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Based on document review and interview, the facility failed to ensure that all staff in the general acute care hospital met the training requirements regarding IV competency when 6 of 14 staff did not complete their bi-annual recertification training required by the facility.

Findings:

A review of the training records for the licensed staff in the hospital indicated that 6 of 14 staff did not complete their bi-annual recertification competency in IV therapy. California state law [Title 22, 70213(c)] requires that policies and procedures that "contain competency standards for staff performance in the delivery of care shall be ...implemented ...for each nursing unit ... " Facility Nursing Procedure No. 92.2, Intravenous (I.V.) Therapy; venipuncture and Care of Site, dated 8/13/12, indicated that staff will complete an IV therapy course and hold a certificate of competency that is issued by the facility. "Recertification is every two (2) years. List maintained in Staff Development office. Certification/re-certification will consist of attending and passing a competency class in I.V. therapy every two years and being observed while drawing blood from a live person by an RN certified in I. V. therapy at PDC ... "

In an interview with supervisory staff on 11/8/12 at 1:05 PM, she stated that staff is required to attend the IV recertification classes every two years. She stated that previously, training had occurred on the unit but is no longer being offered. Some of the staff had missed the bi-annual training offered by the facility. She stated that all staff must now complete the classes through the Staff Development Department. She stated that she was aware that some staff were out of compliance and was working on getting everyone scheduled for the required classes within the next few months.

Based on interview and record review, the hospital failed to ensure that 3 of 20 sampled patients had documentation of the presence or absence of an advance directive (Patients 5, 9, and 15.)

Findings:

1. The medical record for Patient 5 was reviewed on 11/8/12. Patient 5 was admitted to the acute unit from 7/29/12 to 8/13/12. There was no documented evidence that Patient 5 did or did not have an advance directive.

During an interview on 11/8/12 at 10:00 AM, administrative staff confirmed that there was no statement of an advance directive.

2. The medical record for Patient 9 was reviewed on 11/6/12. Patient 6 was admitted to the acute unit from 11/14/11 to 11/30/11. There was no documented evidence that Patient 5 did or did not have an advance directive.

During an interview on 11/6/12 at 3:00 PM, administrative staff confirmed that there was no statement of an advance directive.



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3. Patient 15 was admitted 8/23/12 through 8/30/12. Review of the medical record indicated that there was no documentation that prominently displayed Patient 15's Advance Directive (AD) status.

In an interview with supervisory staff on 11/6/12 at 3:15 PM, she stated she could not find Patient 15's AD documentation.

Based on interview and record review, the hospital failed to complete a health care plan which coincided with each physician's order for restraints for 1 of 20 sampled patients (Patient 19).

Findings:

The medical record for Patient 19 was reviewed on 11/8/12. Patient 19 had physician's orders for the restraint, abdominal binder, dated 6/10/12 at 2:00 AM, 6/10/12 at 6:00 AM, 6/10/12 at 10:00 AM, 6/10/12 at 2:00 PM, 6/10/12 at 6:00 PM, and 6/10/12 at 10:00 PM.

Health Care Plan, P18-10 "Attention to Gastrostomy," was dated 5/18/12, over three weeks prior to these episodes of restraints.
Facility Bulletin No. 110, "Medical Restraints," specified, "Comprehensive Health Care Objective Plan (HCOP) will be completed that coincides with the physician's order and addressed [sic] nursing needs."

Further review of the record revealed no health care plan which coincided with each of the physician's orders for restraint use.

During an interview on 11/8/12 at 3:00 PM, administrative staff confirmed that the health care plan did not coincide with each physician's order for restraints.

Based on interview and record review, the hospital failed to ensure that restraints for 1 of 20 sampled patients were discontinued at the earliest possible time, regardless of the length of time identified in the order (Patient 19).

Findings:

The medical record for Patient 19 was reviewed on 11/8/12. Patient 19 had physician's orders for the restraint, abdominal binder, dated 6/10/12 at 2:00 AM, 6/10/12 at 6:00 AM, 6/10/12 at 10:00 AM, 6/10/12 at 2:00 PM, 6/10/12 at 6:00 PM, and 6/10/12 at 10:00 PM.

