HospitalInspections.org

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Based on document review and interview, hospital staff failed to complete background checks for 2 of 10 employees reviewed.
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Failure to perform and document criminal background checks places patients at risk for potential interaction with employees that have a history of abuse or neglect.
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Findings:
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1. On 2/2/2017 from 11:00 AM to 11:45 AM, Surveyor #1 conducted a review of human resources documents. Two employees, an x-ray technician (hired 12/21/2004) and a hyperbaric technician (hired 11/6/2008) (Staff Members #11 and #12), did not have documentation of a criminal background check performed at hire. The hospital completed background checks for both employees on 2/1/2017, but failed to provide evidence that background checks were present in the file upon hire. The human resources client manager (Staff Member #13) confirmed the finding at the time of document review.
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Based on medical record review and review of policy and procedure, the hospital failed to ensure that hospital staff monitored and documented physical needs of restrained patients every two hours as directed in the hospital's policy.

Failure to monitor restrained patients for physical needs places patients at risk for serious discomfort or harm.

Findings:

1. The hospital policy titled "Restraint or Seclusion Management" (Approved November 2016) stated in part under subsection, Patient Monitoring. . ."2. Monitor and document in Restraint Flowsheet patient physical needs (comfort, nutritional and hydration needs) every 2 hours. . ."

2. On 2/1/2017 at 2 PM, Surveyor #6 conducted a closed record review of Emergency Department patient records to review the use of restraints in the department. Two of three records reviewed were not in compliance with hospital policy regarding patient monitoring of physical needs.

a. On 12/2/2016, Patient #4 was placed in restraint/seclusion for violent behavior at 9:30 AM and remained in restraint/seclusion until 1:30 PM. During the 4 hours of restraint/seclusion, there was no documentation regarding monitoring the patient's physical needs, i.e., oral fluids, food, elimination or range of motion.

b. On 1/7/2017 at 11:14 PM, Patient #5 was placed in 4 point (all limbs) restraint for violent behavior. There was no documentation to indicate that staff offered the restrained patient oral fluids, food or elimination opportunities between 12:15 and 3:10 AM, nor between 3:25 and 6:19 AM, when they discontinued the restraints.
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Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure hospital staff members followed its policy and procedure for identification of patients prior to medication administration.

Failure to follow the hospital's patient identification process places patients at risk of receiving the wrong medication.

Findings:

1. The hospital's policy and procedure titled "Identification and Verification of Patients" (Revised June 2016) under the subsection titled "Policy Statement" read in part: "Patients must be properly identified and an identification band applied prior to any care .....Registrars and clinical staff place the armband during the registration or direct admission process using three identifiers ....Care includes specimen collection, point-of-care testing, medication administration, transfusion, treatment or any invasive procedure and all handoffs and transfers ....Any time an identification band is missing, illegible, or needs to be removed or replaced, the identification process is performed and a new band is generated, verified and placed on the patient".

The hospital's policy titled "Medication Administration Governing Policy" (Copyright 2016) under subsection "Administration" read in part: "Patient Verification: 1. Prior to administration of medications, the identity of the patient is verified using at least two different identifiers (neither may be the patient's room number)".

2. On 1/31/2017 at 11:50 AM, Surveyor #4 observed a medication pass in the special care nursery. The surveyor noted that Patient #3 had only one identification band attached to him/her and not two identification bands as required by policy. The registered nurse (Staff Member #17) attempted to scan the patient's identification band which was located on the foot of patient (Patient #3) but was unsuccessful despite several attempts. Staff Member #17 identified the patient's identification band's barcode was smeared and illegible. Staff Member #17 told Surveyor #4, "Sometimes the barcodes get moist and smudged and they won't scan, this is an issue and we have talked about it". The nurse then proceeded to pick up a patient identification band from a bedside table and scanned this band into the electronic medication record. The nurse did not verify the patient's identity with another staff member prior to administering the medication. After administering the medication, the nurse placed the unattached identification band in the blanket and wrapped the infant.

