HospitalInspections.org

Based on observation and staff interview the facility failed to provide an environment that would ensure safety and well being for all patients on the Inpatient Psychiatric Unit. Findings include:

During tour of the Inpatient Psychiatric Unit, at 1:34 PM on 3/15/10, the windows in 7 of 9 patient rooms, (#317, #319, #320, #321, #322, #323 and #324) as well as in the common living room area, contained window curtains held in place with metal curtain rods and brackets that could be removed and potentially used in an unsafe manner by patients to harm themselves or others. The unit Nurse Director agreed that the rods would "probably come down pretty easily" and further stated that the rods and brackets had detached from at least one room simply from the weight of the heavy drapes. During an environmental tour at 1:40 PM on 3/17/10, the Manager of Housekeeping confirmed that the curtain rods and brackets had recently been reattached in at least two of the patient rooms (#319 and #320) as a result of them detaching from the wall related to the weight of the heavy drapes.

Based on interview and record review, the physician order for use of restraints was incomplete and did not meet hospital policy for one applicable patient. (Patient #4) Findings include:

1. Per record review on 3/15/10, staff in the Intensive Care Unit have been applying soft wrist restraints on Patient # 4 to prevent the patient from pulling on their tracheostomy/ventilation tubing and other monitoring devices. Per review of the physician's "Restraint Order for Intubated Patient", for 3/12/10, 3/13/10 and 3/14/10 the "Less restrictive measures attempted", type of restraint to be used and "Criteria for discontinuation" were not documented by the physician when the order was signed. Per review of hospital policy "Use of Restraints for Medical and Surgical Reasons" effective date 3/17/08, states physicians must "sign approved order which includes: Prior less restrictive measures attempted, type of restraint used and criteria for discontinuation". The omissions identified in the physician orders were confirmed by Quality Management staff on the morning of 3/15/10.

Based on record review and staff interview the hospital failed to adequately record and evaluate fluid intake and output for one patient with impaired renal function. (Patient # 11) Findings include:

1. Per record review, Patient #11 was evaluated in the Emergency Department (ED) and admitted to the hospital on 10/21/09 for treatment related to acute renal failure and an electrolyte imbalance. Physician orders in the ED included the use of medications and intravenous fluids (IV) to decrease Patient #11's abnormal electrolyte levels.

Per review of Patient #11's medical record, the 'Graphic Chart' dated 10/21/09 identified Patient #11 as receiving a total of 2600 cc's (cubic centimeters) of fluids between 11:00 PM and 7:00 AM. The 'Graphic Chart' showed that a total of 600cc's of fluids were given by mouth and 1000cc's of IV fluids, which totals 1600cc's, not 2600cc's. Another document identified as the 'Critical Care Flow Sheet' in the Intensive Care Unit (ICU) dated 10/21/09 showed that Patient #11 consumed 600cc's of fluid by mouth. The total oral intake on the 'Critical Care Flow Sheet' was recorded as 600cc's. The patient's total output was recorded as 3000cc's on both the 'Graphic Chart' and the 'Critical Care Flow Sheet'. Per interview on 3/17/10 at 11:30 AM, the Director of Critical Care Services confirmed there was a discrepancy in the total intake for Patient #11.

2. Per review of nursing and physician notes, there was no evidence the physician was notified the night of 10/21/09 - 10/22/09 concerning Patient #11's intake and output and decreased blood pressure, which had dropped from 129/56 at approximately 1:30 AM to 97/44 at approximately 5:00 AM. This was confirmed during interview with the Director of Critical Care Services on 3/17/10 at 11:30 AM. Per interview with the physician on 3/17/10 at 1:45 PM, the physician did not recall being notified of Patient #11's intake/output or decreased blood pressure during the early morning hours of 10/22/09.

Based on observations, record review and staff interview, the Director of Nutrition and Food Service failed to assure that dietary staff adhered to safe food handling practices and maintained a sanitary environment in the kitchen. Findings include:

1. Per review of temperature logs between December 2009 and March 16, 2010, temperatures in 4 freezers were not within acceptable range which the facility identified as 0 degrees to minus 15 degrees Fahrenheit. Temperatures in the walk-in freezer were recorded as 9 to 10 degrees Fahrenheit for 31 days in December and 7 to 10 degrees Fahrenheit for 28 days in February 2010. Temperature logs for the french fry chest freezer, room service glass door freezer and the 3 door ice cream freezer exceeded 0 degrees Fahrenheit and were recorded some days as being 2 to 10 degrees Fahrenheit in December 2009, February 2010, and March 2010. Per dietary protocol, temperatures that exceeded acceptable ranges were not rechecked and discrepancies were not reported to maintenance. During interview on 3/16/10 at 11:30 AM, the Director of Nutrition and Food Services confirmed that temperatures recorded exceeded the acceptable range. Per interview on 3/17/10 at 9:10 AM, the Director of Food and Nutrition Services reported that dietary staff used the incorrect thermometers located outside the freezers, which register higher, instead of interior thermometers when recording temperatures.

2. Per review of dishwasher temperatures between December 2009 and March 15, 2010, wash and/or rinse temperatures were not recorded each time it was used on 15 days. During interview on 3/16/10 at 11:30 AM, the Director of Nutrition and Food Services confirmed that temperatures had not been recorded each time and stated that staff were to document wash and rinse temperatures each time the dishwasher was used. Wash and/or rinse temperatures were not recorded for 3 days in December 2009, 6 days in December 2010, 3 days in February 2010, and 3 days in March 2010.

3 Per observation on 3/16/10 at 3:42 PM, two fans in the walk-in produce cooler and a fan positioned over the pot sink area were heavily soiled with dust. These observations were confirmed by the Director of Nutrition and Food service at the time of the observation.


.

Based on staff interview the facility failed to assure that at least two doctors of medicine or osteopathy were included as members in the composition of the Utilization Review (UR) Committee. Findings include:

During interview, at 9:30 AM on 3/17/10, the Manager of Care Management services, which includes UR, confirmed that the UR Committee's members included only one doctor. S/he stated that the committee had been without a second physician member for approximately one year and they were actively recruiting for one.

Based on observation and interview, the hospital failed to ensure the floor in the decontamination room of Central Sterile Reprocessing (CSR) was appropriately maintained. Findings include:

1. During a tour of CSR with the CSR manager and Director of Ambulatory Care Services on 3/16/10 at 1:40 PM, a section of floor tiles (measuring 2 x 2 feet) located in the decontamination room at the entrance to the clean processing area of CSR, large spaces were observed between the tiles with caulking material intermittently dispersed within the spaces and on the tile creating a porus surface preventing effective floor cleaning. The CSR manager stated the floor tiles have been removed each time maintenance accesses pipes located under the floor and had confirmed the floor tiles were not in good repair.

Based on observations and staff interview, the hospital failed to assure that refrigerators on the nursing units kitchen were maintained in a sanitary manner. Findings include:

1. During observations on 3/17/10 at 9:00 AM, the interior surface of the refrigerator on 2 North was soiled with dried on food spills. This was confirmed by the Charge Nurse on 3/17/10 at 9:00 AM. During observations on 3/17/10 at 9:40 AM with the Director of Nutrition and Food Service, 2 additional refrigerators on 2 South and the Ambulatory Surgical Care Unit were soiled with spillage and/or food debris on the interior surfaces.