HospitalInspections.org

Based on observation and interview the hospital failed to ensure biologicals were appropriately stored; as evidenced by having hazardous material (SuperSani Cloth Germicidal Disposable wipes, Dispatch, EnPower) stored in unattended unlocked cabinets located in the hallway of the In-patient Medical Unit of the hospital for 2 of 2 cabinets observed. Findings:

Observations on 11/28/2011 at 10:45 a.m. revealed two unattended unlocked cabinets labeled "Wound Care" located in the hall way on the In-Patient Medical Unit. Located in the cabinets were: 1) first unlocked cabinet :160 SuperSani Cloth Germicidal Disposable wipes, 1 32 ounce bottle of Dispatch Disinfectant, 1 64 ounce bottle of Dispatch Hospital Disinfectant, and 1 gallon of EnPower Dual Enzymatic Detergent. 2) second unlocked cabinet: 160 Sani Cloth Plus wipes.

During a face to face interview on 11/29/2011 at 8:50 a.m., Infection Control Officer S14 and Director of Environmental Services S15 indicated the cabinets containing hazardous material which included SuperSani Cloth, Dispatch, and EnPower Dual Enzymatic Detergent should have been locked to prevent access by non-authorized personnel, patients, or visitors. S14 and S15 indicated the Wound Care Staff that had been using the cabinet had been provided with keys and instructed to keep the cabinets locked. S14 and S15 indicated there was no reason why the cabinets should have been unlocked when unattended by authorized staff.

Based on record review and interview the hospital failed to follow their policy and procedure
1) for blood administration by failing to obtain patient consent prior to the patient receiving the blood for 1 of 1 patients with orders to receive blood (Patient #12) out of a total sample of 22 medical records.
2) for "Restraints and Seclusion, approval date 7/28/2011" as evidenced by failure to document change of position, release of restraints, and toileting at a minimum of every two hours as per hospital policy for 1 of 1 patients reviewed in restraints out of a total sample of 22 (Patient #17). Findings:

1)
Review of the medical record for Patient #12 revealed an 83 year old male admitted to the hospital for rehabilitation on 11/04/11 after being treated for osteomyelitis of the left foot in an acute care facility. Review of the Physician's Orders dated 11/18/11 (no time documented) revealed an order to type and crossmatch for two units of PRBC (Packed Red Blood Cells) each to be transfused over 4 hours.

Review of the entire medical record for Patient #12 revealed no documented evidence a consent was obtained from the patient, Power of Attorney or family member for the blood transfusion.

In a face to face interview on 11/28/11 at 2:30pm RN S2 Director of Nursing reviewed the chart and verified there was no consent for blood in the medical record of Patient #12.

Review of the policy titled "Administration of Blood/Blood Products" last reviewed 11/10 and submitted by the hospital as the one currently in use revealed.... "Requires a Transfusion Consent form signed by patient or family".

2)
Review of the hospital policy titled, "Restraints and Seclusion, approval date 7/28/2011" presented by the hospital as current revealed in part, "Changing position and releasing soft restraints will be performed at a minimum of every two hours. . . Assess the status of nutrition, including presence/absence of hunger and thirst, personal hygiene, toileting, ability of patient to exercise extremities. change the patient's position every two hours. . . Documentation: Assessment of patient regarding clinical condition, comfort level, circulation, condition of limbs, skin and attention to hydration, elimination and nutrition at least every two hours.

Review of Patient #17's medical record revealed a physician's order for Soft Wrist Restraints dated 11/25/2011 at 0610 (6:10 a.m.) for "Impaired cognition re: safety. Removing Medical Devices, Restless-picking, kicking covers, fidgeting, (and) climbing over side rails". Further review revealed Patient #17 was in restraints from 0610 (6:10 a.m.) on 11/25/2011 until removed at 1400 (2:00 p.m.) on the same day. Review of Patient #17's entire medical record revealed no documented evidence that Patient #17's soft wrist restraints had ever been released from 11/25/2011 at 7:30 a.m. through 2:00 p.m. (6.5 hours). Further review revealed no documented evidence that Patient #17 had been repositioned or toileted from 11/25/2011 at 7:30 a.m. through 2:00 p.m. (6.5 hours).

During a face to face interview on 11/29/2011 at 3:30 p.m., Director of Nursing S2 confirmed the above findings. S2 further indicated nursing staff were expected to follow hospital policy and document changing of a restrained patient's position, releasing of restraints, and toileting every two hours.






