HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure physician's orders included medical justification prior to restraints use for 3 of 3 patients (#6, 7 & 10).
Findings included:
1. On 10/04/2011 at 10:45 a.m., patient #7 was observed in bed at rest, with a tracheostomy and intraveneous lines in place, and with bilateral wrist restraints in place. The patient also had a sitter in the room. Review of the medical record showed patient #7, age 76, was admitted on 09/09/2011 with a diagnosis of traumatic brain injury. Review of the orders for wrist restraints from 09/27/2011 to 10/03/2011 (sampled due to the length of the patient stay) showed the only medical justification for the restraints is "Promotion Medical/Surgical healing".
During an interview on 10/04/2011 at 11:40 a.m., the registered nurse manager (RN) confirmed "Promotion Medical/Surgical Healing" was not a specific reason for restraint use.
2. On 10/04/2011 at 11:03 a.m. patient #6 is observed to be in bed at rest with one wrist restraint in place to the left wrist. Review of the medical record showed patient #3, age 22, was admitted on 02/22/2011 with a diagnosis of post larynjectomy for cancer (removal of the voice box). Review of the orders for wrist restraints from 09/29/2011 to 10/03/2011 (sampled due to the length of the patient stay) showed the only medical justification for the restraints was "Promotion Medical/Surgical healing".
3. On 10/04/2011 at 12:00 p.m. patient #10 is observed to be in bed at rest with bilateral wrist restraints in place. Review of the medical record showed patient #10, age 21, was admitted on 009/25/2011 with a diagnosis of near drowning. Review of the orders for wrist restraints from 10/01/2011 to 10/03/2011 showed the only medical justification for the restraints was "Promotion Medical/Surgical healing" .
During an interview on 10/04/2011 at 12:10 p.m. the RN manager of intensive care confirmed "Promotion Medical/Surgical Healing" was not a specific reason for restraint use.
Review of the policy #CP 3.02 Utilization of Restraints, dated as revised 05/01/2011, did not include any requirement to staff or physicians to obtain medical justification for use of patient restraints.

Based on observation, interview and record review, the hospital failed to ensure that patients with peripherally inserted central catheter (PICC) lines received the correct amount of normal saline flush after blood draws, and did not ensure the timely change of bloody/soiled and/or loose PICC line dressings in accordance with the physician orders and hospital's policy/procedures for 2 of 3 sample patients observed with dual lumen PICC lines (#22 & 25).

Findings:

1. Review of patient #22's medical record, both electronic and hard copy, revealed the patient was admitted to the hospital on 9/23/11 with the diagnosis of a right nephrostomy (kidney) tube malfunction. Lab results revealed that she had an urinary tract infection (UTI). The bacterial infection was identified as Methylcillin Resistant Staphylococcus Aureus (MRSA). On 9/28/11, she had a dual lumen PICC line inserted in order to receive intravenous (IV) antibiotic therapy for treatment of the UTI.

On 10/04/11 at 12:15 p.m., observation of patient #22's PICC line revealed that it was located in her left antecubital area. Observation also revealed that one of the IV lines had a large amount of visible blood in it. In an interview with the patient's nurse at this time, she stated that the line was occluded. When asked if blood was drawn from the PICC line, she stated "Yes". When asked which of the two lines was designated to draw blood, she stated that she could draw from either line and their was no designation. When asked how the IV was flushed after a blood draw, she stated that she used 10 milliliters (ml.) of normal saline after blood draws. When asked how much she flushed with after antibiotic administration, she stated 10 ml. of normal saline. Also, at this same time, the PICC line site was covered with a clear Tegaderm dressing with a antimicrobial patch covering the insertion site. Dried blood was observed underneath and extended around the biopatch about 2 centimeters. The Tegaderm dressing had peeled up at its inner and lower edges. Continued interview with the patient's nurse at this time, revealed that when asked about the peeling edges of the dressing and the blood underneath the dressing surrounding the insertion site and bio-patch, she stated that it was alright. The nurse stated that the dressing was scheduled to be changed every 7 days which would be "tomorrow", 10/05/11.

Continued review of patient #22's electronic medical record revealed PICC line flush orders dated 9/28/11 as follows: "Treatment Instruction - Special Instructions: IV Flush 10 cc. (cubic centimeters/ml.) before and after use and 20 cc. after blood draw." The nurse had not been aware that 20 ml. was necessary with which to flush the line after a blood draw.

Continued record review of the treatment and medication administration sheets revealed that the PICC line dressing had not been changed since the day of insertion, 9/28/11, 6 days earlier. Review of the physician's order for the PICC line dressing change dated 9/28/11 revealed the following: "Change dressing every 48 hours if a gauze dressing or non-CHG Tegaderm is used in the initial dressing. DO NOT CHANGE dressing within the first 24 hours if bioseal dressing is used unless excessive bleeding continues. Change the dressing every 7 days if biopatch or bioseal (antimicrobial patch) is used in the initial dressing. Change PICC dressing if dressing becomes soiled or non-occlusive.

