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Based on observation, review of associated documentation, and interview with the Behavior Health staff, the hospital failed to ensure and maintain a safe environment in the Behavioral Health Unit of the hospital. All patient rooms contained bathrooms with non-breakaway faucets, exposed plumbing for the toilets, non-breakaway faucets for the showers that failed to be tamper and ligature resistant. Exposed hinges on the bathroom, closet, and entry doors, and door handles that failed to be ligature resistant. The administrative staff of the acute hospital identified a census of 7 patients in the behavioral health unit and all of the 7 patients were on suicide precautions.

Failure to establish and maintain a safe environment for psychiatric patients could potentially result in patient death or other life threatening conditions.

Findings include:

1. Observation on 2/28/12 at 1:45 PM, with Staff H, Manager of Behavioral Health Unit, revealed the following during the tour of the Behavioral Health Unit:

a. 7 of 7 patient bathrooms contained sinks each measured 31 inches from the floor, goose neck faucets 11 inches tall, water handles 4 inches long. The sinks and faucets provide ample space to attach a ligature device for hanging.

b. 7 of 7 patient bathrooms contained a shower with a faucet 27 inches from the floor and protruded out 2.5 inches. The shower faucets provide ample space to attach a ligature device for hanging.

c. 7 of 7 patient bathrooms contained toilets with exposed plumbing 47 inches from the floor and 2 inch pipe. The exposed plumbing provides ample space to attach a ligature device for hanging.

d. 4 of 7 patient bathrooms contained handicapped grab bars 27 inches from the floor and protruded out 2 inches, providing ample space to attach a ligature device for hanging.

e. 2 of 7 patient bathrooms contained moveable handicapped grab bars surrounding the toilet 28 inches from the floor, providing ample space to attach a ligature device for hanging.

f. 7 of 7 patient rooms contained a closet with 2 doors each door having 3 hinges ranging from 39 inches to 90 inches from the floor and protruded out 0.5 inches. Each closet door had 1 L-type handle that protruded out 2 inches and 39 inches from the floor, providing ample space to attach a ligature device for hanging.

g. 7 of 7 patient rooms contained a bathroom door with 3 hinges ranging from 36 to 80 inches from the floor and protruded out 1.5 inches. The bathroom door handle was L-type and protruded out 6 inches, providing ample space to attach a ligature device for hanging.

h. 7 of 7-entry doors to patient rooms contained 3 hinges ranging from 36 to 80 inches from the floor and protruded out 1.5 inches. The door handle was L-type and protruded out 4 inches. The hinges and door handle provided ample space to attach a ligature device for hanging.

2. Review of the "Patient Census" dated 2/29/12 revealed 7 of 7 patients in the Behavior Health Unit had a diagnosis of depression and were on suicide precautions.

Review of the hospital's policy titled, "Suicide/Homicide Policy" on 5/11, revealed in part, "...Suicide Precautions-Includes those patients with suicide ideation who are preoccupied with suicide, self-harm or after assessment are found to be at risk for suicide potential."

Review of the hospital's "Mental Health Services Policy and Procedure Manual" on 5/11 revealed policies titled "Unit Safety Check Monitor," "Patient Safety," "Room Search," all include various aspects of patient safety, but lacked specifics regarding the physical environment for safety.

Review of hospital's undated "Patient Rights/Responsibilities," revealed in part..."6. The patient has the right to receive care in a safe setting."

3. During an interview on 2/29/12 at 4:30, Staff H stated "We want a safe environment and it to be right. I have been on the unit for 10 years; we have not changed the plumbing in that time."

During an interview on 3/06/12 at 10:45 AM, Staff J, Vice-President of Nursing, Staff V, Director of Quality, and Staff W, Interim Chief Executive Officer acknowledged the areas of concern for patient safety in the Behavioral Health Unit.

During an interview on 3/01/12 at 8:45 AM, Staff P, Director of Facility Services acknowledged the sinks in the Behavioral Health Unit failed to be break away and failed to have testing completed for the amount of weight applied before the sink would break free.

Based on review of hospital policy/procedure, observations and staff interviews the acute care hospital staff failed to secure patient medical records from unauthorized personnel on the medical/surgical unit, orthopedic unit, radiology, sleep study, occupational and speech therapy departments.

The hospital administrative staff identified a census of 23 patients on the medical/surgical unit, and 7 patients on the orthopedic unit. Radiology staff reported all radiology procedures were computerized and the stored films were past patient procedures. Respiratory staff reported conducting approximately 3 sleep study procedures per week. Occupational therapy staff reported approximately 30 procedures per week include both inpatients and outpatients. Speech therapy staff reported approximately 5 procedures per week include both inpatients and outpatients .

