HospitalInspections.org

Based on observation and policy review the facility failed to provide storage of confidential patient medical information in a manner to prevent unauthorized access for patients on the 2 North and 2 South units of the facility. The facility census was 72.
Findings included:
1. Review of the facility policy titled "Confidentiality of Patient Information" last reviewed 5/09 revealed in part:
I. Purpose: Under federal and state law, health care providers have a duty of confidentiality that arises in the provider-patient relationships.
II. Definitions:
A. Protected Health Information (PHI) - any patient identifiable information whether oral, written or electronic, pertaining to a person's past, present or future health.
III. Examples of Confidential Information:
A. PHI (details about illnesses, conditions or treatments)

2. Observations revealed on 2/2/10 at 9:35 AM on the 2 South nursing unit revealed outside each patient room, in the main public hallway a wall-mounted storage unit called wallaroos, which contained parts of the patients' medical record having the potential to involve 18 patients on the 2 South end of the hallway.

These wall mounted storage units were unlocked and accessible to the public.
3. Observation on 2/2/10 at 9:55 AM revealed a patient face sheet with diagnosis in a bin on the wall outside the Nurse Manager's office.





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4. Observation and Interview on 02/02/10 at 10:12 a.m. revealed wallaroos, that held approximately 24-hours worth of documented patient information. The Chief Nursing Officer said these wallaroos are used only on the second floor, having the potential to involve 19 patients on the two north end of the hallway.

Each wallaroo contained documented patient information such as Medication Administration Records, Physician orders, Physician notification forms, patient name, date of birth, admission date, sex, weight, physician name, diagnosis, report sheet with code status, diet, intravenous sites, telemetry, activity, oxygen needs, intake and output, laboratory results, diagnostic tests, allergies, past history, and additional comments.

All wallaroos were unlocked, and easily accessible to unauthorized persons passing in the hallways.

Based on interview and record review the facility failed to obtain specific physician's orders indicating type and location of restraints utilized for two patients reviewed with restraints (Patients #3 and #31). The facility also failed to update the care plan to include the use of medical restraints for the same two patients. The facility census was 72.

Findings Included:

1. Review of a facility policy entitled, "Restraints/Seclusion,"revised 04/08, revealed the following:

a) Obtain physician's order using Medical Restraint Order Sheet.

2. Review of Patient #3's physician's orders on 02/01/10 revealed the patient was admitted on 01/31/10 with a diagnosis of Respiratory distress. The patient had an order dated 01/31/10 for restraints because the patient attempted to remove medical devices. The signed physician's orders for the dates of 01/31 and 02/01/10 were not specific to the type of restraint used, such as wrist, unilateral or bilateral, etc.

During an interview on 02/01/10 at 3:31 p.m., Registered Nurse (RN) Staff member D said the behavioral restraint order set included type of restraint, but the medical restraint order set did not. Staff member D said it was a nursing judgment as what type to use.

Review of the patient's care plan revealed no individual, specific interventions or goals regarding the use of a medical restraint.

During an interview on 02/01/10 at 3:48 p.m., RN Manager Staff member C said their computer system had no medical restraint care plan built in to it, according to their computer specialists.

3. Review of Patient #31's physician's orders revealed he/she had been restrained from 12/10-12/21/09 because of attempts to remove medical devices. Facility staff failed to indicate specific type of restraint used, such as wrist, unilateral or bilateral, etc.

Staff failed to update the patient's care plan to include the use of the medical restraint, with specific goals and interventions.

Based on observation, interview and record review the facility failed to administer medication following physician's orders for one patient (Patient #2) of 28 medication opportunities observed. The facility census was 72.
Findings include:
1. Observation of medication administration to Patient #2 on 2/2/10 at 9:15 AM showed Staff I, Licensed Practical Nurse (LPN) applied Nitro-Bid (heart medication) 2% ointment 1" topically.

Review of Patient #2's Medication Reconciliation/Physician Order Form revealed an order signed 1/29/09 to apply Nitroglycerin ointment ? inch every six hours.

In an interview on 2/2/10 at 10:30 AM, Staff I LPN confirmed she did apply one inch of Nitro-Bid ointment to Patient #2. Staff I said the medication administration record had been changed to 1 inch somehow, but the order was for ? inch.

Based on interview and record review the facility failed to ensure physicians' telephone and/or verbal orders were authenticated (signed, timed and dated) within 48 hours for two patients (Patient's #2, and #11) of 14 current sampled patients. The facility census was 72.
Findings included:
1. Review of the facility policy titled "Physician Orders" last updated 10/08 revealed in part:
C. All verbal and telephone orders are signed, dated and timed by the ordering physician within 48 hours (or another physician who is responsible for the care of the patient as specified by law). Physicians are encouraged however, to sign all orders as soon as possible.

2. Review on 2/2/10 of Patient #2's Physician's Orders revealed:
-An order dated 1/19/10 for an 1800 calorie decreased sodium diet.
-An order dated 1/19/10 for Zofran (nausea medication) 4 milligrams (mg) intravenous (IV) one time.
-An order dated 1/19/10 to give additional Metoprolol (blood pressure medication) 25 mg orally one time now.
-An order dated 1/20/10 to give Zofran 4 mg one time now.
-An order dated 1/21/10 nothing by mouth, up in chair and obtain consent for left Denver Drain placement.

