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Based on medical record review and staff interview, the facility failed to ensure that all patients being seen in the Emergency Department were questioned regarding advance directives. This affected five out of six medical records reviewed in the emergency department (Patients 9, 10, 12, 13, and 14. The current census of the emergency department was 68 patients.

Findings include:

The medical record review for Patient 9 was completed on 06/21/10. Patient 9 arrived at 1:20 AM on 06/21/10 with a history of bipolar disorder (mental health disorder in which patients can experience periods of depression and mania); Patient 9 had been off his/her medications to treat this condition. Review of the medical record lacked evidence that Patient 9 had been questioned regarding the presence of an advance directive.

The medical record review for Patient 10 was completed on 06/21/10. Patient 10 arrived at 8:37 AM on 06/21/10 with a dog bite. Review of the medical record revealed no evidence that Patient 10 had been questioned regarding the presence of an advance directive.

The medical record review for Patient 12 was completed on 06/21/10. Patient 12 arrived at 1:19 AM with a complaint of assault and trauma to the face. Review of the medical record revealed no evidence that Patient 12 had been questioned regarding the presence of an advance directive.

The medical record review for Patient 13 was completed on 06/21/10. Patient 13 arrived at 7:51 AM with suicidal and homicidal ideations. Review of the medical record revealed no evidence that Patient 13 had been questioned regarding the presence of an advance directive.

The medical record review for Patient 14 was completed on 06/21/10. Patient 14 arrived at 10:44 AM with alcohol abuse and a laceration to the head. Review of the medical record revealed no evidence that Patient 14 had been questioned regarding the presence of an advance directive.

A review of policy III-9 was completed on 06/23/10. This policy referred to advance directives and under Section D: Procedures for Recording an Advance Directives. Policy III-9 only addressed patients who have already been admitted to the hospital as an inpatient.

An interview conducted with Staff D revealed that at some point in the encounter with the patient they are asked about advance directives especially if they are admitted.

On 06/22/10 at 8:50 AM an interview was conducted with Staff C and Staff E. The current inpatient and outpatient practices regarding advance directives were discussed. From this discussion it was determined that all patients who are treated in the emergency department are not questioned regarding their advance directive status. This was confirmed at 9:00 AM.

Based on observation, interview, and clinical record review, the facility failed to provide the least restrictive restraint mechanisms for Patients 27 and 28. There were seven restrained patients on the trauma intensive care unit at the time of the survey.

Findings include:

The electronic clinical record review for Patient 28 was completed on 06/25/10. The clinical record review revealed the 61-year-old patient's care began with the facility on 06/17/10. The clinical record review revealed a history and physical electronically dated for 06/18/10 that stated the patient had three aneurysms in her brain and was admitted for a coiling procedure (inserting a very thin platinum wire via a catheter which then coils up as it enters inside the dome of an aneurysm that then causes a clot to form inside the aneurysm thereby decreasing the risk of its rupture). The clinical record review revealed the patient had been restrained with bilateral upper extremity soft wrist restraints on 06/20/10 at 10:00 P.M. and was restraint free until 06/22/10 at 10:00 A.M. The clinical record review revealed on 06/22/10 at midnight the patient was assessed as able to move all four extremities and drowsy. The clinical record review revealed a physician's order dated 06/22/10 at 10:37 A.M. for bilateral soft wrist restraints and a waist restraint. The order stated the reason for the restraints was to protect a medical device and prevent injury to self. The clinical record review revealed the patient had bilateral soft wrists restrained at 10:00 A.M. on 06/22/10. The clinical record review revealed the patient was calm and cooperative on 06/22/10 at 11:00 A.M. and 11:30 A.M. The clinical record review revealed the patient had a soft waist restraint applied (in addition to the bilateral soft wrist restraints) on 06/22/10 at 12:00 P.M. The patient was assessed as calm and cooperative. The clinical record review revealed on 06/22/10 revealed the patient was not intubated, and did not have an arterial line or a pulmonary line. The review did reveal the patient had one intravenous catheter to the left forearm. The clinical record review for 06/22/10 did not reveal where bed alarms, constant supervision, or attempts to conceal the intravenous catheter were attempted. On the morning of 06/23/10, the surveyor observed the patient to be sleeping calmly in the trauma intensive care unit and restrained with bilateral wrist restraints on the intensive care unit.

A review of the agency's "Constant Supervision Algorithm" (i.e., an algorithm to determine whether a patient needs an unlicensed caregiver, colloquially referred to as a sitter, to sit by the patient to immediately alert staff of an untoward event) revealed constant supervision can be used for falls prevention. The algorithm directed the staff to also attempt bed and chair alarms.

On 06/21/10 in the afternoon Staff K said in an interview that the hospital doesn't utilize sitters in the intensive care unit because of their expense.

