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Based on clinical record review, policy and procedure review and interview, it was determined the nursing staff failed to administer medication (Norco and Ibuprofen) in accordance with physician orders for three of three (#20, #22 and #24) post-partum clinical records reviewed. Failure to administer medication according to physician orders for severity of mild (score of 1-3) or moderate (4-6) pain did not assure pain response was managed as ordered by physician. The failed practice affected Patient #20, #22 and #24 and was likely to affect all patients treated on the post-partum unit. The findings were:

A. Review of three of three post-partum clinical records on 11/30/16 revealed the following:
1) Patient #20 was admitted to inpatient status on 11/28/16 at 1958. Physician orders for pain management: Hydrocodone-acetaminophen (Norco 5 mg (milligram)-325 mg oral tablet), one tab (tablet) oral every 4 hours PRN (as needed) for pain-moderate 4 to 6 routine. First dose 11/28/16 at 2326; Ibuprofen (Motrin) 800 mg, tab, oral, every 8 hours PRN for pain-mild 1 to 3, routine, first dose 11/28/26 at 2326. Review of the medication "flowsheet" revealed Norco and Ibuprofen were documented as administered at the same time for pain on 11/30/16 at 0724 and 11/29/16 at 1351. The pain score was in the moderate range and there was no separate physician order to administer the Norco and Ibuprofen together. The above findings were confirmed by the Director of Post-partum at the time of review on 11/30/16 at 1100.
2) Patient #22 was admitted to inpatient status on 11/28/16 at 1115. Physician orders for pain management: Hydrocodone-acetaminophen (Norco 5 mg-325 mg oral tablet), one tab oral every 4 hours PRN for pain-moderate 4 to 6 routine. First dose 11/28/16 at 2154; Ibuprofen (Motrin) 800 mg, tab, oral, every 8 hours PRN for pain-mild 1 to 3, routine, first dose 11/28/26 at 2154. Review of the medication "flowsheet" revealed Norco and Ibuprofen were documented as administered at the same time for pain on 11/29/16 at 1822 and 11/30/16 at 0833. The pain score was in the moderate range and there was no separate physician order to administer the Norco and Ibuprofen together. The above findings were confirmed by the Director of Post-partum at the time of review on 11/30/16 at 1330.
3) Patient #24 was admitted to inpatient status on 11/28/16 at 1056. Physician orders for pain management: Hydrocodone-acetaminophen (Norco 5 mg-325 mg oral tablet), one tab oral every 4 hours PRN for pain - moderate 4 to 6 routine. First dose 11/28/16 at 1233; Ibuprofen (Motrin) 800 mg, tab, oral, every 8 hours PRN for pain-mild 1 to 3, routine, first dose 11/28/26 at 1233. Review of the medication "flowsheet" revealed Norco and Ibuprofen were documented as administered at the same time for pain on 11/29/16 at 1946. The pain score was in the moderate range and there was no separate physician order to administer the Norco and Ibuprofen together. The above findings were confirmed by the Director of Post-partum at the time of review on 11/30/16 at 1330.

B. On 11/30/16 at 1400, the Director of Post-partum stated the physician preference on the post-partum unit was for Norco and Ibuprofen to be administered together. The Clinical Educator stated the staff received education regarding the use of NSAIDs in pain management. On 12/01/16 a copy of the facility pain management education was provided by the Assistant Chief Nursing officer. The "Non-opioid Analgesics" section included the statement "Unless contraindicated, a non-opioid should be considered in all analgesics regimens even if pain is serve enough to require an opioid."

C. Review of Pain Management policy statement on 12/01/16 revealed "It is the health care professional's responsibility to accept and respect the patient's report of pain and to proceed with an appropriate assessment and treatment."

Based on policy review and interview, it was determined the Dietary Policies and Procedures were not specific to the facility. The failed practice did not ensure the policies and procedures were up to date and reflected the current practices of the facility and had the potential to affect any patient receiving dietary services. Findings follow.

