HospitalInspections.org

Based on observation, interview and policy review the facility staff failed to provide personal privacy for two (#8 and #9) of two patients receiving medication by exposing patient's body to the public during medication administration.
The facility census was 146.

Findings included:

1. Review of facility policy "Rights and Responsibilities of Patients" which the facility provided to all patients on admission, showed the following direction:
- Patients, or designated representatives, have a right to personal privacy, comfort, and dignity.

Record review of the facility's policy titled, "Medication Administration: Intradermal Injections ", a Mosby Nursing Skills procedure which the facility provided as their policy, showed the following direction:
- Close room curtain or door - Rational: Provides privacy.

2. Observation during medication administration for Patient #8 on 02/07/12 at 8:35 AM showed Staff L, registered nurse (RN) administer Lovenox (thins blood to prevent clotting) injection (introduce fluid into a vein, tissue by a syringe) in the patient's abdomen. Patient was seated in the dining area, a public area. Patient's shirt was pulled up to expose patient's abdomen for the injection.

Observation during medication administration for Patient #9 on 02/07/12 at 8:50 AM showed Staff L, RN, remove a pain patch on patient's back. Staff L pulled up patient's shirt to remove the patch. Staff L exposed Patient #9's entire back and side to the doorway. Staff L failed to close patient's door for medication administration. Hallway outside of patient's room was busy and maintenance staff walked by the room during medication administration.

During an interview on 02/07/12 at 9:30 AM, Staff L stated that we are not supposed to give injections in public, should have taken patient to her room.

Based on record review, interview and observation the facility failed to maintain a complete medical record when they failed to include and maintain rounding precautions sheets in the clinical record for 13 (#24, #26, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38 and #39) of 13 patients reviewed on the psychiatric adult unit, 2 North. The facility census was 146. The psychiatric unit census was 13.

Findings included:

1. Record review of Medical Staff Bylaws, March 3, 2010, Item #21 showed the medical record shall be completed within 30 calendar days after date of discharge.

Record review of Medical Records policy, "IM.7 Content of Medical Records," effective date 1979; revision date 1991," showed the following direction:
Purpose: The content of the medical record for each patient shall be sufficiently comprehensive and detailed to achieve the following:
-reflect the care and assessment including diagnosis, details of diagnostic studies, treatment rendered, and outcome/disposition; and
-serve as a basis for planning a patient's care.

2. Observation on 02/08/12 at 10:54 AM, Staff NN, Psychiatric Certified Nurse Assistant (CNA) and Staff OO, CNA, conducted precaution rounding (ensuring the patients are safe by locating the patients on the unit and observing where the patients are and what they are doing) showed multiple patient names on each of the rounding sheets. Each CNA had one rounding sheet with half the patient names on one rounding sheet and the other half of the patient names on the other rounding sheet.

During an interview on 02/08/12 at 10:54 AM, Staff NN, confirmed multiple patient names are on the one rounding sheet and this is the usual process for documenting the precaution rounding on the psychiatric unit. Staff NN stated she documented the rounding on half of the patients on the unit on one rounding sheet and the other CNA does the same thing for the other half of the patients on the other rounding sheet. Staff NN stated all patients on the unit are monitored every seven minutes unless the patient is on a 1-1 (a staff member assigned to be with the patient at all times).

Review of one of the rounding sheets included rounding documentation for patients #29, #30,#31, #32, #33 and #24.

Review of the other rounding sheet included rounding documentation for the patients #26;#34,#35,#36,#37,#38 and #39.

3. During an interview on 02/08/12 at 11:04 AM, Staff PP, Operations Assistant, stated the completed rounding precautions sheets are kept in the nurse's station on 2 North (psychiatric adult unit) in a folder. After a month's time Staff PP collects the completed rounding sheets from the folder and takes them to her desk and files them for the calendar year. After the end of the calendar year Staff PP boxes up the completed rounding precaution sheets in a box or plastic tub container and moves them to the Outpatient Psychiatric Department storage room. The boxes remain in the Outpatient Psychiatric Department storage for several years. Staff PP stated the reason these documents are not part of the clinical record is the rounding precaution sheets have multiple patient names on the sheet which prevents them from being filed in each patient's clinical record.

4. During an observation 02/08/12 at 11:16 AM of the Behavioral Outpatient Department storage room showed a total of seven boxes and 1 plastic tub filled with psychiatric rounding sheets for 2009, 2010 and 2011. Neither the boxes nor the plastic tub were sealed or secured and the lids were easily removed as demonstrated by Staff PP. The storage room door was open and unlocked, with no one in the room.

During an interview on 02/08/12 at 11:16 AM, Staff PP stated the door to the Behavioral Health Outpatient is unlocked during the day due to patients coming in and out of the area. The Unit is locked at 12:30 PM for the remainder of the day and night. Staff PP confirmed housekeeping staff clean the storage room where the rounding precaution sheets are stored.

During an interview on 02/08/12 at 11:20 AM, Staff QQ, Housekeeper Supervisor, stated housekeepers are assigned to clean the Behavioral Health Outpatient storage room.

During an interview on 02/09/12 at 1:40 PM, Staff FF, Director of Medical Records, stated:
-she was not aware the psychiatric precaution rounding sheets have not been made part of the clinical records;
-she was not aware the psychiatric precaution rounding sheets are being kept in the Outpatient Psychiatric Department in boxes and a plastic tub that date back to 2009;
-the psychiatric precaution rounding sheets are not indexed or tracked by the medical records department;
-if a psychiatric clinical record would have been subpoenaed the missing portion of the clinical record, the rounding precaution documentation, would not be sent as part of the clinical record; and
-the facility will have to make sure the records are made complete.

Based on observation and interview, the facility failed to ensure access to patient identification information was limited to those directly involved in the care of patients. Unauthorized staff, patients and/or visitors had physical access to an unknown number of records which contained patient identification information. The facility census was 146.

Findings included:

1. Observation on 02/08/12 at 10:54 AM, showed Staff NN, Psychiatric Certified Nurse Assistant (CNA) and Staff OO, CNA, conducted precaution rounding (ensuring the patients are safe by locating the patients on the unit and observing where the patients are and what they are doing) for multiple patients on the Behavioral Health Unit. Review of the rounding sheets used by the staff showed multiple patient names on each of the rounding sheets. Each CNA had one rounding sheet with half the patient names on the unit.

2. During an interview on 02/08/12 at 11:04 AM, Staff PP, Operations Assistant, stated that the completed rounding precautions sheets are kept in the nurse's station on 2 North (psychiatric adult unit) in a folder. After a month's time Staff PP collects the completed rounding sheets from the folder and takes them to her desk and files them for the calendar year. After the end of the calendar year Staff PP boxes up the completed rounding precaution sheets in a box or plastic container and moves them to the outpatient psychiatric department storage room. The boxes remain in the storage room for several years. Staff PP stated the reason these documents are not part of the clinical record is the rounding precaution sheets have multiple patient names on one sheet which prevents them from being filed in each patient's clinical record.

3. Observation 02/08/12 at 11:16 AM of the outpatient psychiatric department storage room showed a total of seven boxes and 1 plastic tub filled with psychiatric rounding sheets for 2009, 2010 and 2011. Neither the boxes nor the plastic tub were sealed or secured and the lids were easily removed as demonstrated by Staff PP. The storage room door was open, unlocked and unattended by staff.

During an interview on 02/08/12 at 11:16 AM, Staff PP stated that the door to the Behavioral Health Outpatient area is unlocked until 12:30 PM due to patients coming in and out of the area. The outpatient area is locked at 12:30 PM for the remainder of the day and night. Staff PP stated that housekeeping staff clean the storage room where the rounding precaution sheets are stored.

During an interview on 02/08/12 at 11:20 AM, Staff QQ, Housekeeper Supervisor, stated housekeepers are assigned to clean the Behavioral Health Outpatient storage room.

During an interview on 02/09/12 at 1:40 PM, Staff FF, Director of Medical Records stated that she was not aware the psychiatric precaution rounding sheets were kept in the Behavioral Outpatient Department in boxes and a plastic tub that date back to 2009.

