HospitalInspections.org

Based on record review, policy review and staff interview, it was determined the facility failed to ensure nursing staff followed physician orders for catheterization (placing a tube in the bladder to collect urine) for 1 of 20 sampled patients (Patient # 4). This failure had the potential to place all patients treated in the facility at risk for not receiving ordered treatments.

The findings included:


- Patient #4's medical record revealed the patient was admitted on 5/26/2016 for wound care with a diagnosis of acute brain disease, large stomach incision wound after surgery for removal of bladder and prostate (a gland surrounding the neck of the bladder in men) for prostate cancer. The patient also had surgical creation of an Indiana pouch (surgically-created urinary diversion used to create a way for the body to store and eliminate urine for patients who have had their urinary bladders removed). Indiana pouch is to be catheterized (insertion of a tube) every 4 hours and he must be woke up at night to catheterize. The patient's record lacked documentation of catheterization every 4 hours by straight catheter as ordered by the physician.



Policy titled "Orders, Physician" reviewed on 6/15/2016 at 2:20 PM directed "... Orders will be reviewed and carried out appropriately by facility staff..."

The hospital reported a census of 21 patients. Based on medical record review, document review, and staff interview the hospital failed to ensure the provider signed, dated, and timed verbal/telephone orders promptly for 4 of 20 medical records reviewed (Patient #'s 1, 7, 9, and 10). This deficient practice has the potential to place patients at risk for complications and medical errors.


Findings include:


- Patient #1's medical record reviewed on 6/15/2016 at 1:00 PM revealed the patient was admitted with a diagnosis of an abdominal fistula (an abnormal opening of the stomach that allows the contents of the stomach or intestines to leak out), and wound care needs. Registered Nursing staff (signatures unidentifiable) received the following telephone and verbal orders to initiate new care and discontinue old care from Physician Staff G on 5/18/2016 at 10:05 AM, 5/3/2016 at 9:10 AM, 4/30/2016 at 1:15 PM, , 4/27/2016 at 9:45 AM and 3:35 PM, 4/26/2016 at 7:30 AM and 8:00 AM, 4/25/2016 at 3:47 PM and 4:30 PM and failed to ensure the physician signed the telephone and verbal orders as required.


- Patient #7's medical record reviewed on 6/15/2016 at 9:45 AM revealed the patient was admitted on 5/16/16 with diagnosis of respiratory failure, pleural effusions (water around the lungs) and endocarditis (swelling of the inner lining of the heart muscle). Medical record documentation revealed the patient received physical and occupational therapy (PT and OT) as ordered. The medical record revealed on 6/10/2016 the verbal order for PT and OT was noted but remained unsigned by the ordering physician.


- Patient #9's medical record reviewed on 6/15/2016 at 10:00 AM revealed the patient was admitted on 3/8/2016 for wound care on their stomach and respiratory failure. The Physician failed to sign verbal orders received on 6/6/2016 for the dressing change orders for the patient's stomach wound.


- Patient #10's medical record reviewed on 6/15/2016 at 10:15 AM revealed the patient was admitted on 6/7/2016 with respiratory failure with low oxygen levels and to be weaned from mechanical ventilator (machine that assists with breathing). Respiratory therapy documentation present in the chart. The medical record revealed a verbal order placed on 6/7/16 at 3:15 PM that remained unsigned by the physician.


Quality Manager Staff B interviewed on 6/16/2016 at 3:00 PM acknowledged that physicians are required to sign all verbal and telephone orders as required by state law.


- Policy titled "Clinical Services Policy and Procedure" reviewed on 6/16/2016 at 1:45 PM directed "... All physicians' orders will be written or verbally stated by a Licensed Independent Practitioner (LIP) such as a credentialed physician or other credentialed practitioner. Orders will be reviewed and carried out appropriately by facility staff... and... The responsible practitioner or another licensed independent practitioner or another licensed independent practitioner within the same group practice or specialty of the responsible practitioner who is responsible for the patient's care shall authenticate, time and date all orders promptly, within the time frame specified by state law..."

