HospitalInspections.org

Based on review of hospital policies and procedures, medical records, and staff interviews, it was determined that the hospital failed to provide a written resolution required by the grievance process, submitted by the complainant for 1 for 1 patients (Patient #4).

Findings include:

A review of hospital grievances, revealed the complainant filed a grievance on behalf of Patient #4, in a letter addressed to the Patient Advocate, describing an incident that occurred on 04/14/10.

The hospital policy/procedure titled Patient's Rights and Responsibility requires that patients are provided a copy of the Patient's Bill of Rights (form #9245). Form 9245 requires; "...you have the right to file a complaint related to your stay at this hospital..." with the Patient Advocate, and with the Arizona Department of Health Services.

The hospital policy/procedure titled Customer Service/Concern/Grievance requires; "...A patient grievance...calls, e-mails, faxes, or writes...concerns...not able to be resolved...all the grievance procedure requirements apply. Grievances require a written acknowledgement to the patient...the grievance has been received...This written response, within fourteen days, must include...Results of the...process and date of completion...When extensive...initial letter...This will be no longer than forty-five work days...follow-up letter must include the results...."

There was no documentation that the complainant was provided a written acknowledgement within fourteen work days, that included the name of the person handling the grievance and the steps taken on behalf of the patient to investigate the grievance. There was no documentation from the hospital to the complainant, regarding the grievance resolution

The Chief Executive Officer (CEO) confirmed on 08/27/10 at 1330, that the hospital is required to respond to the complainant.

Based on review of hospital policies/procedures, medical records, staff, and patient interviews, it was determined the hospital failed to require that 3 of 3 obstetric patients were provided the necessary information to ensure informed decisions, regarding the labor and delivery process, as it related to the individual patients (Patients #14, 15, and 16).

Findings include:

The hospital policy titled Informed Consent/Policy (last reviewed 08/09) requires: "...It shall be the responsibility of the physician/licensed independent practitioner to secure the patient's/legal agent's/surrogate's informed consent prior to the initiation of the proposed procedures and or therapies. The explanation should include:...Potential benefits and risks...Potential problems related to recuperation...likelihood of success...possible results of non-treatment...any significant alternative therapies...Code status...Consent is valid for a 'reasonable period of time' usually for the period of the hospitalization, provided the procedure, surgeon, and other stipulations have not changed...."

The hospital policy titled Informed Consent/Guideline (last reviewed 08/09) requires: "...Physician/licensed independent practitioner will discuss risks, benefits, complication and alternative methods of treatment, prior to certifying with his/her signature. The witness signs the consent form after validating the physician/licensed independent practitioner has discussed the content of the consent form...."

The hospital policy titled Labor Patient, Care of The (last revised 04/08) requires: "...Have patient complete:...Informed consent for 'Labor and delivery care with possible cesarean section'...."

The Informed Consent for Childbirth and Anesthesia includes: "...My physician/CNM (certified nurse midwife) has explained the childbirth process, treatment goals, reasonable alternatives...risks involved...possible consequences and...possibility of complications to me...I consent to the performance of any other procedure(s) in addition to, or different from those now contemplated, whether or not arising from unforeseen conditions, which my physician/CNM may consider necessary in the course of the procedure(s)...I have read and understand this consent and all blanks were filled in...."

The Consent requires the delivering physician/CNM to mark 1 of 2 boxes identifying the practitioner as the "Primary Obstetrician/CNM" or the "Covering Obstetrician/CNM." The physician's "Primary Obstetrician/CNM" box "certifies";"...I have personally explained the procedure of childbirth, treatment goals, reasonable alternatives...risks involved...possibility of complications to the patient or her authorized agent...." The physician's "Covering Obstetrician/CNM" box "certifies": "...The patient has attested that per primary obstetrician...has explained the procedure of childbirth, treatment goals, reasonable alternatives...risks involved...possibilities of complications to the patient. I have discussed the immediate delivery plan with this patient...."

Labor/Delivery RNs #18 and 19, indicated during interviews conducted on 08/27/10 at 0930, that patients sign consents on admission, for childbirth and possible cesarean section, according to the hospital's policies/procedures.

The following was determined:

Patient #14, gravida 2 now para 2, was admitted for labor induction post dates, on 08/26/10 at 1426. She delivered vaginally at 0552. The patient signed the consent for "Labor and Delivery Care with Cesarean Section If Indicated" (time not documented). The delivering physician signed the consent at 1733, however did not mark the box indicating "Primary Obstetrician" or the "Covering Obstetrician."

The patient verified during an interview conducted on 08/27/10 at 1000, that she signed the consent on admission, however, stated that the delivering physician did not discuss the risks or possible complications, at any time prior to her signature.

Patient #15, gravida 3 now para 3, was admitted in labor on 08/26/10 at 1146. She delivered vaginally at 1905. The patient signed the consent for "Labor and Delivery Care, Cesarean Section if Needed" (time not documented). The CNM signed the consent at 1230.

