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Based on interview and document review, the hospital failed to obtain a physician order for the use of restraint for 1 of 1 emergency room patients (P1) whose restraint use was reviewed.

Findings include:

P1 was admitted to the emergency department on 7/8/12, at 3:35 a.m. for treatment of a suspected Seroquel (antipsychotic) overdose. The nursing notes at 3:40 a.m. revealed, "Pt [patient] awoke suddenly began tearing at monitoring equipment aggressive and violent. Restrained by Virginia police...." Emergency Physician Records dated 7/8/12, (time not indicated) noted P1 was "combative," however, the record did not include evidence a physician's order was obtained during or immediately after the emergency restraint use.

The hospital Restraint Management policy (revised 8/2/12), directed staff as follows: "Restraints will only be utilized with a physicians order."

The physician responsible for P1's emergency care on 7/8/12, was interviewed on 9/6/12, at 9:25 a.m. The physician was unsure the manner in which P1 was restrained by the police, and verified the record lacked documentation of a physician's order authorizing the restraint use.

Based on interview and document review, the hospital failed to document specific patient behaviors and responses, as well as intervention used for 1 of 1 patient (P1) whose restraint use in the emergency room was reviewed.

Findings include:

P1 was admitted to the emergency department (ED) on 7/8/12, at 3:35 a.m. for treatment of a suspected Seroquel (antipsychotic medication) overdose. The nursing notes at 3:40 a.m. revealed, "Pt [patient] awoke suddenly began tearing at monitoring equipment aggressive and violent. Restrained by Virginia police, patient states he doesn't know what's going on attempt to remove, patient returned to room sitting on bed rocking asking for [woman's name]."

The Emergency Physician Record dated 7/8/12, (no time indicated) noted P1 had a history of schizophrenia, bi-polar and borderline personality disorders, and experienced seizure-like activity after having a fight with his girlfriend. The record said the patient was "combative."

Although the ED records noted the police restrained the patient, it was unclear whether the patient was held down and/or whether a mechanical-type of restraint was used. In addition, the record lacked information regarding the length of time the patient was restrained, as well as the patient's clinical response to the intervention.

The registered nurse ED manager was interviewed on 9/6/12, at 9:40 a.m. The nurse confirmed the documentation regarding the restraint use for P1 on 7/8/12 was not thoroughly documented in the records.

Based on observation, interview, and document review, the hospital failed to assure medications held for disposal were securely stored in 1 of 1 cesarean section surgical suite, 7 of 7 operating rooms in the surgical suite, the post-anesthesia care unit (PACU), and the Short Stay unit.

Finding include:

During a tour of the C-section surgical suite on 9/6/12, at 11:20 a.m. a black plastic box measuring approximately 18 inches in height by 12 inches wide and 12 inches deep contained medications for disposal. The opening at the top of the box measured approximately 6 inches in diameter and bottles, syringes, and vials, many of which contained medications, were observed in the box. Medications observed in the box included at least 11 syringes with 15 ml or more of Propofol (intravenous sedative/hypnotic medication), Propofol vials, Sensorcaine (local anesthetic), Ephedrine 25 mg/5 ml and a Lidocaine Vial (local anesthetic). There were no locks on the doors and the area was accessible to an unobserved hallway connected to the obstetrics and pediatric patient care areas. The nurse manager (NM), interviewed on 9/6/12 at 11:30 a.m., stated the hospital policy required all patient medications be placed in the black boxes for disposal when no longer used. The NM stated the area was never locked and staff, patients, and visitors could access the area without being observed.

The chief pharmacist, interviewed on 9/5/12 at 10:50 a.m., stated the hospital had used the medication disposal system for a long time. He stated any medication bottle, vial or other container which had been opened for a patient and not used completely was disposed of in these containers. The pharmacist verified this would include all medications except for controlled medications. The hospital policy Pharmaceutical Waste (undated) and Evaluating and Disposal of Regulated Hazardous Waste (dated 6/14/08) did not include information related to the security of medications disposed of in the pharmaceutical waste containers. The pharmacist verified there was no other policy related to the security of these discarded medications.


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Medications intended for disposal were observed to be stored in unlocked black boxes in 7 of 7 operating rooms in the surgical suite, the PACU and the Short Stay unit.

During a tour of the surgical suite on 9/4/12, at 2:45 p.m. containers which contained medications were observed in operating rooms A, B, C and D, both endoscopy rooms and the cystoscopy room. These containers were also observed in the PACU and in the Short Stay unit. The medications observed to be present in the containers included many syringes of Propafol, Sensorcaine, Marcaine (local anesthetic), Dexamethson (a corticosteroid), Botox (a muscle paralyzing medication), Glycopyrrolate (inhibits cholinergic action) and Vancomycin (antibiotic).

When interviewed on 7/4/12 at 3:30 p.m., the surgery manager stated the hospital's policy required all medications used, but no longer needed for patients, be placed in these containers. Controlled substances were disposed of in a different manner. The containers were disposed of when they were full. She explained that housekeeping staff cleaned the surgical suite at 4:00 p.m. each day and had access to the surgical suite after surgery personnel were no longer present. The surgery manager verified any medication disposed of in these pharmaceutical waste containers would not be considered secure as the containers could be accessed by unauthorized individuals.

The code blue emergency cart was observed in the PACU on 9/4/12, at approximately 3:15 p.m. The cart was secured with a red tag with numbers printed on the tag. The code blue emergency cart was observed in the Cardio-Pulmonary Rehab Unit on 9/6/12 at 10:20 a.m. The cart was secured with numbered red plastic tag. Review of the Defibrillator Test and Emergency Supplies Inspection Report for the months of August, 2012 and September 1-4, 2012 indicated the tag numbers were not recorded to indicate the cart had not been opened.

