HospitalInspections.org

Based on review of the medical record of one patient (#4), review of hospital polices and procedures, a tour of two patient care units, and interviews with administrative staff, it was determined that patients did not receive care in a safe setting.

Findings include:

Reference #1: Facility policy titled, "Sharps Use, Storage, Disposal, and Safety" states:
"Purpose:
1. To decrease the risk of sharp injuries.
.....
4. To comply with NJSDH (New Jersey State Department of Health) regulations related to storage of sharps.
Policy:
.....
P. All needles and syringes in patient care areas shall be kept in locked, storage areas.
....."

Reference #2: Facility policy titled, "One-to-One Observation" states: ".....
I. Purpose
To provide an appropriate level of observation for patients in order to assure the safety of patients, staff, and visitors in the least restrictive environment.
II. Policy
Patients displaying behaviors placing themselves or others at risk and requiring an increased level of care will be placed on an appropriate level of observation and support to maintain their safety and the safety of others. One-to-one Observations may be initiated for those patients identified as being in imminent risk of harming themselves or others, as well as other indications such as patients who are an elopement risk, or committed.
III. Definitions
1:1- A level of observation requiring a staff member to monitor a patient a distance no greater than arm's length continuously.
.....
Princeton Medical Center
A. Indications patient may be placed on 1:1 observation when assessed to be at risk for:
.....
3. Suicide- the act of willfully ending one's own life. Suicide can also refer to the individual who has attempted suicide in the past and/or is reassessed and has a suicide plan.
.....
C. 1:1 Observation
.....
3. 1:1 Observer shall:
.....
c. Never leave the patient unattended: [sic]
.....
Document on the 1:1 Observer sheet every 15 minutes.
....."

Reference #3: Facility policy titled, "Storage, Distribution, Control, and Disposal of Medical Products" states: ".....
III. Procedure
A. Storage
1. Medical Security
.....
c. Nursing Units
1) Medication is stored securely.
a) Cabinets/nurse server compartments
i. Nurse server and other medication cabinets are locked with security codes as defined by nursing leadership. Access to nurse servers is restricted to nursing personnel, respiratory therapists, pharmacy staff, and materials management. Access to the medication compartment within the nurse server is restricted to nursing personnel, respiratory therapists, and pharmacy staff.
.....
2. Temperature- medications are maintained at temperatures suitable for product stability .....
.....
d. To assure proper potency and sterility, expiration of injectables and liquids is as follows:
1) Multi-dose vials of injectables, once punctured, (e.g. insulin, PPD) and nitroglycerin sublingual tablets have a 28-day expiration. Nursing is responsible for indicating on the product is opened. .....
.....
C. Control- limiting types and quantities of products available on the unit
1. Unit of Use Distribution
.....
d. Patient-specific medication supply
.....
2) During daily medication cart delivery, pharmacy personnel are responsible for removing the medications that are discontinued or expired. The patient's electronic medication profile is used to verify whether product orders are still active.
.....
5. Management of medication products in the Pharmacy Department
a. Unused medications no longer needed for the patient, (e.g. discontinued or not administered), are removed from the patient care unit. These products are retrieved by pharmacy personnel and returned to the pharmacy. The pneumatic tube may be used to return appropriate non-CDS (Controlled Dangerous Substance) medications to the pharmacy from the nursing units. .....
....."

1. A tour of the Emergency Department on 9/16/2020, accompanied by Administrators #10 and #15 revealed the following:

a. Hallway across from the Soiled Utility Room:
An unlocked drawer in an EKG (electrocardiogram) cart contained;

(i) One (1) BD 2 G (gauge) x 1 SafetyGlide Needle

(ii) Two (2) Smith's Medical 23G x 3/4 in (inch) Saf-T Wing Blood Collection Set

b. Medication Area:

(i) A blue bin containing unwrapped graduated plastic medication cups had crumbs at the bottom of the bin.

(ii) The medication refrigerator contained two punctured insulin vials that were not dated when opened.

c. Physician Work Area: There was tape and tape residue on the countertops.

d. Hallway outside of Room D1515: Unlocked "Bedside Cart Rm [room] #22" contained multiple syringes in the top drawer and multiple needles in the second drawer.

e. Hallway Nutrition Station: The interior surfaces of the refrigerator had crumbs, grit, spillage, stains, and pieces of wrappers.

f. Medication Area across from Room 1161: A rolling cabinet had an opened box of syringes atop it.

g. Hallway out of the Trauma Room: An unlocked rolling metal cabinet contained multiple needles and syringes in the top three drawers.

h. Behavioral Health Area: Dust was observed coming through the spaces between the door and the door frame of a door inside of patient Room D1109. The door opened from the patient room to a room containing HVAC (heating, ventilation, air-conditioning) equipment. The floor, equipment surfaces, and walls were covered in a heavy coat of dust. An opened, dust covered, gallon container of windshield wiper fluid on the floor had a patient identification sticker with the name of Patient #13 on it. The patient's admission date on the sticker was "5/07/13."

i. Family Respite Room (Room D1144):

(i) There were crumbs and pieces of crackers at the bottom of a metal mesh bin.

(ii) There were crumbs and grit at the bottom of a plastic bin containing tea bags.

2. Tour of the MNO Unit on the afternoon of September 16, 2020, accompanied by Administrators #17, #20, and #29, revealed the following:

a. Pantry Area:

(i) A plastic bin containing individual saltine cracker packets had cracker pieces and crumbs at the bottom of it.

(ii) A plastic bin containing individual sugar and Equal sweetener packets had a heavy accumulation of white crystals and powder at the bottom of it.

