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Based on record reviews and interview, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to clarify an incomplete medication order for a Cardizem continuous infusion prior to administration for 1(#26) of 1 total patients reviewed who had received a continuous infusion requiring titration out of a total patient sample of 30.

Findings:

Review of Patient #26's medical record revealed an admission date of 2/26/18 with admission diagnoses of Atrial Fibrillation, Rapid Ventricular Response, and shortness of breath.

Review of Patient #26's physician's orders revealed the following order: Cardizem drip 5mg/hr (milligrams/hour) titrate to systolic BP (blood pressure) less than 110 and/or HR (heart rate) of less than 100. Further review revealed no documented evidence that the RN had obtained a clarification order specifying timeframes and dosage increments for titration of the Cardizem infusion.

Review of Patient #26's medical record revealed the Cardizem continuous infusion was started on 2/26/18 at 6:20 a.m. by S16RN. Further review revealed the medication had been titrated up or down based upon patient vital sign response.

In an interview on 3/6/18 at 12:30 p.m. with S10RN, she indicated the nursing staff would have titrated the Cardizem drip to keep the patient's vital signs within the ordered parameters. S10RN indicated the hospital had a protocol for titration of Cardizem infusions posted on the patient care unit. S10RN confirmed there was no protocol for administration/titration of Cardizem infusions in Patient #26's medical record and no further orders related to titration of the Cardizem infusion other than the original order.

Based on record reviews and interviews, the hospital failed to ensure the Registered Nurse (RN) assigned to surgical services remained competent to provide nursing care assigned. This deficient practice was evidenced by failure of the hospital to ensure nursing staff maintained current Advanced Cardiovascular Life Support (ACLS) competency as required per their job description for 2 (S3RNSurgDir, S24RN) of 2 surgical RNs' personnel files reviewed from a total of 14 personnel files reviewed.

Findings:

Review of S3RNSurgDir's (Surgical Director) job description revealed ACLS was a required qualification for surgical services. Further review revealed S3RNSurgDir's current ACLS had expired on 11/4/17.

Review of S24RN's job description revealed ACLS was a required qualification for surgical services. Further review revealed S24RN's current ACLS had expired on 11/4/17.

In an interview on 3/7/18 at 9:50 a.m. with S15HR, she confirmed both S3RNSurgDir and S24RN had expired ACLS cards.

Based on record review and interview the hospital failed to ensure the clinical records system was maintained in accordance with written policies and procedures. This deficient practice was evidenced by failure of the hospital to ensure patient medical records were promptly completed as set forth in the hospital's policies for completion of medical records and failure to enforce consequences for delinquent medical records as set forth in the hospital's Medical Staff Bylaws and Medical Staff Policies/Procedures.

Findings:

Review of the hospital's policy titled Record Completion within 30 days of Discharge revealed, in part, the following:
Twice a month, an incomplete record count is completed identifying the number of delinquent medical records ... Delinquencies are handled in accordance with ... Medical Staff Bylaws and Medical Staff Policies and Procedures.

Review of the hospital's Medical Staff Rules and Regulations, in part, revealed the following:
D. Documentation Rules: ... 3. The attending physician is responsible for the timely preparation and completion of the patient Medical Record. Medical Record entries must be authenticated within 14 days following the patient's discharge.
E. Consequences: 1. If the medical record is incomplete 15 days ... a written notice shall be sent to the Physician by the CEO or his designee notifying him that his clinical privileges shall be suspended seven (7) days from the dated (22 days) of notice. He shall remain suspended until all incomplete records are complete ...

Review of the hospital's Deficiency Report by Physician/*Employee dated 3/5/18 revealed the following medical record deficiencies:

S13MedDir: 31-60 days deficient: 3; 61-90 days deficient: 5; 91 days or greater: 1; Total deficient records: 9.

S18MD: 31-60 days deficient: 2; 61-90 days deficient: 1; 91 days or greater: 0; Total deficient records: 3.

S19MD: 31-60 days deficient: 1; 61-90 days deficient: 0; 91 days or greater: 0; Total deficient records: 1.

S20MD: 31-60 days deficient: 2; 61-90 days deficient: 0; 91 days or greater: 0; Total deficient records: 2.

