HospitalInspections.org

Based on clinical record review and interview, it was determined the Facility failed to ensure an Important Message from Medicare was provided within two days of admission and/or discharge to 4 (#1, #4, #6 and #8) of 10 (#1-#10) Medicare inpatients. The failed practice created the potential for patients to be uninformed of their rights and could affect any Medicare patient admitted to the Facility. Findings follow:

A. Review of clinical records revealed the following:
1) Patient #1 - admitted 02/04/15 through 02/20/15-did not have an Important Message from Medicare (dated 02/12/15) within two days of admission.
2) Patient #4 - admitted 03/13/15 through 03/16/15-did not have an Important Message from Medicare at admission or discharge.
3) Patient #6 - admitted 03/13/15- had not been discharged at the time of clinical record review. There was no evidence of an Important Message from Medicare within two days of admission
4) Patient #8 - admitted 03/12/15, had not been discharged at the time of clinical record review. There was no evidence the Important Message from Medicare (dated 03/19/15) was within two days of admission.
B. During clinical record review on 03/19/15 from 1430-1600, the Cardio Pulmonary Director and Registered Nurse #1 confirmed the missing Important Messages from Medicare.

Based on clinical record review, policy and procedure review and interview, it was determined two of two (#17 and #20) patients with PCA (patient-controlled analgesia) were not monitored according to hospital policy and procedure. Failure to monitor patient vital signs, sedation level and oxygen saturation level as required per policy did not assure complications of PCA, such as respiratory depression, would be identified upon occurrence for intervention. The failed practice affected Patient #17 and #20 and was likely to affect any patient who received PCA. The findings were:

A. Clinical record review revealed:
1) Patient #17 was admitted on 03/15/15. The order for Hydromorphone PCA 10 mg (milligrams) plus Sodium Chloride 09.% was noted for 03/15/15 at 0819. Documentation on the "Flowsheet" revealed vital signs (Temperature, pulse, respiratory rate, SpO2 (oxygenation) and blood pressure) were not documented every four hours throughout PCA usage as required per Facility policy. For example: No vital signs were documented for the following times for Patient #17, 03/16/15 at 0100, 0900, 1700, 03/17/15 at 0100, 0900, 1300 and 1700.

2) Patient #20 was admitted on 03/11/15. The order for Hydromorphone PCA 10 mg plus Sodium Chloride 0.09% was noted for 03/11/15 at 1834 and discontinued on 03/17/15 at 1132. Documentation on the "Flowsheet" revealed vital signs were not documented every four hours throughout PCA usage as required per facility policy. For Example: No vital signs were documented for the following times for Patient #20, 03/12/15 at 0100, 0900, 1700; 03/13/15 at 0500, 0900, 1700; 03/14/15 at 0100, 0500, 0900, and 1700.

B. The facility policy for "Patient-controlled analgesia" was provided on 03/20/15. The policy stated "Monitor the patient's vital signs, sedation level, oxygen saturation level, and capnography (concentration of exhaled carbon dioxide) (if used) frequently during the initial loading dose and at least every 4 hours throughout therapy. Monitor the patient more frequently during the first 24 hours and at night when hypoventilation and nocturnal hypoxia may occur." "Perform a comprehensive pain assessment at the start of therapy and a reassessment every hour."

C. The Cardio-Pulmonary Director and Endoscopy Director confirmed the policy provided that required vital signs, sedation level, and oxygen saturation level every 4 hours was the current policy on 03/20/15 at 1030. Clinical record review findings were confirmed by RN #2 on 03/20/15 at the time of chart review.

Based on observation, review of Pharmacy checklist and interview, it was determined the Facility failed to ensure medications in two of two operating rooms (OR #1 and OR#2) in the Women's Center were secure. Anesthesia cart drugs were not stored in a manner that prevented unmonitored access by unlicensed personnel, therefore the integrity and safety of the medications could not be assured. The failed practice was likely to affect any patient that had a delivery in OR #1 or #2 and resulted in medications that were not locked and secured, therefore the integrity and safety of the medications could not be assured. The findings were:

A. Observation on 03/18/15 at 0845 with RN (Registered Nurse) #3 revealed the Anesthesia Cart in OR#1 in the Women's Surgery Center was not locked. On top of the Anesthesia Cart there was Propofol 200 mg(milligrams)/20 ml (milliliters) and Succinylcholine. The unlocked cart had medication and IV (intravenous) supplies in the top three drawers, which included three additional vials of Propofol. RN #3 stated OR#1 had not been used since the previous day and confirmed that housekeeping staff had access to the area. RN #3 stated the OR staff from the main OR came up for every surgical delivery and when they finished, a member of the housekeeping staff would clean the room. Also noted on the front of the unlocked cart was a piece of tape with the numeric code to unlock the anesthesia cart.

