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Based on policy review, review of a contracted services agreement, observations, and interviews, the facility failed to provide contracted dialysis services in a safe manner and in accordance with facility policies for 1 of 1 dialysis units at Facility A.

Refer to A 0084

Based on policy review, review of a contracted services agreement, observations, and interviews, the facility failed to provide dialysis services in accordance with facility policies for 1 of 1 dialysis units at Facility A.

The findings included:

Review of facility policy "Carbon Filtration Monitoring for Central Water Systems" dated 6/19/13 revealed "...Total chlorine testing will be the only methodology used to ensure the carbon filters are reducing total chlorine levels below the [dialysis provider] action levels of 0.01 ppm [parts per million]...[dialysis provider] staff performing total chlorine testing must have documented evidence of satisfactory knowledge and skills. Training will include return demonstration of total chlorine testing...What to test...Worker Carbon Filter...When to test...Prior to initiation of the first patient treatment of the day and at a minimum of every four hours...Where to test...From a sample port located between the worker carbon filter(s) and polisher filter..."

Review of a contract agreement "IN-HOSPITAL DIALYSIS AND APHERESIS SERVICES AGREEMENT" effective date 6/12/17 revealed "...PROVIDER shall provide dialysis and/or apheresis treatments to HOSPITAL's Patients in the HOSPITAL setting...PROVIDER shall provide...portable water treatment and ancillary equipment...The services shall be performed by non-physician employees or contractors of PROVIDER, all of whom shall be either duly licensed and qualified nurses or qualified technicians...All Provider Staff performing services at HOSPITAL will have current competency record..."

Observations with the Director of Operations on 8/14/17 at 2:00 PM, of the dialysis water treatment room at Facility A, revealed he obtained the water sample to be tested for chlorine from the front of the Reverse Osmosis (RO) filter, which is located at the end of the water treatment process. Further observation revealed a water sample valve labeled "SP" (sample port) 1 located between the first and second carbon filter.

Interview with the Director of Operations 8/14/17 at 2:00 PM, in the water treatment rom, revealed the water was not tested from the SP1 sample valve between the first and second carbon filters and stated he obtained the sample for testing from the RO valve.

Observation with Registered Nurse (RN) #2 on 8/14/17 at 2:10 PM, of the water treatment room at Facility A, revealed the RN obtained the water sample to be tested for chlorine from the front of the Reverse Osmosis (RO) filter, which is located at the end of the water treatment process. Further observation revealed a water sample valve labeled SP (sample port) 1 located between the first and second carbon filter.

Interview with the Director of Operations, in the Dialysis Unit, on 8/14/17 at 2:30 PM, confirmed the correct valve for obtaining a water sample for total chlorine testing was at the SP1 valve located between the first and second carbon filters. Further interview with the Director confirmed the RO valve was not the correct location for obtaining the water sample.

Interview with the Dialysis Inpatient Program Manager (DIPM) on 8/16/17 at 10:45 AM, in the dialysis water treatment room, confirmed the correct location for obtaining water samples for total chlorine testing is the SP1 valve located between the first and second carbon filters and the facility failed to follow facility policy.

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Based on review of facility policy, medical record review, and interview, the facility failed to ensure physician's orders were timed and dated for 1 patients (#2) of 60 medical records reviewed.

The findings included:

Review of facility policy "Medication Orders" dated 6/7/17 revealed "...date and time the order..."

Medical record review revealed Patient #2 was admitted to Facility A on 8/14/17 for a Suicide Attempt.

Medical record review revealed a physician's order for a Glucagon Drip (medication used to treat low blood sugar). Continued review revealed the order was not timed or dated.

Interview with Registered Nurse (RN) #1 on 8/14/17 at 11:25 AM, in the Intensive Care Unit (ICU) at Facility A, confirmed the orders were to be dated and timed.

