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Based on review of the hospital's Quality Assessment and Performance Improvement(QAPI) data, the hospital failed to ensure that a system was in place through its QAPI program to capture the hospital's adverse events, analyze their causes, and implement preventative actions and mechanisms that included feedback and learning throughout the hospital for 2 of 2 hospital identified adverse events reviewed.

The findings are:

On 03/18/16 at 1:15 p.m., review of the hospital's QAPI data revealed 2 adverse events identified as such by the hospital. There was no documentation presented for review related to the hospital's management of the adverse events except that the adverse event was captured. There was no documentation related to an analysis of the cause, and what preventative actions were implemented, and any mechanisms that included feedback and learning throughout the hospital for either of the identified adverse events. On 03/18/16 at 1:45 p.m., Risk Manager 1 revealed, "We do not have any further documentation to show about the incidents."

Based on record review and interview, the hospital failed to ensure documentation of wound care for 1 of 38 in-patient charts (Patient 15), failed to follow physician orders for notification of out of range blood pressures for 2 of 38 in-patient charts (Patient 2 and 3), failed to ensure the patient's physician ordered laboratory work was obtained and resulted for 1 of 38 in - patient charts (Patient 22), failed to obtain and document the patient's vital signs for 1 of 38 in - patient charts (Patient 22), and failed to administer a physician ordered intravenous antibiotic every 6 hours as ordered for 1 of 38 patient charts reviewed for care and services.(Patient 15)


The findings are:


On 03/16/16 at 10:20 a.m., record review of Patient 2 revealed the patient was admitted to the hospital on 03/09/16. Review of the patient's chart revealed physician orders dated 03/09/16 that read, "Notify MD (Medical Doctor) for systolic BP (blood pressure) < (less than) 60 or > (greater than) 160. Review of the patient's vital signs revealed:
03/09/16 at 9:59 p.m.: BP 185/80,
03/11/16 at 11:48 p.m.: BP 169/95,
03/14/16 at 6:55 a.m.: BP 167/72, and
03/14/16 at 3:37 p.m.:BP 172/63, but there was no documentation of physician notification in the patient's chart. On 03/16/16 at 11:00 a.m., the findings were verified by Assistant Manager 1.

On 03/16/16 at 2:10 p.m., review of Patient 3's chart revealed the patient was admitted on 03/03/16. Review of physician orders dated 03/04/16 revealed "notify MD(Medical Doctor) systolic >180 or <80 - hold BP meds for systolic <110. Review of the patient's vital sign documentation revealed:
03/07/16 at 12:07 a.m.:BP 184/101,
03/07/16 at 3:42 p.m.: BP 194/90,
03/09/16 at 7:27 p.m.: BP 178/96,
03/09/16 at 11:59 p.m.: BP 170/91,
03/11/16 8:03 p.m.: BP 198/110, and
03/14/16 at 8:27 a.m.: BP 187/107, but there was no documentation of physician notification for out of range blood pressures. On 03/17/16 at 12:20 p.m., the findings were verified by Manager 3.





36295

On 03/17/16 at 2:28 p.m., review of Patient 22's chart revealed a physician order dated 03/08/16 for a "stat" Hemoglobin and Hematocrit, but there was no lab result on the chart or any other documentation that the Hemoglobin and Hematocrit was obtained and resulted. On 03/17/16 at 3:08 p.m., Registered Nurse Manager 12 verified the finding and reported, "I cannot explain why the Hemoglobin and Hematocrit (H & H) was not obtained and resulted as ordered."

On 03/17/16 at 4:19 p.m., review of Patient 22's chart revealed physician orders to obtain the patient's vital signs every 4 hours, but there was no documentation in the patient's chart that the patient's vital signs were obtained and documented on 03/10/16 at 12:00 p.m., 4:00 p.m., and 8:00 p.m. On 03/17/16 4:40 p.m., Registered Nurse Manager 12 verified the findings and revealed, "I do not know why the vital signs were not done for 12:00 p.m., 4:00 p.m., and 8:00 p.m.".




36397

On 3/17/16 at 11:13 a.m., review of Patient 15's chart revealed physician orders dated 3/7/16 for the patient to receive wound care to the right medial ankle: "Silvadene/band-aid change daily and the right great metatarsal head: Iodoflex/band-aid change daily". There was no documentation of wound care performed on 3/8/16 and 3/13/16. Review of a physician order dated 3/7/16 for Clindamycin 600 milligram (mg) intravenous (IV) every 6 hours, but review of the patient's medication administration record dated 3/8/16 showed the Clindamycin 600 mg IV was administered at 1:15 p.m. and again at 4:27 p.m. Nursing staff failed to follow the physician orders for patient's daily wound care and failed to adhere to the prescribed frequency and time of medication administration. On 3/17/16 at 11:40 a.m., Registered Nurse 11 acknowledged the findings and stated, "The antibiotic was given too early."

