HospitalInspections.org

Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others on both the Geriatric and Adult Behavioral Units.

Findings:

On 2/2/15 at 2:40 p.m., the following observations were made during the initial tour of the Adult Behavioral Unit:
a. 3 patient beds were noted to have bilateral side rails with openings large enough to potentially facilitate ligature.
b. door hinges (both entry door and bathroom door) in patient rooms set apart widely enough to allow for potential ligature.
c. door handles on patient room doors that were positioned in a downward fashion to potentially facilitate ligature over the door frame.
d. screws used to fasten door handles to the doors were not tamper resistant.
e. gooseneck faucets with flanged handles on the sink in patient rooms.

In an interview on 2/4/15 at 8:46 a.m., S2CNO confirmed the environmental issues referenced above were potential risks to patient safety for the patients housed on both the Adult Behavioral Unit and the Geriatric Behavioral Unit.

In an interview on 2/4/15 at 9:44 a.m., with S5BehavioralHealthDirector, she confirmed patients who had not been placed on one to one observation would have been observed every fifteen minutes and could potentially have been out of staff direct sight, in their rooms, during the interval between the every fifteen minute observations. She indicated that all of the rooms on both the Adult and Geriatric Behavioral Units were constructed/equipped the same and the above findings would have been consistent in all patient rooms. She confirmed 3 beds on the Adult Behavioral Unit and all of the beds (10) on the Geriatric Behavioral Unit were equipped with side rails. She agreed not all patients admitted to the Geriatric Behavioral Unit would have required side rails. S5BehavioralHealthDirector also agreed the above referenced environmental findings were potential risks to patient safety on the Behavioral Health Units (Adult and Geriatric).

Based on record review, observations and interviews, the hospital failed to ensure the confidentiality of patient records as evidenced by failing to safeguard clinical records of patients receiving outpatient radiation services from unauthorized access by staff, patients and/or visitors who had accompanied the patients. This deficient practice had the potential to affect 15 (#R1- #R15) of 15 (#R1- #R15) patients who were currently receiving outpatient radiation treatments.

Findings:

Review of the Hospital's Policy & Procedure titled "Patients' Rights and Responsibilities" presented by S3Quality as being current (01/15) read in part: "H. To every consideration of privacy concerning your own medical care program. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. I. To expect that all communications and records pertaining to your care are treated as confidential."

Review of the Hospital's Policy & Procedure titled "Release of Information /Confidentiality of Patient Statement" presented by S20Compliance as being current (June 2010) read in part: " Name of the Hospital, therefore, is responsible for providing adequate safeguards to prevent access to a patient's medical record by unauthorized persons from the time the record is initiated throughout the patient's hospitalization and after his discharge."Patient charts are maintained such that non-authorized individuals do not have access to patient medical records at any time."

Observation on 02/02/15 at 1:40 p.m. of the hospital 's Radiation Oncology Department revealed an open roller storage cart located on the outer edge of the nurse station. The cart was noted to contain 15 (#R1, #R2, #R3, #R4, #R5, #R6, #R7, #R8, #R9, #R10, #R11, #R12, #R13, #R14 & #R15) medical records with medical information related to treatment being rendered. The records were left unattended in the outpatient area at the nurses' station. Observation of the patient medical records in the unsecured/unrestricted area (accessible by other patients and staff) for 5 minutes (1:40 p.m.-1:45 p.m.) revealed no hospital staff had been present in the area during that time.

In an interview on 02/02/15 at 1:50 p.m., S25RN & S26RadiationTherapist confirmed that there were 15 medical records in the storage cart for current patients who were receiving and/or had received outpatient radiation services. S26RadiationTherapist indicated the cart was left open and unlocked all day while patients were receiving treatment. S25RN confirmed that the medical records were accessible to patients and other staff members. She confirmed that the cart was unlocked and it should have been locked.


In an interview on 02/04/15 at 10:30 a.m., S3Quality confirmed the cart with patients' medical records should have been secured. She also confirmed the confidential patient information had been accessible to unauthorized staff, patients and/or visitors when the cart was left open and unlocked.

Based on record review and interview, the Governing Body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services, including those services furnished under contract, involved in the QAPI Program. The Governing Body failed to ensure the QAPI program included Linen Services and Biohazardous Waste Disposal Services.
Findings:
Review of the QAPI records revealed no documented evidence that Linen Services and Biohazardous Waste Disposal Services were included in the QAPI program.
In an interview on 02/4/15 at 3:30 p.m., with S3Quality, she confirmed the QAPI program did not include quality indicators for Linen Services and Biohazardous Waste Disposal Services.

Based on record reviews and interviews, the hospital failed to ensure a RN (Registered Nurse) evaluated the nursing care of each patient as evidenced by:

1) failure to perform an assessment on a dialysis patient for 1 (#15) of 2 (#15 & #32) dialysis patients reviewed out of a total sample of 39 patients;

2) failure to assess a patient before and after the administration of IV (intravenous) Ativan for 1 (#17) of 1 (#17) patients reviewed for Ativan use out of a total sample of 39 patients.

