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Based upon staff interview and document review, for 4 of 6 reviewed contracts (Tissue Vendor 2, 4, 5 & 6) the hospital failed to maintain a complete list of all contracted services which included the scope and nature of each service provided. This failure permitted uses of some contracted services without protocols for quality & safety review, and left the potential for resulting staff or patient harm.

Findings:

On 11/30/15 the hospital's Administrative staff was asked to provide a detailed list of all the contracted services currently being utilized in the hospital. At 3:15 p.m. on 11/30/15, the list provided was concurrently reviewed with the hospital's Chief Administrative Officer (CAO), who acknowledged that the list which was provided did not contain a description of the scope and nature for each service on the list. He explained that the list came from a spreadsheet (Excel) table located in the hospitals computer system and offered to provide a more detailed list for review the following day.

On 12/1/15 the list provided (List of All Contracts) contained 85 rows, with one contract listed on each row. It also contained 12 columns, two of which were named: "Nature of Contract - Description of Product/Service" and "Scope of Contract - Range or Capacity of Service/Product."

On 12/2/15 the contracts with vendors that supplied bone graft tissue and other "allograft tissue" (donated human tissue: bone, ligament, cartilage, tendon or section of skin which have come from people who died in accidents or from sudden illnesses) were reviewed. These tissues are used during some surgeries to replace faulty tissues in patients being operated upon in the hospital.

A list of these 6 contracts were titled "List of Commercial Clients and Suppliers whom conduct business (applicable to tissue)." This list ("Tissue Vendor List") was compared with the List of All Contracts provided on 12/1/15. An observation from this comparison was that 4 of the 6 contrasts from the Tissue Vendor List were not on the List of All Contracts.

On 12/2/15 during an interview at 10:55 a.m. the CAO acknowledged that the List of All Contracts, provided on 12/1/15, was incomplete and the facility did not yet have a more complete list.

Based on document review and staff interview the hospital failed to ensure the quality of high risk products such as intravenous medications when the quarterly quality data for the products obtained from PharMedium were not evaluated for its applicability to patients in the facility and provided medications without the assurance of its integrity. In addition, adverse drug reactions were not reported or evaluated for being potentially caused by medication errors, or that appropriate actions can be taken in a timely manner to prevent future recurrence of harm to patients affected or other patients. Such failure put patients at risk for harm associated with medications.

Findings:

1. On 12/3/15 at 8:30 a.m., the pharmacist in charge (PC) was asked about, PharMEDium, which provided certain injectable medications to the hospital. The PC stated that he received quarterly reports from the company. The data included sampling of the hood area (the work area for preparing injectable medications, which is designed to reduce contamination by providing constant flow of filtered air across the work area).
Review of these documents revealed a situation where PharMEDium action level for both the hood and the hood air samples were positive (not zeros.) For example, the "Memphis Micro Trend Data" showed that 5461 samples were tested, in in April 2015. Under the column for "Hood Surface USP <797> Action Level" the number 6 appeared. When asked what that number meant and how it affects the products purchased/used by the hospital, the PC said that he would need to investigate the issue further.

The same report included a graph titled, "Internal Related Service Issues." This graph had 16 different categories including Incorrect Code Shipped, Wrong Packaging slip, and Short Expiry. The report showed a spike in the data for September. The PC could not explain what that increase in September indicated or if the information was applicable to the products purchased by the hospital from the company.

Similarly, one of the quality report graphs was titled: "Ongoing Media Results All Center (approximately 240 tests per month)" was reviewed. The report included the "Number of Media Positives". September on this graph had two bars (the first bar correlated to three Numbers of Media Positives and the other was one). There were no other data showing what organism or organisms caused these positive results.

There was no documented evidence that the information from these quarterly reports was evaluated as to how it relates to patients in Sutter Surgery Hospital to ensure that patients received sterile and effective injectable medications.

2. On 12/2/15 at 3:30 p.m., the Director of Quality (DQ) was interviewed about adverse drug reaction (ADR) reporting. DQ stated that all ADRs are reviewed on a regular basis. When asked about ADR reports related to a specific patient (Patient 22), she said she needed to check.

On 12/2/15, at approximately 4 p.m., DQ confirmed that there were no ADRs filed for Patient 22. There was no ADR filed for using Narcan to reverse the effect of increased sedation. Additionally, there was no report filed for ADR related to use a combination of medications that affect bleeding time and increase the risk of bleeding (ibuprofen, ketorolac, and Xarelto). However that combination of medications potentially caused bleeding and required Patient 22 to be given two units of blood transfusion. (Refer to A-508 1 and 2).

Review of the facility's policy for medication error and adverse drug event reporting revised in August 2014, showed the following items under procedure:

"Procedures:
1. Medication administration errors, adverse drug reactions and medication incompatibilities as defined are reported to the attending physician immediately when possible.
2. All medication errors and ADEs (adverse drug reactions) should be reported using the occurrence report form. The person making or discovering the error should complete the form.
3. The complete form should be forwarded to the department manager, then to the Pharmacist, then to the Chief Nursing Officer, (CNO) or designee for review. ..."

There was no documented evidence that the procedure for ADR reporting was implemented, as the pharmacist in charge and DQ were not aware if reports were filed for Patient 22, and they were the key staff who were supposed to review these reports or in some situations completing the ADR forms.

Based on interview and document review, the facility failed to ensure services performed under all of its contracts had Quality Assessment Performance Improvement monitoring, related to the clinical care provided for Occupational Therapy, Physical Therapy, Speech Therapy, and Social Services. This had the potential that services in these areas would not be provided in a safe and effective manner.

Findings:

A review of the facility's contract review, dated 11/1/15, included the Quality Metrics (indicators used to evaluate quality) for each contracted service. For Physical Therapy, Occupational Therapy, Speech Therapy, and Social Worker Services, the quality metrics were: "staff available when requested, and staff comply with hospital policies and procedures."

During a concurrent record review and interview on 12/3/15 at 8:45 am, the Director of Quality (DQ)confirmed the metrics for each of the above noted services. DQ stated she was unaware of any quality indicators that related to the actual clinical care provided for each of these services.

Based on medical record review and nursing staff interview the hospital failed to ensure pain management in accordance with nursing procedures for 1 patient (Patient 34) in a sample of 21. Failure to effectively address pain management may result in delaying patient recovery.

Findings:

Patient 34 was admitted on 11/25/15 for repair of a hernia. Medical record review was conducted on 12/2/15 beginning at 9 a.m. A nursing admission assessment dated 11/25/15 at 3:40 p.m., noted that the patient was experiencing pain at a level of 2 on a scale of 10. A physicians' order dated 11/25/15 noted that the patient was on a PCA (patient controlled analgesic) pump. The patient had physician orders for breakthrough pain dated 11/25/15 "Ok to give hydromorphone (strong pain medication) for breakthrough pain while on PCA." There was also an additional order dated 11/29/15 for Tylenol with codeine. Both orders relied on a pain scale to determine medication doseage.

