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Based on medical record review, review of facility radiology documentation, review of facility meeting minutes, review of facility mission statements and interviews, the facility failed to ensure that significant safety data was incorporated to the facility Quality Council. The finding includes:

Review of dosimetry reports dated 12/2016 to 8/2017 identified that multiple staff exceeded hospital ALARA (as low as reasonably achievable) investigation level 1 (125mRem/quarter or 500mRem/year) or level 2 (375mRem/quarter or 1,500 mRem/year) for one or more readings. Five radiology staff exceeded the quarterly allowable limit for the eye lens dosage in accordance with the State of Connecticut Administrative regulation of 1250mRem/quarter. Interview with the Director of Radiology on 8/22/17 at 10:08 AM noted that dosimetry reports were discussed at the radiation safety meetings and corrective action would be put into place when a reading was at or above the ALARA levels. Review of the radiation safety meeting minutes dated 5/31/16 to 5/31/17 lacked specific documentation for exceedances of staff radiation levels and/or remediation's. Review of Quality and Safety Council meeting minutes dated 5/31/16 to 5/25/17 lacked documentation regarding dosimetry badges. Interview with the Director of Quality on 8/23/17 at 8:24 AM identified that the Radiation Safety Committee reported to the Environment of Care Committee which in turn reported to the Quality and Safety Council. She further indicated that the Environment of Care Committee reported on "quality metrics" and that staff radiation exposure was not a quality metric. The Hospital Quality Safety Plan identified that the Quality and Safety Council is the working body that oversees organization- wide performance improvement, safety and risk management. The ECC meets monthly and oversees safety initiatives to include radiation safety. The Quality and Safety Council is responsible for enhancing alignment with hospital wide commitment to safety.

Based on a clinical record review, staff interviews and a review of the hospital's policies and procedures for one sampled patient (Patient #201) the hospital failed to ensure that nursing staff conducted a comprehensive assessment of a pressure ulcer when it was identified. The finding included:


Patient #201 was admitted to the hospital on 4/30/17 and underwent a heart transplant on 5/1/17. Patient #201's diagnoses included ischemic cardiomyopathy, congestive heart failure, pulmonary nodules, lupus anticoagulant disorder and a history of myocardial infarction. Patient #201 was discharged to home on 5/22/17 and was readmitted on 5/26/17 with shortness of breath and extremity edema. Patient #201 was alert and oriented, reported difficulty ambulating and had been incontinent of liquid stools on readmission. On 5/26/17 a nurse's note indicated Patient #201 had a pink coccyx bruise and a Braden score of 18, identifying the patient was at risk for pressure ulcer development. On 6/1/17 at 9:00 PM the nurse's notes indicated a deep tissue injury of the coccyx was present. Barrier cream and a consult with the wound nurse was ordered. On 6/2/17 a wound nurse identified a deep tissue injury of the coccyx that measured 0.5 centimeters (cm) by 0.5 cm by 0.1 cm that was maroon in color. Interview on 8/23/17 at 9:00 AM and review of the clinical record with APRN #202 (wound care nurse) failed to identify that a measurement and staging of the wound was conducted on 6/1/17 at 9:00 PM when the deep tissue injury was noted. APRN #202 indicated it was the responsibility of the Registered Nurse to complete measurements and staging when the wound was identified on 6/1/17.

The hospital policy entitled Assessment Prevention and Treatment of Wounds and Pressure Ulcers Protocol directed a Braden score would be completed in the clinical record on admission, daily and with changes in condition. Interventions would be individualized and based on risk. Appropriate pressure redistribution devices for the bed and chair would be implemented. Turning and repositioning of at risk individuals would be conducted at least every two hours. When patients were up in a chair, repositioning would be implemented every hour. A limit time of two hours in a chair was the recommendation. Barrier products, toileting or incontinence containment would be conducted as appropriate. The application of foam dressing to high risk areas would be utilized. If a pressure ulcer was identified the nurse would document the wound with measurements in a parameter, stage the wound, initiate skin precaution orders if not completed previously, place a wound care consult for verification of staging and choose a dressing from the dressing guideline. The policy further identified educate would be provided to the patient and the family regarding the importance of preventative measures to reduce risk and document the teaching in the plan of care.