A. Review of Dietary Policies revealed the following:
1) Policy titled "Facility Health and Security Screenings (sample)" stated under Dry Storage, "Comply with the general visitor procedures, which include; (List account expectations);" and "The following requirements are associated with this vendor type (List requirements)" No account expectations or requirements were listed.
2) Policy titled "Food and Supply Storage Procedures" stated, "Store dry and staple items at least ____ above the floor and ____ from walls and ____ from ceiling, consistent with local food protection codes." Under "Refrigerated Storage" stated "Store food items ____ above the floor, ____ from the walls, and ____ from the ceiling, consistent with local food protection codes." Under "Frozen Storage" stated, "Store food items ____ above the floor, ____ from the walls, and ____ from the ceiling, consistent with local food protection codes and at a temperature not greater than 0 F."
3) Policy titled "Departmental Food Requisition" stated, "The department must fill out a copy of the requisition form and forward it to the Food and Nutrition Services Department/Dining Services by ____ (time)." Policy also stated, "Emergency items, needed before the designated delivery times, may be obtained if the requesting department presents the requisition form at the store room during the storeroom hours of _______, waits for storeroom personnel to assemble the items, and transports items to the department."
4) Policy titled "Production Support of Trayline/Steamtable" stated under "Hot Production Area" "Deliver hot food to trayline or workstation no more than 15 minutes prior to the start of service. Record temperature on Taste/Temperature Record. Times: B:____ L:____ D:____." Policy also stated under "Cold Production Area" "Deliver cold food to trayline or workstation. Record temperature on Taste/Temperature Record. Times: B:____ L:____ D:____."
5) Policy titled "Consultant Dietitian" stated, "Completes a Consultant Dietitian Report and submits it to the Director no more than ____ days following a visit."
6) Policy titled "Malnutrition and the Hospitalized Patient" stated, "The Registered Dietitian Nutritionist collaborates with other healthcare professional in the development of an organization approved definition for Malnutrition. (SPECIFY YOUR CRITERIA). Informs the LIP (Licensed Independent Practitioner) when a patient meets the organization's criteria for malnutrition (DEFINE YOUR PROCESS HERE)." No criteria or processes were defined in the policy.
7) Policy titled "Orientation and Initial Training" stated "The orientation includes at least: review of emergency procedures, patient confidentiality, infection control and hand washing, Zero Tolerance Policy, and department processes that are a part of the volunteer's assigned tasks. Documentation of the orientation is maintained by __________."
8) Policy titled "Pest Control" stated, "Pest control services are provided by _______ Schedule________."
9) Policy titled "Solid Waste Disposal" stated, "Place trash and garbage directly into designated receptacles: Food waste ____ Nonfood waste _____ Glass, china, cans _____ Tray tickets____." Policy also stated, "When necessary, empty trash bin into dumpster located on _____; rinse trash bins with hot water hose located near dumpster, and tilt to drain water."
10) Policy titled "Storage of Pots, Dishes, Flatware, Utensils" stated, "Remove carbon build up from pots on a _____ basis (per local regulatory agent)."
11) Policy titled "Employee Fire Emergency Guidelines" stated, "If someone is burned, call unit _____, at extension ____ or ____ for assistance."
12) Policy titled "Retail Services Policies" stated "Discounts are authorized by facility/community administration for food sold to employees are honored. Authorized discount _____%."
B. Review of policy manual also revealed numerous policies pertaining to long term care foodservice, which were not applicable to this facility.
C. During an interview on 12/01/16 at 0920, the Foodservice Director confirmed the policies were not specific to that facility.

Based on observation and interview, it was determined the facility failed to maintain one (rear exit corridor of the gift shop) of two means of egress in the gift shop free from all obstructions and impediments to full and instant use in case of fire or other emergency. The failed practice had the potential to affect all visitors and staff to the gift shop because rapid egress through the exit corridor was blocked. Findings follow:

A. While on tour of the facility on 11/30/2016 at 0955, one of three tables was observed blocking the exit door from the exit corridor in the rear of the gift shop to the adjacent corridor in the hospital.
B. While on tour of the facility on 11/30/2016 at 0955, the exit door at the end of the exit corridor in the rear of the gift shop was latched.
C. During the tour, the Director of Plant Operations verified the means of egress was blocked.

Referenced code: NFPA 101, 2012 edition, Section 7.1.10.1. See K211.

Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in two (in the basement above door B020 near room ME014 and above the fire-rated doors outside of the gift shop) of twelve areas observed by protecting penetrations in the barrier with a system or material capable of restricting the transfer of smoke. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While touring the facility on 11/30/2016 at 0910, a wire penetrating the smoke and fire barrier above the door designated as B020 near room ME014 was not sealed with a material capable of limiting the transfer of smoke from one side of the barrier to the other.
B. While touring the facility on 11/30/2016 at 1005, the space around three of eight electrical conduits and one of one electrical junction box penetrating the fire and smoke rated wall above the door near the front of the gift shop was not sealed with a material capable of limiting the transfer of smoke from one side of the barrier to the other.
C. During the tour, the Director of Plant Operations verified the penetrations were not sealed with a material capable of restricting the transfer of smoke from one side of the barriers to the other.

Referenced code: NFPA 101; 2012 edition, Section 8.4.4.1. See K300.

Based on observation and interview it was determined tape was adhered to four of four IV (intravenous) poles in two of two x-ray rooms. The failed practice did not ensure the IV poles were cleanable and created the potential to affect any patient using those IV poles. Findings follow.

A. During a tour of x-ray rooms on 12/01/16 at 0845, the following was observed.
1) Room #1 - two of two IV poles containing a strip of tape roughly every two inches labeled "x-ray."
2) Room #2 - two of two IV poles containing a strip of tape roughly every two inches labeled "x-ray."
B. During an interview at the time of the tour, the Supervisor of Diagnostic Radiology confirmed the tape on the IV poles.

Based on clinical record review and interview, it was determined the facility failed to assure Operative Reports included the date and time of surgery in two (#30-#31) of five (#27-#31) surgical records and time of surgery in three (#27-29) of five (#27-#31) surgical records. Failure to assure the date and time a surgical procedure took place did not establish a time-line of surgical events in the course of a patient's admission to the facility. The failed practice was likely to affect all surgical patients admitted to the facility. Findings follow:

A. Clinical record review was conducted on 12/01/16 from 0915-1050 and revealed the following:

1) Operative Report dated 11/29/16 for Patient #27 revealed no evidence of the time of the surgical procedure.
2) Operative Report dated 11/09/16 for Patient #28 revealed no evidence of the time of the surgical procedure.
3) Operative Report dated 11/29/16 for Patient #29 revealed no evidence of the time of the surgical procedure.
4) Operative Report for Patient #30 revealed no evidence of the date and time of the surgical procedure.
5) Operative Report for Patient #31 revealed no evidence of the date and time of the surgical procedure.

B. Findings in A were verified by interview with the Chief Quality Officer on 12/01/16 at 1315.