Nursing pain assessments dated 11/28/15 at 7:54 a.m., noted pain at 5 out of 10. There was no indication that Patient 34 was offered pain medication, nor was there further assessment of the pain such as duration. The next pain assessment did not occur until 11/28/15 at 8 p.m. which noted pain at 3 out of 10. Lack of pain intervention was also noted on 11/29/15 at 12:05 a.m., with a pain rating of 6 out of 10 and 4 a.m., with pain rating of 7 out of 10. There were no documented pain interventions for each of these instances.

In an interview on 12/3/15 at 2:30 p.m., Clinical Information Technology staff stated that several people reviewed the electronic medical record and were unable to find any documentation for actions in relationship to the identified pain assessments.

Hospital policy titled "Assessment/Management of Acute Pain" dated 11/2015 guided staff that "5. On-going Assessment: On-going assessment for pain will be performed with vital signs, after any known pain-producing event, and with each new report of pain for ALL patients...If the pain screen is positive with a level greater than 4, further assessment which includes location, duration, characteristics, and response to intervention is indicated..." The hospital was unable to verify that nursing staff followed standardized hospital procedures.

Based on interview, record review and hospital policy review, the hospital failed to develop and update a care plan to reflect the necessary care according to the needs of one of 21 sampled patients when Patient 15 developed blisters and a wound and:
a. The care plan was not revised to reflect the blisters and wound,
b. The blisters and wound measurements were not obtained, and
c. The record did not reflect if wound care treatment was provided.

These failures had the potential for the care and needs of the patient not to be met and develop complications from lack of interventions.

Findings:

Patient 15's record was reviewed currently with the Clinical Information Technology Nurse (CIT) on 12/2/15 at 11 am. The record indicated Patient 15 was admitted to the hospital on 11/3/15, and underwent surgery for a total left hip replacement, and was discharged on 11/6/15 to a Skilled Nursing Center (SNC) to continue her care and recovery.

A Nurse's Assessment Note (NAN) dated 11/4/15 at 5:21 pm, indicated in the peri-incisional area (the area next to the surgical incision and dressing) was reddened, bruised, had edema (swelling), blister and to see nurses notes.

A Nurse's Progress Note (NPN) dated 11/4/15 at 5:27 pm, indicated that Patient 15, "had complained of gown being wet, upon inspection patient has a large blister on the edge of the aquacell (a surgical dressing), area reddened and edema to area. Will notify MD, pictures taken."

A Physician's Progress Note (PPN) dated 11/4/15 at 7:14 pm, indicated Patient 15's, "Incision appearance: under the dressing, and some bruising around the dressing, small blister behind has popped, Impression: has a small blister posterior to dressing, question: sheer (friction) or allergy."

The NAN dated 11/4/15 at 8 pm, 11/5/15 at 8 am, and 11/5/15 at 8 pm, indicated the under Peri-incisional assessment: "Comments, large open blister."

A picture dated 11/4/15 at 5:30 pm, of Patient 15's left hip demonstrated a blister with a partially open skin area that was below (posterior) the hip dressing. The picture did not show any measurements of the open skin area or the surrounding discoloration (bruise and redness).

Another picture dated 11/6/15 (no time when taken), demonstrated the same blistered area and indicated the blistered skin was now a completely opened wound. No measurements were indicated on the picture.

A review of Patient 15's Care Plan did not reflect that Patient 15 had developed blisters and an open wound, nor did the Care Plan reflect how the open skin areas and blisters were to be treated.

The record did not show evidence of the treatment provided to the above blisters and open wound after the blister had opened and drained.

The CIT confirmed the above findings and stated the Care Plan was not revised to reflect that Patient 15 had developed blisters and an open wound, there were no indications of measurements of the blister and open wound, and the care or treatment that was provided to the blisters and open wound was not indicated in the record.

A hospital policy dated 11/15, titled, "PC 27" indicated that wound measurement would be obtained and treatment documented.

A hospital policy dated 9/15, titled, "Assessment and reassessment of Patients" instructed, "... any change in the patient's condition shall require an immediate assessment with changes in the Plan of Care reflecting the change in condition."

Based on interview and record review the hospital failed to ensure the medical record was accurately written for nursing documentation for one of 21 sampled patients (Patient 15). This failure had the potential for patient care to be compromised and result in poor patient outcomes when information in the medical record is not accurate.

Findings:

Patient 15's record was reviewed currently with the Clinical Information Technology Nurse (CIT) and the In-Patient Nurse Manager (INM) on 12/2/15 at 2:30 pm. The record indicated Patient 15 was admitted to the hospital on 11/3/15, and underwent surgery for a total left hip replacement, and was discharged on 11/6/15 to a Skilled Nursing Center (SNC) to continue her care and recovery.

a. A Nurse's Assessment Note (NAN) dated 11/4/15 at 8 pm, indicated Patient 15's peri-incisional area (the area next to the surgical incision and dressing) was reddened, bruised, had edema (swelling), blister and to see nurses notes. A review of the record did not show evidence of a Nurse's Progress Note (NPN) on 11/4/15 at 8 pm.

b. A section of the NAN included an area to document the patient's, "Fall Risk Assessment (FRA)" and if the patient had a, "History of Falling." On 11/5/15 at 8 am, the NAN indicated a, "no" to the section, "History of Falling." At 8 pm, the FRA indicated that Patient 15 had a history of falling: "Yes." The next entry under, "History of Falling" indicated, "No" and that Patient 15 had not fallen. The record did not contain evidence that 15 had a recent history of falling.

c. On 11/5/15 at 6:38 am, the, "Order Detail" indicated Patient 15's urinary catheter (a tube inserted into the bladder to drain urine) had been removed by the nurse. The NAN at 8 am, indicated that Patient 15 had urinated and used the toilet. The next entry on the NAN on 11/5/15 at 8 pm, indicated that Patient 15 had an indwelling catheter that was, "draining" and was also using the toilet to urinate.

On 12/2/15 at 3:20 pm, CIT and the INM confirmed the above findings and stated the medical record for Patient 15 was not accurate. The SFM stated that Resident 15 did not have a history of falling, the nurse did not document in the NPN on 11/4/15 at 8 pm as indicated in the NAN, and Patient 15 did not have a catheter after removal on 11/5/15 at 6:38 am.

Based on interview and record review the hospital did not ensure that all surgical records were timely authenticated for one of 21 sampled patients (Patient 11). This failure had the potential for the patient records not to accurately reflect surgical intervention and provide incorrect healthcare information to medical providers which compromise a patient's health.

Findings:

A hospital policy dated 10/14, titled, "Medical Record Audits" instructed that documentation will be completed within 7 days.

Patient 11's record was reviewed concurrently with the Medical Records Supervisor (MRS) on 12/2/15 at 10:30 am. The record indicated that two surgical procedures had been performed, one on 10/27/15, and another on 11/10/15. The record indicated that the surgical report for 10/27/15 was signed on 1/10/15, and the surgical report for 11/10/15 was signed on 11/24/15.

