HospitalInspections.org

A. Based on document review, observational tour and interview, it was determined for 12 of 15 patients (Pts. #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14) on the 5G psychiatric unit, the Hospital failed to ensure safety checks for psychiatric patients were performed every 15 minutes, as required by policy and practice.

Findings include:

1. On 2/23/15 at 2:10 PM, the policy titled "Guidelines for Observation Sheet" (revised 8/2014) was reviewed. The policy required "Procedure: 1. All patients hospitalized on 5 AG (5 A and 5 G) will be rounded on every 15 minutes, at a minimum."

2. During an observational tour of the 5G psychiatric unit conducted with Director of Psychiatric Service (E#1) on 2/23/15 at approximately 10:30 AM, the 15 minute patient rounds monitoring sheet for 2/23/15 on all patients were reviewed. Twelve of fifteen (Pts #3-#14) monitoring sheets were lacking the 10:15 AM, checks that included patient location and behaviors (total of 12 missed checks on 12 patients).

- Pt. #3 was a female, admitted on 2/22/15, with a diagnosis of bipolar disorder.

- Pt. #4 was a female, admitted on 2/17/15, with a diagnosis of depressive disorder.

- Pt. #5 was a female, admitted on 2/17/15, with a diagnosis of bipolar depressive disorder.

- Pt. #6 was a female, admitted on 2/10/15, with a diagnosis of depressive disorder.

- Pt. #7 was a male, admitted on 2/21/15, with a diagnosis of major depression.

- Pt. #8 was a male, admitted on 2/13/15, with a diagnosis of depressive disorder with psychotic features.

- Pt. #9 was a male, admitted on 2/18/15, with a diagnosis of depressive disorder.

- Pt. #10 was a female, admitted on 2/18/15, with a diagnosis of depressive disorder.

- Pt. #11 was a female, admitted on 2/4/15, with a diagnosis of depressive disorder with suicidal ideation's.

- Pt. #12 was a male, admitted on 2/12/15, with a diagnosis of bipolar disorder.

- Pt. #13 was a female, admitted on 2/17/15, with a diagnosis of depression.

- Pt. #14 was a female, admitted on 2/4/15, with a diagnosis of depressive disorder.

3. During an interview conducted with Director of Psychiatric Services (E#1) on 2/23/15 at 10:45 AM, E#1 stated the "observation sheets should have been completed every 15 minutes on all patients."


B. Based on document review, observational tour and interview, it was determined for 3 of 3 potential suicidal patients (Pts. #15, #16, #17) and 8 of 8 potential aggressive patients (Pts. #18, #19, #20, #21, #22, #23, #24, #25) on the 5A psychiatric unit, the Hospital failed to ensure contraband items were not available to psychiatric patients with suicidal ideation and/or aggressive disposition.

Findings include:

1. On 2/23/15 at 3:00 PM, the policy titled "Room Check" (revised 4/2014) was reviewed. Policy requires, "All patient rooms are to be checked for sharp or potentially dangerous articles at least twice daily ...Articles not permitted in rooms: Metal objects, sharp objects, Hospital skin care products (may be locked in patient's closet).

2. During an observational tour of 5A psychiatric unit conducted with Director of Psychiatric Services (E #1) on 2/23/15 at approximately 11:00 AM, the following contraband was noted:

- room 539 - 10 sharpened colored pencils were available to aggressive and suicidal patients.

- room 592 - 2 writing pens were available to aggressive and suicidal patients.

- Hand washing station in hallway by room 595, a 2 once bottle of "Baby Bath Soap" was noted.

3. Patients' potentially affected:

- Pt. #15 was a female, admitted on 2/12/15, with a diagnosis of suicidal ideation's.

- Pt. #16 was a male, admitted on 2/15/15, with a diagnoses of suicidal ideation's, alcohol abuse, and depressive disorder.

- Pt. #17 was a female, admitted on 2/19/15, with a diagnosis of suicidal ideation's.

- Pt. #18 was a male, admitted on 2/13/15, with a diagnosis of schizophrenia.

- Pt. #19 was a female, admitted on 2/4/15, with a diagnosis of schizophrenia.

- Pt. #20 was a female, admitted on 2/11/15, with a diagnosis of schizoid affective.

- Pt. #21 was a female, admitted on 2/20/15, with a diagnosis of psychosis.

- Pt. #22 was a female, admitted on 2/18/15, with a diagnosis of schizophrenia.

- Pt. #23 was a female, admitted on 2/11/15, with a diagnosis of psychosis.

-Pt. #24 was a female, admitted on 2/28/15, with a diagnosis schizophrenia.

- Pt. #25 was a male, admitted on 1/30/14, with a diagnosis of paranoid schizophrenia.

4. During an interview conducted with Director of Psychiatric Services (E#1) on 2/23/15 11:50 AM, E#1 stated "we give the pens and pencil to those patients, we feel are appropriate." E#1 stated there is "nothing to stop other patients from walking in the rooms and accessing the pens and pencils." E#1 acknowledged that the bottle of "Baby Bath Soap" should not be at the hand washing stations.