3. On 1/31/2017 immediately following the medication administration, Surveyor #4 confirmed with the process improvement, quality and trauma coordinator (Staff Member #14), the nurse had not followed the hospital's policy and procedure for patient identification prior to administering the medication.
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Based on record review and review of hospital policy and procedure, the hospital failed to ensure staff members performed blood transfusion procedures according to policy for 2 of 4 patients reviewed (Patients #1 and #2).

Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications.

Findings:

1. The hospital policy and procedure titled "Blood Management: Blood Administration (Adult)" (Approved 12/2015) under the section "Ongoing Assessment" read in part: "1. Evaluate vital signs immediately before sending for blood components (within 30 minutes of the start of transfusion), 15 minutes after start of transfusion, and at completion of transfusion. Vital signs may be completed within five minutes of scheduled time."

2. On 2/2/2017 at 10:20 AM, Surveyor #2 reviewed the records of four patients who received blood transfusions during their hospital stay and observed the following:

a. Nursing staff caring for Patient #1 failed to document a complete set of vital signs at the 15-minute block of time by not recording the temperature and respiratory rate.

b. Nursing staff caring for Patient #2 failed to document a set of vital signs prior to beginning blood administration as required by policy. The surveyor noted the last previous set of vitals were recorded over 4 hours prior to starting the blood transfusion.

3. Staff Member #14 confirmed these findings at the time of the record review.
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Based on review of hospital policy and procedure and medical record review, the staff failed to record the weight of a pediatric patient seen in the Emergency Department following a motor vehicle accident.

Failure to obtain and record pediatric patients' weight could lead to incorrect dosing of critical medications and monitoring of physiological status.

Findings:

1. The hospital policy titled "Vital Signs: Pediatric" (Approved February 2014) stated in part on page 7 of 8, "Height and Weight 1. Height and weight will be done on all patients to provide accurate BMI measurement. . ."

2. During a review of Emergency Department closed records, Surveyor #6 noted that during an admission on 1/1/2017 following a motor vehicle accident, Patient #6, a 15 year old female, did not have a weight recorded in vital signs per hospital policy.
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Based on observation, interview, and review of hospital policy and procedures, the hospital failed to ensure that medications were stored in a secure area.

Failure to secure medications from unauthorized individuals risks patient safety and potential diversion related to theft and or tampering.

Findings:

1. The hospital policy and procedure titled "Medication Administration Governing Policies" (Approved 2016) under the section "Security" read in part: "Medications are stored at all times in secured areas (e.g. locked medication room or drawers in a locked medication cart). . ."

2. On 1/31/2017 at 2:20 PM, Surveyor #5 toured the intensive care unit. One patient room was empty. It had been recently cleaned and set up, awaiting a new patient. The surveyor observed a small plastic basin on a counter, partially obscured by a pillow. The basin contained medications which were left over from the patient who had previously occupied the room (an albuterol inhaler, hydrocortisone suppositories, isotear eye solution and lacrilube eye ointments). The charge nurse, (Staff Member #1) confirmed these findings at the time of the observation.

3. On 2/1/2017 at 10:20 AM during an inspection of the perioperative services areas, Surveyor #2 observed an unattended pharmacy-prepared sterile product on the counter in the nurses' station. The sterile product was a specially prepared irrigation solution with the following medications: ropivacaine 0.5 %, ketorolac 200 mg, epinephrine 600 mg, and morphine 5 mg in a 100 ml of normal saline solution.

4. An interview with the interim director of the perioperative services (Staff Member #15) at the time of the observation confirmed that controlled substances need to be secured or observed continuously by the clinical staff.
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Item #1 Multi-Dose Vials

Based on observation and review of hospital policies and procedures, hospital staff failed to inspect all drug storage areas to prevent administration of outdated or unusable medications.

Failure to ensure medication storage areas are devoid of outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, or stability.

Findings:

1. The hospital policy and procedure titled "Medication Administration Governing Policies" (Copyright 2016) under the subsection titled "Multi-dose/single dose containers" read in part: "1. All multi-dose vial containers are used as single-dose containers. Personnel may re-use multi-dose vial containers on the same patient within the hours of the same shift. The following exceptions apply: Insulins . . . Except for insulin, these vials are not used for more than 28 days. Pharmacy staff place an expiration date on vials dispensed to the patient care area. . . 5. Regular insulin and insulin lispro (Humalog) are stocked in the clinical areas. These are checked daily by Pharmacy for expiration dates and replaced by Pharmacy as needed."

