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The governing body failed to ensure that the services performed under a contract were provided in a safe and effective manner related to hemodialysis and failed to ensure that the provision of care by a contracted security service was under the direction of a registered nurse. These findings include:

1. On 03/13/14 at 1:00 PM the surveyors were not provided with documentation from the Vice President, Administration to indicate that a training program at the Hemodialysis Nursing Unit that included quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues at least annually; i.e. training rosters indicate most all staff not current with water quality testing training within the last year;

2. On 03/13/14 at 1:00 PM the surveyors were not provided with documentation from the Vice President, Administration to indicate that the staff member that is responsible for water quality/water testing (Dennis) at the Hemodialysis Nursing Unit completed a training program at the Hemodialysis Nursing Unit that included quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues ; i.e. Facility Administrator cannot locate training records for water tech-or annual refresher training;

3. On 03/13/14 at 1:00 PM the surveyors were not provided with documentation from the Vice President, Administration to indicate that all employees are in serviced annually as to their duties during a fire emergency as, required by NFPA 101, "Life Safety Code " , section # 19.7.1 and NFPA 99, "Health Care Facility's" section # 11-5.3.8; i.e. documentation provided indicated 10 of 13 staff members from the Hemodialysis Nursing Unit had fire safety training within the last year.

4. Patient #3 was admitted to the in-patient BHU (Behavioral Health Unit) on 02/14/14 with diagnoses that included schizoaffective disorder. During tour of the adult BHU on 03/11/14 at 10:30 AM with Assistant Nurse Manager (ANM) #2, Vice President of Performance/Risk Management, Performance Management Staff #2, the Director of Psychiatry, and MD #6; Security Officer #1 was observed providing hands-on repositioning assistance to Patient #3 by pulling on the patient's right wrist. The patient was sitting in the bed with the head of the bed elevated with his/her right arm in a fully extended position. Subsequently, a Registered Nurse (RN) entered the Patient #3's room, lowered the head of the bed and closed the door.
Interview with The Director of Security on 03/11/14 at 11:45 AM identified that Security Officer #1 should have consulted with the assigned RN regarding the patient's need for repositioning.
Review of a Hospital Policy entitled Guidelines for Management of the Patient Needing One to One (1:1) observation signed by Security Officer #1 on 12/17/13 directed, in part, that Security Officers may only be utilized to provide 1:1 observation for providing and maintaining a safe environment for the patient exhibiting aggressive, combative, or acutely suicidal or homicidal ideation/behavior and/or provide close observation for patients who are behavioral risks. Additionally, if the patient has a specific request, the 1:1 observer will call the patient's nurse immediately and may assist the RN with activities of daily living (ADLs).

Based on observation, review of the clinical record, hospital policies and procedures, contracted security policies and procedures, and staff interviews, for one sampled patient on the in-patient, adult, Behavioral Health Unit (BHU) who required one to one observation by a security officer, Patient #3, the hospital failed to ensure that Security Officer #1 notified Patient #1's nurse of repositioning needs and/or refrained from physical contact with the patient. The findings include:

Patient #3 was admitted to the in-patient BHU on 02/14/14 with diagnoses that included schizoaffective disorder. During tour of the adult BHU on 03/11/14 at 10:30 AM with Assistant Nurse Manager (ANM) #2, Vice President of Performance/Risk Management, Performance Management Staff #2, the Director of Psychiatry, and MD #6; Security Officer #1 was observed providing hands-on repositioning assistance to Patient #3 by pulling on the patient's right wrist. The patient was sitting in the bed with the head of the bed elevated with his/her right arm in a fully extended position. Subsequently, a Registered Nurse (RN) entered the Patient #3's room, lowered the head of the bed and closed the door.
Interview with The Director of Security on 03/11/14 at 11:45 AM identified that Security Officer #1 should have consulted with the assigned RN regarding the patient's need for repositioning.
Review of a Hospital Policy entitled Guidelines for Management of the Patient Needing One to One (1:1) observation signed by Security Officer #1 on 12/17/13 directed, in part, that Security Officers may only be utilized to provide 1:1 observation for providing and maintaining a safe environment for the patient exhibiting aggressive, combative, or acutely suicidal or homicidal ideation/behavior and/or provide close observation for patients who are behavioral risks. Additionally, if the patient has a specific request, the 1:1 observer will call the patient's nurse immediately and may assist the RN with activities of daily living (ADLs).

