HospitalInspections.org

Based on observation, interview, and record review the hospital failed to ensure a care plan was initiated for one (27) of 27 patient's psycho-social needs. This failure had the potential for the patient's safety to be jeopardized.

Findings:

During a review of the clinical record for Patient 27 on 2/3/16 at 2:30 PM, the Psychiatric Consultation History and Physical dated 1/25/16, indicated "Patient is a 15 year old female status post self inflicted gun shot wound to the chest. Patient will continue to close observation for mood and behavior during hospitalization."

During an observation of Patient 27 on 2/3/16 at 2:30 PM, she was lying on her bed in her room, not in view of the nursing station speaking with family members.

During an interview with the Director of Medical Surgical (DMS) on 2/3/16 at 2:30 PM she reviewed the clinical record for Patient 27 and was unable to find a care plan for mood, behavior and safety. The DMS stated, "there should be a care plan for that, I'll get one started."

Based on observation, interview, and record review, the hospital failed to ensure a narcotic pain medication (Morphine) was correctly administered to one patient in accordance with the physician order. This failure had the potential to cause significant harm to the patient receiving incorrect dose(s) of the medication.

Findings:

During a record review and concurrent interview on 2/3/16 at 11:20 AM, a reconciliation of medication order was conducted after the morning medication pass observation on the third floor of the Medical Surgical unit with Registered Nurse (RN) 31 and the Clinical Supervising Nurse (RN 32).

During a review of the clinical record for Patient 31 the "Physician's Order" revealed that the prescriber had written two active Morphine orders for pain management, and the orders were written as followed:

1. Morphine injectable 2 mg/ml; Give 2 mg/1 ml IV (intravenously) every 2 hours as needed for pain 1-4.

2. Morphine injectable 4 mg/ml; Give 4 mg/1 ml intravenously every 2 hours as needed for pain 5-10.

During an observation of a medication pass on 2/3/16 at 10:18 AM, Patient 31 was observed during the morning medication pass, and Patient 31 received a dose of Morphine 2 mg which was administered intravenously by RN 31 for a documented pain level (pain scale level: the 0 to 10 numeric pain distress scale; "0" represents "no pain" and "10" represents the most severe pain the patient has experienced) of 6. However, further review of Patient 31's clinical and nursing record did not show there was documentation from the physician to instruct RN 31 to administer Morphine 2 mg IV instead of the Morphine 4 mg IV dose as prescribed when the assessed pain level for the patient was at 6. When RN 32 was asked which of the two Morphine medication orders should have been administered to Patient 31 when there was documented pain level of 6, and she agreed the Morphine 4 mg IV would be the appropriate dose for administration.

Review of the hospital policy entitled "Administration of Medications" dated 11/2013, on page 3 under "Procedure", it read "B. Dosages or frequencies are not to be altered in any way without an order by the physician or authorized allied health professional."

Based on observation, interview, and record review, the hospital failed to implement infection control practices in accordance with hospital policy and nationally-recognized infection control guidelines as evidenced by:

1. Hospital visitors failed to use appropriate personal protective equipment.
2. Hospital staff failed to follow facility policy and procedure when co-horting (sharing a hospital room) an infectious patient with a non-infectious patient.

These failures had the potential to result in the spread of infectious diseases to patients, visitors and other staff.

Findings:

1. During a concurrent observation and interview with the Director of the Medical Surgical Units (DMS), on 2/3/16, at 2 PM, Patient 28 was in a single patient room that indicated by signage the patient was in contact isolation (a type of isolation that prevents the spread of infection) and droplet precautions (a type of isolation that requires a special mask). A visitor was observed in Patient 28's room speaking with the patient and was not wearing gloves, gown or mask. The signage indicated everyone entering the room must wear gloves, masks and gowns. The sign was placed on the patient's room door at a height of five feet 10 inches. The visitor stated that he had not received information regarding isolation or gowning procedures. The DMS stated the gowns, gloves and masks were kept in an unmarked cabinet down the hall. The DMS stated everyone entering the room should wear protection and she then entered the room to educate the visitor.

During a review of the clinical record for Patient 28, the Physician's orders, dated 1/20/16, at 11:50 PM, indicated "Place Patient in a negative pressure private room (a system to prevent cross contamination from patient to patient). N95 mask (used for people that come into contact with patient's that have or are suspected of having tuberculosis - a contagious respiratory infection) required upon entering the room. Gown and gloves required before entering the room." Patient 28's diagnosis included MRSA (a drug resistant organism causing infections that are hard to treat) and rule-out tuberculosis.

The hospital policy and procedure titled "Isolation Precautions" dated 6/2014, indicated in part: "Visitors will wear the same personal protective equipment (gowns, gloves and masks) that a health care worker wears when entering the patient's room....wear N95 respirator (special mask) in airborne isolation for suspected tuberculosis. Nursing personnel will ensure that the visitor is able to perform a self mask fitting before entering the patient room.

According to the Center for Disease Control 2015, "In all areas where healthcare is delivered, provide supplies and equipment necessary for the consistent observance of Standard Precautions, including hand hygiene products and personal protective equipment (e.g., gloves, gowns, face and eye protection). Screen visitors to high-risk patient care areas."

2. During a concurrent observation and interview with the Director of the Intensive Care Unit (DICU) and the Risk Registered Nurse, on 2/2/16, at 11:15 AM, on the medical surgical floor, Patient 8 and Patient 13 shared a two person room. Four nursing students and one nursing school instructor were wearing gloves and yellow isolation gowns and were in the process of working with Patient 13 at his bedside. Patient 8 had returned to his room from surgery for a toe amputation to his right foot at 9:37 AM. Patient 8's foot rested on the covers of his bed with a large surgical dressing in place. Two of the nursing students were standing in between the two patient beds and brushed against Patient 8's bed with their yellow isolation gowns multiple times during the observation. Signage on the patient room door indicated, "CONTACT ISOLATION, must wear gloves and gowns." The curtain between the two beds was open to enable two jail guards to observe Patient 13 from the hallway. The DICU stated the two patients (8 and 13) should not be in the same room. She stated "I'll have him (Patient 8) moved to another room (a non-isolation room)."

The hospital policy and procedure titled "Isolation Precautions" dated 6/2014, indicated in part: "It is recommended that patients with confirmed infections be placed in a private room and not roomed with any of the following patient types: a. recent post-operative patient."

According to the Center for Disease Control 2015, "Patient placement V.B.2.a. In acute care hospitals, place patients who require Contact Precautions in a single-patient room when available. Place together in the same room (cohort) patients who are infected or colonized with the same pathogen and are suitable roommates. If it becomes necessary to place a patient who requires Contact Precautions in a room with a patient who is not infected or colonized with the same infectious agent: Avoid placing patients on Contact Precautions in the same room with patients who have conditions that may increase the risk of adverse outcome from infection or that may facilitate transmission and have open wounds. Ensure that patients are physically separated (i.e., >3 feet apart) from each other."