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Based on observation and reviews of patient medical records, interviews of the licensed nursing floor staff and Risk Management Staff, it was determined that patient representatives were not always given the opportunity to request or refuse treatment. This was evident for 1 out of 25 patients whose medical records were reviewed.

The findings were:

Patient #2 was 5 months old when she was brought to the Pediatric Emergency Department on 9/16/15 by family for an elevated temperature.

The Emergency Pediatrician ordered that the patient undergo a lumbar puncture (LP) to rule out meningitis. The procedure was performed on 09/16/15 at 0200. A review of the patient's medical record, both paper and electronic, revealed that an LP consent was not in the record. The staff was asked to locate the consent.

On 09/17/15 the surveyor was given an LP Procedure Note that had been completed by the physician on 09/17/15 at 0717. The note stated that the parent had given verbal consent for the procedure. A written consent that outlined the risks and benefits of the procedure was not obtained by the physician prior to the procedure. While the procedure was needed to determine possible causes of the patient's elevated temperature, the hospital policy and procedure for conducting the procedure was not followed. The hospital policy identified the LP procedure as an invasive procedure and that it must be confirmed in writing.

Failure to obtain written consent for the LP and following the specified consenting process potentially placed the patient at risk by not enabling her parents to make an informed decision with all of the needed information.

Based on observation in the Emergency Department (ED), the Post-Anesthesia Care Unit (PACU) and the Ambulatory Surgery Department (ASD) prep area and interviews of the hospital's licensed nursing staff, the Senior Performance Improvement Coordinator and the hospital's equipment/supplies receiver during a tour on 9/16/15, it was revealed that intravenous carts were unlocked and unattended by staff.

Observation of the ED, PACU and ASD prep area revealed that intravenous carts were placed for staff use in hallways and within each ASD/PACU room. Some of the intravenous carts in the ASD/PACU had keys in the locks, and others had no keys. All carts were unlocked, unattended and unsecured. A cart in the ED triage area had a key locking system that was observed as being unlocked. A cart in the main ED hallway (outside of room A14) had a number pad locking system which had been left unlocked. The carts were stocked with various intravenous supplies, such as intravenous catheters (needles) of various sizes and gauges.

Failure of staff to keep intravenous carts locked and secured could potentially create a delay in treatment if needed supplies are empty or are missing. Unlocked carts could also create opportunities for tampering or theft by any individual passing through the ED, PACU or ASD prep area whether a patient or visitor.

In addition, at the time of the survey, the South Tower of the hospital was under construction. The hospital's receiving area for products had been relocated to the Dameron Garage.

On 9/16/15 at 1350 two nurse surveyors were escorted to the garage by the Senior Performance Improvement Coordinator. The surveyors, hospital escort, and Receiver walked through the hallway leading from the building onto a cement side-walk to a parking lot that abutted the South Tower. Half of the lot was being used as a parking lot for employees' cars. Employees were observed exiting the building to access their cars. The other half of the lot was divided in half by a path. On one side of the path was a pile of merchandise that had been received on 9/15/15 and on the day of the survey, 9/16/15. Some of the merchandise observed by the surveyors included Similac infant formula, IV Solutions and Salt tablets. The merchandise at the base of the pile was wrapped in plastic but the top two layers of boxes/bags were not wrapped. The IV Solutions that had been delivered on 9/15/15 had instructions written on the box "store at room controlled temperature." Per the Receiver the loading dock had been moved due to construction and had been in its present location for approximately 2-3 months. In addition, all merchandise that had been received in this area of the hospital had been logged in. Sensitive products, such as tissue for the lab, blood products for the blood bank, medication to pharmacy and food, were sent immediately to the respective units. When the surveyor asked why merchandise that had been delivered the previous day (IV Solutions) was still on the parking lot on the day of the survey the Receiver stated that he had to send a staff member home sick that day.

On the other side of the dividing path, next to the parking lot wall were a large dirt pile and a recessed area (not covered by the garage). Within the recessed area were three packages, each containing two renal acid drums. The drums were in the back of the recessed area and were exposed to the elements, cold, heat and rain. The lids were covered with dirt, and the labels on the lids were faded. There were also labels covered by the plastic used to wrap the two drums together. Close to this area was an area against the parking lot wall where merchandise that was to be donated or discarded was stored.

The surveyor informed the Director of Infection Control and Accreditation, the Senior Director of Supply Chain Management (SCM) and the Supervisor of Receiving that this location as an area for receiving and storing merchandise was not acceptable. The area was not secure from theft or tampering, and there was no way to provide a temperature controlled environment. The merchandise was exposed to the elements as the area was open.