Based on clinical record reviews, review of policies and procedures and interviews with facility personnel for two of eleven sampled patients reviewed for restraint usage (Patient #9 & P#49), the facility failed to ensure that restraints were applied/continued with a physician's order. The findings include:

1. Patient # 9 was admitted to the hospital on 7/12/13 with altered mental status and psychosis. Patient #9 had behaviors of being combative, as well as, self-destructive behavior. Review of the physician's orders dated 7/12/13 at 6:49 PM identified that the patient was to be put in four point restraints. On 7/13/13 at 9:01PM, Patient #9 was to have an Enclosure Bed. On 7/14/13 at 7:13pm, Patient #9 was to have a vest restraint for risk of self-injury. Patient #9 remained in behavior restraints with either a vest restraint and/or an Enclosure Bed until 7/19/13. Review of the clinical record failed to identify a physician order for the initiation and/or the continuation of restraints for violent behavior was obtained.


2. Patient #49 was admitted to the hospital 3/6/14 with exacerbation of Asthma. Review of the physician orders dated 3/6/14 identified that the patient had bilateral soft wrist restraints applied for pulling at tubes. Further review failed to identify that a physician order for the renewal of restraints was obtained for 3/7, 3/8 and 3/9/14. Review of nursing documentation dated 3/6/14-3/11/14, 5 days identified that the patient remained in bilateral soft wrist restraints.

Review of hospital policy identified that an physician/licensed independent practitioner must be informed of the restraint as soon as clinically feasible and must examine the patient within 24 hours and initiate or authenticate the order. Interview with the Director of Critical Care on 3/11/14 identified that a physician order was not obtained with the continuation of restraints.

Based on medical record reviews, review of hospital policies and interviews for three of eleven patients reviewed for restraint usage (Patients #10, #52 & #54), the facility failed to ensure that the patient was consistently monitored by the hospital staff. The findings include:

1. Patient #10 was admitted to the emergency department (ED) on 2/21/14 with a diagnosis of alcohol intoxication. Physician orders dated 2/21/14 at 7:23 PM directed the use of four point restraints due to the patient's combative behavior. Nursing restraint orders identified that psychosocial status, comfort and circulation be assessed every 15 minutes while restrained. Restraint monitoring documentation noted that the patient was assessed at 7:55 PM, 9:30 PM and 11:36 PM on 2/21/14 and at 12:09 AM, 12:58 AM and 1:53 AM on 2/22/14, and was not assessed every 15 minutes per the facility policy.

2. Patient #52 arrived at the ED on 02/03/14 at 3:51 AM with a diagnosis of Opiod Overdose. Review of the clinical record identified that Patient #52 was screaming and combative towards staff at 4:04 AM. A physician's order dated 02/03/14 at 4:51 AM directed the use of 4 point restraints for violent and/or self destructive behavior for a duration of 4 hours. Nursing Restraint orders and/or hospital policy directed monitoring and documentation of Psychosocial Status, Physical Comfort, Circulation, Respiratory Status, Restraints Applied Properly, and Patient free of Restraint Related Injury every (q) 15 minutes. Review of documentation of q15 min monitoring for Psychological Status, Physical Comfort, and Circulation identified documentation at 4:32 AM, 5:43 AM, 6:20 AM, 6:57 AM (no circulation documented at this time) and 7:20 AM (no circulation documented). All restraints were discontinued at 7:20 AM. Respiratory assessment on room air was documented at 4:00 AM, 5:12 AM, 6:25 AM, and 7:51 AM. Assessment for restraint related injury q 15 minutes was lacking. Required assessments were not documented every 15 minutes.

