HospitalInspections.org

Based on observation and document review the facility failed to ensure that monitor lead pads were of a quality that would give accurate readings.

Failure to do so could result in inaccurate heart monitor readings in an emergency circumstance.

Findings:

1. At 9:30 AM on 9/30/2015 Surveyor #2 observed that cardiac monitoring electrode pads were stored in an open bin on the crash cart on the Acute Care unit. Later, at 9:45 AM in the Emergency room the three rooms similarly had the electrode pads stored. It could not be determined how long the pads had been out of the package. The Assistant Director of Nursing Services (Staff Member #1) confirmed these observations.

2. The manufacturer packaging provided by Staff Member #1 read in part: "Prevention: To prevent dryout, do not store out of bag for more than 30 days."

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Item #1 Cross Contamination

Based on observation and document review, the facility failed to effect measures to prevent infection.

Failure to do so places patients at risk of debility related to infectious disease.

Findings:

1. On 10/20/2015 at 3:00 PM Surveyor #2 observed the initiation of an intravenous infusion. Extra supplies were brought into the patient room by a registered nurse (Staff Member #2) and placed on the bedside table, a high touch potentially contaminated area, directly next to the patient. After accomplishing the procedure the registered nurse took the unused, potentially contaminated supplies, out of the room and replaced them with the other patient care supplies stores in the supply room.

2. Facility policy titled "Standard Precautions and Respiratory Hygiene" effective date 10/19/2015 read in part: " Portable Healthcare Equipment -- Hospital approved disinfecting wipes or 70% alcohol wipes shall be used on portable healthcare equipment...between patients in any setting...".

3. On 10/21/2015 at 9:40 AM Surveyor #2 observed Staff Member #3, a registered nurse (RN), administer medications to a patient. The RN moved a computer-on-wheels into the patient's room, gave the medications, then removed the computer. At no time did s/he clean or sanitize the computer.

4. On 10/21/2015 at 9:40 AM Surveyor #2 observed an RN (Staff Member #3) administer medications to a patient. During preparation s/he dropped a keyring on the floor, picked it up, and did not perform hand hygiene afterward;


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Item #2 Sanitizer Solution

Based on observation, and interview, the hospital failed to ensure that staff members were consistently providing the proper concentration of sanitizer solution when cleaning patient rooms.

Failures to provide proper concentration of sanitizer solution places patients at risk for increase infections.

Findings:

On 10/20/2015 at 10:00 AM, during an observation of a daily clean of a patient room, (room #107) surveyor #1 observed a house keeper (Staff Member #4) wiping down surfaces using a sanitizer solution in an unmarked container. When asked how the housekeeper determines the concentration, the infection control officer (Staff Member #5), stated in part that they use a 1:10 ratio. Surveyor #1 observed the housekeeper pour an unspecified amount of bleach and water into an unmarked container unable to determine the correct ratio of sanitizer solution.

Based on interview and record review, the facility failed to ensure that nutritional needs of patients were met.

Failure to do so placed patients at risk of malnutrition or other complications of poor nutrition.

On 10/20/2015 at 10:45 AM Surveyor #2 reviewed the record of Patient #1. The patient 's record revealed that his/her blood sugar had been rising during the hospital stay. His/her diagnosis list included diabetes. The admission assessment indicated that the patient needed diabetes education. However there was no documentation that the consultation with the dietician had been sought. The Assistant Director of Nursing (Staff Member #1) checked with the dietician, who stated s/he had not received notification of the need for a consultation and had not performed one. The patient had been in the hospital since 10/17/2015.

Based on record review and interview, 2 of 2 patients (Patients #2, 3) had no record of advanced directives in their charts.

Failure to do so placed patients at risk of unwanted interventions in the event of a decline in their condition, or failure to implement required measures.

Findings:

1. During review of former patient records on 10/21/2015 beginning at 2:00 PM Surveyor #2 evaluated two records for evidence of advanced directive information.

2. For Patient #2 there was no documentation of advance directive information; this was confirmed by Staff Member #1 (Assistant Director of Nursing) on 10/22/2015.

3. For Patient #3 the document which was to address advanced directives was signed but not filled out, so there was no pertinent information available.

Based on record review, the facility failed to document the benefit of transfer for patients requiring a higher level of emergency care..

Failure to document informed consent placed patients at risk of incomplete documentation of care and consultation.

Findings:

Surveyor #2 reviewed records of former emergency department (ER) patients beginning on 10/21/2015 at 3:00 PM. Four of four patients (Patients #4, #5, #6, #7) who were transferred out to a higher level of care had consent forms that were incomplete or inaccurate.

1. The form "Authorization for Transfer" (no date) read in part that the risks of transfer were "traffic delays, accidents, rough ride...". There was the ability to individualize both the sections on risks and benefits.

2. Review of the transfer consent forms for patients #4, #5, #6, #7 revealed that no documentation of transfer benefits had been done. This was confirmed by the Assistant Director of Nursing (Staff Member #1) during the review.