2. On 1/31/2017 at 10:35 AM in the Family Birth Center medication room, Surveyor #2 found one opened 10 ml vial of insulin lispro (Humalog) with a pharmacy date sticker discard date written "1/29/17".

3. On 2/1/2017 at 2:45 PM in the Interventional Radiology suite, Surveyor #2 found one 50 milliliter vial of 1% lidocaine, open and undated.

Item #2 Fluid Warmers

Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure that staff members labeled and appropriately monitored fluids stored in the warming cabinet.

Failure to label and monitor intravenous and irrigation fluids appropriately risks fluids being available for patient use after their maximum storage time.

Findings:

1. The hospital policy and procedure titled "Warming Devices: Intravenous Fluids, Irrigating Solutions, Blankets, Sage CHG Cloths, and Bag Bath" (Approved November 2013) under the subsection "Procedure" read in part: ". . . 4. IV's with over wrap intact may remain in the warmer for a period of no longer than 14 days. . . Rigid plastic irrigation containers may remain in the warming cabinet at 110 degrees for up to 14 days."

The subsection titled "Restocking Solutions" read in part: "1. IV and irrigation fluids are rotated during the stocking process by placing the newest items toward the back of warmer. 2. Individuals placing solutions in the warmers are responsible for affixing a label indicating the expiration date. Expired fluids are discarded."

2. On 1/31/2017 at 10:10 AM during an inspection of the Family Birth Center, Surveyor #2 observed three 1000 ml bottles of normal saline for irrigation solution with two date stickers attached. One date was labeled "In 1/27/2017" indicating the date the solution was placed in the warmer and the other sticker was labeled "2/27/2017" indicating the date the solution was to be removed and discarded if not used.

3. On 1/31/2017 at 3:00 PM, Surveyor #2 interviewed a surgical scrub technician (Staff Member #16) about the process of placing and removing intravenous and irrigating fluids stored in the warmer. Staff Member #16 confirmed the 30-day discard sticker observed was not in accordance with the hospital policy.

4. On 2/1/2017 at 7:05 AM during a tour of the perioperative areas, Surveyor #2 observed three 1000 ml intravenous (IV) bags of lactated ringers solution in the warmer with missing or unrecognizable markings to indicate when staff placed the bags in the warming cabinet or when staff should remove them. Staff Member #15 confirmed these findings at the time of the observation.
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Item #1- Hand Hygiene

Based on observation and policy review, the hospital staff failed to comply with facility policy for hand hygiene.

Failure to perform hand hygiene as directed in hospital policy puts patients, staff and visitors at risk of exposure to communicable diseases.

Findings:

1. The hospital policy titled "Hand Hygiene: Handwashing and Hand Antisepsis", (Approved 4/2012) , stated under "Routine hand hygiene", "1. Hand hygiene is mandatory for the following: a. Before and after patient contact b. Upon entering and leaving a patient room or area c. Before donning gloves, including donning gloves to enter an isolation room d. After removing gloves".

2. On 1/31/2017 at 10:13 AM, Surveyor #1 observed a daily cleaning procedure in the psychiatric unit of the hospital. The Environmental Services (EVS) staff member (Staff Member #8) did not conduct hand hygiene following glove removal between glove changes as required by hospital policy. The surveyor observed this practice four times during the cleaning procedure.

3. On 1/31/2017 at 11:00 AM, Surveyor #3 observed an EVS staff member (Staff member #5) as s/he completed cleaning a patient room on the 6th Floor. The staff member failed to perform hand hygiene after handling soiled rags that s/he had used to clean the room. The staff member also failed to perform hand hygiene prior to exiting the patient room.

4. On 1/31/2017 at 11:35 AM, Surveyor #3 observed a medical provider (Staff Member #4) as s/he entered a patient room on the 6th floor. The staff member failed to perform hand hygiene prior to entering the patient room.


