HospitalInspections.org

Based on observation, staff interview and review of maintenance records between 6/15 and 6/17/2015, the facility failed to construct, install and maintain the building systems to ensure life safety to patients due to (i) failure to maintain corridor wall of one room smoke resistant; (ii) exit access corridor doors not properly latching in three locations; (iii) lack of proper exit signage to clearly identify the egress path to exits in two locations; (iv) smoke barrier not properly constructed in two locations, and penetrations in one smoke barrier not properly sealed; (v) one set of smoke doors not properly functioning;

(vi) failure to enclose three hazardous areas with properly installed fire-rated walls and self-closing doors; (vii) failure to maintain one exit door operable; (viii) one exit access door from a surgery room not readily operable; (ix) lack of sprinkler protection in three locations; (x) exit access from an space in one room obstructed by handrails; (xi) lack of medical vacuum system shutoff valve in one location; (xii) failure to maintain required relative humidity in two anesthetizing locations; (xiii) failure to maintain sufficient and clear working space in front of electrical equipment and panels, and to provide emergency power supplied electrical outlets in one patient recovery room; and (xiv) lack of proper ventilation in three clean supply rooms and three soiled utility rooms.

The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients.

Refer to the following K-tags and C-tags for detail.
K17, K18, K22, K25, K27, K29, K32, K38, K56, K72, K77, K78, K147, C-226, and C-231.

Based on observation and interview staff at this facility failed to maintain the physical integrity of 3 of 3 Operating Rooms observed (OR #1, 2, and 3), 1 of 25 patient rooms (room 107) and 1 of 1 nurses station on the Medical/Surgical floor.

Findings:

On 6/15/2015 at 3:10 PM the following observations were made in the surgery department: OR #1: chipped paint on the 3 of 4 walls, gouges in the wood panel door to substerile room revealing porous surface; OR #2: gouges in the wood panel door to substerile room revealing porous surface, holes in floor and cracked grout on tile between walls and floor; OR #3: holes in floor and chipped paint on 2 of 4 walls.

These findings were discussed with OR Manager F at the time of the observations. Per interview with OR Manager F on 6/15/2015 at 3:20 PM, OR Manager F stated it is the responsibility of the EVS staff to inspect the OR suites during routine cleaning. Per OR Manager F, EVS staff has been trained to report "cracks, rips in table, broken equipment" to the manager so a work order can be placed.


26711


On 6/16/2015 a tour of the Medical/Surgical unit was completed between and 11:24 AM 12:10 PM accompanied by CNO A. The following observations were made:
Room 107 had a gouge in the drywall exposing a porous uncleanable surface underneath.
The edge of the nurses station (across from patient room 121) has a large section of missing laminate exposing the porous wood surface underneath. The edges of where the laminate are missing are also sharp and jagged.
In an interview with CNO A at the time of discovery, CNO A stated that these areas need to be repaired.

Based on observation and staff interview, the facility did not provide proper ventilation in six spaces due to failure to maintain negative pressure in three spaces, and positive pressure in three other spaces. This deficient practice had a potential of contamination of air in clean spaces with undesirable contaminants, and possible infection to patients. This observed situation is not consistent with CDC and AIA guidelines.

The CDC guidelines can be found in the website


Findings include

During a tour of the facility with Staff C (plant services manager) between 6/15 and 6/16/15, surveyor observed the following deficiency item in six locations:

1. On 6/15/15 at 3:42 pm, the Soiled Linen room 0E100 in the lower level was not under negative pressure with reference to the Clean Linen Room 0E095. The negative, neutral or positive was determined by using a thin one-ply tissue paper and sliding it down along the room door and observing the direction of movement of tissue paper;

2. On 6/16/15 at 9:30 am, in the storage room with housekeeping chemical, mop carts and laundry washer it could not be verified that a proper pressure relationship relative to the Clean Linen Room 0E095 was maintained due to two large openings (4 ' x 10 and 6 ' x 6 ' ) cut in the masonry block walls of the storage room. Furthermore, there was a supply air into but no exhaust out of the storage room to maintain negative pressure;

3. On 6/16/15 at 10:08 am, the Clean Supply and Utility Room FD51 in the patient sleeping unit was not under positive pressure. The space was instead under negative pressure causing airflow in a wrong direction.

