HospitalInspections.org

Based on review of hospital grievance policy, grievance log, closed medical record review, and administrative staff interviews, the facility failed to provide a written response to the patient for 1 of 1 complaints reviewed (#7).

The findings include:

Review of hospital policy #10-2-14, titled "Complaint/Grievance Process," effective date 9/2002, revealed "...if a verbal patient complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and /or requires further action for resolution, then the complaint is a grievance for the purposes of these requirements." The policy further revealed "if the patient is discharged from the facility prior to complaint resolution with the complainant, the complaint may be deemed elevated to a Patient Grievance, and a Patient Grievance Form will be initiated."

Review of the hospital's "Complaint/Grievance Log" for the month of October 2009 on revealed issuance of a verbal complaint on 10/30/2009 from Patient # 7. The "Complaint/Grievance Log" revealed that the patient complained that a "dirty scope was used for his OP (outpatient) procedure." The log revealed that the CNO (Chief Nursing Officer) advised the complainant to follow up with their physician; complete lab work and the CNO provided Hepatitis C education. The Complaint/Grievance Log revealed that during a second discussion with the complainant on November 5, 2009, the CNO documented on the log that the complainant's physician was notified that the facility offered to pay for the patient's lab work and medication. The log reveals that a "RCA" (Root Cause Analysis) was conducted and completed.

Review of the closed medical record of Patient #7 revealed a 57 year old male admitted 10/28/2009 at 0950 to the outpatient surgery unit of named hospital for the following procedures: micro-direct laryngoscope (instrument used to examine the throat) with bronchoscopy (examination of the airway with a special instrument), esophagoscopy (examination of the tube that carries food into the stomach with a special instrument) and biopsy (removal of a sample of tissue for further testing) of a vocal cord lesion.

Interview with CNO revealed that all communication between the facility and Patient #7 was verbal. Interview revealed that the facility failed to provide written correspondence to Patient #7. Interview revealed that the CNO did not follow the facility's "Complaint/Grievance" policy. The CNO stated, "In hindsight, I should have written a letter."

Based on review of hospital policy, review of medical records and staff interviews the nursing staff failed to supervise and evaluate nursing care by failing to reassess for pain after a medication intervention for 2 of 6 open medical records reviewed (#2,8) and failing to perform an initial nursing assessment for 5 of 5 outpatient surgery patients reviewed (#11,12,6,7,13).

The findings include:

Review of the hospital policy, "Pain Management", revised 12/2008, revealed "...B. Reassessment...3. Thirty to sixty minutes after pain relieving interventions the patient's pain will be reassessed to evaluate effectiveness using one of the pain scales or objective findings. This assessment will include any present side effects of medications...".

Review of the hospital policy, "Pre-Operative Interview Process", not dated, revealed "I. PURPOSE: To establish a systematic approach for pre-operative preparation of patients...An attempt will be made at this time to obtain data about the patient's medical history, physical and mental conditions to initiate the best plan of care for every patient's surgical/anesthesia experience. ... IV. PROCEDURE: ...Prior to their surgery, patients will be scheduled to come to the hospital for the following:...Completion of the Adult/Pediatric Assessment Form...Screen for Multi-Drug Resistant Organisms...".

1. Open record review of Patient #2 revealed a 69 year-old admitted 01/03/2010 with end-stage renal disease and diabetes. Record review revealed a physician's order dated 01/03/2010 for Tylenol 650 mg (milligrams) 2 tablets as needed for (prn) pain or temperature greater than 100 degrees. Review of the medication administration record revealed Patient #2 was administered 2 Tylenol tablets on 01/07/2010 at 0725. Record review revealed no documentation by the nurse that the patient's pain was reassessed. Record review revealed a physician's order dated 01/03/2010 for Percocet 5/325 mg every 6 hours as needed for pain. Review of the medication administration record revealed Patient #2 was administered Percocet 5/325 on 01/07/2010 at 0915. Record review revealed no documentation by the nurse that the patient's pain was reassessed.

Interview on 01/13/2010 at 1100 with administrative nursing staff revealed "the nurse should reassess for pain within 30 to 60 minutes after giving the prn medication". Interview confirmed the nurse failed to reassess Patient #2 after the administration of medication for pain. Interview further confirmed the nurse failed to follow the hospital's policy for pain management.

2. Open record review of Patient #8 revealed a 54 year-old admitted on 01/10/2010 with Factor 5 liden (blood clotting disorder) and lupus. Record review revealed a physician's order dated 01/10/2010 for Darvocet-N 100 by mouth every 4 hours as needed for pain. Review of the medication administration record revealed Patient #8 was administered Darvocet-N 100 by mouth on 01/10/2010 at 1030. Record review revealed no documentation by the nurse that the patient's pain was reassessed.

