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Based on clinical record review, it was determined the facility failed to provide nursing care per physician's orders to 7 (#5, #10, #18, #21, #24, #26 and #32) of 16 (#1-#4, #9, #18, #21-#28, #31-#32) patients. Failure to provide nursing care as ordered by the physicians did not ensure the patients were receiving the care ordered by the physician. The failed practice affected seven patients on 09/15/14. Findings follow:

A. Review of the clinical record of Patient #5, admitted 01/15/14 through 02/10/14, revealed the following:
1) Physicians Orders dated 01/15/14 at 0610 revealed an order for General Hygiene once per day and an order dated 01/19/14 at 2037 for Range of Motion Once Per Shift.
2) Review of Nursing Task List revealed a bath was not documented for 25 of 26 days.
3) Review of Nursing Task List revealed Range of Motion was not documented.
4) The above findings were confirmed by Clinical Informatics Analyst #1 on 09/12/14 at 1240.

B. Review of clinical record of Patient #10, admitted 09/07/14 through 09/11/14, revealed the following:
1) Physician Order dated 09/07/14 for Vital Signs every 4 hours.
2) Vital sign documentation on 09/10/14 at 1100 revealed a systolic blood pressure of 81mm HG and a diastolic blood pressure of 38 mm HG. There was no evidence the physician was notified in accordance with Policy #500.4a. "Physician Notification of Change in Patient Condition. The policy required the physician be notified when there was a significant change from the normal baseline which included a systolic blood pressure less than 90. This was confirmed by clinical record review by Systems Analyst #3 on 09/12/14 at 1100 and Regulatory Specialist #1 on 09/15/14 at 1350.
4) Patient #10 had a regular diet ordered on 09/09/14. The meal % consumed was not documented in 3 of 8 opportunities from 09/09/14 through 09/11/14. This clinical record review was confirmed by Clinical Informatics Analyst #3 on 09/12/14 at 1055 and Regulatory Specialist #1 on 09/15/14 at 1350.

C. Review of the clinical record of Patient #18, admitted 08/30/14, revealed the following:
1) Physician Order dated 09/01/14 at 0000 to turn every two hours and an order dated 09/02/13 at 0507 for Range of Motion once per shift.
2) Review of the Nurse's Notes revealed no evidence Patient #18 was turned from 0000 to 0300 on 09/02/14, 0330 to 0730 on 09/02/14, 0100 to 0400 on 09/04/14, and 1700 to 2000 on 09/06/14.
3) Review of the Nurse's Notes revealed no evidence Patient #18 received Range of Motion on the 7PM (post meridian) shift on 09/03/14, 09/04/14, none on 09/05/14 and the 7AM (ante meridian) on 09/06/14.
4) The above findings were confirmed by the Regulatory Specialist at 0930 on 09/15/14.

D. Review of the clinical record for Patient #21, admitted 08/16/14 through 08/21/14, revealed the following:
1) Physician Orders dated 08/16/14 at 0947 to elevate heels with pillows and check pillow placement every 2 hours, to turn the patient every 2 hours and Range of Motion once per shift.
2) Review of the Patient Care Technician Task List revealed there was no evidence Patient #21 had their heels elevated and pillow placement checked during the following times:
a) 08/16/14 at 2000 through 08/17/14 at 0800
b) 08/17/14 at 0800 through 08/17/14 at 1000
c) 08/17/14 at 2000 through 08/18/14 at 0800
d) 08/18/14 at 0800 through 08/18/14 at 2000
e) 08/18/14 at 2000 through 08/19/14 at 0801
f) 08/19/14 at 0801 through 08/20/14 at 0801
g) 08/20/14 at 0801 through 08/20/14 at 1925
h) 08/20/14 at 1925 through 08/21/14 at 0800
3) Review of the Patient Care Technician Task List revealed there was no evidence Patient #21 had been turned during the following times:
a) 08/16/14 at 2200 through 08/17/14 at 0800
b) 08/18/14 at 0000 through 08/18/14 at 0800
c) 08/19/14 at 0000 through 08/19/14 at 0800
d) 08/19/14 at 1000 through 08/19/14 at 1400
e) 08/21/14 at 0606 through 08/21/14 at 1000
4) Review of the Patient Care Technician Task List revealed there was no evidence Range of Motion was performed once per shift during the entire admission.
5) Findings were confirmed by Clinical Informatics Analyst #1 on 09/12/14 at 1425.