4. On 6/16/15 at 11:05 am, the Soiled Utility Room 1B090 across suite B142 in the swing bed unit was not under negative pressure. The space was instead under positive pressure causing airflow in the wrong direction;

5. On 6/16/15 at 11:58 am, the Sterile Supply Room 1B045 in the OR suite was not under positive pressure as required to ensure airflow in the right direction. The space was close to neutral relative to the corridor;

6. On 6/16/15 at 12:03 pm, the Clean Storage 1B185 in the OR suite had a negative pressure relationship with the corridor 1E180, and not a positive pressure.

The above deficient practice was confirmed at the time of discovery by a concurrent observation and interview with the plant services manager, and at the time of exit conference with Staff A (chief executive officer), Staff C, Staff C1 (facilitator), and Staff C2 (director of safety) on 6/17/15 at 2:45 pm.

Based on observation, staff interview and review of maintenance records between 6/15 and 6/17/2015, the facility failed to ensure 'life safety from fire' to patients.

Findings include

Building 04

1. Failed to protect the life safety of patients from fire due to corridor wall of one room not maintained or constructed smoke resistant;

2. Failed to protect the life safety of patients from fire due to exit access corridor doors in three locations not properly latching;

3. Failed to protect the life safety of patients from fire due to lack of proper exit signage to clearly identify the egress path to exits in two locations;

4. Failed to protect the life safety of patients from fire due to smoke barriers not properly constructed in two locations, and penetrations in one smoke barrier not properly sealed;

5. Failed to protect the life safety of patients from fire due to one set of smoke doors not readily operable;

6. Failed to protect the life safety of patients from fire due to failure to enclose three hazardous areas with properly installed fire-rated walls and self-closing doors;

7. Failed to protect the life safety of patients from fire due to failure to maintain one exit door operable in accordance with NFPA 101 19.2.4.2, 19.2.1;

8. Failed to protect the life safety of patients from fire due to one exit access door not readily operable in accordance with NFPA 101 19.2.1, 7.1;

9. Failed to protect the life safety of patients from fire due to lack of sprinkler protection in three locations in accordance with NFPA 101 19.3.5, 9.7.1.1, NFPA 13 5-13.6;

10. Failed to protect the life safety of patients from fire due to exit access from one space in a room obstructed by handrail and not in conformance to the NFPA 101 19.2.1, 7.1.10 requirement;

11. Failed to protect the life safety of patients from fire due to failure to install medical vacuum system shutoff valve in one location in accordance with NFPA 99 (1999) 4-3.2.2.6(a);

12. Failed to protect the life safety of patients from fire due to failure to maintain required relative humidity in two anesthetizing locations in accordance with NFPA 99 (1999) 5-4.1.1; and

13. Failed to protect the life safety of patients from fire due to failure to provide sufficient clear working space free of storage in front of electrical equipment and panels, and provide emergency power supplied electrical outlets in accordance with NFPA 70 (1999) 110-26, Table 110-26(a).

Refer to the C-231 tag, and the following tags for details:
K17, K18, K22, K25, K27, K29, K32, K38, K56, K72, K77, K78 and K147.

Based on record review and interview nursing staff failed to obtain orders for patient restraints per policy in 2 of 2 restrainted patients (#9, #10) out of a total universe of 20 patient medical records reviewed.

Findings:

Facility policy "Restraint Policy" #GN-028, reviewed on 6/16/2015 at 2:00 PM, states "V. Restraint Orders: A. Non-violent: Restraint requires a physician order within one calendar day following initiation of a restraint and will be renewed every calendar day...B. Violent/Self-Destructive: ...Restraints for violent/self-destructive patients are to be renewed: 1. Every 4 hours for adults..."

Pt. #9's MR contains a restraint use flowsheet documenting that Pt. #9 was restrained on 5/20/2015 at 10:00 AM through 5/20/2015 at 12:00 PM for non-violent use. Pt. #9's MR does not contain an order for the use of restraints.

Pt. #10's MR contains a restraint use flowsheet documenting that Pt. #10 was restrained on 6/4/2015 at 10:30 PM for violent or self-destructive behaviors. An initial restraint order is documented on 6/5/2015 at 7:02 PM, more than 20 hours after the initial use of restraints.

