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Based on medical record reviews and interviews for one of two clinic patients (Patient #16), medical staff failed to order the correct medication for the patient. The findings include:

Patient #16 had bilateral miniscal tears and returned to the hospital clinic for follow- up of bilateral knee pain on 12/3/09. The patient's clinic record from 3/12/08 to 12/29/08 identified that the patient's medication included the hypoglycemic medication Glipizide 10mg 2 tablets twice a day. The discharge instruction sheet dated 12/3/09 identified that the patient's Glipizide was changed to10mg one tablet twice a day. The clinic Resident assessed the patient on 12/3/09 and the prescription refill information indicated that the Resident wrote the new prescription refill on 12/3/09. Interview with Patient #16 on 4/28/10 at 10:12 AM noted that when he/she went to fill the prescription, the pharmacist needed to call MD #5 and clarify the prescription because the Glipizide had been written for an extended release form of the medication. Although the patient's record failed to identify that the Glipizide medication had been written incorrectly, interview with MD #5 on 4/29/10 noted he/she did recall that an error was made for one of the patient's prescriptions but did not recall the medication or the exact nature of the error. The patient received the correct medication from the pharmacy subsequent to the pharmacist's phone call.

Based on clinical record reviews and interviews for 2 patients (Patients #61 and #62) who were receiving care in the crisis unit of the emergency department, the hospital failed to ensure that the unit was therapeutic and non-threatening. The findings include:

A tour of the crisis unit was conducted on 4/29/10 at 10:45 AM with RN #30 and members of Administration. The stretchers that Patients #61 and #62 were laying on contained leather shackles (used to restrain a patient) hanging from the stretchers, creating a potentially threatening environment. Interview with RN #30 on 4/29/10 at 10:45 AM identified that the shackles were on the stretchers "just in case."

Based on medical record reviews, observations and interviews for one of three patients who were reviewed for pressure ulcer development (Patient #39) nursing staff failed to perform assessments in accordance with hospital policy. The findings include:

Patient #39 was admitted to the hospital on 4/5/10 with a diagnosis of lung cancer. The initial skin assessment dated 4/5/10 identified that the patient's skin was within defined limits. The plan of care dated 4/22/10 indicated that the patient had actual skin breakdown and a nursing order dated 4/22/10 at 2:33 PM directed 3M paste continuous, daily. Nursing documentation lacked an assessment of the identified skin breakdown to include measurements and location. Nursing documentation dated 4/23/10 at 2 PM noted that the patient's buttocks were red with a skin tear and 3M paste was applied as ordered. Measurements of the skin tear were not documented. The plan of care and nursing notes dated 4/25/10 identified that the patient's coccyx was red with a skin tear, the area was a Stage II and 3M spray and Exuderm dressing were applied. Measurements of the area were not documented. Nursing progress notes dated 4/26/10 indicated a superficial Stage II to the patient's buttocks, the Exuderm dressing was clean, dry, and intact and a message was left for the Wound Ostomy Nurse. Observation on 4/27/10 at 10:35 AM with the Wound Ostomy Nurse noted a Stage II pressure area to the right buttock that measured 5 centimeters (cm) long by 2cm wide and a Stage II pressure ulcer to the left buttock that measured 1cm by 0.5cm both with superficial depth. Interview with the Assistant Nursing Manager of the 11E unit on 4/27/10 at 11AM indicated that nurses were trained to assess/measure wounds. The hospital policy for management of skin integrity identified to measure the length, width and depth of the wound in centimeters and only pressure ulcers are staged. All other wounds are described in terms of location, size, appearance, drainage, presence of necrotic tissue or signs of infection or evidence of healing, but are not staged. Wounds/skin are assessed initially, upon transfer or discharge, with a change in wound status and once a week on Wednesdays.




15482

Based on a review of clinical records and interviews for two of two patients (Patient #32 and #38), the facility failed to ensure that daily weights were completed in accordance with the plan of care and/or for four records reviewed (Patients #18, #19, #20, and #21), the facility failed to ensure discharge paperwork was completed to ensure continuity of care. The findings include the following:


1. Patient #32 was admitted on 4/12/10 with congestive heart failure (CHF), hypovolemia and end stage renal disease. Review of the CHF care plan included monitoring of weights on a daily basis. Review of clinical record on 4/26/10 failed to identify that daily weights had been completed on 4/13/10, 4/14/10, 4/15/10 and 4/22/10.

2. Patient #38 was admitted on 4/13/10 with heart failure, hypertension, and an anterior wall myocardial infarction. Review of the heart failure pathway reflected that daily weights should be obtained. The clinical record failed to identify that weights had been completed on 4/20/10, 4/21/10, 4/24/10 and 4/25/10.

