HospitalInspections.org

Based on record review and interview, the facility failed to ensure 1 of 1 contracted service (Hemodialysis) was performed in a safe manner, in that,

1. Hemodialysis contract nurse did not adhered to the physician orders for 1 of 1 patient (Patient #28); and

2. Each hemodialysis treatment (2 of 2 orders - 9/16/18 and 9/19/18) orders for Patient #28 included range orders and/or orders allowing nurse discretion.

Findings included

A. Patient #28's 9/16/18 Physician Hemodialysis treatment order parameters of Blood Flow Rate (QB), and Removal Goal were not followed by the nurse during the 9/16/18 treatment.
1) QB order for 400 - 350 documented for 1.5 hours of the 2 hour treatment.
2) Goal ordered for 3000 to 4000 - 2562 documented at the end of treatment.

There was no physician notification of not following the orders for QB or Goal.

B. Patient #28's 9/16/18 Physician's Hemodialysis treatment order parameters gave unclear direction and there was no nurse notation for clarification of those orders:

1) Anticoagulation control stated, "Per Policy"
The policy stated, "per physician order."
2) Prime stated, "Nurse Discretion"

There was no nurse to physician clarification documented for the 9/16/18 order.

Patient #28's 9/19/18 Hemodialysis treatment order contained the same unclear direction for Anticoagulation and Prime as the 9/16/18 order.

During an interview on 9/19/18 ending at 10:10 AM, (Contract) Personnel #41 was informed of the above findings. Personnel #41 confirmed the above findings. Personnel #41 was asked about the Parameter of "Prime" and "Nurse Discretion." Personnel #41 stated, "The prime is either given to the patient or dumped at the treatment start. The nurse decides based on the patient overloaded assessment pre-treatment. Sometimes, instead of "nurse discretion", the doctor will put "Discard" and then we don't give it (Dump saline/bleed off at the start of the treatment) to the patient." Personnel #41 was asked if there was not an order for something like dialysate flow rate (QD) or a situation like low blood pressure, what would he need to do. Personnel #41 stated, "call the doctor."

The electronic hemodialysis treatment order did not have a parameter for Dialysate Flow Rate (QD) for the physician to prescribe.

During an interview on 9/19/18 ending at 10:54 AM, Personnel #42 was informed of the above confirmed issues and the location of the ordered parameters on the order as well as the hand written treatment sheet.

The April 2018, last revised "Anticoagulation" policy required, "Heparin is administered per physician's order. Order is to include date and time, patient name, route, heparin loading dose, hourly infusion, or bolus dose and stop/discontinuation time, as applicable ...double verification of heparin is required ..."

Based on observation, interview, and record review, the hospital did not identify widespread break of infection control issues, in that, 3 of 3 departments (surgical department, cardiac catheterization laboratory (cardiac cath lab), and wound care therapy) that performed sterile and/or clean procedures were found not adhering to the infection control standards.

Findings included

1. On 09/17/18 at 12:40 PM a tour of the surgery department was conducted with Personnel #1. During the tour in the semi-restricted and restricted areas of the surgery department, Physician #20 was found to have a mask hanging in his pocket and Physician #21 wore a skull cap that did not restrain his side burns and hair at the nape of the neck. Physician #21 was asked if he provided anesthesia services in the operating room. He replied he did. Personnel #1 who was with the surveyor confirmed the findings. Personnel #48 joined the tour and was informed of the above findings. Personnel #48 stated Physician #21 also performed anesthesia services in the cardiac cath lab. The cardiac cath lab permitted physicians and male staff to wear skull caps. And the physicians would go back and forth from either the surgery department and the cardiac cath lab. At 1:32 PM a male individual wore a skull cap, blue scrubs, and disposable jacket into the semi-restricted area pushing a cart with 4 wheels. The male individual was identified by Personnel #48. He was a cardiac cath technician. At 1:45 PM Physician #22 entered the postanesthesia care unit transporting Patient #20. Physician #22 wore a skull cap and a mask. Patient #20 just had a left lumbar 4-5 hemi-laminectomy surgical procedure.

