HospitalInspections.org

Based on document review, observation, and interview, it was determined that for 2 of 3 patients' (Pts. #20 and #21) records reviewed on the 5NE Surgical Unit, the Hospital failed to ensure that the registered nurse evaluated the effectiveness of the nursing care provided for pain management.

Findings include:

1. The Hospital's Clinical Care Guidelines for "Pain Assessment and Management" (dated December 2019), was reviewed on 9/30/2020 and required, "...Reassess and document pain to evaluate the effectiveness of pain management interventions as determined by the individual patient status/need... The time for reassessment after a pharmacologic intervention is dependent upon the patient, the route of administration and the anticipated time to peak effect of the mediation. Recommended times to reassess include: a) Intravenous/Subcutaneous: 15-30 minutes b) Oral/Rectal: 60-120 minutes..."

2. The clinical record of Pt. #20 was reviewed on 9/29/2020. Pt. #20 was admitted on 9/28/2020 with a diagnosis of abscess of the right thigh. The record included a physician's order, dated 9/28/2020 at 8:06 PM, for Tramadol (pain medication) 50 mg (milligrams) orally every 6 hours for breakthrough pain. The nursing flowsheet indicated that Pt. #20 rated pain at a score of 10 (out of 10 = worst possible pain) on 9/29/2020 at 6:46 AM. The medication administration record indicated that Pt. #20 received a 50 mg oral dose of Tramadol on 9/29/2020 at 6:46 AM. The record lacked documentation of pain reassessment within 120 minutes after administration of oral pain medications.

3. The clinical record of Pt. #21 was reviewed on 9/29/2020. Pt. #21 was admitted on 9/27/2020 with a diagnosis of chest pain on breathing. The record included a physician's order, dated 9/28/2020 at 12:07 AM, for Acetaminophen (pain medication) 1000 mg intravenously every 8 hours as needed for moderate pain. The nursing flowsheet indicated that Pt. #21 rated pain at a score of 5 on 9/28/2020 at 4:30 PM. The medication administration record indicated that Pt. #21 received 1000 mg dose intravenously on 9/28/2020 at 4:32 PM. The record lacked documentation of pain reassessment within 30 minutes after administration as required for intravenous pain medications.

4. On 9/29/2020, at approximately 2:25 PM, an interview with the Registered Nurse (E#27) was conducted. E#27 stated that pain should be reassessed within 60 to 120 minutes for PO (oral) medications and within 15-30 minutes for IV (intravenous) medications.

Based on document review and interview, it was determined that for 2 of 2 patients (Pts. #15 and #16) in the NICU (neonatal intensive care unit), the Hospital failed to ensure that vitals signs were monitored hourly during a blood transfusion in accordance with policy.

Findings include:

1. The Hospital's policy titled, "Blood Component Therapy" (effective 9/22/2020), was reviewed on 9/29/2020 and required, "...To administer blood... take the patient's temperature, pulse, respiratory rate, and blood pressure and record them in the patient's medical record... Monitoring the patient... Vital signs along with signs and symptoms of transfusion reaction are assessed and documented after the first 15 minutes of administration and hourly until completion administration..."

2. The clinical record of Pt. #15 was reviewed on 9/29/2020. Pt. #15 was admitted on 9/17/2020, with a diagnosis of Trisomy 18 (a condition that causes severe developmental delays due to an extra chromosome 18). Pt. #15 had a physician's order, dated 9/25/2020 at 11:04 AM, to transfuse 16 ml (milliliters) of RBC (red blood cells). The transfusion record indicated that the blood transfusion was started on 9/25/2020 at 10:30 PM and was completed on 9/26/2020 at 1:30 AM. The record lacked documentation of the patient's blood pressure on 9/26/2020 between 12:00 AM and 1:30 AM (1 hour and 30 minutes).

3. The clinical record of Pt. #16 was reviewed on 9/29/2020. Pt. #16 was admitted on 8/29/2020, with a diagnosis of 25 weeks prematurity. Pt. #16 had physician's orders, dated 9/28/2020 at 3:47 PM and 3:48 PM, to transfuse 10 ml of RBCs. Pt. #16 received a blood transfusion on 9/28/2020 from 10:30 PM to 9/29/2020 1:30 AM. The transfusion record lacked documentation from 11:30 PM to 1:30 AM (2 hours) of blood pressure and temperature. Pt. #16 received a second blood transfusion on 9/29/2020 from 5:30 AM to 8:30 AM. The record lacked documentation of the patient's temperature and blood pressure from 5:45 AM and 7:30 AM (1 hour and 45 minutes).

