HospitalInspections.org

Based on review of records and interview, it was determined that the facility failed to receive informed consent for treatment from all of its patients.

Findings were:

Facility policy entitled "Informed Consent" stated in part, "Upon registration or admission to a Covenant Health Facility, each patient will be required to sign a "Consent to Treatment & Conditions of Admission" form. In an emergent situation where threat of life or limb exists, the patient's representative may sign for the patient. If no representative is present, the form may be signed when the emergent situation ceases to exist ....
B. Proper Consent Must:
1. To be valid, the consent must be obtained before administering medical treatment or special procedures and must be an informed consent
2. The patient must:
a) Understand the circumstances to which he/she is consenting
b) Freely choose to enter the agreement
c) Understand the consequences of having or not having the procedure ...
Who May Consent:
d) Pursuant to Texas Health and Safety Code, Chapter 133 "Consent to Medical Treatment Act," incapacitated means lacking the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of the treatment decision, including the significant benefits and risks and harms of and reasonable alternatives to any proposed treatment decision. For adult patients who are comatose, incapacitated or otherwise mentally or physically incapable of communication, an adult surrogate from the following list, in order of priority, who has decision making capacity, is available after a reasonable diligent inquiry, and is willing to consent to medical treatment on behalf of the patient may consent to medical treatment on behalf of the patient:
i. The patient's spouse
ii. Adult child of the patient who has the waiver and consent of all other qualified adult children of the patient to act as the sole decision maker
iii. A majority of the patient's reasonably available adult children
iv. The patient's parents
v. The individual clearly identified to act for the patient by the patient before the patient became incapacitated, the patient's nearest relative, or a member of the clergy."

On 12/15/14, Patient B#4 was admitted to the facility. This patient was incapacitated. The consent to treatment was signed under "Patient or Authorized Authority" as "Southern Specialty" (a nursing home.)

On 1/6/15, the Director of Nurses confirmed that the nursing home was not authorized to consent treatment for Patient B#4.

Based on observation and interview, it was determined that nursing staff failed to provide a care environment that was free of the potential for cross-contamination for 1 or 13 patients observed.

Findings were:

While touring floor 8 on the south side, Patient C13 in room# 883 was observed on 1/7/15 to have a container with urine located on the sink, two containers of dried blood on the back of the toilette and blood stained bed sheets along with a blood stained mattress pad. Interview with the patient's spouse conducted on 1/7/15 in the patient's room revealed that these items had not been removed since the morning of the previous day on 1/6/15. No evidence was presented to indicate that the bed sheets and mattress pads were changed on 1/6/15. The charge nurse responsible for the unit confirmed the above findings at the time of the observation on 1/7/15.

Based on medical record review, policy review, and staff interview the facility failed to ensure their staff initiated and kept current a plan of care based on the identified needs of the patient. 8 of 15 patients did not have a plan of care developed to address all of their identified needs as per facility policy.

Findings were:

Medical record review for patient plans of care revealed the nursing staff did not develop or keep current plans of care for patients with identified needs. The following was identified:
* Patient B #11 received 2 units of PRBC on 1/2/15. No mention of anemia was made in the patient's plan of care.
* Patient B#15 was admitted with fever, anemia, and transplant rejection on 1/3/15. No nuring plan of care was initiated by 1/5/15 to address his immunocompromised health state, infection, or anemia.
* Patient B#17 was admitted on 12/24/14 with fever, UTI, and Aspiration Pnuemonia. Patient was on isolation precautions and no plan of care was initiated for isolation precaution or infections by 1/5/15. Patient had a change on her MEWS (Modified Early Warning Score) on 1/2/15 from green to red and no change was made in her plan of care to address the change in her deterioration in health status.
* Patient B#18 was admitted 12/30/14 with a diagnosis of infection and diabetes. No nursing plan of care was initiated for diabetes or infection as of 1/5/15.
* Patient B#19 was admitted with gastric cancer and anemia on 12/29/14. No nursing plan of care was initiated for anemia and patient had blood transfusions for Hgb of 5.8 on admission. Patient had discussions in medical record regarding enteral feedings and end of life care on 1/2/15. No plan of care was initiated to address nutritional needs or spiritual care needs as of 1/5/15.
* Patient B#24 was admitted on 11/25/14 and has had continuous tube feedings. No plan of care for nutritional support related to enteral feedings has been initiated as of 1/5/15.
* Patient B#26 was admitted on 1/3/15 with C-Diff and Influenza. No plan of care was initiated for isolation precautions and infectious process as of 1/6/15.
* Patient B#35 was admitted on 1/3/15 and diagnosed with pulmonary emboli on 1/5/15. No plan of care was initiated for anticoagulant therapy and potential for bleeding when patient was started on Lovenox on 1/5/15.

