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Based on interview and record review, the hospital failed to ensure medication for one of 24 sampled patients (4) was administered according to the physician's orders. The registered nurses failed to notify the physician when a medication was held (Insulin) and when a medication was given (Dextrose 50%) contrary to the physician's order. These failures could result in fluctuating blood sugar levels and the physician's unawareness as to the reason.

Findings:

The clinical record for Patient 4 was reviewed on 4/14/11 at 9 AM. A physician's order was noted for Lantus Insulin (long acting Insulin used to lower the blood glucose levels) give 25 units subcutaneous (SQ) at 9 PM. There was no parameters to hold the Lantus Insulin. A physician's order was noted for Regular Insulin with sliding scale coverage depending on the results of the finger stick. Based on this sliding scale coverage, the instructions indicated if the blood sugar level fell below 70 milligrams per deciliter (mg/dL) give Dextrose (same as glucose) 50 % intravenous (IV) over 5 minutes. Check the fingerstick every fifteen minutes and repeat the dose if the blood glucose remained below 70 mg/dL. On 3/ 25/11 the bedtime Lantus Insulin was held with a blood sugar level of 109 mg/dL. On 3/28/11 the bedtime Lantus Insulin was held with a blood sugar level of 103 mg/dL. On 4/7/11 at 8:55 AM, the blood sugar level was 78 mg/dL and Dextrose 50 % (D50) was administered although the blood glucose level was not below the 70 mg/dL required to administer the D50 according to the physicians order. There was no documentation from the registered nurses as to why the Lantus was held on 3/25 and 3/28/11 and there was no documentation as to why the D50 was administered on 4/7/11 although the blood sugar was not below the 70 mg/dL. There was also no documentation from the nurses the physician was notified when the Lantus Insulin was held and when the D50 was administered contrary to the physician's order.

During an interview with Registered Nurse (RN) 1, on 4/14/11 at 10:40 AM, she was unable to find documentation as to why the Lantus was held on 3/25/11 and 3/28/11 and the physician was notified of the nurses' decision to hold it. She was also unable to find documentation as to why the D50 was administered although the blood glucose level was not below 70 mg/dL or the physician was notified of the nursing decision to administer the D50. She did indicate the patient was scheduled for surgery later in the day, yet there was still no nursing documentation the physician was notified the D50 was administered.

During an interview with Director of the Step Down Unit (D 1), on 4/14/11 at 11 AM, she acknowledged there was no nursing documentation as to why the Lantus was held or why the D50 was administered for Patient 4. She stated it could have been based on the nurses' judgement, but even so the nurses should have called the physician to receive an order. D 1 confirmed no such documentation could be found in Patient 4's clinical record.

Based on observation, interview, and document review, the hospital failed to provide a sanitary environment by reducing the risk of transmitting infections and communicable diseases as evidenced by:

1. Failure to ensure that patients with rule out (possible) Mycobacterium tuberculosis (TB) were not placed in rooms that shared airflow with other patients on the unit (Refer to A Tag 748, item 1).

2. Failure to ensure that all patients admitted to the intensive care unit were screened for methicillin resistant staphylococcus aureus (MRSA, a bacterial infection that is resistant to multiple antibiotics), within 24 hours of admission (Refer to A Tag 748, item 2).

3. Failure to ensure the physician notified the patient or the patient's representative of positive MRSA results (Refer to A Tag 748, item 3).

4. Failure to develop and implement a policy and procedure ensuring that no more than one hour lapsed after inserting the patient infusion tubing (IV tubing or intravenous tubing) into the intravenous solution and patient administration (Refer to A Tag 748, item 4).

5. Failure to ensure that the waste chute (waste or garbage disposable channel) was routinely cleaned and sanitized (refer to A Tag 748, item 5).

The cumulative effect of the system problems resulted in the hospital's inability to provide a sanitary environment and placed all patients and staff at risk of developing infectious and communicable diseases.

Based on observation, interview, and document review, the hospital failed to develop and implement infection control policies and procedures to reduce the potential of spreading infections and communicable diseases.

1. Two of two patients admitted with rule out (possible) Mycobacterium tuberculosis (TB) to rooms that shared airflow with other patients on the unit (22 and 23) which could have spread this infectious disease to other patients, visitors, and staff.

2. Failure to ensure that one of four patients admitted to the intensive care unit were screened for methicillin resistant staphylococcus aureus (MRSA, a bacterial infection that is resistant to multiple antibiotics), within 24 hours of admission (22) which could have left patients with positive MRSA without treatments.

