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A. Based on document review, observational tour, and interview, it was determined for 1 of 2 patients (Pt. #5), the Hospital failed to ensure patients with skin wounds were repositioned at least every 2 hours.

Findings include:

1. On 3/6/17 at 3:35 PM, Hospital policy #2838029, titled, "Skin Assessment and Management / Specialty Beds Policy", revised 5/1/14, was reviewed. The policy required, "C. Preventative Interventions... 2. Sensory Perception... Able to respond meaningfully to pressure related discomfort... Completely limited... increase frequency of turning and repositioning..."

2. On 3/6/17, between 9:50 AM and 11:30 AM, an observational tour was conducted in the 2500 Unit (Medical/ Surgical/ Oncology). At 10:40 AM, the wound nurse was bandaging Pt. #5's sacral area with an approximately 5" by 5" bandage. Pt. #5 was in bed on her left side and was unable to turn independently.

3. On 3/6/17 at 11:05 AM, Pt. #5's clinical record was reviewed. Pt. #5 was a 61 year old female, admitted on 3/2/17, with a diagnosis of end stage renal disease. Pt. #5's Braden scale dated 3/5/17 at 3:52 PM, included a score of 14, requiring turning. Pt. #5's turning flow sheet lacked turning documentation between 3/5/17 at 5:05 AM and 3/5/17 at 11:25 PM, for 18 hours and 20 minutes.

4. On 3/6/17 at 11:15 AM, an interview was conducted with a Clinical Informatic Registered Nurse (E #4). E #4 reviewed Pt. #5's record and stated Pt. #5 should have been turned every 2 hours.

5. On 3/6/17 at 3:25 PM, a meeting was conducted with the Director of Clinical Integration, Quality and Regulation (E #5). E #5 was informed of the finding.



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B. Based on document review, observation and interview, it was determined, for 1 of 1 Patient (Pt. #1) in the ICU (intensive care unit) on NPO status (nothing by mouth - not allowed to eat or drink), the hospital failed to ensure the patient did not drink.

Findings include:

1. The Hospital policy titled, "Medication Administration General Policy" (revised 5/11/16) was reviewed on 3/6/17. The policy included, "Medications are administered upon physician/designee's order".

2. The Hospital policy titled, "Patients NPO or on Clear Liquid Diet Policy" (revised 10/27/16) was reviewed on 3/6/17. The policy included, "The Nursing Unit/Physician is responsible for entering orders in the order management system. This included patients that are NPO".

3. The clinical record of Pt. #1 was reviewed on 3/6/17 at 10:50 AM. Pt. #1 was a 69 year old male, admitted on 3/2/17, with the diagnoses of seizure disorder, anemia, and end stage renal disease. The clinical record included a physician's order dated 3/5/17 at 7:10 PM for, "NPO effective at midnight" for abdominal ultrasound.

4. The Medication Administration Report (MAR) dated 3/6/17 included documentation that Pt. #1 received the following medications: Vitamin B-12 tablet at 9:42 AM, Tricor (cholesterol) tablet at 9:53 AM, folic acid (vitamin) tablet at 9:43 AM, Namenda (treat Alzheimer) tablet at 9:53 AM, Midodrine (Blood pressure) tablet at 7:45 AM, Protonix (stomach) tablet at 6:33 AM, Potassium tablet at 9:43 AM, Crestor (cholesterol) tablet at 9:42 AM, and Zoloft (antidepressant) tablet at 9:43 AM.

5. While reviewing the clinical record of Pt. #1 in the nurses' station, the ultrasound was observed being completed in Pt. #1's room at 10:55 AM.

6. During an interview on 3/6/17 at 11:00 AM, the treating nurse (E#1) stated, "I'm not sure why the patient is NPO, but I did give (Pt. #1) his medications with water. I thought the order said the patient could have his normal medications".

Based on document review and interview, it was determined for 3 of 3 (Pt #14, 30, and 31) clinical record reviewed of patients that required subcutaneous medications, the Hospital failed to ensure the location of the injection was documented.

