HospitalInspections.org

Based on record reviews and interviews, the facility failed to secure informed consent regarding anesthesia services for 1 (P (patient) 5) out of 10 patients sampled needing surgical intervention. This failed practice is likely to lead to lack of understanding of all aspects of anesthesia services by the patient prior to consenting.

The findings are:
A. Record Review of facility's "Informed Consent" policy, effective 01/2018, revealed:

1. "The patient should have a sufficient information upon which to base a decision to give or withhold consent."

2. Anesthesia shall be performed only after informed consent is obtained by the ordering physician or physician representative.

3. "It is the responsibility of the physician or physician representative to provider the patient or the patient's surrogate decision-maker with the information necessary to enable him/her to make an informed treatment decision."

B. Record Review of P5's Anesthesia Evaluation note from 11/11/2020 revealed:

1. Anesthesiologist's (physician trained to administer anesthetics) plan for P5 is "spinal (anesthesia produced by injection of an anesthetic into the subarachnoid (the middle of three membranes that cover the central nervous system) space of the spine) and regional (anesthesia of a region of the body accomplished by a series of encircling injections of an anesthetic)"

C. Record Review of P5's "Consent for use of Anesthesia", signed by P5 on 11/11/2020, revealed:

1. Portion labeled "The primary anesthetic planned for my procedure is.." is blank, not filled in by the provider.

D. On 09/08/2021 at 1:45 pm, interview with S5 (Director of Surgical Services) confirmed that anesthesia providers must complete the consent for Anesthesia entirely in order to demonstrate that the patient has been given all information about the medication they will receive, this information includes planned medications the provider wishes to use. The only time this can be bypassed, S5 continued, was if the patient is unstable and needs emergent intervention.

Based on Record Reviews and Interview, the facility failed to provide care in a safe setting by failing to assess or notify providers regarding changes in patient status for 1 (P (patient)3) out of 10 patients sampled for having orthopedic surgical procedures (surgeries needed to correct problems related to bones or muscles). This failed practice is likely to lead to gaps in identifying needs for patients and an increased risk of harm, such as complications to surgery.

The findings are:
A. Record Review of facility's "Assessment and Reassessment" policy, approved 03/2021, revealed:
1. "A baseline physical assessment is to be performed by the primary nurse upon assuming care of the patient every shift."

2. "Nursing reassessment of a patient should reflect at a minimum, changes in patient condition and/or diagnosis and response to interventions."

3. "Nursing reassessments should be documented in the nursing record."

4. "The provider should be notified when there is a significant change in patient's condition."

B. Record Review of the facility's "PACU (Post Anesthesia Care Unit) Care of the Surgical Patient" policy, effective 02/2016, revealed:
1. "Patients should have a head to toe assessment."

2. "Patients should be assessed for pain and comfort treated per orders and patients should be reassessed after interventions."

C. Record Review of P3's Nursing Documentation from 11/12/2020 revealed:

1. On 11/12/2020, P3 was admitted for a Right Total Hip Replacement.

2. On 11/12/2020 at 11:13 am, P3 was documented as leaving Operating Room after procedure and sent to PACU.

3. Comprehensive Flowsheet (documentation of vital signs, pain, and intake and output) from 11:16 am to 5:14 pm revealed:

a. At 11:16 am, pain assessment states "no pain."

b. At 11:31am, pain assessment states "9/10 pain" no documentation of pain type (surgical, acute, breakthrough), pain interventions, or provider notification.

c. At 11:46 am, pain assessment states "8/10 pain" no documentation of pain type, pain interventions, or provider notification.

d. At 12:46 pm, pain assessment states "7/10 pain" no documentation of pain type, pain interventions, or provider notification.

e. At 1:30 pm, pain assessment states "8/10 pain" no documentation of pain type, pain interventions, or provider notification.

f. At 1:35 pm, pain assessment states "9/10 pain" no documentation of pain type, pain interventions, or provider notification.

g. At 1:59 pm, pain assessment states "8/10pain" no documentation of pain type, pain interventions, or provider notification.

h. At 3:53 pm, pain assessment states "9/10 pain" no documentation of pain type, pain interventions, or provider notification.

i. At 5:14 pm, pain assessment states "10/10 pain" no documentation of pain type, pain interventions, or provider notification.