Based on record reviews and interview, the hospital failed to ensure its nursing staff reviewed and/or revised the patient's care plan, and failed to complete reassessment of the patient's pain after administration of pain medications within the appropriate time frame for 2 of 38 in- patient charts reviewed. (Patient 4 and 15)


The findings are:


On 03/16/16 at 2:10 p.m., review of Patient 4's chart revealed the patient received pain medication of Morphine 2 milligrams intravenous (IV) at 3:13 a.m. on 03/14/16, but the patient's pain level was not reassessed for pain until 4:42 a.m. which was 1 hour and 29 minutes after administration of intravenous medication. Documentation showed the patient received intravenous pain medication on 03/14/16 at 5:02 a.m. and was not reassessed for pain until 6:26 a.m. which was 1 hour and 24 minutes after the administration of the intravenous pain medication. On 03/16/16 at 2:45 p.m., Registered Nurse 9 stated, "Our policy is to reassess for pain when the pain medication is at it's peak."

Hospital policy and procedure, titled, "Pain Management", reads, "....5. After each pain management intervention once a sufficient time has elapsed for the treatment to reach peak effect...".




36397

On 3/17/16 at 11:13 a.m., review of Patient 15's chart revealed the patient was admitted on 3/7/16 with Cellulitis, Unspecified. Review of the Patient 15's nursing plan of care initiated on 3/7/16 revealed the nurse failed to document updates to the patient's nursing plan of care on 3/8/16. On 3/17/16 at 11:40 a.m., Registered Nurse 11 verified the findings acknowledging their unit is on twelve hour shifts and documentation for both shifts was missing.

Based on chart reviews, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure that 2 of 38 in - patients received insulin per physician orders for sliding scale insulin (Patient 2 and 13), failed to follow physician dialysis orders for the Dialysate Flow Rate (DFR) for 1 of 2 Dialysis in - patient charts (Patient 3), and nursing staff used an abbreviation to identify a medication that the nurse documented in a verbal order instead of documenting the name of the medication for 1 of 38 in- patient charts reviewed for care and services. (Patient 29)

The findings are:

On 3/17/2016 at 11:35 a.m., review of Patient 29's chart revealed a physician verbal order dated 3/12/2016 at 12:15 a.m. Review of the verbal order showed staff used an abbreviation to identify the medication ordered instead of writing the name of the medication on the verbal order form. On 3/17/2016 at 10:10 a.m., the Nurse Educator verified the finding.
Review of the hospital policy and procedure, titled, "Prescribing of Medications", reads, "...All medication orders...will contain the following elements...Approved medication generic or brand name...".





30011

On 03/16/16 at 10:20 a.m., review of Patient 2's chart revealed the patient was admitted on 03/09/16. Review of physician orders dated 03/09/16 revealed, "Insulin Lispro sliding scale correction insulin if: < (less than) 70 mg (milligrams)/dl (deciliter): 0 unit, 70-150 mg/dl: 0 unit, 151-200 mg/dl: 2 unit, 201-250 mg/dl: 4 unit, 251-300 mg/dl: 6 unit, 301-350 mg/dl: 8 unit, 351-400 mg/dl: 10 unit, 401-450 mg/dl: 12 unit, > (greater than) 450 mg/dl: 14 unit". On 03/13/16 at 10:48 a.m., the patient's finger stick blood sugar resulted as 154, but no insulin coverage was documented by the nurse. On 03/16/16 at 11:30 a.m., the findings were verified by Assistant Manager 1.

On 03/16/16 at 2:10 p.m., review of Patient 3's chart revealed the patient was admitted on 03/03/16. Review of physician orders dated 03/06/16 at 9:30 a.m. revealed, "DFR (dialysis flow rate) auto and BFR (blood flow rate) 400" for the patient's hemodialysis treatments dated 03/04/16 and 03/05/16. Review of the patient's hemodialysis treatment sheet dated 03/05/16 revealed the BFR ran at 400 and the DFR ran at "x (times) 2". Review of physician orders dated 03/06/16 at 10:30 a.m. revealed, "DFR auto and BFR 400" for hemodialysis treatments administered on 03/07, 03/09, and 03/11. Review of the patient's hemodialysis treatment sheet dated 03/07/16 revealed the BFR ran at 400 and a DFR of "2 x". Review of the patient's dialysis treatment sheet dated 03/09/16 revealed the BFR ran at 400 and the DFR ran at "800-auto". Review of the patient's dialysis treatment sheet dated 03/11/16 revealed the BFR ran at 400 and the DFR was "auto 600". On 03/16/16 at 3:39 p.m., Manager 12 revealed, "Unsure why the DFR is fluctuating based on the documentation on the treatment sheets".

