HospitalInspections.org

Based on policy review, medical record review, and interview the facility failed to ensure a consent for treatment was completed for 1 patient (#56) of 44 records reviewed.

The findings included:

Review of the facility policy "Consent" revised 8/23/17 revealed "...informed consent must be obtained and documented...before proceeding with surgical and medical procedures...upon admission...The physician or other provider performing a medical...treatment is responsible for obtaining the patient's informed consent prior to the procedure/treatment..."

Medical record review revealed Patient #56 was admitted to the Neonatal Intensive Care Unit (NICU) on 6/23/17 with diagnoses including Respiratory Distress, Rule Out Sepsis, Cocaine Exposure, and Down's Syndrome.

Medical record review of a NICU Consent to Treat and Perform Diagnostic Procedures revealed the consent was signed on 7/2/17 (10 days after admission). Continued review revealed the physician signed the consent on 9/13/17 (83 days after admission).

Interview with the NICU Nurse Manager on 9/12/17 at 1:45 PM, in the Nurses station, confirmed the consent for treatment was not completed upon admission and the facility failed to follow facility policy.

Based on policy review, medical record review, and interview, the facility failed to ensure medical records were complete for 4 patients (#54, #55, #56, and #59) of 12 records reviewed for blood transfusions.

The findings included:

Review of the facility policy "Transfusion of Blood and Blood Components" revised 1/2016, revealed "...Transfusionist must ensure that entire transfusion documentation slip is completed including...date/time started and finished..."

Medical record review revealed Patient #54 was a 30 week gestational age infant (premature) born on 8/6/17 and admitted to the Neonatal Intensive Care Unit (NICU).

Medical record review of a blood transfusion record for Patient #54 dated 8/7/17 revealed no documentation of the date and time to indicate when the blood transfusion was completed. Continued review revealed the form was not signed by the nurse who completed the blood transfusion.

Medical record review revealed Patient #55 was a 29 week gestational age infant (premature) born on 9/7/17 and admitted to the NICU.

Medical record review of a blood transfusion record for Patient #55 dated 9/7/17 revealed no documentation of the date and time to indicate when the blood transfusion was completed.

Medical record review revealed Patient #56 was admitted to the NICU on 6/23/17 with diagnoses including Respiratory Distress, R/O Sepsis, Cocaine Exposure, and Down's Syndrome.

Medical record review of a blood transfusion record for Patient #56 dated 8/21/17 revealed no documentation of the time to indicate when the blood transfusion was completed.

Medical record review revealed Patient #59 was admitted to the facility on 1/29/17 with a right hip fracture.

Medical record review of a blood transfusion record for Patient #59 dated 2/1/17 revealed no time to indicate when the blood transfusion was completed.

Interview with the NICU Nurse Manager on 9/12/17 at 1:45 PM, in the Nurses station, confirmed the blood transfusion records for Patient #54, #55, and #56 were not complete and the facility failed to follow facility policy.

Interview with the Blood Management Quality Coordinator on 9/13/17 11:15 AM, in the conference room, confirmed the transfusion record for Patient #59 was not timed to indicate when the transfusion was complete and the facility failed to follow facility policy.

Based on review of facility policy, observation, and interview, the facility failed to ensure medications were secured in 3 anesthesia carts for 8 anesthesia carts observed in the Gastrointestinal (GI) Lab.

The findings included:

Review of facility policy "Security and Storage of Medications in Areas Outside the Pharmacy" revised on 6/2011, revealed "...medications are to be secured at all times either in [named medication dispenser] cabinet, medication room, medication cart...a secure area is one in which staff are actively providing patient care and preparing to receive patients, that is, setting up for procedures before the arrival of the patient..."

Observation on 9/11/17 at 3:25 PM, in GI procedure room #4, revealed an anesthesia cart with the following medications located in the top unlocked drawer of the anesthesia cart: 1 prefilled 10 milliliter (ml) syringe of Phenylephrine (medication used to treat low blood pressure); 1 prefilled 10 ml syringe of Glycopyrrolate (anesthesia medication used to relax the muscles in the airway); and 1 vial of Succinylcholine 10 milligrams (mg) (anesthesia medication used to provide general anesthesia). Further observation revealed no anesthesia provider was in the room.

Interview on 9/11/17 at 3:29 PM, with Certified Registered Nurse Anesthetist (CRNA) #1, in GI room #5, confirmed the anesthesia cart was not locked and the medications were not secured prior to the CRNA leaving the room.

Observation on 9/11/17 at 3:30 PM, in GI Procedure room #5, revealed an anesthesia cart with the following medications located in the top unlocked drawer of the anesthesia cart: 1 prefilled 10 ml syringe of Phenylephrine; 1 prefilled 10 ml syringe of Glycopyrrolate; and 1 vial of Succinylcholine 10 mg. Further observation revealed no anesthesia provider was in the room.

