HospitalInspections.org

A. Based on document review, observation, and interview, it was determined that for 2 of 2 patients (Pt's. #9 and #15) observed receiving intravenous (IV) therapy, the Hospital failed to ensure that the registered nurse supervised the care provided by ensuring that IV tubing was labeled with the date to be changed.

Findings include:

1. The Hospital's policy titled, "IV Peripheral Therapy Policy" (effective 2/2018), was reviewed on 11/18/2020 and required, "...Primary tubing changed every 96 hours... Label all tubing with a date so tubing change can be determined... Peripheral Parental Nutrition (PPN) tubing changed every 24 hours..."

2. During an observational tour of the 5th Floor Telemetry/Stepdown Unit on 11/17/2020, at approximately 10:35 AM, a Registered Nurse (E#4) was administering a bag of IV antibiotics to Pt. #9. E#4 took the tubing from a previously administered bag (undated) and used it to spike the new bag of antibiotics. The tubing was not labeled with a date/time to be changed.

3. During an observational tour of the 4th Floor Medical-Surgical Unit on 11/17/2020, at approximately 10:05 AM, Pt. #15 was receiving Total Parental Nutrition (TPN) intravenously. The tubing for the TPN was not labeled with a date/time to be changed.

4. An interview was conducted with the Registered Nurse (E#4) on 11/17/2020, at approximately 10:45 AM. E#4 stated that IV tubing must be changed every 3-4 days and should be labeled with sticker to indicate the day it needs to be changed.

5. An interview was conducted with a Registered Nurse (E#17) on 11/17/2020, at approximately 10:05 AM. E#17 stated that TPN bags and tubing must be changed every 24 hours and should be labeled with the date and time to be changed.



40079

B. Based on document review and interview, it was determined that for 3 of 5 (Pt. #10, #11, and #22) clinical records reviewed, the Hospital failed to conduct a pain reassessment, to ensure that the registered nurse supervised the patient care.

Findings include:

1. The Hospital's policy titled, "Pain Management Policy" (revised 2/2018) was reviewed on 11/18/20 and required, " ...1. All patients have the right to effective management of pain ... 6. Pain re-assessment is completed within one hour after intervention ....

2. The clinical record of Pt. #10 was reviewed on 11/17/2020. Pt. #10 was admitted on 11/13/2020 with a diagnosis of syncope (loss of consciousness) and hyponatremia (low blood sodium levels). The record included a physician's order, dated 11/14/2020, for Tramadol (pain medication) 50 mg (milligrams) oral tablet every 6 hours for abdominal pain. The medication administration record indicated that Pt. #10 received Tramadol on 11/15/2020 at 2:11 PM and on 11/17/2020 at 3:08 AM. The record lacked documentation of pain reassessment within 1 hour after administration as required.

3. The clinical record of Pt. #11 was reviewed on 11/17/2020. Pt. #11 was admitted on 11/9/2020 with a diagnosis of gastrointestinal bleeding. The record included a physician's order, dated 11/15/2020, for Norco (pain medication) 10 mg-325 mg oral tablet every 4 hours for moderate to severe pain. The medication administration record indicated that Pt. #11 received Norco on 11/16/2020 at 1:07 PM, 5:13 PM, and 10:23 PM for pain. The record lacked documentation of pain reassessment within 1 hour after administration as required.

4. On 11/18/20 at approximately 11:20 AM, the clinical record of Pt. #22 was reviewed on 11/18/2020. Pt. #22 presented to the ED on 11/18/20 at 8:19 AM, with a diagnosis of Sickle Cell (blood disorder that can block blood flow causing pain). The clinical record included a physician's order, dated 11/18/20 at 8:46 AM, included, "Hydromorphone (narcotic used to treat moderate to severe pain) 2 mg (milligrams) IM (intramuscularly) once STAT (Latin word for immediately). The medication administration record indicated that Pt. #22 received Hydromorphone 2 mg IM on 11/18/2020 at 10:33 AM. The clinical record lacked documentation of a pain reassessment within one hour after the pain medication was administered as required.

5. On 11/17/2020 at approximately 12:30 PM, an interview was conducted with the 5th Floor Telemetry/Stepdown Unit Manager (E#3). E#3 stated that pain reassessments should be completed within one hour following administration of pain medication. E#3 confirmed there was no documentation of pain reassessments following the administration of pain medications reviewed for Pt. #10 and Pt. #11.

