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Based on observation, interview and document review, the facility failed to ensure patient privacy was maintained for patients in the Pediatric Intensive Care Unit, Post Partum and the Emergency Department.

Findings include:

1) On 12/8/10 at 11:20 AM, several pediatric patients and the Child Life Specialist were sitting in the Pediatric ICU (Intensive Care Unit) Nurse's Station, completing crafts. There were six monitors located in the nurse's station which showed patients in their rooms visible at the nurse's station.

The Unit Manager confirmed the monitors should only be visible to the staff and not to patients or visitors. The patients were immediately moved out of the nurse's station into the designated playroom.

2) On 12/10/10 at 8:15 AM, on the Post Partum unit, a computer screen with patient identifying information (including patient name, date of birth and diagnosis) was visible to the public. The computer was located directly across from the nurse's station. The screen remained visible until 8:27 AM, when a physician started to use the computer. No screen saver came up to protect the identifying information. During this time, several staff members and a visitor, walked past the computer screen.

On 12/10/10 at 8:27 AM, the QI (Quality Improvement) staff member was informed of the issue and confirmed that patient information needed to be protected.


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3) Emergency Department
- On 12/10/10 at 9:45 AM, an un-sampled Patient (#44) in the Emergency Department explained she had been in the hall since the evening of 12/9/10. The patient indicated the nurses did not check on her very often and she was unable to reach staff if she needed them. The patient explained the nurses were unable to hear her when she would call out to them. The patient indicated during one assessment, the nurse did not provide privacy. The patient stated, "You don't treat someone like this when they come to you for help." The patient was observed having vital signs completed by a nurse with the privacy curtains open. At 10:00 AM, the patient was moved to another area in the hall. At 11:35 AM, the patient was observed holding a Styrofoam cup. The patient explained there was no where to put the cup down. The patient explained she did not appreciate facing another patient who was in a lot of pain. The privacy curtains were observed open.

On 12/10/10 at 9:55 AM, a Registered Nurse in the Emergency Department explained the machine recording the vital signs was turned away from the main flow of traffic to maintain the patient's confidentiality.

On 12/10/10 at 11:20 AM, the Certified Nursing Assistant from the Emergency Department explained each patient was asked if they needed a more private area to talk with the physician. The employee indicated the patients on psychiatric hold were usually placed in front of the nurse's station. The employee explained the staff did not discuss patients by their names, but by using the patient's bed number. The conversations of the staff were easily heard by patients on the gurneys in front of the nursing station.


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- Un-sampled Patient #41 was admitted to the Emergency Department (ED) on 12/9/10 at 7:15 PM, with the complaint of left hip pain.

On 12/10/10 at 9:50 AM, un-sampled Patient #41 indicated she had arrived in the ED on 12/9/10 and was on a gurney in front of the nurse's station in the hallway at 3:00 PM. Un-sampled Patient #41 verbalized when she was on the gurney outside the nurse's station and she could hear the facility staff talking about other patients' medical conditions and was able to see other patients on gurneys in the emergency rooms. Un-sampled Patient #41 indicated she tried not to look at the other patients, but due to where she was located it was hard. Un-sampled Patient #41 indicated there was a lack of privacy in the ED.

- Un-sampled Patient #42 was admitted to the ED on 12/9/10 at 4:20 PM, with the complaint of chronic obstructive pulmonary disease exacerbation.

On 12/10 at 9:10 AM, un-sampled Patient #42 indicated she had arrived in the emergency room and was transferred to the day room on 1 west at 5:00 AM. Un-sampled Patient #42 indicated while in the ED she could hear other patients medical information. She indicated it did not bother her being in the hallway, but she could tell other patients were uncomfortable. She indicated she tried to look away and not listen but it was too hard not too.

The facility's Policy and Procedure entitled, "Patient Rights and Responsibilities," dated 2/06 documented: "The patient has the right to considerate and respectful care, with attention to dignity, privacy, safety and respect for his/her personal beliefs and values. The patient has the right to every consideration of his/her privacy concerning his/her medical care program. The patient has the right to expect that all communications and records pertaining to his/her care should be treated as confidential."

Based on observation, interview and document review, the facility failed to ensure medications were dispensed and stored in accordance with accepted standards of practice for 2 of 40 patients (Patients #42 and #22).

Findings include:

Unsampled Patient #42

Patient #42 was admitted to the facility on 12/8/10, with diagnoses including esophogeal reflux and had a revision of a gastrostomy tube on 12/8/10.

On 12/10/10 at 9:00 AM, the medication Nurse administered medication through Patient #42's gastrostomy tube (G-tube).