The patient verified during an interview conducted on 08/27/10 at 1000, that she signed the consent on admission, however, stated that the CNM did not discuss the risks or possible complications, at any time prior to her signature.

Patient #16, gravida 2 now para 2, was admitted in labor on 08/24/10, at 1942. She delivered by primary cesarean section for failure to progress and fetal distress, on 08/25/10 at 0328. The patient signed the consent for "Labor Y Cuidado de Parto Con Cesearea Si Es Indicado" (Labor and Delivery Care with Cesarean Section as Indicated) (time not documented). The delivering physician signed the consent (no time documented), however did not mark the box to indicating "Obstetra principal" (Primary Obstetrician) or the "Obstetra reemplazante" (Covering/Replacement Obstetrician).

The patient stated during an interview conducted on 08/27/10 at 1000, with the hospital's certified Spanish translator in attendance (staff #18), that she did not recall the physician discussing the risks or possible complications, at any time prior to her signature.

The CEO stated on 08/27/10 at 1300, that the patients may have been advised of the risks and complications of childbirth during prenatal office visits, however, could not verify or provide any confirming documentation.

The hospital did not demonstrate that obstetric patients were informed, prior to signing consents for labor/delivery care and possible cesarean section.

Based on review of hospital policy/procedure, medical record, and staff interview, it was determined that the hospital failed to require manual restraints were used in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient, for 1 of 1 patients in restraints due to violent behavior (Pt #52).

Findings include:

The hospital policy/procedure titled Restraint Use of/Policy required: "...Restraint: Any manual method, physical or mechanical device, material, or equipment attached or adjacent to the patient's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body...Restraint for violent or self-destructive behaviors is ordered in the following manner: An initial order specifying the type, purpose, and duration of restraint...."

Pt #52 presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 11/14/09 at 0529, subsequent to ingesting 20 Unisom tablets at approximately 0400. S/he reported difficulty breathing upon awakening and sought emergency treatment.

The medical record revealed the following documentation:

1021: Mental Health Crisis Specialist completed the Crisis Risk Assessment: "...Pt admitted to 3 prior suicide attempt this year...Pt denied need for services...At this time...recommendation is for pt to be placed in a level 1 treatment facility...pt also presented positive for 'Meth' (Methamphetamine)."

1206: nurse: "...Behavior is anxious, agitated, combative, yelling, patient on/off telephone, asking to see paperwork as to why she can not leave, Title 36 (involuntary commitment) per ER (Emergency Room) MD (Medical Doctor)...."

1213: physician ordered: "...Haldol 5 mg IVP (Intravenous Push) Now x 1...Ativan 1 mg IVP Now x 1...Benadryl 25 mg IVP Now x 1...."

1216: nurse: "...Pt demanded to see paperwork...Showed pt Title 36 paperwork, snatched it away...and struck RN...Security and staff arrive to room to prevent pt from eloping...."

1232: nurse: "...at bedside, security personnel x 3...paramedic...all holding patient still while attempting to reinsert IV (intravenous) lock, patient called 911, now 2 YPD (Yuma Police Department) at bedside for assistance...."

There was no documentation of physician's order for manual restraints.

Case Manager RN #46, confirmed during an interview conducted on 08/27/10, that the medical record documentation verified that the patient was manually restrained, but did not include a physician's order for the restraint.

Based on review of hospital policy/procedure and the medical record, it was determined the hospital failed to require that a patient in restraints is monitored at intervals required by policy, for 1 of 1 patients chemically restrained due to violent behavior (Pt #52).

Findings include:

The hospital policy/procedure titled Restraint Use of/Policy required: "...Restraint:...Drug or medication used as a restriction to manage the patient's behavior, or restrict the patient's freedom of movement, and is not a standard treatment or standard dosage for the patient's condition...Restraint for violent or self-destructive behaviors...patients are assessed and assisted by the RN as behavior warrants (minimum Q (every) 15 minutes). This is documented on the Violent/Self-Destructive Behavior Restraint Flow Sheet...Patients restrained for violent or self-destructive behaviors must be: In full view...In direct continuous observation...."

Pt #52: For specific information, cross reference A0168 Patient Rights: Restraint or Seclusion.

Pt #52's medical record documentation revealed the following:

1213: physician ordered: "...Haldol 5 mg IVP (Intravenous Push) Now x 1...Ativan 1 mg IVP Now x 1...Benadryl 25 mg IVP Now x 1...."

1216: nurse: "...Pt demanded to see paperwork...snatched it away...struck RN...Security and staff arrive to room to prevent pt from eloping...."

1232: nurse: "...at bedside, security personnel x 3...paramedic...all holding patient still while attempting to reinserted IV (intravenous) lock, patient called 911, now 2 YPD (Yuma Police Department) at bedside for assistance...."