Facility policy titled "Documentation in the Medical Record" states in part "Care Plan: A group of problems (or diagnoses), outcomes (or goals), and interventions assigned to a patient. One primary Care Plan will be implemented based on identified care needs of the individual patient. Additional problems can be added as necessary. All/outcomes are reassessed and updated every shift." "The Care Plan is assigned by diagnosis which includes the problem list, long term outcomes, interventions, and outcome evaluations."

Interview with the Chief Nursing Officer, Nursing Director, and Nursing Managers at the time of the findings, confirmed the above. Time was given for evidence and documentation to be presented and no documentation was offered for deficiencies found in the patient medical record.

Based on review of documentation, observation and interview, it was determined that medications were not being administered as ordered in a timely manner.

Findings were:

Facility policy entitled "Medication Administration" stated in part "Scheduled medications may be administered 60 minutes before the scheduled time to 60 minutes after the scheduled time to be considered administered at the correct time."

Facility policy entitled "Medication/IV Administration and Documentation" stated in part "Each patient's response to his or her medication is monitored through interdisciplinary approach according to their clinical needs, the patient's response to the prescribed medication including first dose and subsequent doses, and actual or potential medication related problems through frequent rounding, vital signs, interdisciplinary assessments, by gathering patient's perceptions, and all relevant labs."

Tour of the facility on 1/7/15 revealed the following medication administration errors:
* Patient #E5 had the medication Folic Acid ordered daily and scheduled for administration at 9 am that was given on 10/24/14 at 10:29 am 11/5/14 at 10:24 am. Feosol and Lasix were ordered daily and scheduled for administration at 9 am and were given on 10/5/14 at 10:24 am.
* Patient #E2 had the medication Zestril scheduled for administration at 9 am on 10/2/14, but did not receive it until 12:48 pm. Lovenox was scheduled for 8 am on 10/3/14 but was not given until 9:37 am. Caltrate was scheduled for 8 am on 10/3/14, but not administered until 9:37 am.
* A surveyor watched Staff Member # B5 (RN) pass medications on 1/6/14 to Patient # B3. Medication administration was ordered at 8am but medications were not prepared for administration until 9:30am.
* The same Surveyor watched Staff Member # B7 (RN) pass medications on 1/6/14 to Patient # B4. The scheduled administration time was 9am. These medications were not administered until 10:18am.
* Review of the medication administration record of Patient # B30 revealed the scheduled administration of Lopressor at 6pm. According to the record, this medication was not administered until 8:15pm.
Review of the medical records of Patients # E5, # E2 and #B30 revealed no documentation that would explain why the medications were not given according to policy. These findings were confirmed with staff #E18 (RN, Clinical Analyst) on the morning of 1/7/15. The late administration of medications witnessed by the Surveyor was acknowledged by the Nursing Director on 1/6/14.

During a tour of the Palliative Care Unit on 01/07/15 at 2:17pm the following observation was made:
* In the medication room, an open medication drawer for patient # C9 was observed with a cup of orange liquid and a pill cup containing (2 whole pills and 1 half tablet).
Staff # C26 (RN, Unit Director of Palliative Care) was asked why these medications were open and available in the medication room, with no nurse present to administer them. The staff member stated, "I'm not sure, the patient might have been nauseous, might have been a waste in Meditech, or they might to be trying to give the meds to them later in the day."
The surveyor asked staff # C26 to access the Pyxis system to try to identify to the medication in the cup and when it was pulled for administration. Review of the Medication Administration Record revealed that per physician order, patient # C9 was to received Aspirin, Lopressor (half a tablet), and Celexa at 9am that morning. The record in the Pyxis system revealed these medications were accessed for administration between 9:31am and 9:32am on 01/07/15 (this observation was made at 2:17pm). Staff # C26 stated, "That patient is somnolent. That could be why they have not received their medication." This staff member confirmed that per facility base policy, medication is to be administered "within a one hour window". This medication had been open and available for administration for over five hours.
The Medication Administration Record for patient # C9 reflected the last administration of the medication at 10:28am on 01/07/15. Staff # C26 confirmed that the Medication Administration Record for patient #C9 should have accurately reflected that the medications were not administered.