On the same day (09/17/18) at 1:53 PM the surveyor and Personnel #1 went to the cardiac cath lab. In one of the cardiac cath room Physician #23 was observed wearing a sterile gown. He had sterile gloves and wore a skull cap. The cardiac cath technician within the sterile field also wore a skull cap. Personnel #49 was asked why Physician #23 and the cardiac cath technician were wearing skull caps. Personnel #49 replied they allow physicians and staff to wear skull caps and that they follow a different guideline. The above findings were confirmed by Personnel #1 who had been present throughout the tour.

2. On 09/18/18 at 9:25 AM a tracer patient, Patient #22 was followed in the preoperative unit. The surveyor observed a male individual wearing scrubs with his bouffant rolled up at the back of his nape exposing some short hair. The male individual was identified as Physician #50. This finding was confirmed by Personnel #1 and Personnel #18 who was with the surveyor at that time. At 9:52 AM, Patient #22 was followed to the operating room (OR). At 9:55 AM, the surveyor observed Personnel #48 provided direct patient care to Patient #22. Personnel #48's mask was tied in a lose manner that allowed venting. At 10:00 AM, one of the registered nurses took off the gloves and took a cart out to the substerile area. The surveyor followed her until she returned back to the OR. Without appropriate hand hygiene, the registered nurse then obtained a sterile peel pack, opened it, and handed the sterile instrument to the surgical technician in the sterile field. At 10:06 AM, Personnel #51 was observed not appropriately restraining her hair. A clump of side burn hair (left side) was not restrained inside the bouffant. At 10:13 AM, Personnel #51 was observed taking off the soiled gloves. Without proper hand hygiene, she then had direct patient contact.

3. On 09/18/19 at 2:00 PM, the surveyor conducted a tour at the outpatient wound therapy department with Personnel #17. At 2:20 PM, the surveyor and Personnel #17 was in room #5 with Patient #32 and Personnel #38. Personnel #38 was observed assessing the patient's wounds and measured the wounds. She then took off her gloves and without appropriate hand hygiene she put on a clean glove to her left hand only. Personnel #38 continued to perform direct patient care. Physician #37 came to see the patient, donned on gloves, and performed treatment to the wounds. After the procedure, he took off his gloves. Without appropriate hand hygiene, he talked to the patient and shook the patient's hands. Personnel #17 who was with the surveyor all of this time informed the surveyor that she observed hand hygiene was not performed after the physician and nurse took off their gloves.

Policy procedure "Surgical Attire" effective date and last reviewed on 11/2017 required "Personnel entering the semi-restricted and restricted areas will cover the head, hair, ears, and facial hair."

Policy Procedure "Hand Hygiene" effective date and last reviewed on 05/01/2018 required "3.1 Indications for Hand Hygiene...decontaminate hands before and after all glove use."

Based on observation, interview, and record review the hospital failed to ensure the dietary department requirements were in compliance in that the following was observed:

1) Spoons were observed to have dried food on them. They were with the clean flatware.

2) An assortment of pans were stored wet and were stacked upon one another.

Findings included

During a tour of the facility's only kitchen on 09/19/18 between 11:25 AM and 11:46 AM the following was observed. Personnel #46 was present and verbally confirmed the findings below:

1) Two of 5 spoons had dried food on them. They were with the clean flatware.

2) Two of 5 half pans, 1of 6 full pans, and 1 of 7 sixth pans were stored wet and stacked upon one another on a shelf.

A review of the hospital's 2018 Food Safety Cleaning and Sanitation standards and procedures reflected, "...Keep food-contact surfaces free of food residue, grease deposits and soil accumulations at all times... All food-contact surfaces must air-dry prior to being placed in storage..."