The Hospital reported a current census of 21 patients. Based on document review, medical record review and staff interview, the Hospital failed to ensure patients had a comprehensive medical history and physical examination signed and in the chart within 24 hours after admission for three of 20 medical records reviewed (Patient #'s 7,10, and 19). The failure to ensure patients have a signed and dated medical history and physical examination placed the patients at risk for complications and medical errors.

Findings include:

- Patient # 7's medical record reviewed on 6/15/2016 at 9:15 AM revealed s/he was admitted on 5/28/16 for wound care of left buttocks The medical record review revealed the History and physical dated 5/29/2016 remained unsigned on the chart.

- Patient #10's medical record reviewed on 6/15/2016 at 10:15 AM revealed the patient was admitted on 6/7/2016 with respiratory failure with low oxygen levels and to be weaned from mechanical ventilator (machine that assists with breathing). The medical record revealed the history and physical dictated and signed by the physician on 6/7/2016 but the physician failed to date or time the entry.

- Patient #19's medical record reviewed on 6/15/2016 at 9:00 AM revealed s/he was admitted on 5/20/2016 with a diagnosis cellulitis (a common and potentially serious bacterial skin infection), sepsis (a life threatening complication of an infection), End Stage Renal Disease (condition of end stage renal disease where the kidneys no longer function and filter the blood properly). The medical record reviewed revealed the patient's history and physical was dictated on date of 5/21/2016 but remained unsigned on the chart.

Director of Quality Staff B interviewed on 6/15/2016 at 4:30 PM revealed the history and physical must be completed and signed as required by state law. Staff B indicated the requirement for this facility would be within 24 hours after admission to the hospital.

- Medical Staff Bylaws reviewed on 6/16/2016 at 12:00 PM revealed "...The history and physical examination must be completed by a member of the Medical Staff of Hospital, or other qualified member of the Allied Health Staff of Hospital, in accordance with state law. The hospital recommends that each time a patient is admitted to the Hospital a new history and physical be completed.

Based on observations, staff interview and document review, the hospital's infection control officer failed to ensure hospital personnel followed infection control practices for one of one observed terminal room cleaning (Housekeeper Staff D), one of one observed cleaning of equipment from a patient's room (patient # 2) under contact precautions (Contact precautions are used when a person has a type of bacteria or virus on the skin or in a sore, or elsewhere in the body, such as the intestine, that can be transmitted to someone else if that person touches the infected individual or contaminated surfaces or equipment near the infected individual), and one of two physicians (Physician Staff I) observed entering multiple rooms of patients with contact precautions (Patient #'s 6, 11, and 20).


Findings include:

- Observation on 6/15/2016 between 1:20 PM to 2:30 PM revealed the cleaning of a discharged patient's room (room #124). Housekeeper Staff D entered the room and sprayed the walls with Clorox (an all-purpose cleaner requiring the surface to remain wet for 2 minutes). Staff D then stepped out and allowed the cleaner to remain on the walls for 2 minutes. Staff D failed to evenly distribute the "Clorox" cleaner onto the wall ensuring the entire surface was disinfected and remained wet for the required 2 minutes. Staff D cleaned the bathroom shower and surfaces with a spray disinfectant "Crew" (a bathroom cleaner requiring all surfaces to remain wet for 10 minutes) and immediately wiped the surfaces dry. They sprayed the inside of the commode with "Spartan Germicidal Bowl Cleaner" (a cleaner requiring the surface to remain wet for 10 minutes), used a toilet bowl mop to swab the inside and outside of the commode. Then Staff D immediately wiped the commode dry. Staff K failed to change gloves and perform hand hygiene after cleaning the toilet. Staff K wet mopped the floor and then turned on a fan that caused the floor to dry in 6 minutes.


Housekeeping Staff D interviewed on 6/15/2016 at 2:30 PM acknowledged the Clorox cleaner was sprayed on the walls and they failed to ensure the entire wall was saturated with the cleaner and wet for 2 minutes. Staff D indicated the toilet bowl cleaner used should have stayed wet for 10 minutes and agreed that they wiped it dry immediately. Staff D stated "the toilet bowl cleaner is very acidic and I do not like to use it so I usually use the Clorox instead."

