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Based on interview and record review, the hospital failed to ensure a system for reporting deaths potentially associated with the use of restraints, including 1 of 1 patient (P1) whose record review revealed restraint-use within 24-hours prior to death.

Findings include:

An interview conducted with a registered nurse (RN-A) on 8/3/11, at 10:00 a.m. and RN-B revealed the hospital had not reported any deaths to CMS associated with restraint use in the previous year. The nurses reported that although there were patients who would have met the criteria of restraints and death, because they did not believe they were "associated" with the restraint use, they were not reported. RN-A she was aware of a patient death within 24-hours of the use of a medical restraint within the last couple of months, but the reason for death was the removal of life support versus restraint use. RN-B stated reporting to CMS a death that occurred within 24-hours of the use of a restraint was not part of their restraint policy.

P1's record review noted non-behavioral restraints were utilized due to movement that could result in negative clinical outcomes. The medical restraints were initiated on 7/11/11, at 8:00 p.m. The medical restraints were discontinued on 7/13/11, at 8:00 p.m. Life support was removed and the patient expired on 7/13/11, at 11:55 p.m. The facility did not notify Centers for Medicare and Medicaid Services (CMS) of P1's death that occurred within 24-hours of the use of restraints.

Information from P1's chart was presented to RN-A on 8/4/11, at 11:50 a.m. The RN stated reporting to CMS, "Is not something we are doing," based on their interpretation of the regulation. RN-A said they disagreed with the interpretation deaths should have been reported when the criteria was met, regardless of the facility's decision those deaths were unrelated to the restraint use.

Based on record review and staff interview, the hospital failed to ensure that all medications were administered effectively for 56 patients from February 2011 through July 2011. The deficient practice could potentially affect many patients in the hospital.

Findings include:

Review of the Medication Safety Events noted the patients were not receiving the prescribed medication in a timely manner. The hospital had knowledge of intravenous (IV) medications not being properly infused since 6/30/10 and did not apply a corrective action plan to ensure proper administration of the IV medications.

The Medication Safety Events reports for the hospital were reviewed from February 2011 through July 2011. The following was noted:

February 2011 noted four incidents of patients not receiving intravenous (IV) medication in a timely manner due to the roller clamps not being opened (two incidents) or the bag being fully spiked (two incidents). The action plan was to distribute education on how to mix the duplex bags. However, no information on education was noted about the roller clamps.

March 2011 noted ten incidents of patients not receiving IV medication in a timely manner due to the roller clamps not being opened (seven incidents) or the bag being fully spiked (three incidents).

Action plan documented on the Medication Safety Events reports for March 2011 was as follows:
- On 3/3/11, action taken was to reinforce the importance of checking the tubing to make sure it was unclamped before leaving the room.
- On 3/10/11, Roller clamp not opened. Action taken was to "Remind staff via email to monitor medication infusion more closely."
- On 3/11/11, no action was taken for the unclamped roller on the IV medication.
- On 3/11/11, action taken was "Nurse will take care to be sure clamps are open."
- On 3/13/11, no action was taken for the unclamped roller on the IV medication.
- On 3/17/11, action taken was to "Double check syringe pumps within 5-10 minutes to ensure med is infusing."
- On 3/25/11, Roller clamp not opened. Action taken was to "make sure roller clamp is opened before leaving the room."
- On 3/25/11, seal not broken on IV medication. No action was taken.
- On 3/30/11, seal not broken on IV medication. No action was taken.
- On 3/31/11, roller clamp not opened. Action taken was to "Continue to educate staff to check that med dripping/infusing after hung."

April 2011 noted eight incidents of patients not receiving the IV medication in a timely manner due to the roller clamps not being opened (four incidents) or the IV fluid not being infused (four incidents).

Two incidents indicated the same reminders to staff to ensure medication infusing before leaving the room. Six incidents did not have any action taken.

May 2011 noted 12 incidents of patients not receiving the IV medication in a timely manner due to the roller clamps not being opened (11 incidents) or the IV fluid not being infused (one incident) due to syringe not being activated.

Three incidents of the roller clamps not being opened indicated the same reminders to staff to ensure medication infusing before leaving the room and/or emailing the staff involved. Eight of the roller clamps not being opened did not have any action taken. The syringe not being activated had no action noted.

June 2011 noted eight incidents of patients not receiving the IV medication in a timely manner due to the roller clamps not being opened (three incidents) or the IV fluid not being infused (five incident) due to syringe not being activated or IV medication not connected.

Of the eight incidents, four incidents had the same reminders to staff to be aware of medication infusing before leaving the room. However, four incidents had no action taken.

July 2011 noted 14 incidents of patients not receiving the IV medication in a timely manner due to the roller clamps not being opened (seven incidents) or the IV fluid not being infused (seven incident) due to syringe not being activated or IV medication not connected.

Of the 14 incidents, seven incidents had the same reminders to staff to be aware of medication infusing before leaving the room, how to infuse the IV medications, and emailing the staff that did not open the roller clamps. However, seven incidents had no action taken.

