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Based on record review, interviews and review of the facility's policies and procedure it was determined that the Registered Nurse failed to evaluate and supervise care for two (#1, #20) of thirty one records reviewed. This practice does not provide for safe nursing care and does not ensure patient goals are met.

Findings include:

1. Review of the medical record for patient #1 showed that the patient was admitted on 8/19/10 for abdominal pain. Review of the admitting orders revealed an order for an NGT (Nasogastric Tube) to LIS (Low Intermittent Suction). The emergency room documentation revealed the NGT was inserted prior to transfer of the patient to the nursing unit. Nursing documentation revealed the patient arrived to the room on 8/19/10 at 7:15 p.m. with an NGT in place and clamped. Documentation at 9:00 p.m. revealed the NGT was clamped. Review of the nursing shift assessment on 8/20/10 at 7:46 a.m. revealed the NGT was clamped. Nursing documentation revealed the NGT was to LIS on 8/20/10 at 4:00 p.m. Interview with the director of patient care services on 8/23/10 at 1:30 p.m. confirmed the nursing order was not followed per physician orders.
2. Review of the medical record for patient #20 revealed the patient was admitted on 8/23/10 for a cesarean section. Review of the physician orders revealed an order on 8/23/10 for Percocet (5/325) 1-2 tabs by mouth every 4 hours as needed for pain. Review of the MAR (Medication Administration Record) revealed the patient was medicated on 8/24/10 at 5:20 a.m. for incisional pain of 4 on a scale of 1-10. Nursing documentation revealed the patient was reassessed at 8:00 a.m. with a stated pain level of 0. Review of the facility's policy, "Pain Management", states the effect of pain management interventions will be assessed following the intervention. The patient's response to the pain medication was not reassessed for more than two and a half hours after the pain intervention. Interview with the RN caring for the patient confirmed the patient should be reassessed within one hour following administration of the pain medication to assess the effectiveness of the intervention.

Based on interview and record review it was determined the facility failed to ensure that the nursing staff developed and kept current a nursing care plan for one (#18) of thirty one patients sampled. This practice does not provide for safe nursing care and does not ensure patient goals are met.

Findings include:

Review of patient #18's medical record revealed the patient was admitted on 8/20/10 for a total knee replacement. Review of the nursing admitting assessment revealed the patient was identified as a fall risk. The patient's plan of care was reviewed. The plan of care was initiated on 8/20/10 and fall risk was not identified. There were no interventions or goals documented by nursing. This does not ensure safe nursing care and does not ensure the patient goals are met.

Based on record review and interview it was determined that the medication administration order was not administered in accordance with the physicians orders for one (#3) of thirty one patients sampled. This practice does not promote for the safe administration of medications.

Findings include:

Review of the medical record for patient #3 revealed the patient was admitted on 8/16/10 with progressive numbness to his/her body and to rule out Guillain-Barre syndrome. Review of the physicians orders revealed on 8/16/10 an order for Levaquin 500 mg IV (Intravenous) daily. The MAR (Medication Administration Record) was reviewed for 8/16/10 to 8/22/10. Review of the MAR revealed the patient did not receive the Levaquin on 8/17/10. There was no documentation why the medication was not given. Interview with the director of patient care services on 8/23/10 at 2:15 p.m. confirmed the medication was not given as ordered by the physician.

