HospitalInspections.org

34452


Based on observation, interview, and document review, it was determined that the facility failed to provide information and inform patients of their right to file a complaint with the State Agency as well as or instead of utilizing the facility's grievance process.

The findings include:

During the initial tour of the facility, on February 4, 2019 at 11:13 a.m., a review of the signage posted in the Emergency Department (ED) entrance for walk in patients and the ambulance entrance revealed the complaint process did not include contact information for the State Agency as well as the facility.

An interview with Staff Member # 19 on February 4, 2019 at 11:15 a.m. revealed: "This is a corporate sign."

A review of the form titled "Patient Rights" provided by Staff Member # 19 on February 4, 2019 at 1:20 p.m., revealed the Patient Rights form does not include contact information for the State Agency as well as the facility for patients to file a complaint.

The findings were reviewed with Staff Members # 1, # 2 and # 19 on February 4, 2019 at 4:00 p.m. during the end of day exit interview.

Based on document review and interview, it was determined that the facility's medical staff failed to enforce the bylaws for two (2) of thirty one (31) patients reviewed (Patients # 8 and # 18).

The findings include:

During medical record reviews on February 5 and 6, 2019 the following was revealed:

On February 5, 2019 at 8:50 a.m. Patient # 8's medical record revealed a verbal telephone order dated January 28, 2019 at 10:20 a.m. reading in part "Hemodialysis today". A second verbal telephone order dated January 28, 2019 at 1:30 p.m. reads in part "Hemodialysis tomorrow 1/29/19 if the pt is still here." The verbal orders failed to be signed by the physician giving the verbal order within 72 hours.

An interview with Staff Member # 2 on February 5, 2019 at 8:55 a.m. revealed: "Physicians are strongly discouraged from verbal and telephone orders. The orders must be signed within 72 hours."

The facility's Medical Staff bylaws provided by Staff Member # 2 on February 5, 2019 at 9:30 a.m. reads, in part: "The physician who gave the verbal order or another practitioner (who is credentialed and granted privileges to write orders) who is also responsible for the care of the patient shall authenticate and date any order, including, but not limited to, medication orders, as soon as possible, such as during the next patient visit, and in no case longer that seventy-two (72) hours from dictating the verbal order."

On February 6, 2019 at 10:50 a.m. Patient # 18's medical record revealed the history and physical (H&P) dated 1/31/2019 at 3:38 p.m. was incomplete.

An interview with Staff Members # 2 and # 19 on February 6, 2019 at 11:00 a.m. revealed: "the physician should complete the H&P with 24 hours of admission. The (Physician's Name) stated something happen during the dictation but the completed H&P would be on the chart today."

The facility's Medical Staff bylaws provided by Staff Member # 19 on February 6, 2019 at 3:00 p.m. read, in part: "Within twenty-four (24) hours following all admissions, or prior to the performance of an invasive procedure, the Attending Physician shall have a history and physical dictated documenting the need for the admission."

The findings were discussed with Staff Members # 1, # 2 and # 19 during the exit interview on February 6, 2019 at 4:00 p.m.

34452


Based on observations, interviews, and document review, it was determined that the facility staff failed to develop and accurately keep current a nursing care plan for five (5) of thirty one (31) patients (Patients # 2, # 18, # 19, # 20 and # 31).

The findings include:

1. On 2/5/19 at 10:35 A.M., Staff Member #13 was observed with Staff Member #2 during the administration of Lovenox to Patient #2.

Patient #2's medical record was reviewed with Staff Member #22 on 2/5/19 at 2:30 P.M. and revealed the following information:
Patient #2 was admitted on 2/4/19 with the diagnosis of Right Hip Fracture.
Patient #2 was prescribed Lovenox 40 mg (milligrams) subcutaneous.
The Nursing Care Plan was reviewed and noted Patient #2 was to have FBS (fasting blood sugar) and PT/INRs performed.
When asked if those tests were relevant to Patient #2's care, Staff Member #22 stated: "No, we don't do PT/INRs for Lovenox and there is no reason for FBS for him/her. They should have been removed from the list of problems." Staff Member #22 was asked if they were saying care plans are not individualized and stated, "Somewhat."