Failure to secure patient medical records from unauthorized users could potentially result in the inappropriate use of a patient's identity or medical information.

Findings include:

Review of the hospital policy "Confidentiality Policies Disclosure of Information" effective 6/1/94 revealed in part, "...the hospital has the obligation to safeguard his records against unauthorized disclosure...Reasons for admission, diagnosis, and treatment of patients are absolutely confidential information and must be respected. Information on patients is given to employees on a need-to-know basis..."

1. During an environmental tour on 2/27/12 at 10:20 AM, with the Vice President of Patient Services, revealed four unlocked cupboards with patient information at the four nurses' stations on the medical surgical unit. The cabinets contained shredding bins with the patient information (name, hospital number and miscellaneous patient information- diagnosis, medication orders, etc.)

During an interview on 2/27/12 at 10:20 AM, Staff K, Unit Secretary, stated the shred bins contain patient information that staff would take to the central shredding station. The cabinets were not locked and could not be locked. Staff was not always at the nurses' station and the public could gain access to the information. Staff L, Materials Management Aid picked up the shredding material weekly and transported it to the central shredding area.

During an interview on 2/27/12 at 10:35 A.M., Staff M, Registered Nurse (RN) confirmed the shredding cabinets were not secured, had patient information in them and the unauthorized people could have access to them.

During an interview on 2/27/12, Staff K stated there were 4 unsecured shred bins on the medical/surgical unit and 2 unsecured shred bins on the orthopedic unit. Unauthorized people could access the shred bins.


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2. Observation during a tour of the Radiology department on 2/29/12 at 1:53 PM, with Staff Q, Director of Radiology, revealed a room that stored patient's radiology films. The radiology films contained patient information (names, date of birth, date of service and sex of patient).

During an interview on 2/29/12 at 1:53 P.M., Staff Q stated the room held approximately 25,000 patient radiology films. Staff Q confirmed unsupervised housekeeping staff cleaned the room after hours and would have access to patient information.

3. Observation during a tour of the Sleep Study department on 3/1/12 at 09:20 AM, with Staff R, Respiratory Supervisor, revealed a shelf over the desk with 7 patient medical records and 7 patient medical records in the desk drawer. Each medical record contained patient information including but not limited to: name, address, phone number, medical record number, diagnosis and physician ordered treatment.

During an interview on 3/1/12 at 09:20 A.M., Staff R confirmed the desk drawer did not lock and medical records remained on the shelf over night. Staff R stated unsupervised housekeeping staff cleaned the room after hours and would have access to patient information.

4. Observation during a tour of the Occupational Therapy (OT) department on 3/5/12 at 3:20 PM, with Staff S, Occupational Therapist, revealed 2 tall files with 5 drawer in each file and a lateral file with 3 drawers. Each of the files contained medical records of past and current patients. Each medical record contained patient information including but not limited to: name, address, phone number, medical record number, diagnosis and physician ordered treatment.

Observation in the OT department also revealed an open cardboard box with patient information papers thrown in. The papers contained patient information including but not limited to; name, address, phone number, medical record number, diagnosis and physician ordered treatment.

During an interview on 3/5/12 at 3:20 P.M., Staff S estimated the 3 files held approximately 2,000 past and current patient medical records and did not lock. Staff S went on to say the OT staff put patient information papers in the cardboard box for shredding and once week Staff L, Materials Management Aid, picked up the shredding material and transported it to the central shredding area. Staff S stated unsupervised housekeeping staff cleaned the room after hours and would have access to patient information.

5. Observation during a tour of Speech Therapy on 3/5/12 at 3:40 PM, with Staff T, Speech Therapist, revealed a 5 drawer file with medical records of past and current patients filed in 2 of the 5 drawers. Each patient medical record contained patient information including but not limited to; name, address, phone number, medical record number, diagnosis and physician ordered treatment.

During an interview on 3/5/12 at 3:40 P.M., Staff T estimated approximately 300 medical records stored in the 2 file drawers. Staff T confirmed the file drawers did not lock and stated unsupervised housekeeping staff cleaned the room after hours and would have access to patient information.

Based on medical record review, policy review, document review and staff interviews, the hospital nursing staff failed to ensure the diet ordered by the physician was communicated correctly to the Food and Nutrition Services Department and failed to ensure diet order clarifications were documented on the medical record for 5 of 18 sampled medical records (Patients #1 through #5). The administrative staff reported a census of 39 inpatients. The Director of Food and Nutrition Services reported approximately 75-150 patient meals are served daily.