Patient #42 had a large syringe attached to the G-tube. The nurse disconnected the syringe from the G-tube, instilled a small amount of water, followed by the liquid medication, and then additional water to flush the tube. The nurse then clamped the G-tube. The nurse did not check the G-tube for placement prior to administering the medication.

Following the observation, the nurse indicated she did not check for placement since this was a newly inserted gastrostomy tube.

On 12/10/10 at 9:30 AM, the charge nurse acknowledged a gastrostomy tube should be checked for placement prior to administering medications.

The facility policy titled, 'Gastrostomy and Gastrostomy-Jejunostomy Tubes: Care and Management (Pediatric)," from Mosby's Nursing Skills, 2006 revealed: "...Administer Medication - Verify Placement. "To verify placement (the policy documented)...GT: Attach a syringe and withdraw gastric aspirate or lower syringe below stomach level and check gastric aspirate in syringe..."



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Patient #22

The facility's "Pressure Ulcer: Prevention, Assessment, Treatment, and Documentation" policy, dated 6/2009, included the following pressure ulcer stages in its definitions: Stage I, Stage 2, Stage 3, Stage 4, Deep Tissue Injury (DTI), and Unstageable. According to the policy, "Treatment for pressure ulcers is delivered according to the 'SRDH (St. Rose Dominican Hospital) Pressure Ulcer Guidelines' and the 'Wound Management Orders'...The LIP (Licensed Independent Practitioner) has the option to write their own orders for wound treatment in lieu of the 'Wound Management orders' if they choose to do so."

The "SRDH Pressure Ulcer Guidelines" listed the following treatments for a DTI: "Clean with wound cleanser or saline; Off load; If closed - Apply No Sting Barrier film and allow to dry; If open - Treat the pressure ulcer at the stage it is."

The treatment for a Stage 2 pressure ulcer, according to the "Wound Management Orders," was written as follows: "Cleanse skin with wound cleanser or saline; Apply no-sting barrier film to peri-wound area or intact blister; If no drainage, apply transparent barrier film; If drainage, apply acrylic dressing (minimal drainage) or foam dressing (moderate to heavy drainage); Change dressing every 7 days and as needed for loosening or soiling."

Patient #22 was admitted to the facility on 11/28/10, with diagnoses including chest pain and atrial flutter. The patient had a Foley catheter.

Review of the patient's clinical record revealed a nurse's note written on 11/30/10, which described an "area of fluid-filled blisters and questionable necrotic area." The record indicated the Wound Care Nurse determined the pressure ulcer should be classified as a DTI. This classification as a DTI continued through 12/7/10.

From 11/30/10 through 12/5/10, the patient's pressure ulcer was treated with frequent turning, a low air loss mattress, a barrier cream, and left open-to-air. On 12/5/10 at 8:00 PM, the wound was still intact. A foam dressing was placed on the pressure ulcer at that time by the nursing staff.

On 12/7/10 at 1:00 PM, the wound broke open. The Wound Care Nurse then classified the wound as a Stage 2 pressure ulcer, and the treatment for the wound was changed to using a barrier cream and leaving it open to air.

There was no evidence of a physician's wound management order for Patient #22 until 12/9/10. On 12/8/10 at 12:00 PM, the Chief Nurse Executive, confirmed the absence of the order. The Chief Nurse Executive communicated the treatment for wound care "is not official until orders are signed by the physician." The employee further explained that the Wound Management Orders form, or a written order, should be signed by a physician "ahead of doing standard care."

On 12/10/10 in the morning, the Wound Care Nurse, was interviewed about the treatment which was carried out for Patient #22's pressure ulcer. The nurse agreed a foam dressing should not have been placed on 12/5/10 at 8:00 PM, when the wound was still intact and classified as a DTI. The nurse explained the foam dressing should only be used for high-exudate wounds.

Based on interview and record review, the facility failed to ensure patient care plans were initiated and updated based on the patient's assessment and medical condition for 3 of 40 sampled patients. (Patient #37, #38, and #35)

Findings include:

1. Patient #37 was admitted to the hospital on 11/5/10, with diagnosis of lymphoma.

The admission history and physical dated 11/5/10 documented the patients diagnoses as lymphoma, metastatic to spine, debility, electrolyte imbalance, prior appendectomy and anemia of chronic disease.

A review of the patient's record revealed the care plan for "At risk for injuries related to falls at home" documented the problem as "...suicide/medically unstable." The plans and interventions included, "...initiate seizure precautions, initiate suicide precautions..."

There was no documentation in the patient's record the patient had suicidal ideations or seizures requiring the patient to be placed on suicidal precautions and seizure precautions.

