HospitalInspections.org

Based on observations, interviews and records review, it was determined that the Governing Body was not effective in its oversight of the hospital.

A) Medical Staff failed to adequately supervise and ensure a safe environment was provided for 1 of 1 patient (Patient #1) who was acutely psychotic and demonstrated self-injurious behavior (inserting foreign object (s)) in the rectum and,

B) Failed to provide a sanitary environment and ensure hospital personnel were compliant with infection control standards of practice.

Findings included:

A) (Patient #1) had access to foreign objects which she inserted in her rectum. Hospital personnel including the physician were aware of this behavior but did not order special precautions such as 1:1 supervision or the removal of insertable object (s). (Patient #1) was transferred to Hospital B for continued psychiatric care with a foreign object (s) in her rectum. (Cross refer to A0049 and A0144)

B) Hospital personnel failed to perform handwashing before, during and after patient care and during medication preparation and administration. Patient care equipment was not cleaned and/or sanitized between use. Medication rooms (2 of 2) were left soiled, dirty and needed cleaning. Soiled gloves and lancets were not disposed of properly contaminating clean lancets and glucose testing strips available for patient use. (Cross refer to A0749)

Based on observations, interviews and records review, the Governing Body failed to ensure medical staff provided quality of care for 1 patient (Patient #1) who had access to foreign object (s) which she repeatedly inserted in her rectum with staff knowledge. The physician was aware of this behavior but did not order special precautions such as 1:1 supervision or the removal of insertable objects from the rectum. This practice placed (Patient #1) at risk for injury. (Patient #1) was transferred to Hospital B for continued psychiatric care with a foreign body in her rectum.

Findings included:

(Patient #1's) History and Physical dated 08/01/12 reflected, "Patient presents with delusional thought process...believes everything in electric outlets with vents have all radiation and that my stethoscope is giving radiation....hears voices, sees things...herperreligious...pulling hair out...not bathing...psychiatric hospitalizations..."

The 08/03/12 nursing progress note timed at 14:45 PM reflected, "Order given by M.D. for pt (patient) to bathe...refusing to do so...team assembled as pt has feces under her nails, and poses a threat of transferring E. Coli to others...walked voluntarily to shower room, and took a shower...it was noted she had a foreign object (s) pushed up into her rectum...a pencil (golf pencil) was seen hanging out of her rectum...states she puts toothpaste on the end of pencil and pushes it up, as it makes her hemorrhoids feel better...patient refuses to remove pencil...Dr...present, and advised of findings...M.D. states she has done this for years, and if she won't remove it (pt refused to do so), then leave it alone. M.D. offered hemorrhoidal cream, but refused...still appears psychotic...has been refusing medications..."

The daily nursing assessment/observation dated 08/04/12 timed at 11:52 AM reflected, "Patient is pacing halls...talking to herself...staff witnessed a pencil falling out from under her skirt...Dr. notified stated she had a history of inserting objects in rectum..."

The psychiatric (physician) progress note dated 08/04/12 reflected, "Bizarre, feces under finger nails, tends to put pencils and toothpaste in anal canal, stripping...illogical, paranoid..."

The psychiatric (physician) progress note dated 08/05/12 timed at 11:40 AM reflected, "Objects in anus...delusional...state hospital...psychotic and bizarre..."

The psychiatric (physician) progress note dated 08/09/12 timed at 09:00 AM reflected, "Manic, paranoid, delusional...putting things up her vagina and anal canal..."

(Patient #1's) Medical Record (Nursing Assessment dated 08/10/12 timed at 01:43 PM from Hospital B reflected, "Reported that she has a pencil in her rectum...that she inserted because of hemorrhoids while at Hospital A...was confirmed by Dr...via x-ray that patient has foreign body in rectum ...no acute rectal bleeding noted ...patient reported she informed Hospital A she had inserted a pencil in rectum..."
On 11/21/12 at 12:15 PM Staff #14 was interviewed. Staff #14 stated Staff #2 informed Staff #14 that (Patient #1) had inserted a pencil in her rectum 08/03/12. Staff #14 said she was not too concerned as the patient had a history of putting foreign objects in her rectum and vagina. The surveyor asked Staff #14 how allowing the pencil to stay in the patient's rectum was providing a safe environment for the patient. Staff #14 stated she did not think anything about it as the patient had a history of putting foreign objects in the rectum and vagina. Staff #14 stated (Patient #1) would tell her during her daily visits the status of the pencil. The surveyor asked Staff #14 whether she considered (Patient #1's) behavior a self-harm behavior and how leaving the pencil in was keeping the patient safe especially due to her psychotic behavior. Staff #14 stated after speaking to the surveyor she had not thought of it in that way, but agreed inserting objects in the rectum had the potential for injury.