Based on interview, review of the Rules and Regulations of the Medical Staff and record review, the facility failed to ensure physician's verbal and telephone orders (VO/TO) for three (#8, #24 and #37) of eight patients were authenticated (signed, dated and timed) by the physician within forty-eight hours as required. This placed patients at risk when orders are not authenticated. The facility census was 146.

Findings included:

1. Record review of the facility's undated Rules and Regulations of the Medical Staff "General Provisions" showed the following:
- All orders, including verbal and telephone orders, must be legible, complete, dated, timed and authenticated. All telephone orders must be signed, dated and timed by the prescribing physician within 48 hours.

Record review of the facility's policy titled, "Physician Orders Accepting," a Mosby Nursing Skills procedure which the facility provided as their policy, showed the following direction:
- The verbal, telephone, and standing orders are electronically signed in our computer system by the issuing physician in a time frame specified by medical staff guidelines (48 hours or sooner).

2. Review of current Patient #8's medical record on 02/08/12 showed:
- TO dated 01/26/12 at 10:25 PM for urinalysis (lab test on urine) and Citalopram Hydrobromide (used to treat depression) 20 milligrams (mg).
The physician electronically signed the TO on 02/01/12 (6 days later).
- TO dated 01/27/12 at 3:03 PM for TED (thromboembolitic support-support blood flow in legs) hose.
The physician electronically authenticated the TO on 02/01/12 (5 days later).
- TO dated 01/26/12 at 10:25 PM for Potassium Phosphorous/Sodium Phosphorous 2 tabs (an electrolyte, improves heart function) medication.
The physician electronically authenticated the order on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Enoxaparin (blood thinner) Injection 40 mg medication.
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Fleets (laxative) enema as needed (prn)
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Aspirin (for thinning blood) 81 mg medication.
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Clopidogrel Bisulfate (used to prevent strokes - to prevent blood clots) 75 mg medication.
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Levofloxacin (treats infections) 500 mg medication.
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Lorazepam (treats anxiety) 1-2 mg medication for active seizures.
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Metrodindazole (treats viral infections) 500 mg medication.
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/29/12 at 9:34 PM for Acetaminophen suppository (treats pain) 650 mg medication prn.
The physician electronically authenticated the TO on 02/01/12 (3 days later).
- TO dated 02/01/12 at 12:26 PM for Megestrol suspension (used to treat loss of appetite, malnutrition and weight loss) 400 mg medication.
The physician electronically authenticated the TO on 02/07/12 (6 days later).
- TO dated 02/02/12 at 3:11 PM for Acetaminophen (treats pain) 650 mg tablets medication prn do not exceed 12 tablets in 24 hours.
The physician electronically authenticated the TO on 02/07/12 (5 days later).
- TO dated 02/03/12 at 11:13 AM for Venlafaxine (treats depression) 50 mg tablets.
The physician electronically authenticated the TO on 02/07/12 (4 days later).

During an interview on 02/07/12 at 11:30 AM, Staff A, Registered Nurse (RN), Director of Rehabilitation, stated that the orders were not authenticated within the 48 hour timeframe.

During an interview on 02/07/12 at 2:45 PM, Staff FF, Director of Medical Records verified the orders as "late for authentication".

3. Review of current Patient #24's medical record on 02/09/12 showed:
-TO dated 02/03/12 at 3:16 PM for a social service consult (a social worker to visit the patient). The physician failed to authenticated the order;
-TO dated 02/07/12 at 10:29 AM for seizure precautions (taking precautions to prevent the patient from injury during a seizure). The physician failed to authenticated the order;
-TO dated 02/03/12 at 3:44 PM for Tylenol (pain reliever and a fever reducer used to treat many conditions such as headache and muscle aches) 650 mg, two tablets. The physician failed to authenticated the order; and
-TO dated 02/03/12 at 3:44 PM for Suicide Precautions (precautions taken by the facility to prevent the patient from self injury or attempts to kill one's self). The physician failed to authenticated the order.

4. Review of current Patient #37's medical record on 02/09/12 showed:
-TO dated 02/07/12 at 8:06 PM for Tigan (used to control nausea caused by stomach problems) 300 mg, one capsule. The physician failed to authenticated the order;
-TO dated 02/02/12 at 9:46 PM for Motrin (used for the relief of pain, inflammation and fever), 600 mg, one tablet. The physician failed to authenticated the order;

During an interview on 02/09/12 at 1:40 PM, Staff FF, Director of Medical Records verified the orders for Patient #24 and Patient #37 failed to be authenticated by the physician. Staff FF stated on 12/05/12 she became aware the facility was having software problems causing the TO/VO's to be authenticated late or not at all facility wide and the facility is working on getting the problem corrected.


12943

Based on observation, interview, and policy review, the facility failed to provide patient safety and reduce risk of adverse events with regard to administering high risk medications for three (#6, #9 and #10) of three patients observed receiving insulin (a hormone that lowers the level of sugar in blood). The facility census was 146.

Findings included:

1. Record review of the facility's policy titled, "High Risk Medications," revised 11/11, showed the following direction: Insulin - Double check system when administering insulin doses.

2. Observation on 02/07/12 at 9:20 AM showed Staff H, Registered Nurse (RN), administered insulin to Patient #6 with an insulin flex pen (a device which allows users to "dial in" an insulin dosage and easily administer it). A double check system was not used to verify the insulin dose with another nurse before it was administered to the patient.

Observation on 02/08/12 at approximately 11:15 AM showed Staff R, RN, preparing to administer insulin to Patient #10. Staff R removed Patient #10's insulin flex pen and dialed in the desired dosage. Staff R did not ask another nurse to double check the dosage before administering the insulin to Patient #10.

Observation on 02/07/12 at 08:50 AM showed Staff L, RN preparing to administer insulin to Patient #9. Staff L removed Patient #9's insulin flex pen and dialed in the desired dosage. Staff L did not ask another nurse to double check the dosage before administering the insulin to Patient #9.

3. Staff A, Director of Acute Rehabilitation, on 02/07/12 at 9:45 AM, provided facility High Risk Medication Policy. Medication policy directs staff to double check Insulin dosage before administration.

4. During an interview on 02/08/12 at 3:45 PM, Staff W, Director of Pharmacy, stated that even though insulin flex pens made giving insulin easier and safer, the protocol was for nurses to double check the dosage with another nurse before administering the insulin.

During an interview on 02/09/12 at 2:45 PM, Staff F, Vice President of Patient Care Services stated that insulin was considered a high risk medication, and that staff were required to have the insulin dose, or any other high risk medication dose, verified by a second nurse prior to administering the medication to the patient.



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29047

Based on facility policy review, observation and interview, the facility failed to ensure medications were kept in a locked, secured area to prevent unauthorized access. This had the potential to affect all patients and staff in the facility. The facility census was 146.

Findings included:

1. Record review of the facility's policy titled, "Medication Security," revised 04/11, gave the following direction:
- All drugs, except those intended for emergency or crash cart use, will be stored in lockable containers or areas;
- Crash cart drugs (for emergency use) and other drug boxes/kits will be stored in containers closed with seals;
- Controlled drugs (drugs with high potential for abuse) will be secured at all times;
- Medication security in ancillary departments such as Cath Lab, Imaging, GI Lab and other diagnostic labs is in locked cabinets or drawers. Responsibility for security rests with the department director or designee.

2. Observation on 02/07/12 at approximately 4:00 PM, showed an unlocked cabinet in a procedure room of the Radiology department primarily used for ultrasound exams. Stored within the cabinet were multiple multi-dose vials of Sodium Bicarbonate and Licocaine, which, when combined, are used to produce local anesthesia during a procedure. Observation of additional procedure rooms within the Radiology department showed a variety of medications which were stored within unlocked cabinets.

During an interview on 02/07/12 at 4:15 PM, Staff Y, Director of Medical Imaging, stated that the room used for ultrasounds was staffed until 11:00 PM, however the door was not locked at night. Staff Y stated that none of the cabinets within the Radiology or Nuclear Medicine Department's procedure rooms had locking mechanisms, and with the exception of Nuclear Medicine areas, rooms were not locked after hours.