6. On 11/18/20 at approximately 11:25 AM, an interview was conducted with the ED Manager (E #11). E #11 stated that pain should be reassessed within one hour of administering pain medication to evaluate effectiveness. E #11 stated the clinical record for Pt. #22 did not have documentation that the RN had conducted a pain reassessment after the pain medication was given.

Based on observation, document review, and interview, it was determined that for 3 of 4 (Pt. #3, Pt. #9, and Pt. #15) patients observed for medication preparation and administration, the Hospital failed to aseptically clean the septum of the vial with an antiseptic prior to inserting a needle, to ensure acceptable standards of practice was followed.

Findings include:

1. On 11/17/2020, at approximately 10:05 AM, during the observational tour of the 4th Floor - Medical Surgical Unit a Registered Nurse (E #17) administered medications to Pt. #15. During the medication preparation, E #17 did not wipe and clean the septum of the vial with an antiseptic prior to inserting the needle.

2. On 11/17/2020, at approximately 10:20 AM, during the observational tour of the 3 West - COVID/ Bariatric Pedaitric Unit, a Registered Nurse (E #1) administered medications to Pt. #3. During the medication preparation, E #1 did not wipe and clean the septum of the vial with an antiseptic prior to inserting the needle.

3. On 11/17/2020, at approximately 10:35 AM, during an observational tour of the 5 East Telemetry/Stepdown Unit a Registered Nurse (E#4) administered medications to Pt. #9. During the medication preparation, E#4 did not wipe and clean the septum of the vial with an antiseptic prior to inserting the needle.

4.On 11/18/2020, at approximately 2:00 PM, the Hospital's policy titled, "Administration of Drugs" (approved on 9/2020) was reviewed and included, "...1. Administration of drugs shall comply with all laws of this state, federal laws, rules, and regulations... 2. Procedure...2...1. Drugs shall be prepared... using accepted standards of practice..."

5. On 11/18/2020, at approximately 2:30 PM, the Center for Disease Control (CDC) Guidelines (undated) was reviewed and indicated, " ...Parenteral medications should be accessed in an aseptic manner ...handling medications and the rubber septum should be disinfected with alcohol prior to piercing it ..."

6. On 11/17/2020 between 10:10 AM to 11:15 AM, interviews were conducted with registered nurses (E #1, E #4, and E#17). E #1, E #4, and E #17 stated that the septum of the vial did not need to be cleaned prior to inserting a needle.

7. On 11/19/2020 at approximately 12:15 PM, an interview was conducted with the Director of Infection Control (E #19). E #19 stated that, the expectation is to clean and disinfect the rubber stopper prior to piercing it with a needle.

Based on document review and interview, it was determined that the Hospital failed to manage dietary services to ensure food was safe for consumption. This failure potentially affected an average daily census of 115 patients receiving meals from the dietary department. As a result, the Condition of Participation (CFR 482.28) Food and Dietetic Services was not in compliance.

Findings include:

1. The Hospital failed to measure and record food temperatures to ensure food is being served at safe temperatures. See deficiency A-620 A.

A. Based on document review and interview it was determined that the Hospital failed to manage dietary services by not measuring and recording food temperatures to ensure food is being served at safe temperatures. This failure potentially affected the average daily census of 115 patients receiving meals from the dietary department.


Findings include:

1. The Hospital's policy titled, "Food Handling" (dated 7/5/2019), was reviewed on 11/18/2020, and required, "...Growth of pathogenic bacteria can occur if: Time and temperature requirements are not maintained..."

2. The (Contracted Food Service Company) Food Safety Training Manual (utilized by the Hospital), updated 3/9/18, was reviewed on 11/18/2020, and required, "Foods for service must be monitored and temperature recorded every two hours...Bacteria can grow rapidly when being held between 41 degrees F (Fahrenheit) and 140 degrees (F). This is known as the Temperature Danger Zone. The more time bacteria spend in this zone, the more opportunity they have to grow unsafe levels. If the food is in the temperature danger zone, 41 degrees (F) to 140 degrees (F), it needs to be removed from service and either chilled quickly to 41 degrees (F) or below or heated quickly to 165 degrees (F) for 15 seconds. Temperatures must be recorded and corrective actions listed..."

3. The TCS (Temperature Control for Safety) Hot Holding Log was reviewed on 11/18/2020, and required, "Hold hot foods at 140 degrees F [Fahrenheit]...Record temperatures every 2 hours..."