Medscape Reference updated 03/22/12 entitled, "Rectal Foreign Body Removal" reflected, "Delayed removal of rectal foreign bodies can lead to severe complications, including...perforation, peritonitis, infection or sepsis, mucosal ulcerations, lacerations, or edema, obstruction...bleeding..."

The Hospital Medical Staff Bylaws with an amendment date of 02/15/11 reflected, "The purpose of the medical staff are to ensure all patient receiving treatment...receive uniform quality patient care that is provided in a highly ethical manner...to provide oversight of care, treatment, and services...report to and be accountable to the Governing Board..."

Based on observation, interview and record review the hospital failed to protect and ensure that a safe environment was provided for 1 of 1 patient (Patient #1).

Findings included:

1) (Patient #1) had access to foreign objects which she repeatedly inserted in her rectum with staff knowledge. The physician was aware of this behavior but did not order special precautions such as 1:1 supervison, or the removal of insertable objects from the rectum.

2) Hospital personnel failed to adequately supervise (Patient #1) which placed her at risk for injury due to her mental status. (Patient #1) was transferred to Hospital B with a foreign body in her rectum.

Cross refer to A0144

Based on observations, interviews and records review, the hospital failed to ensure a safe environment was provided for 1 of 1 patient (Patient #1). (Patient #1) had access to foreign objects such as toothpaste tubes and golf pencils. (Patient #1) was not prevented from repeatedly inserting foreign objects in her rectum. (Patient #1) was not provided medical intervention and/or adequate supervision. (Patient #1) was transferred to Hospital B on 08/10/12 for continued psychiatric care with a foreign object in her rectum.

Findings included:

(Patient #1's) History and Physical dated 08/01/12 reflected, "Patient presents with delusional thought process...believes everything in electric outlets with vents have all radiation and that my stethoscope is giving radiation....hears voices, sees things...herperreligious...pulling hair out...not bathing...psychiatric hospitalizations..."

The physician's orders dated 08/02/12 timed at 10:45 AM reflected, "LOS (line of sight) WA (while awake)...patient is stripping and very psychotic..." It was noted (Patient #1) was on LOS while awake and until discharge 08/10/12.

The 08/03/12 nursing progress note timed at 14:45 PM reflected, "Order given by M.D. for pt (patient) to bathe...it was noted she had a foreign object (s) pushed up into her rectum...a pencil (golf pencil) was seen hanging out of her rectum...states she puts toothpaste on the end of pencil and pushes it up, as it makes her hemorrhoids feel better...patient refuses to remove pencil...Dr...present, and advised of findings...M.D. states she has done this for years, and if won't remove it (pt refused to do so), then leave it alone. M.D. offered hemorrhoidal cream, but refused...still appears psychotic...has been refusing medications..."

The daily nursing assessment/observation dated 08/04/12 timed at 11:52 AM reflected, "Patient is pacing halls...talking to herself...staff witnessed a pencil falling out from under her skirt...Dr. notified stated she had a history of inserting objects in rectum..."

The nursing progress notes dated 08/04/12 timed at 14:55 PM reflected, "Late entry pt (patient) did agree to wash hand, also when I (writer) entered the pt room a toothpaste tube was found on shelf with what appeared to be blood..."

The psychiatric (physician) progress note dated 08/04/12 reflected, "Bizarre, feces under finger nails, tends to put pencils and toothpaste in anal canal, stripping...illogical, paranoid..."

The psychiatric (physician) progress note dated 08/05/12 timed at 11:40 AM reflected, "Objects in anus...delusional...state hospital...psychotic and bizarre..."

The 08/06/12 7 AM to 3 PM daily nursing assessment/observation note reflected, "Refusing to bathe...moved to area of decreased stimulation...blood on paperwork discarded...bloody toothbrush discarded...has poor insight...1300 PM...when asked if she was putting objects up her she states...I need my bible..."

The psychiatric (physician) progress note dated 08/09/12 timed at 09:00 AM reflected, "Manic, paranoid, delusional...putting things up her vagina and anal canal..."