S21MD: 31-60 days deficient: 14; 61-90 days deficient: 3; 91 days or greater: 0; Total deficient records 17.

S22MD: 31-60 days deficient: 1; 61-90 days deficient: 1; 91 days or greater: 0; Total deficient records: 2.

Further review revealed a total of 34 medical records that were 31 days to greater than 91 days deficient.

During an interview on 3/7/18 at 8:35 a.m., S12HIM (Medical Records Director) stated no written notifications had been sent to the physicians with deficient medical records and there had been no suspension of physicians' privileges for incomplete charts. S12HIM acknowledged the hospital was not following its Rules and Regulations.

During an interview on 3/7/18 at 9:15 a.m., S1Adm (Hospital Administrator) stated no written notifications had been sent to the physicians with deficient medical records and there had been no suspension of physicians' privileges for incomplete charts. S1Adm acknowledged the hospital was not following its Rules and Regulations.

Based on record review and interview, the hospital failed to ensure medication errors were reported to the physician and documented in the patient's electronic medical record for 1 (#21) of 4 (#20, #21, #22, #23) patient medical records reviewed for hospital identified medication variances out of a total of 30 sampled patient records.

Findings:

Review of the hospital's Medication Administration policy revealed, in part: Purpose: To ensure the safety and appropriated administration of medications is given to the patient as ordered by the physician.
F. Missed or late administration of medications - ...the nurse must consult the Pharmacy as needed for missed medication doses ... Time changes should be noted in the medication record and notify the physician.

Review of Patient #21's chart revealed no documentation of a missed dose of Baclofen 10 milligrams on 3/12/18 at 2:00 p.m. Continued review of Patient #21's chart revealed a dose of Neurontin 300 milligrams had been omitted on 3/12/18 at 2:00 p.m.

During an interview on 3/6/18 at 12:20 p.m. S2CNO confirmed, after review of Patient #21's medical record, that the medication error for the missing Baclofen dose had not been documented in the patient's electronic medical record. S2CNO also acknowledged the nurse had failed to notify Patient #21's physician of the missed Baclofen dose and the omitted Neurontin dose.

Based on record review and interview, the hospital failed to ensure the UR committee included two members who were doctors of medicine or osteopathy. This deficient practice was evidenced by the hospital's UR committee currently having only one physician member (S13MedDir).

Findings:

Review of the hospital's UR plan revealed in part: 3.0 Organization and Composition: The UR Committee is composed of the Physician Advisor (and physician consultant when required), the Chief Nursing Executive, the Director of Case Management, and representatives from Pharmacy, Medical Records, and Finance.

In an interview on 3/7/18 at 11:15 a.m. with S17UR she confirmed the hospital's UR Committee had only one physician member. S17UR reported S13MedDir was the UR Committee's only physician member at this time.

Based on observation, interview, and record review, the hospital failed to ensure the infection control officer developed a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:

1) Failing to ensure the glucose meter was disinfected after patient use and failing to ensure hand hygiene was performed after glove removal for 1 (#26) of 1 patients observed for capillary blood glucose sampling and insulin administration out of a total patient sample of 30; and

2) failing to maintain a sanitary environment.

Findings:

1) Failing to ensure the glucose meter was disinfected after patient use and failing to ensure hand hygiene was performed after glove removal.

On 3/6/18 at 4:15 p.m. an observation was conducted of S9RN performing a capillary blood glucose on Patient
#26. S9RN performed the test and placed the glucose meter back into the carrying case without disinfecting the meter.

On 3/6/18 at 4:35 p.m. an observation was conducted of S9RN administering Patient #26's insulin by injection.
S9RN administered the injection and removed her gloves, failing to perform hand hygiene after glove removal.

In an interview on 3/6/18 at 4:40 p.m. with S2CNO, he confirmed the glucose meter should have been cleaned after use, before placing it back into the carrying case, and S9RN should have performed hand hygiene after glove removal.


2) Failing to maintain a sanitary environment.

Review of the policy titled "Dietary Cleaning Schedule", presented as current by S4DM, revealed in part: The Dietary Manager shall be responsible for completing and enforcing the dietary cleaning schedule.