1341: nurse: "...Behavior...sleeping, monitoring vitals and respiratory status...."

1445: nurse: "...No apparent distress. Resting quietly. Appears to be sleeping...."

1619: nurse: "...Behavior is sleeping...."

1756: nurse: "...pt arousable but not awake enough to communicate properly...."

The Haldol/Ativan/Benadryl combination and effect meets the definition of restraint, per hospital policy.

The medical record did not include a Violent/Self-Destructive Behavior Restraint Flow Sheet, did not contain documentation that an RN assessed/assisted the patient a minimum of every 15 minutes, and/or that the patient was in full view and in direct continuous observation, per hospital policy.

Based on review of the hospital's Quality Improvement and Patient Safety Plan, and staff interviews, it was determined that the governing body, medical staff, and administrative officials failed to ensure the hospital-wide quality assessment and performance improvement efforts were prioritized, and that the governing body evaluated all improvement actions as evidenced by the failure of the Quality Improvement and Patient Safety Plan to require the governing body evaluated and coordinated the Clinical Quality Council's priorities, actions, and decisions, via a reporting requirement.

Findings include:

The Director of Quality Services was interviewed on 08/27/10 at 0945. The current quality plan was requested, and provided, as follows:

The Quality Improvement and Patient Safety Plan, revised 09/24/09, included: "...Objectives...Provide a standardized mechanism for identifying, reporting, and monitoring safety issues throughout the organization...Quality and Safety Structure...Board of Directors...The Board of Directors establishes and adopts priorities for patient safety and quality related activities in accordance with the organizational Strategic Plan...Clinical Quality Council...whose purpose is to coordinate and prioritize clinical quality assurance and performance improvement activities, evaluate patient care quality...The council ensures quality, safety and consistency of patient care by serving as the decision-making body for quality improvement and safety issues...The council reports to the Shared Governance Coordinating Council and the VP (Vice President) of Patient Care Services quarterly...."

The Clinical Quality Council does not have a requirement to report information to another committee that ultimately has quality oversight and sends summaries to the Governing Body, according to the Director of Quality.

The Quality Improvement and Patient Safety Plan indicated that the Governing Body adopts and prioritizes patient safety, similarly, the Clinical Quality Council also indicated its purpose was to coordinate and prioritize clinical quality assurance and evaluate patient care quality. The Plan did not require reporting, evaluation, and coordination of the Clinical Quality Council's priorities, actions, and decisions, with the Governing Body. Therefore, the Plan does not demonstrate that the Governing Body is provided information from the Clinical Quality Council, to ensure performance improvement efforts are prioritized, and that the Governing Body evaluated all improvement actions.

Based on review of medical records, including hospital document titled Medical Caretrac, and staff interview, it was determined the registered nurse failed to supervise and evaluate the nursing care for each patient as evidenced by:

1. failing to discontinue the patient's IV (intravenous line), according to the physician's order, for 1 of 1 patients (Patient #17);

2. failing to complete the Discharge Information Sheet and obtain a physician's discharge order prior to discharging a patient for 1 of 1 patient who required transportation outside of Yuma (Pt #51); and

3. failing to provide nutrition to a patient prior to discharge and a 3-4 hour drive outside of the Yuma community for 1 of 1 patient (Pt #51).

Findings include:

1. Patient #17. The physician ordered to discontinue the intravenous line (IV) on 09/25/09 at 0835, prior to his/her discharge/transfer to a skilled nursing facility. The patient was discharged at 1520, however, there was no documentation in either the hospital or the skilled nursing facility records, to verify that the IV was discontinued.

RN #17, the discharge nurse, confirmed during the medical review and interview conducted on 08/27/10 at 0800, no documentation to verify the IV was discontinued.

2. Patient #51 was admitted to the hospital on 1/4/10, via the Emergency Department (ED) due to fatigue, weakness and confusion. On 1/5/10, a cardiologist documented: "...myocardial infarction... Aortic stenosis...Coronary artery disease...Coronary artery bypass graft...Hypercholesterolemia...Confusion...." The medical record also included "...CVA (cerebral vascular accident), found on MRI (magnetic resonance imaging)...."

The patient was admitted to Medical West (unit) on 01/07/10, and discharged on 01/09/10, at 0750.

On 01/09/10, at 0750, the nurse documented: "...pt. on gurney, transfer scheduled @ 0730, to Tucson, Ariz (Arizona)...Pt placed on 2 L (liters) 02 (oxygen) with YRMC 02 tank...."

The Discharge Information Sheet revealed, "...Discharge Diagnosis(es): blank...Follow-up:...with Cardiologist in 2 to 3 weeks...Diet: blank...Activity: blank...Medication Reconciled: blank...Medication Sheets Given: blank...Special Instructions: blank...Physician Signature: blank...Nursing Signature: blank...Patient Signature: blank...."

