HospitalInspections.org

Based on record review and interview, the hospital failed to ensure that the grievance process was complete by failing to issue a written decision on the grievance to the complainant for 1 of 1 grievance reviewed (Patient #7).
Findings:

Review of the hospital's "Grievance Policy" revealed in part: The Section 1557 Coordinator will issue a written decision on the grievance based on a preponderance of the evidence, no later than 30 days after its filing, including a notice to the complainant of their right to pursue further administrative or legal remedies.

Review of the Complaint/Grievance folder for 2019 revealed Patient #7 had a complaint for care provided on 05/01/2019 and submitted a letter to the hospital regarding diagnostic tests. The DON met with Patient #7 and the patient's sister to discuss the details of the grievance. Further review failed to reveal a letter detailing the investigation's findings was sent to the complainant.

During an interview on 02/18/2020 at 9:00 a.m., S1DON acknowledged that she investigated the grievance but did not send a letter to the complainant.

Based on observation and interview, the hospital failed to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for the patients admitted for acute inpatient psychiatric services by failing to ensure the patient environment was free of ligature risks and safety hazards. This deficient practice had the potential to negatively impact the 13 patients on the psychiatric unit.

Findings:
On 02/17/2020 at 10:45 a.m., the following observations were made during the initial tour of the psychiatric unit:
1) Non-tamper proof screws throughout the unit;
2) Ligature points on the bedside chairs and the handles on the bedside chests in each patient room;
3) Ligature points on the handles of the metal cabinets and drawers in the group room and dining room;
4) The area in the right corner of the isolation room could not be observed by the staff looking through the window on the door of the isolation room.

During an interview on 02/17/2020 at 11:00 a.m., S2RN (Psychiatric Unit Director) confirmed the blind-spot in the isolation room and acknowledge the patient could not be observed in the right corner of the room.

During an interview on 02/17/2020 at 11:20 a.m., S2RN stated the group room and the dining room are not always supervised and acknowledged the ligature points in the patient rooms, the group room, and the dining room.

Based on record review and interview, the hospital failed to ensure the clinical records system was maintained as evidenced by failure to ensure medical records of patients were authenticated promptly by the ordering practitioner as set forth in the hospital's bylaws for physician verbal orders for 2 of 2 records reviewed for telephone order authentication in a total sample of 30 (Patient #12, 24)
Findings:

Review of the hospital Medical Staff By-Laws, Rules and Regulations revealed in part:
4. All orders for treatment shall be in writing. An order shall be considered to be in writing if dictated to an RN, LPN, or other authorized person and signed by the attending physician. Orders dictated over the telephone shall be signed by the person to whom dictated with the name of the physician per his/her name. Verbal orders will be authenticated by prescribing or another practitioner with date and time within ten days.

Patient #12
Review of the medical record revealed the patient was admitted to the inpatient psychiatric unit on 01/15/2020. Review of the admission orders revealed they were received per a telephone order from S15Nurse Practitioner dated 01/15/2020. As of review on 02/19/2020, the telephone order had not been authenticated by the ordering practitioner.

Patient #24
Review of the medical record revealed the patient was admitted to the inpatient psychiatric unit on 01/25/2020. Review of the admission orders revealed they were received per a telephone order from S15Nurse Practitioner dated 01/25/2020. As of review on 02/19/2020, the telephone order had not been authenticated by the ordering practitioner.

On 02/19/2020 at 10:55 a.m., interview with S2RN (Psychiatric Unit Director) revealed that after patients are discharged, the telephone orders are sent to the practitioners to be authenticated. She further stated that she has 30 days after discharge to get the telephone orders signed. When asked if she was aware what the medical staff by-laws stated regarding telephone orders, she stated she did not know.

Based on record review and interview, the hospital failed to ensure all records contained a medical H&P examination completed and documented no more than 30 days before or 24 hours after admission as evidenced by failure of the physician to document a medical H&P for 1 patient (#11) and failure to time and date his authentication on the H&P for 1 patient (#10) within 24 hours of admission in a total sample of 30 patients whose medical records were reviewed.
Findings:

Review of the "Rules and Regulations of the Medical Staff of LaSalle General Hospital", reviewed September 2019, revealed:
Medical Records -
(2) Timely Preparation -
(a) - a complete history and physical examination shall in all cases be written and dictated within 24 hours after admission of the patient.

Patient #11
Review of Patient #11's medical record revealed he was admitted on 01/30/2020 by S12Physician. Further review revealed no evidence that an H&P examination was documented.

Patient #10
Review of Patient #10's medical record revealed she was admitted on 01/23/2020. Further review revealed an H&P examination was documented on 01/23/2020, but was not yet signed and authenticated by S12Physician.

