of infant and child abduction.

At interview with Staff Members #21 and #22 on 08/11/14 at 4:00PM, it was stated that the facility implements a multi-level program to ensure child and infant security. Training Programs and Testing Drills are conducted for "Code Pink" which involves the alert and search system when a child goes missing from any Inpatient Unit. Electronic monitoring is employed in high risk areas (Newborn - Postpartum Unit).

Code Pink Drills are conducted once every six (6) months on the 3rd and 18th Floors. The last Code Pink Drill in 2014 was conducted in the NICU (Neonatal Intensive Care Unit) Area in April 2014. The facility has not conducted one on the Pediatric Unit in the last eight (8) months.

During review on 08/11/14 of the Code Pink Drills, it was determined that these reports did not document testing for all possible elopement or abduction methods that would warrant activation of electronic infant alarms. For example, while staff reported testing includes Drills for conditions where Unit Exit Doors leading from the Units are left unlocked, the Drill Reports did not reflect documented testing for all possible contingencies where portals remain open and/or when the band is cut.
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Based on record review and staff interview, the facility failed to ensure that the Nursing staff developed appropriate Nursing Care Plans with interventions that were patient specific. This was evident in four (4) of thirty-six (36) records reviewed (Patients #4, #7, #12 and #20.)

Findings:

Patient #20 was admitted to the facility on 07/03/14 with diagnoses that included Motor Vehicle Accident with Right Tibula / Fibula Fracture.

Review of the Skin Integrity Consult dated 08/01/14 documented a right posterior heel ulcer measuring 3.5cm x 2cm and right lateral leg deep purple discoloration measuring 6cm x 1cm.

Review of the Interdisciplinary Plan of Care dated 07/14/14 lacked documented evidence that the Care Plan was revised to include a plan to address the patient's alteration in skin integrity.

An interview was conducted on 08/12/14 at 10:27 AM with Staff #11. Staff #11 stated that the patient was wearing a cast, and upon removal of the cast, the patient was noted with the pressure ulcers. Staff Members #11 and #12 confirmed that a Care Plan was not initiated for the pressure ulcers.

Patient #4 was admitted to the facility on 08/03/14 complaining of difficulty swallowing. Medical history included Diabetes Mellitus (DM).

Review of the Physician's Order Summary dated 08/03/14 documented Insulin Humalog Sliding scale every six (6) hours as needed and 08/05/14 Fingerstick Routine.

Review of the Interdisciplinary Plan of Care dated 08/03/14 lacks documented evidence that a Care Plan was initiated for DM.

An interview was conducted on 08/11/14 with Staff #13. The staff member stated that the Nurses were responsible for initiating the Care Plan and that there should have been a Care Plan developed for DM.

Patient #12 was admitted to the facility on 08/10/14 with the diagnosis of 2nd and 3rd Degree Chemical Burns to Bilateral Lower Extremities.

Review of the Medical Record revealed that on 08/11/14 the patient had a post-operative split thickness skin graft to bilateral lower extremities.

Review of the Interdisciplinary Plan of Care dated 08/10/14, in the Section titled Pain; there was no Plan / Interventions identified to address the potential problem of pain due to the burn or following surgery.

Review of the Policy and Procedure titled Interdisciplinary Plan of Care effective 07/01/14 documented, in Introductory Information Section (2.2), that the Plan of Care shall address the Admitting Diagnosis, Patient Comorbidities identified in the History and Physical, Risk Factors identified by the Nurse during the Initial Assessment as well as long and short term goals, and in the Plan / Interventions Section (3.6.1) to check off all the applicable Plans / Interventions.



33919

Review of the Medical Record for Patient #7 revealed that the patient was admitted via birth on 08/04/14. On 08/11/14 the patient was noted to be observably jaundiced and the Record revealed that the patient had been treated with phototherapy for Hyperbilirubinemia until 08/09/14.

On 08/11/14, review of the patient's pre-printed "NICU Interdisciplinary Plan of Care", which was implemented on 08/04/14, revealed on Page 3 that the Care Plan Section titled "Hyperbilirubinemia" was blank.

An interview with Staff #10 on 08/11/14 at 2:50 PM confirmed this finding.
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Based on observation and interview, it was determined that the facility did not ensure that staff could identify, locate and set up the Pediatric Defibrillator Paddles in three (3) out of four (4) staff on different units (Staff Members #1, #2 and #3).

Findings:

On 08/11/14 at 11:10 AM, during the tour of the 3 West Obstetrics and Gynecology Unit, while demonstrating a test of the Code Cart and Defibrillator, Staff #2 was asked to identify the Pediatric Defibrillator Paddles. While holding the Adult / Pediatric Defibrillator Paddles in their hands, the staff member was unable to identify the Pediatric Paddles.

