HospitalInspections.org

Based on observation, review of facility policies and procedures, and interviews in the Child and Adolescent Behavioral Health Outpatient satellite, the hospital failed to have Patient's Rights readily available for review. The findings include:

Tour of the Child and Adolescent Behavioral Health Outpatient satellite on 04/18/13 with Quality Coordinator #2 and Administrative Manager of Outpatient Behavioral Health identified a posting in the waiting area of the Child and Adolescent Behavioral Health area that directed that a copy of the Patient's Bill of rights was available upon request.

Review of Patient #67's (a minor child), clinical record identified an Authorization for Outpatient Treatment and Acknowledgement of Receipt of Privacy Notice signed by Patient #67's parent on 12/20/12. The document included, in part, a section on Patient Rights and Responsibilities that identified that the person who signed acknowledges that the Hospital's Policy on Patient's Rights and Responsibilities is posted and is available to him/her and, additionally, that the individual agrees to comply with this Policy.

The administrative support staff, Quality Coordinator, and/or Administrative Manager were unable to provide a copy of the Patient's Bill of Rights upon request.

The Quality Manager identified that there had been recent changes in the patient space and the Resident's Rights documentation may not have been redistributed in the new space.

Based on review of the clinical record, facility policies and procedures, and interviews for one patient with a legally appointed Conservator of Person (COP) and Estate (COE) who was treated in the Outpatient Dental Clinic, Patient #17, the hospital failed to ensure that the COP authorized treatment, completed a health record, and was allowed to communicate health information to the treating dentist. The findings include:

Patient #17 had diagnoses that included dementia. Review of the clinical record identified that the appointment was requested on 10/17/12 by the COP and was initially evaluated at the facility Dental Clinic on 11/12/12.

An authorization form that included authorization to pay benefits, notification that physician's are independent contractors, right to receive a copy of charges, Veteran Status, Patient Rights and Responsibilities, and Notice of Privacy lacked a signature.

Interview and review of facility investigation with Dental Assistant #1 on 04/17/13 at 3:00 PM identified that Patient #17 arrived at the clinic accompanied by a personal aide. The aide was provided with the registration/medical history form but identified that he/she was unaware what services Patient #17 required, the patient's history, and/or the patient's medications. The aide contacted the COP who requested to speak with the person in charge.

Interview and review of the facility investigation with the Office Coordinator on 04/17/13 at 3:15 PM identified that he/she informed the COP that the Dentist could not provide care and services without a completed registration/medical history form. The COP requested to communicate the complex dental and medical history directly to the Dentist prior to service. The Office Coordinator identified that the COP could not speak to the dentist, but could assist the aide in filling out the form over the phone. Subsequently, Patient #17 was evaluated by Dentist #1 and further treatment was recommended. The Dental Services Progress Record dated 11/12/12 lacked documentation of informed consent for the proposed treatment plan and/or review of clinic policies.

Interview with the Chairman of the Department of Dentistry on 04/21/13 at 12:00 PM identified that consent should be obtained before any assessment and/or treatment unless it was determined to be an emergency situation and the expectation was that the dentist would communicate with the responsible party as needed and document the communication in the clinical record.

Based on clinical record review, review of facility policies and procedures, and interviews, for one Patient who participated in an Intensive Outpatient Program (IOP) of the Child and Adolescent Treatment Service, Patient #67, the facility failed to develop a comprehensive a care plan to address a fear of being touched that resulted in the assault of a staff member. The findings include:

Patient #67 was admitted to the IOP following assessment at the Emergency Department for suicidal ideation on 12/20/12 diagnoses included anxiety disorder, major depressive disorder and sensory processing disorder. A Behavioral Personal Database documented by Patient #67's parent on 12/20/12 identified that Patient #67 did not like to be touched and was sensitive to certain voices and sounds. This was signed as reviewed by Program Manager #1 on 12/21/12.

An IOP Multi-Disciplinary Treatment Plan dated 12/21/12 and reviewed by Patient #67's parent on 12/28/12 identified the problem of mood stability related to depression/anxiety, as evidenced by suicidal ideation with a reported plan, sad affect, and school refusal. The problem that the patient does not like to be touched and/or has a history of aggression towards others was not addressed.