Based on facility policy review, medical record review, and interview, the facility failed to ensure the Conditions of Admission and Consent to Medical Treatment form was signed prior to treatments, procedures, and medications for 14 newborns (#32, #39, #40, #41, #42, #43, #47, #52, #53, #54, #55, #56, #58, and #59) of 18 newborn records reviewed.

The findings included:

Review of facility policy revealed "Inpatient Admission Process" dated 11/1/05 revealed "...minimum standard procedures...for registering patients...required forms...Conditions of Admission and Consent to Medical Treatment...a consent form should be signed for a newborn..."

Medical record review for Patient #32 revealed the infant was born on 8/13/17 at 12:35 PM at Facility A. Continued review revealed the following medications were administered at 2:33 PM:
* Phytonadione (Vitamin K Injection) 1 milligram (mg) Intramuscular (IM)
* Erythromycin (antibiotic)
Further review revealed on 8/14/17 at 2:57 PM a Total and Direct Bilirubin (blood test used to screen for liver disorders) was drawn. Continued review revealed on 8/15/17 at 2:32 AM a Total and Direct Bilirubin blood test was drawn.

Medical record review on 8/15/17 at 10:56 AM revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment had not been signed (34 hours after the baby was born).

Medical record review for Patient #39 revealed the infant was born on 8/14/17 at 3:36 PM at Facility A. Further review revealed at 4:24 PM an Arterial Blood Gas (ABG) (blood test which measures the levels of oxygen and carbon dioxide in the blood to determine how well the lungs are working) was drawn. Further review revealed at 4:32 PM Cord Blood (done to evaluate a newborn's health) laboratory test was drawn. Continued review revealed the following medications were administered at 4:54 PM:
* Phytonadione 1 mg IM
* Erythromycin ophthalmic ointment

Medical record review on 8/15/17 at 2:00 PM, revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment was signed on 8/15/17 at 12:00 PM (21 hours after the baby was born).

Medical record review for Patient #40 revealed the infant was born on 8/14/17 at 6:22 AM at Facility A. Continued review revealed at 6:22 AM a Cord Blood and a Total Bilirubin laboratory tests were drawn. Further review revealed at 6:25 AM, a Urine Drug Screen was completed. Continued review revealed the following medications were administered at 7:52 AM:
* Phytonadione 1 mg IM
* Erythromycin
Further review revealed on 8/14/17 at 8:31 AM, 10:54 AM, 3:52 PM, 10:57 PM, and on 8/15/17 at 3:14 AM, blood glucose tests were drawn on Patient #40.

Medical record review on 8/15/17 at 2:08 PM, revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment was signed on 8/15/17 at 11:26 AM (29 hours after the baby was born).

Medical record review for Patient #41 revealed the infant was born on 8/14/17 at 5:31 PM at Facility A. Continued review revealed at 8:16 PM the following medications were administered:
* Phytonadione 1 mg IM
* Erythromycin ointment

Medical record review on 8/15/17 at 2:15 PM revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment was signed on 8/15/17 at 12:10 PM (18 and 1/2 hours after the baby was born).

Medical record review for Patient #42 revealed the infant was born on 8/13/17 at 1:22 PM at Facility A. Further review revealed a Total Bilirubin laboratory test was drawn at 2:05 PM. Continued review revealed on 8/15/17 at 8:39 AM a Total and Direct Bilirubin laboratory test was drawn. Further review revealed the following medications were administered at 3:50 PM:
* Phytonadione 1 mg IM
* Erythromycin ophthalmic ointment

Medical record review on 8/15/17 at 2:22 PM revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment was signed on 8/15/17 at 1:00 PM (23 hours after the baby was born).

Observation and interview with Registered Nurse (RN) #6 on 8/15/17 at 2:30 PM, in the Labor and Delivery (L&D) nurses' station at Facility A, revealed the RN was signing, dating, and timing the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment for Patient #42. Interview with RN #6 confirmed she was signing, dating, and timing the form at the nurses' station and she did not follow the process to obtain the consent at the bedside when the parent's signature was obtained.