Based on clinical record review, staff interviews and a review of the hospital's policies and procedures for one sampled patient (Patient #201) the hospital failed to conduct, implement and/or document interventions to prevent pressure ulcer development in accordance with the plan of care. The finding included:

Patient #201 was admitted to the hospital on 4/30/17 and underwent a heart transplant on 5/1/17. Patient #201's diagnoses included ischemic cardiomyopathy, congestive heart failure, pulmonary nodules, lupus anticoagulant disorder and a history of myocardial infarction. Patient #201 was discharged to home on 5/22/17 and was readmitted on 5/26/17 with shortness of breath and extremity edema. Patient #201 was alert and oriented, reported difficulty ambulating and had been incontinent of liquid stools on readmission. On 5/26/17 a nurse's note indicated Patient #201 had a pink coccyx bruise and a Braden score of 18, identifying the patient was at risk for pressure ulcer development. On 6/1/17 at 9:00 PM the nurse's notes indicated a deep tissue injury of the coccyx was present. Barrier cream and a consult with the wound nurse was ordered. On 6/2/17 a wound nurse identified a deep tissue injury of the coccyx that measured 0.5 centimeters (cm) by 0.5 cm by 0.1 cm that was maroon in color.

Interview on 8/23/17 at 9:30 AM and review of the clinical record with APRN #202 (wound care nurse) indicated Patient #201 was at risk for the development of pressure ulcers on admission. Individualized skin interventions were implemented in the plan of care that included a low air loss bed, a chair cushion, turning and repositioning every two hours and a foam dressing to the sacrum. On 6/1/17 a deep tissue injury was identified on the coccyx (0.5 cm by 0.5 cm by 0.1 cm). Further interview and review of the nursing flow sheets with APRN #202 on 8/23/17 at 9:45 AM failed to identify that interventions for the prevention of pressure ulcer development were conducted and/or documented on 5/28/17 from 10:00 PM through 5/29/17 at 7:25 AM (9 hours and 25 minutes), and on 5/29/17 from 8:32 PM through 5/30/17 at 8:20 AM (11 hours and 48 minutes), and on 5/31/17 from 8:03 PM through 6/1/17 at 8:00 AM (11 hours and 57 minutes). APRN #202 indicated interventions to prevent pressure sore development should have been conducted at least every two hours and documented in the clinical record and were not.

Interview and review of the clinical record with APRN #202 on 8/23/17 at 10:00 AM identified that Patient #201 was in a chair on 6/1/17 at 8:25 AM, 10:07 AM, 10:28 AM, 2:24 PM, 3:00 PM, 3:30 PM, 4:16 PM, 6:15 PM, 6:48 PM, 7:51 PM, 11:00 PM, and on 6/2/17 at 1:00 AM. Documentation failed to indicate that a chair cushion was utilized until 6/2/17 at 8:15 AM. Further interview with APRN #202 indicated although it was the choice of Patient #201 to sit in a chair a pressure relieving cushion should have been utilized and documented in the clinical record in accordance with the plan of care.

The hospital policy entitled Assessment Prevention and Treatment of Wounds and Pressure Ulcers Protocol directed a Braden score would be completed in the clinical record on admission, daily and with changes in condition. Interventions would be individualized and based on risk. Appropriate pressure redistribution devices for the bed and chair would be implemented. Turning and repositioning of at risk individuals would be conducted at least every two hours. When patients were up in a chair, repositioning would be implemented every hour. A limit time of two hours in a chair was the recommendation. Barrier products, toileting or incontinence containment would be conducted as appropriate. The application of foam dressing to high risk areas would be utilized. If a pressure ulcer was identified the nurse would document the wound with measurements in a parameter, stage the wound, initiate skin precaution orders if not completed previously, place a wound care consult for verification of staging and choose a dressing from the dressing guideline. The policy further identified educate would be provided to the patient and the family regarding the importance of preventative measures to reduce risk and document the teaching in the plan of care.

