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Based on review of policy and procedures, interview, review of Patient Acuity and Staffing Worksheets and schedules, it was determined the facility failed to have a clear policy and procedure to address how acuity scoring and censusdefined the staffing requirements. The failed practice did not assure the number of staff deployed would meet the patient care needs. The failed practice affected all patients on the 4th floor unit from 11/01/15 through 11/17/15. Findings follow:

A. Review of the policy and procedure titled "Patient Acuity Classification" received from the Director of Nursing at 1515 on 11/17/15 revealed the following: ...
"#1. Each patient will have a Patient Kardex/Classification Worksheet that is maintained in the notebook labeled "Acuities". It will be reviewed and/or updated each shift at 1600 and 0400, respectively. It is a projection for the next shift's staffing needs ..."
"#4: Once all patients are scored, the scores are recorded on the Patient Acuity Worksheet in the spaces provided on the left hand column (designated by room number). The score of all patients are added and recorded in the space titled "Total". This number is recorded in the designated space in the upper right hand column. The total score is divided by 24 and recorded. This is the number of staff required by acuity for the next shift."
"#5. Looking at the table for the staffing appropriate to the census and recording that number completes the bottom right hand column section."
"#6: " Staffing needs will usually be met by census, but acuity numbers will be used for special conditions or to justify extra staffing for a high-acuity population of patients."
B. Review of the policy and procedure titled "Nursing Staffing" received from the Director of Nursing at 1515 on 11/17/15 revealed the following under Procedure:
"1. The Director of Nursing or his/her designee are responsible for scheduling staff according to patient care needs, adjusting staffing as needed for optimal coverage. He/she is responsible for ensuring that personnel are qualified to conduct patient care activities within their scope of practice. .."
"3. Each nursing department/area will have an established staffing schedule/grid that takes into account patient census and acuity. The Director of Nursing is ultimately responsible for ensuring adequate staffing."
"4. On the inpatient unit, the RN Supervisor is responsible for monitoring the number of staff scheduled daily in relation to the census and acuity. He/she will attempt to find the appropriate coverage, when needed, for the subsequent shift and will notify the Director of Nursing of schedule changes or unfilled needs ... "
C. During an interview with RN (registered nurse) #1 At 0905 on 11/18/15 she stated staffing was supposed to be by acuity but the unit can pull nurses from all over the building (Medical Surgical, Emergency Room, Infection Control or Utilization Review) if additional staff was needed during each shift. Review of the staffing schedules did not reveal any of the above nurses assigned to a unit.
D. Review of the Patient Acuity and Staffing Worksheets revealed 24 shifts (11/2/15, 11/3/15, 11/4/15, 11/6/15, 11/7/15, 11/8/15, 11/9/15, 11/10/15, 11/11/15, 11/12/15, 11/14/15, 11/15/15, 11/16/15, and 11/17/15 shifts) staffed less than levels as determined by acuity scoring. Examples are: 11/06/15 day shift acuity score indicated 9 staff on the unit and 7 was scheduled; 11/08/15 night shift acuity score indicated 10 staff on the unit and 6 was scheduled; 11/10/15 night shift acuity score indicated 9 staff on the unit and 6 was scheduled.
E. Review of the staffing schedules from 11/1/15 through 11/17/15 revealed one RN, one licensed practical nurse (LPN) and four mental health technicians (MHT) on the 7am (ante meridian) to 7 pm (post meridian) shifts, and one RN, one LPN and three MHTs on the 7pm to 7am shifts.
F. During an interview with the Director of Nursing at 1130 on 11/19/15 he confirmed the findings of A, B, D and E.