On 03/17/16 at 2:00 p.m., review of Patient 13's chart revealed the patient was admitted on 03/09/16. Review of physician orders dated 03/12/16 revealed, "Insulin Regular sliding scale, correction insulin if <(less than) 70 mg (milligrams)/dl (deciliter): 0 unit, 70-150 mg/dl: 0 unit, 151-200 mg/dl: 2 unit, 201-250 mg/dl: 4 unit, 251-300 mg/dl: 6 unit, 301-350 mg/dl: 8 unit, 351-400 mg/dl: 10 unit, 401-450 mg/dl: 12 unit, > (greater than) 450 mg/dl: 14 unit". On 03/16/16 at 8:00 p.m., the patient's finger stick blood sugar was documented as 154 and 1 unit of insulin was documented as administered, but the physician order required 2 units Insulin based on the glucose value. On 03/17/16 at 2:45 p.m., the findings were verified by Manager 13.

Based on record reviews, interviews, and review of the hospital's policy and procedures, the hospital failed to ensure progress notes, physician orders, history and physicals, consults, and authentication of verbal orders were authenticated, and/or dated, and/or timed for 4 of 38 In-patient charts reviewed for care and services. (Inpatient 7, 15, 27, 29, and 32)

The findings are:

On 3/17/2018 at 10:10 a.m., review of Patient 32's chart revealed the patient's history and physical entry dated 3/16/2016 had no time documented for completion of the patient's history and physical.

On 3/17/2016 at 1:25 p.m., review of Patient 27's chart showed the hospitalist progress note dated 3/12/2017 and physician orders dated 3/17/2016 had no time documented.

On 3/17/2016 at 11:35 a.m., review of Patient 29's chart revealed a verbal order dated 3/12/2016 at 12:15 a.m. that had no physician authentication, no date, or time.






36397

On 3/17/16 at 11:13 a.m., review of Patient 15's chart revealed a request for wound assessment by the wound consult team dated 3/7/16, but the progress note/wound dictation had no date and time when completed. On 3/17/16 at 11:40 a.m., Registered Nurse 11 verified the findings.



31395

On 03/16/16 at 11:36 a.m., review of Patient 7's chart revealed the history and physical was performed during the patient's physician office visit dated 03/10/16, and had the signature of a Registered Nurse only. There was no physician signature, date, or time on the patient's history and physical dated 03/10/16. On 03/16/16 at 11:38 a.m., Nurse Manager 12 verified the physician had not signed the patient's history and physical and reported, "That should have been done."

Based on record reviews, interview, and review of the hospital's policy and procedure for verbal orders or telephone order, the hospital failed to ensure telephone orders were completed to included a read-back and verification process for 1 of 38 In- patient records. (Patient 10)

The findings are:


On 3/16/16 at 11:50 a.m., review of Patient 10's chart revealed a telephone order dated 3/14/16 with no documentation that the verbal order was verified and read back by nursing staff. On 3/1616 at 12:20 p.m., Registered Nurse 7 verified the findings.

Hospital policy and procedure, titled, "Verbal Orders or Telephone Order", reads, ".....Verbal or telephone orders must be "read-back" to the person verbalizing the order to verify the accuracy of the order. "Read-back" means that the person receiving the order writes the order on a physicians' order sheet and then "reads-back" what was transcribed to the person verbalizing the order. ("Write it and Read it").....".

Based on record review and interview, the hospital failed to ensure the consulting physician performed a consult for 1 of 38 In-patient charts reviewed where the patient had an ordered consult. (Patient 3)

The findings are:

On 03/16/16 at 2:10 p.m., review of Patient 3's chart revealed the patient was admitted on 03/03/16. Review of physician orders dated 03/04/16 showed, "Consult Dr. Surgery". Review of the patient's chart revealed there was no documentation of a consult by "Dr. Surgery". Review of the patient's history and physical completed by the hospitalist revealed, "The patient was evaluated by the surgical resident here in the emergency room.....they will however, follow the patient along during hospitalization." On 03/17/16 at 12:20 p.m., Manager 3 revealed that no consult report had been dictated although the patient's history and physical mentioned the patient had been seen for the consult.