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Based on record review and interview the hospital failed to implement a system for monitoring annual TB (Tuberculosis) screening for all credentialed staff physicians performing patient care in the hospital for 4 of 7 ( MD S6, S7, S9, S12) credentialing files reviewed out of a total of 114 physicians listed as being on staff. Findings:

Review of the credentialing files for MD S6, S7, S9 and S12 revealed no documented evidence TB screening had been performed in the last twelve months.

In a face to face interview on 11/29/11 at 11:00am S13 medical Staff Coordinator indicated she was the person responsible for monitoring the credentialing files for the medical staff. Further S13 indicated the credentialing process was performed by a contracted company; however the hospital was responsible for ensuring the physicians received annual TB screenings. S13 indicated at the present time she did not know how many physicians were not in compliance with annual TB screenings.

Based on record review and interview the hospital failed to ensure a post-anesthesia evaluation was performed by the anesthesiologist or his/her designee qualified to administer anesthesia included at a minimum the cardiovascular status or level of consciousness before a patient was discharged from the hospital for 3 of 3 patients receiving general anesthesia (#19, #21, #22) out of a total sample of 22 medical records. Findings:

Patient #19
Review of the medical record for Patient #19 revealed a 62 year old female admitted to the hospital on 11/02/11 for repair of an umbilical hernia and a laparoscopic cholecystectomy. Review of the Anesthesia Intra-op Notes dated 11/02/11 for Patient #19 revealed surgery began at 10:00am, ended at 11:25am and the patient was transferred to PACU (Post-Anesthesia Care Unit) extubated. Review of the section titled "Post-op Evaluation" revealed the following: Anesthesia recovery - a box checked next to "satisfactory" Nausea/Zofran/Reglan; Pain Management in Recovery Room - a box checked for "yes" ; Complications - a box checked "None"; and Discharge Instructions Given - a box checked "Yes". Further review revealed a signature; however there was no documented evidence of the time or discipline of the person making the entry.

Patient #21
Review of the medical record for Patient #21 revealed a 71 year old male admitted to the hospital on 10/03/11 for a cholecystectomy under general anesthesia. Review of the Anesthesia Intra-op Notes dated 10/03/11 for Patient #21 revealed surgery began at 1:20pm, ended at 3:15am and the patient was transferred to PACU (Post-Anesthesia Care Unit) extubated. Review of the section titled " Post-op Evaluation " revealed the following: Anesthesia recovery - a box checked next to " satisfactory " ; Pain Management in Recovery Room - left blank; Complications - a box checked " None " ; and Discharge Instructions Given - left blank. Further review revealed a signature; however there was no documented evidence of the time or discipline of the person making the entry.

Patient #22
Review of the medical record for Patient #22 revealed a 53 year old male admitted to the hospital on 10/14/11 for repair of an umbilical hernia under general anesthesia. Review of the Anesthesia Intra-op Notes dated 10/14/11 for Patient #22 revealed surgery began at 9:05am, ended at 10:15am and the patient was transferred to PACU (Post-Anesthesia Care Unit) extubated. Review of the section titled " Post-op Evaluation " revealed the following: Anesthesia recovery - a box checked next to " satisfactory " ; Pain Management in Recovery Room - a box checked for " yes " ; Complications - a box checked " None " ; and Discharge Instructions Given - a box checked " Yes " . Further review revealed a signature; however there was no documented evidence of a date, time or discipline of the person making the entry.

In a face to face interview on 11/29/11 at 11:00am RN S3 Director of Quality indicated the CRNA (Certified Registered Nurse Anesthetist) is usually the person who discharges the patient from PACU. Further S3 indicated the CRNA reviews the information documented by the PACU nurse concerning the status of the patient and then signs the post-op evaluation. S3 verified the anesthetists were not timing his/her entry.

Review of the policy titled "Post-Operative Anesthesia Care "last revised 09/12/11 and submitted as the one currently in use revealed ... ... "f. At least one post anesthetic visit will be recorded, describing the presence or absence of anesthesia complications. i. The number of visits will be determined by the nature of the procedure, the anesthesia and the patient ' s condition. A visit shall be made early in the post-operative period and again after complete recovery from anesthesia. g. When the post anesthesia visit and documentation cannot be completed by the attending anesthetist because of an early patient discharge, the attending physician who discharges the patient will be responsible for meeting the same requirements" .

Review of the Medical Staff By-Laws/Rules and Regulations approved 11/15/10 submitted as the one currently in use revealed...... "7. ..... The anesthesiologist or CRNA is responsible for writing a post-anesthetic note after the patient has completed post-anesthesia recovery care which includes at least a description of the presence or absence of anesthesia-related complications which must include the patient's level of consciousness, cardiopulmonary status and management of any identified post-anesthesia problems. Each anesthesia record shall be dated, signed and authenticated by the responsible practitioner".