Based on clinical record review and interview, it was determined the facility failed to notify the physician for a blood glucose greater than 401 milligrams/deciliter (mg/dl) for one (#25) of two (#21 and #25) patients with orders for sliding scale insulin. Failure to notify the physician of the elevated blood glucose did not allow medical oversight and intervention when blood glucose results were outside of established parameters for insulin administration. The failed practice affected patient #25 and was likely to affect Patient #21 and any patient who had orders for sliding scale insulin. The findings were:

A. Clinical record review on 11/20/15 revealed Patient #25 was admitted on 11/14/15 at 0715 with physician orders for sliding scale insulin, "Moderately Insulin Sensitive." The Sliding Scale Insulin orders included the statement "Notify Physician/APN if Blood Glucose > (greater than) 401".

B. Review of the "Finger stick Blood Glucose (FSBS) Monitoring Flowsheet" for 11/14/15 at 1200 revealed the FSBS result was documented as 420. The insulin given was documented 11/14/15 at 1235, Novolog, 15 units". Review of the Medication administration record, admission and shift nursing assessments, nursing notes and physician orders for 11/14/15 through the patient discharge on 11/17/15 at 1200, revealed no documentation of physician notification for the blood glucose of 420 and no physician order for the 15 units of Novolog Insulin documented as given 11/14/15 at 1235.

C. The Director of Nursing reviewed the contents of the medical record on 11/19/15 at 0930 for evidence of physician notification of the 420 mg/dl blood glucose results and insulin order. The Director of Nursing confirmed at the time of medical record review, "It's not there. I would expect to see it on the sliding scale insulin flow sheet."

Based on clinical record review, Medical Staff Bylaws review, and interview, it was determined the facility failed to ensure verbal orders were dated and timed when they were signed for 22 (#7-#12, #14-#24, #26-#29, and #31) of 26 (#6-#31) inpatients. The failed practice did not ensure the physician signed the orders within 24 hours as stated in the Medical Staff Bylaws and had the potential to affect any patient admitted to the facility. Findings follow.

A. Review of Medical Staff Bylaws revealed, "The responsible practitioner shall authenticate such orders (verbal/telephone orders) within 24 hours ..."
B. Review of clinical records revealed the following verbal orders were not dated and timed as to when they were signed:
1) Patient #7 - two of two orders
2) Patient #8 - four of four orders
3) Patient #9 - two of two orders
4) Patient #10 - seven of seven orders
5) Patient #11 - one of one order
6) Patient #12 - one of one order
7) Patient #14 - one of one order
8) Patient #15 - two of two orders
9) Patient #16 - three of three orders
10) Patient #17 - four of four orders
11) Patient #18 - two of two orders
12) Patient #19 - two of two orders
13) Patient #20 - three of three orders
14) Patient #21 - one of one order
15) Patient #22 - one of one order
16) Patient #23 - one of one order
17) Patient #24 - two of two orders
18) Patient #26 - five of five orders
19) Patient #27 - four of four orders
20) Patient #28 - three of three orders
21) Patient #29 - three of three orders
22) Patient #31 - four of four orders
C. During an interview on 11/19/15 at 1145, the Director of Nursing confirmed the orders were not dated and timed as to when they were signed.

Based on observation and interview it was determined that the facility did not meet the Life Safety Code requirements related to two (west fire-rated door in second floor stairwell Building #1 and fire-rated door in east corridor of the third floor Acute Care Unit) of nine fire-rated doors' ability to latch when allowed to self-close, failure to seal penetrations in smoke barriers in two (above drop-down ceiling in corridor near Room 108 and above the fire-rated door near Room 108) of seven areas observed with a material which is capable of maintaining the smoke resistance of the smoke barrier, and failure to replace the cover of an electrical panel in one (Mechanical Room east side of Building #1 on the first floor) of three areas observed. Failure to maintain the ability of fire-rated doors to latch had the potential to affect all patients, visitors, and staff by failing to insure that the fire-rated doors would remain closed in the event of a smoke and fire event thus allowing smoke and fire to spread more rapidly between the smoke compartments. Failure to seal penetrations in the smoke and fire rated walls had the potential to affect all patients, visitors, and staff by allowing smoke and fire to spread more rapidly during a smoke and fire event. Failure to replace the cover to the electrical panel had the potential to affect all patients, visitor, and staff because it could not provide protection to staff working near the panel and it could not provide protection against sparks from being emitted from the panel which could have caused a fire event. See K18 Building #1, K25 Building #3, and K146 Building #1

