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Based on observation, interview, and policy review, the CAH failed to ensure that 2 of 2 blanket warmer temperatures were monitored and maintained at a safe patient use temperature. Findings include:

The temperature on the nursery, and general patient use blanket warmer machines was not being monitored.

During an environmental tour at 10:15 am on 8/16/11, with the director of obstetrics, a Steris brand warming machine that held 5 blankets was observed in the clean utility room. The built in digital thermometer located on the front of the machine read 155 degrees. On 8/18/11, at 9:10 a.m. the same Steris blanket warmer was observed to store 5 warmed bath blankets and the built in digital thermometer read 154 degrees. Shortly thereafter, a Lakeside Healthcare blanket warmer was observed in the nursery with the built in digital thermometer located on the front panel reading 145 degrees.

On 8/16/11, at 10:15 a.m. the director of obstetrics verified the blanket warmer temperatures were not being monitored.

On 8/17/11, at 2:52 pm. maintenance staff (MS)-A verified the temperatures were not being monitored and stated the warming unit temperatures were only monitored if they contained intravenous fluids.

On 8/18/11, at 9:15 a.m. Health Unit Coordinator-B (HUC) stated the maintenance department monitored the blanket warmer temperatures "a couple times a week." In addition, HUC-B verified the nursery warmer blankets were used on "newborns after delivery" and the other blankets were for all other patients use.


28649

Policy for emergency room temperature check of warmers last revised 5/1/2009 indicated,
"The blanket warmer will not be set higher than the manufacturer recommendation of 150 degrees Fahrenheit." The procedure indicated, "Each unit will assign a person to check warmers. Check the warming unit three times each week and record results on log sheets (days to be determined by department). Maintenance will maintain documentation of warmer maintenance. Nursing will complete a quality assurance report (occurrence report) if warmer checks too warm without the automatic alarm sounding. Completed temperature logs will be kept on file. The logs may be reviewed to determine general effectiveness of each warmer." No weekly checks were completed by unit staff.

During interview on 8/17/11 at 3:28 p.m. Product Service Director (PDS) confirmed the policy and procedures were not followed and should have been. PDS stated he performs a preventative maintenance check on warmers annually. PDS stated the birthing unit staff reported to him today that no monitoring was completed on the temperatures of the blanket warming system.

Based on observation and interview, the CAH failed to ensure appropriate temperatures were maintained in 2 of 2 food and lab specimen storage refrigerators on the obstetrics unit. Findings include:

The facility failed to monitor the temperatures in refrigerator where breast milk, placentas, and cord blood were stored.

On 8/16/11, at 10:15 a.m. during the environmental tour with the director of obstetrics (DO), a refrigerator containing 5 sealed placentas and 5 cord blood vials was observed in the soiled utility room. In the clean utility room, there was a refrigerator with a sign indicating "for beast milk only" taped to the door. There was no visible thermometer to determine refrigerator temperatures. The DO stated specimens were stored in the soiled utility room refrigerator to be available for lab analysis should a patient's condition require it. The DO verified the temperatures on both refrigerators were not being monitored or logged to ensure appropriate storage temperatures were maintained.

On 8/17/11, at 1:30 p.m. Health Unit Coordinator (HUC)-A verified there were 3 sealed placentas and 3 cord blood vials in the refrigerator. HUC-A stated there were 8 placentas stored in the refrigerator the week prior. In addition, HUC-A stated the temperature of the refrigerators was not monitored or recorded.

At 2:25 p.m. the DO stated the CAH did not have a policy and procedure specifically related to appropriate temperatures for storage requirements for breast milk, placentas, or cord blood.

The patient teaching "Breastmilk Collection and Storage" form indicated breastmilk was to be stored in the refrigerator at 39 degrees or lower for 3 to 8 days.


28649

During observation at 9:34 am on 8/17/11, there was a refrigerator used to store expressed breast milk in a clean utility room. The refrigerator did not have any breast milk in it at time of observation. The CAH did not have a system to ensure the refrigerator temperatures were held at the national guideline of 39 degrees or lower for the storage of breast milk.
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During interview on at 9:35 am on 8/17/11, HUC- A stated the unit stores expressed breast milk in the refrigerator and that expressed breast milk could be stored up to two weeks. HUC-A stated the pharmacy was responsible for monitoring the refrigerator. No evidence was provided that the refrigerator was monitored by anyone.

