HospitalInspections.org

A. Based on clinical record review and staff interview, it was determined that in 1 of 3 (Pt #2) clinical records reviewed in ICU, the Hospital failed to ensure that all treatments were implemented as required by physician order.

Findings include:

1. The clinical record of Pt #2 was reviewed on survey date 4/19/10 at approximately 11:00 AM. Pt #2 was a 47 year old female admitted to the Hospital on 4/17/10 with a diagnosis of Abdominal Pain. The clinical record contained a physician order dated 4/17/10 at 8:45 AM that required wet to dry dressings two times a day to Pt #2's abdomen. Nursing documentation indicated that the initial dressing change did not occur until 4/18/10 at 8:00 PM, for a total of three dressing changes missed.

2. The finding was verified by the Accreditation and Performance Improvement Coordinator and Director of the Intensive Care Unit during an interview on survey date 4/19/10 at approximately 11:15 AM.






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B. Based on a review of Hospital policy, observation and staff interview, it was determined that in 2 of 3 (Pts. #4 and 5) patients identified as level 2, elevated risk for fall on the Medical Surgical unit (Y2), the Hospital failed to ensure staff placed a fall risk magnet on the patient's door as required by policy.

Findings include:

1. The Hospital policy titled, "Fall Prevention Program" was reviewed on 4/19/10 at approximately 12:45 PM. The policy required, "Elevated Risk Safety Precautions: These additional safety precautions will be maintained for each patient classified as Elevated Risk ...Place risk magnet on the patient's door."

2. A tour of the Y2 Medical/Surgical Unit was conducted between 9:00 AM and 10:00 AM on 4/19/10. Two of 3 patient's rooms identified as level 2 elevated risk for falls did not have a "risk" magnet attached to the door.

3. The clinical record of Pt. #4 was reviewed on 4/19/10 at 10:00 AM. Pt. #4 was a 73 year old male, admitted on 4/13/10, with diagnoses of Vomiting and Small Bowel Obstruction. The admission assessment dated 4/13/10, indicated Pt. #4 was at elevated risk for falls. There was no fall risk magnet attached to Pt. #4's door as of 4/19/10.

4. The clinical record of Pt. #5 was reviewed on 4/19/10 at 11:15 AM. Pt. #5 was a 79 year old female, admitted on 4/16/10, with diagnoses of Syncope Episode and Left Humoral Fracture. The admission assessment dated 4/13/10, indicated Pt. #5 was at an elevated risk for falls. However as of 4/19/10 there was no fall risk magnet attached to Pt. #5's door.

5. The above findings were confirmed with the Director Medical Surgical Unit during an interview on 4/19/10 at 11:30 AM.

A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that in 3 of 9 (Pts. #4, 8, & 10) open records reviewed in the Medical/Surgical Units, the Hospital failed to ensure individualized nursing care plans were updated.

Findings include:

1. The Hospital policy titled "Assessment, Documentation and Plan of Care" was reviewed on 4/19/10 at 2:00 PM. The policy required, "Plan of Care...The admitting RN will identify the patients's problem (s) and develop an appropriate plan of care... the plan of care will be specific to that individual... the Plan of Care must be evaluated at least every 24 hours or as the patient's needs change...."

2. The clinical record of Pt. #4 was reviewed on 4/19/10 at 10:00 AM. Pt. #4 was a 73 year old male, admitted on 4/13/10, with diagnoses of Vomiting and Small Bowel Obstruction. The admission assessment dated 4/13/10, indicated Pt. #4 was at elevated risk for fall. Nursing documentation dated 4/14/10 at 5:30 PM, indicated Pt. #4 was agitated and crawling out of bed. The clinical record contained an order dated 4/14/10 at 4:40 PM, for "1:1 sitter for patient safety". As of survey date 4/19/10 the nursing care plan failed to address the elevated fall risk identified on the admission assessment and the agitation that resulted in the use of a sitter.


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3. The clinical record of Pt. #8 was reviewed on 4/19/10 at 10:00 AM. Pt. #8 was a 57 year old female, admitted on 4/15/10, with the diagnosis of Pulmonary Embolus (blood clot in the lung) secondary to a Deep Vein Thrombosis (DVT) from the Left Leg blood clot. The Plan of Care dated 4/15/10, lacked inclusion of the DVT.

4. The clinical record of Pt. #10 was reviewed on 4/19/10 at 10:30 AM. Pt. #10 was a 73 year old male, admitted on 4/13/10, for a Left Total Hip Arthroplasty (Replacement). The clinical record included an order dated 4/16/10, for BiPAP (breathing machine). Pt. #10 remained on BiPAP until early AM on 4/19/10. The Plan of Care lacked inclusion of Pt. #10's respiratory status or interventions and lacked updates from 4/14/10 thru survey date of 4/19/10.

5. These findings were verified during interviews by the Director of Medical/Surgical Services on 4/19/10 at 11:30 AM and 1:00 PM.

A. Based on review of Hospital policy, clinical record review and staff interview it was determined that for 1 of 5 (Pt. #11) clinical records reviewed for blood transfusions, the Hospital failed to ensure a consent for blood transfusion was signed.

Findings include:

1. The Hospital policy titled "Blood and Blood Product Administration" was reviewed on 4/19/10 at 11:30 AM. The policy included "Patient must sign the Agreement For Blood Transfusion form".

2. The clinical record of Pt. #11 was reviewed on 4/19/10 at 9:30 AM. Pt. #11 was a 74 year old male, admitted on 4/12/10, with the diagnoses of Mental Status Change and Hypokalemia (low potassium). The clinical record included a blood transfusion slip dated 4/14/10 that indicated a unit of packed blood cells was transfused from 6:00 PM until 9:50 PM. The clinical record lacked a signed agreement for blood transfusion.

