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Based on record review and interview, the facility failed to ensure that 1 of 15 sampled patients (Patient 12) in a universe of 47, was provided the information needed to make an informed decision prior to receiving an epidural anesthetic (anesthesia/pain relief which is inserted into the lower spine with a needle and blocks the nerves of the lower spine causing the lack of feeling). This failure resulted in the violation of Patient 12's rights to make an informed decision regarding the care and treatment which was provided.

Findings:

A record review, on 8/21/12 at 9:50 AM, of Patient 12, indicated that the patient was admitted on 8/21/12 for induction of labor (the use of medications to assist in the initiation of the delivery of the baby). Patient 12 was administered an epidural on 8/21/12.

On 8/21/12, at 9:50 AM, a record review of Patient 12 and a concurrent interview with Registered Nurse (RN) 2 was conducted. Patient 12's medical record did not contain an informed consent by the physician who administered the epidural. RN 2 stated that she was unable to find the informed consent in the medical record.

On 8/21/12, at 10:15 AM, an interview was conducted with Patient 12. The patient stated that she did not sign an informed consent prior to the epidural. Patient 12 also stated that the anesthesiologist (physician who administers the epidural anesthetic medication; the physician's name could not be recalled) was "very rude and didn't explain anything. All she said was 'I'm going to numb you'. I cried and told her I was hurting and she rudely raised her voice and said 'stop crying and moving'." Patient 12 stated that the risks and side effects of the procedure were explained by the nurses.

A record review, on 8/22/12 at 10:35 AM, of the hospital policy titled, "Consent and Informed Consent, reviewed on June 2011," was conducted. The policy indicated the following: "The patient shall be given, by his/her physician, as much information about any proposed treatment of procedure as he/she may need in order to give an informed decision or to refuse the course of treatment. Except in emergencies, this information shall include the following: a) nature of the procedure or treatment b) the expected benefits, risks involved in this treatment, and the risks of refusing to undergo the recommended procedure c) the alternative course of treatment and the associated risks d) the name(s) of the individual(s) who will perform the procedure or treatment."

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Based on interview and record review, the facility failed to ensure that all entries for 4 of 15 sampled patients (Patient 2, 10, 7 and 15) in a universe of 47, were complete and legible.

For Patient 2, there were two (2) separate physician's orders that contained a month and day. There was no year or time recorded.

For Patient 10, the hospital failed to ensure that a physician order was legible, complete, dated and timed.

For Patients 7 and 15, orders, progress notes, or other entries in the medical records were not legible.

These failures had the potential to have patient records be misread or misinterpreted increasing the risk of patient harm.

Findings:

1. A review of the physician's orders for Patient 2, on 8/22/12, revealed two separate orders on 8/21/12 that included an incomplete date of "8/21". There was no time recorded on the orders.

During a concurrent interview with Charge Nurse 1 for Patient 2, she verified that the two physician's orders did not contain a year or a time. She stated that all physician's orders are supposed to have an accurate date and time.

A record review, on 8/23/12 at 10 AM, of the hospital's "Medical Staff General Rules and Regulations, revised on 8/2/10," indicated, "The physician's orders must be written clearly, legibly and completely, transcribed accurately, dated and timed ..."

2. A record review, on 8/21/12 at 11:40 AM, indicated that Patient 10 was admitted on 8/11/12 with a diagnosis which included gallstones (solid crystal deposits which form in the gallbladder {an organ which stores bile which are needed for digestion} and contributes to pain).

A record review, on 8/21/12 at 11:40 AM, of Patient 10's physician's telephone order, obtained by a registered nurse (RN) on 8/13/12 at 9:27 AM, did not contain a legible physician signature and did not contain a date nor time of when the physician signed the order.

During an interview, on 8/21/12 at 11:40 AM, with RN 1, she stated that there was no date or time of when the physician signed the telephone order for Patient 10. She stated that the physician's signature was not legible.

A record review, on 8/23/12 at 10 AM, of the hospital's "Medical Staff General Rules and Regulations, revised on 8/2/10," indicated the following; "The physician's orders must be written clearly, legibly and completely, transcribed accurately, dated and timed ..."
3. Medical records for Patient 7, reviewed on 8/ 23/12, revealed that the patient was admitted to Ambulatory Services on 8/8/12 for a surgery on the right hand. He was discharged on the same day after recovery.

The entry in the Doctor's Progress Notes, dated 8/8/12, were not legibly written which could have been misread or misinterpreted and led to delayed provision of care and interventions.

RN 3, the nurse in charge of the Ambulatory Services, was requested to read the Physician/ Surgeon's handwriting in the Doctors Progress Notes. She had a hard time reading what was written in the progress notes.

4. A review of the Doctor's Progress Notes for Patient 15, dated 8/22/12, revealed that Patient 15 was referred to the Physician/Surgeon by the attending Physician.