3. Patient #18 presented to the ED on 5/23/09 from an Assisted Living Facility with complaints of chest pressure. The patient was subsequently admitted to the observation area and discharged back to the facility on 5/24/09. Review of the discharge instructions dated 5/24/09 with the Manager (on 4/28/10) failed to identify the patient's diagnosis, rational for admission and/or the last time medications were administered. Interview with Person #3 identified that incomplete discharge paperwork impedes continuity of care that the Assisted Living Facility provides upon receiving the patient back from the hospital.

4. Patient #19 presented to the ED on 6/7/09 from an Assisted Living Facility with complaints of difficulty breathing. The patient was admitted to the hospital and subsequently discharged back to the facility on 6/9/09. Review of the discharge paperwork failed to identify the last time medications were administered to the patient.

5. Patient #20 presented to the ED on 5/12/09 from an Assisted Living Facility after sustaining a fall, the patient was diagnosed with a compression fracture and discharged home. On 5/13/09, the patient returned with complaints of being unable to sit up. Review of the medication administration record identified that the patient received Dilaudid 0.25mg at 3:02 pm and 3:19 PM for pain, and Tylenol #3 at 1:33 PM for pain. The patient was subsequently discharged back to the facility at 4:30 PM. Review of the ED discharge instructions with the ED Manager on 4/29/10 failed to reflect administration of these medications.

6. Patient #21 presented to the ED on 8/20/09 at 8:15 AM from an Assisted Living Facility with complaints of left hip and back pain after falling. The patient received Percocet at 9:30 AM and Dilaudid at 10:31 AM and was subsequently discharged back to the facility at 11:00 AM. The patient returned to the ED on 8/20/09 at 1:00 PM (two hours later) with complaints of pain. At 1:18 PM, the patient rated his/her pain level as a 10 on a scale of 1-10 scale (10 worst possible pain). The clinical record indicated that at 2:52PM and 3:29 PM, the pain rated his/her pain as a 10 and at 4:36 PM, a level 8. Review of the clinical record failed to indicate that the patient's pain was addressed. Interview with the ED Manager on 4/29/10 indicated that the record should contain documentation that the patient's pain was addressed.




19907

Based on clinical record reviews and interviews with facility personnel, the facility failed to ensure that patients receiving sedating medications were monitored and/or that orders were complete.

The findings include:

1. Patient #31 was admitted to the hospital on 4/22/10 with Difficulty Breathing. Review of the physician's orders dated 4/22/10 identified that the patient was started on Propofol IV 5mcg/kg per protocol. Further review failed to identify that a sedation goal was ordered and/or that the patient's level of sedation was assessed. Review of hosptial policy identified that a sedation goal and assessment of the patient needs to be completed. Interview with the Nurse Manager on 4/29/10 identified that the Emergency Department (ED) was not ordering and/or assessing the sedation goal while in the ED.

In addition, further review of physician's orders dated 4/26/10 identified that the patient was to receive Fentanyl IV at 36.9ml/hr for sedation. Further review failed to identify the sedation goal for the patient. Review of hospital policy identified that although a protocol existed for Fentanyl IV, the protocol only addressed utilizing it for pain management and not sedation. Interview with the Nurse Manager on 4/26/10 identified that the sedation goal was not ordered for Patient #31.

Based on review of clinical records, facility policy, and interview for two patients (Patient #20, #21) the facility failed to ensure that medication orders were complete. The findings include the following:

1. Patient #20 presented to the ED on 5/12/09 after a fall and was diagnosed with a compression fracture. The physician ordered Tylenol #3 by mouth. The order failed to specify the dose and frequency of administration.

In addition, Patient #20 returned to the ED on 5/13/09 with complaints of being unable to sit up. The physician's orders included Tylenol #3 one tablet by mouth and Dilaudid 0.25mg IVP. The physician's order failed to specify the frequency and parameters for level of pain. Review of the MAR reflected that the patient received Dilaudid 0.25mg on 5/13/09 at 3:02 pm and 3:19 PM and Tylenol #3 at 1:33PM. Interview with the ED Manager on 4/29/10 indicated that the physician should have included a frequency and parameters for administration.

2. Patient #21 presented to the ED on 8/20/09 at 8:15 with complaints of left hip and back pain after a fall. Physician orders directed Percocet one tablet by mouth and Dilaudid 2 mg intramuscularly. The orders failed to specify the frequency and parameters for level of pain. The patient received Percocet at 9:30 AM for a pain level of 8 and Dilaudid at 10:31 AM for pain level of 10. Review of the facility policy indicated that atll orders should contain the name of the medication, dose, frequency and parameters as appropriate.

