HospitalInspections.org

Based on document review and interview, it was determined for 1 of 4 (Pt. #14) clinical records reviewed on the 5th floor Detox Unit, the Hospital failed to provide documentation that advance directive were discussed with Pt.#14 during the admission.

Findings include:

1. On 9/27/16 at approximately 10:45 AM, the clinical record of Pt. #14 was reviewed. Pt. #14 was a 27 year old female admitted on 9/25/16 with a diagnosis of heroine withdrawal. The clinical record of Pt. #14 lacked documentation that advance directives were discussed with Pt.#14 during admission.

2. On 9/27/16 at approximately 1:00 PM, the Hospital's policy titled, "Advance Directives" (reviewed 04/15) indicated, "...Procedure...2. At the time of admission, all competent adult patients or their authorized representatives(s) will be asked whether or not they have properly executed Advance Directive."

3. On 9/27/16 at approximately 10:50 AM, the finding were discussed with the Chief Nursing Officer (E #2) who stated that Pt. #14's clinical record lacked documentation regarding execution of an Advance Directive.

Based on document review, observation and interview, it was determined for 2 of 2 patient group rooms (activity and dining room) on 3 East (psychiatric unit), the Hospital failed to ensure the trash cans did not contain plastic bags. This potentially affected the 19 patients on census for potential harm (self or others).

Findings include:

1. The Hospital policy titled, "Adult Mental Health Unit - Contraband Items" (revised 3/16) was reviewed on 9/27/16. The policy included, "The following items are examples of prohibited items: ... plastic bags".

2. During a tour of the 3 East psychiatric unit conducted on 9/27/16 at 9:40 AM, the following was observed:

a. The activity room had a garbage can in the corner of the room that contained a plastic bag. Three patients were in the room at the time of the tour (one on suicide precautions).

b. The patient dining room had a garbage can by the doorway that contained a plastic bag.

3. During an interview on 9/27/16 at approximately 10:00 AM, the Chief Nursing Officer (E#2) stated, "the bags should be paper, never plastic and there really does not need to be a garbage can in the activity room at all".

A. Based on observation, interview, and document review, it was determined for 1 of 2 patients (Pt. #17) in the Emergency Department (ED), the Hospital failed to ensure a call light was available when needed, to assist with patient safety

Findings include:

1. On 9/27/16 between 1:00 PM and 1:45 PM, an observational tour was conducted in the ED. Pt. #17 was in ED room #2 with the door closed. At 1:26 PM, the Surveyor, sitting with the Chief Nursing Officer (E #2) in the ED nursing station, heard a soft voice call from ED room 2 "nurse." No staff was near room #2 and no one checked on the patient.

On 9/27/16 at 1:27 PM, the Surveyor heard the same quiet voice again call "nurse". The Surveyor went to ED room #2 and asked Pt. #17 if he had called for a nurse and Pt. #17 stated he had. Pt. #17 stated he did not have a call light. The Surveyor informed E #2 about Pt. #17 and she went to assist Pt. #17.

2. On 9/27/16 at 1:30 PM, Pt. #17 ' s clinical record was reviewed. Pt. #17 was a 51 year old male, seen in the ED on 9/27/16, with a complaint of chest pain for 2 days.

3. On 9/27/16 at 1:30 PM, an interview was conducted with E #2. E #2 stated the call light in room 2 was disconnected.

4. On 9/27/16 at 1:50 PM, a call light policy was requested. On 9/27/16 at 3:10 PM, the Chief Nursing Officer (E #2) stated the Hospital does not have a call light policy.

B. Based on document review and interview, it was determined for 1 of 2 patients (Pt. #18) in the Emergency Department, the Hospital failed to ensure vital signs were reassessed as required.

Findings include:

1. On 9/27/16 at 1:35 PM, Pt. #18's clinical record was reviewed. Pt. #18 was a 60 year old male, seen in the ED on 9/27/16, with a complaint of abdominal pain. At 10:50 AM, triage notes indicated Pt. #1 was prioritized as "urgent". At 10:55 AM, Pt. #18's vital signs included: blood pressure 141/93, pulse 66, respiration 18, and temperature 97.4. As of 1:35 PM, Pt. #18's vital signs had not been reassessed(over 2 1/2 hours).