3. Patient #54 arrived at the ED on 02/03/14 at 5:21 PM for a chief complaint of decreased mental status. A physician's order dated 02/03/14 at 8:58 PM directed non-violent or non-self destructive restraint, a Soma Bed (net safety bed enclosure), due to Risk for Elopement as the patient was unable to remain on the stretcher despite redirection. Nursing Restraint orders and/or hospital policy directed monitoring and documentation of a Visual Check, Circulation, Range of Motion, Fluids, Food/Meals, and Elimination every 2 hours. Review of documentation identified monitoring was completed on 02/03/14 at 8:50 PM, 10:37 PM and, on 02/04/14, at 12:06 AM, 2:09 AM, 6:17 AM, 8:43 AM, 11:10 AM and 2:38 PM Required assessments were not documented every 2 hours between 2:09 AM and 6:17 AM. Additionally, hospital policy directed to conduct and document respiratory status assessment every 2 hours. Respiratory Status was documented as Breathing and Airway on 02/03/14 at 6:32 PM and Oxygen Therapy on 02/03/14 at 5:25 PM, 8:36 PM, 10:45 PM, and on 02/04/14 at 1:40 AM, 7:46 AM, 10:04 AM and 1:03 PM. Required assessments were not consistently documented every 2 hours.

Interview with the ED Educator on 3/11/14 at 10:40 PM indicated that patients who had behavioral restraints required monitoring every 15 minutes when in restraints. The hospital restraint policy identified that visual checks every 15 minutes to include psychological status, physical comfort, respiratory status, restraints applied properly and patient is free from restraint- related injury was required for patients restrained for violent or self- destructive behavior.

Based on clinical record reviews, review of facility policies and procedures and interviews with facility personnel for three of three sampled patients reviewed for restraint usage, (Patients #49, #50 and #51), the facility failed to ensure that a one to one evaluation was conducted by a physician with the initiation of restraints.
The findings include:

1. Patient #50 was admitted to the hospital on 3/8/14 with lethargy and hypotension. Review of the physician orders dated 3/9/14 identified that the patient was to have bilateral soft wrist restraints for unwilling/unable to follow commands. Review of the progress notes dated 3/9/14-3/11/14 failed to identify that a one to one evaluation was conducted with the placement of restraints. Review of nursing documentation dated 3/9/14-3/11/14 identified that the patient remained in bilateral wrist restraints.

2. Patient #49 was admitted to the hospital 3/6/14 with exacerbation of Asthma. Review of the physician orders dated 3/6/14 identified that the patient had bilateral soft wrist restraints applied for pulling at tubes. Review of the progress notes dated 3/6/14-3/11/14 failed to identify that a one to one evaluation was conducted with the placement of restraints. Review of nursing documentation dated 3/6/14-3/11/14 identified that the patient remained in bilateral soft wrist restraints.

3. Patient #51 was admitted to the hospital on 2/24/14 with Pancreatitis. Review of the physician orders dated 3/10/14 identified that the patient was to have bilateral soft wrist restraints applied for pulling at tubes. Review of the progress notes dated 3/10/14-3/11/14 failed to identify that a one to one evaluation was conducted with the placement of restraints. Review of nursing documentation dated 3/10/14-3/11/14 identified that the patient remained in bilateral soft wrist restraints.


Review of hospital policy identified that a physician/licensed independent practitioner must be informed of the restraint as soon as clinically feasible and must examine the patient within 24 hours and initiate or authenticate the order. Interview with the Director of Critical Care on 3/11/14 identified that the one to one evaluation was not completed by the physician.

Based on medical record reviews, review of facility policies observations and interviews for two of nine patients reviewed for dialysis services and/or falls (Patients #30 and #35), the facility failed to ensure that care was administered per the plan of care and/or the facility policy. The finding includes:

1. Patient #30 was admitted to the S7 unit on 2/27/14. The fall risk assessment dated 3/1/14 at 4 AM identified that the patient was at risk for falls (fall score > or equal to 10). The plan of care dated 3/1/14 at 3:51 PM indicated that the patient was at risk for falls and to implement interventions as appropriate. Nursing narratives dated 3/1/14 noted that the patient was on the bedside commode, pushed the call light and was found sitting on the floor. The nursing narrative also indicated that the patient thought he/she could reach the toilet paper (not within reach), got weak and sat on the floor. The hospital policy for fall prevention and management directed to implement universal fall precautions to include keeping call light, assistive devices and personal items in reach for those patients who were at risk for falls.
2. Patient #35 was admitted to the hospital on 3/9/14 and required daily hemodialysis treatment. The plan of care dated 3/10/14 identified a problem of hemodialysis and a goal to prevent potentially related complications of hemodialysis to include fluid management. The patient's weight record identified that the patient was weighed once daily on 3/9/14, 3/10/14 and 3/11/14. Observation of the patient on 3/13/14 at 9:30 AM in the 6th floor dialysis suite noted that the patient was in the bed and receiving dialysis treatment. Review of the patient's record and interview with RN #6 on 3/13/14 at 9:55 AM identified that the patient received dialysis treatments daily, had trouble standing and the patient's weight was not obtained on 3/12/14 and 3/13/14. RN #6 further indicated that the patient's bed did not have a scale as did other hospital beds and the standard was to weigh patients before and after dialysis treatment. The hospital did not have a policy regarding dialysis pre and post weights. Subsequent to surveyor inquiry, Patient #35 was provided a bed that had a bed scale.

