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Complaint #TX00191648

Based on record review and interview, the facility failed to protect the confidentiality of clinical records for 2 of 2 patients (#12 and #13) who were provided services at Hospital #3.

Findings include:

Record review of a Complaint Investigation Record for Patient #14 dated 2/14/14 revealed the patient had out-patient surgery on 2/10/14 at Hospital #3. When he was discharged, he received the discharge instructions for Patient #12 and a prescription with the information sticker for Patient #13.

Record review of Patient #14's closed clinical record revealed he had an endoscopic procedure on 2/10/14. He was in PACU (Post-Anesthesia Care Unit) at 9:38 a.m. under the care of RN #76. He was discharged from PACU at 10:38 a.m. There were no discharge instructions in his electronic medical record.

Record review of Patient #13's closed clinical record revealed he had a spinal procedure on 2/1014. He was in PACU at 9:38 a.m. under the care of RN #76. He was discharged from PACU at 10:38 a.m. His information sticker had his name, hospital identification number, date of birth, age, sex, and physician's name.

Record review of Patient #12's closed clinical record revealed she had a spinal surgery on 2/10/14. She was in PACU at 9:35 a.m. under the care of RN #75. She was discharged from PACU at 10:50 a.m. Review of the patient's electronic clinical record revealed she had two discharge instructions; one signed by RN #75 and one signed by RN #76. Both instructions had the patient's name, hospital identification number, date of birth, physician's name and a list of 11 medications. Patient #14 had received the one signed by RN #76.

Interview on 3/27/14 at 8:35 a.m. with CNO (Chief Nursing Officer) #63 and Clinical Director #71 from Hospital #3 revealed they investigated the incident as soon as they became aware of it on 2/12/14. When they questioned RN #76, she informed them she had discovered the error on 2/10/14. She said she called Patient #14 the same day and asked him where he would like the prescription called into. She said she had another nurse call in the prescription for her. She said the patient did not act like he was upset, so she did not report the error. CNO #63 said RN #76 was counciled about the incident being a HIPAA (Health Insurance Portability and Accountability Act) violation and should have been reported immediately. RN #76 was terminated on 2/21/14.

Record review of the facility's Policy and Procedure for Protected health Information Uses, disclosures, and Requests dated 4/14/03 revealed the following:
"Except as authorized by Section 241.153, a hospital or an agent or employee of a hospital may not disclose health care information about a patient to any person other than the patient or the patient's legally authorized representative without the written authorization of the patient or the patient's legally authorized representative."

Based on observation, interview and record review the facility failed to assess and secure physician's orders, and implement a Nursing Care Plan for patients with pressure sores in 2 of - sampled patients. #s 1, 2,

Findings:
Patient #2
Patient #2 was observed in his room on unit # 500 on 03/25/2014 at 10:50 a.m. The Registered Nurse who was present in the room examined the patient in the presence of the Surveyor and the Unit Director.
Observation at this time revealed a wound to the patient's left heel, approximately 2 cm X 1. cm. The skin was broken and there was no dressing in place to the wound.
Review of the patient's clinical record revealed an initial skin assessment conducted in the Emergency room on 03/23/2014 which indicated a stage one pressure sore to the patient's sacral are. The assessment was as follows: " Stage 1 sacral decubiti. Skin intact. "
Review of the patient's clinical record ( physician's order) in the patient's clinical record (computer and hard copy) revealed no assessment by the nurse or the physician of the patient having a stage two pressure sore to the patient's left heel.

Interview on 03/25/2014 at 1:05 p.m. with Registered Nurse (# 3 ) who is assigned to the patient revealed he did not notify the attending physician of the wound to the patient's left heel.
Immediately after the Surveyor's interview with Registered Nurse (#3) The Registered Nurse placed a telephone call to the patient's Attending Physician. The Physician ordered wound care evaluation for the patient.

Patient #1
Patient #1 was observed on 03/25/2014 at 10:30 a.m. in his room on the fifth floor unit . The patient was examined by the Licensed Practical Nurse assigned to the patient. Observation of the patient's skin revealed a stage 2 pressure sore to the patient 's right inner buttocks. There was no dressing in place.

During an interview on 03/26/2014 at 10:05 a.m RN #40 who was assigned to the patient revealed she was told that the patient had a skin tear to her buttocks but she had not seen the patient's buttocks.
Subsequent observation on 03/26/2014 at 10:07 a.m. revealed a stage two pressure sore in place to the patient's inner buttocks. There was no dressing in place. Registered nurse (#40) asked the patient if it hurts. The patient replied " yes "

During an interview on 03/26/2014 at 10:12 a.m. at the nurses' station with Physician Assistant assigned to the patient revealed she was notified yesterday that the patient had a wound on his buttocks but she had not examined the patient. She said she was about to order wound care evaluation for the wound.