When Staff #2 was shown the location of the Pediatric Paddles, the staff member was unable to slide off the Adult Paddles to reveal the Pediatric Paddles underneath.

This was observed in the presence of Staff #4.

On 08/11/14 at 11:20 AM during the tour of the Nursery Unit, while demonstrating a test of the Code Cart and Defibrillator, Staff #3 was asked to identify the Pediatric Defibrillator Paddles. While holding the Adult / Pediatric Defibrillator Paddles in their hands, the staff member was unable to slide off the Adult Paddles to reveal the Pediatric Paddles underneath.

This was observed in the presence of Staff #4.

On 08/11/14 at 10:30 AM during the tour of the Labor and Delivery Unit, while demonstrating a test of the Code Cart and Defibrillator, Staff #1 was asked to identify the Pediatric Defibrillator Paddles. While holding the Adult / Pediatric Defibrillator Paddles in her hands, the staff member was unable to slide off the Adult Paddles to reveal the Pediatric Paddles underneath.

This was observed in the presence of Staff #4.

On 08/11/14, in the afternoon during interview, Staff #4 was asked if the Nurses in Labor and Delivery, Maternity and the Nursery should know where the Pediatric Paddles were on the Defibrillator, and how to access them, she replied "Yes".
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Based on record review and staff interview, the facility failed to ensure that Orders for Biologicals (Packed Red Blood Cells) were obtained from a Practitioner responsible for the care of the patient prior to administration in one (1) out of six (6) Blood Transfusion Administration Records reviewed (Patient #44).

Finding:

Review of the Medical Record for Patient #44 on 08/14/14 revealed that the patient was admitted with a history of Alcoholic Hepatitis and Anemia. The Physician's Progress Note on 08/12/14 at 7:10AM, documented hemoglobin 6.9 will transfuse one (1) more unit of Packed Red Blood Cells (PRBC) and Fresh Frozen Plasma (FFP).

The electronic "Physician Order Summary" documented that the Physician ordered one (1) unit of Leukocyte Reduced Packed Red Blood Cells from the Blood Bank at 10:57AM on 08/12/14. Review of the electronic "Blood Bank: Results" revealed that the Blood Bank allocated a unit of Leukocyte Reduced PRBC to the patient at 11:06AM on 08/12/14.

Review of the "Blood Component Transfusion Record" Form documented that the Blood Bank released the unit of PRBC on 08/12/14 at 12:42PM, the Nurse received the unit at 12:52PM, and that two (2) Nurses verified the Physician's Order for the component. However, the Form documents that the transfusion was started at 1:20PM, prior to the Transfusion Order being written by the Physician.

Review of the Physician Order dated 8/12/14 documented that the order to transfuse one (1) unit of PRBC over four (4) hours was written at 1:30PM.

An interview with Staff #14 at 11:00AM on 08/14/14 revealed that the staff member placed the Order to the Blood Bank for the unit of PRBC around 10:30AM on 08/12/14 then checked the Blood Bank results to ensure it was available. The staff member then placed another Order for RBC at around 12:00PM after speaking with the Nurse because the staff member could not find the original Order.

An interview with Staff #15 at 11:38AM on 08/14/14 revealed that the staff member did not recall speaking with the Physician about the Order to transfuse the patient.

Review of the current Policy titled "Nursing: Transfusion of Blood and or Blood Products" states in "Section 3.0 Procedure: Part 3.5.1 (A) two (2) RNs or a Nurse with a Physician performs the verification process"; Part 3.5.2 "all verification shall include actual visualization and repeat verbalization of the information specific to the patient (including) the patient ID Band, MR Number, Physician Order, Consent, Blood Component, Expiration Date and Blood Type" and Part 3.5.3 "Document with initials in the designated area on the Form #2. Physician Order" verification.

These findings were confirmed with Staff #16.
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Based on Medical Record review, review of facility Policy and staff interview, it was determined that the facility failed to ensure that Medical Records were completed in a timely manner in twelve (12) out of twelve (12) Patient Records reviewed (Patients #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60 and #61).

Findings:

Review of the Medical Record for Patient #50 on 08/15/14 noted that this patient had surgery on 03/19/14. The Operative Report dictated and transcribed on 03/19/14 was not signed.

Review of the Medical Record for Patient #51 on 08/15/14 noted that this patient had surgery on 02/14/14. The dictated Operative Report was not signed.

Review of the Medical Record for Patient #52 on 08/15/14 noted that the patient was discharged on 11/13/13. The Discharge Summary was not signed.

Similar findings of Discharge Summaries not signed were noted for Patients #53, #54 and #55.

Review of the Medical Record for Patient #57 on 08/15/14 noted that the patient was discharged on 04/17/14. The dictated Operative Report signed by the Resident on 06/04/14 was not countersigned by the Attending Physician as required by facility Policy.