4. No documentation of Head to Toe Assessment (assessment of patient entire body systems)till 10:06 pm by S(staff) 11 (Registered Nurse). Assessment states:

a. Musculoskeletal: "WDL (within define limits, normal or acceptable range)"

5. On 11/12/2020 at 4:51pm, Nursing Note from S11 reports care handed off to S12 (Registered Nurse).

6. No documentation of head to toe assessment done by S12.

7. On 11/12/2020 at 8:40 pm, Nursing Note from S10 (Registered Nurse) reports care assumed from S13 (Registered Nurse). No documentation of assessments from S10 or S13.

D. Record Review of P3's Medical Provider Documentation from 11/12/2020 to 11/16/2020 revealed:

1. 11/12/2020 Post-Operative Provider Assessment indicates that P3 told the provider that their (P3's) hip "popped" when someone pulled it and they had pain. Provider notes assessment of right leg as anteriorly rotated (shortening in length of the leg when compared to the left) and suspicious for a dislocation needing a second surgery.

2. On 11/13/2020, P3 went back to the Operating Room for a open reduction. Operative note indicates that the procedure was not a success as P3's hip continued to "pop" out of place.

3. On 11/14/2020 Post-Operative Provider Documentation indicates P3 having recurrent dislocation of the right total knee.

4. On 11/16/2020 P3 went back to the Operating Room for a revision of right total hip replacement.

E. Record Review of X-Ray Hip Right from 11/12/2020 revealed:

1. Findings: "Patient has undergone a right total hip arthoplasty (replacement). However, there is a dislocation of the femoral prothesis in relation to the acetabular prothesis."

2. Impression: "Dislocation of the patient's right hip arthoplasty."

F. Record Review of facility's "Patient Relation Worksheet (Risk incident report)" from 11/16/2020 revealed:

1. "Patient (P3) wanted to make a complaint about needing a third surgery on right hip. They said they were transferred from the bed to another bed and had hip pain later an x-ray tech (technician) came took x-rays and later replied their hip dislocated. They said the provider went to their room and discussed with them the options. Provider attempted to get hip back in place was unable and they needed to have another surgery."

G. On 09/09/2021 at 3:00 pm, interview with S17 (Registered Nurse) confirmed that patient assessments are done initially and then as needed. When ask what would constitute a need for an assessment, S17 indicated it should be done if a patient has a change of status, such as severe pain. S17 also reported that at a minimum assessments are done every 12 hours. In regards to focus assessments when a nurse takes over care, S17 confirmed that it is the expectation to have all nurses that assume care of the patient to perform and document an assessment.

Based on observation and interview, the facility failed to ensure items utilized for direct patient care are furnished appropriately by not using items past expiration dates and not identified as being under an extended use authorization by the United States Food and Drug Administration. This failed practice is likely to poor treatment and delayed progression to goals.

The findings are:

A. On 09/08/2021 10:30 am, during a tour of the 6th floor Post-Operative Unit (PACU) (the period following a surgical operation procedure), the following was observed to include expired (exp) medical supplies used in direct patient care:

1. Near Patient Bay #10 (recovery area) along the wall on top of a storage cart
HeartSync (product name) ECG (electrocardiogram)(test that records the timing and strength of the electrical signals that make the heartbeat) Monitoring Electrodes (a conductor through which electricity enters or leaves an object.): One exp on 03-20-2020 and one exp on 12-04-2020

2. One package of Kendall 700 Clear Tape Electrodes: exp on 06-28-2020

3. An open package of Kendall 700 Clear Tape Electrodes should have been stored in a plastic Ziploc (a sealable plastic bag with a two-part strip along the opening that can be pressed together and readily reopened) bag

4. A Stryker (product name) Max-A Pulse Oximeter Sensor (a medical device that indirectly monitors the oxygen saturation (moisture) of a patient's blood): exp on 12-05-2020.

B. On 09/08/2021 at 10:45 am, during an interview, S#8 (Division Director of Regulatory) confirmed the expired HeartSync (product name) packages.

C. On 09/08/2021 at 11:05 am, during an interview, S#7 (Nurse Manager) confirmed the expired medical supplies. The open medical supply package needs to be in a Ziploc bag, and discard open medical supply packages.