The above findings were discussed with CNO A, RN L and RN Manager N on 6/16/2015 at 10:45 AM. Per interview with CNO A and RN Manager N on 6/16/2015 at 10:45 AM, A and N were unable to explain the discrepancies between the restraint use flowsheet and restraint orders. RN Manager N stated the current documentation shows a "need for education" for the staff in regards to restraint documentation.

Based on observation, record review and interview OR staff failed to ensure disposal of medications per policy in 3 of 3 Operating Rooms (OR #1, 2, and 3).

Findings:

Facility policy "Disposable Supplies and Medication Storage Area Inspections" states in part: "All departments will be responsible for auditing disposable supplies and medication storage areas...staff will audit disposable supplies and medications on a monthly basis looking for expiration."

During observations on 6/15/2015 at 3:50 PM, the supply cabinet in OR #3 contained 1 open, undated bottle of chlorahexadine and 1 open, undated bottle of betadine prep. Per interview on 6/15/2015 at 3:50 PM, ST G stated the products were, "Single use per patient, not sure why that's in there."

On 6/15/2015 at 4:00 PM, the supply cabinet in OR #2 contained an uncapped, undated multidose vial of Sensorcaine (anesthetic agent). Per interview on 6/15/2015 at 4:00 PM, OR Manager F stated the vial, "Should not be in here."

On 6/15/2015 at 4:10 PM, the supply cabinet in OR #1 contained opened bottles of hydrogen peroxide and rubbing alcohol. The bottles were labeled as opened on 7/9/2014. The hydrogen peroxide had a manufacturer expiration date of 3/2015. OR Manager F stated, "The products are good for 1 month after opening."

On 6/15/2015 at 4:15 PM, OR Manager F stated the OR staff is responsible to remove expired supplies, products and medications from the department and that is done "monthly." Per interview on 6/15/2015 at 4:15 PM, OR Manager F confirmed supplies used in the OR are single use and should be disposed after each patient.

Based on observation, record review, and interview, RN and OT staff at at this facility failed to follow it's policies and procedures and the recommendations of nationally recognized professional standards of practice for handwashing and glove changes during 1 of 1 wound care observation (Pt. #21) out of a total of 9 observations. MD staff failed to follow facility expectation for handwashing in 1 of 1 MD provision of care observation (Pt. #5) out of a total of 9 observations and staff at this facility failed to maintain an environment that is free from potential contaminants in 2 of 8 departments observed (kitchen and laundry area).

Findings include:

Content source: CDC, MMWR, Date last modified: October 12, 2007 IV.A. Hand Hygiene IV.A.2. When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water. IV.A.3. If hands are not visibly soiled, or after removing visible material with nonantimicrobial soap and water, decontaminate hands in the clinical situations described in IV.A.3.a-f. The preferred method of hand decontamination is with an alcohol-based hand rub. Alternatively, hands may be washed with an antimicrobial soap and water. Frequent use of alcohol-based hand rub immediately following handwashing with nonantimicrobial soap may increase the frequency of dermatitis. Perform hand hygiene: IV.A.3.a. Before having direct contact with patients. IV.A.3.b. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings. IV.A.3.c. After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient). IV.A.3.d. If hands will be moving from a contaminated-body site to a clean-body site during patient care. IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient . IV.A.3.f. After removing gloves.
IV.B.2. Gloves IV.B.2.a. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intactskin (e.g., of a patient incontinent of stool or urine) could occur. IV.B.2.c. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens. IV.B.2.d. Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face).


