HospitalInspections.org

A. Based on review of Hospital policy, clinical record review and interview, it was determined that in 5 of 6 (pt. # 4, 5, 7, 8, 9) clinical records reviewed of patients on telemetry monitoring, the Hospital failed to ensure the patients' cardiac rhythm was documented on each rhythm strip.

Findings include:

1. The Hospital policy titled "Telemetry" was reviewed on 5/18/09 at 2:15 PM. The policy included "Nursing Documentation: ... II. A six second telemetry strip will be run every eight hours (record name, medical record number, date, time, heart rate, PR, QRS, QT intervals and rhythm of each strip) and placed in the medical record in the cardiology section..."

2. The clinical record of Pt. #4 was reviewed on 5/18/09 at 10:00 AM. Pt. #4 was an 87 year old female admitted on 5/15/09 with the diagnosis of Rhabdomyolysis. The cardiac strips in the clinical record dated 5/15 at 5:33 PM, 5/15 at 10:35 PM, 5/16 at 2:33 AM, 5/17 at 1:21 AM and 5/18 at 1:05 AM, lacked documentation of the patients' cardiac rhythm.

3. The clinical record of Pt. #5 was reviewed on 5/18/09 at 11:00 AM. Pt. #5 was a 37 year old female admitted on 5/17/09 with the diagnosis of Syncope. The cardiac strip in the clinical record dated 5/18 at 1:58 AM lacked documentation of the patients cardiac rhythm.

4. The clinical record of Pt. #7 was reviewed on 5/18/09 at 1:00 PM. Pt. #7 was a 59 year old male admitted on 5/3/09 with the diagnosis of Fever. The cardiac strips in the clinical record dated 5/3 at 11:51 PM, 5/4 at 10:19 AM, 5/4 at 7:08 PM, 5/4 at 11:41 PM, 5/5 at 4:56 PM, 5/5 at 10:32 PM, 5/6 at 10:22 PM, 5/7 at 7:24 AM, 5/7 at 3:38 PM and 5/7 at 7:18 PM, lacked documentation of the patients' cardiac rhythm.

5. The clinical record of Pt. #8 was reviewed on 5/18/09 at 1:30 PM. Pt. #8 was a 91 year old male admitted on 5/15/09 with the diagnosis of Congestive Heart Failure. The cardiac strips in the clinical record dated 5/16 at 8:20 AM, 5/16 at 3:16 PM, 5/17 at 1:30 AM, 5/17 at 7:58 PM and 5/18 at 12:02 AM, lacked documentation of the patients' cardiac rhythm.

6. The clinical record of Pt. #9 was reviewed on 5/18/09 at 1:45 PM. Pt. #9 was an 83 year old female admitted on 5/13/09 with the diagnosis of Syncope. The cardiac strips in the clinical record dated 5/13 at 7:20 AM, 5/13 at 8:32 PM, 5/14 at 12:18 AM, 5/14 at 8:33 AM, 5/14 at 11:15 PM, 5/15 at 7:44 AM, 5/16 at 8:00 PM and 5/17 at 8:19 AM, lacked documentation of the patients cardiac rhythm.

7. The above findings were conveyed to the Nurse Manager, during an interview, on 5/18/09 at 2:00 PM.

B. Based on review of Hospital policy, clinical record review, dietary order summary list review, and staff interview, it was determined, for 1 of 3 clinical records reviewed on 43 North unit (Pt. #2), that the Hospital failed to ensure that dietary consultations were requested for patients, when indicated.

Findings include:

1. Hospital policy titled "Assessment, Patient" was reviewed on 5/18/09 at 2:50 PM. The policy required: "... To identify patients whose condition warrants a nutritional assessment and refer these patients for an appropriate assessment/ follow-up by a clinical dietician or other qualified professionals..."

2. On 5/18/09 at 1:45 PM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 48 year old male, admitted on 5/8/09, with diagnoses of Weakness, Positive HIV Test, and Profound Weight Loss. The Nursing Admission History dated 5/8/09 at 10:45 PM, included a nutrition screeng which included: "Have you had greater than 10 pounds weight loss during the past 1 month? Yes... Nutrition consult if yes..." An Initial Nutrition Assessment was not found until 5/15/09, 7 days later.

3. An interview was conducted with a Registered Dietician (RD) (E #1) on 5/18/09 at 2:05 PM. The RD stated that nursing had not informed dietary that a nutritional consultation was needed for Pt. #2.

4. On 5/18/09 at approximately 2:30 PM, the Dietary Order Summary List was reviewed. Pt. #2's name did not appear on the list on 5/8/09 or 5/9/09.

