HospitalInspections.org

Based on record review, observations, and interview the facility failed to meet the Condition of Participation to protect patient's rights:

A. The facility failed to provide an informed consent for private vehicle transfer. Refer to tag A-0131

B. The facility failed to maintain the personal privacy of patients. Refer to tag A-0143

Based on record review the facility failed to provide an informed consent for private vehicle transfer for a higher level of care needed for 1 (P (patient)18) out of 13 (P3, P6, P8, P9, P10, P11, P12, P13, P14, P15, P16, P18, and P20) patients being reviewed for informed transfer consent in privately owned vehicles. This deficient practice could possibly lead to the patient transferring to another hospital without having any knowledge of all of the risks involved in the transfer.

A. Record review of the facility's policy titled Patient Rights and Responsibilities dated 02/02/23 stated "Except in emergencies, or when otherwise permitted by law, (patients) give informed consent prior to receiving treatment and after a clear explanation of the risks, benefits, medical consequences, including potential problems that might occur during recuperation, and alternative treatments"

B. Record review of P18's medical record revealed the following:
- Section titled "Physician Certification written on 11/25/2023 at 7:18 pm "the risks of transfer included "Deterioration; discomfort; MVA [Motor Vehicle accident] [S.I.C]"
-Section titled "Patient Request/Refusal Consent to Transfer" dated 11/26/2023 at 7:40 pm, P18 gave consent to transfer in POV (privately owned vehicle) with the only risk mentioned on the consent form was MVA (motor Vehicle Accident). This transfer form failed to inform the patient of all the risks of a POV transfer.

Based on record review, interviews, and observations, the facility failed maintain the personal privacy of patients. The Protected Health Information (PHI) for 62 (P (Patient) 22 - P84) of 62 (P22-P84) patients. This deficient practice is likely to lead to a breach in an increased risk of misuse in patient confidentiality and privacy.

The findings are:

A. Record review of facility's policy titled "HIPPA: Administrative, Technical and Physical Safeguards for PHI [Protected Health Information]", dated 01/09/2024, stated "POLICY: 2. Physical Safeguards [bolded in policy] a. Securing the Physical Environment x. Password protected [facility name] approved screen savers should be utilized (where available) on computer workstations located in public areas. xi. Workforce should close electronic records containing PHI when not in use, log off computer applications when not actively using and log off computer workstations at the end of each shift."

B. During an observation on 01/23/2024, at 11:41 am of an open area nursing station the following PHI was visible on computer workstations:

1. Workstation 1 showed the following PHI of P22: patient name, date of birth, age, sex, location, suicide screen, vaccine status, drug allergies, chief complaint, temperature, pulse, respiratory level, weight, blood work results and medical record number.

2. Workstation 2 showed the following PHI of P23: patient name, date of birth, age, location, suicide screen, vaccine status, drug allergies, chief complaint, temperature, pulse, respiratory level, blood pressure, sex, and medical record number.

3. Workstation 3 showed the following PHI for P22, P24, P25, P26, P27, P28, P29, P30, P31, P32, P33: location, patient name, chief complaint, acuity level, sepsis level, comments, time spent in room and age.

4. Workstation 4 showed the following PHI for P24, P25, P26, P27, P28, P29, P30 - P49: patient name, location, acuity level, chief complaint, sepsis level, blood pressure, pulse, oxygen level, respiratory level, temperature, age and length of stay.

5. Workstation 5 showed the following PHI for P22 - P49: patient name, age, location, blood pressure, chief complaint, acuity level, early sepsis screening, comments, and length of stay.

C. During an observation on 01/25/2024, at 11:39 am, of an open area nursing station the following PHI was visible on computer workstations:

1. Workstation 1 showed the following PHI for P50 - P71: location, patient name, age, sex, chief complaint, acuity level, early sepsis screening, disposition, comments, and length of stay.

D. During an observation on 01/25/2024, at 1:07 pm, of Workstation on Wheels (WOW) showed the following PHI for P72: location, patient name, sex, age, date of birth, medical record number, suicide screen, vaccine status, allergies, blood type, chief complaint with comments, blood pressure, temperature, pulse, respiratory rate, oxygen level, weight, emergency department vitals, physical exam with comments, and emergency department provider note.

