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Based on observation, interview, and record review, for three patients (Patient 25, Patient 26 and Patient 29) of 30 sampled patients, the hospital staff failed to place call lights within the patient's reach. This failure did not ensure the patients were able to contact the nursing staff to ask for assistance with care or in the event of an emergency.


Findings:


1. During an observation of the Emergency Department (ED) and concurrent interviews, on 12/4/17 at 11:15 a.m., Patient 29 stated he is supposed to have a call light to assist him in calling the nurse and could not locate the call light. The surveyor observed his closed privacy curtain that is out of nursing staffs' view and the call light cord hanging on the back wall behind Patient 29's gurney. Patient 29 stated he could not call anyone without the call light. Registered Nurse (RN) 3 confirmed the inaccessible call light and stated it should be placed within Patient 29's reach.


In an interview, on 12/7/17 at 11a.m., the Emergency Department Manager (EDM) stated nurses are expected to provide the call light to patients in the ED, and there is no unit specific policy to address this.


2. In an observation, on 12/5/17 at 7:10 a.m., Patient 26's call light hung over the side rail and out of Patient 26's reach. RN 6 verified the inaccessible location and stated the call light should be placed within reach.


Record review of the policy and procedure titled, "Adult Basic Unit Care Medical Surgical/Telemetry Units", with an approved date of 5/16 indicated as follows: "1.0 Policy Statement. 1.1 Care of the patient will be delivered in a safe, effective, and caring manner using evidence-based practice. 5.4 Safety: 5.4.3 Place call lights, equipment, and supportive devices for easy accessibility to patient. Adapt equipment to meet the patent's age, sensory, and functional capabilities/requirements."


3. In an observation of the Intensive Care Unit (ICU) and concurrent interview, on 12/5/17 at 11:40 a.m., Patient 25's call light hung on the back wall and not within reach. The Responsible Party (RP) stated she did not know where Patient 25's call light is located and is usually placed near Patient 25's bedside, over the arm of the IV (intravenous) pole. On 12/5/17 at 11:50 a.m., RN 7 verified the call light location and stated the call light should be placed within reach for Patient 25 and/or the family member's use.


Review of the policy and procedure titled, "Basic Unit Care Standards for Critical Care Adult," with an approved date of 4/17 indicated as follows: "1.0 Policy Statement 1.1 Care of the patient will be delivered in a safe, effective, and caring manner using evidence-based practice. 5.4 Safety: 5.4.5 Place call lights, equipment and supportive devices for easy accessibility to the patient."

Based on interview and record review, for one patient (Patient 23) of 30 sampled patients, the hospital failed to follow the policy and procedure (P&P) for the continual use of restraints to prevent the unintentional pulling of lines and tubing for patient safety. This failure resulted in the unauthorized continuance of restraints without a physician's order, and has the potential for not using the least restrictive interventions possible or discontinuance of restraints based on a comprehensive patient assessment.


Findings:


In an interview and concurrent record review on 12/7/17 at 8:45 a.m. with the Department Manager Leader (DML) and the Quality Outcomes Nurse Consultant (QOC), Patient 23 was admitted to the hospital on 11/2717 for diagnoses that included septic shock (an infection that results in low blood pressure (BP) that requires infusing fluids and or medications to raise the BP and has the potential for injury or damage to organs), diabetes ketoacidosis (DKA), a life-threatening condition when the body produces high levels of ketones from the incomplete metabolism of fatty acids when there is not enough insulin in the body to manage blood sugar levels), acute kidney injury (AKI, an abrupt decline in kidney function), and altered mental status (AMS). Patient 23 was admitted to the intensive care unit (ICU).


Patient 23's order indicated as follows: "12/2/17. Time: 11:53 a.m. Type: Restraints. Description: RESTRAINTS FOR NON-VIOLENT BEHAVIOR Restrain Type? Limb-soft: Restraint placement location (s)? BOTH ARMS: Clinical reason for restraints? CONFUSION W (with) / SAFETY RISK "Restraint order is valid until the end (midnight) of next calendar day." The DML confirmed on 12/2/17 at 11:53 a.m. through 12/4/17 at 2:33 p.m., Patient 23 continued to have restraints applied without a renewed physician order on 12/3/17.


Record review of the P&P titled, "Restraints," and approval date of 7/17, (Restraint Use Algorithm) indicated for MD (physician) Order/Renewals: Restraint order will be obtained and renewed by the end of the next calendar day after MD assessment.


In an interview, on 12/7/17 at 11:23 a.m., the DML stated nurses should review and seek out the physician to re-order the restraints if needed, and the continual use of restraints are re-ordered during interdisciplinary rounds.