MSW #43 confirmed during an interview on 08/26/10, no documentation of a physician's discharge order. S/he also confirmed that the Discharge Information Sheet is required documentation for the physician and nurse.

RN #36 and RN #13 confirmed during interviews conducted on 08/27/10, no documentation of a physician's discharge order, and that the Discharge Information Sheet was not completed.

3. Cross reference #2 above regarding Pt #51.

The Medical Caretrac; Section Physiological: Nutrition form, requires nursing documentation to assess the percentage of diet taken by the patient at each meal. The medical record contained no documentation regarding the patient's nutritional intake for lunch and dinner on 01/08/10, and no documentation that the patient was provided nutrition prior to discharge and 3 - 4 hour ride to Tucson on 01/09/10.

Based on review of random patient medical records, and staff interview, it was determined that the hospital failed to require care plans were developed for Neonatal Intensive Care Unit (NICU) neonates.

Findings include:

The hospital maintains a 20 bed NICU. A random review of patient records revealed no care plans.

The Director of Women and Infant Services confirmed during an interview conducted on 08/27/10 at 0930, that care plans are not written for NICU infants.

Based on review of hospital policies/procedures, patient acuity documentation, staffing assignments, and staff interviews, it was determined the registered nurse failed to require that the numbers and qualifications of the clinical staff, i:e: discipline type, were identified, and assignments made in consideration of the patient's individual needs, according to the acuity plan, as demonstrated by:

1. assignments did not identify the licensed staff by skill level i:e RN vs LPN;

2. the nursing staff could not articulate how patients were assigned to the clinical staff, as it related to the numbers of patients with assigned acuities, and staff skills mix;

3. Care Assistant (CA) assignments were made without considering patient acuities;

4. ED patient acuity levels were not utilized for staffing assignments.

Findings include:

1. The hospital policy titled Nursing: Staffing and Scheduling (last revision 01/09) requires: "...Staffing acuity is a way to approximate the hours of nursing care needed on a shift-to-shift basis, taking into consideration the complexity of care and needs of each patient...assignments reflect credentials of caregivers (i.e.: RN, LPN...)...."

The hospital policy titled Adult Acute Care/Acuity/Staffing Guidelines (08/09) requires: "...The RC (Resource Coordinator) will...determine:..number and skill level of staff required...and what disciplines...."

The 2 West Staffing Matrix Minimum Staffing Guidelines (revised 06/25/10), and Tower 2 Staffing Matrix Minimum Staff Guidelines (revised 09/09) require the nurse to document the following for each 12 hour shift: "...Census...Licenses...." The MedWest Nursing Assignment Sheet requires the nurse to document, "...RN/LPN...."

The staff indicated that "licenses" refers to either RN or LPN.

The "Daily Assignment Sheets", reviewed at random, did not identify the staff by skill level i:e RN vs LPN, as follows:

2 West Medical Unit:

05/09/09: 7A - 7P Census 48 Staffing: 8 RNs, 1 LPN, 1 "license"
05/09/09: 7P - 7A Census 49 Staffing: 8 "licenses"

05/09/10: 7P - 7A Census (not indicated) Staffing: 4 "licenses"

08/25/10: 7P - 7A Census 35 Staffing: 6 "licenses"....7A - 7P notation: "high acuity for licenses."
08/26/10: 7P - 7A Census 32 Staffing: 5 "licenses"
08/27/10: 7A - 7P notation: "per (the Director) need an extra license."

Tower 2 Unit:

08/26/10: 7A - 7P Census 27 Staffing: 9 "licenses"
08/26/10: 7P - 7A Census 27 Staffing: 6 "licenses"
08/25/10: 7A - 7P Census 27 Staffing: 6 "licenses"
08/25/10: 7P - 7A Census (not indicated) Staffing: 5 "licenses"

Med West (2 nd floor) Unit:

05/09/09: 7A - 7P Census 33 Staffing: 9 "licenses"
05/09/09: 7P - 7A Census 31 Staffing: 7 "licenses"

08/27/10: 7A - 7P Census 31 Staffing: 7 "licenses"
08/26/10: 7A - 7P Census (not indicated) Staffing: 2 RNs, 4 "licenses"
08/26/10: 7P - 7A Census 33 Staffing: 7 "licenses", 2 "licenses" orienting
08/25/10: 7A - 7P Census 33 Staffing: 2 RNs, 5 "licenses", 1 "license" orienting
08/25/10: 7P - 7A Census 29 Staffing: 6 "licenses"
08/24/10: 7A - 7P Census 33 Staffing: 8 "licenses", 2 "licenses"orienting
08/24/10: 7P - 7A Census 28 Staffing: 6 "licenses"
08/23/10: 7A - 7P Census 25 Staffing: 6 "licenses", 2 "licenses" orienting
08/23/10: 7A - 7P Census 24 Staffing: 4 "licenses"

The staffing matrixes and assignment sheets, do not define "Licenses", do not distinguish RN from LPN, and do not reflect caregiver credentials i.e. RN, LPN.