Findings:

1) Failure to perform an assessment on a dialysis patient.

Patient #15
Review of Patient #15's electronic medical record revealed an admission date of 01/30/15 with diagnoses including the following: Dysphagia & Odynophagia, Weight Loss, ESRD (End-Stage Renal Disease) & UTI (Urinary Tract Infection).

Review of Patient #15's admit orders revealed the following: Hemodialysis Monday, Wednesday and Friday.

Review of the orders dated 01/31/15 revealed the following: Hemodialysis Tuesday, Thursday and Saturday.

Review of the Hospital's dialysis schedule revealed Patient #15 received Hemodialysis treatment on 01/30/15, 01/31/15 & 02/03/15.

Review of Patient #15's nurses' notes from 01/30/15 to 02/03/15 revealed the only assessment of the hemodialysis site, by a hospital staff nurse, was on 01/30/15 at 0745. There was no documented evidence of pre and post dialysis assessments by hospital staff nurses. Further review revealed no hemodialysis site assessments had been performed by a hospital staff nurse on Patient #15's assigned unit except for the date/time referenced above.

In an interview on 02/03/15 at 10:30 a.m., S17RN indicated that all hemodialysis was performed in a specified area within the hospital and the patients were assessed by the contracted dialysis nurses upon arrival to the unit and before leaving the unit, prior to returning to their rooms. S17RN indicated that the hospital's staff nurses had been trained to check dialysis patients' access site.

In an interview on 02/04/15 at 10:25 a.m., S3Quality presented policies/procedures from the hospital's contracted Dialysis Services as the hospital's Dialysis policy. S3Quality confirmed the hospital had no policy which addressed care of the hemodialysis patients (physical assessment and access site assessment).

In an interview on 02/04/15 at 1:30 p.m., S17RN, after review of Patient #15's Nurses' notes, confirmed there was no documented evidence of pre and post hemodialysis assessments by the hospital staff. S17RN also confirmed there was no documented evidence of access site monitoring/assessments.

2) Failure to assess a patient before and after the administration of IV (intravenous) Ativan.

Review of the Hospital's Policy/Procedure titled "Medication : Nursing Drug Administration (Nursing Reference Center) NR-2-9-010" presented by S3Quality as being current (04/2014) read in part:
"Lorazepam (Ativan):
Nursing Implications: Assessment:
Conduct regular assessment of continued need for treatment.
Anxiety: Assess degree and manifestations of Anxiety and mental status (orientation , mood behavior) prior to and periodically throughout therapy.

Patient # 17
Review of Patient #17's electronic medical record revealed an admission date of 02/23/15 with diagnoses including the following: Acute Kidney Injury, Hyperkalemia, UTI (Urinary Tract Infection), Leukocytosis & Suspected Aspiration Pneumonia.

Review of Patient #17's orders, dated 01/28/15 at 1537 (3:37 p.m.), revealed the following: "Ativan 0.5 mg (milligram) IV (intravenous) every 4 hours prn (as necessary) for Anxiety and agitation."

Review of Patient #17's MARs (Medication Administration Record) revealed Ativan 0.5 mg IV was administered on the following dates/time: 01/28/15 1537 (3:37 p.m.) & 2155 (9:55 p.m.); 01/29/15 10:31 a.m., 1620 (4:20 p.m.) & 2230 (10:30 p.m.); 01/30/15 20:18 (8:18 p.m.); 01/31/15 0357, 2235 (10:35 p.m.) & 02/03/15 0023.

Review of Patient #17's nurses' notes revealed no documented evidence of assessment of Patient #17's orientation, behavior and/or mood prior to administration of Ativan. Further review revealed no assessment was performed to assess for the effectiveness of the Ativan dose after administration.

In an interview on 02/04/14 at 1:20 p.m., S2CNO (Chief Nursing Officer) confirmed an assessment should have been conducted prior to and after the administration of IV Ativan to Patient #17.

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were administered according to physician orders and hospital policy for 3 (#11, #24, #25) of 3 (#11, #24, #25) patient medical records reviewed involving the administration of a sedative (Propofol) in a mechanically ventilated patient, from a total sample of 39.

Findings:

Review of hospital policy #ICCU-PR-150, titled "ICCU (Intensive Coronary Care Unit) Continuous IV (Intravenous) Sedation for Mechanically Ventilated Patients (last revised/Approved date of 6/11), provided by S8DirectorICU/ER (Intensive Care Unit/Emergency Room) as current, revealed the following, in part:
...The physician will determine the desired level of sedation using the modified Ramsey Scale. The RN (Registered Nurse) administering the sedation will follow the policy/procedure and the Guidelines for Ventilator Sedation for titration of the ordered medication.... Procedure:
1. Verify specific written order for continuous IV (Intravenous) sedation/medication...NOTE: Patient requirements for sedation vary considerable, and as such, dosage must be individualized for each patient...5. The physician will determine the desired level of sedation ( Modified Ramsey Scale) (patient condition and response assessment),
Level 1: - anxious, agitated, restless
Level 2- patient cooperative, oriented, and tranquil
Level 3- patient responds to commands only
Level 4- a brisk response to a light glabellar tap or loud auditory stimulus
Level 5- a sluggish response to a light glabellar tap or loud auditory stimulus
Level 6- no response.
Dosing of Continuous IV Sedation * Propofol (Diprivan) infusion starting dose 5 mcg/kg/min-titrate to ordered level of sedation. Usual maintenance dose 50 mcg/kg/min (micrograms per kilogram per minute) or higher. Maximum dose determined by physician for desired clinical response. 9. Documentation of monitoring will occur on the nurse's notes every two (4) [clarified as every four hours by S8DirectorICU/ER] hours and PRN (as needed) with changes in patient condition or dosage. Monitoring assessment to include vital signs (every one hour), Oxygen saturation (every one hour), Glasgow coma rating (every four hours), Modified Ramsey Scale rating (every four hours), and Rate of infusion/ hr (hour) (every one hour).

Patient #11
Review of the medical record for Patient #11 revealed, in part, she received Propofol continuous sedation during part of the time she was on a mechanical ventilator in the ICU.
Review of a screen shot of the electronic medication detail, provided 2/2/15 at 6:10 p.m. by S40HIMTech, revealed Propofol IV was ordered with a start date of 1/27/15 at 11:00 p.m. The order read, under "Label text", " Start at 5 mcg/kg/min ( micrograms per kilogram, per minute). Titrate to ordered Level of Sedation. Usual maintenance dose-50 mcg/kg/min or HIGHER. Max dose determined by M.D." Protocol : Condition Dose/Route/Rate Instruction Starting dose 5 MCG/KG/MIN,
Text: Titrate to ordered level of sedation.
Review of the electronic medication administration record (MAR) provided for 1/28/15- 2/1/15 revealed the following doses and times documented:
1/28/15
5:32 a.m. - 30 ml (milliliters)/hr (hour)
3:00 p.m.- 10 ml/hr
1/29/15
1:07 a.m. -15 ml/hr
10:56 a.m.-10 ml/hr
8:04 p.m. -20 ml/hr
1/30/15
1:15 a.m.- 10 ml/hr
6:08 p.m. -10 ml/hr
1/31/15
1/25 a.m. - 15 ml/hr
6:40 a.m. - 15 ml/hr
10:27 p.m. -10 ml/hr
2/1/15
2:40 p.m. - 12 ml/hr
Comments noted on MAR included the following:
-1/28/15 -Label Comment: Start at 5 mcg/kg/min. Titrate to ordered level of sedation. Usual Maintenance dose- 50 mcg/kg/min or higher. Max dose determined by MD (Medical Doctor).
-Dose Instruction: Titrate to keep minimally sedated, Max 25 mcg.


Review of nursing assessments for 1/28/15- 2/1/15 provided were at the following times.
1/28/15
12:00 p.m. (noon)
4:00 p.m.
8:00 p.m.
1/29/15
12:00 a.m. (Midnight)
4:00 a.m.
8:00 a.m.
12:00 p.m. (noon)
4:00 p.m.
8:00 p.m.
1/30/15
12:00 a.m. (Midnight)
4:00 a.m.
8:00 a.m.
12:00 p.m. (noon)
4:00 p.m.
8:00 p.m.
1/31/15
12:00 a.m. (Midnight)
4:00 a.m.
8:00 a.m.
12:00 p.m. (noon)
4:00 p.m.
8:00 p.m.
2/1/15
12:00 a.m. (Midnight)
4:00 a.m.
8:00 a.m.
12:00 p.m. (noon)
4:00 p.m.
8:00 p.m.
Further review of the nursing assessments provided revealed no level of sedation using the Modified Ramsey Scale, as required in Policy and Procedure #ICCU-PR-150, Continuous IV Sedation for Mechanically Ventilated Patients.

Patient #24
Review of the medical record for Patient #24 revealed she was admitted to the hospital 2/1/15, was mechanically ventilated and received continuous IV (Propofol) sedation.

Review of a screen shot of a medication detail for Patient #24's Propofol revealed it was ordered 2/2/15 at 12:00 a.m. (midnight) with a label text "titrate to maintain light sedation. Protocol: Starting rate 1, Titrate to 20. titrate form minimal sedation.

Review of Patient #24's MAR for 2/1/15 -2/3/15 revealed the following entries, in relation to Propofol administration :
2/1/15
9:25 a.m. 3 ml/hr
2/2/15
12:02 a.m. 5 ml/hr
7:20 a.m. 14 ml/hr
1:34 p.m. 16 ml/hr
8:03 p.m. 15 ml/hr
2/3/15
3:54 a.m. 15 ml/hr
7:23 a.m. 15 ml/hr
2:10 p.m. 13 ml/ hr
10.25 p.m. 13 ml/hr
2/4/15
3:31 a.m. 13 ml/hr
10:12 a.m. 25 ml/hr
1:48 p.m. 19 ml/hr

Review of nursing assessments revealed assessments revealed no Modified Ramsey scores documented.