Based on observation, interview and record review the facility failed to administer medications in accordance with the approved medical staff policies and procedures to meet drug labeling requirements.
1. On 8/23/2010 at 10:20 am during tour of the CVICU (Cardiovascular Intensive Care Unit), located in the medication room refrigerator inside a bin marked room 255 was an open vial of Cardizem 25 mg/5 ml for IV (Intravenous) use. The open vial was noted to have medication remaining in the vial with no open date on it. Inspection of the vial revealed it was a single use vial. Interview with the charge nurse, at the time of the tour, confirmed the vial was single use and should have been disposed of after one use.
2. On 8/23/2010 at 12:30 pm accompanied by the unit nurse manager and the Director of Emergency services during tour of 5 South, trauma and medical/surgical unit, an observation was made in the medication room of an open Morphine vial. During an interview with the nurse manager at 1:30 p.m., it was confirmed that the Morphine vial did contain medication, was not labeled with the patients name and should have been locked up or wasted by the nurse.
3. On 8/23/2010 at 2:20 pm during tour of the Anesthesia Work room the medication refrigerator was found containing a Biohazard Plastic bag with a 10ml vial of Sodium Chloride 0.9% for Injection and a 1 ml Phenylephrine HCl vial. Both vials had broken seals that indicated they had been opened and they also had remaining medication in them. They did not contain an open date or an expiration date upon opening which resulted in the inability to determine how long they had been opened and stored in the refrigerator.
4. On 8/23/2010 at 4:00 pm during tour of the Emergency Room the medication refrigerator in the Critical Care A room contained one opened multi-dose Novolog Insulin vial without an open date on it. Interview with the charge nurse confirmed this multi-dose vial should have been dated as the policy was to label with the opened date and then proceeded to remove the vial from the refrigerator.
5. On 8/23/2010 at 4:20 pm, accompanied by the Director of Pharmacy and the Compliance Coordinator, during tour of the Fast Track Area, the medication refrigerator was found containing three opened multi-dose vials of Novolin-R Insulin without labeling of an open date. Interview with charge nurse confirmed these vials should have been dated upon opening and proceeded to remove them from the refrigerator.
6. A tour of the Joint/Spine Unit was conducted on 8/24/10 at 9:40 a.m. Located in the medication room refrigerator was an open vial of Novolin R Insulin. The vial contained no indication of the date or time the vial was opened. Review of the facility's policy, "Use of Multi dose Vials", states the vial should be labeled with the expiration date upon opening. Interview with the nurse manager, at the time of the tour, confirmed the vial should be dated when opened.
7. On 8/25/10 at 1:35 pm a review of the facility's Policy and Procedures for Use of Multi Dose Vials (Clinical Practice Structure Standards 9.01) indicated that the normal precautions for use of multi-dose vials is that the vials be labeled with an expiration date upon opening and that the expiration date for multi dose vials will be 28 days from the time the vial is open.
8. On 8/23/2010 at 2:50 pm accompanied by the Director of Pharmacy and the Nurse Manager of Surgical Services during tour of the Operating Room Area, a medication cart in a clean operating room (#2) was found that contained six (6) syringes with pre-drawn medications that were not properly labeled according to facility's policies and procedures. Each syringe at time of finding contained only a pre printed medication stick on label that identified the name of the drug with black marker writing on each sticker that was illegible and smeared. The staff present at the time of finding was not able to identify the written contents on the labels nor were initials or expiration date found to identify the medical staff who prepared the syringes or the expiration dates of these solutions.
9. On 8/23/2010 at 2:53 pm during interview of the Certified Registered Nurse Anesthetist who came to remove the syringes from the medication cart in presence of the surveyor and medical staff, shortly after finding, it was confirmed that she had not discarded the solutions after the end of the procedure stating "she was just coming back to remove them and did not write an expiration date and initials because she had been the one to "draw them" .
10. On 8/25/10 at 1:40 pm review of the facility's Policy and Procedures for Medication/Solution Labeling for Procedure (Clinical Practice Structure Standards 4.17) indicated that: "3. Labeling will be done when any medication or solution is transferred from the original packaging container to another container, 4. The label must include the medication name, strength, quantity, diluents and volume (if not apparent from the container), expiration date when not used within 24 hours and expiration date occurs in less than 24 hours, 7. All unused medications and labeled containers are discarded at the end of the case."

Based on observation, interview and record review the facility failed to ensure that drugs be stored under proper and safe conditions of sanitation and suitable product stability temperatures in accordance with accepted professional principles.