Drugs.com documented the following information related to the administration of Lovenox, review date 12/1/18:

Lovenox Generic Name: enoxaparin sodium; Dosage Form: injection;
Monitoring for Safety:
Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are not adequate for monitoring the anticoagulant effects of Lovenox.

2. During medical record reviews on February 5 and 6, 2019 the following was revealed:

On February 5, 2019 at 11:00 a.m. Patient # 18's medical record revealed Patient # 18 was admitted to the facility on January 31, 2019 with admitting diagnoses of Apraxic Aphonia, Essential hypertension, Type 2 Diabetes Mellitus, Right Hemiparesis and Cerebrovascular Accident.

The care plan was initiated on January 31, 2019 but did not include Diabetes as a problem until February 3, 2019. The problem of stroke was added on February 3, 2019. The expected date of achievement for all of the problems on the care plan was May 13, 2019.

On February 5, 2019 at 12:00 p.m. Patient # 19's medical record revealed Patient # 19 was admitted to the facility on January 26, 2019. Patient # 19 was admitted to the Intensive Care Unit (ICU) intubated and on the ventilator with diagnoses of Influenza A, Pneumonia and Severe Sepsis. Patient # 19 was extubated and removed from the ventilator on February 5, 2019. The care plan failed to be updated to remove interventions related to the endotracheal tube and ventilator.

On February 5, 2019 at 12:30 p.m. Patient # 20's medical record revealed Patient # 20 was admitted to the facility on February 5, 2019. The History and Physical dated February 5, 2019 reads "LOS (length of stay) 24 to 48 hours." The expected date of achievement for all problems for this short stay patient was documented as May 11, 2019 on the care plan.

On February 6, 2019 at 2:00 p.m. Patient # 31's medical record revealed Patient # 31 was admitted on January 31, 2019. The expected date of achievement for all problems on the care plan was May 10, 2019.

An interview with Staff Members # 2, # 19 and # 22 revealed they were unaware of how the expected date of achievement populates on the care plan. Staff Member # 2 stated: "the care plans are updated daily."

A review of the facility policy titled "Standard of Clinical Nurse Practice" provided by Staff Member # 19 on February 6, 2019 at 2:00 p.m. reads, in part: "The Registered Nurse will review the Nursing Admission History and complete the physical assessment on all patients and initiate the Standard(s) of Care and/or problem list/care plan appropriate to the patient's individualized care. The Standard of Care (SOC) will be noted on the Interdisciplinary problem list/care plan withe the implementation date. The RN will initiate the Stand of Care within 24 hours of admission. Nursing documentation will be focused on the progression toward expected patient outcomes and nursing interventions utilized to achieve the expected outcomes will occur once every 12 hours. A RN will review patient care plan every 24 hours and modify the Standards of Care/Interdisciplinary problem list/care plan as appropriate."

The findings were reviewed with Staff Members # 1, # 2 and # 19 during the exit interview on February 6, 2019 at 4:00 p.m.

Based on observation and interview, the facility staff failed to ensure stairwells were safe and secure for emergency egress for one (1) of approximately four (4) stairwells.

The findings include:

On 2/5/19 at approximately 11:15 A.M. while exiting the second floor to the administration area via the stairwell, it was noted each step had a metal plate with a rough surface to prevent slipping. One of the metal plates on one of the steps was loose presenting a trip hazard.

Staff Member #19 was present during the exit in the stairwell and stated, "We will get that fixed immediately. That could cause a fall."

Based on observations, interview, and documentation review, the facility staff failed to ensure they followed the facility's infection control plan in five (5) areas of the hospital (Nuclear Medicine, Laboratory, Outpatient Rehabilitation, clean linen storage area, and 2nd floor patient care area).