Patient #25
Review of the medical record for Patient #25 revealed she was admitted to the hospital 1/27/15. Further review revealed Patient #25 was on a mechanical ventilator and was receiving Propofol sedation.
Review of of a screen shot of a Medication Detail of ordered Propofol for Patient #25, provided by S8DirectorICU/ER 2/4/15 at 4:30 p.m., revealed the start date for the Propofol was 1/28/15, the Label text read, "keep lightly sedated". Protocol read, "Starting rate 3".
Review of Patient #25's MAR revealed the following entries related to Propofol:
1/28/15
9:30 p.m. 3 ml/hr, Label comment: Keep lightly sedated
1/30/15
2:59 p.m. 50 mg

Review of nursing assessments for the following assessments revealed no documentation of a Modified Ramsey Score.
2/2/15: 12:00 a.m. (midnight), 4:00 p.m., 8:00 p.m., 12:00 p.m. (noon), 4:00 p.m., 8:00 p.m.
2/3/15: 4:00 a.m., 8:00 a.m., 12:00 p.m. (noon)

Review of the medical records for Patient #11, #24, and #25 revealed no physician orders that specified the use of the hospital ICU Conscious Sedation Protocol, or specific parameters of the amount of Propofol to be administered to start the sedation, how often the Propofol could be increased, and by how much, and to what level of sedation , using the Modified Ramsey Scale as per hospital policy, the Propofol was to be titrated.

In an interview 2/4/15 at 9:20 a.m. S8DirectorICU/ER verified the above findings. S8DirectorICU/ER verified that the physician's orders did not specify how much medication was to be administered to begin each patient's continuous IV Sedation (Propofol) infusion. The amount or increments to increase the medication and the frequency in which it could be increased, until a specified level of sedation was achieved in the patient, was not documented in the provided orders,. S8DirectorICU/ER verified the nurses were not using the Modified Ramsey Scale for patient assessment throughout their care. S8DirectorICU/ER verified the nurses did not document an assessment/ Modified Ramsey Score with each rate change to document the reason or need for the rate increase or decrease.

Based on record review (policy and procedures),observation and interview, the hospital failed to ensure patients' medical records in the permanent file room and the incomplete chart room were protected from potential damage and/or destruction.
Findings:
Review of the policy entitled, "Incomplete Medical Record/Perm File" (CSFC-MR-3.12) presented as the current policy with a review date of 01/2015, revealed, in part: "...2. Therefore, space shall be selected to meet the following specifications: a. Adequate lighting; b. Controlled environment (60-80 degrees Fahrenheit, 50% humidity; c. Freedom from dust; d. Protection against fire, smoke, and heat detectors; e. Freedom from potential hazards, such as flooding or damage from broken water pipes."
An observation on 02/03/15 at 11:00 a.m. in the medical records permanent file room revealed three rolling medical record carts located in the permanent medical records storage room with no covering over the medical records; six fan-file type folders with medical records from the Emergency Department stored on open and uncovered shelves. Further observation in the medical records permanent file room revealed the hospital had sprinkler system valves located throughout the ceiling.
In an interview on 02/03/15 at 11:30 a.m., S6CodingSpecialist indicated the 2014 medical records located on the three rolling carts were being stored there until the 2012 and 2013 medical records were removed from the permanent shelves and brought to an offsite storage facility. S6CodingSpecialist confirmed the emergency department medical records stored on the open shelves and the 2014 medical records stored on the rolling carts were not protected from potential damage and/or destruction. She also confirmed the medical records should be stored in a manner that would protect them from damage and/or destruction.
An observation on 02/03/15 at 11:45 a.m. in the incomplete chart room revealed 3 five-shelf open shelving units and 6 six-shelf open shelving units with patients' medical records stored on the shelves. Further observation revealed the incomplete chart room had sprinkler system valves located throughout the ceiling.

In an interview on 02/03/15 at 12:00 p.m., S6CodingSpecialist confirmed the medical records stored on the open shelves in the incomplete chart room were not protected from potential damage and/or destruction. She also confirmed the medical records should be stored in a manner that would protect them from potential damage and/or destruction.

In an interview on 02/04/14 at 9:00 a.m., S9HIM (Health Information Management)Team Leader confirmed the medical records stored on the open shelves and the rolling carts in the permanent file room and the incomplete chart room were stored in a manner that would not protect the medical records from potential damage or destruction.

Based on record review and interview, the hospital failed to ensure all medical record entries were authenticated, dated and timed by the person responsible for providing or evaluating the service provided for 2 (#2, #21) of 4 (#2, #21, #22, #23) records reviewed for dated and timed entries of a total sample of 39.

Findings:

Review of Medical Staff Rules and Regulations, with an effective date of 3/12/14, provided by S3Quality as current, revealed the following, in part:
Section 2: Rules and Regulations for Medical Records
1. ORDERS: All orders for treatment should be in writing and recorded with date and time in the medical record...
2. Authentication, Dating, and Timing of Pre-Printed Orders: All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures...