Based on observation and interview, the CAH failed to ensure sanitary conditions for 1 of 1 laboratory specimen prep area to prevent potential cross contamination for accurate specimen results. Findings include:

Observations on 8/16/11 at 11:23 a.m. and 8/18/11 at 9:16 a.m. indicated the laboratory microbiology testing room had an approximately three by two foot disposable lab mat liner on the counter in the testing area. The disposable lab mat was taped down with clear tape and was visibly soiled/stained with testing reagent. This area was a preparation area for micro-scan panels used to determine microorganisms and antibiotic sensitivities.

During interview on 8/18/11 at 9:17 a.m. the microbiology technician (MT) confirmed this area was used to prep multiple microorganisms to identify their type and sensitivities. MT stated the lab mat liner was changed once a month and the area would be considered uncleanable but the rest of the counter was wiped down with antibacterial wipes. MT verified the area has the potential to contaminate other slides with other bacteria during the micro-scan preparation.

During interview on 8/18/11 at 9:18 a.m. the director of laboratory services (DLS) confirmed the disposable lab mat was soiled and only changed once a month. DLS verified this was an uncleanable surface which could have the potential to contaminate other micro-scan panels.

Based on interview and policy review, the CAH failed to obtain/document formal medical staff approval for the scope of rehabilitation services offered as well as the written patient care policies and procedures utilized and qualifications and competencies for program staff. Findings included:

The rehabilitation services manager (RSM) verified, during interview on 8/17/11 at 1:30 p.m., that the patient care policies utilized by the CAH had been developed by the manager directly. The RSM was not aware of involvement in, or approval by, the medical staff in the process. In addition, the RSM was not aware of any medical staff involvement in defining qualifications of the staff that performed all programs and services offered.

The RSM stated the department did not have a functional clinical medical director and the CAH's administrative structure did not include regular direct involvement by a designated member of the medical staff. The administrative clinical director had a laboratory background, but there was no regular medical liaison function between the rehabilitation department and the medical staff. The RSM added that he had presented an educational program on occupational therapy to the physician committee during a meeting 4/7/11 and some medical staff were not even aware it was a service that could be billed by the CAH.

The acute care services director (ACSD), interviewed at 11:30 on 8/18/11, stated there was some physician involvement in the committee; however, records from meetings during the past year indicated only policies related to rehabilitation department dress code and beverage and food use were reviewed. The ACSD also verified the competencies and qualifications of staff to provide rehabilitation services had only been defined by the human resources department and without any medical staff input or approval.

Based on observation, staff interview, review of manufacturer instructions and policy and procedure review, the CAH failed to assure that manufacturer's instructions and facility policy for storage and handling of test strips for finger stick glucose testing. Findings include:

Findings include: Four of five blood glucose monitors used on the medical/surgical unit, intensive care unit and obstetrical care unit had opened and undated containers of SureStep Pro glucose test strips.

During observation of a finger stick blood glucose monitoring on 8/17/11, at 11:01 a.m. completed by nursing assistant (NA)-A, one opened bottle of undated glucose test strips was observed in the blood glucose monitoring tray. NA-A stated they do not date the test strip bottles because they go through them so fast. NA-A stated there were a total of 4 glucose monitors for the medical/surgical and intensive care unit and one on the obstetrical unit.

On 8/17/11, at 11:20 a.m. RN-A went with the surveyor and checked the three remaining blood glucose monitors in the medical/surgical and intensive care unit. Two of the three trays with glucose monitors had opened and undated test strips. RN-A stated she did not know if the test strip bottles were to be dated.

On 8/17/11, at 11:50 a.m, the blood glucose monitor for the obstetrical unit was checked with two opened and undated bottles of test strips with the monitor.

Review of the manufacturer's instructions for the SureStep Pro glucose test strips indicated that the test strips expired 120 days after the container was opened, and " Write the opened date on the test strip bottle when it is first opened."

Review of the facility policy titled " LifeScan SureStep Flex Meter " dated 11/4/10, indicated that under storage of the (glucose) test strips, " Date test strip container after opening."

