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Based on document review, observation and interview, it was determined for 1 of 8 (Pt #11) patients observed on the Medical-Surgical Unit, the Hospital failed to ensure the patient had the right to be free from a restraint that was not medically necessary. This has the potential to affect all patients admitted to the Medical-Surgical Unit.

Findings include:

1. The policy titled, "Restraints" (revised 07/2017), was reviewed on 12/19/17 at approximately 1:00 PM. The policy indicated on page 1 "All patients have the right to be free from restraints that are not medically necessary or are used for purposes other than patient benefit and safety." Page 2 indicated under "H. Documentation in medical record will include: 1. Clinical justification for use, and 2. Physician's order for restraint use."

2. The medical record of Pt#11 was reviewed on 12/18/17 at approximately 11:55 AM. Pt #11 was admitted to the Medical-Surgical Unit on 12/18/17 at 8:20 AM with a diagnosis of Pneumonia and Clostridium difficile infection
(C-Diff). During a tour of the Medical-Surgical Unit with the Medical-Surgical Director (E #4) conducted on 12/18/17 at approximately 4:00 PM, Pt #11 in room #602 was seen lying in bed with the four side rails up. The clinical record lacked documentation of the clinical justification or an order by a physician for the use of the restraint.

3. An interview with the Medical-Surgical Unit Director (E #4) was conducted on 12/18/18 at approximately 4:10 PM. E#4 stated, "We are never to put the 4 rails up as it is a form of a restraint. We can only have the 4 rails up if the patient is having seizures or if the patient requests for fear of falling out of bed."

Based on document review, observation and interview, it was determined for 1 of 2 (Pt #22) patients on the Medical-Surgical Unit determined a high risk for falls, the Hospital failed to ensure fall precautions were properly implemented per facility policy. This has the potential to affect all patients receiving services at the Facility.

Findings include:

1. The policy titled "Fall Risk Assessment" (Approved 7/2017) was reviewed on 12/20/2017 at approximately 4:00 PM. The policy indicated on page 2 and page 3 the following for "High Risk (3 point or above) B. Bedrails up X 3 at all times. Patients are identified as high risk for falls by: A. Falling star sign on door. C. High Risk for falls on problem list."

2. The medical record of Pt #22 was reviewed on 12/21/17 at approximately 10:00 AM. Pt #22 was admitted on the Medical-Surgical Unit to room #619 on 12/19/17 at 4:30 PM with a diagnosis of Intractable Right Wrist Pain. Documentation indicated on 12/19/17 at 4:30 PM, Pt #22 had a fall risk score of 6, indicating a high risk for falls. During an observational tour on 12/20/17 at approximately 10:35 AM, Pt #22 had two side rails up and there was not a falling star sign posted on Pt #22's door. The clinical record of Pt #22 was further reviewed on 12/20/17 at approximately 11:00 AM and lacked documentation of a high risk for falls on the problem list.

3. An interview was conducted on 12/20/17 at approximately 11:15 AM with the Registered Nurse (E #15) whom was assigned to Pt #22. Both of the findings during the tour were confirmed by E #15. E#15 reviewed the medical record of Pt #22 and stated that the problem list should have indicated a high risk for falls.

Based on document review and staff interview, it was determined for 3 of 30 patients (Pt #1, #5, and #10) whose medical records were reviewed, the Hospital failed to ensure the medical record was accurately written and complete. This has the potential to affect all patients receiving services at the Facility.

Findings include:

1. On 12/18/17 at approximately 11:30 AM, the medical record of Pt #1 was reviewed. Pt #1 was a patient in the Emergency Department (ED) on 11/23/17 for complaint of abdominal pain. The "ED Progress" note from ED physician E #6, reads "Pt much better after passing large clot w/c looks like product of conception......"

2. On 12/18/17 at 2:30 PM, the Hospital policy "Abbreviation List" last approved 06/2017 was reviewed and indicated the abbreviation for w/c stood for "wheel chair".

3. On 12/18/17 at approximately 11:50 AM, an interview with the Quality Coordinator (E #2) was conducted. E #2 reviewed Pt #1's chart and confirmed that E #6 used the abbreviation "w/c" E #6 stated that the physician should not have used that abbreviation, "because it doesn't make any sense in that sentence".

4. On 12/18/17 at approximately 11:45 AM, the medical record of Pt #4 was reviewed. Pt #4 expired in the ED on 12/3/17. The "Death Notification Form" dated 12/3/17 indicated "Not suitable donor. If not, reason........." There was no reason listed.