3. Observation on 02/08/12 at 1:55 PM showed an unlocked Malignant Hyperthermia (MH - life threatening condition triggered by general anesthesia - drug induced loss of responsiveness) cart in the Surgical Hospital Unit pre and post operative area, which had been closed for the day. The cart contained:
-Epinephrine (used to increase the heart rate);
-Atropine (used to increase the heart rate);
-Lasix (used to remove excess fluid from the blood system), and other miscellaneous medications.

During an interview on 02/08/12 at 2:10 PM, Staff II, Operating Room (OR) Supervisor stated that the MH cart remains unlocked at all times. Staff II added that housekeeping staff cleaned after hours in the pre and post operative area and that security and plant maintenance would also have access to the area after hours.

4. Observation on 02/09/12 at 9:15 AM, showed the Jefferson Campus Operating Room (OR) suite #2 was prepared for a patient procedure. Inside the unsupervised room, was an unlocked anesthesia cart. Inside the top drawer of the cart were filled syringes which were labeled as:
-Lidocaine (used for postoperative pain control);
-Propofol (powerful hypnotic agent);
-Fentanyl (narcotic pain reliever), and contained other miscellaneous medications. Also inside the anesthesia cart were two anesthesia trays which included vials of:
-Succinylcholine (causes paralysis of muscles);
-Etomidate (used for general anesthesia or sedation);
-Sevoflurane (used to maintain general anesthesia), and other miscellaneous medications. Further observation of the anesthesia cart contents showed a narcotic box which was filled with:
-Nine ampoules (amps - small glass containers) of Fentanyl 100 micrograms (mcg - unit of measure);
-Five amps of Fentanyl 250 mcg;
-One vial of Ketamine (used for anesthesia - also associated with recreational drug use) 500 milligrams (mg - unit of measure);
-Nine vials of Midazolam (used for general anesthesia or sedation) 2 mg;
-Two injectable syringes of Morphine (narcotic pain reliever - also associated with recreational drug use) 10 mg;
-Four amps of Ephedrine (used to increase blood pressure - also associated with misuse) 50 mg.

Observation on 02/09/12 at 9:20 AM, showed the Jefferson Campus OR suite #9 was prepared for a patient procedure. Inside the unsupervised room, was an unlocked anesthesia cart which contained emergency medications such as Lidocaine , Epinepherine, and Soduim Bicarbonate (neutralizes acid in the body).

During an interview on 02/09/12 at 9:25 AM, Staff MM, OR Director stated "They (OR staff) were told about this, this morning", indicating the OR staff were advised to ensure medications and carts were locked and secured. Staff MM added that when anesthesia staff left the OR suite, they should have locked the anesthesia cart. Staff MM stated that she doesn't monitor the anesthesia staff's Quality Assessment and Performance Improvement (QAPI) for unsecured anesthesia carts, because they were a contracted group, but admitted that she had noticed the anesthesia carts left unlocked before, and "I just go behind and lock it for them".

During an interview on 02/09/12 at 2:45 PM, Staff F, Vice President of Patient Care Services, stated that all narcotics and emergency medications should be secured at all times.


29047

Based on observations, record review, interview, standards review and policy review, the facility failed to:
-Ensure planned maintenance was performed on over 1100 devices or pieces of equipment;
-Ensure Operating Room (OR) temperatures and humidity were within specified ranges; and failed to
-Record daily OR temperatures and humidity.

The cumulative effect presented hazards that directly affect the safety and well-being of all patients within the facility. As a result the hospital was found to be out of compliance with 42 CFR Part 482.41, Condition of Participation: Physical Environment.

Please see deficiencies at A0724 and A0726

Based on observation, interview, record review and policy review, the facility staff failed to ensure acceptable levels of safety and quality for equipment by failing to complete planned maintenance on over 1100 devices or pieces of equipment, some of which included:
-Anesthesia Delivery Units (provides general anesthesia during surgical procedures);
-Electrosurgery Units (provides cautery - to cut with and/or prevent bleeding by burning tissue with high amounts of heat, produced by electrical currents during surgical procedures);
-Pulmonary Function Testing (PFT, measurements of how well the lungs take in and release air) machine for one of one PFT machines observed, on an annual basis. The facility census was 146.

Findings included:

1. Record review of the facility's undated policy titled "Planned Maintenance", showed that Planned Maintenance (PM) was a systematic form inspection that supported the safety and reliability of medical devices, which would be tracked, monitored, and reviewed. The policy showed that:
-After equipment has been evaluated according to Procedure CEM-002 for inclusion in the Medical Equipment Planned maintenance (PM) Program, PM inspections are performed according to the intervals established in the Priority Description.
-PM was to be completed and documented by close of business of the last business day of the scheduled month;
-All PM not completed in the specified time frame would be considered incomplete and overdue;
-Overdue devices would be removed from patient use and returned to the Clinical Engineering Department until the PM has been completed.

2. Observation on 02/08/12 at approximately 2:52 PM, showed three Anesthesia Delivery Units (provides general anesthesia during surgical procedures) in the Surgical Hospital Unit's Surgical Suites. The units were not labeled with a PM sticker which indicated PM had not been completed. All three unit's missing PM stickers were verified by Staff KK, BioMed Technician and Staff LL, BioMed Director.

Record review of an Anesthesia Delivery Unit work order indicated that the units should receive semi-annual PM in February and August, which included:
-Verifying if and when the battery needed to be replaced (prevents the unit from complete loss of power during surgery);
-Verifying oxygen and nitrous oxide (laughing gas) flow was within specified limits (prevents too much or too little of the gas mixture from being administered to the patient during surgery);
-Checking, cleaning, and replacing air filters (ensures administered gasses are not blocked from reaching the patient during surgery);
-Verifying proper function of suction (used to remove a patient's secretions or vomit during surgery and prevents aspiration - inhaling vomit into the lungs);
-Testing all alarms (ensures alarms are functional if the anesthesia machine does not function properly).

3. Observation on 02/08/12 around 2:35 PM, showed three Electrosurgery Units (provides cautery - to cut with and/or prevent bleeding by burning tissue with high amounts of heat, produced by electrical currents during surgical procedures) in the Surgical Hospital Unit's Surgical Suites. Two units were labeled with PM stickers dated 11/10, and the third unit was labeled with a PM sticker dated 07/09, which indicated PM had not been completed since that time. All three unit's overdue PM stickers were verified by Staff KK and Staff LL.

Record review of an Electrosurgery Unit work order indicated that the units should receive annual maintenance in November, which included:
-Verifying the correct power output during usage (ensures the patient does not receive electrical burns);
-Verifying ground resistance is within specified limits (prevents electrical shock or fire to the patient and/or hospital staff);
-Testing all alarms (ensures alarms will sound if the electrosurgery unit does not function properly).

During an interview on 02/08/12 at 3:50 PM, Staff KK stated that Staff LL had reviewed the computer database, used to track PM work orders (a checklist of maintenance, specific to each device or piece of equipment that receives PM), and that the Anesthesia Delivery Units and Electrosugery Units found without current PM stickers could not be located in the database.

During an interview on 02/08/12 at 4:00 PM, Staff LL stated that PM of all equipment and devices in the hospital should be performed annually (the Anesthesia Delivery Unit work order indicated that PM should be completed semi-annually). Staff LL didn't understand why the Anesthesia Delivery Units and the Electrosugery Units did not contain up to date PM stickers or why the equipment was not found in the computer database, but indicated he would continue to investigate this. Staff LL added that the facility moved the hospital based PM to a contracted service in August 2011. When this occurred, the contracted company brought in people from multiple states and dispersed them throughout the facility to do PM on all equipment and devices found in the hospital.

During an interview on 02/09/12 at 11:10 AM, Staff LL stated that the Anesthesia Delivery Units and the Electrosurgery Units were overdue and had not been captured because they were "kicked out" when the hospital's electronic management system was converted to the contracted services electronic system. Staff LL added that he didn't realize this had happened until he investigated the overdue PM survey findings on 02/08/12, and added that additional devices and equipment had also been found which had been dropped from the electronic system during the software conversion.

