HospitalInspections.org

Based on record review and interview, the facility failed to assure hemodialysis staff were correctly monitoring RO (reverse osmosis- a water purification machine) machine parameters. 56 of 65 delta (pre-filter pressure minus post-filter pressure) pressure readings were out of limit, with no evidence of biomed (machine maintenance personnel) being notified.


Findings include:

Review of RO machine logs for March and April 2012 revealed 56 of 65 delta (pre-filter pressure minus post-filter pressure) pressure readings were out of limit, with no evidence of biomed (machine maintenance personnel) being notified.

During an interview in the dialysis unit on 4/23 at 2:30pm, staff #25 confirmed that the delta pressures were out of limits and that biomed had not been contacted.

Based on record review and interview the facility failed to ensure that 17 of 26 ( #2, #3, #4, #6, #11, #12, #13, #14, #15, #18, #19, #21, #22, #23, #24, #25, #27) patients ' medical records were complete.

A review of the 17 deficient patients ' medical records revealed:

Medical Record #2 contained 1 verbal order that was not signed, dated or timed.
Medical Record #3 contained 1 verbal order that was not dated or timed.
Medical Record #4 contained 2 verbal orders that was not signed, dated or timed.
Medical Record #6 contained 1 verbal order that was not dated or timed.
Medical Record #11 contained 2 verbal orders that was not signed, dated or timed.
Medical Record #12 contained no History and Physical or Discharge Summery.
Medical Record #13 contained 1 verbal order that was not dated or timed.
Medical Record #14 contained 1 verbal order that was not dated or timed.
Medical Record #15 contained 1 verbal order that was not dated or timed.
Medical Record #18 contained 1 verbal order that was not dated or timed.
Medical Record #19 contained a History and Physical but it was not completed within the required 24 hours of admission of the patient to the hospital.
Medical Record #21 contained 1 verbal order that was not signed, dated or timed.
Medical Record #22 contained a History and Physical that was not signed by the admitting physician.
Medical Record #23 contained 1 verbal order that was not dated or timed.
Medical Record #24 contained 1 verbal order that was not dated or timed.
Medical Record #25 contained 1 verbal order that was not dated or timed.
Medical Record #27 contained 1 verbal order that was not dated or timed.

An interview with staff #5 confirmed the 17 charts reviewed contained deficiencies.

Based on observation and interview, the facility failed to assure a phlebotomy chair (a chair where patients sit to have blood drawn for laboratory lasts) was maintained to avoid contamination. The facility also failed to assure expired items were removed from patient care areas.

Findings include:

During a tour of the lab on 4/24, a phlebotomy chair was found to have multiple tears in its covering. These tears could allow liquid contaminants, such as blood, to soak into the cushion beneath. Once in these cushions, decontamination of the chair is impossible. Staff #24 confirmed the finding of the tears in the chair.

During a tour of the Surgery Department on 4/24, the following expired items were found on the crash cart:
Defibrillator Pads X2 12/2010
Adhesive Electrodes X2 packages 07/2011
5-1 Connector X2 10/2011
Adult Electrode Pads X2 11/2011
Multiple Central Venous Catheter Kit X1 03/2012

During an interview on 4/24/2012 at approximately 2:00PM, the Chief Nursing officer and Director of Surgery confirmed the emergency supplies on the crash cart in the surgery department were expired.

Based on observation and interview, the facility failed to assure patient care areas and clean storage areas were maintained to control infection. High dust was found in the NICU (neonatal intensive care unit), MICU (medical intensive care unit), and CVICU (cardiovascular intensive care unit). Two soiled IV pumps were found in the MICU clean utility room. Cardboard shipping boxes were found in the NICU and the emergency department.


Findings include:

During a tour of the NICU on 4/25 at 11:20am, the following observations were made:
-high dust in the NICU isolation room
-2 cardboard shipping boxes in the NICU isolation room
-1 cardboard shipping box in the NICU isolation room
-15 cardboard shipping boxes in the NICU respiratory therapy storage room
-staff #24 confirmed these findings

During a tour of the MICU and CVICU on 4/25 at 1:20pm, the following observations were made:
-high dust in CVICU bed #9
-high dust in MICU beds #6 and 9
-two soiled IV pumps in the MICU clean utility room
- staff #24 confirmed these findings

During a tour of the Emergency on 4/25/2012 at approximately 10:00AM, cardboard shipping boxes were on the shelf in the Trauma Room. The Chief Nursing Officer and Director of Emergency Room confirmed this finding.