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Based on clinical record review and interview, it was determined one (Patient #11) of ten (patients #11-20) went to surgery without an authenticated electronic or written order from the physician. The failed practice did not provide staff the ability to authenticate the physician order in order to establish accuracy and follow verified physician instructions. The failed practice affected one (Patient #11) of ten (#11-20). Findings follow:

A. Review of Patient #11's clinical record on 09/26/18 at 1:38 PM showed no order from the physician for the patient to go to surgery.
B. The finding in A was verified by the Operation Room Manager on 09/26/18 at 1:45 PM.

Based on policy and procedure review, clinical record review and observation, it was determined the facility failed to follow its own policy and procedure in that a History and Physical (H&P) less than 30 days old was not documented prior to procedure being performed. Failure to assure the presence of a current history and physical did not ensure staff was knowledgeable and prepared to provide care of the patient. The failed practice affected Patient #31 and had the likelihood to affect any patient with a procedure done by Physician # . Findings follow:

A. Review of policy and procedure on 09/27/18 at 12:15 PM showed the H & P must be within 30 days.
B. Review of Patient #31s clinical record on 09/27/18 at 10:10 AM showed the H & P was dated 08/24/18 and was greater than 30 days old. On 09/27/18 at 9:06 AM, the procedure physician documented that the "patient was seen and examined, unchanged. All questions answered."
C. During continuous observation of Patient #31 on 09/27/18 from 8:30 AM-10:00 AM, the physician did not update his examination of the patient prior to the procedure.
D. The findings in A, B, and C were verified with the Operating Room Manager on 09/27/18 at 12:15 PM.

Based on clinical record review, review of policy and interview, it was determined the facility failed to assure one (#18) of ten (#11 - #20) surgical patients had evidence of a signed consent to treat and patient rights acknowledgement as required by facility policy prior to admission to a nursing unit. Failure to follow the facility policy did not ensure patients were given an opportunity to consent to and make informed decisions regarding their care. The failed practice affected Patient #18 and was likely to affect all surgical patients. The findings included:

A. Record review of the policy titled, "Consent for Treatment," effective date 02/2016 and reviewed 05/2018, showed that patients were to have the Conditions of Admission and Consent form signed for each patient prior to sending them to a nursing unit. The consent was described in the policy as a record of consent to routine hospital services, diagnostic procedures, and medical treatment. The form included Patient rights and responsibilities acknowledgment.
B. Patient #18 was admitted to Outpatient Surgery on 04/04/18. Clinical record review on 09/26/18 showed no evidence of a signed Consent for Treatment or patient rights acknowledgment by Patient #18 or their representative prior to admission the Outpatient Surgery.
C. The findings in B was verified by interview with the Nursing Assistant Director and the Operating Room Manager on 09/26/18 at 2:31 PM.

Based on observation, interview, review of Radiation Dosimeter Reports, policies and manufacturer's instructions for use, it was determined the facility failed to ensure personal radiation dosimeters were stored with controls, in a radiation free environment, and with dosimeters of the same type and wear date when not in use according to manufactures instructions for 16 of 16 radiology employees. The failed practice did not ensure the facility could accurately monitor the amount of radiation exposure for each employee. The failed practice affected 16 of 16 employees in the Radiology Department. Findings included:

A. Record review on 09/26/18 at 3:10 PM of the policy titled, "Personal Radiation Dosimeters," dated 03/01/14, showed that personal radiation dosimeters would be provided for any staff member who worked with radiation or in areas where exposure to medical radiation was possible. The policy did not include how or where the personal dosimeters were to be stored when not in use.
B. The manufacturer's instructions for storage of the personal radiation dosimeters used by staff was requested from the Director of Radiology. On 09/26/18 at 3:10 PM, the Director of Radiology provided a manufacturer's document that stated dosimeters were to be stored with controls, in a radiation free environment, and with dosimeters of the same type and wear date when not in use. The Director of Radiology stated on 09/26/18 at 3:10 PM that he had spoken with a manufacturer's representative and was unaware of the personal radiation dosimeter storage recommendations.
C. Observation of the Radiology Department on 09/26/18 from 12:30 PM to 1:00 PM showed no designated area for the storage of personal radiation dosimeters when not used by staff. The Director of Radiology was interviewed on 09/26/18 at 1:35 PM and stated the employees take their personal radiation dosimeters home and there was not a designated storage location when they were not in use. On 09/26/18 at 1:35 PM, Radiology Technician #1 was interviewed and stated the radiation badge worn at work was taken home or sometimes left at work.


31039

Based on review of policy, review of Universal Crash Cart Check Sheet and interview, it was determined the facility failed to perform preventative maintenance on testing the defibrillator each shift per policy on one (Medical/Surgical) of three (Medical/Surgical, Operating Room and Emergency Department) crash carts surveyed. By not testing the defibrillators, the Facility could not assure they were being maintained at an acceptable level of safety and quality. The failed practice had the likelihood to affect all patients treated in the Medical/Surgical Unit. Finding follow:

A. Record review of the facility's policy titled, "Crash Cart Exchange and Consistent Recording of Log," reviewed in January 2017, showed the crash carts along with equipment on them, were to be checked and tested every shift (shifts are 7 AM-7 PM= AM shift and 7 PM to 7 AM=PM shift) and the findings should have been documented on the approved form.
B. Review of Universal Crash Cart Check Sheet for 08/01/18 through 09/23/18 showed the following:
1) August 2018-33 of 62 shifts had missing defibrillator checks on 08/01-4,06-18, 21-27, and 29-30; and
2) September 2018-15 of 46 shifts had missing defibrillator checks on 09/04-07, 11-12, 14, 18-19, and 21-23.
C. During an interview on 09/24/18 at 2:30 PM, the Regional Director of Quality Assurance verified the defibrillator was not tested for the shifts listed above.

