HospitalInspections.org

Based on a review of the Patient Bill of Rights and staff interview, the hospital failed to include in the notice of Patient Bill of Rights, the right of the patient to 'have his or her own physician notified promptly of his or her admission to the hospital'. This failed practice had the potential to affect all patients of the hospital. Census first day of survey was 84.

Findings are:

A. Review of the facility Patient Bill of Rights (no date), lacked evidence of the following documentation:

-The patient has the right to have his or her own physician notified promptly of his or her admission to the hospital.

B. Interview with the Social Worker Supervisor on 10/28/13 at 4:00 PM confirmed the Patient Bill of Rights lacked the above information.

Based on a review of the Patient Bill of Rights and staff interview, the hospital failed to include in the notice of Patient Bill of Rights, the patient has the 'right to be free from all forms of abuse or harassment'. This failed practice had the potential to affect all patients of the hospital. Census first day of survey was 84.

Findings are:

A. Review of the facility Patient Bill of Rights (no date), lacked evidence of the following documentation:

-The patient has the right to be free from all forms of abuse or harassment.

B. Interview with the Social Worker Supervisor on 10/28/13 at 4:00 PM confirmed the Patient Bill of Rights lacked the above information.

Based on a review of medical records, review of policies and procedures, review of Quarterly Medical Staff meeting minutes and staff interview, the hospital failed to ensure that 2 of 3 physicians who ordered restraints for 2 of 2 records reviewed where restraints were utilized, received training and had a working knowledge of the hospital's restraint or seclusion policy. The hospital identified 80 physicians who could potentially order restraints and only 39 of those physician had received training on the hospital's restraint or seclusion policy. This failed practice has the potential to affect any patient where restraint or seclusion is utilized.

Findings are:

A. Review of the policy and procedure titled Utilization of Restraints/Seclusion (revised 12/12) revealed the following information concerning training:
"Hospital and medical staff members receive training in the following subjects as it relates to duties performed under this policy. Training takes place before a new staff member is asked to implement the provisions of this policy. Training is repeated annually....Physicians who order restraint or seclusion shall be trained in the requirements of this policy and shall demonstrate a working knowledge of this policy through ongoing compliance."

B. Review of Medical Record 16 revealed that Physician S ordered a physical restraint for the patient on 9/15/13 at 6:35 PM and Physician T ordered a physical restraint for the patient on 9/16/13 at 4:40 PM.

Review of Medical Record 22 revealed that Physician B gave a verbal order for "soft ties-wrist" restraints for the patient on 10/21/13 at 12:01 AM.

C. An Interview with the Director of Behavioral Health (considered by the facility to be the subject matter expert for restraint or seclusion) on 11/4/13 from 2:50 PM to 3:00 PM revealed the following:
-Did restraint training at the Staff Meeting in February 2013;
-When physicians are newly appointed to the Medical Staff it was thought they completed the computer based training for restraints, but the interview confirmed this was not happening; and
-Related that the only physicians who have received restraint training are the ones that attended the Medical Staff meeting held in February 2013.

A review of the quarterly Medical Staff meeting minutes dated 2/26/13 revealed that the Behavioral Health Unit Director gave a presentation on the hospital's restraint policy with 44 physicians listed as 'present'. Further review of this list revealed Physician B and Physician S (physicians that had ordered restraints use for Patients 16 and 22) were not present for this training.

D. An interview with the Chief Medical Officer on 11/5/13 from 8:00 AM to 8:30 AM (after concerns were raised in regard to physician restraint training) revealed the development of a list of physicians who had the potential to order restraints and needed restraint training had been developed as well as a list of those still needing training. A review of this document titled RWMC (Regional West Medical Center) Restraint Training provided on 11/5/13 at 1:45 PM revealed a total of 39 physicians requiring restraint training attended the Medical Staff meeting on 2/26/13 where restraint training was provided and listed 41 physicians who still needed training. Physicians B and S were listed with the physicians still needing training.

Based on random observations, review of policy and procedure and staff interview, the hospital failed to secure and lock drugs and biologicals in 3 of 9 (2 East, 2 West and 3rd floor) nursing unit medication preparation rooms. THis had the potential to affect all patients admitted to 2 East, 2 West and 3rd floor. Census first day of survey was 84.

