HospitalInspections.org

Based on review of facility documentation and interview, the hospital failed to provide oversight of dialysis services, a contracted service, to ensure patient safety. The finding includes the following:

Review of portable reverse osmosis logs for the dialysis unit during the period of 1/1/11 through 9/6/11 identfied abnormal pump pressures. Although the pump pressure should be > 150, review of the logs identified pump pressures of 130-152. Documentation failed to reflect that biomedical staff were made aware of the low pump pressures in an effort to resolve the issue. Interview with the Biomedical staff member stated that pump pressures are based on manufacturers guidelines and was unsure if the identified "normal" pressure was accurate.

Based on observation and interviews, the facility failed to maintain a safe environment in a patient care area. The finding includes:

a. During a tour of the North 2 unit on 9/8/11 at 10:12 AM, a maintenance cart containing multiple paint cans and other equipment was observed unattended in the corridor. Continued observation for more than a full minute identified that the cart remained in the center of the corridor, unattended and unsupervised by any staff member. Upon walking toward the cart, Maintenance Person #1 was observed in a patient room, two doors away from the cart, with his/her back to the opened door, and was speaking with another employee. Upon closer observation of the top shelf of the unattended cart, the cart was observed to have a screwdriver, a putty knife, and multiple paint can openers, accessible to passersby. Interview with Maintenance Person #1 at the time of the observation identified that he/she reported that he/she had only left the cart unattended "for a minute." Interview with Clinical Leader #10 on 9/8/11 at 10:15 AM identified that based on the patient population on the unit, facility policy would direct that all carts be secured at all times and not left unattended for any length of time.

Based on clinical record review and interview for one of two sampled patient's (Patient #3) who utilized restraints, the clinical record lacked a comprehensive assessment and /or evidence that the least restrictive device was attempted prior to the initiation of restraints. The findings include:

1. Patient #3's diagnoses included hypertension, diabetes and recent hip fracture. A review of an Emergency Department record dated 3/8/11 at 10:55 AM identified Patient #3 ' s behavior as confused, pulling at tubes and that a belt restraint was applied. Interview with Registered Nurse #5 on 6/29/11 at 3:15 PM identified that a waist restraint was utilized following the fall as the patient attempted to get out of bed independently resulting in a fall with injury. A review of the hospital physical restraint and seclusion policy identified that alternatives to restraint must be considered prior to the application of restraint. Stepwise progression should always be attempted starting with the least restrictive nonphysical intervention. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, staff or others. Interview and review of the clinical record with Nurse Manager #2 on 6/15/11 at 11:15 AM failed to provide evidence that alternative interventions were attempted prior to the application of a waist restraint.

2. Physician orders dated 3/8/11 at 2:13 PM directed to utilize a Soma bed (enclosed bed) due to increased confusion/ trying to get out of bed. Interview with Nurse Manager #3 on 6/16/11 at 11:40 AM identified that the patient utilized a Soma bed from 3/8/11 to 3/10/11 at which time a personal alarm was implemented. The Nurse Manager further identified that he/she initiated the Soma bed as a result of the patients history of falls, however failed to provide evidence that alternative interventions were attempted prior to the initiation of a Soma bed.

Based on clinical record review and interview for one of two sampled patients (Patient #3), who utilized restraints and/or antipsychotic medications, the clinical record lacked documentation of specific behaviors necessitating the use of antipsychotic medication. The findings include:

Patient #3's diagnoses included hypertension, diabetes and recent hip fracture. Physician orders dated 3/9/11 directed to administer Haldol 1 milligram (mg) intramuscularly (IM) every six hours as needed for agitation. A neurological consult dated 3/9/11 identified that the worsening confusion was possibly due to worsening congestive heart failure, although possible medication related. Recommendations included continuing Seroquel for agitation if needed, but avoiding sedating medications if possible. A review of the medication administration record for the time period of 3/8/11- 3/11/11 identified that Haldol 1 mg IM (intramuscular) was administered on 3/10/11 at 1:30 AM. Interview and review of the clinical record with Nurse Manager #3 on 7/13/11 at 10:45 AM identified that Haldol was given at 1:30 AM for agitation/confusion, however the clinical record lacked documentation of specific behaviors that were exhibited to warrant the use of Haldol IM.