The Medication Safety Events reports from February 2011 to July 2011 alone indicated 32 incidents of where the roller clamp was not opened to allow the medication to be infused and 20 incidents of the IV medication bag not being activated, hooked up properly or the pump not being turned on.
Registered nurse (RN)-A provided a copy of the summary report from MEDMARX (A National Database to Reduce Hospital Medication Errors) for antibiotics alone dated 8/1/11.
The summary indicated that from 6/1/10 to 12/31/10, indicated 20% (13/65) of the patients did not receive their antibiotics due to roller clamps not being unclamped and 16.9% (11/65) patients did not receive the prescribed antibiotics due to the antibiotics not being hooked up properly, pumped not turned on or duplex bag not being activated. The summary also indicated that from 1/1/11 to 6/30/11, 16.7 % (7/42) of the patients did not receive their antibiotics due to roller clamps not being unclamped and 14.3% (6/42) patients did not receive the prescribed antibiotics due to the antibiotics not being hooked up properly, pumped not turned on or duplex bag not being activated. The summary noted that on 11/18/10, the pharmacy provided education to the Education Council regarding the duplex bag activation units. Nothing was noted about the roller clamps not being properly unclamped, bags hooked up properly or the pumps being turned on.
The pharmacy indicated via email to RN-A on 7/25/11, at 8:26 a.m. that the pharmacy "reminded the group on how to activate this product." The email further indicated the type of errors noted are a nursing practice issue. "Meaning the nurses should not leave the room after hanging any IV product without making sure the medication is infusing." The email further documented, "Unfortunately, there are these types of errors on various medication IV syringes and piggybacks where the pump wasn't turned on, roller clamp not released, etc. Errors can occur with any product regardless of what package it is dispensed in."
The director of pharmacy was interviewed on 8/4/11, at 1:30 p.m. and she acknowledged the information was brought forward to the various committees in the hospital but no action had been taken for the IV medication that had not been infused.
RN-A indicated through an interview on 8/4/11, at 2:45 p.m. that she had requested information via email on the IV antibiotics from the pharmacy on 7/22/11, at 10:41 a.m. She had just started to investigate the reasons the patients were not receiving the prescribed medication.

Based on observation, record review, interview and policy review, the hospital failed to ensure physician orders for medications were complete before administrating medication for 1 of 1 patient (P2) observed receiving eye drops.

Findings include:

P2 received three different eye drop medications and the physician's order had not been clarified to which eye, the drops were to be administered.

Observation at 11:51 a.m. on 8/3/11, indicated registered nurse (RN)-E administered one drop of Ketorolac (a medication that treats itchy and swollen eyes) eye drop into P2's right eye.
The physician orders that RN-E checked before administering the eye drops to P2 was dated 8/2/11, at 2:33 p.m. The order indicated it was current at the time the eye drops were administered. The orders read: Ketorolac 0.5% 1 drop, four times a day; Ofloxacin (medication used to treat eye infections) 0.3% ophthalmic drops 1 drop four times a day; and Prednisolone (a medication used to reduce infection and inflammation of the eyes) 1 drop, four times a day. The three eye drop bottles repeated these orders as stated above and did not include which eye(s) the medications were to be administered in.

Review of the medication administration record (MAR) dated 8/2/11 and 8/3/11, for the three eye drops indicated the hospital did not record which eye the eye drops had been instilled after they were administered. Three different nurses had administered these medications over two days without clarifying the physician's order to which eye the drops were to be administered.

Interview at 11:50 a.m. on 8/3/11, with RN-E who was about to administer the eye drops indicated she had asked the patient which eye the eye drops were for. She further indicated after she had administered the drop that she knew the orders were incomplete and had planned to call the pharmacy that morning but got busy and forgot. The RN orientating with her confirmed that she had mentioned that to her.

Interview with the director of nursing (DON) at 12 noon on 8/4/11, confirmed it was their policy to get the order clarified before the medication was administered and the orders should have included which eye the patient was to receive the three different drops.

The policy review by the hospital dated 3/11, indicated: "GUIDELINES: A. Medications are to be administered as ordered by the prescriber. B. A medication order includes medication name, dose, route, frequency and rate when applicable... D. All new medication orders will be checked by Registered Nurse (RN)." The eye drop orders had an unclear route for which eye(s), the three different eye drop medications, where to be administered.

Based on the Life Safety Code Substantial Complaint Validation survey completed on 8/4/11, the facility was found not in compliance with Life Safety from Fire found at CFR 482.41 (b).

Refer to Life Safety Code deficiencies-K0011, K0029, K0033, K0050, K0052, K0070, K0078, K141 and K0050, for additional information.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

Based on observation, interview, record and policy review, the hospital did not ensure the 38 of 38 anti-embolism electrical pumps used in surgery were serviced yearly, and the facility failed to ensure safe temperatures was maintained for 1 of 9 blanket warmers observed.

Findings included:

Thirty-eight electrical pumps, utilized for hospital patients receiving anti-embolism stockings, were not routinely checked and serviced by the biomedical equipment department.