3. Failure to ensure the physician notified the patient or the patient's representative of positive MRSA results for two of three patients (4 and 25) which had the potential for these patients to spread the disease to the public.

4. Failure to develop and implement a policy and procedure ensuring that no more than one hour lapsed after inserting the patient infusion tubing (IV or intravenous tubing) into the intravenous solution and administering the solution to patients. Such failure had the potential to cause bacteria infection via IV tubing.

5. Failure to ensure that the waste chute (opening where bags of waste are inserted and travel down a slide ending in the basement) was routinely cleaned and sanitized. The black stick material left around the shute opening had the potential to cause cross-contamination along the channel.

Findings:

1a. On 4/13/11 at 9:38 AM, an initial tour was conducted of the medical intensive care unit. During the tour, a sign posted outside Patient 22's room indicated that airborne precautions (Airborne Precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air such as Mycobacterium tuberculosis (TB), were in effect.

On 4/13/11 at 9:40 AM, Patient 22's medical record was reviewed. Documentation in the medical record showed that the patient was admitted to the hospital on 4/12/11, at 6 AM, with a diagnosis of respiratory failure and rule out TB (an infectious communicable disease). Additional documentation in the medical record showed that five years ago, the patient was diagnosed, and treated for active TB.

A review of the physician orders section of the medical record disclosed an order written 4/12/11 at 5:25 AM to place the patient in respiratory isolation (airborne precautions). A second order written 4/13/11 at 8:55 AM, directed, per health department recommendation, collect acid fast bacilli's (laboratory procedure which turns TB bacteria red and easier to identify), times three days.

During a concurrent interview, Registered Nurse (RN) 8 stated that the local public health department directed that the patient remain in airborne precautions until three acid fast bacilli's reports were negative. RN 8 replied, no, when asked if Patient 22 was in a negative pressure room (air in this type of room is maintained by a ventilation system that removes more exhaust air from the room than air is allowed into the room to prevent cross-contamination).

b. On 4/12/11, at 11:59 am, an initial tour was conducted of the 4th floor medical unit. During the tour a sign was posted outside Patient 23's room indicating that airborne precautions were in effect.

On 4/12/11 at 12:10 PM, Patient 23's medical record was reviewed. Documentation in the medical record disclosed that the patient was admitted to the hospital on 4/8/11 with diagnoses that included respiratory failure and sepsis.

During a concurrent interview, RN 9, stated that the patient was in airborne precautions until TB was ruled out. RN 9 stated that the patient's room was not a negative pressure room (an isolation technique used in hospitals and medical centers to prevent cross-contaminations from room to room. It includes a ventilation system that generates negative pressure to allow air to flow into the isolation room, but not escape from the room, as air will naturally flow from areas with higher pressure to areas with lower pressure, thereby preventing contaminated air from escaping the room). RN 9, stated that a portable HEPA (high efficiency particulate air filter which removes at least 99.97% of airborne particles), filter had been placed in the patient's room.

On 4/13/11 at 11:35 AM, an interview was conducted with Plant Operations Manager (POM). During the interview POM was asked if Patients' 22 and 23 rooms were negative pressure rooms. POM stated that the two rooms were not negative pressure rooms. POM was asked if the air from the two rooms was vented directly outside, or was the air shared with other patient rooms on the units? POM stated that the airflow from the two rooms did not vent outside directly, and the airflow from those two rooms mixed with the air from other patient rooms. POM stated that for over a year he had discussed the issue with nursing supervisors and management staff about not placing patients with possible TB in rooms that shared airflow with other patients. When asked if the HEPA filter used in Patient 23's room, allow the airflow from that room to be vented directly outside, POM replied that it would be very difficult to directly vent the airflow from that room using a HEPA filter.

On 4/13/11 at 3 PM, the hospital's 4/10, policy and procedure titled, "Airborne precautions" was reviewed. On page 1 under item B. of the procedure section hospital staff were directed, "Patient placement: The patient will be placed in a private room with negative pressure or a negative air flow machine correctly installed. On page 2 under item 4, hospital staff were directed that, "Air should be discharged directly to the outside, or by monitored high-efficiency filtration of room air before the air is circulated to other areas of the hospital."

The hospital failed to implement their policy and procedure for placing patients with possible TB in rooms that were either negative pressure or vented directly outside. This practice places all patients at risk of being exposed to, and the possibility of contacting TB.