Review of the clinical record identified that Patient #67 attended the adolescent IOP which included multiple sessions on Monday, Wednesdays, and Fridays each week. The patient's family participated in the program on Mondays.

On 01/23/12, Patient #67 arrived at the group wearing a mask and identified that he/she had been sick for several days. The group members were required to place, all electronic devices in a basket. Patient #67 placed his/her cellular phone in the basket, but continued to listen to music on another device with buds in place. Social Work Intern #1 approached the patient from behind and tapped him/her on the shoulder to get his/her attention. Patient #67 quickly stood up from the chair, turned, and slapped Social Work Intern #1 across the face.

Patient #67 was subsequently discharged from the adolescent IOP for refusing to apologize to Social Work Intern #1.

Interview with Social Work Intern #1 on 04/22/13 at 2:10 PM
identified that he/she was unaware that Patient #67 did not like to be touched and/or that the patient had a history of aggression. He/she did not attend weekly staff meetings and/or have specialized training to deal with aggressive patients.

Based on a review of clinical records, staff interviews and a review of the facilities policies and procedures for two of five sampled patients reviewed for restraints (Patient #19 & 48), the facility failed ensure that restraints were discontinued at the earliest possible time and/or were the least restrictive. The findings include:


a. Review of the clinical record identified Patient #19 was transferred to the behavior health unit on 4/29/12 after an intensive care admission secondary to a Salicylate overdose. On 4/29/12 at 7:07 PM, Patient #19 displayed aggressive behavior toward staff. A physician's order directed the use of four point restraints. Review of the nursing assessment report identified that on 4/29/12 between 10:45 PM and 1:43 AM on 4/30/12, Patient #19 was quiet and/or asleep. Four point restraints were discontinued at 1:43 AM. Further review of the clinical record identified on 5/3/12 at 1:06 PM, Patient #19 was agitated, aggressive, and unable to gain behavioral control. A physician's order directed the use of four point restraints. Review of the nursing assessment report indicated during the period between 2:50 PM and 4:54 on 5/3/12, Patient #19 was quiet and/or asleep. Four point restraints were discontinued at 4:54 PM. The facility failed to ensure the restraints were removed at the earliest possible time and/or that the least restrictive restraints were utilized. Interview with Nurse Manager #2 on 4/17/13 at 1:00 PM identified restraints should have been reduced and/or discontinued if the patient was asleep. The hospital policy for restraint and seclusion, directed in part, the use of restraints shall be frequently evaluated and ended at the earliest possible time. The policy further directed staff to continually assess and monitor the patient to ensure that that restraints are released at the earliest possible time.



b. Review of Patient #48's clinical record identified that the patient was admitted on 4/14/13 with seizures related to alcohol detoxification. A physician's order dated 4/14/13 directed the use of bilateral ankle, wrist restraints and mitts. The restraint flow sheets dated 4/14/13 identfied that the patient had bilateral ankle and wrist restraints in place in addition to the mitts. An order dated 4/15/13 directed four (4) siderails, bilateral wrist restraints and mitts. The flow sheets dated 4/15/13 indicated that the patient had the bilateral wrist restraints in place in addition to the mitts. The clinical record failed to identify that restraints utilized were the least restrictive.


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1. Based on review of the clinical record and interview, the hospital failed for one patient (#39) to document that the patient was monitored throughout the recovery phase post procedure. The finding includes:

a. Patient #39 underwent an esophagogastroduodenoscopy and Halo ablation on 4/16/13. Review of the patient's clinical record identified that the procedure did not end until 9:04 am. The record timeline then reflected that the patient remained in the procedure room until 9:12 AM. The patient was then transferred to the recovery area, arriving according to the timeline at 9:26 AM. Review of the clinical record failed to reflect where the patient was for fourteen minutes, when the units are side by side. The documentation failed to reflect that the patient's vital signs were monitored from 8:50 AM until 9:28 AM. During interview with the Nurse Manager on 4/16/13, identified that the timeline was likely inaccurate since the pattern of care would be to assess the patient immediately upon arrival to the recovery unit.