The telephone/verbal orders had not been co-signed by the physician.

3. Review of Patient #11's Physician's Order revealed on 1/22/10 an order for Hydrocodone APAP (pain medication) 10/325 by mouth every four hours as needed.
The telephone/verbal orders had not been co-signed by the physician.
In an interview on 2/2/10 at 1:25 PM, Staff H, Nurse Manager for 2 South said verbal/telephone orders are to be signed by the physician within 48 hours. Staff H said staff are supposed to flag the orders so the physicians know what to sign. Staff H said he/she did not know why the orders were not flagged and/or signed.

Based on observation and interview the facility failed to ensure medications were secured and not accessible to unauthorized individuals on the 2 South nursing unit. The facility census was 72.
Findings included:
1. Observation on 2/2/10 at 9:15 AM and 10:30 AM revealed an unlocked cart in an open area behind the nurses' station on 2 south containing patient labeled medications including: 5-Aspirin Suppositories 300 milligrams (mg), 1-Diltiazem CD (heart medication) 120 mg, 4-Doxepin HCL (antidepressant) 10 mg, and 1 bottle of Polymyxin B Sulfate and Trimethoprim solution (used for eye infections) 10 mg.
In an interview on 2/2/10 at 1:25 PM, Staff H, RN Nurse Manager of 2 South said the cart with the medication should have been locked. Staff H said the cart is used for medications being sent back or received from pharmacy.
2. Review of the facility policy titled Medication Storage Between Receipt and Administration effective 9/16/08 revealed in part:
A. Safe storage. All drugs should be placed in an approved storage area (i.e., locked or secured medication room) as soon as possible, not to exceed 30 minutes from the time of receipt.

Based on observation, interview and record review the facility failed to dispose of, and/or label multi-use solutions/medications when opened or expired. The facility census was 72.

Findings Included:

1. Review of a facility policy entitled, "Sterile Preparations: Single-dose and Multi-dose Vials," effective 05/09, revealed once opened, multi-dose containers will be discarded after 28-days. Personnel puncturing/opening a multiple-dose container that will be used more than a single time will write the beyond-use date and their initials on the container.

Observation and interview on 02/01/10 at 1:50 p.m., in the psychiatric unit medication room, revealed an accessed 30-milliliter (ml) vial of Sodium Chloride 0.9%. The vial had an open date and initial sticker on it dated 10/20/09, approximately 66-days past the discard date per the policy. Registered Nurse Staff member E said the vial should have been discarded 30-days after opening.

2. Observation on 02/01/10 at 3:17 p.m., in the intensive care unit medication room, revealed an accessed 20-ml vial of Lidocaine 1% 10 milligrams/ml that had not been labeled with the date, time, or initials of the staff opening it. The vial was approximately 1/3 used. There was also a four ounce bottle of Betadine that was approximately 1/2 full, without a date, time or initial label.

Based on observation, interview and record review the facility failed to perform adequate hand hygiene during medication pass for two patients (Patients #10 and #11) and failed to ensure intravenous tubing was dated and timed for two patients (Patient #2 and #14). The facility census was 72.
Findings included:
1. Review of the facility policy titled "Hand Washing: Decontamination of Hands", last revised 4/08 revealed in part:
B. 2 a. Decontaminate hands before and after having direct contact with a patient.
b. Decontaminate hands before and after having direct contact with patient care, equipment or patient belongings.

2. Observation on 2/1/10 at 3:00 PM during medication pass, Staff K, Register Nurse entered Patient #10's room, put on gloves and started hanging intravenous medications without washing or using alcohol-based gel/foam to decontaminate his/her hands. Staff K left the patient's room to obtain supplies and returned. Staff K re-enter Patient #10's room, put on gloves without washing or using alcohol-based gel/foam to decontaminate his/her hands before continuing to hang the intravenous medication.

3. Observation on 2/2/10 at 9:35 AM during medication pass, Staff B, Registered Nurse entered Patient #11's room without washing or using alcohol-based gel/foam to decontaminate his/her hands and administered oral and intravenous medications.

In an interview on 2/2/10 at 9:40 AM, Staff B said hands are to be washed or use gel/foam before and after patient contact.

In an interview on 2/2/10 at 1:25 PM, Staff H Nurse Manager for 2 South said staff should wash their hands or use gel/foam when entering or exiting patients' rooms.

4. Review of the facility policy titled "Infusion Therapy, Initiation and Maintenance of" last revised 2/07 revealed in part:
C. 6. Label tubing for changes in 96 hours.

5. Observation on 2/2/10 at 9:15 AM revealed Patient #2's primary intravenous medication tubing had no label with date or time.

6. Observation on 2/2/10 at 10:45 AM revealed Patient #14's intravenous medication tubing had no label with date or time.

In an interview on 2/2/10 at 10:45 AM, Staff I, Licensed Practical Nurse confirmed the tubing had no label. Staff I said a label with date and time should be on the tubing.

In an interview on 2/2/10 at 11:07 AM, Staff G Chief Nursing Officer said intravenous tubing is labeled and changed every 96 hours.