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On the days of the Recertification Survey based on interview, clinical record review, and review of medical staff rules and regulations, the hospital failed to ensure the patient's chart had medical orders prior to an invasive procedure (endoscopy) for 1 of 9 inpatient charts reviewed for patients undergoing invasive procedures. (Patient #24).


The findings are:


On 4/24/13 at 1455, review of Patient #24's chart revealed the patient was admitted for an Abdominal Mass Unspecified Site. Review of the patient's chart revealed the patient had an Esophagogastroduodenoscopy (EGD) on 4/24/13. Review of the patient's chart showed there was no physician order for the EGD procedure on the chart. On 4/24/13 at 1510, Staff Member
#58 verified there was a procedural charge in the computer for the EGD, but there was no physician order for the procedure on the patient's chart.

Hospital policy, "Orders for Patient Treatment/Testing/Care, Policy Number IM1100.111, POLICY: 1.", reads, "Orders for patient treatment, testing, or care must be legible and clear to be a valid order. Such orders for inpatients will show space for the date and time of the order, patient's name, written or electronic physician signature including date and time of signature, and patient bar-coded label in bottom right hand corner. For outpatients, the order should include patient name, diagnosis, ICD-9 Code, test to be ordered plus the written or electronic signature of the physician, dated and timed....".

On the days of the Recertification Survey based on review of hospital quality data and minutes and interview, the hospital Quality Assessment and Performance Improvement body failed to ensure oversight of its acute renal unit that that measures, analyzes, and tracks quality indicators and other aspects of performance to assess its dialysis services and operations for water quality safety (product water cultures) and dialysis machine safety (dialysis machine cultures).


The findings include:


On 4/26/13, a review of the the hospital's Quality Assurance and Process Improvement (QAPI) data and minutes revealed no documentation that the hospital's QAPI body had an active relationship, oversight, or system that measures, analyzes, or tracks the dialysis unit's product water cultures, product water analysis, and/or water quality and/or no active system for monitoring hemodialysis machine cultures and disinfection processes to assess for action level ranges. On 4/25/2013 at 1015, the Director of Quality Control verified the finding, and stated the hospital had a renal oversight committee, but the Director reported that he/she wasn't sure what was monitored in that committee, and any data reviewed wasn't evaluated through the hospital's QAPI process.

On the days of the Recertification Survey based on review of the hospital's Quality Assurance and Process Improvement minutes, quality data, and interview, the hospital Quality Assessment and Performance Improvement body failed to incorporate a system that measures, analyzes, and tracks quality indicators and other aspects of performance to assess its dialysis services and operations for water quality safety (cultures) and dialysis machine safety (cultures) for its renal dialysis unit, a high risk patient care environment.


The findings are:


Cross Reference to A 0273: The hospital Quality Assessment and Performance Improvement body failed to incorporate a system that measures, analyzes, and tracks quality indicators and other aspects of performance to assess its dialysis services and operations for water quality safety (cultures) and dialysis machine safety (cultures).

On the days of the Recertification Survey based on record review, and review of the hospital policy and procedures, hospital staff failed to ensure the authentication of physician verbal and/or telephone orders per the hospital's policy and procedures for 3 of 48 inpatient records reviewed for care and services. (Patient #33, #32, and #17)


The findings are:


On 04/25/13 at 1130, review of Patient #33's chart revealed the patient was admitted on 04/13/13 with the diagnosis of " Respiratory Abnormality " to the 4 Heart floor. Further review of the physician orders in Patient
#33's chart revealed telephone/verbal medical orders which showed the physician had not authenticated the medical orders electronically or in writing per the hospital's policy and procedure for:
04/21/13 at 0900 - telephone/verbal order- Xanax PO(by mouth) 0.5 mg(milligrams) BID (twice a day) prn (as needed);
04/20/13 at 1630- telephone/verbal order- (change) IVF(intravenous fluid) to NS(Normal Saline) @(at) 75 ml (milliliters)/hr(hour);
04/19/13 at 0920-telephone/verbal order- Administer A.M.(morning) dose of Coreg 3.125 PO now;
04/18/13 at 2048- telephone/verbal order- Extubate; O2(oxygen) per protocol; SMI Q 2 hours WA; MDI with 2 p Combivent Q 4;
04/18/13 at 1445- verbal order- Pain pump 400 ml (with) Marcaine 0.25% to start post op(operative);
04/14/13 at 1700- telephone/verbal order- Norvasc 10 mg PO x 1 ASAP(as soon as possible); Norvasc 10 mg q(every) daily PO start tomorrow; Clarification: Coreg 6.25 mg PO BID " ;
04/14/13 at 0800- telephone order- Potassium 20 meq(Millie-equivalent) PO x 1 STAT; Coreg (decrease) 6.25 mg q 12 (hour) PO;
04/13/13 at 2100- telephone order - 1 G Magnesium IV NOW; 240 mg PO Bid start on 04/14/13 at 0900;


