HospitalInspections.org

Based on review of documents and interview, the hospital failed to include 2 services directly-provided by the hospital and 3 services provided by a contractor as part of its comprehensive quality assessment and improvement (QA&I) program.

Findings:

1. Review of the facility's QA&I program indicated it did not include the directly-provided services of EEG and sleep lab and the contracted services of biohazardous waste, blood bank and tissue transplant.

2. On 02-04-10 at 12:30 PM, employee #A12 was requested to provide the above documentation and none was provided prior to exit.

Based on review of documents and interview, the facility did not follow its policy to perform an informed consent in 1 instance.

Findings:

1. Review of the facility policy entitled Consent for Surgery and Other Invasive Procedures, indicated the physician will be responsible for obtaining the informed consent for medical and surgical procedures.

2. Review of the INFORMED CONSENT AND AUTHORIZATION FOR ANESTHESIA on patient MR#1 indicated an area for the type (s) of anesthesia (planned) to be completed. This area was not completed at all. Thus, the patient was not fully informed of the type of anesthesia to be administered.

3. Further review of the above consent indicated there was no signature on it to indicate the physician responsible for obtaining the informed consent.

4. On 2-3-10 at 10:25 AM, employee #A10 indicated the consent was not fully completed and it contained no physician signature.

Based on review of documents and interview, the hospital failed to ensure cardiopulmonary resuscitation (CPR) competence in accordance with current standards of practice for 2 of 3 health care worker credential files reviewed (AH#1 and AH#3), who provide direct patient care.

Findings:

1. Review of 3 allied health credential files indicated files AH#1 and AH#3 did not contain any documentation of CPR competence.

2. On 02-02-10 at 11:15 AM, employee #A6 was requested to provide the above documentation and none was provided prior to exit.

Based on review of documents and interview, the hospital failed to ensure that improvements are sustained in 1 instance.

Findings:

1. Review of a document entitled 2008 Delinquent Medical Records Rate indicated the average rate of delinquency for that year was approximately 12%.

2. Review of a document entitled 2009 Delinquent Medical Records Rate indicated the average rate of delinquency for the months of January through March was approximately 27%.

3. Review of the minutes of the Medical Record Committee on April 7, 2009 indicated the committee addressed the increased delinquency rate by taking certain actions. However, the delinquency rate for May through December, 2009 averaged approximately 45%, with a range from 29%-63%. Based on the results of actions taken, the effectiveness was not sustained as the outcome worsened and did not improve.

Based on pediatric medical record review, policy and procedure review and interview, the nursing staff failed to implement facility policies related to the admission assessment of pediatric patients in 1 of 3 records reviewed (N19).

Findings:
1. At 2:40 PM on 2/3/10, review of pediatric medical records indicated:
a. pt. N19 was an 18 month old admitted on 10/26/09 with a diagnosis of pneumonia
b. the "Pediatric Admission Assessment" form was lacking documentation of the "Height/length" and "Head Circumference" for this patient

2. Interview with staff member NN at 3:15 PM on 2/3/10 indicated:
a. after thorough review of the N19 medical record, documentation of the patient's length and head circumference could not be found
b. facility policy is that all pediatric patients under 2 years of age have documentation on admission of length, weight and head circumference

3. Review of the policy and procedure "Assessment/Reassessment" indicated:
a. on page two under "Special Consideration", it read: "1. The assessment and/or reassessment of infants, children, and adolescents will include as appropriate: a. Patient's developmental age, length, height, head circumference, and weight..."

Based on observation, policy and procedure review and interview, the facility failed to ensure that drugs are secure and accessible only to authorized facility staff in one nursing unit (ICCU) surveyed.

Findings:
1. On 2/2/10 at 2:45 PM, while touring the ICCU (Intensive Coronary Care Unit) in the company of staff members NI and NJ, it was observed that:
a. the medication refrigerator with Novolog Insulin and Lorazepam, among other medications, was without any type of locking mechanism and was accessible to persons other than authorized staff
b. there was a shelf/compartment in the refrigerator that the Lorazepam was located on/in that was unlocked

2. Review of the policy and procedure "Drug Acquisition/Floor Stock" Policy # DAS-003 at 8:45 AM on 2/3/10 indicated:
a. under "Policy", it read: "...Schedule III, IV, and V substances used for floor stock and requiring refrigeration will be stored in a secure locked drawer in the unit refrigerator...Floor stock will be secured in a locked cabinet or under direct supervision of nursing staff at all times."

