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Based on review of Medical Staff Rules and Regulations, medical records, and staff interviews, it was determined that the medical staff failed to enforce its bylaws to require authentication of physician verbal orders within 48 hours of such orders for 2 of 3 patient records ( #'s 18 and 19).

Findings include:

The hospital's Medical Staff Rules and Regulations (last updated 04/13) require: "...Verbal and telephone orders shall be signed, dated and timed by the receiver of the verbal order...the physician should sign, date, and time such orders within 48 hours...."

Patient # 18 was admitted for acute respiratory failure requiring intubation on 5/31/2014. The patient required bilateral soft upper extremity restraints for agitation and restlessness, safety judgment and potential dislodging of tubes. Verbal orders for continued restraints, obtained by an RN on 6/6/14 through 6/9/14, were not authenticated by a medical provider.

Patient # 19 was admitted for acute hypoxemic respiratory failure on 2/13/2014. On 2/15/2014, the patent required mechanical ventilation. The patient was placed in soft, bilateral upper extremity restraints for agitation/restlessness, non-compliance, confusion, impaired safety judgment and potential dislodging of tubes. Verbal orders for continued restraints, obtained by an RN on 2/7/2014 and 2/20/2014, were not authenticated by a medical provider.

Interviews with the Director of the Intensive Care Unit and Director of Quality confirmed the verbal orders for restraints for Patient #'s 18 and 19 were not authenticated by a medical provider.

Based on review of medical records, policies/procedures, and interviews with staff, it was determined the hospital failed to require a registered nurse supervise and evaluate care provided to 3 of 3 patients ( #'s 21, 22, and 25) as demonstrated by:

1. failing to adequately control and reassess pain interventions for Patient #'s 21 and 25; and

2. failing to follow medication titration per protocol orders for the Ramsey scale, and failing to document the Ramsey score per hospital policy/procedure for Patient # 22.

This is a repeat deficiency from survey 3/28/13 Event #XI8A11 Tag A0395.


Findings include:

1. The hospital policy titled "Pain Management", policy # HW1157 required:"...reassessment of pain will be performed with each new report of pain...after pain management interventions have been initiated and sufficient time has elapsed for the benefit of the intervention to occur...within 30 minutes after parenteral drug therapy...response to inadequately controlled pain...additional analgesia will be given (utilizing prescribed analgesics as appropriate)...contact the prescriber when patient consistently fails to achieve the comfort-function goal...uncontrolled moderate to severe pain is treated emergently...call physician/licensed independent practitioner immediately for pain that is uncontrolled...."

The hospital document, "Adult Pain Management Orders", describes moderate pain as 4-6 and severe pain as 7-10.

Patient # 21 was admitted to the Intensive Care Unit (ICU) 6/23/2014 at 0910 after an interventional heart catheterization for an acute myocardial infarction. Upon arrival to the ICU, the patient was receiving nitroglycerin intravenously (vasodilator) and Integrilin intravenously (anticoagulant). Physician # 9 ordered morphine 4 milligrams (mg) every hour at 0950 hours. Between 0910 hours and 1900 hours, the nitroglycerin rate was increased per order and the patient continued to rate chest pain 5/10 to 8/10. The patient received the first dose of morphine 4 mg at 1913 hours, for a rated chest pain of 5/10. There was no reassessment of pain after that dose, until 2100 hours. At 2109 hours, the patient received morphine 4 mg for a rated chest pain of 5/10. On 6/24/2014 at 0052, the next pain assessment was documented as a rated chest pain of 4/10. Between 0200 hours and 0300 hours the RN documented that Physician # 9 was aware that the patient continueed to report chest tightness. At 0300 hours, the patient rated the chest pain as 5/10, and the nitroglyerin infusion was decreased in rate. At 0429 hours the patient received morphine 4 mg intravenously. There was no assessment of the patient's pain prior to administering the pain medication. At 0506 hours the patient rated the chest pain at 5/10.

Patient # 25 was admitted 6/24/2014 to ICU for diabetic ketoacidosis (DKA).

Morphine 2 mg/ml was ordered intravenous (IV) every three (3) hours as needed for pain on 6/24/2014 at 1452 hours. At 1900 hours the patient complained of chronic back pain getting worse and a headache. At 1948 hours the patient received morphine 2 mg intravenously. No pain assessment was documented until 2132 hours, when the patient rated back and headache pain as 8/10.

The Director of ICU confirmed in an interview conducted on 6/25/2014 that Patient # 21 had chest pain between 0910 hours and 1900 hours, that additional pain interventions were not instituted by the RN, that no pain reassessment was documented 30 minutes after intravenous pain medication for 2 out of 3 times, that there was no rating of chest pain prior to the third dose of morphine and that Physician # 9 was not notified of continued chest pain until 6/24/2014 between 0200 hours and 0300 hours.

The Director of ICU confirmed in an interview conducted on 6/26/2014 that Patient # 25 did not have a documented pain reassessment 30 minutes after receiving intravenous pain medication as required by hospital policy/procedure.

