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Based on document review and interview, the Governing Body failed to maintain oversight to ensure that all patient safety issues related to the ordering, collection and labeling of laboratory specimens are promptly addressed and corrected. The failure to promptly address and correct issues related to the proper identification of specimens can place patients at risk for harm due to patient misidentification.

Findings include:

See Tag # 263

Based on document review and interview, the facility failed to utilize its Quality Assessment and Performance Improvement (QAPI) Program to ensure that identified variances related to the ordering, collection and labeling of specimens have been addressed. Failure to thoroughly investigate and address variances has the potential for patient harm.

Findings include:

Review of Department of Pathology meeting minutes dated 1/15 revealed a list of 6 tissue variances from the 4th quarter of 2014 with a deficiency rate of 1.2% for the quarter, with the goal being less than 1%. It was noted that the variances had been reported in the facility's event reporting system - RL Solutions.

Review of Department of Pathology meeting minutes dated 9/15 revealed a monthly deficiency rate ranging between a low of 1.3% in April 2015 and a high of 8.0% in June 2015.

Review of Department of Pathology meeting minutes dated 6/16 revealed a list of 14 cases involving specimen problems for March 2016, 8 for April 2016, 10 for May 2016 and 8 for June 2016, all requiring attestation from the ordering physician. The specimen problems included a lack of tissue source on the container, source different from what was ordered, and non-matching patient information on requistion and specimen.

Interview with Staff #15 on 7/14/16 at 9:00am revealed the Department of Pathology meeting minutes are forwarded to the Medical Executive Committee.

Review of the Medical Executive Committee meeting minutes for 2015 and 2016 revealed no evidence to indicate the specimen variances were addressed.

Review of the RL Solutions Endoscopy lab specimen labeling issues report dated 9/1/15 to 7/13/16 revealed a total of 14 specimen labeling issues were reported during this time frame, including two cases in May 2016 that involved the placement of two correctly labeled patient specimens in the wrong patient specimen bag.

Review of Quality Council meeting minutes dated November 2015 revealed the July through October 2015 GI specimen labeling dashboard was presented with a plan to follow-up at the January 2016 meeting. This was delayed until June 2016, at which time it was noted that a meeting with the lab would be arranged to identify areas for improvement. There is no evidence to indicate corrective action was taken.

Review of the facility's event reporting system revealed 3 blood tubes drawn from Patient #22 and placed in one specimen bag were received in the lab on 7/9/16 at approximately 2:12pm. One tube was labeled with Patient #23's information and 2 tubes were labeled with Patient #22's information. On arrival in the laboratory, the discrepancy between the 3 tubes of blood was identified, the blood was discarded and Patient #22's blood was redrawn.

Interview with Staff #45 on 7/14/16 and Staff #48 on 7/15/16 revealed that the Rover (hand held patient identification band scanner) does not immediately connect approximately 20-30 percent of the time, which affects the printing of labels.

Review of the Lab Daily Huddle notes from 4/1/16 to 5/31/16 revealed the section to document whether the Rover is working was blank 50% of the time, with the remaining days noting no problems with the Rover.

Interview with Staff #52 on 7//11/16 at 11:00am revealed problems are experienced daily with the Rover not connecting correctly, which requires rebooting of the system. The connectivity problem has been particularly prominent since an update in May 2016.

Review of Quality Council and Nursing Leadership meeting minutes for 2016 revealed no evidence to indicate that the problems with the Rover were brought to committee.

Based on document review and interview, the hospital has not reviewed their event reporting system, RL Solutions, to identify problems and assess processes of care related to the verification of glucometer results below or above a defined threshold.

Findings include:

Review of facility policy "Glucometer Testing Protocols" dated 5/9/16 revealed that test results on an adult that are below 60 or above 400 are considered critical and must be repeated. If the results are not within 10% or the meter reads HI or LO, a lab glucose must be obtained immediately.

Review of RL Solutions events from July 2015 to July 2016 revealed 62 events that involved failure of the nursing staff to follow facility policy and procedure related to the verification of critical glucometer results. Each of these events was addressed individually by the respective unit manager.

Review of Nursing Leadership meeting minutes from January 2016 to June 2016 revealed no evidence to indicate this issue was brought to the committee for discussion despite the frequency of occurrence.

Interview with Staff #14 on 7/13/16 at 1:15pm verified these findings.

Based on medical record review and policy review, the facility did not develop or keep current nursing care plans for 6 of 9, (# 6-10 and 12) patients.

Failure to develop complete nursing care plans could lead to omission of appropriate patient assessment and care.

Findings include:

Review of the medical record for Patient #6 revealed a medical history that included Congestive Heart Failure (CHF) and Type 2 diabetes (DM). Review of the nursing care plan revealed no goals and/or nursing intervention related to these complex medical diagnosis.

Review of the medical record for Patient #7 revealed a medical history that included respiratory disease, seizures and oxygen dependency. Review of the nursing care plan revealed no goals or interventions related to seizure precautions and did not address the use of oxygen or respiratory issues.