Based on medical record reviews, review of hospital policy and interviews for one of two orthopedic patients reviewed (Patient #16), staff failed to correct the medical record in accordance with hospital policy. The findings include:

Patient #16 had bilateral miniscal tears and returned to the hospital clinic for follow- up of bilateral knee pain on 12/3/09. The clinic Resident assessed the patient on 12/3/09 and documented the assessment and plan in the patient's record. Words that had been written by the Resident were scribbled out in a portion of the documentation (2.5 lines) and could not be read. MD #5 on 12/3/09 also cosigned the documentation. Interview with MD #5 on 4/29/10 indicated that he/she recalled that the Resident had written an opinion in the patient's chart and informed the Resident that opinions were not to be documented in the patient ' s record. MD #5 further noted that a single line should have been placed through the documentation to correct the record and that this was reviewed with the Resident. The hospital policy for medical record entries and corrections to entries directed to draw a single line through the incorrect entry and print error above the entry.

Based on review of the clinical record and interview one of one chart reviewed (Patient #26), the facility failed to ensure the clinical record was accurate. The finding includes the following:

Patient #26 presented to the ED on 4/25/10 with confusion and lethargy. The record indicated that the patient had a history of Aspergers syndrome, Autism and Bipolar disorder. The patient was cleared medically and transferred to the CIU for behavioral dyscontrol. Physician orders dated 4/25/10 at 12:25 PM, 4:25 PM and 6:30 PM directed that the patient be placed in seclusion for four hours. Review of the clinical record failed to identify that the patient was placed in seclusion in accordance with the order. Interview with the Manager on 4/25/10 at 10:40 AM stated that the seclusion order was an error and the physician should have ordered the patient be placed in "behavioral care".

Based on observation, review of hospital policy and interview with hospital personnel, the hospital failed to ensure timely removal of outdated medication in accordance with facility policy. The finding includes:

During tour of the anesthesia workroom of the main operating room on 4/26/10, one vial of succinylcholine stored in the emergency box was dated 4/18/10. During interview on 4/26/10, Anesthesia Tech #1 stated that each vial of medication was dated with upcoming dates which identfied when the medication should no longer be utilized, however, this vial of medication was missed. Review of the hospital policy for Anesthesia Supply Management identified that all items that had expiration dates of less than 3 months would be removed from the supply.

Based on observations and interviews with facility personnel, the facility failed to ensure that juices in patient refrigerators were labeled.

The findings include:

During tour of the Cath Lab and Postpartum Area on 4/27/10 it was identified that individual containers of juices were not labeled with expiration dates. Review of hospital policy identified that items that must be dated and/or items that do not have an expiration date must be discarded after 72 hours. Interview with the Nurse managers on 4/27/10 identified that all food and drinks are to have expiration dates on them and rotation is usually done by dietary staff.

Based on observation and interviews for one patient (Patient #34) who had an indwelling urinary catheter, the hospital failed to ensure that infection prevention practices were followed. The findings include:

1. A tour of unit 12 West was conducted on 4/26/10 at 2 PM with the Nurse Manager. Patient #34 was observed with an indwelling urinary catheter. The catheter tubing and collection bag were noted touching the floor. According to the Nurse Manager, the catheter was about to be removed, however; the bag and tubing should not have been touching the floor.



14271

Based on observation during tour, review of hospital policy and interviews with hospital personnel, the hospital failed to ensure that infection control practices were followed. The findings include:

2. During tour of the soiled utility room in the Main OR on 4/26/10, multiple bottles of hydrogen peroxide and betadine were observed to be stored in the cabinets. Interview with the OR Manager, these supplies were utilized throughout the OR.

3. Review of the Steris sterilizer biological testing log on 4/26/10, identified that the date and time the test result was read failed to be identified in the log. Review of the hospital policy for Steris Sterilizer identified that the biological test occurred weekly and must incubate for 48 hours to obtain accurate results, however, the policy failed to direct staff to record the date, time and person reading the test.

4. During tour of the outpatient Endoscopy Suite on 4/27/10 with the OR Manager, review of the Steris sterilizer log failed to identify that biological testing was performed on 1/15/10, 1/22/10, 2/19/10, 2/26/10, 3/19/10, 3/26/10 and 4/16/10. Additionally, of the tests recorded as completed, the date and time of the person reading the test failed to be recorded.

