HospitalInspections.org

Based on document review and interview, the facility failed to develop and maintain its policy/procedures regarding notice of patient rights including a provision for documenting when all patients and/or their representatives are provided with notice of patient rights prior to receiving or discontinuing care.

Findings:

1. On 8-25-14 at 1645 hours, the director of quality A4 was requested to provide an administrative or departmental policy/procedure regarding Notice of Patient Rights including the specific patients rights information or notice provided to all patients and/or their representative and indicating the process for documenting when, where, and how the notice of patient rights was provided by the designated department personnel and accepted or refused by the patient or the patient's representative and no policy/procedure was received prior to exit.

2. During an interview on 8-26-14 at 1615 hours, the director of quality A4 confirmed that the facility failed to develop and maintain a policy/procedure regarding Notice of Patient Rights including the notice of all rights provided to patients and the process for providing the notice of patient rights.

3. During an interview on 8-26-14 at 1620 hours, the director of quality A4 confirmed that the Patient Guide and Information folder failed to indicate a patient bill of rights or list of patient rights and responsibilities.

4. During an interview on 8-27-14 at 1120 hours, quality specialist A21 confirmed that no patient access [patient registration] policy indicated the responsibility of the patient access representative to provide the notice of patient rights during admission registration or indicated how to document when the notice of rights was received or refused by the patient.

5. During an interview on 8-27-14 at 1245 hours, the patient access manager A23 indicated that the registration staff provide each patient with a 1 page document titled patient rights and responsibilities (no approval date) in the Patient Guide and Information folder. The manager A23 confirmed that the admitting process checklist titled Admits From Emergency Room failed to indicate or require staff to provide a notice of patient rights and responsibilities to the patient. The patient access manager A23 confirmed that no medical record documentation by admission staff was available to indicate that the notice of patient rights was received or refused by the patient or representative.

Based on document review and interview, the governing board failed to ensure that the responsibility for the grievance review process was delegated to a grievance committee (composed of more than one person) or otherwise be directly responsible for reviewing and resolving grievances.

Findings:

1. The Governing Board bylaws (reviewed 1-13), executive committee description and board quality council committee description failed to indicate a provision for reviewing and resolving grievances or delegating the grievance process to a grievance committee.

2. The policy/procedure Patient Complaints/Grievances (revised 7-06) indicated the following: "the Board of Directors is responsible for assuring that an effective and efficient grievance resolution process is maintained ...[and] ... delegates authority to ...the Guest Relations Coordinator [who] shall provide written acknowledgement and resolution/response to complainants ..."

3. During an interview on 8-27-14 at 1340 hours, the patient experience officer A22 confirmed that the Governing Board bylaws failed to indicate a provision for delegating the grievance process to a grievance committee and confirmed that the Patient Complaint/Grievance policy (revised 7-06) failed to indicate that patient grievances would be reviewed and resolved by a committee. The patient experience officer confirmed that they (A22) were the person responsible for reviewing and resolving all patient grievances at the facility.

Based on document review and interview, the facility failed to develop and maintain its policy/procedures and assure that a patient's family member or designated representative was promptly notified about the admission.

Findings:

1. On 8-25-14 at 1645 hours, the director of quality A4 was requested to provide an administrative or departmental policy/procedure regarding Notice of Patient Rights including the notification of a family member or representative of choice and the notification of his/her physician about the admission and no policy/procedure was received prior to exit.

2. During an interview on 8-27-14 at 1120 hours, the quality specialist A21 confirmed that no administrative policy/procedure indicating a process for notifying a family member or representative of choice and notifying the patient's physician about the admission by a hospital representative was available.

3. During an interview on 8-27-14 at 1255 hours, the patient access manager A23 confirmed that no patient access (registration) policy/procedure indicated a process for notifying a family member or representative of choice about the admission including a requirement for documenting when requested or declined was available and the patient access manager A23 confirmed that no medical record documentation indicating that a family member or representative of choice was notified by a patient access staff about the admission was available.

Based on policy and procedure review, medical record review, and staff interview, the nursing executive failed to ensure implementation of the policy related to restraint monitoring for two of two patients restrained (pts. #8 and #9).

Findings:
1. Review of the policy and procedure "Restraints", no policy number, last reviewed on 5/15/14, indicated:
a. On page 8, under "Patient Assessment, Monitoring, & Documentation", it reads: "...3. Every two hours document: a. Extremity assessments b. Assistance with toileting c. Provision of nutrition and fluids d. Release of restraints and ROM (range of motion) of affected extremity e. Mental/behavior status. For Management of Violent or Self-Destructive Behavior:...If the patient's behavior requiring restraint application improves, the RN (registered nurse), thorough assessment monitoring and reevaluation of the patient, may discontinue the restraints prior to the expiration of the order or at the earliest possible time. If restraints are discontinued prior to the expiration of the original order, a new order must be obtained prior to reapplying the restraints."