2. On 9/27/16 at 1:40 PM, an interview was conducted with an ED Registered Nurse (E #3). E #3 stated vital signs are seen on the monitors and should be taken every 2 hours.

3. On 9/29/16 at 9:30 AM, Hospital policy #A-1, titled, "Assessment of Patient in the Emergency Department", reviewed/revised September 2013. The policy, required, "... vital signs shall be obtained... every two hours prior to discharge."





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C. Based on observation, document review and interview, it was determined for 1 of 2 patient records reviewed (Pt. #4) on the 6 North Unit, the Hospital failed to ensure fall precaution interventions were implemented as required.

Findings include:

1. An observational tour was conducted on the 6 North Medical Surgical unit on 9/27/16 between 9:00 AM and 11:10 AM. During the tour, "Fall Precaution" signs were noted on the door entering room 614, bed 1. However Pt. #4, in in room 614-1 was not wearing a yellow fall precaution wrist band, as part of the fall prevention intervention.

2. The clinical record for Pt. #4 was reviewed on 9/27/16. Pt. #4 was a 52 year old female admitted on 9/26/16 with complaints of mid-sternal chest pain. The nursing admission assessment indicated a fall risk score of 35, medium risk for fall.

3. The Facility policy titled, "Patient Fall Risk Assessment" required, "Staff Nurse: Assesses each patient on admission and each shift to determine, a. the patients fall risk potential...After assessment, the patient is given a fall risk score...communicates interventions to other members of the health team... Fall Risk: Use Morse Fall Scale Score to see if the patient is in the low, medium, or high risk level...Implement interventions that corresponds with the patient's fall risk level...Please see attachment B for Intervention Plan."

4. The "Attachment B for Intervention Plan" reviewed on 9/27/16 required, "Medium Risk Score 25-44: In addition to measures listed under low fall risk score: Institute flagging system by fall wrists band..."

5. The above finding was discussed with the Unit Manager (E #12) on 9/27/16 at approximately 11:00 AM who stated that patients who are identified at medium to high fall risk should be wearing the yellow fall risk band.

Based on document review and interview, it was determined for 1 of 4 (Pt #16) clinical records of patients on 5th Floor Detox Unit, the Hospital failed to document the reason for not administering a medication as ordered.

Findings include:

1. On 9/27/16 at approximately 9:30 AM, the clinical record of Pt. #16 was reviewed. Pt. #16 was a 65 year old male patient admitted on 9/25/16 with a diagnosis of heroin withdrawal and a history of hypertension. On 9/25/16, Pt. #16's clinical record contained a physician's order dated 9/25/16 that required, Clonidine 0.1 mg (blood pressure medicine) two times a day (10:00 AM and 6:00 PM) and to hold the medication for blood pressure below 90 systolic or pulse below 60. On 9/26/16 at 10:37 AM, Clonidine was documented as not given; however, the reason for holding the medication was not documented.

2. On 9/27/16 at approximately 10:30 AM, the finding was discussed with the night shift Nursing Supervisor (E #1) who stated that the reason for holding the medication was not documented.

3. On 9/27/16 at approximately 12:45 PM, the Hospital's policy titled, "Medication Administration" (reviewed 05/16 ) was reviewed and required, "... B. Electronic Medication Administration Records (EMAR)... 5. If a medication is not administered as ordered, the documentation should include...c. The reason the medication was held is documented on the EMAR."

Based on observational tour, interview, and document review, it was determined for 1 of 2 off- site locations (Site #2), the Hospital failed to ensure clinical records were secured from unauthorized access.

Findings include:

1. On 9/28/16 at 2:00 PM, an observational tour was conducted at an off-site location (Site #2). Approximately 12,000 clinical records were observed, stored on open shelves in a room without a door behind the reception area. A contractual janitorial service was observed cleaning the office after the office was closed and hospital staff were not present, potentially permitting unauthorized access of patient's confidential information.