On 12/2/15 at 10:40 am, the Medical Records Manager confirmed the above findings and stated the hospital policy had not been followed when both surgical records were signed after seven days and were considered late.

Based on medical record and policy review and staff interview, the facility failed to ensure accurate accountability of all controlled substance when they failed to account for hydromorphone (pain medication) removed for Patient 21. Similarly, the record keeping for hydromorphone for Patient 22 was not accurate; the record showed that more medications were on hand (16.1 milligrams) compared with the amount initially removed for Patient 22 (15 milligrams) from the automated dispensing cabinet (ADC). Lack of accountability facilitates misuse or abuse of controlled substances, and subsequently put patients at risk of harm by being cared for by intoxicated staff, or suffer in pain when the medications intended to treat these patients is diverted or used by staff.

Findings:

1. On 12/1/15 at approximately 11 a.m., the electronic clinical record for Patient 21 was concurrently evaluated with a clinical information technological nurse, (CIT). The record showed that 61 year old, Patient 21 had a history of chronic pain and was admitted to the facility on 9/17/15 for a surgical procedure. During recovery, Patient 21 received orders for pain medication including hydromorphone (Dilaudid). Hydromorphone is a pain medication similar to morphine, but about six times stronger. The order was to administer 0.2 milligrams (mg) of hydromorphone every 5 minutes as needed for pain ranging from 4-6 on a pain scale of 1-10 (zero meaning no pain, and 10 indicating the worst pain.)

Hydromorphone and other medications are stored in a computerized drug storage device or cabinet (ADC) designed to store and dispense medications while controlling and tracking drug distribution.

Review of the removal record for hydromorphone from the ADC and matching that to the medication administration record (MAR) showed that 0.4 mg could not be reconciled. In the recovery area, between 14:40 (2:40 pm) and 17:31 (5:51 pm) on 9/17/15, 2 units (carpuject), one milligram each, of injectable hydromorphone were removed. The MAR showed documentation that on 9/17/15, five doses of 0.2 mg were administered at the following times: 1447 (2:47 pm), 1453 (2:53 pm), 1511 (3:11 pm), 1532 (3:32 pm) and 1625 (4:25 pm). The ADC record also showed that on 9/17/15 at 1731 (5:31 pm), 0.6 mg of hydromorphone was wasted. There was accountability of 1.6 mg out of 2 mg of hydromorphone. The difference of 0.4 mg was not reconciled. Two facility staff CIT and the Pharmacist in Charge (PC) were interviewed and reviewed the ADC document and Patient 21's medical record, but they could not account for the 0.4 milligrams of hydromorphone.

2. On 12/3/15 at approximately 10 a.m., the record for Patient 26 was concurrently reviewed with facility staff, CIT. The record showed that Patient 26, a 47 year old, was admitted to the facility on 10/28/15 for joint exploration. Patient 26 was prescribed hydromorphone to be administered as injections on demands by the patient through a computerized pump called the Patient-Controlled Analgesia (PCA). The PCA pump contains the prescribed pain medication and is connected directly to a patient's (intravenous) IV line. The hydromorphone PCA order was to deliver an initial loading dose of 0.5 mg, and on demand dosing 0.3 mg every 10 minutes as needed.

The hydromorphone PCA is a 30-milliliter syringe that contains 15 mg of hydromorphone. The total amount of hydromorphone administered was concurrently verified with CIT to be 7.1 milligrams. According to the ADC record, 9 milligrams of hydromorphone was wasted on 10/29/15 at 18:57 (6:57 pm) (possibly at the time of nursing shift change). The syringe contained 15 milligrams. The total amount used was 7.1 mg adding the wasted amount (9 mg) would give a total of 16.1 mg. There is a small volume of medication that is not included in the amount given or amount wasted, because it is remaining in the IV line (used to prime the IV tubing). The total amount of medication (given and wasted plus what remains in the tubing) should add up to no more than 15 mg. It is not possible to have more than the amount that was initially removed.

Control substance excess is a discrepancy. Any discrepancy (shortage or overage) can be a result of inadequate documentation, inaccurate measurement of what was left unused, diversion, use by staff, or record falsification.

Review of the Pyxis policy, revised October 2015, showed the following under discrepancies:
"If the discrepancy cannot be resolved, an occurrence report must be generated... Pharmacy will provide each department manager a copy of the discrepancy report."

There was no documented evidence that a system to screen and identify potential discrepancies was employed. Additionally, there was no documented evidence that the pharmacist identified the above discrepancies for Patient 21 and Patient 26 or communicated them to department managers as outlined in the policy.

Based on policy review and staff interview, the hospital failed to ensure that policies and procedures that addressed emergency medications were developed. The failure to develop, and implement policies and procedures for ensuring appropriate use and availability of emergency medications had the potential of placing patients at risk for delayed treatment in emergencies.

Finding:

On 12/2/15 at 9 a.m., while inspecting the emergency medication (crash) carts, the policy was requested. The pharmacist in charge (PC) provided the lists of medications the facility established for inclusion in the pediatric and adult crash carts. The pharmacist in charge confirmed the absence of procedures for restocking, sealing, or periodically checking the supplies. There was no policy to address the emergency crash cart. The only policy emergency crash carts appeared in, was the policy titled, "Unit Inspections" dated August 2014: Item 3.8 included the following: "Emergency (crash cart) dugs are available, complete, secure, and within the expiration period." It did not have any procedures outlining how to complete any of the items listed.

It is required by State and Federal regulations that hospitals establish policies and procedures for medication use. There is a specific requirement for establishing the content of the emergency carts, the procedure for use, restocking and sealing of the carts which is outlined in California Code of Regulations Title 22, Division 5, section 70263 (f) (1).

Based on records, documents, and policy review and staff interview, the facility failed to ensure that adverse drug reactions (ADRs) were immediately reported in accordance with the facility's policy. Facility staff failed to complete three ADRs for two patients (Patient 22 and Patient 23) as follows:

1. Patient 22 was given pain medication, which caused him excessive sedation and required the use of Narcan (medication) to reverse the sedation effect.

2. Patient 22 was given three different medications (ibuprofen, Ketorolac, and Xarelto); all of these medications have similar effect/side effects, which increase the risk of bleeding. Even though bleeding was not documented in the record, Patient 22 was administered two units of blood on the day these medications were administered.

3. Patient 23 was administered Dextrose (sugar) 50 % (D50) by injection before and during the surgical procedure. D50 is used to raise blood sugar. Patient 23 blood sugar was within normal range before the procedure.

By failing to screen for, report ADRs, or take necessary actions related to adverse medication reactions, the facility put patients at risk of experiencing similar or more severe adverse reactions in the future. Lack of reporting ADRs prevented the facility form identifying and implementing efforts directed at medication safety, and subsequently put patients at risk of harm associated with medication use.