Based on observation and interview it was determined the physical condition of the grounds were not maintained to ensure the safety of staff and visitors in one (service walkway to the kitchen of Building #1) of three outdoor areas (the front of the Building #1, the generator area, and the service walkway to the kitchen of Building #1) observed. The failed practice had to the potential to affect all staff and visitors who utilize this area. Findings follow:

A. On a tour of the facility on 11/18/2015 at 1030 with the Director of Plant Operations/Maintenance it was observed and verified that the service walkway to the kitchen contained:
1) Seven pieces of Polyvinylchloride (PVC) pipe and conduit.
2) Six pieces of Electrical Metallic Tubing (EMT) conduit.
3) Litter mixed in with the PVC and EMT.
4) A five gallon bucket with cigarette butts inside.
5) An empty container marked "Corrosive" on the label.
B. While on the tour the Director of Plant Operations/Maintenance verified the above items in A.

Based on review of the medication refrigerator temperature logs and interview, the facility failed to ensure there was daily documentation reflecting the temperature on one (medical/surgical unit) of two (medical/surgical, psychiatric unit) medication refrigerators. The potential existed for medications not to be stored according to manufacturer guidelines and the integrity of the medications compromised. Findings follow:

A. The medical/surgical unit was toured on 11/17/15 at 1006. At that time the temperature log for the medication refrigerator was reviewd for the time period of 09/01/15-11/17/15. A total of eighteen days lacked evidence on the log of the temperature of the refrigerator to ensure proper storage of medications
B. An interview was onducted on 11/17/15 at 1010 with Registered Nurse #2 in which the findings were verified.

Based on observation, review of policies and procedures, manufacturer's Safety Data Sheets (SDS), and interview, it was determined the Infection Control Nurse failed to control infection in that disinfectants were not used according to manufacturer's directions for one of one (Room 412) environmental cleaning procedure observed. The disinfectants (Buckeye Terminator and PDI Super Sani Cloth Plus) were used simultaneously without the facility's knowledge of their compatibility and without protection from inhalation exposure. Failure to use the disinfectants in accordance with manufactures directions did not assure the stability, efficacy and safety of the products as used and was likely to affect all patients. The findings were:

A. Observation and interview on 11/16/15 at 0900 with the Environmental Services Director revealed the spray bottle used by Environmental services staff for general cleaning and disinfection was Buckeye Terminator. The disposable wipes in use was PDI Super Sani Cloth Plus.

B. On 11/18/15 at 0900 Environmental Services employee #1 was observed cleaning patient room 412. Environmental Services Employee #1 wore disposable gloves, sprayed the Buckeye Terminator on spots on walls and then immediately proceeded to clean the area just sprayed using the PDI Super Sani Cloth Plus wipe. The process of spraying the Buckeye Terminator on other surfaces in the room, (i.e. doorknobs, floors, sink and bathroom surfaces), then immediately using the PDI super Sani Cloth Plus wipes on the same areas was repeated throughout the room cleaning process. Environmental Services Employee did not wear mask or protection from vapors generated when the Buckeye Terminator was sprayed in the enclosed room.

C. Review of the SDS as provided by the Environmental Services Director and the Infection Control Nurse on 11/18/15 at 0950 revealed: Super Sani-Cloth Plus, hard surface disinfectant wipes, "Stability and Reactivity: reacts violently with acids. This product may react with strong oxidizing agents. Do not mix with acids or ammonia, will cause hazardous vapors. Hazardous decomposition products may be produced when mixed with other chemicals or incompatible materials." The Buckeye Terminator, cleaner disinfectant SDS revealed: "Keep separated form incompatible substances ...incompatible with chlorine bleach and anionic detergents. Thermal decomposition can lead to release of irritating and toxic gases and vapors." The toxicological information included "inhalation: avoid breathing vapors or mists."