Based on medical record reviews, review of facility policies, observations and interviews for one of three patients who had a urinary catheter (Patient #26), the facility failed to ensure that the patient's nursing care plan was comprehensive. The finding includes:

Patient #26 had a diagnosis of pneumonia and was admitted from the Schine 9 unit to the Rehabilitation Unit (T8) on 2/26/14. Physician orders and/or nursing documentation identified that the patient had urinary retention that the patient's urinary catheter was placed on 2/28/14, removed and reinserted on 3/4/14, removed on 3/9/14 and reinserted on 3/10/14. Observation on 3/11/14 at 11:20 AM noted Patient #26 had a urinary catheter and drainage bag and ambulated in the hall with a walker and assistance. Review of the patient's record and interview with the T8 Assistant Nurse Manager on 3/12/14 at 11:35 indicated that the patient required the catheter due to urinary retention and although the care plan identified that the patient had a urinary catheter, the patient's plan of care did not include the problem of urinary retention with goals and/or interventions. The hospital care plan policy identified that the patient plan of care is an interdisciplinary plan, which documents the patient's health problems, expected outcomes or goals and interventions/actions that assist the patient in meeting expected outcomes.

Based on clinical record review and interview for 2 (P#4 and P#31) of 5 patients reviewed who had an indwelling urethral catheter during the hospital admission the facility failed to obtain a physician's order for continued use of an indwelling urethral catheter. The findings include:

1. Patient (P) #4 was admitted to the hospital on 3/11/14 for a posterior lumbar fusion. An operative report dated 3/11/14 indicated a #16 indwelling urethral catheter was inserted intraoperatively for monitoring of urine output and was scheduled to be removed postoperatively on 3/12/14. The medical record lacked physician orders for the continuation or discontinuation of the indwelling urethral catheter postoperatively.

2. P#31 was admitted to the hospital on 3/9/14 for a scheduled cesarean section. An operative report dated 3/9/14 indicated an indwelling urethral catheter was inserted intraoperatively for monitoring of urine output. The medical record lacked a physician orders for the continuation of the indwelling urethral catheter postoperatively.



During an interview with the Director of Performance Management on 3/13/14 at 2:00 PM he/she indicated that during a review of the medical record of P#31 a postoperative physician's order for an indwelling urethral catheter was lacking in the medical record. The Director of Performance Management further indicated that upon record reviews it was found that at times an indwelling urethral catheter is inserted in the operating room. When the patient is transferred to the unit postoperatively the postoperative physician orders lack an order for the continuation or discontinuation of the indwelling urethral catheter.

Based on a tour of the hospital, review of facility policies, observations and interviews, for one of two automated medication dispensing machines reviewed for medication storage, the facility failed to ensure that all opened multi- dose medication vials were properly labeled . The finding includes:

A tour of the R7 unit was conducted on 3/12/14 with the R7 Nurse Manager. Observation of the automated medication dispensing machine on 3/12/14 at 1:37 PM identified two multidose vials of insulin located in a dispensing drawer. One of the vials was unopened and a preprinted sticker with the expiration date was observed on the outside of the vial. The other vial was observed opened, was 1/4 full, and lacked the expiration date/sticker. Interview with the R7 Nurse Manager on 3/12/14 at 1:37 PM noted that pharmacy staff labels the insulin vials and the sticker must have fallen off. The insulin vial was subsequently discarded by the R7 Nurse Manager. The hospital policy for expiration of multiple dose vials identified that insulin will be dated with the expiration date by the Department of Pharmacy when delivered to the patient care units.

