HospitalInspections.org

Based on hospital policies and procedures, review of medical records, and staff interviews, it was determined the hospital's administrator failed to ensure that the medical record contained complete medication orders for one (1) of one patient (Patient # 18) which has the potential to increase the risk of medication errors in the patient population.

Findings include:

Review of facility's policies and procedures titled: "Medication Administration" revealed: "...Administration of drugs shall be in accordance with all the laws of this state, federal laws, rules, and regulations that govern such acts, and medical staff rules and regulations...requirement for a valid order...Individuals who prepare, dispense, and administer drugs shall do so only upon the order of a practitioner...."

Facility's Medical Staff Rules and Regulations reveal: "...The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient...This record shall be ...therapeutic orders...A practitioner's routine orders...shall be reproduced in detail on the order sheet of the patient's record...All orders for treatment shall be in writing, timed and dated and then signed by the physician...The practitioner's orders must be written clearly, legibly and completely. Orders which are illegible or improperly written will not be carried out until rewritten and understood...."

Patient # 18's medical record revealed orders written on 9/13/14, were as follows: "...Morphine IV 8mg IM Q 3 hours PRN...Oxycodone -Acetaminophen 1 tab Q 4 hours PRN... Oxycodone -Acetaminophen 2 tab Q 4 hours PRN...."

Director of Pharmacy # 21 confirmed in an interview conducted on 5/21/15, that these orders were not complete and should not have been transcribed to a medication administration record without clarification. He also confirmed that these orders were not written according to the facility's policies and procedures.

The Chief Clinical Officer # 6 confirmed in an interview conducted on 5/21/15 that these orders were not complete and should not have been transcribed to a medication administration record without clarification. He also confirmed that these orders were not written according to the facility's policies and procedures.
The Director of Quality and Risk Management # 2 confirmed in an interview conducted on 5/21/15, that these orders were not complete and should not have been transcribed to a medication administration record without clarification. She also confirmed that these orders were not written according to the facility's policies and procedures. There is no clarification to which medication should be given when. She also confirmed that without clarification, the nurse administering the pain medications could give Morphine 8 mg IM, and a total of 3 tablets of Oxycodone with Acetaminophen within a span of four hours.

Based on hospital policies and procedures, review of medical records, and staff interviews, it was determined the hospital's administrator failed to ensure that the medical record contained documentation to assess a patient's condition as evidenced by the lack of an assessment of the patient's pain prior to administration or after administration of pain medications for six (6) out of ten (10) patients (Patient # 4, 5, 6, 18, 27 and 32), which have the potential to increase the risk of pain not being controlled in the patient population.

Findings include:

Review of facility's policies and procedures titled: "Medication Administration" revealed: "...Administration of drugs shall be in accordance with all the laws of this state, federal laws, rules, and regulations that govern such acts, and medical staff rules and regulations...requirement for a valid order...Individuals who prepare, dispense, and administer drugs shall do so only upon the order of a practitioner...."

Review of facility's policies and procedures titled: " Pain, Care of Patient with" revealed: "...Patients should be monitored for pain, at a minimum, once a shift...Comprehensive assessment of pain will be performed...at each new report of pain...Pain will be assessed using a scale of 0-10 with 0 being absence of pain and 10 being th most intense..The clinical (sic) should document the pain on the 24 Hour Care Record and should document the interventions that were utilized for pain relief...A reassessment for the presence and intensity of pain shall be performed at least once every shift for patients, any patient complaint of pain...and following interventions intended to reduce the patient's pain...reassessments shall take place within a clinically appropriate interval following intervention, such as within an hour of the administration of oral medications and within a half hour of the administration of intramuscular or intravenous pain medications...."

Patient # 4 medical record revealed that Dilaudid pain medication was given at 0100, 0400 and at 0600 on 5/19/15, with no documentation of a pain assessment prior to or after the administration of the Dilaudid, as required per the facility's policies and procedures.

Patient # 4 medical record revealed that Dilaudid pain medication, was given at 1330 on 5/19/15, with a score of eight out of ten, but no reassessment was documented. It further revealed that another Dilaudid pain medication, was given at 1730 on 5/19/15, for a pain level of seven out of ten; but again no reassessment was documented as required per the facility's policies and procedures.