Observation on 3/6/18 at 10:05 a.m. of the walk in freezer floor revealed food particles, paper, trash, and blackened stained areas under the shelves. The floor was very sticky to walk on. There was a large buildup of ice frozen to the lines of the condenser unit inside the freezer.

In an interview on 3/6/18 at 10:15 a.m. with S4DM (Dietary Manager), she confirmed the freezer floor was very dirty and should be cleaned. S4DM stated that the freezer was to have been cleaned weekly by staff. S4DM also stated that staff had to break off the ice formation inside the freezer weekly when it became too large.


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Based on record reviews, observations, and interviews the hospital failed to ensure the hospital's Surgical Services followed acceptable professional standards of practice governing surgical services and infection control as evidenced by:

1) failing to ensure that staff adhered to acceptable standards of professional practice in surgical attire in the restricted area as evidenced by failure of staff to completely cover all head and facial hair in the restricted surgical area (OR suite), and

2) failing to ensure contaminated flexible endoscopes were transported properly for decontamination, leak tested prior to manual cleaning, and stored, after cleaning, according to AORN guidelines for reprocessing of endoscopes.

Findings:

1) Failing to ensure that staff adhered to acceptable standards of professional practice in surgical attire in the restricted area as evidenced by failure of staff to completely cover all head and facial hair in the restricted surgical area (OR suite).

Review of the AORN Guidelines for Perioperative Practice, 2016 edition - Guideline for Surgical Attire, revealed in part: Recommendation III: All personnel should cover head and facial hair, including the sideburns, the ears, and the nape of the neck, when in semi-restricted and restricted areas. Human hair can be a site of pathogenic bacteria such as MRSA. Hair acts as a filter when it is uncovered and collects bacteria. A clean surgical head covering or hood that confines all hair and covers the ears, scalp skin, sideburns and nape of neck, to include beards, should be worn in the semi-restrictive and restrictive areas. The head covering or hood should be designed to minimize microbial dispersal. Skull caps (surgeon caps) fail to contain the side hair above and in front of the ears and hair at the nape of the neck and the ears. Reusable head coverings (cloth head coverings) should be laundered in a health care-accredited laundry facility or completely covered by a disposable bouffant hat if home laundered.

On 3/7/18 at 8:40 a.m. an observation was made of S6RadTech in the OR surgical suite. S6RadTech was in the OR suite to perform x-rays to evaluate port placement on Patient #R3. S6RadTech was wearing a skullcap type head covering which did not fully cover all of his hair on his neck and did not cover his ears. Further observation revealed he was wearing a surgical mask which did not completely cover his facial hair (beard) and sideburns.

In an interview on 3/7/18 at 9:05 a.m. with S2CNO, he agreed S6RadTech's hair and beard/facial hair/sideburns should have been completely covered in the OR surgical suite.


2) Failing to ensure contaminated flexible endoscopes were transported properly for decontamination, leak tested prior to manual cleaning, and stored, after cleaning, according to AORN Guidelines for Reprocessing of Endoscoscopes.

Review of the AORN Guidelines for Reprocessing of Endoscoscopes, copyright 2016 AORN, Inc., revealed in part: Transporting: Transport contaminated endoscopes and accessories to the decontamination room as soon as possible. Transport endoscopes in a closed container or closed transport cart. The container must be leak proof and puncture resistant and should be large enough to contain all contents with the endoscope coiled in large loops. Label the transport cart or container with a biohazard legend.
Leak Testing: For flexible endoscopes designed to be leak tested, perform a leak test after each use, after damage may have occurred, and before use of a new, repaired, or loaned endoscope. Perform leak testing before manual cleaning and before endoscope is placed in the cleaning solution. Leak testing can reduce damage and repair costs and decrease the potential for patient infection or injury that might result from use of an endoscope that is not completely sealed.
Storing: Place flexible endoscopes in a drying cabinet. Store mechanically reprocessed flexible endoscopes in a cabinet that is either designed and intended for horizontal storage of flexible endoscopes or is of sufficient height, width, and depth to allow the endoscopes to hang vertically, without coiling, and without touching the bottom of the cabinet.