Based on observation, record review, and interview, the facility failed to maintain a safe physical environment by identifying and managing the condition of patient recovery areas and furniture in the patient recovery areas to minimize the spreading of infections or contagious (spread from one person to another) diseases. This failed practice is likely to expose patients to infectious diseases while receiving medical treatment.

The findings are:

A. On 09/08/2021 at 10:30 am, during a tour of the 6th floor Post-Operative Unit (PACU) (the period following a surgical operation procedure), the following was observed:

1. At the entrance to the PACU on the corner floor to the right behind the door, the metal trimming was loose, and a sharp edge was noticeable if someone were to get near could be hurt by it.

2. At the entrance to the PACU on the left-hand side behind the Symphony Series Ice Maker for patient use, the countertop had areas where the caulking (a waterproof filler and sealant, used in building work and repairs ) was missing.

3. At the entrance to the PACU, next to the ice maker, a Sanyo (product name) microwave for patient use, the inside was dirty (not clean, food stains), and near the food heating area, small sections of the metal had spots of rust.

4. The bathroom used for patient use, the emergency alert pull cord (this notifies a nurse to help the person in need when pulled and a light near the bathroom flashes), did not work.

5. In the dirty utility room (provides for cleaning and holding used equipment for collection and sterilization, disposal of clinical and other wastes, and soiled linen), the inside of the sink had rust all around the base. In addition, the nozzle (round spout at the end of a hose) connected to the faucet had corrosion (destroyed or damage (metal, stone, or other materials) slowly by chemical action), and the wall next to the sink had water damage.

6. Patient Bay #6 (recovery area) upon entering the site on the right side of the room, a corner near the wall of the linoleum (linoleum made of natural materials that are much more susceptible to damage from water and cleaning products), the integrity (quality) of the fabric cracked.

7. Patient Bay #9 upon entering the area on the left side of the room, a corner near the linoleum wall, the fabric's integrity cracked. In addition, a three-drawer solid wood used for medical supplies storage was missing the front wheels making it difficult to open and close the bottom drawer.

B. Record review of an unnamed work order for the Symphony Series Ice Maker in PACU, undated. Revealed, under Order section, "order by S#14 (Unit Clerk)", under Dates section, "Entry 07/15/2021 8:37 AM", under Description section, "PLEASE CAN YOU FIX THIS MACHINE DOCTORS NOT VERY HAPPY PLEASE HELP US OUT!!!!!!"

C. On 09/08/2021 at 11:10 am during an interview, S#7 (Nurse Manager) confirmed for equipment in the patient recovery area needing repairs, a work order is an upload into the facility's computer system, and the facility director will assign it to a technician. Additionally, S#7 confirmed a work order to have the ice maker serviced was in July 2021. Surveyor requested confirmation of the work order to ensure the date the ice maker was last serviced.

Based on observation and interview, the facility failed to maintain the integrity (quality) or replace equipment to prevent the spreading of infectious (from one person to another) diseases. Provide and monitor a sanitary (clean and free from dirt, bacteria, etc.) environment to minimize the transmission of contagious disease within the unit by ensuring proper housekeeping processes. This failed practice can place patients at risk for exposure to infectious diseases while receiving treatment.

The findings are:

A. On 09/08/2021 at 10:30 am, during a tour of the 6th floor Post-Operative Unit (PACU) (the period following a surgical operation procedure), the following was observed:

1. In the hallway near (PACU) unit, on a stretcher (used for moving patients who require medical care) the mattress, the lining on two corners had tears (approximately 1/2 inch in diameter)

2. There were three stretchers in Patient Bay #7 (recovery area); each mattresses' lining had tears on the corners (approximately 1/2 inch in diameter.)

B. On 09/08/2021 at 10:35 am, during an interview, Staff (S)#3 (Interim Quality Director/ Quality Manager) confirmed the tears on the four mattress linings.

Based on observation and interview, the facility failed to ensure consistent infection control processes by having a plastic bin with computer connectors filled with water in the patient recovery area. This failed practice is likely to create an infectious waterborne (bacteria) environment and expose patients and staff to communicable (one person to another) diseases.

