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Based on a review of the clinical record and review of medical staff rules & regulations, the facility failed to ensure that physician's orders were complete to include dialyzer type. The finding includes the following:

Patient #105 was admitted on 2/18/12 and subsequently was started on hemodialysis. Review of Patient #105's clinical record indicated that the patient was receiving hemodialysis. Review of the clinical record identified that on seven occasions (4/9/12, 4/6/12, 4/4/12, 3/19/12, 3/16/12, 3/5/12 and 3/2/12), an Exeltra 170 type dialyzer was utilized, absent of a physician's order. Review of the Rules & Regulations of the Medical Staff identfied that all orders for treatment shall be in writing on a physician order form. Orders that are incomplete will not be carried out until rewritten or clarified in writing by the nurse.

Based on clinical record review, staff interviews, and a review of the hospital bylaws for one sampled patient (Patient #131), reviewed for infusion therapy, the hospital failed to follow the bylaws for the collaborate practice for midlevel practitioners and/or failed to verify infusion orders that were written by a midlevel practitioner. The finding included:
a. Patient #131 was admitted to the hospital on 4/11/12 with a diagnosis that included ovarian cancer. An order was written on 3/28/12 by APRN #1 for the administration of Paclitaxel 250 milligrams (mg) in 500 cubic centimeters (cc) of 5% Dextrose and water intravenously (IV) over three hours followed by Carboplatin 680 mg in 250 cc of Dextrose and water IV over 30 minutes. Interview and review of the clinical record with RN #13 on 4/11/12 at 12:00 PM identified, although a date of 4/11/12 was placed under the order dated 3/28/12 the name of the provider and/or nurse that verified the order was not documented. In addition the order sheet indicated a physician's signature was required for the order. Review of the hospital bylaws identified the nurse practitioner can prescribe chemotherapy based on a collaborative agreement, however review of the collaborative agreement for APRN #1 did not identify that he/she could order chemotherapy.

Based on review of facility documentation, interviews and review of facility policy, for one person (Person #1) who voiced a complaint, the hospital failed to ensure that a written response was provided in accordance with the grievance policy. The finding includes the following:

a. Review of facility documentation indicated that Person #1 called the Customer Service Department on 12/18/11 with concerns related to care and services. Documentation reflected that Person #1 stated that he/she received a letter that identfied a follow-up to the stated concerns would be completed by 1/26/12. Interview with the Director Customer Services on 4/17/12 at 1:00 PM identified that if a phone complaint was made, the complaint would be investigated, however, there may not be a written response unless the grievance was not resolved while the patient was in the hospital. The Director stated that in this case, the grievance was resolved therefore, no further follow-up required. The Director further stated that the initial letter sent to Person #1 reflected a response in writing would follow, however, this letter was sent in error.

Based on clinical record review, interview with hospital personnel, and a review of hospital policies/procedures for one of six patients requiring behavioral restraints (Patient #151), the hospital failed to ensure a current physician order was in place for the placement of behavioral restraints. The findings included:
a. Patient #151 (P#151) presented to the Emergency Department (ED) on 1/6/2012 with altered mental status and alcohol intoxication. The behavioral management restraint/seclusion physician order sheet dated 1/6/2012 through 1/7/2012 indicated that four point restraints were initiated on 1/6/2012 at 8:00 PM. Review of ED nursing notes identified that on 1/6/2012 at 9:06, P#151's lower extremity restraints were released, with upper extremity restraints still in place. On 1/6/2012 at 10:37 PM, the four point restraints were replaced without obtaining a physician's order to do so. On 1/7/2012 at 1:00 AM, the patient's four point restraints were removed. Review of the clinical record with the ED Nurse Manager #8 on 4/11/2012 at 11:00 AM indicated that no additional order for behavioral restraints were ordered once the initial restraint expired on 1/6/2012 at 12:00 AM or when P#151's restraints were increased from two point restraints back to four point restraints at 10:37 PM. In addition, the ED Nurse Manager #8 identified that when restraints are decreased and then increased, a new restraint order would be necessary. Review of the hospital policy titled "Restraints and Seclusion" failed to address the need to obtain a new order if a patient's restraints were decreased and then increased.

Based on a review of clinical records and policy review for three or three patient's reviewed for restraints (Patients 134, 135, and 136 ), the hospital failed to ensure the type of restraints utilized and/or that the patients were evaluated for reduction at the earliest possible time in accordance with policy. The findings include the following: CGS 19a-550 (b) (8)

a. Review of Patient #134's clinical record with the Director of Regulatory on 4/11/12 identified a physician's order dated 4/7/12 at 9:14 PM that directed the use of four point restraints for aggressively jumping towards staff. The restraint flow sheet reflected that the patent was placed in four point restraints at 9:14 PM on 4/7/12. The flow sheet indicated that at 1:00 AM on 4/8/12 the patient was "fully released from restraints." The restraint monitoring flow sheet failed to have a section to identify the type of restraints being utilized and/or an assessment when the patient was noted to be quiet/sleeping.

b. Review of Patients #135's clinical record identified a physician's order dated 4/7/12 that directed the use of four point restraints for aggressive behavior towards security. The restraint flow sheet indicated that the patient was placed in four point restraints at 9:05 PM on 4/7/12. The flow sheet indicated that at 11:30 PM the patient was "fully released from restraints". The restraint monitoring flow sheet failed to have a section to identify the type of restraints being utilized and/or an assessment when the patient was noted to be quiet/sleeping.

c. Review of Patients #136's clinical record identified a physician's order dated 3/31/12 at 1:25 AM directed the use of four point restraints for aggressive behavior. The restraint flow sheet indicated that all limbs were restrained at 1:25 AM. The flow sheet indicated that at 3:15 AM on 3/31/12 that " all limbs released from restraints". The restraint monitoring flow sheet failed to have a section to identify the type of restraints being utilized and/or an assessment when the patient was noted to be quiet/sleeping.

Review of the restraint policy identified that patients should be maintained in restraints no longer than absolutely necessary, frequently evaluated, and discontinued at the earliest possible time.