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2. Based on medical record reviews, review of facility policies and interviews for one of two patients who received titrated medications (Patient #32), the facility failed to follow the titration protocol and/or physician's orders. The finding includes:


a. Patient #32 was admitted to the Family Birth Center on 4/10/13 at 5:54 PM. The physician order dated 4/10/13 at 6:30 PM directed Oxytocin 30 units @ 1 milliliter (ml)/hour, call MD for rate changes. The Labor and Delivery (L&D) flowsheet noted that the Oxytocin was started as ordered on 4/10/13 at 7:11 PM for one uterine contraction every 10 minutes of mild quality and was increased to 2 ml/hr at 7:43 PM. The L&D flowsheet further identified that the nurse increased the Oxytocin to 6 ml/hr at 8:58 PM and to 8 ml/hr at 10:09 PM. Review of the patient's record with Manager #1 on 4/15/13 at 10:23 AM indicated that additional physician orders for the Oxytocin increases were not documented and the hospital had a policy for Oxytocin augmentation of labor. Review of the hospital Oxytocin policy and further interview with Manager #1 on 4/15/13 at 10:23 AM noted that Oxytocin be increased by 1 or 2 ml/hour as ordered every 30 minutes for a maximum dose of 20 ml/hr and that the policy as well as physician order were not followed.



3. Based on medical record reviews, review of facility policies and interviews for three of three patients reviewed for pain medication administration (Patient #31, 46 & 47), the facility failed to ensure timely intervention and/or reassessment for pain. The findings include:


a. Patient #31 had a cesarean section on 4/13/13 at 11:51 AM. The plan of care dated 4/13/13 noted a problem related to cesarean section discomfort and a goal to maintain pain level between 0-1 on a scale of 1-10. Physician orders dated 4/13/13 directed Torodol 7.5 milligrams (mg) intravenous push (IVP) every 6 hours (for pain). The pain documentation sheet identified that the patient had a pain level of "4" at 7:30 AM on 4/14/13 and the patient received Torodol 7.5 mg 2 hours later at 9:40 AM. In addition, reassessment of the patient's pain was documented at 2:30 PM and reported to be a level "6". Interview with Manager #1 on 4/15/13 at 11:18 AM noted that a patient with complaint of pain should not wait longer than 30 minutes for an intervention for pain such as pain medication and the patient's pain should be reassessed in 1 hour following pain medication administration. The hospital policy for pain management identified that patients will be reassessed within 1 hour of intervention.


b. Patient #46 presented to the ED on 4/15/13 at 5:21 AM for detoxification. Review of an assessment at 5:40 AM indicated that the patient rated pain as a 5 on a scale of 1-10 (10 being the worst possible pain), however, failed to identify the source of the pain. Further record review failed to identify that the patient's pain was addressed and/or rationale for not treating the identified level of pain.

c. Patient #47 was admitted on 4/15/13 with epigastric pain. The record indicated that the patient rated pain as a 7 out of 10 at 9:00 AM and was medicated with Dilaudid 0.25 mg. Review of the clinical record failed to identify that the patients level of pain was reassessed.



4. Based on medical record reviews, review of facility policies and interviews for one of three infants (Patient #34) observed in the neonatal intensive care unit (NICU), the facility failed to ensure infant identification in accordance with hospital policy. The finding includes:


a. Patient #34 was born a twin on 3/14/13 and was admitted to the NICU following delivery. Observation on 4/15/13 at 11:46 AM noted that Patient #34 was in the nurse's arms, did not have IV access lines and was being fed a bottle of milk. The observation also noted that 2 identification (ID) bands were attached to Patient #34's bassinet and Patient #34 was not wearing an ID band. Interview with RN #6 on 3/14/13 at 11:46 AM indicated that she/he saw the bands on the patient's crib at the beginning of the shift on 4/15/13 and that sometimes both ID bands are placed on the bassinet if the infant had multiple IV lines. She/he further noted that Patient #34 should have at least one ID bracelet on. Subsequent to Patient #34's feeding, the nurse placed an ID bracelet on Patient #34's left ankle. The hospital policy for identification of newborns directed to apply 1 small barcode band and 1 small baby ID band to each of the baby's ankles. The hospital infant abduction policy identified that for NICU infants, each nurse will verify that the ID bands are in place at the beginning of her shift and document on the NICU flow sheet.

