HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure that 4 of 7 sampled patients in restraints (Patient ID #s 35, # 26, # 34, # 49) of a total sample of 49 patients had a physician order for restraint.

Findings include:

Patient ID # 35

Observation on 05-29-12 at 10:50 a.m. on the 5-East Neurology Unit revealed Patient ID # 35 lying in bed asleep. Further observation revealed Patient ID # 35 had bilateral soft ankle restraints and a left hand mitten restraint.

Interview with Staff RN Z-12, Patient ID # 35 had suffered a Brain Hemorrhage and was admitted to the hospital on 05-20-12. She went on to say Patient ID # 35 was restrained due to his cognitive impairment that contributed to his attempts at removal of his intravenous lines and indwelling urinary catheter.

Review of Patient ID # 35 ' s medical record revealed a physician order dated 05-21-12 " initiate bilateral ankle and wrist restraints ... " An additional order to continue restraints was written on 05-29-12. Further review of the physician orders failed to reveal a physician order for restraints for 5 days (May 22 through 26, 2012). Review of the nursing assessment documentation revealed Patient ID # 35 was in restraints during those 5 days May 22-26, 2012).

Patient ID # 26

Observation on 05-30-12 at 11:20 a.m. on the 5-East Neurology Unit revealed Patient ID # 26 lying in bed asleep. Further observation revealed Patient ID # 35 had bilateral soft wrist restraints on place.

Review of Patient ID # 26 ' s medical record revealed he was admitted to the facility on 05-14-12; his admission diagnoses were syncope and right-sided facial/ arm deficits.

Review of the physician orders for Patient ID # 26 revealed restraints were instituted on 05-14-12 because the patient " was pulling at tubes and lines. " Review of the nursing assessment documentation revealed Patient ID # 26 was in bilateral wrists and ankle restraints from May 14 through May 30, 2012. Further record review failed to reveal daily physician orders for restraints for 14 of the 16 days. There were physician orders for restraints on 05-14-12 and 05-3012.

Patient ID # 34

Review of the medical record for Patient ID # 34 revealed a physician order dated 05-14-12 for " bilateral wrist " restraints. Review of the nursing assessments for Patient ID # 34 revealed she was in restraints from May 14, 2012 through May 30, 2012. Daily physician orders for continued restraints were not completed for 8 days: 05-17-12; 05-21-12 and 05-23-12 though 05-28-12.

Patient ID # 49

Review of the medical record for Patient ID # 49 revealed he was admitted to the Burn unit on 05-17-12.

Review of the physician orders revealed wrist restraints were initiated by physician order on 05-18-12. Further review revealed a physician order for continued restraint on 05-19-12. There were no daily physician restraint orders for May 20-30, 2012.0

Interview on 05-30-12 at 2:00 p.m. with Performance Improvement Staff RN (Staff ID M) she stated orders for continued restraint must be written every calendar day.

Review of facility policy titled " Restraints, review date 02-02-12, read: " ...11.Policy Statements: F. Restraints must have a physician ' s order, appropriate clinical justification for the restraint, s start time, and a time limit ...IV. Procedure for Restraint Application ... C. Restraint-non-violent self Destructive Behavior Patients ...e. Continued use of restraints beyond the first 24 hours must be authorized by a physician ...Such renewal or new order should be issued no less often that once daily ... "

Based on observation, interview and record review, facility ' s nursing staff failed to monitor and document range of motion on patients with restraint and document restraint readiness in 1 of 7 sampled patients with restraint from a sample of 49 patients. Patient # 9

Findings:

Review of the facility's current policy and procedure on Restraints Policy # CLI -00022 directed staff as follows :

" Monitor and documentation of the patient: Ensure the protection and preservation of patient's rights, dignity and assessed needs.
(B0 Observe at least every two hours for continued need for restraint, Safety of patient, Pulses and skin condition, Emotional and physical needs of patient . Release restraints every (2) hours, reposition patient, assess condition of skin, Assess pulses in restricted limbs (S), Address fluid nutrition and toileting needs."

On 05/29/2012 at 11:40 a.m patient # 9 was observed in bed in room C331 of the facility. The patient had bilateral arm restraint in place,

Interview with the unit Charge nurse on 05/29/2012 at 11:40 a.m revealed the patient was wearing restraints to prevent her removing her naso- gastric tube.

Review of the patient ' s clinical record revealed a physician ' s order dated 05/29/2012 for " Non violent restraint mittens right and left. "


Review on 05/29/2012 of the patient ' s clinical record (Restraint assessment progress notes) revealed there were no documentation indicating that the patient was monitored for restraint discontinuation readiness and range of motion done on the following days:
May 27, 2012 from 08:00 a.m to 22:18 p.m.
May 29, 2012 from 12:43 a.m to 8:00 a.m

On 05/29/2012 at 12:30 p.m. the unit Charge Nurse reviewed the patient ' s clinical record with the Surveyor and confirmed that there was no documentation that the patient was monitored for restraint discontinuation readiness and range of motion done.