Review of the Facility's current policy and procedure on pressure ulcer documentation directed staff as follows: " Effective October 1,2008, the admitting physician must, within 24 hours of admission, complete the Pressure Ulcer Admission Assessment on every patient. One Pressure Ulcer Admission Assessment must be completed for each decubiti ulcer found on the patient. The Pressure Ulcer Admission Assessment is filed as the first sheet in the Progress note Section of the Medical record. The wound Care Team may be consulted for treatment recommendations. "

Based on observation, interview and record review the facility ' s registered nurse failed to flush PEG tubes Based on observation, interview and record review, the facility's registered nurse failed to follow standard of practice adopted into facility's policy and procedure when administering medication via PEG (Percutaneous endoscopic gastronomy tube) in 1 of 1 patient observed with PEG tube. Patient #19

Findings:

Patient #19
On 03/2762014 at 08:50 a.m. Registered Nurse # 38 was observed in patient # 19's room on unit 500, administering medication to the patient who had a PEG tube in place to her abdomen. The medications were crushed and mixed in a slurry to be administered to the patient. Medication crushed were Plavix, Digoxin, Losartan, Aspirin and Metoprolol .

Observation of the medication administration via the patient's PEG tube revealed, Registered Nurse # 38 disconnected the patient's PEG from the feed she was receiving, checked for residual feed, returned the residual feed aspirated from the patient's stomach to the patient then administered the medication to patient #19 with the plunger of the syringe. The nurse did not flush the tube prior to administering the medication to the patient. The nurse did not administer the medication by gravity into the patient's stomach.

During an interview on 03/26/2013 at 09:05 a.m. with Registered Nurse # 38, the Surveyor notified her that she the Surveyor had observed that she the Registered Nurse did not flush the residual feed from the PEG tube prior to administering the medication and that she had forced the medication into the patient's stomach with the plunger of the syringe instead of allowing the medication to flow by gravity into the patients stomach. Registered nurse # 38 agreed with the Surveyors observation and stated " You are correct."

Interview on 03/26/2014 at 12:40 p.m. with the facility's Pharmacist assigned to the unit revealed medication is supposed to be crushed individually and not mixed in a slurry.

Review of Lippincott Procedures on Gastrostomy Tube Drug Instillation, page 2 of 5. directs staff as follows: " Request liquid forms of medication if available. If a liquid form of medication is not available and the medication is an immediate - release tablet, crush the prescribed dose of each medication separately into a fine powder, in a cup or plastic bag designed for this purpose using a mortar and pestle or other pill crushing device. if you're administering more than one medication, administer each medication separately and flush the tube with sterile water after administering each medication.
Flush the tube with 30 mls of sterile water to clear any enteral feeding from the tube and prevent mixing with medications. Clamp the tube and remove the syringe.
Reattach the syringe, without the piston to the end of the tube. Begin to pour the medication into the syringe and unclamp the tube. If medication flows smoothly, slowly add more until the entire dose has been given. If the medication doesn't properly don't force it, instead , raise the syringe slightly. If too thick, dilute with additional sterile water."

Complaint #TX00191648

Based on record review and interview, the facility failed to ensure the accuracy of discharge instructions and a prescription for 2 of 3 out-patients (#14 and #12) seen on 2/10/14 at Hospital #3.

Findings include:

Record review of a Complaint Investigation Record for Patient #14 dated 2/14/14 revealed the patient had out-patient surgery on 2/10/14 at Hospital #3. When he was discharged, he received the discharge instructions for Patient #12 and a prescription with the information sticker for Patient #13.

Record review of Patient #14's closed clinical record revealed he had an endoscopic procedure on 2/10/14. He was in PACU (Post-Anesthesia Care Unit) at 9:38 a.m. under the care of RN #76. He was discharged from PACU at 10:38 a.m. There were no discharge instructions in his electronic medical record. The scanned prescription had his correct information sticker on the form.

Record review on 3/26/14 of an e-mailed copy of the prescription and discharge instructions Patient #14 received on 2/10/14 revealed the following:
-The prescription had Patient #13's sticker on it.
-The Discharge Instructions had Patient #12's name and personal information on it including her medications. It had her physician's telephone number which was not the same physician as for Patient #14.

Record review of Patient #13's closed clinical record revealed he had a spinal procedure on 2/1014. He was in PACU at 9:38 a.m. under the care of RN #76. He was discharged from PACU at 10:38 a.m. His information sticker had his name, hospital identification number, date of birth, age, sex, and physician's name.

Record review of Patient #12's closed clinical record revealed she had a spinal surgery on 2/10/14. She was in PACU at 9:35 a.m. under the care of RN #75. She was discharged from PACU at 10:50 a.m. Review of the patient's electronic clinical record revealed she had two discharge instructions; one signed by RN #75 and one signed by RN #76. The instructions signed by RN #75 had the patient take Celebrex 200 mg every 12 hours for 3 days and that ice was to be applied to the operative site for 20 minutes 3 to 4 times that day. The instructions signed by RN #76 did not have that information. Patient #14 had received the one signed by RN #76.