2. On 4/13/11 at 9:38 am, an initial tour was conducted of the medical intensive care unit. During the tour, Patient 22's medical record was reviewed. Documentation in the medical record showed that the patient was admitted to the hospital on 4/12/11 at 6 am.

A review of the laboratory section of the medical record contained no evidence that the patient was screened for MRSA within 24 hours of admission. A review of document titled, inpatient MRSA screening checklist disclosed that MRSA screening must be provided within 24 hours of admission to all patients admitted or transferred to the intensive care unit.

During a concurrent interview, RN 8 was asked if Patient 22 was screened for MRSA. RN 8 reviewed the patient's chart, and contacted the laboratory, and confirmed that Patient 22 was not screened for MRSA within 24 hours of admission to the hospital. RN 8 stated the hospital's policy and procedure for MRSA screening was consistent with the MRSA screening checklist.

On 4/13/11 at 4 PM, the hospitals' 5/10 policy and procedure titled, Methicillin-resistant staphylococcus aureus (MRSA) active surveillance/screening cultures" was reviewed. On page two of the policy and procedure, under item A.3., hospital staff were directed that all patients admitted to the intensive care unit would be screened for MRSA. Under item B.1 direction was that the MRSA screening would be performed as soon as possible following admission within 24 hours.

The hospital failed to implement their policy/procedure and MRSA screening process ensuring that patients who met the criteria were screened for MRSA within 24 hours of admission.

3a. On 4/12/11 at 10:30 AM, Patient 4's medical record was reviewed. Documentation in the medical record showed that the patient was admitted to the intensive care unit on 12/19/10. Documentation in the medical record also showed that the patient was screened and negative for MRSA (not carrying the microbe that causes the disease).

A review of the laboratory section of the medical record showed that on 1/10/11, the patient tested positive for MRSA (not a carrier of the disease).

A review of the physician progress section of the medical record revealed an undated progress note that had a white sticker attached to the page. Printed on the sticker was, "I have informed the patient or the patient's representative of the positive MRSA test results. It was noted that the signature and date areas were blank.

During a concurrent interview, Director of Quality Compliance (DQC) confirmed that the medical record contained no documentation showing that the physician notified the patient or the patient's representative of the positive MRSA result.

b. On 4/13/11 at 9 AM, Patient 25's medical record was reviewed. Documentation in the medical record showed that the patient was admitted to the intensive care unit on 3/31/11. The medical record contained no information showing that the patient was MRSA positive prior to admission.

A review of the laboratory section of the medical record revealed that the patient was screened and positive for MRSA. A white sticker placed on the laboratory report documented that, "I have informed the patient or the patient's representative of the positive MRSA test results. It was noted that the signature and date areas were blank.

During a concurrent interview, RN 10, confirmed that the medical record contained no documentation showing that the physician notified the patient or the patient's representative of the positive MRSA result.

On 4/13/11 at 4 PM, the hospitals' 5/10 policy and procedure titled, Methicillin-resistant staphylococcus aureus (MRSA) active surveillance/screening cultures" was reviewed. The policy and procedure contained no direction about notifying the patient or the patient representative when a patient tested positive for MRSA.

During an interview on 4/13/11 at 4:15 PM, the Infection Preventionist (IP) was asked to explain the hospital's process for notifying the patient or their representative of a positive MRSA culture? The IP stated the hospital had tried different ways to achieve physician compliance, indicating the policy was not current with hospital practice.

The hospital failed to develop and implement a policy and procedure that ensured the physician notified the patient or their representative when patients tested positive for MRSA.

4. On 4/13/11 at 8:45 AM, an initial tour was conducted of the pre-admission area for surgery. During the tour, 14 bags of lactated ringers intravenous solution, 1000 ml (milliliter), were observed hanging on an intravenous pole. It was noted that the patient infusion tubing had been inserted into the intravenous solution. It was also noted that white labels were adhered to the plastic bags of intravenous solution indicated that the patient infusion tubing was inserted into the intravenous solution on 4/13/11 at 4 AM (over 4 hours earlier).

On 4/13/11 at 8:55 AM, the pre-admission area for the gastrointestinal (GI) laboratory was toured. Eleven bags of normal saline intravenous solution, 500 ml were observed hanging on an intravenous pole. It was noted that the patient infusion tubing had been inserted into the intravenous solution. White labels adhered to the plastic bag of solution indicated that the patient infusion tubing was inserted into the intravenous solution on 4/13/11 at 4 AM (over four hours earlier).

