HospitalInspections.org

A. Based on document review, observation, and interview, it was determined, for 1 of 2 contracted dialysis nurses (X #1) on the Cardiac Renal Unit (2 South), the Hospital failed to ensure a contracted dialysis nurse administered the dialysate prescription ordered by a physician.

Findings include:

1. On 4/26/16 at 3:10 PM, Hospital policy titled, "Medication Management", revised 10/21/16, was reviewed. The policy required, "RNs at NCH may give any medication as ordered by the prescribing practitioner... Prior to medication administration the nurse will verify the five (5) rights... right medication... right dose..."

2. On 4/25/16 at 1:45 PM, an observational tour was conducted of the 2 South Unit. A Patient (Pt. #11) was receiving hemodialysis in room 221. The dialysate container included a 4.0 mEq/L potassium (K) and 2.5 mEq/L calcium (Ca) concentration.

3. On 4/25/16 at 1:15 PM, Pt. #11's clinical record was reviewed. Pt. #11 was a 77 year old female, admitted on 4/22/16, with diagnoses of end stage renal disease, diabetes mellitus type II, and hypertension. Pt. #11's physician's orders, dated 4/24/16 at 4:34 PM, included dialysate with 4.0 K and 2.25 Ca, not the 2.5 Ca being administered.

4. On 4/25/16 at 2:00 PM, an interview was conducted with the contracted nurse (X #1) providing Pt. #11's dialysis treatment. X #1 stated there was no 4.0 K/ 2.5 Ca dialysate concentration in stock, only 4.0 K/ 2.25 Ca was available.

B. Based on document review, observational tour, and interview, it was determined, for 1 of 2 contracted dialysis nurses (X #1) on the Cardiac Renal Unit (2 South) for a patient receiving hemodialysis, the Hospital failed to ensure a contracted dialysis nurse knew the safe range of dialysate pH and used appropriate testing strips.

Findings include:

1. On 4/26/16 at 11:35 AM, Hospital policy titled, "Utilization of Nursing Services", revised 5/1/13, was reviewed. The policy required (page 4), "Utilization of Staff and Staffing: 1. Staffing will be sufficient in numbers and competency to insure that... A staff RN retains responsibility for all patients co-assigned to students or outside agency providers (e.g. dialysis)..."

2. On 4/27/16 at 11:30 AM, the Association for the Advancement of Medical Instrumentation (AAMI) guidelines: "Dialysis Water and Dialysate Recommendations: A Users Guide", edition May 2014 was reviewed. The recommendations included the safe range of dialysate pH is 6.9 to 7.6 mEq/L.

3. On 4/25/16 at 1:45 PM, an observational tour was conducted of the 2 South Unit. A Patient (Pt. #11) was being treated with hemodialysis in room 221. The dialysate pH testing strips being used were, "Precision pH Control Paper" No. 6080". The pH markers were: 6.0, 6.4, 6.8, 7.0, 7.4, and 8.0. The testing strips were not sensitive to identify a pH of 6.9 mEq/L or 7.6 mEq/L.

4. On 4/25/16 at 2:00 PM, an interview was conducted with the contracted Nurse (X #1) providing Pt. #12's dialysis treatment. The Surveyor asked what was AAMI's recommended safe dialysate pH range. X #1 stated "7.0 to 7.5". When asked again, X #1 answered "6.5 to 7.5".

5. On 4/25/16 at 2:05 PM, an interview was conducted with the 2 South Manager (E #1). E #1 stated she was not familiar with the safe range of dialysate pH and relied on the contracted nurses to provide safe dialysis treatment.

Based on document review and interview, it was determined, for the Health Information Management Department, the Hospital failed to ensure medical records were completed within 30 days of discharge.

Findings include:

1. The Medical Staff Rules and Regulations (reviewed 04/2016) was reviewed on 4/26/16 and required, "...Medical records will be completed within 30 days following the patient's discharge or they will be considered delinquent..."

2. On 4/26/16 at approximately 2:20 pm, the Director of Health Information System (E #4) presented the surveyor with a letter of attestation, dated 4/26/16, which included, "...as of today, the total number of delinquent charts at [Hospital] is 2,722."

3. On 4/26/16 at approximately 2:20 pm, E #4 stated the charts should be completed within 30 days of the patient's discharge.