Patient # 5 medical record revealed that Lortab pain medication, was given at 0750 on 5/19/15, with a score of 6 out of ten; but no reassessment was documented. It further revealed that another pain medication,Vicoden (two tablets) was given at 0000 on 5/19/15, for a pain level of nine out of ten, in the patient's right foot; but again no reassessment was documented as required per the facility's policies and procedures.

Patient # 6 medical record revealed that Tramadol pain medication was given at 2300 on 5/18/15, with no documentation of a pain assessment prior to or after administration of the Tramadol as required per the facility's policies and procedures. Patient # 6 medical record revealed that Tramadol pain medication was given at 1020 on 5/18/15 with a score of five out of ten, but no reassessment was documented.

Patient # 18 medical record revealed that Oxycodone pain medication (2 tablets), was given at 2200 on 10/21/14, 10/22/14 and 10/23/14, and at 0130 on 10/20/14 with no documentation of a pain assessment prior to or after the administration of the Oxycodone as required per the facility's policies and procedures. Patient # 18 medical record revealed that Oxycodone pain medication, 1 tablet, was given at 1700 and 0445 on 10/21/14, with no documentation of a pain assessment prior to or after the administration of the Oxycodone.

Patient # 27 medical record revealed that Dilaudid pain medication, 1 mg IVP, was given at 0255 on 5/18/15, with no documentation of a pain assessment prior to or after the administration of the Dilaudid. Patient # 27 medical record further revealed that Dilaudid pain medication, 2 mg by mouth was given at 2330 on 5/18/15, for pain eight out of ten with no documentation of a pain reassessment after the administration of the Dilaudid.

Patient # 32 medical record revealed that pain medication,was given on 5/18/15, with no documentation of a pain assessment prior to the administration of the pain medication.

The Chief Clinical Officer # 6, confirmed in an interview conducted on 5/21/15, that the documentation for pain medication was not complete for patients # 4, 5, 6, 18, 27 and 32, and does not follow the facility's policies and procedures..

Director of Quality and Risk Management # 2, confirmed in an interview conducted on 5/21/15, that the documentation for pain medication was not complete for patients # 4, 5, 6, 18, 27 and 32, and does not follow the facility's policies and procedures.

Based on the hospital Infection Prevention and Exposure Control Plan, observations on tour and staff interviews, it was determined the hospital's infection control officer failed to establish, document and implement policies that identified the following deficiencies which have the potential to increase the risk of infection in the patient population:

1. Personnel not washing hands prior to entering isolation rooms or when exiting;

2. The process for cleaning/disinfection of the hanging cloth bags containing clean supplies for dialysis on the machines in Isolation Rooms;

3. Personnel not wearing appropriate Personal Protective Equipment (PPE) when working with a patient on dialysis;

4. Medical Staff not washing hands prior to or after donning gloves, and

5. The facility did not have a policy and procedure to address infection control during procedures relevant to construction, renovation, maintenance, demolition and repair.
Findings include:

Review of facility's policies and procedures titled: " Acute Services Policy and Procedure Manual, Infection Control in the Hospital Dialysis Setting" revealed: "Teammate personal protective equipment (PPE)...Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and Enviromental surfaces. PPE is to be removed prior to leaving the treatment area...If a common supply care is used to store clean supplies in the hospital dialysis setting, this cart is to remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. The cart will not be moved between stations to distribute supplies. Items taken to the patient station during the treatment will not be returned to the supply care...Clean areas should be clearly designated for the preparation, handling, and storage of unused supplies and equipment. Clean areas should be clearly separated form contaminated areas where used supplies and equipment are handled... The outside surfaces of all equipment will be wiped with a bleach solution prior to removal from the treatment area...."

Director of Quality and Risk Management and Director of Infection Control confirmed in an interview conducted on 5/18/15 that the policies for Dialysis were adopted by the governing body.