5. On 12/18/17 at approximately 11:50 AM, an interview with the Quality Coordinator (E #2) was conducted. E #2 reviewed Pt #4's chart and confirmed the "Death Notification Form" did not have a reason the patient was not a suitable donor and stated "It should have indicated why."

Based on document review and staff interview, it was determined for 1 of 2 (Pt #10) patients receiving a blood transfusion, the Hospital failed to ensure the physician order was authenticated. This has the potential to affect all patients receiving services at the Facility.

Finding include:

1. On 12/18/17 at approximately 1:00 PM, the Hospital policy "Medical Record Completion Requirement" (last approved 05/2017), was reviewed. It indicated "The medical records are required to be completed within the 30 days after discharge."

2. On 12/18/17 at approximately 12:30 PM, the medical record of Pt #10 was reviewed. Pt #10 received one unit of packed red blood cells (PRB's) on 10/20/17 at 3:51 PM. The "Physician Order" dated 10/20/17 for the PRB's lacked the physician's signature.

3. On 12/18/17 at approximately 12:55 PM, an interview with the Medical Unit Director (E #4) was conducted. E #4 reviewed the medical record of Pt #10 and confirmed there was no physician signature for the PRB's and verbalized "there should have been".

Based on observation, document review and staff interview, it was determined in 2 of 30 (Pt # 7, Pt #9) patient's charts reviewed, the Facility failed to obtain a proper informed consent. This has the potential to affect all patients receiving services at the Facility.

Findings include:

1. On 12/18/17 at 12:30 PM the medical chart of Pt #7 was reviewed. Pt #7 was admitted to the hospital with diagnosis of colon obstruction on 12/16/17. Pt #7's consent for treatment was not signed by the patient; (wife signed consent).

2. On 12/18/17 at 4:00 PM the closed medical chart of Pt #9 was reviewed. Pt #9 was admitted to the hospital on 10/16/17 with a diagnosis of Congestive Heart Failure. The record indicates that on 10/18/17 a telephone blood consent for Pt #9 was obtained for one unit of packed red blood cells by "power of attorney". However, no power of attorney form was found in Pt #9's chart.

3. Review of Facility policy "Consent/Informed Consent" (revised 11/2016) on 12/20/17 found "C. Who may give consent. 1. Adults patients (18 years of age or older) who have decision-making capacity have the right to determine which health care treatments or procedures will be accepted or refused".

4. An interview was completed with Medical/Surgical Nurse Manager (E #4) on 12/18/17 at approximately 12:45 PM. E #4 stated Pt #7 should have signed the consent for treatment, "That is the Hospital's policy." On 12/19/17 at 10:00 AM E #4 also stated that the staff should have obtained a copy of the power of attorney form for Pt # 9 and placed it in Pt #9's chart.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Sample Validation Survey conducted on December 19, 2017, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of Sample Validation Survey conducted on December 19, 2017, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation, document review and staff interview, it was determined the Hospital failed to maintain a proper sanitary system to ensure all environmental surfaces were properly cleaned and disinfected. This has the potential to affect all patients,staff and visitors at the Facility.

Findings include:

1. On 12/18/17 at approximately 11:30 AM, a tour of the Emergency Department (ED) was conducted while being escorted by the Quality Coordinator (E #2). Under a sink near the treatment rooms was a spray bottle with the handwritten word "Bleach" marked on it. It had no expiration date or beyond use date.

2. On 12/18/17 at 2:00 PM the Clorox Bleach solution package insert was reviewed. Under "For Killing Clostridium difficile spores" it indicated "Prepare fresh solution daily."

3. On 12/18/17 at 11:40 AM, an interview with E #2 was conducted. E #2 indicated the spray bottle was used to disinfect and clean surfaces to rid them of clostridium difficile. E #2 verbalized "The spray bottle should of had an expiration date or beyond use date to determine when to dispose of it." E #2 also indicated the spray bottle should have been removed from the patient care area.

B. Based on document review, observation and interviews, it was determined for 1 of 1 (Pt #8) patient on contact isolation, the Hospital failed to ensure adherence to infection control policy and procedures to help reduce and/or prevent the spread and cross contamination of infectious organisms. This has the potential to affect all patients,staff and visitors at the Facility.