5. Based on medical record reviews, review of facility policies and interviews for three of six patients who had a pressure ulcer (Patients #51, #52, #58), the facility failed to ensure timely physician and/or Certified Wound Ostomy Continence Nurse (CWOCN) notification of the ulcer and/or administer ulcer treatment per the physician's order or skin protocol. The finding includes:

a. Patient #51 was admitted to the hospital on 6/14/12 with a diagnosis of bronchial asthma exacerbation. The skin assessment dated 6/15/12 identified that the patient was at moderate risk for skin breakdown and interventions included repositioning at least every 2 hours with a turning sheet, skin barrier cream and skin assessments every shift (hospital utilizes either pressure redistribution or low air loss mattresses). The nursing assessment report dated 6/21/12 at 6 PM identified that the patient had deep tissue injury (DTI) pressure ulcers to the left and right buttocks. The assessment documentation indicated that that left buttock ulcer measured 3 centimeters (cm) wide by 4.2 cm long with purple discoloration and blister formation and 3M spray followed by a Mepilex (occlusive) dressing was applied. The assessment documentation also noted that the right buttock ulcer measured 5 cm long by 0.3 cm wide and treatment to the area was not documented. Nursing notes and/or physician orders and/or progress notes dated 6/21/12 through 6/24/12 lacked documentation that the physician and/or CWOCN were notified of the pressure ulcers. Although nursing documentation of the pressure ulcer assessments were placed in the physician progress notes and dated 6/25/12, the physician's critical care progress note dated 6/26/12 at 8 AM noted that the patient's skin was intact and without ulcer. Wound Ostomy progress notes dated 6/26/12 identified that the DTI had opened and directed Silvasorb gel with Mepilex cover dressing every 2 days and as needed to the DTI. The physician was notified and the recommended treatment order was obtained on 6/26/12. Interview with the CWOCN on 4/18/13 at 10:30 AM indicated that a Mepilex dressing would not be used for treatment of an unopened DTI so that wound progression could be better monitored. Documentation by the CWOCN dated 4/19/13 noted that nursing notified the CWOCN of the DTI on 6/23/12 and the patient could not be assessed on 6/25/12 by the CWOCN because the patient was unstable and could not be turned. The hospital policy for management of skin integrity identified that wound care is directed by the physician and consult of the CWOCN and treatment of wounds is ordered by the physician. The policy also noted do not break blister or cover with an occlusive dressing.


b. Patient #52 was admitted to the hospital on 12/25/12 with respiratory failure secondary to chronic obstructive pulmonary disease exacerbation. The initial nursing assessment dated 12/25/12 identified that the patient's skin was intact. The physician's order dated 12/25/12 directed bi-level positive airway pressure (BiPAP) every 4 hours and the physician's order dated 1/1/13 directed continuous BiPAP therapy. Respiratory notes dated 1/1/13 indicated stage I redness when skin beneath BiPAP mask was assessed. The nursing assessment reports dated 1/1/13 lacked documentation that nursing was made aware of the reddened area, assessed the area or that that the area received treatment. The nursing assessment report dated 1/2/13 at 8:17 AM noted that the bridge of the patient's nose was a little purplish in color and padding was ordered. Although the nursing assessment report dated 1/2/13 at 8:45 PM indicated that Allevyn padding was applied to the bridge of the patient's nose, a physician's order for the dressing was not noted and a full assessment of the "purplish" area to include measurements was not documented by the nurse. Nursing assessment reports identified that the Allevyn padding remained in place from 1/2/13 to 1/6/13 (4 days), was removed on 1/7/13 and a 1 cm long by 1/2 cm wide DTI pressure ulcer to the bridge of the nose was observed. The record lacked documentation that the physician was notified of the DTI until 1/8/13. Nursing assessment reports dated 1/7/13 to 1/11/13 indicated and the area was left open to air, 3M spray was applied and the area was covered with an Allevyn dressing when the patient received BiPAP. The pressure ulcer was assessed as a scabbed DTI by the CWOCN on 1/11/13 noting that the patient refused a full face mask. Although a physician's order directed to leave the DTI open to air, the nursing assessment report dated 1/14/13 identified that the foam (Allevyn) dressing, applied on 1/11/13, was intact. The patient was discharged on 1/14/13 with visiting nursing assistance at home. The nursing assessment report dated 1/14/13 and/or discharge paperwork lacked current assessment of the pressure ulcer and/or direction for treatment. Interview with the Quality Coordinator and review of the hospital skin integrity management policy noted that wound care is directed by the physician and consult of the CWOCN and appropriate order is obtained. The skin integrity management policy further identified that wounds/skin are assessed at each dressing change with measurements taken initially, upon transfer, upon discharge, with change in wound status and every 7 days.