The findings include:

1. The following items were noted during tours of the various areas of the facility during the dates of the survey:

On 2/5/19 at approximately 10:35 A.M. with Staff Member #2, the following observations were made on the second floor:
Staff Member #14 was observed handling soiled linen with right hand gloved and left hand not gloved. The soiled linen was placed on top of an ultrasound machine. Staff Member #14 then removed the soiled linen and placed it in a linen hamper. Staff Member #14 then returned to the ultrasound machine and gloved the left hand. No hand hygiene was performed. Staff Member #14 then began to clean the ultrasound probe cord but did not clean the top of the ultrasound machine. Staff Member #14 removed both gloves, disposed of them, and did not perform hand hygiene.

On 2/6/19 at approximately 1:30 P.M. the clean linen storage area was observed with Staff Member #2. There were approximately 4 vents blowing air across the linen. The vents were dusty and rusted. Staff Member #20 stated: "we are supposed to be having these painted." There was one linen cart with no full coverage over the clean linen. On the ceiling were pipes running across the ceiling that had been painted and taped at one time. There were areas where the paint was flaking, peeling and had black speckled spots in numerous areas appearing as mildew. Over the speckled spots, the ceiling showed evidence of old water damage that had been painted over and now bubbling up and had gray discolored areas that appeared to have been painted over.

The facility policy titled "Guidelines for Cleaning, Disinfection and Sterilization of Patient Care Items 04-04-01" documents on Page 1-2 of 10 Classification of Items Noncritical Items (Class III) as:
1. Noncritical items include equipment that comes in contact with patients and their intact skin.
2. Examples on non critical items include: blood pressure cuffs, stethoscopes, walkers and wheelchairs.
3. Routine cleaning with soap and water, and an EPA/hospital approved disinfectant is sufficient to reduces the number of microorganisms on the surface of noncritical items....

The policy failed to address the frequency of the cleaning i.e.; between each patient use.


The Hot Lab/Nuclear Medicine Area was toured on 2/4/19 at approximately 12 noon with Staff Member #19. In the office/medication administration/medication prep area, a venipuncture chair was observed whose two (2) arms had a water absorbent (chux) covering tapped over them. The chux on the chair arms were soiled. The chair was dirty with dried drops of something on the exposed metal. The storage drawers under the chair arms had droplet stains inside them where the clean/sterile supplies were stored.
One IV pole was rusted on the leg portion and was dirty.
One overbed table with a chux tapped over it was observed to be soiled with debris on top.
Staff Member #4 stated, "We change the chux every Friday."

On 2/4/19 at approximately 12:45 P.M. the laboratory was toured with Staff Member #19 and the following was noted:
The counter top, where urine and blood are processed, had information tapped down on the counter. Tape residue is sticky and cannot be disinfected should there be a spill of blood or urine. The counter at the back of one sink and the splash guard had exposed porous areas. In one area, the wood under the laminate covering could be seen. The other sink had the blue outer layer of the laminate counter worn away behind the faucet leaving a porous white exposed area. Porous surfaces cannot be cleaned and disinfected.

On 2/5/19 at approximately 8:55 A.M., the outpatient rehabilitation area was toured with Staff Members #2, #11, #12 and #19. The following items were noted:
The wooden floor section of the parallel bars was worn to bare wood leaving a porous surface that could not be disinfected. A treatment table in treatment room #2 was torn with the porous foam cushion visible. There were 2 chairs, one in treatment room #2 and one in treatment room #3, with torn armrests.
The tables in all four treatment rooms were soiled with debris in between the divided cushions and along the frames of the tables.


34452


2. During the initial tour of the facility on February 4, 2019 at 12:10 p.m., there were two (2) chairs and one (1) bedside table observed that were worn down exposing bare wood in Room 255. Wood being porous could not be disinfected between use by patients and or family members present.

An interview with Staff Member # 2 on February 4, 2019 at 12:15 p.m. revealed: "We are getting new furniture for the patient rooms."

A review of the facility policy titled "Infection Control" provided by Staff Member # 16 on February 6, 2019 at 3:00 p.m. reads, in part: "Contaminated patient care equipment, instruments and supplies can be a source of hospital acquired infection. Meticulous cleaning and proper disinfection and sterilization techniques are key to preventing the transmission of microorganisms to patients via patient care equipment and supplies. Disinfection is a process that eliminates many or all pathogenic microorganisms or inanimate objects with the exception of bacterial spores."