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Based on observation, clinical record review and interview, it was determined the facility failed to ensure the Plan of Care for one (#13) of one patient in restraints was modified to include the restraint. The lack of a Plan of Care related to the restraint affected Patient #1 and had the potential to affect any patient placed in restraints without modification of the Plan of Care. Evidence follows:

A. Review of the clinical record for Patient #13 revealed the following:
1) The Initial Physical Assessment by the Registered Nurse at 1257 on 01/04/11 revealed the patient was a high fall risk, his mobility was only slightly limited and he was able to get out of bed as his activity included occasional walking with a walker. The patient was documented as having four side rails up at the time of the Initial Physical Assessment.
3) Review of Patient Progress Notes revealed the following:
a) At 1330 on 01/04/11, the patient was confused, agitated and attempted to get out of bed.
b) At 1602 on 01/04/11, all four side rails were up.
c) At 1800 on 01/04/11, all four side rails were up.
B. On 01/05/11 at 1030 and 1325, Patient #13 was observed in bed with four side rails up.
C. The Plan of Care lacked goals and interventions related to the restraint.
D. The failure to care plan the restraint was confirmed by the Obstetrics/Emergency Room Manager at 1355 on 01/045/11.

Based on observation, clinical record review and interview, it was determined the facility failed to ensure one (#13) of one patient in restraints had a physician's order for the restraint. The lack of physician's order for a restraint affected one of twelve current patients and had the potential to affect any patient placed in restraints without a physician's order. Evidence follows:

A. Review of the clinical record for Patient #13 revealed the following:
1) The Physicians Orders lacked an order for restraints.
2) The Initial Physical Assessment by the Registered Nurse at 1257 on 01/04/11 revealed the patient was a high fall risk, his mobility was only slightly limited and he was able to get out of bed as his activity included occational walking with a walker. The patient was documented as having four side rails up at the time of the Initial Physical Assessment.
3) Review of Patient Progress Notes revealed the following:
a) At 1330 on 01/04/11, the patient was confused, agitated and attempted to get out of bed.
b) At 1602 on 01/04/11, all four side rails were up.
c) At 1800 on 01/04/11, all four side rails were up.
B. On 01/05/11 at 1030 and 1325, Patient #13 was observed in bed with four side rails up.
C. The above documentation in the clinical record was confirmed by the Obstetrics/ Emergency Room Manager at 1355 on 01/045/11.

Based on review of Summary Data-Anesthesia Department 2010, Quality Improvement Meeting Minutes 2010 and interview, it was determined the facility failed to collect and analyze data to identify potential problems in the Anesthesia Department from July to December 2010. The potential outcome existed for patients having a surgical procedure to experience complications related to anesthesia that could have been identified in the Quality Improvement Program. The failed practice had the potential to affect one surgical patient on the first day of survey (01/04/11) and all surgical patients. Findings follow:

A. Review of the Quality Improvement Meeting Minutes 2010 revealed there was no evidence of quality improvement activities for July through December being reported or discussed.
B. Review of the Summary Data-Anesthesia Department revealed there was no evidence of quality improvement activities for July through December.
C. Findings were confirmed in Interview with the Director of Performance Improvement at 0915 on 01/06/11.

Based on clinical record review and interview, it was determined the facility failed to ensure one of one patient (#2) with orders for blood glucose checks and sliding scale insulin received the blood glucose checks and sliding scale insulin as ordered. The failed practice had the potential to affect 1 of 12 current patients and any patients admitted with orders for blood glucose checks and sliding scale insulin. Evidence follows:

Patient #2: A. Review of Physicians Orders revealed an order written on 01/03/11 to check the patient's blood sugar twice daily and to provide insulin per the regular sliding scale. The order was not timed, but the subsequent order was written at 0742 on 01/03/11, making the time sometime prior to that.
B. Review of the Diabetic Flow Sheet revealed Patient #2's blood sugar was not checked on 01/03/11, was checked only once on 01/04/10 at 0615, and was not checked the morning of 01/05/11.
C. Interview with the Obstetrics and Emergency Room Manager at 1415 on 01/05/11 revealed facility policy was to check the blood sugars before breakfast and before supper when ordered twice daily. She confirmed the blood sugars were not checked with insulin provided per the regular sliding scale on the evening of 01/03/11, the evening of 01/04/11 and the morning of 01/05/11 as ordered by the physician.