Patient #2

Review of the medical record for Patient #2 revealed she was admitted 1/28/15 for an aortic valve replacement, and was a current patient in the hospital. Further review revealed the following, in part:
-Cardiovascular Perfusion Orders dated 1/28/15 and signed by S13MD (Medical Doctor). No time was documented.

-Physician's Restraint Order sheet dated 1/30/15 and timed for 11:00 a.m., documented as a telephone order, taken from S39NP (Nurse Practitioner) by the RN (Registered Nurse). Further review of the order revealed the order was co-signed by S13MD with no date and time of S13MD's authentication co-signature.

-S13MD: Routine Cardizem Orders signed off as SO (standing order) with a date and time of 1/30/15 at 2:55 p.m. Further review revealed an authentication signature of S13MD with no date or time documented of the physician's signature.

In an interview 2/2/15 at 5:30 p.m. S8DirectorICU/ER (Intensive Care Unit/Emergency Room) reviewed the medical record of Patient # 2 and verified the above noted findings.


Patient #21

Review of the medical record for Patient #21 revealed he was admitted 2/3/15 to the Day Surgery department for outpatient surgery. Further review of the medical record revealed admission orders which included "Admit to Day Surgery on 2/3/15", and signed by S37MD. No date or time was documented on the orders or the physician's signature.

In an interview 2/3/15 at 12:15 p.m. S13RN and S23RN verified the above findings after review of Patient #21's medical record. S23RN verified the physician's orders should have been dated and timed.

Based on record review and interviews, the hospital failed to ensure patients' medical records were completed within 30 days after patients' discharges.
Findings:
Review of the Medical Staff By-laws, Section 2, Rules and Regulations for Medical Records, revealed the following, in part: "12...At the time of discharge the attending physician shall see that the record is complete, state his final diagnosis, and sign, date, and time the record.
16. Procedure for Incomplete and Delinquent Medical Records.
c. A medical record is considered incomplete when it has been in a physician's box for fourteen (14) days or less. A medical record is considered delinquent when it has been in the physician's box for fifteen (15) days or more.
e...If there are incomplete medical records but no delinquent records in a box on a review date, the incomplete medical record notice is sent by the Medical Record Department. If there are delinquent medical records in a box on a review date, a delinquent medical record letter is sent by the Medical Record personnel. Two (2) weeks are given to complete the delinquent records.
f. Seven (7) days after notice to the physician of delinquent medical records, if those records have not been completed, the physician will receive a letter from the President of the Medical Staff notifying him that all clinical privileges including performing and posting of surgical cases, (unless emergency), attending, consulting, and admitting of patients will be suspended seven (7) days from the date of the notice.
g. If a physician still has delinquent medical records one week (7 days) after the letter of intent to suspend privileges was mailed, and he has not requested initiation of the Fair Play Plan, all of his clinical privileges are automatically suspended and letters to this effect are sent to the Medical Record Department, Admitting Office, Emergency Room, Surgery, Nursing Administration, Medical Staff Services, and all nursing units.
h. If suspension reaches 10 days, the member is personally called by the VPMA (Vice President of Medical Affairs); if suspension reaches 20 days, the member is personally called by the Administrator; at least 48 hours prior to enforcement of penalty of automatic expulsion at 30 days of suspension, the member will be personally contacted by the Medical Staff President or his designee.
Review of a document entitled Hospital Medical Records Statistics Form revealed the following delinquency rates for 2014: 1st quarter had a delinquency rate of 56%; 2nd quarter had a delinquency rate of 46%; 3rd quarter had a delinquency rate of 57%; 4th quarter had a delinquency rate of 49%. Review of a document entitled "Provider's Incomplete Records List by Days Outstanding" revealed the delinquency rate greater than 120 days was a rate of 69%.
In an interview on 02/04/15 at 12:15 p.m., S7MedicalRecordsDirector indicated she was the Regional Director for the hospital's medical record department and the Medical Record Director over a "sister" hospital site, and has been the Regional Medical Record Director for about 2 years. She also indicated the hospital has not had a Medical Record Department Manager since October, 2014. S7MedicalRecordsDirector verified the hospital's medical record delinquency rate for January, 2015 was 55%. She also indicated that she was not aware of any physicians that had privileges suspended for delinquent medical records since her employment with the hospital. S7MedicalRecordsDirector confirmed the hospital had difficulty in attaining and maintaining compliance with medical record delinquencies.
In an interview on 02/04/15 at 3:15 p.m., S36MedicalStaffCoordinator indicated she had been the medical staff coordinator for about 5 years at the hospital. She further indicated she does not recall any physicians having been suspended in the recent past few years for medical record delinquencies.

