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A. Based on review of Medical Staff Bylaws and Rules and Regulations, clinical record review, and staff interview, it was determined for 1 of 2 clinical records reviewed in the Family Birth Center (Pt. #1), that the Hospital failed to ensure that a medical history and physical examination was completed no more than 30 days before or 24 hours after admission or registration.

Findings include:

1. The Medical Staff Bylaws and Rules and Regulations were reviewed on 6/16/09 at 9:10 AM. The Rules and Regulations required: "E. A working history and physical examination, shall, in all cases, except normal routine deliveries, be written or dictated within twenty-four (24) hours after admission of the patient..."

2. On 6/15/09 at 10:40 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 24 year old female, admitted on 6/14/09 at 7:47 AM, with diagnoses of Intrauterine Pregnancy, Vaginal Birth, and Post Partum Hemorrhage. The last History Summary was dated 10/18/08. The record lacked a History and Physical completed in the past 30 days and 24 hours from admission.

3. This finding was conveyed to the Clinical Manager of the Family Birthing Center during an interview on 6/15/09 at 10:50 AM.

4. An interview was conducted on 6/18/09 at 10:05 AM with the Chief Nursing Officer (CNO). The CNO stated that the Bylaws exempted patients with normal routine deliveries from a history and physical because prenatal care is usually provided in the Physicians's office on a weekly basis. The finding was conveyed to the CNO during the interview.

A. Based on Hospital policy review, observation, and staff interview, it was determined, for 6 of 6 patients on 2 West with telemetry monitoring, (Pt. #s 4, 5, and 27-30) it was determined that the Hospital failed to ensure that the monitor alarms were audible.

Findings include:

1. Hospital policy #IMC T 1.1 entitled, "Use of Telemetry," was reviewed on 6/16/09 at approximately 10:00 A.M. The policy requires, "Initial alarm parameters will be set... In case of malfunction, the Bio-medical Engineer should be contacted and equipment malfunction procedures followed..."

2. On 6/15/09 at approximately 10:57 A.M. during a tour of 2 West, the 6 patients that were identified as receiving telemetry monitoring were Pt. #s 4, 5, and 27-30. The EKG tracing for these patients was visualized on the telemetry monitor at the nursing station. However, the alarms were not audible enough to be heard by staff that were in close proximity behind the nursing station, even though visually, the monitor was indicating "multiple alarms" for Pt. #27. The nurse for Pt. #5 also tested the alarms by removing 2 of the leads from the patient. Again, the alarms were not audible enough to be heard by the staff that were in close proximity behind the nursing station.

3. The above findings were conveyed to the 2 West Nurse Manager during an interview on 6/15/09 at approximately 11:00 A.M. The Nurse Manager stated that no one is assigned to watch the telemetry monitor, but that all of the nurses answer any alarms that they hear or any problem tracings that they see on the monitor.

B. Based on Hospital policy review, clinical record review, and staff interview, it was determined, for 2 of 3 patients on 2 West, (Pt. #3 and #5) and 4 of 4 patients in the Intensive Care Unit (ICU) (Pt. #s 11, 12, 32, and 33) who were identified as at risk for falls, that the Hospital failed to ensure complete implementation of Hospital policy governing fall prevention.

Findings include:

1. Hospital policy #9850-134 entitled, "Fall Prevention Program," was reviewed on 6/16/09 at approximately 10:30 A.M. The policy requires, "Patients identified as at risk for falls will be placed on the Fall Risk Protocol... Patients on the Fall Risk Protocol will be identified in the following manner... Bright Green Fall Precaution ID wrist band..."

2. The clinical record for Pt. #3 was reviewed on 6/15/09. This was a 60-year-old female, admitted on 6/14/09 with a diagnosis of Pancreatitis. The record included a fall risk assessment dated 6/14/09 at 4:00 P.M. The assessment indicated that the patient required ambulation with 1 assist and that the patient was an enhanced risk and required enhanced precautions.

3. The clinical record for Pt. #5 was reviewed on 6/15/09. This was a 76-year-old female, admitted on 6/14/09 with a diagnosis of Chronic Obstructive Pulmonary Disease. The record included a fall risk assessment dated 6/14/09 at 12:07 P.M. The assessment indicated that the patient had fallen within the last 6 months, required ambulation with 1 assist, and that the patient was an enhanced risk and required enhanced precautions.

4. On 6/15/09 from approximately 9:30-11:30 A.M., a tour of the 2 West Unit was conducted. Pt. #3 and #5 were not wearing a bright green fall precaution wrist band, in accordance with policy.