B. The Anesthesia cart in OR #2 was locked, but the numeric code to unlock the anesthesia cart was written on a piece of tape on the front of the cart. Anesthesia Safety Technician #1 was contacted on 03/18/15 at 0915 by RN #3. Upon Anesthesia Safety Technician #1's arrival in OR #2, she confirmed the code for unlocking the anesthesia cart was the code taped to the front of the anesthesia cart. Anesthesia Safety Technician #1 was observed opening Anesthesia Cart #2 using the posted code.

C. Review of the Pharmacy Checklist on 03/19/15 at 1230 revealed the form for monthly inspections of the Women's Center Surgery Area included the criteria statement "Access to meds (medication) limited to licensed personnel." RN #3 was present and confirmed the presence of unsecured medications on the anesthesia carts at the time of observation on 03/18/15.

Based on review of policy, interview and observation of an indwelling urinary catheter insertion on 03/16/15 at 1525, it was determined Registered Nurse (RN) #3 failed to perform hand hygiene while performing insertion of an indwelling urinary catheter for one of two patients selected for observation. The failed practice likely placed the patient at increased risk of infection. The findings were:

A. Review of the policy and procedure "Indwelling urinary catheter (Foley) insertion, female" on 03/16/15 at 1600 revealed under the heading "Implementation" it was written, "Wash the patient's perineal area with warm water and soap. Rinse and dry thoroughly. Alternately, if the catheter insertion kit contains soap-containing wipes, use them to clean the perineal area. Remove and discard your gloves. Perform hand hygiene. Using sterile technique, open the insertion kit wrap. Put on sterile gloves." Upon completion of the procedure the policy and procedure listed the following steps: "Dispose of all used supplies in the appropriate receptacles. Remove and discard your gloves and other personal protective equipment if worn. Perform hand hygiene. Document the procedure."

B. On 03/16/15 at 1525, RN #3 was observed inserting an indwelling urinary catheter for a female patient. RN #3 performed hand hygiene, donned non-sterile gloves, cleaned the patient's genital area with a clean washcloth, removed the non-sterile gloves and then donned sterile gloves. RN #3 failed to perform hand hygiene after removal of non-sterile gloves before applying sterile gloves. RN #3 then proceeded with the same sterile gloves to catheterize the patient. Upon completion of the catheterization of the patient, RN #3 removed sterile gloves, adjusted bed covers, retrieved a pen, label and placed the label on the urinary drainage bag, then performed hand hygiene. RN#3 confirmed the failure to perform hand hygiene as specified above at the conclusion of the procedure on 03/16/15.

Based on observation, policy and procedure review, and interview it was determined the Facility failed to assure one of one (#10) physician who performed a spinal injection in the restricted area of the operating suite (OR #1) wore a facemask that covered the mouth and nose without venting. Failure to assure the nose and mouth of Physician #10 was covered without venting did not protect Patient #11 from potential exposure to microbial droplets from the physician's nose and mouth. The failed practice was likely to expose the patient to a possible source of infection. The findings were:

A. Observation of Physician #10 perform a spinal injection occurred in the surgical suite, OR #1 on 03/17/15 prior to the surgical procedure "left total knee arthroplasty". Physician #10 had a facemask on that was not secured in a manner to prevent microbial droplets from venting to the sides and bottom of the mask.

B. A copy of the Facility policy was provided on 03/16/15 at 1430 for "Surgical Asepsis: Surgical Attire". The policy defined the restricted area of the operating room as the "operating room suite, procedure rooms, and clean core. Surgical attire and hair coverings are required. Masks are required in the presence of open sterile items or scrubbed personnel." The procedure stated "Put on a surgical mask to reduce the dispersion of microbial droplets from your mouth and nasopharynx" and "Ensure that the mask covers your mouth and nose completely."

