HospitalInspections.org

Based on observation and staff interview, the hospital failed to ensure privacy was maintained for 1 of 2 sample patients (#9) in the behavioral health unit. The findings were:

Observation of the behavioral health unit on 10/3/11 revealed a video monitor was located on the desk in the nursing station, which showed the seclusion room. Observation also showed the nursing station had windows on two sides, one of which was by the entrance into the unit. Observation from 2:30 PM to 4 PM on 10/3/11 revealed patient #9 was in the seclusion room and could be seen on the monitor by any person entering the unit. Interview with the unit manager, RN #1, and RN #2 at the time revealed they had not identified that the monitor might be a violation of a patient's privacy, but agreed it could be.

Based on patient and staff interview, medical record review, and review of hospital policy and procedure, the hospital failed to ensure nursing assessments, monitors, and measures were implemented for preventive pain management for 2 of 17 sample patients (#6, #22) who had pain. The findings were:

1. Review of the medical record for patient #22 showed s/he was admitted with squamous cell vulvar cancer and an active MRSA (Methicillin Resistant Staphylococcus Aureous) infection in an abdominal wound. Review of the 9/26/11 physician's orders showed an order for Dilaudid 2 to 4 milligrams (mg) every four hours for pain, Vicodin 5/500 mg one tablet every four hours for pain, and Tylenol 325 mg one to two tablets every four hours for pain as needed. Review of the plan of care showed pain was identified as a problem and included the following interventions: use a numeric pain scale to monitor pain, reassess the pain after implementation of interventions, administer pain medications as requested, and position for comfort. The patient's pain goal was identified as 3/10 (level 3, on a scale from 0 to 10). The following concerns were identified:
a. Review of the 9/27/11 nursing notes showed at 2:42 AM the patient rated his/her pain at 8/10. Continued review showed no evidence medications or interventions were provided at that time. The nursing notes written at 4:01 AM that same day showed the patient again rated the pain as 8/10 and was medicated with Dilaudid 4 mg. The patient had pain rated 8/10 from 2:42 AM until 4:01 AM (one hour and nineteen minutes) before interventions were implemented.
b. Review of the 9/30/11 nursing notes written at 6 PM showed the patient's pain level was 9/10. Review of the MAR showed the patient received Dilaudid 4 mg at 6:35 PM, thirty five minutes later. Review of the nursing notes showed no evidence the patient's pain was re-assessed to determine the effectiveness of the Dilaudid in relieving the patient's pain within one hour as required by hospital policy. The re-assessment was not performed until three hours and twenty one minutes later, (9:56 PM), at which time the patient was noted to be resting with his/her eyes closed.

2. Review of the medical record for patient #6 revealed s/he was admitted with diagnoses including history of esophageal cancer, pleural effusion, and worsening congestive heart failure with shortness of breath and coughing. Interview with the patient on 10/5/11 at 4:05 PM revealed s/he had a lot of pain and was very uncomfortable. The patient said the pain medications helped reduce the pain but did not relieve the pain. The patient described the pain as in the chest and said it was from "shingles." Review of the 9/27/11 physician's orders showed an order for Percocet 5/325 (mg) every six hours as needed for pain. The following concerns were identified:
a. Review of the plan of care for this patient showed pain was not identified as a problem and therefore no plan with interventions was developed. Interview with quality improvement staff on 10/5/11 at 3 PM confirmed she had talked with the nurses who provided care for this patient and they said they had forgotten to develop a plan of care for pain.
b. Review of the 9/29/11 nursing notes written at 7:01 AM showed the patient's pain level was 6 out of 10 and his/her pain goal at that time was a 4/10. Percocet 5/325 mg was given but there was no evidence a re-assessment of the patient's pain was performed until 2:38 PM (7 hours and 40 minutes later).
c. Review of the nursing notes showed on 10/1/11 at 7:52 PM the patient was administered a Percocet 5/325 mg for pain but there was no documented intensity level or description of the pain. The documented pain goal was 3/10. According to the re-assessment at 9:15 PM the pain level was 4/10, which was still at a greater level of intensity than the goal set by the patient.
d. Review of the nursing notes showed on 10/5/11 at 3:43 AM the patient had pain rated 7/10 with a pain goal of 4/10 at that time. Staff administered a Percocet 5/325 mg for pain at 3:42 AM. At 5:10 AM the patient's pain was re-assessed and was 5/10. Review of the record showed no evidence additional interventions were implemented to relieve the patient's pain to an acceptable level.

