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Based on observation, interview, clinical record and administrative document review, the governing body failed to ensure contracted nursing services were provided in a safe and effective manner for 1 of 8 patients (Patient 8). These failures occurred when 2 of 2 contracted Licensed Nurses (LN) 5 and LN 6, failed to relay abnormal patient findings to designated individuals (MD's) before surgery, and placed patient safety and outcome from surgery at risk for complications.

Findings:

1. On 4/4/13 at 4:30 p.m. in room 207, during a concurrent interview and clinical record review of Patient 8 (P 8), the Director of Quality Management (DQM), stated"...he had to be reintubated (breathing tube reinserted) immediately after surgery...the pre surgical abnormal findings had not been reported to the doctor..." by Licensed Nurse (LN) 5 or LN 6 "...as required." The DQM stated,"...both of the Registered Nurses were travelers (contracted temporary staff)...Patient 8's history of organ transplant, diabetes and other problems...low oxygen level of 88 (normal 98-100 %) and lung congestion (noisy lung sounds) required more screening than a EKG..."

2. On 4/4/13 a review of the hospital's Policy and Procedure titled," Pre-Admissions Anesthesia Consultation," dated 1/15/13, was reviewed: "Purpose...provide guidelines for screening patients scheduled for procedures (surgery, testing, etcetera)...to supplement...nurse's critical thinking (understand possible consequences) regarding anesthesia consultation...Policy...patients...will be identified as needing anesthesia consult will be passed to the...anesthesiologist...for review...2. a. Based on the patient's responses, the nurse's critical thinking skills...the nurse will identify the need for anesthesia consult..."

Based on staff interview, and clinical and administrative document review, the hospital failed to prepare and administer medications according to the doctor's orders and following the pain scale for (Patient 9) when one of ten patients did not receive the proper does of pain medication. This failure had to potential to provide inadequate pain control to Patient 9.

Findings:

On 4/2/13 at 3:48 p.m., Patient 9 had a physician order of Percocet 5 mg., and it was to be administered orally one tablet as needed for mild pain or two tablets as needed for moderate to severe pain one time.

On 4/2/13, a review of Patient 9's clinical record with the Director or Pharmacy (DPH) and the Inpatient Manager (IPM), indicated one tablet of Percocet (pain medication) 5 mg (unit of measure) was removed from the controlled substances cabinet on 4/1/13 at 5:50 p.m. Further review of Patient 9's clinical record showed her pain assessment was performed by a nurse and was recorded as 5 on a scale of 10 according to the IPM prior to administration of the Percocet 5 mg.

On 4/4/13 at 3:08 p.m., when the IPM was asked whether 5 on a pain scale of 10 was considered mild or moderate pain, she stated according to the hospital policy it was defined as moderate pain, and she agreed that two tablets of the Percocet 5 mg should have been administered. Furthermore, there was no documented nursing note or change of order in Patient 9's clinical record to justify such deviation from the original physician order.

On 4/4/13 at 3:15 p.m., during the interview with the IPM, she acknowledged the nurse who administered the Percocet 5 mg. order failed to appropriately assess, and to follow the conditional physician pain medication order.

On 4/4/13, a review of the hospital policy titled (Policy#MM 16.003) dated 1/15/13, on the top of page four read, "...determine pain severity. The following pain scale will apply:' Mild (1-4) Moderate (5-7), Severe (8-10)."

Based on staff interview, clinical record, and administrative policy and procedure review, the hospital failed to maintain complete clinical records for 3 of 10 Patients, (Patient 3, 7, and 8) prior to transfer. The clinical records reviewed did not contain patient assessments, completed transfer forms and had missing transfer forms. These failures had the potential to negatively affect the continued care and safety of Patients 3, 7, and 8 when physical assessments, transfer information and clinical record documentation had not been provided to recipient hospitals.

Findings:

1. On 4/3/13 at 3:45 p.m. during a concurrent interview and clinical record review for Patient 3, the Quality Manager confirmed the transfer form did not contain: a entry of transfer risks by MD 2, a physical assessment of Patient 3 prior to transfer. The Quality Manager was unable to provide an explanation.

2. On 4/3/13 at 3:50 p.m. during a concurrent interview and clinical record review for Patient 7 (P 7), the Quality Manager confirmed the transfer record did not have documentation of clinical records sent at the time of transfer, or that a physical assessments had not been done or documented for 6 hours and 40 minutes prior to P 7's transfer.

3. On 4/3/13 at 4:00 p.m. during a concurrent interview and clinical record review for Patient 8 (P 8), the Quality Manager confirmed the transfer record did not contain documentation of a physical assessment of P 8 prior to transfer. The Quality Manager indicated a physical assessment is required to be done and documented prior to transfer.

On 4/3/13 during review of the hospital policy and procedure titled, "Patient Transfer," dated 1/10/13, "Purpose...to establish guidelines for transfer of patients to a higher level of care...by physician request...Procedure 1. When a patient needs a higher level of care...the attending physician, Medical Director or designee will be responsible for...a. Writing an order for transfer to a higher level of care...b...Indicating the mode (how the patient will be transferred)...BLS (basic life support requiring no special equipment), ACLS (advanced cardiac life support requires special life sustaining equipment during transporting to another hospital)...c...make decision for professional medical assistance and equipment that will be provided during transfer...f...informing the patient, or legal representative, of the need for transfer, the alternatives to transfer...the benefits and risks...of the proposed transfer...4. c. The transferring physician will need to fill out the Interfacility Transfer Form...5. d. The following forms must be completed . Copies are to be sent with the patient and the originals placed in the medical record prior to the patients discharge: d. 1. Patient Transfer Form; signed by the transferring physician and containing relevant information pending to the patients condition and treatment...d. 3. Physician's Certificate of Transfer...e. Copies of the following information will be sent with the patient...History and Physical, Physicians order to transfer, diagnostic tests, Progress notes, Physician Certificate of Transfer, Patient transfer form, Patient consent to transfer, Interfacility Transfer Report, OR Surgical Report, Medication Discharge Summary...6. A patient assessment will be performed and documented prior to any type of patient transfer."