3. Interview with staff member NL at 8:50 AM on 2/3/10 indicated:
a. Lorazepam is a scheduled drug (IV) and is to be locked/secured
b. it was thought that a compartment in the refrigerator on ICCU had the capacity for locking--it was unknown that compartment lock was not working, or was not secured by nursing staff
c. even though other medications in the ICCU refrigerator are not scheduled, without a lock on the refrigerator they are accessible to persons other than authorized staff in situations where nurses are called away from the nurse station and the refrigerator would no longer be "under direct supervision" as the policy stated

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Based on observation and interview, the facility failed to ensure that the environment was maintained to ensure the safety and well-being of patients in 8 instances.

Findings:
1. At 3:25 PM on 2/1/10, while touring the Emergency Department (ED) in the company of staff members NI and NJ, the following supplies located in the trauma cart were found to be expired:
a. Arrow brand Thoracentesis Kit, expired 8/09
b. Pneumothorax kit, expired 10/09
c. 3-0 Vicryl sutures, expired 7/09

2. Interview with staff members NI and NJ at 3:30 PM on 2/1/10 indicated the monthly review of contents and expiration dates for the trauma cart is the responsibility of the materials management department.

3. On 2/1/10 at 4:10 PM, interview with staff member NP indicated:
a. materials management was not responsible for the trauma cart in the ED (they are responsible for the code/crash cart, but not the trauma cart)
b. it seems there has been a lack of communication between the nursing staff and materials management staff and the trauma cart is being missed in monthly checks for contents and expiration dates

4. On 2/2/10 at 10:25 AM, while touring with staff members NI and NK, it was observed in pantry of the pre/post (day surgery) nursing area that staff had a ziploc bag with blueberries and a plastic spoon in the freezer compartment of the patient food refrigerator (the bag was opened and not labeled)

5. Interview at 10:30 AM with staff member NK indicated staff food is not supposed to be in the patient food refrigerator.

6. While touring the endoscopy suites (room #1) in the company of staff member NK at 10:35 AM on 2/1/10, it was observed that the 20 ml vial of Propofol in an emergency pack expired January 2007.

7. Interview with staff member NK at 10:40 AM indicated:
a. the Propofol was to have been removed from the emergency packs as this drug is available in the Omnicell machines
b. it was unknown that Propofol was available anywhere besides the Omnicell machine

8. On 02-01-10 at 1:35 PM in the presence of employees #A3 and #A8, it was observed in the boiler room that there were caustic chemicals used to test the water. It was also observed that there was no eyewash station in the immediate area.

9. On 02-01-10 at 1:45 PM in the presence of employees #A3 and #A8, it was observed in the chiller room that there were caustic chemicals used to test the water. It was also observed that there was no eyewash station in the immediate area.

10. On 02-01-10 at 1:50 PM in the presence of employees #A3 and #A8, it was observed in the maintenance garage storage area that there were 4 fire extinguishers on the floor unsecured by chain or holder.

11. On 02-01-10 at 1:50 PM in the presence of employees #A3 and #A8, it was observed in the maintenance garage shop area that there were 6 fire extinguishers on the floor unsecured by chain or holder.

12. On 02-01-10 at 3:20 PM in the presence of employees #A3 and #A8, it was observed in the medical gas room that there were 7 nitrogen tanks on the floor unsecured by chain or holder.

Based on observation, the facility installed alcohol-based hand sanitizers in 2 instances that created a fire hazard.

Findings:

1. On 02-01-10 at 2:15 PM in the presence of employees #A3 and #A8, it was observed in the CT Scan Room, there was an alcohol-based hand sanitizer on the wall within 2 inches of an electrical switch. It was also observed the dispenser had a spray nozzle on top that was angled downward and rotated 360 degrees.

2. On 02-01-10 at 2:20 PM in the presence of employees #A3 and #A8, it was observed in the Radiology Work Room, there was an alcohol-based hand sanitizer on the wall within 2 inches of an electrical outlet. It was also observed the dispenser had a spray nozzle on top that was angled downward and rotated 360 degrees.

Based on observation, interview and review of documents, the hospital failed to identify and address an infection control problem in 1 instance.

Findings:

1. On 02-01-10 at 1:25 PM in the presence of employees #A3 and #A8, it was observed there was an entryway from the floor to the ceiling between the dirty and clean laundry areas. It was also observed there was a large cabinet in the clean area blocking the entryway from the floor to approximately two foot below the ceiling, creating an open gap. The open gap posed a possible infection control exposure issue due to cross contamination from the dirty area into the clean area.

Based on interview, the hospital failed to provide evidence of preventive maintenance (PM) on 7 pieces of equipment.

Findings:

1. On 02-01-10 at 12:15 PM, hospital staff was requested to provide documentation of PM on an anesthesia machine, a blood warmer, a medication pump, a floor scrubber, a ventilator, a polysomnography machine and the emergency generator. No documentation was provided prior to exit.