HospitalInspections.org

Based on document review and interview, it was determined for 2 of 2 (Pts. #4 and #5) patients receiving pain medications, the Hospital failed to ensure a pain scale assessment was used before and after administration of the pain medication per policy.

Findings include:

1. The Hospital policy titled, "Pain Management (reviewed 2/14)" was reviewed on 7/18/16. The policy required, "If the patient is having pain, assess the pain for severity using a verbal analog (mild, moderate, severe) or Numerical Rating Scale (0 - 10 rating - 10 being the worse). ...Reassess pain within 1 hour of intervention".

2. The clinical record of Pt. #4 was reviewed on 7/18/16. Pt. #4 was a 62 year old female admitted on 7/14/16 with the diagnosis of back pain. The medication administration record (MAR) included that Pt. #4 received Norco (narcotic) for pain at the following times:
- on 7/17/16 at 4:45 AM, the nurses notes lacked a pain reassessment after administering the Norco until 7:00 AM (2.25 hours after administration).
- on 7/18/16 at 6:48 AM, the nurses notes lacked a pain assessment prior to administering the Norco.

3. The clinical record of Pt. #5 was reviewed on 7/18/16. Pt. #5 was a 97 year old female admitted on 7/14/16 with a fractured right hip. The MAR included that Pt. #5 received Norco for pain at the following times:
- on 7/17/16 at 9:19 AM, the nurses notes lacked a pain assessment prior to administering the Norco and a reassessment was completed at 12:00 PM (3 hours after administration).
- on 7/17/16 at 3:17 PM, the nurses notes lacked a pain assessment prior to administering the Norco.

4. During an interview on 7/18/16 at approximately 1:30 PM, the Nurse Manager of 3 East (E#1) stated there should be a pain assessment before and after medication administration.

Based on document review and interview it was determined, the Hospital failed to ensure that medical records were completed within 30 days after discharge.

Finding include:

1. The Hospital policy titled, "Hospital Medical Record Completion (revised 4/2016) was reviewed on 7/20/16. The policy included, "A discharge summary shall be completed and signed on all patients within 36 hours of discharge. ... If a Practitioner's documentation is determined to be incomplete for more than 6 days without a valid excuse (i.e. illness, vacation), that Practitioner will be required with the President of the Medical Staff ... to establish a set date for completion, not to exceed two days from the date of the meeting".

2. On 7/20/16 at approximately 1:10 PM, the Hospital presented an attestation letter that indicated the Hospital had a total of 4 delinquent medical records.

3. On 7/20/16 at approximately 1:10 PM, the Supervisor of Health Information Management (E#7) stated that the 4 records included in the letter were not completed within 30 days of discharge.

Based on document review, observation, and interview, it was determined, for 3 of 7 staff members (E#8-10) preparing food in the tray line, the Hospital failed to ensure adherence to the dress code policy for the kitchen. This potentially affected a total of 50 patients on census, who received meals from the kitchen.

Findings include:

1. Policy entitled "Associate Hygiene" (rev 11/2013) indicated "2. Scope: The associate hygiene standards and procedures apply to: All associates engaged in food preparation, production, or services. All associates working in warewashing and storage areas...4.1.3 Hair Restraints: Associates must wear hair restraints to keep their hair out of food.

2. On 7/20/2016 an observational tour was conducted in the kitchen from 11:25 AM to 12:00 PM. The following was observed during the tray line preparation:

-11:30 AM a Cook (E #8) was wearing a hairnet with approximately an inch of hair exposed around the neck.

-11:34 AM another Cook (E #10) was wearing a hairnet with approximately one inch of hair exposed around the forehead, bilateral ears and neck.

-11:45 AM the Supervisor (E #9) was walking around the kitchen with a hairnet partially on, exposing approximately 2 inches of hair around the ear and neck.

3. On 7/20/2016 at approximately 11:55 AM the findings where discussed with the Dietary Manager ( E #11). E #11 stated hairnets should be on at all times to contain the staffs' hair.

A. Based on document review, observational tour, and interview, it was determined, for 3 of 6 call lights in the Radiology department, the Hospital failed to ensure call light sound alarms were functional, potentially affecting more than 130 radiology patients each day.

