HospitalInspections.org

Based on five records reviewed (R.R) accompanied by the Nursing Assistant Director (employee #1), performed during follow up survey on 11/9/16 from 8:00 am thru 3:35 pm, it was determined that the facility failed to ensure that the policies and procedures for the Does Not Resuscitate (DNR) Consent are implemented by the physicians as observed on 1 out of 5 records reviewed (R.R #24).

Findings include: Deficiency Not Corrected

1. During RR # 24 performed on 11/9/16 at 1:55 pm accompanied by the Nursing Assistant Director (employee #1), it was found on the clinical record that this female patient of 81 years old was admitted on 11/1/16 with a diagnose of Abscess Sub Maxilar Left. On 11/1/16 at 11:40 am, the physician wrote on the physician's order form: "DNR". The physician only wrote "DNR" on his progress notes. No evidence was found of the justification, orientation and re-evaluation of the patient related to the DNR. Also, the physician failed to identify the progress notes with date and hour, leaving a blank space.

2. Related to the Does Not Intubate (DNI) consent, it is under review by the Legal Division and it is not available to be implemented by the physicians.

According to interview performed with the Executive Director (employee #14) performed on 11/9/16 at 3:00 pm she stated the following: "The DNI consent is under discussion by the Legal Division members. There are some issues and the review will take more time. After the Legal Division finishes the discussion then they pass their resolution to a Committee and then to the Governing Body. "

The facility failed to establish an alternate mechanism to ensure how the physicians will address those patients that their health condition is compromised and there is not available a DNI consent in case a patient/family refuses to be intubated.

Based on a follow up survey performed on 11/9/16 from 8:00 am thru 3:35 pm, observational tour, records reviewed (R.R) and review of policies and procedure, it was determine that the facility failed to promote the patient's right to be free of restraints and failed to continually assess and monitor for 1 out of 24 record reviewed (R.R. #11).

Findings include: Deficiency not corrected

1.R.R. #11 is a 81 years old female who was admitted at fight floor on 10/26/16 with a diagnosis of Urosepsis Rhabdomyolytis. According to the record review performed on 11/09/16 at 8:30 a. m. with nurse supervisor (employee #13), it was found that on 10/29/16 at 8:45 p. m. the nurse call the physician because the patient was observed disoriented and aggressive and the physician (employee #15) ordered by telephonic order to start restraint protocol on both hands with soft restraint for 24 hours. The restraint protocol was activated however, the order lacks of physician signature. No evidence of physician order's on 10/30/16 at 8:45 p. m. The patient restraint sheet performed per the nurse lacks of the date that be documented and lacks to identified the time when the nurse performed the patient rounds was maintain in blank. No evidence of patient skin assessment performed by the nurse on 10/30/16. On 10/31/16 at 7:00 a. m. a telephone order was performed per the nurse (employee #17) and the physician orders discontinue the soft restriction.

On 11/01/16 a new telephone order was performed by the physician (employee #15) and provided evidence that the patient was initiated on soft restriction of upper extremities per 24 hours and provide evidence that on 10/31/16 at 9:00 a. m. the physician ordered to place a nasogastric tube (NGT) and the patient removed the NGT. The physician telephone orders for 10/29/16, 10/31/16 and 11/01/16 were not sign by the physician according with the polices/procedures of the facility.

The nurse progress notes were performed by the nurses however lacks documentation related to if the patient was in restraint protocol. No evidence was found related to patient behavior to be restrained. No evidence was found related to physician evaluation previous to restraint. No evidence was found related to less restrict measure to be performed previous to restraint the patient.

The facility ' s policy and procedure related to restraint were reviewed on the follow up survey visit performed on 11/09/16 at 1:30 p. m and in the items #1 says that the physician or the professional nurse that identified patient at risk to harm themselves or other patient initiate the restraint process after taken other less restricted alternative or option.

No evidence was found that the physician counter sign the restrain verbal order's no more that 6 hour.

No evidence was found related to the physician's restriction evaluation ordered on 10/29/16 at 8:45 p. m.

No evidence was found related to the less restricted measure taken before restraint the patient.

No evidence was found related to restraint consent be sign by patient or relative.

No evidence was found related to restraint plan of care be activated by the registered nurse.

Based on five records reviewed (R.R) during follow up survey performed on 11/9/16 from 8:00 am to 3:35 pm accompanied by the Respiratory Therapist Supervisor (employee #2) it was determined that the facility failed to ensure a mechanism where the nursing and respiratory therapy services coordinate their interventions when a physician's order does not has complete information related to medication's dose, frequency and route of administration, as observed in 3 out of 5 records review for respiratory services (R.R #5, #6 and #7).

