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Based on interview, clinical record and document review, the facility failed to ensure an advance directive was formulated or included in the patient clinical record for a no code status for 3 of 30 sampled patients (Patient #13, #16, #24).

Findings include:

Patient #13

Patient #13 was admitted 10/10/14 with diagnoses to include difficulty breathing, low sodium level, high blood pressure, anemia and low potassium level and several falls at home.

The history and physical for Patient #13 dated 10/10/14 documented the patient's code status as, "Do not Resuscitate"(DNR).

A physician's order dated 10/10/14 in Patient #13's clinical record indicated a do not resuscitate order. There was no documentation the decision for a DNR was discussed with the patient.

The clinical record lacked documentation of a signed informed consent for Patient #13 for a DNR order or if the patient had made an advance directive regarding the patient's wishes.

Patient #16

Patient #16 was admitted on 10/10/14 with diagnoses to include chest pain, a history of cholangiocarcinoma and hypothyroidism.

The physician's order (electronic medical record) dated 10/21/14 for Patient #16 documented:

-10/21/14 20:52 (8:52 PM) Resuscitation status: Full Resuscitation.
Constant order-Yes

-10/21/14 (12:33 AM) Resuscitation status: after: do not resuscitate. before: full resuscitation.

The history and physical for Patient #16 dated 10/21/14 documented ...4. She is avid DNR/DNI (do not intubate).

The clinical record lacked documentation of a signed informed consent for a DNR for Patient #16.

The consent for treatment form dated 10/20/14, indicated Patient #16 had an advance directive, however it was not available in the clinical record..

On 10/21/14 in the morning, the Director of Medical Records explained the facility was in the process of creating a new policy and procedure for DNRs since the electronic medical record system was put into place several months ago. The present policy was applicable to the hard copy records. Both the hard copy and EMRs were being used.

The policy number: RI-123-No Code /Emergency Resuscitation (revised 12/11 documented:

- No code status must be indicated specifically on the Code Order form or on the Physician Order form.

-Upon admission a copy of the Code Order/Informed Consent form will be placed on the patient's medical record (hard copy of chart). The code order will be kept in the clear yellow jacket in the front of the patient's chart.

Procedure:

1.) Code status will be documented on the Code Order/Informed Consent form (see attachment) or on the Physician Order form.
3.) The physician is responsible for discussing with the patient or his/her legally responsible representative the use of withholding of life sustaining procedures. This discussion must occur prior to any altered code status being ordered. Witnesses to this discussion must sign the Code Order form in the place indicated.
The patient's wishes will be documented in the medical record in the form of an advance directive or a progress note.
5.) Reversal of a no code status must be in writing. Verbal orders initiating and /or changing of a no code status must be witnessed by two nurses.

The clinical record for Patient #13 and Patient #16 did not contain documentation of signed Physician Order forms for DNR.



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Patient #24

Patient #24 was admitted on 10/21/14 with diagnoses including multisystem organ failure, metabolic acidosis and renal failure secondary to possible suicide attempt. Review of the patient's medical record revealed upon admission, the patient was unresponsive and on ventilator support.

The initial physician orders documented the patient was a full code.

The patient's medical record included consents for a heart catheterization and insertion of a vascath for dialysis, signed by the patient's father on 10/21/14.

The physician orders dated 10/21/14 documented the patient's status was changed to DNR (Do not resuscitate).

The physician progress notes dated 10/21/14 documented "Code status. Discussed with family: father, mother and sister at bedside. They understand the problems listed above, including unapparent risk of anoxic brain injury. They want to make her DNAR (sic). Will change her code status per family's request."

The patient's medical record contained a form titled Physician Orders Code Order/ Informed Consent. The form was blank. The form did not include the code order or signatures of the physician, nurse, or family member.

Based on observation, interview, and document review, the facility failed to ensure medications administered through a gastrostomy tube followed standards of practice.

Findings include:

Patient #23

Patient #23 was admitted on 10/11/14 with diagnoses including sepsis, and community acquired pneumonia. Review of the patient's medical record revealed the patient was intubated, on a ventilator and had an orogastric (OG) tube for feedings.

On 10/22/14 at 9:00 AM, observed the Registered Nurse (RN) administer the patient's medications through the OG tube. The patient's medications which were supplied in a pill format, included:
- Famotidine 20 mg
- Prednisone 30 mg
- Abilify 15 mg
- Benztropine 2mg

The RN crushed all the medications together and added 30 cc (cubic centimeters) of water to dilute the medications.