Findings include:

1. On 8/23/10, at the 10:40 am, the 6th floor, NW unit (which services Gynecology and Oncology Nursing units) medication temperature read 48 degrees. This was verified with unit nursing manager.
2. On 8/23/2010 at 11:30 am accompanied by the Director of Pharmacy and the Compliance Coordinator during tour of the 5th South Medication room, the medication refrigerator was found to be below accepted temperature standards (ranges between 36 - 46 F) at a temperature of 30 Fahrenheit degrees.
3. On 8/23/2010 at 11:46 am accompanied by the Director of Pharmacy and the Compliance Coordinator during tour of the 4th floor Progressive Care Unit the medication refrigerator was found to be at a temperature of 49 Fahrenheit degrees.
4. On 8/23/2010 at 2:40 pm accompanied by the Director of Pharmacy and the Compliance Coordinator during tour of the Anesthesia work room, it was found that the medication refrigerator had a digital thermometer that was not displaying the temperature and only the letters " H H " on the screen were displayed. Present at the time of finding was the Pharmacy Director who stated that because of a " battery issue " the temperature was not displaying on the thermometer screen.
5. On 8/23/2010 at 4:24 pm accompanied by the Director of Pharmacy and the Compliance Coordinator during tour of the Intermediate Care Unit, the medication refrigerator was found to be at a temperature of 49 Fahrenheit degree. Interview of a unit nurse sitting in the area where refrigerator was located revealed that the refrigerator had been " beeping " earlier and that Pharmacy had been called to inform they were having issues with the temperature.
6. On 8/24/2010 at 9:52 am interview with the Director of Pharmacy confirmed that they had been having issues with temperature monitoring of the drug refrigerators and were in the process of resolving this with other temperature monitors but at this time were replacing all the digital thermometers with mercury ones as they were "more accurate" and did not require batteries.
7. On 8/25/10 at 1:35 pm review of the facility's Policy and Procedures for Refrigerator Maintenance, Temperature Monitoring and Food Storage (Standard 6.03) indicated that "refrigerator temperature for drugs should always remain between 35-46 Fahrenheit degrees."

1. Based on observation, interview and record review the facility failed to ensure that food was prepared , stored and served under clean and sanitary conditions in the hospital main kitchen. And failed to ensure that previously cooked food was cooled for storage in a manner that protected it from microbial growth.
2.. Based on observation, interview, and review of the operating room humidity monitoring logs, the infection control program failed to monitor an appropriate sanitary physical environment to control infections.

Findings Include:

1: During the initial tour of the main kitchen--which began on 8/23/10 at 9:30 a.m.--the following were observed:

The handwash sink that serves the dishmachine room was inaccessible for staff use due to being blocked by two garbage cans.

These garbage cans, which were in active use at the time and contained garbage, did not have lids.

In the janitor's closet two wet mops, which were available for use, were observed stored coiled in mop buckets rather than hanging so that air could circulate around them. The Food Service Director (FSD)stated at this time that the mop heads should have been replaced after they were used but he also confirmed that these mops were available at this time for staff to use as needed.

A large round garbage can, in active use at this time which contained garbage, positioned next to a drink machine and to a door leading to behind the cafeteria serving line--did not have a lid.

Very heavy soil build-up was observed on all of the doors leading from the main kitchen to the area behind the cafeteria serving line.

All of these doors were propped open, allowing unrestricted air flow from other parts of the hospital into the main kitchen. The FSD was asked at this time if these doors were always kept propped open and he confirmed that they were.

A baseboard tile behind and next to the cafeteria hot food service steamtable was not grouted/caulked to the wall. Gaps into the wall cavity behind were visible. A live insect--which appeared to be a roach--was observed crawling near this tile at this time.

A garbage can positioned near this steamtable, which contained garbage and was available for active use, did not have a lid.

A handwash sink, also positioned near this steamtable, had a heavy build-up of white soil on the floor under it.

The freezer behind the Krispy Kream cafeteria service line measured an internal temperature of +10 degrees Farenheit.

The garbage can positioned to serve this area contained garbage and did not have a lid.

Moderate soil and food debris build-up was on the floor behind the main cookline equipment.

A garbage can in the food preparation area, which was available for active use and which contained garbage did not have a lid.

A significant amount of dried on food spatters were built-up on the ceiling of the trayline microwave oven.

A full size steamtable pan containing Jello was stored in a trayline cooler uncovered.

A pan of meatloaf was stored uncovered in walk-in cooler #3.

A baseboard tile was missing from the wall in cooler #3 next to the door leading to the walk-in freezer #4.