Findings include:

1. Hospital policy entitled, "Medication Administration Record (EAR/MAR) Policy," (last reviewed 5/11/2017) was reviewed and required, "Procedure: Electronic Medication Record (MAR)...V. Insulin Documentation...B. The...injection site are entered on the EMAR."

2. The clinical record of Pt #14 was reviewed on 3/6/17 at approximately 10:50 AM. Pt #14 was a 64 year old male admitted on 2/18/17 with a diagnosis of acute kidney injury. Pt #14's clinical record contained a physician's order dated 2/23/17 that required Homology insulin per sliding scale. Pt #14's clinical record contained EMAR documentation that failed to include the injection site of the insulin administration on: 3/3/17 at 6:58 PM, 2 units subcutaneous; 3/5/17 at 12:28 AM, 2 units subcutaneous; and 3/6/17 at 6:05 AM, 2 units subcutaneous.

Pt #14's clinical record contained a physician's order dated 2/19/17 that required 5000 units heparin subcutaneous every 8 hours. Pt #14's clinical record contained EMAR documentation that failed to include the injection site of the heparin administration on: 3/5/17 at 12:58 PM, 3/5/17 at 8:16 PM, and 3/6/17 at 4:05 AM.

3. The clinical record of Pt #30 was reviewed on 3/8/17 at approximately 9:00 AM. Pt #30 was a 42 year old male admitted on 12/25/16 with a diagnosis of hyperglycemia (high blood sugar). Pt #1's clinical record contained a physician's order dated 12/26/16 for Heparin 5,000 units subcutaneous every 8 hours. The EMAR included the medication was administered on 12/27/16 at 12:17 PM and 8:50 PM. However, the EMAR lacked documentation of the injection site of the medication.

Pt #30's clinical record contained a physician's order dated 12/25/16 for Levemir (insulin) 15 units subcutaneous once. The EMAR included the Levemir was administered on 12/25/16 at 6:25 AM. However, the EMAR lacked documentation of the injection site of the medication.

4. The clinical record of Pt #31 was reviewed on 3/8/17 at approximately 10:00 AM. Pt #31 was a 59 year old male admitted on 10/31/16 with diagnoses of end stage renal disease and diabetes mellitus. Pt #31's clinical record contained a physician's order dated 11/1/16, that required Levemir sliding scale insulin. Pt #31's clinical record contained EMAR documentation that failed to include the injection site of the insulin administration on: 11/1/16 at 10:11 AM, 8 units given; 11/2/16 at 9:34 AM, 8 units given; 11/3/16 at 9:09 AM, 8 units given; and 11/4/16 at 6:37 AM, 4 units given.

Pt #31's clinical record contained a physician's order dated 10/31/16 that required 5000 units Heparin subcutaneous every 12 hours. Pt #31's clinical record contained EMR documentation that failed to include the injection site of the heparin administration on: 10/31/16 at 10:20 PM, 11/1/16 at 10:54 PM, 11/03/16 at 7:47 AM, and 11/4/16 at 8:39 AM.

5. The Vice President of Clinical Services (E #11) stated, during an interview on 3/8/17 at approximately 1:30 AM, that the injection sites should have been documented when the medications were given.

Based on document review and interview it was determined, the Hospital failed to ensure that medical records were completed within 30 days after discharge.

Finding include:

1. The Hospital "Rules and Regulations of the Medical Staff" (revised March 2, 2017), reviewed on 3/7/17, included, "Each medical record shall be completed within thirty (#30) days of discharge... "

2. On 3/7/17 at approximately 1:00 PM, the Hospital presented an attestation letter that indicated the Hospital had a total of 302 delinquent records past 30 days.

3. On 3/7/17 at approximately 1:10 PM the Director of Health Information Services (E#13) stated, "our expectation is to have zero delinquent records".

Based on document review, observation, and interview, it was determined, for 1 of 1 freezer in the kitchen (D3), the Hospital failed to ensure that opened food product was labeled with date of opening. This potentially affected the patients being served the unlabeled food products.