Medical record review for Patient #43 revealed the infant was born on 8/13/17 at 9:18 PM at Facility A. Further review revealed on 8/13/17 at 9:18 PM a cord blood laboratory test was drawn. Continued review revealed the following medications were administered at 11:17 PM:
* Phytonadione 1 mg IM
* Erythromycin ophthalmic ointment
Further review revealed on 8/13/17 at 11:56 PM, on 8/14/17 at 2:11 AM, at 5:23 AM, and 7:08 AM blood glucose tests were drawn on Patient #43. Continued review revealed on 8/14/17 at 10:20 PM a Total and Direct Bilirubin laboratory test was drawn.

Medical record review on 8/15/17 at 2:53 PM revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment was signed on 8/15/17 at 9:37 AM (36 hours after the baby was born).

Medical record review for Patient #47 revealed the infant was born on 8/12/17 at 6:45 PM at Facility B. Further review revealed the patient had laboratory tests on 8/13/17, 8/15/17, and 8/16/17 for Phenylketonuria (PKU test used to check for decreased metabolism of the amino acid phenylalanine). Further review revealed on 8/12/17 at 8:00 PM the patient was administered Erythromycin Eye Drops, Vitamin K injection.

Medical record review on 8/16/17 at 12:35 PM revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment had not been signed for the patient (3 days after the baby was born).

Medical record review for Patient #52 revealed the infant was born on 6/13/17 at 8:30 AM at Facility A. Continued review revealed the following medications were administered at 10:20 AM:
* Phytonadione 1 mg IM
* Erythromycin ophthalmic ointment
Further review revealed the following laboratory tests were drawn:
* Cord Blood on 6/13/17 at 8:30 AM
* Total and Direct Bilirubin, Complete Blood Count (CBC), and Reticulocyte Count (blood test to measure how fast red blood cells are released) on 6/13/17 at 12:00 PM
* Total and Direct Bilirubin, CBC, Reticulocyte Count, and PKU on 6/14/17 at 9:25 AM
* Total and Direct Bilirubin, CBC, and Reticulocyte Count on 6/15/17 at 9:30 AM

Medical record review on 8/16/17 at 12:35 PM revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment had not been signed for the patient (76 hours after the baby was born).

Medical record review for Patient #53 revealed the infant was born on 1/20/17 at 1:51 PM at Facility A. Continued review revealed the infant was 34 and 6/7 weeks gestation with Trisomy 21 (Downs Syndrome) and transferred to the Neonatal Intensive Care Unit (NICU) at 2:40 PM. Further review revealed medications, Intravenous (IV) fluids, Total Parenteral Nutrition (TPN, feeding that bypasses the gastrointestinal tract), Tube Feeding (TF, feeding into stomach or small intestine), oxygen, and diagnostic testing were performed during the admission.

Medical record review on 8/16/17 at 12:40 PM revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment was signed on 1/26/17 at 2:30 PM (6 days after the baby was born).

Medical record review for Patient #54 revealed the infant was born on 3/24/17 at 10:24 PM at Facility A. Continued review revealed the following medications were administered at 11:17 PM:
* Phytonadione 1 mg IM
Further review revealed at 10:24 PM, Cord Blood, and at 11:30 PM, a Total Direct Bilirubin laboratory tests were drawn. Continued review revealed on 3/26/17 at 11:30 AM and 11:15 PM, a Total Direct Bilirubin laboratory test was drawn on Patient #54.

Medical record review on 8/16/17 at 12:45 PM revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment was signed on 3/27/17 at 1:40 PM (2 days and 15 1/2 hours after the baby was born).

Medical record review for Patient #55 revealed the infant was born on 4/12/17 at 3:33 PM at Facility A. Continued review revealed the following medications were administered at 4:13 PM:
* Phytonadione 1 mg IM
* Erythromycin ophthalmic ointment
Further review revealed on 4/13/17 at 4:40 PM a PKU and Total and Direct Bilirubin laboratory tests were drawn.