Based on observation of the kitchen, review of Nutrition and Food Services policies, and interview, it was determined the Infection Control Manager failed to report and implement corrective action after identifying cabinets and drawers had an accumulation of rust and dust for four of four (06/08/18 to 09/27/18) months. The surfaces were irregular, with peeling paint and therefore could not be sanitized. The failed practice was likely to affect all patients and staff. The findings included

A. Record review of Nutrition and Food Services policy titled, "Cleaning and Sanitizing," dated 10/17, showed that work surfaces were to be cleaned, rinsed and sanitized at the beginning of the work shift, throughout the day and at the end of the work shift.
B. Observation on 09/25/18 from 9:12 AM-10:08 AM showed peeling paint on the front surface of cabinets on the retail side, patient side and below the three compartment sink. There was an accumulation of rust on the inner shelves and cabinet on the retail and patient side of the kitchen. The rust and peeling paint created an irregular surface that could not be sanitized.
C. Review of the Infection Control Manager rounds showed kitchen observations were conducted on 06/05/18 and cabinets and drawers had an accumulation of rust and were not cleanable. There was no documentation of interventions or a plan to correct the findings. This was confirmed by interview with the individual responsible for Regional Quality Assurance on 09/25/18 at 1:20 PM.



38994

Based on observation, policy and procedure review and interview, it was determined the Infection Control Manager failed to identify and control infections in that 3 of 9 laryngoscope blades were found in plain "Ziploc" baggies in Trauma Room 1 in the Emergency Room undated and unable to determine if or when they had been sterilized. The failed practice did not assure the equipment had been cleaned or sterilized and stored in a manner to ensure protection from damage or contamination. The failed practice had the potential to affect all patients who needed the use of a laryngoscope for intubation. Findings follow:

A. Review of policy and procedure titled, "Approved Packaging Systems," showed Cloth Wraps, Peel Pouches and Spunguard One-Step Wraps were the only approved packaging systems.
B. During tour of the Emergency Room on 09/24/18 at 1:30 PM, 3 of 9 laryngoscope blades were found in undated "Ziploc" baggies in Trauma Room 1 in the Emergency Room.
C. During Interview on 09/24/18 at 1:45 PM, the Emergency Room Manager stated that she was not able to determine the sterility of the 3 laryngoscope blades found in "Ziploc" baggies.
D. The findings in A, B and C were verified with the Emergency Room Manager on 09/24/18 at 1:50 PM.


Based on observation and interview, it was determined the facility failed to identify and control infections in that one of one Certified Registered Nurse Anesthetist (CRNA #1) failed to use a new needle and syringe to reenter one of one vial of Propofol that was then administered to Patient #31 during a Monitored Anesthesia case (MAC). The failed practice did not ensure the needle, syringe, or vial of medication was free of contaminates. The failed practice affected Patient #31 on 09/27/18 at 9:25 AM. Findings follow:

A. On 09/27/18 at 9:25 AM, CRNA #1 was observed reusing the same needle and syringe to reenter the same vial of medication on 3 separate injections into Patient #31s intravenous line (IV). After each entry into the medication vial CRNA #1 placed the used needle on top of the anesthesia cart and then returned it to the same syringe for each entry.
B. The finding in A was verified with the Operating Room Manager on 09/27/18 at 10:00 AM.

Based on observation, clinical record review and policy and procedure review, it was determined the pre-anesthesia evaluation was not performed prior to the start of a Monitored Anesthesia case for one of one (Patient #31) procedural case observed. The failed practice did not assure patients receiving anesthesia where examined for anesthetic risk prior to their procedure. The failed practice had the potential to affect all patients who were assessed by Certified Registered Nurse Anthetist (CRNA) #1. Finding follow:

A. Review of policy and procedure titled, "Administrative Manual for the Department of Anesthesia," on 09/27/18 at 11:00 AM showed:
1) A pre-anesthesia examination would be performed.
2) A plan of anesthesia care would be based on interviewing, examining the patient, and assessment of physical condition and concurrent health problems that could affect decisions of perioperative risk management.
B. During observation of Patient #31 prior to the planned procedure on 09/27/18 at 8:20 AM, CRNA #1 informed the patient that he would be giving Propofol during her procedure. CRNA #1 did not have a stethoscope nor did he auscultate Patient #31's lung sounds. CRNA #1 did not assess Patient #31's oral airway for anesthetic risk and did assign a Mallipatti Score of II. (Malipatti scores are used to predict the ease of endotracheal intubation and to assess risk for sleep apnea.
C. On 09/27/18 at 8:35 AM during clinical record review of Patient #31, it showed that CRNA #1 documented that he auscultated Patient #31's lung sounds and they were clear to auscultation on 09/27/18 at 8:14 AM. Documentation did not reflect the observation made.
D. The findings in A, B, and C were verified with the OR manager on 09/27/18 at 8:45 AM.