Review of the Medical Record for Patient #58 on 08/15/14 noted that the patient had surgery on 03/18/14. It was noted that the History and Physical done by a Resident was not countersigned by the Attending Physician as required by facility Policy.

Similar findings of Records that needed Attending Physician countersignatures were noted for Patients #56, #59, #60 and #61.

An interview was conducted with Staff #5 on 08/14/14 at 11:30AM. Information about incomplete Medical Records was discussed. The staff member stated that all Medical Records of discharged patients must be completed within thirty (30) days of the date of discharge.

Review of the Delinquent Records List created for July 2014 noted that there were two thousand and thirty-four (2034) Delinquent Medical Records.

These findings were confirmed with Staff #6.
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Based on observation and staff interview, the facility failed to maintain the physical plant in a manner to ensure an environment of patient safety for patients receiving treatment for psychiatric illnesses. This was evident on the 12th Floor and 14th Floor (East Side) of the DCB Building as well as the 1st and 2nd Floors of Building D.

Findings include the following physical hazards that were noted in these areas:

DCB BUILDING

During the tour of the 14th Floor on 08/12/14 at approximately 9:00AM, it was noted that the sprinkler was installed in the Art / Recreation / Exercise Room (Room #1460) and the heads of the sprinklers were of the regular type. They were not concealed and had the potential to be a location to be used for a looping hazard.

During the tour of the 12th Floor on 08/12/14 at approximately 2:00PM, the door handles on the Patient Rooms, Patient Closets, Activity Room and Dirty Utility Rooms were the type that had the potential of being used to create a loop that would hang on the other side of the door.

The door hinges of the Patient Rooms, Activity Rooms and Dirty Utility Rooms were of the pivot type and had the potential of becoming a looping hazard on the Unit.

A metallic door closure was observed on the Kitchen door that has the potential of creating ligature and becoming a looping hazard.

D BUILDING

Tour and observation conducted on 08/14/14 on the two (2) Inpatient Psychiatric Floors (1st and 2nd Floors) revealed the following:

The door handles of the Patient Rooms and Patient Closets were the type that had the potential of being used to create a loop that would hang on the other side of the door.

The door hinges on the Patient Rooms were the pivot type and had the potential of becoming a looping hazard on the Unit.

Metallic door closures were observed in the Day Room that have the potential of creating ligature and becoming a looping hazard.

Two (2) hand washing sinks in the Grooming Room were observed to have regular faucets. These regular faucets allow the formation of ligatures and are potential looping hazards.

A protruding drain pipe in the shape of a U, approximately eight (8) inches from the floor, was observed in the Grooming Room, which could also be used to form a ligature and therefore was a potential looping hazard.

During the tour of the North Side Patient Bathrooms and South Side Patient Bathrooms on the 1st Floor, it was noted that the hand washing sink was protruding approximately 12" (twelve inches) from the wall and was approximately 4' (four feet) high from the floor. The sinks were observed to have regular faucets. The protruding sink and the regular faucets allow the formation of ligatures and are potential looping hazards. A similar arrangement was observed in the Boys Grooming Room and Bathroom on the 2nd Floor.

During the tour of the Patient Bathrooms, half doors were noted on the two (2) toilets. One (1) of the two (2) toilets had a protruding flushometer 3" (three inches) from the wall. This arrangement in the bathrooms was noted on both the 1st and 2nd Floors and is a potential looping hazard. Sharp metallic door stoppers were observed on the wooden frames at the entrance of both toilets in each of these Bathrooms.

A flat top surface mounted Bathroom tissue dispenser and hand towel dispenser were observed in all Patient Bathrooms on both floors. This type of tissue dispenser is capable of becoming a looping hazard in a Psychiatric Unit.

A hopper sink with long plumbing fixtures was noted in the Girls Grooming Room on the 2nd Floor. Interview with staff revealed that this sink was for patient use to wash and brush teeth. The plumbing fixtures on this sink posed a looping hazard due to the possibility of creating ligatures around it.

A public phone was observed to be installed in the hallway on the 2nd Floor. This phone had a long metallic cord approximately 17" (seventeen inches) in length and had the potential of being used as a weapon and becoming a looping hazard.

During interview with Staff #23 on 08/12/14 at approximately 11:00AM, it was revealed that the facility had renovated the West Side of the 14th Floor, but had not renovated the 12th Floor Inpatient Psychiatric Unit and the two (2) Psychiatric Units in the D Building.
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Based on observations, record review and staff interview, it was determined the facility failed to monitor and implement Infection Control Practices to prevent the potential for cross contamination and spread of infections related to: a) the maintenance of a sanitary environment, and b) the facility's failure to follow its own Policy for cleaning and storage of commodes.