The RN checked the OG tube for patency, administered approximately 60 cc water, administered the diluted medications, then administered 30 cc water.

The patient received 3 medications in a liquid format:
- Ducosate 10 ml (milliliter)
- Sulfamethoxazole 20 ml
- Miralax 17 Gm (grams)

The liquid medications were given separately, with an infusion of 30 cc water between the medications.

Following the medication pass, the RN acknowledged the medication in the pill format should have been crushed, diluted, and administered separately.

The Institute for Safe Medication Practices article titled Preventing Errors When Administering Drugs via Enteral Feeding Tube dated 5/6/2010, documented "Each medication should be administered separately through the feeding tube using a clean 30 ml. or larger oral (non-luer tip) syringe."

Based on interview, record and document review, the facility failed to ensure the guidelines for the policy on no code (do not resuscitate) were followed for 3 of 30 sampled patients (Patient #13, #16, #24).

Findings include:

Patient #13

Patient #13 was admitted 10/10/14 with diagnoses to include difficulty breathing, low sodium level, high blood pressure, anemia and low potassium level and several falls at home.

The history and physical for Patient #13 dated 10/10/14 documented the patient's code status as, "Do not Resuscitate"(DNR).

A physician's order dated 10/10/14 in Patient #13's clinical record indicated a do not resuscitate order.

The clinical record lacked documentation of a signed informed consent for Patient #13 for a DNR order.

Patient #16

Patient #16 was admitted on 10/10/14 with diagnoses to include chest pain, a history of cholangiocarcinoma and hypothyroidism.

The physician's order (electronic medical record) dated 10/21/14 for Patient #16 documented:

-10/21/14 20:52 (8:52 PM) Resuscitation status: Full Resuscitation.
Constant order-Yes

-10/21/14 12:33 AM Resuscitation status: after: do not resuscitate. before: full resuscitation.

The history and physical for Patient #16 dated 10/21/14 documented ...4. She is avid DNR/DNI (do not intubate).

The clinical record (hard copy) lacked documentation of a signed informed consent for a DNR for Patient #16.

On 10/21/14 in the morning, the Director of Medical Records explained the facility was in the process of creating a new policy and procedure for DNRs since the electronic medical record system was put into place several months ago and the current policy was applicable to the hard copy charts.

The policy number: RI-123-No Code /Emergency Resuscitation (revised 12/11 documented:

- No code status must be indicated specifically on the Code Order form or on the Physician Order form.

-Upon admission a copy of the Code Order/Informed Consent form will be placed on the patient's medical record. The code order will be kept in the clear yellow jacket in the front of the patient's chart.

Procedure:

1.) Code status will be documented on the Code Order/Informed Consent form (see attachment) or on the Physician Order.
3.) The physician is responsible for discussing with the patient or his/her legally responsible representative the use of withholding of life sustaining procedures. This discussion must occur prior to any altered code status being ordered. Witnesses to this discussion must sign the Code Order form in the place indicated.
The patient's wishes will be documented in the medical record in the form of an advance directive or a progress note.
5.) Reversal of a no code status must be in writing. Verbal orders initiating and /or changing of a no code status must be witnessed by two nurses.

The clinical record for Patient #13 and Patient #16 did not contain documentation of signed Physician Order forms for DNR.



26907

Patient #24

Patient #24 was admitted on 10/21/14 with diagnoses including multisystem organ failure, metabolic acidosis and renal failure secondary to possible suicide attempt. Review of the patient's medical record revealed upon admission, the patient was unresponsive and on ventilator support.

The initial physician orders documented the patient was a full code.

The patient's medical record included consents for a heart catheterization and insertion of a vascath for dialysis, signed by the patient's father on 10/21/14.

The physician orders dated 10/21/14 documented the patient's status was changed to DNR (Do not resuscitate).

The physician progress notes dated 10/21/14 documented "Code status. Discussed with family: father, mother and sister at bedside. They understand the problems listed above, including unapparent risk of anoxic brain injury. They want to make her DNAR (sic). Will change her code status per family's request."

The patient's medical record contained a form titled Physician Orders Code Order/ Informed Consent. The form was blank. The form did not include the code order or signatures of the physician, nurse, or family member.

Based on observation, review of quality control logs and patient's medical records, the Division of Public and Behavioral Health database inquiry for personnel certification validation and interview with laboratory personnel, the hospital's laboratory services did not meet the requirements of part 493 of this chapter.

Findings include:

1. A database inquiry of the Division of Public and Behavioral Health for personnel certification revealed 2 of 7 point of care testing personnel performing activated clotting times determined by FDA to be a moderate complexity test did not have current certification as Point of Care Analysts in the Cath Lab.