Based on clinical record review, interview with hospital personnel, and a review of hospital policies/procedures for one of six patients requiring behavioral restraints (Patient #139), the hospital failed to ensure appropriate monitoring of the patient as documented on the restraint/seclusion flowsheet. The findings included:

a. Patient #139 (P#139) was admitted to the hospital on 1/30/2012 for unresponsiveness. P#139 had a past medical history of alcohol abuse with alcohol related seizures, hypertension, pancreatitis, polysubstance abuse, and traumatic brain injury. The behavioral management restraint/seclusion flowsheet dated 4/10/2012 from 12:00 AM through 5:15 AM lacked monitoring/documentation of limb release/range of motion, CMS checks (circulation, sensation, motion), and skin integrity checks. Review of the hospital policy titled "Restraints and Seclusion" indicated that every two hours, or more frequently as requested by the patient, the patient is offered range of motion and skin and circulation assessment

Based on clinical record review, interview with hospital personnel, and a review of hospital policies/procedures for one of six patients requiring behavioral restraints (Patient #139), the hospital failed to provide a face-to-face evaluation in a timely manner. The findings included:

a. Patient #139 (P#139) was admitted to the hospital on 1/30/2012 for unresponsiveness. P#139 had a past medical history of alcohol abuse with alcohol related seizures, hypertension, pancreatitis, polysubstance abuse, and traumatic brain injury. The behavioral management restraint/seclusion physician order sheet dated 3/29/2012 indicated that although the restraint start time was 9:40 AM and expired at 1:40 PM, a face-to-face evaluation was not completed until 1:30 PM. Review of the hospital policy titled Restraints and Seclusion" indicated that a face-to-face evaluation by a physician must be completed within one hour after the initiation of this intervention.

Based on clinical record review, interview with hospital personnel, and a review of hospital policies/procedures for two of six patients requiring behavioral restraints (Patient #139 and Patient #152), the hospital failed to include the patient's behaviors on the physician order sheet. The findings included:

a. Patient #139 (P#139) was admitted to the hospital on 1/30/2012 for unresponsiveness. P#139 had a past medical history of alcohol abuse with alcohol related seizures, hypertension, pancreatitis, polysubstance abuse, and traumatic brain injury. The behavioral management restraint/seclusion order sheet dated 4/10/2012 indicated that although P#139 was documented to be a danger to self and to others, the order sheet lacked a description of behaviors. Review of the hospital policy titled "Restraints and Seclusion" indicated that all restraint orders must include the rationale for use.

b. Patient #152 (P#152) presented to the Emergency Department (ED) on 5/16/2011 with anxiety. Behavioral management restraint/seclusion physician order sheet dated 5/16/2011 indicated that behavioral restraints were ordered at 4:45 PM. Although the order sheet indicated that P#152 was documented to be a danger to self and to others, the order sheet lacked a description of behaviors. Review of the hospital policy titled "Restraints and Seclusion" indicated that all restraint orders must include the rationale for use.

Based on clinical record reviews and interviews with facility personnel for one of three sampled patients (Patient #11), the facility failed to ensure documentation of an assessment and/or that the clinical record failed to reflect that Medical Intern # 10 notified the Chief Resident of Patient # 11's condition. The findings include:

a. Patient #11 was admitted to the hospital on 10/5/10 for an Esophageal Resection. Review of the progress notes dated 10/7/10 identified that the patient had a nasogastric (NGT) Dobhoff tube inserted by MD #30. Review of the stat chest x-ray report dated 10/7/10 at 11:08 am identified that the feeding tube has it's tip in the expected location of the stomach, however it follows an atypical course extending through the right chest which could be reflective of a previous esophagectomy . If this does not represent an anatomic alteration created surgically, then this could represent a feeding tube that has perforated through the lung. Review of the nurse's notes dated 10/7/10 at 11:14 am identified that the patient's feeding tube was clamped, awaiting physician decision with surgical rounds. Further review on 10/7/10 at 12:45 pm, identified that MD #30 ok ' d to restart tube feeding. Interview with MD #30 3/21/12 identified that he had checked the x-ray and it was a positive placement and had recommended to start tube feedings. Review of the physician orders dated 10/7/10 at 1:00 pm identified that the patient was receiving Impact with fiber, begin at full strength at 15ml per hour with no advance. Review of the progress notes dated 10/7/10 at 11:20 pm and interview with Medical Intern #10 on 4/25/12 at 2:30 pm identified that he was called multiple times related to the patient ' s agitation and fighting the ventilator. Patient #11 was given Versed and Dilaudid multiple times but after no more than 30 minutes the patient began fighting the ventilator. Patient #11 ' s oxygen saturation levels decreased, tidal volumes decreased and the intern had ordered a Versed IV drip and also gave the patient Vecuronium IV. On 10/8/10 at 3:00 am, the Medical Intern ordered a stat chest x-ray and to hold tube feedings. Further review failed to identify that a documented assessment of the patient's condition and/or that the chief resident/ attending physician was notified of the patient's conditon. Interview with Medical Intern # 10 on 4/25/12 at 2:30 pm identified that he did not document an assessment of the patient and could not recall who he spoke with regarding the patient ' s change in condition. Review of the nurse's notes dated 10/8/10 identify that the patient had tube feedings held at 3:00 am and was found to have tube feeding material draining from the right-sided pleurovac. Patient #11 was emergently sent to the operating room for a repair of an esophageal leak. Interview with MD # 10 (Attending Surgeon) on 2/29/12 at 8:30 am identified that he was unaware that the patient had a NGT re-inserted on 10/7/10 and was not notified until 10/8/10 at 4:00 am, when the patient needed to go back to the operating room due to the tube feeding draining into the right-sided pleurovac. Subsequently, Patient #11 ' s post -operative course continued to be extremely unstable and the patient was made comfort measures only and expired on 10/8/10.
Review of the medical staff rules and regulations identified that at all times residents and fellows in approved training programs will work under the direction and supervision of a designated member of the hospital attending staff. In addition, the physician of record should see the patient at least daily and co-sign the house officer's note. If the physician of record is the intensivist, all decisions involving the patient's medical management should be discussed with the primary care physician. When the physician of record is unavailable, it should be possible for the house officers in the ICU service to contact a covering physician expeditiously.