5. The above findings were conveyed to the 2 West Nurse Manager during an interview on 6/15/09 at approximately 11:00 A.M.

6. The clinical record for Pt. #11 was reviewed on 6/15/09. This was an 87-year-old female, admitted on 6/13/09 with multiple diagnoses including Sinus Ventricular Tachycardia and Methicillin Resistant Staphylococcus Aureus (MRSA). The record included a fall risk assessment dated 6/13/09 at 8:00 P.M. The assessment indicated that the patient had fallen within the last 6 months, was unable to ambulate, was an enhanced risk and required enhanced precautions.

7. The clinical record for Pt. #12 was reviewed on 6/15/09. This was an 74-year-old male, admitted on 6/15/09 with Gastrointestinal Bleeding. The record included a fall risk assessment dated 6/15/09 at 2:40 A.M. The assessment indicated that the patient had disorganized thinking, was unable to transfer, was an enhanced risk and required enhanced precautions.

8. The clinical record for Pt. #32 was reviewed on 6/15/09. This was a 90-year-old male, admitted on 6/15/09 with Pleural Effusion. The record included a fall risk assessment dated 6/15/09 at 6:29 A.M. The assessment indicated that the patient was on 2 or more meds, was an enhanced risk and required enhanced precautions.

9. The clinical record for Pt. #33 was reviewed on 6/15/09. This was an 87-year-old female, admitted on 6/14/09 with diagnoses of Syncope and Left Hip Fracture. The record included a fall risk assessment dated 6/14/09 at 3:15 P.M. The assessment indicated that the patient had fallen within the last 6 months, was unable to ambulate, was an enhanced risk and required enhanced precautions.

10. On 6/15/09 from approximately 1:15-2:30 P.M., a tour of the ICU was conducted. Pt. #11, 12, 32 and 33 were not wearing a bright green fall precaution wrist band, in accordance with policy.

11. The above findings were conveyed to the ICU Nurse Manager, during an interview on 6/15/09 at approximately 2:30 P.M.

C. Based on Hospital policy review, clinical record review, observation, and staff interview, it was determined, for 2 of 2 clinical records reviewed on 2 West (Pt. #3 and #6) and 1 of 2 clinical records reviewed on the ICU (Pt. #12) for patients with allergies, that the Hospital failed to ensure that patients with allergies, wore allergy bands.

Findings include:

1. Hospital policy #600-24 entitled, "Identification Bands (Patient)," was reviewed on 6/16/09 at approximately 12:00 P.M. The policy requires, "Patient allergies will also be noted on a separate identification band that is to be worn throughout the hospital stay."

2. The clinical record for Pt. #3 was reviewed on 6/15/09. The record included documentation on the medication reconciliation form that Pt. #3 was allergic to Penicillin.

3. The clinical record for Pt. #6 was reviewed on 6/15/09. This was a 69-year-old male, admitted 6/6/09 with diagnoses of Urinary Tract Infection and Pancreatitis. The record included documentation on the Meds/Allergy History of the following allergies: Cephalexin, Levofloxacin, Penicillin and Derivatives, and Sulfa.

4. On 6/15/09 from approximately 9:30-11:30 A.M., a tour of the 2 West Unit was conducted. Pt. #3 and Pt. #6 were not wearing allergy bands to indicate the above noted allergies.

5. The above findings were conveyed to the 2 West Nurse Manager during an interview on 6/15/09 at approximately 11:00 A.M.

6. The clinical record for Pt. #12 was reviewed on 6/15/09. The record included documentation that Pt. #12 was allergic to Penicillin and Sulfa.

7. On 6/15/09 from approximately 1:15-2:30 P.M., a tour of the ICU was conducted. Pt. #12 was wearing an allergy band, however, the band failed to indicate the Penicillin and Sulfa allergies.

8. The above findings were conveyed to the ICU Nurse Manager, during an interview on 6/15/09 at approximately 2:30 P.M.


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D. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 4 (Pt. #20) records reviewed in the Behavioral Health Unit, the Hospital failed to ensure daily vital signs were completed as ordered.

Findings include:

1. The Hospital policy reviewed on 6/15/09, titled "Nursing Assessment/ Reassessment and Documentation" required, "The following factors are to be assessed and reassessed by an RN: vital signs; and documented on the Admission Assessment and /or daily assessment."

2. The clinical record of Pt. #20 was reviewed on 6/15/09 at 10:35 AM. Pt. #20 was a 25 year old male admitted on 5/27/09 with diagnosis of Schizophrenia. The Physician orders dated 5/27/09 included daily vital signs. The record lacked vital signs taken for 6/6/09 and 6/7/09.