Review of the medical record for Patient #8 revealed a medical history that included significant cardiac history including: Atrial Fibrillation, Atrioventricular block, Asymptomatic left ventricular systolic function and CHF. Additionally the patient had a history of seizures. The nursing care plan did not have goals and interventions related to Patient #8' s cardiac status and/or seizure precautions.

Review of the medical record for Patient #9 revealed a medical history of Type II DM, chronic severe diarrhea and a history of falls. The nursing care plan did not have goals and/or interventions related to any of these medical conditions.

Review of the medical record for Patient #10 revealed the patient was admitted for knee replacement surgery. The nursing care plan only addressed nursing goals and intervention related to the knee replacement. Other medical needs, such as history of coronary artery disease status post coronary artery bypass grafting, depression, allergy to sulfa drugs and obstructive sleep apnea with required use of a CPAP device were not addressed.

Review of the medical record for Patient #12 revealed the patient was admitted for a left hip replacement surgery. The nursing care plan only addressed goals and interventions related to the hip replacement. No allergies were listed on the care plan despite a documented allergy to latex, pollen, potatoes, rice, poultry, apples, kiwi, mold and hazelnuts. Patient #12 was also on telemetry, which was not noted on the nursing care plan.

Review of policy # CH 600-8 titled, "Assessment and Reassessment of In-patients " last reviewed 9/30/15 revealed patients who are admitted will have an RN assessment completed within 24 hours of admission and will be reassessed every shift and as needed until discharged. Staff # 13 provided this policy to surveyor as the "Nursing Care Plan" policy.

Based on observation and document review nursing staff did not verify blood type and Rh factor (ABO/Rh) on the blood component bag in accordance with facility policy for 1 of 2 patients. Failure to verify ABO/Rh has the potential to result in patient harm.

Findings include:

Review of facility policy entitled "Administration of Blood Components" dated 3/24/16 under the section "Initiating the Transfusion" revealed that staff must verify that the ABO/Rh on the blood component bag matches the ABO/Rh on the transfusion record.

Observation of blood administration to Patient #25 on 7/11/16 at 12:58pm revealed that although the transfusionist and a second person verified the laboratory labeling on the blood component against the patient's identification band and transfusion record, the blood component bag was not turned over to verify the ABO/Rh labeling on the bag.

Based on document review and interview the facility does not ensure completion of medical records within 30 days of discharge.

Findings include:

Interview with Staff #9 at 1:00pm revealed the tracking of closed medical records is completed but many providers have omissions beyond the 30 day time frame.


Interview with Staff #61 on 7/13/16 at 10:00am revealed the facility does not have a system of progressive actions to ensure the completion of medical records by providers in a timely fashion.


Review of document titled "Providers with Delinquent Deficiencies" for patients discharged on or before 5/31/16 revealed approximately 38 providers have open medical records ranging 31 to 551 days from the day of discharge. Examples include: Staff # 62 has 13 delinquent medical records ranging from 127 to 331 days overdue. Staff # 63 has 4 delinquent medical records ranging from 84 to 294 days overdue and Staff # 64 has 9 delinquent medical records ranging from 47 to 269 days overdue.

Review of policy #CH-768-25 "Chart Completion: Interdepartmental Work Flow" effective 05/02/16 revealed if a chart remains incomplete after 30 days, the provider will be considered delinquent.

Review of the Medical Staff Rules & Regulations updated 5/16 revealed a medical record will not be permanantly filed until it is completed by the responsible practitioner. The President of the hospital will suspend physicians for delinquent records based on criteria established by the Medical Executive Committee.

Review of the Clinical Quality meeting minutes revealed that in December 2015 the percentage of delinquent medical records (January to November 2015) was 2.8% (391 records). In May 2016 the percentage of delinquent medical records (January to April 2016) was 4.7% (258 records). No evidence was found to indicate measures were implemented to address this identified issue.

Based on document review, policy review and interview, surgical staff do not follow facility policy related to emergency equipment, specifically the monitoring of the Malignant Hyperthermia and Crash Carts in the Operating Room. This has the potential for emergency equipment and medication to be unavailable in emergent situations.

Findings include:

Review of the 2016 monthly checklist for the Malignant Hyperthermia cart in the operating room storage area on 7/13/16 at 11:15am revealed the cart was not checked by nursing staff during months of February, March and April.

Review of facility policy titled " Malignant Hyperthermia" effective 10/30/14 revealed no guidelines for scheduled monitoring of the cart to ensure all needed supplies and equipment are available for use.

Review of the May 2016 daily checklist for the Crash Cart in the operating room storage area on 7/13/16 at 11:20am revealed the cart was not checked by nursing staff on May 12, 13 and 27. Staff #24 stated that the charge nurse is responsible to check cart daily when cases are scheduled.

Review of facility policy titled "Crash Cart Checks and Replacement " effective 12/12/15 revealed the crash cart is to be checked daily by the charge nurse or designee. Each unit is responsible for checking the entire cart monthly on the last Friday of the month.

Interview with Staff #24 and Staff #34 on 7/13/16 at 11:30am verified these findings.