2. Patient #38 was admitted to the hospital on 12/07/10, with a diagnoses including infected knee replacement and was placed on a sepsis protocol.

A review of the clinical medical record revealed the physician ordered Vancomycin 1 gram intravenous every 12 hours and the patient had an infectious disease consult. The clinical medical record lacked a care plan related to infection. The Director of the Medical Surgical Unit confirmed the chart lacked a care plan for infection.

On 12/09/10 at 1:20 PM, the Director of the Medical Surgical Unit indicated the nurses who initiated and updated the care plan failed to individualize the care plan based on the patient's assessment and medical condition.


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3. Patient #35 was admitted to the hospital on 12/1/10, with a diagnosis of abdominal trauma and fractured knee.

The admission history and physical, dated 12/1/10, documented the patient diagnosis including coronary artery disease and high cholesterol.

A review of the patient's chart revealed the care plan included Alteration in Comfort, Infection and Alteration of Mobility and ADL's (activities of daily living). There was no documented evidence the coronary artery disease was addressed in the care plan.

On 12/9/10 at 1:25 PM, the Clinical Educator of the Medical and Surgical floors indicated the nurses who initiated and updated the care plan should have addressed the patient's cardiac condition.

Based on interview, record review and document review, the facility failed to ensure the verbal orders for electrolyte replacement therapy was signed by the physician per facility policy for 2 of 40 sampled patients. (Patient #37 and #33)

Findings include:

On 12/09/10 in the morning, the charge nurse indicated the "Adult Electrolyte Replacement Order" protocol was a standing order and required a physician signature. The charge nurse indicated the expectation would be to have a written order by the physician to follow the electrolyte replacement protocol and for the physician to sign the protocol order form.

On 12/09/10 in the morning, a Clinical Pharmacist explained the "Adult Electrolyte Replacement Order" was a protocol approved by the hospital to allow nursing staff to order electrolyte replacement medications based on the patient's electrolyte laboratory values. The process to use the protocol was to have the ordering physician sign and date the Adult Electrolyte Replacement Order when the physician would like the protocol to be used. The order would then be scanned to pharmacy and added to the patient's medication profile. Once the nursing staff received the patient's electrolyte laboratory value, the nurse would review the order and chose which medication to administer to the patient. The nurse would then send a medication request to pharmacy. The pharmacist would review the request for accuracy and provided the requested medication for administration. The intent of the protocol was to have the physician sign the order once. If the licensed nurse documented the order on the physician order form, the physician would be required to sign the order.

On 12/09/10 in the morning, the Director of the Medical/Surgical Unit indicated if the physician desired the Adult Electrolyte Replacement Order to be used, the physician would sign and date the order. When the licensed nurse received the laboratory results, the licensed nurse would review the protocol to select the desired medication. The nurse would then write the laboratory results along with the requested medication to be administered in the medication administration record. The licensed nurse would not need to write an order for the medication in the physician order form and the nurse would not need to get a new Adult Electrolyte Replacement order form. If the nurse did write an order for the medication, the physician would need to sign the order per facility policy.

The facility policy titled, "Telephone & Verbal LIP (Licensed Independent Practitioners) Orders," with an original date of 09/03, and revised on 01/09 and 04/10, documented: "...4.4 All telephone and verbal orders must be signed by a LIP within 48 hours..."

The Adult Electrolyte Replacement Orders documented: "1. Give replacement doses as indicated in the preceding charts.; Oral replacement is preferred unless contraindicated; 2. Contact physician if after giving electrolyte replacement the electrolyte level remains below the normal range.; 3. Recheck electrolyte level as follows: For IV (intravenous) Replacement: Mg 2+ (magnesium) and Potassium = 4 hours after replacement; Phosphorous = 6 hours after replacement; and Oral Replacement = 6 hours after replacement...the replacement orders is based on the electrolyte level and the serum creatinine level..."

1. Patient #37 was admitted to the hospital on 11/5/10.

The physician orders dated 11/08/10 at 12:04 AM, documented an order for Tylenol PM, 1 tablet at bedtime as needed for insomnia, electrolyte replacement protocol. The verbal order was taken by the licensed nurse. The order was not signed by the ordering physician.

The physician orders dated 11/08/10 at 4:25 AM, documented potassium chloride 40 milliequivalents in 250 milliliters intravenous over 4 hours times 1 per electrolyte replacement protocol. The potassium level was 3.3 and creatinine level was 0.96. The order was written and signed by the licensed nurse. The order was not signed by the ordering physician.