Finding:

1. On 12/1/15 at approximately 3 p.m., review of the record for Patient 22 revealed that the 69 year old was admitted to the facility on 8/19/15. Patient 22 had a history of pain for which methadone was prescribed. Methadone is an opiate type medication for pain similar to morphine but stays in the body longer. Methadone is usually used in patients tolerant to the effects of opiates. On 12/2/15 at approximately 8 a.m., concurrent review of Patient 22 record with the pharmacist in charge (PC) revealed that Patient 22 was administered 0.5 milligram (mg) of Narcan, on 8/20/15 at 11:49 a.m. Narcan, also known as naloxone, is used to reverse the effect related to excessive use of opiates/opioid medications (morphine, or morphine like medications such as methadone or hydromorphone). Hence, naloxone and similar medications are known as antidotes, reversal or rescue agents. Review of the medication administration records showed that Patient 22 was administered several medications with the same or similar effects and side effects, such as sedation and respiratory depression. Patient 22 was administered methadone and hydromorphone.

According to the product information, methadone caused central nervous system (CNS) depressions, which includes sedation. Methadone has a boxed warning which is the most serious warning required by the Food and Drug Administration to be placed in the product labeling for a medication. Boxed warnings document potential problems that can lead to serious injury or death. The boxed warning for methadone included that it causes "Respiratory depression:... May cause serious, life-threatening, or fatal respiratory depression. Monitor closely for respiratory depression, especially during initiation or dose escalation. Carbon dioxide retention from opioid-induced respiratory depression can exacerbate the sedating effects of opioids. Peak respiratory depressant effect of methadone occurs later and persists longer than the peak analgesic effect, particularly during the initial dosing phase..."

Similarly, according to the product information for hydromorphone, it also can cause CNS (central nervous system) depression. It recommends using the drug "...with caution and monitor for respiratory depression ... particularly when initiating therapy and titrating with hydromorphone; even therapeutic doses may decrease respiratory drive to the point of apnea (stop of breathing).

On 8/20/15, Patient 22 was administered 10 milligrams of methadone at 830 a.m., and 0.6, 1 and 1 milligrams of hydromorphone at 0046 (1:46 am) 4:30 am and 6:30 a.m. respectively. Patient 22 was also given other doses of methadone and hydromorphone between 9 p.m., and midnight on 8/19/15.

According to Lexi.com, an online drug reference, methadone usual dose is 2.5 mg every 8 hours (total 7.5 per day). Patient 22 was given 20 milligrams, which is about 3 times the usual dose.

The documentation for monitoring Patient 22 showed that on 8/20/15 at 8 a.m., Patient 22 was at level 4 of sedation; level 4 sedation was defined by the facility as "Asleep, responds to gentle shaking or loud auditory stimulus." On 8/20/15, at 12 noon, it was documented that Patient 22 sedation level was 1, meaning anxious, agitated or restless. Ortho progress notes assessment, dated 8/20/15 at 12:33 pm, (entered after the Narcan dose) included: "Pt (patient) very lethargic, thought over narcotized. I have her 0.2 mg of Narcan (sp) and work up but very confused..."

On 8/20/15, between 8 a.m. and 12:33 pm afternoon, there were no additional notes describing Patient 22 situation in details. In the absence of documentation, it is not clear what happened to Patient 22 or what necessitated the need to administer the rescue agent Narcan.

On 12/2/15 at approximately 8 a.m., the pharmacist in charge (PC) stated on interview that he runs report of rescue agents used and evaluates their use on a regular basis. When asked for use of Narcan in Patient 22, he stated that it was evaluated. But when asked if an ADR was filed, he said that DQ (Director of Quality) would have the information about all ADRs.

There was no documented evidence that the facility pharmacist evaluated using Narcan as a potential for investigating medication error, giving too much methadone or hydromorphone for example.

2. On 12/1/15 at approximately 3 p.m., review of the record for Patient 22 revealed that the 69 year old was admitted to the facility on 8/19/15. Patient 22 was prescribed Xarelto (known as Rivaroxaban), an anticoagulant medication used to prevent clotting after joints surgery (hip or knee).

On 8/19/15 at 6 a.m., Patient 22 was administered 800 milligrams of ibuprofen (anti-inflammatory) by injection prior to surgery. In addition, Patient 22 was given 30 milligrams of Ketorolac (anti-inflammatory), which is two times the appropriate dose for Patient 22's age.

According to the manufacture's specification for ketorolac, the dose for adults 65 or older is 15 mg in single dose or 15 mg every 6 hours as needed. Ketorolac is another anti-inflammatory medication similar to ibuprofen. Both medications can increase the risk of bleeding. In addition to the ibuprofen and ketorolac, Patient 22 was administered Xarelto. According to the manufacturer for this medication, the most common complication associated with Xarelto use is major bleeding. Between 8/19 and 8/20/15 Patient 22 was given three medications that have the same effects or side effects (bleeding or major bleeding).

On 12/3/15 at approximately 10 a.m., a Patient 22's record was concurrently reviewed with CT and DQ. On 8/19/15 at 19:22, it was documented that a "large bluish purple area to L (left) inner thigh" was detected. The note also included that "Pt. (patient) stated it has been there a long time." However, review of the assessment before the surgery (on 8/19/15 at 11:14 a.m.,) there was no mention of the hematoma (bleeding under the skin that can appear bluish purple) in the record.

There were no additional notes describing Patient 22 situation in detail or describing any bleeding episode. The record had documentation that Patient 22 was administered two units of blood on 8/20/15 at 1820 (6:10 pm) and 2310 (11:10 pm). In the absence of documentation, it is not clear what happened to Patient 22 or what necessitate the need to administer the two units of blood.

There was no documented evidence that the pharmacist intervened regarding the dose of ketorolac. Patient 22 was given two times the manufacturer's recommended dose for patients at that age range. Additionally, there was no documented evidence of any interventions related to the combination of the medications (ibuprofen, ketorolac, and Xarelto) ordered and administered to Patient 22.

There was no documented evidence that the pharmacist, nursing staff, or the physician completed any adverse drug reaction form related to bleeding as a potential outcome of the medication given. On 12/2/15 at 4 p.m., DQ stated on interview that there were no ADR reports for Patient 22 related to bleeding.

3. On 12/1/15 at approximately 5 p.m, review of the record for Patient 23 showed the patient was in the hospital on 7/8/15 for a surgical procedure. Patient 23 had a history of diabetes (fluctuation and lack of control of blood sugar). Patient 23 was administered 12.5 grams of Dextrose (sugar) 50% (D50) before surgery. Dextrose 50% is an injectable sugar formulation that is used in emergency situations to treat hypoglycemia (low blood sugar), manage coma (unresponsiveness, unconsciousness) of unknown origin, or used for providing nutritional calories by injection (total parenteral nutrition). This preparation is also known as an antidote (counteracts the effects of other medications or agents) which counteracts the effects of insulin. Antidotes, reversal or rescuer agents sometimes are used interchangeably. Dextrose is a rescue for low blood sugar. Patient 23's record had no evidence of low blood sugar to justify the use of the D50.

