HospitalInspections.org

Based on observation, interview and record review, the hospital:

1. Failed to ensure their injection practices were performed in a manner to prevent the spread of infection.

2. Failed to ensure their equipment (a thermometer) used for multiple patients was sanitized after using on a patient.

3. Failed to ensure portable vital sign carts did not contain cracks or tape, to make it difficult to assure the equipment was sanitized properly between patients.

4. Failed to ensure a portable vital sign cart did not have used gauze and a used disposable oxygen saturation finger probe (a device used to measure the amount of oxygen dissolved in the blood).

These failures increased the risk of a poor health outcome for all hospital patients and the increased risk of infection.

Findings:

1. During an observation on June 2, 2015 at 3:30 PM of RN 4 administering an intramuscular (into the muscle) injection of Dilaudid (a pain medication) to a patient. RN 4 flipped the top off the vial (bottle) of Dilaudid and pierced the rubber stopper of the vial without first sanitizing it with an alcohol swab.

In an interview with RN 4 on June 2, 2015 at 3:40 PM. RN 4, when asked why he did not swab the top of the medication vial before piercing the rubber stopper with the needle and syringe, he stated he did not think it was necessary unless the vial of medication was open and used on more than 1 patient.

During a review on June 3, 2015, of a hospital policy and procedure titled "Injection-Intramuscular (IM)" with a revision date of January 2014, showed the following:

"IM Injection Procedure:
...Clean top of vial or break top of ampule with alcohol swab."

2. During an observation on June 1, 2015 at 10:30 AM, RN ASU (Registered Nurse Ambulatory Service Unit) was observed to have an electronic thermometer on a patient's over bed table. The nurse was observed taking the patient's temperature and set the thermometer back on top of the over bed table. Before RN ASU left the patient's room, she picked up the thermometer and placed it in an IV (intravenous) tray that was used for more than one patient. The RN ASU then set the IV tray on a counter that contained another IV start tray. The RN ASU did not wipe the thermometer with an antiseptic after using it on a patient.

In a concurrent interview with RN ASU, she stated that she had been taking the patient's vital signs (temperature, pulse, respirations, blood pressure and pain level), started an IV and did a pre-operative assessment of the patient. She stated that she generally sanitizes the thermometer by wiping it down with Cavi-Wipes (a disinfectant wipe) between patients, and "didn't do it."



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3. Observations of the surgical unit, conducted on June 1, 2015 at 10:25 AM, revealed two portable vital sign carts connected to a wall outlet. Further observation revealed the handles and sides of both machines had visible cracks.

Continued observations of the two portable vital sign carts revealed one machine with elastic tape wrapped around the handle, the other vital sign machine contained a transparent-like tape on the handle and the sides of the machine.

On June 1, 2015 at 10:30 AM, an interview was conducted with the surgical unit Charge Nurse (CN). The CN was asked how long the two portable vital sign carts had visible cracks, the CN stated she did not know.

At approximately 10:33 AM, an interview was conducted with Certified Nurse's Assistant (CNA) 1. CNA 1 was asked if the two portable vital sign carts were used in isolation rooms, CNA 1 responded, "Yes." In addition, CNA 1 was asked if the machines were sanitized between patient usage, CNA 1 stated, "No."


4. Observations of the surgical unit, conducted on June 1, 2015 at 10:25 AM, revealed a portable vital sign machine cart with a basket attached. Further observations revealed used gauze and a used oxygen saturation probe in the basket.

On June 1, 2015 at 10:30 AM, an interview was conducted with the surgical unit Charge Nurse (CN). The CN was asked if the used gauze and the used oxygen saturation probe should be in the basket of the portable vital sign machine, the CN stated, "No."

Based on interview and record review, the hospital failed to complete a discharge evaluation and plan for 1 of 11 sampled patients (Patient 4). This failure had the potential for patient care staff to be unaware of the need of a discharge plan for Patient 4, which could result in the patient not receiving the care and services needed after discharge.

Findings:

During a review of Patient 4's medical record on June 2, 2015, the record showed that the patient was admitted to the hospital on May 11, 2015 with a diagnosis of knee dislocation and dehydration.

A review of a document titled "Discharge Planning Psychosocial Assessment Screening" showed the following:

"...spoke with program manager at group home. Pt (Patient 4) had been at (name of skilled nursing facility) for 3 mo (months) and just returned. He was there for the same issue (knee dislocation). I called IRC (Inland Regional Center-an organization that oversees the care of developmentally and intellectually disabled persons) worker to discuss placement option and left urgent message. Pt $ stable (financially stable). Good support. DC (discharge) plans pending)".

There was no assessment of Patient 4's activities of daily living (ADL) level of functioning. The section on the discharge planning form titled "Anticipated Post Hospital Plan" was blank. There were no other discharge planning notes in the patient's medical record.

In an interview on June 2, 2015 at 9:40 AM, with the Licensed Clinical Social Worker (LCSW) regarding Patient 4's discharge plan, she stated that the patient was discharged back to the skilled nursing facility. She stated that the group home he lived in only had 1 person available to lift him and he needed 2 persons to lift him. She was unable to explain why the discharge evaluation and plan were incomplete.

During a review on June 2, 2015 of a hospital policy and procedure titled "Discharge Planning Policy," with a revision date of August 2010, showed the following:

"It is the policy of (name of hospital) to ensure that the patient's needs for continued health and welfare are maintained or enhanced following their discharge. It is a process of identification of patients who will require assistance in the post-hospital planning. This will include patients who are likely to suffer adverse health consequences without discharge planning. This must be initiated upon admission and be based on the patient's age, disability and plan of care to ensure for a smooth continuum of care for each patient."

In a review on June 2, 2015 of a hospital policy and procedure titled "Evaluation-Documentation," with a revision date of November 2009, showed the following:

A. Evaluation/Documentation:
1. Minimum standards for documentation are as follows:
a. There will be a psychosocial evaluation and discharge plan documented in the
patient's medical record for each patient seen...
b. The initial chart note will contain the following information:
iii. Plan of action..."