3. Review of the hospital policy and procedure on pain management, ND/P.005-1, revised 8/1/07, showed "The goal of pain management for all patients will be decreasing pain to their stated level of comfort/function and controlling their pain to this level...." Further review showed the following instructions: "The patient's response to interventions will be assessed as follows:.....60 minutes following PO [by mouth] medication administration. All pain assessments and patient response to interventions must be documented, including pain scoring..." Interview with quality improvement staff on 10/5/11 at 3 PM verified this policy was current and should be followed.

Based on staff and resident interview and medical record review, the facility failed to ensure a care plan addressing pain was developed for 1 of 17 sample patients (#6) who had pain. The findings were:

Review of the medical record for patient #6 showed s/he experienced pain. Interview with the patient on 10/5/11 at 4:05 PM verified s/he had pain. Interview with a quality improvement staff member on 10/5/11 at 3 PM confirmed the patient had pain. Review of the current plan of care for this patient, however, revealed pain was not addressed and there were no interventions identified for symptom relief. Further interview with the quality improvement staff revealed she had spoken with the nursing staff who provided the care for the patient, and they confirmed no care plan for pain was developed, but it should have been.

Based on observation, staff interview, and review of policies and procedures, nationally recognized standards for infection control practices, and manufacturer's instructions, the facility failed to ensure effective infection control practices were used for disinfecting the glucometer: (a device for monitoring whole blood glucose) after use for 2 of 2 patients (#6, #12) observed receiving glucose testing. The findings were:

Review of the CDC information entitled "Recommended Infection-Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne Pathogens" revealed "...Glucometers should be assigned to individual patients. If a glucometer that has been used for one patient must be reused for another patient, the device must be cleaned and disinfected..." Review of the hospital's Infection Prevention Policy and Procedure, dated 5/31/11, revealed the cleaning process for clinical areas included, "Glucose monitors are cleaned with Hospital-approved disinfectant [PDI Sani-Cloths] between each patient use." Review of the PDI Sani-Cloth manufacturer's instructions revealed to effectively disinfect and remove harmful organisms ..."Use a wipe to remove heavy soil. Unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full two (2) minutes. Use additional wipe(s) if needed to assure continuous two (2) minute wet contact time. Let air dry." The facility's failure to follow their policy, CDC recommendations and the manufacturer's instructions were noted during the following observations:

1. RN #3 was observed on 10/4/11 at 7:45 AM as she performed a finger-stick glucose test on patient #12. After completing the test procedure, she cleaned the glucometer by wiping it with a disposable disinfecting wipe (PDI Sani-Cloth); the total contact time of the disinfecting wipe on the glucometer was forty-eight seconds. At that time the RN stated she was not aware of the manufacturer's required two minute contact time.

2. RN #4 was observed on 10/4/11 at 8:10 AM as she performed a finger-stick glucose test on patient #6. After completing the test procedure, she carried the glucometer to another patient's room, placed it on the counter top while she provided care for the patient, then returned the glucometer to the glucometer storage area. The RN used hand hygiene and wore gloves during the above tasks, but failed to disinfect the glucometer. At that time the surveyor talked with the RN about disinfecting the glucometer between patient use. The RN stated she "forgot to do it this time." She further stated she routinely used the PDI Sani-Cloths for disinfecting the glucometer between patient use, but she was not aware of the manufacturer's required two minute contact time.

Based on review of the organizational chart, facility documentation, and job descriptions, and staff interview, the facility failed to assign the responsibility of outpatient services to one designated individual. The findings were:

Review of a list provided by the facility revealed clinical outpatient services included: medical oncology, radiation oncology, cardiac rehabilitation, pulmonary rehabilitation, rehabilitation services (physical/occupational/speech therapy), cardiopulmonary, and behavioral health. Review of the facility organizational chart (dated 4/6/11) revealed one person was not assigned responsibility for the various outpatient services. During an interview on 10/5/11 at 2:25 PM, the director of quality confirmed that all outpatient services were not the responsibility of one designated staff person. The director of quality stated the director of nursing (DON) and the vice president (VP) of patient care services each had some responsibilities related to outpatient services. Review of the job descriptions for the DON and the VP of patient care services revealed neither job description included specific duties or responsibilities related to outpatient services.