Based on record review and interview the facility failed to have systems in place to ensure physician's verbal orders were signed by a physician within 48 hours of making the orders. Citing two (2) of four (4) records reviewed at the cancer center #s 44 and 45.

Findings:

Patient # 44

Review on 5/31/12 of physicians order sheet for patient # 44 revealed a verbal order dated 4/23/ 12 for 720 milligrams of Gencitabine to be administered weekly for three weeks.

There was a verbal order dated 5/17/12 for Nulasta 6 mg subcutaneous to be administered every 24-48 hours ordered 5/17/12. There was no physician's signature for the orders.

Patient # 45

Review on 5/31/12 of physicians order sheet for patient # 45 revealed a verbal order dated 2/23/12 for CBC(complete blood count) and Chem 12, to be done weekly, There was no physician's signature for the order.
Review of the facility's policy titled management of medical orders # CLI-00094 discussed verbal orders but did not give a time frame for signing verbal orders by the physicians.

During an interview with the Clinical Manager at the cancer center she stated there was a problem in getting the verbal orders authenticated in a timely manner.

Based on observation, interview and record review the hospital failed to:
(1) Ensure medications were not expired in the in-patient gastro-intestinal unit (Procedure room ID# 4)
(2) Ensure Normal Saline irrigation solution was stored appropriately inside a warmer on the wound unit
(3) Ensure a narcotic was secured inside an operating room (OR# 35)

Findings include:

Observation 5/29/12 at 11 a.m. in the inpatient gastro-intestinal unit
(Procedure room ID# 4) inside a drawer labeled " meds " revealed the following expired medications:
-Lidocaine 10mg/ml (two vials) expired December 1, 2011
-Lidocaine 10mg/ml expired June 1, 2011
-Epinephrine 10ml expired November 1, 2011
-Lidocaine 50mg/5ml (four vials) expired 2/1/12

Record review of a policy titled " Medication Expiration Date Check " dated 3/1/2011 stated " Purpose: To outline a procedure that ensures expiration dates of medications stored in the pharmacy and nursing units are reviewed routinely. Policy: Expiration date check of medications in the pharmacy and on the nursing units shall be done monthly ... "

Observation 5/29/12 at 2:10 p.m. in operating room #35 revealed a 5ml syringe labeled " Fentanyl " inside an unlocked drawer. Two surgical technicians were the only staff in the operating room when the Fentanyl syringe was noted.

The anesthesiologist (ID# Z10) responsible for operating room ID# 35 stated 5/29/12 at 2:20 p.m. that a Physician Resident was assigned to operating room ID #35 and was negligent for not securing the narcotic Fentanly upon leaving the room.

Based on observation and interview, facility failed to ensure expired supplies/ biologicals were not used for patient care.

Findings:

On 05/30/2012 at 9:55 a.m during observation on the facility ' s treatment floor of the acute care hemodialysis unit revealed two containers of Serim Guardian Bicarb PH strips lot # 045089 in use on the floor.

On 05/30/2012 at 9:57 a.m the Surveyor asked Registered Nurse (S) what strips he used to check for the PH of the hemodialysis dialysate solution. Registered Nurse (S) presented the Surveyor with the two bottles of Serim Guardian Bicarb PH strips lot # 045089. Observation at that time revealed the containers lot #s 045089 were expired on 08/2011.

Observation of the two containers of strips revealed they were opened for use on 04/05/12 and 04/19/12 after the manufacturer ' s expiration dates.



23032

Observation on 05-30-12 at 10:40 a.m. in the Wound Care / Hyperbaric Unit revealed a fluid warmer. Interview at this same time with Unit Manager Staff ID N , she stated the fluids were used for wound care. She went on to say the facility process was to date all bottles of fluid before they were placed in the warmer and were discarded after 14 days.

Further observation revealed 10 bottles of Sodium Chloride solution (250 milliliters each), dated April 2012. The Unit Manager stated the bottles should have been discarded.

