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On the days of the hospital Validation Survey based on observations, interviews, record reviews, and review of hospital policies and procedures, the facility failed to provide nursing care to all patients as needed for 1 of 1 Registered Nurses observed on the Dialysis unit(Registered Nurse (RN) #7 and 3 of 35 concurrent patient records reviewed for care and services. (Patient #25, 20, and 24)

The findings included:

On 4/19/1 0 at 1115, observations in the dialysis unit of Registered Nurse (RN) #7 showed RN #7 touched the dialysis machine of a patient receiving dialysis but RN #7 had no gloves on his/her hands. RN #7 failed to wash or sanitize his/her hands after touching the patient's dialysis machine. Observation on 4/19/10 at 1222 showed RN #7 donned gloves when he/she disconnected the dialysis patient from the dialysis machine. After RN #7 disconnected the patient from the dialysis machine, he/she removed the gloves but failed to wash or sanitize his/her hands. Then, RN #7 removed strips of tape from a roll, and attached the tape strips onto the side of the patient's over-bed table without disinfecting the table top. After the patient was disconnected from the dialysis machine, RN #7 removed his/her gloves and gown, touched the patient's dialysis machine, and then washed his/her hands for three seconds. On 4/21/10 at 0815, the Charge Nurse of the dialysis unit stated that a patient's dialysis machine was considered dirty, and staff should wear gloves when touching the dialysis machine. The Dialysis Charge Nurse verified that handwashing and/or hand sanitization by staff should be performed after each glove removal.

Review of hospital Policy #203.03, effective 4/2004, "General Hand Hygiene", read, " ... C. Proper hand hygiene will be performed: 1. Before direct contact with patients or their environment. 2. Before donning sterile gloves or clean exam gloves. 3. After contact with the patient's intact skin...6. After contact with inanimate objects, including medical equipment, in the immediate vicinity of the patient. 7. After removing gloves... C. Wash hands with a non-antimicrobial soap and water: ... 3. Before donning and after removing gloves and other Personal Protective Equipment...".





28630

On 4/21/2010 at 0830, a review of Patient #24's chart showed the 85 year old was admitted with diagnoses of Lung Cancer, Chronic Obstructive Pulmonary Disease (COPD), and Pneumonia. Patient #24's chart contained a physician's order dated 4/12/2010 for "Oxygen: 2 Liters NC (nasal cannula) humidified". From 4/19/2010 through 4/21/2010, the nurse Kardex/Hand off Report had the patient's Oxygen amount recorded at 3 lpm (Liters per Minute) by Oxygen device: NC (nasal cannula)". The finding was verified by the Two (2) East Clinical Manager who stated he/she was unable to locate a physician's order to increase the oxygen dose from 2 LPM to 3 LPM.

On 4/21/2010 at 1300, a review of Patient #20's chart showed the 82 year old was admitted with a diagnosis of COPD. Patient #20's chart contained a physician's order dated 4/19/2010 for Oxygen 3 Liters per Minute via NC, humidified and to titrate /taper to 2.5 LPM to keep sats (saturations) > (greater than) 92%. On 4/20/2010, the Nurse assessment conducted at 1955 but recorded at 2304, reads, "O2 (oxygen) maintained on 2 Liters". On 4/21/2010, the Nurse Assessment conducted at 0800 but recorded at 1015, reads, "O2 sats (saturation) maintained on 2 L NC ". There was no physician order for Oxygen to run at 2 Liters per Minute in the physician's order sheets on the patient's chart. The finding was verified by the Three (3) East Clinical Manager who stated that the oxygen should have been administered at 2.5 Liters per minute as prescribed and not at 2 LPM as recorded in the Nurse's Assessment form.

Hospital Policy # CP 892.5 Oxygen Therapy, reads, "...Oxygen devices shall be set up by nursing personnel for routine oxygen administration upon receipt of physician order. ...Nursing personnel or Respiratory Care Practitioners shall perform titration of oxygen administration upon physician order....A physician's order for type of oxygen device, liter flow/FIO2 and titration parameters must be written in the medical record prior to administration of oxygen therapy".