Interview on 3/27/14 at 8:35 a.m. with CNO (Chief Nursing Officer) #63 and Clinical Director #71 from Hospital #3 revealed they investigated the incident as soon as they became aware of it on 2/12/14. When they questioned RN #76, she informed them she had discovered the error on 2/10/14. She said she called Patient #14 the same day and asked him where he would like the prescription called into. She said the patient did not act like he was upset, so she did not report the error. RN #76 did not address the Discharge Instruction error. CNO #63 said RN #76 was counciled about the incident being a HIPAA (Health Insurance Portability and Accountability Act) violation and should have been reported immediately. When the CNO was asked how Patient #14's scanned prescription was correct in the electronic file, but Patient #14 had the incorrect prescription, she said she believed RN #76 tried to cover up her error by putting the correct sticker over the incorrect one before it was scanned into the system. When she was asked which Discharge Instructions Patient #12 received, she said she did not know.

Based on observation and review of facility documentation at the William Way campus the facility failed to ensure all medical records were complete as 10 of 13 medical records in the medical surgical and perinatal department did not contain the physician signature on the informed consents prior to the procedures.

Findings were:

During a tour of the medical surgical unit at the William Way campus on the morning of 3/26/14 at 9:50 am, accompanied by staff #49, 2 of 4 medical records reviewed contained unsigned Disclosure and Consent Medical and Surgical Procedures forms.

Review of patient #32's medical record revealed the Disclosure and Consent Medical and Surgical Procedures form dated 3/22/14 for blood administration revealed the section for the physician signature and date that the risks and benefits of the treatment had been explained to the patient was blank.

Record review of patient #35's medical record at the Williams Way campus revealed the Disclosure and Consent Medical and Surgical Procedures form dated 3/24/14 for dialysis. The section for the physician signature and date that the risks and benefits of the treatment had been explained to the patient was blank.
The above findings were confirmed by staff #49 during the tour of the facility.



29937


Findings were:

During a tour of the perinatal department on the afternoon of 3/25/14 accompanied by staff # 43, 8 of 9 medical records where patients had procedures reviewed, contained informed consents forms without the physician signatures .

Review of the inform consents for medical and surgical procedures for the perinatal unit stated, "I have explained to the patient the risks and benefits of and alternatives to this treatment and he/she agrees to proceed." The physician signature lines were blank on 8 of 9 inform consent forms that were reviewed.

The findings were confirmed by staff #43 during the tour of the facility.

Based on observation, review of documentation and interviews with facility staff, the facility failed to properly secure medications as the medication refrigerator located in the post anesthesia recovery unit at the Hospital for Surgical Excellence facility was found to be unlocked. This was not consistent with facility policy.
The findings were:
During a tour of Hospital #3 on 3/27/14 at 9:00 am, the medication refrigerator next to the Pyxis unit located in the post anesthesia recovery unit was found to be unlocked. The medication refrigerator contained medications. The Pyxis unit was located in an area where there were patients and their family members preparing for discharge from the facility. The pharmacy manager, staff #60 stated the keys to the refrigerator were kept secured in the Pyxis unit and the medication refrigerator should be locked.
The facility policy entitled "Medication Management-Storage" #09-01 dated 1/12 reflected in part "All drugs and biologicals must be secure ...All drugs and biologicals must be stored in a manner to prevent access by non-authorized individuals."

Based on review of documents and interviews with facility staff, the facility failed to conduct fire drills in all required locations as no fire drills were conducted at an outpatient physical rehabilitation department located in a professional office building next to Hospital #1. This was not consistent with facility policy and staff potentially could have been unprepared to deal with a fire in that location.
The findings were:
During a tour of the outpatient physical rehabilitation department located in the professional office building next to Hospital #1 on 3/25/14 at 12:30 pm, the rehab manager, staff #9 was asked how fire drills were conducted in that location. Staff #9 stated they haven't had fire drills there. In an interview with the plant manager, staff #24 on 3/26/14 at 8:30 am in the conference room, staff #24 stated he checked with his staff and fire drills had not been conducted at the outpatient physical rehabilitation department located in the professional office building next to Hospital #1.
The facility policy entitled "Management of Fire Safety" with a revised date of 11/2/11 reflected in part "III.C. Fire drills will be conducted in all buildings classified as business occupancies in which patients are seen and treated every 12 months."

Based on observation and interviews with facility staff, the facility failed to properly maintain equipment as stretcher pads were observed in two departments with tears and holes which made proper cleaning and disinfection impossible and were potentially a source of contamination.
The findings were:
During a tour of Hospital #1 on 3/25/14, the stretcher pad in the ultrasound room was observed to have a ?" hole and two 2" tears in the vinyl covering exposing the fabric below. This made proper cleaning and disinfection impossible and were potentially a source of contamination. This finding was confirmed during the tour on 3/25/14 at 2:30 pm by the radiology director staff #77.