On 6/17/2015 at 8:05 AM an observation of wound care on Pt. #21 was completed accompanied by QF RN X. OT V and RN W were observed changing Pt. #21's first day post-operative dressing to the right knee after a knee replacement on 6/16/2015.
After washing hands and applying gloves, RN W set up clean supplies (in the packages) on the pull out portion of Pt. #21's over-bed table without cleaning the table top. RN W then began removing the old dressing while OT V (with gloved hands) held Pt. #21's leg. When Pt. #21's leg did not need to be held OT V assisted with the dressing removal (dressing had many layers). RN W removed the soiled dressing material and discarded it in the trash.
With the same gloves RN W applied a new dressing to Pt. #21's fresh incision and OT V applied a clean thigh level support stocking. The following tasks were observed while RN W and OT V still had the contaminated gloves on: picked up unused clean supplies (in the package) and put them away for the next use, closed the tray table, touched Pt. #21's walker and gait belt, handled Pt. #21's pressure relief wraps for the legs (used while laying in bed) and put one wrap on the floor, touched the IV pole and IV tubing, privacy curtain, Pt. #21's clothes which were stored in a closed cabinet.
Then RN W left the room (still with the same gloves) to discard the trash in the soiled utility room across the hall (touching the soiled utility room door, entry key pad, and handle). As RN W returned through the hallway back to Pt. #21's room RN W began removing the gloves and once back in Pt. #21's room discarded them and washed hands.
In an interview with QF RN X on 6/14/2015 at 8:20 AM regarding these observations, RN X agreed with the observations and stated that there are opportunities for learning.


On 6/17/2015 at 8:30 AM an observation of provision of care to Pt. #5 by MD Y was completed accompanied by QF RN X. MD Y entered Pt. #5's room, provided consultation, education, and a heart and lung assessment. At 8:58 AM MD Y left Pt. #5's room. There was no hand hygiene observed on entry or exit from the room. In an interview with QF RN X on 6/14/2015 at 9:00 AM regarding these observations, RN X confirmed that MD Y did not do hand hygiene.


In an interview with Divisional IP T and U on 6/17/2015 at 10:05 AM, IP T stated that this facility follows the standards of practice and recommendations from CDC, APIC, and AORN among other organizations. IP T verbalized the time points for hand hygiene and glove changes and stated that the facilities expectations were not followed in the wound care observation.


18816


The following is observed in the kitchen on 6/16/2015 between 8:00 AM and 8:45 AM:
At 8:00 AM there are two containers in the refrigerator that have no label identifying the contents, this is confirmed at time of observation with Mgr I who agreed they should be labeled.

Per interview with Mgr I at 8:00 AM, Mgr I does not do many test food trays to monitor temperatures for Pt trays. Mgr I confirmed there is no log for test food trays.

At 8:25 AM, Cook J began running trays through the dishwasher. Cook J stated in interview on 6/16/15 at 8:25 AM, s/he runs the dishwasher a couple times to bring up the temperature before checking the wash and sanitizing temperatures. Cook J was observed running 4 trays of dishes through the dishwasher before looking at the temperatures and recording them on the daily log. Cook J stated s/he does not rerun the first trays after the water temperature is up in the dishwasher.

During the dishwashing observation, on 6/16/15 between 8:25 AM and 8:45 AM, Cook J did not have a water proof apron on to prevent contamination of his/her scrubs from spray and food debris. This observation was shared with DON A on 6/17/16 at 9:22 AM.

At 8:25 AM bucket next to the dishwashing sink is 1/2 full with a clear solution. Per interview with Cook J at 8:25 AM, it is water and Mikro-Quat. Cook J said it is mixed with 1 squirt Mikro-Quat to 1 gallon water. When asked how s/he determines there is 1 gallon of water, Cook J pointed to 1 inch below the top rim, and proceeded to add some water to bring the level to 3/4 full. Cook J stated the solution is used to clean all the counters in the kitchen. Per the Mikro-Quat label the cleaner is for "Sanitizing Non-Food contact Surfaces" and states "Use 1 oz. Mikro-Quat per gal. (gallon) of water". Per interview with Mgr I on 6/16/15 at 8:30 AM revealed Mgr I was unaware the cleaner should not be used on food prep surfaces. Facility policy reviewed on 6/16/17 at 1:50 PM titled Hard Surface and Flatware Sanitation, dated 4/14, states under Guidelines A. 2. "Mix quaternary ammonia according to the recommendations of the manufacturer; 1/2 oz. (1 squirt) per gallon of warm water".

Per interview with Mgr I at 8:30 AM, there are no logs confirming automated dispenser of the dishwashing solution is monitored for the correct concentration. Mgr I said the contracted company does not provide receipts for visits related to monitoring the dishwasher or automated dispenser system.