On 4/21/2010 at 1400, a review of Patient #25's chart showed the patient was admitted with R/O (Rule Out) Stroke/ TIA (Transient Ischemic Attack). The patient's chart showed the patient was initially evaluated in the Emergency Department (ED) where a Nursing Orders box for "INT" was checked on 4/19/2010 at 1754. There was no physician order for a saline intervenous lock or Heplock noted on the Physician Admission Orders dated 4/20/2010 at 0145. On 4/20/2010 at 1523, the Nurse Assessment Note, read, "Patient C/O (complaint of) pain at Heplock in right hand site. Heplock started in Right Hand #20 gauge. Good blood return. 1st Heplock started in ED discontinued with catheter intact and dressing applied". The finding was reviewed with Three East Clinical Manager who could not find a physician's order for the intravenous catheter to be discontinued or for another intravenous catheter to be inserted. The Clinical Manager on Three East was asked to clarify the meaning of the abbreviation "INT" box checked in the ED Nursing orders but he/she did not know the meaning of the abbreviation. The Clinical Manager in the Emergency Department stated that "INT" was for a saline lock but he/she was unable to state what the initials meant. At 1645, the Clinical Manager of the Emergency Department found that the initials "INT" meant Intermittent Needle Therapy but stated that this abbreviation was not part of the hospital's approved abbreviation list.
Hospital Policy Number CP 830.1, reads, "Intravenous therapy will be instituted upon the order of physician".

On the days of the Validation Survey based on random observations, patient chart reviews, and interviews with the clinical staff, the hospital failed to ensure that all patients had a Plan of Care consistent with physician orders for 3 of 35 concurrent patient records reviewed for nursing care plans. (Patient #20, 24, and 25)

The findings are:

On 4/21/2010 at 0830, a review of Patient #24's chart showed the 85 year old was admitted with diagnoses of Lung Cancer, Chronic Obstructive Pulmonary Disease (COPD), and Pneumonia. Patient #24's chart contained a physician's order dated 4/12/2010 for "Oxygen: 2 Liters NC (nasal cannula) humidified". From 4/19/2010 through 4/21/2010, the nurse Kardex/Hand off Report had the patient's Oxygen amount recorded at 3 lpm (Liters per Minute) by Oxygen device: NC (nasal cannula)". The finding was verified by the Two (2) East Clinical Manager who stated he/she was unable to locate a physician's order to increase the oxygen dose from 2 LPM to 3 LPM.

On 4/21/2010 at 1300, a review of Patient #20's chart showed the 82 year old was admitted with a diagnosis of COPD. Patient #20's chart contained a physician's order dated 4/19/2010 for Oxygen 3 Liters per Minute via NC, humidified and to titrate /taper to 2.5 LPM to keep sats (oxygen saturations) > (greater than) 92%. On 4/20/2010, the Nurse assessment conducted at 1955 but recorded in the patient's chart at 2304, reads, "O2 (oxygen) maintained on 2 Liters". On 4/21/2010, the Nurse Assessment conducted at 0800 but recorded at 1015, reads, "O2 sats(saturation) maintained on 2 L NC ". There was no physician order for Oxygen to run at 2 Liters per Minute in the physician's order sheets on the patient's chart. The finding was verified by the Three (3) East Clinical Manager who stated that the oxygen should have been administered at 2.5 Liters per minute as prescribed and not at 2 LPM as recorded in the Nurse's Assessment form.

Hospital Policy # CP 892.5 Oxygen Therapy, reads, "...Oxygen devices shall be set up by nursing personnel for routine oxygen administration upon receipt of physician order. ...Nursing personnel or Respiratory Care Practitioners shall perform titration of oxygen administration upon physician order....A physician's order for type of oxygen device, liter flow/FIO2 and titration parameters must be written in the medical record prior to administration of oxygen therapy".

On 4/21/2010 at 1400, a review of Patient #25's chart showed the patient was admitted with R/O (Rule Out) Stroke/ TIA (Transient Ischemic Attack). The patient's chart showed the patient was initially evaluated in the Emergency Department (ED) where a Nursing Orders box for "INT" was checked on 4/19/2010 at 1754. There was no physician order for a saline intervenous lock or Heplock noted on the Physician Admission Orders dated 4/20/2010 at 0145. On 4/20/2010 at 1523, the Nurse Assessment Note read, "Patient C/O (complaint of) pain at Heplock in right hand site. Heplock started in Right Hand #20 gauge. Good blood return. 1st Heplock started in ED discontinued with catheter intact and dressing applied". The finding was reviewed with Three East Clinical Manager who could not find a physician's order for the intravenous catheter to be discontinued or for another intravenous catheter to be inserted. The Clinical Manager on Three East was asked to clarify the meaning of the abbreviation "INT" box checked in the ED Nursing orders but he/she did not know what the abbreviation meant. The Clinical Manager in the Emergency Department stated that the abbreviation "INT" was used for a saline lock but was unable to state what the initials meant. At 1645, the Clinical Manager of the Emergency Department found that the initials "INT" meant Intermittent Needle Therapy but verified that this abbreviation was not part of the hospital's approved abbreviation list.
Hospital Policy Number CP 830.1, reads, "Intravenous therapy will be instituted upon the order of physician".