4. The Food Holding Daily Temperature Logs (hot/cold) from 10/1/2020 through 11/17/2020, were reviewed on 11/17/2020. The following dates lacked documentation of hot food holding temperature readings every two hours:

- 10/1/2020, between 7:00 AM through 11:32 AM
- 10/6/2020, between 6:53 AM through 12:00 PM
- 10/12/2020, between 6:33 AM through 11:00 AM and between 1:39 PM through 6:30 PM
- 10/16/2020, between 6:37 AM through 12:00 PM
- 10/20/2020, between 7:01 AM through 7:21 PM
- 10/26/2020, only temperature recorded at 6:46 AM. The log lacked any further temperature readings that day for hot foods.
- 11/2/2020, between 7:00 AM through 11:00 AM
- 11/4/2020, between 6:48 AM thorugh 1:00 PM
- 11/9/2020, between 6:43 AM thorough 3:37 PM

5. On 11/18/2020 at approximately 12:00 PM, an interview was conducted with the Food Services Director (E #18). E #18 stated that the food service runs continuously from 6:30 AM through 6:30 PM (menu service). E #18 stated that it is very important that the food temperatures are taken every 2 hours, both hot and cold, while on the serving line to ensure that the food is safe. E #18 stated that the importance of checking every two hours is to ensure that the food doesn't enter into the "danger zone", in which the foods can begin to grow bacteria. E #18 stated that if hot food drops below 140 degrees Fahrenheit and it is noted before the 2 hours, then the temperature could be adjusted by reheating the food. E #18 stated that if it is longer than 2 hours, then it would be too late to adjust the food temperature.

B. Based on document review, observation, and interview, it was determined that for 3 of 7 dietary staff (E #20, E #21, and E #22) the Hospital failed to manage dietary services by not ensuring that the staff adhered to the dress code policy.

Findings include:

1. The (Contracted Food Service Company) Food Safety Training Manual (utilized by the Hospital), updated 3/9/18, was reviewed on 11/18/2020, and required, "...Hair and hair restraints: Keeping hair from contaminating the food is also important...Everyone is required to wear a hair restraint..."

2. On 11/17/2020 at 11:35 AM, an observational tour of dietary services was conducted. During the tour, the Dietary Manager (E #20), the Executive Chef (E #21), and a Dietary Aide (E #22), were observed with hair restraints on. However, the front portion of their (E #20, E #21, and E #22) hair was exposed and not contained under the hair net.

3. On 11/17/2020 at 11:45 AM, an interview was conducted with the Dietary Manager (E #20). E #20 stated that the hair should be completely contained and covered under a hair restraint, while in the kitchen.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on November 17 - 19, 2020, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on November 17 - 19, 2020, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review, observation, and interview, it was determined that for 2 of 3 staff (E#5 and E#6) observed on the 5 East Floor Telemetry/Stepdown Unit, the Hospital failed to ensure that personal protective equipment (PPE) was used upon entering an isolation room and removed upon exiting in order to prevent and control the transmission of infection.

Findings include:

1. The Hospital's policy titled, "Isolation Precautions" (revised 9/2020), was reviewed on 11/17/2020 and required, "...Contact Isolation Precautions: ...Gloves and gowns are worn by all personnel when entering the room. Gloves and gowns are removed and hands washed with waterless hand sanitizer upon leaving the patient room..."

2. An observational tour of 5th Floor Telemetery/Stepdown Units (5 East & West) was conducted on 11/27/2020, between approximately 10:00 AM and 1:20 PM:

- At approximately 11:00 AM, an Environmental Services (EVS) staff (E#5) was observed exiting Pt. #11's contact isolation room with a gown and gloves on. E#5 then went to Pt. #10's room, who was not on any isolation precautions, with the same gown and gloves on. After exiting Pt. #10's room, E#5 went into Pt. #9's room, who was on contact precautions. E#5 then exited Pt. #9's isolation room without removing the gown and gloves and went to push the housekeeping cart in the hallway.

- At approximately 1:15 PM, a Registered Nurse (E#6) was observed at the bedside in Pt. #16's contact isolation room without a gown on.

3. An interview was conducted with the EVS staff (E#5) on 11/17/2020, at approximately 11:05 AM. E#5 stated that she should have changed her gown and gloves when leaving the isolation rooms.

4. An interview was conducted with the Registered Nurse (E#6) on 11/17/2020, at approximately 1:17 PM. E#6 stated that she should have put a gown on before going into Pt. #16's room.