A. Based on observation, document review, and interview, it was determined, for 1 of 3 patients (Pt. #1) on contact precautions on the Cardiac Renal Unit (2 South), the Hospital failed to ensure visitors entering contact isolation rooms were instructed to wear a cover gown and mask.

Findings include:

1. On 4/25/16 at 10:25 AM, an observational tour was conducted in the 2 South Unit. A contact precaution sign, hanging on the door on room 228, included, "Visitors: Please report to the nurses' station before entering this room... wear gloves and gown for contact with patient or contaminated surfaces/equipment." At 10:55 AM, Pt. #1 was in bed being cared for by a staff member. A man was standing near Pt. #1's bed, not wearing a gown or gloves.

2. On 4/25/15 at 11:05 AM, Pt. #1's clinical record was reviewed. Pt. #1 was a 100 year old male, admitted on 4/20/16, with diagnosis of pneumonia and sepsis. A physician's order for contact isolation was dated 4/21/16 at 9:02 PM.

3. On 4/25/16 at 11:00 AM, an interview was conducted with the man standing near Pt. #1's bed. The man stated he was Pt. #1's son and visited his father every day. Pt. #1's son stated he had not been asked to wear gloves or a gown when visiting his father in the contact isolation room.

4. On 4/25/16 at 2:00 PM, an interview was conducted with the 2 South Manager (E #1). E #1 stated and provided documentation confirming a nurse spoke to Pt. #1's son on 4/21/16 about wearing a gown when visiting his father. However, there were no subsequent nursing notes indicating Pt. #1's son was instructed to wear gloves and gown in a contact isolation room.

B. Based on document review, observational tour, and interview, it was determined, for 1 of 1 Respiratory Therapist (E #5) and 1 of 1 Anesthesiologist (MD #1), the Hospital failed to ensure staff disinfected their hands after removing gloves.

Findings include:

1. On 4/27/16 at 12:05 PM, Hospital policy titled, "Hand Hygiene", revised 1/25/16, was reviewed. The policy required, "A. General... 2. There are many instances in which staff at NCW must perform hand hygiene... j. After removal of personal protective equipment, including gloves..."

2. On 4/26/16 at 9:30 AM, an observational tour was conducted in the Critical Care Unit. A Respiratory Therapist (E #5) was assisting a Registered Nurse perform tracheostomy care for a Patient (Pt. #23). During the procedure, E #5 changed gloves, but did not perform hand hygiene.

3. On 4/26/16 at 10:35 AM, an observational tour was conducted in the Labor and Delivery Operating Room #2. At 10:45 AM, an Anesthesiologist (MD #1) performed an epidural procedure on Pt. #22, in preparation for a Cesarean Section. MD #1 changed his gloves but did not perform hand hygiene after the procedure.

4. On 4/26/16 at 10:50 AM, an interview was conducted with the Infection Prevention and Control Practitioner (E #3). E #3 stated staff are required to disinfect their hands after removing gloves.

C. Based on document review, observation, and interview, it was determined, for 1 of 1 Cesarean Section (C Section) Patient (Pt. #22), the Hospital failed to ensure sterile instruments in a Labor and Delivery operating room (room #2) were monitored when open.

Findings include:

1. On 4/27/16 at 2:25 PM, Hospital policy titled, "Infection Prevention Activities for Surgical Areas", revised March 2016, was reviewed. The policy required, "I. Principles of the Sterile Field... 6. The sterile field will be established as close as possible to the time of use and will be monitored continuously once it has been established."

2. On 4/26/16 at 10:35 AM, an observational tour was conducted in the Labor and Delivery (L&D) Operating Room (OR) #2. Sterile supplies and instruments were open in L&D OR #2. However, no one was present in OR #2, or monitoring the sterile supplies and instruments. At 10:40 AM, Pt. #22 entered L&D OR #2 via a cart for a C Section.

3. On 4/26/16 at 11:00 AM, an interview was conducted with the L&D Manager (E #10). E #10 stated she was not sure, but thought L&D OR #2 was not occupied for "a few minutes" and someone should be in the room when sterile instruments are open.

D. Based on document review, observational tour, and interview, it was determined, for 1 of 1 Cesarean Section Patient (Pt. #22), the Hospital failed to ensure the skin prep was dry before affixing the sterile drape and not wiping off the prep.