4. Observation on 02/08/12 at approximately 4:00 PM in the Respiratory Services (RS) department showed a PFT machine with a PM sticker dated 6/10.

During an interview on 02/08/12 at approximately 4:10 PM, Staff EE, Director of RS stated that there is a new company doing maintenance and the machine just got missed.

5. Record review of a list of overdue PM, produced by Staff LL on 02/09/12 at 11:10 AM, showed greater than 1100 devices or equipment with overdue PM (without dates) which included:
-Anesthesia Delivery Units;
-Electrosurgery Units;
-Anesthesia vaporizers (attached to Anesthesia Delivery Units to deliver a concentration of anesthetic agents);
-Medical Gas Systems (manages oxygen, air, and nitrous oxide in surgery);
-Surgical instrument control panels (contains medical gas alarms and temperature and humidity indicators with address the requirements for powering surgical instruments);
-Heart Lung Bypass Systems Pump and Monitor (used during open heart surgery - acts as a heart to circulate blood when a patient's heart is purposefully stopped for the procedure);
-Defibrillators (used to shock a patient's heart to begin pumping, when the patient's heart has stopped);
-IV infusion pumps (used to administer medications, fluids, or blood into a patient's vein);
-Hoists (used to lift and support patients in the air for transfers);
-Telemetry Transmitters and Monitors (used to observe changes in a patient's heart rhythm);
-Water Purification Systems (removes salts and other impurities from water used during dialysis - the removal of toxins from a patient's blood);
-Steam Sterilizer (used to remove bacteria from used surgical instruments);
-Nurse Call System (sounds an alarm when a patient's call for help);
-Chemistry Analyzer (determines if components of a patient's blood are within the expected ranges);
-Hyperbaric Chamber (used to increase oxygen pressures to improve healing);
-Additional miscellaneous items.


29047

Based on observation, interview, record review, standards review and policy review, the facility failed to ensure Operating Room (OR) temperatures and humidity were within policy specified ranges on the Jefferson campus and failed to check and record daily OR temperatures and humidity on the Surgical Hospital Unit campus. Temperature and humidity control helps provide an electrically and microbial (organisms which cause infections) safe environment and could impact any patient having surgery when the temperatures or humidity are out of range. The facility performs an average of 296 cases per month on the Jefferson campus and an average of 46 cases per month at the Surgical Hospital Unit campus. The facility census was 146.

Findings included:

1. Review of the AORN (Association of Perioperative Registered Nurses) Perioperative Standards and Recommended Practices, dated May 2009, Recommendation V showed:
V.b. Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use and increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed.
V.b.2 Humidity should be monitored and recorded daily using a log format or documentation provided by the heating, ventilation and air conditioning (HVAC) system.
V.c. Temperature should be monitored and recorded daily using a log format or documentation provided by the HVAC system.

Record review of the facility's policy titled "Environmental Monitoring" reviewed on 02/11, showed operating rooms temperatures would be maintained at 68 to 72 degrees Fahrenheit (F) and humidity 50% to 60%, and showed instructions to:
-Check for correct temperature and humidity range daily prior to the start of the surgery schedule;
-Record the temperature and humidity levels daily in the log for monitoring purposes;
-Notify the Operating Room Charge Nurse and Facility Manager, who would notify the appropriate personnel to correct any variance in the set standards.

2. During an interview on 02/08/12 at 2:50 PM, Staff JJ stated that recommended temperatures for OR suites was 68 to 72 degrees F. and recommended humidity was 50% - 60%, according to the AORN guidelines, which the facility follows.

3. Observation on 02/08/12 at 2:40 PM, showed the Surgical Hospital Unit's surgical suite #2's temperature was 62.2 degrees F.(low) with a humidity of 30% (low), which was verified by Staff II, OR Supervisor and Staff JJ, OR Interim Director.

Observation on 02/09/12 at approximately 9:25 AM, showed the Jefferson campus main OR surgical suite #2's temperature was 61.8 degrees F.(low) with a humidity of 30% (low), which was verified by Staff MM, OR Director.

4. Record review of the Jefferson Campus OR temperature and humidity log for the month of February 2012 showed OR Suite #2's temperatures and/or humidity for the following dates were not maintained within policy stated ranges on:
-02/01/12, recorded at 66.3 degrees F.(low) and 49%(low);
-02/02/12, recorded at 67.3 degrees F.(low) and 43%(low);
-02/03/12, recorded at 65.1 degrees F.(low) and 56%;
-02/06/12, recorded at 65.3 degrees F.(low) and 56%;
-02/07/12, recorded at 63.2 degrees F.(low) and 59%;
-02/08/12, recorded at 64.7 degrees F.(low) and 53%;
-02/09/12, recorded at 61.8 degrees F.(low) and 60%.
OR Suite #5's temperatures for the following dates were not within range on:
-02/01/12, recorded at 67.3 degrees F.(low) and 51%;
-02/02/12, recorded at 65.3 degrees F.(low) and 54%;
-02/03/12, recorded at 63.0 degrees F.(low) and 59%;
-02/06/12, recorded at 64.3 degrees F.(low) and 56%;
-02/07/12, recorded at 65.3 degrees F.(low) and 53%;
-02/08/12, recorded at 65.5 degrees F.(low) and 57%.
OR Suite #9's temperature and/or humidity for the following dates were not within range on:
-02/01/12, recorded at 65.1 degrees F.(low) and 49%(low);
-02/02/12, recorded at 67.4 degrees F.(low) and 31%(low);
-02/03/12, recorded at 67.1 degrees F.(low) and 30%(low);
-02/06/12, recorded at 65.4 degrees F.(low) and 30%(low);
-02/07/12, recorded at 67.2 degrees F.(low) and 35%(low);
-02/08/12, recorded at 65.1 degrees F.(low) and 49%(low).

During an interview on 02/09/12 at 11:50 AM, Staff MM stated that she could not produce a temperature and humidity log for the Ambulatory Surgical Hospital Unit, because they did not maintain a log of OR room temperatures and humidity. Staff MM stated that she did not realize there was no temperature and humidity log maintained for the Ambulatory Surgical Hospital Unit until the surveyor requested it.

During an interview on 02/08/12 at 2:45 PM, Staff II stated that OR staff kept temperatures around 60 to 65 degrees F and humidity around 30% - 40%, because the surgeons get hot under the surgical lights and prefer the temperature and humidity to be kept low.

During an interview on 02/09/12 at 9:27 AM, Staff MM, OR Director stated that one of the physician's like to keep the temperature low so he doesn't get hot. Staff MM added that the lower temperature and humidity doesn't affect anything in the OR suite other than the patient's body temperature, which they maintain with warming blankets.

Based on observation, interview, policy and protocol review, the facility failed to adhere to approved facility infection control policies to prevent the spread of infection to patients and employees when they failed to:
- Ensure non-critical equipment was decontaminated/disinfected between patient rooms for three of three pieces of equipment observed in the Obstetrics/Pediatrics/Gynecology Unit;
- Ensure staff performed hand hygiene to prevent potential contamination of patient medication during medication administration for four (#4, #6, #8 and #9) of 12 patient medication passes observed;
- Ensure staff cleaned medication vial before replacing in the Pyxis (an automated cabinet used to store medication) for one of one observation during medication observation for Patient #9;
- Prevent potential contamination of patient medications when staff blew into plastic medication sleeves (used to crush medications) before placing pills inside the sleeves to crush the medication for one (#7) of one patient medication pass observed and
- Failed to ensure staff changed gloves and performed hand hygiene, to prevent wound contamination, during one (Patient #15) of one dressing change observed. The facility census was 146.

Findings included:

1. Record review of the facility's policy titled, "Cleaning/Disinfecting Patient Care Equipment & Other Surfaces/Instruments," reviewed 06/10, showed the following direction:
- All patient care supplies, equipment, surfaces, and instruments are cleaned and disinfected thoroughly between patient use, when visibly soiled or according to a specific schedule.
- Low-Level/Intermediate-Level Disinfection - Patient care equipment (non-critical items) include: pulse-ox (used to measure the amount of oxygen in blood), glucometer (used to measure the amount of sugar in blood), electronic thermometer, blood pressure cuff/holder, wheelchairs, infusion poles/pumps, walkers, any other equipment that is used from one patient to another and equipment that is contaminated.