The physician orders dated 11/11/10 at 9:30 PM, documented to discontinue the PICC (percutaneous intravenous central catheter) line in the morning, access port in the morning, and continue Lovenox and aspirin. The verbal order was taken by a licensed nurse. The order was not signed by the ordering physician.

The physician orders dated 11/13/10 at 3:10 AM, documented an order for magnesium oxide 400 milligrams orally, 2 tablets every 2 hours times 2 doses per electrolyte protocol. The magnesium level was 1.8 and the creatinine level was 1.14. The order was written and signed by the licensed nurse. The order was not signed by the physician.

The physician orders dated 11/14/10 at 5:00 AM, documented an order for magnesium oxide 400 milligrams orally, 2 tablets every 2 hours times 2 doses per electrolyte replacement protocol. The magnesium level was 1.8 and the creatinine level was 0.92. The order was written and signed by the licensed nurse. The order was not signed by the ordering physician.

Note: The physician orders dated 11/15/10 at 4:30, documented an order to continue electrolyte replacement. The order was signed by the ordering physician.

The physician orders dated 11/16/10 at 8:19 PM, documented an order for potassium chloride 20 milliequivalents orally every 2 hours times 2 doses per electrolyte protocol. The potassium level was 3.4 and the creatinine level was 0.40. The order was written and signed by the licensed nurse. The order was not signed by the ordering physician.

The Adult Electrolyte Replacement Orders form undated, documented an order for magnesium oxide 400 milligrams orally 2 tablets every 2 hours times 2 doses. The magnesium level was 1.8 and the creatinine level was 0.91. The order was written and signed by the licensed nurse. The order was not signed by the ordering physician.

The physician orders dated 11/19/10 at 5:00 AM, documented an order for K-dur 20 milliequivalents orally times 2 doses and magnesium oxide 400 milligrams, 2 tablets times 2 doses as per electrolyte protocol. The potassium level was 3.1, magnesium level was 1.8 and the creatinine level was 0.74. The order was written and signed by the licensed nurse. The order was not signed by the ordering physician.

The physician orders dated 11/23/10 at 5:00 AM, documented an order for potassium chloride 20 milliequivalents, 1 tablet orally every 2 hours times 2 doses and magnesium oxide 400 milligrams orally, 2 tablets every 2 hours times 2 doses, per the electrolyte replacement protocol. The potassium level was 3.5, magnesium level was 1.8, and creatinine level was 0.79. The order was written and signed by the licensed nurse. The order was not signed by the ordering physician.

The physician orders dated 11/25/10 at 3:30 AM, documented an order for K-dur 20 milliequivalents orally times 2 doses as per the electrolyte protocol. The potassium level was 3.5 and creatinine level was 0.91. The order was written and signed by the licensed nurse. The order was not signed by the ordering physician.

The physician orders dated 11/26/10 at 1:45 AM, documented an order for magnesium oxide 400 milligrams, 2 tablets orally every 2 hours times 2 doses. The magnesium level was 1.8 and creatinine level was 0.86. The order was written and signed by the licensed nurse. The order was not signed by the ordering physician.

The physician orders dated 11/29/10 at 7:05 AM, documented an order for K-dur 20 milliequivalents 1 tablet orally every 2 hours times 2 doses and magnesium oxide 400 milligrams orally 2 tablets every 2 hours times 2 doses. The potassium level was 3.5, magnesium level was 1.8 and creatinine level was 0.86, The order was written and signed by the licensed nurse. The order was not signed by the ordering physician.

The Adult Electrolyte Replacement Orders form dated 12/01/01 at 5:00 AM, documented an order for potassium chloride 20 millie-equivlants orally every 2 hours times 2 doses. Potassium level was 3.5 and creatinine level was 0.78. The order was written and signed by the licensed nurse. The order was not signed by the ordering physician.

The Physician Orders dated 12/02/10 at 2:10 AM, documented an order for magnesium oxide 400 milligrams, 2 tablets by mouth every 2 hours times 2 doses per electrolyte replacement protocol. This order was written and signed by the licensed nurse. The magnesium level was 1.8 and creatinine level was 0.77. The order was not signed by the ordering physician.

2. Patient #33 was admitted to the hospital on 12/01/10.

The Physician Orders dated 12/3/10 at 3:30 PM, documented an order for potassium chloride 20 milliequivalents in 250 milliliters of intravenous fluids over 4 hours times one dose per Electrolyte Replacement Protocol. The order was written and signed by the licensed nurse. There was no physician signature.

Based on interview, record review and document review, the facility failed to ensure verbal orders were signed by the physician per facility policy for 2 of 40 sampled patients (Patient #37 and #33).