4. An interview was conducted with NICU Nurses (E #4 and E #5) on 9/29/2020, at approximately 11:35 AM and 11:45 AM. E #5 stated that a complete set of vital signs should be documented hourly during the transfusion and should include temperature, blood pressure, heart rate and respirations. E #4 and E #5 could not find documentation in the record for the missing vitals for Pts. #15 and #16.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on September 29 - October 1, 2020, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on September 29 - October 1, 2020, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

A. Based on document review, observation, and interview, it was determined that for 1 of 8 isolation supply carts on the Medical Intensive Care Unit (MICU), the Hospital failed to ensure that staff's personal belongings (E #2) were not stored in an isolation supply cart, with clean supplies, potentially contaminating the supplies.

Findings include:

1. On 9/29/2020, the Hospital's policy titled, "Standard and Transmission Based Precautions, Use of Personal Protective Equipment," effective 3/16/2020, was reviewed. The policy included, "C. Isolation Carts/ Isolation Supply Holders - 1. Isolation carts for patients in TBP [transmission-based precautions] in the intensive care units (ICU) will be stationed outside the room..." The policy did not include what should be and should not be included in the isolation supply cart.

2. On 9/29/2020 at 10:00 AM, an observational tour was conducted in the MICU. There was 1 of 8 isolation carts outside of room #634. Inside the top drawer, with clean isolation supplies, was a note book binder with a name (E #2) on it. There was also a paper bag containing a surgical mask.

3. On 9/29/2020 at 10:05 AM, an interview was conducted with the MICU's Patient Care Director (E #6). E #6 stated that staff's personal belongings should not be stored in the isolation supply cart.



39802


B. Based on document review and interview, it was determined that for 1 of 1 Respiratory Therapist (E #30), the Hospital failed to ensure methods for preventing and controlling the transmission of infection within the hospital by not disinfecting a device used for a patient (Pt. #33) before being returned to a clean area.

Findings include:

1. On 10/1/2020, the Hospital's, "Guide for Disinfection of Equipment Used on Patients or Patient Care Areas - COVID-19," (dated 4/26/2020), was reviewed. The Guidelines included cleaning/disinfecting "Work Station on Wheels (WOW)/ Interpreter Devices... Daily..." The guidelines failed to include instruction to disinfect the WOW scanner after each patient use.

2. On 9/30/2020 at approximately 1:55 PM, during a tour of the Pediatric Intensive Care Unit (PICU), a Respiratory Therapist (E #30) took a scanner from the WOW to record Pt. #33's identity and then set the scanner on a table in Pt. #33's room. When E #30 left Pt. #33's room, E #30 picked up the scanner and returned the scanner to the WOW, without disinfecting the scanner. The WOW was taken back into the clean Respiratory Supply Room.

3. On 9/30/2020, at approximately 2:15 PM, an interview was conducted with the Respiratory Therapist Director (E #31). E #31 stated that the scanner should have been disinfected before being returned to the WOW.

A. Based on document review, observation, and interview, it was determined that for 1 of 3 operating room (OR) staff (E #16) observed, the Hospital failed to ensure that earrings were not exposed in restricted areas of the OR as required by policies governing surgical care to maintain standards of medical practice and patient care.

1. The Hospital's policy titled, "Surgical Services Traffic Flow and Surgical Attire Infection Control Practices" (effective 10/10/2019), "...Jewelry must be confined within surgical attire..."

2. During an observational tour of the Perioperative Area on 9/30/2020, at approximately 9:25 AM, OR#8 was being setup for a surgical procedure. The sterile field was opened and the Circulating Nurse (E #16) had 3 stud earrings exposed on her left ear and 1 stud earring exposed on her right ear.

3. An interview was conducted with the Director of Perioperative Services (E #20) on 9/30/2020, at approximately 10:45 AM. E #20 stated that button earrings were okay to wear in the OR and were not required to be confined. E #20 stated that this should be reflected in the Hospital's surgical attire policy.


B. Based on document review, observation, and interview, it was determined that for 1 of 2 operating room (OR) setup observed (OR #3 and OR #8), the Hospital failed to ensure that the operating table was adequately cleaned prior to room preparation as required by policies governing surgical care.

Findings include:

1. The Hospital's policy titled, "Operating Room Environmental Cleaning" (effective 12/18/2018), was reviewed on 9/30/2020 and required, "...Personnel Responsibilities... f) Operating table ... 4) Disinfect the reusable safety strap..."