2. The hospital policy titled Adult Acute Care/Acuity/Staffing Guidelines (08/09) requires: "...The patient classification assessment (acuity) sheets for the Med/Surg/ICU (Intensive Care Unit) have four levels of acuity for their patients...each nurse will score their patients using the patient classification assessment sheet...assess which category the majority of the patient care items fall. This will be your patient classification ration for each patient...."

2 Med West RNs #14 and #13, and 2 West Medical RN #8, interviewed on 08/27/10 at 0900, could not articulate how many patients of what acuity levels, a nurse could be assigned.

3. The hospital policy titled Adult Acute Care/Acuity/Staffing Guidelines (08/09) requires: "...All departments have a baseline matrix establishing minimum staffing requirements...This will be your patient classification ration for each patient..."

The Tower 2 Staffing Matrix Minimum Staffing Guidelines (last revised 09/09) indicated that the minimum staffing for CAs ranged from "1.5" CAs for 15 patients, to "3.5" CAs for 36 patients. The 2 West Staffing Matrix Minimum Staffing Guidelines (last revised 06/25/10) indicated that the minimum staffing for CAs ranged from "1" CA for 20 patients, to "5" CAs for 52 patients.

2 Med West RNs #14 and #13, stated during interviews conducted on 08/26/10 at 1030, CAs are not assigned according to patient acuities, and that the unit typically assigns 9 - 12 patients to each CA.

2 Med RN #8, stated during an interview conducted on 08/27/10 at 0900, "...CA's are assigned by a matrix - not by patient acuity...."

4. The hospital policy titled Adult Acute Care/Acuity/Staffing Guidelines required: "...Shift to shift staffing process: The RC is responsible for determining staffing needs for the on coming shift, based on the department staffing matrix and patient acuity information. Staffing availability and/or needs will be communicated by the RC at the bed meetings to Nursing Support Services...Patient classification (acuity) assignments: The patient classification assessment (acuity) sheets for...The ED has 5 levels of acuity for their patients...each nurse will score their patients using the patient classification rating for each patient...."

The hospital's policy titled Over Capacity Guidelines included: "...Service capacity is reviewed minimally every shift and on an as needed basis during peak hours and/or during times of seasonal fluctuations...When the ED is holding 2 ICU patients and 50% of the Main ED (Side A) is filled with inpatients the department will refer to their Over capacity Flow Chart...."

The hospital conducts bed meetings twice a day and receives reports from all areas of the hospital on census, admissions, and discharges. The Daily Staffing Acuity Sheets are filled out during the meetings, and indicates the numbers and types of staff for each day, as follows:

03/26/10 (day shift), census was 39. The Ed was staffed with 8 RN's, 5 telemetry/care assistants (CA), 2 business associates (BA), and 2 transport associates (TA). The night shift census was 40. The ED was staffed with 14 RN's, 6 telemetry/1 CA, and 2 BA's. 03/27/10 (day shift) census was 26. The ED was staffed with 8 RN's, 6 telemetry/CA's, and 2 BA's. The night shift census 66. The ED was staffed with 12 RN's, 6 telemetry/3 CA's, and 2.5 BA's. 03/28/10 (day shift) census was 20. The ED was staffed with 11 RN's, 4 telemetry/6 CA's, and 3 BA's. The night shift census was 44. The ED was staffed with 13 RN's, 5 CA's, and 2 BA's.

The ED Resource Coordinator (RC) stated during an interview on 08/25/10 at 0900, that s/he is responsible for staffing in the ED, and provided the ANSOS (time keeping system) form as a reference for scheduled staff. The RC documents on this form the calls made in attempts to obtain staff, however did not have the form for March 2010 and April 2010.

None of the forms indicated the ED patients acuities. In March 2010 and April 2010, the ED census may have increased unexpectedly, requiring an increase in staffing. The hospital could not provide documentation that they implemented the acuity policies/procedures, and could not demonstrate that staffing was determined based on the needs of the patients.

Based on observation, review of hospital policies/procedures, and staff interviews, it was determined that drugs and biologicals were not stored in accordance with the manufacturers' requirements and appropriate use of medication-related equipment, as demonstrated by:

1. no temperatures were taken for the refrigerator located in the Radiology Specials Overflow room that contained Novolin insulin, Succinylcholine and tetracaine;

2. the contrast warmer in the computerized tomography (CT) Radiology Specials room contained Xylocaine 2% prefilled syringes, which may not be stored above 77 degrees Farenheit (F);

3. the CT room #3 refrigerator contained Barium solution and food items;

4. no temperatures or guidelines were approved for the contrast warmer in the magnetic resonance imaging (MRI) room, which contained IV solutions; and

5. CT room #3 contained two (2) patient ready enema bags (unlabeled) filled with mixed gastrografin, and the gallon jug of the mixture did not indicate the expiration date.