On 8/17/11, at 2:05 p.m. the director of nurses (DON) verified the current policy directed staff to date the glucose test strip containers when they were opened and this was included in the annual staff competency training on finger stick glucose monitoring. The DON stated that the glucose test strip containers have to be dated when opened.

Based on interview and record review, the CAH failed to ensure all medical records were promptly completed and contained all pertinent information necessary to monitor the patient's condition, progress and response to treatments for 1 of 20 in-patient records (P18) reviewed during the survey. Findings included:

P18 was admitted to the CAH on 7/6/11 for cerebrovascular accident(CVA) and pneumonia. P18 remained in acute care in-patient status until discharge to swing bed status on 7/12/11. There was no evidence of a documented history and physical being completed during the in-patient or swing bed hospitalizations.

The health information (HIM) manager verified on 8/18/11 at 11:30 a.m. the record audit completed by the HIM department had also identified the history and physical was missing. A search through the paper record as well as the multiple electronic medical record systems utilized could not locate the history and physical for P18.

The acute care services director verified on 8/18/11 at 1:50 p.m. the CAH policy on rules and regulations for medical staff dated 7/29/10 identified a complete history and physical examination shall be written within 24 hours after admission and the medical record on a discharged patient shall be completed by the attending physician within 30 days after the date of discharge.

Based on record review, interview and policy review, the CAH failed to ensure time/date/signature of medical record entries for 11 of 23 patient (P1, P10, P18, P8, P19, P13, P14, P15, P16, P20, P21) medical records reviewed. Findings included:

P1's medical record contained entries that were not timed. P1 was admitted 8/15/11 for surgical mesh revision for vaginal bleeding. Physician's progress notes and orders dated 8/15/11 and discharge orders dated 8/16/11 lacked the time of entry in the record.

P10's medical record contained entries that were not timed. P10 was admitted 3/21/11 for surgical treatment of osteomyelitis (toe amputation.) Physician's orders dated 3/24/11 and discharge orders dated 3/25/11 lacked time entry in the record.

P18's medical record contained entries that were not timed and/or dated. P18 was admitted 7/6/11 for cerebrovascular accident (CVA) and pneumonia. Physician's orders dated 7/6/11, 7/7/11,7/8/11, 7/10/11 and 7/11/11; as well as progress notes dated 7/11/11 and 7/12/11 lacked time entry in the record.

The acute care services director, interviewed on 8/18/11 at 1:50 p.m. stated the CAH policy on rules and regulations for medical staff dated 7/29/10 identified all entries in the record should be dated, timed and signed.


28035

P8 was admitted 8/15/11. The newborn admitting physician orders lacked the physician's signature authenticating the order. On 8/16/11, at 9:30 a.m. the director of obstetrics stated the orders should have been signed by the physician.


28649

Patient 19 was admitted on 5/18/11. Telephone and verbal orders on the physician's order sheet included nurse transcribed orders dated 5/19/11, 5/20/11 and 5/21/11. The physician signed all of the orders but did not indicate the date/time of signature.


29440

P13 was admitted to the CAH on 8/12/11. The physician's signatures on orders dated 8/12/11, 8/15/11, and 8/16/11; as well as physician progress notes dated 8/13/11, 8/14/11, 8/15/11, 8/16/11, and 8/18/11, did not include the time of entry.

P14 was admitted to the CAH on 8/14/11. The physician's signatures on orders dated 8/17/11; and physician progress notes dated 8/14/11, 8/15/11, 8/16/11, 8/17/11 and 8/18/11, did not include the time of entry.

P15 was admitted to the CAH on 8/15/11. The physician's signatures on orders dated 8/17/11, and 8/18/11, did not include the time of entry.

P16 was admitted to the CAH on 8/14/11. The physician's signatures on orders dated 8/14/11, 8/15/11, 8/17/11, and 8/18/11; as well as physician progress notes dated 8/14/11, 8/15/11, and 8/17/11, did not include the time of entry.

P20 was admitted to the CAH on 6/21/11. The physician's signatures on orders dated 4/19/11 for a procedure on 6/21/11; inpatient orders dated 6/21/11 and 6/24/11; and physician progress notes dated 6/22/11, 6/23/11, and 6/24/11, did not include the time of entry.