Per follow up interview on 6/16/16 at 1:50 PM there are no policies on labeling food and running the dishwasher, but the expectation is to have all food labeled and trays run through the dishwasher before the water temperature is high enough should be run through again once the temperature is up.


The following is observed in the laundry area:
Per observation on 6/16/15 at 8:45 AM , there are no physical barriers between the dirty and clean areas of the laundry, and access to the dirty side of the laundry area, from the main corridor, is blocked by carts. Per interview with Mgr I on 6/16/15 at 8:45 AM, staff bring the dirty mop heads and privacy curtains in through the double doors on the clean side of the laundry.

Based on record review and interview nursing staff at this facility failed to ensure patient care plans are unique to the patient based on an assessment of their needs in 3 of 13 out of a total of 20 MRs reviewed (Pt. #1, 2, and 3) and also failed to reassess pain per care plan in 3 of 3 patients with an active pain care plans (#8, #11, #13) out of a total of 20 MR reviewed, and failed to update the plan of care to reflect the use of restraints in 2 of 2 restrained patients (#9, #10) out of a total of 20 MR reviewed.

Findings include:

Review on 6/16/15 at 2:00 PM of facility policy titled Medical-Surgical Services Standards of Care, dated 1/1/15, it states "The Nurse will develop an individualized Plan of Care within 24 hours of admission."

Facility policy "Pain Management" #GN-037, reviewed 6/16/2015 at 2:00 PM, states in part: "3. After any pharmacological pain management intervention for unacceptable pain, pain scores are reassessed within two hours and documented...in cases where the patient is asleep, the documentation will indicate that the patient is sleeping."

Facility policy "Restraint Policy" #GN-028, reviewed 6/16/2015 at 2:00 PM, states in part: "The individualized patient plan of care will include restraint care."



Pt. #1's MR review revealed Pt. #1 was admitted with pneumonia on 5/26/15. The CP dated 5/26/15 for Activity included the intervention to "Turn Patient", and the CP for Nutrition included the interventions"Assist patient with eating" and "Encourage patient to take supplement as ordered". The Activity Nursing Assessment dated 5/26/15 indicated Pt. #1's Activity is "adequate". The Nutrition Nursing Assessment dated 5/26/15 indicated Pt. #1 did not need assistance eating, and MD orders did not include dietary supplements. This is confirmed in interview with RN M, during MR review on 6/16/15 at 10:00 AM, who stated that there should not have been interventions on turning the Pt., assisting with eating and providing supplements.

Pt. #2's MR review revealed Pt. #2 was admitted with gastroenteritis (inflammation of intestinal system) on 3/24/15. There is no CP related to Pt. #2's gastroenteritis. This is confirmed in interview with RN M, during MR review on 6/16/15 at 10:40 AM, who stated there should be a CP with interventions related to Pt. #2's diagnosis.

Pt. #3's MR review revealed Pt. #3 was admitted with COPD (Chronic Obstructive Pulmonary Disease) on 4/29/15. The CP dated 4/29/15 for Activity included the interventions to "Turn Patient" and "Active/passive ROM (range of motion) as tolerated/ordered", and the CP for Nutrition included interventions "Assist patient with eating" and "Encourage patient to take supplement as ordered". The Activity Nursing Assessment dated 4/29/15 indicated Pt. #3's Activity is "adequate". The Nutrition Nursing Assessment dated 4/29/15 indicated Pt. #3 did not need assistance eating, and MD orders did not include dietary supplements. This is confirmed in interview with RN M, during MR review on 6/16/15 at 11:00 AM, who stated there should not have been interventions on turning the Pt., assisting with eating and providing supplements.


34337


Pt. #8's MR revealed Pt #8 was admitted to the facility on 6/12/2015 with a fractured right humerus. Pt. 8's MR includes a care plan problem of Pain started on 6/12/2015. The patient's goal details: "Assess and monitor patient's pain using appropriate pain scale...Re-assess patient's pain level 30-60 minutes after pain management intervention." Pt. #8 received pain medication on 6/13/2015 at 3:00 AM. Pt. #8 is noted as sleeping on 6/13/2015 at 6:28 AM, more than 3 hours after the intervention. Pt. #8 received pain medication on 6/14/2015 at 5:48 AM and was re-assessed on 6/14/2015 at 8:20 AM, more than 2 hours after the intervention. Pt. #8 received pain medication on 6/14/2015 at 10:10 PM and was re-assessed on 6/15/2015 at 2:52 PM, more than 4 hours after the intervention. These findings were confirmed with RN L on 6/16/2015 at 9:50 AM. RN L stated pain level "should be" reassessed within 1 hour of pain medication administration.