Based on observation and interview, the hospital failed to ensure equipment was maintained to ensure an acceptable level of quality as evidenced by:
1) patients' beds having a nurse call feature on the handrails that was inoperable for 97 of the hospital 's beds (located throughout the hospital).
2) storing food preparation equipment without being properly cleaned, having a light fixture (located in a food preparation area) coated in fuzzy substance, having food preparation equipment with missing on/off knobs.
Findings:
1) Patients' beds having a nurse call feature on the handrails that was inoperable for 97 of the hospital's beds (located throughout the hospital).
Observations during the initial tour on 2/2/15 at 2:30 p.m. revealed patient beds had nurse call buttons on the handrails bilaterally which were non-functional. S35RN confirmed the nurse call feature on the handrails was non-functional. She explained patients were instructed to use the nurse call feature on the cord attached to the wall to call for assistance. She agreed patients that were confused and or family members who had not received instruction to use the nurse call feature on the cord attached to the wall may use the buttons on the handrail in an attempt to call a nurse for assistance or in an emergency.
In an interview on 2/4/15 at 8:46 a.m. with S2CNO, she agreed patients that were confused or family members who had not been oriented to use the call button on a cord attached to the wall may use the buttons on the handrail in an attempt to call a nurse for assistance or in an emergency.
2) Storing food preparation equipment without being properly cleaned, having a light fixture (located in a food preparation area) coated in fuzzy substance, having food preparation equipment with missing on/off knobs.

An observation of the hospital's dietary department on 02/02/15 at 1:30 p.m. revealed the following:
Large table mounted can opener was noted to have a dry white, orange-brown colored substance on the inner grooves.
Bottom surface of the braiser (broiler/roaster) was noted to have a coating of a colorless shiny substance.
Toaster was noted to have a small amount of bread crumbs on the top surface and a large amount of bread crumbs on the crumb surface plate.
Grill & hot plate had no on/off knobs and two pairs of pliers were noted underneath the hot plate.
4 Ovens- 2 of the 4 were noted to have a dark black substance on the oven floor and dried drippings of a substance on the inner oven doors.
Light fixture located over the grills was noted to have large amount of thick fuzzy grayish matter on the outer covering of the light.

In an interview on 02/02/15 at 1:30 p.m., S28DietaryManager and S29RD (Registered Dietician) confirmed the above observations. S28Dietary Manager confirmed the grill & hot plate had to be turned on and off with pliers. S28Dietary Manager confirmed the equipment should have been cleaned after use and before being stored.




31206

Based on record review and interview, the hospital failed to implement a discharge planning assessment for a patient identified as likely to suffer adverse health consequences upon discharge if there was no adequate discharge planning according to the hospital's policy for 1 (Patient #39) of 5 (Patient #31, #36, #37, #38 and #39) patients reviewed for discharge planning.
Findings:
Review of the hospital's policy on Plan for Case Management, Policy Number CC-A-010, revealed in part, Case Management is available to all patients and their families. Specific services provided are based on individual needs and available resources. The "High Risk Screening and Referral Guide " is utilized by the Case Management Department as a tool to assist in identifying those patients whose diagnosis, health problems, or psychosocial circumstances may require a more comprehensive intervention and planning than a physician follow-up appointment or self-care instructions ...
Review of the High Risk Referral Guide revealed in part, Nursing Home Resident or Potential Resident and CHF (Congestive Heart Failure) are considered high risk... C. Discharge Planning Assessment- Within one business day, the Case Manager will review the medical record to determine if post-discharge needs or barriers to discharge exist. Once discharge planning needs or barriers to discharge has been identified, the Case Manager will either directly or through collaboration with other disciplines, formulates a plan of action to meet these needs and implement it upon physician approval. The patient and/or caregivers will be included in formulating plan for discharge. Arrangement of any Home Care Services or Home Care equipment/Supplies is based on patient/family preference and available vendors.
Patient #39
Review of Patient #39's medical record revealed the patient was an 89 year old female who resided in a nursing home prior to her 10/16/14 admission to the hospital. Patient #39 was admitted to the hospital on 10/16/14 for Aspiration Pneumonitis, Hypoxia and Congestive Heart Failure (CHF). The patient was discharged on 10/18/14 to the hospital's in-house hospice and subsequently discharged to a different inpatient hospice shortly afterwards.
An interview was conducted with S30RN Case Manager on 2/4/15 at 10:30 a.m. With review of Patient #39's EMR (Electronic Medical Record) and the patient's hard copy of their medical record, S30RN Case Manager reported a discharge high risk screening/evaluation was not conducted on the patient according to policy and should have been. She further reported Patient #39 was high risk due to her diagnosis of CHF and due to her residing in a nursing home prior to her 10/16/14 hospital admission.

Based on record/policy review, observation and interview, the hospital failed to ensure policies and procedures governing surgical care were designed and implemented to assure the achievement and maintenance of high standards of medical practice and patient care as evidenced by :

1) policies and practices that allow staff to launder surgical scrubs at home, and

2) Allowing the use of skull caps to be worn in the restricted areas, thereby having hair exposed in the OR (Operating Room) and other restricted areas.