Record review of the facility's policy titled, "Medication Administration: Oral," a Mosby Nursing Skills procedure which the facility provided as their policy, showed the following direction:
- Perform hand hygiene.
- If oral dosing requires a tablet to be broken in half, use a pill cutter if the tablet is not prescored (marked with a line that facilitates breaking the tablet in half).
- Discard used supplies and perform hand hygiene.
- Remove gloves and perform hand hygiene

Record review of the facility's policy titled, "Patient Specific Medication Administration", a Mosby Nursing Skills procedure which the facility provided as their policy, showed the following direction:
- For patient specific medication administration, the [Registered Nurse] RN or [Licensed Practical Nurse] LPN removes the correct number or amount of medication then returns the clean medication bottle, vial, tube, etc. to the labeled bin within the Pyxis system. Examples include but are not limited to: insulin multi-dose vials, labeled and sealed prescription bottles, etc. where dose preparation occurs in the medication room with the container never having been touched by the patient.

2. Observation on 02/07/12 at 8:35 AM showed a metal intravenous (IV) pole (used to suspend solutions during infusions) at the bedside of Patient #11. The base of the pole had an approximately one inch by two inch area of black residue that could not be wiped off.

Observation on 02/07/12 at 8:50 AM showed a computer on wheels (COW) within the nursing station which had been used to deliver medications to several patients. Two streaks of an unknown dark substance were noted along the left edge of the top of the COW. The base of the COW showed approximately five circular areas of an unknown white substance that appeared to be "splash marks" from falling droplets.

Observation on 02/07/12 at 10:15 showed a cart in the medication room which was wheeled from room to room to obtain blood pressures (BP). The BP machine affixed to the top of the cart had been labeled with a typed sign that read, "OB (Obstetrics) and Peds (Pediatrics)." The label had been attached to the machine with a clear tape, but approximately four inches of the tape had come loose. The adhesive edges of the tape that had been used to affix the sign were tattered and had particles of unknown substances adhered to the tape. The base of the cart showed numerous clear circular spots that appeared to be dried droplets of an unknown substance.

During an interview on 02/07/12 at 10:00 AM, Staff N, Registered Nurse (RN), stated that she had not noticed the smear marks on the side of the COW or the splotch marks on the base when she used the cart to administer medications. Staff N stated that employees were required to wipe down the cart when it was dirty, and stated that there wasn't a set cleaning schedule.

During an interview on 02/07/12 at 10:20 AM, Staff E, Director of Women and Child Services, viewed the IV pole in Patient #11's room and agreed that the material adhered to the base prevented the pole from being thoroughly cleaned. Staff E also observed the BP cart in the Medication Room and agreed that the surface where the label was applied was not cleanable and the cart's base was not clean. Staff E stated that employees were required to clean IV poles before placing them in patient rooms, and then clean them again when they were removed from patient rooms. She also stated that employees were required to clean the COWs as needed, but stated that determination of whether an item was visibly soiled and required cleaning was subjective.

During an interview on 02/09/12 around 2:00 PM, Staff K stated that the COWs, as well as other miscellaneous equipment, should be cleaned when visibly soiled and at the end of every shift.

3. Observation for Patient #8 on 02/07/12 at 8:35 AM showed the following medication administration by Staff L, RN:
- removed Patient #8's medication from the packaging with his fingers (package design is to prevent unnecessary staff contact with patient medication)
- dropped pill package on floor, picked up and then continued to open medication without hand hygiene
- wore gloves to administer medication by injection (introduce fluid into a vein, tissue by a syringe) - no hand hygiene after glove removal
- completed medication administration - left patient area - no hand hygiene

Observation on 02/07/12 at 9:00 AM showed Staff L, RN administered Insulin (a hormone that lowers the level of sugar in blood) by injection to Patient #9. Staff L removed gloves after injection. Staff L failed to perform hand hygiene after glove removal. Staff L replaced insulin flex pen (a device which allows users to "dial in" an insulin dosage and easily administer it) into the Pyxis medication cabinet. Staff L failed to clean the flex pen prior to replacing into the Pyxis cabinet, risking contamination of any medications that come into contact with the flex pen.

During an interview on 02/07/12 at 9:10 AM Staff L stated that:
- should have washed hands between patients
- should have washed hands before and after patient care
- should have washed hands after glove removal
- should have washed hands before glove application
-"I touched pills guess I should have washed my hands first"
- should have wiped off insulin injection pen before putting back in the Pyxis.

During an interview on 02/07/12 at 9:45 AM Staff A, Director of Acute Rehabilitation, verified the need for hand hygiene before and after patient contact and during medication administration.

4. Observation on 02/07/12 at 9:00 AM showed Staff H, RN, administered medications to Patient #4 without first washing or sanitizing her hands.

During an interview on 02/07/12 at 9:00 AM, Staff H asked, "Did I forget?", when questioned why she didn't wash or sanitize her hands before administering medications to Patient #4.

During an interview on 02/09/12 around 2:00 PM, Staff K stated that staff should wash or sanitize their hands before and after patient contact and after contact with a contaminated surface.

5. Observation on 02/07/12 at 9:20 AM showed Staff H used her bare hands to remove Patient #6's pills from a package, placed them in a cup, and administered them to the patient.

During an interview on 02/07/12 at 9:20 AM, Staff H stated that staff can touch a patient's pills with their bare hands as long as the staff member has performed hand hygiene first.

During an interview on 02/09/12 around 2:00 PM, Staff K stated that staff should not handle patient medications with their bare hands, and would recommend using a pill punch (to push a medication out of a package) or dropping the medication into a container directly from the opened pill package.

5. Observation on 02/07/12 at 9:50 AM showed Staff H blew into a plastic medication sleeve (used to place pills in to crush for administration) to open it. Staff H then placed a pill inside the plastic sleeve and crushed the medication with a pill crusher. This technique was repeated four times for four different medications, before she administered them to Patient #7.

During an interview on 02/07/12 at 9:50 AM, Staff H stated that it was common practice to open the plastic medication sleeves by blowing into them, because they were so difficult to open.

During an interview on 02/09/12 around 2:00 PM, Staff K stated that she would not recommend staff blow into a medication sleeve because of the risk of droplet transmission (bacteria or viruses that are transferred by drops of moisture from the mouth or nose) and contamination inside the bag where the patient's pills are placed.

6. Record review of the facility's protocol titled, "Mosby's Nursing Skills - Specimen Collection: Wound Drainage Quicksheet" revised 10/09, showed direction for staff to cleanse the wound, remove and discard contaminated gloves, and perform hand hygiene before reapplying gloves and re-dressing the wound.

7. Observation on 02/07/12 at 2:15 PM, showed Staff P, Wound Care Nurse, removed a soiled dressing from Patient #15's groin wound. Staff P then removed her gloves, sanitized her hands, and cleansed the wound with wound cleanser and gauze. After the wound was cleansed, Staff P failed to remove her contaminated gloves and failed to wash her hands before she proceeded to place a clean dressing on the wound, thus contaminating the clean dressing with her soiled gloves.

During an interview on 02/07/12 at 2:15 PM, Staff P stated that the gloves used to cleanse Patient 15's wound were considered "clean" for the dressing application, because she had used a wound cleanser and because the dressing change was not considered sterile.

During an interview on 02/09/12 around 2:00 PM, Staff K stated
she had never heard of using three sets of gloves (with hand hygiene) during wound care, only two, changing gloves after the removal of a soiled dressing, and after the wound was dressed, but would refer to the facility policy.

During an interview on 02/09/12 around 3:15 PM, Staff K, stated that she referred to the "Mosby's Nursing Skills Specimen Collection: Wound Drainage Quicksheet" for information regarding glove changes and hand hygiene after cleansing a wound. Staff K stated that staff should have removed gloves after cleansing the wound and performed hand hygiene, before the wound was re-dressed, according to the protocol.