1. Based on a review of clinical records, review of facility policies, documentation, and interviews for 1 of 4 patients reviewed for fall risk (#7) the facility failed to ensure that monitoring checks were completed in accordance with policy and/or physician's order and/or that the plan of care was followed. The findings include the following:

a. Patient #7 was admitted to the hospital on 6/21/11 with hyperkalemia and acute renal failure. Review of the clinical record dated 6/21/11 at 4:26 PM identified that the patient was identified as a high fall risk. The care plan identified the use of a bed alarm, frequent monitoring, two side rails up and call bell within reach. Review of an MD notification note dated 6/21/11 at 7:55 PM identified that the RN notified the physician that the patient had increased agitation and combativeness with an order for Ativan 1 mg x 1. The medication order was faxed and administered. A physician's order dated 6/22/11 at 2:15 AM directed Ativan 0.5 mg IVP now.

Review of the fall risk flow sheet dated 6/22/11 at 12:47 AM and 3:00 AM indicated that the call bell was within reach and the bed alarm was on and functioning. A physician's progress note dated 6/22/11 at 6:30 AM identified that the patient was agitated as s/he had been earlier in the night with Ativan administered. The patient was now yelling incoherently, spitting and biting with a decision to calm the patient with Haldol. The physician identified that almost immediately following writing the order for Haldol 5 mg x 1 at 4:30 AM, a loud thump was heard and the patient was observed lying on the floor. The patient was assessed to be minimally responsive to pain, not responding to commands, pupils were constricted and minimally responsive to light. A laceration on the right side of the head was bleeding. A CT scan of the head identified a left subdural hematoma. The patient was subsequently admitted to the intensive care unit.

Interview with RN #12 on 2/15/12 at 10:30 AM stated that prior to the patient falling, the bed alarm did not sound. Review of the facility investigation indicated that the Technician stated that at 4:00 AM he/she lowered the patient's bed, however, did not check the bed alarm. Review of the facility documentation reflected that the bed alarm was not activated at the time of the fall.

b. Review of Patient #7's clinical record indicated that monitoring checks were completed on 6/21/11 at 5:00 PM, 9:27 PM, 11:00 PM, 12:47 AM and 3:00 AM. Interview with RN #12 on 2/15/12 at 10:30 AM stated that checks are to be completed hourly by the Technician and documented every two hours. Review of the facility investigation indicated that the technician stated that at 4:00 AM he/she entered the room to lower the bed but did not check the bed alarm. The facility failed to ensure that the checks were completed per facility policy. Review of the facility policy indicated that every hour the RN or Technician are to enter each patient's room and document hourly rounds on a check off sheet or in the computer.

c. Review of Patient #7's clinical record identified that the patient was found on the floor at 4:40 AM. An assessment identified that the patient sustained a head injury resulting in a subdural hematoma. The clinical record indicated that vital signs with neurological checks were obtained at that time. Review of the physician's order dated 6/22/11 at 8:50 AM directed that hourly neurological checks be completed. Review of the neurological monitoring section of the clinical record indicated that neurological checks were completed next at 10:00 am, then again at 3:00 PM.

2. Based on a review of clinical records, policies and/or rules & regulations, the facility failed to ensure that the type of dialysate bath utilized during treatment was documented and/or that physician orders were obtained prior to initiation of dialysis treatment. The findings include the following:

a. Patient #105 was admitted to the hospital on 2/18/12 with diagnoses that included acute renal failure. Review of the clinical record identified that the patient required hemodialysis. The dialysis treatment flow sheets failed to identify the type of dialysis bath utilized for hemodialysis on 4/2/12, 3/23/12, 3/12/12 and 3/9/12. Review of the Documentation of Nursing Care policy directed that documentation of patient care should be written as close as possible to the time of the intervention.

b. Review of Patient #105's clinical record identified that on seven occasions (4/9/12, 4/6/12, 4/4/12, 3/18/12, 3/16/12, 3/4/12 and 3/2/12), an Exeltra 170 type dialyzer was utilized, absent of a physician's order. Review of the clinical record failed to reflect that nursing had contacted the physician prior to initiating dialysis for clarification of the orders. Review of the Rules & Regulations of the Medical Staff identified that all orders for treatment shall be in writing on a physician order form. Orders that are incomplete will not be carried out until rewritten or clarified in writing by the nurse.

3. Based on review of the clinical record and interview, the facility failed to ensure that a patient output was appropriately monitored for one patient who experienced constipation and/or dehydration. The finding includes the following:

a. Patient #99 was admitted to the hospital on 12/18/11 with seizures and a history of CVA and A-fib. Review of the intake and output records for the period of 12/17/11 through 12/26/11 indicated that the patient had not had a bowel movement. Review of the nurse's notes for the same period failed to identify that staff notified the physician that the patient had not had a bowel movement for ten (10) days.

Review of physician orders dated 12/26/11 from 10:00 AM- 3:15 PM directed administration of Dulcolax 10 mg PR x1 now, a fleet enema x1 now, a soap suds enema x 1 now, and Lactulose 30 ccs x 1 now. A physician's progress note dated 12/27/11 identified that the patient had a large bowel movement per nursing.
Interview with MD #16 on 4/13/12 at 3:00 PM indicated that he was not aware the patient had not had a bowel movement until Person #1 notified him of this concern.

b. Review of Patient #99's clinical record indicated that a speech evaluation for dysphasia was initiated on 12/18/11 and the patient was made NPO. A modified barium swallow was completed on 12/19/11 that directed a puree diet, nectar thick liquids, aspiration precautions and one to one feeds. Review of the initial nutrition assessment dated 12/20/11 indicated that the patient required 1750-2100 cc's of fluid daily. Review of Patient #99's I&O for the period 12/19/12-12/27/12 indicated that the patient was taking 0-75 % of meals and 0-400 cc's of fluid per 24 hour period.
Nursing staff failed to report the patient's decrease in fluid intake to the physician.
MD #16 indicated that on 12/22/12, IV fluids (Normal Saline at 75 cc's per hour) were restarted related an increase in the patients BUN that ranged from 42 to 56 (normal 9-20) and creatinine 1.45 to 2.25 (normal .8-1.5). Interview with MD #16 on 4/13/12 at 3:00 PM indicated that he was not aware of the patient's poor fluid intake and had not been notified by nursing of Patient 99's poor oral intake.