On 06/23/10 at 1:00 P.M. in an interview with Staff L, he/she stated sitters could be utilized in the intensive care unit but done so infrequently because of the low nurse to patient ratios there.

On the afternoon of 06/21/10 while touring the intensive care unit, the surveyor observed Patient 27 resting quietly in his/her bed in the trauma intensive care unit, with bilateral wrist restraints applied.

The clinical record review for Patient 27 was completed on 06/25/10. The clinical record review revealed the patient's care began with the facility on 06/17/10 for surgery for adhesions and ankylosis of the temporomandibular joint. The clinical record review revealed a physician's order dated 06/20/10 at 10:09 A.M. that stated to restrain the patient with bilateral wrist restraints and mittens to protect the patient's medical devices. The clinical record review revealed a nursing note for 06/20/10 at 10:30 A.M. that indicated the patient was placed in bilateral wrist restraints only because mitts were unavailable. The clinical record review revealed a physician's order dated 06/21/10 at 6:44 A.M. that directed the staff to restrain the patient with bilateral wrist restraints and mittens to protect the patient's medical devices. The clinical record review revealed nursing documentation for 06/21/10 from 7:00 A.M. to Noon that stated the patient was in bilateral wrist restraints only.

On 06/22/10 in the afternoon in an interview, Staff L confirmed that Patient 27, on 06/20/10 and on 06/21/10 was in bilateral wrist restraints only because the mitts were not available.

Based on observations of care in the emergency department and staff interview,the facility failed to ensure that patients were receiving aseptic care in the emergency department. This was observed with Patients 62 and 63. The emergency department census was 68 at the time of the observations.
Findings include:
On 06/21/10 at 2:15 PM Staff G was observed during the start of an intravenous line on Patient 62. Staff G cleansed the skin of Patient 62's arm with an alcohol prep pad and then proceeded to dry the area by using his/her hand in a sweeping motion over the site, thereby possibly further contaminating the site that was cleansed with the alcohol.
On 06/22/10 at 9:30 AM Staff F was observed during the administration of a narcotic medication for pain and a medication to treat nausea for Patient 63. Staff F cleansed the intravenous tubing port with an alcohol prep pad and then proceeded to dry the port on the tubing by using his/her hand in a sweeping motion over site, thereby possibly further contaminating the port after it was cleaned with the alcohol.
This was confirmed with Staff A, C, and D on 06/22/10 at 10:25 AM.

Based on observation, interview, clinical record review, and policy review, the facility failed to follow its sedation protocol for Patient 25, and provide anti-hypertensive medication as ordered to Patient 26. This affected two of the 23 patients on the trauma intensive care unit. A total of 61 clinical records were reviewed.

Findings:

The clinical record review for Patient 25 was completed on 06/25/10. The clinical record review revealed the 53-year-old's care began at the facility on 06/16/10 to have surgery on his/her cervical spine to relieve neck pain and the difficulty of lifting the right arm. On the afternoon of 06/21/10 the surveyor observed the patient in the trauma intensive care unit with Diprovan, Fentanyl, and Versed-all agents of anesthesia-and on a respiratory ventilator. The clinical record review revealed a physician's order dated 06/18/10 at 5:47 A.M. for Diprovan to be given at an initial dose of 10 mcg/kg/min and to titrate per sedation protocol. The clinical record review revealed the patient on 06/18/10 from 9:00 P.M. to 1:00 A.M. (06/19/10) was receiving the medication at 15 mcg/kg/min. The clinical record review revealed on 06/19/10 at 01:15 A.M. the patient's dose was increased to 28 mcg/kg/hour for increased agitation.

A review of the hospital's sedation management plan was completed on 06/25/10. The plan stated to do a trial sedation reduction, to reduce sedation by one-half of the current infusion. The plan stated if the patient begins to become agitated after the attempt, to provide the patient with a bolus and resume the infusion at one-half the dose administered before reduction.

On 06/23/10 at 9:00 A.M. in an interview, Staff O stated that prior to the Diprovan running at 15 mcg/kg/min on 06/18/10, it had been infusing at 30 mcg/kg/min. She said it had been cut in half because the patient had been calm and the nurse wanted to determine if he could tolerate a lesser dose. She said the dosage should have been placed back to 30 mcg/kg/hour when it was determined 15 mcg was not effective.

On 06/23/10 at 9:00 A.M. in an interview, Staff L stated that he/she believed the nurse did bolus the patient with Diprovan prior to increasing the dosage from 15 mcg/kg/min to 28 mcg/kg/hour, but that the electronic chart does not allow the nursing staff to enter a bolus onto the electronic medication administration record.

