HospitalInspections.org

Based upon review of the Emergency Department (ED) physician on-call list, and staff interviews, the Governing Body failed to ensure the hospital maintained the ED on-call list of physicians as evidenced by identifying a group of physicians who were on-call instead of the specific physician who was available to provide medical care. Findings:

Review of the physician on-call list on 12/15/10 at 9:20 a.m. revealed the on-call list of specialists available to the Emergency Department (ED) included the name of a physicians group as being on-call to the ED. In an interview on 12/15/10, 9:20 a.m. with S4RN, S5RN, S6RN and S8RN, it could not be confirmed which specific physician was responsible for being on-call if requested by the ER Physician. Further review of the on-call lists revealed that there were 5 Physicians and 2 Nurse Practitioners listed as being on call for the physician group on 12/15/10.

Further interview with the ED Clinical Coordinator S8RN, revealed one of the physicians in the physician group would be carrying the on-call pager. When asked who would be responsible if there was no response from the on-call physician, S8RN stated during the day they would call the physicians group office to see who was on-call. If the problem occurred at night, the house supervisor would be notified the on-call physician had not responded to the page.

Based on review of contract services, Quality Assurance Performance Improvement Program (QA/PI) activities, and staff interview, the governing body failed to ensure all contract services were assessed through the hospital's QA/PI program as evidenced by failing to ensure the contracted service for Environmental Services was monitored through the QA/PI program to identify quality and performance problems and ensure the services provided were in accordance with the contract. Findings:

In an interview on 12/15/10 at 12:38 p.m. with S10, Systems Infection Control; and S9RN, QA/PI; both stated the hospital had not developed QA/PI indicators for the contracted housekeeping service. They further indicated that QA/PI had presented no data to the Governing Body to assess the services provided under contract to identify quality and performance problems.

In an interview on 12/16/10 at 10:40 a.m. with S1DON and S31COO it was confirmed no QA/PI indicators were being tracked for the contracted housekeeping service since the beginning of it's contract on 07/17/10.

Based on record review and interview the hospital failed to ensure medications were administered according to acceptable standards of practice as evidenced by: 1) failing to ensure the Registered Nurse clarified incomplete medication orders prior to administering Hydrocodone for pain management in the Post Anesthesia Care Unit (PACU) for 1 of 6 outpatient surgery medical records reviewed in a total sample of 23 patients (#23); and 2) failing to ensure that medications were administered according to documented medication orders for 1 of 4 endoscopy medical records reviewed in a total sample of 23 patients (#8).
Findings:

1.
Review of Patient #23's "Nursing Post Anesthesia Care Record" dated 12/15/10 revealed, in part, "Medications- 12/15/10 at 9:45a.m. Hydrocodone/Acetaminophen (APAP) 10/500mg 1 tablet given by mouth".

Review of Patient #23's "Anesthesiology protocol for PACU" standing orders dated 12/15/10 revealed, in part, "14. Outpatient may give first dose home pain medications prior to discharge as follows: Hydrocodone 10 milligrams by mouth". The order failed to include the prescribed dosage for Acetaminophen (APAP) to be administered.

In interview on 12/16/10 at 10:10a.m., S12, RN Clinical Coordinator for Surgery, confirmed that the post-anesthesia orders for Hydrocodone failed to include the prescribed dose for the Acetaminophen contained in the Hydrocodone tablet.


2.
Review of Patient #8's medical record revealed a total of 12 milligrams (mgs) of Versed was ordered to be administered at 6 different dosing times during the endoscopy procedure performed on 11/15/10. Review of the medical record revealed a total of 17mg of Versed was administered by S4 (RN) at 8 different dosing times during the endoscopy procedure on 11/15/10. Further review revealed a total of 100 ( micrograms) mcg of Fentanyl was ordered to be administered at 2 different dosing times during the endoscopy procedure on 11/15/10. Review of the medical record revealed a total of 200 mcg of Fentanyl was administered by S4 (RN) at 4 different dosing times during the endoscopy procedure on 11/15/10.

Review of hospital documents relating to medication variance reports revealed no documentation to indicate the hospital had identified that the Versed and Fentanyl were administered to Patient #8 in the absence of a documented physicians order.

In an interview on 12/14/10 at 4:15 p.m., S4 (RN) reviewed the medical record of Patient #8 and confirmed that there was no documented medication orders for 5mg of Versed and 100mcg of Fentanyl that were administered to Patient #8 during the endoscopy procedure on 11/15/10. S4 reported that the physician gave a verbal order for the administration of these medications, but the orders were not documented in the medical record of Patient #8.

Based on observation and interview the hospital failed to ensure that outdated drugs were not available for patient use by having 6 vials of insulin in the Emergency Room (ER) medication refrigerator available for patient use. Findings:

In an observation made on 12/15/10 at 9:20 a.m. with S4PI Coordinator, S5Accreditation, and S6RN, ER Clinical Coordinator it was confirmed that there were 4 vials of Humulin R insulin and 2 vials of Novolin N insulin with no documented evidence of date of first puncture.

Review of a hospital policy titled "Multiple Dose and Single Dose Vials", no date effective, last revision date 11/10/2009, presented as current hospital policy read in part: "Purpose: To establish a policy on the labeling and expiration of multiple dose vials and single dose vials...Policy: Multiple dose vials will be discarded 28 days after the vial is opened...Procedure: 1. Multiple dose vials will be labeled with the date opened. 2. The vials will expire after 28 days from the date the vial is opened..."