19907

4. Based on clinical record reviews, review of facility policies and procedures and interviews with facility personnel for three of three sampled patients who required tube feedings, the facility failed to ensure that patients with nasogastric tubes were managed per hospital policy. The findings include:

a. Patient #11 was admitted to the hospital on 10/5/10 for a Esophageal Resection. Review of the physician orders dated 10/7/10 at 1:00 pm identified that the patient was receiving Impact with fiber, begin at full strength at 15 ml per hour with no advance. Further review identified that the nursing care indicated to check residuals every four hours, keep the patient's head elevated at 30-45 degrees at all times, free water 100 ml every eight hours and hold the tube feeding for two hours if residuals are greater than 500 ml.
Review of the nursing flow sheets dated 10/7/10-10/8/10 failed to identify that the patient was given free water every eight hours per physicians order.
Although the nursing flow sheets dated 10/7/10 at 8:00 pm identified that the patient had an abdominal assessment and/or gastric residuals were checked, the clinical record failed to identify that the patient had further assessments and/or gastric residual checks every four hours per physician orders or the hospital policy. Subsequently, Patient #11 had tube feedings that were held at 3:00 am and was found to have tube feeding material draining from the right-sided pleurovac. Patient #11 was emergently sent to the operating room for a repair of a esophageal leak.
Review of hospital policy identified that for continuous feeding, check residuals every four hours. Interview with the ICU Nursing Director on 2/7/12 identified that the hospital policy was not followed.

b. Patient #53 was admitted to the hospital on 1/24/12 for a cervical fusion. Review of the physician orders dated 2/2/12 identified that the patient was receiving Fibersource HN, begin at full strength at 25 ml per hour and advance by 25 ml per hour each eight hours to a goal of 50 ml per hour. Further review identified that the nursing care indicated to check residuals every four hours, keep the patient ' s head elevated at 30-45 degrees at all times, free water 100ml every eight hours and hold the tube feeding for two hours if residuals are greater than 500ml.
Review of the intake and output sheets dated 2/2/12-2/9/12 failed to identify that the patient was given free water every eight hours per physicians order. Review of the nursing flow sheets dated 2/2/12-2/9/12 failed to identify that abdominal assessments were completed every shift. Review of hospital policy identified that bowel sounds are to be completed every shift.
Review of the nursing flow sheets dated 2/2/12-2/9/12 failed to identify that the patient had gastric residuals checked every four hours per physicians ' orders. Patient #53 had no residual checks on 23 occasions. Review of hospital policy identified that for continuous feeding, check residuals every four hours. Interview with the ICU Nursing Director on 2/7/12 identified that the hospital policy was not followed

c. Patient #52 was admitted to the hospital on 1/14/12 with a small bowel obstruction and an appendectomy. Review of the physician orders dated 1/30/12 identified that the patient was receiving Impact with fiber at 10ml per hour. Further review identified that the nursing care indicated to check residuals every four hours, keep the patient's head elevated at 30-45 degrees at all times, free water 100 ml every eight hours and hold the tube feeding for two hours if residuals are greater than 500ml.
Review of the intake and output sheets dated 2/2/12-2/9/12 failed to identify that the patient was given free water every eight hours per physicians order. Review of the nursing flow sheets dated 1/31/12-2/8/12 failed to identify that the patient had his/her gastric residuals checked every four hours per physicians orders. Patient #52 had no residual checks on 21 occasions. Review of hospital policy identified that for continuous feeding, check residuals every four hours. Interview with the ICU Nursing Director on 2/7/12 identified that the hospital policy was not followed.




29049

5. Based on review of the clinical record and staff interviews for one of two sampled patients (Patient #127), reviewed for a pediatric respiratory condition the facility failed to follow physician's orders in a timely manner. The finding included:

a. Patient #127 was admitted to the hospital on 4/9/12 with an acute exacerbation of asthma. Physician orders dated 4/9/12 directed respiratory distress indicators to be completed hourly while receiving continuous nebulizer treatments. Respiratory distress indicators included in part respiratory rate, lung sounds, oxygen level via pulse oximetry, peak flow readings, dyspnea ratings and the use of accessory muscles. Review of the clinical record identified from 4:00 AM on 4/9/12 through 10:30 AM on 4/10/12 on six occasions the respiratory distress indicator was not completed in a timely manner as ordered by the physician. Interview on 4/10/12 at 11:00 AM with Nurse Manager #6 identified respiratory distress indicators should have been completed every hour as ordered.

6. Based on review of the clinical record and staff interviews for one of two sampled patients (Patient #125), reviewed for a behavioral health condition, the facility failed to have an accurate admission nursing assessment. The finding included:

a. Patient #125 was admitted to the hospital on 4/9/12 with diagnoses that included depression, borderline personality disorder, vascular necrosis of the hips and asthma. Interview and review of the admission nursing assessment on 4/10/12 at 11:30 AM with Nurse Director #3 identified the musculoskeletal assessment was within normal limits, however Patient #125 utilized a walker for vascular necrosis of the hips secondary to long term steroid use. Nurse Manager #3 indicated the musculoskeletal assessment should have been initiated as a problem and an assessment of the musculoskeletal system should have been completed.