2. On 9/28/16 at 2:15 PM, an interview was conducted with the Director of Ambulatory Services (E #10). E #10 asked if the clinical records could be stored in boxes. The Surveyor responded, the clinical records needed to be secured from unauthorized access.
3. On 9/29/16 at 10:10 AM, policy #RR-1, titled, "Medical Record Sign Out Control", (reviewed/ revised October 2015), was reviewed. The policy required, "To safeguard the medical record and its informational content against loss, defacement, tampering, and use by unauthorized individuals. Medical records shall be stored in secure locations where they are protected from fire, water damage and other threats."

Based on document review and interview, it was determined the Hospital failed to ensure 5 medical records were completed as required. This potentially affected the 5 patients whom the records represented.

Findings include:

1. The Hospital's "Medical Staff Rules and Regulations", (dated 8/17/2016) required, "Completion of Records...The patient's medical record shall be complete at time of discharge, including progress note, final diagnosis and clinical summary. Where this is not possible because final laboratory or other essential reports have not been received at the time of discharge, the patient's chart will be available in a stated place in the Health Information Management Department. If the record still remains incomplete thirty (30) days after discharge, the President shall notify the Practitioner by mail that his/her Admitting and Surgical Privileges shall be suspended..."

2. On 9/27/16 at approximately 1:30 PM, the Director of Health Information Management (HIM) was interviewed, who stated and presented a letter of attestation indicating that as of 9/27/16 there were 5 delinquent records, greater than 30 days.

Based on observation, interview and document review, it was determined that the Hospital failed to maintain proper supervision of medications stored in surgery, to ensure expired emergency medications and unusable medications were not available for patient use.. This potentially affected an average of 65 surgical cases performed per week.

As a result the Condition of Participation 42 CFR 482.25 Pharmacy Service was not met.

Findings include:

1. The Hospital failed to ensure expired emergency medications were not available for patient use (A-505A).
2. The Hospital failed to ensure unusable intravenous fluid was not available for patient use (A-505B).

A. Based on observation, interview and document review, it was determined in 1 of 1 malignant hyperthermia cart, in the surgery department the Hospital failed to ensure expired emergency medications were not available for patient use. This potentially affected an average of 65 surgical cases performed per week.

Findings include:

1. During an observational tour of the surgical department on 9/28/16 at approximately 9:00 AM the following was observed. In the anesthesia workroom the Hospital's malignant hyperthermia cart was opened. The following was found: forty-two (42) 20 milligram vials of Dantrolene with expiration dates of 9/2014 for all vials.

2. The Director of Anesthesia (MD #1) stated during an interview on 9/28/16 at approximately 9:00 AM that 2 weeks ago we discovered that all of the Dantrolene is expired.

3. The medication insert for Revonto (Dantrolene) (revised 7/2014) reviewed on 9/28/16 at approximately 10:15 AM included, "Indications and Usage: Revonto (Dantrolene Sodium for injection) is indicated,...for the management of the fulminate hypermetabolism of skeletal muscle characteristic of malignant hyperthermia crisis in patients of all ages...Dosage and Administration...Revoto should be administered by continuous rapid intravenous push beginning at a minimum of 1 mg/kg and continuing until symptoms subside or the maximum cumulative dose of 10 mg/kg has been reached."

4. Hospital policy entitled, "Malignant Hyperthermia Management," (Reviewed 9/16) required, "I. Policy: Management of a malignant hyperthermia (MH) crisis requires an immediate multidisciplinary team response...Pharmacy/Pharmacy Tech...Ensure the MH cart has adequate stock of Dantrolene..." The policy does not include who is responsible for checking the stock of Dantrolene for expiration.

5. The "Department of Surgery" committee meeting minutes for 2015 and 2016 were reviewed on 9/28/16 at approximately 11:00 AM. The minutes did not include documentation of expired Dantrolene.