On 12/2/15 at approximately 4 p.m., Patient 23's record was concurrently reviewed with facility staff nurses (IPC and CIT). The record showed that D50 was given at 9:47 a.m., prior to the procedure by the anesthesiologist, and again during the procedure around 11:10 a.m. On 7/8/15 at 9:15 a.m., shortly before the procedure, Patient 23's blood sugar was documented as 101 milligrams per deciliter (mg/dL). This blood sugar is considered normal: according to the US National Library of Medicine, National Institute of Health, the normal range for fasting (before eating) blood sugar level between 70 and 100 mg/dl. Both staff looked for written documentation in the record about blood sugar and for any notes to explain the rationale for administering the D50 to Patient 23, but no clinical documentation to justify the use of D50 was found.

On 12/2/15 at 11 a.m., the pharmacist in charge (PC) was interviewed regarding use of D50 for Patient 23. He stated that the D50 was not used as a rescue agent because it was administered intraoperatively (during surgery). It was not given when the patient was inpatient.

Review of the facility's policy for medication error and adverse drug event reporting revised in August 2014, showed the following items under procedure:
"Procedures:
1. Medication administration errors, adverse drug reactions and medication incompatibilities as defined, are reported to the attending physician immediately when possible.
2. All medication errors and ADEs (adverse drug reactions) should be reported using the occurrence report form. The person making or discovering the error should complete the form.
3. The complete form should be forwarded to the department manager, then to the Pharmacist, then to the Chief Nursing Officer, (CNO) or designee for review..."

There was no documented evidence that the procedure for ADR reporting was implemented for Patient 23, as the PC and DQ were not aware if reports were filed or not, especially considering that they were key staff that were supposed to review these reports or in some situations completing the form.

Based on dietetic services observations, interview and document review the hospital failed to ensure the development of policies and procedures that reflected the depth and scope of the department. Failure to provide written guidance to dietary staff, in accordance with hospital and professional standards of practice may result in practices consistent with risk for food borne illness and cross contamination of patient food.

Findings:

On 12/1/15 beginning at 9 a.m., the departments' sanitation process was reviewed with Dietary Staff (DS) 36 (Cross Reference A749). During the review it was noted that the process did not meet the standard of practice, nor was there a written procedure. Review of the dietetic department policy and procedure manual on 12/1/15 at 11 a.m., revealed that that the departments' guidance was limited to 9 policies. It was also noted that while some of the policies, such as the policy titled "Dietary Menus" dated 10/15, provided procedural information, other policies such as "Food Preparation, Storage and Handeling [Handling]" dated 10/15 was limited to conceptual principles such as food storage temperatures. This policy did not provide comprehensive procedures for ensuring food safety for leftover foods, a process that was routinely utilized within the department.

In an interview on 12/1/15 at 2 p.m., with the Dietary Supervisor she stated that the hospitals' parent company was in the process of making many changes and she stated she could likely obtain more detailed standardized procedures.

Based on dietary staff and Registered Dietitian (RD) interview and dietary document review the hospital failed to ensure comprehensive oversight of dietetic services by the RD. Failure to ensure RD oversight may result in foodservice practices that were not in accordance with physicians orders or promote activities that place patients at risk for foodborne illness.

Findings:

During an interview on 12/1/15 beginning at 9:30 a.m., with the Dietary Supervisor (DS) she was asked to describe the role of the Registered Dietitian (RD). She stated that the hospital had a dietitian who was on call for clinical nutrition care. She stated that while the RD was on call for questions, she usually did not come to the facility; however did sign patient menus.

In an interview on 12/2/15 at 1 p.m., with RD 37 she stated that she was hired to primarily take care of any clinical nutrition needs of inpatients. She stated that she would occasionally speak with the DS, was available for questions, reviewed the menus and in-services that were provided. She further stated that she did not participate in foodservice oversight or policy and procedure development. She stated that while she reviewed the diet manual she had not identified that the approved diet manual did not accurately reflect the scope of services provided within the hospital.

Review of the position description titled, "Dietitian" dated 8/15 noted it was the responsibility of this position to monitor and evaluate the quality and appropriateness of nutrition and dietetic services. Review of payroll records from 9/1/15 to 11/21/15 noted that while the RD was receiving compensation for 2 hours of on call time per day the last time she was onsite was 9/8/15. In an interview with the DS on 12/2/15 at 2 p.m., she stated that the RD did come in after the last Department (CDPH) survey to review departmental documents; however did no formal monitoring of operations.

Based on dietary staff interview and dietary document review the hospital failed to ensure the development of a menu that consistently met physician specified parameters of the nutritional needs of patients. Failure to ensure accurate menu development may compromise patients' medical and nutritional status.

Findings:

On 12/1/15 beginning at 3 p.m., the nutritional analysis of the patient menu was reviewed. In a concurrent interview with the Dietary Supervisor she stated the analysis was completed; however the menu was not reviewed for nutritional adequacy by the hospitals' dietitian. She also stated that the hospital utilized the Dietary Reference Index (DRI) to determine nutritional adequacy of the menu and that the diet manual was utilized as a basis for physician ordered dietary restrictions. It was noted that the menu did not consistently meet physician specified parameters. As an example, the consistent carbohydrate diet was physician approved to contain 75 grams of carbohydrate at each meal. Review of the analysis revealed that 2 of the 7 days did not meet the parameters. On Day 2 the noon meal contained 86 grams (a metric unit of measure) of carbohydrate and the evening meal contained 68 grams of carbohydrate. Similarly on Day 7 the noon and evening meals contained 83 and 81 grams of carbohydrate respectively. Similar review of the regular diet revealed that it did not meet the DRI for Vitamin D or for dietary fiber. Concurrent review of the facility diet manual revealed that there was no information related to the adequacy of the diet.

Based on dietary staff interview and dietary document review, the hospital failed to ensure the development of a diet manual that fully reflected the depth and scope of dietetic services. Failure to provide a comprehensive diet manual may result in providing inadequate guidance for staff responsible for ordering and preparing patient meals which may result in compromising patient medical status.

Findings:

The purpose of a diet manual is to establish a common language and practice for physicians and other healthcare professionals to use when providing nutritional care to patients. An effective diet manual would include those diets routinely ordered. Additionally, the diet manual would include the purpose, diet principles, adequacy in relationship to the hospitals' menu, foods allowed and foods to avoid and a sample meal plan based on the hospitals' menu.

In an interview on 11/30/15 at 11 a.m., with RN F she was asked to describe the diet ordering mechanism. She stated all diet orders were done by either the physician directly or as a telephone order by nursing staff. She also demonstrated the selection of diets a physician could choose from which was limited to 6. She also stated most of the diets were either clear liquid, regular or on occasion there would be a diabetic diet.