Based on observation, review of documentation and interviews with facility staff, the facility failed to make outdated medications not available for patient use as expired medications were found in 3 of 3 pharmacy departments surveyed available for use in patient care. This was not consistent with facility policy and could have resulted in ineffective or unsafe medications being used in patient care.

The findings were:

The facility policy entitled "Drug Storage" # RX 4.77 with a revised date of 10/13/14 reflected in part "Expired, damaged, or contaminated medications shall be stored separately from other medications until they are removed and appropriately disposed ...On a monthly basis, the Pharmacy Department will inspect all medication storage areas in the organization. Medications not stored in a manner consistent with this policy will be removed or restored as appropriate and indicated."

During a tour of the main pharmacy on the afternoon of 1/5/15 in the company of the Pharmacy Clinical Director, staff #E8, the following expired medications were found in general storage available for use in patient care.
1. Potassium chloride injection vials, 5 boxes of 25 vials expired 7/14, and 5 boxes of 25 vials expired 9/14.
2. Milk of magnesia, 16 oz. bottle, 2 expired 10/14.
3. Dankins solution 16 oz. bottle, 3 expired 12/14.
In an interview with staff #E8 during the tour on 1/5/15 at 3:00 pm, staff #E8 agreed that the above listed medications were expired and should have been removed.

During a tour of the Surgery Department pharmacy on the morning of 1/6/15 in the company of the Chief Medical Officer, staff #E2, the following expired medications were found in general storage available for use in patient care.
1. Bonney blue dye solution, 1 bottle expired 12/3/14.
2. Metoprolol 12.5 mg, 5 tablets expired 12/12/14
In an interview with staff #E2 during the tour on 1/6/15 at 9:15 am, staff #E2 agreed that the above listed medications were expired.

During a tour of the Lakeside Campus pharmacy on the morning of 1/6/15 in the company of the manager, staff #E17, the following expired medications were found in refrigerated general storage available for use in patient care.
1. Diltiazem HCl injection 50 mg/10 ml, box of 10 expired 9/14, and 3 boxes of 10 expired 1/14.
In an interview with staff #E17 during the tour on 1/5/15 at 3:00 pm, staff #E17 agreed that the above listed medications were expired and should have been removed.

Based on a review of facility documentation and staff interviews, the facility failed to ensure that radiologic services were provided only on the order of a practitioner with clinical privileges for 1 of 1 patients undergoing central line placement.

Findings were:

A review of the medical record of Patient #C4 included no documented evidence of a physician order for the placement of the patient's central line.

A nursing note on 1/4/15 at 1:03 a.m. stated in part:
"Procedure Type: PICC Insertion ...Insertion Complications: Unable to Access Vein
Insertion Complications Comment: On first attempt to right basilica I was unable to pass the 0.018 guidewire past the axiallary. Re-assessed on the left and attempted the brachial vein and needle dead center in the vein via U/S, however when I attempted to pass the wire reisitance [sic] met. Needle repositioned and unable to pass the wire without patient flinching. Procedure stopped ...
Comment: Difficulty passing wire through axiallary on the right and unable to pass wire into vein with two separate attempts. Patient requestion [sic] to go to IR to have central line placed..."

In an interview with the unit nurse manager, Staff #C31, on the morning of 1/7/15, she stated, "This patient definitely had a central line placed. It's really hard to tell what happened here. It looks like a PICC line was ordered, but they had trouble doing it. I'm sure what happened is that the PICC nurse got a telephone order from the doctor to change it to a central line, but the order isn't showing up anywhere. Maybe she had a protocol she was following..."

A review of the facility's "PICC Line Post Insertion Protocols" revealed the following in part:
"17. PICC nurse may order for PICC line repositioning of malpositioned PICC catheter to be done in interventional radiology..."

A review of the Department of Imaging Services Policy #0201 entitled "Checking Patient Orders" revealed the following, in part:
"All orders must be check either in the patient's chart or written orders. This assures that the correct exam is done and that the radiology department has received correct orders regarding ordering physician, exam, preparation ...Verify Physician's Signature on order for all exams ...An order must be present and confirmed prior to performing the procedure..."

In an interview with the Director of Nursing, Staff #30, on the afternoon of 1/7/15, she agreed that the record appeared to contain no physician order for placement of a central line and that the facility PICC line protocol did not serve as basis for the PICC line nurse to change the peripheral access to a central line without a physician's order.