2. Review of medical records for two patients, who had been in ICU, indicated:
a. Pt. #8 had physician orders for medical restraints (pt. dislodging endotracheal tube and pulling out IV [intravenous] line) on 12/11/13, 12/12/13, 12/13/13, and 12/14/13 with every two hour documentation lacking as follows:
A. On 12/11/13 between 2:17 AM and 4:24 AM = 7 min. late; 6:09 AM to 9:07 AM was 58 minutes late; 9:07 AM to 1:29 PM was 2 hours and 22 minutes late for restraint checks; 1:29 PM to 8:54 PM was a 7 hour and 25 minute lapse in nursing documentation.
B. On 12/12/13 between 4:03 AM and 6:20 AM was 17 min. late; between 6:20 AM to 9:32 AM was a 1 hour and 12 minute delay; between 9:32 AM and 3:53 PM was a 6 hr and 21 minute lapse in charting; and between 3:53 PM and 6:45 PM was a 52 minute delay in charting.
C. On 12/13/13, between 2:30 AM and 7:30 AM, there was a 5 hour gap in nursing restraint documentation; and between 7:30 AM and 11:50 AM, a 2 hour and 20 minute delay.
D. On 12/14/13, between 8:40 AM and 12:00 PM was a 1 hour and 20 minute gap; between 12:00 PM and 3:40 PM was a 1 hour and 40 minute delay; and between 6:07 PM and 8:54 PM was a 47 minute delay in nursing documentation.
b. Pt. #9 had physician orders for medical restraints on 1/4/14 due to pulling out their NG (naso gastric) tube and dislodging their endotracheal tube. Every two hour documentation while the patient was in restraint was lacking as follows:
A. On 1/4/14, between 5:45 AM and 8:20 AM, was a 35 minute lapse; between 8:20 AM and 10:30 AM was a 10 minute gap, and between 10:30 AM and 12:40 PM was a 10 minute gap.
B. A note written by nursing at 10:30 AM states: "Restraints have been off since 1000".
C. Documentation of restraints noting "loosened" was written at 12:40 PM, 1:40 PM, and 2:00 PM, with no new order for restraints found in the medical record.

3. At 2:00 PM on 8/27/14, interview with staff member #50, the director of quality, indicated:
a. As listed in 10. above, nursing failed to follow facility policy related to restraints, with the lack of every two hour documentation related to restraints as required by facility policy.
b. Pt. #9 lacked a new order for restraints when nursing noted that restraints were released at 10:00 AM on 1/4/14, and then began documenting restraint activity again at 12:40 PM without a new order.

Based on review of the medical staff rules and regulations, patient medical record review, and staff interview, the facility failed to ensure that a history and physical was performed within 24 hours of admission for 1 of 2 pediatric patients (pt. #11).

Findings:
1. Review of the medical staff rules and regulations, last approved 5/17/13, indicated:
a. Under section "III. Medical Records, Documentation", it reads: "...4. A complete history and physical exam must, in all cases, be written or dictated no more than thirty (30) days before or within 24 hours after admission of patient...".

2. Review of closed pediatric medical records indicated:
a. Pt. #11 was admitted to the ICU (intensive care unit) at 12:01 AM on 6/3/14 and had a history and physical dictated at 7:56 AM on 6/4/14.

3. Interview with staff member #50, the facility director of quality, at 2:00 PM on 8/27/14, indicated:
a. The history and physical for pt. #11 was not within 24 hours of admission, it would need to have been dictated between midnight (12:01 AM) on 6/3/14 and midnight on 6/4/14--it is almost 8 hours beyond the 24 hours requirement.

Based on policy and procedure review, medical record review, observation, and staff interview, the nursing executive failed to: ensure implementation of the policy related to the refrigerator log; ensure the blanket warmer log was completed daily, as per expectations; and failed to ensure implementation of the policy related to the marking of glucometer test strips and control solutions once opened.

Findings:
1. Review of the policy and procedure "Refrigerator/Patient Log", no policy number noted, with a last reviewed date of 7/11/13, indicated:
a. The first line of the policy reads: "The inside temperature of the refrigerators shall be checked and logged daily...".

2. At 2:40 PM on 8/25/14, while on tour of the ICU (intensive care unit) in the company of staff member
#53, the ICU nurse manager, it was observed that the pantry/patient refrigerator log sheet for temperature checks lacked:
a. Documentation for 28 of 31 days in July 2014.
b. Documentation for 11 of 25 days, to date, for August 2014.