E. Review of the clinical record of Patient #24, admitted 09/03/14 through 09/09/14 revealed the following:
1) Physician Orders dated 09/03/14 at 1312 for General Hygiene daily, an order dated 09/03/14 at 1312 for daily weights, an order dated 09/03/14 at 1510 for Neurological checks every one hour, an order dated 09/03/14 at 2325 for Range of Motion every shift and an order dated 09/03/14 at 2325 to turn Patient #24 every two hours.
2) Review of the Nurse's Notes revealed no evidence General Hygiene was provided on 09/04/14, 09/10/11/14 and 09/11/14.
3) Review of the Nursing Notes revealed no evidence daily weights were performed from 09/05/14 to 09/09/14.
4) Review of the Nurse's Notes revealed no evidence neurological checks were performed at 1600, 1700, 1800, 2000, 2299 and 0000 on 09/03/14; at 0200, 0400, 0500 and 0600 on 09/04/14. Further review revealed no neurological checks were done from 0815 to 1343, from 1443 to 2056, from 2156 on 09/04/14 to 0759 on 09/05/14 and from 0859 to 1540 on 09/05/14.
5) Review of the Nursing Notes revealed no evidence Patient #24 was turned from 0300 to 0600 on 09/04/14, 0400 to 0800 on 09/05/14, 0600 to 0900 and 1404 to 1800 on 09/08/14, 1200 to 1500 on 09/09/14, 0400 to 0735, 100 to 1515 and 1930 to 2200 on 09/10/14.
6) Review of the Nursing Notes revealed no evidence Patient #24 received Range of Motion only twice, at 1503 on 09/05/14 and 2000 on 09/07/14.
7) The above findings were confirmed by Clinical Informatics Analyst #2 at 0825 on 09/12/14 and again by the Regulatory Specialist at 1530 on 09/12/14.


F. Review of the clinical record of Patient #26, admitted 09/05/14 through 09/10/14, revealed the following:
1) Physician Order dated 09/05/14 through 09/10/14 for a 2000 calorie diabetic diet.
2) The meal percent consumed was not documented in 9 of 18 opportunities from 09/06/14 through 09/11/14.
3) Review of Policy # 503.15, "Food and Water Provision," revised 06/12, procedure item #4 "Observe/document type of diet and amount consumed in percent of total."
4) The findings were confirmed by Clinical Informatics Analyst #3 on 09/12/14 at 1430 and Regulatory Specialist #1 on 09/15/14 at 1345.


G. Review of the clinical record of Patient #32, admitted 09/05/14 through 09/11/14 revealed the following:
1) Physician Orders dated 09/06/14 at 0413 for General Hygiene daily and an order dated 09/06/14 at 0413 to turn Patient #32 every two hours.
2) Review of the Nurse's Notes revealed no evidence General Hygiene was performed from 09/07/14 to 09/09/14.
3) Review of the Nurse's Notes revealed no evidence Patient #32 was turned from 0600 to 1600 on 09/07/14, and from 1809 on 09/09/14 to 0001 on 091014.
4) The above findings were verified by the Clinical Informatics Analyst at 1350 on 09/12/14 and again by the Regulatory Specialist at 1225 on 09/15/14.

Based on review of the clinical record and interview, it was determined that the facility failed to administer medications in accordance with the orders of practitioners in two of two (Patient #27 and #28) in-patient records reviewed. By not administering medications according to practitioner's orders, the facility could not assure the patient's care conformed to the practitioner's plan of care. The failed practice had the likelihood to affect all patients who received medication. Findings follow:

A. Review of Patient #27's clinical record revealed the following physician order:
1) Heparin 5000 Units Subcutaneous Every 8 hours, stop after 14 days, priority Now. Order to start 09/03/14 1854, stop 09/08/14 1458 (at discharge).
2) The Medication Administration Record revealed the following missed doses:
09/03/14 1854 Not given (no documentation why)
09/04/14 0600 Not given (no documentation why)
09/07/14 0600 Not given (no documentation why)
09/08/14 0701 last shift's dose given
09/08/14 1400 Not given (no documentation why)