On the days of the hospital Validation survey based on record review and interview, the hospital failed to provide the necessary documentation to ensure that medications (heparin) are infused according to physician orders for 2 of 4 dialysis patients whose charts were reviewed for care and services. (Patient #17 and 18)

The findings are:

On 4/20/10 at 1330, a review of Patient #17's medical record revealed the eighty three year old was admitted on 4/19/10 with diagnoses of acute congestive heart failure, chronic obstructive pulmonary disease and chronic renal failure. Physician orders dated 4/19/10 included hemodialysis for four hours with a target weight of 77.5 kgs. (kilograms), heparin 2000 units loading dose IV (intravenous), and heparin 1000 units/hour maintenance dose IV (Stop last hour of treatment).
Review of the hemodialysis treatment sheet dated 4/19/10 showed staff documented a pre- dialysis weight of 84.0 kgs., initiation of treatment at 1622 and treatment completed at 2009 for a total of three hours and forty-seven minutes. The patient's dialysis access was a right upper arm AV (arteriovenous) graft. The patient's post weight was recorded as 79.6 kgs. The patient's "Pre- Dialysis Summary" that was documented by the nurse at 1839 showed that a heparin loading dose of 2000 units, and a heparin maintenance dose of 1000 units, stopping the last hour, was to be administered. Nurse notes at 2040 showed the nurse documented termination of the patient's treatment early per the patient's request. The "Post Dialysis Summary" on page 1 of the treatment sheet showed staff documented a heparin loading dose of 2000 units and a heparin maintenance dose of 1000 units for a total dose of heparin administered as 3,000 units.
Physician orders dated 4/20/10 showed documentation of a change in treatment time to 3 hours and thirty minutes duration. The heparin loading dose and maintenance dose remained unchanged. Review of the hemodialysis treatment sheet dated 4/20/10 showed staff documented a pre-dialysis weight of 78.6 kg., initiation of treatment at 0845, and patient treatment was completed at 1217 for a total of three hours and thirty-two minutes. There was no documentation on 4/19/10 or 4/20/10 of the amount of heparin administered as the maintenance dose.

On 4/20/10 at 1430, a review of Patient #18's medical record revealed the fifty-four year old was admitted on 4/05/10 with a chief complaint of shortness of breath and diagnoses of Diabetes Mellitus type II and Hypertension. The chart showed the Physician prescribed acute hemodialysis orders, written on 4/14/10, included a treatment time of three hours and forty-five minutes, heparin 1000 units loading dose IV, and heparin 500 units maintenance dose IV (stop last hour of treatment). The hemodialysis treatment sheet, dated 4/14/10, showed staff documented a pre-dialysis weight of 86.2, initiation of patient treatment at 0820 and patient treatment completed at 1206 for a total treatment time of three hours and forty-six minutes. The dialysis access was a right jugular dialysis catheter. The "Post Dialysis Summary" on page 1 of the patient's treatment sheet showed staff documented a heparin loading dose of 1000 units and a heparin maintenance dose of 500 units. The hemodialysis treatment sheet, dated 416/10, showed staff documented a predialysis weight of 86.8 kgs., patient treatment initiation time at 0806 and patient completion time of 1213 for a total treatment time of four hours and seven minutes. The "Post Dialysis Summary" on page 1 of the treatment sheet, showed staff documented a heparin loading doses of 1000 units and a heparin maintenance dose of 500 units. There was no documentation on 4/14/10 or 4/16/10 of the amount of heparin administered as the maintenance dose.

On 4/21/10 at 0815, the findings were reviewed and discussed with the Dialysis Unit Manager and Dialysis Charge Nurse who verified that the amount of heparin administered as the maintenance dose was not documented on the patient's treatment sheets.

Review of hospital policy # MM1000.04, effective date 10/01/2009, "Medication Management", read, " ... 4. Administering: ... B. All medications given must be recorded either in the electronic Medical Administration Record or on specific flow sheets or appropriate computer system ... ".

