HospitalInspections.org

Based on medical record review and interviews, the facility failed to ensure to care plan services for 1 of 3 sampled patients (patient #2).

Findings:

A review of the medical record for patient #2 revealed the lack of a care plan developed from an assessment indicating patient specific problem, goals, and interventions. There was no evaluation of interventions documented or reassessments as the patient's status changed. Noted on a kardex care plan was one problem with five interventions and no goals .

Patient # 2 was admitted on 01/29/2011 was identified with a diagnosis of respiratory failure and hypoxia. Patient #2 was admitted to the critical care unit (CCU). There was only one problem identified for care planing. Further review showed that on 01/30/2011 at 7 PM the patient's oxygen saturation was not documented from 7:00 PM to 12 midnight, there are three saturation's notes from 1:00 AM to 6:00 AM but it does not have oxygen saturations noted.
Further review of medical record shows that the patient's blood pressure was decreasing from 1:00 AM to 6:00 AM, and no reassessment was completed to show that there was any plan to correct the blood pressure issue. Review of nurses notes shows that the patient was placed on a bipap, but there is no documentation to determine the reason why the patient was placed on the bipap machine.
Noted in nurses notes that the nurse documented at 4:50 AM that medication was discontinued and the patient's blood pressure was low. Next nurses note shows that at 6:25 AM there was code blue initiated.

Interview with Director of Nursing Operations on 07/24/2012 at 2:30 PM revealed, when looking at nurses notes, that she felt that there should have been more nurses notes specific to vital signs and that there was no report of oxygen saturation in the 70's. and vital signs hourly. Stated that according to policy on patient reassessment that this patient should have reassessment of oxygen saturation completed more frequently due to condition changes, as indicated by the nurses' notes.

Review of policy number 138 implemented on 2/29/2008 and reviewed 02/16/2009, 02/15/2010, 02/11/2011 and 02/20/2012. Subject Patient Assessment and reassessment under number 3 reassessment is done with any change in patients' status, diagnosis, or any condition that necessitates immediate reassessment with notification of physician for changes.
Interview the License Practical Nurse in CCU on 07/25/2012 at 10:15 AM who states that a goal is set every day for the patient, based on needs of the care plan to accomplish that goal for the day. Saturations are checked every hour and reassessment every 4 hours.

Based on observation and interviews, the facility failed to ensure that medications were prepared and administered in accordance with accepted standards of practice.

Findings:

Observation on 07/24/2012 at 9:10 AM of the Registered Nurse preparing and administering two medications. One pill needed to be cut in half, the nurse removed the medication from the package and put it on the pill cutter with her ungloved, hands and moved the pill to cut in half.

Observation on 07/24/2012 at 9:12 AM, in the medication room, the nurse prepared to draw 4 milligrams (mg) or 4 Cubic centimeter (cc) of the medication from two syringes and pulled the medication into one syringe without labeling the syringe. Normal saline flush was placed near the syringe. The nurse then moved away from the unlabeled syringe and two other nurses walked into room. The nurse was away from the unsecured/unlabeled medication. The nurse picked up the medications and went out of the room, to patients room, where again medication was unattended on table in hall.

Interview with Registered Nurse on 07/24/2012 at 5:30 PM who states that "yes" she had touched the pill, but did not remember that she had left the dilaudid unattended. The nurse stated that she usually labels syringes, but not today, also stated that she knows that the medication in the syringe is less than what is in the saline syringe and that is how she would know that it is the medication syringe.

Based on observations and interviews the facility failed to ensure that both respiratory and oxygen saturation alarms that communicates a problem were turned on in five of nine patients' rooms ( Patient #4, #27, #28, #29 and #30). Based on observation, interview and facility policy, it was confirmed the facility failed to ensure patient linen and other patient related "clean" equipment and belongings were maintained in a sanitary manner and under sanitary conditions throughout the hospital to prevent the potential for contamination.

Findings:

1. Observation on 07/25/2012 at 3:00 PM in patient # 4's room noted that monitor in room had an alarm off, checked and it was the respiratory alarm. patient admitted for altered mental status, fever and hypoxia.

Observation on 07/26/2012 at 10:35 AM, in patients # 4's room again that respiratory monitor showed alarms off. Check of the rest of Critical Care Unit showed that in room 233 patient # 29, room 235 patient # 28, room 238 patient # 27, alarms off and room 241 patient # 30 had respiratory alarms off on monitor. Room 235 patient # 28 had both respiratory and oxygen saturation alarms off on monitor.

Interview with Interim Manager of Critical care Unit on 07/26/2012 at 10:45 AM shows that this is " not her expectations on this unit and that all alarms should be on the monitors."

Interview with Direct care Registered nurse for patient # 4, on 07/26/2012 at 10:45 AM " Didn't notice alarms off and now will be part of initial assessment".

Interview with Team Leader on 07/26/2012 at 10:47 AM : that didn't know why alarms off and had not observed them to be off. "

Review of policy numbered 251, Patient alarm safety-clinical. Implemented 12/29/2008, and revised 01/18/2012 that policy shows that the hospital will identify and assess critical clinical alarms systems to ensure patient safety is maintained. Under procedure it is noted that alarm settings are activated and appropriately monitored according to the area/unit specific criteria or according to the patients medical condition medical condition/activity level. It is noted that under policy that equipment alarms will remain on at all times unless continuous monitoring is in place.