On 12/1/15 beginning at 11 a.m., the hospitals' menu was reviewed concurrently with RN F. It was noted that the availability of physician ordered selections was also limited to 6 diets ranging from a clear liquid to a regular diet. Concurrent review of the diet manual revealed there were greater than 50 diets listed as being offered, a selection far greater than was reflected by actual hospital physician practice. It was also noted that the diets that were similar to what was in use did not meet all the elements of a diet manual. As an example the physician approved diet manual contained a carbohydrate controlled diet. While the document noted the purpose of the diet it also guided staff that there were 3 levels available, 45, 60 and 75 grams (a metric unit of measure) of carbohydrate per meal; however the hospital standardized menu provided only the 75 grams of carbohydrate level. Review of the Cardiac diet noted that the principle of the diet was to lower the intake of total dietary fat, cholesterol and sodium. The document provided guidance for the level of fat and sodium; however there was no mention of the amount of cholesterol in the diet. The diet manual did not address the nutritional adequacy of the diet nor provide a sample meal plan based on the hospital menu. Similar missing elements were noted in the remaining diets.

In an interview on 12/2/15 at 9 a.m., RN F confirmed that the hospitals' menus was limited to the 6 menus. She also stated she could not recall an instance where there were additional diets ordered.

Based on observation, interview, and record review, the hospital failed to ensure: 1) all emergency equipment was checked and maintained in accordance with its policy, 2) all available supplies were not expired; and 3) the ice machine was cleaned properly.

1. All equipment in the adult crash cart (used for emergency resuscitation measures) was not checked daily in the Post Anesthesia Care Unit (PACU, unit where patients go immediately after surgery). This failure had the potential to create a delay in emergency measures.

2. An expired intravenous (IV) bag of fluids was found on PACU. This had the potential to result in infection control problems for patients.

3. The interior components of the ice machine was not clean and was not sanitized in accordance with manufacturers' guidance. Failure to maintain equipment in a sanitary manner may result in cross contamination and promote practices associated with foodborne illness.

Findings:

1. The policy titled, "Code Blue" (code for medical emergencies) dated 1/2015, was reviewed. Under the, "Background Information" section it indicated the facility was committed to providing trained personnel and necessary medical equipment in order to deal with medical emergencies. Medical equipment (i.e. crash cart) will be readily available in patient care areas in order to deal with medical emergencies.

The policy titled, "Unit Inspections," dated 8/2014, with the attached procedure, "Adult Crash Cart Check Record," was reviewed. It indicated the crash cart was to be checked daily including the laryngoscope (an instrument with a light used to insert a tube through the throat into the lungs for a patient who is not breathing, that comes with an attachment called a blade) light source check.

During a concurrent interview and observation on 12/2/15 at 10 am, Registered Nurse (RN) C was asked to demonstrate the checking of the laryngoscope light source. RN C stated she'd have to connect the blade in order to check the light source. The blade was in sterile packaging which she opened and attempted to connect the two. RN C had some difficulty connecting the two instrument parts and was assisted by RN D who was also present. RN C stated they did not always check the laryngoscope light source daily because the blade was in sterile packaging and they did not have another one with which to practice.

During a concurrent interview and observation on 12/3/15 at 8:15 am, the PACU charge nurse stated and demonstrated there was a light on the laryngoscope handle that could be pressed to make sure the light source worked without connecting the blade. The Chief Nursing Officer (CNO) stated they needed to have a consistent method of testing the laryngoscope light source throughout the facility.

2. During an initial tour of the hospital's inpatient unit on 11/30/15 at 11:40 am, a 1000 milliliter bag of IV fluids, with an expiration date of 10/2015, was observed in the clean utility room on PACU.

The CNO was present during this observation and confirmed the above expiration date. She explained, the materials management department was responsible for checking and removing outdated IV fluids.




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3. On 11/30/15 beginning at 9:30 a.m., ice machine sanitation was reviewed with Engineering Staff (ES). It was noted that on the inside of the machine, there was a build-up grey fuzzy particles resembling dust. It was also noted there were grey spots on the cubing mechanism that could be wiped off with a paper towel. In a concurrent interview with ES he stated that he did not clean this particular machine, rather it was the responsibility of the Engineering Supervisor.

In an interview on 12/1/15 with the Director of Plant Operations (DPO) he described a process whereby an ice machine cleaner would be circulated through the ice producing mechanism which was followed by an ice machine sanitizer of quaternary ammonia as the active ingredient. Concurrent review of manufacturers' guidance guided staff to utilize a 5.25% (percent) food safe bleach solution.

Based on observation, interview and record review, the facility failed to:
1. Ensure the Surgical Floor (SF) equipment and supplies on the Crash Cart (CC, holds supplies used in medical emergencies) and the Wound Supply Cart (WSC) were kept clean and sanitary. This had the potential for patient care supplies to be unclean and increase the patients exposure to infection and complications;
2. Ensure food production equipment was cleaned/sanitized in accordance with accepted standards of practice. Failure to ensure effective cleaning/sanitation may contribute to cross contamination of food and/or contribute to foodborne illness;
3. Develop a system for controlling infections and communicable diseases of patients when:
a. Surgical Attire was not worn in accordance with facility policy and nationally accepted guidelines;
b. No documentation existed for the cycles, times and temperatures of an enzymatic (substance produced by a living organism that acts as a catalyst) washer used for surgical instruments;
c. Medications were not opened in a manner that maintained asepsis (free from contamination);
d. Documentation of required immunizations and testing was not found in the health files of facility healthcare workers.

Findings:

1. a. On 11/30/15 at 9:45 am, the CC on the SF was observed concurrently with the Chief Nursing Officer (CNO) and the In-Patient Nurse Manager (INM). There were multiple supplies stored on top of the CC and there was visible dust particles covering equipment and supplies that were stored on top of the cart. The CC daily log to check if equipment was operational did not show evidence that cleaning of the equipment and supplies was performed.

Both the CNO and INM verified the above findings and stated the CC equipment and supplies needed to be kept clean to prevent unnecessary patient exposure to infection.

1. b. On 12/1/15 at 10:15 am, the WSC was observed concurrently with the INM.

The WSC had supplies stored on top of the top of the cart (tape, gloves, and Intravenous supplies) and there were five drawers that contained different types of bandages, dressings, and wound care treatment supplies. There was visible dust particles on the top of the WSC and also in the drawers where items were stored.

The INM verified the above findings and stated the cart needed to be kept clean and needed to be scheduled for routine weekly cleaning.




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2. The standard of practice for cleaning in place equipment would be to ensure three distinct steps that included washing with a detergent, rinsing with water followed by a sanitation step (Food Code, 2013).
On 12/1/15 beginning at 9 a.m., surface and equipment sanitation procedures were reviewed with Dietary Staff (DS) 36. She stated that when surfaces were cleaned it would consist of wiping the surface with a sanitizer. DS 36 was concurrently ask how the strength of the sanitizer was verified. She stated that the product was mixed earlier in the day and was tested at that time. The surveyor requested demonstration of the sanitizer testing procedure. It was noted that on the test strip there was little to no reaction of the test strip. In a concurrent interview with the Dietary Supervisor she stated the sanitizer bucket was filled approximately 30 minutes earlier at which time it was tested and found to be within manufacturer specific parameters of 200 parts per million (a unit of measure). DS also stated that while the sanitizer bucket may be refilled multiple times/day it was tested only one time/day. She acknowledged that the frequency of testing may not accurately reflect the sanitizer strength of all buckets that were filled. She also stated that the hospital did not have a standardized procedure for this process.