On 02/19/2020 at 9:30 a.m., review of the above records and interview with S7RN confirmed that the above H&Ps for patient #10 and #11 were not completed within 24 hours after admit.

Based on observation and interview, the hospital failed to ensure the proper storage of all medications as evidenced by storing medications used in Radiology in the patient nourishment refrigerator.
Findings:

On 02/17/2020 at 3:00 p.m., observation of the radiology department with S16Radiology Director revealed that an opened medication vial of Kinevac was stored in the patient nourishment refrigerator. At that time, S16Radiology Director stated that he was unaware that the medication was stored in this place.

On 02/17/2020 at 3:30 p.m., phone interview with S13Nuclear Med Tech revealed that he stores the medications used for nuclear med testing in the patient nourishment refrigerator in radiology. He further stated that there was no medication refrigerator in the radiology department.

On 02/18/2020 at 2:00 p.m., interview with S1DON revealed that medications should not be stored in the patient nourishment refrigerator.

Based on observation and interview, the hospital failed to ensure that outdated, mislabeled or otherwise unusable drugs and biologicals were not available for patient use as evidenced by 1) having expired and/or unusable medications available for patient use and 2) having multi-dose vials of medication that were unlabeled with first puncture date and/or had gone beyond the time frame allowed for use after the first puncture.
Findings:

1) Having expired and/or unusable medications available for patient use

Review of the hospital policy titled, Medication Use-3AM Cabinet Expiration of Medications, revealed in part that monthly, the pharmacy department will print an expiration report detailing any drugs expiring within the next 60 days. This report will be used to determine the removal of medication which will expire prior to being used.

On 02/18/2020 at 10:30 a.m., interview with S10Pharmacy Tech revealed that the hospital uses an automated medication delivery system (3AM Cabinet). When asked the process for monitoring for expired medications in the medication delivery system, she stated that she runs a report whenever she has time that lists the expiration dates of the medications. Review of the list provided by S10Pharmacy Tech revealed multiple medications in the automated delivery system had expired, with some that had been expired for two years. S10Pharmacy Tech further stated that she was aware of the expired medications, but those expired medications were not used very often in the hospital.

On 02/18/2020 at 10:45 a.m., observation of the automated medication delivery system in the ED with S9Pharmacist revealed multiple expired medications which included:
Keppra 500mg tablets, expired 09/30/19
Lasix 20mg tablets, expired 10/31/19
Eldepryl 5mg tablets, expired 12/23/17

Interview with S9Pharmacist confirmed the multiple expired medications in the ED automated medication dispensing system were available for patient use.

2) Having multi-dose vials of medication that were unlabeled with first puncture date and/or had gone beyond the time frame allowed for use after the first puncture.

Review of the hospital policy titled Multi-Dose Vial Use, revealed in part that multi-dose injectable vials will be discarded 28 days after initial entry or upon manufacturers expiration, whichever is first. Vials will be dated when opened and initialed by the person first entering them.

On 02/17/2020 at 11:45 a.m., observation of the medication room refrigerator (Behavioral Health Unit) with S5LPN revealed the following:
Novolin N insulin vial, open date 8/31/19
Lantus insulin vial, open date 01/05/2020
Flu vaccine vial, open 09/01/19
Tuberculin vial, open date 12/13/19 - vial indicates to discard after 30 days of first puncture

At that time, S5LPN confirmed the above medications were available for patient use.

On 02/17/2020 at 1:45 p.m., observation of the medication room on the acute care floor with S1DON revealed the following opened multi-dose vials had no date or initials of the staff who first opened the vials:
(2) Lidocaine 1% 50 mL vials
(2) Xylocaine 1% 50mL vials
(1) Sterile Water 10 mL vial

At that time, SDON confirmed the above medications were available for patient use.

On 02/17/2020 at 2:00 p.m., observation of the automated medication delivery system in the emergency department revealed the following opened multi-dose vials had no date or initials of the staff who first opened the vials:
(1) Xylocaine 2% 50 ml vial
(1) Xylocaine 1% 20 ml vial
(1) Bupivacaine 0.5% 30 ml vial
(2) Xylocaine 2% with epinephrine 50 ml vials

At that time, SDON confirmed the above medications were available for patient use. S1DON further confirmed that multi-dose vials should be discarded 28 days after the first open date.

Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of 30 of 30 patient beds.
Findings:

On 2/17/2020 at 1:15 p.m., an observation of unoccupied inpatient rooms revealed that the patient bed in rooms a and b had a non-functional nurse call feature (a red cross symbol) on the siderail of the bed. The red cross symbol was pressed during the observation and no alert of any type was generated when it was pressed.

