HospitalInspections.org

Based on review of reported grievances, policy review, staff interview and review of other hospital documents, it was determined that for 1 of 8 (13%) patients in the sample (Patient #2) who had filed grievances, the hospital failed to provide the complainant with written notification of the hospital's investigative findings and decision. Findings include:

The hospital policy entitled "Grievance Management Process" stated, "...All grievances will be investigated thoroughly. Once the investigation is complete, the investigator will provide the patient or their representative a written notice of their findings including steps taken during the investigation..."

Review of a 7/18/10 e-mail communication sent at 7:13 PM from Patient #2's daughter to registered nurse (RN) B, revealed a written grievance detailing patient care concerns that Patient #2's daughter asked RN B to address. RN B responded to the e-mail on 7/19/10 at 8:18 AM, stating that Patient #2's daughter would receive a response "within seven days".

On 9/21/10, the State Agency received a written complaint indicating that the hospital had failed to provide written resolution to the complaint submitted to RN B on 7/18/10.

During an interview with RN B on 10/29/10 at 1:25 PM, RN B reported that he could not confirm that a written notice regarding the hospital's findings had been sent to Patient #2's daughter.

Based on observation, patient rights information and staff interview, it was determined that for 1 of 3 (33%) observational tours in the Milford Memorial Hospital emergency department (ED), the hospital failed to protect each patient's right to privacy. Findings include:

The hospital's patient handbook entitled "Patient Guide" stated, "...Patient's Rights...While you are a patient we respect your rights including the following...confidentiality of your information..."

While in the ED triage area on 10/29/10 at 11:35 AM, Surveyor A, accompanied by the Director of Accreditation Services and registered nurse (RN) B, observed the following instance in which the hospital failed to ensure patient privacy:

A blue identification (ID) band was observed under the unoccupied stretcher in Room #4. The ID band contained personal information including Patient #6's full name, date of birth, date of treatment, treating physician and medical record number.

RN B accessed the medical record and reported that Patient #6 was examined by the ED physician on 10/27/10 at 2:27 PM and discharged at 2:53 PM. RN B confirmed that unauthorized individuals had access to the ID band for a two day period.

Based on observation, policy review, position description review and staff interview, it was determined that for 1 of 3 (33%) observational tours in the Milford Memorial Hospital emergency department (ED), staff failed to ensure a safe and sanitary environment. Findings include:

The hospital position description entitled "ED Technician" stated, "...responsibilities include administering direct patient care...Maintains and follows established departmental policies and procedures, standards of care...infection control standards..."

The hospital policy entitled "Infection Control Guidelines for the Emergency Department" stated, "...staff will practice standard precautions at all times...Infection Prevention Practices...All soiled linen is treated as potentially contaminated..."

During an observational tour of the ED on 10/29/10 at 10:40 AM, Surveyor A, accompanied by the Director of Accreditation Services and registered nurse (RN B), observed Patient Care Technician A removing soiled linen from a stretcher in Room #4. Patient Care Technician A held the soiled linen against his green scrubs and carried the soiled linen over to the "dirty" linen cart.

During a phone interview on 10/29/10 at 2:05 PM with RN C, an Infection Prevention Specialist, RN C reported that during orientation all staff were educated on breaking the chain of infection. RN C confirmed that Patient Care Technician A did not follow recommended infection control practice and should have held the soiled linen away from his clothing.

Based on observation, policy review and staff interview, it was determined that for 1 of 11 (9%) nursing staff (RN A) observed performing patient care, the nurse failed to follow the hospital policy for hand hygiene. Findings include:

The hospital policy entitled "Hand Hygiene" stated, "...All healthcare providers are required to comply with recommended indications for hand hygiene...use of gloves during procedures does not eliminate the need for hand hygiene before glove application and following glove removal...Hand hygiene is required...Before, between and after contact with patients...After touching any source that is likely to be contaminated with pathogens, (ie, bedrails...telephones, computer keyboard, etc.)...After touching...any material or surface contaminated by pathogens even when gloves are worn...Remove gloves after caring for patient..."