Tour of the surgical department was conducted on 8/2/11, at 7:15 a.m. with the Director of Quality and the Director of Surgery. Thirty-eight pumps utilized for patients receiving anti-embolism stockings, were observed on a cart in the hall. In checking the pumps, no biomedical equipment tags were present to indicate when the equipment was last checked or serviced. At 10:15 a.m. the Director of Surgery indicated the pumps are considered a low hazard risk to patients, so the pumps were not routinely checked and serviced.

On 8/3/11, the hospital policy for Medical Equipment Inclusion Criteria, last revised on 4/5/10, was reviewed. The policy indicated equipment would be categorized for priority and criticality to determine the level of preventive maintenance and inspections. Only those devices having a medical equipment management number of twelve or greater would be included in the medical equipment management program. The anti-embolism stocking pumps were given a score of six.

On 8/4/11, at 11:05 a.m. an interview was conducted with the Clinical Engineer in charge of the biomedical equipment. He indicated when a new piece of equipment was delivered to the hospital, two people utilized a set scoring standard, to check the equipment and determine the priority and criticality of the equipment. He further indicated if the equipment did not score 12 or above it was not routinely checked and serviced by the biomedical department. He indicated the anti-embolism stocking pumps scored a six, so would not be routinely serviced.

On 8/5/11, the manufacturers' guidelines for the anti-embolism pumps was received from Flowtron Universal Service. The manual indicated a potential electrical shock hazard existed even with the pump switch off. The manual indicated the pumps be serviced every 12 months.


28595



The temperature of a blanket warmer containing infant receiving blankets was observed to be set at 130 degrees Fahrenheit (F).

During a tour of the 3 north area of the hospital (the family birthing center) at 1:00 p.m. on 8/2/11, the temperature of a blanket warmer containing infant receiving blankets was set at 130 degrees F. The thermometer attached to the warmer was not working and no read out of the temperature was available. There was a warning posted on the front of the warmer that read "Set at 110 degrees F."

A review of the Blanket Warmer Temperature Log revealed the temperature was documented to be 124 degrees F on 6/6/11, and the temperature gauge had been set at 140 degrees F. It had been turned down at that time and a recheck of the warmer 30 minutes later revealed the temperature to be 110.6 degrees F.

On 7/9/11, the temperature was documented to be 122 degrees F and the gauge had been set at 130 degrees F. The temperature was turned down but no follow up temperature was documented. The temperature log did not specify what temperature it was turned down to or if maintenance had been notified of the problem.

At 1:05 p.m. on 8/2/11, registered nurse (RN)-D stated the personal care attendants (PCA) and sometimes the licensed practical nurses (LPN) were responsible for monitoring the temperatures. LPN-A was interviewed and explained if the temperature reading is too high or too low, it is just turned up or down. LPN-A verified she had removed a blanket from the warmer on a past occasion and it was very hot. LPN-A stated, "I just shook it out a bit before I used it on a patient."

RN-D verified maintenance should have been called and stated, "I will check with them to see if they received a request." RN-D stated, "This is a good opportunity for quality improvement."

A review of the Blanket Warmer Temperature Control Policy revision date 7/10, revealed all blanket warmers were to be set at 110 degrees F and maintain temperature between greater than 105 F and less than 115 degrees F.

At 12:15 p.m. on 8/4/11, care center director RN-C verified there had been no previous maintenance requests made on the blanket warmer.

Based on observation, record review, interview and policy review, the facility failed to ensure infection control practices were adhered to for 1 of 2 Magnetic resonance imaging (MRI) rooms in the outpatient radiology location.
Findings include:
A tour of the outpatient radiology service area was completed on 8/2/11, at 2:10 p.m. The outpatient imaging area had two MRI rooms both of which were utilized. Radiology tech (RT)-A had just completed the imaging process and RT-A assisted the patient off the table. RT-A readied the MRI table by replacing the soiled sheet with a clean sheet. The table had not been disinfected.
RT-A was interviewed on 8/2/11, at approximately 2:20 p.m. RT-A acknowledged that the table should have been disinfected and that it should be done between every patient. On 8/3/11, at 4:05 p.m. RT-A was again interviewed and acknowledged she had done about 5-10 patients the day before and did not disinfect the table between each table.
The policy for Cleaning of Ambulatory Care Exam rooms revised 3/10, was reviewed. The section of procedure Room/Infusion Areas directed the staff "Use disinfectant cleaner on all horizontal work surfaces, mayo stands (a surgical tray that adjusts to heights), and equipment after every patient." The horizontal MRI tables were not disinfected after patient use.

Based on review of the organizational chart of outpatient services and interview, the hospital failed to ensure that there was one single person responsible for the 22 outpatient services.

Findings include:

On 8/1/11, at 2:30 p.m. the locations of the outpatient services were reviewed and the hospital indicated they had approximately 22 outpatient off-sites.

The facility's organizational chart dated 9/16/10, was reviewed. The chart indicated that there were was no one person in charge who directs the overall operation of the 22 outpatient services.

On 8/3/11, at 8:50 a.m. the assistant vice president was interviewed and the assistant vice president acknowledged that no one person oversees the outpatient services. The duties have been disseminated throughout the system.