HospitalInspections.org

Based on observation, document review and interview, the facility did not ensure access to patient information was restricted and not easily accessible.

This lapse in the protection of patient information placed patients at risk for the accidental disclosure of their private information to unauthorized individuals and staff.

Findings included:

During observations in the facility's 2 East and 2 West Units on 12/18/19 at 11:00AM, Patient #7's medical record (MR) information was found visible, unsecured and unattended on a portable computer.

This observation was made in the presence of Staff H (Nurse Manager) who confirmed Patient #7's MR information should have been secured.

Observations in the facility's Emergency Department (ED) on 12/19/19 during a tour between 2:00PM and 2:45PM identified the following:

Patient #12's MR information was found visible, unattended and accessible on a portable computer in the hallway near the facility's Fast Track/ED area. The hallway was accessible by staff, visitors and patients. This surveyor was able to click the mouse and visualize Patient #12's MR information.

Patient #13's MR information was also found visible, unattended and accessible on a portable computer in the hallway near the facility's Fast Track/ED area. The hallway was accessible by staff, visitors and patients. This surveyor was able to click the mouse and visualize Patient #13's MR information.

Similar findings of unsecured and unattended patient information were observed for Patient #'s 14 and 15.

These observations were made in the presence of Staff C (Clinical Educator) and Staff M (Director of ED Services), who confirmed the patients' MR information should have been secured.

The facility policy and procedure (P&P) titled "Patient Health Information Privacy Policy," last revised 11/9/16, contained the following statements: "Every inpatient and outpatient of the facility is guaranteed by law to the right of privacy. All facility staff must respect this right and treat all protected health information properly or in the most confidential manner possible. Protected health information can be written or oral, it can be recorded on paper, computer or other media."

Based on observation and interview, the facility did not ensure lancets [pricking needles used to obtain drops of blood] and Angiocatheters [catheters and needles used to access intravenous lines] were secured and not accessible in patient care areas.

This lapse in environmental safety placed patients and visitors at increased safety risk.

Findings included:

Observations in the facility's Emergency Department (ED) on 12/19/19 between 2:00PM and 2:45PM identified the following:

A box containing glucose testing equipment and lancets was found unsecured and unattended in the hallway near the ED/Fast Track area. This hallway was accessible to patients, visitors and staff.

An angiocatheter was found unsecured and unattended on a portable computer in front of Patient Bay #7.

A box containing glucose testing equipment and lancets was found unsecured and unattended on the nursing station counter in the Pediatric Area of the ED.

These observations were made in the presence of Staff C (Clinical Educator) and Staff M (Director of ED Services) who acknowledged the lancets and angiocatheters should have been secured.

During interview of Staff A (Chief Nursing Officer) on 12/19/19 at 2:50PM, Staff A stated that a facility policy or evidence of staff education on the securement of sharps in patient care areas could not be furnished.

Based on observation, medical record (MR) review and interview, in 3 (three) of 4 (four) MRs, the nursing staff did not confirm medication routes or obtain corrected medication orders for patients with NPO [nothing through the mouth] orders.

This lack of verifying medication routes and orders potentially placed patients at risk for aspiration or other adverse outcomes.

Findings included:

The facility's policy and procedure (P&P) titled "Medication Administration," last revised 10/2016 stated the following: "...the RN [Registered Nurse] will check the five (5) rights of medication administration [including the]...right route...a review of orders will be completed by the RN on their shift...nursing will request clarification from the physician for any unclear orders before administering medications."

Review of Patient #5's MR identified the following information: This patient was a 79-year-old admitted on 12/8/19 with a CVA (Cerebral Vascular Accident).

The Nursing Assessment Note dated 12/8/19 at 8:45PM stated that Patient #5 had failed the Dysphagia [swallowing difficulty] Screen and that the physician had ordered for this patient to be NPO and placed on aspiration precautions.

The Speech Pathologist Evaluation Note dated 12/9/19 at 11:00AM documented Patient #5 was a risk for aspiration [choking], and recommended Patient #5 remain NPO for all oral intake. This patient was re-evaluated on 12/11/19 with no improvement, remained NPO, and had a Percutaneous Endoscopic Gastrostomy (PEG) feeding tube placed on 12/14/19.

Four days later, on 12/18/19 at 10:50AM, during observation of Staff E's (Registered Nurse) medication pass, Staff E was observed pouring oral medications [Plavix, Carafate, Lopressor, Pacerone, Multivitamin and Folvite] into a medication cup, then entering Patient #5's room. Patient#5's wife was present when Staff E entered the room with the uncrushed medications. Patient #5's wife stated, "They give him everything in his tube [PEG feeding tube] because he can't swallow." Staff E left the patient's room and crushed the medications. The nurse then administered the medication via the PEG feeding tube at 11:58AM.