Based on record reviews, interviews, and review of the hospital's policy and procedures, the hospital failed to ensure that a written informed consent was executed for 4 of 38 In-patient Charts reviewed for care and services. (Patient 2, 3, 32 and 34)

The findings are:

On 3/17/2016 at 10:10 a.m., review of Patient 32's medical record revealed there was no written consent for the placement of a central venous catheter and for intubation in the hospital's Emergency Department. On 3/18/2016 at 12:25 p.m., the Nursing Director of Critical Care reported, "There is no written informed consent."

On 3/18/2016 at 8:30 a.m., review of the hospital's policy and procedure, titled, "Consent for Surgical, Medical Services, and Blood Consent", stated, "...When written consent is not possible, verbal or telephone consent may be obtained. In general, verbal consents may be either witnessed or recorded as required for some services such as an autopsy. Document verbal consent in the medical record including the physician and witness signatures...Where an adult patient is unable to consent and the procedure cannot reasonably wait until the patient is able to consent, health care decisions may be made by...5. a parent or adult child of the patient...".




37212

On 3/16/16 at 11:20 a.m., review of Patient 34's chart revealed the patient was admitted on 03/15/16 at 5:38 p.m. Documentation in the patient's chart revealed the patient received Epidural anesthesia, but there was no consent form for the Epidural anesthesia on the patient's chart. On 3/16/16 at 11:30 a.m., RN 30 revealed, "We do not have to have them."

Review of hospital policy, IM300.115, titled, "Consent for Surgical , Medical Services, and Blood Consent, "original date 06/99, effective date 10/15, reads, "Verification of Consent . . . The written consent will be signed by the patient, the physician involved, and a witness. . . Procedures where anesthesia is used, regardless if there is entry into the body. . .".



30011

On 03/16/16 at 10:20 a.m., review of Patient 2's chart revealed the patient was admitted on 03/09/16, and there was no "consent to treat" authenticated by the patient on the chart. On 03/16/16 at 11:00 a.m., the findings were verified by Assistant Manager 1.

On 03/16/16 at 2:10 p.m., review of Patient 3's chart revealed the patient was admitted on 03/03/16. Review of the patient's chart and physician orders for hemodialysis treatments revealed there was no consent for treatment authenticated by the patient defining the hemodialysis procedure with an explanation of the risk and benefits in the patient's chart. On 03/16/16 at 1:30 p.m., Manager 7 verified the finding.

Based on observations, record reviews, and interviews, the hospital failed to ensure physician orders were obtained for 2 of 6 Out-Patient (Patient 1 ) charts, and for 1 of 38 In-patient (Patient 20) charts reviewed.

The findings are:

On 03/15/16 at 10:19 p.m., observations of (out) Patient 1 revealed upon arrival to the hospital's emergency center via Emergency Medical Services (EMS), Registered Nurse (RN 4) placed the patient on 3 liters of oxygen via nasal cannula. On 03/15/16 at 12:29 a.m., review of the patient's chart revealed the patient received Oxygen at "3 L(liters)-NC(nasal cannula)" at 10:27 a.m., 11:03 a.m., and 11:56 a.m.. Further review of the patient's records revealed there was no physician order for the oxygen administration/therapy documented.

On 03/17/16 at 11:15 a.m., observations of Patient 20 revealed the patient had a Foley placed while in the "CVRU(Cardiovascular Recovery Unit) 5". Review of the patient's chart revealed there was no documentation of a physician order for Foley insertion.

On 03/17/16 at 11:30 a.m., Director 2 revealed the order for the Foley did not exist and would get added to the protocol orders on the next forms meeting held on the second Monday of each month.

Hospital policy and procedure, titled, "Oxygen Nasal Annular Protocol", reads, "....If O 2 saturations indicated the need for oxygen, the Registered Nurse will obtain the physician order...".

Based on record review and interview, the hospital failed to ensure a completed discharge summary for 1 of 11 closed patient records. (Patient 2)

The findings are:

On 3/16/16 at 2:30 p.m., review of closed Patient 2's chart revealed the patient was admitted on 12/14/15 for "encounter for full term+" and discharged on 12/16/15. Review of the discharge summary in the patient's chart revealed the discharge summary was incomplete in that there was no date, time, or discharge diagnosis. On 3/16/16 at 3:50 p.m., Manager 1 verified the findings.

Based on observations and interviews, the hospital failed to ensure that its staff removed expired patient supplies from the Emergency Care Department and from the pharmacy.

The findings are:

On 03/14/16 at 3:35 p.m., random observations in the Emergency Care Department revealed expired supplies that consisted of a 3 millimeter endotracheal cuff tube dated 02/2016; pediatric electrodes dated 01/16; no date or label on a bin of open electrodes, and expired sutures in Operating Room 9 dated 01/2015 and 01/2016.