Based on observation, review of hospital documentation, review of policies and procedures and interviews the hospital failed to ensure that dosimetry badges were exchanged monthly per hospital practice and/or that staff radiation exposure did not exceed national guidelines and/or that appropriate signs were posted during ionizing procedures and/or that the required annual training was documented as provided for all radiology staff and/or that that staff was informed when radiation doses exceeded acceptable levels and/or that radiation policies included dosimetry badges for use/monitoring and/or that the personnel radiation safety was reported to the hospital-wide quality assurance council all of which resulted in condition level non-compliance.

Please see A-535, A-536, and A-538.

Based on medical record review, review of facility radiation documentation, review of facility policies and interviews the facility failed to ensure that radiation policies were comprehensive. The finding includes:

On 8/22/17 and 8/23/17, review of staff dosimetry reports during the period of 1/1/16 to 8/16/17 identified that dosimetry badges were to be read on a monthly, quarterly and yearly basis by the contracted company for all appropriate radiology staff. The review also identified that MD's #201 through #208 (Interventional Radiologists) had exceeded radiation exposure levels for the monthly and/or quarterly and/or yearly ALARA (as low as reasonably achievable) levels 1 or 2 on one or multiple occasions. The reports noted instances of dosimetry badges worn for greater than one month and/or not turned in timely. Interview with the RSO (Radiation Safety Officer) on 8/22/17 at 10:11 AM indicated that the facility followed NCRP (National Council on Radiation Protection and Measurements ) guidelines, staff stored their badges in the breakroom when not working and all staff utilized one badge that was placed on their lead thyroid shield. He/she further indicated that staff were to return their badges for a new badge on a monthly basis. A policy related to dosimetry badges to include badge donning, distribution, storage and maximum permissible radiation doses could not be provided by the facility as requested on 8/22/17 and 8/23/17. In addition, the policy for radiation safety lacked direction for the unequivocal use of leaded protection when performing ionizing radiation emitting procedures.

Based on a tour of the radiation department, observations and interviews for two areas in the radiology department IR (interventional radiology) and cardiac IR, the facility failed to ensure that appropriate safety signs were posted and/or that all radiation procedure doors positively latched. The findings include:

a. A tour of the cardiac interventional radiology department was conducted on 8/22/17 at 10:25 AM with the Manager of Cardiac IR. Observation on 8/22/17 at 11:28 AM identified that the department had 4 procedure rooms (A, B, C and D) and the sign for "Radiation Area" was posted on all 4 main procedure room doors instead of the required x-ray radiation signage. In addition, signage was lacking on the side entrance door to room C and the technician entry door to room A. Interview with the Manager of Cardiac IR noted that she was unaware of the wrong signage or the need for the two signs that were lacking. The facility did not have a policy related to radiation signage.

b. Tour of the radiology department failed to identify that conspicuously posted radiation signs were observed for one of the entrances for PET/CT in room 280, and one of the entrances for radiation oncology.

According to R.C.S.A 19-24-8 (5)(C), each area or room in which sources of ionizing radiation other than radioactive materials are used shall be conspicuously posted with the sign or signs bearing the radiation caution symbol and appropriate wording to designate the nature of the source.

c. A tour of the cardiac IR department was conducted on 8/22/17 at 10:25 AM with the Manager of Cardiac IR unit. Observations on 8/22/17 at 11:54 AM identified that the main doors to procedural rooms B and C would not close completely and/or automatically latch upon closure. Interview with the Director of Engineering on 8/23/17 at 10:00 AM noted that all doors to the procedure rooms should latch automatically, the doors were subsequently fixed on 8/22/17 and radiology staff should have been filed out an electronic work order when the doors did not close as required.