7. Based on a review of the clinical record, staff interviews and a review of the hospital policies and procedures for one of two sampled patients (Patient #97), who received Oxytocin for the induction of labor, the facility failed to titrate Oxytocin in accordance with the hospital policy. The finding included:

a. Patient #97 was admitted to the hospital on 4/26/10 for a medical induction of labor at 36 and ½ weeks gestation for preeclampsia. On 4/26/10 Patient #97 was started on Magnesium Sulfate for seizure prophylaxis due to high blood pressures and was administered Cervidil to prepare for an induction of labor. Review of the clinical record identified Patient #97's blood pressure responded to the administration of Magnesium Sulfate and had stabilized. On 4/27/10 at 5:45 AM Oxytocin was administered per protocol and at approximately 12:00 PM Oxytocin had reached the maximum dose with only mild contractions and minimal cervical change. Oxytocin administration was discontinued at 12:30 PM and Patient #97 was offered a cesarean section at that time and declined. Review of the clinical record indicated the fetal status was reassuring and Patient #97's clinical status was stable. Further review of the clinical record identified Patient #97 was not experiencing symptoms suggesting worsening preeclampsia, therefore a second dose of Cervidil was placed and Magnesium Sulfate was continued. Oxytocin was restarted on 4/27/10 at 2:15 AM. Further review of the clinical record identified on 4/27/10 at 6:45 AM Oxytocin was infusing at 14 milliunits/minute and was discontinued by RN #15 due to a prolonged deceleration (a decrease in the fetal heart rate below the baseline that is equal to or greater than 15 seconds and lasts equal to or greater than 2 minutes but less than 10 minutes). A position change was implemented, and oxygen was administered with recovery of the deceleration. Oxytocin was restarted at 7:00 AM at 14 milliunits/minute. Interview and review of the clinical record on 4/15/12 with RN #15 identified that according to the hospital policy for the administration of Oxytocin, the infusion should have been restarted at no more than half the rate that was used prior to the identified problem. RN #15 indicated that she should have restarted the Oxytocin at 6 milliunits/minute. Further review of the clinical record identified on 4/28/10 after approximately five hours of pushing a vacuum extraction was attempted without further descent of the infant. A cesarean section was performed for cephalopelvic disproportion. Patient #133 was delivered on 4/28/10 at 6:18 PM with an apgar score of 7, 8 and 8. Patient #133 weighed 6 pounds and 12 ounces and was admitted to the normal newborn nursery. The hospital policy for the use of Oxytocin administration in the induction of labor directed in part, when resuming Oxytocin after discontinuation due to a non-reassuring fetal status, if the infusion is discontinued for less than 20-30 minutes, Oxytocin may be restarted at no more than one half the rate that was used prior to the identified problem and to be increased per protocol thereafter.

8. Based on a review of hospital policies and staff interviews for the monitoring of an obstetrical patient in labor, the facility failed to ensure that a comprehensive fetal monitoring policy was in place. The finding included:

a. Review of the hospital policy for fetal heart rate monitoring in the labor and delivery room on 4/16/12 at 1:30 PM with Nurse Manager #7 failed to direct comprehensive interpretations and/or interventions to be implemented by staff related to fetal heart rate patterns. The facility failed to have a policy and/or protocol to assist staff in the identification of reassuring and non-reassuring fetal monitoring and appropriate corresponding interventions.


29051


9. Based on clinical record review, interview with hospital personnel, and a review of hospital policies/procedures for two of two patients who received transfusions of blood products (Patient #137 and Patient #138), the hospital failed to monitor and/or document vital signs during the process of a transfusion of blood products per policy. The findings included:

a. Patient #137 (P#137) was admitted to the hospital on 4/7/2012 with left leg pain. An x-ray of the left femur identified an intertrochanter fracture. Laboratory reports indicated that P#137 had a transfusion of leukocyte reduced red blood cells on 4/8/2012 that was initiated at 1:00 PM and was completed at 4:00 PM. Review of vital signs performed on 4/8/2012 indicated that although full sets of vital signs (temperature, heart rate, blood pressure, respiratory rate, oxygen saturation) were performed at 11:45 AM, 2:30 PM, 3:48 PM, and at 4:35 PM, a blood pressure was documented; vital signs were not obtained at specific intervals, per policy.
In addition, laboratory reports indicated that P#137 had a transfusion of leukocyte reduced red blood cells on 4/8/2012 that was initiated at 4:45 PM and was completed at 8:35 PM. Review of vital signs performed on 4/8/2012 indicated that a full set of vital signs was performed at 3:48 PM, at 4:35 PM, the patient's blood pressure was documented, and full sets of vital signs were documented at 6:09 PM and at 7:45 PM.
Interview with Assistant Nurse Manager #1 on 4/10/2012 at 11:15 AM identified that the documented vital signs did not correlate with the transfusion of the blood products, and that vital signs should be checked at the initiation of transfusion, 15 minutes after initiation of transfusion, and at the completion of transfusion. Review of hospital policy titled "Care of the Patient Receiving Blood Products" indicated that prior to the initiation of the transfusion, monitoring of baseline vital signs and blood pressure is to be performed. In addition, the policy indicated that within 15 minutes after initiating the transfusion, and hourly until completion, monitoring of vital signs and blood pressure is to be performed.

b. Patient #138 (P#138) was admitted to the hospital on 4/4/2012 with left hip pain and an x-ray identified a left intertrochanter fracture. Laboratory reports indicated that P#138 had a transfusion of leukocyte reduced red blood cells on 4/6/2012 that was initiated at 3:30 PM and was completed at 7:30 PM. Review of vital signs performed on 4/6/2012 indicated at 3:35 PM, the patient's heart rate was documented, full sets of vital signs were performed at 3:45 PM, 5:45 PM, and 6:50 PM, and at 7:31 PM, P#138's blood pressure and heart rate were documented. The clinical record failed to include documentation of temperature, respiratory rate, or oxygen saturation.
In addition, laboratory reports indicated that P#138 had a transfusion of leukocyte reduced red blood cells on 4/8/2012 that was initiated at 1:25 PM and was completed at 5:10 PM. Review of vital signs performed on 4/8/2012 indicated that full sets of vital signs were performed at 1:42 PM, 2:47 PM, 3:44 PM, and at 4:51 PM. At 6:04 PM, P#138's blood pressure and heart rate were documented, although there was no documentation of temperature, respiratory rate, or oxygen saturation. A full set of vital signs was performed at 8:26 PM. P#138's vital signs were not obtained at specific intervals, per policy.