Findings include:

The Radiology Department was toured with the Radiology Resource Coordinator (RCC) on 08/24/10, from 1410 through 1555.

1. The Radiology Specials Overflow room contained a locked refrigerator on a counter in the back of the room, contained Novolin insulin, Succinylcholine, and Tetracaine. The refrigerator did not contain a thermometer and the staff could not provide information which verified the temperature at which the medications were stored.

The Novolin insulin drug insert recommendations for storage included: "...should be stored in a cold (36-46 degrees F [2-8 C]) place, preferably in a refrigerator, but not in the freezer...."
Succinylcholine injectable requires refrigeration, or, may be at room temperature for 14 days. The United States Pharmacopeia (USP) definition of cold is "...Any temperature not exceeding 8 degrees C (46 F). A refrigerator is a cold place in which the temperature is maintained thermostatically between 2-8 degrees C (36-46 degrees F)...."
The RRC stated that the refrigerator was new, and could not articulate the process for temperature recording, nor could verify the temperatures.
2. The CT Radiology Specials Room contained a contrast warmer with Xylocaine 2% prefilled syringes. A temperature strip on a shelf in the warmer, did not indicate temperatures. The CT Resource Coordinator stated "it must not be working", and stated the warmer temperatures should register 37 to 39 degrees Celsius (C). The Xylocaine 2% drug insert revealed: "...All solutions should be stored at 20 to 25 degrees C (68 to 77 degrees F)...."

The CT RC confirmed the warmer was warm to touch, but could not ensure the procedure for storing the Xylocaine in the warmer was pharmacy approved.

3. The refrigerator in CT room #3, contained Barium solution for patients' exams as well as, tuna salad, yogurt, and jello. The contrast was stored in a refrigerator with food items. The RRC confirmed the findings of the contents of the refrigerator.

4. The MRI contrast warmer contained IV solutions. The MRI technician in the room could not articulate the procedure for storing IV solutions.

The RRC confirmed that IV solutions were in the contrast warmer, and the MRI technician confirmed s/he did not know how long IV's may be stored and at what temperatures.

The RRC confirmed the radiology department had not established policies/procedures regarding medication refrigerators or contrast warmers.

5. CT room #3, contained two patient ready enema bags, on an IV pole. The enemas were void of patient names, contents, and expiration dates. The technician in the room, explained that the enema bags contained Gastrografin solution for lower gastrointestinal exams. S/he stated that the Gastrografin is mixed with water then poured into the bag. Additional enema mixture was observed in a gallon jug with no expiration date.

Based on observation, and staff interviews, it was determined that the hospital failed to require the premises were maintained to ensure an acceptable level of safety and quality, as demonstrated by:

1. the patient couch outside Outpatient Diagnostic Imaging Ultrasound Room #5, was in poor repair; and

2. the sanitizing spray used on the mammography equipment at Foothills Imaging Center and YRMC Diagnostic Imaging Department/Wormen's Health Specialist facility, had limited germicidal properties.

Findings include:

1. A large black, tattered fabric couch with holes exposing the inside upholstery, was observed outside the Outpatient Diagnostic Imaging Ultrasound Room #5, on 08/25/10 at 0900. The staff confirmed the couch was intended for patients waiting for tests.

The Director of Compliance confirmed the couch in poor repair, during the tour and interview conducted on 08/24/10 and 08/25/10.

2. During tour of Foothills Imaging, on 08/25/10, and tour of the YRMC Diagnostic Imaging Department/Women's Health Specialist, on 08/26/10, the sanitizing spray Clorox Anywhere used on the mammography equipment was found to have limited germicidal properties, i.e., it was only effective against bacteria.

The Clinical Resource Coordinator confirmed that the Clorox product was selected without consultation from the hospital's Infection Control Specialist or the Medical Director. Another product, Dispatch, was approved by the manufacturer of the digital mammography equipment, and had broader germicidal effectiveness (fungicidal and viricidal) but was not selected.

Based on observation, review of hospital policies/procedures, hospital documents, The National Fire Protection Associations (NFPA) 1999 Standard for Health Care Facilities, the Association of periOperative Registered Nurses' (AORN) Perioperative Standards and Recommended Practices 2010 Edition, and staff interviews, it was determined the hospital failed to monitor, maintain, and document, operating room temperatures/humidity levels.

Findings include:

The National Fire Protection Association's (NFPA) 1999 Standard for Health Care Facilities requires operating rooms to maintain humidity levels at 35% or greater.