- The hospital's policy/procedure titled, "Cleaning patient room after discharge" reviewed on 6/15/16 directed "...prepare the germicidal detergent solution per manufacturers' specifications" and "...damp wipe the ceiling vents, lights, ceiling corners, door tops, T.V., window casings ..." and ... "Damp wipe walls from floor to working height 4-5 feet, wall fixtures, doors, door handles, door kick plates and door casings"... and ..."Pour a small amount of disinfectant restroom cleaner onto the toilet bowl swab. Scrub the inside of toilet bowl and let stand while you clean the rest of the bathroom using the disinfectant restroom cleaner ..."


- The manufacturer's guidelines for "Spartan Germicidal Bowl Cleanse" disinfectant reviewed on 6/15/16 directed "...for toilet bowls/urinals ...with swab mop applicator, remove water from bowl by forcing over trap ...Allow Germicidal Bowl Cleanse to remain wet on surface for at least ten minutes..."

- PCT Staff E observed on 6/15/2016 at 1:00 PM revealed them rolling a hoyer lift (an assistive device that allows patients to be transferred between a bed, chair or other resting place) into the hallway after use in Patient #2's room (a patient under contact precautions for Clostridium Difficile (a bacterial infection that can cause diarrhea to more serious and potentially fatal inflammation of the colon)) and then wiped it down with Dispatch (a type of sanitizing cloth). The time the lift was to stay wet with the Dispatch cloth per the manufacturer's label for Clostridium Difficile is 5 minutes. The actual time observed was approximately 1 minute. Staff E rolled the hoyer lift into the clean supply room. A tear to the foam handle on the hoyer lift had been identified making the surface non-cleanable.

PCT Staff E interviewed on 6/15/16 at 1:25PM revealed they were unaware of the tear and they would put in a work order to have it replaced. Staff E indicated the time the hoyer lift should have stayed wet with the Dispatch cloth should have been 7 minutes (actual required time was 5 minutes per manufacturer's guidelines).

Dispatch wipes manufacturer's instructions reviewed on 6/16/2016 at 7:45 AM revealed "...Kills Clostridium Difficile Spores in 5 minutes on Pre-cleaned, Hard Non-Porous Surfaces..."

- Physician Staff I observed on 6/16/2016 at 8:20 AM revealed Staff I going into patient #20's room (room #125), a patient on contact precautions, without donning gloves or gown. Staff I then stepped into patient # 11's room (room #126), a patient on contact precautions, without donning gloves and gown. Staff I then preceded to patient # 6's room (room #128), a patient on contact precautions, without gloves and gown. During the observations, Staff I failed to perform hand hygiene when enter or leaving patient rooms. This deficient practice placed patients at risk for cross contamination.

Infection Control Officer Staff B interviewed on 6/16/2016 at 10:00 AM indicated they were surprised that the physician failed to glove, gown and perform proper hand hygiene. Staff B revealed they have observed many physicians correctly donning personal protective equipment and performing hand hygiene. Staff B indicated that since they have now taken over the Infection Control Program they would be increasing infection control audits to ensure staff compliance and identify education needs.

- Policy titled "Contact/Contact Enteric Precautions" reviewed on 6/16/2016 at 3:00 PM directed "...A sign reading" Contact Precautions" will be posted on the door and on the patient's chart. If the patient is in contact precautions for an enteric illness such as C-Diff/Norovirus, then use the Contact Special Enteric Precautions sight to prompt the staff to perform hand hygiene with soap and water. PPE will be available at the entrance to the room. 3. Gowns should be worn when soiling will be likely to occur or when contact with the patient or environmental surfaces that have been contaminated will occur. 5. Hand hygiene with alcohol-based cleanser must be performed upon entering and leaving the room. 6. Non-sterile gloves are to be worn by persons having direct contact with the patient and the environment. Gloves must be removed before leaving the room ..."