The clinical record review for Patient 26 was completed on 06/25/10. The clinical record review revealed the 64-year-old patient was admitted to the facility on 05/24/10 after a traffic accident that caused a splenic laceration, fluid around the aorta, and left iliopsoas (a muscle used to flex the leg) hematoma. The clinical record review revealed a physician's order dated 06/11/10 to give the patient five milligrams of lopressor (an antihypertensive agent) every six hours, intravenously. The clinical record review revealed an electronic medication administration record for 06/20/10 that revealed the medication was given at midnight, 3:00 A.M., 6:00 A.M., 2:00 P.M., and 6:00 P.M. On 06/21/10 at 2:30 P.M. in an interview, Staff L confirmed the documentation that the patient was given the medication at the documented times.

Based on observation on tour and interview with hospital staff it was determined the facility failed to ensure all medications in the operating rooms are kept in a secure area unavailable to unauthorized staff including housekeeping staff. This affects all operating room staff in the main hospital and the ambulatory surgical center.

Findings include:

Tour of the offsite ambulatory surgical center was conducted on 06/24/10 at 9:30 AM. The ambulatory surgical center had four operating rooms each found with an open container holding multiple vials of unused medications. Interview with Staff H during the tour at 9:55 AM revealed the vials of medication were being collected in the open container for future disposal in accordance with EPA (Environmental Protection Agency) standards. Staff H reported that none of the medications were narcotics but others included Lidocaine and Proprofol. The ambulatory surgical center employs 24 non-physician staff and 5 housekeeping staff.

Interview with Staff I and J on 06/25/10 at 9:20 AM revealed all 20 of the operating room suites at the main hospital contained a similar open container collecting unused medications. Staff J confirmed none of the collected medications were narcotics but did include Lidocaine and Proprofol. The main hospital surgery department employs 60 non-physician staff and 12 housekeeping staff.

Based upon observations during the Life Safety Code tour of the hospital on June 21, 2010 through June 25, 2010 and interview with staff, the hospital did not meet all the requirements of the 2000 Life Safety Code of the National Fire Protection Association.

Findings include:

Please refer to A 710.

1. Fire barrier between nonconforming buildings have penetrations
2. No flame spread ratings for carpeting
3. Penetrations in smoke partitions
4. Corridor doors not latching
5. Devices holding smoke barrier doors in open position
6. Penetration in smoke barriers
7. Penetrations in Hazardous areas
8. Door in smoke barrier need to be on a self closer and fire rated
9. Horizontal exit doors lack rating
10. Egress lights not working
11. Emergency battery lights checked monthly and annually
12. No smoke detector sensitivity testing
13. Sprinkler heads dirty and no quarterly sprinkler testing
14. Soiled linen and trash receptacle storage
15. Medical gas storage light switch not located at least 5 foot from floor
16. *Smoke detectors located where air flow may obstruct their normal operation
17. Generators inspected weekly and load tested monthly
18. Alcohol Based Hand Rub's located over carpeting

Based on tour of the emergency department and staff interview, the facility failed to ensure that all treatment areas were sanitary. This was observed in rooms 2, 9, 29, and 36. The emergency department census was 68 at the time of the observations.

Findings include:

An observation was completed in the Emergency Department on 06/21/10 and 06/22/10. During these observations it was noted there was dirt on all floors in treatment rooms 2, 9, 29, and 36 which were occupied by patients. It was also noted that the cabinet in room 9 had a brown substance dried on the cabinets. This was confirmed with Staff A, C, and D on 06/22/10 at 10:25 AM.

Based upon observations during the Life Safety Code tour of the hospital on June 21, 2010 through June 25, 2010 and interview with staff, the hospital did not meet all the requirements of the 2000 Life Safety Code of the National Fire Protection Association.

Findings include:

Refer to the Life Safety Code Survey Report Form.

Deficiencies were issued at K-11 (Fire barrier between nonconforming buildings have penetrations), K-15 (No flame spread ratings for carpeting), K-17 (Penetrations in smoke partitions), K-18 (Corridor doors not latching), K-21 (Devices holding smoke barrier doors in open position), K-25 (Penetration in smoke barriers), K-29 (Penetrations in Hazardous areas), K-27 (Door in smoke barrier need to be on a self closer and fire rated), K-44 (Horizontal exit doors lack rating), K-45 (Egress lights not working), K-46 (Emergency battery lights checked monthly and annually), K-54 (No smoke detector sensitivity testing), K-62 (Sprinkler heads dirty and no quarterly sprinkler testing), K75 (Soiled linen and trash receptacle storage), K-76 (Medical gas storage light switch not located at least 5 foot from floor), K-130 (*Smoke detectors located where air flow may obstruct their normal operation ) K-144 (Generators inspected weekly and load tested monthly), and K-211 (Alcohol Based Hand Rub's located over carpeting).