Based on clinical record review and interviews for one of three discharged patients (Patient #8), the facility failed to ensure that the discharge summary accurately reflected the medication orders. The findings include:

Patient #8 was admitted on 5/28/11 to 5/31/11 with diagnoses which included End Stage Renal Disease (ESRD), hypertension and diabetes for treatment of right lower extremity edema. A review of the transfer summary dated 5/31/11 identified that the patient was being discharged to a short term rehabilitation facility with medications that included Insulin Novolog 8 units subcutaneous before meals and Insulin Detamir 12 units subcutaneous at bedtime. A nurse's note dated 6/1/11 at 5:00 AM from the extended care facility identified that the patient was found unresponsive, with an oxygen saturation of 80% on 2 liters of oxygen and a blood sugar reading of low. A review of the Emergency Department record dated 6/1/11 identified that Patient #8 was found unresponsive by the staff at the extended care facility and presented to the Emergency Department in respiratory arrest and subsequently admitted to the Intensive Care Unit. A review of the Intensive Care Unit attending note dated 6/3/11 at 2:30 PM identified that the cause of the patient's altered mental status may be related to a low blood sugar that resulted from an excessively high dose of 70/30 insulin that was ordered in error. This low blood sugar may have interfered with his breathing, contributing to his unresponsiveness.

Although the transfer summary dated 5/31/11 identified that the patient was being discharged to a short term rehabilitation facility with medications that included Insulin Novolog 8 units subcutaneous before meals and Insulin Detamir 12 units subcutaneous at bedtime, a review of the patient discharge medications/ instructions dated 5/31/11 identified newly added medications that included Humulin insulin 70/30, 10 units subcutaneous in the morning and Humulin insulin 70/30, 50 units in the evening. Interview with the Director of Nurses from the extended care facility on 6/14/11 at 12:30 PM identified that Patient #8 received 50 units of Humulin insulin on 5/31/11 at 9:00 PM. A review of the hospital discharge planning policy identified that the physician must provide the discharge order, record discharge medications on the W-10 or the instruction form, and record any other instructions on the discharge instruction form. Interview and review of the clinical record with MD #3 on 6/14/11 at 2:00 PM identified that MD#2 verified the correct dose of insulin (12 units of Insulin detamir at bedtime) to be ordered at the time of discharge with his/her supervising attending, however did not update the discharge medication list prior to the patient being transferred to the extended care facility which resulted in a discrepancy of the discharge medications.

Based on review of the clinical record, review of facility policies, and interview, the facility failed to ensure that pain assessments/reassessments were completed in accordance with facility policies for three of four patients, Patients #56, #80 and #81, who required pain management. The findings include:

1. Patient #56 was admitted to the hospital on 9/6/11 with a hernia repair. Review of the physicians orders dated 9/6/11 identified that the patient was to receive Dilaudid 0.2mg IV every five minutes as need for a pain rated at 4-5. Review of the Post Anesthesia Care Unit (PACU) record identified that although the patient received pain medication at 9:03 A.M., the patient was not assessed for pain prior to administering pain medication. Review of hospital policy " Pain Management " identified that all patients are to be evaluated for pain prior to any intervention. Interview with the Nursing Director of Surgical Services on 9/6/11 identified that pain assessments are to be completed prior to medication administration.

2. Patient #80 was admitted to the facility on 9/1/11 with diagnoses than included depression and a fractured right finger, casted prior to admission. Patient #80's medical history included a lobectomy with chest tube placement within the previous year. The treatment plan dated 9/1/11 identified the potential for chest pain and pain due to the fracture with interventions that included to assess Patient #80's pain every shift and to monitor the effectiveness of administered medications. Review of the clinical record identified that on 9/5/11 at 4:07 PM, Patient #80 reported chest pain at a level of six out of ten, utilizing a scale of zero to ten, zero reported if no pain and ten if reported as the worst pain. The clinical record lacked documentation to reflect that any intervention was administered to relieve Patient #80's pain level at that time. At 7:48 PM, Patient #80 reported a pain level of eight at which time a nebulizer treatment was administered with effect.