Findings include:

1. On 4/27/16 at 2:25 PM, surgical services policy titled, "Skin Preps: Surgical Guidelines, reviewed March 2016, was reviewed. The policy required, "F. Types of Skin Preparation Antiseptics: Providone Iodine (Betadine)... Must dry completely before draping..."

2. On 4/26/16 at 10:35 AM, an observational tour was conducted in the Labor and Delivery (L&D) Operating Room (OR) #2. At 10:44 AM, an Anesthesiologist (MD #1) prepped Pt. #22's back for an epidural anesthesia injection. A sterile plastic drape was placed on Pt. #22's back 20 seconds after completing the skin prep, not allowing the prep to dry. In addition, the remaining wet skin prep was wiped off with 4 x 4 gauze, at the injection site.

3. On 4/26/16 at 10:50 AM, an interview was conducted with the Infection Prevention and Control Practitioner (E #3). E #3 stated the prep should be left to dry before draping and not wiped off.

E. Based on document review, observational tour, and interview, it was determined, for 1 of 1 Cesarean Section Patient (Pt. #22), the Hospital failed to ensure the medication vial rubber septum was disinfected prior to needle insertion.

Findings include:

1. On 4/29/16 at 9:55 AM, the book, "Fundamentals of Nursing", by Potter and Perry, eighth edition, unit 5, page 624, was reviewed. The book was provided by the Director of Service Excellence (E #11), as a reference used by Hospital nursing staff, as there is no policy addressing disinfection of medication vials. The information included, "Skill 31-4 Preparing injections... Not all drug manufacturers guarantee that caps of unused vials are sterile. Therefore swab seals with alcohol before preparing medication..."

2. On 4/26/16 at 10:35 AM, an observational tour was conducted in the Labor and Delivery (L&D) Operating Room (OR) #2. At 10:43 AM, an Anesthesiologist (MD #1) opened an epinephrine vial and inserted a needle to remove medication, without disinfecting the rubber septum.

3. On 4/26/16 at 10:50 AM, an interview was conducted with the Infection Prevention and Control Practitioner (E #3). E #3 stated the rubber septum of the vial should have been disinfected.





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Based on document review, observation and interview, it was determined for 8 of 8 culture swabs available for use on the unit, the Hospital failed to ensure supplies were checked for expiration date as required. This potentially affected the 15 patients receiving care at the Facility on 4/25/16.

Findings include:

1. On 4/26/16 at approximately 1:00 PM, the Facility's policy titled, "Supplies with Expiration Dates" was reviewed and required, "Purpose: To provide a method to ensure that all stocked (Unit) supplies do not expire... 3. The material handlers picking stock are responsible for ensuring that what is picked is not expired or short dated..."

2. On 4/25/16 at approximately 2:00 PM, an observational tour of the Facility's Rehabilitation Unit was conducted. During the tour, eight (8) culture swabs with expiration date of 2/16 were observed in the supply drawer and available for use.

3. On 4/27/16 at 10:10 AM, an observational tour was conducted in the surgical sterile supply area. Eight of 9 Prolene (6.0) sutures found in a supply cart included an expiration date of January 2016.

4. On 4/25/16 at approximately 2:00 PM, an interview was conducted with the Rehabilitation Unit Nurse Manger (E #2) who stated the expired items should have been checked and disposed of.

5. On 4/27/16 at approximately 10:50 AM, an interview was conducted with the Infection Preventionalist (E #3). E #3 stated the expired items should have been removed from the cart and disposed of.

Based on document review, observation, and interview, it was determined that for 2 of 6 (E #6 & 7) staff observed, the Hospital failed to ensure jewelry was not worn in the OR, in accordance with stated practice.

Findings include:

1. The AORN "2016 Guidelines for Perioperative Nurse Practice" were reviewed on 4/27/16 at approximately 11:00 AM, and included, "Rings should not be worn by health care personnel in the perioperative setting."

2. During observation of Operating Room (OR)14 on 4/27/16 between 9:15 and 11:00 AM, two registered nurses (E #6 & #7) were observed wearing rings while in the OR suite.

3. On 4/27/16 at approximately 11:00 AM, the OR Manager (E #8) and Executive Director of Surgical Services (E #9) were interviewed. E #8 stated the policy does not address the wearing of rings in the department, however E #8 and 9 both stated that the surgical services department follows all standards required by the Association of Operating Room Nurses (AORN), and rings should not be worn in the OR. E #8 and #9 also stated the policy should include the "no ring" requirement.