2. During an observational tour of the Perioperative Area on 9/30/2020, at approximately 9:25 AM, OR#8 was being setup for a surgical procedure. There were clean linens and supplies on the operating table. The operating table safety strap had two strips (approximate size 1-inch by 6-inch) of sticky residue that contained white lint and other debris.

3. An interview was conducted with the Registered Nurse/RN (E #16) on 9/30/2020, at approximately 9:26 AM. E #16 stated that the room was already cleaned and they were ready to start setting up the sterile field.

4. On 9/30/2020 at approximately 9:35 AM, an interview was conducted with the OR Service Line Coordinator (E #19) . The afore mentioned findgins were discussed with E #19. E #19 stated, "We need to clean this." E#19 had the RN (E #16) attempt to remove the adhesive residue with alcohol. E #16 could not remove the residue. E #19 stated, "We'll need to use adhesive remover or change the entire belt." E #19 stated that the belt should have been cleaned or replaced during turnover before the room was setup for the next procedure.


C. Based on document review, observation, and interview, it was determined that for 1 of 2 staff (E #17) observed donning sterile attire in the OR (operating room), the Hospital failed to ensure that staff dried hands and arms prior to donning the sterile gown as required by policies governing surgical care.

Findings include:

1. The Hospital's policy titled, "Surgical Hand and Antisepsis/Hand Scrub" (effective 7/1/2019), was reviewed on 10/1/2020 and required, "...The scrub person must thoroughly dry hands and arms after the anatomic time scrub method before donning the gown to prevent organisms on the wet skin from soaking through and contaminating the sterile gown. This soaking through, known as strikethrough allows microorganisms from the wet skin or scrub attire to contaminate the sterile gown..."

2. During an observational tour of the Perioperative Area on 9/30/2020, at approximately 9:25 AM, OR #8 was being setup for a surgical procedure. At approximately 9:40 AM, the Surgical Technician (E #17) walked into the room with wet hands and arms and drops were seen dripping from E #17's elbows. E #17 picked up the sterile gown and put it on without first drying her hands and arms.

3. An interview was conducted with the Medical Director of Infection Prevention (MD #2) on 10/1/2020 at approximately 2:00 PM. MD #2 stated that hands and arms should be dried with a sterile towel prior to putting on the sterile gown.

Based on document review, observation, and interview, it was determined that for 1 of 1 (Pt. #33) reviewed for respiratory treatment, the Hospital failed to ensure that respiratory services were delivered as required by policy.

Findings include:

1. The Hospital's policy titled, "Aerosol Medication Delivery by Metered Dose Inhaler" (effective 9/23/2014), was reviewed on 10/1/2020 and required, "...Prior to beginning treatment: A. Assess: 1. HR [heart rate] & RR [respiratory rate]. 2. Breath sounds. 3. Peak flows 4. State of consciousness. 5. Ability to cough, and 6. The breathing pattern... H. Reassess HR, RR, PFR, and breath sounds following treatment. Assess change in patient's breathing pattern and ability to cough... Chart findings specific to therapy in the computer charting system..."

2. The electronic clinical record of Pt. #33 was reviewed on 9/30/2020 at approximately 1:35 PM, with the Respiratory Therapist (E #30). A physician's order, dated 9/30/2020 at 7:00 AM, indicated that Pt. #30 should receive albuterol inhaler treatments of 8 puffs every 2 hours. The medication administration record indicated that Pt. #30 received albuterol treatments on 9/30/2020 at 8:00 AM, 10:00 AM, and 11:09 AM. There were no respiratory assessments documented in the record for these treatment times.

3. During an observation of a respiratory treatment on the PICU (Pediatric Intensive Care Unit) on 9/30/2020, at approximately 1:54 PM, the Respiratory Therapist (E #30) entered Pt. #33's room to administer the albuterol treatment. E #30 did not auscultate the patient's breath sounds before or after the treatment was completed.

4. An interview was conducted with the Respiratory Therapist (E #30) on 9/30/2020 at approximately 1:36 PM. E #30 stated that respiratory assessments are required with each treatment and should be documented right away in the electronic health record. E #30 stated that he documented the patients vital signs on a piece of paper. E #30 could not produce the document at the time of the interview. During a second interview on 9/30/2020, at approximately 2:00 PM, E #30 stated that he should have listened to the patient's breath sounds before and after the treatment.