This finding was confirmed with Staff C (Nurse Educator) and Staff K (Nurse Manager) at the time of observation.

Review of Patient's #5's Medication Orders identified the following: Plavix 75 mg one time daily, Carafate 1000 mg four times a day, Lopressor 50 mg twice daily, and Pacerone 200 mg one time daily were all ordered via the PEG feeding tube, but the Multivitamin and Folvite tablets were ordered orally (by mouth) once daily.

Review of Patient #5's MAR (Medication Administration Record) revealed that Staff E signed as having administered the Multivitamin and Folvite orally, despite having had crushed and administered the medications via the PEG tube. There was no documented evidence that Staff E had requested clarification about the route of administration from the physician for this NPO patient.

During interview of Staff C on 12/18/19 at 12:45AM, Staff C stated, "The nurse should have gotten the order clarified before giving the medication." On interview of Staff K at this time, Staff K confirmed this finding.

The same unclarified medication orders were found in the MRs for Patients #3 and #4 for review period 12/18/19 to 12/20/19.

Based on observation, document review and interview, in two (2) of five (5) observations of patients receiving Intravenous (IV) medications, nursing staff did not ensure IV tubings were labeled as per facility policy.

This lapse in IV tubing labeling potentially placed patients at increased risk for infection.

Findings included:

Observations in the facility's 2 East and 2 West Units on 12/18/19 and 12/19/19 identified the following:

On 12/18/19 at 11:00AM, Patient#7, admitted with a diagnosis of Sepsis, was observed receiving IV fluids and antibiotics via a primary IV tubing and two IV piggyback tubings that were not labeled with the due dates, indicating when the tubing required changing.

On 12/19/19 at 10:00AM, Patient#9, admitted with a fever and receiving Immunotherapy treatments, was observed with IV tubing used to administer two antibiotics. The tubing was not labeled with the due dates, indicating when the tubing required changing.

These observations were made in the presence of Staff G (Clinical Educator) and Staff H (Nurse manager) who confirmed that all IV tubing should have been labeled with the replacement due dates.

The facility policy and procedure (P&P) titled, "Venipuncture/ Insertion Peripheral Short Catheter for Continuous or Intermittent Infusion, including Site and Tubing Change," last revised 10/2017, instructed staff to "...attach to the tubing a color coded 'Change Label' for the day of the week to be changed, along with the due date [for changing]."

Based on observation, document review and interview, the facility did not ensure: (A) Staff performed hand hygiene; and (B) Staff cleaned patient care rooms in accordance with acceptable standards of infection control and facility policy.

These lapses in infection prevention placed patients, staff and visitors at increased risk for infections.

Findings pertinent to (A):

The facility policy and procedure (P&P) titled, "Hand Hygiene Program," last revised 08/2018, contained the following statements: "Hands must be decontaminated before and after every episode of care that involves direct contact with patient's skin, their food, invasive devices or dressings....Hand rubbing with alcohol-based hand sanitizer: Rub hands briskly covering all surfaces until dry."

Observations in the facility's 2 East and 2 West Units on 12/18/19 and 12/19/19 during a tour identified the following:

On 12/18/19 at 11:00AM, Staff I (Registered Nurse) was observed administering medication to Patient #7. Staff I disconnected the IV piggyback medication from the patient without gloves, then without performing hand hygiene, opened her medication cart, retrieved a saline flush and flushed the patient's IV lock.

During interview of Staff I at the time of the observation, Staff I confirmed this finding.

On 12/19/19 at 10:25AM, Staff N (Environmental Services Aide) was observed exiting Patient #9's room. Staff N applied the alcohol-based sanitizer then proceeded to wave her hands to dry them.

These observations were made in the presence of Staff G (Clinical Educator) who confirmed these findings.
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Findings pertinent to (B):

The facility P&P titled, "Routine Room Cleaning Procedure," last revised 04/2016, directed staff during routine room cleaning to, "...wash hands...remove all garbage and regulated waste...replace liners...If sink in room, clean sink and counter as per policy and procedure and discard rags...spot clean walls if visibly soiled and dust and disinfect window sills..." This policy lacked instruction on when to discard cleaning rags between dirty and clean tasks.

During observations in the facility's 2 East and 2 West Units on 12/18/19 at 11:00AM, Staff N (Environmental Services Aide) was observed cleaning patient Room #203. Staff N wiped the garbage can with a wet towel, then proceeded to wipe the sink, walls and window sill with the same towel, until intercepted by the facility's staff.

These observations were made in the presence of Staff G (Clinical Educator) and Staff H (Nurse Manager) who confirmed this finding.

During interview of Staff O (Director of Environmental Services) and Staff P (Director of Infection Prevention) on 12/19/19 at 1:00PM, both Staff O and Staff P acknowledged that Staff N should have discarded the cleaning rags between dirty and clean tasks.