On the days of the hospital Validation survey based on observations, record reviews, and interviews, the hospital failed to ensure that the hospital had policies and procedures to ensure that multidose vials of medication were transported, stored, and administered in accordance with accepted professional principles and infection control guidelines for all patients receiving medications from multidose vials. (Registered Nurse #2)

The findings are:

On 4/21/10 at 0910, random observation of patient care on the Two North Telemetry Nursing unit revealed Registered Nurse (RN) #2 was transporting an open vial of Novolog Insulin in his/her pocket. During an interview, RN #2 reported that there were two single vials of Insulin on the unit which were used for all patients requiring Insulin dosing. RN #2, the Unit Nurse Manager, and the Unit Clinical Coordinator/Charge Nurse reported that the hospital had no policy and procedure for the transport, storage, and/or the administration of multidose medications to and from the patient bedside or for the transport and storage of medications from a multidose vial after administration to patients. Staff reported that they have always used the same vial of insulin for all patients including Isolation patients. Review of the hospital Policy and Procedure manual revealed the hospital had no policies or procedures for the transport, storage, and administration of medications in multidose vials. On 4/21/10 at 1035, during an interview with the Nurse Manager for 2 North, he/she reported that the medication (Insulin) could be taken into an isolation room as long as the medication vial was placed into a plastic bag with only the neck the bottle exposed to draw up the medication into a syringe. Upon exiting the isolation room and prior to returning the vial of medication to the refrigerator in the medication room, staff should use alcohol to wipe down the entire vial of insulin.

On the days of the Validation Survey based on observation, interview, and review of hospital policy and procedure, the hospital failed to ensure that outdated biologicals and drugs were removed from patient care areas. (Grand Strand Ambulatory Center, Grand Strand Regional Medical Center-Radiology)

The findings are:

A tour was conducted of the Radiology Department of Grand Strand Ambulatory Center on 04/21/10. Observation of the CAT(Computerized Axial Tomography) Scan Room at 0900 revealed 1-200 cubic centimeter(cc) bottle of Isovue with approximately 125 cc left that was labeled with the date of 04/21/10 at 0900. Radiology Technician (RT) #1 reported that the bottle was labeled with the date and time that the bottle was opened. The bottle would be discarded 24 hours from that date. Observation of the label on the bottle reads, "... Discard container no later than 10 hours after initial entry....".

A tour of the Radiology Department of the Grand Strand Regional Medical Center was conducted on 04/20/10 at 1300. Observation of the emergency box in the MRI (Magnetic Resonance Imaging) Room revealed 2- 1 cc vials of Naloxone dated February 2010. The finding was confirmed with the Radiology Manager.

Review of hospital policy and procedure, titled, Medication Management, reads, "...4F. All containers are labeled adequately including the addition of appropriate accessory or cautionary statements as well as expiration dates where applicable...".

On the days of the hospital Validation Survey based on observations, interviews, and review of hospital policies and procedures, the facility failed to ensure a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel for hospital staff who failed to use proper handwashing hygiene in the Dialysis unit (Registered Nurse(RN) #7, proper use of single use oxygen connector tubing in the Radiology department, and proper storage and handling of a Novolog Insulin vial between multiple patient use on Two North Telemetry Nursing Unit (RN #2).

The findings include:

Observations in the dialysis unit on 4/19/1 0 at 1115 showed Registered Nurse #7 touched the dialysis machine of a patient receiving dialysis without wearing gloves or performing handwashing and/or hand sanitization prior to or after touching the patient's dialysis machine. On 4/19/10 at 1222, RN #7, who was wearing gloves, disconnected the dialysis patient from the dialysis machine, and then removed his/her gloves but did not perform hand washing and/or hand sanitization. Observation of RN #7 as he/she removed strips of tape from a roll of tape, and then, attached the tape strips onto the side of the patient's over-bed table without disinfecting the table top. After the patient was disconnected from the dialysis machine, RN #7 removed his/her gloves and gown, touched the patient's dialysis machine, and then performed handwashing for three seconds. In an interview on 4/21/10 at 0815, the Charge Nurse of the hospitals's dialysis unit reported that a patient's dialysis machine was considered dirty and gloves should be worn by staff when touching the dialysis machine. The Charge Nurse also verified that handwashing and/or hand sanitization should be performed by staff after glove removal.

Review of hospital policy #203.03, effective 4/2004, "General Hand Hygiene", read, " ... C. Proper hand hygiene will be performed: 1. Before direct contact with patients or their environment. 2. Before donning sterile gloves or clean exam gloves. 3. After contact with the patient's intact skin...6. After contact with inanimate objects, including medical equipment, in the immediate vicinity of the patient. 7. After removing gloves... C. Wash hands with a non-antimicrobial soap and water: ... 3. Before donning and after removing gloves and other Personal Protective Equipment...".