B. Review of Patient #28's clinical record revealed:
1) Physician's orders for HumaLOG and Regular Insulin Sliding Scales as needed at bedtime and through the day: Orders to start 09/04/14 1825, stop 09/08/14 1551(at discharge).
2) The Medication Administration Record revealed the following:
09/05/14 0948 Blood Sugar 460, sliding scale stated call MD if over 451, no documentation MD was notified.
09/05/14 1157 Blood Sugar 371, sliding scale stated give 18 Units, no documentation insulin was given.
09/06/14 2236 Blood Sugar 277, sliding scale stated give 6 Units, no documentation insulin was given.
09/08/14 1252 Blood Sugar 309, sliding scale stated give 15 Units, no documentation insulin was given.

C. Findings were verified, through interview, on 09/12/14 at 1030 with Clinical Informatics Analyst #1 for Patient #27 and #28.

Based on clinical record review and interview, it was determined the discharge summary for two of two (#29 and #30) maternal-child patients contained an incorrect date of discharge. Failure to document the correct date of discharge did not allow Patient #29 and Patient #30 to have an accurate clinical record. The failed practice affected Patients #29 and #30. Findings follow:

A. Review of Patient #29's clinical record revealed the discharge summary authored by Physician #1 at 2324 on 09/10/14 stated Patient #29 was discharged on 09/10/14. Review of the nursing note authored by Registered Nurse #1 at 1603 on 09/11/14 revealed Patient #29 was discharged home at that time.
B. Review of Patient #30's clinical record revealed the discharge summary authored by Physician #2 at 0838 on 09/10/14 stated Patient #30 was discharged on 09/10/14. Review of the nursing note authored by Registered Nurse #2 at 1541 on 09/11/14 revealed Patient #30 was discharged home at that time.
C. The above findings were verified by Clinical Informatics Analyst #2 at 1000 on 09/12/14.

Based on observations and interview, it was determined the facility failed to ensure only currently dated supplies were available for patient use. Failure to ensure that only currently dated supplies were available for patient use had the potential to contribute to healthcare associated infections and compromise the efficacy of treatment. The failed practice had the potential to affect any patient whose care necessitated supplies from the Trauma Cart and Crash Cart in Trauma Room #9. Findings follow:

A. During the tour of the Emergency Department at 1345 on 09/09/14 the following expired supplies were noted in the Trauma Cart of Trauma Room #9: 2 of 2 2x2 gauzes expired 11/13, 1 of 2 Premium Extractor expired 03/13, 2 of 2 Betadine Swabs expired 07/14, 1 of 1 Ultrasite Addition IV Administration Set expired 02/14; the following expired supplies were noted in the Crash Cart of Trauma Room #9: 16 gauge cathalon 1 of 2 expired 03/14, 22 gauge cathalon 1 of 2 expired 01/11 and 1 of 2 expired 10/12, 24 gauge cathalon 1 of 2 expired 05/14.
B. The above findings were confirmed by the Emergency Department Director at 1430 on 09/08/14.


31039

Based on observation, review of policy and interview, it was determined the facility failed to mitigate the risk of contamination related to placing dirty items in a clean storage area in that four bags of rape victims' clothes/belongings were stored on top of the Omnicell. By not maintaining a sanitary environment, the facility could not ensure cross contamination would not occur. The failed practice had the likelihood to affect all patients in the Emergency Department that received medications/supplies out of the Medication Room. Findings follow:

A. During a tour of the Emergency Department on 09/08/14 from 1340 to 1438 observation revealed four bags, three paper sacks and one plastic bag, for patient belongings (dirty) were stored on top of the Omnicell Medication storage unit in the Medication Room (clean). Of the three paper sacks, one was taped shut. The other two were folded closed but not secured. The plastic patient belongings bag was partially closed.
B. Review of policy titled Standard Precautions stated the following: Standard Precautions combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. When asked for a policy specific to storing rape victims' belongings and sexual assault evidence, the facility did not produce one.
C. Findings were verified through interview on 09/08/14 at 1438 with the Director of Pharmacy.