C. The facemask findings were confirmed by Registered Nurse #5 on 03/17/15 at 1100.


Based on observation, review of Manufacturer's directions for use and policy and procedure review, it was determined the Facility failed to dispose one of one single dose sterile water bottle after opening and failed to label or dispose two (4 South and 3 West) blood glucose monitor control solutions after 3 months of opening. The integrity of the sterile water and control solutions could not be assured. The failed practice was likely to affect any patient admitted who required bedside glucose testing or use of irrigation solution. The findings were:

A. On 03/17/15 at 1500, observation in Room 4417 revealed 1000 milliliter (ml) capacity sterile water for irrigation bottle opened with 800 ml remaining and stored at the bedside. The bottle Manufacturer's label listed it as single use only, contained no antimicrobials and to discard unused portion. The finding was confirmed by RN (Registered Nurse) #6 on 03/17/15 at the time of observation.

B. Observation on 03/17/15 revealed 4 South had two (Level 1 and Level 2) control solutions for use with a bedside glucose testing device that were not dated when opened or dated with an expiration date. The control solutions have a Manufacturer's label that stated it is good for three months once it was opened. Without a date it could not be assured the control solution was within the three months. The control solution findings of no date were confirmed by RN #9 at the time of observation.

C. Observation on 03/17/15 revealed 3 West had two (Level 1 and Level 2) control solutions dated as opened 11/19/14. The solutions were still in use at the time of observation on 03/17/15 which was past the 3 month expiration date once opened. The findings of expired date on the control solutions was confirmed by the Infection Prevention Nurse on 03/17/15 at the time of observation.

D. The Facility policy "Blood glucose monitoring" stated "When using a blood glucose meter, calibrate it and run it with a quality-control test following the Manufacturer's instructions to ensure accurate test results."


Based on observation and interview, it was determined the Facility failed to assure a room being used for one of one patient in airborne isolation had signage that described the type of isolation the patient required. It could not be assured staff and visitors would be aware and take precautions to prevent exposure. The failed practice likely affected all staff and visitors on the Unit. The findings were:

Observation on 03/17/15 at 0945 revealed no airborne precautions signage on the room door or the anteroom door for Room 3530. The Infection Preventionist confirmed the patient occupying the room required airborne precautions for suspected TB (tuberculosis). By interview on 03/17/15 at 0955, the lack of signage was verified by the Infection Preventionist who stated "there should be a sign for airborne precautions".


Based on observation and interview, it was determined four endoscopy devices observed were stored with the tips touching the bottom of two storage cabinets (#1 and #2). Patients would not be protected from potential sources of contamination. The failed practice was likely to affect any patient who had a procedure using the endoscopy devices. The findings were:

On 03/18/15 at 0830 observation of the endoscopy area revealed four endoscopy scopes were stored in cabinets #1 (one) and #2 (three) with the tips touching the bottom of the cabinet. The Director of Endoscopy confirmed the scopes were stored with the tips touching the bottom of the cabinet at the time of observation.



30634

Based on physician file review and interview, it was determined the Facility failed to ensure 8 (#2, #4, #5, #7 and #9-#12) of 12 (#1-#12) physicians had a current TB (tuberculin) skin test. The failed practice created the potential for a TB exposure to go unnoticed and could affect any patient receiving services from those physicians. Findings follow.

A. Review of credential files revealed Physician #2, #4, #5, #7 and #9-#12 did not have a current TB skin test.

B. During an interview on 03/19/15 at 0900, the Endoscopy Director confirmed the lack of current TB skin tests.

Based on clinical record review and interview, it was determined the Facility failed to ensure the time of the operation was included in the operative report for 10 of 10 (#11-#20) surgical patients. Failure to include the time of surgery did not allow knowledge of which surgical procedure was performed in what order in the event of multiple surgeries in one day. Findings follow:

A. Review of operative reports revealed the time of surgery was not documented for Patients #11-#20.

B. During interviews on 03/19/15 at 1542 through 03/20/15 at 0956, the Cardio Pulmonary Director, the Endoscopy Director and Registered Nurse #1 all confirmed there was no time of surgery on the operative reports.