30011

On 03/14/16 at 3:15 p.m., random observations in the pharmacy revealed (22) Exacto mix empty Eva bags expired 08/15. On 03/14/16 at 3:15 p.m., the findings were verified by Director 7.

Based on personnel record review and interview, the hospital failed to ensure the Dietary Director was employed full-time with the authority and delegated responsibility by the governing body to oversee the operation of the dietary services.

The findings are:

On 3/18/16 at 3:00 p.m., the Dietary Director revealed that he/she is not a full time employee of the hospital, but is a contracted employee through .....Management Specialists, Incorporated. On 3/18/16 at 3:15 p.m., Manager 4 verified the finding, and reported that he/she thought the food service contract/agreement was enough.

Based on interview, review of the hospital's governing body minutes, and review of the hospital's policy and procedure for its Nutrition Protocol, the hospital failed to ensure its Registered Dieticians were granted diet-ordering privileges by the hospital's medical staff for 7 of 7 Registered Dieticians (RD). (RD 1, 2, 3, 4, 5, 6, and 7)

The findings are:

On 3/15/16 at 11:15 a.m., the Dietary Director revealed the hospital's dieticians are allowed to prescribe patient diets as well as physicians. On 3/15/16 at 12:40 p.m., Manager 5 verified the hospital's Dietary Managers prescribe patient diets.

On 3/17/16 at 2:00 p.m., review of the hospital's governing body minutes revealed the hospital's governing body had no documentation granting RD 1 diet-ordering privileges.

On 3/17/16 at 2:01 p.m., review of the hospital's governing body minutes had no documentation that RD 2 had been granted diet-ordering privileges by the hospital's governing body.

On 3/17/16 at 2:02 p.m., review of the hospital's governing body minutes had no documentation that RD 3 had been granted diet-ordering privileges by the hospital's governing body.

On 3/17/16 at 2:03 p.m., review of the hospital's governing body minutes had no documentation that RD 4 had been granted diet-ordering privileges by the hospital's governing body.

On 3/17/16 at 2:04 p.m., review of the hospital's governing body minutes had no documentation that RD 5 had been granted diet-ordering privileges by the hospital's governing body.

On 3/17/16 at 2:05 p.m., review of the hospital's governing body minutes had no documentation that RD 6 had been granted diet-ordering privileges by the hospital's governing body.

On 3/17/16 at 2:06 p.m., review of the hospital's governing body minutes had no documentation that RD 7 (Manager) had been granted diet-ordering privileges by the hospital's governing body.

On 3/17/16 at 2:20 p.m., Manager 4 verified the hospital's Registered Dieticians had not been granted privileges to order patient diets by the hospital's governing body.

Hospital's policy and procedure, titled, "Nutrition Protocol", reads, "Registered Dieticians (RD's) at Spartanburg Medical Center are authorized to write Registered Dietician protocol orders per the guidelines and conditions listed below.....".

Based on observations, interview, and review of the hospital's equipment inspection program policy and procedure, the hospital failed to repair and/or replace broken equipment located in the kitchen area and failed to promote safety in the kitchen area by using a lower oven for storage while the top oven is operational.

The findings are:

On 3/14/16 from 3:07 p.m. - 3:40 p.m., random observations in the kitchen area revealed 027-refrigerator #4 (3 large doors) labeled not in use. Oven # 560 (sitting under oven # 559 in use) was not labeled, but was verified as not working and used for storage. Oven 560 was filled with paper products: tissue, bowls, plates, 4 cans of Pam 17 ounces and Splenda 9.7 ounces. Oven # 21 was labeled not in use. A Star Pro-Max grill (penny press) was verified as out of order but not labeled.

On 3/15/16 at 10:16 a.m., random observations in the pots and pans dish wash area revealed heavy water droplets from the build up of condensation on the ceiling tiles. The ceiling tiles had an numerous black specks throughout the dish wash area. On 3/15/16 at 10:16 a.m., the Chef verified the findings reporting that it's coming from the steam in the dishwasher. On 3/15/16 at 10:37 a.m., Facility Maintenance 1 verified the exhaust hood was checked recently and presented a work order dated 12/23/15 that had no staff signature, no date, and or hours to indicate task completion. Facility Maintenance 1 verified the heavy condensation and black specks on the ceiling tiles.

On 3/15/16 at 11:36 a.m., the Dietary Director revealed he/she has no work orders for the multiple out of use equipment. Facility Maintenance 1 acknowledged he was not able to get parts for many of the items because of the age of the equipment and some of the equipment has been broken greater than 4 years now.