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2. A tour of the nursing units (3 floors) was conducted on 7/26/2012 beginning at 9:40 AM with the facility Director of Housekeeping Services. During the tour, the following observations with the Director of Environmental Services were identified and confirmed:

a.) Medical/Surgical 3rd floor across from room 322, a black multi-level cart with what was determined by staff to be clean linen on the cart uncovered and not on a protective barrier to prevent potential contamination. An Environmental Services worker was interviewed at 9:45 AM, stating she was unaware of the need for a protective barrier under the linens.
b.) Medical/Surgical 3rd floor across from room 302 a linen cart not covered, covering thrown over top of cart.
c.) Pulmonary Care Unit at 9:50 AM, a linen cart not covered, covering thrown over top of cart.
d.) Pulmonary Care Unit at 9:53 AM, a clean linen cart, open and exposed (covering thrown over the top of the cart) with 5 pillows stored on top of the cart.
e.) 4th floor clean utility room (Heart/Catheter) with a clean linen cart, open and exposed (covering thrown over the top of the cart).
f.) 2nd floor clean utility room with clean linen cart, open and exposed (covering thrown over the top of the cart). A second clean linen cart was observed in the clean utility room across from room 200, door propped open with the cart open and exposed (covering thrown over the top of the cart).
g.) 2nd floor multi-level rolling cart in the hallway observed at 10:13 AM, with what was confirmed as clean linen on the cart, uncovered without a barrier to prevent potential contamination.
h.) Critical Care Unit clean utility room observed at 10:21 AM, linen cart open and exposed (covering thrown over the top of the cart).

A review of the facility Policy & Procedure #IC-12 for clean linen handling revealed, " Clean linen must be placed on a clean surface. " Further interview with the Director of Housekeeping at 11:03 AM revealed the inability to produce a policy specific to how linens should be stored while on the nursing unit, aside from the policy provided of storing on a clean surface. The Director confirmed staff has been instructed in the proper storage of linen.

In addition during the tour conducted on 7/26/2012 beginning at 9:40 AM, multiple areas of concern were identified related to items, identified as ready to use for patient care, stored in the soiled utility rooms. Those areas identified included:

i.) Pulmonary Care Unit: Personal belongings (ready for pick up by patient or family) were found stored in the soiled utility room next to the bins marked for hazardous waste, with the bins not securely covered.
j.) Pulmonary Care Unit: A Hoyer life, respiratory machine both unmarked as "soiled" or do not use, were found in the soiled utility room.
k.) 4th floor soiled utility room contained 5 full oxygen tanks which would be ready for transport to a patient's room observed at 9:59 AM. A vacuum cleaner was found in the soiled utility room at this time placed partially under a biohazard collection barrel. It was confirmed with the Director of Environmental Services the vacuum had no tag on it identifying it "not for use," and would/could be used in a patient or public area.
l.) 2nd floor soiled utility room contained 3 bedside commodes, each with a green "clean" tag on them. It was later confirmed with the Director of Infection Control on 7/26/2012 at 11:30 AM, the tags should have been removed if they had been previously used by a patient.

An interview was conducted with the facility Director of Infection Control and Director of Environmental Services on 7/26/2012 at 11:25 AM. Through review of policies, it was confirmed the facility failed to identify those items which should not be placed in the soiled utility rooms. Further discussion revealed the confirmation of the items found, which appeared to be "clean use" items and personal belongings which had been stored in the soiled utility rooms. It was confirmed a contamination risk was present due to the placement of clean use items in the soiled utility rooms.

No further information could be provided.

Based on medical record review and interview, it was confirmed the facility failed to ensure an informed consent was completed thoroughly, providing information specific to the person administering moderate sedation during a procedure for 1 of 31 patients reviewed, Patient #21.

Findings:

A review of the medical record for Patient #21 revealed a surgical procedure involving a tunneled Hemodialysis catheter insertion was scheduled for 2/03/2012. A review of the surgical consent revealed the lack of the name or signature of the person administering the anesthesia, (moderate sedation), with notification of the risks and benefits to the patient prior to the procedure.

Further review of the document revealed the lack of the patient's initial (where requested) regarding the facility policy of "Do Not Resuscitate" (DNR) during such procedures. The document indicates the DNR or No Code status is void during such procedures. There is no indication the patient was made aware of this. A Physician's Progress note dated 1/29/2012 indicates the resident's DNR and DNI (Do Not Intubate) status.

A review of the facility policy and procedure #C-196 indicates, "It is the policy of Citrus Memorial Health System that patients must be given the opportunity to give informed consent. Written verification of informed consent is required prior to the administration of anesthesia or sedation and prior to operative procedures that are performed by a physician or LIP, except in emergency situations. Written verification of the informed consent must be documented on the Surgery/Invasive Procedure Consent form and placed on the patient's chart prior to initiation of anesthesia, sedation or any operative procedures. It is the responsibility of the Anesthesiologists and/or treating physician to provide the patient necessary information for informed consent before hospital personnel obtain consent signatures. This is a non-delegable duty."

An interview was conducted with the facility Risk Manager on 7/26/2012 at 10:35 AM regarding the lack of the informed consent signatures. It was confirmed the signatures had not been documented. No further information could be provided.