Findings include:

1. A review of Patient #37's record revealed the physician did not sign verbal orders for medication administered per the electrolyte replacement protocol. (Also see Tag A406)

2. A review of Patient #33's record revealed the physician did not sign a verbal order for medication administered per the electrolyte replacement protocol. (Also see Tag A406)

The facility policy titled, "Telephone & Verbal LIP (Licensed Independent Practitioners) Orders," with and original date of 09/03, and revised on 01/09 and 04/10, documented: "...4.4 All telephone and verbal orders must be signed by a LIP within 48 hours..."

On 12/09/10 in the morning, the charge nurse indicated the "Adult Electrolyte Replacement Order" protocol was a standing order and required a physician signature.

On 12/09/10 in the morning, a clinical pharmacist indicated if the licensed nurse documented an electrolyte replacement protocol order on a physician order form, the physician would be required to sign the order.

On 12/09/10 in the morning, the Director of the Medical/Surgical Unit indicated if the licensed nurse wrote an order for a medication per the electrolyte replacement protocol, the physician would need to sign the order per facility policy.

Based on interview, record review and document review, the facility failed to ensure the general consent for treatment was signed by the patient or patient representative and maintained in the patient's chart for 2 of 40 sampled patients (Patient #40 and #38).

Findings include:

Patient #40 was admitted to the hospital on 12/8/10. A review of the chart on 12/10/10, revealed there was no signed consent for treatment. The Director of the Medical/Surgical Unit was unable to produce the signed consent.

Patient #38 was admitted to the hospital on 12/7/10. A review of the chart on 12/10/10, revealed there was no signed consent for treatment. The Director of the Medical/Surgical Unit was unable to produce the signed consent.

On 12/10/10 in the morning, the Director of the Medical/Surgical Unit indicated the charge nurse was responsible to ensure all paperwork was completed and in the patient's chart. The case manager would also be responsible to ensure the signed consents were obtained and placed in the patient's chart. The charge nurse and the case manager met each morning regarding the patients on the unit.

The facility policy titled, "Consent for Care and Services," dated 12/82, and revised in 03/10 and 06/10, documented: "...4.1 Consent is required for the general medical care provided to patients admitted to the hospital for inpatient or outpatient services, including services provided in an emergency situation...5.2.1 Admitting - Upon admission or as soon thereafter as reasonably possible the patient or an incompetent patient's surrogate decision-maker will be asked to give consent to the general medical care and the general terms and conditions for receiving care from the Hospital..."

Based on observation, interview and policy review, the facility failed to secure medication cabinets and supply carts.

Findings include:

On 12/9/10 at 1:15 PM, the ante-room across from room 353 contained a supply cart that was unlocked and unattended. The supply cart contents included: five pre-filled syringes of Sodium Chloride, dressing supplies, needles, spare intravenous fluid bags and respiratory therapy supplies. A Nurse on Station 3 verbalized, "The cart should be locked, but it's not." The Nurse indicated the cart should be locked so nobody can go in and take things they are not suppose to take.

On 12/10/10 at 9:15 AM, a supply cart was unlocked and unattended on Station 1 West. The supply cart contained five drawers and the contents included: pre-filled syringes of Sodium Chloride, Providone Iodine, Cavi-wipes, Alcohol wipes, laboratory specimen tubes, suture removal trays, syringes, secondary intravenous tubing, and intravenous fluids.

On 12/10/10 at 9:18 AM, the Charge Nurse on 1 West indicated, the cart was supposed to be locked. The Charge nurse on 1 West indicated it should be locked due to the contents of the cart. She stated, "...(the contents of the cart) should not be accessed by anyone but an RN (Registered Nurse)."

The facility's Policy/Procedure entitled, "Medication Access and Security," dated 8/10, documented: "Authorized employees and/or contract staff -who handle, stock, dispense and/or administer medications and medication supplies, are responsible to ensure medications, medication supplies, and medication storage areas containing medications, syringes, or needles are secured at all times."


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On 12/7/10 at 9:00 AM, during the initial tour, two Intravenous (IV) trays with syringes were on top of the counter between Rooms 419 and 420 in the Pediatric Unit. At 10:45 AM, the two IV trays were still sitting on the counter.

The Unit Manager indicated the trays should not be left on the counter where it was accessible to patients and visitors. The IV trays should be kept in the medication room. She added the night shift had started an IV on a patient and left the IV equipment out.


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During an initial tour of the second floor on 12/7/10 at 9:45 AM, a cabinet containing patient medications was observed to be unlocked near the second-floor South nurses station. The cabinet was not in a locked room. The charge nurse reported the lock was broken, and "It's supposed to be locked." The nurse communicated she would contact the maintenance department to repair it.