10. Based on clinical record review, interviews with hospital personnel, and a review of hospital policies and procedures for one patient (Patient #149), the hospital failed to re-assess a patient for low blood sugar after interventions were implemented. The findings included:

a. Patient #149 was admitted to the hospital on 4/9/2012 for shortness of breath and chest pain. P#149's past medical history included Type 2 Diabetes Mellitus. The blood glucose monitoring form indicated that on 4/9/2012 at 11:00 AM, P#149's blood glucose result was 68. Interview with RN#16 indicated that the patient was started on D5 Normal Saline at a rate of 75 milliliters/hour. The subsequent blood sugar result is documented as 96 at 5:45 PM.
In addition, the general chemistry form indicated that on 4/10/2012 at 5:00 AM P#149's random glucose level was 50. RN#16 identified that the patient was given 4 ounces of orange juice. The blood glucose monitoring form indicated that at 7:15 AM, the patient's blood sugar level was 67. RN#16 indicated that the patient was given breakfast at 8:00 AM. The subsequent blood glucose monitoring result was at 11:40 AM, in which the result was 138. Interview with RN#16 indicated that for blood sugar results below 70, the intervention would be to give the patient 4 ounces of orange juice and then re-assess the blood sugar within 15-30 minutes. Review of the oral diet subcutaneous insulin physician order forms indicated that although the target pre-meal blood glucose range is 100-150 mg/dl, P#149 was not activated under the hypoglycemia management protocol which requires 15 grams of a fast acting carbohydrate (4 ounces of juice) and a recheck of the blood glucose level in 15 minutes.

1. Based on clinical record review, policy review, and interview the facility failed to ensure that a comprehensive plan of care was developed for one patient with Dysphasia (Patient #99). The finding includes the following:

a. Patient #99 was admitted to the hospital on 12/18/11 with seizures and a history of CVA and A-fib. Review of the clinical record indicated that a speech evaluation for dysphasia was initiated on 12/18/11 and the patient was made NPO. A modified barium swallow was completed on 12/19/11 that directed a puree diet, nectar thick liquids, aspiration precautions and one to one feeds. Review of the initial nutrition assessment dated 12/20/11 indicated that the patient required 1750-2100 cc's of fluid daily. Review of Patient #99's I&O for the period 12/19/12-12/27/12 indicated that the patient was taking 0-75 % of his meals and 0-400 cc's of fluid per 24 hour period. Review of the care plan on 4/12/12 with the Director of Nursing failed to identify a problem and/or interventions related to nutrition/feeding.

Review of the facility policy indicated for the Documentation of Nursing Care directed in part the care planning note will include documentation on all active/actual problems utilizing a problem, impression and plan. Further review of the policy identified the nurse must document a care planning note on all active problems at least daily for the first five days and then three times a week and a review of the care plan must be recorded every shift.


2. Based on review of the clinical record, staff interviews and hospital policies and procedures for two of two sampled patients (Patient # 124, and #125), the facility failed to complete a comprehensive plan of care. The findings included:

a. Patient #124 was admitted to the hospital on 4/8/12 with a diagnosis that included depression, substance abuse, and asthma. Interview and review of the clinical record on 4/10/12 at 11:50 AM with Nurse Director #3 failed to identify asthma as an active problem with interventions that were individualized for Patient #125. Review of the hospital policy for the Documentation of Nursing Care directed in part the care planning note will include documentation on all active/actual problems utilizing a problem, impression and plan. Further review of the policy identified the nurse must document a care planning note on all active problems at least daily for the first five days and then three times a week and a review of the care plan must be recorded every shift.

b. Patient # 125 was admitted to the hospital on 4/9/12 with a diagnosis that included depression, borderline personality disorder, vascular necrosis of the hips and asthma. Interview and review of the clinical record on 4/10/12 at 11:45 AM with Nurse Director #3 failed to identify asthma as an active problem with interventions that were individualized for Patient #124. Review of the hospital policy for the Documentation of Nursing Care directed in part the care planning note will include documentation on all active/actual problems utilizing a problem, impression and plan. Further review of the policy identified the nurse must document a care planning note on all active problems at least daily for the first five days and then three times a week and a review of the care plan must be recorded every shift.


3. Based on clinical record review, interviews with hospital personnel, and a review of hospital policies and procedures for one patient (Patient #140), the hospital failed to implement a plan of care for a patient admitted for pain. The findings included:

a. P#140 was admitted to the hospital on 4/8/2012 for right-sided abdominal pain. Review of the Medication Administration Record (MAR) from 4/8/2012 through 4/12/2012 indicated that P#140 was administered intravenous pain medication (Morphine 2-8 milligrams) on four occasions for a pain scale rating ranging from 5 out of 10 to 9 out of 10. Review of the clinical record with Nurse Manager #9 on 4/10/2012 at 10:20 AM identified that there was no pain plan of care in place for P#140. Review of the hospital policy titled "Care of the Adult Patient with Pain" indicated that the patient should have an understanding of their pain management plan and goals of care.

1. Based on clinical record review, policy review, and interview the facility failed to ensure that a comprehensive plan of care was developed for one patient with Dysphasia (Patient #99). The finding includes the following:

a. Patient #99 was admitted to the hospital on 12/18/11 with seizures and a history of CVA and A-fib. Review of the clinical record indicated that a speech evaluation for dysphasia was initiated on 12/18/11 and the patient was made NPO. A modified barium swallow was completed on 12/19/11 that directed a puree diet, nectar thick liquids, aspiration precautions and one to one feeds. Review of the initial nutrition assessment dated 12/20/11 indicated that the patient required 1750-2100 cc's of fluid daily. Review of Patient #99's I&O for the period 12/19/12-12/27/12 indicated that the patient was taking 0-75 % of his meals and 0-400 cc's of fluid per 24 hour period. Review of the care plan on 4/12/12 with the Director of Nursing failed to identify a problem and/or interventions related to nutrition/feeding.

