HospitalInspections.org

Based on medical record review and interview, the facility does not always obtain informed consent prior to a medical procedure. (Patient#60)

Findings Include:

Medical Record review on 11/08/13, failed to find documented evidence of a signed informed consent prior to a cardiac catheterization that was performed on 10/26/13.

Interview with Staff #1 on 11/08/13 indicated written patient consent should be obtained prior to cardiac catheterization.

Based on observation and interview the hospital failed to ensure exhaust fans in the facility were functioning.
Findings include:
During the facility tour on 11/04/13 exhaust fans in the following areas were not functioning:
- 3 West - restroom next to room 300
- Restroom 02WD89
- Housekeeping closet 02WBB94
- Toilet room 02WB93A
- Shower room 02EB38

During interview with Staff #31 on 11/05/13 it was noted that the non-functional exhaust fans were due to an electrical issue.

Based on observation and interview the facility does not maintain all sterilization equipment.
Findings include:
During the facility tour on 11/05/13 it was revealed, in Central Processing, that the stainless steel panels at the top of the cart washer on the clean and dirty side, were not in place. The absence of these panels would allow air to flow from the space the cart washer occupies, to the clean side.
At the top of the cart washer a large volume of steam was venting from the machine. There was an appreciable accumulation of condensation on the ceiling, which was unsealed drywall, and was forming water droplets.
The ceiling on the clean side of the cart washer, in the area where the stainless steel panels would be placed, had evidence of damage due to moisture.
Along the side of the cart washer there were three blue storage bins.
During interview with Staff #31 on 11/05/13 it was confirmed that the stainless steel panels at the top of the cart washer were not in place.

Based on observation and interview, the facility failed to ensure that air monitor equipment is maintained in good repair.
Findings include:
During the facility tour on 11/04/13 it was observed in airborne infection isolation rooms (AIIR) 02BE13A and 02SBW16 that the air sensors inside each room were painted over.
Interview with Staff #31 on 11/04/13 confirmed that the air sensors in the above noted rooms were painted over.
During the facility tour on 11/04/13 it was observed, in the operating room suite, that 5 of 8 air monitor indicators did not indicate the correct air relationship. The air monitor indicators outside of rooms 5 and 6 had no bulb illuminated. The air monitor indicator outside of rooms 1, 2 and 4 had the " alarm " instead of "normal" illuminated.
During interview with Staff #31 on 11/04/13 it was stated that all operating rooms were in the correct pressure relationship with the corridor, but that the indicators were not working correctly.

Based on policy and medical record review, during an inpatient-to-inpatient transfer, the facility does not always provide the receiving facility with all required information. Specifically, there is no evidence of a transfer order, the patient's status and pertinent medical information. (Patient #70)
Findings Include:
Review on 11/08/13 of policy #PM.6 "Discharge Planning", revised 07/2013, revealed no patient who requires continuing health care services in accordance with the patient ' s discharge plan may be discharged until such services are secured or determined by the hospital to be reasonably available to the patient. Patients are transferred with necessary medical information to appropriate facilities, agencies, or outpatient services, as needed for follow-up or ancillary care.

Review on 11/08/13 of policy "Guidelines for Completing the Adult Patient-Resident Discharge Form (KH00505)", revised 4/2011, revealed that the form should be completed for all patients being sent to another facility outside of Kaleida Health. The original copy is kept with the medical record and a copy is sent with the patient to the receiving facility. Information documented on this form includes (but is not limited to): name of receiving facility, allergies, family notification of discharge, advanced directives, mental status and assistive device(s).

Review of Patient #70's medical record on 11/08/13 revealed the following:

- On 10/11/13 the patient was admitted to the hospital with a diagnosis of congestive heart failure exacerbation
- An Interim Discharge Summary, dictated by the physician on 10/16/13, revealed a past medical history of congestive heart failure, coronary arterial by-pass graft with atrial septal repair, systolic biventricular heart failure, type II diabetes, schizoaffective disorder bipolar type, anemia, hyponatremia, chronic obstructive pulmonary disease and paroxysmal atrial fibrillation. While hospitalized the patient has had erratic behavior: cursing and physically abusive to staff. He has an allergy to Haldol. He is currently on 1:1 observation waiting for an inpatient psychiatric bed at another hospital.
- The Medicine Attending note, dated 10/22/13 and timed 11:38am, indicates "psych is arranging transport to another hospital. "
- A Psychiatry Resident ' s note, dated 10/22/13 and timed 12:00pm, indicates " awaiting inpatient transfer to inpatient psych once bed is available.
- An Attending Physician note, dated 10/22/13 and timed 12:20pm, indicates the patient needs inpatient stabilization.
- A Medicine note, dated 10/22/13 and timed 2:10pm, indicates Staff #2 approved a sitter until the patient is transferred to inpatient psych.
- A Nursing note, dated 10/22/13 and timed 6:09pm, revealed the patient was discharged to a psychiatric unit at another hospital via ambulance with security assistance.
- No documentation was found that medical information such as laboratory studies, allergy status or patient assessments were sent with the patient on transfer.
- Review of Discharge Instructions, dated 10/22/13, revealed medical and psychological diagnoses and with instructions to follow-up with the hospital physician and primary physician in 5 to 7 days. Discharge medications are listed but allergies are not. The document is signed at 5:07pm by the patient and nurse. This document is for a discharge to home. It does not correctly indicate that the patient was transferred to another facility for inpatient psychiatric care
- Review of the Discharge Summary Addendum, dated 10/24/13 (2 days post discharge), instructs the patient to follow up with his psychiatrist, take all his medications, follow up with the cardiologist and come to the emergency department with increased shortness of breath, cough, fever, chills, leg swelling and visual/auditory hallucinations. This document is for a discharge to home. It does not correctly indicate that the patient was transferred to another facility for inpatient psychiatric care