15697




29047

Based on observation, interview, and policy review, the facility failed to provide patient safety and reduce risk of adverse events with regard to administering high risk medications for three (#6, #9 and #10) of three patients observed receiving insulin (a hormone that lowers the level of sugar in blood). The facility census was 146.

Findings included:

1. Record review of the facility's policy titled, "High Risk Medications," revised 11/11, showed the following direction: Insulin - Double check system when administering insulin doses.

2. Observation on 02/07/12 at 9:20 AM showed Staff H, Registered Nurse (RN), administered insulin to Patient #6 with an insulin flex pen (a device which allows users to "dial in" an insulin dosage and easily administer it). A double check system was not used to verify the insulin dose with another nurse before it was administered to the patient.

Observation on 02/08/12 at approximately 11:15 AM showed Staff R, RN, preparing to administer insulin to Patient #10. Staff R removed Patient #10's insulin flex pen and dialed in the desired dosage. Staff R did not ask another nurse to double check the dosage before administering the insulin to Patient #10.

Observation on 02/07/12 at 08:50 AM showed Staff L, RN preparing to administer insulin to Patient #9. Staff L removed Patient #9's insulin flex pen and dialed in the desired dosage. Staff L did not ask another nurse to double check the dosage before administering the insulin to Patient #9.

3. Staff A, Director of Acute Rehabilitation, on 02/07/12 at 9:45 AM, provided facility High Risk Medication Policy. Medication policy directs staff to double check Insulin dosage before administration.

4. During an interview on 02/08/12 at 3:45 PM, Staff W, Director of Pharmacy, stated that even though insulin flex pens made giving insulin easier and safer, the protocol was for nurses to double check the dosage with another nurse before administering the insulin.

During an interview on 02/09/12 at 2:45 PM, Staff F, Vice President of Patient Care Services stated that insulin was considered a high risk medication, and that staff were required to have the insulin dose, or any other high risk medication dose, verified by a second nurse prior to administering the medication to the patient.



15697




29047

Based on facility policy review, observation and interview, the facility failed to ensure medications were kept in a locked, secured area to prevent unauthorized access. This had the potential to affect all patients and staff in the facility. The facility census was 146.

Findings included:

1. Record review of the facility's policy titled, "Medication Security," revised 04/11, gave the following direction:
- All drugs, except those intended for emergency or crash cart use, will be stored in lockable containers or areas;
- Crash cart drugs (for emergency use) and other drug boxes/kits will be stored in containers closed with seals;
- Controlled drugs (drugs with high potential for abuse) will be secured at all times;
- Medication security in ancillary departments such as Cath Lab, Imaging, GI Lab and other diagnostic labs is in locked cabinets or drawers. Responsibility for security rests with the department director or designee.

2. Observation on 02/07/12 at approximately 4:00 PM, showed an unlocked cabinet in a procedure room of the Radiology department primarily used for ultrasound exams. Stored within the cabinet were multiple multi-dose vials of Sodium Bicarbonate and Licocaine, which, when combined, are used to produce local anesthesia during a procedure. Observation of additional procedure rooms within the Radiology department showed a variety of medications which were stored within unlocked cabinets.

During an interview on 02/07/12 at 4:15 PM, Staff Y, Director of Medical Imaging, stated that the room used for ultrasounds was staffed until 11:00 PM, however the door was not locked at night. Staff Y stated that none of the cabinets within the Radiology or Nuclear Medicine Department's procedure rooms had locking mechanisms, and with the exception of Nuclear Medicine areas, rooms were not locked after hours.

3. Observation on 02/08/12 at 1:55 PM showed an unlocked Malignant Hyperthermia (MH - life threatening condition triggered by general anesthesia - drug induced loss of responsiveness) cart in the Surgical Hospital Unit pre and post operative area, which had been closed for the day. The cart contained:
-Epinephrine (used to increase the heart rate);
-Atropine (used to increase the heart rate);
-Lasix (used to remove excess fluid from the blood system), and other miscellaneous medications.

During an interview on 02/08/12 at 2:10 PM, Staff II, Operating Room (OR) Supervisor stated that the MH cart remains unlocked at all times. Staff II added that housekeeping staff cleaned after hours in the pre and post operative area and that security and plant maintenance would also have access to the area after hours.

4. Observation on 02/09/12 at 9:15 AM, showed the Jefferson Campus Operating Room (OR) suite #2 was prepared for a patient procedure. Inside the unsupervised room, was an unlocked anesthesia cart. Inside the top drawer of the cart were filled syringes which were labeled as:
-Lidocaine (used for postoperative pain control);
-Propofol (powerful hypnotic agent);
-Fentanyl (narcotic pain reliever), and contained other miscellaneous medications. Also inside the anesthesia cart were two anesthesia trays which included vials of:
-Succinylcholine (causes paralysis of muscles);
-Etomidate (used for general anesthesia or sedation);
-Sevoflurane (used to maintain general anesthesia), and other miscellaneous medications. Further observation of the anesthesia cart contents showed a narcotic box which was filled with:
-Nine ampoules (amps - small glass containers) of Fentanyl 100 micrograms (mcg - unit of measure);
-Five amps of Fentanyl 250 mcg;
-One vial of Ketamine (used for anesthesia - also associated with recreational drug use) 500 milligrams (mg - unit of measure);
-Nine vials of Midazolam (used for general anesthesia or sedation) 2 mg;
-Two injectable syringes of Morphine (narcotic pain reliever - also associated with recreational drug use) 10 mg;
-Four amps of Ephedrine (used to increase blood pressure - also associated with misuse) 50 mg.

Observation on 02/09/12 at 9:20 AM, showed the Jefferson Campus OR suite #9 was prepared for a patient procedure. Inside the unsupervised room, was an unlocked anesthesia cart which contained emergency medications such as Lidocaine , Epinepherine, and Soduim Bicarbonate (neutralizes acid in the body).

During an interview on 02/09/12 at 9:25 AM, Staff MM, OR Director stated "They (OR staff) were told about this, this morning", indicating the OR staff were advised to ensure medications and carts were locked and secured. Staff MM added that when anesthesia staff left the OR suite, they should have locked the anesthesia cart. Staff MM stated that she doesn't monitor the anesthesia staff's Quality Assessment and Performance Improvement (QAPI) for unsecured anesthesia carts, because they were a contracted group, but admitted that she had noticed the anesthesia carts left unlocked before, and "I just go behind and lock it for them".

During an interview on 02/09/12 at 2:45 PM, Staff F, Vice President of Patient Care Services, stated that all narcotics and emergency medications should be secured at all times.


29047

Based on observation, interview, policy and protocol review, the facility failed to adhere to approved facility infection control policies to prevent the spread of infection to patients and employees when they failed to:
- Ensure non-critical equipment was decontaminated/disinfected between patient rooms for three of three pieces of equipment observed in the Obstetrics/Pediatrics/Gynecology Unit;
- Ensure staff performed hand hygiene to prevent potential contamination of patient medication during medication administration for four (#4, #6, #8 and #9) of 12 patient medication passes observed;
- Ensure staff cleaned medication vial before replacing in the Pyxis (an automated cabinet used to store medication) for one of one observation during medication observation for Patient #9;
- Prevent potential contamination of patient medications when staff blew into plastic medication sleeves (used to crush medications) before placing pills inside the sleeves to crush the medication for one (#7) of one patient medication pass observed and
- Failed to ensure staff changed gloves and performed hand hygiene, to prevent wound contamination, during one (Patient #15) of one dressing change observed. The facility census was 146.

Findings included:

1. Record review of the facility's policy titled, "Cleaning/Disinfecting Patient Care Equipment & Other Surfaces/Instruments," reviewed 06/10, showed the following direction:
- All patient care supplies, equipment, surfaces, and instruments are cleaned and disinfected thoroughly between patient use, when visibly soiled or according to a specific schedule.
- Low-Level/Intermediate-Level Disinfection - Patient care equipment (non-critical items) include: pulse-ox (used to measure the amount of oxygen in blood), glucometer (used to measure the amount of sugar in blood), electronic thermometer, blood pressure cuff/holder, wheelchairs, infusion poles/pumps, walkers, any other equipment that is used from one patient to another and equipment that is contaminated.