The findings are:

A. On 09/08/2021 at 10:30 am, during a tour of the 6th floor Post-Operative Unit (PACU) (the period following a surgical operation procedure), the following was observed:

1. Near the entrance to the PACU, the cabinet below the Symphony Series (product name) ice maker, a white plastic bin approximately 2 ½ feet long and 1 ½ foot wide and 3 inches deep, there were several computer extension cables commonly used for Mac multiSync (multiple vertical and horizontal frequency standards) monitors, and midi (digital interface) audio), in the plastic bin filled with water.

B. On 09/08/2021 at 10:40 am during an interview, Staff (S)#7 (Nurse manager) confirmed the plastic bin with the computer extensions filled with water in the cabinet below the ice maker can create an infectious (bacteria) environment.

Based on record reviews and interviews, the facility failed to modify discharge plans to include Home Health Care Physical Therapy (HHC PT) or Home Health Care Occupational Therapy (HHC OT) for 2 (P (patient) 1 & P9) out of 10 patients sampled. This failed practice is likely to lead to ineffective discharge planning and an increased risk of readmission.

The findings are:

A. Record Review of facility's "Discharge Planning" policy, effective 04/2019, revealed:

1. "The hospital will arrange for initial implementation of the discharge plan including referrals to specialized ambulatory services/community services, e.g transportation services, new dialysis referrals, home health, hospice, home oxygen etc."

2. "Documentation of the implementation of the discharge plan will be placed in the medical record in the most appropriate locations. Additionally, the patient/caregiver will be given written information and instructions upon discharge."

B. Record Review of P1's Medical Record from 10/07/2020-10/08/2020 revealed:

1. On 10/07/2020, P1 was admitted for a revision of a right hip replacement.

2. On 10/07/2020 at 4:00 pm, initial Physical Therapy Evaluation note states "Discharge: Home health care PT" and "OK to Discharge from PT? No"

3. On 10/08/2020 at 9:31 am, Case Management note reports discharge plan as "home with friend [name] to transport."

4. On 10/08/2020 at 12:14 pm, After Visit Summary (Discharge paperwork) printed and given to P1. No instructions regarding HHC-PT referral.

5. On 10/08/2020 at 12:27 pm, Physical Therapy Deferral Note indicates "Pt (P1) has been discharged from the hospital." No documentation if P1 was cleared from PT or if P1 no longer needed HHC-PT.

6. On 10/08/2020 at 12:27 pm, Physical Therapy Daily Treatment Note, filed at same time as Physical Therapy Deferral Note, states: "Discharge: Home health care PT."

C. Record Review of P9's Medical Record from 11/05/2020 to 11/10/2020 revealed:

1. On 11/05/2020, P9 was admitted for a right hip replacement.

2. On 11/06/2020 at 7:55 am, Orthopedic provider note states "Anticipate discharge home today with home healthcare"

3. On 11/06/2020 at 9:30 am, Initial and Discharge Physical Therapy Evaluation note states "pt (P9) agreeable to DC (discharge) home today with family support and HHC PT services."

4. On 11/06/2020 at 9:50 am, Initial Occupational Therapy Evaluation note states "Discharge: home with family, home health care OT"
5. On 11/06/2020 at 10:38 am, After Visit Summary (Discharge paperwork) printed and given to P9. No instructions regarding HHC PT referral or HHC OT referral.

6. On 11/09/2020 at 4:17 pm, outpatient communication note states "Patient daughter is calling would like to get a referral for PT, please call once done."

7. On 11/10/2020 at 1:11 pm, outpatient Orthopedic provider note states "Put in a physical therapy consult for (Facility Name) (Outpatient Physical Therapy Facility). Please make it as soon as possible they (P9) has not had the home therapy."

D. On 09/09/2021 at 2:30 pm, interview with S (staff)15 (Social Worker) confirmed that when physical therapy or occupational therapy makes a recommendation for home care services, case management will help set up the services for the patient and will include "Start of Care" instructions in the After Visit Summary.

E. On 09/09/2021 at 2:45 pm, interview with S16 (Registered Nurse-Case Manager) confirmed that if a patient is recommended for homecare, they will place referrals and set up with the agency prior to discharge. S16 endorsed that discharge planning is done on every single inpatient patient.