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Based on review of hospital's policy and procedures, record review and interview, the hospital failed to ensure hospital staff members evaluated and documented patients' response to pain interventions for 4 of 6 patient records reviewed (Patients #1, #2, #3, #5).

Failure to assess response to interventions could lead to negative health outcomes.

Findings:

1. The hospital's policy and procedure entitled "Assessment, Plan of Care, and Minimum Charting Standards" (Revised 4/2014), read in part as follows: "Pain Assessment: Adult Units. Upon admission, with routine vital signs, within 1 hour prior to pain intervention, within 2 hours after pain intervention. Pediatric Unit: Upon admission, with routine vital signs, within 1 hour prior to pain intervention, within 1 hour after pain intervention."

2. Review of patient medical records on 5/22/2014 indicated the following information:

a. Patient #1 was a 38-year-old patient who had been admitted to the hospital's obstetrical unit on 4/9/2014 for a repeat cesarean section and bilateral tubal ligation (tube tie). Review of the patient's medical record revealed that between 4/11/2014 at 10:14 AM and 4/12/2014 at 12:01 AM, hospital staff members administered five doses of hydrocodone 5/325 mg to the patient for pain. Only two of five pain reassessments had been documented in the patient's record.

b. Similar observations were observed during record review for Patient #2 who had been admitted to the same hospital unit on 4/9/2014 for a repeat cesarean section. The patient received an epidural spinal infusion for pain control between 4/9/2014 at 9:34 PM and 4/10/2014 at 12:45 PM. No pain assessments before, during, or after the patient's spinal infusion could be found. On 4/13/2014 at 1:35 PM, the patient received hydromorphone 4 mg orally for pain. This intervention did not include an assessment before or after pain medication was given.

c. Patient #3 was a 3-day-old newborn who had been admitted to the hospital's special care nursery on 4/18/2014 for respiratory distress. On 5/20/2014 at 7:46 AM, the newborn was given morphine 0.16 mg intravenously for distress. Review of the record revealed that one hour later no assessment was documented in the patient's record.

d. Patient #5 was a 64-year-old patient admitted on 4/26/2014 for generalized weakness and recent falls. The patient had a recent history of a hip fracture treated at another facility and was non-weight bearing which required the use of crutches. The evaluation determined that the patient required surgery for an infection in her/his neck vertebrae, including bone removal and stabilization. Blood cultures were positive for a multidrug resistant organism. Pain medications were ordered for post-operative pain.

After surgery, the patient received oxycodone 10 mg at 4:39 AM and 8:41 AM on 5/21/2014. Additionally, at 8:00 PM that day the patient rated her/his pain as 8/10 and received an injection of ketorolac 30 mg. There was no documentation of assessment (response to the medication and pain rating) within 2 hours of each of the above pain medication administrations.

3. During an interview with Surveyor #2 on 5/23/2014 at 8:50 AM, the director of women's and children's services (Staff Member #2) confirmed that assessments before or after pain medication administration had not been documented in the medical records of Patient #1, #2, and #3 as directed by hospital policy.
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Based on observation, interview and document review, hospital staff members failed to properly document maintenance of safety and biomedical equipment.

Failure to ensure that all clinical equipment undergoes routine preventive maintenance risks injury of patients and staff members.

Findings:

Item #1- Eyewash Stations

1. The hospital's policy and procedure for the Laboratory Department entitled "Eye Wash Maintenance" read as follows:

"1. Each week all eyewash stations are checked to ensure that the water of appropriate temperature is available at each station by turning the eyewash on and running for approximately 3 minutes.
a) Documentation of the check is kept in the General Equipment notebook.
b) A notation of OK for each station indicates that the station is functioning properly."

2. On 5/20/2014 at 10:00 AM, Surveyor #3 reviewed the log for the 2014 Eyewash station checks. The last entry was dated on 4/18/2014. Surveyor #5 interviewed a laboratory employee (Staff Member #6) who indicated s/he had checked the eyewash station since the last documented entry, but had failed to record the results of the check.


Item #2- Alternate Equipment Maintenance (AEM) Schedule

On 5/21/2014 at 9:00 AM, Surveyors #3 and #5 met with biomedical staff to review their maintenance process. The Manager of Facility and Technology Services (Staff Member #7) indicated that some of the equipment used in the hospital is on a "risk-based" maintenance schedule rather than adherence to the Manufacturer's maintenance schedule. Staff Member #2 acknowledged that at the present time, s/he has not inventoried which items are on an AEM schedule and which items follow manufacturer-recommended maintenance frequency and activities.
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Based on observation, interview and document review, the hospital failed to assure infection control practices were implemented.