Medical record review on 8/16/17 at 12:50 PM revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment was signed on 4/14/17 at 10:45 AM (43 hours and 12 minutes after the baby was born).

Medical record review for Patient #56 revealed the infant was born on 2/23/17 at 1:06 PM at Facility A. Continued review revealed the following medications were administered at 1:12 PM:
* Phytonadione 1 mg IM
* Erythromycin ointment
Further review revealed at 2:15 PM a Total and Direct Bilirubin, and at 2:50 PM an ABO (blood group system) and Direct Coombs (test to confirm antibodies attached to the infant's red blood cells) laboratory test was drawn. Continued review revealed on 2/25/17 at 7:40 AM a Total and Direct Bilirubin laboratory test was drawn.

Medical record review on 8/16/17 at 12:56 PM revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment was not signed for the infant (5 months and 24 days after the baby was born).

Medical record review for Patient #58 revealed the infant was born on 7/17/17 at 12:41 PM at Facility A. Further review revealed at 1:00 PM an ABO and Direct Coombs laboratory test was drawn. Continued review revealed on 7/18/17 at 2:25 PM a PKU laboratory test was drawn. Further review revealed the following medications were administered:
* Phytonadione 1 mg IM at 2:30 PM on 7/17/17
* Erythromycin ophthalmic ointment at 6:28 PM on 7/17/17

Medical record review on 8/16/17 at 1:07 PM revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment was signed on 7/21/17 at 11:41 AM (3 days and 23 hours after the baby was born).

Medical record review for Patient #59 revealed the infant was born on 8/13/17 at 4:22 AM at Facility A. Further review revealed on 8/14/17 at 4:22 AM a Total and Direct Bilirubin laboratory test was drawn. Continued review revealed on 8/15/17 at 8:25 AM a Total Bilirubin laboratory test was drawn. Further review revealed the following medications were administrated at 6:42 AM:
* Phytonadione 1 mg IM
* Erythromycin ophthalmic ointment

Medical record review on 8/16/17 at 1:15 PM revealed the Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment was signed on 8/14/17 at 12:12 PM (31 hours and 50 minutes after the baby was born).

Interview with Nurse Leader #6, Quality Coordinator #1, and RN #6 on 8/15/17 at 11:15 AM, in Facility A L&D nurses' station, confirmed the facility failed to ensure consent for Inpatient/Outpatient Conditions of Admission and Consent to Medical Treatment was signed, dated, and timed prior to treatment and failed to follow facility policy.

Interview with RN #3 on 8/15/17 at 3:50 PM, in Facility B's Labor and Delivery nurses' station, confirmed there was no signed consent for treatment form in the medical record for Patient #47.

Interview with the Metro Chief Quality Officer on 8/16/17 at 12:56 PM, in Facility A Conference Room, confirmed the facility failed to follow facility policy.

Based on facility policy review, review of facility document, medical record review, observation, and interview, the facility failed to ensure intravenous sites (IV) were timed and dated when inserted for 3 patients (#23, #25, #37) of 4 patients observed with peripheral IV's; failed to ensure expired patient care supplies were not available for patient use in 2 of 3 Emergency Departments (ED), in 1 of 2 Special Care Nurseries observed, in 6 of 45 clean supply storage areas observed, and 1 of 2 Post-Operative Care Units (PACU); failed to maintain a sanitary environment in 1 of 4 laboratories observed; and failed to ensure expired medications were not available for patient use in 2 of 22 medication storage areas observed.

The findings included:

Review of a facility policy "Nursing Procedures" dated 6/2/16 revealed "...Refer to Mosby's [medical textbook] and/or AACN [American Association of Critical-Care Nurses] for procedures (ex [example] IV Therapy)..."