Findings:

Review of Perioperative Standards and Recommended Practices for Inpatient and Ambulatory Settings (Association of periOperative Registered Nurses [AORN], 2013 Edition) revealed, in part, the following:
"...AORN recommended practices for perioperative nursing practice...are based on principles of nursing science, microbiology, research, review of the scientific literature, and the opinions of knowledgeable experts...
Recommended Practices for Surgical Attire: ...
Recommendation II. Clean surgical attire, including shoes, head coverings, masks, jackets, and identification badges should be worn in the semi restricted and restricted areas of the surgical or invasive procedure setting... IIa. Facility-approved, clean, and freshly laundered or disposable surgical attire should be donned daily in designated dressing areas before entry or reentry into the semi restricted and restricted areas.
Recommendation III. All individuals who enter the semi restricted and restricted areas should wear freshly laundered surgical attire that is laundered at a health care-accredited laundry facility or disposable surgical attire provided by the facility and intended for use within the perioperative setting.
Recommendation IV: All personnel should cover head and facial hair, including side burns and the nape of the neck, when in semi restricted and restricted areas... IV.a. A clean, low-lint surgical head cover or hood that confines all hair and covers scalp skin should be worn...IVa.2. Reusable head coverings should be laundered in a health care-accredited laundry facility after each daily use.
Recommendation V: Surgical attire should be laundered in a health care-accredited laundry facility... Health care-accredited laundry facilities are preferred because they follow industry standards... An accredited health care facility laundering process includes monitoring correct measurement of chemical, sufficient water, correct temperature, mechanical action, and the duration of the washing cycle...Home laundering is not monitored for quality, consistency, or safety... V.a. Laundered surgical attire should be protected during transport to the practice setting to prevent contamination...
Recommendation IX: The health care organization's quality management program should evaluate compliance with surgical attire policies and identify and respond to opportunities for improvement..."

Review of Hospital Operating Room Policy # 701, titled, "Home Laundering of Scrub Uniforms",(issue date: 6/03, last review/approval 5/14), provided by S23RN (Registered Nurse) as current revealed the following, in part:
Policy: 1. Surgical Services Associates will be responsible for purchasing and laundering of their own scrubs. 2. Scrub suits are not considered personal protective equipment.
Procedure:...2. ... It is the responsibility of the Associate to launder their scrub uniforms on a daily basis... "For surgical scrubs or other surgical attire not visibly contaminated, organizations can choose between home laundering (acceptable per CDC [Center for Disease Prevention]/HICPAC [Healthcare Infection Control Practices Advisory Committee]) or a healthcare-accredited laundry facility (recommended per AORN). [bolded in hospital policy]For all visibly contaminated clothing, the employer must be responsible for laundering per OSHA [Occupational Safety and Health Administration] standards. Your organization should develop a policy addressing how they will manage this process and what guidelines they are following which will drive our survey process. (TJC [The Joint Commission], 2013). * IC.01.05.01 EP 1 requires organizations to follow evidence-based national guidelines. The two main guidelines regarding this topic do not agree, therefore an organization may choose one or the other: -CDC/HICPAC Recommendations- Laundry and Bedding I. Employer Responsibilities A. Employers must launder worker's personal protective garments that are contaminated with blood or other potentially infectious garments that are not contaminated with blood or other potentially infectious materials. -AORN's [Association of periOperative Registered Nurses] most recent Recommended Practices- Recommendation V states, "Surgical attire should be laundered in a health care-accredited laundry facility." (TJC, 2013).

Review of a document provided by S23RN titled Surgical Attire Plan-Phase 1 (hospital associates) revealed the following, in part: Scrub Clothing * OR (Operating Room) and SPD (Special Procedure Department) associates shall wear scrubs intended for use only within the department...Scrub attire will be laundered by associates... Hair Covering * In OR, GI (gastrointestinal) Lab, and SPD all possible head and facial hair should be covered when in semi-restricted and restricted areas...Personal hair covering may be used, but must be laundered daily.
An observation 2/3/15 at 11:00 a.m. in the restricted area, at a scrub sink just outside of an OR, revealed S22MD (Medical Doctor) walking up to the scrub sink. S22MD was wearing a surgical cap, also called a "skull cap", with parts of his hair uncovered at his sideburns and back of his hair near his neck. S23RN, present during the observation, confirmed the observation, and reported that a bouffant surgical hat should be worn over the surgical/skull cap to ensure all hair is covered.
An observation 2/3/15 at 12:00 p.m., made at the surgical nurses's desk next to an exit door leading out of the restricted surgical area, revealed S13MD left the surgical department wearing a surgical cap (skull cap) with his hair partially uncovered by the cap. S13MD had come from the restricted area containing the operating rooms. S15RN, present at the nursing station, confirmed the observation,
In an interview 2/3/15 at 12:15 p.m. S23RN reported that OR personnel launder their own scrubs at home. S23RN reported the hospital's policy on laundering of OR scrubs, was based on an understanding that the hospital could choose between laundering at home, which she (S23RN) reported was acceptable by CDC , and AORN's recommended practices. After review of the policy, S23RN verified the CDC/HICPAC Recommendations quoted in the policy, "There is no stated guidance on garments that are not contaminated with blood or other potentially infectious materials." S23RN confirmed this did not say CDC approved the home laundering of surgical scrubs. S23RN confirmed the policy contained no procedure as to how or under what conditions the scrubs were to be cleaned and disinfected. S23RN was unable to provide any documented evidence that staff surgical scrubs were cleaned and disinfected under conditions and procedures recommended for cleaning, decontamination, and/or disinfection of health care related laundry. When asked how surgery staff knew the procedure for laundering their surgical scrubs, such as temperature, length of cleaning cycle, etc., S23RN reported she referred staff to read the AORN recommended practices. S23RN reported the practices for the surgery department mainly followed AORN recommendations. S19RN, present during the interview with S23RN, agreed that laundering surgical scrubs by staff in their home did not ensure scrubs were adequately decontaminated and disinfected. S19RN agreed that the AORN recommendations were the accepted practice in the surgical setting. Both S19RN and S23RN agreed that surgical/skull caps should not be worn without a surgical bouffant hat over it to ensure all hair was covered.