5. During tour of OR #5 on 4/26/10 with the Director of Peri-Operative Services, a staff member was observed to wear a bouffant head covering that failed to cover the bottom half of the head, ears and jewelry (earrings) in OR #5. Although the Director addressed this issue immediately with the staff member, a subsequent observation identified that the staff member's attire had not changed and he/she was actively participating in the patient's surgery. Review of the hospital policy for Surgical Attire directed that all staff in the restricted and semi-restricted areas of the OR were to wear head coverings to include sideburns, necklines and jewelry.

6. During tour of the operating suites on 4/26/10, numerous rooms were observed to contain anesthesia supplies, bookbinders on open shelving and a stack of linen towels that remained in place throughout the day, from case to case. Additionally, a personal waist pack was observed lying on top of the anesthesia cart in an unoccupied room. During interview on 4/26/10 at 11:36 AM, the Director of Peri-operative Services stated that such items should not be routinely left in the operating room. The hospital did not have a policy governing contents of the operating room remaining from case to case. Review of the AORN Standards for Cleaning of the Surgical Practice Setting identified that all horizontal surfaces should be cleaned and a visual inspection for cleanliness of the OR should be completed prior to introducing supplies, case carts and instrument sets to the room.

7. During tour on 4/26/10 with the Director of Peri-operative Services, identified that OR "B" had sterile packs that had been opened and contents set out on several tables, however, the room was empty. Review of the hospital policy for Guidelines for Scrub Personnel, identified that the sterile field should always be monitored.







14528

A tour of the 11W unit (Pediatric) was conducted with the Director of the unit on 4/27/10. Observation on 4/27/10 at 11:05 AM noted an unlocked large playroom that contained books and toys. A toy-cleaning schedule was observed on the wall of the room that denoted specific dates that toy cleaning was performed from January 1, 2010 to April 27, 2010. The cleaning schedule lacked documentation that the toys had been cleaned during the time period of 3/16/10 to 3/30/10 to include the Monday dates of 3/22/10 and 3/29/10. Interview with the Director of the 11W unit on 4/27/10 at 11:35 AM indicated that toys were cleaned at least weekly on Mondays. The hospital toy cleaning policy identified that the playroom will be kept locked on the in-patient unit. Toys will be on the day the room is used or at a minimum of once weekly. A log will be kept in the playroom to monitor this policy.

a. During tour of the operating suites on 4/26/10, numerous rooms were observed to contain anesthesia supplies and bookbinders on open shelving and a stack of linen towels that remained in place throughout the day, from case to case. Additionally, a personal waist pack was observed lying on top of the anesthesia cart in an unoccupied room. During interview on 4/26/10 at 11:36 AM, the Director of Peri-operative Services stated that such items should not be routinely left in the operating room. The hospital did not have a policy governing contents of the operating room remaining from case to case, however, the policy for Operating Room Housekeeping stipulated that daily cleaning should include damp cleaning of the furniture including utility carts. Review of the AORN Standards for Cleaning of the Surgical Practice Setting identified that all horizontal surfaces should be cleaned and a visual inspection for cleanliness of the OR should be completed prior to introducing supplies, case carts and instrument sets to the room.
b. During tour on 4/26/10 with the Director of Peri-operative Services, identified that OR " B " had sterile packs that had been opened and contents set out on several tables, however, no one was in the room. Review of the hospital policy for Guidelines for Scrub Personnel, identified that the sterile field should always be monitored.
c. Observation of the hallway approach to the OR with the Director of Peri-operative Services on 4/26/10, reflected signage at the door and overhead that the area was restricted to appropriate personnel, however, there lacked a distinguishable mark that indicated at what point surgical appropriate dress (scrubs and hair covering) was required secondary to entering the semi-restricted area of the OR. Although the Director stated that visitors would stop at the door, there lacked eye-level signage that would indicate appropriate dress was required.





19907

Based on observations and interviews with facility personnel, the facility failed to ensure that fluid warmers were monitored and serviced when the temperatures were out of range.

The findings include:

During tour of the operating rooms #1 and #2 in labor and delivery on 4/27/10, it was observed that the fluid warmer temperatures were out of range. Review of the fluid warming logs dated 1/10-4/10 identified that the fluid warmers were out of range 65 times in a four month period. Further review identified that no documentation of follow up with the maintenance department for repair and/or adjustment was completed. Review of hospital policy identified that when the warmer exceeds normal range, all fluid will be discarded, maintenance will be notified, and documention completed on the maintenance log sheet. Interview with the Nurse Manager on 4/27/10 identified that they are currently evaluating other devices for warming of fluids.