27544

A tour was conducted of the Radiology Department of South Strand Medical Center on 04/20/10 at 1200. Observation of the CAT(Computerized Axial Tomography) Scan Room #1 revealed oxygen extension tubing wrapped around the oxygen meter that looked cloudy and speckled in spots on the tubing. RT (Radiology Technician) #2 revealed that the tubing was changed if the oxygen tubing had been used by a patient when staff cleaned the room in between patients. RT#2 reported that the oxygen tubing was considered clean if the oxygen tubing was wrapped around the oxygen flow meter. The findings were confirmed with the Radiology Manager on 04/20/10 at 1200.

On 04/20/10 at 1430, a tour was conducted of the Nuclear Medicine Department of the Grand Strand Regional Medical Center with the Nuclear Medicine Supervisor. Observation of the procedure room showed oxygen extension tubing had scotch tape around the connection site. The Nuclear Medicine Supervisor reported that the oxygen extension tubing was used on the last person who had oxygen ordered, but the oxygen tubing had not been changed out even though another patient was undergoing a procedure in the procedure room. The findings were confirmed with the Director of Radiology on 04/22/10 at 1000.

On 04/21/10 at 1000, a tour was conducted of the Grand Strand Ambulatory Center Radiology Department with the Supervisor of Radiology. Observation of the patient bathroom in the Fluoro Room revealed several folded towels and a patient gown lying over the open garbage can.


27669

On 4/21/10 at 0910, observation of patient care of the Two North Telemetry Nursing unit revealed Registered Nurse #2 was transporting an opened vial of Novolog Insulin in his/her pocket for use on multiple patients. RN #2 reported that there were two single vials of Insulin on the unit which were used for all patients who required Insulin dosing. RN #2, Nurse Manager, Unit Supervisor, Chief Nursing Officer, and Infection Control Nurse reported that the hospital has no policy and/or procedure for the transport and/or storage of multidose medication vials used for the administration of medications to multiple patients. RN #2, Nurse Manager, Unit Supervisor, Chief Nursing Officer, and Infection Control Nurse reported that staff had always used the same vial for medicating all patients requiring the medication (insulin) including Isolation patients. On 4/21/10 at 1035, during an interview with the Nurse Manager for 2 North, he/she reported that the Insulin could be taken into an isolation room as long as the medication vial was placed into a plastic bag with only the neck the bottle exposed to draw up the medication into a syringe. Upon exiting the isolation room and prior to returning the vial of medication to the refrigerator located in the medication room, staff should use alcohol to wipe down the entire vial of insulin. During an interview with the Infection Control Nurse on 4/21/10 at 1340, he/she verified that the hospital had no Policy and Procedure prior to the survey that specified the proper technique for transport and storage of multidose medication vials into an isolation room with the intention of returning the multidose vial back to the unit's medication refrigerator.

Review of the hospital policy, Reference number 204.03, "Infection Control- Isolation", with an effective date of April 2004, revised May 2009, reads, "...Equipment should be dedicated to the use of the isolation patient for the duration of precautions. If this not possible and equipment must be used between patients, all mobile equipment must be decontaminated prior to use on another patient...". There were no documentation of a hospital policy and procedure for the storage and handling of drugs and biologicals for multidose vials.

On the days of the Validation Survey based on interview and facility record review, the hospital failed to ensure radiopharmaceuticals were prepared under the direct supervision of a qualified physician or pharmacist.(Nuclear Medicine Department)

The findings are:

During an interview on 04/20/10 at 1430, the Nuclear Medicine Supervisor revealed that approximately once a month the hospital finds it necessary during non business hours for the nuclear technologist to prepare radiopharmaceuticals for patient use because of an add on test or an emergency situation. The Nuclear Medicine Supervisor reported that after non business hours, radiopharmaceuticals are prepared by the nuclear technologist without direct supervision from the physician or a pharmacist. During an interview on 04/21/10 at 1400 with the Medical Director of Nuclear Medicine, the Medical Director confirmed that the nuclear technologist prepares radiopharmaceuticals without the direct supervision of a trained physician or pharmacist. On 04/20/10, a review of hospital form, titled, Packing Slip, verified that MAA and DTPA kits were prepared by the Nuclear Technologist on 03/13/10.