Review of the facility policy indicated for the Documentation of Nursing Care directed in part the care planning note will include documentation on all active/actual problems utilizing a problem, impression and plan. Further review of the policy identified the nurse must document a care planning note on all active problems at least daily for the first five days and then three times a week and a review of the care plan must be recorded every shift.


2. Based on review of the clinical record, staff interviews and hospital policies and procedures for two of two sampled patients (Patient # 124, and #125), the facility failed to complete a comprehensive plan of care. The findings included:

a. Patient #124 was admitted to the hospital on 4/8/12 with a diagnosis that included depression, substance abuse, and asthma. Interview and review of the clinical record on 4/10/12 at 11:50 AM with Nurse Director #3 failed to identify asthma as an active problem with interventions that were individualized for Patient #125. Review of the hospital policy for the Documentation of Nursing Care directed in part the care planning note will include documentation on all active/actual problems utilizing a problem, impression and plan. Further review of the policy identified the nurse must document a care planning note on all active problems at least daily for the first five days and then three times a week and a review of the care plan must be recorded every shift.
b. Patient # 125 was admitted to the hospital on 4/9/12 with a diagnosis that included depression, borderline personality disorder, vascular necrosis of the hips and asthma. Interview and review of the clinical record on 4/10/12 at 11:45 AM with Nurse Director #3 failed to identify asthma as an active problem with interventions that were individualized for Patient #124. Review of the hospital policy for the Documentation of Nursing Care directed in part the care planning note will include documentation on all active/actual problems utilizing a problem, impression and plan. Further review of the policy identified the nurse must document a care planning note on all active problems at least daily for the first five days and then three times a week and a review of the care plan must be recorded every shift.


3. Based on clinical record review, interviews with hospital personnel, and a review of hospital policies and procedures for one patient (Patient #140), the hospital failed to implement a plan of care for a patient admitted for pain. The findings included:

a. P#140 was admitted to the hospital on 4/8/2012 for right-sided abdominal pain. Review of the Medication Administration Record (MAR) from 4/8/2012 through 4/12/2012 indicated that P#140 was administered intravenous pain medication (Morphine 2-8 milligrams) on four occasions for a pain scale rating ranging from 5 out of 10 to 9 out of 10. Review of the clinical record with Nurse Manager #9 on 4/10/2012 at 10:20 AM identified that there was no pain plan of care in place for P#140. Review of the hospital policy titled "Care of the Adult Patient with Pain" indicated that the patient should have an understanding of their pain management plan and goals of care.

Based on a review of the clinical record and policy review, the facility failed to ensure that physician orders were signed and dated. The finding includes the following:

a. Review of Patient #105's clinical record indicated that the patient was receiving hemodialysis. Review of the physician orders for the period of 3/7/12 through 4/9/12 indicated that on five occasions (4/9/12, 4/6/12, 4/4/12, 3/4/12 and 3/2/12) the physician failed to date and/or time the orders. Review of hospital policy indicated that each entry in the medical record must contain date and time of the entry.

Based on observation and interview, the hospital failed to ensure that medications were secured and/or labeled when drawn into a syringe. The findings include:
a. During tour of the operating suite on 4/10/12 with the Operating Room Manager and the Director of Perioperative Services, an unoccupied operating room was observed with an unlocked anesthesia cart. During interview on the above date, the Director stated that the anesthesia cart should be locked when unattended.
b. Review of the medication drawer within the anesthesia cart identified several syringes of pre-drawn medication with varying amounts of identifying information written on the label. One syringe of propofol failed to be labeled with date, time, medication and/or the person drawing the medication. When the surveyor requested a hospital policy delineating rules for pre-drawing and labeling medications, it was identified that the hospital failed to have such a policy.

Based on tour, review of hospital documentation and interviews, the facility failed to ensure that the overall hospital environment was developed and maintained in such a manner that the safety and well-being of patients was assured. The findings include:

1. On 04/11/12 at 2:21 PM, the surveyor, along with the Psychiatric Unit Director and Director of Engineering while touring the Behavioral Health Unit, observed the following:

a. That all of the patient bathrooms within the Psychiatric Unit (Pavilion Building-West side) were provided with non-institutional-style, liquid, soap dispensers that posed a potential hazard to patients that were not designed to a psychiatric institutional standard; i.e. plastic dispensers installed that have the potential to harm individual patients or others.

b. That the patient shower rooms within the Psychiatric Unit (Pavilion Building-West side) were provided with sprinkler heads that posed a potential hazard to patients that were not designed to a psychiatric institutional standard ; i.e. concealed-style sprinkler heads used instead of institutional style sprinkler heads that have the potential to be used as anchor points.

2. On 04/12/12 at 2:21 PM, the surveyor, while accompanied by the Director of Facilities and upon a tour of the Emergency Department, it was observed that the patient, behavioral holding areas within the Emergency Department (ED) were provided with sprinkler heads, cords and nurse call devices that posed a potential hazard to patients that were not designed to a psychiatric institutional standard ; i.e. in the seclusion room, the isolation room and bath rooms.

Based on tour, review of hospital documentation and interviews, the facility failed to ensure, that the overall hospital environment was developed and maintained in such a manner that the safety and well-being of patients was assured.

1 On 04/11/12 at 09:40 AM, the surveyor was not provided with documentation from the Facilities Manager at Bradley Memorial Campus to indicate that the wet pipe sprinkler system at the facility had preventative maintenance conducted on it that is required every 5 (five) years by sections 2-1, 9-4.1.2 & 9-4.2.1 of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems; i.e. no record of obstruction investigation, (interior) alarm valve inspection, strainer, filter & orifice inspection or (interior) check valve inspections.