On 12/9/10 at 10:00 AM, the same cabinet was observed to still be unlocked. Another charge nurse was asked why the cabinet was unlocked, and he stated, "The key lock is hard to open."

Based on a review of the laboratory look-back procedure, the laboratory failed to have a system which included all required actions to be taken when the laboratory was notified that blood or blood components it had received were at increased risk of transmitting HIV or HCV.

Findings include:

The laboratory had a system in place in order to take action when notified of the receipt of blood or blood components at increased risk of transmitting HIV or HCV, however, the written policy did not meet current federal regulatory requirements.

Based on observation and interview, the facility failed to ensure equipment was maintained and readily available for use.

Findings include:

On 12/7/10 at 9:00 AM, during the initial tour, the Pediatric emergency crash cart with its defibrillator, in the hallway in front of the Pediatric Nurse's Station, was not plugged into a red emergency power outlet to recharge the defibrillator.

On 12/7/10 at 11:00 AM, the crash cart and defibrillator was still in the same position, not plugged in to an emergency outlet.

The unit manager indicated the crash cart and defibrillator had always been kept in the same location. When the manager was interviewed about having the cart's defibrillator plugged into an emergency outlet, she verbalized the cart's defibrillator should be plugged into an emergency outlet in case there was a power outage. The unit manager then moved the cart and plugged the defibrillator into the red emergency power outlet.

Based on observation, interview and document review, the facility failed to ensure appropriate measures were implemented to prevent the spread of infection.

Findings include:

On 12/7/10 at 10:45 AM, a housekeeping staff member was cleaning a patient's room in the Pediatric ICU (Intensive Care Unit). The housekeeper had gloves on. After cleaning the room, the housekeeper picked up two bags of trash and a bag of dirty linen, which were on the floor in the hallway. The housekeeper carried the bags down the hallway and, with the dirty gloves in place, proceeded to enter the code on the door to the soiled utility room. The housekeeper came out of the utility room wearing the same gloves. The housekeeper removed the gloves in the hallway, disposed of the gloves and applied a hand sanitizer.

On 12/7/10 at 11:00 AM, the Charge Nurse confirmed the staff should not wear dirty gloves to open the utility room door, and gloves should be removed and disposed of in the utility room.


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On 12/10/2010, in the morning, a cardiac catheterization procedure was being performed in the catheter lab. The top cover of the biohazard container was being used as a table to place patient personal items and the patients telemetry monitor. During the procedure the RN (Registered Nurse) staff placed, on top of the biohazard bin cover, sterile packaged medical equipment used for the procedure. After the procedure, the staff opened the top of the bin with their soiled gloves, clean gloves, and their bare hands to place soiled items in the bin.

On 12/10/2010, in the morning, the manager of the catheter lab confirmed that using the top of the biohazard bin to use as a table was not acceptable.

On 12/8//2010, in the morning, the entrance to room 207 had a contact isolation precautions sign that read:

"...Use hand hygiene-aseptic technique
Gown and Glove when entering the room
Wear regular surgical mask, if indicated
Use dedicated patient equipment..."

Upon entering the room the staff RN and the surveyor obtained new yellow gowns from the closet next to the rooms front entrance. The RN and surveyor donned on the new gowns prior to entering the patients room. Observed in the room were used yellow gowns hanging next to the sink, on the entrance door, and gowns hanging on the wall light fixture next to the patient head of the bed. Before exiting the room the RN and the surveyor removed the used gowns and placed them in the trash container. An RN outside the room indicated that the gowns hanging in the room were reused by the respiratory staff when entering and exiting the room. The RN also indicated that family members sometimes reused their gowns.

When removing the gowns, the gown sleeves, would sometimes be reversed when pulling the gown off. If a person was to don on a used gown, it was difficult to determine which side of the gown was soiled and which side was clean and possibly exposing their clothing to soiled material if the used gown was reversed.

On 12/10/2010, in the morning, the infection control coordinator indicated it was not acceptable to reuse gowns when entering a patients room who was placed in isolation precautions. The gown had to be disposed in the trash prior to leaving the room.


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On 12/9/10 and 12/10/10, three of five Environmental staff members were not able to verbalize the correct procedure for cleaning the floors in the patient care areas.

On 12/9/10 at 8:25 AM, an Environmental staff member #1 verbalized she was instructed to clean the floors in the Emergency Department (ED) with water only, so the wax on the floor can be saved. The staff member's mop bucket was observed on the unit. Environmental staff member #1 indicated her mop bucket had only water in it.