Kent General Hospital Emergency Department (ED)

10/28/10 at 9:25 AM: Patient #7's triage assessment/treatment by registered nurse (RN) A:

- Applied gloves
- Obtained a throat culture with a culturette (swab)
- Dropped culturette on patient's jacket
- Retrieved culturette with gloved hands
- Touched computer mouse with gloved hands
- Removed right hand glove
- Answered phone
- Discarded culturette
- Donned new glove on right hand
- Opened a new culturette kit
- Obtained a new throat culture
- Removed gloves
- Filled in paperwork with pen
- Entered information into the computer with keyboard and mouse
- Escorted patient to "Fast Track" area
- Returned to triage area
- Performed hand hygiene

During Patient #7's triage, RN A failed to:
- Remove gloves and perform hand hygiene when moving from the initial throat culture to contaminated sources (telephone and computer keyboard)
- Perform hand hygiene after removing gloves

The Director of Patient Care Services was present during the 10/28/10 observation at 9:25 AM and confirmed these findings. During an interview with the Director of Accreditation Services on 10/28/10 at 1:30 PM, it was confirmed that RN A failed to follow the infection control policy.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 3 (33%) medical records (Patient #1) reviewed at Kent General Hospital, the medical record failed to contain accurate information. Findings include:

The hospital policy entitled "Insertion of IV (intravenous) Access Devices" stated, "...nursing responsibilities for insertion of peripheral (external surface of a body part) IV access devices...Documentation...In patient's medical record...Number and location of unsuccessful attempts, if applicable..."

Patient #1
On 9/29/10, a written complaint referral was received by the State Agency, detailing concerns related to the care provided to Patient #1 at Bayhealth Medical Center - Kent General Hospital. The complainant reported that registered nurse (RN) D inserted IV line #1, which immediately became very painful with observed swelling at the IV insertion site. The complainant reported that RN D left IV line #1 in place and started IV line #2, prior to removing IV #1.

Review of the 9/25/10 "Emergency Department Chart" nursing note entries revealed the following:

- 08:05 PM - IV started by RN D
- 12:30 AM - IV discontinued by RN E; Pressure dressing applied; No redness, swelling, bleeding

There was no documentation in the medical record related to a failed IV insertion attempt or observed inflammation/pain at the IV insertion site.

During a phone interview with RN D on 10/28/10 at 3:10 PM, RN D reported that she had unsuccessfully attempted to insert IV line #1 on her first attempt, removed the angiocath (IV needle) and inserted IV #2 successfully using a new angiocath. RN D reported that there was no evidence of swelling or redness at IV #1 insertion site and Patient #1 did not complain to her about pain or swelling during her care.

Interview with the Director of Emergency and Trauma Services on 10/27/10 at 12:30 PM, confirmed that according to hospital policy, nursing staff was expected to document in the medical record all unsuccessful IV attempts.

Based on observation, staff interview and policy review, it was determined that the hospital failed to maintain environmental surface cleanliness in a manner to assure patient safety in 2 of 2 (100%) patient care/activity areas toured. Findings include:

The hospital policy entitled "Infection Control Guidelines for Environmental Services" stated, "...To reduce the risk of healthcare associated infections that may occur as a result of exposure to contaminated surfaces, equipment, air, dust, and other inanimate objects...Patient Rooms...All upward-facing horizontal surfaces (i.e. high touch surface area...)...Hard surface floors...shall be wet-cleaned daily...Upon patient discharge, all surfaces of the bed and mattress shall be wet-cleaned with an approved disinfectant solution before the bed is remade for the next patient...Clean all horizontal upward-facing surfaces of the room...Environmental Services personnel shall report any maintenance need to equipment to supervisor... "

The hospital policy entitled "Infection Control Guidelines for the Emergency Department" stated, "...Procedure...Responsibilities...Nurse Manager...Assure proper equipment maintenance and cleaning...Environmental Services...The contracted environmental services company will maintain oversight of the cleaning maintenance schedule of the Emergency Department per their established standards and guidelines..."

The following environmental observations of a lack of surface cleanliness in patient care and patient service areas were identified by Surveyors A and B:

I. Bayhealth - Kent General Hospital (KGH)

A. Emergency Department (ED) - Environmental tour conducted on 10/28/10 by Surveyor B accompanied by the Director of Environmental Services beginning at 9:35 AM and ending 10:40 AM.