On 3/6/18 at 9:20 a.m. an observation was conducted of Patient #R2's endoscopy procedure. An observation was also made of the room where the procedure was being performed and no biohazard endoscope cart or container for transport of contaminated endoscopes into the adjacent decontamination room for disinfection was observed in the room.

During the observation on 3/6/18, S7ScrubTech was observed manually cleaning the endoscope following the procedure. S7ScrubTech was asked if a leak test had been performed prior to beginning the manual cleaning of the endoscope and she reported she had not performed a leak test prior to beginning manual cleaning of the scope. S7ScrubTech indicated the automated processor would perform a leak test on the endoscope after it had been manually cleaned.

On 3/6/18 at 10:00 a.m. an observation was made of the clean endoscopes, hanging in the storage cabinet, with the ends of the scopes resting at an angle, touching the blue pad on the floor of the storage cabinet.

In an interview on 3/6/18 at 2:20 p.m. with S7ScrubTech, she confirmed the contaminated endoscopes were hand carried, after initial point of care cleaning at the bedside, into the decontamination room. S7ScrubTech confirmed the hospital did not have a biohazard box, cart, or biohazard container of any kind to transport the contaminated scopes into the adjacent room for decontamination.

Interview on 3/7/18 at 11:20 a.m. with S3RNSurgDir, she confirmed the automated processor would perform a leak test, and if a leak was found an alarm would sound and the processor would stop. She also confirmed the processor was utilized after manual cleaning of the endoscopes had been completed. S3RNSurgDir indicated the endoscopes should be manually leak tested prior to manual cleaning of the scopes and the leak test performed by the processor was no substitute for performing manual leak testing. S3RNSurgDir also confirmed the cleaned endoscopes should not touch the floor of the storage cabinet. She indicated the bar where the endoscopes were hung would have to be raised so they no longer touched the floor of the cabinet.

Based on record review and interview, the hospital failed to ensure all patients had an updated history and physical in their medical record when the history and physical had been completed within 30 days of admission or registration for 1 (#1) of 3 (#1- #3) of S11MD's surgical patients reviewed out of a total of 30 sampled patient records.

Findings:

Patient #1
Review of Patient #1's medical record revealed the patient had a breast lumpectomy performed on 1/10/18 by S11MD.
Further review revealed the patient's history and physical was not in the patient's medical record. S10RN called S11MD's office to request a copy of the patient's history and physical. Review of the requested History and Physical revealed it had been had performed on 12/20/17. Additional review of the patient's entire electronic medical record revealed there was no updated history and physical within 24 hours of the patient's admission/registration.

S10RN assisted with patient medical record navigation and confirmed the above referenced findings at the time of the record review on 3/5/18.

Based on record review and interview the Governing Body failed to ensure that the direction of the Anesthesia Department was under the supervision of a Medical Doctor who met established criteria and qualifications for the Director of Anesthesia Services established by the Medical Staff and approved by the Governing Body. This deficient practice was evidenced by failure of the Medical Staff to establish the criteria and qualifications,written in accordance with state law and acceptable standards of practice, to be met by the Director of Anesthesia Services, in the Medical Staff ByLaws and Medical Staff Rules.

Findings:

Review of the Medical Staff ByLaws and Medical Staff Rules and Regulations, revealed no documented evidence of established requirements and/or qualifications,written in accordance with state law and acceptable standards of practice, for the Director of Anesthesia Services.

Review of S23MD's credentialing file revealed no documented evidence of privileging for anesthesia services. Further review revealed no documented evidence of experience and/or training in provision of anesthesia services.

In an interview on 3/7/18 at 1:50 p.m. with S14Compliance, she verified S23MD, a gastroenterologist, was physician director of the hospital's Anesthesia Services. She confirmed S23MD's credentialing file contained no documented evidence of experience and/or training related to anesthesia services.

In an interview on 3/7/18 at 2:00 p.m. with S2CNO, he verified, after review of the Medical Staff ByLaws and Medical Staff Rules and Regulations there was no established criteria and/or qualifications for the Director of Anesthesia Services.