3. Patient #81 was admitted to the facility on 9/3/11 with diagnoses that included depression and substance abuse. Patient #81's medical history included chronic arthritis. The treatment plan dated 9/3/11 identified the potential for pain due to arthritis with interventions that included to assess Patient #81's pain every shift and to reassess the patient after intervention. Review of the clinical record identified that on 9/7/11 at 9:21 PM, Patient #81 reported a pain level of seven out ten. The clinical record lacked documentation to reflect that any interventions were implemented at that time. No further reassessment for pain was provided until 6:44 AM on 9/8/11 at which time Patient #81 reported his/her pain level remained at seven. The physician was notified and a one time order of Percocet, two tablets, was administered.
In addition, the clinical record lacked documentation that Patient #81 was reassessed for pain after the intervention of Percocet at 6:44 AM, for more than four hours. At the time of the reassessment at 10:45 AM, Patient #81 reported his/her pain level remained at a seven out of ten.
Interview with Clinical Leader #10 on 9/8/11 at 11:00 AM identified that staff was expected to provide timely assessments and pain management in accordance with facility policies. Facility policy directed that pain assessments be completed at least every shift. The policy directed that anytime an intervention to relieve pain is employed, a reassessment of pain level will be made within one hour.




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Based on clinical record review, review of hospital policy and procedure and interviews with facility personnel for one sampled patient (Patient #73) who had pressure ulcers, the facility failed to ensure that the pressure ulcers were assessed and/or the care plan developed/revised in accordance with facility policy and procedure. The findings include:

a. Patient #73 was admitted to the facility on 4/16/11 with mental status changes and difficulty breathing. The nursing admission assessment dated 4/16/11 identified that the patient had multiple skin issues including a Stage II pressure ulcer in the thoracic vertebre area. On 4/23/11, a Stage II pressure ulcer to the right outer elbow was identified. A subsequent progress note dated 4/28/11 identified that the pressure ulcer to the right outer elbow was assessed as an unstageable area which measured 1 centimeter (cm) by 0.8cm. Review of the clinical record from 4/16/11-5/5/11 failed to reflect that wound assessments were consistently completed per hospital policy.

b. On 4/27/11, Patient #73 was taken to the operating room for a tracheostomy. Review of nursing docuementation identified that the patient had a Stage III pressure ulcer under the trach device. Further review failed to identify that the area was measured. Review of a wound care consult dated 5/5/11 identified that the patient had an unstageable pressure ulcer to the patient's superior sterum related to contact with the trach flange with the ulcer measuring 4cm by 0.5cm with a thin slough layer. Patient #73 was noted to be very kyphotic with increased protusion of the sterum in this area. A subsequent assessment conducted by the wound care consultant on 5/12/11 identified that the patient had a Stage III pressure ulcer measuring 3cm by 1.5cm by 1cm with 40% thin white slough and 60% pink despite the silflex stoma pad. On 5/18/11, Patient #73's trach was changed to a #8 portex to provide a softer base.
Review of the nursing care plan dated 4/11-5/11 failed to reflect the patient's skin integrity issues.
Review of the facility "Pressure Sore Policy" identified that on admission and minimally every seven days, additional assessment and documentation should include stage, measurements, wound bed appearance, drainage, overall assessment and plan of care continued or changed. Interview with the Nurse Manager on 9/7/11 identified that the patient's skin issues were not consistently documented.




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Based on clinical record review and interviews for one of two sampled patients (Patient #3) who were known to be at a risk for falls, the clinical record lacked a comprehensive fall risk assessment. The findings include:

Patient #3's diagnoses included hypertension, diabetes and recent hip fracture. The patient was seen in the Emergency Department (ED) on 3/7/11 for changes in mental status and increased agitation at the extended care facility. A review of the Emergency Department record dated 3/7/11 at 8:48PM identified that Patient #3 was alert, confused and that the bed was placed in a low locked position with two side rails up. An ED nursing note dated 3/8/11 at 10:02AM identified that the patient was found sitting on the floor near the door at 9:15 AM. The physician assessed the patient and directed to obtain a pelvic X-ray which revealed a left superior pubic ramus and ischium fracture. Interview and review of the clinical record with Nurse Manager #2 on 6/15/11 at 11:15AM identified that although the patient's history of falls and the need for a 1:1 sitter in the extended care facility was known, a comprehensive fall risk assessment was not completed until 3/8/11 at 10:07AM following the fall.