Review of the policy and procedure titled, "Restraints", with an approved date of 7/17 indicated as followed: "1.0 Policy Statement. 1.1 All patients have the right to be free from physical or mental abuse and corporal punishment. Restraint may only be used to ensure the immediate physical safety of the patient, a staff member, or others or to protect the patient a staff member or others from harm (See Policy Detail 5.0). The use of restraint must be discontinued as soon as possible based on an individualized patient assessment and re-evaluation. Restraint may only be used when less restrictive interventions have been determined to be ineffective. 2.0 Purpose. 2.1 To provide guidelines for the appropriate and safe use of patient restraints. 4.0 Definitions (See Appendix A, Examples of Restraint). 4.1 Restraint: A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. 5.18 Physician/LIP Order Must Be Obtained. 5.18.1 Restraint may only be initiated or continued upon the order of a physician or authorized licensed independent practitioner (LIP) primarily responsible for the patient's ongoing care. LIP's authorized to order restrain include: (hospital to define: for example Clinical Psychologists, CRNA, PA's, Nurse Midwives, applicable residents)."

Based on observation, interview, and record review, the hospital failed to ensure the provision of nursing services by the following when:


1. For two patients, (Patient 28 and Patient 30) of 30 sampled patients, the nursing staff did not administer and/or titrate medications in accordance with the physician orders which resulted in the underdosage of pain medication. (Refer to A 0405).


2. For one patient, (Patient 23) of 30 sampled patients, the nursing staff did not change the Foley catheter drainage bag when the spigot at the base of the drainage bag that provides a means to emptying the bag was on the floor. This had the potential to contaminate the drainage system and risk infection. (Refer to A 0749).


3. Nursing Staff did not perform hand hygiene before and after donning gloves in the Operating Room (OR) that had the potential for transmitting germs and risk for infection.(Refer to A - 0749).


4. For three patients, (Patient 25, Patient 26 and Patient 29) of 30 sampled patients, the nursing staff did not ensure call lights were within reach for Patient use to call for assistance with care or for an emergency. (Refer to A 0144).


5. For one patient, (Patient 23) of 30 sampled patients,2 the nursing staff did not obtain a physician order for the continual use of restraints that had the potential for not using the least restrictive approach. (Refer to A 0168).


6. For three patients, (Patient 22, Patient 24, and Patient 29 ) of 30 sampled patients, did not have either a focused and/or a full assessment completed in the Emergency Department that had the potential for changes of condition to go undetected. (Refer to A 0395).


The cumulative effect of this organizational systematic problem resulted in the hospital's failure to ensure the safe provision of patient care by qualified individuals to perform their assigned duties, and placed the health and safety of the patients in the hospital at risk.

Based on observation, interview, and record review, for three patients (Patient 22, 24, and 29) of 30 sampled patients, the hospital failed to follow the policy and procedure (P&P) for continuous monitoring of the patient's condition based on their emergency severity index level (ESI), a criteria used to rapidly identify patients in need of immediate medical attention and identify patients who can safely wait for Emergency Department (ED) services, and perform a nursing assessment prior to discharge from the hospital.


These failures placed the health and safety of Patient 22, Patient 24, and Patient 29 at risk when nurses failed to maintain nursing frequency assessments and per patient condition. This had the potential for patients to not receive care and treatment in a timely manner.


Findings:


Record review of the P&P titled, "Triage/ESI ) and Initial ED Admission Policy," and approval date of 11/16 indicated as follows: "1.0 Policy Statement. 1.1. All patients arriving to the ED will be triaged in accordance with ESI criteria 4.0 Definitions. 4.2 Triage - Determining the order of patients to receive medical care in the Emergency Department or Rapid Care Settings. 4.4 Focused System Assessment - A Registered Nurse performs a focused system assessment and evaluation upon assuming care of the patient (including a change of patient condition, but, only after an initial assessment is completed). 4.7 ESI Priority Levels. 4.7.1 Priority levels are based on the ESI classification system. A priority level described below will be assigned by the RN for each patient: 4.7.1.2 Priority II - Emergent. 4.7.1.2.1 Patients with illnesses or injuries that place them at high risk and/or in severe distress, or present with unstable vital signs and require prompt intervention. 4.7.1.3 Priority III - Urgent. 4.7.1.3.1 Patients with illnesses or injuries that are not immediately life or limb threatening but require prompt medical attention and require two or more resources. If no medical emergency exists, this patient may be referred to other resources outside the ED for further evaluation and treatment. Consider RC (rapid care setting). 5.19 Assessment. 5.1.9.1 Nursing Assessment. 5.1.9.1.13 A focused systems assessment related to the chief complaint and treatment/care delivered in the ED should be documented per the patient condition, ESI level and/or at a minimum of every 4 hours. 5.1.9.1.18 Reassessments are done/documented as defined by their priority level or more frequently as clinical condition warrants: 5.1.9.1.18.2 ESI 2: Reassess every 1 hour or per patient condition. 5.1.9.1.18.4 ESI 3: Reassess every 2 hours or per patient condition. 5.1.9.2 Reassessments: 5.1.9.2.1 Reassessments are done after medications or treatments are administered and as indicated by patient condition and/or at a minimum within 4 hours or unless otherwise stated based on patient ESI level. 5.1.9.2.7 Discharge Assessment is required on all patients and is documented in the Intermediate Flowsheet, by adding the Group "Discharge - ED NTL."