On 04/25/13 at 1200, review of Patient #32's chart revealed the patient was admitted on 03/20/13 to the 4 Heart floor. Further review of Patient #32's chart revealed physician medical telephone/verbal orders that showed the physician had not authenticated the medical orders electronically or in writing per the hospital's own policy and procedure for:
04/21/13 at 1100- telephone orders- Morphine 8 mg IV x 1 dose now for dressing change;
04/21/13 at 0255- telephone/verbal order- Morphine Sulfate 2-4 mg IV Q 4 (hour) prn for pain;
04/16/13 at 1400- telephone order- Renew previous ? bolus feeds at 8 am, 12 PM., 16 PM.; flush (with)100 ml after each bolus;
04/09/13 at 1030- (late entry) Morphine 8 mg IV x 1 before dressing change;
04/05/13 at 1818- telephone/verbal order- Turn off wound vac; leave wound vac; do not remove dressing;
04/05/13 at 1105- telephone/verbal order- Give ? amp(ampule) of D 50(Dextrose) for FSBS(fasting blood sugar) of 70;
04/02/13 at 1050- telephone/verbal order- Morphine IV 4 mg x 1 Now;
03/31/13 at 1125- telephone/verbal order- please change KCL(Potassium) 20 meq q day to elixir form; please change Docusate 100 mg PO q 12 (hours) to elixir; Lorazepam 0.5 mg via PEG(percutaneous esophagogastrostomy) q 4 (hours) prn anxiety;
03/30/13 at 2025- telephone/verbal order- Morphine 2-4 mg IV q 4 (hours) prn pain;
03/30/13 at 1444- telephone/verbal order- OK to give 1600 dose of Lortab now for dressing change.
Further review revealed the physician had not authenticated the Nutritional Protocol orders written by the Registered Dietitian on:
04/19/13 at 1215- per nutritional protocol- Zinc Sulfate 220 mg q day; check prealb(pre albumin) on 04/23;
04/17/13 at 1200- per nutritional protocol- Arginaid (1) via feed tube bid;
04/16/13 at 1200- per nutritional protocol- (increase) nocturnal TF(tube feed) cycle; Jevity 1.5 to 80 ml/hr from 6 p.m.- 6 a.m.; please weigh pt daily; add zinc and prealb to am. lab for 4/17 " ; and
04/09/13 at 1430- per nutritional protocol- Change tube feeding to: with Jevity 1.5 ? can bolus @(at) 8 am., 12 noon, 4 pm; flush (with) 100 H2O(water) flush after bolus; continuous feeding (with) Jevity 1.5 from 6 pm.-6 a.m. @ 60 ml/hr (with) 100 H2O flush before and after cycle; BMP(Basic Metabolic Panel), Mg(Magnesium), Phos (Phosphorous) (on) 4/11.

Hospital policy: "Nutrition Protocol", reads, "Procedure:...The Physician will be required to sign registered dietitian protocol orders....".

Hospital policy, "Orders for Patient Treatment/Testing/Care", reads, "....Such orders for inpatients will show space for the date and time of the order, patient's name, written or electronic physician signature including date and time of signature....".

Hospital policy, "Verbal Orders or Telephone Orders", reads, "....Verbal and telephone orders must be authenticated by the ordering physician or another practitioner who has hospital privileges and is responsible for the care of the patient within 48 hours....".