Based on interview, review of online and printed policies, it was determined the facility failed to assure a process was in place to minimize the risk of surgical fire with the use of alcohol based skin preparations in the operating rooms. Although the final copy of a policy was provided that included fire safety with the use of alcohol skin preparations, the policy was not available for staff and there was no evidence the staff had been educated on the contents. The failed practice affected all patients treated at the hospital. The findings were:

1) Review of online and printed policies and procedures 09/10/14-09/12/14 and 09/15/14 revealed the facility lacked a policy that included fire safety measures with the use of an alcohol-based skin preparations in anesthetizing locations. A copy of the facility policy and procedure for fire prevention safety in the OR (Operating Room)was requested from CNM (Clinical Nurse Manager) #1. On 09/15/14 at 1100, CNM #1 reviewed policies available online and policies printed and in a notebook binder. CNM #1 provided Policy 100.52 for Electrical Equipment safety. There was no mention of safety with the use of alcohol based skin preps.
2) CNM#1 stated on 09/15/14 at 1115 "There's not a policy and procedure for the operating room for fire prevention and safety when using alcohol skin preps." CNM#1 stated training was "nurse to nurse" for the use of the preps.
3) CNM #1 was interviewed on 09/15/14 at 1215 and provided a list of skin preparations used in the surgery and the following included alcohol: Duraprep, Chloraprep and alcohol.
4) CNM #1 on 09/15/14 at 1220 provided a policy "(Named) Surgery Center, PLLC OR Policy and Procedure Manual: Fire Plan in the OR for Alcohol Based Skin Prep."The CNM stated the policy was from the facility Ambulatory Surgery Center and confirmed there was nothing specific for the main hospital OR.
5) On 09/15/14 at 1300, CNM #1 provided a policy she stated was on her computer. The policy was "(Named) Hospital Association, Inc. Operating Room Policy and Procedure Manual: Alcohol Prep and Fire Safety." CNM #1 also provided a copy of "Surgery Staff Meeting Agenda" dated 06/07/13. The staff meeting agenda contained the statement "Chlorprep in-service - Staff members in-serviced on Chlorprep Product labeling changes." A copy of a letter outlining the label changes for Chloraprep skin prep products was attached to the agenda and sign in sheet.

Based on observation, interview and policy and procedure review, the facility failed to assure: expired items were not available for use in the surgical and cystoscopy area; four of four worn bedrail pads were not available for use; three of seven containers used to transport instruments for sterile processing had broken lids; and failed to assure two of two Crash Carts observed in the surgical area were checked every shift. The failed practice was likely to affect all patients who had surgery at the facility.

A. The following expired urinary catheters were observed in the Cystoscopy supply room on 09/09/14 at 1033: 7, size #20, expired 07/2014; 1, size #18, expired 07/2014; 2, size #16 expired 06/2014. The findings were confirmed at the time of observation by CNM #1.

B. Observation on 09/09/14 at 1005 of surgery suture supplies revealed Vicryl Plus 4.0 suture, 7 of 32, expired 07/2014; 4.0 Chromic gut, 27" suture, 1 of 22 expired 07/2014. The findings were confirmed at the time of observation by CNM #1.

C. Observation on 09/09/14 at 1100 of a storage closet in Same Day Surgery Unit revealed four of four bed/stretcher rail pads with worn and cracked areas that exposed the cusion beneath and one area with cloth type tape covering a cracked area. The practice did not allow effective cleaning and disinfection between patient use. The findings were confirmed at the time of observation by CNM #1.

D. Observation on 09/09/14 at 1130 revealed three of seven rigid containers used for instrument transport by the Surgical Processing Department had cracked and broken areas on the lids. The findings were confirmed by CNM #2 at the time of observation

E. The two crash carts in the surgical area were not checked every shift per interview and policy review as follows:
1) CNM #1 was interviewed while on tour on 09/09/14 at 1023 and stated one of the nurses checked the crash cart and performed a defibrillator test each shift. Registered Nurse (RN) #3 was interviewed on 09/09/14 at 1025 and asked to perform the routine shift checks for the crash cart. RN #3 stated "I turn it on to make sure it comes on. I don't do any other testing except on Mondays. That's the way I was told when I was hired." CNM#1 confirmed the findings 09/09/14 at 1025.
2) RN #4 was interviewed on 09/09/14 at 1150 and asked to perform the routine shift check of the crash cart. RN #4 stated the crash cart was checked for integrity of the breakaway lock and number, checked to assure other emergency supplies were on the cart and that the defibrillator was not checked except on Mondays. CNM #1 confirmed the findings on 09/09/14 at 1150.
3) The policy for "Code Blue Process and Crash Cart Maintenance", Section 4.21, effective 05/01/12 was provided by the facility. The policy stipulates, item C, "Crash Cart and Defibrillator Maintenance". Item C.1. "Crash cart and defibrillator maintenance is to be performed by licensed personnel every shift during which patient care is rendered."