20241

During a tour of the outpatient department of the Williams Way campus (#2) on 3/25/14 at 10:30 am a one inch tear in the stretcher cover in Room #4 was observed with exposed fabric beneath. This tear made proper disinfection of the stretcher impossible and was a potential source of contamination and spread of infection. This finding was confirmed during the tour on 3/25/14 by facility staff #49.

Based on observation, review of documentation, and interviews with dietary staff, the facility failed to ensure that the dietary department was maintain in a sanitary condition as there was unlabeled, undated food in the freezers, refrigerators, storage pantry, and multiple appliances were observe in unsanitary conditions. Citing 3 of 3 kitchens facility # 1,2, and 3.

Findings were:

During a tour of the dietary department located at William Way(#2) on the morning of 3/25/14 accompanied by staff # 43 and # 45 multiple appliances located in the dietary department were observed to contain greasy yellowish, material sticky to touch and dark brownish stains on the doors and handles. Particles appearing to be food were observed on the shelves and floors of the refrigerator and freezers.
1. Oven used for storage containing creamer in the top section and cookies in the bottom draw.
2. Refrigerator containing salads and desserts
3. Small skillet contained burnt residue
4. Plate warmer located at the end of the counter where trays are prepared
5. Food warmer
6. Steamer
7. Steam Kettle
8. Floors behind the oven, grill and fryer and on the floor in front of the fryer, contained brown greasy looking liquid substance appearing to be grease.
9. Microwave outside doors and inside walls were greasy to touch, yellowish sticky to touch substance was observed on and in the microwave.
10. 2 white bins with clear tops containing flour and meal
11. Multiple packages of food were observed on the shelves and counters that was greasy, slimy, sticky to touch.
12. Tray holder containing brown trays used to carry the patients meals


The shelves in the freezers and refrigerators were observed to contained food crumbs and where greasy to touch. The floors in freezers 1 and 2 contained pieces and crumbs of what appeared to be food particles were observed on the floor including cherry tomatoes on the floor in the second fridge.
Multiple containers of condiments were observed on counters, pantry shelves, refrigerator and freezer shelves, with no date open and when to use by labels were observed on the containers.
1. Large bag of brown sugar
2. Gallon of vinegar
3. Gallon of Blended oil
4. Gallon of Olive oil
5. 3 boxes of grits
6. 2 boxes of cream of wheat
7. 2 boxes of oatmeal
8. 1 bottle A-1 sauce
9. 1 plastic uncovered container containing 3 bags of instant potatoes, 1 package of miniature marshmallows with a greenish blackish substance on some of the marshmallows. White food particles were observed at the bottom of the plastic container.
10. 5 gallon container of bacon bits and tea bags in the storage pantry was observed uncovered exposed to the elements in the storage pantry.
11. Protein powder, Quaker oatmeal.
12. In Freezer #1 was observed Red food coloring, zip lock bag of cooked mushrooms, foil pan of cooked shirred beef or pork with plastic covering that was not sealed.
13. In fridge # 2 boxes of meat was observed stacked directly on the floor about 8 ft. high. The floors were observed to contain vegetables and food particles on the floor.
Review of documentation Food and Nutrition Services Department, Storage Procedures, Policy Number: FN-03-01-005, revision date 02/13 stated, " purpose to provide for safe and sanitary storage of food and non-food supplies. Dry Storage of Food, D. open packages are sealed air tight or stored in closed containers, labeled and dated. E. Dry bulk foods may be stored in plastic containers with tight covers or bins which are easily sanitized. Storage Procedures E. Food to be refrigerated is covered, dated and stored loosely to permit circulation of air. J. Food items are arranged so that older items will be used first. Label and date open cases of frozen products.
During a tour of the dietary department at Oak Bend WW on the morning of 3/25/14, the findings were confirmed by staff # 43 and # 45.








17028

Observation on 3/25/2014 at 10:45 am in the kitchen at the Jackson Street (#1) location revealed the following information:

36 containers of ready to eat food item and 38 bowls of uncooked vegetables in a refrigerator were not labeled or dated.

Further observation in the kitchen at that time revealed a heavy build up of brown crumb like substance and grease at the base of a food warmer with multiple containers of cooked food.
There was a build up of brown greasy substance along the front and base of the oven.

During an interview on 3/35/2014 at 11:05 pm with Staff ( #42) Dietary Supervisor, who was present at the observations , she stated the items in the refrigerator were pudding and green salad prepared for the day and should have been labeled and dated.

Staff (#42) stated the dietary staff will be instructed to clean the outsides of the kitchen equipment more frequently.










29934

During a tour of Hospital #3 on 3/27/14, the following expired juices were found in the inpatient nursing unit nourishment refrigerator.
1. Apple juice, 4 oz. containers, 3 expired 1/29/14
2. Cranberry juice, 4 oz. containers, 6 expired 3/20/14.
This finding was confirmed during the tour on 3/27/14 at 9:45 am by the food service manager, staff #65.

