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Based on clinical record review, staff interview and policy review it was determined that facility failed to obtain a informed blood/blood products consent form for 1 (#22) of 30 sampled patients. This practice does not ensure the patient's right to an informed decision.

Findings include:

Patient #22's physician order dated 6/13/11 at 3:20 p.m. indicated to transfuse 2 units of Fresh Frozen Plasma. A review of the transfusion records revealed the patient received the first unit at 2:15 a.m. and was completed at 3:00 a.m. Review of the clinical record revealed a signed "Informed Consent for Administration of Blood and/or Blood Products", dated and timed for 6/14/11 at 12:00 p.m., approximately 9 hours after the transfusion had been completed.

An interview conducted with the Director of Intensive Care Services on 6/14/11 confirmed the findings. The Director stated she had spoken with the nurse involved and she confirmed she had not obtained a consent prior to the transfusion.

A review of the facility's policy for " Transfusing Blood and Blood Components", policy # 5.5 (BBTS), reviewed 5/11 revealed paragraph #2, Be sure that informed consent had been signed.

Based on record review, staff interview, and review of policy and procedures it was determined the Registered Nurse failed to evaluate and supervise the nursing care for six (#12, #18, #21, #26, #27, #28) of thirty patients sampled. This practice does not ensure that patient's goals are met and may cause a delay in discharge.

Findings include:

1. Review of patient #18's physician order dated 6/8/11 at 10:20 a.m. instructed for the patient to have Accuchecks before meals and before bedtime with the emergency room sliding scale for insulin coverage. Review of the nursing documentation revealed on 6/8/11 at 4:00 p.m. and 9:00 p.m. no blood glucose results were documented.

Review of physician order dated 6/10/11 at 8:50 a.m. instructed for the patient to have Accuchecks before meals and before bedtime and insulin coverage per sliding scale. Review of nursing documentation revealed on 6/11/11 at 8:30 a.m. the blood glucose was 204. Four units of insulin was to be given according to the sliding scale. There was no insulin documented in the Medication Administration Record (MAR). At 8:00 p.m. no blood glucose was documented. Documentation on the MAR revealed two units of regular insulin was given. Review of nursing documentation on 6/13/11 at 11:30 a.m. revealed no blood glucose was documented. At 9:00 p.m. the blood glucose was documented as 160. There was no documentation in the MAR of insulin being given according to the sliding scale.

2. Patient #21's physician order dated 6/12/11 at 8:40 a.m. instructed for the patient to received Labatelol 10 milligrams (mg) intravenously (IV) over one to two minutes for systolic blood pressure(SBP) greater than two hundred or diastolic blood pressure(DBP) greater than one hundred and twenty two readings 15 minutes apart. Review of nursing documentation on 6/12/11 at 11:35 p.m. revealed the blood pressure was 181/95 and no second reading was found. Documentation on the MAR indicated the nurse gave 10 mg of Labatelol IV.
Patient #21's physician order dated 6/12/11 at 8:40 p.m. instructed for oxygen two to three liters via nasal canula. The order stated to check the oxygen saturations every shift while on oxygen and to call the physician if the oxygen saturation was less than ninety percent. Review of nurses' and respiratory therapists' documentation revealed no documentation of oxygen saturation every shift.

Interview with the Chief Nursing Officer on 6/15/2011 at approximately 2:45 p.m., confirmed the above findings.

3. Patient #27's physician order dated 6/13/11, no time, instructed for an incentive spirometer every hour while awake and maintain oxygen saturation at more than ninety three percent. Review of nursing and respiratory therapy documentation revealed no documentation of incentive spirometer use every hour while awake.

Patient #27's physician telephone order dated 6/14/11 at 10:40 p.m. instructed for Lopressor 2.5 mg intravenously every four hours as needed for systolic blood pressure more than one hundred and eighty and diastolic blood pressure of more than one hundred and ten. Review of nursing documentation revealed on 6/15/11 at 12:00 a.m. the systolic blood pressure was two hundred and five over ninety one. There was no documentation to indicate the patient received Lopressor. Review of nursing documentation for 6/15/11 at 8:00 a.m. revealed the systolic blood pressure was two hundred and ten over seventy eight. There was no documentation to indicate the patient received Lopressor. Review of nursing documentation revealed on 6/15/11 at 8:00 a.m. the systolic blood pressure was two hundred and twenty one over one hundred and seven. There was no documentation to indicate the patient received Lopressor.
Patient #27's physician telephone order dated 6/13/11 at 5:05 p.m. instructed for the patient to use an incentive spirometer every hour while awake. No documentation could be located for the use of the incentive spirometer.
Interview with respiratory therapist on 6/15/11 at 2:30 p.m. indicated that he did not have any orders in his assignment for the patient to use the incentive spirometer.
Interview with unit secretary on 6/15/11 at 2:40 p.m. indicated that the order had been entered for respiratory therapy on 6/13/11 at 6:32 p.m.
Interview with unit Registered Nurse (RN) on 6/15/11 at 2:45 p.m. indicated that it was both nursing and respiratory's responsibility to ensure patient was using incentive spirometer.

4. Patient #28's physician order dated 06/03/11 9:50 a.m. instructed for a psychological consult due to depression. Review of the progress and consult notes did not reveal that a psychologist had evaluated the patient.