The electronic health record reviews (EHR) and concurrent interviews were conducted in the presence of the Emergency Department Manager (EDM) and the Quality Outcomes Nurse Consultant (QOC) and reflected the following information.


Record review of Patient 24's EHR, on 12/6/17 at 8:15 a.m., showed Patient 24 presented to the Emergency Department (ED) on 12/4/17 for chief complaint of Altered Mental Status. The EDM stated Patient 24's ESI (Emergency Severity Index) is 3. (This required the nurse to reassess every 2 hours or per patient condition). The EDM stated there is no nursing documentation of a focus and/or full head-to-toe assessment for Patient 24 on 12/4/17 at 2:41 p.m. through 12/5/17 at 12:56 a.m. The EDM stated the nurse should complete a focused and head-to-toe nursing assessment according to the patient's ESI per department P&P.


Record review of Patient 29's EHR, on 12/6/17 at 8:42 a.m., indicated Patient 29 presented to the ED on 12/4/17 for chief complaint of angioedema (an area of swelling of the lower layer of skin and tissue just under the skin or mucous membranes) to the upper lip and ESI of 3. On 12/4/17 at 9:12 a.m., Patient 29 arrived in the ED, and later discharged the same day at 3:09 p.m. The EDM confirmed a full head-to-toe assessment completed at 9:34 a.m., but nursing staff did not perform a subsequent focused or discharge nursing assessment. The EDM stated the nurse should complete a focus nursing assessment according to the patient's ESI and discharge nursing assessment for Patient 29.


Record review of Patient 22's EHR, on 12/6/17 at 8:55 a.m., showed Patient 22 presented to the ED on 12/3/17 for chief complaint of head injury and ESI of 3. The EDM confirmed a complete head-to-toe nursing assessment for Patient 22 on 12/3/17 at 9:41 a.m., through 12/4/17 at 9:19 a.m., but no focused assessment completed according to the Patient's ESI level 3, and no discharge assessment according to Patient 22's ESI.


In an interview, on 12/7/17 at 11 a.m., the EDM stated the importance of a nursing focus and full head-to-toe assessment is to show if there is a change of the patient's condition.

Based on interview and record review, for two patients (Patient 28 and Patient 30) of 30 sampled patients, the hospital failed to administer/titrate (adjust dosage infusion rate until a particular desired response is obtained or until the maximum dosage rate given by the range is reached) in accordance with the physician orders.


These failures resulted in nursing staff underdosing the amount of narcotic pain medication used for pain management (Morphine) for Patient 28 on comfort care. For Patient 30, the administration of (HYDROmorphone) as prescribed by the physician and implementing non-pharmaceutical interventions for pain management in the PACU (Post Anesthesia Care Unit) which had the potential for ineffective pain control.


Findings:


1. In an interview and concurrent electronic health record (EHR) review, on 12/7/17 at 9:05 a.m. with the Department Manager Leader (DML), reflected Patient 28's admission to the hospital on 11/30/17 for comfort care (end of life care). The DML confirmed that Patient 28 is non-verbal and the physician's order for a continuous Morphine Drip (narcotic pain medication) as follows:


"Morphine in NS (normal saline) 1 mg/ml (milligram per milliliter) IV Premix. Ordered Dose: 3 mg/hr (hour) Frequency: CONTINUOUS. Start: 12/2/17 4:30 p.m. Route intravenous. Admin (administration) Amount: 3 mg/hr. Rate: 3 ml/hr. Volume: 100 ml. Admin Instructions: Do NOT use the CNVI (Checklist of Non-verbal Indicators) or CPOT (Critical Care Pain Observation Tool) Scale for Non-Verbal Comfort Care patients. If non-verbal, use Respiratory Rate as a guide below. If Respiratory Rate is GREATER THAN or EQUAL TO 18: IV (intravenous) bolus (to give fast) 3 mg and increase base rate by 1 mg/hour. Reassess 15 minutes after dose given and repeat as needed. When infusion rate=10 mg/hr, BOLUS 3 mg and CALL PHYSICIAN."


