HospitalInspections.org

Based on review of 2 of 2 medical records for patients undergoing surgical procedures, interviews with staff, and review of policies and procedures it was determined that the hospital has in use two different anesthesia consent forms that provide conflicting informed consent documentation in regard to the hospitals policy for honoring a patient ' s Advanced Directive in the intraoperative setting. This conflicting information places the hospital at risk for violating patients ' rights and wishes.


During a tour on 11/4/2015 of the endoscopy outpatient department and of the surgical department, staff interviews were conducted. Staff were asked what would happen if a patient would go into cardiac arrest. Staff from both departments responded that ' Do Not Resuscitate ' (DNR) wishes of patient ' s are not " followed " in the intraoperative setting (when the patient receives and is under the effects of anesthesia). Staff stated that intraoperative patients would be administered all life-saving/supportive measures.


Review of policies and consents forms for the surgical and anesthesia departments revealed that the hospital has 2 different anesthesia consent forms currently in use. One Anesthesia Consent form #7040 revised 04/04/05 states " I understand it is the hospital ' s policy that DO NOT attempt resuscitation orders will be suspended during anesthesia and surgery " was in use in the hospital surgical department. The second Anesthesia Consent form # 7040 revised 8/4/08 states " I wish to continue my DNR status throughout the perioperative setting which includes OR, PACU, and the immediate postoperative period " and then the patient is to initial this section if desired. This form was used by anesthesia providers in the endoscopy outpatient department. This contradicts what the staff stated would happen if a patient went into cardiac arrest. The surgical or operative consent form does not address a patient ' s DNR wishes.


The hospital also has in effect 2 different Do Not Resuscitate policies. The first policy # SS-8 last revised 1/2015 is from the surgical services department. This states, " It is the policy of the hospital that the DNR policies will be rescinded on surgical patients upon entering the operating room and continuing through phase 1 of recovery. The second Do Not Resuscitate policy # Anes-11 last reviewed 1/2015 is from the anesthesia department which states in summary that a patient may elect to suspend DNR orders for the perioperative period or uphold their decision to continue their DNR status in the operative setting.


These conflicting policies and consent forms were reviewed and confirmed by the risk manager and the director of surgical services on 11/4/2015. Failure of the hospital to have consistent policies and consenting procedures in place for patient wishes should a medical emergency arise in the operative setting places patients at risk for their rights being violated.

Based on a review of the hospital policy " Restraint, Violent and Non-Violent (revised 6/25/14, and two records containing documentation for violent restraint episodes, one of two records failed to document the elements of a face-to face by a physician within one hour of the restraint application.

Hospital policy " Restraint, Violent and Non-Violent " states in part, " 3. e) Within one hour of the application of restraint by an RN, the patient must be evaluated face-to-face by a physician, and this evaluation must be documented in the patient ' s medical record. The one hour evaluation will include:

-the patient ' s immediate situation
-the patient ' s reaction to the intervention
-the patient ' s medical and violent (sic) condition;
-the need to continue or terminate the restraint ...

Patient #13 was an adolescent female who due to intoxication, became violent and required 4-point restraints. The restraints were discontinued approximately 20 minutes later. An attestation signed by the physician at 0102 at the time of restraint stated " A face to face evaluation of this patient was performed. " However, none of the elements noted in hospital policy and regulation for conducting a face to face are documented. A medical screening exam is noted at 0429, and a narrative note was found at 0841.

While survey indicates that the facility has a thoughtful restraint process with short restraint times, the facility failed to document the required elements in the face to face note.

Based on review of the medical record for patient #5 and interview with the Post Anesthesia Care Unit (PACU) nurse, a standing order sheet for admission to the PACU was determined to contain orders for pain medication that were not specifically and clearly written to address the patient ' s pain needs.


On the PACU Admission Order sheet for patient #5 both Morphine Sulfate 2 mg IV every 5 minutes as needed up to 10 mg max dose and Fentanyl 25 mcg IV every 10 minutes as needed up to 100 mcg max dose were ordered. Morphine was to be administered for a pain greater the 3 (based on a 1 to 10 number scale with 1 being the least pain and 10 being the most pain). Fentanyl was to be administered for reported pain greater than 5. This order reads that if patient #5 reports pain 5 or greater that the nurse may choose to administer either drug at his/her discretion. This order also does not indicate if the drugs were ordered as ' morphine or fentanyl ' , or ' morphine and fentanyl ' to be administered and the different time intervals.