There was ice on the coolant line near the condenser fans in walk-in freezer #1.

There was a one inch in diameter hole in the wallboard in the entrance way door wall in the beverage storage room.

Six or seven blue cotton kitchen towels-- saturated with water -- were lying on the floor in front of the two deep fat fryers. When asked why the towels were there a line cook stated that when it rains water leaks in between the two hoods and falls on the floor next to these units. The FSD confirmed that this was the case.

Day light was visible near the bottom between the double alarmed doors in the cafeteria. The sweep, which should have been filling this gap, was not intact. These doors face the East garage.

An intact piece of meatloaf about six inches by six inches by 24 inches was being stored in the #3 walk-in cooler. When asked about this product, the Chef stated that it had been cooked the previous evening and placed in the #4 walk-in freezer to quick cool and then brought into the #3 cooler for storage until use. When the "HACCP (Hazard Analysis Critical Control Points) Cooling and Reheating Chart Time/Temperature Log for Potentially Hazardous Foods" was reviewed for this product it was revealed that no "temperature after 2 hours" had been logged for this product. This made it impossible to determine if the product had been safely cooled to 70 degrees Farenheit within two hours of placement into cold storage.

A subsequent interview with the FSD revealed that all of the facility recipes are developed using HACCP guidelines.

A review of the "Beef Meatloaf" recipe revealed that the following procedure should have been followed: "...5. Remove from oven. Let stand for 15 to 20 minutes before slicing into 4 oz. portions. Critical Control Point (CCP)--Hold hot (140 degrees Farenheit or above) for service or cool quickly (HACCP) to internal temperature of 40 degrees Farenheit or below..." This indicates that the meatloaf should have been sliced and then cooled, which would have provided more surface area of product and would have allowed fastest cooling.

A review of the facility Policy and Procedure for Sanitation Precautions issued by Food and Nutrition Services (Policy Number: 147-4002) Original Issue date 02/91, Revision Date: 06/95, 05/08, 03/09 Review Date: 01/99, 01/00, 01/01, 01/02, 09/05, 07/10 and signed off on by the Hospital Chief Clinical Dietitian/ Clinical Nutrition Manager, revealed the following: "Policy--The Food and Nutrition Services Department follows sanitary precautions in the handling , preparation and serving of food. Procedure--Sodexo's Food Safety Standards and Requirements - Sodexo's Food Safety Audit and Comprehensive Food Safety Audit shall serve as the standard for compliance; unless local food code provides more stringent standards. Sodexo's audit is in compliance with the state of Florida, Department of Business and Professional Regulation..." "Foods are properly cooled to 70 degrees Farenheit within two hours and 40 degrees Farenheit within an additional 4 hours, all temperatures are recorded on the HACCP cooling log and the HACCP Roast Meat Charts..."

2. Review of humidity and temperature monitoring logs was conducted on 8/24/10, at approximately 3:00 pm. Operating Room #11, reflected elevated humidity levels. Data recorded as follows:

DateHumidity PercentOR # 11OR # 128/24/1079.847.18/23/1079.054.78/20/1079.046.88/19/1083.745.88/18/1082.755.68/17/1080.648.88/16/1088.648.08/13/1083.249.18/12/1083.449.78/11/1090.355.88/10/1086.351.88/9/1096.152.08/6/1083.446.5
Interview of the Plant Operations Systems Tech., on 8/24/10, at 3:30 pm was conducted with a review of the humidity/temperature logs. He/She stated that the log printouts are not correct for Operating Room (OR) #11. Further, He/She stated that OR #11 and OR #12 are paired on the systems and should be approximately the same temperature. A review of the humidity/temperature logs reveal a significant documented difference between OR #11 and OR #12. He/She stated that the sensor for this area has not worked properly since 2007. The surveyor asked if manual humidity checks are conducted based on elevated values. He/She stated that manual humidity checks have been conducted on OR #11, however none have been recorded.

A review of the Policies and Procedures, Policy # 2000.2, Surgery/Maintenance states; OR (operating rooms) temperature and humidity readings are taken daily. Guidelines as per AIA (American Institute of Architects) of humidity between 30% and 70% will be maintained.