c. Patient #58 was admitted to the Medical/Surgical Unit on 04/12/13 with diagnoses that included dementia, history of a cerebral vascular accident (CVA), dysphagia, and gastrostomy tube.

Nursing Admission Assessment identified a dry, intact scab on the right elbow. A Braden Score for Predicting Pressure Sore Risk was calculated each shift with at risk scores of 12-14 (high risk 10-12, moderate risk 13-14). A Skin Integrity Multidisciplinary Treatment Plan identified interventions that included, in part, protect the patient's elbows where exposed to friction, use pillows to reduce pressure on bony prominences.

A Wound/Ostomy progress note dated 04/15/13 at 10:51 AM identified that the patient presented within intact scab 0.2 centimeters (cm) round on the right elbow within a scar and directed to elevate and have no pressure over the site. 3M spray daily to maintain integrity. Does not require an external dressing.

A physician's order dated 04/16/13 at 12:15 AM directed Allevyn dressing to right elbow, change every 72 hours and as needed (prn).

Observation of Patient #58 on 04/16/13 at 11:20 AM with RN #5 identified that the right elbow was in direct contact with the pillow without benefit of a dressing. Interview with the nurse assigned to Patient #58, RN #8 identified that he/she was responsible for checking the placement of the dressing, but had not yet checked the elbow. Interview with Nurse Aide (NA) #1 at 11:30 AM identified that he/she had not observed a dressing in place during morning care and was unaware that a dressing was required.




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6. Based on a review of clinical records, policy, and interview, for one of one patient's (#48) reviewed, the facility failed to ensure that CIWA monitoring was completed in accordance with policy The finding includes:

a. Patient #48 was admitted on 4/14/13 with seizures related to alcohol detoxification. The clinical record dated 4/14/13 at 1:50 AM identfied that the patient scored a ten (10) on the CIWA scale. The record reflected that the patient was not monitored until 6:00 AM with a score of 12. The hospital failed to monitor the patient every two (2) hours in accordance with policy.
Review of the CIWA policy identified that the patient would be monitored every two hours until CIWA score is less than 15 for 24 hours.


7. Based on a review of clinical records and interview, for one of four patients (#66) reviewed for fall risk, the hospital failed to ensure that the patient was assessed for the ability to independently ambulate post-operatively. The finding includes the following:


a. Patient #66 was transferred to the ED via ambulance from the Obstetricians office on 2/23/12 at 8:03 PM with a miscarriage and a chief complaint of hypotension. The ED record identified that the patient's blood pressure was 60/40 in the physician's office then 80/60 when EMS arrived. The patient was diagnosed with a miscarriage and admitted to the operating room and underwent a Dilatation and Curettage (D&C) for an incomplete abortion at 11:53 PM.

Review of the record reflected the patient was admitted to PACU on 2/24/12 at 12:10 AM and was transferred to Phase II for continued monitoring at 12:30 AM. Review of the Phase II flowsheet identified that the patient ambulated independently with aides at 2:00 AM. A nursing note dated 2/24/12 at 6:20 AM indicated that the patient ambulated to the bathroom without difficulty and while in the bathroom a noise was heard and patient was found on the floor with blood over her right eye.