Findings are:

A. An observation of the unlocked 2 East nursing unit medication preparation room with the Director of Medical Surgical Services on 10/22/13 at 11:10 AM revealed the following unsecured medications:

Medication room counter:
1-Levofloxacin in D5W piggyback (Intravenous (IV) antibiotic)
1-Zyvox 600 mg (milligram) (IV antibiotic)
1-Lidocaine-Prilocaine 2.5-2.5% (topical anesthetic)

B. An observation of the 3rd floor nursing unit medication preparation room (which lacked doors) with the Director of Medical Surgical services on 10/23/13 at 7:30 AM revealed the following unsecured medications:

Medication room counter:
1-Pepercillin (IV antibiotic)

Unlocked refrigerator:
3-Ampicillin piggybacks (IV antibiotics)

C. An observation of the unlocked 2 West nursing unit medication preparation room with the Director of Medical Surgical Services on 10/23/13 at 11:00 AM revealed the following unsecured medications:

Medication room counter:
5-1000 ml (milliliter) 20meq (milliequivalent) potassium chloride IV solutions in 5% Dextrose and 0.45% Sodium Chloride (chemical compound)
6-Zosyn IV piggybacks (IV antibiotics)
2-Rochephin IV piggybacks (IV antibiotics)
1-Fat Emulsion 20% 250 ml (dietary supplement)
2-Cleocin IV piggybacks (IV antibiotics)
1-Ancef piggyback (IV antibiotic)
2-Levaquin in D5W IV piggyback 750 mg in 150 ml 5% Dextrose (IV antibiotics)
1-Protonix IV piggyback Sodium Chloride 0.9% 40 mg/100 ml (proton pump inhibitor)

Unlocked refrigerator:
6-Oxacillin Sodium IV piggyback 0.9% Sodium Chloride 2 G (gram) 100 ml (IV antibiotics)
1-Vancomycin Sodium Chloride 0.9% 1,800 mg 250 ml (IV antibiotic)

D. A review of policy and procedure titled Unit Dose Distribution (revised 8/5/13) revealed that "Medications are stored and secured on the patient care areas in individual room locked boxes, a medication preparation room, or in an automated dispensing cabinet. STAT and ASAP medications may be tubed to the patient care area utilizing the pneumatic tube system at which time a pharmacy staff member will call the nursing unit to ensure security of the tubed medications. All routine medications will be delivered to the patient care area by pharmacy staff, ensuring proper storage and security from the time of dispensing until the medication is administered by a health care professional."

E. An Interview with the Director of Medical Surgical Services on 10/23/13 at 12:00 noon confirmed the above unsecured and unlocked medications and stated that it has "always been a concern."

Based on observation and staff interviews, the facility failed to maintain an environment to assure the safety and well-being of patients related to the conditions of:
-The mopboards, wall, floors and laminate counters on 2 of 9 units (2nd and 3rd floor).
-The floor in the kitchen storeroom (off the dining room).
-The shower in the women's bathroom (in the Rehabilitation Therapy Pool area).

Findings are:

A. A tour of random rooms and the hallways on 3rd floor from 4:25 PM to 4:40 PM with the Director of Nurses (DON), Patient Safety Officer and Interim Housekeeping Supervisor revealed:
3rd FLOOR HALLWAYS:
-The carpet in the west hallway and by the elevator showed soiled spots.
-The wallpaper in the southeast hallway showed loose rolled wallpaper at the seam of the paper above the hand rail.
-The wallpaper in the west hallway had a tear approximately 1 inch x 1/2 inch in the wallpaper below the hand rail.
ROOM 316:
-A painted wall, mopboard and floor under the wall mounted hand sanitizer dispenser showed white residue from sanitizer leakage.
-The floor/mopboard under the shelf on the wall to the left of the windows, and in the corner of the room next to the windows showed a yellow residue and debris on the mopboard and along the seam of the mopboard and the floor.
-The shower floor and gripper strips in the shower showed white residue on the floor. The shower gripper strips had torn and rolled up corners.
-A piece of broken plastic was noted on the wall with sharp edges and 2 screws.