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3. a. On 11/30/15 at 11:25 a.m., Vendor was observed in the restricted area hallway, outside Operating Room (OR) 3, wearing a surgical mask. When asked why he was wearing a mask outside of the operating room, he stated that he wears masks in the restricted area hallways in all of the facilities that he visits.

On 11/30/15 at 4:15 p.m., during an Interview with CNO, she stated that the facility adopted Association of perioperative Nurses (AORN), Standards of Perioperative Nursing Practice as one of their nationally recognized guidelines for the infection control program.

According to AORN, Standards of Perioperative Nursing Practice 2015, Guideline for Sterile Technique, Recommendation I, Perioperative personnel should wear a clean surgical mask that covers the mouth and nose and is secured in a manner to prevent venting when open sterile supplies are present and when preparing, performing or assisting with surgery and other invasive procedures.

On 1/30/15, at 11:50 a.m., during an observation of a surgical procedure in OR 1, Circulating Nurse (Circ RN) had visible hair hanging from beneath her surgical head cover on the back of her neck; Medical Doctor (MD) 1 and MD 2 had sideburns/hair in front of ears, visible outside of the surgical head cover.

According to facility policy titled, "Attire in the Perioperative Area", dated 9/15, surgical head covers/hoods are required that confine all head and facial hair including sideburns, the nape of the neck and ears.

According to AORN, Standards of Perioperative Nursing Practice 2015, Surgical Attire, Recommendation III, Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair. A clean surgical head cover or hood that confines all hair and completely covers the ears, scalp skin, sideburns, and nape of the neck should be worn.

b. On 11/30/15 at 4:07 p.m. during a tour of the decontamination room (where used supplies and equipment are cleaned and sanitized) of the facility, Instrument Washer #2 was observed to be operational and in use with a defective cycle printer. In an interview with Sterile Technician (Tech), she stated that the printer has been broken and is scheduled for repair as soon as the new part is available. She stated that the cycles are monitored by decontamination personnel, but no documentation is kept of the cycle parameters (time, temperature, cycles, warnings and instructional messages, including abnormal conditions).

In an interview with Supervising Tech on 12/1/15 at 10:50 a.m., she stated that Instrument Washer #2 was taken out of service at end of day,11/30/15.

On 11/30/15 at 4:15 p.m., during an Interview with CNO, she stated that the facility adopted Association of perioperative Nurses (AORN), Standards of Perioperative Nursing Practice as one of their nationally recognized guidelines for the infection control program.

According to AORN, Standards of Perioperative Nursing Practice 2015, Guideline for Cleaning and Care of Surgical Instruments, IX.d. Mechanical methods (eg, ultrasonic cleaner, washer disinfector/decontaminator) should be used for cleaning surgical instruments unless otherwise specified by the instrument manufacturer. Mechanical cleaning is preferred over manual cleaning because it is reproducible and provides consistent detergent concentration, temperature control, and washing and rinsing processes, whereas manual cleaning is subject to variation among personnel.

The manufacturer's instructions for the Steris ®Single chamber Washer/Disinfector state that the control panel displays the results of seven preprogramed cycles in memory. It generates a printout of the actual water temperature and chamber air temperature during the drying phase. It also prints out a complete record of all currently set cycles and cycle values. It provides a record of whether the load was properly rinsed at the preset temperature and a complete list of the alarm and abort in-cycle messages.

c. On 11/30/15 at 11:50 a.m. during an observation in Operating Room 1, Circ RN, opened a vial of Lidocaine (numbing medication) by popping off the stopper and pouring the contents into a sterile container held by OR Tech (ORT).

On 11/30/15 at 4:15 p.m., during an Interview with CNO, she stated that the facility adopted Association of perioperative Nurses (AORN), Standards of Perioperative Nursing Practice as one of their nationally recognized guidelines for the infection control program.

According to According to AORN, Standards of Perioperative Nursing Practice 2015, Guideline for Medication Safety, Recommendation IX, Aseptic (free from contamination) technique should be used when transferring medications to the sterile field. Medication vials are not designed to aseptically pour the contents into a secondary container on the sterile field. Transfer devices are designed to minimize splashing, spilling, and the need to reach over the sterile field, which could cause contamination of the sterile field. The RN circulator should obtain commercially available sterile transfer devices (eg, sterile vial spike, filter straw, plastic catheter) to prepare products for aseptic presentation to the sterile field. Stoppers should not be removed from vials for the purpose of pouring medications.

d. On 12/1/15, during a record review of ten health records of facility HCWs (health care workers) with the Infection Prevention Coordinator (IPC), there was no documentation of immunization status of measles, mumps, varicella (Chicken Pox) and Hepatitis B (a virus that infects the liver) in 1 out of 10 records (MD 2); there was no documentation of rubella (German Measles) immunization status in 2 out of 10 records (MD1, MD2); there was no documentation of Diphtheria (a serious bacterial infection), Tetanus (a serious illness caused by bacteria that can enter the body through a deep cut) and Pertussis (commonly known as Whooping Cough, an infectious bacterial disease that causes uncontrollable coughing) immunization status in 1 out of 10 records (MD 1); and there was no documentation of current TB (tuberculosis: a disease of the lungs caused by the organism Mycobacterium tuberculosis) screening for 1 out of 10 (Vendor) health records. These findings were validated by the IPC.

According to facility policy entitled Employee Vaccination Requirements and Annual Health Screening dated 10/14, employees who are unable to provide documentation of vaccine or immunity will receive the appropriate titer testing and vaccines at the expense of the employer. These include: Hepatitis B, Measles, Mumps, Rubella, varicella zoster, and Tdap. Additionally the policy stated that all new employees will be required to have proof of a TST (tuberculin skin test) or have a TST and this shall be repeated annually. The policy cites the CDC (Centers for Disease Prevention and Control) and ACIP (Advisory Committed on Immunization Practices) as references.

According to the CDC, those who work directly with patients or handle material that could spread infection should get appropriate vaccines to reduce the chance that they will get or spread vaccine-preventable diseases. The CDC further states that healthcare workers include physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, pharmacists, hospital volunteers, and administrative staff.

Employee health policies and procedures did not follow the facility adopted, nationally recognized CDC guidelines for immunizations and TB screening of health care workers that state:
I. " ( ...recommends that health care providers receive vaccinations for diseases for which routine vaccination or documentation of immunity is recommended because of risks in the workplace (i.e. hepatitis B, seasonal influenza, measles, mumps, rubella, pertussis, and varicella) "
II." Healthcare personnel should receive a single dose of Tdap (a vaccine that includes tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, that prevents the diseases of Diphtheria, Tetanus and Whooping Cough) as soon as feasible upon hire if they have not been vaccinated previously " .
III." Healthcare organizations should review health care provider vaccination and immunity status at the time of hire and at least annually thereafter " .
IV." All healthcare personnel should receive baseline TB (tuberculosis screening upon hire. Follow-up screening/testing should be completed annually " .