3. Interview with staff member #53 at 2:40 PM on 8/25/14 indicated agreement that the nursing staff was not completing the refrigerator temperature log daily, as required per facility policy.

4. At 2:45 PM on 8/25/14, while on tour of the ICU in the company of staff member
#53, the ICU nurse manager, it was observed that the blanket warmer temperature log:
a. Lacked documentation of a daily temperature for 18 of 25 days, to date, for August 2014.
b. Lacked documentation of a daily temperature for 13 of 31 days in July 2014.

5. Interview with staff member #53 at 2:45 PM on 8/25/14 indicated nursing staff was not documenting daily temperature checks.

6. At 4:15 PM on 8/26/14, interview with staff member #50, the director of quality, indicated there is no facility policy related to documentation required for daily blanket warmer temperature checks, but that is the facility expectation.

7. At 10:42 AM on 8/26/14, while on tour of the pre/post op area in the company of staff member #54, the nursing surgery director, it was observed that the pantry/patient refrigerator lacked documentation of temperature checks for:
a. Five days in August 2014, between August 1 and August 25.
b. One day in July, 2014.

8. Interview with staff member #54 at 10:45 AM on 8/26/14 indicated confirmation of dates missing for documentation of refrigerator temperatures as listed in 7. above.

9. Review of the glucometer test strip package insert from the manufacturer indicated that the test strips are good to the expiration date on the vial, even after opening.

10. Review of the facility policy and procedure "Glucose Monitoring: Accu-Chek Inform Proficiency Testing", with no policy number, and dated with a last revised date of 6/18/13, indicated:
a. Under "Quality Control", on page two, it reads: "Quality control material must be appropriate for the type of assay strips in use. Store Q.C. (quality control) material and test strips at room temperature...Q.C. material is stable for 3 months once opened. Opened reagent strips are stable until the expiration date indicated on the bottle. Upon opening a new bottle of Q.C. material, document the date it was put into use, the expiration date is 3 months from opened for Q.C. material...".

11. At 1:45 PM on 8/25/14, while on tour of the ED (emergency department) in the company of staff member #52, the ED nurse manager, it was observed that the glucometer test strips were dated with a 30 day expiration date after opened.

12. At 2:55 PM on 8/25/14, while on tour of the ICU in the company of staff member #53, the nurse manager of the unit, it was observed that the glucometer test strips were dated with a 30 day expiration date after opened.

13. At 3:00 PM on 8/25/14, interview with staff member #53 indicated staff are dating a 30 day expiration date on glucometer test strips which is incorrect as the manufacturer indicates they are good to the expiration date on the viall, which was 5/2015.

14. At 11:15 AM on 8/26/14, while on tour of the newborn nursery in the company of staff member #55, the nurse manager of the unit, it was observed that two sets of glucometer control solutions (4 vials total) lacked a documentation on the vials of the date opened, or the 90 day expiration date once opened, per facility policy.

15. Interview with staff member #55 at 11:20 AM on 8/26/14 indicated there was no notation on the four glucometer control solutions indicating when they had been opened so that nursing staff would know when the 90 day expiration date would occur.

Based on policy and procedure review, employee health file review, and staff interview, the infection control committee failed to ensure that the policy related to TST (tuberculin skin testing) was implemented for 3 of 12 employees (staff members N1, N7, and N12).

Findings:
1. Review of the Exposure Control Plan, specifically regarding "Tuberculosis Exposure Control Plan", with a policy number "TB ECP (exposure control plan)", with an effective date of 1988, indicated:
a. On page 7, it reads: "...f. All TST's shall be administered, read, and interpreted by personnel specifically trained and certified in administration and interpretation of the Mantoux Skin Test...2) Skin test results will be read in 48 - 72 hours...".

2. Review of employee health files indicated:
a. Staff member N1 had a TST given on 11/20/13 that was read on 11/22/13, the time of the reading was not documented making it unknown if this reading was within the 48 to 72 hour time frame.
b. Staff member N7 was given a TST on 4/13/14 but did not have the time noted in the area for "Date/time/given by:".
c. Staff member N12 was given a TST on 8/26/13 but did not have the time noted in the area for "Date/time/given by:".

3. At 2:35 PM on 8/27/14, interview with staff member #60, a human resource assistant, indicated:
a. After review of the TST documentation for employees N1, N7 and N12, it was noted that no time given, or read, was documented for the TSTs for these staff members as written in 2. above.
b. It cannot be determined that the TSTs were given, or read, within the 48 to 72 hour time frame with the lack of documentation.