Per Pt. #9's MR, Pt. #9 was restrained on 5/20/2015 at 10:00 AM through 5/20/2015 at 12:00 PM. Pt. #9's care plan was not updated to reflect the use of restraints. This was confirmed with RN L on 6/16/2015 at 10:30 AM.

Per Pt. #10's MR, Pt. #10 was restrained on 6/4/2015 at 10:30 PM through 6/7/2015 at 10:00 AM. Pt. #10's care plan was not updated to reflect the use of restraints. This was confirmed with RN L on 6/16/2015 at 10:40 AM.

Pt. #11's MR revealed Pt. #11 received inpatient services from 1/10/2015 through 1/14/2015 for abdominal pain. Pt. #11's MR contained a care plan for Pain, Acute initiated on 1/10/2015. Pt. #11 received pain medication on 1/13/2015 at 3:00 PM and was re-assessed on 1/13/2015 at 5:21 PM, more than 2 hours after the intervention. This was confirmed with RN L on 6/16/2015 at 11:05 AM.

Pt. #15's MR revealed Pt. #15 received inpatient services from 4/13/2015 through 4/20/2015 for a right hip fracture after a fall. Per Pt. #15's MR, Pt. #15's MR contained a care plan for Pain, Acute initiated on 4/13/2015. Per MR review, Pt. #15 received pain medication on 4/14/2015 at 2:00 AM and was re-assessed on 4/14/2015 at 6:14 AM, more than 4 hours after the intervention. Pt. #15 received pain medication on 4/14/2015 at 10:41 AM and was re-assessed on 4/14/2015 at 3:00 PM, more than 3 hours after the intervention. Pt. #15 received pain medication on 4/14/2015 at 9:57 PM and was re-assessed on 4/15/2015 at 1:15 AM, more than 3 hours after the intervention. Pt. #15 received pain medication on 4/15/2015 at 1:15 AM and was re-assessed at 5:08 AM, nearly 4 hours after the intervention. These findings were confirmed with RN L on 6/16/2015 at 11:35 PM.

Based on record review and interview, Emergency Department staff failed to maintain medical records that are complete and accurate by: 1. Failing to document the time patients were seen by the MD and had an exam in 2 of 6 ED MRs (Pt. #1 and 3) out of 20 MRs reviewed, 2. Failing to follow a chronological time line in the ED record in 2 of 6 ED MRs (Pt. # 14 and 16) out of 20 MRs reviewed, and 3. Failing to ensure risks and benefits were documented on transfer forms in 2 of 2 patients transfered to another facility (Pt. #15 and 17) out of a total of 20 MRs reviewed.

Findings include:

Pt. #1's MR review revealed Pt. #1 arrived in the ED on 5/26/15 at 3:48 PM with a complaint of shortness of breath. There is no documentation when the MD is notified Pt. #1 is ready to be seen nor when the MD performed the MSE. This is confirmed in interview with RN M during the MR review on 6/16/15 at 10:00 AM who stated there should be documentation of both times in the event log in the MR.

Pt. #3's MR review revealed Pt. #3 arrived in the ED on 4/29/15 at 6:00 PM with a complaint of shortness of breath. There is no documentation when the MD is notified Pt. #3 is ready to be seen nor when the MD performed the MSE. This is confirmed in interview with RN M during the MR review on 6/16/15 at 11:00 AM who stated there should be documentation of both times in the event log in the MR.


26711


The facility's Medical Staff Rules and Regulatioins dated 1/2012 were reviewed on 6/16/2015 at 11:30 AM. Regarding the transfer of patients, the Rules and Regulations state in part in section 5. b. "The attending physcian informs the patient or responsible party of the reason for, the risks, and likely benefits of the transfer. The appropriate consent is obtained and documented in the medical record."

