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Based on observation, and interview the facility failed to post grievance/complaint resolution information in 2 (Emergency Department, (ED) and Outpatient Rehabilitation) of 4 admission areas.The facility failed to include the grievance resolution information in all patient admission packets and failed to demonstrate complaint resolutions from October of 2013 throught March of 2014.

On 4/1/2014 at 9:00 AM during observations in the ED, the Patient Rights posting did not contain the Hotline information for complaint resolution for the state agency. This was confirmed by staff #2.

On 4/2/2014 during observations in the Outpatient Rehabilitation department no patient rights posting were observed in the registration or waiting areas. This was confirmed by staff # 4

On 3/31/2014 in the conference room the Patient Rights admission information was reviewed and revealed the grievance officers contact information was not included in the packet. This was confirmed by staff #4.

On 4/1/2014 at 2:30 PM, in the conference room the complaint log for October of 2013 through March of 2014 were reviewed and revealed the following:
In October 2013, 43 complaints were documented
In November 2013, 18 complaints were documented
No documentation was provided for December of 2013
In January 2014, 45 complaints were documented
In February 2014, 31 complaints were documented
In March 2014, 40 complaints were documented

One hundred and seventy seven (177) complaints were recorded and identified by date, last name, room number, a comment explaining the complaint and the follow-up. The follow-up documentation indicated what action had been taken on behalf of the complainant, however, no resolution was recorded. This was confirmed by staff #11.

Based on observation, document review and interview the facility failed to develop and enforce a process based on the recommended standard of care for the use of surgical mask in the Operating Room.
A tour of the surgical department was done on 4/1/2014 at approximately 9:30 AM with staff#3 and staff#5. Surgical staff were observed wearing surgical mask in the hallways of the Surgical Departments. Surgical staff were observed wearing surgical mask hanging from their necks.
At the time of the tour staff#3 and staff#5 confirmed the above findings.
An interview was held with the Surgical Charge Nurse on 03/31/2014 in the Surgical Department, with staff#3 and staff#5 present. The Surgical Charge Nurse was asked what the process was for staff wearing surgical mask. The Surgical Charge Nurse replied with hesitancy, the staff should remove the mask when they are not involved in a surgical case. The Surgical Charge Nurse further explained, the doctors and anesthesia staff do not always comply.
A request was made on 03/31/2014 and again on 04/01/2014 for a policy or procedure for the wearing of surgical mask in the Surgical Department. No policy was provided.
A review of the document titled "Implementing AORN Recommended Practices for Surgical Attire", published in the AORN Journal ¿ January 2012 Vol 95 No 1, revealed: "Surgical attire should not include a surgical mask that is worn hanging from the neck or a surgical mask that becomes soiled or wet. Only one mask should be worn at a time, and soiled or wet masks should be discarded and replaced. The perioperative nurse should confront any health care provider who is wearing a contaminated surgical mask .... After each procedure, the surgical mask should be discarded by carefully handling only the ties of the mask. After discarding his or her mask, the perioperative team member should perform proper hand hygiene."

Based on document review and interview the facility failed to provide a policy/procedures for the administration of a "Rapid Infusion" blood transfusion. No procedures were in place to monitor the patient for adverse reactions and ensure patient safety. Citing 1 of 1 patient blood transfusion record reviewed. (Patient #2).
Findings include:
Review of patient medical record #2 on 4/1/2014 at 1:45 pm in the facility conference room revealed the following:
Review of Emergency Room documentation revealed the patient was admitted into the emergency department on 3/30/2014 at 2:13 am and transferred to Intensive Care Unit at 9:30 am.
1. Patient medical record #2- Blood Bank Infusion Record revealed the following:
#1 blood transfusion record dated 3/30/2014 starting at 5:24 am- and ending at 5:33 am- Documentation included Pre and Post infusion vital signs only. Documentation noted that the infusion was a "Rapid Infusion over 15 minutes per physician order".
#2 blood transfusion starting at 5:38 am- and ending at 5:48 am- included pre and post treatment vital signs only. Documentation noted that the infusion was a "Rapid Infusion over 15 minutes per physician order."
#3 blood transfusion starting at 6:48 am and ending at 7:04 am- provided no documentation to indicate "rapid infusion" per physician order, and only documented pre and post treatment vital signs.
#4 blood transfusion starting at 7:08 am revealed no documentation of ending date/time and/or documentation of volume given. Vital signs documented as follows- , Pre-treatment, 15 minutes, 30 minutes, and 1 hour. No documentation of 2 hour, 3 hour, post-treatment, and/or 6 hour found. No documentation to indicate the blood transfusion was a "rapid infusion over 15 minutes per physicisn order" found.
Review of the "Daily Focus Assessment Report" dated 3/30/2014 during Emergency Department stay from 2:13 am until transfer to Intensive Care Unit at 9:30 am revealed no further assessment and/or documentation of patient status pre-transfusion, during infusion, and/or post-transfusion.