Based on observation, interview and record review, the facility's staff:
1) Failed to wash/ cleanse hands after removal of gloves post direct care of patients,
2) Failed to wear gown and or gloves while in direct contact with patient on contact isolation or handling contaminated objects. patient #s 1, 3, 4, 19. 20 and 42.
3) Failed to ensure expired supplies were removed from stock
Findings:
Review of the facility ' s current policy and procedure on isolation precaution revised 2/14. Revealed the following entries: Hand Washing " Wash hands with soap and water when visible dirty. If they are not visible dirty, then use alcohol hand gel to decontaminate hands ( this is the preferred method) "
Gloves : " Wear gloves ( clean non sterile gloves are adequate) when touching blood, body fluids secretions, excretions and contaminated items.; put on clean gloves just before touching mucous membranes and non intact skin. Remove gloves promptly after use , before touching non contaminated and environmental surfaces and before going to another patient. , and use alcohol hand gel immediately to avoid transfer of microorganisms to other patients or environments. "
Gown " Wear a gown ( a clean nonsterile gown is adequate) to protect skin and prevent soiling of clothing during procedures and patient care activities that are likely to generate splashes or excretions or cause soiling of clothing. "
Observation 3/25/14 at 11:30 a.m. in the Day Surgery Unit of Williams Way Campus revealed Nurse ID# 53 drawing blood from a patient. The nurse was wearing gloves. After completing the blood draw the nurse removed her gloves and did not wash her hands. The nurse proceeded to begin charting in the patient's medical record.

Patient # 1
On 03/25/2014 at 10:30 a.m. Certified Nursing Assistant ( #1) was observed on the fifth floor of the facility providing care to patients. Observation on 03/25/2014 at 10:30 a.m. revealed Certified Nursing Assistant (#1) donned a pair of gloves, and entered the room of patient #1. The sign on the patient's door indicated that the patient was on contact isolation.
After leaving the patient's room Certified Nursing Assistant(#1) exited the patient's room who was on contact isolation wearing her contaminated gloves. She removed he contaminated gloves, held them in her hands and then proceeded to room # 507 . The Certified Nursing Assistant was still holding the contaminated gloves in her hands. She then entered Room # (508) and left the room holding a tray. The Certified Nursing Assistant did not wash/ clean her hands after going into the patients room who was on contact isolation.

Patient #3 and 4
On 03/25/14 at 10: 55 a.m. Registered Nurse # 2 was observed on unit 500. Registered Nurse (#2) entered the room of patient # 3, donned a pair of gloves and examined patient #3's PEG tube and abdomen.. After direct contact with the patient's abdomen and PEG tube, Registered Nurse (#2) removed her contaminated gloves, picked up her folder and left the patient's room. Registered Nurse (B) did not wash or /clean her hands after examining the patients PEG site and abdomen. Registered Nurse (#2) then walked into Patient # 4's room and discontinued the patient's intravenous line with her contaminated hands

On 03/25/2014 at 11:05 a.m. the Surveyor notified Registered Nurse (#2) that she did not wash /clean her contaminated hands after examining patient #3 and that she had used her contaminated hands to discontinue patient #4's intravenous line. Registered Nurse (#) agreed with the observation of the Surveyor.

Patient #19
On 03/26/2014 at 08:50 a.m. Registered Nurse # 38 was observed in patient # 19's room on unit 500, administering eye medication to the patient. Registered Nurse #38 cleaned her hands, donned a pair of gloves and administered eye medication of Xalantan to the patients eyes . After administering the eye medication the registered nurse did not wash/ clean her hands. Registered Nurse #19 proceeded to the computer station and opened individual medication packets of Digoxin, Aspirin, Losartan, Metoprolol, Plavix and Lipitor with her contaminated gloves she used to administer eye drop to the patient. Registered Nurse #38 touched and handled the patient ' s oral medication with the contaminated gloves.

During an interview on 03/26/2014 at 09:05 a.m ,with Registered Nurse ( #38) the Surveyor informed the Registered Nurse that she had used the contaminated gloves she had used to administer eye drop to the patient to prepare oral medication for the patient. Registered Nurse (#38) said "you are correct. "

Review of Fundamental and Advanced Nursing Skills Third Edition pages 548 and 549 adopted in facility ' s policy and procedure directed staff as follows: " Eye Medication, Wash hands , don nonsterile latex free gloves if needed. Distribute solution over conjunctival surface and anterior eyeball. Remove gloves; wash hands. "