The "Acute Medical Restraint Record" documentation for the 24-hour period was reviewed. There was no documentation of patient behaviors which warranted the continued use of restraints. However, the following was documented during episodes of restraint use:

6/10/12 6:00 AM - "No attempts by [patient] to manipulate GT [gastrostomy tube]";
6/10/12 6:30 AM - "sleeping";
6/10/12 12:30 PM - "asleep";
6/10/12 1:00 PM - "asleep";
6/10/12 3:00 PM - "asleep";
6/10/12 3:30 PM - "asleep";
6/10/12 8:00 PM - "no attempts to manipulate GT";
6/10/12 10:00 PM - "Released from abdominal binder demonstrating no effort to grab GT" binder was reapplied;
6/11/12 12:30 AM - "asleep";
6/11/12 2:00 AM - "application of the abdominal binder" "sleeping".

Further review of the medical record revealed no documentation of an assessment of the patient for the continued use of restraints during the length of time identified in the physician's orders.

Facility Bulletin No. 110, "Medical Restraints," specified that the restraint "will be used no longer than is needed to safely provide the medical care/treatment."

There was no documentation that any medical care or treatment requiring the use of restraints was provided during the episodes of restraints.

During an interview on 11/8/12 at 3:30 PM, administrative staff confirmed that the patient was restrained throughout the entire time of each physician's order.

Based on interview and record review, the hospital failed to ensure that a face-to-face evaluation by a qualified practitioner was conducted within one hour of an episode of restraint use for 1 of 20 sampled patients (Patient 19).

Findings:

The medical record for Patient 19 was reviewed on 11/8/12. Patient 19 had a physician's order for the restraint, abdominal binder, dated 6/10/12 at 6:00 PM.

There was no documentation that a qualified practitioner had conducted a face-to-face physical and behavioral assessment of the patient within one hour of the restraint intervention.

During an interview on 11/8/12 at 3:30 PM, administrative staff confirmed there was no documentation that the face-to-face evaluation had been conducted.

Based on interview and record review, the hospital failed to document a description of the patient's behavior that warranted the use of restraints for 1 of 20 sampled patients (Patient 19).

Findings:

The medical record for Patient 19 was reviewed on 11/8/12. Patient 19 had physician's orders for the restraint, abdominal binder, dated 6/10/12 at 2:00 AM, 6/10/12 at 6:00 AM, 6/10/12 at 10:00 AM, 6/10/12 at 2:00 PM, 6/10/12 at 6:00 PM, and 6/10/12 at 10:00 PM.

The "Acute Medical Restraint Record" documentation for the 24-hour period was reviewed. There was no documentation of patient behaviors which warranted the use of restraints. However, the following was documented during episodes of restraint use:

6/10/12 6:00 AM - "No attempts by [patient] to manipulate GT [gastrostomy tube]";
6/10/12 6:30 AM - "sleeping";
6/10/12 12:30 PM - "asleep";
6/10/12 1:00 PM - "asleep";
6/10/12 3:00 PM - "asleep";
6/10/12 3:30 PM - "asleep";
6/10/12 8:00 PM - "no attempts to manipulate GT";
6/10/12 10:00 PM - "Released from abdominal binder demonstrating no effort to grab GT" binder was reapplied;
6/11/12 12:30 AM - "asleep";
6/11/12 2:00 AM - "application of the abdominal binder" "sleeping".

Facility Bulletin No. 110, "Medical Restraints" specified that an Interdisciplinary Note (IDN) describing the patient's behavior, condition, or symptoms that warranted the use of restraints was to be documented.

Review of the IDNs for the 24 hours from 6/10/12 at 2:00 AM through 6/11/12 at 2:00 AM, revealed no documentation of any patient behaviors which warranted the use of restraints.

During an interview on 11/8/12 at 3:30 PM, administrative staff confirmed that there was no documented evidence of the patient's behavior which warranted the use of restraints for each of the episodes of restraints.

Based on interview and record review, the hospital failed to document the less restrictive interventions considered or tried before initiating restraints for 1 of 20 sampled patients (Patient 19).

Findings:

The medical record for Patient 19 was reviewed on 11/8/12. Patient 19 had physician's orders for the restraint, abdominal binder, dated 6/10/12 at 2:00 AM, 6/10/12 at 6:00 AM, 6/10/12 at 10:00 AM, 6/10/12 at 2:00 PM, 6/10/12 at 6:00 PM, and 6/10/12 at 10:00 PM.

The Interdisciplinary Notes (IDNs) for each of the episodes of restraint use were reviewed. None of the IDNs documented any less restrictive interventions that had been considered or tried before the restraint was applied.

Facility Bulletin No. 110, "Medical Restraints," specified that an IDN describing "alternate or less restrictive interventions attempted" was to be documented every shift.