The Hospital Unit Environmental Check for (PICU) Night Shift, Day Shift and Eve Shift from 08/01/12 to 08/10/12 reflected that there was no documented evidence that environmental checks had been completed on the following dates:

08/01/12 environmental check was not completed for the evening shift.
08/02/12 environment check was not completed for dayshift and evening shift.
08/03/12 environment check was not completed for days, evenings and the nightshift.
08/06/12 environment check was not completed for the evening shift.
08/08/12 environment check was not completed for the evening shift.
08/10/12 environment check was not completed for the evening shift.

(Patient #1's) Medical Record (Nursing Assessment) dated 08/10/12 timed at 01:43 PM from Hospital B reflected, "Reported that she has a pencil in her rectum...that she inserted because of hemorrhoids while at Hospital A ...was confirmed by Dr...via x-ray that patient has foreign body in rectum ...no acute rectal bleeding noted ...patient reported she informed Hospital A she had inserted a pencil in rectum..."
On 11/20/12 at 16:25 PM Staff #8 was interviewed. Staff #8 informed the surveyor that LOS while awake (line of sight) means the patient is to be in view of staff while awake. Staff #8 stated (Patient #1) was a challenge when she was inpatient. Staff #8 said (Patient #1) would put foreign objects in her rectum. Staff #8 was asked by the surveyor how they ensured (Patient #1) did not have access to objects to place in her rectum. Staff #8 stated safety rounds were made.

On 11/21/12 at 10:30 AM Staff #2 was interviewed. Staff #2 stated she saw the patient on 08/03/12 in the shower with a pencil in her rectum. Staff #2 stated she informed the psychiatrist who was in the building and the physician informed her (Staff #2) (Patient #1) had a history of putting foreign objects in her rectum and to leave it. Staff #2 stated the staff were supposed to be watching the patient on LOS (line of sight). Staff #2 said the physician made the decision to leave the pencil in (Patient #1's) rectum and not send her out to have it removed.

On 11/21/12 at 10:50 AM Staff #9 was interviewed. Staff #9 stated patient's were allowed to have toothpaste and a toothbrush in their room. Staff #9 did not know whether special measures were initiated to prevent (Patient #1) from access to foreign objects which could be used by (Patient #1). Staff #9 was asked what line of sight while awake meant. Staff #9 stated the patient was supposed to be in line of sight even in the bathroom.

On 11/21/12 at 12:15 PM Staff #14 was interviewed. Staff #14 stated Staff #2 informed Staff #14 that (Patient #1) had inserted a pencil in her rectum 08/03/12. The pencil was found when showered. Staff #14 said she was not too concerned as the patient had a history of putting foreign objects in her rectum and vagina. The surveyor asked Staff #14 how allowing the pencil to stay in the patient's rectum was providing a safe environment for the patient. Staff #14 stated she did not think anything about it as the patient had a history of putting foreign objects in the rectum and vagina. Staff #14 stated (Patient #1) would tell her during her daily visits the status of the pencil. The surveyor asked Staff #14 whether she considered (Patient #1's) behavior a self-harm behavior and how leaving the pencil in was keeping the patient safe especially due to her psychotic behavior. Staff #14 stated after speaking to the surveyor she had not thought of it in that way, but agreed inserting objects in the rectum had the potential for injury.

On 11/20/12 at 16:05 PM observation rounds were conducted with Staff #3 on the PICU (psychiatric intensive care unit). The table located in the dayroom had a plastic spoon sitting on top of the table. Patient's were observed in the dayroom. The surveyor asked about the spoon and was informed a count of the plastic utensils was supposed to be done at meals and should not be available to patients. A container of golf pencils was observed in the nursing station.

On 11/21/12 at 12:07 PM observation rounds were conducted on the PICU Unit with Staff #3. During rounds the surveyor observed a plastic spoon sitting on the table in the dayroom available for patient use.

The Patients Bill of Rights document reflected, "You have a right to a clean and humane environment in which you are protected from harm...you have the right to receive treatment of any physical problems which affect your treatment..."