An interview at this time with S1DON confirmed the red cross nurse call feature on the siderails of the inpatient beds was not functional. She reported patients/patient families were instructed to use the nurse call feature on the corded call light located at the patient's bedside to call for staff assistance. The surveyor discussed the possibility of patient/patient family/visitor confusion with having the non-functional nurse call feature available for use as well as the nurse call feature on the corded call light and the potential of the non-functional nurse call feature being pressed to summon help from staff. S1DON agreed that having the non-functional nurse call feature available for use could result in potential confusion when calling for staff assistance.

On 02/19/2020 at 1:30 p.m., a follow-up interview with S1DON confirmed all 30 of the hospital's inpatient beds had a non-functional nurse call feature on the hand rails.

Based on observation and interview, the hospital failed to ensure the infection control officer assured the system for controlling infections and communicable diseases of patients and personnel was implemented according to acceptable standards of infection control practices. This deficient practice is evidenced by: 1) failure to ensure that the disinfectant used for the entire hospital was not expired, 2) failure to ensure expired supplies were not available for patient use, 3) failure to ensure that the hospital was maintained in a sanitary manner.
Findings:

1) Failure to ensure that the disinfectant used for the entire hospital was not expired

Observation on 02/17/2020 at 1:50 p.m. in the ED revealed the staff were disinfecting the surfaces of patient care equipment with a solution in a spray bottle labeled LPH.

An interview at that time with S17RN revealed she did not know what ingredients were in the bottle, but stated the solution was premixed in the housekeeping department and distributed to the units.

Observation on 02/18/2020 at 9:15 a.m. on the nursing unit revealed a bottle of LPH was on the housekeeping cart.

An interview with S18EnvServ Staff at that time confirmed that the LPH was used for cleaning and disinfecting the patient care equipment and was premixed in the housekeeping department, but she was not sure what the contents were.

On 02/18/20 at 1:00 p.m., an interview with S11EnvServSupervisor confirmed that the LPH solution is premixed using an automatic dispenser that mixes the undiluted solution from the original container with water and fills the spray bottles, which are then distributed to the housekeeping staff and units in the entire hospital . Observation of the label on the EPA registered LPH disinfectant container attached to the dispensing system revealed that the container currently being used to fill the spray bottles distributed throughout the hospital expired on 10/01/19.

An interview at that time with S11EnvServSupervisor confirmed that the spray bottles containing the disinfectant currently in use throughout the hospital was dispensed from the container of expired disinfectant solution.

2) Failure to ensure expired supplies were not available for patient use

On 02/17/2020 at 1:40 p.m., observation of the ED with S1DON revealed the following expired supplies on the cart in ED room #2:
(3) vials of sodium chloride expired 02/01/2020
(1) size 4 airway expired 07/28/19
An interview at this time with S1DON confirmed the expired supplies were available for patient use.

On 02/18/2020 at 2:40 p.m., observation of the sterile supply room with S6RN revealed it contained the following expired supplies:
(9) PICC kits, expired 11/30/19
(6) PICC kits, expired 12/31/19
At that time, interview with S6RN confirmed the expired supplies were available for patient use.

3) Failure to ensure that the hospital was maintained in a sanitary manner

On 02/17/2020 at 1:15 p.m., observation of room b with S1DON revealed it had a cut in the mattress. Interview with S1DON at that time revealed that the room was available for a patient and that the tear in the mattress prevented disinfection.

On 02/17/2020 at 2:00 p.m., observation of the crash cart in ED room #2 revealed small pieces of a black substance were on top of the cart. Interview with S1DON at that time confirmed that room had been cleaned.


On 02/17/2020 at 2:15 p.m., observation of the medication refrigerator in the ED revealed multiple sticky spills and debris in the refrigerator.

On 02/17/2020 at 2:30 p.m., observation of the pediatric pulse oximeter revealed it had multiple pieces of old tape stuck and a black sticky substance on it.




20310

Based on record review and interview, the facility failed to ensure patients admitted to the Swing Beds were notified of their rights prior to admission for 1 of 1 patient admitted to a Swing Bed (Patient #25).
Findings:

Review of the facility's Swing Bed policy revealed in part: The patient has a right to a dignified existence, self-determination, and communication with an access to persons and services inside and outside the facility. A facility must protect and promote the rights of each patient...

Review of Patient #25's medical record failed to reveal the patient received their Swing Bed rights on admission.

During an interview on 02/18/20 at 1:30 p.m., S1DON confirmed there was no documentation that patient #25 was made aware of, or given a list of, their Swing Bed rights.