Observation on 9/11/17 at 3:35 PM, in GI Procedure room #8, revealed an anesthesia cart with the following medications located in the top unlocked drawer of the anesthesia cart: 1 prefilled 10 ml syringe of Phenylephrine); 1 prefilled 10 ml syringe of Glycopyrrolate; and 1 vial of Succinylcholine 10 mg. Further observation revealed no anesthesia provider was in the room.

Interview with the GI Nurse Manager on 9/11/17 at 3:39 PM, in the GI Lab hallway, confirmed the anesthesia carts were not locked and the facility failed to follow facility policy.

Interview with Anesthesiologist #1 on 9/11/17 at 3:40 PM, in the GI Lab hallway, confirmed the anesthesia carts should be locked when an anesthesia provider is not in the room.

Based on facility policy, observation, and interview, the facility failed to store food in a sanitary manner in 1 of 2 dietary department freezers and 1 of 33 dietary refrigerators and failed to prepare food in a sanitary environment in 1 of 10 dietary food prep areas.

The findings included:

Review of a facility policy "Expiration Dates/Dated Supplies" last revised 6/2017, revealed "...To ensure no outdated food/beverage, medications, or supplies reach a patient...Food & Nutrition Services have departmental policies and procedures to monitor all dated items, which are received, stocked, or distributed..."

Review of a facility policy "Uniform Dress Code" last revised 1/2017, revealed "...Wear...hair restraint when on duty...Facial hair must be effectively restrained..."

Observation with the Director of Nutrition Services on 9/11/17 at 10:18 AM, in the Cooks Freezer, revealed:
* 10 pieces of uncooked cod fish in an open and undated cardboard box
* 4 opened and undated bags of chicken nuggets.

Interview with the Director of Nutrition Services on 9/12/17 at 10:45 AM, in the Nutrition office, confirmed the facility failed to ensure food was stored in a sanitary environment.

Observation and interview with the Administrator of Day Surgery on 9/12/17 at 10:10 AM, in the Post-Anesthesia Care Unit (PACU) Refreshment Area, revealed:
*Two 4 ounce (oz) containers of cranberry juice expired 7/19/17
*Two 4 oz cranberry juice containers expired 9/7/17
Interview confirmed the juices were expired and were available for patient use.

Observation and interview with the Director of Nutrition Services on 9/12/17 at 11:20 AM, in the Café food service preparation and cooking area, revealed 1 employee with no hair covering and 3 employees with visible hair unrestrained or uncovered. Interview with the Director of Nutrition Services confirmed the employees failed to prepare food in sanitary manner and the facility failed to follow facility policy.

Based on facility policy, observation, and interview, the facility failed to ensure expired patient care supplies were not available for patient use in 1 of 2 radiology holding rooms and failed to ensure 5 of 5 surgical waste fluid removal machines were stored in a clean environment.

The findings included:

Review of a facility policy "Inventory Management" dated 9/30/15 revealed "to ensure that medical supplies, pharmaceuticals and food supplies...are rotated appropriately in inventory and removed from service prior to expiration...stocked in refrigerators in patient care areas...Each Department shall implement internal departmental procedures for the routine monitoring and managing of dated supplies within their area whenever supplies are relocated to areas other than official inventory sites..."

Observation and interview with the Radiology Nurse Manager on 9/12/17 at 1:50 PM, in the Interventional Radiology holding room #1, revealed:
*100 blue top vacutainers (specimen tube used to draw blood) with an expiration date of 6/30/17
*91 blue top vacutainers with an expiration date of 8/31/17
*38 green top vacutainer with an expiration date of 5/2017
*26 purple top vacutainer with an expiration date of 8/2017
*16 purple top vacutainer with an expiration date of 4/2017
*1 purple top vacutainer with an expiration date of 3/2017
Interview with the Radiology Nurse Manager confirmed the supplies were expired and were available for patient use.

Observation and interview with the Director of Perioperative Services and the Executive Director of the Perioperative Services, on 9/13/17 at 2:10 PM, in the dirty equipment storage room, revealed 5 uncovered surgical waste management systems (used during surgical procedures to collect and dispose of surgical waste) stored in the dirty equipment room with dirty equipment and patient specimens. Interview with the Director of Perioperative Services confirmed the uncovered waste systems were stored in the dirty equipment room with dirty contaminated bio-hazard waste and patient specimens. Further interview confirmed the machines were taken from the dirty equipment room to the operating room (OR) and the facility did not have any process for ensuring the waste management systems were cleaned prior to taking the machines into the sterile OR.