Based on clinical record review and interview, it was determined the facility failed to ensure two of two blood transfusions provided to Patient #3, prior to 1500 on 01/05/11, were administered according to the medical staff approved policy and procedure. The failed practice affected one of one (#3) current patient who received blood transfusions and any patients admitted to the facility who received blood transfusions. Evidence follows:

A. Interview with the Obstetrics and Emergency Room Manager at 1445 on 01/05/11 revealed the medical staff approved facility procedure included completing the Blood/Blood Products Administration Record/Checklists with documentation of infusion stop times and documentation of vital signs one hour post infusion.
B. Review of the Blood/Blood Products Administration Record/Checklists for blood transfused for Patient #3 on 12/29/10 revealed the following lack of required documentation to show the medical staff approved policy and procedure was followed:
1) The Blood/Blood Products Administration Record/Checklists for Unit #1 showed the infusion was initiated at 1310 on 12/29/10, but lacked evidence of the time the infusion was stopped.
2) The Blood/Blood Products Administration Record/Checklist for Unit #2 was initiated at 1720, but lacked evidence of the time the infusion was stopped.
3) The Blood/Blood Products Administration Record/Checklist for Unit #2 lacked evidence vital signs were taken one hour post infusion per facility policy.
C. The above was confirmed by the Obstetrics and Emergency Room Manager during interview at 1500 on 01/05/11.

Based on observation and interview, the facility failed to ensure two (Procedure Cart in Procedure Room In Operating Room Suite, Ophthalmic and Otic Cabinet in Exam Room #3 in Emergency Department) of five (Operating Room, Labor and Delivery, Medical/Surgical Unit, Intensive Care Unit, Emergency Department) areas with medications were locked when not in use. The potential existed for unauthorized individuals to access medications. The failed practice allowed unauthorized users access to all medications and administer those medications to patients. Findings followings:

A. A tour of the Operating Room Suite to Include the Procedure Room was conducted on 01/04/11 at 1330 after all surgeries/procedures had been completed for the day. The Procedure Cart in the Procedure Room was observed to be unlocked. The cart contained two ampules of Diprivan 1000 milligrams (mg)/ 100 milliliters (ml) and seven vials of Lidocaine 100 mg/5ml. The Certified Registered Nurse Anesthetists (CRNA) who utilized the cart had left the facility for the day.
B. A tour of the Emergency Department was conducted on 01/05/11 at 0900. An unlocked cabinet in Exam Room #3 was observed to contain ophthalmic and otic medications to include the following:
1) One Atropine Sulfate Ophthalmic Solution 1%;
2) One Pilocarpine Hydrochloride Ophthalmic Solution 1%;
3) One Neomycin and Polymyxin B Sulfates and Hydrocortisone Ophthalmic Solution;
4) One Gentamycin Ophthalmic Ointment; and
5) One Neomycin and Polyyxin B Sulfates and Hydrocortisone Otic Suspension.
C. An interview was conducted with the Operating Room Manager on 01/04/11 at 1335 in which it was verified the Procedure Cart was not locked and available to unauthorized individuals. The Chief Nursing Officer verified through interview on 01/05/11 at 0920 the cabinet maintaining ophthalmic and otic medications was not locked making the medications available to unauthorized individuals.

Based on observation and interview, the facility failed to ensure labels on all dispensed oral medications contained lot numbers and expiration dates located on one (Medical Surgical Unit) of two (Medical Surgical Unit, Intensive Care Unit) inpatient nursing units. The practice affected 5 (Patients in Rooms #408, #412, #302, #105-2, #301-1) of 12 patients and had the potential to affect all 12 patients. The potential existed for all patients to be administered expired medications and medications that had been recalled by manufacturers' lot numbers. Findings follow:

A. A tour of the Medical/Surgical Unit was conducted on 01/05/11 between 0950 and 1030. The labels on the following oral medications were observed dispensed to patients lacking lot numbers and expiration dates:
1) Two Methergine 0.2 milligrams (mg) dispensed to patient in Room #408 lacked lot numbers and expiration dates;
2) Five Anaspaz 0.125 mg dispensed to patient in Room #412 lacked lot numbers and expiration dates;
3) One Bystolic 10 mg and one Imdur 30 mg dispensed to patient in Room #302 lacked a lot number and expiration date;
4) One Melatonin 3 mg dispensed to patient in Room 105-2 lacked a lot number and expiration date; and
5) Two Lovera dispensed to patient in Room 301-1 lacked lot numbers and expiration dates.
B. An interview was conducted with the Chief Nursing officer on 01/05/11 at 1035. The Chief Nursing Officer verified through interview the labels on five patients lacked lot numbers and expiration dates.