Findings include:

1. The Hospital policy titled, "Food and Supply Storage Policy" (revised 1/10/17), was reviewed on 3/7/17. The policy required, "Stored food, if removed from the immediate container or package in which it was obtained, is enclosed in a clean, covered container and labeled with the name of the product and the date. Labels on cases are exposed for easy identification".

2. An observational tour was conducted in the dietary department on 3/7/17 at 10:45 AM. The following opened and unlabeled food was found at 11:00 AM in freezer D3:

- 1 half bag of frozen vegetables (wrapped in a plastic wrap);
- 3 bags of frozen chicken nuggets (placed in clear open bags);
- 1 box frozen hamburger patties (original box - unlabeled); and
- 1 box of frozen biscuits (original box - unlabeled).

3. During an interview on 3/7/17 at approximately 11:05 AM, the Director of Operations of Dietary (E#12) stated, "all open product should be dated with the date it was opened".

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Sample Validation Survey conducted on March 6 - 8, 2017, that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Sample Validation Survey conducted on March 6 - 8, 2017, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review and interview, it was determined, for 3 of 3 code carts in ICU A, ICU B and ICU/CV, (intensitve care unit/cardiovascular), the Hospital failed to ensure the code carts were checked daily. This potentially affected the average daily census of 13 ICU/CV patients.

Findings included:

1. The Hospital policy titled, "Code Blue Policy" (revised 2/2/16), was reviewed on 3/6/17. The policy required, "An RN (registered nurse) or designee will be assigned to check the code cart daily..."

2. The ICU/CV code cart check lists were reviewed on 3/6/17 at approximately 10:00 AM. There were 3 code carts on the ICU/CV unit. The following daily checks were missing:

ICU A - 2/19/17, 2/23/17, 2/24/17, 2/26/17, and 2/27/17.

ICU B - 2/23/17, 2/24/17, 2/26/17, and 2/27/17.

ICU/CV - 11/24/16, 2/23/17, 2/24/17, 2/26/17, and 2/27/17.

3. During an interview on 3/6/17 at approximately 10:10 AM, the Director of ICU (E#2) stated, "The crash carts need to be checked everyday".

A. Based on document review, observational tour, and interview, it was determined for 1 of 1 patient (Pt. #4) in droplet isolation, the Hospital failed to ensure droplet isolation was enforced.

Findings include:

1. On 3/6/17 at 2:35 PM, Hospital policy # IC-505, titled, "Droplet Precautions Policy", revised 11/30/15, was reviewed. The policy required, "C. Mask: Wear a mask before entering the patient room..."

2. On 3/6/17, between 9:50 AM and 11:30 AM, an observational tour was conducted in the Hospital (location #1) in the 2500 Unit (Medical/ Surgical/ Oncology). At 10:30 AM, a Droplet Precaution sign was on the door of room 2534. Pt. #4 was in bed in room 2534 and a female, not wearing a mask, was sitting in a chair in the same room.

3. On 3/6/17 at 10:30 AM, an interview was conducted with a female who was standing outside of room 2534. The female stated that she was Pt. #4's daughter and that the female sitting in the room was Pt. #4's wife. Pt. #4's daughter stated Pt. #4 was admitted this morning (3/6/17) and no one had informed her or her mother about droplet precaution isolation and the requirement to wear a mask when entering room 2534.

4. On 3/6/17, at 10:30 AM, an interview was conducted with the Nurse Manager (E #3). E #3 was present during the interview with Pt. #4's daughter and provided instruction to her regarding wearing a mask when entering Pt. #4's droplet isolation room. Pt. #4's daughter told E #3 she would inform her mother of the requirement to wear a mask.

5. On 3/6/17 at 10:45 AM, Pt. #4's clinical record was reviewed. Pt. #4 was a 67 year old male, admitted on 3/5/17, with a diagnosis of complicated urinary tract infection. Pt. #4's physician order dated 3/6/17 at 4:02 AM, required droplet isolation precaution "until specified".