Based on clinical record review and interviews for three of eight patients (Patients #4, #45 and #60) who required intake and output monitoring, the facility failed to ensure that intake and outout monitoring was done in accordance with physician orders. The findings include:

1. Patient #4 was admitted to the hospital on 5/6/11 for an anterior cervical discectomy at C5-6, C6-7. Physician orders dated 5/6/11 directed to monitor intake and output each shift and to remove the indwelling catheter in the recovery room. A review of the nurse's notes dated 5/6/11 at 8:00 PM identified that the patient was transferred to the nursing unit from the post anesthesia care unit and was due to void between 10 PM and 12 AM. Nurse's notes dated 5/6/11 at 8:00PM identified that the patient was transferred to the nursing unit. A review of the intake and output documentation from 5/6/11 to 5/7/11 identified a total intake of 5220 (cubic centimeters) cc's and a total output of 500cc's which was documented in the operating room and post anesthesia care unit. Although the nursing assessment for 5/7/11, 11 PM-7 AM shift identified that the patient utilized the urinal, the intake and output summary for 5/6/11 through 5/7/11 lacked documentation of urinary output. Interview with Nurse Manager #10 on 9/6/11 at 11:20 AM identified that it is the responsibility of the nurse to document intake and output in the clinical record, which includes accurate measurement of the patient 's output. He/ she further identified that if the patient does not void following the removal of an indwelling catheter, the physician is notified and directs the staff to perform further bladder assessment which may include a bladder scan, straight catheterization and/or reinsertion of the indwelling catheter. A review of the hospital intake and output policy directed to measure and record the amount in milliliters (ml) of output, to include urine, emesis, liquid stool, drainage, and significant insensible water loss.

2. Patient #48 (P#48) was admitted to the hospital on 8/26/2011 for gastroenteritis, diahrrhea and dehydration. Subsequently, P#48 underwent a sigmoid resection on 9/1/2011. Review of physician orders indicated that post-procedure on 9/1/2011 at 2:23 PM, orders were entered for strict intake and output every four hours, nothing by mouth (NPO), a foley catheter, and intravenous fluids (Lactated Ringers) at a rate of 100 ml/hour. Review of the Intake and Output Summary from 9/1/2011 through 9/6/2011 indicated that on 9/3/2011 at 8:00 AM, 9/4/2011 at 4:00 PM, and 9/5/2011 at 4:00 PM, P#48's urine output was not measured and documented in millileters (ml). Review of hospital policy titled "Intake and Output" directed to measure and record the amount in milliliters of output to include urine, emesis, liquid stool, drainage, and significant insensible water loss. Interview with RN#15 on 9/6/2011 at 1:50 PM identified that for a patient on strict intake and output, all output should be measured and documented in milliliters.

3. Patient #60 (P#60) was admitted to the hospital on 9/4/11 with diagnosis that included pneumonia, congestive heart failure and chronic obstructive pulmonary disease. Patient #60 was treated with oxygen therapy, antibiotics, diuretics, steroids, and respiratory treatments. Physicians orders dated 9/4/11 directed strict intake and output every shift. Review of the Intake and Output Summary from 9/5/11 to 9/7/11 indicated that on two occasions P #60's urine output was measured in milliliters (ml). On all other occasions the Intake and Output Summary sheet indicated that the patient had voided but an amount was not measured and documented in milliliters (ml). Interview with RN #16 on 9/7/2011 at 11:00 AM identified that for a patient on strict intake and output, all output should be measured and documented in milliliters. Review of the hospital policy for "Intake and Output" directed to measure and record the amount in milliliters of output to include urine, emesis, liquid stool, drainage, and significant insensible water loss.