Based on observation of the bathroom doors abutting the showers in multiple patient rooms on the adult, in-patient Behavioral Health Unit (BHU), the hospital failed to ensure that the laminate surface was free of signs of deterioration including cracks, loosened and removable fragments, and sharp edges, and failed to ensure that an oxygen tank was stored in a safe manner as per hospital policy. The findings include:

1. During tour of multiple patient bedrooms on the adult, in-patient BHU on 03/11/14 at 10:15 AM, bathroom doors that opened into the shower opening were observed to exhibit signs of deterioration. The lower portion of the laminate surface was discolored, cracked, and chipped. Shards of laminate were loosened and were lifting from the lower portion of the door. Edges were sharp and pieces up to 8 inches in length could be easily be removed from the door.

Review of doors and interviews with Assistant Unit Manager (AUM) #2 as well as the Vice President of Performance and Risk Management identified that not all of the patient rooms had showers with abutting doors. Door deterioration was directly observed in Rooms 970, 973, and 974. Although AUM #2 identified that nursing staff conducted walking rounds on Tuesdays and Thursdays each week and environmental rounds were conducted monthly, the deterioration of the doors had not been identified.


2. During tour of the Medease Department on 3/12/14, an observation was made of an oxygen tank lying horizontally on a counter. The oxygen tank was not stored in a stand or carrier with wheels as per hospital policy. Interview with the Medease Nurse Manager identified that the Respiratory Services Department had been notified about the tank several hours earlier that day.

Based on a tour of the facility, observations and interviews the facility failed to implement infection control practices and/or failed to maintain sanitary conditions throughout patient care areas and/or failed to ensure safe food storage in the kitchen. The findings include:


1. On 3/13/14 at 11:30 AM, during a tour of a hospital unit (Unit 9 Schine) contact precautions signage was noted on the wall outside of P #33's room indicating gown and gloves were required upon entering the room. In addition signage indicated handwashing was to be completed using soap and water. Personal protection equipment (PPE) was noted on the wall outside the room. Medical Doctor (MD) #4 was noted to be in P#33's room wearing gloves only. MD#4 exited the room, did not remove the gloves and wash his/her hands and began putting on an isolation gown. Performance Management Staff #1 immediately intervened and educated MD#4 on hospital infection control practices. Upon surveyor inquiry Nurse Manager (NM) #6 indicated P#33 was on contact precautions for Clostridium Difficile (C. diff.).

According to the facility contact precautions policy if the patient has C.diff. a sign noting the need to use soap and water for hand hygiene will be placed outside of the room in addition to the Contact Isolation sign. Gowns and gloves are to be used and should be worn by anyone entering the room and removed before leaving the patients room. Hands should be washed with soap before leaving the patient's room.


2. P#2 was seen in the Urology department for a cystoscopy. A facility investigation indicated P#2 had observed Registered Nurse (RN) #5 drinking tea in the patient care area and had not washed his/her hands immediately after. Upon interview with Nurse Manager #5 on 3/17/14 at 9:15 AM, NM#5 indicated upon investigation RN#5 has verified that he/she had been drinking tea in the patient care area while patients were present. RN#5 was educated on infection control practices related to ingestion of food/drink items in a patient care area in addition to the principles of hand washing.

According to the facility hand washing policy hand washing should be completed prior to patient contact to remove microbial contamination acquired by recent contact with patients or environmental sources

3. During a tour of the Urology Department on 3/13/14 a nutrition area separated from the preoperative and postoperative areas by a curtain partition was noted. Multiple glass cups were noted hanging from a "mug tree" immediately adjacent to the sink in the nutrition area . Nurse Manager (NM) #5 indicated the glass cups were the personal property of the staff. Upon surveyor inquiry NM#5 indicated the glass mugs should not be stored in a patient care area.