Patient # 20
On 03/26/2014 at 8:32 a.m, Housekeeping staff (#39) was observed on unit 500 cleaning the room of Patient # 20. A sign on the patient's door indicated that the patient was on contact isolation. The staff was not wearing a gown while cleaning and mopping the patient's room. After cleaning the room, housekeeping staff ( # 39) walked from the room removed the covering from the mop and then proceeded to room # 518 wearing the contaminated gloves she had used to clean the room of the patient on contact isolation. She used her contaminated hands to touch the door and door jam of the patient's room.
Review on 03/26/2014 of the patient's clinical record revealed a laboratory result dated ( 03/25/2014 positive for Clostridium Difficile.
Review of the facility's policy and procedure on Droplet Precaution directed staff as follows " In addition to wearing gown as outlined in Standard Precautions wear a gown ( a clean nonsterile gown is adequate)when entering the room if you anticipate your clothing will have substantial contact with the patient, environmental surface, or items in the patient's room or if the patient is incontinent or had diarrhea, or wound drainage not contained by dressings "




12000

Observation 3/25/14 at 10:30 at the Williams Way Campus revealed the following expired supplies:
In the emergency department:
-In the OB /Gyn exam room inside a drawer was a swab with medium that expired 8/31/13.
-In the Resusitation exam room on a cart were two boxes (36 each box) of Vicryl 5-0 sutures that expired January 2014.
-Behind the nurses station inside a suture cart were three boxes (36 each box) Chromic Gut 4-0 sutures that expired Janurary 2014
In the Endscopy area was a wash sink. On the wall beside the sink were two boxes (30 each box) of Utradex scrub brushes that expired December 2013.
Record review of a policy titled "Sterile Processing: Infection Control / Storage of Supplies" (no date) stated "Supplies will be stored in such a manner as to maintain the integrity, as well as sterility when appropriate, of the items. All supplies shall be rotated regularly."








17028

Observation on 3/26/2014 at 9:25 am in the Emergency Room at the Jackson Street location revealed the following information:
Staff (#70) Emergency Room (ER) staff was observed cleaning a patient bed with ungloved hands.

During an interview on 3/26/2014 at 9:35 am with Staff (#70) he stated he was sanitizing the bed because he was not sure if it was previously used. When asked why he was not wearing gloves he responded ' he probably should have worn gloves ' ' .

During an interview with the ER RN Director who was present during the observation she stated the staff was a recently hire and would be retrained.

Observation on 3/26/2014 at 9:40 am in the ER revealed Patient (#42) was placed in room # 2 by EMS personnel. The patient had a blood stained dressing and tourniquet on her upper
right arm. She had very long curved finger nails with streaks of blood hanging from them. There was blood on her hands, on her clothing, and on the bed linen.
The patient was bleeding from a dialysis access site.
Staff (#78) RN Charge Nurse assisting the patient was handling the blood stained clothing, touching the patient ' s hand, arm, and clothing. The gloves she had on were visibly soiled with blood. Still wearing the soiled gloves Staff (#78)went to the clean supply cupboard and removed oxygen mask without changing her gloves and washing her hands.

Staff (#78) removed the soiled gloves did not wash her hands. She went out into the hallway and wheeled in a clean supply cart with sutures and bandages.

The staff donned clean gloves, assisted in removing the patient ' s blood stained clothing and bed linen. Staff (#78) then, removed the soiled gloves she was wearing did not wash her hands. She went to the clean supply cart and retrieve clean bandages and other supplies.

Observation on 3/26/2014 at 10:15 am in ER Room # 2 revealed Staff (#79) RN who was also attending Patient (#42) with the bleeding access removed the blood stained tourniquet from blood soaked dressings that was on the floor without using gloves.
The Staff placed the blood soaked tourniquet on a counter top in the room that contained clean supplies.

During an interview on 3/26/14 at 11:05 am with Staff (# 79) he stated would be sanitizing the counter top.

During an interview on 3/26/2014 at 11:20 am with the ER Director regarding infection control issues in the department she stated she will in-service staff on infection prevention precautions.

Observation on 3/25/2014 at 2:50 pm in the laboratory revealed Staffs (# 26) was observed handling specimen (blood and tissue) , documenting on paper record, logging the receipt of specimen in an electronic system and making notes on a computer the staff was wearing the same gloves for all those processes.

Staff (#80) was observed making notes on paper documents and on computers without wearing gloves.

During an interview on 3/25/2014 at 2:58 pm with the Laboratory Director she stated with the exception of her office and the staff lounge all areas in the laboratory is considered contaminated and staff should be wearing gloves.

On 3/25/2014 at 3:10 pm Staff (#26) was observed documenting on the same computers and paper records with ungloved hands that she was previously touching with contaminated gloved hands. Another laboratory Staff was also observed using the same gloved hands he used to handle specimens to access the computers the Staff had used earlier without wearing her gloves.






20241

Findings were:

During a tour of the sterile processing room of the Williams Way campus on 3/25/14 at 11:50 am, 12 of 19 hinged and/or closed surgical instruments which had been sterilized, packaged, stored and were available for patient use were observed. The closed and/or clamped position of the sterilized packaged surgical instruments hindered the sterilization process and was a potential for harm for infections in post-operative patients.