Based on record review and interview, the hospital failed to ensure all patients administered anesthesia received a post anesthesia evaluation within 48 hours after surgery which included assessment of respiratory function, cardiovascular function, mental status, temperature, pain, presence of nausea and vomiting, and post-op hydration according to current standards of anesthesia care for 4 (#1,#2,#3,#5) of 5 (#1- #5) surgical patients reviewed out of a total of 30 sampled records.

Findings:

Patient #1
Review of Patient #1's medical record revealed the patient had a breast lumpectomy performed on 1/10/18 by S11MD. S5CRNA adminstered the patient's anesthesia.

Review of Patient #1's medical record revealed a Post Anesthesia Evaluation had been documented on 1/10/18 at 12:05 p.m. by S5CRNA. Further review revealed the evaluation documentation was on a typed form which had a box with the notation: "seen, examined" (the choice was checked) and another box with the notation: "no anesthesia complications" (the choice was checked). Additional review revealed an assessment of the patient's respiratory function, cardiovascular function, mental status, temperature, pain, presence of nausea and vomiting, and post-op hydration status was not documented on the Post Anesthesia Evaluation.

S10RN assisted with patient medical record navigation and confirmed the above referenced findings at the time of the record review on 3/5/18.


Patient #2
Review of Patient #2's medical record revealed the patient had a right forearm wide excision of a basal cell carcinoma performed on 1/10/18 by S11MD. S5CRNA adminstered the patient's anesthesia.

Review of Patient #2's medical record revealed a Post Anesthesia Evaluation had been documented on 1/10/18 by S5CRNA. Further review revealed the evaluation documentation was on a typed form which had a box with the notation: "seen, examined" (the choice was checked) and another box with the notation: "no anesthesia complications" (the choice was checked). Additional review revealed an assessment of the patient's respiratory function, cardiovascular function, mental status, temperature, pain, presence of nausea and vomiting, and post-op hydration status was not documented on the Post Anesthesia Evaluation.

S10RN assisted with patient medical record navigation and confirmed the above referenced finding at the time of the record review on 3/5/18.


Patient #3
Review of Patient #3's medical record revealed the patient had a Laparoscopic Cholecystectomy performed on 1/10/18 by S11MD. S5CRNA adminstered the patient's anesthesia.

Review of Patient #3's medical record revealed a Post Anesthesia Evaluation had been documented on 1/10/18 at 10:02 a.m. by S5CRNA. Further review revealed the evaluation documentation was on a typed form which had a box with the notation: "seen, examined" (the choice was checked) and another box with the notation: "no anesthesia complications" (the choice was checked). Additional review revealed an assessment of the patient's respiratory function, cardiovascular function, mental status, temperature, pain, presence of nausea and vomiting, and post-op hydration status was not documented on the Post Anesthesia Evaluation.

S10RN assisted with patient medical record navigation and confirmed the above referenced finding at the time of the record review on 3/5/18.

Patient #5
Review of Patient #5's medical record revealed the patient had a right index finger reticulogranular cyst excision performed on 12/26/17. S5CRNA adminstered the patient's anesthesia.

Review of Patient #5's medical record revealed a Post Anesthesia Evaluation had been documented on 12/26/17 by S5CRNA. Further review revealed the evaluation documentation was on a typed form which had a box with the notation: "seen, examined" (the choice was checked) and another box with the notation: "no anesthesia complications" (the choice was checked). Additional review revealed an assessment of the patient's respiratory function, cardiovascular function, mental status, temperature, pain, presence of nausea and vomiting, and post-op hydration status was not documented on the Post Anesthesia Evaluation.

S10RN assisted with patient medical record navigation and confirmed the above referenced finding at the time of the record review on 3/5/18.


In an interview on 3/7/18 at 1:30 p.m. with S5CRNA, she confirmed her documentation of patient Post Anesthesia Evaluation was to check the boxes labeled : "seen, examined" and "no anesthesia complications" and to sign and date the document. S5CRNA further confirmed an assessment, performed by her, of the patient's respiratory function, cardiovascular function, mental status, temperature, pain, presence of nausea and vomiting, and post-op hydration status was not documented on the Post Anesthesia Evaluations. S5CRNA indicated some of the referenced information was already assessed and documented in the nurses notes.