Interview with the manager of the nursing unit , on 06/15/11 at 10:25 a.m., revealed that the psychologist reported that he had been to see the patient but the patient was having a procedure done and was not available. Review of the medical record revealed that the procedure to which he referred had been completed on 06/07/11.
Review of the care plan did not reveal that depression had been included as a problem for the patient .
Patient #28's physician order dated 06/02/11 was noted for a fluid restriction and strict I&Os (input and output). A second physician's order dated 06/05/11 was noted for daily weights. Review of the daily weights revealed no weight had been documented on 06/06/11, 06/07/11, 06/08/11, 06/09/11, and 06/10/11.
Interview with the Registered Dietitian on 06/15/11 at 2:15 p.m. revealed the physician had confirmed that the fluid restriction, strict I&O's and daily weights were due to the patient's edematous lower extremities at admission.


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5. Patient #26's physicians post operative orders written on 6/10/11 at 2:00 p.m. revealed an order for vital signs every 4 hours. Review of nursing documentation revealed the vital signs were obtained once a shift (every 12 hours) from 6/10/11 at 10:30 p.m. to 6/13/11 at 7:30 a.m. Then every 8 hours from 6/13/11 at 7:30 a.m. to 6/14/11 at 10:44 p.m. The vital signs were obtained on 6/15/11 at 12:00 a.m., 7:00 a.m., and 1:30 p.m.

A interview was conducted on 6/14/11 with the Unit Charge Nurse, who confirmed the findings.

6. Patient #12's nursing documentation and MAR revealed the patient was medicated for pain with a physician ordered dose of Morphine at 5:32 p.m. Review of the documentation did not reveal where the patient's pain was located or a measurement of the patient's pain intensity. Review of the documentation did not reveal if the medication was effective. On 5/30/11 at 8:00 p.m. patient #12 was assessed as having a pain level of 5 on a scale of 1 to 10 with 10 being the worst possible pain. Review of the documentation did not reveal where the patient's pain was located. Review of the MAR revealed the patient was medicated with Percocet, as ordered by the physician, at 8:48 p.m. Review of the nursing documentation did not reveal if the pain was effective.

Review of the facility's policy, "Pain Assessment and Management Program - Hospital Wide", last reviewed 5/2011, stated the pain assessment includes five elements: quality, intensity, radiation, duration and location. The policy also stated the patient's response to an intervention should be completed within 30-60 minutes (PO/IM within 60 minutes and IV within 30 minutes).

The above findings were confirmed on 6/14/11 at 2:20 p.m. with the director of staff development.

Based on clinical record review, staff interview and policy review it was determined that the nursing staff failed to administer medications according to the physician orders for 1 (#22) of 30 sampled patients. The practice does not ensure safe and effective medication therapy.

Findings include:

Patient #22's physicians order written on 6/13/11 at 1:40 p.m. instructed for Decadron 2 milligrams (mg) every 6 hours as needed. A clarification order was obtained by nursing on 6/13/11 at 8:10 p.m. for Decadron 2 mg intravenously (IV) every 6 hours, 7 1/2 hours after the initial order. A review of the Medication Administration Record for 6/13/11 revealed the patient received the first dose of Decadron at 9:17 p.m. and a second dose was administered at 11:28 p.m., only 2 hours apart.

A interview with the Director of Pharmacy on 5/16/11 at 1:00 p.m. revealed he had reviewed the administration records and confirmed the Decadron had been pulled from the Pyxis and administered by the nurse at the above times. The Director also confirmed there was no documentation as to why the second dose was given when the nurse had to override the system to obtain the medication.

A review of the facility's policy for " Medication Administration, General Guidelines", policy #MPC 003:1, revised 5/11, revealed paragraph #2, Compliance with Medication Orders, Medications shall be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice.

Based on observation and interview with the Manager for Plant Operations, the facility failed to ensure that the dumpster/compactor was located on an impervious surface with a drain that prevented water from pooling and becoming a breeding or harborage area. This practice does not ensure a safe and sanitary environment.

Findings include:
On 06/14/11 at 10:40 a.m., a two foot by two foot pool of brown, foamy water was observed to have collected under a corner of the dumpster/compactor. On 06/15/11 at 1:30 p.m. the pool of water was again noted under the same corner of the dumpster/compactor. There had been no rain either day as an explanation for the water and there was no other standing or surface water indicating the area had been hosed down. The pool of water was noted to be in a depression that was rimmed with cracked cement.
Interview by the Life Safety Surveyor on 06/15/11 at approximately 10:00 a.m. with the Manager of Plant Operations revealed that the surface of the cement pad had fallen below the drain, probably from the compactor consistently being dropped onto the cement. This depression left the drain above the surface of the cement and ultimately unable to drain water, unless the level of collected water rose above the top of the drain.

Based on observation, policy review and interview it was determined the facility failed to ensure the availability of a defibrillator for all 8 operating room suites. This practice could result in a delay in treatment or negative outcomes for a surgical patient.

Findings include:

A tour of the surgical department was conducted on 6/15/11 at approximately 1:00 p.m., accompanied by the Surgical Services Director, the Chief Nursing Officer, the Director of Pharmacy and the Risk Manager. During the tour it was observed there were 8 Operating Room Suites and 1 Code Cart with a Defibrillator next to the nursing desk.

An interview with the Director of Surgery was conducted during the tour. The Director confirmed that none of the 8 surgical suites contained a defibrillator. When questioned on the process for when the defibrillator would be required she stated someone would bring it into the surgical suite. This would leave the other 7 surgical suites without the access to a defibrillator.

A review of the facility's policy, "Cardiopulmonary Resuscitation in the Operating Room (Code Blue)," policy # SUR 006.9, revised 5/11, revealed the "Emergency crash cart is brought into operating room immediately by assisting personnel or scrub tech." Post Code procedure, Code cart was to be returned to Central Supply immediately and another obtained.