Review of the facility policy entitled "Sterile Processing Infection Control: Assembly and Wrapping of Sterile products, Shelf Life" with a revision date 1/2009 reflected in part "II. Procedure ... Assembly ...Place the instruments in the tray in an unlocked position. "

The Centers for Disease Control article entitled, "Guideline for Disinfection and Sterilization in Healthcare Facilities" dated 2008 states, "Packaging. Once items are cleaned, dried, and inspected, those requiring sterilization must be wrapped or placed in rigid containers and should be arranged in instrument trays/baskets according to the guidelines provided by the AAMI and other professional organizations 454, 811-814, 819, 836, 962. These guidelines state that hinged instruments should be opened ..."

During an in-person interview on 2/24/14 at 11:50 am, staff # 50, acknowledged the above surgical instruments had been sterilized and packaged in the closed and/or clamped position.


During a tour of the outpatient department of the Williams Way campus on 3/25/14 at 10:30 am accompanied by staff #49 a one inch tear in the stretcher cover in Room #4 was observed with exposed fabric beneath. This tear made proper disinfection of the stretcher impossible and was a potential source of contamination. This finding was confirmed by facility staff #49.



29934

During a tour of Hospital #1 on 3/25/14 the following medical supplies were found in patient care areas available for patient use.
1. Found in the outpatient physical rehabilitation area: Dankins solution, 0.125%, 16 oz. bottle, expired 11/12; zeroform dressing, 1" x 8", partial box of 50, expired 3/12; Intrasite gel wound dressing, partial box of 10, expired 9/09. These findings were confirmed during the tour on 3/25/14 at 12:30 pm by the rehab manager, staff #9.
2. Found in Radiology room #1, surgical lubricant, 3.5 oz. tube, expired 5/13; providone iodine swabsticks, 3 expired 9/13. Found in Radiology room # 3, 0.9% NaCl 500 cc IV bag with beyond use date marked 3/21/14. Found in the mammography room, Chloraprep kit, expired 3/13; NS 0.9% 10 cc pre-filled syringes, 4 expired 8/12. These findings were confirmed during the tour on 3/25/14 at 2:40 pm by the radiology director, staff # 77.







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Findings were:
During a tour of the magnetic resonance imaging (MRI) procedure room located at William Way accompanied by staff # 43 on the morning of 3/25/14, a 6-7 inch tear exposing the yellowish cushion was observed on the MRI exam table.
The finding was confirmed by staff # 43 during the tour of the facility on the morning of 3/25/14.
During a tour of the dietary department at William Way, on the morning of 3/25/14 accompanied by staff #43 a linen cart was observed uncovered containing linen used by the dietary department in food preparation, causing a potential for transmission of infections.
Based on observation, review of documentation, and interviews with dietary staff, the facility failed to ensure that food and dietary organization requirements were met, as there was unlabeled, undated food in the freezers, refrigerators, storage pantry causing a potential for unsanitary conditions and transmission of infections in the dietary department.

Findings were:
During a tour of the dietary department located at William Way on the morning of 3/25/14 accompanied by staff # 43 and # 45 multiple appliances located in the dietary department were observed to contained greasy yellowish, material sticky to touch and dark brownish stains on the doors and handles. Particles appearing to food were observed on the shelves and floors of the refrigerator and freezers.
1. Oven used for storage containing creamer in the top section and cookies in the bottom draw.
2. Refrigerator containing salads and desserts
3. Small skillet contained burnt residue
4. Plate warmer located at the end of the counter where trays are prepared
5. Food warmer
6. Steamer
7. Steam Kettle
8. Floors behind the oven, grill and fryer and on the floor in front of the fryer, contained brown greasy looking liquid substance appearing to be grease.
9. Microwave outside doors and inside walls were greasy to touch, yellowish sticky to touch substance was observed on and in the microwave.
10. 2 white bins with clear tops containing flour and meal
11. Multiple packages of food were observed on the shelves and counters that was greasy, slimy, sticky to touch.
12. Tray holder containing brown trays used to carry the patients meals
The shelves in the freezers and refrigerators were observed to contained food crumbs and where greasy to touch. The floors in freezers 1 and 2 contained pieces and crumbs of what appeared to be food particles on the floor including cherry tomatoes in the second fridge.
Multiple containers of condiments were observed on counters, pantry shelves, refrigerator and freezer shelves, with no date open and when to use by labels.
1. Large bag of brown sugar
2. Gallon of vinegar
3. Gallon of Blended oil
4. Gallon of Olive oil
5. 3 boxes of grits
6. 2 boxes of cream of wheat
7. 2 boxes of oatmeal
8. 1 bottle A-1 sauce
9. 1 plastic uncovered container containing 3 bags of instant potatoes, 1 package of miniature marshmallows with a greenish blackish substance on some of the marshmallows. White food particles were observed at the bottom of the plastic container.
10. 5 gallon container of bacon bits and tea bags in the storage pantry was observed uncovered exposed to the elements in the storage pantry.
11. Protein powder, Quaker oatmeal.
12. In Freezer #1 was observed Red food coloring, zip lock bag of cooked mushrooms, foil pan of cooked shirred beef or pork with plastic covering that was not sealed.
13. In fridge # 2 boxes of meat was observed stacked directly on the floor about 8 ft. high. The floors were observed to contain vegetables and food particles on the floor.
Review of documentation Food and Nutrition Services Department, Storage Procedures, Policy Number: FN-03-01-005, revision date 02/13 stated, " purpose to provide for safe and sanitary storage of food and non-food supplies. Dry Storage of Food, D. open packages are sealed air tight or stored in closed containers, labeled and dated. E. Dry bulk foods may be stored in plastic containers with tight covers or bins which are easily sanitized. Storage Procedures E. Food to be refrigerated is covered, dated and stored loosely to permit circulation of air. J. Food items are arranged so that older items will be used first. Label and date open cases of frozen products.
During a tour of the dietary department at William Way on the morning of 3/25/14, the findings were confirmed by staff # 43 and # 45.