Based on interview, review of policy and procedure, review of "Steam Flash Sterilization" records and review of "Flash sterilization and biological test documentation", it was determined the facility failed to assure documentation of immediate use sterilization was performed per facility policy and failed to assure the results of immediate use steam sterilization were documented and evaluated for four of four (#1-#4) steam sterilizers in the surgical suite. It could not be assured items sterilized for immediate use were processed to ensure the efficacy of the sterilization process. The failed practice did not assure surgical patients were protected from infection. The findings were:

A. The facility policy and procedure for "Flash Sterilization", Section 100.63, revised 03/10, listed the procedure "When an item is flash sterilized, it must be documented in the Flash Autoclave Log with accompanying patient information and the date of the flash sterilization along with the recording chart. On a daily basis (Monday thru Friday), the Orderly/surgical assistant will perform a biological indicator test in a flash cycle and record the results appropriately. Any sterilizer failure will be reported to the Surgical Services Management immediately."
B. CNM #1 stated on 09/09/14 at 0950, "The four steam sterilizers in the core area are used for flash sterilization. We do a biological test on them every day through the week. A biological test is done if we use one on the weekend before we use it." A binder for Steam Sterilizer #1-#4 was provided at the time of the interview and identified as the "Flash sterilization and biological test documentation".
C. Review of steam sterilizer "Steam Flash Sterilization" records revealed incomplete documentation of immediate use sterilization as follows:
1) Sterilizer #1 "Flash Sterilization" documentation was reviewed on 09/09-10/14 for the dates 07/01/14-09/09/14. The documentation of instruments processed for immediate use was incomplete 10 of 53 days reviewed in that it did not consistently include a list of load items processed, doctor, and patient receiving the items, operators name or the reason for the immediate use steam sterilization. The dates of incomplete immediate use load documentation included: 07/15, 07/23, 07/29, 07/30, 08/01, 08/04, 08/05, 08/11, 08/19 and 09/03/14.
2) Sterilizer #2 "Flash Sterilization" documentation was reviewed on 09/09-10/14 for the dates 07/01/14-09/09/14. The documentation of instruments processed for immediate use was incomplete 2 of 53 days reviewed in that it did not consistently include a list of load items processed, doctor, and patient receiving the items, operators name or the reason for the immediate use steam sterilization. The dates of incomplete immediate use load documentation included: 07/01and 07/15/14.
3) Sterilizer #3 "Flash Sterilization" documentation was reviewed on 09/09-10/14 for the dates 07/01/14-09/09/14. The documentation of instruments processed for immediate use was incomplete 11 of 53 days reviewed in that it did not consistently include a list of load items processed, doctor, and patient receiving the items, operators name or the reason for the immediate use steam sterilization. The dates of incomplete immediate use load documentation included: 07/01, 07/08, 07/11, 07/25, 07/30, 08/01, 08/15, 08/20, 08/21, 08/22, 08/26 and 09/04/14.
2) Sterilizer #4 "Flash Sterilization" documentation was reviewed on 09/09-10/14 for the dates 07/01/14-09/09/14. The documentation of instruments processed for immediate use was incomplete 11 of 53 days reviewed in that it did not consistently include a list of load items processed, doctor, and patient receiving the items, operators name or the reason for the immediate use steam sterilization. The dates of incomplete immediate use load documentation included: 07/01, 07/16, 07/18, 07/28, 07/30, 08/01, 08/04, 08/26, 08/28, 08/29 and 09/06/14.
D. The findings were confirmed by CNM #1 at 1030 on 09/10/14 and reviewed with the Regulatory Specialist on 09/15/14 at 0935.