2 On 04/10/12 at 11:05 AM, the surveyor along with the Director of facilities observed that the egress corridor on the north wing, third floor had an desk built into a corridor alcove and staff were utilizing it as a RN/MD charting station with multiple chairs and work stations on wheels not maintaining the egress corridor as required by the LSC.
3 On 04/11/12 at 11:50 AM, the surveyor while accompanied by the Director of Engineering observed that portable, wheeled, privacy curtains throughout the Labor & Delivery/NICU Department were not provided with labels or tags that indicated they were constructed of materials that were flame resistant, as required by the Life Safety Code; i.e. items placed into service without verification/documentation of compliance with NFPA 701, for flame resistance.

4 On 04/11/12 at 11:00 AM, The surveyor was not provided with documentation by the Director of Engineering that electrical receptacle outlets in patient areas are inspected based upon documented performance data as required in NFPA 99, Section 3-3.3.3 and 3-3.4.2.3. , and as part of the facilities preventive maintenance program i.e. interview on the day of survey indicated that the facility was no longer going to test electrical outlets due to all outlets had been changed to hospital grade

5 On 04/11/12 at 10:30 PM, the surveyor was not provided with documentation by the Safety Associate responsible for conducting fire drills, that fire drills were held at unexpected times under varying conditions at least quarterly on each shift as required by the referenced LSC i.e. the facility was utilizing the exception in the LSC 19.7.1.2 for silent fire drills between the hours of 9:00 PM through 6:00 AM. Documentation reviewed indicated that the drills conducted were question and answer sessions with no overhead announcement as required and the staff was not required to practice closing doors, clearing hallways.

1. Based on observation, review of hospital policy and interview, the hospital failed to ensure that infection control practices were followed. The findings include:

a. During tour of OR #1 with the Director of Perioperative Services on 4/10/12, identified several cloth rolls lying in the basket of the tourniquet rack that remained from case to case. Additionally, books and papers were stacked on a cart in the corner of the OR. According to hospital policy, terminal cleaning included washing all furniture to ensure furniture, ledges and stainless steel surfaces were clean and free of dust, debris, streaks and blood/body fluids.

2. Based on observation and interview, the hospital failed to ensure that surgical staff members covered the entirety of hair while in the restricted and semi-restricted areas of the surgical suite. The finding includes the following:

a. During tour of the New Britain and Southington surgical arenas on 4/10/12 and 4/11/12 with the Director of Peri-operative Services, several staff members (a resident working over a surgical incision and a scrub tech setting up for a total hip) were observed to wear a style of cap in a way that failed to cover the hair at the back and sides of the head. During interview on 4/11/12, the Director stated that the surgical staff member would later don a hood for the actual surgery. Review of the hospital policy for surgical attire identified a failure to direct the accepted coverage of head and facial hair while in the semi and restricted areas of the OR Suite.
b. Review of the hospital policy failed to delineate the attire required for the semi-restricted area of the OR Suite (peripheral support areas of adjoining corridors outside of the OR). Traffic in this area should be limited to patients and authorized personnel wearing surgical attire with coverage of all head and facial hair. (AORN Standards, 2010). Review of hospital policy failed to address the semi-restricted environment and directed that "street clothes are permitted in all perioperative areas except the operating rooms".

3. Based on observation and interview, the hospital failed to maintain equipment to ensure infection control practices were followed. The finding includes:

a. During tour of the operating rooms on 4/10/12, stirrup covers were observed to have worn areas throughout the edges of the cover, exposing the webbing beneath the vinyl cover, rendering it impossible to be disinfected between patients. During interview on 4/10/12, the Director of Perioperative Services stated that the equipment was checked routinely by staff members.

Based on a review of the clinical record, interview and review of the facility policy the facility failed to ensure that informed consent was obtained in accordance with hospital policy. The finding includes the following:

a. Review of Patient #105's clinical record indicated that the patient had a permacath placed on 2/20/12. Review of the consent reflected that the patient was "unable to sign verbal consent for procedure". The patient had a bone marrow biopsy completed on 2/21/12. Review of the consent for the procedure indicated that the patient was "unable to sign, on Bi-pap but gives verbal consent". The record identified that the patient had two additional procedures on 2/21/12 and 2/23/12 and the consents indicated "verbal ok", the consents failed to have a patient ' s signature.

Review of the facility policy indicated an informed consent should be completed for all surgical procedures, the administration of anesthesia or conscious sedation. The policy indicated that the informed consent form must be filled out in its entirety, the physician should personally obtain the patients signature.

Based on a review of clinical records and interview, for two patients (#117 and #120), the hospital failed to ensure that the anesthesia record included time-based documentation. The findings include:
a. Review of the clinical record for Patient #117 identified that the patient underwent an excision of a chest wall mass on 4/10/12. Review of the anesthesia record identified that the patient underwent anesthesia care at 10:48 AM and was discharged from anesthesia care at 11:35 AM, however, the record failed to include written notation of the times the patient received medication, patient assessment occurred and/or when the patient was transferred to PACU (post anesthesia care unit). Although anesthesia personnel were not available for interview, the Director of Perioperative Services identified that the times were missing.
b. Review of the clinical record for Patient #120, identified that the patient underwent a right groin hernia repair on 4/10/12. Review of the anesthesia record identified that although documentation reflected that anesthesia started at 8:00 AM and ended on 8:48 AM, the record lacked times for medication administration and patient assessment.

Based on review of the clinical record and interview, the facility failed to ensure that one patient in the psychiatric holding area was evaluated by psychiatry in a timely manner.

a. Review of Patient #100's clinical record identified that the patient presented to the ED on 4/9/12 at 2:00 AM with self-inflicted cuts to the forearm. The clinical record indicated that the Crisis Worker initiated the Behavioral health services intake and assessment form by completing the problems and intake information on 4/9/12, however failed to reflect a time the information was obtained. Review of the clinical record identified that the patient was not evaluated by psychiatry until 4/10/12 at 10:00 AM, 32 hours after admission. Interview with the Director of the ED on 4/10/12 at 10:00 AM indicated that the hospital does not have a policy directing a time frame for patients to be seen.