6. An interview was conducted with the Director of Pharmacy (E#16) on 9/28/16 at approximately 1:00 PM. E#16 stated, "The pharmacy is responsible for monitoring all medications in the Omnicells (machines that store medications on each unit). The pharmacy also orders the medications and restocks as needed...I was unaware of any medications being stored in the anesthesia work area; so the area was never checked for medication outdates. Once I was made aware of the Dantrolene being stored there and out of date, I ordered a new supply as requested by the department".

7. Hospital policy entitled, "Inventory Control - Expired/Unusable Medications," (revised 06/16) reviewed on 9/28/16 at approximately 2:00 PM required, "Intent: Expired medications and other unusable medications are stored in a manner that prevents their use and distribution and ensures that they are disposed of safely. Policy: The Pharmacy Department shall have systems in place to monitor all medications used in the Hospital and all hospital-owned clinics for expiration dating..."

8. On 9/28/16 at approximately 1:30 PM The Director of Surgery (E #5) was interviewed. E #5 stated, "The Dantrolene was identified as expired last week when I mentioned to anesthesia it was time for an in-service. I have incorporated malignant hyperthermia into the Hospital's Health Stream online yearly training. I know the policy does not indicate who is responsible for the checking the medication. As the Director of Surgery I take full responsibility for the expired medications. I ordered 7 boxes last week but only had 1 box (8) vials delivered."

B. Based on observation, interview and document review it was determined for 1 of approximately 10 intravenous fluid bags (IVF) in the surgery crash cart, the Hospital failed to ensure the unusable intravenous fluid was not available for use. This potentially affected the average 65 scheduled patients.
Findings include:

1. During an observational tour of the Surgery Department on 9/28/16 at approximately 9:00 AM the following was observed. In the crash cart: One (1) intravenous fluid bag of 100 cc 5% Dextrose was observed out of the Vialflex protective wrapper.

2. The Surgery Charge Nurse (E #13) stated during an interview on 9/28/16 at approximately 9:00 AM that she was unaware how long the IVF had been out of the wrapper.

3. Hospital policy entitled, "Inventory Control - Expired/Unusable Medications," (revised 06/16) reviewed on 9/28/16 at approximately 2:00 PM required, "Intent: Expired medications and other unusable medications are stored in a manner that prevents their use..."

4. On 9/28/16 at approximately 2:30 PM the Hospital presented, "Viaflex Container Directions," (undated) that indicated, "Labeled Volume (mL) 100 - Storage Recommendations (maximum time out of overwrap) 30 days."

Based on document review and interview, it was determined the Hospital failed to ensure dishwashing temperatures were obtained for 2 of 27 days (9/15 and 9/23/16) for the month of September 2016, as required. This potentially affected approximately 40 patients on the average daily census.

Findings include:

1. The Dish Washing Temperature Log was reviewed on 9/28/16 at approximately 12:10 PM. The log lacked documentation of the dishwashing temperature for the wash, rinse, and final rinse on 9/15/16 for the lunch dishes; and on 9/23/16 for the breakfast and lunch dishes.

2. The Hospital policy titled, " Dishwashing" (rev. 8/1/16) was reviewed on 9/28/16 at approximately 12:15 PM. The policy required, Dish machine Set Up...10...Check and record water temperatures on the dish machine Temperature Log and notify supervisor if incorrect...a. wash 160 F; Rinse- 170 F; Final Rinse -180 F.

3. The above findings were discussed with the Director of Food Services during an interview on 9/28/16 at approximately 12:15 PM, who stated that the expectation is that all dishwashing temperatures for wash, rinse and final rinse are to be taken and documented.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on September 27-29, 2016, 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 observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on September 27 - 29, 2016, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags.

A. Based on interview, document review and observation, it was determined for 1 of 1 staff observed (E #11), the Hospital failed to ensure endoscopes were pre-cleaned in accordance with manufacturer's directions for use (DFU). This potentially affected an average of 30 EGD (esophagogastroduodenoscopy) and 50 colonoscopy patients per month.

Findings include:

1. An interview with the Surgical/Endoscope processing Technician (E #11) was conducted on 9/28/16 at 8:00 AM. E #11 stated that pre-cleaning fluid used for soaking the scopes (endoscopes/colonoscopy scopes) is a mixture of warm water and the enzymatic cleanser (Prolystica Enzymatic Presoak and Cleaner 2X concentrate) E #11 didn ' t know what the ratio of water to enzymatic cleanser for the cleaning solution and stated that there was no policy indicating ratios for the mixture.