Based on a tour of the radiology department, review of facility policies, observations and interviews the facility failed to ensure that infection control procedures/practices were followed. The findings include:

a. A tour of the Cardiac IR (interventional radiology) unit was conducted on 8/22/17 with the Manager of the Unit. Observation at 10:37 AM noted a cardiac procedure in progress in Room A. The observation further identified a male staff member in the room assisting MD #201 donned with a surgical mask and hair covering. Short facial hair was noted to be exposed at both sides of the mask (start of beard). The Circulator Nurse was also observed in the room with her hair exposed at the sides and not completely contained beneath the surgical cap. Interview with the Manager of the Unit on 8/2/217 at 10:42 AM indicated that staff should follow the same policy for hair coverage that is practiced in the OR (operating room) and that Cardiac IR did not have a separate policy to address proper procedure room attire.

b. Observation of Cardiac IR Room B, during a procedure on 8/22/17 at 11:54 AM identified RN #205 with her hair exposed at the sides of the bouffant hair covering.

The facility policy for perioperative dress code identified that disposable hood must be worn to cover long sideburns, long neckline and beards. The policy further directed the selected hair covering must cover all head hair.

c. Observation of Cardiac Procedure Room A on 8/222/17 at 12:00 PM identified that the room was being cleaned between patients and disposable surgical attire to include shoe covers were observed in a waste receptacle inside of the room as well as several areas of blood located on the procedure room floor. The observation further noted seven dried blood shoe/sneaker prints that exited from Room A to the patient recovery area. Interview with the Unit Supervisor (RN #1) on 8/22/17 at 12:11 PM indicated that the prints were from MD #1 and MD #1 did not wear shoe covers. The facility policy for perioperative dress code identified that impervious protective coverings be used whenever gross contamination by blood or body fluids can reasonably be anticipated.

The Condition of Participation for Discharge planning has not been met.

Based on a clinical record review, staff interviews and a review of hospital policies and procedures for one of five sampled Patients (Patient #201), the hospital failed to ensure the discharge planning process involved a comprehensive determination of an appropriate post-hospital destination.

Please refer to A800

Based on a clinical record review, staff interviews and a review of hospital policies and procedures for one of five sampled Patients (Patient #201), the hospital failed to complete a comprehensive discharge plan to ensure the prevention of adverse health consequences upon discharge. The finding included:


Patient #201 was admitted to the hospital on 4/30/17 and underwent a heart transplant on 5/1/17. Patient #201's diagnoses included ischemic cardiomyopathy, congestive heart failure, pulmonary nodules, lupus anticoagulant disorder and a history of myocardial infarction. Patient #201 was discharged to home on 5/22/17 and readmitted to the hospital on 5/26/17 for the treatment of heart failure. Patient #201 was discharged on 6/7/17 to a skilled nursing facility. On 6/27/17 Patient #201 was readmitted to the hospital after imaging revealed two large cavitary lesions in his/her left lung. A lung biopsy was positive for mucourmycosis and the patient underwent a left thoracotomy pneumonectomy. Further imaging identified evidence of a right lung lesion concerning for mucor. Patient #201 also developed a skin lesion that was concerning for disseminated mucor. The patient's renal and pulmonary status declined and Patient #201 expired on 7/20/17. The certificate of the death identified disseminated mucormycosis as the immediate cause of death and although the source/cause of the infection could not be determined, the organism of mucor would be present in a home undergoing renovations/construction zone.


Review of the pre-heart transplant patient education dated 10/5/16 indicated that Patient #201 had received education regarding heart transplant. Part of the education directed that construction in the home for the first year post-heart transplant was contraindicated.


Review of the initial discharge plan status post heart transplant dated 5/5/17 identified physical therapy had recommended short term rehabilitation. However Patient #1 wanted to be discharged to a family member's home with visiting nurse services.