Further review of the medical record failed to reveal documentation of less restrictive interventions attempted.

During an interview on 11/8/12 at 3:30 PM, administrative staff confirmed that there was no documented evidence that less restrictive interventions had been attempted prior to each episode of restraints.

Based on observation, document review, and interview, the facility failed to ensure that a nursing care plan was kept current for 1 of 20 sampled patients (Patient 1), when Patient 1's nursing care plan had steps listed for the need for continuous observation of the patient to prevent him from pulling at his ventilator tubings when he was unable to even move his arms to reach his tubings.

Findings:

A review of Patient 1's nursing care plan for pneumonia, dated 10/25/12 indicated that Patient 1 "required observation at all times due to grabbing and pulling ventilator tubings frequently." There was no documented evidence that the care plan had been individualized or updated since the start date.

Multiple observations of Patient 1 during the survey showed him to be in a room alone, in bed with full side rails and connected to a ventilator at all times. Both of Patient 1 's arms and hands were extended and were never observed anywhere near his ventilator tubings. There was no evidence of staff on the unit continuously supervising him to prevent him pulling at his ventilator tubings.

In an interview with licensed staff on 11/7/12 at 9:00 AM, she stated that the nursing care plans for the patients are "canned" but are always supposed to be individualized to the patient. She stated that Patient 1 is ventilator dependent and is quadriplegic. She stated that he does not move his hands or arms at all and certainly does not pull at his ventilator tubings. She acknowledged that the care plan for pneumonia had not been edited or changed to make it more individual to this patient and that he does not need continuous supervision.

Based on observation, document review and interview, the facility failed to ensure that drugs were administered according to accepted standards of practice when a pill that had been crushed was poured into a syringe connected to the patient ' s gastrostomy tube in a dry form and then water was added to flush the drug through the tubing. The facility also failed to ensure that its policies addressed medications not eligible for scheduled dosing times, medications eligible for scheduled dosing times, time critical and non-time critical medications.

Findings:

1. During a medication pass observation on 11/7/12 at 11:30 AM, the licensed staff was observed to pour a crushed pill into the syringe connected to Patient 6 ' s gastrostomy tube followed by 30 milliliters of water to flush the drug through the tube. This was then followed by another 10-15 milliliters of water as some of the crushed drug remained in the syringe.

A review of Nursing Procedure No. 7.5, Medication via Nasogastric, Gastrostomy and Jejunostomy tube, dated 10/12/12, indicated that staff is to " Ensure medication is dissolved in liquid prior to administration. " Staff is then to " Pour medication into syringe allowing to flow in by gravity...".

In an interview with licensed staff on 11/7/12 at 2:10 PM, she indicated that the expectation is that drugs are always dissolved in 10-15 milliliters of water then placed in the tube.

2. A review of Facility Bulletin No. 46 Drug Control/ Medication Errors, dated 08/2012, indicated that there was no documentation that the facility had addressed which medication were not eligible for scheduled dosing times, e.g., first time or loading doses, one time doses, doses dependent on serum blood levels of the medications, doses prescribed on an as needed basis. There was no documentation in the policy of which medications are time-critical and which medications are eligible for scheduled dosing times and are not time critical. The policy did not address total windows of time not exceeding 1 hour for time-critical scheduled medications, 2 hours for medications prescribed more frequently than daily but no more frequently than ever four hours, four hours for medications prescribed for daily or longer administration intervals. There were no requirements identified in the policy for the administration of identified time-critical medications.

In an interview with the Director of Nursing on 11/8/12 at 10:00 AM, he acknowledged that the requirements listed above were not addressed in the facility policy. He also acknowledged that he was not aware of the requirements listed in the regulation.

Based on interview and record review, the hospital failed to ensure that verbal orders for 1 of 20 sampled patients were authenticated by the physician within 24 hours per facility policy (Patient 9).

Findings:

Patient 9 was admitted on 11/14/11 and transferred out on 11/30/11. During that admission, eight verbal orders were not authenticated by the physician within 24 hours. This was confirmed by administrative staff on 11/8/12 at 4:00 PM.

Nursing Procedure No. 7, "Administration of Medication, General Rules," specified that verbal orders were to be authenticated by the physician within 24 hours.

Based on clinical records review and staff interview, the facility failed to ensure that 1 of 20 sampled patients (Patient 15) had a medical history and physical done within the required timeframe (no more than 30 days before or 24 hours after admission).