Findings include: Deficiency Not Corrected

1. According to RR #5 performed on 11/9/16 at 8:45 am, this female patient was admitted with a diagnose of Asthmatic Bronchitis on 11/1/16. The Head physician placed an order on 11/1/16 at 2:40 pm for Albuterol 0.083% plus Atrovent 0.02% but failed to include the frequency and route of administration. It was not found documentation of the respiratory therapist nor the registered nurse of their interventions with the physician to obtain the information that was absent on the previous physician's order from 11/1/16. It was found that the respiratory therapist staff was providing treatment every 4 hours without the physician's order specification.

a. On 11/4/16 at 6:50 am, the respiratory therapist placed a reminder label on the physician's order form for renovation of orders for Albuterol 0.083% every 4 hours. However, the physician ordered the respiratory treatment on 11/5/16 at 4 pm but the written order was illegible. This renovated order was signed by the registered nurse but not by the respiratory therapist.

The Respiratory Therapist Supervisor (employee # 2) stated during interview at 9:00 am the following: "If a physician's order is not clear, the respiratory therapist has instructions of not signing it. They have to talk with the registered nurse to call the physician and to clarify the order. As soon as they have the legible order they can sign it."

During RR performed on 11/9/16 at 8:45 am it was not found documentation of the registered nurse of the efforts performed with the physician for obtaining a clear respiratory treatment order. Also, the respiratory therapist failed to write on his/her progress notes information related to his/her efforts to obtain a legible physician's order.

b. On 11/6/16 at 1:30 pm it was found on the clinical record that the registered nurse obtained a phone call order from the head physician for the respiratory therapy. In this order he specified that the Albuterol and Atrovent treatment will be provided every 4 hours. Four days has been passed to obtain a clear and legible order for the respiratory therapy treatment.

The nursing staff and the respiratory therapy staff failed to keep communication on an ongoing basis to obtain a legible order from the physician.

c. On 11/1/16 at 2:40 pm the physician ordered Pulmicort 0.05 but failed to specify the frequency and route of administration. The respiratory therapist has provided treatment every 12 hours as evidenced through the documentation on the clinical record. However, the physician's order was not clear and legible until it was renewed on 11/6/16 at 1:30 pm through a phone call that the registered nurse made to the physician.

2. During RR #6 performed on 11/9/16 at 9:55 am it was found that the head physician ordered on 11/8/16 at 6:48 pm respiratory therapy with Albuterol 0.42% plus Atrovent 0.02% every 4 hours times 2. However, the physician failed to establish the route of administration on the written order.

3. During RR #7 performed on 11/9/16 at 10:15 am it was found that the head physician ordered on 11/4/16 at 7:15 pm respiratory therapy with Albuterol 0.083% plus Atrovent 0.02% every 8 hours. However, the physician failed to establish the route of administration.

The Respiratory Therapy and Nursing Services has failed to establish a mechanism to ensure that all physician's orders for respiratory therapy treatment are legible and have complete information in a manner that the treatment can be provided according to the specifications established by the physician. It is not observed a continuous communication between respiratory therapy and nursing staffs to coordinate on time their intervention when a physician's order is not legible.

Based on follow up survey, observations, medications carts verifications, medications storage check and interviews during a follow up survey performed on 11/9/16 from 8:00 am thru 3:35 pm, it was determined that the facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized personnel on 1 out of 5 patients wards (PWs), (PW #5).

Findings include: Deficiency not corrected

1. On 11/09/16 at 8:41 am a tour was perform for the verification of proper storage of the drugs and biological

a. On 11/09/16 at 8:43 am on the 5th floor medicine ward it was found two medications carts unsecured. The medication cart from room 507A to 512B the drawers lock did not work and the mdication cart from room 510A to 520B was not lock.
The facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized personnel.

Based on a recertification survey, tests performed on equipment and observations made during a follow up survey for the physical environment with the facility's Physical Plant Supervisor (employee #7) and performed on 11/9/16, it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well-being of patients receiving services.

Findings include: Deficiencies not corrected

1. All maintenance closets (emergency room and hospital) were visited on 11/9/16 from 8:00 am until 11:00 am. These closets were found with chemicals to clean the facility and equipment and were all found unlocked and accessible to non-authorized persons.