The Association of periOperative Registered Nurses' (AORN) Perioperative Standards and Recommended Practices 2010 Edition, requires: "...Relative humidity should be maintained between 30% and 60% within...operating rooms...Low humidity increases the risk of electrostatic charges, which pose a fire hazard in an oxygen-enriched environment or when flammable agents are in use...Temperature should be monitored and recorded daily...should be maintained between 68 degrees F (Farenheit) to 73 degrees F...within the operating room suite...."

The hospital policy titled Monitoring and Recording Temperatures of OR (operating room) Suites and Warming Cabinets requires: "...Temperature...humidity...recorded daily...Temperature...maintained...within operating room suite...."

The Temperature/Humidity Log required: "Room Temperature Range 68 F to 73 F" and "Humidity Range 30% - 60%." Temperature/humidity levels are recorded for each OR on days of operation.

The July 2010 Temperature/Humidity Log revealed the following recordings for the 20 of 31 days the operating rooms were in use:

The following temperatures were out-of-range:

OR #1: 1 of 20 (days).
OR #2: 10 of 20.
OR #3: 2 of 20.
OR #4: 18 of 20.
OR #6: 2 of 20.
OR #7: 10 of 20.
OR #8: 7 of 20.
OR #9: 5 of 20.
OR #10: 9 of 20.

The following humidity levels were out-of-range:

OR #1: 4 of 20 (days).
OR #2: 7 of 20.
OR #3: 20 of 20.
OR #4: 20 of 20.
OR #5: 20 of 20.
OR #6: 20 of 20.
OR #7: 6 of 20.
OR #8: 1 of 20.
OR #9: 3 of 20.
OR #10: 2 of 20.

The August 2010 Temperature/Humidity Log revealed no temperature or humidity level recordings.

Three (3) of 10 ORs, rooms #3, 4, and 5, were observed without humidity level gauges, during a tour conducted on 08/24/10.

The OR Nurse Educator RN #31, and the Director of Surgical Services/Materials Management (employee #32) confirmed during the tour and interviews conducted on 8/24/10, at 1330, that there were no humidity gauges in OR's #3, 4, and 5, that temperature/humidity levels were not maintained according to national standards and hospital policy for July 2010, and that the August 2010 Log was incomplete.

Based on observation, review of hospital policies/procedures, and staff interviews, it was determined the infection control preventionist failed to require the hospital maintained a sanitary environment, monitored compliance with policies/procedures/protocols for cleaning and disinfecting environmental surfaces, required disinfectants and germicides to be used in accordance with the manufacturer's instructions, and maintained nationally acceptable humidity levels in the operating rooms, as demonstrated by:

1. dirty linen in the Post Anesthesia Care Unit (PACU) were not placed in a hamper;

2. unused hemodialysis supplies were not disinfected/disposed post treatment, and left on the top of the hemodialysis machine for the next patient;

3. Operating Room (OR) humidity was not maintained at nationally acceptable levels;

4. the water damaged wall in the dialysis unit posed the potential for mold accumulation.

Findings include:

1. The PACU nurse was observed removing dirty linen from the patient's bed/gurney, during a tour conducted on 08/24/10 at 1345, and tossing the pile on the floor, instead of the hamper provided for contaminated linen.

RN #21 observed the same and confirmed that hampers provided for disposing contaminated linen, were not used.

2. The policy titled Infection Control In The Hospital Dialysis Setting #7-03-01 (last revised 09/09) requires: "...If the potential for contamination exists, the device outercasing is wiped with an appropriate disinfectant before being returned to clean area or using on another patient...Items taken into the dialysis station will be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before taken to a common clean area or used on another patient...Unused...supplies...taken to the patient's station should be used only for that patient and should not be returned to a common clean area or used on other patients...."

The following was observed during a tour of the Acute Dialysis Unit conducted on 08/25/10:

The unused intravenous (IV) bag on top of the hemodialysis machine, the multiple blue bloodline clamps hanging on a hook on the machine, and the porous clipboard and paper (to document machine parameters) were not disinfected or disposed, post patient treatment.

The dialysis staff verified during interviews conducted during the tour, that the top of the machine was considered contaminated, and that anything remaining after a patient's treatment was "suppose" to be disinfected or disposed. The staff stated, however, that this was not the practice.

3. The Association of periOperative Registered Nurses' (AORN) Perioperative Standards and Recommended Practices 2010 Edition, requires: "...Relative humidity should be maintained between 30% and 60% within...operating rooms...Low humidity increases the potential for dust. High humidity increases the risk of microbial growth in areas where sterile supplies are stored or procedures are performed...."

The National Fire Protection Association (NFPA) 1999 Standard for Health Care Facilities requires operating rooms to maintain humidity levels at 35% or greater.

Cross reference A0726 Ventilation, Light, Temperature Controls.

4. The hospital's Acute Dialysis Unit includes 5 patient bays (each plumbed for dialysis). The following was observed during a tour conducted on 08/25/10:

The wall behind the patient bay nearest the nurses' station, was water-damaged. The wall was buckled with holes in the wallboard around the water spigot, exposing the inside of the wall, posing the potential for mold accumulation.