3. The above findings were conveyed to the Manager of Behavioral Health Unit during an interview on 6/15/09 at 11:30 AM.


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E. Based on review of Hospital policy, clinical record review, and staff interview, it was determined for 1 of 2 clinical records reviewed in the Telemetry Unit (Pt. #17), that the Hospital failed to ensure that a nursing admission assessment was completed for all patients.

Findings include:

1. The "Nursing Assessment/ Reassessment and Documentation" policy was reviewed on 6/16/09 at 1:00 PM. The policy required: "A Registered Nurse (RN) will assess each patient upon admission..."

2. On 6/15/09 at 1:40 PM, the clinical record of Pt. #17 was reviewed. Pt. #17 was an 87 year old female, admitted on 6/8/09, with diagnoses of Fluid Overload, Hypertension, Atrial Fibrillation, and Renal Failure. The clinical record lacked an admission nursing assessment.

3. This finding was conveyed to the Clinical Manager of the Telemetry Unit during an interview on 6/15/09 at 1:50 PM.

F. Based on review of Hospital policy, treatment log review, bicarbonate container log review, observation and staff interview, it was determined, for 1 of 2 bicarbonate containers and 1 of 1 bicarbonate container disinfection log, that the Hospital failed to ensure that Registered Nurses, under contract, properly disinfected, rinsed, stored, and documented disinfection of bicarbonate containers.

Findings include:

1. On 6/17/09 at 10:40 AM, the "Bicarbonate Concentrate System Disinfection and Logs" policy was reviewed. The policy required: "7. If individual bicarbonate containers are used to supply dialysis delivery systems, the container and wands should be rinsed with dialysis quality water at the end of the treatment day and then stored inverted to dry. Additionally, the containers and wands will be disinfected with household bleach diluted to a 1:100 solution at least weekly..."

2. On 6/16/09 at 10:55 AM, a tour was conducted in the dialysis equipment storage room. Two bicarbonate containers were found. One bicarbonate container, positioned upright, contained significant bicarbonate sediment, including 1 quarter size, approximately 1/8 inch of thick white crystallized deposit. Thus the bottle was not properly rinsed and inverted to dry.

3. On 6/17/09 at approximately 9:00 AM, the dialysis treatment logs for May and June 2009 were reviewed. The logs included dialysis treatments for 16 days in May 2009 and 8 days in June 2009.

4. The bicarbonate container disinfection log was reviewed on 6/17/09 at 10:45 AM. The log entry sheet was blank. The log did not document that the bicarbonate container and wand disinfection were completed during each week in May and June 2009.

5. This finding was conveyed to the Dialysis Contractor Facility Administrator and the Hospital Clinical Educator for Intensive Care and Intermediate Care during an interview on 6/17/08, at 11:10 AM.

G. Based on review of contractual service policy, treatment log review, water start up log review, and staff interview, it was determined, for 4 of 16 treatment days in May 2009 (May 1, 3, 5, & 6) and 2 of 8 treatment days in June 2009 (June 15 & 16), that the Hospital failed to ensure that water start up, including reverse osmosis (RO) measurements were completed and documented, as required.

Findings include:

1. On 6/17/09 at 10:40 AM, the contracted dialysis company's (DaVita) policy titled: "Water Treatment System and Chlorine/ Chloramine Monitoring" was reviewed. The policy included: "5. Prior to each treatment day, reverse osmosis (RO) function is measured by:

- Percent rejection value...

- Other parameters are monitored per manufacturer's recommendations..."

2. On 6/17/09 at approximately 9:00 AM, the dialysis treatment logs for May and June 2009 were reviewed. The logs included 16 dialysis treatments in May 2009 and 8 days in June 2009.

3. The RO water start up logs for both RO (55695 and 55913) were reviewed on 6/17/09 at 10:45 AM. The log entry sheets lacked documentation for start up on 4 of 16 treatment days in May 2009 (May 1, 3, 5, & 6) and 2 of 8 treatment days in June 2009 (June 15 & 16),

4. This finding was conveyed to the Dialysis Contractor Facility Administrator and the Hospital Clinical Educator for Intensive Care and Intermediate Care during an interview on 6/17/08, at 11:10 AM.

A. Based on observation and staff interview, it was determined, for 1 of 1 residue test strip bottle found in the dialysis equipment storage room, that the Hospital failed to ensure that outdated biological residual test strips are removed and replaced.

Findings include:

1. On 6/16/09 at 10:55 AM, a tour was conducted in the dialysis equipment storage room. One of 1 Minntech Residual Test Strip bottle contained an expiration date of January 2009. Test strips were used to determine the absence of bleach.