Review of the PACU record failed to indicate that the patient was assessed to ambulate independently. The patient was transferred to the ED for evaluation. The ED record identified that the patient "passed out" while in the bathroom and that the symptoms began while standing. The patient sustained a right eye laceration that was repaired.

The physicians note identified that the patient had blood loss anemia, syncope related to the same and required further management.

Interview with the PACU Director on 4/23/13 at 1:30 PM indicated that after the fall the patient was evaluated by the anesthesiologist who determined to send the patient to the ED for evaluation. Review of the clinical record failed to identify a note/evaluation by the anesthesiologist. Further interview with the Director stated that the fall risk policy pertained to inpatients only. Subsequent to this incident, patients are now screened for mobility status.

Based on a review of clinical records, interview and policy review, for one of four patients (#65) reviewed for fall risk, the hospital failed to ensure that the plan of care was reviewed and/or revised when the patient was noted to be noncompliant with the plan. The finding includes the following:

a. Patient #65 was admitted on 2/22/12 with a change of mental status secondary to chronic hepatic encephalopathy. The admission nursing assessment identified that the patient scored a 75 on the Morse fall risk indicating a high fall risk (45 or greater=high risk) with interventions that included yellow band, yellow triangle on the door frame, bed/chair alarm, all necessary items within reach, and fall risk rationale with the patient. A nurse's note dated 2/24/12 at 2:41 PM identified that the patient refused to keep the bed alarm on. A nurse's note on 2/26/12 at 3:35 PM reflected the patient expressed a desire to go home, doesn't call for help, and refused the bed alarm. An assessment dated 3/1/13 at 9:20 AM identified that the patient was weak, over-estimates and/or forgets limitations, was at high risk for falls (score of 85), and encouraged out of bed activities with assistance. A nurse's note dated 3/1/13 completed at 7:35 PM indicated that the patient was disoriented, lethargic for most of the day and was found sitting on the floor sitting against the wall, the physician was notified and examined the patient. The physician's note dated 3/1/12 at 4:15 PM identified no lower extremity swelling, non-tender with new orders for neurological checks every four hours, 1:1 sitter, fall precautions, and CT of the head.

Review of the clinical record failed to identify that a bed alarm was utilized in accordance with the plan of care and/or that the plan was revised when the patient refused the alarm and/or based on the physician's note for a 1:1 sitter on 3/1/12. The patient was subsequently diagnosed with a right hip fracture that required surgical intervention.

Based on observation, review of facility policies and procedures, and interviews the facility failed to ensure that perishable, refrigerated, food items were discarded in accordance with facility policy. The findings include:

Observation of refrigerator storage with the Director of Food and Nutrition on 04/16/13 at 2:40 identified container of Caramel sauce labeled as opened October, 2012 with a use by date of 11/2012. Facility policy identified that refrigerated caramel sauce has time limit for use of 60 days.

A gallon jar of Maraschino cherries was opened on 10/24/12 and lacked a use by date. Facility policy identified that opened canned fruits have a time limit for use of 4 days.

An open container of Coconut Milk dated 04/09/13 lacked a use by date. Facility policy identified that juices thawed on site have a time limit for use of 7 days.

An open package of Swiss cheese dated 03/37/13 lacked a use by date. Facility policy identified that cheese had a time limit for use of 7 days, or 14 days for hard cheese.

Interview with the Director of Food and Nutrition on 04/18/13 at 9:45 AM identified that the kitchen supervisor conducted a brief, random, observation of food labels daily for expiration.