P21 was admitted to the CAH on 5/4/11. The physician's signatures on orders dated 5/4/11, 5/5/11, 5/6/11, 5/9/11, 5/10/11, and 5/11/11; as well as physician progress notes dated 5/4/11, 5/5/11, 5/6/11, 5/8/11, 5/9/11, 5/10/11 and 5/11/11, did not include the time of entry. The wound care note dated 5/5/11, did not include the time of entry.

Based on observation, interview, and policy review, the CAH failed to ensure proper procedures to reduce the risk of burns or fires related to use of an electrosurgical pencil/blade (instrument used to cut and cauterize tissue during surgical procedures) were followed for 1 of 1 patient (P23) observed during a procedure with the use of the electrosurgical cautery. Findings include:

Surgeon-A did not follow CAH policy and procedure for use of a safety holster between uses of the electrosurgical pencil/blade. The CAH policy dated 01/04/11 indicated the electrosurgical pencil would be placed in the safety holster when it was not in use during surgery.

P23 was observed at approximately 9:14 am on 8/17/11 during a right hemicolectomy. An alcohol based skin prep was utilized and oxygen was provided for P23 throughout the procedure. The holster for the cautery pencil was clipped to the drape above and to the left of the surgical site. During observations from 9:26 a.m. through 10:03 a.m., the electrosurgical cautery pencil was not placed in the holster between uses. The cautery pencil was laid on the surgical drape or gauze 21 times, for time periods of 15 seconds to 2 minutes; as well as multiple time periods of one to 10 seconds that were not recorded.

The Instruction for Use of the Electrosurgical Pencil/blade, revised 02/2011, included the warning: "Fire Hazard Do not place active accessories near or in contact with flammable materials (such as gauze or surgical drapes). Electrosurgical accessories which are activated or hot from use can cause a fire. Use a holster to hold electrosurgical pencils and similar accessories safely away from patients, personnel, and surgical drapes." The instructions indicated increased fire/explosion hazard with the use of substances such as alcohol based skin prepping agents and an oxygen enriched atmospheres.

Interview with the circulating nurse (RN-4) on 8/17/11, at 10:10 a.m., confirmed the electrosurgical pencil /blade should have been placed in the holster when not in use.

The Regulatory Patient Safety Director/Interim Surgical Director, interviewed at 3:30 pm on 08/17/11, stated it was the expectation and the CAH policy to holster the electrosurgical pencil/blade when not being used during surgery.

Based on interview and record review, the CAH lacked a Quality Assurance (QA) program that evaluated the quality and appropriateness of contracted services or services provided by arrangement. Findings include:


21978

The CAH QA program did not include active participation by the contracted medical diagnostic imaging provider; or assurance by the CAH that the activity was adequately performed and reports communicated to the CAH QA committee.

The radiology department manager, interviewed at 9:00 am on 8/16/11, stated there were no specific QA reports submitted, and no participation in the CAH QA process by the contracted medical diagnostic imaging provider that performed magnetic resonance imaging (MRI) by mobile unit. The manager reported 87-90 MRI procedures were performed monthly by the vendor, down from over 100 per month the previous year.

The department manager was unable to locate any quality reports and requested quality information be faxed to the CAH by the contractor. On 8/16/11 at 11:27 a.m. the vendor submitted six field service reports performed under the manufacturer's service contract agreement. The reports included only routine testing, inspections and checks and minor repairs completed. Twenty of the twenty-two functions performed were listed as preventative maintenance or software maintenance items. The only quality checks involved a check of image quality of the MRI's.

The contracted imaging services did not report any ongoing data collection, analysis or process for other problem identification, prevention or evaluation of any corrective actions. In addition, there were no measures to evaluate or improve quality on a continuous basis performed by the contractor or the CAH QA committee.

The patient safety director (PSD), who was in charge of the Quality Assurance program for services provided by contract or arrangement, was interviewed at 11:45 am on 08/17/11. The PSD stated there were no policies or procedures for monitoring, data collection or QA activity for services contracted or provided by arrangement. The PSD stated that she asked the service providers for documentation of the QA projects they were doing; however, the providers refused to share the information. The PSD stated there were no QA activities for services contracted or provided by arrangement.