2. A review of the urine dipstick quality control log sheets for ER for October 2014 revealed results recorded on 3 different log sheets with one log sheet lacking columns to record the specific gravity for the negative and positive controls. There were no corrective actions taken and noted for results that were out of the acceptable ranges for results as required on the log sheets. Seven of 21 results for pH of the negative control were out of the acceptable range and 2 of 21 were out for the positive control.

3. An inspection of the urine dipstick testing area in ER on 10/21/14 revealed a urine specimen sitting on the counter that was not labeled according to the hospital specimen labeling requirements of the patient's name and medical record number as noted on the Urine Dipstick QC Sheet. An investigation and medical record review showed that patient MR#618289 had been seen and the urine sample tested on 10/20/14.

4. Laboratory personnel confirmed during the tour of the point of care testing areas on 10/21/14 that the quality control and specimen labeling instructions on the QC sheet were not followed by the testing personnel in ER.

Based on review of pathology specimen log book, laboratory reports, patients' medical records and interview with laboratory personnel, the laboratory did not follow written protocol for the proper receipt and reporting of tissue specimens.

Findings include:

1. Two kidney biopsy specimens from patient MR#463355 and MR#610403 collected on 09/18/14 were not recorded in the "Northern Nevada Medical Center Pathology Specimens Sent to Western Pathology" log book.

2. Reports for each specimen dated 09/20/14 indicated that the specimens were forwarded to a reference laboratory for testing and another report was to follow. No subsequent reports on the kidney biopsy samples were found in the log book or in the patients' medical records during the inspection on 10/21/14.

3. Laboratory personnel confirmed during the inspection that the two specimens were not recorded in the log book and there had been no follow up on the missing reports from the reference laboratory.

Based on observation and documentation review, the facility failed to ensure issues with infection control were identified and addressed with hospital staff.

Findings include:

On 10/22/14 in the morning, prior to a surgical procedure to be performed on Patient #19, the Anesthesiologist was observed not disinfecting the hub of the intravenous (IV) tubing before administering IV medications to Patient #19. The anesthesiologist was observed not using hand hygiene between glove changes.

The Manager of Surgery was informed the physician did not follow proper hand hygiene and failure to sanitize the IV hub before administering medication by syringe.

The policy: Intermittent Infusion Device Drug Administration- Lippincott Procedures (revised April 04, 2014) documented:

Implementation:

-Perform hand hygiene
-Thoroughly disinfect the connector with an antiseptic pad using friction and allow to dry.



26907


Patient #23

Patient #23 was admitted on 10/11/14 with diagnoses including sepsis, and community acquired pneumonia. Review of the patient's medical record revealed the patient was intubated, on a ventilator and had an orogastric (OG) tube for feedings.

On 10/22/14 at 9:00 AM, observed the Registered Nurse (RN) administer the patient's medications.

The patient's medications included Ceftriaxone 1 Gm (Gram) in 50 ml (milliliters) IV (Intravenous) piggyback. The nurse verbalized the IV piggyback tubing would be changed.

The RN donned gloves to hang the IV medication and tubing.

While the RN was in the room preparing to hang the IV medications, the patient began coughing and expelled mucous. The nurse suctioned the patient's mouth removing more secretions. The patient's breathing improved.

The nurse did not remove the gloves and wash her hands. The nurse picked up the IV tubing and medication and hung the IV. After the IV was hung, the nurse removed the gloves and washed her hands prior to leaving the room.

On 10/22/14 at 1:15 PM, the sharps container located on the crash cart on the 4th floor, was over the fill line. The Director of Nursing confirmed the observation and informed the staff to change the sharps container.

The facility policy titled Isolation Precautions, Standard Precautions dated 9/13, documented:

- "Standard Precautions...
- A. Hand Hygiene...
-Wash hands or disinfect immediately after gloves are removed, between patient contacts, and when otherwise indicated....

- B. Gloves
- Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated items. Use sterile gloves when indicated. Put on clean gloves just before touching mucous membranes and no-intact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient."

-"M. Occupational Health and Bloodborne Pathogens/Sharps Safety
-1. ... "Place used disposable needles, scalpels, blades, and other sharp items in appropriate puncture resistant sharps containers, which are located as practical to the area in which the items were used, and place reusable syringes and needles in a puncture resistant sharps container for transport to the reprocessing area. Sharps containers will be replaced by Environmental Services and/or nursing staff when the containers are 3/4 full."