Findings:

Review of medical record for Patient 15 on 11/6/12 indicated that he was admitted on 8/23/12. Further review of medical records indicated that the medical history and physical (H&P) for Patient 15 was not done within the required time period per regulation (no more than 30 days before or 24 hours after admission).

During an interview with supervisory staff on 11/6/12 at 3:25 PM, she confirmed that the medical history and physical in Patient 15's chart was not done within the required timeframe. She was not able to give an explanation as to why Patient 15's H&P was not done as required by regulations.

Based on record review, facility policy and procedures (P&P) review, and staff interview, the facility failed to ensure that the facility's Utilization Review Committee (URC) met quarterly as required by the facility policy.

Findings:

On 11/7/12 at 10 AM the facility's P&P for Utilization Review Plan dated December 2010 (Facility Bulletin No. 65) was reviewed. This policy required that "The committee [URC] shall meet not less than once each quarter". Review of the facility's URC minutes of the meetings for 2011 revealed that the URC did not meet for the first 3 quarters of 2011. The committee only met once in the last quarter of 2011.

In an interview with administrative staff on 11/7/12 at 11 AM, he confirmed that the URC did not meet for three quarters of 2011. He further stated that the URC tried to make up for the three quarters they did not meet by doing all the meetings they missed for the first three quarters on the last quarter of the year.

Based on observation and facility staff interview, the facility failed to maintain a sanitary environment.

Findings:

An initial tour of the facility was conducted on the afternoon of 11/5/12. At 2:05 PM two vital sign monitor machines were found in Room 1173 stored immediately adjacent to a dirty linen cart. Additionally, at 2:10 PM in Utility Room 1160, a vital sign monitor machine was observed stored on the side of the room clearly marked for dirty utility and also was immediately adjacent to a dirty linen cart.

During interview with supervisory personnel that same afternoon, she acknowledged the poor infection control practice but could not offer a reason why the monitors had been stored in that manner.

Based on record review and staff interview, the facility failed to ensure that 12 licensed staff (RNs/LVN) and 3 Respiratory Therapists (RT) had completed the required annual training on infection control.

Findings:

The training records of all staff providing patient care in the acute unit were reviewed on 11/8/12. This revealed that 12 licensed staff (RNs/LVN) and 3 Respiratory Therapists (RTs) did not have the required annual training on infection control.

In an interview with the supervisory staff and training staff on 11/8/12 at 2 PM, both confirmed that 12 licensed staff and 3 RTs did not have the required annual trainings on infection control. Supervisory staff stated she was not aware that many staff in the unit had not taken the annual required training for infection control.

Based on document review and interviews, the facility failed to ensure that its protocol for organ procurement requirements was implemented when staff were not completing the Donor Referral Worksheet prior to contacting the Donor Referral Hotline.

Findings:

A review of Facility Bulletin No. 106, Organ, Tissue and Ocular Donations (Anatomical Gifts), dated 11/2011, indicated that when death of a patient is imminent or has occurred, the nursing person in charge will "complete Donor Referral Worksheet, PVL 921. Used in assisting in determining medical suitability for donation type." There was a laminated sign on the bulletin board in the nursing station that had the Donor Network's phone number on it and information on who to call. There was a handwritten note attached to that page that stated "Pull worksheet in file drawer and fill out."

In an interview with both a licensed staff and the Supervisory staff on the unit on 11/6/12, neither knew of the location of the worksheet or the policy that required that it be filled out prior to calling the Donor Network. They both said that the Donor Network was just called by staff and the Network filled out all of the paperwork.

Based on document review and interview, the facility failed to ensure that a definition of imminent death was included in its agreement with the designated Organ Procurement Organization.

Findings:

A review of the agreement between the facility and California Transplant Donor Network indicated that there was no definition of "imminent death".

In an interview with Standards Compliance staff on 11/8/12, he acknowledged that there was no definition of "imminent death" in the agreement between the facility and the organ donor network.

Based on document review and interviews, the facility failed to ensure that the Organ Procurement Organization with which it has an agreement for organ donation, had ever worked cooperatively with the facility to review death records.

Findings:

A review of the agreement between the facility and the Organ Procurement Organization indicated that the donor network would have "access to review all death records to improve identification of potential donors."

In an interview with the supervisory nursing personnel on 11/8/12 at 10:00 AM, he stated that as far as he knew, the facility and the donor network had never done any death record reviews.