On 12/10 at 9:30 AM, Environmental staff member #3 verbalized she was instructed to clean the unit floors with plain water. The staff member demonstrated how by hitting a button/lever the staff member can change the concentration of chemicals and water used to clean. The Environmental staff member indicated soap was not used because it makes the floors sticky and damages the wax.

On 12/10/10 at 9:45 AM, Environmental staff member #2 indicated floors were the last area done when cleaning a room. Environmental staff member #2 verbalized she was trained to use a little cleaner and mostly water, otherwise the floor was too sticky. Environmental staff member #2 stated, "...(she used a) little bit more chemical for cleaning the public bathrooms."

On 12/10/10 at 11:10 AM, The Environmental Services Supervisor indicated in the past there had been issues with sticky floors at the facility. He indicated staff was using the wrong concentration of chemicals on the floor. The Environmental Services Supervisor indicated the staff was to clean the floors with a general 3 and 1 neutral cleaner, which had detergent in it.

Documentation received from the facility indicated a vendor cleaning system was used. An application chart was posted in the Environmental Service closets on patient floors for staff use as a reference. The chemicals used were coded by color and number for an easy visual reference. The Environmental Service staff could look at the pictures on the charts and match up the chemical with the cleaning surface(s).

The vendor cleaning system and dispenser in the Environmental Service closets was preset to dispense the chemicals as ready to use so employees did not have to mix chemicals.

Based on observation, interview, and document review, respiratory therapy department personnel did not follow hospital procedure in regard to specimen labeling.

Findings include:

On 12/7/10, during an inspection of the blood gas laboratory located on the Intensive Care Unit, two respiratory therapists were found in the laboratory, one of whom was completing a blood gas test. The specimen that had been tested was in a syringe, which did not contain a patient label or other identifying information. The plastic bag which had been used to transport the syringe had a patient label on it. Employee #7 confirmed that it was acceptable for blood gas specimens to be placed in bags which were labeled with the patient information.

The St. Rose Dominican Hospital Respiratory Therapy Procedure entitled, "Specimen Collection, Transportation," stated: "The label must be attached to the sampling syringe at the time of collection, and may not be deferred to a later time." The St. Rose Dominican Respiratory Therapy Procedure entitled, "Blood Gas Sampling," directed respiratory therapists, after drawing a blood gas specimen, to "Label syringe."

Based on observation, interview, record review and document review, the facility failed to ensure that respiratory services were provided in accordance with physician orders for 2 of 40 patients (Patients #22 and #40).

Findings include:

Patient #22

Patient #22 was admitted to the facility on 11/28/10, with diagnoses including chest pain and atrial flutter. Initial physician orders included the aerosolized medication Xopenex 0.63 mg (milligrams)/3 mL(milliliters) every 6 hours.

On 12/3/10, a new respiratory care order was prescribed for the patient: Albuterol unit dose (2.5 mg/3 mL 3 mL each) every 4 hours and every 2 hours prn (as needed); Atrovent unit dose every 4 hours and every 2 hours prn. On 12/3/10 a respiratory therapist (RT) completed a "Respiratory Protocol and Assessment per Policy" form and indicated the new order on the form.

According to respiratory therapy (RT) notes and the Omnicell medication dispensing record, aerosolized medications were given by respiratory therapist, beginning 12/4/10, to Patient #22 as follows:

12/4/10, 3:15 AM - Albuterol unit dose; Atrovent unit dose.
12/4/10, 7:00 AM - Albuterol unit dose; no Atrovent according to Omnicell.
12/4/10, 10:30 AM - Albuterol unit dose; no Atrovent according to Omnicell.
12/4/10, 2:20 PM - Albuterol 2.5 mg/0.5 mL 0.5 mL; no Atrovent according to Omnicell.
12/5/10, 1:35 AM - Albuterol unit dose and Atrovent unit dose.
12/5/10, 7:05 AM - Albuterol unit dose; no Atrovent according to Omnicell.
12/5/10, 11:07 AM - no RT notes indicating medication administration; Albuterol unit dose dispensed from Omnicell.
12/5/10, 1:56 PM - no RT notes indicating medication administration; Albuterol 2.5 mg/0.5 mL 0.5 mL dispensed from Omnicell.
12/5/10, 6:18 PM - no RT notes indicating medication administration; Albuterol 2.5 mg/0.5 mL 0.5 mL and Atrovent unit dose dispensed form Omnicell.
12/5/10, 11:05 PM - Albuterol 2.5 mg/0.5 mL 0.5 mL; no Atrovent according to Omnicell.
12/6/10, 2:30 AM - Albuterol 2.5 mg/0.5 mL 0.5 mL and Atrovent unit dose.