Review of facility policy "Stock Rotation and Expiration Policy" dated 3/9/17 revealed "...Expired products and devices shall not be made available for patient use...Expiration dates must be monitored on a regular basis...special attention must be given to expiration dates...the expiration dates of products and devices shall be checked during the routine review of area inspections and all products and devices scheduled to expire during the next month shall be removed...each department manager should conduct a quarterly review of supplies checking for expired or close dates..."

Review of facility document "Elsevier Performance Manager" (healthcare education and learning management system), with no date, revealed "...label the dressing...with the date and time of application and the nurse's initials...Rational: A label provides immediate access to data regarding when the IV catheter was inserted and when to change the dressing and rotate the site...inspect the color of the insertion site and check for swelling...unexpected outcomes...bleeding at venipuncture site..."

Medical record review revealed Patient #25 was admitted to Facility A on 8/13/17 for Left Sided Weakness.

Observation and interview with Registered Nurse (RN) #4, on 8/14/17 at 1:13 PM, in the Neurosurgical Intensive Care Unit (ICU), revealed an Intravenous (IV) line in the left forearm. Continued review revealed the IV site was not dated, timed, or initialed by the staff member who inserted the IV. Interview with RN #4 confirmed the IV should have been dated, timed, and initialed with the insertion date.

Medical record review revealed Patient #23 was admitted to Facility A on 8/11/17 for Chest Pain.

Observation and interview with Nurse Leader (NL) #1 of Patient #23 on 8/14/17 at 2:18 PM, in the patient's room, revealed the patient had an IV line in the right forearm. Continued observation revealed the IV site was not dated, timed, or initialed by staff member who inserted the IV. Interview with NL #1 confirmed the site was not dated, timed, or initialed when inserted.

Medical record review revealed Patient #37 was admitted to Facility A on 8/15/17 for a Right Partial Knee Replacement.

Observation of Patient #37 on 8/15/17 at 2:09 PM, in the patient's room, revealed the patient had an IV in the left hand. Continued observation revealed the IV was not dated, timed, or initialed by the staff member who inserted the IV. Interview with NL #5 on 8/15/17 at 2:15 PM, at the nurses' station, confirmed the IV should be dated, timed, and initialed upon insertion.

Observation and interview with the Emergency Department (ED) Director on 8/14/17 at 11:13 AM, in the ED clean utility room at Facility A, revealed 5 blue top vacutainers (used to collect blood) and one blood culture specimen bottle with an expiration date of 6/30/17. Interview with the ED Director confirmed the vacutainers and blood culture bottle were expired and were available for patient use.

Observation and interview with the Special Care Nursery NL on 8/14/17 at 11:15 AM, of a supply storage area in the Special Care Nursery at Facility A, revealed 3 Special Needs Feeders (bottle and nipple use for infants with impaired sucking ability) with an expiration date of 1/2017. Interview with the NL confirmed the special needs feeders were expired and were available for patient use.

Observation and interview with the Laboratory Director at Facility A, on 8/14/17 at 1:25 PM, in the microbiology lab, revealed an air conditioner vent with a buildup of white debris. Continued observation revealed a fan was positioned in front of the air conditioning unit and was blowing air toward the microbiology table. Further observation revealed a laboratory technician was seated at the table processing microbiology specimens. Interview with the Laboratory Director confirmed the debris was able to be removed with tissue paper and she was not aware of when the air conditioning vent was last cleaned.

Observation and interview with the Risk Manager (RM) and NL #1 on 8/14/17 at 1:58 PM at Facility A, in the Neuro ICU Clean Supply room, revealed a 18 french (Fr) 30 cubic centimeter (cc) (size of the catheter and balloon) catheter with an expiration date of May 2015 and a 22 Fr 30 cc catheter with an expiration date of September 2015. Interview with the RM and NL #1 confirmed the items were expired and were available for patient use.