2. This finding was conveyed to the Dialysis Contractor Facility Administrator and the Hospital Clinical Educator for Intensive Care and Intermediate Care during an interview on 6/17/08, at 11:10 AM.

A. Based on review of the portable exchange carbon tank Manufacturer's guidelines, observation, dialysis reverse osmosis (RO) maintenance log review, and staff interview, it was determined, for 4 of 4 carbon filters, that the Hospital failed to ensure that the carbon was replaced every 6 months, to protect dialysis patients from receiving excessive/dangerous levels of chlorine and chloramine.

Findings include:

1. On 6/17/09 at 10:40 AM, the General Electric Portable Exchange Carbon Tank guidelines was reviewed. The guidelines required: "GE Osmonics recommends that carbon tanks be re-bedded at least every six (6) months..."

2. On 6/16/09 at 10:55 AM, a tour was conducted in the dialysis equipment storage room. Two portable RO machines (55695 & 55913) were found, each with 2 carbon containers.

3. On 6/17/09 at approximately 10:45 AM, the RO maintenance log was reviewed. The log included the last carbon exchange for the carbon containers for both RO machines (4 carbon containers) was on 10/14/08. over 8 months ago.

4. This finding was conveyed to the Dialysis Contractor Facility Administrator and the Hospital Clinical Educator for Intensive Care and Intermediate Care during an interview on 6/17/08, at 11:10 AM.



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B. Based on observation and interview it was determined that in the supply areas of the Surgical Suites and the Emergency Department, the Hospital failed to ensure that sterile supplies had not expired and were safe for use.

Findings include:

1. A tour of the Surgical Suite was conducted on 6/16/09 from 7:00 AM to 8:15 AM. A room identified, by the Manager, as the clean supply room contained seventeen (17) sterile needles that had an expiration date of 2/09 available for use.

2. The above finding was conveyed to the Manager of Surgical Services on 6/16/09 at 7:15 AM, during an interview.

3. A tour of the Emergency Department was conducted on 6/17/09 from 10:10 AM to 11:00 AM. A clean supply cart contained the following items that had expired:
- Three 5.0 Monocryl Suture - expired 1/07
- One 4.0 Vicryl Suture - expired 1/09
- Sixteen 6.0 Prolene Suture - expired 1/08
- Twenty six 3.0 Chronic Gut Suture - expired 7/07
- Thirty one 3.0 Vicryl Suture - expired 7/07

4. The above finding was conveyed to the Emergency Department Manager on 6/17/09 at 10:30 AM, during an interview.


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C. Based on review of Hospital policy, observation and staff interview, it was determined that in 2 of 2 crash carts in the Emergency Department, the Hospital failed to ensure the crash carts were checked according to policy.

Findings include:

1. The Hospital policy reviewed on 6/17/09 at 11:15 AM, titled "Code Blue" required, "Maintenance of Crash Carts...B. The integrity of the lock on the crash cart and the manual operation checks of the monitor and defibrillator shall be performed once every twelve (12) hours...E. The crash cart checking procedures will follow the CRASH CART DAILY CHECK LIST...."

2. During the tour and observation of the Emergency Department on 6/17/09, between 10:10 AM and 11:00 AM, 2 of 2 crash carts lacked documentation of crash cart checks on the following days:

-Crash Cart #1 -5/28/09 (7 PM-7 am).
-Crash Cart #2 -1/4/09 (24 hours), 1/18/09 (AM-PM), May- 14, 20, 21, 28, 29 & 31(various shifts).

3. The above findings were conveyed to the Nurse Manager during an interview on 6/17/09, at approximately 11:00 AM.

A. Based on review of Hospital policy, observation, clinical record review, and staff interview, it was determined, that in 1 of 1 patient (Pt.#4) being transported from the Emergency Department to the Telemetry unit, the Hospital failed to ensure that transported patients who required droplet precaution isolation, were transported wearing mask.

Findings include:

1. On survey date 6/16/09 at 8:45 AM, the "Droplet Precautions Policy" was reviewed. The policy required: "C. Patient Transport - ... If transport or movement is necessary, minimize patient dispersal of droplets by masking the patient (surgical mask) and asking patient to follow Respiratory Hygiene/ Cough Etiquette. Area receiving patient must be notified of precaution..."

2. On 6/15/09 at 1:50 PM, while a tour was being conducted on the Telemetry Unit, Pt. #14 was transported by stretcher from the Emergency Room into the Telemetry Unit, room 234. Pt. #14 was not wearing a mask. The 234 room door had a warning sign to see the nurse prior to entering.