Review of Policy Title: "Transfusion of Blood" on 4/1/2014 at 2:00 pm revealed the following:
"Purpose: To restore circulating blood volume, improve oxygen carrying capacity or supply a specific blood component.
Responsibility of: Registered Nurse- Hospital Designee with Special Training and Competency Verification (for pick-up and delivery ONLY)
I. Equipment:
One unit of blood or blood component from laboratory (blood bank) after IV started.
Patent IV with #20 or larger gauge cathlon.
0.9% normal saline IV solution
Blood infusion tubing
Infusion Pump
II. Procedure
A. Verify physician's order for type (packed cells or whole blood) and amount of blood product to be administered.
B. Check patient's two identifiers then obtain informed consent. Consent must be obtained for each new order for transfusion. Explain procedure to patient and verify patient's understanding.
1. Inquire about previous transfusions.
2. Instruct patent to report any unusual symptoms immediately.
C. Gather equipment equipment and obtain and record baseline vital signs (temperature, pulse, respiration and BP) prior to going to lab (blood bank) for blood.
D. Check blood out of blood bank. The blood or blood component must be checked before leaving the lab to assure that all information is accurate.
1. Prior to coming to the lab for blood, staff must obtain a chart sticker with corresponding blood identification band number. Verify that the nurse collect form is for the correct patient by verifying name against the physician order. Write the blood identification band number from he red blood bracelet on the form for lab verification. NO NOT REMOVE the red blood bracelet.
2. The technologist issuing the blood must confirm that the name and identification number on the "pick-up" form agrees with the information on the component unit (s) to be issued.
3. The technologist and hospital designee shall verify that the following information correct on the crossmatch slip and donor unit: donor number, unit number, and expiration of donor unit; patient name and ID number, ABO group and Rh of both patient and donor.
4. The technologist shall:
* Review the crossmatch slip to make sure that the slip indicates a compatible crossmatch.
* Bring to the attention any special instructions; e.g. blood warmer, autologous donation, etc.... Blood slip will be stamped with specific infusion instruction if applicable.
* Check the component bag (s) for clots and any abnormal color or appearance.
* Verify the inspection, patient name, donor, type and Rh, service, type of component being issued with unit number and expiration date, issue date and time and document in the Transfusion Log Book.
Assure that crossmatch tags are secured to each unit.
5. After all verifications/checks are completed, the technologist and designee shall sign the Transfusion logbook.
6. The blood units will be placed in biohazard, labeled plastic bags and transported immediately to requesting area by designee.
Procedural Notes:
Only one unit may be checked out at at time with the exception of Surgery, ED Dialysis, or in special circumstances. If more than one unit is required they will be placed in a Cell Safe Blood Transport Cooler. A Safe-T-Vue temperature check will be placed on the back of each unit of blood. Only one patient's blood per check out. Blood may be returned tot he laboratory for reissue within 30 minutes of checkout time or if the Safe-T-Vue is "white". If more that 30 minutes or if Safe-T-Vue is "red" the blood must be taken back to lab for discard.
E. Wash hands and apply gloves,.
F. Prime blood tubing with normal saline, covering the filter in the drip chamber to prevent damage to the blood cells.
G. Attach blood tubing to primary IV line. The primary tubing is turned off and does not infuse while the blood is infusing.
H. Administration:
1. Prior to administering the blood, two licensed nursed must enter the patient's room and again do verification of information at the bedside. Information to be verified at bedside must include verification of patient using two identifiers.
a. Patient name: verify that the name on the Physician Order match:
* the name on the COMPATIBILITY LABEL on the unit of blood.
* the name of the Cross-match slip,
* the name of the Identa-band (red blood band), and
* the name on the hospital armband.
b. Blood Identification Band Number: verify that the number on the Identa-band (red blood band) match:
* the identification number on the COMPATIBILITY LABEL on the unit of blood, and
* the identification number on the Cross-match slip.
All of the above information must match exactly.