2. Review of patient #25's medical record, both electronic and hard copy, revealed that she was admitted to the hospital on 9/28/11 with the diagnosis of acute pancreatitis. On 9/28/11, she had a dual lumen PICC line inserted in order to receive intravenous total parental nutrition (TPN).

On 10/04/11 at 2:20 p.m., observation of patient #25's PICC line revealed that it was located in her right antecubital area. The PICC line site was covered by a clear Tegaderm dressing with a antimicrobial patch covering the insertion site. Dried blood was observed underneath and extended around the antimicrobial patch about 2 cm. The Tegaderm dressing had peeled up at its inner edge and had been taped down with a strip of paper tape about 4 inches in length. Interview with the patient at this time stated that she had been asking for the staff to change dressing because of the itching and blood underneath it.

Interview with the patient's nurse on 10/04/11 at about 2:25 p.m. revealed that when asked about the peeling dressing edge, the paper tape, and the blood underneath the dressing surrounding the insertion site and bio-patch, she stated that the dressing was scheduled to be changed every 7 days and that is was not time yet. When asked how the PICC line was flushed after a blood draw, she stated that she used 10 ml. of normal saline after blood draws.

Review of the facility's policy/procedure entitled "Insertion, Maintenance and Removal of Central Lines, Ports, Midlines/PICC lines" revealed that following blood draws, the PICC line is to be flushed with 20 ml. of normal saline.

On 10/04/11, at 2:30 p.m. and again at about 3:30 p.m., interviews with the hospital's IV nurse validated that PICC lines needed to be flushed with 20 ml. of normal saline, rather than 10 ml. after a blood draw. She also validated, after observation, that both patients #22 and #25, should have had their PICC dressings changed due to the amount of dried blood underneath in order to reduce the risk of infections as well as concern related to the peeling up of the dressing edges, the need to use paper tape to hold the dressing intact, and the patient's complaints of itchiness.

Based on record review and interview, the facility failed to ensure 3 of 3 agency staff (staff H, I , & J) received risk management training, and failed to ensure 2 of 3 (staff H & I) agency staff received restraint and restraint first aid training prior to working.
Findings included:
Review of the agency staff resource list showed a total of 11 agency staff available to be called for staffing.
1. Review of the human resources file for staff H agency registered nurse (RN), hired 09/08/2010 showed no risk management training, restraint application, or restraint first aid training at hire or during the year of 2011. Information provided by quality manager showed staff H last worked on 09/09/2011 from 7 p.m. to 7 a.m. Information provided by quality manager showed staff H worked 9 days in July 2011, 4 days in August 2011, and last worked on 09/09/2011 from 7 p.m. to 7 a.m. Review of the e-learning requirement sheet for staff H did not show risk management or restraint training as part of the mandatory learning.
2. Review of the human resources (HR) file for staff I agency RN, hired 03/07/2011, showed no risk management training at hire. Information provided by quality manager showed staff I worked 1 day in July 2011.
3. Review of the HR file for staff J agency RN, hired 04/14/2010, showed no risk management training at hire or during the year of 2011.
During an interview on 10/05/2011 at 10:15 a.m. the HR administrator said there was no documentation that agency/contract staff H, I and J had risk training and no documentation that staff H and I had restraint training at hire or annually.

Based on record review, observation and interview, the facility failed to assure Anesthesia Services were provided consistent with facility policies and practices in all anesthesia areas.

Findings:

Review of facility policy CP 4.04 "Dating of Sterile Medication Containers", revised 09/01/2011; III, 5 stated label with expiration date. ... when opening." Interview with the pharmacy safety officer on 10/05/2011 at 3:30 p.m. confirmed the intent of the policy was that the vials are to be labeled when first opened.

During the facility tour of the OR 10/05/2011 at 2 p.m., open vials of medication were observed in anesthesia carts which were not dated follows:
OR #10 Glycopyrrolate 1 milligram (mg.)/5 milliliter (ml.)
OR #9 Glycopyrrolate 1 mg./5 ml., Rocuronium 10 mg./ml. 10 ml., and (2) vials of Neostigmine 1:1000 10 ml.
OR #12 Glycopyrrolate 1 mg./5 ml., Lidocaine 2% 20 mg./ml; 20 ml., and Neostigmine 1:1000 10 ml.

Interview on 10/05/2011 at 2:30 p.m. with the nurse manager of the OR confirmed the presence of the vials.

In an interview with the Chief of Anesthesia on 10/05/2011 at 2:15 p.m., he stated we don't label them because the anesthesia technicians throw them out after the case is over.
Room 12 was a room already set up for the next case, which was confirmed by the OR manager.