Based on document review, observation and interview, it was determined the Hospital failed to ensure outdated biological's were not available for patient use. This had the potential to affect all patients serviced on these units.

Findings include:

1. The policy titled "Administration of Medications" (revised 11/14) was reviewed on 2/24/15. The policy stated "Multiple Patient Use Products, examples include...hydrogen peroxide. Discard at Product Expiration Date. Discard if product becomes contaminated or is taken into patient room."

2. The policy titled "Outdate Monitoring and Lock Check of Crash Carts and Emergency Kits" (revised 1/15) was reviewed on 2/24/15. The policy stated "Policy #4, E. Outdated supplies are to be discarded".

3. During an observational tour of the radiology department conducted with Director of Outpatient Imaging Services (E#4) on 2/24/15 at 10:15 AM, in the "Hot Material Lab" one 16 ounce opened bottle of hydrogen peroxide, which was available for patient use, with an expiration date of 5/14 was observed.

4. During an interview conducted with E#4 on 2/24/15 at 10:30 AM, E#4 verbalized the product should had been discarded.

5. An observational tour of the family maternal suites with Nurse Manager (E#18) on 2/24/15 at 9:30 AM was completed. In an equipment room, two 100 mililiter bags of 5% Dextrose with an expiration of May 2014 were found available for patient use.

6. An interview was completed with E#18 on 2/24/15 at 10:45 AM. E#18 verbalized the fluids were expired and removed them from the area.

A. Based on document review, observational tour and interview it was determined for 11 of approximately 40 condiment/seasoning substances with no manufacture's expiration dates or delivery dates (garlic powder, white pepper, ground mustard, Italian seasoning, ground orange peel, ground nutmeg, ground allspice, ground ginger, garlic salt, red sugar, and salt) in dietary services, the hospital failed to ensure condiments/seasonings packages were rotated per policy.

Findings include:

1. The policy titled "Safe Food Handling and Food Storage" (revised 9/2014) was reviewed on 2/24/15. The policy required "Open packages of non perishable dry items... are not labeled with a "use by" date but are used frequently and rotated using first in and first out."

2. On 2/24/14 at approximately 7:30 AM an observational tour of the Dietary Services Department was conducted with Director of Food and Nutrition Services (E #3). 11 of approximately 40 condiment/seasoning substances (garlic powder, white pepper, ground mustard, Italian seasoning, ground orange peel, ground nutmeg, ground allspice, ground ginger, garlic salt, red sugar, and salt) had no expiration or delivery dates

3. During an interview conducted with E# 3 on 2/24/15 at 7:45 AM, E #3 stated the dry goods were discarded based on expiration or delivery dates, as well as first in first out policy. E #3 could provide no documentation of the dry good rotation schedule, expiration dates, and/or delivery dates.


B. Based on document review, observation and interview, it was determined that for 1 of approximately 50 dietary department employees on duty and 1 of 1 food processor blades , the Hospital failed to ensure the dietary staff followed established policies and procedures to maintain a sanitary food service environment. This has the potential to affect all patients receiving dietary food services in the hospital.

Findings include:

1. The policy titled "Food & Nutrition Infection Prevention & Control" (revised 1/2015) was reviewed on 2/24/15. The policy stated "C. All employees in the food service must wear a hair restraint that covers their hair completely. D. All food grinders, choppers, mixers, etc. are cleaned, sanitized, dried, and reassembled after each use."

2. On 2/24/14 at approximately 7:30 AM an observational tour of the Dietary Services Department was conducted with Director of Food and Nutrition Services (E #3). The following was noted:

-Dietary Aide (E#5) had multiple long (approximately 8 inches) strands of hair uncovered by the hair restraint.

-Food processing blade in the baking dry storage area had white powdery substance on it.

3. During an interview conducted with E#3 on 2/24/15 at 8:00 AM, it was verbalized that the staff should have all hair covered by a hair restraint and the food processor blade had white powdery substance on it and should be cleaned.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety portion of a full survey due to complaint conducted on February 23-26, 2015 the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety portion of a full survey due to complaint conducted on February 23-26, 2015 the surveyors find that the facility does not comply with the applicable provisions of the 2000 edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies identified with K-tags on the CMS form 2567, dated February 26, 2015.

Based on observation and interview, it was determined 1 of 1 crash carts on 5B and 1 of 1 crash carts on 6B, the facility failed to ensure equipment was maintained for safety. This has the potential to affect all patients on these units.

Findings include:

1. On 2/24/15 at 4:00 PM the policy titled "Crash Cart Broselow Pediatric Bag Cart Monitor Defibrillator Maintenance" (revised 11/2014) was reviewed. The policy required "Routine crash cart checks are required daily... and documented. All monitors/defibrillators will be checked daily... and documented."