5. This finding was conveyed to the 43 North Unit Manager during an interview on 5/18/09 at 2:10 PM.
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A. Based on Hospital policy review, clinical record review, and staff interview, it was determined, for 3 of 6 clinical records reviewed in the Birthing Center, (Pt. #s 10, 11, and 13) that the Hospital failed to ensure a nursing care plan was developed for each patient.

Findings include:

1. Hospital policy entitled, "Plan of Care, Patient," was reviewed on 5/19/09 at 1:00 P.M. The policy requires, "Each patient admitted to the hospital will have a specific care plan... The plan of care is evaluated and modified, as necessary, to ensure that the patient's goals and outcomes are appropriately addressed."

2. On 5/18/09 the clinical record for Pt. #10 was reviewed. This was a 32-year-old female admitted to Labor and Delivery on 5/18/09 with a diagnosis of Induction of Labor. The clinical record lacked documentation of a nursing care plan for this patient.

3. On 5/18/09 the clinical record for Pt. #11 was reviewed. This was a 6-day-old male admitted to Mother/Baby Unit on 5/12/09 with a diagnosis of Newborn Cesarian Section Delivery. The clinical record lacked documentation of a nursing care plan for this patient.

4. On 5/18/09 the clinical record for Pt. #13 was reviewed. This was a 3-day-old female admitted to Special Care Nursery (SCN) on 5/15/09 with a diagnosis of Hyperbilirubinemia/Coombs +. The clinical record lacked documentation of a nursing care plan for this patient.

5. The above findings were conveyed to the Director of the Birthing Center, during an interview on 5/18/09 at approximately 11:30 A.M.

A. Based on review of Hospital policy, clinical record review, and staff interview, it was determined for 1 of 7 patients (Pt. #1) receiving blood transfusions, that the Hospital failed to ensure that blood was not administered greater than 4 hours and that blood form documentation was complete.

Findings include:

1. On 5/18/09 at 3:00 PM, the Blood Transfusion policy was reviewed. The policy required: "L. Blood may infuse for only 4 hours. At the 4 hour mark the infusion must be stopped even if the unit of blood is not finished... P. Once the blood product is infused, return the completed yellow transfusion copy of the requisition to Blood Bank. The pink copy of the requisition should be placed in the medical record."

2. On 5/18/09 at 10:40 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 51 year old male, admitted on 5/14/09, with diagnoses of Abdominal Pain, Cirrhosis, and Ascites. The Report of Blood Transfusion, for Packed Red Blood Cells, dated 5/18/09, included the start time as 1:15 AM and end time as 5:40 AM, (4 hours and 25 minutes). The blood report did not indicate that the transfusion was stopped after 4 hours.

3. Pt. #1's second Report of Blood Transfusion, for Packed Red Blood Cells, dated 5/18/09, included the start time as 6:00 AM and end time as 10:00 AM. However, neither the yes or no box was checked on the report form for "adverse reaction".

4. These findings were conveyed to the 42 South Unit Manager and Medical Surgical Director during an interview on 5/18/09 at 10:45 AM.

A. Based on Hospital policy review, clinical record review, and staff interview it was determined, for 1 of 3 clinical records reviewed on the Mother /Baby Unit, (Pt. #16) that the Hospital failed to ensure the informed consent was complete to include the responsible physician's signature.

Findings include:

1. Hospital policy entitled, "Informed Consent," was reviewed on 05/19/09 at 12:30 PM. The policy requires, "All physicians, including physicians in training, and/or other allied health practitioners who are anticipated to participate in the procedure, should be identified on the consent form."

2. On 05/18/09, the clinical record of Pt. #16 was reviewed. This was a 65 year old female admitted on 5/12/09 for Total Abdominal Hysterectomy for a large endometrial mass. The clinical record contained documentation of an "Authorization for the Performance of Surgical and Other Procedures/Treatments" form which required the responsible physician's signature. The form lacked the physician's signature to attest that the physician explained to the patient, risks and complications of the procedure.

3. The above finding was conveyed to the Director of the Birthing Center, during an interview on 5/18/09 at approximately 11:30 AM.

A. Based on review of the Hospital's Bylaws of the Medical Staff, review of an attestation letter, and staff interview, it was determined that the Hospital failed to ensure all medical records were completed within thirty days as required.

Findings include:

1. The Hospital's, "Bylaws of the Medical Staff of Mac Neal Hospital", were reviewed on survey date 5/20/09 at 10:45 AM. The Bylaws required, "...The Medical Records Department shall notify the physician of an incomplete record 10 days after discharge, and the physician shall have 20 days to complete the charts that are available to them in the Medical Records Department."