Based on clinical record review and interviews for one of four post -operative patients (Patient #4), vital signs were not completed according to physician orders and /or the clinical record lacked documentation of a comprehensive physical assessment. The findings include:

a. Patient #4 was admitted to the hospital on 5/6/11 for an anterior cervical discectomy at C5-6, C6-7. Postoperative physician orders directed to obtain vital signs every hour times 4, every 2 hours times 4 then every shift. Interview and review of the Director of Regulatory Affairs on 6/15/11 at 11:15AM identified that the clinical record lacked documentation of the every two hour vital signs as directed by the physician.

b. Patient #4 was transferred from the PACU to the nursing unit on 5/6/11 at 5:10 P.M. A review of Patient #4's progress notes dated 5/7/11 at 4:05AM identified that the patient was seen at 3:25AM at which time a new intravenous(IV) solution bag was hung. A subsequent entry identified that Registered Nurse (RN)#7 entered the room again at 4:05AM and the patient was found unresponsive at which time a Code was initiated. Patient #4 was transferred to the Intensive Care Unit following the Code where he expired on 5/12/11. Interview with RN#7 on 6/16/11 at 8:45AM identified that vital signs were completed by the nurse aide at 11:30PM and he/she assessed the patient at 1:30AM at which time the patient was alert, oriented and sitting up in bed. RN #7 further identified that he/she entered the room at approximately 3:25AM to change the IV fluids at which time the patient was sleeping. RN#7 responded to the IV pump alarm a short time later, at which time the patient was found unresponsive. Although review of the hospital policy regarding documentation of the nursing process identified that ongoing assessment must be done at least every eight hours as evidenced by documentation on flow sheets, care worklists, problem list or clinical pathway and/or progress notes, interview and review of the clinical record with Nurse Manager #4 on 6/15/11 at 1:05PM identified that although neurological signs and the surgical site were monitored, the clinical record lacked a comprehensive physical assessment that included but not limited to, respiratory assessment, bowel sounds and/or complaints offered.


Based on clinical record review and interviews for two of four postoperative patients (Patient #31 and 32), neurological assessments were not completed as directed by physician's orders. The findings include:

1. Patient #31 was admitted on 6/9/11 for a lumbar fusion for L1-through L4. Physician orders dated 6/10/11 directed to monitor vital signs and neurological checks every four hours. Interview and review of the clinical record with Nurse Manager #4 on 6/16/11 at 11:55AM identified neurological checks were completed on 6/10/11 at 1:07PM and then not again until 6/12/11.

2. Patient #32 was admitted on 6/14/11 for an anterior cervical discectomy and fusion at C6-7. Physician orders dated 6/14/11 directed to monitor vital signs and neurological checks every four hours for 24 hours. Interview and review of the clinical record with Nurse Manager #4 on 6/16/11 at 11:55AM identified neurological checks were completed on 6/14/11 at 12:20PM, 4:30PM and at the time of discharge on 6/15/11. He/she further identified that the clinical record lacked consistent documentation of vital and neurological signs as directed by the physician.





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Based on clinical record reviews, hospital documentation, and interviews with facility personnel for three of three sampled patients (Patient #60, #45 and #44), the facility failed to complete a comprehensive plan of care. The findings include:

1. Patient #60 was admitted to the hospital on 9/4/11 with diagnosis that included pneumonia, congestive heart failure, and chronic obstructive pulmonary disease. Patient #60 was treated with oxygen therapy, antibiotics, diuretics, steroids, and respiratory treatments. On 9/4/11 a physician's order directed Heparin Sodium 5000 units subcutaneous every eight hours as a prophylactic measure. Interview and review of the clinical record with RN #16 on 9/7/11 at 11:15 AM failed to identify bleeding risk as an active problem with interventions that were individualized for Patient #60. Review of the hospital policy for "Documentation of Nursing Process" directs in part that problems specific to patient's needs must be identified on each patient and followed daily.

2. Patient #45 was admitted to the hospital on 9/3/11 with diagnosis that included bipolar disorder, opiate dependence. diabetes mellitus and respiratory compromise secondary to a lung tumor. Patient #60 was treated with mood stabilizers, opiates, insulin and oxygen therapy. On 9/3/11 a physician's order directed oxygen administration at 2 liters via nasal cannula to keep oxygen saturation levels greater then 92%. Interview and review of the clinical record with the Nurse Manager of the psychiatric unit on 9/6/11 at 1:30 PM failed to identify respiratory compromise as an active problem with interventions that were individualized for Patient #45.