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Charge Nurse # 64
On 03/27/2014 at 10:12 a.m. in the Emergency Room with Emergency cart revealed 3 disposable skin stapler removers expired in 6/2013. The Surveyor notified the ER Charge Nurse (#64) she said, "Oh yeah, these 3 expired supplies should no longer be here, I will remove them now!"

Based on record review and interview, the facility failed to ensure informed consent forms were properly executed prior to surgery for 2 of 6 patients (#36, #43 ) scheduled for surgery.

Findings include:

Record review of the facility's Policy and Procedure for General Guidelinse for Informed Consents dated 2/1994 and revised on 2/2014 revealed the following:
"It is the legal responsibility for the physician or licensed independent practitioner who will perform the surgical or diagnostic procedure or treatment to give information required to provide informed consent and to ensure signature is obtained from the patient. It is NOT the responsiblity of Hospital employees to provide this information, though they may be involved in obtaining signatures.....4. Hospital staff cannot be responsible for providing information that is necessary for informed consent, only the responsible physician or anesthesiologist can provide the information..."

Observation on 3/25/14 at 8:35 a.m. in Hospital #1's pre-operative area revealed a nurse was filling out a consent form, filling in the patient's name, the procedure, and checking boxes for risks.

During an interview at this time with the Director of Perioperative Services #12, she was asked if the physician was responsible for giving the risks and benefits and checking the boxes that pertained to the surgery to be performed. She said the hospital staff filled out the form, but the physician was required to sign a statement that he had given the risks and benefits.

Record review on 3/26/14 of Patient #36's medical record from Hospital #2 revealed a Disclosure and Consent Medical and Surgical Procedures form dated 3/23/14 at 6:30 a.m. for a Blood and Blood Product Transfusion. There was a section on the form that read as follows:
"I have explained to the patient (or legally responsible person) the risks and benefits of, and alternatives to this treatment, and he/she agrees to proceed. There were lines for the physician's signature and a date. Both were blank.

Record review on 3/26/14 of Patient #43's medical record from Hospital #1 revealed a Disclosure and Consent Medical and Surgical Procedures form dated 3/25/14 at 8:55 p.m. for an open reduction and internal fixation of a distal left tibia. The section where the physician signed and dated that he had given the risks and benefits of the treatment was blank. The Anesthesia Disclosure and Consent form dated 3/25/14 at 10:35 p.m. for general anesthisia had no place for the Anesthesiologist to sign and date.

During an interview on 3/27/14 at 1:35 p.m. with the Director of Perioperative Services #12, she was shown the Anesthesia consent form and informed her that it did not have a place for the Anesthesiologist to sign. She said the Anesthesiologist was not required to sign the form. When she was shown the facility's policy and procedure that only the Anesthesiologist was responsible for providing the informed consent, she said she guessed they did need to sign and that the form would have to be revised.

Based on interview and record review, the facility failed to ensure the anesthesia services were under the direction of one medical director for 3 of 3 facilities (hospitals #1, #2 and #3) that offered anesthesia services.

Findings included:

Interview on 3/25/14 at 8:30 a.m. with The Director of Perioperative Services #12, she said Anesthesia Medical Director for hospitals #1 and #2 was Doctor #13. She said anesthesia services were provided for the endoscopic department, the cath lab, the operating room and for labor and delivery. She said anesthesia Group A was under Doctor #13 and the group did not provide services to hospital #3.

Interview on 3/27/14 at 8:15 a.m. with CNO (Chief Nursing Officer) #71 at hospital #3, she said both anesthesia Groups A and B worked at the hospital. She said Doctor #74 was the anesthesia Medical Director for Group B and Doctor #73 was the anesthesia Medical Director for Group A. She said that Group A only provided anesthesia services for pediatric ENT (ears, nose and throat) and urology cases.

Record review of the facility's Policy and Procedure for Anesthesia dated 1/2009 revealed the following:
"...C. The Medical Director of Anesthesiology is a physician member of the medical staff who has responsibility for the clinical management and supervision of Anesthesia Services...."