Based on policy review, clinical record review and interview, it was determined the facility failed to ensure three (#2, #3 and #9) of four (#2, #3, #4 and #9) patients at nutritional risk with stays long enough to require follow up per facility policy, received follow up as required. The failed practice affected 3 of 30 patients and had the potential to affect all who were admitted at nutritional risk and were in the facility for five days or longer. Evidence follows:

A. Review of the Screening Patients Policy, revised 01/02/02 revealed all patients were screened for nutrition risk within 24 hours of admission and those at nutrition risk were followed up on every three days.
B. Review of twelve current patients revealed the following:
1) Patient #2 was admitted on 12/25/10 at nutrition risk due to a Stage II decubitus, decreased visceral protein stores evidenced by a serum albumin of 2.5; an elevated glucose level of 161; a current weight of 169 pounds which was 41% above her ideal weight and receiving enteral feedings. The patient was assessed on 12/26/10, but was not followed up on until 6 days later on 01/01/11.
2) Patient #3 was admitted on 12/28/10 at nutrition risk due to decreased visceral protein stores evidenced by a serum albumin of 2.6; a current weight of 90 pounds which was 82% of her ideal weight; and elevated glucose levels of 171. The patient was assessed on 12/29/10, but was not followed up on until 5 days later on 01/03/11.
3) Patient #9 was admitted on 12/29/10 at nutrition risk due to dehydration, peptic ulcer disease, chronic renal insufficiency and decreased visceral protein stores evidenced by a serum albumin of 2.5. The patient was assessed on 12/30/10, but was not followed up on until 5 days later on 01/04/11.
C. The above was confirmed by the Dietary Director at 1100 on 01/06/11.

Based on observation and interview, it was determined the facility did not meet Life Safety Code requirement related to maintaining penetrations of smoke barrier walls properly sealed and inspection of fire and smoke dampers. Failure to properly seal penetrations of smoke barrier walls has to the potential to affect the health and safety of patients, visitors, and staff because a compromised smoke barrier wall allows the passage of fire and smoke from one side of the smoke barrier to the other. Failure to inspect fire and smoke dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect 12 of 12 patients on census on 01/04/11 and all staff and visitors. See CMS 2567, K25 and K67.

Based on observation, clean linen was observed on the floor of the Clean Utility Room. Failure to ensure the clean linens did not mingle with dirty surfaces had the potential to allow contaminated linens (patient gowns, towels, sheets and blankets) to be used in patient care. The failed practice had the potential to affect the 12 patients on census on 01/04/11 and any patient admitted to the facility. Findings follow:

A. During the hospital tour 14 bags of clean linen was observed on the floor of the Clean Utility Room.
B. The above findings were confirmed by the Housekeeping Supervisor and the Chief Nursing Officer at 0940 on 01/05/11.

Based on review of surgical clinical records (#14-#23) and interview, it was determined 2(#17 and #18) of 10 patients did not have a history and physical examination performed and on the clinical record before surgery. The potential existed for the surgeon to fail to assess and identify changes in the patient's condition before undergoing anesthesia and the surgical procedure. The failed practice had the potential to affect one surgical patient on the first day of survey (01/04/11) and all surgical patients. Findings follow:

A. Review of closed Surgical Record #17 revealed the patient had a surgical procedure on 12/04/10 with no evidence of a history and physical examination performed and on the clinical record before surgery. On the day of the clinical record review 01/06/11, a history and physical examination was not on the surgical chart.
B. Review of closed Surgical Record #18 revealed the patient had a surgical procedure on 12/28/10 with no evidence of a history and physical examination performed and in the clinical record before surgery. On the day of the clinical record review 01/06/11, a history and physical examination was not in the surgical chart.
C. Findings were confirmed in interview with the Operating Room Manager at 1100 on 01/06/11.

Based on review of clinical records (#14-#23) of patients having surgery, Anesthesia Care Standards Policy and Procedure, and interview it was determined the facility failed to ensure 6 (#16-#19, #21 and #22) of 10 surgical patients received a post-anesthesia evaluation within 24 hours after the procedure per facility policy. The outcome existed for anesthesia personnel to fail to assess surgical patients and identify complications of anesthesia. The failed practice had the potential to affect one surgical patient on the first day of survey (01/04/11) and all surgical patients. Findings follow:

A. Review of surgical records for Patient #16, #17, #18, #19, #21, #22 revealed there was no evidence of a post anesthesia evaluation being completed within 24 hours after the procedure.
B. Review of Anesthesia Care Standards Policy and Procedure revealed a post anesthesia evaluation would be completed within 24 hours.
C. Findings were confirmed in interview with the Operating Room Manager at 1045 on 01/06/11.

Based on review of policies and procedures for the swingbed program, closed clinical record of Patient #1 and interview, the facility failed to have a qualified person responsible for providing activities based on the needs and interests of patients admitted to the Swingbed Program. The outcome existed for activities to improve mental function and social interests of swingbed patients not be available to assess the patients needs and plan activities. The failed practice had the potential to affect all patients admitted to the Swingbed Program. Findings follow:

A. Interview with the Swingbed Coordinator at 1330 on 01/05/11 revealed an available Case Manager would complete an assessment of the needs and interests of the swingbed patients at the time of their admission. However, there was not a Case Manager designated as being responsible for the Activity Program.
B. Review of the policies and procedures for the swingbed program revealed there was no evidence of a designated person to be responsible for the Activity Program.