Record review of the facility's policy titled, "Medication Administration: Oral," a Mosby Nursing Skills procedure which the facility provided as their policy, showed the following direction:
- Perform hand hygiene.
- If oral dosing requires a tablet to be broken in half, use a pill cutter if the tablet is not prescored (marked with a line that facilitates breaking the tablet in half).
- Discard used supplies and perform hand hygiene.
- Remove gloves and perform hand hygiene

Record review of the facility's policy titled, "Patient Specific Medication Administration", a Mosby Nursing Skills procedure which the facility provided as their policy, showed the following direction:
- For patient specific medication administration, the [Registered Nurse] RN or [Licensed Practical Nurse] LPN removes the correct number or amount of medication then returns the clean medication bottle, vial, tube, etc. to the labeled bin within the Pyxis system. Examples include but are not limited to: insulin multi-dose vials, labeled and sealed prescription bottles, etc. where dose preparation occurs in the medication room with the container never having been touched by the patient.

2. Observation on 02/07/12 at 8:35 AM showed a metal intravenous (IV) pole (used to suspend solutions during infusions) at the bedside of Patient #11. The base of the pole had an approximately one inch by two inch area of black residue that could not be wiped off.

Observation on 02/07/12 at 8:50 AM showed a computer on wheels (COW) within the nursing station which had been used to deliver medications to several patients. Two streaks of an unknown dark substance were noted along the left edge of the top of the COW. The base of the COW showed approximately five circular areas of an unknown white substance that appeared to be "splash marks" from falling droplets.

Observation on 02/07/12 at 10:15 showed a cart in the medication room which was wheeled from room to room to obtain blood pressures (BP). The BP machine affixed to the top of the cart had been labeled with a typed sign that read, "OB (Obstetrics) and Peds (Pediatrics)." The label had been attached to the machine with a clear tape, but approximately four inches of the tape had come loose. The adhesive edges of the tape that had been used to affix the sign were tattered and had particles of unknown substances adhered to the tape. The base of the cart showed numerous clear circular spots that appeared to be dried droplets of an unknown substance.

During an interview on 02/07/12 at 10:00 AM, Staff N, Registered Nurse (RN), stated that she had not noticed the smear marks on the side of the COW or the splotch marks on the base when she used the cart to administer medications. Staff N stated that employees were required to wipe down the cart when it was dirty, and stated that there wasn't a set cleaning schedule.

During an interview on 02/07/12 at 10:20 AM, Staff E, Director of Women and Child Services, viewed the IV pole in Patient #11's room and agreed that the material adhered to the base prevented the pole from being thoroughly cleaned. Staff E also observed the BP cart in the Medication Room and agreed that the surface where the label was applied was not cleanable and the cart's base was not clean. Staff E stated that employees were required to clean IV poles before placing them in patient rooms, and then clean them again when they were removed from patient rooms. She also stated that employees were required to clean the COWs as needed, but stated that determination of whether an item was visibly soiled and required cleaning was subjective.

During an interview on 02/09/12 around 2:00 PM, Staff K stated that the COWs, as well as other miscellaneous equipment, should be cleaned when visibly soiled and at the end of every shift.

3. Observation for Patient #8 on 02/07/12 at 8:35 AM showed the following medication administration by Staff L, RN:
- removed Patient #8's medication from the packaging with his fingers (package design is to prevent unnecessary staff contact with patient medication)
- dropped pill package on floor, picked up and then continued to open medication without hand hygiene
- wore gloves to administer medication by injection (introduce fluid into a vein, tissue by a syringe) - no hand hygiene after glove removal
- completed medication administration - left patient area - no hand hygiene

Observation on 02/07/12 at 9:00 AM showed Staff L, RN administered Insulin (a hormone that lowers the level of sugar in blood) by injection to Patient #9. Staff L removed gloves after injection. Staff L failed to perform hand hygiene after glove removal. Staff L replaced insulin flex pen (a device which allows users to "dial in" an insulin dosage and easily administer it) into the Pyxis medication cabinet. Staff L failed to clean the flex pen prior to replacing into the Pyxis cabinet, risking contamination of any medications that come into contact with the flex pen.

During an interview on 02/07/12 at 9:10 AM Staff L stated that:
- should have washed hands between patients
- should have washed hands before and after patient care
- should have washed hands after glove removal
- should have washed hands before glove application
-"I touched pills guess I should have washed my hands first"
- should have wiped off insulin injection pen before putting back in the Pyxis.

During an interview on 02/07/12 at 9:45 AM Staff A, Director of Acute Rehabilitation, verified the need for hand hygiene before and after patient contact and during medication administration.

4. Observation on 02/07/12 at 9:00 AM showed Staff H, RN, administered medications to Patient #4 without first washing or sanitizing her hands.

During an interview on 02/07/12 at 9:00 AM, Staff H asked, "Did I forget?", when questioned why she didn't wash or sanitize her hands before administering medications to Patient #4.

During an interview on 02/09/12 around 2:00 PM, Staff K stated that staff should wash or sanitize their hands before and after patient contact and after contact with a contaminated surface.

5. Observation on 02/07/12 at 9:20 AM showed Staff H used her bare hands to remo

Based on observation, interview, record review and policy review, the facility staff failed to ensure acceptable levels of safety and quality for equipment by failing to complete planned maintenance on over 1100 devices or pieces of equipment, some of which included:
-Anesthesia Delivery Units (provides general anesthesia during surgical procedures);
-Electrosurgery Units (provides cautery - to cut with and/or prevent bleeding by burning tissue with high amounts of heat, produced by electrical currents during surgical procedures);
-Pulmonary Function Testing (PFT, measurements of how well the lungs take in and release air) machine for one of one PFT machines observed, on an annual basis. The facility census was 146.

Findings included:

1. Record review of the facility's undated policy titled "Planned Maintenance", showed that Planned Maintenance (PM) was a systematic form inspection that supported the safety and reliability of medical devices, which would be tracked, monitored, and reviewed. The policy showed that:
-After equipment has been evaluated according to Procedure CEM-002 for inclusion in the Medical Equipment Planned maintenance (PM) Program, PM inspections are performed according to the intervals established in the Priority Description.
-PM was to be completed and documented by close of business of the last business day of the scheduled month;
-All PM not completed in the specified time frame would be considered incomplete and overdue;
-Overdue devices would be removed from patient use and returned to the Clinical Engineering Department until the PM has been completed.

2. Observation on 02/08/12 at approximately 2:52 PM, showed three Anesthesia Delivery Units (provides general anesthesia during surgical procedures) in the Surgical Hospital Unit's Surgical Suites. The units were not labeled with a PM sticker which indicated PM had not been completed. All three unit's missing PM stickers were verified by Staff KK, BioMed Technician and Staff LL, BioMed Director.

Record review of an Anesthesia Delivery Unit work order indicated that the units should receive semi-annual PM in February and August, which included:
-Verifying if and when the battery needed to be replaced (prevents the unit from complete loss of power during surgery);
-Verifying oxygen and nitrous oxide (laughing gas) flow was within specified limits (prevents too much or too little of the gas mixture from being administered to the patient during surgery);
-Checking, cleaning, and replacing air filters (ensures administered gasses are not blocked from reaching the patient during surgery);
-Verifying proper function of suction (used to remove a patient's secretions or vomit during surgery and prevents aspiration - inhaling vomit into the lungs);
-Testing all alarms (ensures alarms are functional if the anesthesia machine does not function properly).

3. Observation on 02/08/12 around 2:35 PM, showed three Electrosurgery Units (provides cautery - to cut with and/or prevent bleeding by burning tissue with high amounts of heat, produced by electrical currents during surgical procedures) in the Surgical Hospital Unit's Surgical Suites. Two units were labeled with PM stickers dated 11/10, and the third unit was labeled with a PM sticker dated 07/09, which indicated PM had not been completed since that time. All three unit's overdue PM stickers were verified by Staff KK and Staff LL.