30011

On 4/23/13 at 1445, review of Patient #17's chart revealed the patient was admitted on 4/12/13 for a left hip fracture. The patient was a renal dialysis patient. Review of the physician orders for the patient's hemodialysis treatment dated 4/13/13, reads, "Next HD (hemodialysis): 4/13/13, 4 hrs (hours) duration, QB (blood flow rate) 400/QD (dialysis flow rate) 800....K+ (potassium) bath-sliding scale/ Ca 2+ (calcium) bath 2.5....". The patient received the hemodialysis treatment as ordered on 4/13/13. Review of the patient's chart, dialysis flow sheet, showed the patient received a hemodialysis treatment dated 4/14/13, that reads, "treatment duration of 2 hours, QB 350/QD 700, K+ 2.0/ Ca 2+ 3.0....". Review of the physician orders in the patient's chart revealed there was no physician orders written for the hemodialysis treatment dated 4/14/13. The patient's chart showed the next set of physician order for hemodialysis was dated 4/18/13. Review of the patient's dialysis treatment sheet dated 4/13/13 showed the nurse recorded, "TO/VO (telephone order/verbal order) Dr. ...", but the actual verbal/telephone order for the hemodialysis prescription was not recorded by the nurse in the chart, and therefore, was not authenticated by the physician."

On the days of Recertification Survey based on record review and Medical Staff Rules and Regulations, the hospital failed to ensure a history and physical was on the patient chart within 24 hours of admission to the hospital for 2 of 48 inpatient records review for the presence of a history and physical. (Patient #25 and #23)


The findings are:

On 4/24/13 at 0955, review of Patient #25's chart revealed the patient was admitted on 4/19/13 at 1201 to the renal floor with abnormal respiratory symptoms. Review of the patient's chart revealed there was no patient history and physical present at the time of the review on 4/24/13. The finding was verified by Staff Member #59.

On 4/24/13 at 1615, record review of Patient #23 revealed the patient was admitted on 4/23/13 at 0200 to the floor with a Femoral Neck Fracture. Surgery to repair the fracture was on 4/24/13, 1330-1545. Review of the patient's chart revealed there was no evidence of a history and physical completed for the patient prior to the surgery. On 4/24/13 at 1630, during an interview, Staff Member #52 verified the chart had no history and physical prior to the patient's procedure, there was no history and physical present in the computer system, and there was no history and physical competed after the patient's surgery.

On the days of the Recertification Survey based on random observations, interview, and review of the hospital policy and procedures, hospital staff failed to ensure expired medication and supplies were not available for patient use and all medication vials were accurately labeled in the hospital owned physician practice( Physician Practice #1's) and in the hospital's operative area.


The findings are:


On 04/24/13 at 1105, observation of the Medication Refrigerator located in Module One (1) of the hospital owned physician practice. (Physician Practice #1) revealed a multidose vial of Influenza Virus vaccine, 0.5 milliliters (ml) opened without a date, time, and initials. On 04/24/13 at 1117, Staff Member #67 revealed that if a vial of medication is opened, the vial should have a date, time and initial on the vial. On 04/24/13 at 1130, random observations of the Medication Refrigerator in Module Two (2) of the hospital owned physician practice (Physician Practice #1) revealed a multidose vial of Tuberculin Purified Protein Derivative opened without a date, time, and intimals. Hospital policy, "Multiple Dose Containers & Room Temperature Dating", reads, "....The vial will be dated with the expiration date....".








30011

On 4/25/13 at 1420, observation of the anesthesia cart located in Trauma Room #8 revealed one (1) 10 milliliter (ml) syringe with 5 milligrams (mg) Epinephrine labeled prepared at 0700 on 4/24/13, (1) Neostigmine 1:1000 (one to one thousand) (10 mg/10 ml) multidose vial opened but not labeled with the date, time and initials, and (1) Labetalol Hydrochloride Injection 100 mg/20 ml (5 mg/ml) multidose vial opened but not labeled with a date, time, and initials. The findings were verified by Staff Member #64.

On 4/25/13 at 1435, observation of the difficult airway cart in the clean core area revealed (3) 20 gauge (g) x 1 3/4 (three fourth inch) Safety Intravenous (IV) catheter needle expired 09/12, (2) 20 g x 1 3/4 Safety IV catheter needles expired 03/13, (4) brown top blood culture vials expired 01/12, (1) Catheter introducer tray expired 06/11, (1) Catheter introducer tray expired 02/12, and (1) Two-Lumen central Venous Access Kit expired 06/12. The findings were verified by Staff Member #64.