During a concurrent interview, the Director of Surgery (DOS) stated that a night nurse inserted the administration tubing into the intravenous solutions to save time because, the patient turn over time was very fast in the GI lab and pre-admit surgery areas. The DOS was asked if she was aware of a time limit beginning when the patient infusion tubing was inserted into the intravenous solution? The DOS replied she was not aware of a time limit. The DOS also stated that the hospital did not have a policy and procedure limiting the infusion time once the patient infusion tubing was inserted into the intravenous solution.

On 4/13/11 at 10 AM, the APIC position paper: Safe injection,infusion, and medication vial practices in health care, by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. (Am J Infect Control 2010;38:167-72.), was reviewed. On page 168, direction is that According to USP ,797., immediate-use CSPs (compounded sterile products) in USP (United States Pharmacopeia)
,797..14 "... requires a 1-hour limit from completing preparation (eg, spiking an IV bag) until beginning administration of the immediate-use CSPs to patients. Their rationale is that the 1-hour limit is expected to preclude microbial population increase when accidental contamination of such drugs occurs with small quantities of microorganisms. Once microbial contamination occurs, the organism replication can begin within 1 to 4 hours with exponential growth occurring rapidly afterward..."

The hospital failed to develop and implement a policy and procedure limiting the time after the patient infusing tubing was inserted into the intravenous solution, increasing the patients' risk of developing a blood stream infection.

5. On 4/12/11 at 10:30 AM, the waste chute (opening where bags of waste are inserted and travel down a slide ending in the basement) on the 5th floor was inspected. It was noted that the waste chute was approximately 24 inches by 24 inches. It was also noted that the entire framing ridge (about one inch) around the waste chute opening was encrusted with a black sticky substance.

During a concurrent interview, the IP was asked about a cleaning schedule for the waste chute. The IP replied she was not aware, but would check with environmental services.

On 4/12/11 at 3 PM, the IP stated the waste chutes were to be cleaned daily. The IP was asked if environmental services had a policy and procedure about the cleaning of the waste chute. A procedure 8.15, dated 8/1/09, titled, "Linen and trash chute cleaning" was provided and reviewed. It was noted that the procedure directed housekeeping staff on how to clean the waste chute, but did not indicate the cleaning frequency. It was also noted that the purpose of the linen and trash chute cleaning procedure was "...to ensure they remain an infectious free area..."

The hospital failed to develop a policy and procedure ensuring that the trash chutes were routinely cleaned and sanitized reducing the risk of organism growth.



21905

Based on interview and record review, the hospital failed to ensure History and Physical (H & P) was completed prior to outpatient procedures for four of six records reviewed (16, 17, 18, and 19). This had the potential to affect these patients' overall outcome associated with scheduled procedures.

Findings:

On 4/13/11 at 2:30 PM, six outpatient patient records were reviewed. The following issues were identified:

1. Patient 16 was scheduled for an outpatient procedure on 3/31/11. The physician who performed the procedure did not document "Chief Complaint/Indications for Procedures" on Patient 16's H & P. The physician wrote on the form that he completed the H & P at "1355 (1:55 PM)" on 3/31/11. However, he also documented that he discharged Patient 16 at 1355 on 3/31/11. The physician did the pre-operative H & P the same time he discharged the patient.

2. Patient 17 was scheduled for an outpatient procedure on 3/30/11. The physician left the "Chief Complaint/Indications for Procedures" blank on the H & P form.

3. Patient 18 was scheduled for an outpatient procedure on 4/7/11. The physician also left the "Chief Complaint/Indications for Procedures" blank on the H & P form.

4. Patient 19 was scheduled for an outpatient procedure on 4/4/11. Her pre-operative procedure was completed on 4/4/11 at "1240 (12:40 PM)." His physician wrote the discharge order also at 1240 on 4/4/11. The physician did the pre-operative H & P the same time he discharged the patient.

On 4/13/11 at 3:15 PM, during an interview, the Director of Endoscopy confirmed the above findings.

On 4/13/11 at 4:10 PM, the hospital's Policy on "Medical Records Content Policy" was reviewed. Under "OUTPATIENT SURGERY/INVASIVE PROCEDURES-SPECIAL CONSIDERATIONS" read in part, "An abbreviated history and physical can be utilized for all patients treated as outpatients and shall consisted of all the elements of the comprehensive history and physical, with a provision that the information may... At a minimum, the written physical examination (dictated and transcribed or hand written) shall include:

? Medical history
? A review of the system
? Allergies
? Major complaints
? Reason for operative procedure
? Initial diagnosis."