2. Forty-four patient's sleeping rooms were visited from 11/9/16 from 8:00 am until 11:00 am and the following was determined:

a. Room #304, #312 and #314 ceiling tile with mold and cross t with rust.

b. Room # 314 B, #405 A,B, #501 A,B, #515 A,B, #517 A, #519 rest panel board broken and repaired with tape.

c. Rooms #302,#307, #308 A,# 310,#312, #402 B, #404, #405, #407, #408 B, #409,#411,#501,#502 A, # 503,# 505 A, #507 A,# 508B, #509 A,#511 B,#514 B and # 515 with rust and scratches on side rails.

d. Rooms #302 and #305 (with broken floor tiles) #310, #403,#404,#405 #409 (broken tiles in front of the closets)#410, #416 (without rubber base), #510 with dirty floor tiles and detaches rubber base.

e. Rooms #305, #307 (water running down the wall on the side b of the room), #310,#401,#402 (with mold), #403,#404, #405,#406, #408, #409, #413 and #505 with peeling off paint.

f. Bathrooms wall and floor from patient ' s rooms # 508 without one tile and #510 with mold.

g. Rooms #302,#304,#305,#306,#307,#308,#309,#310,#312,#314,#415,#503,#504,#505,#506,#507,#508and #509 with broken closet Formica cover.

h. Rooms #308 AB, #403 A, B, #410 A, B, #502 A, #503 A, #507 AB, #508 A, B and #509 A with door night tables broken.

i. Rooms #304 A,B, #306 A,B, #307(broken cover), #402 A, #403B, #405 A,B,#410 A,B, #502A, #503A, #507 A,B, #508 A,B and #509 A with rusty base and damaged tires.

j. Rooms #302B, #305B, #310B, #403 B, #409 A,B, #410 ,B, #412 A,B, #413 B and # 416 B with chair cover broken.

3. A lot of mold in the bathroom accessories was observed; this condition repeats thru all the bathrooms on this floor and all the bathrooms on floors (2, 3, 4 and 5).

4. Patient's bathrooms in the emergency room area can be locked from the inside and personnel do not have readily accessible keys or a device to open the door. However, Safety officer (employee #8) submitted evidence that she gave to all departments a device to open the doors. At the moment of the test the device was in the medication room. The device was not readily accessible.

5. Patient ' s bathrooms in the emergency room the nursing call was on the hand sink area.

Based on a Follow up visit performed on 11/9/16 , observations made during the survey for the physical environment with a Physical Plant Supervisor (employee #7) and interview, it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality.

Findings include: Deficiency not corrected

1. Maintenance carts were observed from 11/9/16 from 8:00 am until 11:00 am with cleaning chemicals on top and in the middle of the carts and did not have a cabinet on these carts where personnel can lock these cleaning solutions to limit its accessibility to non-authorized persons.
Interview with (employee #7) at 10:25 am stated " we are waiting to receive plastic boxes to put the detergent inside of it".
However, no evidence was provided for the purchased of the plastic boxes.

Based on a follow up visit performed on 11/09/2016, tests performed on equipment and observations made during the survey for the physical environment , it was determined that this facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff.

Findings include: Deficiencies not corrected

1. Emergency staff does not have a key or a special device readily accessible to open bathroom doors if patients activate the emergency call system and the door is locked from the inside as observed on 11/9/16 at 9:45 am.

2. On 11/9/16 at 8:30 am a patient was observed in the hallway in front of the X-ray department in a stretcher. The patient was connected to an I.V solution and left in front of a set of seats which reduced the width of this exit passage to less than three feet. The patient was not accompanied by nursing personnel or an escort.

3. The triage area in the emergency room was observed on 9/22/16 at 9:23 am and provided evidence of two chairs was on one side of one of the triage room. It was observed a clear glass door only one curtain with two oxygen regulator. The chairs did not have privacy curtains between them, also were not separated from each other by at least four feet. It was observed a chair to take blood sample in the same room. It was observed one patient waiting to receive treatment and another patient sit on a chair and the register nurse is taking a blood sample. This patient was accompanied by her husband.

Based on a follow up survey performed on 11/9/16, the observations tour with the infection control officer (employee #15), procedure observations, documents review and interviews, records reviewed (RR) it was determined that the facility failed to promote a sanitary and safe care through its infection control program in the emergency room, medical/surgical ward, Operating Room (OR) and laundry department related to improper infection control procedures and failed to follow infection control standards of practice for 1 out of 24 records reviewed (RR#13).

Findings include Deficiency Not Corrected

1. During the emergency room observational tour and evaluation on 11/09/16 at 9:20 am accompany with (employee #15) the following was found:

a. On 11/09/16 at 9:20 am on the room CPR 1 it was found the Intra Venous (I.V) fluid bag stand wrap around with tape.

b. On 11/09/16 at 9:25 am in the emergency room pediatric area door 158 is respiratory therapy storage. The storage was with heavy dust on the floors and on the respiratory therapy material.

2. The facility failed to promote a sanitary and safe care through its infection control program in the emergency room related to improper infection control procedures and failed to follow infection control standards of practice.