Based on observation, review of hospital policy and staff interviews, the hospital failed to maintain fluids within a safe temperature range in accordance with facility policy and/or that oxygen cylinders were secure and/or that dialysis machines were stored in a manner to prevent contamination and/or that operating room equipment was in good repair, and/or that endoscopy scopes were stored in a manner consistent with infection control practices. The findings include:


a. During tour of the operating suite on 4/15/13 with the Director of Perioperative Services, a fluid warmer that contained rigid pour bottles, was observed with temperatures of 124 degrees Fahrenheit (F). There failed to be evidence that the warmer's temperature was monitored on a regular basis. Review of the hospital policy posted on the warmer identified that the temperature maximum should be 110 degrees (Fahrenheit). Subsequent to observation, the Director readjusted the temperature setting to read 110 degrees.

b. During a tour of the hemodialysis area on 4/15/13 and 4/16/13, oxygen cylinders were observed in the horizontal position on the window ledge. The hospital failed to ensure that the oxygen cylinders were rendered stable either by being secured against a wall by a chain or provided with a base designed to render the cylinder(s) stable.


c. On 4/15/13 and 4/16/13 during tour of the hemodialysis unit, three treatment rooms were observed to contain an additional dialysis machine in each room while patients were dialyzed. Interview with staff on 4/16/13 stated that "clean" machines were covered by a sheet and left in the rooms during treatments due to a lack of storage space.

d. Tour of the cesarean section rooms on 4/15/13 at 11:25 AM the off-campus surgical center on 4/16/13 at 10:40 AM identified rusted and/or peeling paint on surgical suite stand equipment and/or peeling, cracked vinyl on surgical tables rendering the items unable to be properly cleaned. Subsequent to the observations, the affected equipment was removed from service and replacements were made.

e. Tour of the off-campus endoscopy suite in the surgical center on 4/16/13 at 10:40 AM identified three scopes in the scope storage closet. The tip of one scope was observed touching the drip cloth below the scope and a wet ring on the drip cloth was also observed. Interview with the Surgical Center Director on 4/16/13 at 10:40 AM noted that either the scope hanger needed to be raised or the drip cloth needed to be thinner to allow the scope to hang freely to ensure proper drying and storage. The hospital policy for disinfection/cleaning of endoscopic/bronchofibroscopes noted to place scope in appropriate storage cabinet with appropriate colored clip and did not direct that scopes be free-hanging as per standard. The World Gastroenterology Organization/World Endoscopy Organization, Global Guidelines, Endoscope disinfection, February 2011 Web page identified to "avoid contamination of disinfected endoscopes by contact with the environment or by prolonged storage in an area that may promote pathogen growth."




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Based on observation during tour of the Operating Room (OR) Suite and Dialysis Unit, the hospital failed to ensure proper disinfection of equipment in the OR and/or hemodialysis unit. The findings include:

a. During tour of the Operating Suite on 4/15/13, observation of a Wilson frame identified slits and abrasions in the vinyl surface, rendering the cleaning and disinfection of the piece ineffective. Additionally, a chair located within one of the operating rooms had Elastoplast wrapped around the arm of the chair.

b. During tour of the Dialysis Unit on 4/17/13, three vinyl covered chairs located at the nurse's station were identified to have the vinyl covering ripped and torn, rendering them unable to be adequately cleaned.

Based on a review of clinical records and interview, for four (4) of four (4) patient records (#39, #40, #41, #42) reviewed in Endoscopy, the hospital failed to ensure that the history and physical (H&P) was comprehensive. The findings include:

a. Patient #39 underwent an esophagogastroduodenoscopy and Halo ablation on 4/16/13. Review of the patient's H&P dated 4/16/13, identified that the heart and lung assessment was described as "normal", rather than a comprehensive assessment of that organ.

b. Patient #40 underwent an esophagogastroduodenoscopy and colonoscopy on 4/16/13. The patient's H&P described the heart and lung "physical" as "normal", rather than a comprehensive assessment of that organ.

c. Patient #41 underwent an esophagogastroduodenoscopy on 4/16/13. A review of the patient's H&P reflected that the patient's heart and lungs were "normal", rather than a comprehensive assessment of that organ.

d. Patient #42 underwent a colonoscopy on 4/16/13. Review of the patient's H&P reflected that the patient's heart and lungs were "normal", rather than a comprehensive assessment of that organ.