On the days of the hospital's Recertification Survey based on observations and interview, the hospital failed to ensure a safe mechanism for the evacuation of standing water in the hospital's dish room and failed to provide a schematic diagram for the water components installed in the hospital's dialysis water treatment room.


The findings are:


On 4/23/2013 at 1000, a random tour of the Dietary Department's dish room revealed water puddles in some areas on the dish room floor, and dirty water covered over 3/4 of the dish room floor area. There was no drain in the dish room floor area. On 4/23/2013 at 1002, the Dietary Director revealed that when the dirty tray carts are washed in this area with a sprayer, the water drains into the dish room onto the floor. Staff use a "squeegee" to clean up the water after completing the cleaning of the tray carts. On 4/25/2013 at 1400, the Quality Director revealed the dietary department was aware of this issue and were required to clean the area immediately after cart clean-up.




30011

On 4/22/13 at 1700, observation of the hospital's dialysis water treatment room revealed the water room had no schematics diagram for the water components. On 4/22/13 at 1700, Staff Member #56 verified the finding.

On the days of Recertification Survey based on interviews, observations, and review of hospital policy and procedures, the hospital failed to ensure hospital staff used measures to minimize the potential cross transmission of infections in the renal dialysis unit, the emergency department, and 2 of 2 medical surgical units where procedures were observed, and 1 of 3 intensive care units where a procedure was observed.


The findings are:


On 4/22/13 from 1555 to 1615, observation of the dialysis treatment area revealed unopened clean supplies sitting on the bedside table at dialysis dialysis machine #7 while a patient was dialyzing. A 3 K (potassium) 2.5 Ca (calcium) dialysis bath jug was placed on the dialysis machine prior to the termination of the patient's dialysis treatment. After staff disinfected the dialysis machine, Staff Member #70 placed the clean supplies from the bedside table and the dialysis bath jug back on the dialysis machine for the next patient's dialysis treatment.

On 4/22/13 from 1555 to 1615, observation showed strips of tape hanging on the patient's left bedside rail without a tape anchor throughout the patient's treatment. When the patient's cannula was de-accessed at the end of the treatment, the strips of tape were applied to the patient's left lower extremity site by Staff Member #71.

On 4/22/13 at 1630, observation of the dialysis treatment room revealed the patient at station #9 had a right side chest catheter. When Staff Member
#60 de-accessed the patient's chest catheter, neither Staff Member #60 nor the patient donned a mask during the procedure.

On 4/22/13 from 1555 to 1700, observation of the dialysis treatment area revealed the escort for the surveyor, Staff Member #7, remained in the dialysis unit the entire period with the surveyor without any encouragement from dialysis staff for Staff Member #7 to don personal protective equipment (PPE) although 2 dialysis patient's catheters were de-accessed at 1615 at station #7 and 1630 at station #9 when Staff member #7 was present. Donning PPE is necessary for persons present in the dialysis treatment area when patient's accesses are cannulated or de-accessed and the potential for blood spurting is high, PPE protects the individual from the risk of blood and body fluid exposure.

On 4/22/13 at 1700, observations of the dialysis water room floor revealed
white powdery substances on the floor, rusting areas on the walls, and salt pellets on the floor behind the brine tank. On 4/22/13 at 1700, Staff Member #56 verified the finding.

On 4/23/13 at 0940, observations of the dialysis treatment area revealed staff used non-disposable gowns that were laundered once a week. On 4/23/13 at 0940, Staff Member #51 revealed the non disposable gowns are taken to an outside clinic for laundering once a week only.

Hospital policy, "Surface Cleaning In The Acute Dialysis Setting, POLICY:...3., reads, " No supplies for another patient should be set on the machine or bedside table until the patient currently using that area has finished dialysis....".

Hospital policy, "Universal Precautions in the Acute Dialysis Setting," reads, "POLICY: 1. There will be no visitors in the dialysis room. Exceptions will be approved by the Nurse Manager or charge for the day, only for extremely unusual circumstances. (They will be provided with protective equipment)....".