17959


3. RR #13 was reviewed on 11/09/16 at 11:00 a. m. patient with 61 years old male who was admitted on 11/05/16 due to a diagnose of Right Foot Infected Ulcer and secondary diagnoses of Diabetes Mellitus. The record was reviewed and the following was found:

On 11/09/16 on shift 7:00 a. m. till 3:00 p. m. the patient #13 on Medicine Ward second floor was visit at 11:30 a. m. with the Nurse Supervisor (employee #6) the Associated Nurse Director (employee #1) and the Nursing Director (employee #11).

The patient record was reviewed on 11/09/16 at 11:00 a. m. and provided evidence that the nurse initial assessment was performed on 11/05/16 at 2:30 p. m. and revealed that the patient was admitted per infected ulcer on the plantal area on right foot.

The nurse supervisor (employee #6) was interview and referred that the patient was put on contact isolation (room #214-A ) when was admitted because the patient has an infected ulcer and was treated on this hospital previously.

The record provides evidence of a ulcer culture taken on emergency room on 11/4/16 and revealed that the patient has a positive culture with three microorganism '' Staphylococcus Aurous, Enterobacter Cloacae and Stenotrophomonas.''

On 11/6/16 at 12:15 p. m. a physician order was placed to provide local care with Hybicleans soap to cleanse wound daily, Solosite wound dressing and dry sterile dressing however, the nurses notes did not provide evidence of the foot local care since the admission to the day of the survey on 11/9/16.

No evidence isolation order performed per the physician since the admission to the day of the survey on 11/9/16.

No evidence of the intervention of the Infection Control Nurse and the Skin care nurse intervene to educated the patient, families and personnel related to the infection control measures.

The nurse supervisor (employee #6) was interviewed related to the patient local care, the precautions measures and the nursing education and she stated: '' The local care was provided per the staff register nurse, per the practical nurse and per the podiatrist. When the podiatric perform the local care on occasions the staff nurse accompany the physician to see the procedure. ''

The form used per the facility to evaluated the weekly skin integrity performed by the register nursing staff initiated on 11/4/16 revealed that the nursing personnel on 11/4/16 classified the ulcer on stage III and on 11/7/16 and 11/8/16 classified the ulcer on stage II. No evidence of evaluation of the ulcer on 11/5/16, 11/6/16 and 11/9/16. On 11/6/16 the nurse written local care performed per the podiatric.

The infection control nurse failed to follow agency's policies and procedures related to the local care when the facility admitted a patient with infected ulcer ' s according with appropriate standards of infection control, which pose risk of cross contamination.

Related to the skin care nurse on the recertification survey performed on 9/23/16 at 2:40 p. m. the skin care nurse (employee #18) was interviewed related to her functions and he stated: '' I worked at this facility for 7 years on medicine floor until April 2016. I am s Associate Degree Nurse ADN. The position was available and I pass the interview process. I work rotary shifts and work one alternate weekend. When I am free the ward staff provides the ulcer treatment to the patients and general skin care. I do not do surgical wound cleaning. When I am not here I leave all the necessary supply and the staff on the shifts does the treatment. If the surgeon provides specification for treatment it is follow as per physician orders. I have no training or certification as skin care nurse. I took a course of skin care of 12 hours of continue education. Related to my Job description when a case is referred to me for skin care I interview the patient and proceeded to evaluated all the patient's and performed the care. I do not have an office assigned for skin care the supply is located at the general supervisor ' s office. "
On 11/09/16 at 3:00 p. m. the Nurse Director (employee #11), the Associated Nurse (employee #1), the Infection Control Nurse (employee #18) were interviewed related to the ''Skin and Wound Local Care Program and stated that: '' The nurse (employee #19) was pending to take a course of skin care however at this moment she did not received the course. Actually we have pending a skin care program but it is not structure, it is pending.

Based on records reviewed (R.R) during follow up survey performed on 11/9/16 from 8:00 am to 3:35 pm accompanied by the Respiratory Therapist Supervisor (employee #2) it was determined that the facility failed to ensure that the organization of respiratory therapy services is appropriate to the scope and complexity of the services provided as observed in 1 out of 5 records reviewed for respiratory services (R.R #5).

Findings include: Deficiency Not Corrected

1. According to RR #5 performed on 11/9/16 at 8:45 am, this female patient was admitted with a diagnose of Asthmatic Bronchitis on 11/1/16. The Head physician placed an order on 11/1/16 at 2:40 pm for Albuterol 0.083% plus Atrovent 0.02% but failed to include the frequency and route of administration. The registered nurse obtained a phone call order on 11/6/16 at 1:30 pm clarifying the frequency of administration of the Atrovent, which is every 4 hours. However, no evidence was found on the progress notes of the respiratory therapy staff of the administration of Atrovent from 11/1 thru 11/6, 2016 nor a justification explaining the lack of treatment provided during 5 days.

The facility failed to ensure that the respiratory therapy staff performed their duties according to standards of practice.