Failure to provide a patient with the correct therapeutic diet could potentially result in complications for the patient including gastrointestinal intolerance, texture intolerance, and inadequate or excess nutrient intake which could lead to weight loss, fluid imbalance, electrolyte imbalance, choking, aspiration, nausea or vomiting.

Findings include:

1. Review of a Food and Nutrition Services policy titled "Nutrition Care Order and Status Changes", last approved on 2/24/12, revealed in part "Policy: A Nutrition Care Order is accepted upon the written order of a physician. . . Procedure: 1. Nursing personnel send nutrition care orders via Meditech computer or by phone call to diet office. 2. New orders/changes are entered into CBORD. . ." CBORD is the hospital's electronic food and nutrition service management software system which generated patient tray tickets based on diet order.

Review of a Food and Nutrition Services policy titled "Nursing Communication with Food and Nutrition Services Department", last approved on 2/24/12, revealed in part ". . . Purpose: To provide standardized, timely and accurate communication about patient nutritional care from the medical and nursing staff to the Food and Nutrition Services staff. . . Procedure: 1. Nutrition Care Orders are entered into Meditech by nursing. 3. Diet orders are entered into CBORD by Food and Nutrition staff. . ."

2. Review of medical records revealed the following problems with diet orders.

a. Review of the medical record for Patient #1 revealed a physician order set dated 2/27/12 at 11:00 AM, included a low salt diet order. Review of Meditech (hospital electronic medical record system) diet order entries revealed a diet order entry for a heart healthy diet on 2/27/12 at 12:00 PM. Review of CBORD diet order entries revealed a diet order entry for a heart healthy diet on 2/27/12 at 12:07 PM. During an interview on 2/28/12 at 10:40 AM, Staff B, Clinical Dietetics Supervisor, verified the discrepancy between the diet order written in the medical record and the diet order entry in Meditech. Staff B reported the differences in the diets included a sodium restriction for a low salt diet and a sodium, fat and cholesterol restriction for a heart healthy diet.

b. Review of the medical record for Patient #2 revealed the admission orders on 2/16/12 at 1:45 PM, included a low fat diet order. Further review of the medical record revealed order sets, dated 2/19/12, 2/22/12, 2/24/12 and 2/27/12. The order set on 2/19/12 included a pre-procedure order for a light breakfast no later than 6 hours before the procedure, clear liquids up to 4 hours before the procedure and then NPO (nothing by mouth) 4 hours prior to the procedure. The order sets on 2/22/12, 2/24/12 and 2/27/12 included a pre-procedure order for nothing to eat or drink after midnight. The post-procedure portion of the order sets, for all 4 dates, included an order to resume regular diet as tolerated.

Review of Meditech diet order entries revealed a diet order entry on 2/16/12 at 3:51 PM for a low fat diet, with no subsequent diet order entries. During an interview on 2/28/12 at 10:10 AM, Staff B verified the order sets included diet order changes and reported he/she would expect the changes to be entered into Meditech. Staff B lacked an explanation as to why the entries did not occur.

During an interview on 2/29/12 at 10:55 AM, Staff H, Mental Health Unit Clinical Supervisor, reported these types of procedures are scheduled for 1:00 PM and the patient is able to eat shortly afterwards, so unit staff hold the meal tray for service after the procedure, rather than entering the NPO order and diet resumption order into the computer. Staff H further reported his/her interpretation of the post-procedure order to resume regular diet as tolerated, was to resume the patient's usual or previous diet and, since the patient had previously received a low fat diet, did not see a need for a diet order change. Staff B, present at that time, reported a regular diet was defined as a diet without any restrictions.

c. Review of the medical record for Patient #3 revealed a physician order on 2/27/12 at 6:30 PM for nectar-thick liquids. Physician orders on 2/28/12 at 9:00 AM included an order for diet as tolerated. Review of Meditech diet order entries revealed a diet order entry on 2/28/12 at 9:37 AM for a nectar-thick, full liquid diet and a diet order entry on 2/28/12 at 1:15 PM for a regular diet with nectar-thick liquids. Review of CBORD diet order entries revealed a diet order entry on 2/28/12 at 9:41 AM for a full liquid, nectar-thick liquids diet and a diet order entry on 2/28/12 at 1:17 PM for a regular, nectar-thick liquids diet.

During an interview on 2/28/12 at 3:40 PM, Staff B verified the written diet order for diet as tolerated and reported he/she was not aware of a hospital policy directed toward such an order. Staff B further reported such an order should not be written.