If any item does not match, STOP!!!! Call lab, re-draw cross-match and start over.

2. Both nurses must sign, date and time the cross match slip on the lines indicated.
3. Assess 30 minutes later and every 1 hour until blood is finished for any pre-transfusion symptoms which could be confused with a transfusion reaction.
4. Premedicate patient with prophylactic medication (e.g., antihistamines, acetaminophen) if ordered by physician.
5. Observe patient for first 5 minutes, retuning after 10 minutes to ensure that transfusion is proceeding uneventfully. If signs of transfusion reaction occur, immediately proceed with he transfusion reaction procedure. After initial vital signs obtain and record 15 minutes after infusion started, 30 minutes later and every hour until blood is finished. This procedure is for each time a new unit is hung.
6. Infusion Rate: Prepare the infusion site and start the IV 0.9 percent normal saline. Spike blood tubing into blood bag. Close saline roller clamp. Infuse the blood slowly (20 Gtts/min) for the first 15 minutes. Adjust the flow rate to the specific order usually 2-3 hours per unit of whole blood or packed cells. Four hours is the maximum amount of time a unit of blood can be transfused.
7. The facility recommends that following guidelines: Blood filter tubing may be changed after 2 units of blood have been given, if the units are given consecutively. If problems develop the tubing should be changed sooner. Blood filter tubing and the empty blood bag (s) should be discarded immediately after use in a biohazard bag in biohazard room.
8. The blood bank slip must be filled out completely. When completed, the white copy is retained on the chart and the yellow copy is returned to the Blood Bank.

I. Post transfusion evaluation to include:
1. Vital signs and assessment for adverse symptoms two hours after completion of therapy or prior to dismissal if discharged within two hours of completing transfusion.
2. If patient has demonstrated any reaction to transfusion document assessments according to blood transfusion reaction. See attached form.
III. Considerations:
A. Only 0.9% normal saline may be infused in the same IV line prior to or during the administration of blood products. Never, under any circumstances, add any medication to blood.
B. Most units of blood products should be administered in approximately 2 hours unless a specific order is written for infusion time. Patient's condition may warrant slower administration.
C. All units of blood must be completed in less that 4 hours because of the dangers of bacterial growth and hemolysis of red blood cells at room temperature. when physician requests longer duration, the nurse should:
1. Offer to order the unit(s) divided (increment units)
2. Notify the blood bank if physician does not accept option 1. (They will have pathologist assist physician to determine alternative method).
D. If possible, avoid transfusion of febrile patients (fever greater that 38 degrees C). Fever can mask symptoms of an adverse reaction and/or decrease desired effect of component. However, this should not be considered an absolute contraindication for a needed transfusion.
IV. DOCUMENTATION IN EMR UNDER NURSING ASSESSMENT/INTERVENTION TAB, IV LINES, BLOOD (OR IN NURSES NOTES DURING DOWNTIME):
A. Time IV started: solution and catheter used. Time unit number of blood hung. Nurse must use co-sign electronically that all was verified. If downtime, then nurse initials/signature must be present.
B. Time blood discontinued/completed.
C. Patient assessment: pre, during, and post transfusion
D. Response to each transfusion
E. Status of IV site.
F. Amount of IV solution infused.
G. Vital signs"

Interview with staff member #2 on 4/1/2014 at 2:00 pm confirmed the findings.

Based on record review and interview, the facility failed to ensure the patient medical record was complete. Citing 13 of 30 patient medical records reviewed. (Patient #'s 1, 2, 3, 4, 5, 6, 17, 18, 20, 22, 25, 27, and 29).