Findings include:

1. On 7/20/16 at 10:35 AM, Hospital policy titled, "Clinical Alarm System and Patient Safety", effective 1/28/13, was reviewed. The policy required, "Clinical system alarms are intended to protect the patient and alert the staff that the patient needs assistance... Clinical systems include... call lights..."

2. On 7/20/16 at 9:15 AM, an observational tour was conducted in the radiology department. Call lights sound alarms in 3 of 6 washrooms (1. North East corner, 2. attached to "digital room", and 3. near ultrasound room) did not function when turned on. In addition, the switch for the call light in the North East corner was upside down - if the cord is pulled, the alarm is turned off, not on.

3. On 7/20/16 at 9:30 AM, during the tour with the Director of Imaging and Cardiac Services (E #3), E #3 stated that the 3 bathroom sound alarms were not working.



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B. Based on document review, observation, and interview, it was determined that for 1 of 2 crash carts in the Emergency Department (ED), the Hospital failed to ensure routine daily checks were performed as required. This potentially affected approximately 80 patients (average daily census) in the ED.

Findings include:

1. On 7/20/16 at approximately 2:00 PM, the Hospital's policy titled, "Code Blue Plan" (effective 7/15) was reviewed and required, "...Routine Crash Cart Checks: d. It is the responsibility of the Clinical Director or designee to ensure daily check is complete..."

2. On 7/20/16 at approximately 1:20 PM, an observational tour of the ED was conducted. The checklist, located near room 6 & 7 (cart 1), lacked documentation that the crash cart was checked on two occassions (7/10/16 and 7/18/16) for the month 7/1/16 to 7/19/16.

3. On 7/20/16 at approximately 1:25 PM, the above finding was discussed with the Director of the Emergency Services who stated that the crash cart should have been checked daily and documented.

Based on document review and interview, it was determined, for 15 of 185 days in 2016 when surgical instruments were being disinfected, the Hospital failed to ensure disinfection documentation was complete, potentially affecting approximately 305 patients undergoing surgery each month.

Findings include:

1. On 7/19/16 at 3:50 PM, Hospital policy titled, "Log Book Documentation", written 7/2010, was reviewed. The policy required, "All items sterilized in the Sterile Processing Department will be documented in the appropriate sterilizer log book with... name of staff member starting cycle..."

2. On 7/19/16 at 3:15 PM, Hospital sterilization logs for 2016 were reviewed. The Steris SPD high level disinfection log lacked documentation of the staff member who started the sterilization cycle on 15 of 185 days (Jan. 6, 7, 16, 17, 20, 29, Feb. 15, 17, March 15, 16, 28, April 22, May 3, and June 7 and 8) in 2016.

3. On 7/19/16 at 3:40 PM, an interview was conducted with the Lead Sterilization Processing Technician (E #2). E #2 stated staff should have initialed the sterilizer slips.

Based on document review, observation, and interview, it was determined that for 3 of 5 employees and 1 of 1 anesthesiologist (E #'s 4, 5, 6 and MD #1) observed in the surgical operating room (OR) 3, the Hospital failed to ensure staff''s adherence to surgical attire policy.

Findings include:

1. On 7/20/16 at approximately 11:30 AM, the Facility's policy titled, "Infection Control - Dress Code Within Operating Room", effective 12/2012, was reviewed. The policy required, "CAPS 1. Hair must be covered at all times with a cap provided by the department when going into the the OR restricted areas".

2. On 7/20/16 at approximately 9:30 AM, an observational tour of OR #3 was conducted:

- E #4 (Surgical Technician) had approximately 3 inches of hairs exposed from the back of the head.

- E #5 (OR Registered Nurse) had approximately 4 inches of hairs exposed from the back of the head.

- E #6 (OR Registered Nurse) had approximately 4 inches of hairs exposed from the back of the head.

- MD #1 had approximately 3 inches of hairs exposed from the back of the head.

3. On 7/20/16 at approximately 10:30 AM, the above findings were discussed with the Director of Surgical Services who stated that all hair should be covered.