3. The above finding was confirmed with the Director of Medical/Surgical Services on 4/19/10 at 1:00 PM, during an interview.

A. Based on a letter of attestation and staff interview, it was determined that the Hospital failed to ensure completion of all medical records within 30 days of discharge.

Findings include:

1. An Attestation letter from the Director of Health Information Management/Risk Management was presented on 4/20/2010 at 1:15 PM. The letter indicated that as of survey date 4/20/2010 there were 82 incomplete clinical records greater than 30 days.

2. The finding was confirmed with the Director of Health Information Management during an interview on 4/20/2010 at 1:15 PM.

A. Based on review of Hospital policy, observation and staff interview, it was determined that for 1 of 9 vials of Bupivacaine, the Hospital failed to ensure outdated drugs were not available for patient use.

Findings include:

1. The Hospital policy titled' "Patient care Medication Storage Area Inspections" was reviewed on 4/20/10 at 8:45 AM. The policy required, " Purpose: To assure medications on all patient care areas are stored properly and to prevent the inadvertent administration of out-dated or deteriorated drugs... B. all outdated and deteriorated drugs will be replaced...."

2. During a tour of the Surgical Services conducted on 4/20/10 between 6:58 and 7:55 AM, 1 of 9 vials of 5 % Bupivacaine, 50 ml expired on 1/09 and was available for patient use.

3. The above finding was confirmed with the Surgical Services Nurse Educator during an interview on 4/20/10 at approximately 7:30 AM.

A. Based on review of Hospital policy, Dishwashing Machine Temperature Log review, and staff interview, it was determined that the Hospital failed to monitor Dishwashing Machine temperatures as required.

Findings include:

1. The Hospital policy titled "Dishwashing/Warewashing Machine Temperature" was reviewed on 4/20/10 at 10:00 AM. The policy included "Record temperatures, flow pressure once during each meal period".

2. The Dishwashing Machine Temperature Log for April 2010 was reviewed on 4/20/10 at 9:30 AM. The following temperatures were missing:

- April 1st - lunch and dinner
- April 2nd - lunch and dinner
- April 4th - dinner
- April 5th - dinner
- April 9th - dinner
- April 12th - dinner
- April 15th - dinner
- April 16th - breakfast and lunch
- April 19th - dinner

3. The above findings were confirmed with the Director of Food Services on 4/20/10 at 10:00 AM, during an interview.

B. Based on review of Hospital policy, observation and staff interview, it was determined that for 3 of 6 containers of fruit in the refrigerator, the Hospital failed to ensure all food was stored according to policy.

Findings include:

1. The Hospital policy titled "Food Safety Standards and Requirements" was reviewed on 4/20/10 at 1:30 PM. The policy included "All foods prepared in operation must be covered... and date of preparation prior to storage in refrigerators and freezers".

2. A tour of the Food Service area was conducted on 4/20/10 at 9:15 AM. During the tour it was observed that 3 metal containers were filled with cut up fresh fruit and left uncovered and undated in the main refrigerator.

3. The above finding was confirmed with the Director of Food Services on 4/20/10 at 10:00 AM, during an interview.

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A. Based on review of Hospital policy, observation, and staff interview, it was determined for 2 of 2 irrigation solutions, 1 of 5 Chromic Gut suture, and 1 of 4 Nasopharyngeal Airways, the Hospital failed to ensure that all expired supplies were not available for patient use.

Findings include:

1. Hospital policy entitled, "Patient Care Medication Storage Area Inspections," reviewed on survey date 4/20/10 at 8:45 AM required, "Purpose: To assure stock medications on all patient care areas are stored properly and to prevent the inadvertent administration of out-dated or deteriorated drugs. II Policy: A. All patient care medication storage areas other than automated outdated Pyxis units will be inspected monthly by the registered Pharmacist or designee according to established criteria....III Guidelines: B. All outdated and deteriorated drugs will be replaced."

2. A tour was conducted in the surgical area on survey date 4/20/10 between 7:00 AM and 8:30 AM. The following expired biologicals were found:

- Recovery area - two 3,000 millimeters of 1.5 % Glycine Bladder Irrigation solution with an expired date of 3/1/2007.

- Inner core - 1 of 5 Chromic Gut suture, expired on 7/09; 1 of 4 Nasopharyngeal Airway expired on 1/2008.

3. The findings were verified with the Surgical Services Nurse Educator during an interview on 4/20/10 at approximately 7:30 AM.

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A. Based on review of Hospital policy, observation and staff interview, it was determined that for 2 of 5 ( E #1 & 2) staff observed in OR suite 2, the Hospital failed to ensure adherence to policy governing attire in the Surgical Services.

Findings include:

1. The Hospital policy titled "Attire-Operating Room" was reviewed on 4/20/10 at approximately 8:25 AM. The policy required, " Mask shall be worn at all times in the restricted areas of the surgical suites and other areas where open sterile supplies or scrubbed personnel are located."

2. The Hospital policy titled "Traffic Control in Surgical Services" was reviewed on 4/20/10 at approximately 8:25 AM. The policy required, "Restricted area...b. scrub attire and caps ar required... in addition masks are required... if open sterile supplies are present... B...2 Doors to the operating room should be closed."

3. A tour of Surgical Services was conducted on 4/20/10 between 6:58 and 7:55 AM. OR surgical suite 2 had sterile packs opened and the following was observed:

- At 7:08 AM, an Anesthesia student (E #1) entered the room holding an unsecured mask over her nose and mouth with her hand.

- At 7:50 AM, the surgeon (E #2) entered the room without donning a mask and stood inside the doorway with the doors open.

3. The above findings were confirmed with the Surgical Services Nurse Educator during an interview on 4/20/10 at 7:50 AM.