2. The "Prolystica Enzymatic Presoak and Cleaner 2X Concentrate", directions for use (DFU), reviewed on 9/28/16 at approximately 8:30 AM indicated, "Fill sink or basin with warm water to the appropriate level to fully immerse surgical instruments. Dilute chemistry 1/8 to 1/2 fl. oz per gallon (1-4 ml per L) of warm water. Activity increases as the water temperature increases. Clean for a minimal of 1-5 minutes..."

3. The Hospital policy titled, "Endoscopic Cleaning and High Level Disinfection", (rev 9/16) was reviewed on 9/28/16 at approximately 8:30 AM. The policy required, "Fill the sink with fresh solution of de-enzymatic solution. Immerse scope in detergent, wipe exterior and bush channels while submerged." The policy did not indicate the amount of water the de-enzymatic solution is to be mixed with.

4. On 9/28/16 at approximately 10:10 AM, scope cleaning was observed. E #11 filled the sink with water and poured Prolystica Enzymatic Cleanser into the sink water without measuring the amount of water or enzymatic cleanser used. In addition, there was no measuring equipment available to measure the volume of water and/or enzymatic cleanser.

5 The above finding was discussed on 9/28/16 at approximately 1:20 PM, with the Director of Surgical Services (E #6) who stated, "we follow the directions to fill the sink to fully immerse the scopes" but when asked about the dilution chemistry, E #6 state "that's the part we didn't follow."

6. The Hospital policy titled, "Approval of Hospital Disinfectant", (rev. 9/15) was reviewed on 9/29/16 at approximately 10:00 AM. The policy required, "All products will be used in accordance with the Manufacturer's instruction."



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B. Based on document review, observation and interview, it was determined for 3 of 4 (OR #1, #2 and #4) operating rooms, the Hospital failed to ensure equipment was maintained to allow proper cleaning and prevent cross contamination. This potentially affected all patients having surgery in those rooms.

Findings include:

1. The Hospital policy titled, "Cleaning and Sanitation in the Operating Room (OR) (revised 9/16)" was reviewed on 9/28/16 at approximately 7:30 AM. The policy included, "The assigned personnel will wipe down the room using the hospital-grade chemical".

2. The operating room suite was toured on 9/28/16 at 7:45 AM. During the tour, the following was observed:
- 7:50 AM - In OR #2, two arm boards were worn out on all four corners, exposing the cloth material underneath the vinyl, preventing them from being cleaned properly.
-8:00 AM - In OR #4, one arm board was worn out on all four corners, exposing the cloth material underneath the vinyl, preventing them from being cleaned properly.
- 9:35 AM - In OR#1, two arm boards were worn out on all four corners, exposing the cloth material underneath the vinyl, preventing them from being cleaned properly.

3. During an interview on 9/28/16 at approximately 9:50 AM, the Director of Surgery (E#6) stated, "The arm boards will be replaced to ensure they can be cleaned correctly".




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C. Based on observation, interview and document review it was determined, for 6 of 6 previously worn (dirty) lab coats stored in the Emergency Department's (ED) clean linen closet, the Hospital failed to ensure clean linen was not soiled. This could potentially affect approximately 20 patients treated each day in the ED.

Findings include:

1. On 9/27/16 between 1:00 PM and 1:45 PM, an observational tour was conducted in the ED. At 1:10 PM, the Surveyor opened the clean linen closet door. There were 2 pole racks holding 5 used lab coats. There was also 1 lab coat on the floor. A pocket scheduler was visible in the breast pocket of 1 lab coat.

2. On 9/27/16 at 1:10 PM, an interview was conducted with the Chief Nursing Officer (E #2). E #2 stated the doctor's lab coats would be relocated from the linen closet.

3. On 9/28/16 at 7:45 AM, the Chief Nursing Officer (E #2) stated there is no policy for separation of clean from contaminated linen.