Record review of an Electrosurgery Unit work order indicated that the units should receive annual maintenance in November, which included:
-Verifying the correct power output during usage (ensures the patient does not receive electrical burns);
-Verifying ground resistance is within specified limits (prevents electrical shock or fire to the patient and/or hospital staff);
-Testing all alarms (ensures alarms will sound if the electrosurgery unit does not function properly).

During an interview on 02/08/12 at 3:50 PM, Staff KK stated that Staff LL had reviewed the computer database, used to track PM work orders (a checklist of maintenance, specific to each device or piece of equipment that receives PM), and that the Anesthesia Delivery Units and Electrosugery Units found without current PM stickers could not be located in the database.

During an interview on 02/08/12 at 4:00 PM, Staff LL stated that PM of all equipment and devices in the hospital should be performed annually (the Anesthesia Delivery Unit work order indicated that PM should be completed semi-annually). Staff LL didn't understand why the Anesthesia Delivery Units and the Electrosugery Units did not contain up to date PM stickers or why the equipment was not found in the computer database, but indicated he would continue to investigate this. Staff LL added that the facility moved the hospital based PM to a contracted service in August 2011. When this occurred, the contracted company brought in people from multiple states and dispersed them throughout the facility to do PM on all equipment and devices found in the hospital.

During an interview on 02/09/12 at 11:10 AM, Staff LL stated that the Anesthesia Delivery Units and the Electrosurgery Units were overdue and had not been captured because they were "kicked out" when the hospital's electronic management system was converted to the contracted services electronic system. Staff LL added that he didn't realize this had happened until he investigated the overdue PM survey findings on 02/08/12, and added that additional devices and equipment had also been found which had been dropped from the electronic system during the software conversion.

4. Observation on 02/08/12 at approximately 4:00 PM in the Respiratory Services (RS) department showed a PFT machine with a PM sticker dated 6/10.

During an interview on 02/08/12 at approximately 4:10 PM, Staff EE, Director of RS stated that there is a new company doing maintenance and the machine just got missed.

5. Record review of a list of overdue PM, produced by Staff LL on 02/09/12 at 11:10 AM, showed greater than 1100 devices or equipment with overdue PM (without dates) which included:
-Anesthesia Delivery Units;
-Electrosurgery Units;
-Anesthesia vaporizers (attached to Anesthesia Delivery Units to deliver a concentration of anesthetic agents);
-Medical Gas Systems (manages oxygen, air, and nitrous oxide in surgery);
-Surgical instrument control panels (contains medical gas alarms and temperature and humidity indicators with address the requirements for powering surgical instruments);
-Heart Lung Bypass Systems Pump and Monitor (used during open heart surgery - acts as a heart to circulate blood when a patient's heart is purposefully stopped for the procedure);
-Defibrillators (used to shock a patient's heart to begin pumping, when the patient's heart has stopped);
-IV infusion pumps (used to administer medications, fluids, or blood into a patient's vein);
-Hoists (used to lift and support patients in the air for transfers);
-Telemetry Transmitters and Monitors (used to observe changes in a patient's heart rhythm);
-Water Purification Systems (removes salts and other impurities from water used during dialysis - the removal of toxins from a patient's blood);
-Steam Sterilizer (used to remove bacteria from used surgical instruments);
-Nurse Call System (sounds an alarm when a patient's call for help);
-Chemistry Analyzer (determines if components of a patient's blood are within the expected ranges);
-Hyperbaric Chamber (used to increase oxygen pressures to improve healing);
-Additional miscellaneous items.


29047

Based on interview, review of the Rules and Regulations of the Medical Staff and record review, the facility failed to ensure physician's verbal and telephone orders (VO/TO) for three (#8, #24 and #37) of eight patients were authenticated (signed, dated and timed) by the physician within forty-eight hours as required. This placed patients at risk when orders are not authenticated. The facility census was 146.

Findings included:

1. Record review of the facility's undated Rules and Regulations of the Medical Staff "General Provisions" showed the following:
- All orders, including verbal and telephone orders, must be legible, complete, dated, timed and authenticated. All telephone orders must be signed, dated and timed by the prescribing physician within 48 hours.

Record review of the facility's policy titled, "Physician Orders Accepting," a Mosby Nursing Skills procedure which the facility provided as their policy, showed the following direction:
- The verbal, telephone, and standing orders are electronically signed in our computer system by the issuing physician in a time frame specified by medical staff guidelines (48 hours or sooner).

2. Review of current Patient #8's medical record on 02/08/12 showed:
- TO dated 01/26/12 at 10:25 PM for urinalysis (lab test on urine) and Citalopram Hydrobromide (used to treat depression) 20 milligrams (mg).
The physician electronically signed the TO on 02/01/12 (6 days later).
- TO dated 01/27/12 at 3:03 PM for TED (thromboembolitic support-support blood flow in legs) hose.
The physician electronically authenticated the TO on 02/01/12 (5 days later).
- TO dated 01/26/12 at 10:25 PM for Potassium Phosphorous/Sodium Phosphorous 2 tabs (an electrolyte, improves heart function) medication.
The physician electronically authenticated the order on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Enoxaparin (blood thinner) Injection 40 mg medication.
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Fleets (laxative) enema as needed (prn)
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Aspirin (for thinning blood) 81 mg medication.
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Clopidogrel Bisulfate (used to prevent strokes - to prevent blood clots) 75 mg medication.
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Levofloxacin (treats infections) 500 mg medication.
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Lorazepam (treats anxiety) 1-2 mg medication for active seizures.
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/26/12 at 10:25 PM for Metrodindazole (treats viral infections) 500 mg medication.
The physician electronically authenticated the TO on 02/01/12 (6 days later).
- TO dated 01/29/12 at 9:34 PM for Acetaminophen suppository (treats pain) 650 mg medication prn.
The physician electronically authenticated the TO on 02/01/12 (3 days later).
- TO dated 02/01/12 at 12:26 PM for Megestrol suspension (used to treat loss of appetite, malnutrition and weight loss) 400 mg medication.
The physician electronically authenticated the TO on 02/07/12 (6 days later).
- TO dated 02/02/12 at 3:11 PM for Acetaminophen (treats pain) 650 mg tablets medication prn do not exceed 12 tablets in 24 hours.
The physician electronically authenticated the TO on 02/07/12 (5 days later).
- TO dated 02/03/12 at 11:13 AM for Venlafaxine (treats depression) 50 mg tablets.
The physician electronically authenticated the TO on 02/07/12 (4 days later).

During an interview on 02/07/12 at 11:30 AM, Staff A, Registered Nurse (RN), Director of Rehabilitation, stated that the orders were not authenticated within the 48 hour timeframe.

During an interview on 02/07/12 at 2:45 PM, Staff FF, Director of Medical Records verified the orders as "late for authentication".

3. Review of current Patient #24's medical record on 02/09/12 showed:
-TO dated 02/03/12 at 3:16 PM for a social service consult (a social worker to visit the patient). The physician failed to authenticated the order;
-TO dated 02/07/12 at 10:29 AM for seizure precautions (taking precautions to prevent the patient from injury during a seizure). The physician failed to authenticated the order;
-TO dated 02/03/12 at 3:44 PM for Tylenol (pain reliever and a fever reducer used to treat many conditions such as headache and muscle aches) 650 mg, two tablets. The physician failed to authenticated the order; and
-TO dated 02/03/12 at 3:44 PM for Suicide Precautions (precautions taken by the facility to prevent the patient from self injury or attempts to kill one's self). The physician failed to authenticated the order.

4. Review of current Patient #37's medical record on 02/09/12 showed:
-TO dated 02/07/12 at 8:06 PM for Tigan (used to control nausea caused by stomach problems) 300 mg, one capsule. The physician failed to authenticated the order;
-TO dated 02/02/12 at 9:46 PM for Motrin (used for the relief of pain, inflammation and fever), 600 mg, one tablet. The physician failed to authenticated the order;

During an interview on 02/09/12 at 1:40 PM, Staff FF, Director of Medical Records verified the orders for Patient #24 and Patient #37 failed to be authenticated by the physician. Staff FF stated on 12/05/12 she became aware the facility was having software problems causing the TO/VO's to be authenticated late or not at all facility wide and the facility is working on getting the problem corrected.


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