Findings:

a) Specific reference is made to the following deficiencies identified at the facility between 08/11/14 and 08/15/14 during the hours of 8:30AM and 3:00PM as noted below:

During the tour of the Isolation Room(s) in the Emergency Department, ICU (Intensive Care Unit) and Medical Surgical Units, it was noted that the ceiling tiles were acoustical tiles and were of the non-cleanable type.

The tour of the Operating Room Suite found that the ceiling tiles over the sterile corridor were observed to be metal panels with holes.

The tour of the Isolation Rooms (Rooms #1844 and #1845) on the 18th Floor were observed to have positive airflow, instead of negative airflow as required.

Operating Room #1 in the LDR (Labor and Delivery Room) Suite located on the 3rd Floor of the facility did not have positive air pressure in relation to the corridor and therefore was negative.

During the tour of the Triage Room (Room #2212 A) in the PACU (Post Anesthesia Care Unit) Area and the Contact Isolation Treatment Room, staff did not have a separate hand washing sink to wash hands.

During the tour of the Operating Suite on the 2nd Floor on 08/13/14 at approximately 2:00PM, it was noted that the floor of Operating Room #5 was pitted in a few different places beside the operating table.

During the tour of the LDR, it was observed that the facility failed to maintain a clear separation of clean and dirty. Observations in the Dirty Utility Room revealed that the facility stored clean items (clean white plastic containers with Formalin, Formalin jars, boxes of vinyl gloves and white plastic basins) in the Dirty Utility Room.

During the tour of the Inpatient Psychiatric Unit in the DCB Building, it was noted that the perimeter of the floor in the Art Therapy Room was observed to be heavily soiled and dirty. The window sills were covered with dust.

During the tour of the Restraint Room on the 12th Floor on 08/12/14 at approximately 2:30PM, it was noted that the toilet and the hand washing sink in the Patient Bathroom was soiled, the window sill of the Patient Room was covered in dust, and the floor of the room was heavily soiled and grimy.

During the tour of the Labor and Delivery Suite, the floor of Operating Room #4 was observed to be heavily soiled.

Similarly, the perimeter of the floor of OR #5 was observed to be dusty and dirty.

A ceiling tile was missing from the ceiling of Room #1026 in the Inpatient Rehab Unit.

The plaster on the walls of the Bronchoscopy Room, #2301, was observed to be in disrepair and there was a hole in the wall approximately 4" (four inches) in diameter.

On tour of the Supply Room on the 1st Floor of the D Building, it was noted that eight (8) tiles were missing from the tiled wall.

The cove base of the wall in the Girls Grooming Room on the 2nd Floor of the D Building was observed to be peeling off.

A ceiling tile in the Soiled Utility Room of the Pediatric Clinic, and a ceiling tile in the Clean Utility Room of the Emergency Room, were noted to be wet and stained.

The observation of these findings were made in the presence of Staff #23.

Interview with Staff #23 on 08/15/14 at approximately 2:00PM revealed that the facility staff were aware of the findings.



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b) During the tour of the Ambulatory Surgery Unit on 08/12/14 at 10:00AM, a Bariatric commode was observed in the Dirty Utility Room.

An interview with Staff #18 at this time revealed that this Bariatric commode was being stored in this room for use when needed and that staff or Housekeeping would clean it before giving it to a patient.

Staff #18 advised that there was nowhere else to store this commode.

This was brought to the attention of Staff #17.



33919

During the tour of the Rehabilitation Floor on 08/12/14 at 11:00AM, three (3) commodes were observed stacked in the Dirty Utility Room.

In an interview with Staff #20 on 08/12/14 at 11:05AM, when asked who was responsible to clean them, replied "Housekeeping is supposed to come and do it, but Nursing can take one out and wipe it down if a patient needs it."

When asked where the clean commodes are stored, Staff #20 stated "We don't really have a storage place for them. They are kept here until we need them."

This was stated in the presence of Staff #9, who confirmed the statements.

Review of the facility Policy titled "Cleaning of Medical Equipment" revealed in Section D: #2 and #3 that "Housekeeping will clean with hospital germicide detergent the commode seat and frame", and "Upon completion of cleaning, Housekeeping will cover with plastic bag and place in Clean Utility Room for next patient use."
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Based on documentation review and interview, the facility failed to ensure that the Respiratory Therapy staff had the required certification in one (1) out of three (3) Personnel Files reviewed (Staff #7).

Findings:

On 08/15/14 at 10:00AM, review of Personnel Files revealed that Staff #7's Basic Life Support (BLS) / Cardiopulmonary Resuscitation (CPR) Certification expired in April 2013.

Review of the "Division of Pulmonary Medicine Respiratory Therapy Service" Policy document titled "Cardio-Pulmonary Resuscitation (CPR)" revealed in Section I, "Respiratory Therapist will be required to have valid BLS cards".

This was confirmed on 08/15/14 at 11:00AM during an interview with Staff #8.