Failure of medical staff to provide clear, specific pain medication orders for all patients places the patient at risk for over sedation leading to harm.

Based on the findings of the Life Safety Code survey performed on 11/4/2015 it was determined that the Condition of Physical Environment was not met due to the following Life Safety Code deficiencies.

1. K0015 due to two areas with unsealed penetrations;
2. K0018 due to 2 fire doors that were unable to close due to impediments;
3. K0046 due to two emergency lights that were not operational;
4. K0052 due to the failure to perform periodic sensitivity testing to the smoke detectors;
5. K0062 due to sprinkler heads that were dirty or corroded;
6. K0064 due to two unmounted fire extinguishers;
7. K0130 due to the failure to securely chain a carbon dioxide tank;
8. K0144 due to the failure to have appropriate placarding on the emergency generator's fuel tank; and
9. K0147 due to the use of power strips for non compliant electrical devices.

Based on observations, interviews with staff and patients, and review of policies and procedures it was determined that staff failed to:


1. Label intravenous (IV) fluid bags after being spiked with tubing with the date and time of being spiked.


2. Transport contaminated equipment in a sealed container to prevent additional spread of contamination.


1. On 11/3/15 during an interview with patient #1 and observation in the room for patient #1, IV fluid was observed spiked with IV tubing connected to patient #1 ' s peripheral IV. Intravenous fluid and medication had been infused from this bag and tubing. The tubing and IV fluid were not labeled with the date and time that the fluids were spiked and initiated. This was evident for 1 of 3 observed patients on the medical/surgical unit.


On 11/4/2015 at 9:25 AM multiple 500 ml IV fluid bags were observed spiked with the IV tubing (one for each patient scheduled). These spiked IV bags were not labeled with the time and date in which they were spiked. Interview with the manager of the endoscopy department confirmed that the first nurse to arrive each morning will spike the IV fluids bags in preparation for the number of scheduled patients for the day.

Different IV fluids have specified recommended fluid and IV tubing change requirements. Also, IV bags should be prepared as close to administration as possible to prevent the risk of contamination as possible. Failure of staff to label all IV fluids and tubing places patients at risk for the potential for infection.

2. Observation of a colonoscopy procedure for patient #4 was completed on the morning of 11/4/2015 which included the registration process, preoperative preparation and assessments, staff observations, recovery phase and the disinfection process of the procedure room and equipment. At the completion of the procedure the endoscopy technician was observed pre-cleaning the colonoscope in the procedure room, then placing the colonoscope on a chux pad (absorbent pad used to collect fluid). The colonoscope, wrapped in the chux pad partially exposed, was then carried by the technician out of the procedure room, into a hallway, then into the decontamination processing room. According to hospital policy #E-1 last revised 9/2015, ' Disinfection of Endoscopes ' , scopes are to be transported to the decontamination room in a red biohazard bag or container.
Failure of staff to place contaminated scopes in a sealed biohazard container for transport has the potential to expose staff, patients, and the environment to infection.

Based on a review of three hospital outpatient sites inclusive of an endoscopy suite, a walk-in care facility and a behavioral health facility, it is determined that 2 of 3 outpatient sites fail to appropriately verify credentials of outside practitioners who submit orders for patients served at those sites.


Hospital policy for " Requirements For Verifying Physician Status on Practitioners Ordering Outpatient Services " states in part, If a patient presents and the physician ordering the service is not in (the hospital system), Schedulers and Registrars must determine if the ordering physician is licensed in the state in which he/she resides. " The policy goes on to describe access to the database on physicians to, " ...verifies the (physician) license status is active and acting within the scope of practice. "


During an 11/4/2015 onsite survey of a walk-in care facility and a behavioral health outpatient facility, it was determined by separate staff interviews at approximately 8:30 am and 9:15 am respectively that verifications of physicians' credentials are made by " Calling the physician office. "


A hospital administrator stated on 11/5/2015 at approximately 10 am that all outpatient facilities have access to the database of physicians, and that the reviewed outpatient facilities may not have appropriately verified physician licensure and scope of practice due to the fact that there are very few orders submitted from providers outside the hospital's system, but that this was an opportunity for improvement.


While no patients were reviewed who had orders from outside providers, the hospital staff were unable to articulate the appropriate verification processes for these outpatient facilities.