Observation and interview with the Director of Operations for Inpatient Services for the Dialysis department at Facility A on 8/14/17 at 2:30 PM, in the Dialysis department, revealed the following: 1 package of five electrodes with an expiration date of 2/2017and 1 package of five electrodes with an expiration date of 11/2016. Interview with the Director of Operations confirmed the electrodes were expired and were available for patient use.

Observation and interview with Chief Nursing Officer (CNO) #1 and NL #3 on 8/15/17 at 9:34 AM, in ED room #4 at Facility C, revealed the following items were stored in a cabinet under the sink: a call light, an oxygen flow meter, a suction meter and tubing, a suction tube, patient belongings bags, and handy wipes. Further observation revealed a sign under the sink stated "nothing under the sink." Interview with CNO #1 and NL #3 confirmed the items were not to be placed under the sink.

Observation and interview with the ED NL on 8/15/17 at 10:00 AM, of the ED medication room at Facility C, revealed 1 bottle of urinalysis dipsticks with an expiration date of 4/2016 and 1 box of Silver Nitrate Applicators (used to stop bleeding or prevent a wound from becoming infected) with an expiration date of 6/2017. Interview with the ED NL confirmed the supplies were expired and were available for patient use.

Observation and interview with the ED NL on 8/15/17 at 10:30 AM at Facility C, of the Neonatal (Infant) Resuscitation Cart revealed:
*14 green top lab specimen tubes with expiration date of 12/2016
*5 green top lab specimen tubes with expiration date of 5/2017
*2 vacutainers (used to draw blood) with expiration date of 11/2015
*1 Umbilical Venous Catheter (catheter placed in the vein of the umbilical cord to
administer IV fluids) with an expiration date of 2/2015.
Interview with the ED NL confirmed the supplies were expired and were available for patient use.

Observation and interview with the Assistant Chief Nursing Officer (ACNO) and the Infection Control Preventionist (ICP) #1, on 8/15/17 at 12:58 PM, in the Intensive Care Unit (ICU) Medication Storage Area at Facility C, revealed the following: one 500 milliliter (ml) bag of 5% (percent) Dextrose (IV sugar solution) with an expiration date of 5/2016; 49 Hemoccult cards (device to test for blood in stool) with an expiration date of 1/31/17. Interview with the ACNO #1 and ICP #1 confirmed the supplies were expired and were available for patient use.

Observation and interview with the ACNO #1 and the ICP #1 on 8/15/17 at 1:25 PM, in the Neuro Step Down Unit Medication Storage Area at Facility C, revealed 3 bags of 1000 ml 5% Dextrose solution with an expiration date of December 2016; 1 bag of 1000 ml of Dextrose solution with an expiration date of November 2016; and 1 1000 ml bag of 5% Dextrose with an expiration date of February 2017. Interview with ACNO #1 and ICP #1 confirmed the items were expired and were available for patient use.

Observation and interview with ACON #1, ICP #1, and the Director of Surgical Services (DSS) on 8/15/17 at 1:57 PM, in the PACU Clean Storage Room at Facility C, 2 Stockinettes (supplies used to isolate limbs during surgery) with an expiration date of June 2017; 2 Pressure Monitoring Sets (single-use kits that relay blood pressure information from a pressure monitoring catheter to a patient monitoring system) with an expiration date of 1/23/16; and 2 Pressure Monitoring Sets with an expiration date of 8/9/17. Interview with the ICP #1 and the DSS confirmed the items were expired and were available for patient use.

Observation and interview with the DSS on 8/15/17 at 2:05 PM, in the PACU at Facility C, revealed 20 culture swabs with an expiration date of 11/2015. Interview with the DSS confirmed the culture swabs were expired and were available for patient use.

Observation and interview with ACON #1, ICP #1 and the DSS on 8/15/17 at 2:20 PM, in the Gastroenterology Lab hallway at Facility C, revealed a storage cart with a specimen cup of Formalin solution (fixative solution for biopsy tissue) with an expiration date of March 2017. Interview with ACON #1, ICP #1 and the DDS confirmed the solution was expired and was available for patient use.