D. Review of the policy "Chemical Safety" on 11/18/15 revealed "A Safety Data Sheet supplies detailed information on a chemical and its hazards. Use all necessary Personal Protective Equipment such as protective eye goggle or gloves. All chemicals should be handled according to package safety precautions and should be mixed only according to instruction." Review of the policy "Disinfectant and cleaning agent review" revealed "all cleaning agents and disinfectants in use will be reviewed annually by the Infection Control Committee. It will be the Department head or Supervisor's responsibility to take the following actions: ...cover any special information needed for safe use of the item. Examples are: need for safety glasses, gloves, and ventilation."

E. The Infection Control Nurse and the Environmental Services Director confirmed in an interview on 11/18/15 at 1340 they were unaware if the PDI Sani Cloth Plus and the Buckeye Terminator disinfectants were evaluated or approved for simultaneous use by the Safety Committee.

F. The Director of Safety/Risk Manager confirmed by interview on 11/18/15 at 1400 the PDI Sani Cloth Plus and the Buckeye Terminator disinfectants were not evaluated or approved by the safety committee for simultaneous use and he could not assure the products were compatible.


Based on observation, review of hand hygiene policy and interview, it was determined the infection control nurse failed to prevent infection in that the rubber septum of an unopened medication vial was not cleaned with alcohol after removal of the protective cap and prior to piercing for one of one (#27) patient observed who received an injection and failed to perform hand hygiene after glove removal. The failed practice did not assure the patient would be protected from likely sources of infection and was likely to affect all patients who received an injection. The findings were:

A. Observation on 11/16/15 at 1300 with the Director of Nursing revealed Registered Nurse #1 removed the protective cap from a vial of medication. The vial of medication was accessed with a needle without cleaning the rubber septum with alcohol. Registered Nurse #1 removed her gloves after administering the medication and did not perform hand hygiene.

B. Review of the policy, "Hand Hygiene Employee Procedure" revealed "hands should always be washed or decontaminated in the following clinical situations ...after removing gloves."

C. The findings of failure to clean the rubber septum with alcohol and lack of hand hygiene after glove removal were confirmed at the time of observation by the Director of Nursing and by Registered Nurse #1.


Based on interview, it was determined the Infection Control Nurse failed to prevent infection in that there was not a respiratory protection program to include fit testing of at risk personnel. Failure to perform fit testing did not allow protection of employees in the event of likely respiratory exposure. The findings were:

On 11/18/15 at 1345, the Infection Control Nurse was interviewed and confirmed fit testing for employees or risk assessment had not been documented for 2015 and there was no documentation of fit testing from 2012 - 2014.



29485

Based on observations and interview it was determined the facility failed to ensure only currently dated supplies were available for patient use in two (Medical/Surgical Unit and Emergency Room) of three (Medical/Surgical Unit, Emergency Room and 4th floor) units. The failed practice had the potential to allow unsterile supplies to be used in patient care. The failed practice affected all patients whose care on the Medical/Surgical Unit required the use of a Foley catheter insertion tray or gauze or an intravenous (IV) start kit in the Emergency Room. Findings follow:

A. During the tour of the Medical/Surgical Unit at 1010 on 11/17/15 two of two 16 French Foley catheter trays expired 07/14 and one of one 4 inch by 4 inch conforming stretch rolled gauze expired 04/15. During an interview with the Director of Nursing at 1015 on 11/17/15 he verified the above findings.
B. During the tour of the Emergency Room at 1020 on 11/17/15 two of two IV start kits were observed expired 04/15. During an interview with the Director of Nursing at 1020 on 11/17/15 he verified the above findings.