The policy entitled, "Level of Observation/Hand-off Communication with a review date of 07/2012 refected, "Line of sight (LOS)...when patients shower, change clothes or use the bathroom the staff will remain outside the bedroom or bathroom door with the door slightly opened and visually check the patient at least every 30 seconds...staff will attempt to maintain the patient's privacy as much as possible, however the safety of the patient must be the main consideration...staff assigned to line of sight must hand off responsibility for maintaining observation...guidelines for LOS...extremely confused and at risk of inadvertent self-harm, medically unstable...assaultive risk but not meeting 1:1 guidelines...guidelines for 1:1...seclusion, restraint or emergency use of meds (medications), actively attempting to harm self or others, hallucinations which have the potential to result in harm to self or others, demonstrated unpredictable behavior, patient failed LOS, unsafe at lower level of care..."

Based on observations, interviews and records review, the hospital failed to provide a sanitary environment which placed patients and staff at risk for acquiring infections from lack of hand washing, contamination of equipment and failure to provide a clean environment.

Findings included:

A) Handwashing was not performed before/during and after patient care according to infection control standards of practice.

B) Soiled items (gloves, Lancets) were stored in a clean bin used for blood glucose monitoring equipment. Glucometer's were not sanitized and/or cleaned between patient use.

C) Medication room on the Geriatric and PICU (Psychiatric Intensive Care Unit) were soiled/dirty and needed cleaning.

Cross Refer to A749

Based on observations, interviews and records review, the Infection Control Officer failed to ensure that proper infection control practices were implemented and/or performed as follows:

A) Handwashing before/during and/or after glucose testing, medication preparation/administration, proper storage/disposal of soiled items such as lancets/gloves and/or sanitizing glucose monitoring equipment between patient use for 4 of 4 patients (Patient #21, #22, #23 and Patient #24).

B) 2 of 2 medication rooms located on the (Geriatric Unit and the Psychiatric Intensive Care Unit) were soiled, dirty and required cleaning. This practice placed both patients and staff at risk for acquiring infections.

Findings included:

A) On 11/20/12 at approximately 04:25 PM observation rounds were conducted with Staff #3 on the PICU (Psychiatric Intensive Care) Unit. Staff #7 was observed with a plastic bin in her hand. The bin contained clean lancets and glucose monitoring strips. Staff #7 placed a pair of gloves on and took the bin and the glucometer to the dayroom. Staff #7 identified (Patient #23) and proceeded to collect a blood glucose sample via finger-stick. Staff #7 removed the soiled glove from the left hand with the soiled/bloody lancet and placed both items in the right gloved hand. Staff #7 removed the glove from the right hand and pulled the glove down over the items. Staff #7 placed the soiled gloves and lancet in the bin with the clean lancets and glucose testing strips. Staff #7 did not sanitize the glucometer and wash hands prior to and/or after the procedure was completed.

On 11/20/12 at 04:35 PM Staff #7 returned to the nursing station after collecting (Patient #23's) blood glucose. Staff #7 did not perform hand washing, left the balled up soiled gloves in the bin and then proceeded to collect a blood glucose sample from (Patient #21). Staff #7 removed the left hand glove and placed the used soiled /bloody lancet and glove in the right hand and pulled the glove from the right hand over all the soiled items and then placed the gloves in the bin and returned to the nursing station. Staff #7 did not perform hand washing before and or after patient contact and did not sanitize the glucometer between patient use.

On 11/20/12 at approximately 04:40 PM Staff #7 took a clean pair of gloves and the bin which contained the soiled gloves and lancets. Staff #7 picked up the bin and placed a clean pair of gloves on and proceeded to collect a blood glucose sample from (Patient #22). Staff #7 removed the glove from left hand and placed the soiled, bloody lancet and glove in the right hand. Staff #7 pulled the glove in the right hand over all the items and placed the gloves in the bin. Staff #7 went into the nursing station and did not wash her hands before and/or after patient contact and did not sanitize the glucometer between patient use.

On 11/20/12 at approximately 04:45 PM Staff #7 returned to the nursing station after collecting (Patient #21 and Patient #22's) blood glucose. Staff #7 did not perform hand washing. Staff #7 entered the medication room and removed a bottle of regular insulin from the refrigerator for (Patient #23). Staff #7 took the opened bottle of regular insulin, did not sanitize the top of the bottle before removing 10 units of regular insulin from the multi-dose vial. The surveyor informed Staff #7 the top of the opened vial was not sanitized before insulin was removed. Staff #7 discarded the insulin and the needle, then proceeded to clean the top of the bottle with an alcohol pad and removed 10 units of regular insulin. Staff #7 left the medication room to administer (Patient #23's) insulin. Staff #7 removed her gloves after administering the medication. Staff #7 was asked if she was aware she had not washed her hands before and/or after patient care. Staff #7 did not offer any explanation.