4. Patient #26 was admitted to the Schine 9 unit on 1/30/14 with a diagnosis of pneumonia. Nasal swab and/or culture reports dated 1/30/14, 3/1/14 and 2/7/14 identified Methicillin resistant Staphylococcus Aureus (MRSA). Patient #26 was admitted from the Schine 9 unit to the Rehabilitation Unit (T8) on 2/26/14. Physician orders and/or the medication administration records identified that the patient received Vancomycin on the T8 unit from 2/26/14 to 3/11/14 as ordered. Physician orders and/or the medication administration records indicated that the patient received respiratory nebulizer treatments by the respiratory therapist or nurse from 1/30/14 to 3/12/14 as ordered. Observation on 3/12/14 at 11:20 AM noted a contact precautions sign on the patient's door and staff donned gown and gloves to ambulate the patient. Interview with the T8 Assistant Nurse Manager on 3/12/14 at 11:35 AM noted that staff never wore masks when caring for Patient #26, the patient was on contact precautions and masks were not required. Interview with Respiratory Therapist # 1 on 3/17/14 at 10:45 AM identified that he/she provided respiratory treatments to patients throughout the hospital and would wear a yellow gown and gloves when providing treatment to patients who were positive for MRSA. Interview with Infection Preventionist #1 and #2 on 3/17/14 at 10:00 AM indicated that staff were expected to follow standard precautions along with contact precautions and would be required to wear a mask if the care being provided providing might elicit a potential exposure. The hospital policy for multi- drug resistant organism (including MRSA) and/or contact precautions identified that patients infected or colonized must be placed on contact precautions, a contact precaution sign will be placed outside the patient's room and goggles, eye protection and/or masks are necessary when splashing or aerosolization of infective material is anticipated (i.e. with respiratory treatments).
5. Patient #28 was admitted to the emergency department on 3/10/14 from an extended care facility (ECF) with a fractured right hip and history of colonization with Vancomycin resistant enterococcus. Patient #28 was admitted to the S7 unit on 3/11/14 and following surgery, was transferred to the R7 unit on 3/11/14. The surveillance nasal swab collected on 3/12/14 identified MRSA. Observation on 3/12/14 at 1:36 PM noted a contact precaution sign outside of Patient #28's door and visitor in the room wearing a uniform and donned with a yellow gown. Observation and interview with the R7 Nurse Manager on 3/12/14 at 1:46 PM indicated that the visitor was not wearing gloves, was a hospital employee and a family member of the patient. Subsequent to surveyor inquiry, the R7 Nurse Manager educated the visitor regarding glove usage. The hospital policy for contact precautions identified that gloves are worn when entering the patient's room.
In addition, interview with the Patient #28's nurse on 3/12/14 at 1:51 PM noted that surveillance nasal swabs for MRSA should be collected from all patients who are admitted from an ECF on the day of admission. Interview with IP #1 and #2 on 3/17/14 at 10 AM indicated that emergency department nurses were also required to perform surveillance nasal swabs. Then hospital policy for MRSA surveillance directed that all patients admitted from an ECF will be screened for MRSA, a physician's order was not required and if the ED nurse does not obtain the nasal swab, the nurse on the unit where the patient is admitted will obtain the sample.
6. A tour of the endoscopy unit was conducted on 3/13/14 at 10:10 AM with the Unit Manager. Observations on 3/13/14 at 10:15 AM identified that the unit had 5 procedure rooms, two of which were in use. Observations of procedure rooms #1, #5, and #6 identified a thick build-up of dust over door jams and on top of door hardware as well as a film of dust observed on top of the scope cabinets. Interview with the Nurse Manager at this time indicated that although endoscopy staff cleaned procedure rooms between cases, more extensive cleaning was performed by a designated environmental service staff member at the end of each procedure day. The hospital was unable to provide a cleaning procedure policy at the time of the survey.
In addition, each procedure room had multiple vented cabinets utilized for scope storage. Observation on 3/13/14 at 10:30 AM noted that two of five scope cabinets in Room #1 were not vented and, therefore did not allow for airflow that would enhance the scope drying process. Two of four upper endoscopes were observed with the top portions looped, not allowing the scopes to hang completely vertical to ensure draining of residual fluid following the disinfecting process. Interview with the Nurse Manager on 3/13/14 at 10:31 AM indicated that he/she was unsure whether or not the closets required a vent and believed that the part of the scope that entered the patient was the part of the scope that was required to hang vertically. The hospital policy for care and cleaning of endoscopes and accessories directed to hang scopes in cabinets with valves removed to prevent retention of moisture in the channels. According to the AORN Standards and Recommended Practices (2010), flexible endoscopes should be stored in a closed cabinet with venting and hanging in a secure vertical position to prevent coiling or kinking with removable components and accessories removed.
7. Observation during a tour of the in-patient, geriatric, BHU on 03/12/14 at 10:00 AM with Assistant Nurse Manager (ANM) #3 and multiple administrative staff identified that a large, open, shower room contained 2 large shower chairs. Various types of debris were visible on the shower room floor that included 2 probe covers, a disposable needle sheath, and a brownish, stain-like substance near the drain.