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Item #2 - Transmission-Based Precautions
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Based on observation, review of policy and procedure and interview, the hospital failed to ensure that staff members wore proper personal protective equipment (PPE) when caring for patients on transmission-based precautions.
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Failure to wear proper PPE when caring for patients on transmission-based precautions placed patients and staff at risk for infection.
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Reference: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. "Part III. HICPAC Precautions to Prevent Transmission of Infectious Agents. III.B.1. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment."
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Findings:
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1. The hospital policy titled, "Droplet Precautions" (Approved 1/2013) stated in part, "Procedure: 10) To enter room: a. Put on mask ..."

2. On 1/31/2017 at 9:30 AM, Surveyor #1 conducted a tour of the intensive care unit of the hospital. During the tour, the surveyor observed a registered nurse (RN)(Staff Member #6) caring for a patient on droplet precautions. S/he was not masked while in the room as per hospital policy. The Plant Operations Manager (Staff Member #7) confirmed the observation and instructed the nurse to don proper PPE.

3. On 2/1/2017 at 12:30 PM, Surveyor #5 toured the Intermediate Care Unit. There were notices outside a patient room indicating that the patient was on Contact Precautions and Droplet Precautions. The surveyor observed a Registered Nurse (RN) (Staff Member #2) enter the room without first donning gloves, as required by Contact Isolation guidelines. An additional RN (Staff Member #3) entered the room without first donning a mask, as required by droplet isolation guidelines. .
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Item #3 - Hepatitis B Vaccination
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Based on document review, policy and procedure review, and interview, the hospital failed to ensure that staff members received a full Hepatitis B vaccination series, an antibody titer to document previous immunity, or signed a declination form at the start of employment for 1 of 10 staff members reviewed.
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Failure to ensure that staff members have received Hepatitis B vaccinations, provided documentation of immunity, or signed a declination form placed patients and staff at risk of infection.
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Reference: Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. "CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management" December 20, 2013. 62(RR10); 1-19. "Vaccination: All HCP whose work-, training-, and volunteer-related activities involve reasonably anticipated risk for exposure to blood or body fluids should be vaccinated with a complete, ?3-dose HepB vaccine series. OSHA mandates that vaccination be available for employees within 10 days of initial assignment ...HCP lacking documentation of HepB vaccination should be considered unvaccinated (when documentation for HepB vaccine doses is lacking) or incompletely vaccinated (when documentation for some HepB vaccine doses is lacking) and should receive additional doses to complete a documented HepB series ... OSHA mandates that HCP who refuse HepB vaccination sign a declination statement..."
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Findings:
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1. The hospital policy titled "Employee Health Services" (Approved 10/2013) states in part, "Addendum. Employee Health Screen and Immunization Requirements for Swedish Workforce. Hepatitis B vaccine - at-risk workforce personnel. Who Needs It? Workforce personnel who during the course of their duties can reasonably anticipate that skin, eye, mucous membrane, or parenteral (e.g. cut, needlestick) contact with blood or potentially infectious materials may result (at-risk workforce personnel). What is Needed? Documentation of Hepatitis B vaccine series or laboratory documentation of immunity; Hepatitis B vaccination is offered to all at-risk workforce personnel; Signed declination required if at-risk workforce personnel is not immune and chooses not to be vaccinated."

2. On 2/2/2017 from 11:00 to 11:45 AM, surveyor #1 conducted a review of human resources documents for ten staff members. One staff member, a medical assistant working in a clinic at the hospital (Staff Member #9), did not have documentation of 3 doses of Hepatitis B vaccine, an antibody titer to assess immunity, or a signed declination form until 2/1/2017. S/he started employment on 10/2014 and had documentation of a second dose of the vaccine prior to starting employment.

3. The surveyor interviewed the Employee Health Manager (Staff Member #10) regarding the employee's Hepatitis B vaccinations. S/he stated that the employee was certain that they had received the full series of the vaccine prior to starting employment, but the hospital was unable to verify that a third dose was received.
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