On 11/21/12 at 02:30 PM Staff #16 was observed administering Motrin 400 mg (milligrams) po (by mouth) every four hours as needed to (Patient #24). Staff #16 did not wash hands and/or sanitize hands prior to opening the medication packages. The surveyor asked Staff #16 about hand washing procedures. Staff #16 stopped and went to the wall mounted hand sanitizer dispenser in the nursing station. Staff #16 could not reach the dispenser. Staff #16 then proceeded to remove a sani-wipe from a container sitting on the desk and proceeded to wipe her hands. Staff #16 did not offer an explanation as to why hand washing was not performed prior to medication administration.

On 11/21/12 at approximately 02:40 PM the Geriatric Unit medication room was observed with Staff #17. The Accu-chek compact plus glucometer was observed sitting on top of the counter. The glucometer was soiled and dirty and the exterior surface had not been cleaned. The manufacturer's recommendations for cleaning was requested and provided. Staff #17 stated she was unsure about cleaning recommendations but stated she cleans it between each patient. The glucometer book reflected no documentation indicating the glucometer was being cleaned.

On 11/29/12 at 10:45 AM Staff #11 was interviewed. Staff #11 stated she was new at doing the infection control program. Staff #11 stated she started the infection control program 10/2012 and alternated two days one week and three days the next week. Staff #11 stated the hospital was supposed to provide infection control training for her. Staff #11 was asked what types of surveillance she was doing in the hospital. Staff #11 stated she had no infection control experience except what she was currently learning.

On 11/29/12 at approximately 10:50 AM Staff #11 was interviewed. Staff #11 reviewed the manufacturer's cleaning recommendations for the glucometer. Staff #11 stated she did not know whether the cleaning recommendations were initiated hospital wide.

B) Staff #11 was asked to accompany the surveyor to the PICU Unit 11/29/12 at 11:05 AM. The medication room cabinet shelves were dusty with a collection of debris. The floor was soiled, dirty and stained, caps to multi-dose vials, alcohol pre pads and a package of 4 x 4's was observed on the floor of the room. Cabinets were in disrepair. The ceiling vent in the medication room was soiled and needed cleaning. The counter surfaces were soiled and dirty. Staff #11 acknowledged infection control practices were not being followed.

On 11/29/12 at 01:30 PM the Geriatric Unit medication room was observed with Staff #2. The floor of the medication room was dirty, soiled with debris spread all over the floor. A roll of gauze was on the floor, a bottle of hydrogen peroxide had no label. The shelves inside the cabinets were dusty and dirty. Staff #2 stated the medication room was supposed to be cleaned daily by housekeeping.

The Accu-chek Compact Plus System Manufacture guide reflected, "Cleaning your meter...if the display or the outside of the meter is dirty wipe if off with a slightly damp cloth or cotton swab...may use water, 10% bleach solution, 70% alcohol (ethyl alcohol) or 70% rubbing alcohol (isopropyl alcohol)...bleach solution must be prepared fresh the day you use it..."

The policy entitled, "Hand Washing" with a review date of 07/12 reflected, "Personnel should wash their hands before and after direct care of significant contact with any patient...before and after donning gloves...during the performance of normal duties (handling dressings, bedpans...) if soap and clean water are not available, use an alcohol-based hand rub to clean your hands..."

The policy entitled, "Waived Testing" with a review date of 07/12 reflected, "Blood glucose monitoring...the nurse will wash his/her hands, and put on disposable gloves prior to testing...if possible, the nurse should ask the patient to wash his/her hands with warm water and soap...dispose of the lancet and test strip directly into a sharps containers, after the finger-stick blood glucose test has been performed...nursing competency...during new hire orientation, an initial competency assessment is completed on all nurses..."

Staff #7's Initial/Annual glucometer test for 2012 and the Fire, Safety, Emergency, & Hazardous Waste Examination and Infection Control Examination was completed on 05/06/12 and reflected the following:

The "Medical Equipment Management Section...before using a medical device on a patient...ensure the device has been cleaned..."

The "Infection Control Examination...proper hand washing is the most crucial step in preventing and controlling hospital acquired infections..."