Based on record review and interview, the hospital failed to ensure a current History and Physical (H&P) or an update of a current H&P was on patient charts before surgery was performed for 2 (#16, #21) of 4 (#2, #16, #21, #22) surgical patient's medical records reviewed for an H&P or update of a current H&P prior to the surgery or procedure out of a total sample of 39 patients reviewed.

Findings:

Review of hospital policy # 240, titled "Written History and Physical" (issued date 9/97, most recent review/approved date of 3/14), provided by S3Quality as current, revealed the following, in part: ...1. A signed History and Physical will be present on the chart of every patient requiring sedation, analgesia, or anesthesia prior to entry into the operating/procedure room. 1.1 The H&P must be less than thirty (30) days old...1.3 The surgeon, if different from the admitting physician must make a statement that includes, at least: a focused assessment, a plan of care, and and indication that he has reviewed the H&P... 1.4 Surgery will be delayed until the H&P is present, unless the admitting physician/surgeon states, in writing, that the delay constitutes a hazard to the patient's health...1.6 An office H&P must be updated prior to surgery (as a break in care has occurred between the H&P and the patient's admission to include: noted changes or lack of changes, in the patient's condition since the H&P was written. This notation must be signed, dated, and timed.

Review of the Medical Staff Rules and Regulations revealed, in part, the following:
H&P Requirements are contained in the Medical Staff Bylaws, a. A complete medical H&P shall be recorded on the patient's chart within 24 hours following admission of the patient... If a complete H&P has been performed and written (dictated) within thirty (30) days prior to admission and/or procedure, such as in an office of a physician member of the medical staff, ...a copy of this report may be used in the patient's hospital medical record, provided this report was recorded by a Medical Staff member and any changes subsequent to the original examination, or the fact that there have been no changes since the original examination, are documented in the patient's medical record within 24 hours after admission or registration but prior to to surgery or procedure requiring anesthesia services (an "updated medical record entry)...

Patient #16

Review of the record for Patient #16 revealed an admit date of 01/18/15 with a diagnosis of status post motor vehicle accident with multiple fractures. Further review of the record revealed the patient had orthopedic surgeries on the following dates: 01/19/15, 01/20/15 and 01/26/15.

Review of the patient's History and Physical revealed it was dated 01/18/15. There was no documented evidence that the patient's admit History and Physical had been updated prior to the surgeries.

On 02/02/15 at 5:30 p.m., S8DirectorICU/ER (Intensive Care Unit/ Emergency Room) reviewed the patient's electronic medical record and paper record with the surveyor and confirmed that there was no documented evidence that the patient's physician had updated the History and Physical prior to each of the patient's surgeries.

Patient #21

Review of the medical record for Patient #21 revealed he was admitted 2/3/15 and underwent the surgical debridement of a Right Parietal (scalp) wound with hardware removal the same morning. Further review of the patient's medical record revealed a form titled "Day Surgery Short Stay Record". Additional review revealed S37MD had documented "See H&P 2/3/15 on chart" under the History section of the form.

Review of a H&P for Patient #21 with an admission date of 2/3/15 revealed it was signed by S37MD on a line with " Physician's Signature" typed below the line. No time or date was noted by S37MD's signature. Further review of the H&P revealed, below S37MD's signature (on the Physician's Signature line), in darker thicker writing the following: " 2/3/15 No change, (S37MD's signature)". No time was documented with the second signature.

In an interview on 2/3/15 at 12:15 p.m. with S23RN (Registered Nurse) and S19RN they confirmed the date and time the H&P was performed was not documented. S23RN and S19RN confirmed the update to the H&P was not timed. S19RN verified she was the Director of Surgical Services. S19RN reported that updates to H&Ps should be done within 24 hours of the surgical procedure, and should be dated and timed. S19RN agreed that without a time, the H&P was not evidenced to be performed and documented prior to the surgery or procedure.


17450