Findings include:

1. The policy titled "Contact Precautions" (Approved 01/2017), was reviewed on 12/19/17 at approximately 2:00 PM. The policy indicated under " 2. Gloves should be worn when entering the room ...C. Gowns: A gown should be worn when entering the room..."

2. The medical record of Pt #11 was reviewed on 12/18/17 at approximately 11:55 AM. Pt #11 was admitted to the Medical-Surgical Unit on 12/18/17 at 8:20 AM with a diagnosis of Pneumonia and Clostridium difficile infection (C-Diff). During a tour of the Medical-Surgical Unit with the Medical-Surgical Director (E #4) on 12/18/17 at approximately 1:00 PM to 4:00 PM, a visitor in Pt #11's room #601 was not wearing Personal Protective Equipment (PPE), gown and gloves.

3. An interview was conducted with the visitor on 12/18/17 at approximately 12:30 PM. The visitor
stated "I was told (Pt#11) has a bad infection that can be transferred. Nobody told me I needed to wear anything but you guys need to."

4. An interview was conducted with the Medical-Surgical Director (E #4) on 12/18/17 at approximately 12:40 PM. E #4 stated that the staff should have educated the visitor on Contact Precautions.

C. Based on observation and interview, it was determined for 1 of 1 Magnetic Resonance Imaging (MRI) patient transport stretcher, the Hospital failed to ensure the stretcher mattress was properly cleaned to prevent the potential for cross contamination. This has the potential to affect all patients requiring transport via stretcher into the MRI.

Findings include:

1. An observational tour of the Radiology Department was conducted on 12/19/17 at approximately 11:30 AM with the Radiology Technician (E #13). A stretcher with a mattress with a hole in it was parked in the hallway to the mobile MRI and was available for patient care use.

2. An interview was conducted with E#13 on 12/19/17 at approximately 11:30 AM. E#13 had observed the hole in the stretcher mattress and agreed the stretcher mattress could not be properly cleaned and should not be available for patient care use.

D. Based on interview and stated practice, it was determined for 1 of 1 contracted linen service, the Facility failed to monitor the laundry services to ensure quality standards were met. This has the potential to affect all patients using linens in the Hospital.

Findings include:

1. An interview with the Laundry manager (E #7) was conducted on 12/20/17 at approximately 2:00 PM. E #7 indicated that her process of monitoring the laundry services is to visually check the clean laundry as it is delivered to the facility. E # 7 stated that she was not familiar with reports from the linen service listing machine temperature levels and laundry detergent used.

2. On 12/20/17 at 3:00 PM, E #7 stated that she talked to the linen service and obtained the most recent quarterly report and plans to begin utilizing the data in the reports along with visual inspection for monitoring of the linens.

E. Based on observation, and staff interview, it was determined the Facility failed to ensure proper cleaning of the flexible gastrointestinal endoscope, as per stated practice. This was found in 2 of 2 (Pt #19 and #21) patients observed having a flexible endoscope procedure. This has the potential to affect all patients receiving endoscopic procedures at the Hospital.

Findings include:

1. An observation of Pt #19 having a flexible endoscope procedure on 12/19/17 at 10:47 AM was conducted. At the completion of the procedure, Registered Nurse (E #17) hand wiped the scope, then flushed the scope with water/detergent. E #17 did not pre-clean the scope by purging it with air as per stated practice.

2. An observation of Pt #21 having a flexible endoscope procedure on 12/19/17 at 11:45 AM was conducted. At the completion of the procedure, Registered Nurse (E #17) hand wiped the scope, then flushed the scope with water/detergent. E #17 did not pre-clean the scope by purging it with air as per stated practice. E #17 was asked to verbalize the scope cleaning process. E #17 described the above process without indicating purging the scope with air.

3. A review of document, Society of Gastroenterology Nurses and Associates, Inc. (SGNA) Revised 2016 indicated "Standards of Infection Prevention in Reprocessing Flexible Gastrointestinal Endoscopes, 6A. MANUAL HIGH LEVEL DISINFECTION Endoscopes must be purged with air..."

4. An interview with Surgery Manager (E #18) was conducted on 12/19/17 at approximately 11:30 AM. E #18 verbalized that E #17 should have pre-cleaned the scope purging it with air. E #18 stated this Facility bases their standard of practice on the Society of Gastroenterology Nurses and Associates (SGNA). E #18 said she has an in-service planned for staff with "medical equipment name" scheduled to review pre-cleaning and cleaning of scopes.