2. The Hospital presented an attestation letter dated 5/20/09 that indicated the Hospital had 1202 clinical records that were incomplete, past thirty days.

3. The findings were conveyed to the Regional Health Information Management Director Chicago Market during an interview on survey date 5/20/09 at 10:00 AM.

A. Based on review of Hospital policy, Refrigeration Temperature log review and interview, it was determined that the Hospital failed to ensure the milk cooler was kept at the proper temperature.

Findings include:

1. The Hospital policy titled "Food Storage Temperatures" was reviewed on 5/20/09 at 10:45 AM. The policy included "..B. Foods, which require cold storage, will be held at a temperature below 40 degrees..."

2. A tour of the Food and Nutrition area was conducted on 5/20/09 from 8:45 AM until 10:45 AM. The Refrigeration Temperature Logs for April and May 2009 were reviewed at 10:30 AM. The milk cooler temperatures were recorded daily with a range from 44 to 46 degrees. All daily temperatures were over 40 degrees for April and May 2009.

3. The above findings were conveyed to the Senior Director of Support Services, during an interview, on 5/20/09 at 10:45 AM.


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B. Based on review of Hospital policy, observation and staff interview, it was determined that for 7 of 12 female staff, the Hospital failed to ensure staff adhered to policy relative to uniform standard.

Findings include:

1. The Hospital policy reviewed on 5/20/09 at 1:30 PM, titled, "Department Uniform Standards" required, "3. Jewelry... earrings are to be no longer than 1/2 " in diameter... Only one earring should be worn in each ear. Hoops or dangling earrings are not appropriate...."

2. A tour of Dietary Services was conducted on 5/20/09 between 8:45 AM and 10:45 AM. Seven (7) of 12 female staff encountered in the kitchen, salad prep and tray line areas were either wearing loop, dangling or two earrings in each ear.

3. The above findings were conveyed to the Executive Director of Support Services and the Manager of Dietary Services during an interview on 5/20/09 at approximately 10:45 AM

A. Based on Hospital policy review, observation, and staff interview, it was determined, in 3 of 7 rooms toured in Labor and Delivery, (rooms 3, 4, and 6) that the Hospital failed to ensure disposal of trash during discharge room cleaning.

Findings include:

1. Hospital policy # 018 entitled, "Discharge Room Cleaning," was reviewed on 5/19/09 at 11:00 AM. The policy fails to require emptying of trash during discharge room cleaning.

2. On 05/18/09 at approximately 9:15 AM a tour of Labor and Delivery was conducted. Rooms 3, 4, and 6 were vacant and identified as ready to receive patients. Garbage was in the trash cans in each room.

3. The above findings were conveyed to the Director of the Birthing Center on 5/18/09 at 11:30 AM.

A. Based on observation, review of the HeartStart defibrillator check list and staff interview,it was determined that in 1 of 1 HeartStart defibrillator the Hospital failed to ensure the defibrillator was checked each shift according to checklist requirement.

Findings include:

1. During a tour of the ICU on 5/18/09 between 9:30 AM and 11:00 AM, the HeartStart Defibrillator checklist was reviewed. The checklist required, "Inspect the MRx, accessories and supplies at the change of every shift per AHA (American Heart Association) guidelines. Place a check mark in the box as you check each item in the list below... Then initial the list to indicate the check was performed for that shift." The MRx 2009 check list lacked documentation of inspection for the 2nd and 3rd shifts.

2. The above findings were conveyed to the Manager of Critical Care during an interview on 5/18/09, at approximately 10:30 AM.

B. Based on observation and staff interview, it was determined that in 1 of 2 (OR #10) surgical rooms observed the Hospital failed to ensure expired sutures were not available for use.

Findings include:

1. During a tour and observation of the surgical room #10, on 5/19/09 between 7:00 AM and 8:15 AM, a box containing 25 silk sutures 6.0 expired on 1/09.

2. The above findings were conveyed to the Director of Surgical services during an interview on 5/19/09 at 8:25 AM.

C. Based on observation and staff interview, it was determined that 2 of 2 Hobart mixers in the kitchen bakers area, the Hospital failed to ensure equipment used to prepare food were cleaned after use.

Findings include:

1. A tour of the kitchen and food preparation areas was conducted on 5/20/09 between 8:45 AM and 10:45 AM. The 2 Hobart mixers were dirty, and splattered with dried cream and brown colored substance that could potentially fall onto food being prepared.