On 3/14/16 at 2:48 p.m., random observations in the kitchen area revealed a medium size plastic bin filled with contents of an unlabeled white substance, multiple opened containers that included: 17.5 lbs.(pounds) canola oil, 18 oz. (ounces) McCormick cinnamon, 16 oz. imperial pure exact vanilla, and 32 oz. Monarch red food color with no label with the opened date, a large plastic bin filled with contents of an unlabeled white substance that was located near the handwash sink, Oven # 00559 had dark black dried grease on the inner racks, a sticky substance covered the oven windows blocking visibility, and the lower oven was used for storage. On 3/14/16 at 3:06 p.m., Executive Chef 111 verified the findings, and stated, "The medium sized plastic bin is sugar and the large sized plastic bin is flour, but the label must have rubbed off over time".

On 3/14/16 at 3:41 p.m., random observations in the kitchen area revealed the star pro-max grill, the high batch - turbo chef cooker /oven, and the warming cabinet on wheels- flavor hold had large amounts of black sticky substances. On 3/14/16 at 3:47 p.m., Chef verified the findings.

On 3/14/16 at 3:25 p.m., random observations of Cooler #34 revealed an opened bag of blue cheese labeled with an expiration date of 3/8/16, Freezer #0006 had an opened bag of chicken wings that had no label with the opened date and 3 clear bottles near grill #280 that had no labels: 1 with yellow liquid and 2 with white liquid. On 3/14/16 at 3:38 p.m., Retail 11 Manager verified the findings and acknowledged the bottles were "butter, oil, and water".

On 3/15/16 at 10:37 a.m., Executive Chef 111 presented a request letter for replacement of the multiple broken items in the kitchen, and also acknowledged not having a cleaning schedule for the kitchen, but will have one in place starting now.

Hospital's policy and procedure, titled, "Equipment Inspection Program", reads, "Complete the Equipment Inspection Checklist monthly. Perform the following checks of each item and any or all supporting parts or connection. Visual inspection to determine that the unit is in good condition, is not being used beyond its safe operating limits, and is effectively fulfilling its intended use..... Identify repairs needed. Monitor completion of repairs."

Based on observations, interview, and review of the hospital kitchen temperature logs, the hospital failed to ensure accurate documentation of the refrigerator temperature logs and adequate temperature controls for food storage areas. (Refrigeration Unit #12 and Grill # 280 lower rack refrigeration drawer # 2)


The findings are:


On 3/14/16 at 2:14 p.m., random observations during a tour of the kitchen area with the dietary Director revealed Refrigeration Unit #12's temperature log's last documented entry was dated 3/11/16. The log was missing updates for 3/12/16, 3/13/16 and 3/14/16. On 3/15/16 at 11:00 a.m., random observations during a revisit of the kitchen area revealed Refrigeration Unit #12's temperature log had been updated with the missing temperature data for 3/12/16, 3/13/16, 3/14/16, and for 3/15/16 for the a.m. data. On 3/15/16 at 11:00 a.m., the Catering To You Associate 1 verified the information and reported that he/she was unable to explain the entries. On 3/15/16 at 11:00 a.m., both the dietary Director and the Patient Service Manager verified the findings acknowledging the inaccurate documentation.

On 3/14/16 at 3:30 p.m., random observations of the grill # 280 lower rack refrigeration drawer # 2 revealed there was no thermometer present to monitor the temperature and no log available for review. The drawer revealed a half pan (full size) of uncooked hamburger patties and 1 large full pan of raw seasoned chicken. On 3/14/at 3:30 p.m., Retail Manager 11 verified the findings and removed both the pans of hamburger patties and chicken.

The hospital policy and procedure, titled, "Storage Times and Temperature", reads, "Temperature of food storage areas and cold food vendors are monitored and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies....Each mechanically refrigerated unit storing potentially hazardous food shall be provided with a numerically scaled indicating thermometer, accurate to -/+3 degrees Fahrenheit, located to measure the air temperature in the warmest part of the unit and located to be easily readable. Recording thermometers, accurate to -/+3 degrees Fahrenheit, may be used in lieu of indicating thermometers.....Each morning at opening and evening at closing, record temperature of each storage unit.....If storage unit thermometer readings are not accurate, contact maintenance to repair."

Based on observations, interviews, and review of the hospital's policy and procedures, the hospital failed to ensure 4 of 12 Registered Nurses(RN) cleaned equipment between patients (RN 1, 2, 8, and 67), and 5 of 12 Registered Nurses failed to use acceptable gloving and hand hygiene techniques during provision of patient care to prevent potential cross contamination of infectious agents in the hospital setting (RN 3, 4, 5,and 21), 1 of 1 Certified Registered Nurse Anesthetist (CRNA) failed to clean the septum on the medication vials when administering intravenous medications, 1 of 1 Registered Respiratory Therapist (RRT 1) failed to disinfect equipment between patients, and staff failed to follow policies for management and labeling for refrigeration of breast milk for 3 of 3 bottles of unlabeled breast milk, and observations in the hospital kitchen of uncovered foods and foods present outside of their expiration dates that present the potential for contamination and food borne illnesses.