The nurse manager of the Surgical Suite, interviewed on 9/6/12, at 11:05 a.m., stated the red security tag numbers are not recorded and could be replaced without being noted.

The vice president of nursing was interviewed on 9/6/12 at 10:20 a.m. and verified staff did not record the numbers on the security tags when the emergency carts were checked.


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An emergency crash care was observed on the Intensive Care Unit (ICU) on 9/4/12 at approximately 2:50 p.m. The cart was secured with a numbered red plastic tag. A review of the Defibrillator Test and Emergency Supplies Inspection Report for the months of August, 2012 and September 1-4, 2012 indicated the nurse had signed the record but the tag numbers were not recorded.

The chief nursing officer was interviewed on 9/4/12 at 2:50 p.m. and verified the tag numbers were not documented to indicate the emergency cart had not been opened.

An emergency crash care was observed on the Medical/Surgical unit on 9/4/12 at approximately 2:30 p.m. The cart was secured with a red plastid numbered tag. A review of the Defibrillator Test and Emergency Supplies Inspection Report for the months of August, 2012 and September 1-4, 2012 indicated tag numbers were not documented.

Based on observation, interview, and document review, the hospital failed to ensure outdated medications were not available for administration to patients in 1 of 2 crash carts that were observed for unusable medications.

Findings include:

Outdated single dose medications were found in the cardiac rehabilitation crash cart.

During the tour of the cardiac rehabilitation area on 9/4/12, at 9:45 a.m. outdated medications were stored for use in a crash cart. The expired medications included three single dose syringes of 1 milligram of Atropine (anticholinergic antispasmodic medication) and three Amiodarone Hydrochloride (anti arryhthmia injections).

The rehabilitation director was interviewed on 9/4/12, at 10:00 a.m. and confirmed the above medications were out dated. She explained that the pharmacy was responsible to ensure medications in the emergency carts were not expired.

Review of the hospital policy Crash Cart Emergency Drugs (dated as reviewed 7/12) directed staff as follows: "The Pharmacy or the pharmacy's designee shall inspect crash cart emergency drug containers at least once a month and after each use to remove deteriorated and outdated drugs and assure completeness of content. The inspection shall assure that all items required for immediate availability are actually present and are in usable condition."

Based on observation and interview, the hospital failed to develop a preventive maintenance program that included periodic safety inspections of equipment in the nuclear medicine and therapy departments.

Findings include:

The rehabilitation gym walk through on 9/4/12, at 10:00 a.m. revealed periodic safety checks were not completed for two electric high low mats and one stationary bike. The rehabilitation manager stated at the time of the observation, that she would call the manufacturer to request repair of the the equipment if a problem was noted.

In addition, observations in the nuclear medicine department on 9/5/12, at 3:00 p.m. revealed three machines were not periodically checked for safety. The stress treadmill, Quinton Instrument and the Imex Lab 9000 machine (used to check the strength of patients' pulses) were not being periodically inspected to ensure proper function and safety.

Based on observation, interview, and document review, the hospital failed to ensure 1 of 4 X-ray technicians (radiology director) was being monitored for radiation exposure.

Findings include:

The radiology director was not wearing a badge to measure radiation exposure during a tour of the radiology department tour on 9/5/12, at 1:45 p.m. At 2:15 p.m. the director explained that she never wore a badge because her exposure was low. She said the most recent X-ray she performed had been three weeks prior, and she performed radiation testing approximately monthly.

The hospital's bi-monthly badge reports revealed the radiology director did not have a badge for monitoring of radiation exposure.

The imaging services' Policy and Procedure Manual Management Policy Standard (effective 9/25/04) instructed staff in "a protocol to insure all radiation workers dose levels were monitored with the use of monitoring badges on a regular basis."

The hospital was found out of compliance with the Condition of Participation related to the Physical Environment (42 CFR 482.41) as evidenced by deficiencies issued as a result of a Life Safety Code inspection.

Findings include:

Please refer to Life Safety Code inspection tags: K0015, K0017, K0021, K0033, K0038, K0052, K0056, K0072, K0154 and K0155 for additional information.

Based upon interview and document review, the hospital failed to ensure current surgical privileges were available in the operating room and in the area where surgery scheduling occurred for 5 of 5 surgeons whose privileges were reviewed (MD-A, MD-B, MD-C, MD-D and MD-E).

Findings include:

At the time of the tour of the surgical suite on 9/4/12,at 2:30 p.m. he nurse manager (NM) was interviewed and stated physician surgical privileges were available at the surgery control desk. The surgical privileges for five surgeons were reviewed on 9/5/12. There was no list available in the surgical suite that identified the surgical privileges each surgeon had been granted. The only documentation related to the surgeons' privileges was a signed document which indicated the dates the individual surgeon's privileges had been approved by the appropriate committees. The date on this documentation was not the date of the most recent re-approval of the surgeons' surgical privileges

Physician (MD-A) surgical privileges had been approved and were dated 12/15/08.

Physician (MD-B) surgical privileges had been approved and were dated 12/14/09.

Physician (MD-C) surgical privileges were approved and were dated 12/14/09.

Physician (MD-D) surgical privileges had been approved and were dated 12/14/09.

Physician (MD-E) surgical privileges had been approved and were dated 12/14/09.

The NM was interviewed on 9/5/12 at 10:30 a.m. and stated surgeons requested and were granted surgical privileges every two years. The medical staff office did not send an entire list of the surgical privileges granted to each individual surgeon when re-credentialing occurred. The NM stated the medical staff office sent documentation of the date the surgeon had been granted privileges, but not the specific surgical privileges granted. The medical staff office was then able to verify the surgeons had been re-credentialed and granted surgical privileges within the approved period of time.