Failure to implement infection control practices creates risk for the transmission of communicable diseases.

Findings:

1. On 5/22/2014 at 9:30 AM, review of the hospital's quality assessment performance improvement program revealed that the infection rate for Clostridium difficile was above the hospital's benchmark. The infection rate had increased in 4th quarter 2013 and was unchanged in 1st quarter 2014. In addition, the hospital's hand hygiene compliance data for 2013 was below the hospital's benchmark.

2. The hospital's policy and procedure entitled "Infection Control Precautions" (revised 3/11), on page 10 about Contact Precautions, under section 6 about "Hand Hygiene and Glove Use", read as follows: "(1) Put on gloves on entry into the room. (2) Remove and dispose of gloves before exiting the room . . . "

3. On 5/21/2014 at 9:30 AM, Surveyor #1 observed a RN (Staff Member #4) provide care to Patient #4 on the oncology unit. The patient was in the hospital for chemotherapy administration and was in Contact Precautions (isolation) precautions for a highly contagious intestinal infection (Clostridium difficile). The isolation precautions required staff to wear a gown and gloves.

During the course of care, the nurse obtained vital signs and recorded them in the computer and then administered oral medications and recorded them in the computer. While in the patient room, the RN changed her/his gloves 3 times and performed interim hand hygiene at the sink. However, between glove changes and prior to putting on a new pair of gloves, the nurse used the computer keyboard located in the room at least twice with ungloved hands. The same keyboard was used with gloved hands before and after use with ungloved hands.

4. Subsequent to the above observation, Surveyor #1 interviewed Staff Member #4 about hand contact (gloved and ungloved) with the computer keyboard inside the room of a Patient #4 in the Contact Precautions room. S/he stated that s/he understood that gloves should not be worn while using computer keyboards.

At 10:15 AM that day, another RN (Staff Member #5) was interviewed about use of gloves in Contact Precaution rooms. S/he stated that gloves should not be removed for computer keyboard use during patient care activities while in the room.
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Based on record review, interview, and review of hospital's policies and procedures the hospital failed to ensure hospital staff members screened patients early in their hospitalization to determine if they needed discharge planning for 2 of 6 patient records reviewed (Patients #1,#3).

Failure to identify early in their hospitalization, patients that need a discharge plan can lead to an adverse impact on the patient's health.

Findings:

1. The hospital's policy and procedure entitled "Discharge Patient Procedure" (Revised 4/2014), read in part as follows:"POLICY STATEMENT: ... 4. Discharge planning begins upon admission and involves the patient, family and all care team members. Plans are based upon continuing assessment of patient needs and adjusted as needed. PROCEDURE: Discharge to home or other facility. The registered nurse (RN) verifies completion of the following: ... C. Notify case manager, if appropriate, for coordination discharge needs with the rest of the care team."

The hospital's policy and procedure entitled "Assessment, Plan of Care, and Minimum Charting Standards" (Revised 4/2014), read in part as follows: "POLICY STATEMENT: Each patient admitted to an inpatient unit at PSPH is assessed by a qualified individual. Assessment includes the collection and analysis of relevant ... PROCEDURE: ... 6. Assessment includes, but is not limited to: ... t. Discharge Planning."

2. Review of patient medical records on 5/22/2014 revealed the following:

a. Patient #1 was a 38-year-old patient who had been admitted to the hospital's obstetrical unit on 4/9/2014 for a repeat cesarean section and bilateral tubal ligation (tube tie). Review of the patient's medical record revealed that the initial assessment did not include a screening for discharge needs. The patient was discharged from the hospital on 4/13/2014.

b. Similar observations were observed during record review for Patient #3, a 3-day-old newborn who had been admitted to the hospital's special care nursery on 4/18/2014 for respiratory distress. The patient was undergoing oxygen therapy for respiratory distress. Initial assessment did not include screening for post-hospital care or services the patient may require upon discharge.

3. An interview on 5/21/2014 at 3:30 PM with Surveyor #2, the charge nurse (Staff Member #3), and women's and children's director (Staff Member #2) confirmed the initial discharge screenings were missing.
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