2. The hospital policy titled "Care of a Patient on Mechanical Ventilation", Guideline
# IC1023GL Effective Date 4/15/2013 required: "...sedation will be per physician orders, using the Ramsey scale for long term sedation...with every 2 hour assessment, Ramsey scale will be documented...anytime sedation is titrated, Ramsey scale will be documented...Ramsey Scale is as follows: 1. Anxious, agitated, restless; 2. Cooperative, oriented, tranquil; 3. Responds to commands only; 4. Brisk response to light glabellar tap or loud noise; 5. Sluggish response to light glabellar tap or loud noise; 6. No response...."

The medication titration per protocol orders for Patient # 22 required: "...midazolam (Versed) titrate by 0.02 milligrams (mg)/killograms (kg)/hour (hr) every 5 minutes to a maximum of 0.2mg/kg/hr...Goal: Ramsey scale of 3...."

Patient # 22 was admitted 6/23/2014 for altered mental status required mechanical ventilation and intravenous sedation. On 6/23/2014 at 2300 hours the patient received a continuous Versed infusion for sedation. The Ramsey score was documented intermittently at a score of between 4 and 5, without adjustment to the Versed infusion. On 6/24/2014 at 1930, the patient's Ramsey score was documented at 5. The Versed infusion was increased at this time without documented justification by RN # 7.

The Director of ICU confirmed in an interview conducted on 6/26/2014 that Patient # 22 did not have the Versed infusion adjusted when the Ramsey score was greater than 3, that there was no documentation to justify the increase in the Versed infusion on 6/24/2014 at 1930, and that the Ramsey scores were not documented every two hours as required by policy.

This citation does NOT raise to a CONDITION level.
Based on review of the Association of Perioperative Registered Nurses' (AORN) standards, manufacturer's recommendations, hospital documents, observation and interviews, it was determined the Administrator failed to provide a sanitary environment for surgical services in the hospital as evidenced by:

1. failure to provide the quantity of surgical instruments necessary for the scheduled daily surgical procedure volume;

2. failure to follow nationally accepted standards of practice; failure to follow manufacturer's recommendations for high level disinfection; and

3. failure to ensure the volunteers follow the hospital guidelines in the surgical suite.

Findings include:

1. AORN Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings 2014 Edition; Recommendation VII.a. pg. 582 requires: "...Immediate use steam sterilization should not be used as a substitute for sufficient instrument inventory...."

The hospital Sterilization Policy and Procedures requires: Flash sterilization/unwrapped items...only used when there is insufficient time to sterilize an item by the preferred package method...."

Steam Sterilization Record Keeping Envelopes revealed the following information: sterilizer ID, date, load #, exposure, load contents, instant read chemical indicator and biological indicator.

Sterilizer ID # 3's sterilization records dated 06/02/14 through 06/24/14 revealed a total of 20 loads/cycles of immediate use loads completed.

Sterilizer ID # 4's sterilization records dated 06/02/14 through 06/23/14 revealed a total of 28 loads/cycles of immediate use loads completed.

Sterilizer ID # 5's sterilization records dated 06/02/14 through 06/23/14 revealed a total of 28 loads/cycles of immediate use loads completed.

A total of 74 loads of immediate use loads were completed in the surgical suite during the above time frame.

The Operating Room Charge nurse and the Surgical Technician confirmed during an interview conducted on 06/24/14, that the immediate use cycle is used because the facility "does not have enough instrumentation."

The Peri-Operative Manager confirmed the above findings during the same interview.

2. AORN Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings 2014 Edition; Recommendation IV.a.4, IV.c and IV.c.2 pg. 519 requires: "...High- level disinfection should occur at appropriate temperature, contact time ...Manufacturer's written instructions should be followed ...test strip ...specific for the disinfectant ...should be used for monitoring solution potency prior to each use ...."

Cidex OPA directions for use revealed: "...High level disinfectant at a minimum of 20 degrees centigrade (68 Fahrenheit), immerse device completely, for a minimum of 12 minutes. It is recommended that the solution is tested with the test strips prior to each use.

Review of the Solution Testing Log Sheet located in the facility's Radiology Department revealed no documentation of the solution concentration prior to each patient use, no documentation of the temperature of the disinfectant and no documentation of the immersion time of the vaginal probe.

The Director of Radiology confirmed during an interview conducted 06/25/14 that the solution concentration is only tested daily, not prior to each patient use.


3. Hospital policy titled "Guidelines for Volunteers in Surgery" revealed what volunteers may do in the surgery department. The Guidelines include: ...clean and make up the carts...assist in pre-op and recovery room tidiness...."

Observations in the pre-operative area revealed four (4) volunteers (employee #'s 32, 33, 34, 35) disinfecting the pre-op bed located in room #3. The volunteers were using Virex 256 disinfectant. Directions for the Virex 256 revealed: "...for disinfection "treated surfaces must remain wet for ten (10) minutes...."

Volunteer #33 confirmed during an interview that the treated surfaces are sprayed and then wiped before the 10 minute recommendation.

Review of the Volunteer Orientation Checklist does not contain any documentation of Infection Control.

The Director of Environmental Services confirmed during an interview conducted 06/26/14 that the housekeeping department does not train any volunteers to disinfect the pre-operative area.

The Infection Preventionist (IP) confirmed during an interview conducted 06/26/14 that she was not aware of the volunteers disinfecting beds in the pre-operative area.