Based on review of the clinical record and hospital policy, for one (#39) of four (4) patient records reviewed who underwent a gastrointestinal procedure, the hospital failed to ensure that the pre-anesthesia review included an assessment of the heart and lungs in accordance with hospital policy. The finding includes:

a. Patient #39 underwent an esophagogastroduodenoscopy and Halo ablation on 4/16/13. Review of the anesthesia record failed to reflect that the patient's cardiac and pulmonary status was assessed prior to the procedure in accordance with hospital policy.

Based on a review of the clinical record, review of ASA standards, and interview, for one (#39) of four patient records reviewed who underwent a gastrointestinal procedure, the hospital failed to ensure that the patient's vital signs were monitored throughout the procedure. The finding includes:

a. Patient #39 underwent an esophagogastroduodenoscopy and Halo ablation on 4/16/13. Review of the anesthesia record identified that anesthesia began at 8:41 AM. The record reflected that the patient's vital signs were monitored every five (5) minutes until 8:50 AM. According to the procedural report, the patient's procedure ended at 9:04 am. Review of the anesthesia report failed to reflect monitoring of vital signs from 8:50 AM to 9:04 AM. During interview with the Anesthesiologist on 4/16 at 10:20 AM, stated that s/he could not recall why the patient's vital signs were not documented for the last ten (10) minutes of the procedure.
According to the ASA Standards for Anesthesia Care, the anesthesiologist should monitor and record the vital signs of the patient intraprocedurally as well as document the status of the patient at the conclusion of anesthesia.

Based on a review of clinical records, review of hospital policy and interview, for four (4) of four (4) patient records (#39, #40, #41, #42) reviewed for anesthesia services, the hospital failed to ensure that post anesthesia assessments were conducted during the post-anesthesia recovery phase. The findings include:

a. Patient #39, who underwent an esophagogastroduodenoscopy and Halo ablation on 4/16/13, left the procedure room at 9:12 AM according to the clinical record. Review of anesthesia post-procedure assessment identified that the patient was assessed for recovery from anesthesia at 9:12 AM.

During interview on 4/18/13 at 11:00 AM, the Director of Anesthesia stated s/he expected that anesthesia providers would assess the patient for anesthesia recovery while in the recovery area.

Review of hospital policy directs that the patient shall receive a post anesthesia evaluation prior to patient discharge from the ambulatory unit.

b. Patient #40, who underwent an esophagogastroduodenoscopy and colonoscopy on 4/16/13, left the procedure room at 10:05 AM according to the clinical record. Review of the anesthesia post procedure assessment identified that the patient was assessed for recovery from anesthesia at 10:02 AM, prior to leaving the Operating Room (OR).

c. Patient #41, underwent an esophagogastroduodenoscopy on 4/16/13, left the procedure room at 8:44 AM according to the clinical record. Review of the anesthesia post procedure assessment identified that the patient was assessed for recovery from anesthesia at 8:41 AM, prior to leaving the OR.

d. Patient #42, who underwent a colonoscopy on 4/16/13, left the procedure room at 8:20 AM according to the clinical record. Review of the anesthesia post procedure assessment identified that the patient was assessed for recovery from anesthesia at 8:15 AM, prior to leaving the OR.

Based on review of the clinical record, facility policies and procedures, and interviews, for 2 staff members of the the Child and Adolescent Behavioral Health Outpatient satellite, Program Manager #1 and Social Work Intern #1, the facility to ensure that training was provided related appropriate management of the aggressive patient in accordance with professional standards of practice and facility policy. The findings include:

Review of a facility policy for Psychiatric Emergencies identified that all staff would receive training in non-violent crisis intervention techniques. New staff would receive 8 hours of training as part of formal department training and recertification would occur annually.

Review of Program Manager #1's personnel file included a Performance Review for the time period of 10/01/11 through 09/30/12 that identified that Program Manager #1 had not participated in non-violent crisis intervention training for 2012. Interview with Manager #1 on 04/22/13 at 2:10 PM identified that he/she had not yet completed the annual renewal of non-violent crisis intervention training.

Interview with Social Work Intern #1, who had been participating in the Adolescent Intensive Outpatient Program since 09/2012, on 04/22/13 identified that he/she had not completed the non-violent crisis intervention training. Additionally, he/she did not attend patient rounds conducted 3 times per week.