31395

On 04/23/13 at 0915, one disposable blood pressure cuff with the wrap removed was observed in three (3) of the hospital's emergency triage rooms.

On 04/23/13 at 1010, observations of Staff Member #53 revealed he/she removed soiled gloves before exiting the room, but failed to perform hand hygiene. On 04/23/13 at 1013, Staff Member #53 revealed, "I should have, and I usually do wash my hands before leaving the room."

On 04/23/13 at 1105, observation of Staff Member #63 revealed that he/she failed to re- disinfect the site chosen for intravenous catheter placement after he/she palpated the site area.

Hospital policy, "Peripheral Intravenous Line Administration", reads, "....Aseptic technique shall be maintained throughout the procedure....".

Hospital policy, "Hand Hygiene", reads, "....After removing gloves and/or other personal proactive equipment....".







25877

Patient #27 was admitted to the neuro intensive care unit on 03/21/2013 with a diagnosis of Other Unspecified Injury. Patient #27 had a surgical procedure (Fasciotomy) performed on both lower legs on 04/07/2013 (right medial (inner) calf, right lateral (outer) calf, left medial calf, and left lateral calf). On 04/17/2013, the physician ordered bilateral (both legs) wound vac dressing changes three times a week, as well as other dressing changes (left toes, left heel, left knee, posterior (back of) right calf) to both of the patient's legs. On 04/24/2013 from 950 to 1040, observation showed Registered Nurse (RN) #24 and RN #25 performed bilateral wound vac dressing changes and other dressing changes to both of Patient # 27's legs. During the course of the observation, RN #24 and RN #25 cleaned their hands and fingers with alcohol hand sanitizer before starting the procedure, but failed to perform hand hygiene again until the procedure and other dressing changes were completed. Observation showed RN #24 changed soiled gloves 5 times during the procedure without any hand hygiene observed between gloving. Observation showed RN #25 changed soiled gloves 8 times during the procedure without any hand hygiene observed between gloving. In an interview on 04/24/2013 at 1100, the Wound Care Team Clinical Manager (RN #24) verified the findings.

Patient #4 was admitted to a medical surgical unit on 04/20/2013 with a diagnosis of Other Dyspnea (difficulty in breathing) and Respiratory Abnormality. On 04/23/2013 at 1320, Respiratory Therapist (RT) #26 was administering a medication treatment. Prior to starting care, RT #26 cleansed her hands with alcohol sanitizer in less than 5 seconds, and not thoroughly cleaning all surfaces of the hands and fingers until dry. At the end of the procedure, RT #26 cleansed the hands with an alcohol sanitizer in less than 3 seconds but not thoroughly cleaning all surfaces of the hands and fingers until dry. In an interview with RT #26 on 04/23/2013 at 1335, RT #26 verified the findings. On 04/24/2013 at 1610, RN #22 was observed administering Patient #4's medications. Before flushing the intravenous line in Patient # 4's upper right arm, RN #22 cleansed the hands with alcohol sanitizer in less than 10 seconds but not thoroughly cleaning all surfaces of the hands and fingers until dry. After documenting on the computer, RN #22 cleansed the hands with alcohol sanitizer in less than 10 seconds but not thoroughly cleaning all surfaces of the hands and fingers until dry. Then, RN #22 proceeded to prepare and administer Patient # 4's medications. In an interview on 04/24/2013 at 1630, RN #22 verified the findings.

Patient #26 was admitted to the medical surgical unit on 04/22/2013 with a diagnosis Right Shoulder Rotator Cuff Arthropathy and a post surgical diagnosis of Right Shoulder Hemiarthroplasty on 04/22/2013. On 04/24/2013 at 1345, observation showed RN #23 administered Patient #26's medication. After completing the medication administration, RN #23 cleansed the hands with alcohol sanitizer in less than 5 seconds but not thoroughly cleaning all surfaces of the hands and fingers until dry. In an interview on 04/24/2013 at 1400, RN #23 verified the finding.