Further record review indicated on 12/2/17 at 1717 (5:17 pm), a New Bag: Morphine Drip set at 1 mg/hr: 1 ml/hr IV, and remained at this dosage and rate until 41 hours and 43 minutes later, on 12/4/17 at 11 a.m., when staff increased Patient 28's Morphine Drip rate to 2 mg/hr. Subsequently, the Morphine drip increased to 3 mg/hr, on 12/4/17 at 1:50 p.m. The DML confirmed there is no documentation in Patient 28's EHR to indicate the nurses administered a 3 mg IV bolus of Morphine as ordered by the physician.


The DML verified the nurses did not follow the physician's order to increase Patient 28's Morphine Drip according to the patient's respiratory rate greater than or equal to 18 on the following dates and times: 18 respiration rate (RR) on 12/3/17 at 8 a.m.; 18 RR on 12/3/17 at 4 p.m.; 18 RR on 12/4/17 at 12:10 a.m.; 18 RR on 12/4/17 at 2:07 a.m.; 18 RR on 12/4/17 at 6 a.m.; 18 RR on 12/4/17 at 10 a.m.; and 20 RR on 12/4/17 at 11:15 am.


In an interview, on 12/7/17 at 11:23 a.m., the DML stated it is expected that nurses adhere to the physician orders to ensure a dignified death of the patient, and it is expected of the nurses to operate within their scope of practice.


2. During an interview and concurrent record review, of Patient 30's EHR, on 12/7/17 at 10:05 a.m. with the Perioperative Services Director (PSD) and the Quality Outcomes Nursing Consultant (QNC), Patient 30 had a Gastric Sleeve Laparoscopic procedure (designed to decrease the size of the stomach and absorption of food) in the Operating Room on 12/6/17. Patient 30 had two Post-Operative orders of HYDROmorphone (narcotic pain medication) to be administered according to Patient 30's severity of pain as follows:


"1. HYDROmorphone in NS (normal saline) Inj (injectable) Syg (Syringe) 0.5 mg. Admin Instructions: To be given in PACU (Post Anesthesia Care Unit). Administer every 10 minutes as needed for moderate pain (4-6). Hold medication and call MD for respirations less than 12. RN, please discontinue this order when the patient is being transferred from PACU. 2. HYDROmorphone in NS Inj Syg 1 mg. Admin Instructions: To be given in PACU. Administer every 10 minutes as needed for severe pain (7-10). Hold medication and call MD for respirations less than 12. RN (registered nurse), please discontinue this order when the patient is being transferred from PACU." The PSD confirmed the nurse administered a dose of HYDROmorphone 0.5 mg on 12/6/17 at 11:30 a.m., when Patient 30 reported a pain level of 7 and respiration rate of 17. On 12/6/17 at 11:45 a.m. (fifteen minutes later), Patient 30 continued to report a severe pain level of 7 and had a respiration rate of 12. The PSD verified the nurse did not administer additional HYDROmorphone or provide any non-pharmacological interventions, and there is no documentation to indicate a rationale for not implementing pain management interventions. The PSD stated the nurse did not follow the physician orders and should have provided any non-pharmacological interventions for Patient 30.

Based on observation, interview, and record review, the hospital failed to follow their policy and procedure and standards of practice when:


1. Patient 23's Foley urinary catheter drainage bag spigot at the base of the drainage bag that provides a means to emptying the bag was on the floor in the Intensive Care Unit (ICU).


2. Nursing staff did not perform hand hygiene before and after donning and doffing gloves in the Operating Room (OR).


These failures placed patients at risk to acquire infections and/or communicable diseases.


Findings:


1. In an observation, on 12/5/17 at 12:05 p.m., Patient 23's Foley urinary catheter drainage bag hung on the left lower adjustable bed rail, and the spigot of the Foley catheter drainage bag is on the floor. Registered Nurse (RN) 4 observed the Foley catheter drainage bag, and stated it is not supposed to be on the floor because the bed is at the lowest position, and the Foley catheter drainage bag is to be placed in a basin so it does not touch the floor.