E. During an observation on 01/25/2024, at 4:56 pm, of open nursing area station the following PHI was visible on computer workstation:

1. Workstation 1 showed the following PHI for P73: patient name, location, sex, age, date of birth, medical record number, suicide screen, allergies, blood type, vaccine status, chief complaint, blood pressure, temperature, pulse, respiratory rate, oxygen level, weight, event log, medications, doctor orders and results.

2. Workstation 2 showed the following PHI for P74 - P84: location, patient name, age, sex, complaint, sepsis screen, and length of stay.

3. Workstation 2 showed specific PHI for P81: patient picture, patient name, sex, age, date of birth, vitals, blood pressure, temperature, pulse, and oxygen level.

F. During an interview on 01/30/2024, at 12:30 pm, with Staff (S)1, Charge nurse when asked what the policy is on workstation HIPPA, S1 explained when an employee walks away, we're supposed to be locking the screen. When asked if an employee should ever leave a workstation screen open, S1 answered "No, we should be locking them."

G. During an observation in the waiting room on 01/24/2024, at 12:00 pm, surveyor was able to hear the triage of a patient complaining of an earache and sore throat. Triage nurse stated, "well you don't have a fever."

Based on record review and interview the facility failed to ensure staff followed policies for 21 (P (Patient) 1-21) of 21 patients reviewed.
1. Obtain a full set of vital signs every two hours on P1-21 patients.
2. Follow the procedure on obtaining a urine specimen (urine sent for testing) from foley (a tube inserted in bladder for drainage of urine) for P7.
These deficient practices are likely to lead to serious injury, harm or death to all patients presenting to the emergency room.

The findings are:

Facility failed to obtain full set of vital signs:

A. Record review of facility's policy titled "Triage in the Emergency Department" dated 06/20/2022, on page 2 number 5 stated, "Triage should include a full set of vital signs to include blood pressure, temperature, pulse, respirations, pulse oximetry (measure the amount of oxygen in the body) and pain level."

B. During an interview on 02/05/2024, at 2:43 pm, with Staff (S)13, Emergency Room Manager confirmed that Emergency room nurses should obtain a full set of vital signs every two hours.

C. Record review of P1 through P21's medical records did not have a full set of vital signs every two hours while in the emergency room.

Facility failed to obtain a full set of vital signs and did not follow procedure on obtaining a urine specimen:

D. Record review of document named "The Quick Sheet" how to perform a procedure: this procedure is how to collect a urine specimen from a foley. On the top of this page it was stated "Alert: Do not collect a urine specimen for culture from a urine drainage bag."

E. During record review for P7's medical record revealed:
1. "Arrived at facility on 12/09/2023, at 3:01 pm, there was no temperature obtained during triage or during the emergency room visit. This patient was discharged with a urinary tract infection."

2. "Foley was changed on 12/05/2023 per caregiver." On 12/09/2023 at 3:38 pm CNP (Certified Nurse Practitioner) ordered for urine to be collected, with instructions "If indwelling catheter has been placed > (more than) 48 hrs (hours), remove and insert new catheter".

F. During an interview on 01/25/2024, at 10:30 am, with S5, Registered Nurse confirmed that a full set of vital signs especially temperature should be taken at triage and through emergency department visit especially on patients with a diagnosis of an infection or receiving antibiotics. During interview when asked how the urine from a foley is obtained S5 confirmed the urine is obtained from the foley bag.

G. During interview on 02/05/2024, at 2:43 pm, with S13, Emergency Room Manager confirmed, the foley is not changed, we get the urine from the foley bag, we fill a urine cup and take it to the lab.

Based on observation and interview the facility failed to meet the Condition of Participation to maintain a physical environment in a manner that ensures the safety and well-being of patients. This deficient practice could result in the inability for ambulances to access the patients that need transportation in an emergency.

The findings are:

The facility failed to maintain a physical environment by having the ambulance bay locked and blocked with supplies. Refer to tag A-0701

Based on observation and interview, the facility failed to maintain a physical environment in a manner that ensures the safety and well-being of patients, by having the door to the ambulance bay locked and having the ambulance bay access blocked. This deficient could result in the inability for ambulances to access the patients that need transportation in an emergency.