Based on observation and interview the hospital failed to 1) ensure that defective equipment was removed from patient care areas and properly tagged for service by having one vital sign machine in the emergency room with a broken temperature probe available for patient use; 2) ensure that curtains in the Emergency Room (ER) were constructed in a way as to promote infection control by having the bottom 2" - 3" touching the floor in ER rooms 17 and 18; 3) ensure that ER rooms presented as clean and ready for patient use were thoroughly cleaned as evidenced by a reddish-brown substance in a specimen/procedure tray in ER room 24; and 4) ensure that a section of a wall in the kitchen was maintained in a sanitary manner. Findings:

1) In an observation made on 12/15/10 at 8:40 a.m. with S4PI Coordinator, S5Accreditation, and S6RN, ER Clinical Coordinator it was confirmed that there was one Dynamap Pro Care 400 vital signs machine in the Emergency Room hall available for patient use with a broken temperature probe. S6RN stated the equipment should not be available for patient use.

Review of a hospital policy titled "Defective Equipment", policy number 6.5, effective 12/01/01, last revised 04/27/10, presented as current hospital policy read in part: "Purpose: This instruction is implemented to provide a means of effectively identifying those pieces of equipment that are defective and should be taken out of service...Procedure:..1. Defective pieces of equipment should be tagged with a "Defective - Do Not Use...If equipment can be removed from the area, it should be brought to the Maintenance shop for repairs..."

2) In an observation made in the ER on 12/15/10 at 8:40 a.m. with S4PI Coordinator, S5Accreditation, and S6RN, ER Clinical Coordinator it was confirmed that the bottom 2" - 3" of the curtains used to divide ER beds 17 and 18 were in contact with the floor of the ER. In an interview with the staff present it was confirmed that this would present an infection control problem as the curtains would drag along the floor.

3) In an observation made in the ER on 12/15/10 at 8:40 a.m. with S4PI Coordinator, S5Accreditation, and S6RN, ER Clinical Coordinator it was noted in ER room 24 that in the bottom of the specimen/procedure tray there was a reddish-brown substance. Attempts to remove the substance with an alcohol pad by hospital staff were minimally successful with the stain color being transferred to the pad but not completely being removed from the specimen/procedure tray.

4) Observations in the kitchen on 12/16/10 at 11:05 a.m. with the Director of Facilities present revealed a missing section of wall near the main walkway of the kitchen with food carts stored near the missing section of wall. The missing section of wall was measured to be 5.5 inches in height (from floor up) and 87.5 inches in length. There was a buildup of dirt and grime noted on the floor under this missing section of wall. The Director of Facilities was interviewed at the time of this observation. The Director of Facilities indicated the section of the wall had been removed approximately 30 days ago due to water damage The Director of Facilities indicated the source that caused the water damage has been repaired but the wall has yet to be repaired.

Based on tour observations, review of medical records, and staff interview, the hospital's infection control officer failed to ensure the implementation of an effective infection control program that included interventions to assist in controlling and/or identifying infections and communicable diseases. This was evidenced by the hospital's failure to 1) ensure each patient room was cleaned by the housekeeping staff after the patient was discharged as outlined in the hospital's policies/procedures; and 2) ensure that surveillance activities to monitor for hospital acquired infections included an effective system for the identification of post-operative infections: Findings:

1)
On 12/14/10 at 10:00 a.m. a tour of the rooms on the Medical Surgical unit revealed one room, which was empty and ready for a patient admission, had toilet paper torn and stuffed into the corners of the call bell system box located over the hospital bed.

On 12/14/10 at 10:05 a.m. in an interview with S14, RN, she confirmed the toilet paper was in place in the corner of the call bell system box and removed the pieces of tissue.

On 12/14/10 at 10:15 a.m. in an interview with S44, Director of Environmental Services, he stated when patients were discharged a "detailed" cleaning of the room was done. He added the last time this room was cleaned was on 12/12/10; however, the form did not indicate a time as to when the room was cleaned.

Record review of the Policy and Procedure provided by the contracted Housekeeping services (HHS), titled "Checkouts" pg 3 reads: "Nurses' call button (TV) and other instruments attached to the wall including cords are to be cleaned."


2)
Review of Patient #6's medical record revealed the patient presented to the hospital's ED (Emergency Department) on 12/11/10 with complaints of an elevated temperature and redness and tenderness at the incision site where a caesarian section had been performed 3 weeks earlier. Patient #6 was admitted to the obstetric unit for inpatient services and her course of treatment included antibiotic therapy (Ancef). Review of the computerized medical record system revealed that Patient #6 was hospitalized at this hospital (Ochsner Medical Center Baton Rouge) approximately 3 weeks earlier from 11/19/10 thru 11/21/10 and underwent a caesarian section during this hospitalization.

The Infection Control Officer (S9) and the Systems Manager for Infection Control (S10) were interviewed on 12/14/10 at 10:55 a.m. When asked if the infection control department had been notified of Patient #6's return to the hospital after presenting with an elevated temperature and redness and tenderness at the caesarian section incision site after being hospitalized at this hospital 3 weeks earlier, both indicated that the infection control department had not been notified. When asked about the surveillance activities used to monitor for the identification of post-operative infections, both indicated that a surveillance form that identifies the patient and surgical procedure is sent to the physician who performs surgery in the hospital and the physician is expected to complete the form and return the form to the hospital so that data relating to post-operative infections could be monitored and included in the hospital's quality assurance program. When asked to review the completed surveillance forms returned to the hospital for the months of September and October of 2010, S10 reported that she was unable to produce any of the surveillance forms for the months of September and October of 2010. S10 indicated that the hospital's infection control department has been in a transition period as the previous infection control officer is no longer employed at the hospital and S9 recently assumed the role of infection control officer.