Pt. #14's MR review revealed Pt. #14 arrived in the ED on 5/2/15 at 2:12 PM with complaints of anxiety and suicidal ideation. Pt. #14 was triaged and roomed by the nurse at 2:24 PM. The MD indicates the MSE started at 2:16 PM, prior to Pt. #14 being triaged.
This is confirmed in interview with RN L during the MR review on 6/16/15 at 1:10 PM who stated the MD MSE should not indicate it was done prior to the patient being in the ED room.

Pt. #15's MR review revealed Pt. #15 arrived in the ED on 5/20/2015 in respiratory distress and needed to be transferred to a higher level acute care facility for treatment. The transfer form is incomplete. It does not indicate Pt. #15's risks or benefits for the transfer.
This is confirmed in interview with RN L during the MR review on 6/16/2015 at 1:35 PM who stated the risks and benefits should be filled in.

Pt. #16's MR review revealed Pt. #16 arrived in the ED on 4/9/15 at 1:30 PM with complaints of vaginal bleeding. Pt. #16 was triaged and roomed by the nurse at 1:37 PM. The MD indicates the MSE started at 1:30 PM, prior to Pt. #16 being triaged.
This is confirmed in interview with RN L during the MR review on 6/16/15 at 1:50 PM who stated the MD MSE should not indicate it was done prior to the patient being in the ED room.

Pt. #17's MR review revealed Pt. #17 arrived in the ED on 3/1/2015 with mid back and chest pain and needed to be transferred to a higher level acute care facility for treatment. The transfer form is incomplete. It does not indicate Pt. #17's risks or benefits for the transfer.
This is confirmed in interview with RN L during the MR review on 6/16/2015 at 2:00 PM who stated the risks and benefits should be filled in.

Based on record review and interview the facility staff failed to effectively analyze patient incident data to identify trends with the potential to affect patient outcome in 1 of 1 Quality Program.

Findings:

Facility policy "Quality Assessment and Performance Improvement Plan" #MS-002 states: "A. The Quality Assessment and Performance Improvement Plan is an ongoing, integrated, coordinated and systematic program to: 1. Measure, track and analyze quality indicators, including adverse patient events...E. Prioritize: ...Processes that affect health outcomes, patient safety, and quality of care...Medical errors and adverse events...H. Aggregate and Analyze: Statistical tools and techniques are used to identify levels of performance, patterns, trends, and variations. Hospital data is compared with external sources when available."

Review of facility incident report log on 6/15/2015 at 2:00 PM reveals incidents of intra-operative gallbladder rupture during laparoscopic cholecystectomy (gallbladder removal) procedures on 4/6/2015, 4/22/2015 and 5/7/2015. All 3 incidents were associated with MD P.

During an interview on 6/16/2015 at 9:25 AM, Quality RN B stated that the above incidents had "stood out" to B and RN B notified Risk Manager O via email on 5/11/2015. RN B stated the incidents were "not an unusual occurance" per Risk Manager O. RN B stated the facility had not done anything further regarding the data, but that B was "keeping an eye on it." RN B was not able to confirm how many laparoscopic cholecystectomy procedures had been performed as compared to the reported incidents of intra-operative rupture.

Requested analysis of the OR log data revealed 27 patients had underwent laparoscopic cholecystecomy surgeries from 12/1/2014 through 6/16/2015. Of those 27, 6 patients suffered intraoperative rupture. Further analysis revealed MD P performed 9 of the 27 surgeries with 4 incidents (44%); MD Q performed 16 of the 27 surgeries with 2 incidents (12.5%) and MD R performed 2 of the 27 surgeries with no incidents.

During an interview on 6/16/2015 at 5:30 PM, MD S stated that S had not been made aware of the above data "prior to today" and the data was "certainly concerning." MD S stated that it is expected that quality of care concerns or deviations are brought to S's attention and that the incident rates "sound high" and warrant further investigation.

RN B stated on 6/16/2015 at 4:15 PM that RN B had not reported the incidents to the OR department. Per RN B, risk management "did not seem concerned" but B was monitoring the incidents and "we haven't had one in awhile." Data shows the last incident of intra-operative gallbladder rupture was on 5/7/2015, the date of the most recent laparoscopic cholecystectomy surgery per the OR log was 5/7/2015. RN B stated incident reports are tracked but not trended in any way to aid in the identification of patterns or variations.