An interview with the DON on 10/23/13 at 4:34 PM revealed:
-Related to the wall under the hand sanitizer in Room 316, "I think that is from the dripping after using the sanitizer. That area was too small to mount the sanitizer with the tray to catch the drips."
-Related to the mopboard floor seams in Room 316, "I do see what you are saying about the floors and mopboards. I think it is from the waxing in the rooms and not getting the old wax stripped completely.
-Related to the broken plastic on the wall, "That broken paper cover on the wall should have been taken down. I will have maintenance come and remove it."

B. A tour of random rooms and the hallways on 2nd floor from 4:40 PM to 4:50 PM with the DON, Patient Safety Officer and Interim Housekeeping Supervisor revealed:
2nd FLOOR HALLWAYS:
-The carpet in the south hallway near Room 229 showed soiled spots.
-The carpet at the intersection of the south and east hallway showed soiled spots.
-Cracks in the plastic corner protector over the wallpaper in the south hallway were noted.
ROOM 261:
-The laminate on the left side in front of the sink in Room 261 was broken with a piece of laminate missing.
-The floor/mopboard under the shelf on the wall to the left of the windows, showed a yellow residue and debris on the mopboard and along the seam of the mopboard and the floor.
ROOM 262:
-The laminate on the right side of the sink in Room 262 was broken with a piece of laminate missing.
ROOM 214:
-The wallpaper border had torn and missing pieces of the bottom border edge.
-The drywall next to the recliner was marred along the upper edge of the mopboard and showed a yellow residue and debris on the mopboard and along the seam of the mopboard and the floor.


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C. Tour of the Rehabilitation Therapy area on 10/22/13 from 2:00 PM to 4:00 PM with the Rehabilitation Compliance Manager revealed the 3rd shower in the women's bathroom off of the therapy pool was soiled with pink and blue residue that was in a line down from the faucet. The pink residue could be wiped off with a paper towel. This area was observed in the same condition on 10/23/13 at 4:47 PM.

D. Tour of the dietary area on 10/29/13 from 10:00 AM to 10:45 AM with the Director of Food and Nutrition Services revealed the floor in the storage area off the dining room had a floor that was not easily cleanable. The floor in this area was made up of floor tile, concrete and an area that looked like it was a poured flooring. The tiled area had 2 areas where tile was missing and the concrete was unfinished which made surfaces that were not easily cleanable.

Based on a review of inpatient surgical medical records, review of Medical Staff Bylaws Rules and Regulations and staff interview, the hospital failed to ensure each surgical patient received a completed documented evaluation by an individual qualified to administer anesthesia per Medical Staff Bylaws in accordance with standards of practice for proper anesthesia recovery for 2 of 5 surgical inpatient medical records (Records 3 and 5) reviewed. This failed practice had the potential to affect all surgical inpatients receiving anesthesia. On first day of survey 14 patients received surgery with anesthesia.

Findings are:

A. A review of Medical Record 3 on 10/23/13 at 9:20 AM revealed a surgery date of 10/22/13. Surgery performed was a transvaginal hysterectomy under general anesthesia. A review of the form titled Post-Anesthesia Evaluation lacked evidence of a completed post-anesthesia assessment. The form revealed a box marked for "see RN charting for vital signs." Patient assessment questions 1-7 lacked completion. The Anesthesiologist signed the post-anesthesia evaluation on 10/22/13 at 1320 (1:20 PM).

B. A review of Medical Record 5 on 10/23/13 at 9:55 AM revealed a surgery date of 10/22/13. Surgery performed was a right orbital floor reconstruction under general anesthesia. A review of the form titled Post-Anesthesia Evaluation lacked evidence of a completed post-anesthesia assessment. The form revealed a box marked for "see RN charting for vital signs." Patient assessment questions 1-7 lacked completion. The Anesthesiologist signed the post-anesthesia evaluation on 10/22/13 at 1622 (4:22 PM).

C. A review of Medical Staff Bylaws Rules and Regulations (approved 8/29/13) revealed the following:
" Section 10. Anesthesia and Sedation Note:
(b) ...The post-anesthesia evaluation shall be recorded in the medical record by an individual qualified to administer anesthesia, no more than 48 hours following the procedure, and shall describe the presence or absence of anesthesia or sedation-related complications."

D. An interview with the Chief Medical Officer on 10/29/13 at 8:35 AM confirmed the incomplete post-anesthesia evaluations for anesthesia recovery in the above charts and stated the "forms were not completed as intended, you found the only two that were not filled out correctly because I went out and reviewed them all."