Record review of Patient 23's electronic health record (EHR) with the Department Management Leader (DML) and the Quality Nurse Consultant (QNC), on 12/7/17 at 8:45 a.m., showed Patient 23's admission to the hospital's intensive care unit (ICU) on 11/27/17 with diagnoses that included septic shock (an infection that results in low blood pressure (BP) that requires infusing fluids and or medications to raise the BP and has the potential for injury or damage to organs), diabetes ketoacidosis (DKA, a life-threatening condition when the body produces high levels of ketones from the incomplete metabolism of fatty acids when there is not enough insulin in the body to manage blood sugar levels), acute kidney injury (AKI, an abrupt decline in kidney function), and altered mental status (AMS).


In an interview, on 12/7/17 at 11:23 a.m., the Department Management Leader (DML) stated the Foley catheter drainage bag is placed on the inside rail of the bed, and not the adjustable bed rail, and that nurses are expected to place a basin beneath the Foley catheter drainage bag so it would not come into contact with the floor for infection control purposes.


In an interview, on 12/7/17 at 11:45 a.m., the Infection Control Nursing Consultant (ICC) stated the Foley catheter drainage bag should not touch the floor and if it does, the nurses are to change the Foley catheter drainage bag for infection control.


Review of the "Lippincott RESOURCE FOR Foley care and management," provided by the hospital's Performance Improvement Clinical Director (PIC), and bases their nursing practice on for the management of Foley catheters and drainage bag, instructed nurses as follows: "Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI (Catheter-associated Urinary Tract Infections). However, don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI."


2. In an observation of Operating Room #4, on 12/5/17 at 8:32 a.m., RN 1 donned sterile gloves to insert a Foley catheter for Patient 21, then removed and discarded his sterile gloves, and proceeded to don new sterile gloves without performing hand hygiene between glove changes.


In an observation of the Operating Room #5, on 12/6/17 at 10:06 a.m., RN 2 assigned, as break relief for RN 5, donned gloves and then removed them. RN 2 proceeded to enter information into the computer, touch and look under Patient 30's sterile drape, and touched medication located on the computer mobile station, and her eye glasses, and bouffant (hair cover).


In an interview, on 12/7/17 at 10:20 a.m., the Perioperative Services Director (PSD) stated nurses are expected to perform hand hygiene before and after patient contact, and before and after donning and doffing gloves because it reduces cross contamination and prevents infections.


In an interview, on 12/7/17 at 11:45 a.m., the Infection Control Nurse Consultant (ICC) stated staff are expected to perform hand hygiene before and after donning and doffing gloves because there is a possibility of transmission of infection.


Review of the policy and procedure titled, "Hand Hygiene", and approved date of 7/17 indicated as follows: "1.0 Policy Statement. 1.1. The Centers for Disease Control and Prevention states that hand hygiene is the single most important procedure for preventing healthcare associated infections. 2.0 Purpose. 2.1 To provide guidelines for proper hand hygiene (i.e., the removal and/or destruction of dirt, organic material and transient microorganisms from the hands), so as to decrease the risk of cross contamination. 4.0 Definitions. 4.1 World Health Organization (WHO) 5 Moments of Hand Hygiene - (Hospitals) employees, staff, students and providers will follow the World Health Organization (WHO) 5 Moments of Hand Hygiene which focus on the concept of hand hygiene before, after or during interaction with the patient zone (room, bay or pod) and healthcare zone (areas external to patient's zone). The 5 Moments include: 4.1.1 Before touching a patient (or before gloves donned, gown or other PPE [Personal Protective Equipment] use).4.1.2 Before clean/aseptic procedures (prior to gloves and other PPE use). 4.1.3 After body fluid exposure/risk (or after gloves, gown or other PPE use). 4.1.4 After touching a patient, (or after gloves removed). 4.1.5 After touching patient surroundings."



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During an observation and subsequent interview, on 12/4/17 at 1:30 p.m., the respiratory therapist (RT) in Patient 31's room had on a gown. The signage on Patient 31's door directed staff to observe Contact Plus isolation and requires gloves and gowns to be worn. RT said she did not wear gloves because she has not touched the patient yet. The Telemetry (heart monitoring unit) Manager (TM)said the patient has MRSA (Methicillin Resistant Staphylococcus Aureus), a bacterial infection that is resistant to the antibiotic Methicillin, and spread by direct contact. TM intervened and instructed RT to remove the gown at the door, perform hand hygiene and don both a fresh gown and gloves in order to enter the room.


Record review of the Medical Records of the Center for Disease Control guidelines that the hospital follows [Hand Hygiene: page 10, approved 6/17, [ hospital name] gloves are worn to reduce the likelihood that hands of personnel contaminated with microorganisms from a patient or a fomite (inanimate objects) can transmit these microorganisms to another patient. In this situation, gloves must be changed between patient contacts and hands should be washed after gloves are removed. [cdc.gov].