2. During a tour of 5B urology unit conducted with 5 B Unit Nurse Manager (E#13) on 2/24/15 at 2:00 PM, 1 of 1 crash cart safety check list logs lacked documentation the doppler machine was checked on 12/29/14, 12/30/14, and 12/31/14.

3. During a tour of 6B cardiac unit conducted with 6 B Unit Nurse Manager (E#14) on 2/24/15 at 3:00 PM, 1 of 1 crash cart safety check list logs lacked documentation that the defibrillator pacer test was completed 1/1/15-1/19/15.

4. During an interview conducted with 5 B Unit Nurse Manager (E#13) on 2/24/15 at 2:15 PM, E#13 stated "the logs should be completely filled out."

5. During a interview conducted with 6 B Unit Nurse Manager (E#14) on 2/24/15 at 3:15 PM, E#14 stated "the safety check list should be accurate and completed."

A. Based on document review, observation and staff interview, it was determined in 1 of 1 surgical procedures observed, the Hospital failed to ensure proper hand hygiene practices were followed. This has the potential to affect all patients receiving surgery at the Hospital.

Findings include:

1. The documents titled "Hand Hygiene" was reviewed on 2/24/15 (revised December 2014) at 10:20 AM. The policy stated under "II. Policy Hand Hygiene is to be performed by all employees....Hand hygiene is to be performed AFTER: ...4. Removing gloves."

2. On 2/23/15 in Operation Room 6, the following observations were made: at approximately 12:05 PM, the circulating nurse (E#8) picked up a blue surgical towel off the floor and placed it in a receptacle. No hand hygiene was performed until verbally told to do so by the Director of Cardiovascular Services (E#10). A resident (E#9) was observed to change blue, non-sterile gloves 3 times and did not perform hand hygiene in between glove changes. When the resident removed the second pair of gloves, at approximately 12:53 PM, they were thrown nearly half way across OR 6 at a trash receptacle but landed on the floor behind the receptacle. They remained there until another staff member picked them up and disposed of them properly.

3. During an interview with E#10 conducted on 2/23/15 at approximately 1:40 PM, it was verbalized that the actions E#8 and E#9 were not in compliance with policy and procedure for hand hygiene.

B. Based on observation and interview, it was determined the Hospital failed to ensure all floors were properly cleaned to prevent cross contamination of organisms. This has the potential to affect all staff and patients served in the pre-operative (pre-op) unit.

Findings include:

1. During a tour of the pre-op unit conducted on 2/23/15 at 11:20 AM, it was observed in the clean utility that an unopened package of surgical socks had fallen behind a neighboring cart. There was also debris around the socks. In the dirty utility, behind a food cart containing empty trays, it was observed there was a dried brown spot approximately the size of half of a dollar bill.

2. During an interview with the Director of Cardiovascular Services (E#10) it was stated that it is housekeeping responsibility to clean the floors.

C. Based on observation and interview it was determined the Hospital failed to ensure the clean scrubs clothing in the men's locker room were stored in such a manner as to prevent the cross contamination of the clean scrubs. This has the potential to affect all staff and surgical patients that come into contact with male surgical personnel.

Findings include:

1. During a tour of the surgery unit conducted on 2/23/15 at 12:05 PM, it was observed in the men's locker room that the clean scrubs were stored in the bathroom area of the locker room on an uncovered, shelved, metal rack. This rack was located within approximately 6 to 7 feet of a toilet and a sink.

2. During an interview with the Infection Prevention and Control System Director (E#11) on 2/24/15 at approximately 9:45 AM, it was stated that some type of action needs to be implemented to correct the storage of the men's clean scrub storage rack to prevent the cross contamination of organisms.


D. Based on document review, observation and interview it was determined the Hospital failed to ensure lab specimens were labeled per hospital policy. This has the potential to affect all patients having blood drawn in the Cardiac Surgery Intensive Care Unit (census of 7 patients)
Findings include:
1. The Hospital policy titled "Arterial Blood Draw Procedure" (revision date 10/5/2012) page 6, 12. required "After specimen collection, label specimen with patient chart label. Match the label on the specimen with the patient ' s armband. Record username, date, and time of collection on the patient chart label."
2. On 2/23/2015 at 11:00 AM a tour of the Cardiac Surgery Intensive Care Unit was conducted at approximately 11:00 AM with the Cardiac Surgery Intensive Care Unit Manager (E#15). During the tour an unattended, unlabeled, 3 milliliter syringe containing 2 ½ milliter ' s of blood was observed lying on a cart across the hall from the Cardiac Recovery Bay 10. Next to the syringe were three droplets of fresh blood. On 2/23/2015 at approximately 11:00 AM, E#15 verified the syringe was unattended and unlabeled.
3. An interview was conducted with registered nurse (E#16) who was assigned to Cardiac Recovery Bay 10 at 11:10 AM. E#16 stated "the syringe was an arterial blood gas for the patient in Cardiac Recovery Bay 10 and the syringe should have been labeled."