The findings are:


On 03/18/16 at 10:10 a.m., observations of RN 67 administering medications revealed RN 67 transported medication cart into the random patient room. RN 67 administered the patient's medications, but failed to clean the medication cart after exiting the patient's room. On 03/18/16 at 10:43 a.m., RN 67 reported, "I wipe down the medication cart at the beginning of the shift and at the end of the shift." On 03/18/16 at 10:42 a.m., RN Manager 12 revealed, "The medication cart is wiped down doing night shift."



37024

On 3/14/016 at 4:40 p.m., random observations in the medial intensive care unit revealed RN 21 touched the inside of a trash can, but failed to perform hand hygiene and apply new gloves prior to administering a medication via the patient's central venous catheter. On 3/17/2016 at 4:45 p.m., RN 21 revealed, "We wash our hands before we come into the room and before we leave the room."

Review of the hospital policy and procedure, titled, "Hand Hygiene", revealed, "...The WHO refers to these as the "5 Most Important Moments for Hand Hygiene...B. Before A clean or aseptic procedure...E. After touching the patient's surroundings including equipment or devices...".



37212

On 3/15/16 at 10:55 a.m., observations in the hospital's Neonatal Intensive Care Unit (NICU) with RN 26 revealed RN 10 failed to perform hand hygiene prior to providing care of Patient 37. RN 26 verified the findings.

Review of the hospital's policy, titled, "Breast Milk Management", original date 1993, effective date 10/14, reads, "Thawing and Warming of Breast milk, Policy: 4. Slow thawing may be done in the refrigerator. These bottles must be dated, timed, and discarded if not used within 24 hours. Policy: 6. Breast milk cannot be refrozen if thawed."

On 3-17-16 at 10:30 a.m., observations in the Neonatal Intensive Care Unit (NICU) with RN 26 revealed a refrigerator used for Breast milk storage. Observation of the refrigerator contents revealed three bottles of breast milk without labels documenting the date and the time of the removal of the bottles of breast milk from the freezer to the refrigerator. RN 26 verified the findings.

Review of the hospital's policy, Number IM1200.412 , titled, "Standard Precautions", original date 11/95, effective date 10/16, reads, ". . . Hand washing with soap and water or the use of a waterless hand sanitizer is necessary before donning and after removal of personal protective equipment, before and after direct patient contact. . .".



36397

On 3/14/16 at 2:14 p.m., random observations during a tour of the kitchen area revealed a tray of bread rolls uncovered on the work station center aisle and a large bin of uncovered plastic supplies for patient use: cups and tops located on the lower shelf at the tea station. On 3/14/16 at 2:33 p.m., Executive Chef 111 verified the findings.

On 3/14/16 at 2:35 p.m., random observations of Cooler #9 revealed an uncovered rack of bacon carried to the cook station to prep for bacon, lettuce, and tomato sandwiches. On 2:37 p.m., Infection Prevention 1 verified the findings.

On 3/14/16 at 2:43 p.m., random observations of Cooler # 18 revealed an opened package of ham labeled with an expiration date of 3/14/16. On 3/14/16 at 2:43 p.m., Patient Service Manager verified the findings.

On 3/15/16 at 10:47 a.m., random observations in the kitchen area revealed 1 small pan labeled grilled turkey with an expiration date of 3/14/16. On 3/15/16 at 10:47 a.m., Executive Chef 111 verified the findings, stating, "Oversight, out of sight, out of mind".








30011

On 03/15/16 at 11:00 a.m., random observations of a respiratory treatment revealed Registered Respiratory Therapist (RRT 1) entered the patient's room with a computer on wheels and after the patient's treatment, the computer on wheels was transported from the patient's room without disinfection. On 03/15/16 at 11:10 a.m., RRT 1 revealed, "I clean the machine in the mornings when I use it".



31395

On 03/14/16 at 2:40 p.m., observations in the Emergency Care (EC) Department revealed RN 1 obtained a patient's temperature with an oral thermometer and then, replaced the oral thermometer in the holder. RN 1 called another patient to the triage room and used the oral thermometer to obtain the patient's temperature. RN 1 failed to disinfect the oral thermometer between patient use. On 03/14/16 at 2:51 p.m., RN 1 stated, "We try to clean each thing that touch the patient between each patient use. The entire thing gets wiped down a couple of times a shift."