Based on observation, record review and interview, it was determined that the facility failed to manage dietary services to ensure that all aspects of food safety were maintained in 2 of 2 kitchens.

Findings were:

During a tour of the Lakeshore retail food service area on 01/06/15, a visible layer of dust was present on horizontal surfaces such as cabinets. A cabinet in the food serving area was observed to contain empty condiment shakers, packets of grated parmesan cheese, and a can of "Purge III" spray insecticide. Clean spoons were found on dirty kitchen surfaces at main restaurant. Two kitchen food storage refrigerators were dirty. Dirty Aprons were found to in a drawer alongside clean towels.

During a tour of the main facility kitchen on 01/06/15, in the tray line preparation area, a container was observed full of metal spoons ready for patient use. Approximately 50 of these metal spoons were observed to have droplets of water present, creating a risk for bacteria growth.

During a tour of the main facility retail food service area on 01/06/15, 10 boxes of pastries were observed with no "used by" date note or expiration date noted. Staff member C4 (Director of Food and Nutrition) confirmed that these pastries "should have a sticker" noting an expiration date. A freezer containing ice cream was noted to not have a temperature log present. Staff member C4 stated this freezer should have temperature log present to monitor any temperature fluctuations to maintain food integrity.

Based on observation and interview, it was determined that the facility failed to maintain a clean environment in nursing care areas, the radiology department, and dietary areas.

Findings were:

During a tour of the Covenant Medical Center main campus on the afternoon of 1/5/15, a visible layer of dust was noted on horizontal surfaces in patient procedure rooms, including an interventional procedure room, throughout the radiology area. In treatment room #1 , thick dust was observed on radiology equipment along with a drawer that contained unlabeled brown in color ointment which had spilled onto several other items in the drawer.

During a tour of the Lakeshore campus on the morning of 1/6/15, a visible layer of dust was noted on cabinets in the patient group room and in the medication room of the Behavioral Health Unit on the Lakeshore Campus. Also on this unit, the patient laundry area included a single-stall shower for patients. The shower had a thick layer of soap scum in the soap dish recess and dark areas in the corners which seemed to be mold. The shower did not appear clean in general. The floor was dirty floor in seclusion rooms #1 & #2.

During a tour of the Lakeshore Campus Radiology Department on the morning of 1/6/15, a visible layer of dust was noted on horizontal surfaces throughout patient procedure rooms.

During a tour of the Lakeshore retail food service area on 1/6/15, a visible layer of dust was present on horizontal surfaces such as cabinets.

During a tour of the Lakeshore retail food service area on 01/06/15, a visible layer of dust was present on horizontal surfaces such as cabinets. A cabinet in the food serving area was observed to contain empty condiment shakers, packets of grated parmesan cheese, and a can of "Purge III" spray insecticide. Clean spoons were found on dirty kitchen surfaces at main restaurant. Two kitchen food storage refrigerators were dirty. Dirty Aprons were found to in a drawer alongside clean towels.

During a tour of Patient Care Areas on 1/7/15, throughout the facility, refrigerators available for patient use were noted to need cleaning. Spills and sticky substances were noted in drawers and on shelves in these refrigerators.

During a tour of South 6 on 1/7/15, Patient Room S663 was noted to be on neutropenic precautions. A sign on the door instructed that if visitors were "not feeling well" to wear a mask. No masks were observed to be available outside the patient room or in the hallway for use. Staff member C2 confirmed that masks should have been available and readily accessible for visitor use.

The above findings were confirmed during the tours with Staff C1 (V.P. of Facilities) and Staff C2 (Infection Prevention Specialist).

Facility policy # IC 1.15 titled "Sanitary Environment Policy", stated the following in-part "Covenant Health System shall provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases...All areas of the hospital must be clean and sanitary. This includes units/departments, campuses and off-site locations...It is the responsibility of each department manager to ensure that their department maintains a clean and sanitary environment."

Based on record review and interview, it was determined that the facility failed to ensure that respiratory care services were provided as ordered by a physician for 1 of 13 patients reviewed.

Findings were:

A CPAP (Continuous positive airway pressure) therapy was ordered on 12/27/14 for Patient C13, but was not provided on the night of 1/6/15. Interview with the nursing staff manager on 1/7/14 at the nursing station located on floor 8 south confirmed that the patient did not receive CPAP therapy on 1/6/15 as ordered by the attending physician. Additionally, there was no evidence in the patient's record that the CPAP therapy was provided on 1/6/15.