1. Inside entrance to ED: moderate dust on the top surfaces of two (2) Auto Linen Exchange System Carts
2. Waiting Room: six (6) single and one (1) double worn, cracked vinyl-upholstered chair seats, unable to be completely cleaned and disinfected; ten (10) soiled chair seats (upholstery intact)
3. Waiting Room: red liquid on floor at entrance to bathroom and at the children's play area Reception Area: chair upholstery torn and soiled
4. Triage: tape residue on wall above nurses' desk, area of uncleanable damaged wall surface
5. Discharge Area: bathroom with stained floor tiles and leaking water beneath the toilet
6. Room 141B: torn vinyl upholstery on chair
7. Outside Rooms 141C & D: dusty shelf beneath stretcher, adhesive tape residue on surface of stretcher mattress
8. Outside Room 142A: adhesive tape residue on isolation cart
9. Hallway Station #24: adhesive tape residue on stretcher; dusty and soiled "Pulmo Aide" (CTS 826328) nebulizer (machine to administer breathing treatments); hole in drywall; adhesive tape residue on wooden storage chest
10. Hallway Station #'s 24, 25, 26 and 27: dusty shelves beneath stretchers
11. Trauma Room: adhesive tape residue on doors, dusty window ledge
12. Opposite Exam Room 8: three (3) dusty and soiled portable x-ray machines
13. Consult Room: damaged uncleanable chair seat; damaged cardboard box of coloring books on floor
14. Exam Room 8: damaged, uncleanable vinyl chair seat
15. Exam Room 7: damaged, uncleanable laminate; dusty stretcher shelf
16. Hallway: adhesive tape residue and rust rendering wheeled steel table uncleanable
17. Outside Bathroom: masking tape holding glove dispenser box together, uncleanable
18. Hallway: dusty, rolling exam light (CTS 291000)
19. Staff Locker Bank in Hallway: adhesive tape residue

The above findings #1-19 were confirmed on 10/28/10 by the Director of Environmental Services at the time of observation.

II. Bayhealth - Milford Memorial Hospital (MMH)

A. ED - Environmental tour conducted on 10/28/10 by Surveyor B accompanied by the Director of Environmental Services, the Senior Manager of Environmental Services for MMH and the MMH ED Nurse Manager beginning at 11:45 AM and ending at 12:20 PM.

1. Fast Track Room #2: soiled, torn stretcher mattress cover; shelf below stretcher, dusty; rolling infusion pump base dusty
2. Room #3: stretcher mattress cover damaged and uncleanable
3. Room #6: tape residue on stretcher mattress pad
4. Waiting Room: three (3) single and two (2) double vinyl upholstered chair seats were torn and uncleanable; six (6) additional chairs had soiled seats
5. ED Ambulance Entrance: ceiling vent very dusty, paper signs taped to sliding doors; adhesive tape residue present; dusty sprinkler head
6. Ladies Room: area surrounding toilet missing tiles, the gap remaining was messy and stained
7. Men's Room: malodorous, smelling of urine
8. Vending Area: all overhead light fixtures contained dead insects
9. ED Entrance Hallway: all overhead light fixtures contained dead insects
10. Triage: damaged vinyl upholstered chair seat; torn vinyl cover on exam table
11. Room #8: adhesive tape residue on stretcher mattress; vinyl surface of casting table torn; delaminated, uncleanable areas on table; dusty exam light; adhesive tape on rolling table

The above findings #1-11 were confirmed on 10/28/10 by the Director of Environmental Services, the Senior Manager of Environmental Services for MMH and the MMH ED Nurse Manager at the time of observation.

B. ED - Environmental tour conducted on 10/29/10 by Surveyor A accompanied by RN B and the Director of Accreditation Services beginning at 10:40 AM and ending at 11:00 AM.

1. Room #10: two (2) areas with dried blood spatter observed on blue bumper guard of stretcher (bed borrowed from same day surgery)
2. Room #9: gauze 2x2 dressing with blood observed on the floor
3. Room #6: dried blood observed on blue bumper guard of stretcher

The above findings #1-3 were confirmed by RN B and the Director of Accreditation Services at the time of discovery.