The dialysis RN stated that the damage had been there for "some time," and that the hospital's plant maintenance staff were aware and had plans for repair.

The Infection Control Preventionist confirmed during an interview conducted on 08/26/10, that s/he was unaware, and uninformed, of the wall damage in the dialysis unit.

Based on review of hospital policy/procedure, the medical record, and staff interview, it was determined the hospital failed to require a reassessment of the discharge plan for appropriateness, for 1 of 1 patients who required transportation outside of the Yuma community (Pt #51).

Findings include:

The hospital policy/procedure titled Discharge Planning, Interdisciplinary Patient/Policy revealed: "...has a coordinated program of discharge planning to insure the continuity of care to the patients it serves...discharge planning takes into consideration not only the immediate problem and its consequences, but the patient's return to the community with the ability to maximize potential...The patient and family are involved in the assessment and planning process for continued care. The Case management Department takes a lead role in coordinating discharge planning with other members of the health care team...If a recommended plan of action cannot be carried out/accomplished, the accountable party should immediately contact the Director/Resource Coordinator and Case management. Alternative action plans and decisions will be designed and implemented in a timely manner...."

Patient #51's medical record documentation revealed:

01/07/10, at 1630: Social Worker: "...Patient's daughter would like to have the Patient go to short term rehab...If acute rehab is not an option, she prefers to bring the Patient directly to an assisted living facility in Tucson and utilize home health services. She anticipates that an ambulance will be used for transfer. Discussed Statewide as a more cost effective option for transport, if physician agrees that this is a safe and appropriate...Requested YRH (Yuma Rehab Hospital) eval (evaluation) from (physician) Updated RN...regarding need for referral...."

01/08/10, at 1600: nurse: "...Pt was denied by YRH and is now scheduled to be transferred to assisted living in Tucson at 0730 tomorrow...."

01/08/10: physician: "...PT/OT (physical therapy/occupational therapy) today!...." The nurse noted the order at 1610. The same physician documented progress notes on 01/08/10: "...PT/OT - Family wants to take him to assisted living in Tucson in AM...."

01/08/10, at 1802: Social Worker: "...Proposed Discharge Plan: To Northwest Assisted Living Home...Patient and family in agreement with plan...Estimated DC (Discharge) date: Sat (Saturday), January 9, 2010 at 0730...Recommended transportation: Statewide private pay via stretcher and oxygen provided by Lin Care. Family paid for transport and two family members will accompany patient...."

01/09/10, at 0750: nurse: "...pt. on gurney, transfer scheduled @ 0730, to Tucson...Pt placed on 2 L (liters) 02 (oxygen) with YRMC 02 tank...."

The Discharge Information Sheet revealed: "...Discharge Diagnosis(es): blank...Follow-up:..with Cardiologist in 2 to 3 weeks...Diet: blank...Activity: blank...Medication Reconciled: blank...Medication Sheets Given: blank...Special Instructions: blank...Physician Signature: blank...Nursing Signature: blank...Patient Signature: blank...."

There was no documentation by social services or the physician regarding YRH's denial, no documentation that the physician agreed with the method of transport, and no physician's discharge order.

MSW #43 confirmed during an interview conducted on 08/26/10, no documentation that the physician agreed with the method of transport, and no discharge order. Statewide is a non-medical transport. S/he also confirmed that the physician and the nurse are required to complete the Discharge Information Sheet at discharge.

RN #36 and RN #13 confirmed during interviews conducted on 08/27/10, no discharge order, the Discharge Information Sheet was not completed, a discharge order is required, as well as completion of the Discharge Information Sheet.

On 09/03/10, during phone interview, a representative from Yuma Lincare stated that the Lincare company has not provided 02 for patients transported by Statewide. When Lincare does provide 02 for transport, a service representative provides an "E-tank" that provides 02 at 2L for 4 hrs.

Based on review of hospital policy/procedure, review of the medical record, and staff interview, it was determined that the hospital failed to require that family members were counseled and provided adequate information regarding transportation options for 1 of 1 patients transported outside of the Yuma community (Pt #51).

Findings include:

Cross reference A0821 Reassessment of a Discharge Plan, for Pt. #51.

There was no documentation to conclude that the Social Worker discussed transportation options with the patient and/or family.

The Social Worker who documented the "recommended transportation" was unavailable for interview during survey, however, MSW #43, Case Manager RN #45, and Case Manager RN #46, concurred during interviews on 08/27/10, that the hospital's practice is to discuss alternatives of transport with the patient and family and document the discussion. MSW #43 confirmed no documentation of such a discussion and no documentation that the physician had agreed to Statewide as an appropriate method of transport for this patient. (Statewide is a non-medical transport.)