Based on interview and record review, the hospital failed to ensure its policy for infection control was followed when two of 21 sampled patients that were scheduled to be admitted to the Surgical Floor (SF) did not have prescreening for a multidrug resistant organism (MDRO), Methacillin resistant staph aurous (MRSA, a bacteria that is highly resistive to antibiotics, can spread to other patients. Patients with MRSA require isolation to prevent the spread of the infectious bacteria) as indicated by the infection control policy. (Patients 12 and 13)

This failed practice had the potential for the spread of infection to patients and compromise their recovery from surgery and compromise their health.

Findings:

A hospital policy dated 10/15/15, indicated that all patients would complete a pre-operative (pre-op, a visit with a RN to complete the surgical consent, screening for MDRO's; and ensure physician's orders for lab work and testing is completed before the patient's surgical procedure) visit and be screened (asked questions) for potential MDRO exposure. The policy indicated if the patient was scheduled to be admitted to the hospital after their surgery was performed, that the patient would have a test to check the patient for MRSA by performing a nasal swab.

Patient 12 was seen for a pre-op visit on 10/28/15, underwent surgery (gall bladder removal) on 10/28/15, and was then admitted to the hospital. Patient 12 was discharged on 11/1/15.

A review of Patient 12's record did not show evidence he had been tested for MRSA, either pre-op or after admission to the hospital, as indicated in the policy.

Patient 13 was seen for a pre-op visit on 11/24/15, underwent surgery on 11/30/15, and was then was admitted to the hospital. Patient 13 was discharged on 12/1/15.

A review of Patient 13's record did not show evidence that a test for MRSA had been performed at the pre-op visit or after Patient 13 was admitted to the hospital after surgery.

On 12/3/15 at 8:40 pm, the Infection Prevention Coordinator confirmed that Patients 12 and 13 had not been tested and screened for MRSA as indicated by the policy. She stated both patients needed to be tested because it was planned and they were admitted to the hospital surgical floor after surgery.

Based on interview, record review and policy review, the hospital failed to identify, for one of 21 sampled patients, the medical records that were sent with the patient when transferred to another facility. (Patient 15) This failure had the potential for the subsequent provider to lack understanding of the care of the patient, compromising their health.

Findings:

Patient 15's record was reviewed currently with the Clinical Information Technology Nurse (CIT), Registered Nurse (RN) E, and the In-Patient Nurse Manager (INM) on 12/2/15 at 2:30 pm. The record indicated Patient 15 was admitted to the hospital on 11/3/15, and underwent surgery for a total left hip replacement, and was discharged on 11/6/15, to a Skilled Nursing Center (SNC) to continue her care and recovery.

The Nurse's Discharge Noted dated 11/6/15 at 1:54 pm, indicated a report about Patient 15's condition was called to the SNC by RN E. The Nurse's Assessment Note, dated 11/6/15 at 2:56 pm, indicated that Patient 15 was discharged with instructions, prescriptions, belongings, and left in a private car to go another facility. Patient 15's record did not show evidence of what specific documents were sent to the facility to provide information to continue with Patient 15's care.

On 12/2/15 at 3 pm, RN E, and the INM confirmed the above information. INM stated that when patients are referred to another facility, that information is sent for the facility to review and decide if they will accept the patient. RN E stated that at the time of Patient 15's discharge she had been given copies of current records which included therapy notes, the medication list, and physician discharge orders to take to the facility. RN E acknowledged that Patient 15's record did not indicate what records were sent at the time of discharge.

A hospital policy dated 10/15, titled, "Discharge Planning" indicated, the RN or Case Manager identify any discharge needs, contacts referring agencies to report medical status and documents information provided to the agency in the medical record.

Based on interview and record review the facility failed to include all necessary medical information at the time of discharge for two of 21 sampled patients. (Patient 14 and 15) This failure had the potential for incomplete care and compromised the patient's health.

Findings:

Patient 14 and 15's records were reviewed currently with the Clinical Information Technology Nurse (CIT), Registered Nurse (RN) E, and the In-Patient Nurse Manager (INM) on 12/2/15 at 2:30 pm.

a. Patient 15's record indicated Patient 15 was admitted to the hospital on 11/3/15, and underwent surgery for a total left hip replacement, and was discharged on 11/6/15, to a Skilled Nursing Center (SNC) to continue her care and recovery.

Patient 15's record indicated on 11/4/15, Patient 15 developed a large blister by the surgical dressing, and that the blister had opened.

The Nurses Assessment Note dated 11/4/15 at 8 pm, 11/5/15 at 8 am, and 11/5/15 at 8 pm, indicated the under Peri-incisional (by the surgical incision or dressing) assessment: "Comments, large open blister."

A picture dated 11/4/15 at 5:30 pm, of Patient 15's left hip, demonstrated a blister with a partially open skin area that was below (posterior) the hip dressing. Another picture dated 11/6/15 (no time when taken), demonstrated the same blistered area and indicated the blistered skin was now a completely opened wound. No measurements were indicated on the picture.

The Nurse's Discharge Noted dated 11/6/15 at 1:54 pm, indicated a report about Patient 15's condition was called to the SNC by RN E. The Nurse's Assessment Note, dated 11/6/15 at 2:56 pm, indicated that Patient 15 was discharged with instructions, prescriptions, belongings, and left in a private car to go another facility. None of the documents in Patient 15's record described the condition of Patient 15's open blister/wound, nor did the discharge instructions include information how the open wound should be cared for.

2. Patient 14 was admitted to the facility on 11/9/15 for knee surgery, and was discharge to home on 11/11/15 with a referral to a Home Health Agency (HHA) to continue care at home.

A Nurse's Assessment Note (NAN) dated 11/12/15, at 8:15 am, indicated Patient 14 had a, "right elbow small abrasion and a scant amount of blood drainage. Picture taken." The NAN dated 11/12/15 at 1:17 pm, indicated that Patient 14 was discharged with his belongings and discharge instructions.

A review of Patient 14's discharge instructions including the Physician's Discharge Instructions, and another document titled Discharge Instructions, both dated 11/11/15, did not indicate that Patient 14 had an open skin area on his right elbow. There was no evidence in Patient 14's record that the facility had informed the HHA that Patient 14 had an open skin area on his right elbow.

A hospital policy dated 10/15, titled, "Discharge Planning" indicated, the RN or Case Manager identify any discharge needs, contacts referring agencies to report medical status and documents information provided to the agency in the medical record.

On 12/2/15 at 3 pm, RN E, and the INM confirmed the above information and stated Patient 14 or 15's record indicated they had open skin areas (Patient 15's hip and Patient 14's elbow). INM stated that when patients are referred to another facility or a HHA, that the condition of the patient including all open wounds should be included in the discharge information.