D. Based on observation, interview, and document review it was determined, for 2 of 3 surgical areas (sterile processing and surgery department) the Hospital failed to ensure supplies were not available for use beyond the expiration date, potentially affecting approximately 65 patients undergoing surgery each week.

Findings include:

1. On 9/28/16 between 8:00 AM and 8:15 AM, an observational tour was conducted in the surgical reprocessing area. The following expired supplies were found:

- 1 of 1 box of 2.0 Plain suture, expired 6/1/16;

- 1 of 1 box of 6.0 Plain suture, expired 6/1/16; and

- 1 on 1 gallon bottle of enzymatic cleaner, expired 6/1/16.

The following were found in the Surgery Department's crash cart:

Twelve (12) 10 ml syringes with expiration dates of: 3 expired 5/2015; 1 expired 11/2015; 3 expired 5/2016; 1 expired 6/2016; 3 expired 7/2016; and 1 expired 8/2016.

The following were found in the malignant hyperthermia cart:

Twelve (12) 10 ml syringes with expiration dates: 3 expired 5/2015.

2. On 9/28/16 at 8:15 AM and 9:30 AM, interviews were conducted with the Surgical Reprocessing Supervisor (E #4) and Director of Surgery (E #6). Both stated the expired supplies should have been removed.

3. On 9/29/16 at 10:15 AM, policy #MM-16, titled, "Expired Supplies", initiated September 2016, was reviewed. The policy required, The Hospital "... allows the administration and use of medical supplies only if they are used within their date of expiration."

Based on document review and interview, it was determined for 1 of 12 (Pt #27) open clinical records reviewed for discharge planning, the Hospital failed to initiate the discharge planning evaluation within 24 hours of the request.

Findings include:

1. On 9/28/16 at approximately 2:00 PM, the clinical record of Pt. #27 was reviewed. Pt. #27 was a 79 year old male patient admitted on 9/21/16 with diagnoses of sepsis (infection) and urinary tract infection. Pt. #27's clinical record contained an automatic nursing request for discharge planning on 9/21/16 at 1:43 AM. However, the discharge planning evaluation was not documented until 9/23/16 at 8:22 AM (53 hours 37 minutes).

2. On 9/29/16 at approximately 10:00 AM, the Hospital's policy titled, "Patient Referral Procedure", (revised 9/15) indicated, "...D. Timeliness of Evaluations: 1. Case management will process referrals in the first 24 hours of a receipt of a request..."

3. On 9/29/16 at approximately 9:00 AM, an interview was conducted with the Director of Social Services (E #14) who stated that the process is for discharge plan evaluations to be done within 24 hours (during weekdays) when a request is made. In this case, "I think the policy was not followed."

Based on document review, observation and interview, it was determined for 3 of 5 staff (E #7, #8 and #9) entering the sub-sterile surgical area, the Hospital failed to ensure staff adhered to the attire policy.

Findings include:

1. The Hospital policy titled, "Surgical Attire (revised 9/16)" was reviewed on 9/28/16. The policy required, "...7. All persons entering the restricted areas of the surgery department will wear head covers/surgical hats. Head covers/surgical hats must cover all exposed head and facial hair. 8. All persons in the restricted area of the surgery department will wear masks... 10. Jewelry, other than watches, is not allowed in the restricted areas of the main operating room."

2. The operating room suite toured was initiated on 9/28/16 at 7:45 AM. During the tour, the following was observed:
- 8:00 AM - E#7 (surgical assistant) entered the substerile area while tying his mask and continued into OR #3 still tying the mask. E#7 was also wearing a gold colored necklace.
- 8:30 AM - E#8 (product representative) entered OR#3 with approximately 2 inches of hair exposed below the surgical cap.
- 9:40 AM - E#9 (housekeeping) entered the sub-sterile area from OR #1 without wearing a mask.

3. During an interview on 9/28/16 at approximately 9:50 AM, the Director of Surgery (E#6) stated the substerile area is considered restricted and is treated as such. E#6 stated, "They all know their hair should be covered and masks need to be worn".