Review of hospital policy and procedure, "...POLICY STATEMENT TITLE: Hand Hygiene" reads, "PURPOSE: To provide guidelines for hand hygiene in various patient care settings. ORIGINATION DATE: 11/95 KEY WORD: Hand Hygiene; Hand Washing; Fingernail; Jewelry; Waterless Handrubs REVISION DATES: ... 09/11... RESPONSIBILITY: Employees, Infection Prevention, Facilities and Environmental Services...GUIDELINES: I. Hand Hygiene is Always Indicated: A. Before donning sterile or clean gloves. B. Before and after contact with patients. C. Before performing any invasive procedure. D. Before and after contact with a wound including different wound on same patient. E. After contact with a source that is likely to be contaminated, including patients and or equipment and devices. F. After contact with body substances or contact with a piece of equipment or device contaminated with body substances. G. Between tasks on same patient. (i.e. Foley care or mouth care) H. After skin contamination with blood or other potentially infectious materials. I. After removing gloves and or other personal proactive equipment. J. After using toilet facilities. K. Before eating. II. The wearing of gloves does not replace the need for hand hygiene.

"Guidelines and standard nursing practice in the health care setting set forth in the Recommendation and Reports for the Centers for Disease Control", reads, "Morbidity and Mortality Weekly Report Recommendations and Reports October 25, 2002/Vol 51/No. RR-16 Guideline for Hand Hygiene in Health-Care Settings...2. Hand-Hygiene technique...B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacture to hands and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (lb) (90-92,94,411)...". Guidelines and standard nursing practice in the health care setting set forth by the Centers for Disease Control, reads, "...Hand Hygiene Guidelines Fact Sheet...When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry...".





29886

On 4/24/2013 at 1150, the hospital's appointed Infection Control Officer reported the hospital has a renal oversight committee. When queried about the infection control department's oversight and management of the renal dialysis unit's water cultures, machine cultures, and action level requirements, the Infection Control Officer reported the renal oversight team does not review the water cultures or machine cultures when the committee convenes on a quarterly basis. On 4/24/2013 at 1300, the Renal Oversight Committee meeting minutes were reviewed for the past 2 quarters, and there was no documentation of a review of the renal unit's machine cultures and/or water cultures. Review of the hospital's infection control data revealed no monitoring of the renal dialysis water and machine cultures.

On 4/25/2013 at 1430, direct observation of Patient #38 who was admitted to the hospital on 4/21/2013 revealed the patient had an intravenous (IV) catheter that had been inserted in the patient's right arm that was not labeled with the date, time, gauge, and nurse's initials. Review of the patient's medical record revealed the intravenous catheter was inserted on admission on 4/21/2013 which showed the catheter had been inserted four days previously and had not been changed per the hospital's policy. There was no documentation why the intravenous catheter site had not been changed. On 4/25/2013 at 1515, Employee #43 verified the finding.

Review of hospital policy # IM400.822.1, "Peripheral Intravenous Catheter Care and Maintenance ", reads, "...Peripheral Intravenous catheter with benign sites may remain in place for 72 hours unless ordered by a physician...Label site with date, time, gauge and nurse's initials..."

On the days of Recertification Survey based on interview, record review and review of Medical Staff Rules and Regulations, the hospital failed to ensure a history and physical was a part of the patient record prior to surgery for 1 of 9 patient charts reviewed for care and services for surgical services. (Patient #23)


The findings are:


On 4/24/13 at 1615, record review of Patient #23 revealed the patient was admitted on 4/23/13 at 0200 to the floor with a Femoral Neck Fracture. Surgery to repair the fracture was on 4/24/13, 1330-1545. Review of the patient's chart revealed the patient had no history and physical prior to the patient's surgery. On 4/24/13 at 1630, Staff Member #52 verified there was no history and physical documentation either in the computer and/or on the patient's chart after surgery.

Hospital policy, reads, "Medical Staff Rules and Regulations, revised, April 25, 2012, Section 13 Medical Record Documentation 2. A complete admission history and physical examination shall be recorded within no more than twenty-four (24) hours of an inpatient admission (but in all cases prior to surgery or an invasive procedure requiring anesthesia services) by an individual who has been granted privileges by the Hospital to perform histories and physicals....7. Prior to surgery or any potentially hazardous therapeutic/diagnostic procedure which requires an informed consent, the medical record shall document a current, thorough physical examination....".