2. The above findings were conveyed to the Executive Director of Support Services and the Manager of Dietary Services during an interview on 5/20/09 at approximately 10:45 AM


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D. Based on observation and staff interview, it was determined that in 3 of 7 rooms toured in Labor and Delivery, (rooms 2, 3, and 5) the Hospital failed to ensure patient rooms were maintained in an acceptable condition.

Findings include:

1. On 05/18/09 a tour of the Labor and Delivery Unit was conducted. The wall paper had tears in rooms 2, 3, and 5.

2. The above finding was conveyed to the Director of the Birthing Center on 5/18/09 at approximately 11:30 AM.

A. Based on review of Hospital policy, observation and staff interview, it was determined that on the Intensive Care Unit, 1 of 4 isolation room, the Hospital failed to ensure gown and gloves were worn upon entry into a contact isolation room as required by policy.

Findings include:

1. The Hospital policy titled, "Transmission Based Precaution" reviewed on 5/18/09 at 2:00 PM required, "Gowns are indicated when entering the room... Gloves are indicated for any person entering the room...."

2. During a tour of the Intensive Care Unit on 5/18/09 between 9:30 AM and 11:00 AM, 3 visitors were observed in room 3209 in which a contact isolation sign was posted at the door. The visitors were not wearing gowns and gloves.

3. The above findings were conveyed to the Rapid Response Team (RRT) Nurse during an interview on 5/18/09 at approximately 11:15 PM.


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B. Based on review of Hospital policy, gas sterilizer biological indicator manufacturers's guidelines review, clinical record review, and staff interview, it was determined that the Hospital failed to ensure, that 2 of 3 biological processed indicators were not incubated over 48 hours; that 2 of 3 control biological indicators were dated; that 1 of 3 control biological indicators were dated correctly; and that gas biological indicators tests results were documented.

Findings include:

1. Hospital policy titled: "Gas Sterilizer Monitoring - Biological Indicator" required: B. The Central Service Technician, responsible for operating the gas sterilization is also responsible for using, examining and recording the results of the biological indicator..."

2. The 3M Attest 1278/1278F EO Pack gas sterilizer biological indicator manufacturers's guidelines were reviewed on 5/19/09 at 10:05 AM. The guidelines required: "9. Incubate at least one non-processed Attest biological indicator (positive control) each day a processed control is incubated... 10. Write a C and a date on the label of the positive control indicator...11. Incubate the processed and control biological indicators for 48 hours... for a visual color change readout... The final negative reading (media remains green) is made after 48 hours of incubation... 12. Record the processed and control biological indicator results..."

3. On 5/19/09 between 6:45 AM and 7:45 AM, the Operating Room instrument sterilization area was toured. The gas sterilizer incubator held 6 biological indicators, 3 were processed first load biological indicators. Three were marked "C" for control. Two of the processed indicators (dated 5/15/09 and 5/16/09) were still in the incubator, longer than 48 hours from sterilization.

4. Two of the control biological indicators in the incubator did not contain a date. The third control biological indicator was dated 5/18/09. However, a matching processed indicator (dated 5/18/09), was not in the incubator.

5. The Biological Monitoring System for Ethylene Oxide Sterilization book was reviewed on 5/19/09 at 7:15 AM. The book lacked documentation for the 48 hour results for the 5/15/09 and 5/16/09 processed first load biological indicators. In addition, the book lacked 48 hour test results for biological indicators on 2/2/09, 2/3/09, and 2/4/09.

6. These findings were conveyed to the Regional Director of Supply Chain Management on 5/19/09 at 7:30 AM, during an interview.

A. Based on review of Hospital policy, observation and staff interview, it was determined that in 1 of 2 Surgical Rooms, the Hospital failed to ensure staff adhered to the dress code policy in the Operating Room suite.

Findings include:

1. The Hospital policy titled "Infection Control Guidelines for Operating Room Suite" required, "d. Mask must be worn before entering the operating theater, even if the room is vacant, if it is prepared for a case....mask shall be worn...properly placed to prevent venting at the sides... f. Operating members should remove rings, watches and bracelets.... "

2. A tour and observation of OR suite 10 was conducted on 5/19/09 between 7:00 AM and 8:20 AM. The Surgical Assistant (E#3) entered the room at 7:10 AM wearing a watch. The Surgeon (E #2) entered the room at 7:17 AM, holding on to the mask over the nose and mouth.

3. The above findings were conveyed to the Director of Surgical services during an interview at 8:25 AM on 5/19/09.