Review of a progress note dated 5/10/17 identified Patient #201 disclosed to LCSW #1 that construction was currently in progress at his/her family member's home where the patient would be discharged to. Patient #201 identified there was another room in the home that he/she could stay in but wanted to be sure it would be a safe discharge. Further review of the progress note indicated LCSW #201 identified he/she would speak to the patient's family member regarding the risk of active construction in the home and would discuss the discharge plan with the transplant team. LCSW #201 indicated after these discussions he/she would follow up with Patient #201.


Review of the nursing progress note dated 5/11/17 indicted Patient #201 and his/her family member were provided post heart transplant education by RN #203. The patient's family member confirmed that construction was currently in progress in the home. The family member identified the "deconstruction" was completed and he/she was in the process of putting up the walls. The plan was for the patient to reside upstairs and away from the construction.


Interview with RN #203 on 8/23/17 at 10:30 AM and LCSW #201 on 8/23/17 at 11:30 AM identified physical therapy ultimately indicated Patient #201 did not require short term rehabilitative services and the discharge plan changed to the family member's home with visiting nurse care. When LCSW #201 and RN #203 became aware of the active construction in the family member's home on 5/11/17 they informed APRN #201, the nurse practitioner on the transplant team, as transplant patients are not allowed to be discharged into a construction zone for one year after surgery.


Interview with APRN# 201 on 8/23/17 at 12:00 PM indicated the construction in the family member's home was discussed in a treatment team meeting in the presence of MD #209, who was the Director of the Heart Failure Program. It was decided that discharging Patient #1 into this environment was acceptable due to the later part of the construction phase and that the patient would be residing in a separate part of the home.


Interview with MD #209 on 8/22/17 at 2:00 PM identified he/she could not recall a discussion regarding Patient #1's discharge to a construction zone.


Interview with Case Coordinator # 201 on 8/23/17 at 10:00 AM identified he/she was the discharging Case Coordinator on 5/22/17 and indicated he/she could not recall that construction was an issue in the home. Further interview with Case Coordinator #201 identified it was his/her practice to review all of the progress notes prior to discharge including rehabilitative services, medical staff, nursing, social work staff, and the transplant team. Case Coordinator #201 indicated if he/she had any concerns she would have notified the provider and could not explain why the potential risk to the patient was not documented at the time of discharge.


Interview with Nurse Manager #201 (Case Management) on 8/23/17 at 10:15 AM indicated it was an interdisciplinary responsibility to ensure a safe discharge. Nurse Manager #201 would expect the discharging Case Coordinator to inform the provider with any concerns regarding a safe discharge and document the rationale/information in the clinical record.


Interview and review of the clinical record with the Director of Quality on 8/23/17 at 2:15 PM failed to identify that a discussion regarding the risk and/or safety for the discharge of Patient #1 into a construction zone was documented.


Interview with the Director of Infectious Disease on 8/23/18 at 2:00 PM indicated he/she was not aware that Patient #201 was discharged into an environment with construction. Further interview with the Director of Infectious Disease identified he/she would not have recommended Patient #1's discharge into a construction zone at any phase of construction after a heart transplant due to the risk of infection in an immunosuppressed patient.


The hospital policy entitled Case Coordination Department Care Discharge Planning Policy directed in part the case coordinator would complete an initial assessment within 1-2 business days of an inpatient admission. The assessment would include a review of the patient's diagnosis, treatment plan and potential discharge needs. Any information related to discharge planning would be documented in the clinical record. The care coordinator would gather additional information through interviews with the patient, consultation with the family, consultation with the health care team and contact with known community agencies. Once a thorough assessment was completed the case coordinator would develop a discharge plan. After gaining consensus regarding the discharge plan, documentation in the clinical record would include all relevant communications and plans. The case coordinator would re-assess the patient's discharge plan on an ongoing basis through clinical progression rounds and through discussion with the health care team. If there were factors that may affect the appropriateness of the post-acute discharge plan, the case coordinator would modify the plan.