On 8/23/12 at 10:30 AM, RNs 5 and 6 in the medical/ surgical unit were requested to read the Physician/ Surgeon's handwriting on the Doctor's Progress Notes. The two nurses helped each other to read what was written on the Doctor's Progress Notes. Both stated, "It's hard to read."

During a subsequent interviews with RNs 5 and 6, it was confirmed that the handwriting of the Physician / Surgeon was difficult to read.

The Medical Staff Bylaws approved by Board of Directors on May 27, 1998 and revised on January 25, 2012 was reviewed and read in part, "Progress Notes: Must give legible, pertinent, chronological report of the patient's course of treatment reflecting any changes in condition and the results of treatment."

Based on interview and record review, the facility failed to ensure that 1 of 14 sampled patients (Patient 12) in a universe of 47, had a history and physical exam documented in the medical record, prior to the patient having an epidural (anesthesia/pain relief which is inserted into the lower spine with a needle and blocks the nerves of the lower spine causing the lack of feeling). This failure had the potential for Patient 12's overall condition or possible allergies to not be disclosed prior to the procedure which could contribute to negative outcomes from the treatment for the patient.

Findings:

A record review, on 8/21/12 at 9:50 AM, of Patient 12, indicated that the patient was admitted on 8/21/12 for induction of labor (the use of medications to assist in the initiation of the delivery of the baby). Patient 12 was administered an epidural on 8/21/12.

A record review, on 8/21/12 at 9:50 AM, indicated that there was no history and physical in Patient 12's medical record.

During an interview, on 8/21/12 at 9:50 AM, with Registered Nurse (RN) 2, she stated that she was unable to find a history and physical for Patient 12. RN 2 also stated, "I usually don't see a history and physical for vaginal deliveries."

A record review, on 8/23/12 at 10 AM, of the hospital's "Medial Staff Bylaws, revised on 1/25/12," indicated, "A medical history and physical be completed and documented for each patient no more than 30 days before or 24 hours after admission, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by a physician."

Based on observation, interviews and record reviews, the hospital failed to ensure that medications were stored in accordance with accepted professional principles when (1) A container of oral barium sulfate suspension was not stored in the medication room. The container labeled, "Banana Smoothie, barium sulfate suspension" (barium is a material used to help visualize organ structures during x-ray procedures) was observed stored in the nutrition pantry with nutritional supplements (2) IV (intra-venous) fluids and Irrigation solutions were stored not according to facility policy. These deficient practices had the potential to result in patient harm for a universe of 47 patients.

Findings:

1. During an observation of the nursing nutrition pantry on the medical floor, on 8/21/12 at 2:50 PM, an unopened 250 milliliter bottle labeled "Banana Smoothie, barium sulfate suspension" was noted in the cupboard with nutritional supplement drinks. The finding was concurrently verified by the Director of Ancillary Services (DAS).

During a concurrent interview with Charge Nurse 1 for the medical floor, she stated that the barium suspension was a medication and should be stored in the med (medicine) room. She further stated that it should not be stored with the nutritional supplement drinks. She stated that the night nurses were responsible for checking the nutrition pantries to ensure that there was nothing stored in the pantry that should not be. She was unable to state why the barium suspension was not locked in the med room.

A review of the hospital's policy titled, "Contrast Media Guidelines" (barium suspension is a contrast media) dated 8/2012, revealed that it was the policy that the pharmacy shall distribute and maintain contrast media. It further stated that contrast media shall only be administered by a currently license: radiologist, physician, RN/radiology nurse or certified technologist.

During an interview with the Director of Pharmacy on 8/23/12 at 10:55 AM, he stated that the contrast media should be under the control of the radiology department. He stated it should be stored in the med room.

During a concurrent interview with the DAS, she confirmed that the barium suspension should be stored in the med room.

There was a potential that the barium suspension labeled "Banana Smoothie" would be given to a patient by an unlicensed staff and the patient could have a negative outcome as a result.

2. On 8/21/12 at 9:40 AM, during the tour of the operating room with the Operating Room (OR) Supervisor and the Director of Anesthesia, it was observed that the facility stored several one (1) liter IV fluids and irrigation solutions in the fluid warmer.

A concurrent interview with the OR Supervisor, revealed that the IV fluids and the irrigation solutions should be stored no more than 14 days.

A random check of the IV fluid and irrigation solution bags from each shelf showed:

Normal Saline (IV fluid solution for fluid and electrolytes. The IV fluid is a liquid to maintain the body normal state) bags dated 6/13, 9/01, 9/09, 9/09.

Lactated Ringers (IV fluid that is isotonic or with the same concentration of materials as with blood and is intended to maintain fluid volume with in the blood stream) bags dated 4/29, 9/01, 8/31.

Normal Saline Irrigating Solution (fluid used to flush body areas of undesired materials) bags dated 6/13, 8/20.

The OR Supervisor explained that there were two OR staff that stocked the warmer. "They probably did not rotate the bags so that the bags with the shorter expiration date will be used first."

The policy and procedure was requested from the OR Supervisor.