The hallway leading from the parking lot to the building did not have a cleanable surface due to missing floor tiles. The surveyor contacted the Office of Health Care Quality and requested a Registered Environmental Health Specialist (REHS) for the second day of the survey.

On 9/17/15 the nurse surveyors and an REHS met with the Director of Infection Control and Accreditation, the Director of Construction and the Senior Director of SCM to discuss the concerns regarding the receiving area in the garage. The meeting occurred in the Senior Performance Improvement Coordinator's Office at 1330. The surveyors were informed that the receiving area was relocated to the garage on 7/20/15 and was only to be a staging area with product received and moved to the unit/department or the storage areas of the hospital. It was determined that no Infection Control Risk Assessment (ICRA) had been performed for the relocation. The hospital felt that it was only to be a staging area. The hospital presented written documentation of the actions that had been taken since 9/16/15. The actions included:

Notification of floor removal to be done between 10:00 PM and 6:00 am.

Site walk occurred, and the plan included items received on 9/16/15 to be processed and placed into storeroom inventory.

Supplies delivered prior to 9/16/15 date were sequestered within the storeroom and they will not be delivered to patients.

Interfinish flooring arrived on-site at 8:00 am on 9/17/15. Vinyl flooring to be installed. The floor installment was completed by 12:00 PM on 9/17/15.

Another delivery arrived at 10:00 PM on 9/16/15, was received and processed into the storeroom inventory.

Construction was notified to install a dust barrier between the construction job site and the supply delivery area on 9/16/15 at 4:20 PM. Contractors were on-site on 9/17/15 at 6:30 am to begin barrier installation.

On 9/17/15 at 6:00 am work began on relocating shelving, supply bins, etc., to Supply Chain Space with a temperature controlled environment with completion estimated by 5:00 PM.

On 9/17/15 at 8:00 am the pressure washing of the garage supply dock area began and was completed by 10:00 am.

The hospital submitted new purchase orders for sequestered IV fluids on 9/17/15 at 10:30 am.

On 9/17/15 at 10:30 am removal of temporary fencing for the supply dock began with estimated completion by 5:00 PM.

The hospital has since removed all products from the garage, repaired the floor and arranged for the delivery of products to the departments or the storage area. The REHS surveyed the hallway to ensure that floor was installed and the garage area cleared of merchandise and the corrective actions were complete. A tour of the area occurred at 3:45 PM and included a survey of the storage area where supplies had been re-directed.

Failure of the hospital to perform an ICRA to identify all risk factors related to the move of the receiving area into a garage could have potentially led to the patients receiving product that had been contaminated and had not been kept at appropriate temperatures or had been tampered with resulting in injuries to the patients.

Based on review of the medical record for patient #4, review of infection control policies and interviews it was determined that the hospital staff failed to maintain isolation precautions for patient #4.

Patient #4 arrived at the hospital Emergency Department (ED) on the evening of 8/8/15 and required admission to the Intensive Care Unit (ICU). The patient had a history of Vancomycin-resistant enterococci (VRE), a type of bacteria found in the human intestines that can cause infection. The patient was also suspect for a current Methicillin-resistant Staphylococcus aureus (MRSA), a bacteria that is resistant to many antibiotics and surgical wound infection (culture was obtained on 8/9/15). An interview with staff C on 9/18/15 confirmed that due to the patient's history of past VRE infection the patient was ordered by the physician to be placed on isolation precautions in ICU on 8/9/15.

Patient #4 was transferred to the Cardiac Intermediate Care unit (CICU) on the evening of 8/10/15 to a shared room with another patient. Review of the medical record for patient #4 revealed no nursing assessment documentation or acknowledgement of the isolation precaution order when the patient was transferred to the CICU.

An interview with the accepting CICU nurse (staff A) and the CICU nursing assistant (staff B) on 9/17/2015 confirmed that the patient was not placed in isolation precautions on arrival to the unit as ordered and staff obtained vital signs without the proper isolation precautions. The patient reported to the nurse (staff A) that he should have been placed in isolation when he arrived to the CICU and that the staff should have been following the proper precautions (gowning, gloving, hand washing). Subsequently staff placed the patient in isolation. The patient was transferred to a private room later that night on 8/10/2015.

Failure of all staff to maintain required isolation precautions for all patients placed patients at risk for acquiring infections.