During an interview on 2/28/12 at 3:45 PM, Staff G, RN, reported he/she was unsure if a hospital policy existed to outline how such an order should be handled, but described the determination of the diet occurred based on nursing judgement. Staff G reported a patient would be started on ice chips and advanced up to a regular diet based on individual toleration, with assessment of such areas as mental status and bowel activity. Staff G reported Patient #3 started with nectar-thick clear liquids, advanced to nectar-thick full liquids and regular with nectar-thick liquids, as the patient demonstrated tolerance each advancement.

During an interview on 2/29/12 at 11:10 am, Staff J, Vice President of Nursing and Staff I, Medical/Surgical Unit Manager confirmed the hospital lacked a policy, procedure or protocol to direct staff on how to handle a "diet as tolerated" order. Staff I reported unit staff determine the diet based on nursing judgement and assess areas such as mental status and bowel activity but would not necessarily expect a nurse to document his/her determination of the diet changes. Staff I further reported the patient would generally be started on ice chips, progress to liquids and up to their usual diet, previous to admission.

d. Review of the medical record for Patient #4 revealed an un-timed physician order on 2/25/12 for the patient to be NPO at midnight on 2/26/12. Further review of the medical record revealed no diet order changes until an untied diet order occurred on 2/28/12 for a low fat, low sodium, diabetic diet. Review of Meditech diet order entries revealed a diet order entry on 2/27/12 at 4:44 PM for a clear liquid diet. Review of CBORD diet order entries revealed a diet order entry on 2/27/12 at 4:48 PM for a clear liquid diet.

During an interview on 2/28/12 at 4:00 PM, Staff B verified the lack of a physician order for an advancement to a clear liquid diet.

e. Review of the medical record for Patient #5 revealed an physician order on 2/23/12 at 3:27 PM for a mechanical soft, low sodium diet with pureed vegetables and pudding-thick liquids. Review of Meditech diet order entries revealed a diet order entry on 2/23/12 at 3:31 PM for a mechanical soft, low sodium diet with pureed vegetables and pudding-thick liquids. Review of CBORD diet order entries revealed the current active diet order included a low salt, low sodium, pureed diet with pudding-thick liquids.

During an interview on 2/28/12 at 10:20 AM, Staff B verified the discrepancy between the diet order entry in Meditech and CBORD. Staff B explained the diet order was clarified with the provider, following the written order at 3:27 PM and he/she entered the diet clarification into CBORD. Staff B confirmed the medical record lacked documentation of the diet order change.

I. Based on observation, policy review and staff interviews, the dietary staff failed to protect food from contamination and follow hospital policy during patient meal tray service. The Director of Food and Nutrition Services reported the hospital served approximately 75-150 patient meals daily.

Failure to follow the hospitals established sanitation standards and procedures could potentially lead to contamination of patient food.

Findings include:

1. Review of a hospital policy titled "Table and Tray Service", last reviewed and approved on 2/24/12, revealed in part " . . . Procedure: Tray Service . . . 3. Cover all foods and utensils on meal trays that are transported through a public hallway in an open cart or otherwise unprotected . . . "

2. During patient meal delivery service on 2/28/12, from 11:52 a.m. to 12:14 p.m., observed 12 meal tray deliveries on the medical/surgical unit and 7 meal tray deliveries on the orthopedic unit. Patient meal trays arrived on each unit in an enclosed cart, which was placed in one central area of the hallway. On each unit, Staff C, Staff D, Staff E and Staff F, tray passers, removed patient meal trays from the enclosed cart and carried the trays throughout the halls of each unit to the respective rooms. Staff C carried two patient meal trays to other units. The meal trays included uncovered items such as peaches, cookies, gelatin, lettuce salads and coffee. During an interview at the time, Staff F confirmed confirmed patient meal meal trays may contain uncovered items and the observed procedure for passing the patient meal trays, was their usual procedure.

3. During an interview on 2/28/12 at 3:50 PM, Staff A, Director of Food and Nutrition Services, reported he/she would expect all items on a patient meal try to be covered if transported a distance beyond right outside the patient's room. Staff A acknowledged concern regarding uncovered food items transported the distance observed by surveyor and reported a change in the procedure would be implemented. During a follow-up interview on 2/29/12 at 3:35 PM, Staff A reported he/she directed staff to begin covering all foods items on patient meal trays.