3. Patient #44 was admitted to the hospital on 8/27/11 with diagnosis that included a cerebral vascular accident, coronary microvascular disease, and ventricular tachycardia. A cardiac catheterization was performed on 9/1/11 and an automated implantable cardioverter defibrillator was placed on 9/7/11. Review of the clinical record identified that Patient #44 was treated with anticoagulant therapy and will be undergoing open heart surgery in a few weeks . Interview and review of the clinical record with RN #14 on 9/7/11 at 2:00 PM failed to identify a bleeding risk as an active problem with interventions that were individualized for Patient #44. Subsequent to surveyors inquiry a nursing care plan for bleeding risk was initiated.

Based on observations and interviews with facility personnel, the facility failed to ensure that appropriate personnel had access to medications in a secure location.
The findings include:

During tour of the anesthesia work room on 9/6/11, it was observed that housekeeping staff had access to the security code to enter the work room where all medications for anesthesia are stored. Review of the hospital policy " Medication Storage " identified that ancillary areas shall store medications in secure/locked storage areas. Interview with the Nursing Director of Surgical Services on 9/6/11 identified that housekeeping staff are not to have the code to enter the anesthesia room.

Based on observation, review of facility policies and interview, the facility failed to ensure that expired solutions were discarded promptly. The finding includes:

During a tour of the North 2 medication/supply room on 9/8/11 at 10:20 AM, two bottles of Betadine solution stored in the cabinets were observed to have expired in July of 2010 and June of 2011. The expiration on a third bottle of Betadine was worn and unreadable. In addition, two bottles of alcohol for topical use were observed to have expired in August of 2011. Facility policy directed that expired medication/solutions would be discarded promptly. Interview with the Vice President/Executive Director at the time of the observation identified that the items would be immediately discarded and likely not restocked due to limited use of the products.

Based on review of facility records, procedures, and equipment, the facility failed to conduct a periodic inspection and/or survey of equipment to ensure a safe environment. The findings include:

Review of the Nuclear Medicne Department on 9/27/11 identified that a survey meter was in use that was uncalibrated and was potentially contaminated with hazardous material.

Based on review of the clinical record, interview and review of facility policy, the facility failed to ensure that for one patient who was identnfied as a moderate nutritinal risk (Patient #43) was re-assessed in accordance with policy and procedure. The finding includes the following:

Review of Patient #43's clinical record on 9/6/11 identified that the patient was admitted on 8/16/11 with intractable vomiting, gastroparesis and required hemodialysis. The clinical record indicated that the patient was evaluated by the Dietician on 8/20/11 and 8/23/11. The Dietician's note dated 8/23/11 identified that the patient was a moderate nutritional risk however the clinical record failed to identify that the patient had been seen by the Dietician for the period of 8/24/11 through 9/6/11. Interview with the Dietician on 9/6/11 identified that when a patient has been identified as a moderate risk they are re-screened again, but this re-screening process was done on the computer and a note is not necessarily placed in the record. The Dietician stated that patients are seen based on priority and that all high risk patients are seen first. Review of the policy indicated that patients identified as a moderate risk will be reassessed every 5-7 days.

Based on observation and interview, the hospital failed to ensure that emergency supplies were maintained at an acceptable level of safety and quality. The finding includes the following:

During a tour of the Emergency Walk-in Center on 9/7/11 with the Charge Nurse, expired endotracheal tubes, with expiration dates of 12/08 and 4/09 were observed in the triage room in a pediatric tackle box on top of the crash cart.

Based on observations and interviews with facility personnel, the facility failed to ensure that infection control practices were maintained.
The findings included:

1. During tour of the ambulatory surgery area on 9/6/11, it was observed that the soiled utility room contained multiple bags of trash and soiled items on the floor. Review of hospital policy " Medical Waste Handler " identified that environmental staff rounds regularly to remove waste, however if additional services are needed the staff would need to call for pick up. Interview with the Nursing Director of Surgical Services on 9/6/11 identified that staff could call environmental services if the trash was overflowed.

2. During tour of the GI Suite on 9/6/11, it was observed that clean scopes, ready for use were noted to be hanging in a closet with the distal end of the scopes making contact withe the floor. Review of hospital policy " Standards for Gastrointestinal Endoscopes " identified that endoscopes are to be vertically hung with the distal tip hanging freely in a clean, well-ventilated, dust-free area. Interview with the Nursing Director of Surgical Services on 9/6/11 identified that the scopes should not have been touching the floor.






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