(iii) The refrigerator had heavy staining, grit, dust, dust clumps, and other refuse beneath and behind it. The surfaces of the interior of the refrigerator had splatter and spillage stains, food particles, wrapper scraps, and hair.

b. Patient A Nurses Station: A code cart in an alcove had gypsum powder on the suction canister and suction machine which were placed in a bin at the lower part of the cart. The top of the cart was rubbing against the wall causing the wall to wear down allowing the gypsum powder to fall onto the exposed equipment and floor.

c. Patient Room 445: The nurse server in the wall cabinet outside of the room was unlocked. Inside the cabinet was:

(i) One (1) pre-drawn syringe containing 32 units of insulin glargine with the name of Patient #18 on it.

(ii) One (1) Novolog Flexipen with the name of Patient #18 on it.

(iii) Two (2) BD SafetyGlide needles.

(iv) One (1) BD 3ml (milliliter) syringe.

Administrator #29 stated that Patient #18 had been discharged at 7:56 PM on the previous day and that a different patient had been placed in the room. The unused medications had not been retrieved by pharmacy or sent back to pharmacy by nursing staff per the referenced medication policy.

e. Nurses Station:

(i) The interior of the refrigerator had various stains, grit, hair, and spillage inside of it.

(ii) The floor tiles in front of the ice machine were separating from the floor.

(iii) A plastic bin in a cabinet above the sink containing sugar packets had sugar crystals on the bottom of the interior of the bin.

f. Outside of Room #414, in the unlocked "nurse server" cabinet on the bottom shelf, an unlocked storage cabinet was found with a three (3) drawer plastic storage unit containing the following:

(i) Drawer one contained four (4) 18G needles, six (6) 20G needles, one (1) 24 G needle, and one (1) 22G needle.

(ii) Drawer two contained five (5) 9% Sodium Chloride injection syringes, one (1) Vanishpoint insulin syringe, five (5) 22G needles, three (3) 25G needles, and seven (7) 20G needles.

(iii) Drawer three contained one (1) 9% Sodium Chloride Injection syringes, seven (7) 22G needles, two (2) 20G needles, one (1) 24G needle and one (1) 22G needle.

g. Outside of Room 434, in the unlocked "nurse server" cabinet on the middle shelf, an unlocked storage cabinet was found containing a box of seven (7) 9% Sodium Chloride injection syringes.

h. Outside of Room 428, in the unlocked "nurse server" cabinet on the middle shelf, an unlocked storage cabinet was found containing a box of two (2) 9% Sodium Chloride injection syringes.

i. Outside of Room 427, in the unlocked "nurse server" cabinet on the middle shelf, an unlocked storage cabinet was found containing a box of seven (7) 9% Sodium Chloride injection syringes.

The above findings were confirmed by Staff #17 and Staff #29 at 1:10 PM.

j. Review of an OBSERVATION SHEET, dated 9/16/2020, for Patient #4 revealed:

(i) The patient was being maintained on 1:1 supervision for SI (suicidal ideation).

(ii) There were no entries on the form to indicate that the patient was being observed between 10:00 AM and 10:45 AM.

Based on staff interview, medical record review, and review of policy and procedure, it was determined that the facility failed to ensure that a restraint is imposed only to ensure a patient's physical safety.

Findings include:

Reference: Facility policy titled, "Restraint and Seclusion Utilization Policy" states: "...
III. Policy...
G. Restraint Orders ... An order authorizing the use of restraints or seclusion should specify the reason for the restraint ..."

1. On 9/18/2020 at 9:45 AM, a review of Medical Record #17 revealed the following:

a. On 6/1/2020 at 12:57 PM, Staff #31, a Registered Nurse (RN), documented in the "ED [Emergency Department] Triage Notes," an attempt to check the blood glucose level of Patient #17 and that the patient stated, "no needles," withdrew his/her hand, and indicated that he/she "does not want anything inserted into [his/her] body."

(i) At 2:30 PM, Staff #31 documented in the "ED Notes" that Patient #17 was "still refusing bloodwork" and that per another staff member, he/she "do (does) not have to receive bloodwork for pt [patient] if pt refuses."

(ii) At 4:09 PM, Staff #32, a Medical Doctor, entered a physician order, "Restraints Violent or Self-Destructive Adult (Age 18 and Older)" with the "Restraint Type: Physical Hold" and "Clinical Justification: Self Injury."

(iii) At 4:10 PM, Staff #31 documented in the "Violent Restraints" Flowsheet, "Restraint Type, physical hold by security to give pt meds [medications] and do bloodwork."

(iv) The order for the Physical Hold restraint does not indicate the reason for administering medication or extracting a blood sample.

2. The above findings were confirmed by Staff #21 at 10:15 AM.



41646

Based on staff interview, review of three (3) medical records of patients that were restrained, and review of policy and procedure, it was determined that the facility failed to ensure a physician documented a face-to-face evaluation within one hour of restraint initiation in one (1) out of three (3) medical records (Medical Record #9).

Findings include:

Reference: Facility policy titled, "Restraint and Seclusion Utilization Policy" states: "I. Emergency Restraints... 2. When restraint or seclusion is used to manage violent or self-destructive behavior, a physician must see the patient face to face within 1 hour after the initiation of the intervention to evaluate the following and document in the medical record: The patients immediate situation; The patient's reaction to the intervention; The patient's medical and behavioral condition ..."

1. On 9/18/2020 at 10:15 AM, a review of Medical Record #9 revealed the following:

a. On 5/30/2020 at 11:23 AM, an order for "Restraints Violent or Self Destructive Adult" was entered by Staff #27, a Registered Nurse (RN) for Staff #30, a physician.

(i) The medical record lacks documentation of a physician seeing the patient within one hour of restraint application including the patient's immediate situation, reaction to the intervention, and the medical and behavioral condition.

2. The above findings were confirmed by Staff #21 at 12:45 PM.