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II. Based on observation, document review, and staff interview, the hospital failed to ensure that employees followed manufacturers' recommendations for the use of a hospital approved disinfection product (Metricide 28) in cleaning trans-vaginal probes used for ultrasounds for the Radiology department. The Director of Radiology reported completed approximately 20 pelvic ultrasound procedures monthly.
Failure to use disinfection products as directed by the manufacturer potentially puts patients at risk for exposure to infections and blood borne pathogens.
Findings include:
An observation on 02/29/12 at 1:53 PM, during the tour of the Radiology department, with Staff O, Radiology Technician, showed MetriCide 28 disinfectant used for disinfection of Ultrasound trans-vaginal probes. The opened bottle of MetriTest strips lacked an opened and discard date. Staff O verified there were no additional test strips in the Radiology Department available for use.

A review of the product insert for MetriTest strips provided by Staff O, on 02/29/12, revealed in part ... " Shelf Life-When opening the bottle for the first time, record the date opened in the space provided on the immediate container label and fill in the 90-day " Do not use after " date directly below ....Precautions: Do not use any remaining strips 90 days after opening the bottle. "

A review of the product insert for the MetriCide 28 provided by Staff O, on 02/29/12, revealed in part ... " High-Level Disinfectant: MetriCide 28 and MetriCide Plus 30 solutions are high-level disinfectants when used or reused, according Directions for Use, at full strength for a maximum of 28 days at 28 degrees Celsius with an immersion time of at least 90 minutes.

A review of the policies and procedures for the Radiology Department revealed the hospital staff failed to develop and implement policies and procedures that delineated the proper use of the MetriCide 28 disinfectant in the Radiology Ultrasound Department.

A review of the log used to record the use of the undated MetriTest strips revealed a title of "Cidex Testing" used to record the effectiveness of the MetriCide 28 disinfectant.

During an interview on 2/29/12 at 1:53 PM, Staff Q, Director of Radiology revealed the ultrasound department had been using MetriCide 28 and MetriTest strips for approximately 6 months. Staff Q revealed the facility lacked a policy for the use of MetriCide 28 and MetriTest strips and failed to update the log used for recording the effectiveness of the MetriCide 28 and the use of the MetriTest strips.

During and interview on 2/29/12 at 1:53 PM, Staff O revealed the Ultrasound trans-vaginal probes were soaked for approximately 20 minutes in the MetriCide 28 solution, when the product insert recommended soaking the probes for 90 minutes.

Based on document review, observations and staff interviews the anesthetist failed to maintain 36 vials of Dantrium, a medication used to treat a surgical emergency condition called Malignant Hyperthermia. Malignant Hyperthermia involves high fever, fast and irregular heartbeat, and breathing problems that can lead to death if not treated immediately. Surgical staff stated approximately 30 procedures requiring general anesthesia are done a day in surgery, same day surgery and/or scope procedures .

Failure to maintain the standard 36 bottles of Dantrium in surgery could potentially lead to an incomplete treatment of Malignant Hyperthermia which could lead to death of the patient.

Findings include:

1. Review of Anesthesia policies revealed the administrative staff failed to develop and implement policy and procedures that delineated the proper use and dosage of Dantrium for the crisis intervention for Malignant Hyperthermia developed during surgery.

Review of the acute care hospital policy, "Drug Procurement - Emergency orders - Nonformulary Requests" effective date 6/83 revealed in part, "A true emergency of a critical situation demands prompt response...
Procedure: The search to locate a drug not stocked, or perhaps deleted, shall begin at the local level...list of hospitals routinely called before trying one in Des Moines..." A search of MapQuest revealed the closest hospital would be approximately 32 minutes from the acute care hospital in an immediate need of Dantrium.

Review of a "Variance Report" dated 3/6/12 revealed in part, "'Date of incident 3/5/12: On examination, it was found that there were only 35 bottles of Dantrium instead of the anticipated 36 bottles. The drug is kept in the M.H. (Malignant Hyperthermia) cart with 6 boxes of 6 bottles each. The disposition of this missing bottle was unknown..."

Reviewed of a medication invoice dated 3/5/12 revealed in part, "...Dantrolene Sodium...selling unit 6..."

2. During initial tour of surgery operating room #5 on 3/5/12 at 12:01 PM, revealed a locked anesthesia cart. Practitioner A, Certified Registered Nurse Anesthetist, opened the anesthesia cart to reveal 6 boxes of Dantrium. Practitioner A stated there needed to be 36 bottles of Dantrium on hand to treat the emergency condition Malignant Hyperthermia. Practitioner A, after opening the 6 boxes of Dantrium, confirmed 1 box contained only 5 bottles of Dantrium for a total of 35 bottles. Practitioner A stated there should be 36 bottles of Dantrium and did not know where the one bottle missing could be.

During an interview on 3/5/12 at 12:15 PM, Practitioner A stated Pharmacy did not have a record of the missing bottle of Dantrium.