Review of the manufacturer ' s instructions for the Sodium Chloride solutions, dated May 2012, read: " ...solutions (plastic bottles) can be warmed to temperatures not exceeding 150 Fahrenheit and for no longer than 72 hours. Once the plastic pour bottle containers have been warmed for their maximum time period the containers should be removed from the warming device and identified as having been warmed. They should not be subsequently returned to the warmer ... "

Based on observation, interview and record review, facility's Infection Control Officer failed to implement facility's policy and procedure to ensure facility ' s direct care staff wear gloves and wash hands after removing gloves, failed to wear gowns and eye protection and failed to clean contaminated glucometer in 2 of 49 sampled patient #s 20, 35

Findings:

Review of the facility's current Policy and procedure on Bloodborne Pathogen Guidelines # OHS- 00006 directed staff as follows:
" Hands should be washed immediately after gloves are removed. If handwashing facilities are not available, antiseptic hand cleaners may be used. Hands must then be washed as soon as facilities are available."
" Gloves should be worn when the employee has a potential for direct skin contact with blood, other potentially infectious materials, mucous membranes, non - intact skin of patient , when handling items or surfaces with blood or other potentially infectious material, and when performing vascular access procedures with No exception. "

Patient #20
Patient # 20 was observed receiving hemodialysis treatment in the acute dialysis center of the hospital on 05/30/2012 at 8:36 a.m. The patient was receiving hemodialysis treatment via a left arm graft.

On 05/30/2012 at 8:40 a.m. patient # 20 was canualated by a Patient Care Technician in the presence of Registered Nurse (L). Registered Nurse (L) donned a pair of gloves and handled and touched the patient ' s external blood line and reset the control panel on the Gambro Phoenix hemodialysis machine.
After handling the patient ' s external blood line, Registered Nurse (L) removed one hand of her contaminated gloves while the left hand remained gloved. Registered nurse (L) then proceeded to write in the patient ' s chart which was on the patient ' s bedside table. Registered Nurse (L) did not remove her contaminated glove and wash her hands.
After writing in the patient ' s chart the nurse then walked over to the suction pump and repositioned the pump with her ungloved hand.
Registered Nurse (L) then walked back to the patient ' s chart and documented in the patient ' s chart with her contaminated hand.

During an interview with Registered Nurse (L) on 05/30/12 at 9:00 a.m. the Surveyor informed the nurse that she had observed that she did not remove her gloves and wash her hands after contact with potentially contaminated items at the patient ' s bedside. Registered Nurse (L) stated " I was going back to the machine that ' s why I
did not wash my hands. "




11754

On 05/31/2012 at 9:00 a.m nursing assistant Z8 was observed providing care to patient #35. During the observation, the nursing assistant donned a pair of gloves and retrieved the patient ' s contaminated linen from the patient ' s room. The nursing assistant then picked up clean linen from a cart in the hallway and then proceeded to arrange personal items on the patient ' s bedside table. The nursing assistant did not remove her contaminated gloves and wash her hands prior to retrieving the clean linen and arranging the patient ' s personal items on the bedside table.




12000

(Protective Barrier Precautions)
Observation 5/29/12 at 11:45 a.m. in an in-patient gastro-intestinal (GI) procedure room revealed a patient having an EGD (Esophagogastroduodenscopy). The technician
(ID# H) assisting the physician was positioned a few feet from the patient ' s mouth during the procedure. The technician was not wearing a protective mask during the procedure. (The technician was wearing a pair glasses)

Interview 5/30/12 at 11:30 a.m. with the Nursing Director (ID# U) of the GI unit revealed that technicians should be wearing protective gear when assisting with an EGD or a procedure.

Record review of a policy titled " Blood borne Pathogen Guidelines " dated 3/5/12 stated " Policy Purpose: To ensure compliance with the Occupational Health and Safety Administration (OSHA) standard fro all employees who have occupational exposure to blood or other potentially infectious materials. Standard Precautions: All health-care workers should routinely use appropriate barrier precautions to prevent skin and mucous-membrane exposure when contact with blood or other body fluids of any patient is anticipated ...Mask and protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or other body fluids to prevent exposure of mucous membranes of the mouth, nose, and eyes. "

(Glucometer)
Observation 5/29/12 at 10:30 a.m. in the Day Surgery pre-operative area revealed a Glucometer with small red specs (splatter) on the devise.

The Nursing Director (ID# Z11) acknowledged at this time that staff should clean the Glucometers after each use.







17028

Patient # 10

Observation on 5/30/2012 at 11:30 am in room 72 revealed the following information:

Staff # 27 (RN) put on gloves and used a scanner to scan the arm band of patient # 10, the staff then opened sterile dressing packages and removed the sterile items with the same gloved hand.

The Staff then retrieved garbage bin with the same gloved hands, disposed of soiled dressing, then proceeded to clean the patient's wound without changing his gloves and washing his hands between tasks.

Further observation revealed Staff # 27 changed his gloves, put on clean gloves and did not wash his hands, he then applied clean dressing to the patient's wounds.

During an interview on 5/30/12 at 11:42 am with the Infection Control Director she stated staff were instructed to change gloves and wash hands after each task.