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B. Based on document review, observation, and interview, it was determined that for 1 of 2 linen carts in the recovery room, the Hospital failed to ensure the linen was stored adequately as required. This potentially affected all surgical patients.

Findings include:

1. The Hospital policy titled, "Clean Linen Distribution Policy" (reviewed 10/27/16), indicated, "Procedure: D. Clean linen is to be properly stored and covered at all times, while on the units and during transportation from Linen Services to patients areas."

2. On 3/7/17 at approximately 11:00 AM, during an observational tour in the Recovery Room of the Surgical Department there was a cart located in the supply room that contained the following: pillow cases, flat sheets, gowns, boxes filled with paper, and large envelopes filled with paper.

3. On 3/7/17 at approximately 11:05 AM, the Recovery Room Charge Nurse ( E #14) was interviewed. E #14 stated the linen in this linen cart located in the supply room was additional linen, that may be used on the weekend. E #14 also stated the boxes and envelopes in the linen cart were for documentation of monitoring of the equipment in the recovery room. E #14 stated that this where it is always kept.

4. On 3/17/17 at approximately 11:20 AM, the Director of Perioperative Department (E #6) was interviewed. E #6 stated that linen should not have been kept in that cart and there is a designated area for linen storage.



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C. Based on observation, interview, and document review, it was determined for 1 of 1 (E #10) certified registered nurse anesthetist (CRNA) observed, the Hospital failed to ensure the CRNA disinfected the intravenous injection port prior to medication administration.

Findings include:

1. On 3/7/17 between 9:50 AM and 10:30 AM, an observational tour in OR (operating room) #6 was conducted. A CRNA (E #10) was observed administering intravenous medications to Pt. #37 without disinfecting the injection port. Medications administered included: Fentanyl, Propofol, Rocuronium, and Lidocaine (all used in the anesthetic process).

2. On 3/7/17 between 11:00 AM and 11:30 AM, the finding was discussed with E #6 (Director of Perioperative Department) and E #7 (Perioperative Department Manager) who both stated that the injection port should have been disinfected.

3. On 3/7/17 at approximately 3:00 PM, the Hospital's policy titled "Medication - Intravenous Policy" (reviewed 3/10/16) was reviewed and indicated, "... II. Method for IV (intravenous) Administration... 3. IV push (IVP) Medications 1.a. Cleanse injection port with approved antiseptic..."

Based on observation, interview, and document review, it was determined for 3 of approximately 5 employees (E #'s 7, 8, and 9) and 2 of approximately 3 physicians (MD #1 and 2) observed in operating room (OR) #6, where a sterile field was opened, the Hospital failed to ensure adherence to the operating room attire policy.

Findings include:

1. On 3/7/17 between 9:50 AM and 10:30 AM, an observational tour in OR #6 was conducted:

- The Perioperative Manager (E #7), had hair exposed from the back of head cover. Registered Nurses' (E #8 E #9) hair was exposed on the side of the face. An Anesthesiologist (MD #2) had approximately 1 inch of hair exposed on both temples.

- An Orthopedic Surgeon (MD #1) entered the room with his surgical mask untied.

2. On 3/7/17 between 11:00 AM and 11:30 AM, the findings were discussed with E #6 (Director of Perioperative Department) and E #7 (Perioperative Department Manager) who both stated that hair should be covered and that mask should be tied.

3. On 3/8/17 at approximately 9:30 AM, the Hospital policy titled "Attire, Operating Room Policy" (reviewed 6/2016) was reviewed and required, "...B. Personnel must cover head and facial hair, including sideburns and necklines, when in the semi restricted or restricted areas of the surgical suite... C. All individuals entering the restricted areas of the operating room (OR) suite must wear a mask when open sterile items or equipment are present. (See "Face Mask" policy)

4. On 3/8/17 at approximately 9:45 AM, the Hospital policy titled "Face Masks Policy" (reviewed 1/2016) was reviewed and required, "...All individuals entering the restricted areas of the operating suite must wear a face mask when open sterile supplies or equipment are present... Guidelines...3. The strings of a mask shall be tied behind the head and neck."