The findings are:

A. During observation on 01/25/2024 at 12:43 pm an ambulance arrived and was unable to enter the emergency room due the inner ambulance bay door was locked, and a security guard was unable to open the ambulance bay doors and could not let the ambulance in. Then another staff member from the emergency room had to come and unlock the ambulance bay door and the ambulance entered the bay and picked up a patient to be transferred to a higher level of care.

B. During an observation on 01/26/2024 at 8:57 am of the Emergency Department ambulance bay a delivery truck parked in the ambulance parking and unloaded biohazard medical waste containers into the ambulance bay doorway that blocked the entrance to the emergency room. The driver of the delivery truck drove away and left the boxes in the bay between the outer and inner doorway.

C. During an observation on 01/26/2024 at 10:14 am of the Emergency Department a delivery truck in the ambulance bay unloaded linens. The delivery truck driver left the linen in the ambulance bay which blocked the entrance to the Emergency Room.

D. During an observation on 01/26/2024 at 12:46 pm of the Emergency Department ambulance bay entrance an ambulance was parked, and a gas truck parked in front of the ambulance, which blocked the ambulance from exiting the facility.

E. During an interview on 01/26/2024 at 9:05 am with S (staff) 9 (clinical) when asked about the ambulance bay being blocked and who would move the items being delivered S9 stated "I am unaware who has access to the ambulance bay door, and I don't know who would remove the delivery items I don't even know how to open doors when they are locked."

F. During an interview on 01/26/2024 at 11:29 am with S3 (non-clinical) confirmed, if the ambulance bay is blocked it could delay the care of a patient.

Based on record review, observation and interviews the facility failed to provide a clean and sanitary environment. This deficient practice places all patients entering the emergency room at risk for infections.

The findings are:

A) Record review of the facility's policy titled "Identification of Clean and Dirty Reusable Medical Equipment.", dated 02/01/2019, stated: "Purpose: To provide guidance on identifying clean and soiled equipment to prevent the transmission of infection to staff, visitors, and patients. To define the type of cleaning, disinfection, and/or sterilization appropriate for reusable medical equipment. Policy: Ensuring that patients receive clean equipment is required to prevent the transmission of infectious pathogens (A germ that could cause infection). Patient care equipment needs to be appropriately identified as clean, soiled, or in use. Section 2.1 Once a patient is no longer using a piece of equipment, it is placed in the Soiled Utility Room for cleaning. After cleaning, the item is placed in the Clean Utility Room. 2.3 Any equipment that is not cleaned immediately after use is placed in the Soiled Utility Room. 3.2 Patient care equipment without clear definition of clean/soil status is assumed soiled and must be cleaned/disinfected before the next patient use."

B) Record review of mattress care: Manufacturer instruction "Cleaning the Mattress" stated, "Inspect mattress covers for tears, punctures, excessive wear, and misaligned zippers each time the covers are cleaned. If compromised, the mattress should be removed from service immediately and replaced to prevent cross-contamination."

C) During an observation on 01/26/2024, at 9:12 am, of the decontamination room (patient room) behind a curtain was five bedside commodes, a large trash can with other patient care items such as reacher's, (equipment used by patients to grab items out of reach for them), foot rests used on wheelchairs to place the patients feet on while being transported, a plastic kiddie pool to be used for patients were in the decontamination room to wash them from the chemical exposure, a plastic bin with holes on the bottom of it on the floor with linen wrapped in plastic.

D) During an interview on 01/26/2024, at 9:13 am, with Staff (S)9, Registered Nurse (RN) when asked if the decontamination room was an appropriate place to store supplies, S9 stated "I have no idea why there were supplies in the decontamination room behind the curtain."

E) During an interview on 01/26/2024, at 9:13 am, with S7 Charge Nurse when asked if the decontamination room was an appropriate place to store supplies S7 stated "JCAHO (Joint Commission on Accreditation of Healthcare Organization, independent organization develops standards and guidelines to improve the safety, effectiveness, and quality of health care and accredits medical providers and programs) doesn't have a problem with it so we shouldn't." S7 confirmed that the linens shouldn't be in there.

F) During observation on 01/26/2024, at 9:12 am, of a trauma room being cleaned by S11 Tech, the mattress being cleaned had a patch on it covering a tear that had brown residue around the edges.

G) During an interview on 01/26/2024, at 9:13 am, with S7 RN Charge Nurse regarding mattress care it was explained if there is a tear, they place a patch on it to prevent the tear from growing and to cover it.