3. On 6/15/09 at 2:00 PM, the clinical record of Pt. #14 was reviewed. Pt. #14 was a 52 year old male, admitted on 6/15/09, with diagnoses of Fever and Productive Cough. Physician pre-printed orders dated 6/15/09, included Pneumonia Adult Orders.

4. On 6/15/09 at 2:05 PM, an interview was conducted with the Telemetry Unit Manager. The Manager stated that Pt. #14 was a Rule Out Pneumonia and droplet precaution isolation was required. Pt. #14 should have worn a mask while transported from the ED to the Telemetry Unit. The finding was conveyed to the Telemetry Unit Manager during the interview.


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B. Based on Hospital policy review, clinical record review, observation, and staff interview, it was determined, for 1 of 1 patient with suspected infection, (Pt. #4) that the Hospital failed to ensure the patient was placed in isolation.

Findings include:

1. Hospital policy #IPC 3.4 entitled, "Contact Precautions," was reviewed on 6/17/09 at approximately 10:00 A.M. The policy requires, "Precautions will be instituted when a patient is colonized and/or infected with significant multi-drug resistant organisms... These organisms include... Clostridium difficile... Precautions will also be utilized for certain infectious diseases and patients... with diarrhea of unknown etiology."

2. On 6/15/09 the clinical record was reviewed for Pt. #4. This was an 82-year-old male, admitted on 6/9/09 with a diagnosis of Fever/Leukocytosis. The record included a physician's order, dated 6/12/09 at 2:00 P.M. for stool for Clostridium difficile (C-diff). The record also included documentation that the patient had a stool on 6/12/09 between 7-11 P.M. The record lacked documentation that a stool specimen had been sent as ordered and there were no results of whether or not the patient was positive or negative for C-diff.

3. On 6/15/09 from approximately 9:30-11:30 A.M., a tour of the 2 West Unit was conducted. Pt. #4 was not in contact isolation even though there was a suspicion of C-diff.

4. The above findings were conveyed to the 2 West Nurse Manager during an interview on 6/15/09 at approximately 11:00 A.M.


C. Based on observation and staff interview it was determined, for 2 of 3 staff (E #2 and E#3) in Operating Room (OR) #1, that the Hospital failed to ensure proper hand hygiene.

Findings include:

1. At approximately 7:11 AM on June 16, 2009, E #2 picked up a paper from the floor with ungloved hands, then touched the OR table that had clean linen. E#2 proceeded to use the phone and exited the room without washing her hands.

2.. At approximately 7:26 AM on June 16, 2009, E #3 picked up a blood pressure cuff from the floor with ungloved hands, stored it in the anesthesia cart without cleaning it, and continued to handle other clean equipment without washing her hands.

3. These findings were conveyed to Manager of Surgical Services on 6/16/09 at approximately 8:15 AM.

A. Based on Hospital policy review, observation, and staff interview, it was determined, in 1 of 2 operating rooms (OR) toured, (OR#1) that the Hospital failed to ensure that a Pre-Anesthesia Assessment was completed prior to the initiation of anesthesia.

Findings include:

1. Hospital Policy #A6680-04 titled, "Pre-Anesthesia Assessment," was reviewed on 6/16/09 at approximately 1:00 P.M. The policy requires, "All patients will be evaluated by an anesthesiologist prior to the provision of anesthesia services... The required pre-anesthesia evaluation will be documented on the anesthesia record at that time..."

2. A tour was conducted in OR#1 on June 16, 2009. At approximately 7:31 AM. the surveyor asked the Certified Registered Nurse Anesthetist, E #3 to review the Pre Anesthesia Assessment, (prior to Pt. #34 entering the room). E#3 stated that it could be reviewed later. E#3 intubated Pt. #34 and initiated anesthesia at approximately 7:40 AM. The CRNA failed to provide documentation to indicate that the Pre-Anesthesia Assessment was completed prior to the initiation of anesthesia.

3. The above finding was conveyed to the the Manager of Surgical services on 6/16/09 at approximately 8:15 A.M.

A. Based on a review of surgical services quality council data and staff interview, it was determined that the hospital failed to ensure monthly reporting of data for 1 of 12 months in 2008 and 4 of 4 months in 2009.

Findings include:

1. On 6/16/09 at approximately 10:50AM, surgical services quality council data for fiscal year 2008 and 2009 was reviewed. The monthly quality indicator for the surgical processing department (SPD) included," Surgical trays will be complete" The hospital failed to collect monthly quality indicator data from SPD since November of 2008.

2. The above finding was conveyed to the Director of Nursing Support Services on 6/16/09 at approximately 11:00 AM.