Facility Policy and Procedure titled: " Infection Prevention and Control Exposure Control Plan 2015" revealed: "...Tasks that involve exposure to blood, body fluids or tissue, require protective equipment...Hand hygiene is the single most important strategy for preventing hospital acquired infections...All hospital and medical personnel are to wash their hands or use alcohol based hand sanitizer...Before and after each direct contact with patient or patient care items...before and after using gloves...Personal Protective Equipment (PPE)...PPE includes, but is not limited to gloves, gowns ...Wear PPE gowns to protect skin and clothing during procedures and patient care activities that are likely to generate splashes or sprays of blood or body fluids...Gloves do not replace handwashing...Change your gloves between patients...once you have touched the patient, or anything in the room, you must remove your gloves and wash your hands before leaving the room...."

1. During a tour of the telemetry unit, the Housekeeping Supervisor was observed removing his gown and gloves and exiting the contact isolation room, #113. The Housekeeping Supervisor did not perform hand hygiene after leaving the contact isolation room, nor did the Supervisor perform hand hygiene prior to entering another patient room #112.

Review of the Housekeeper's personnel file revealed infection control training from the contracted service where he is employed.

The Infection Preventionist/Quality Director confirmed during an interview conducted 05/20/15, that the hospital has not provided the Housekeeping Supervisor any hospital infection control training.

2. During a tour of the hospital on 5/18/15 at 1100 to 1230 hours, and on tour on 5/21/15 at 0900 to 0930 hours, the following was observed. There was a cloth bag containing clean supplies for the dialysis patient hanging on the top of the dialysis machine in room ICU 5 on 5/18/15, and in room 113 on 5/21/15. Patient # 5 and #14 were both on Contact Isolation.

RN # 28 confirmed in an interview conducted on 5/18/15, that the cloth bag is taken with supplies from room to room because there is not enough dialysis supply carts. She confirmed that the machine is considered dirty, and clean supplies should not be stored on the machine. She also confirmed that the bag cannot be cleaned between patients due to it being made of cloth. She confirmed that the items inside the bag are used for the patient or disposed of prior to going to another patient room.

RN # 37 confirmed in an interview conducted on 5/21/15, that the cloth bag is taken with supplies from room to room because there is not enough dialysis supply carts.

The Infection Preventionist/Quality Director confirmed in interviews conducted on 5/18/15 and 5/21/15, that she was not aware of the Dialysis nurses storing clean supplies in cloth bags on the machines, and being taken room to room regardless of isolation status of the patients.

3. During a tour of the hospital on 5/18/15 at 1100 to 1230 hours, the following was observed. Patient # 13 was receiving dialysis in ICU 1. Respiratory Therapist # 7 at 1120 am was observed not wearing a gown, yet was leaning on the bed, on the side of the dialysis catheter to reach patient to suction him. MD # 8 at 1145 am was observed not wearing a gown, yet was leaning on the bed, on the side of the dialysis catheter to assess patient and observe the catheter site.

RN # 27 confirmed in an interview conducted on 5/18/15 that the policy states that anyone working near a dialysis machine needs to wear the gown and gloves due to the potential for contact with blood. She confirmed that this includes all staff and medical personnel.

The Infection Preventionist/Quality Director confirmed in interviews conducted on 5/18/15, that she was not aware of the staff not wearing appropriate PPE when working with Dialysis patients.

4. During a tour of the hospital on 5/18/15 at 1145 hours, the following was observed. Patient # 13 was receiving dialysis in ICU 1. MD # 8 was observed not washing hands prior to entering room , ICU 1, putting gloves on, assessing the patient and observing the catheter site, picking up dialysis paperwork, and then removing gloves as he left ICU 1. MD # 8 was observed leaving room ICU 1 and proceeding to the desk to chart, without washing his hands after removing gloves.

RN # 27 confirmed in an interview conducted on 5/18/15, that the policy states that hands should be washed prior to entering a room and after removing gloves.

The Infection Preventionist/Quality Director confirmed in interviews conducted on 5/18/15, that she was not aware of the medical staff not washing hands prior to entering the room, and after glove removal.

5. The Infection Preventionist/Quality Director confirmed during an interview conducted on 05/20/15, that the hospital did not have a policy and procedure to address infection control during procedures relevant to construction, renovation, maintenance, demolition and repair.