Interview on 01/13/2010 at 1100 with administrative nursing staff revealed "the nurse should reassess for pain within 30 to 60 minutes after giving the prn medication". Interview confirmed the nurse failed to reassess Patient #8 after the administration of medication for pain. Interview further confirmed the nurse failed to follow the hospital's policy for pain management.

3. Closed record review of Patient #11 revealed a 73 year-old admitted 01/12/2010 for surgical revision of the urinary sphincter. Record review revealed no documentation of the initial nursing assessment performed by the nurse prior to surgery.

Interview on 01/14/2010 at 0900 with administrative nursing staff revealed "the assessment form should be completed by the nurse prior to the patient's surgery". Interview further revealed "the nurse has not been doing this job very long and we need to remind her to complete this assessment". Interview confirmed the nurse failed to complete the initial nursing assessment for Patient #11 prior to surgery.

4. Closed record review of Patient #12 revealed a 30 year-old admitted on 01/12/2010 for the surgical release of carpal tunnel of the left wrist. Record review revealed no documentation of the initial nursing assessment performed by the nurse prior to surgery.

Interview on 01/14/2010 at 0900 with administrative nursing staff revealed "the assessment form should be completed by the nurse prior to the patient's surgery". Interview further revealed "the nurse has not been doing this job very long and we need to remind her to complete this assessment". Interview confirmed the nurse failed to complete the initial nursing assessment for Patient #12 prior to surgery.








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5. Closed record review of patient #6 revealed a 27 year-old admitted on 10/28/2009 for the removal of an ovarian cyst. Record review revealed no documentation of the initial nursing assessment performed by the nurse prior to surgery.

Interview on 01/14/2010 at 0900 with administrative nursing staff revealed "assessment should be completed by the nurse prior to the patient's surgery." Interview further revealed "the nurse has not been doing this job very long and we need to remind her to complete this assessment." Interview confirmed the nurse failed to complete the initial nursing assessment for Patient #6 prior to surgery.

6. Closed record review of patient #7 revealed a 57 year-old admitted on 10/28/2009 for the removal of a vocal cord lesion. Record review revealed no documentation of the initial nursing assessment performed by the nurse prior to surgery.

Interview on 01/14/2010 at 0900 with administrative nursing staff revealed "assessment should be completed by the nurse prior to the patient's surgery." Interview further revealed "the nurse has not been doing this job very long and we need to remind her to complete this assessment." Interview confirmed the nurse failed to complete the initial nursing assessment for Patient #7 prior to surgery.

7. Closed record review of patient #13 revealed a 34 year-old admitted on 01/12/2010 for carpal tunnel release of the right wrist. Record review revealed no documentation of the initial nursing assessment performed by the nurse prior to surgery.

Interview on 01/14/2010 at 0900 with administrative nursing staff revealed "assessment should be completed by the nurse prior to the patient's surgery." Interview further revealed "the nurse has not been doing this job very long and we need to remind her to complete this assessment." Interview confirmed the nurse failed to complete the initial nursing assessment for Patient #13 prior to surgery.

Based on manufacturer's guidelines, observation during tour and staff interview the facility staff failed to monitor the temperature of a high-level disinfectant and failed to dispose of a non-reusable supply item.

The findings include:

1. Review of the manufacturer's package insert for the high-level disinfectant Cidex OPA (a glutaraldehyde solution used to disinfect surgical instruments) revealed "A) Indications for Use...Manual Processing: High Level Disinfectant at a minimum of 20 degrees C (Celsius) 68 degrees F (Fahrenheit)... D) Directions for Use... During the use of Cidex OPA Solution, it is recommended that a thermometer and timer be used to ensure that the optimum usage conditions are met."

Observation during tour on 01/13/2010 at 0900 of the scope processing room in the Gastroenterology/Endoscopy unit revealed Cidex OPA in a basin in the room. Observation revealed no thermometer in the basin of Cidex OPA. Review of the monitoring log of the Cidex OPA revealed no documentation that the temperature was monitored.

Interview on 01/13/2010 at 0905 with a registered nurse revealed the Cidex OPA was used to disinfect equipment used for surgical patients. Interview further revealed "I didn't know we were supposed to check the temperature."

2. Observation during tour on 01/13/2010 at 0900 of the scope processing room in the Gastroenterology/Endoscopy unit revealed cleaning brushes on the sink used to wash the scopes after an endoscopy/colonoscopy/bronchoscopy.

Interview on 01/13/2010 at 0910 with a registered nurse revealed the brushes are used 3 to 4 days before they are thrown away.

Observation of the package containing the brushes revealed "Disposable". Further review of the package revealed a "2", marked through in red by the manufacturer.

Interview on 01/13/2010 at 0910 with a registered nurse revealed "that means they're not supposed to be reused. They're not supposed to be used twice".

Interview on 01/13/2010 at 0915 with a registered nurse revealed "Joint Commission came through here and said it was ok to reuse the brushes". Interview confirmed the packaging of the brush states "Disposable" and marked through the "2". Interview confirmed this symbol meant not for reuse.

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