According to RT notes and dispensing information from the Omnicell, the amount and frequency of administration of Albuterol and Atrovent did not match the physician's order.

Another 'Respiratory Protocol' form was completed by a RT on 12/6/10 at 3:28 AM, and it indicated no changes in the medication order. However, on that same day, Xopenex (0.63 mg/3 mL 3 mL) was substituted for Albuterol without a new order from the physician.

12/6/10, 7:10 AM - Xopenex 0.63 mg and Atrovent unit dose.
12/6/10, 11:20 AM - Xopenex 0.63 mg and Atrovent unit dose.
12/6/10, 3:35 PM - Xopenex 0.63 mg and Atrovent unit dose.
12/6/10, 7:05 PM - Atrovent unit dose, according to Omnicell.
12/6/10, 11:00 PM - Xopenex 0.63 mg and Atrovent unit dose.
12/7/10, 3:00 AM - Xopenex 0.63 mg and Atrovent unit dose.

On 12/10/10 at 12:10 PM, a RT supervisor, Employee #15, reported the respiratory department should have obtained a new physician's order before administrating Xopenex. The employee further confirmed the Omnicell dispensing record was used by the facility to indicate which medications were administered to each patient.

On 12/7/10 at 7:30 AM, another 'Respiratory Protocol' form was completed by an RT which documented Albuterol unit dose was to be given every 4 hours as needed, and not on a routine basis. The form indicated the RT determined the routine aerosolized medications (every 4 hours) were not necessary because the patient's breath sounds were "diminished."

There was no documented evidence in the record the physician was notified of this change in the order by the respiratory therapy staff to discontinue the routine inhalers for Patient #22. The 'Respiratory Protocol' forms were never countersigned by the physician to indicate the physician was aware the RT's were no longer administering Albuterol and Atrovent every 4 hours.

12/7/10, 12:00 PM - Albuterol 2.5 mg/0.5 mL 0.5 ml No Atrovent according to Omnicell.
12/7/10, 2:10 PM - Albuterol 2.5 mg/0.5 mL 0.5 mL according to Omnicell. No RT notes.
12/7/10, 3:10 PM - Albuterol unit dose. No RT notes.

According to RT notes and the Omnicell dispensing record, no further aerosolized medications were administered to Patient #22 on 12/7/10, 12/8/10, and 12/9/10.

On 12/9/10 in the afternoon, two days after the inhalers were discontinued by the RT staff, the patient underwent a chest-tube placement for pneumothorax. According to physician notes transcribed on 12/9/10 at 1:11 PM, the patient's breathing was also markedly improved following chest tube placement."

The facility's "Respiratory Care Protocol" policy, dated 6/19/09, was reviewed. The following procedure was included in the policy: "Each time the therapy is modified, the therapist will sticker the patient's chart to notify the physician." There was no documented evidence the physician aware of changes being made to Patient #22's original respiratory care order.


22462


Patient #40

Patient #40 was admitted to the facility on 11/26/10. The aerosolized medications Atrovent and Albuterol were administered by the respiratory department, per physician orders.

In an interview on 12/8/10 at approximately 3:00 PM, Employee #7 confirmed a review of the patient chart revealed a physician wrote an order on 12/3/10 at 6:30 PM to administer Atrovent only and to discontinue Albuterol. Respiratory Therapy department Nebulizer-Respiratory Care stickers on the patient chart indicated the following:

12/7/10, 6:45 AM: Albuterol was administered by a respiratory therapist
12/7/10, 2:30 PM: Albuterol was administered by a respiratory therapist
12/7/10, 7:15 PM: Albuterol was administered by a respiratory therapist
12/8/10, 7:33 AM: Albuterol was administered by a respiratory therapist
12/8/10, 10:47 AM: lines were written on the sticker through the words "Albuterol" and "Duoneb," a medication containing Atrovent and albuterol.
12/8/10, 1:12 PM: a line was written on the sticker next to the word "Albuterol."

On 12/10/10 at approximately 9:30 AM, Employee #7 reported the respiratory therapist who wrote the lines on the last two Nebulizer-Respiratory Care stickers listed above wrote the lines to indicate the medications were not given. Related Omnicell records from 12/8/10, indicated Albuterol 0.5% 2.5 mg/0.5 ml 0.5 ml was removed from the pharmaceutical dispensing system on the IMC2 (Intermediate Care Unit #2) unit at 10:17 AM by the respiratory therapist referenced above, and was not returned to the system. Albuterol 0.5% 2.5 mg/0.5 ml 0.5 ml was removed from the pharmaceutical dispensing system on the IMC2 unit at 1:24 PM and was returned to the system at 1:24 PM by the same respiratory therapist.