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Based on record review, and interview, the governing body did not ensure that the dialysis services performed under a contract were provided in a safe and effective manner for 1 of 1 patient (Patient #1). This deficient practice presented a risk of harm to all hemodialysis patients on census at the facility.

Findings included:

On 08/24/11 at 11:10 AM, a review of Patient #1's Hemodialysis treatment record reflected that the treatment record included contradictory labeling. The treatment record did not include the actual concentration level results of the chlorine/chloramine test. The treatment record included in the Hemodialysis Machine and RO Pre-Safety Checks section that the result of the chlorine/chloramine test was recorded as "negative." The surveyor asked a Certified Clinical Hemodialysis Technician (CCHT-Personnel #5) employed by the contracted service about the "negative" result on the treatment sheet and requested the test strips used to get the "negative" result. The CCHT (Personnel #5) produced the WaterCheck RC residual chlorine reagent with bleach indicator test strips used to monitor the chlorine concentrations during the process of disinfection. The surveyor interviewed the Biomedical Technician (BMT-Personnel #13) employed by the contracted service. The BMT (Personnel #13) stated that the facility used RPC Ultra-Low Total Chlorine K100-0118 test strips to test the water for total chlorine/chloramines.

During an interview on 08/24/11 at 11:30 AM, the Supervising Nurse and the Regional Quality Manager employed by the contracted service (Personnel #1 and #2) confirmed the record was contradictory, and that the maximum allowable concentration of chlorine/chloramines is 0.1 mg/L.

The Acute Dialysis Therapeutic Apheresis Services Agreement dated June 1, 2011 included:
"1. Duties of the Provider
1.07 Provider agrees to maintain and ongoing Quality Management Program that includes
the following activities: continuous quality improvement, safety and infection control, and
risk management."

Based on review of records and interview, the hospital failed to ensure that drugs were administered according to the physician's orders for 2 of 4 patients (Patient #4 and #5) who were hospitalized after 06/01/11 and received sliding scale insulin injections during their hospitalization. This presents the risk of potential harm to patients who received insulin injections.

Findings included:

Patient #4:
The "History and Physical" of Patient #4, age 68, indicated that Patient #4 was admitted to the hospital on 06/04/11 with "severe anemia." Patient #4's medical history included, "insulin-dependent diabetes mellitus type 2." The "Doctor's Orders" dated 06/04/11 11:00 AM included sliding scale insulin "Novolin R" 4 units for a fasting blood sugar of 201-250 and 6 units for a fasting blood sugar of 251-300.

Patient #4's "Laboratory-Chemistry Report" indicated that at 07:46 AM on 06/05/11, Patient #4 had a point of contact glucose level of 248 (high). The "Medication Discharge Summary" indicated that at 08:17 AM, Patient #4 was given 6 units of insulin into the left lower abdominal quadrant instead of 4 units as ordered by the physician. The 10:05 AM nurse's notes indicated that Patient #4 was "resting quietly with no signs of pain or distress...respirations...even and unlabored at this time..." At 11:04 AM, Patient #4's glucose level was high at 241. At 12:10 PM, 4 units of insulin was injected into Patient #4's right upper arm per the physician's sliding scale insulin order. The physician's "progress record" indicated that on 06/06/11 Patient #4 was doing well and discharged to a nursing home.

Patient #5:
The "History and Physical" of Patient #5, age 36, indicated Patient #5 was admitted to the hospital on 06/04/11 with "flank pain, fever and vomiting for 3 days, with evidence of pyelonephritis." Patient #5's medical history included "diabetes mellitus type 2, insulin requiring." The "Doctor's Orders" dated 06/04/11 02:40 PM included sliding scale insulin "Humalog" with zero units for a blood sugar of 0-150, 2 units for a blood sugar of 151 to 200, and 6 units for a blood sugar of 251-300.

Patient #5's "Laboratory - Chemistry Report" indicated that at 02:50 AM on 06/05/11, Patient #5 had a point of contact glucose level of 275 (high). The "Medication Discharge Summary" indicated that at 02:53 AM, Patient #5 received 6 units of insulin into the right lower abdominal quadrant. Patient #5's random glucose at 06:40 AM was 188 (high). At 08:35 AM, the "Medication Discharge Summary" indicated 6 units of insulin were administered to the right lower abdominal quadrant. The 06/05/11 11:08 AM point of contact glucose level was 145 and designated at high. The 12:30 PM nurse's notes indicated that Patient #5's lunch was served, "no other needs voiced." At 03:15 PM no insulin was given per the physician's sliding scale order.

The 06/05/11 07:42 PM nurse's notes indicated that Patient #5 was "...resting quietly with no signs of pain or distress...respirations are even and unlabored..." The physician's "progress record" indicated that on 06/06/11 Patient #5 felt better, had no fever, and no abdominal pain. Patient #5 was discharged home.

During an interview at approximately 03:15 PM on 08/24/11, the Nurse Manager (Personnel #15) reviewed the medical record information for Patients #4 and #5. Personnel #15 agreed that there were discrepancies between the physician's orders and documented medication administration information.

The "Medication Handling and Administration Policy" revised 06/30/11 included "Medication Administration...should be checked for the five (5) rights of medication(s) to be given...right dosage..."

Based on review of records and interview, the operating room register was not complete in that the time anesthesia began and ended was not included in the register for 2 of 2 patients (Patient #2 and #3) who received surgical procedures after 06/01/11 at this hospital. The hospital failed to produce a policy that contained the register's required information.

Findings included:

The "Operative Report" electronically signed 07/07/11 for Patient #2, age 83, included that Patient #2 had a "left knee arthroscopic partial medial lateral meniscectomy...chondroplasty to the medial femoral condyle" on 06/29/11. The electronic "Daily Surgery Log" produced for the surveyor on 08/25/11 did not include the time anesthesia began and ended for Patient #2.

The "Operative Report" electronically signed 06/02/11 for Patient #3, age 49, included that Patient #3 had a "laparoscopic cholecystectomy with intraoperative cholangiogram...umbilical hernia repair with mesh" on 06/02/11. The electronic "Daily Surgery Log" produced for the surveyor on 08/25/11 did not include the time anesthesia began and ended for Patient #3.

During an interview at approximately 02:15 PM on 08/25/11, the Manager of Surgical Services (Personal #14) reviewed the electronic operating room register with the surveyor and agreed that the time anesthesia began and ended was not included in the register. Personnel #14 was not able to produce a policy that included the information that was to be included in the operating room register.