The policy and procedure for the use of the fluid warmer in the operating room indicated that, "The IV bags must be labeled with an expiration date of 14 days, after which the bags must be discarded. When stocking the warmer with the new IV bags, the bags must be placed under the current bags."

Upon review of the policy and procedure, the finding was confirmed with the OR Supervisor and the Director of Anesthesia on 8/21/12.

Based on observations, record reviews and staff interviews, the hospital failed to ensure that 1 of 3 patients (Patient 2), reviewed for nutrition care, had a physician ordered diet before sending a diet to the patient and feeding him. For Patient 2, the diet order was NPO (nothing by mouth) when the patient was served and assisted with eating a meal. This failure resulted in the patient being fed a diet when the physician's order was to not feed the patient food by mouth. For a universe of 47 patients, this failure could lead to choking, or may require medical tests to be rescheduled because these tests need to be completed without food.

Findings:

The medical record for Patient 2 was reviewed on 8/22/12. The patient was admitted to the hospital on 8/20/12 with diagnoses that included weight loss and required a gastrostomy tube (a feeding tube that is surgically placed directly into the stomach) placement. A review of the physician's orders on 8/22/12 revealed that the last diet order was, "NPO after midnight", on 8/20/12. The patient had a gastrostomy tube placed on 8/21/12.

During an observation of the patient in his room on 8/22/12 at 10:10 AM, he was noted to have a meal tray at his bedside. This observation was concurrently verified by the registered dietitian (RD).

During an interview with the patient's certified nursing assistant (CNA) 1, on 8/22/12 at 10:35 AM, she stated that she was feeding the patient slowly. She stated that he had eaten his cereal.

During an interview with the RD, on 8/22/12 at 10:40 AM, she verified that there was no diet order for Patient 2 except for the last order on 8/20/12 for NPO after midnight. She instructed CNA 1 to remove the patient's food tray. The RD was unable to explain why Patient 2 was served and fed a diet when the physician's order was for NPO.

A review of the hospital's policy titled, "Diet Orders, Changes and Deletions", dated 6/2011, revealed that diet changes must be in a written order from the patient's physician.

28135


Based on observation, record reviews and interviews, the hospital failed to ensure that there were infection control measures in place to prevent the development of food borne illness and cross contamination with regards to the food service. The hospital failed to have a thorough infection control surveillance system that monitored the conditions and practices of the dietetics services staff. By not having these measures and a thorough surveillance system in place, potentially hazardous foods were stored, prepared and distributed under unsafe and unsanitary conditions for a universe of 47 patients. There was a potential for the continuation of this practice in the absence of identification and remediation.

Findings:

A review of the Nutritional Service's policy titled, "Infection Control Safety Plan" dated 6/2011, revealed that it was the policy of the hospital to establish guidelines to ensure the safety of the staff and patients. It stated that it was the director's responsibility to evaluate the cleanliness of the department and food handling practices. It also stated that these responsibilities included providing safe food service for patients and customers.

1. During the tour of the kitchen on 8/21/12 at 10:15 AM, cut cantaloupe was observed in the walk-in refrigerator.

During a concurrent interview with Dietary Staff 1, he stated that his job duties included cutting the melons daily. He stated that before he cut the melons, he sprayed them with water to remove any dirt. He stated that he did not scrub the skin of the melons before he cut them.

During a concurrent interview with the Director of Food Service, he stated that his staff either sprayed the melons with water or ran water over them in the sink to remove dirt. He stated that the dietary staff did not scrub the skin of the melons before they cut them. He further stated that he was not aware that melons needed to be scrubbed before cutting.

According to the Food and Drug Administration's (FDA) "Guidance for Industry: Guide to Minimize Microbial Food Safety Hazards of Melons; Draft Guidance", dated July 2009, the FDA recommends before cutting, washing the outer surface of the melon thoroughly under running cool tap water to remove sur?face dirt, scrubbing melons with a clean produce brush, and cutting away any bruised or damaged areas before serving.

According to the FDA, melons are classified as a potentially hazardous food because food-borne illness outbreaks have been associated with the consumption of melons. Although not the only route of contamination, edible portions of the melon flesh may be contaminated in the cutting or rind removal process because microbial contamination on the outside rind of the melon may be spread by the knife blade involved in the cutting and/or peeling process.

2. During the tour of the kitchen on 8/21/12 at 11:00 AM, the dish room floor was observed to be painted cement. The paint was worn off in areas and there was an area approximately 15 inches by 15 inches of pitting and worn concrete adjacent to the floor drain.

During a concurrent interview with the Director of Food Service (DFS) and the Director of Plant Operations (DPO), they both verified the findings. Both the DFS and the DPO verified that the dish room floor was not a smooth, easily cleanable surface and created a risk for bacterial harborage resistant to cleaning. They were unable to state why these problems with the floor had not been remedied.

According to the 2009 Food and Drug Administration's Food Code, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. It further states that floors that are of smooth durable construction and that are nonabsorbent are more easily cleanable.