Review of 2 Environmental Checklist, 1 documented by an RN on 03/04/14 and 1 documented by a Patient Care Technician (PCT) on 03/04/14 lacked inspection of the sanitary conditions of the shower rooms on the unit. Review of a daily assignment of defined work activities dated 03/12/14 identified that the shower room was to be cleaned between 8:00 AM and 10:15 AM.

Observation and interview with ANM #3 during tour of the shower room identified that the debris should have been removed as part of the cleaning process.


8. Tour of a walk-in refrigerator with the Director of Food and Nutrition on 03/13/14 at 1:00 PM identified an open box with a manufacturers label that read, frozen sugar free dessert topping. The box had a date of 03/11/14 handwritten on the side and contained multiple, sealed, plastic pastry bags. Palpation of the bags identified that the contents of the bags was soft. The tip of 1 pastry bag protruded from the top of the box without benefit of a protective cover, exposing the dessert topping to the refrigerator environment.
Interview with the Production, Procurement, and Catering Manager at the time of the observation identified that the pastry bag should not be stored without a cover and the bags of sugar free topping were not stored in the freezer because the hospital used a large quantity of the product daily. The hand written date on the side of the box was the date the product was delivered. There was no visible "use by" date on the box or on the open bag. Subsequent to the observation, the open pastry bag was removed.






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Based on medical record reviews, review of hospital policies, observation of the hospital electronic messaging system (e- mail), and interviews for one of five discharge records reviewed (Patient #39), the facility failed to ensure that the operative report was authenticated/signed timely by the surgeon who performed the procedure. The finding includes:

A tour of the medical records department was conducted on 3/13/14 at 11:05 AM. Patient #39's electronic medical record was reviewed with the Vice President of Performance/Risk Management and the Acting Site Director of Medical Records on 3/13/14 at 11:30 AM. The discharge summary for Patient #39 identified that the patient was discharged on 3/4/14. The operative report indicated that the patient had a surgical procedure on 2/17/14 by MD #7, the operative report was dictated and transcribed on 2/17/14 and was not sign by MD #7 until 3/4/14 (15 days after transcription). Interview with the Acting Site Director of Medical Records on 3/13/14 at 11:45 AM noted that the operative report is not complete without a signature and the report would not be released until the report was signed. Interview with the Chief of Surgery and observation of his/her e-mail in- box on 3/13/14 at 12:55 PM indicated that once the operative report was transcribed a notification of this is sent to the surgeons in- box to cue the surgeon that the report was ready to be signed. The hospital's Medical Staff Rules and Regulations identified, in part, that complete operative or procedure reports, when required, shall be dictated or completed within 24 hours of the operation or invasive procedure.

Based on review of hospital policies, observations and interviews for one of three anesthesia carts, the facility failed to ensure that medication syringes were properly labeled. The finding includes:

A tour of the endoscopy unit was conducted on 3/13/14. The anesthesia cart in procedure Room #1 was observed with the Chairman of Anesthesia on 3/13/14 at 10:30 AM. The observation identified three medication syringes in the top drawer of the cart. The three syringes lacked the name of the medication and one of three medication syringes lacked the date or time that the medication was drawn. Interview with the Chairman of Anesthesia on 3/13/14 at 10:30 AM indicated that the Certified Registered Nurse Anesthetist (CRNA) drew up the syringes earlier and should have initialed, timed and dated all syringes. The anesthesia policy for drug labeling and storage identified that each syringe shall be labeled with either the generic or brand name of the drug, dilution (if it is not standard), the date of preparation, time of expiration, and the initial of the individual who prepared the syringe.