Based on observation, interview, and administrative document review, the hospital failed to monitor storage condition of various refrigerated medications and to ensure they were at the appropriate temperatures as specified by the manufacturer recommendations and state regulations. This failure had the potential to have significant impact on patient care since numerous medications had minimal tolerance for temperatures outside of a narrow range. These medications could have been rendered less than optimally effective or ineffective.

Findings:

On 4/3/13 at 4:05 p.m., during an inspection of the Pre Operating (Pre-Op) area of the inpatient hospital with the Director of Pharmacy (DPH), a medication refrigerator was found behind the nursing station. Numerous refrigerated medications including PPD (Tuberculosis skin test), Humalog and Regular Insulin (hormone used to control blood sugar)etc. were available inside.

On 4/3/13, a review of the March 2013 temperature log for this refrigerator revealed temperature monitoring was not consistently carried out by staff on the weekend and the recorded temperature readings were missing from the refrigerator temperature log on the following dates: 3/30/13 and 3/31/13.

On 4/3/13, a review of the March 2013 data from the Temperature Control Record (TCR) provided by Pre-Operative Coordinator (POC) revealed the temperature reading for the Pre-Op refrigerator was missing for the period between 3/5/13 and 3/10/13. Additionally, the TCR temperature data from another Post Acute Care Unit (PACU) medication refrigerator revealed similar findings and inconsistencies in terms of the failure to replace the TCR graphing papers on a timely manner, and to ensure consistent monitoring of the temperature for the medication refrigerator on the weekends for the month of March 2013.

On 4/3/13 at 4:18 p.m., during an interview with the POC and PACU Charge Nurse (PACUCN), they both acknowledged the temperature for two medication refrigerators should have been monitored on those days, and on weekends to ensure acceptable storage conditions were met for all of their refrigerated medications.

Based on observation and staff interview, the hospital failed to securely store medications located in one area of the hospital, and to prevent access to them by unauthorized individuals when medications were left unlocked and not secured in the outpatient area of the hospital. The hospital failed to keep medications in a safe and secure manner.

Findings:

On 4/3/13 at 2:58 p.m., an inspection tour was conducted with the Chief Nursing Officer (CNO) in the out-patient area of the hospital. During the inspection, a medication cabinet was found behind the Post-Acute Care Unit (PACU) nursing station with one of its doors opened. Numerous medications including Narcan (medication that reverses the effects of opoids), Reglan (medication for the treatment of gastric esophageal reflux disease, and nausea), and SoluMedrol (medication to treat inflammation) etc. were found inside the cabinet and there was not a person on duty in the PACU recovery area at the time. The medications were stored in a manner where anyone entering the area had access.

On 4/3/13 at 3:05 p.m., the CNO acknowledged the medication cabinet door should have been locked at all times to prevent unauthorized access.

On 4/3/13,a review of the hospital policy and procedure titled, "Medication Floor Stock in Nursing Unit" on page 1 under Procedure read, "2. a. Storage of Floor stock - Floor stock will be kept in an area that is locked and is inaccessible to unauthorized persons."

Based on observation, staff interviews, administrative document reviews and manufacturer's directions for use, the hospital failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases when:
1. The operative area staff did not sanitize Operating Room (OR) 8 with products according to manufacturer's directions of dwell time (length of time wet product is required to remain in contact with surfaces prior to removal).
2. Surgical towels were not removed from the Anesthesia cart and surfaces cleansed prior to the next surgery.

Findings:

1. On 4/3/13 at 3:09 p.m., during an observation in OR 8, the Manager of the Operating Room (MOR) was observed spraying "Clorox Broad Spectrum Quaternary Disinfectant" on the surgical table (table where patient surgery performed) and immediately wiped off with a towel.
On 4/3/13 at 3:40 p.m. during an interview outside of OR 8, the MOR stated,"...the sanitizer should be left in contact with the surfaces for at least 2 minutes before to wiping off..."

2. On 4/3/13 at 3:45 p.m., during a concurrent observation and interview, MD 1 stated, "the...surgical towels on the anesthesia cart have not been changed since the last surgery..."
On 4/3/2013 at 3:50 p.m. during a interview outside of OR 8, the non sterile surgical towels were identified to the MOR, who stated,"...all linen should be removed from the room as part of the cleaning process...the towels should not be left in the room..."

On 4/3/2012 during review of the facility's administrative policy and procedure titled, "Daily and Terminal Cleaning if Operating Room," dated 1/6/11, read, "Purpose:...establish proper in-depth cleaning of the operating rooms, core, and associated areas...same responsibility for cleanliness, patient safety and comfort, and functionality in the OR suite continues throughout the day. Policy: Daily and terminal cleaning of the operating rooms will be according to the following procedure...2. Daily cleaning between cases...b...remove all...linens, disposing properly in appropriate hampers and receptacles...f...wipe down all contaminated surfaces with disinfectant...g. OR table to be cleaned thoroughly, including pads and base..."