Findings include:
While reviewing patient medical records on 4/1/2014 thru 4/4/2014 the following was noted:
1. Patient medical record #1- Surgery consent dated 3/26/2014- no documentation of date/time of physician signature found. Emergency Room physician exam sheet dated 3/24/2014- no documentation of date/time of physician signature found.
2. Patient medial record #2- Emergency Room physician exam sheet dated 3/30/2014- no documentation of the date/time of physician's signature found.
3. Patient medical record #3- Emergency Room physician exam sheet dated 2/4/2014-no documentation of the date/time of physician's signature found.
4. Patient medical record #4- Emergency Room physician's exam sheet dated 2/9/2014-no documentation of the date/time of physician's signature found.
5. Patient medical record #5- Emergency Room physician exam sheet dated 12/19/2013- no documentation of the date/time of physician's signature found.
6. Patient medical record #6- Emergency Room physician's exam sheet dated 1/14/2014- no documentation of the date/time of physician's signature found.
7. Patient medical record #17- Verbal orders x 4 dated 3/13/2014- no date/time/and/or signature of physician found. Verbal orders x 1 dated 3/19/2014- no date/time/ and/or physician's signature found. Physician order for Venous Thromboembolism (VTE) Screen- no documentation of the physician's signature and/or date/time found.
8. Patient medical record #18- Disclosure of Risks for Medical and Surgical Procedure dated 3/16/2014- no signature of physician and/or date/time found. Physician order for VTE Screen- no documentation of the physician's signature and/or date/time found. Verbal orders dated 3/14/2014 and 3/16/2014- no documentation of physician's signature and/or date/time found.
9. Patient medical record #20- Physician order for VTE Screen- No documentation of physician's signature and/or date/time found. Surgery consent dated 3/4/2014- No date/time documentation by physician's signature. Pre-Procedure Moderate Sedation Physician Assessment and Plan- No date/time documentation physician's signature found. Verbal orders dated 3/3/2014 x1, 3/4/2014 x 4, 3/5/2014 x 2, and 3/7/2014 x 2- No documentation of physician's signature and/or date/time found.
10. Patient medical record #22- Pre-op Anesthesia Order dated 3/20/2014- No documentation of physician's signature and/or date/time found.
11. Patient medical record #25- Emergency Room Physician exam sheet- No documentation of date/time of physician's signature found. Verbal orders dated 3/18/2014 x1, 3/20/2014 x 2, and 3/21/2014 x1- no physician's signature and/or date/time found.
12. Patient medical record #27- Disclosure of Risks for Medical and Surgical Procedure- No documentation of the physician signature and/or date/time found. Emergency Room Physician exam sheet- No documentation of the date/time of the physician's signature found.
13. Patient medical record #29- Anesthesia Pre-op Order- No documentation of the physician's signature date/time found.

Interview with staff #2 on 4/1/2014 and 4/3/2014 confirmed the findings.

Based on obsevation and interview the facility failed to remove expired items from patient care area and properly store supplies. Expired items were available for patient use.
A tour of the surgical department was conducted on 3/31/2014 at approximately 1:30 PM with staff #3, staff #5 and staff #28. Upon entering the cystoscopy suite's storage room, the following was observed:
A. two stacks of suction containers were observed sitting on the floor (a total of four suction containers were in the two stacks);
B. one open blue surgical gown was on the floor under a storage rack;
C. one white blanket was lying in the corner of the room on the floor;
D. one grasper (in a sterile packet) was lying on the floor.
A large quantity of foley catheters (too numerous to count) were observed hanging on a rack. Closer observation of the catheters revealed:
A. one of the catheters expired in 11/2010;
B. eight of the catheters expired in 10/2013.

An inspection of the anesthesia cart found the cart to be unlocked. In the bottom drawer of the cart:
A. one can of sevoflurane was observed;
B. one can of Supprane was observed;
C. two glass bottles of Isofloran were observed.
At the time of the tour, staff #3, staff #5 and staff #28 confirmed the above findings.
An interview with staff #3 in the administrative Conference Room on 4/1/2014 at approximately 11:00AM confirmed the facility's process was to secure the anesthesia cart. The anesthesia cart should have been locked in order to secure the anesthesia drugs.

Based on observation and interview, the facility failed to ensure supplies were protected from being soiled. Ten (10) wire racks with patient supplies were found with no impermeable barrier on the bottom shelves. This practice failed to protect supplies stored on the bottom shelves from being contaminated from floor debris. The facility also failed to ensure contaminated cardboard shipping boxes were not present in patient care and clean storage areas.

Findings include:

During a tour of the Central Supply Warehouse on 3/31/14 at 3:45pm, 10 wire storage racks with patient supplies were found with no impermeable barrier on their bottom shelves. During the tour, staff #29 confirmed these findings.

A tour of the facility on 3/31/14 at 1:40pm revealed 10 soiled cardboard shipping boxes stored directly on the floor in the sterile processing hallway, leading to potential contamination. During the tour, staff #2 confirmed these findings.

A tour of the lab storage room on 4/01/14 at 9:20am revealed 10 soiled cardboard shipping boxes stored with clean supplies, leading to potential cross-contamination. During the tour, staff #30 confirmed these findings.