On 03/14/16 at 3:00 p.m., observations in the Emergency Care Department revealed RN 2 placed a blood pressure cuff and pulse oximetry probe on the patient, and then used an oral thermometer to obtain the patient's temperature. RN 2 disinfected the blood pressure cuff and the oral thermometer, but did not disinfect the pulse oximetry probe used on the patient. RN 2 called another patient into the triage room and placed the pulse oximetry probe on the patient. RN 2 failed to disinfect the pulse oximetry probe between patients.

On 03/15/16 at 10:22 a.m., observations in the Emergency Care Department revealed RN 3 removed soiled gloves and donned clean gloves, but failed to perform hand hygiene after removing the soiled gloves.

On 03/15/16 at 10:23 a.m., observations in the Emergency Care Department revealed RN 4 donned clean gloves, palpated the patient's left antecubital area,cleaned the antecubital area with an alcohol pad, palpated the antecubital site, and inserted the Jelco intravenous catheter. RN 4 failed to clean the antecubital site after the second palpation and prior to insertion of the Jelco catheter.

On 03/15/16 at 10:30 a.m., observations in the Emergency Care Department revealed RN 5 donned clean gloves, palpated the patient's right antecubital area, cleaned the antecubital area with an alcohol pad, palpated the antecubital site, and inserted the Jelco catheter. RN 5 failed to clean the antecubital site after the second palpation and prior to insertion of the Jelco catheter.

On 03/16/16 from 9:45 a.m. through 10:21 a.m., observations in Operating Room 9 revealed Certified Registered Nurse Anesthetist 1 failed to disinfect the rubber septum of new vials of medication opened at 9:45 a.m., 10:00 a.m., and 10:21 a.m. The findings were verified by Nurse Educator 1. On 03/16/16 at 10:05 a.m., Nurse Educator 1 reported the new vials should also get wiped with an alcohol pad.

On 03/16/16 at 3:45 p.m., observations on 6 North revealed RN 8 took the glucose meter and clear plastic container with alcohol pads and lancets into the patient's room. RN 8 performed a finger stick on the patient. RN 8 completed the task and returned the glucose meter to the dock and placed the clear plastic container on top of the shelf. RN 8 failed to disinfect the equipment and container after the patient use and prior to returning the equipment to a clean area.

Hospital policy and procedure, titled, "Cleaning and Sanitation in Clinical Areas", reads, "...non-critical items are cleaned and low-level disinfected-items that contact intact skin-patient care equipment that does not touch mucous membranes or sterile body systems-clean when visible soiled and after each patient use...".

Hospital policy and procedure, titled, "Donning and Removing Personal Protective Equipment (PPE)", reads, "...Standard Precautions requires the use of Personal Protective Equipment (PPE) for direct or indirect contact with blood or body fluids, non-intact skin or mucous membranes of all patients....Personal Protective Equipment includes: eye protection (glasses, goggles, or face shields), masks, shoe, and leg covers, fluid resistant gowns or cover coats and gloves.

Based on patient record review and interview, the hospital failed to ensure a follow up history and physical was completed for 1 of 6 surgical patient charts reviewed. (Surgical Patient 7)

The findings are:

On 03/16/16 at 11:36 a.m., review of Patient 7's record revealed the patient had a "Right Colon Resection with lighted Ureteral Stents" performed on 03/6/16. Review of Patient 7's chart revealed an "Immediate Pre Procedural History and Physical Update Exam" revealed the box on the for identified as "no substantive changes" was not checked by staff and the section for "H& P Updates" was blank with no documentation. On 03/16/16 at 11:38 a.m., Nurse Manager 12 stated the update should have been completed.

Based on observations and interview, the hospital failed to ensure its staff was trained for non-medical emergencies such as fire training for 2 of 2 hospital staff members. (Environmental Service (EVS 1) and Patient Care Assistant (PCA 1)

The findings are:

On 3/16/16 at 10:46 a.m., during an interview with EVS 1, he/she was unable to verbalize safety on fire training and protocol. When given the acronym of "race" and "pass", EVS 1 was unable to verbalize the acronyms used for fire. On 3/16/16 at 10:50 a.m., Infection Prevention 1 witnessed the findings.

On 3/17/17 at 10:52 a.m., during an interview with PCA 1, he/she was unable to verbalize safety on fire training and protocol. On 3/17/16 at 10:54 a.m., PCA 1 reported that he/she could not remember the last fire training, stating, "I am a diabetic and my sugar is up a little. I think it is aim, pull fire extinguisher, and all that".