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Based on observation, interviews and review of policies it was determined the facility failed to ensure patients' right to privacy as evidenced by posting patient's names outside of patient rooms in public view and posting signs on patient room doors indicating medical diagnoses.

The findings include:

Throughout the survey conducted 4/26/10 to 4/29/10 the names of patients were observed outside of patient rooms in public view throughout the north and south campuses.

The hospital produced Policy Number S-021 Dated October 2009 which detailed that the patient's last name and first initial may be used outside the patient door and that "if the patient does not wish his/her name on the placard outside the door, the wish will be honored". The policy did not address any mechanism to obtain the patient's permission to display his/her name in public view.

Patient diagnostic information was observed on numerous patient doors throughout the survey. The hospital produced Policy Number S-021 dated October 2009 which stated "signage should not disclose patient diagnostic information". The following are examples of said signage:

On 4/27/10 at 10:55 AM, a sign stating "vancomycin resistant precautions" was observed on the door of Patient #5's room. A sign stating "seizure" was observed on the door of the next room.

Based on observations throughout units on the South Tower, patient names were on the outside beside each door. Patient Conditions, diagnosis and treatments were noted.

Confidential information on 7 East and 7 West on doors included: " Bleeding Precautions " , " Seizures, " " VRE " (Vancomycin-Resistant Entetococci), and " Aspiration
Precautions " .

Based on observation and interview it was determined the facility failed to ensure patients had the rights to receive care in a safe setting as evidenced by failing to answer a call bell promptly; failing to ensure Optiflex units were locked; and failing to ensure non-licensed personnel were denied access to a medication room.

The findings include:

1. During a tour of the psychiatric unit conducted on 4/27/10 at 8:50 AM the surveyor pushed the call light button in the bathroom of the procedure room in the presence of the nurse manager. At 9 AM there was still no response to the call light. The nurse manager stated "I'm not sure what happened here. It's not working." At 9:05 AM the Unit Clerk was asked if the call light had signaled at his desk. He replied that it had. When asked why he did not respond or page someone to check the call light he stated "I was waiting to see what happened". The nurse manager stated she was "very surprised" by the clerk's actions as he had recently been retrained in call bell protocols.

2. During the initial tour of the hospital conducted on 4/26/10 and in the presence of a Quality Manager, the following Optiflex units containing intravenous (IV) supplies were found to be unlocked:

At 2:15 PM in the Emergency Room, Pediatric/Minor Care area.
At 2:35 PM in the Emergency Room outside of Trauma 2.
At 2:50 PM in the Emergency Room in Core 1.
At 3:18 PM in the Labor and Delivery suite.
At 3:55 PM in the Newborn Intensive Care Unit II.




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3.) During the tour of the facility on 4/26/10 on the 8th floor of the South Tower, in the Medication room, the Optiflex system doors were unlocked. This contained IV fluids.

Interview with the Clinical Director of the unit stated that she didn't know how that happened as they should be locked at all times. It was later learned that it was a software glitch.

4.) During the tour of the facility on 4/26/10 on the 8th floor of the South Tower, housekeeping personnel was asked how they cleaned the medication room. The response was, "I know the code so I just go in and clean the room by myself."

Based on record review and interview it was determined the facility's nursing staff failed to develop and keep current a nursing care plan for two (#5 and #11) of 55 sampled patients.

The findings include:

1. Review of the clinical record 4/27/10 revealed Patient # 5 was admitted to the facility on 4/25/10 with diagnoses of peristomal cellulitis requiring wound care twice daily, urinary tract infection, diabetes mellitus and vancomycin resistant enterococci. In an interview conducted on 4/27/10 at 10:52 AM the charge nurse stated the patient's pain levels were charted as falling between "2" and "8" on a scale of 1 to 10 where 10 was the most severe pain. Review of the record revealed care planning for "impaired physical mobility", "risk for injury", "knowledge deficit", and "discharge planning". The care plan did not address the patient's pain, infection or diabetes. The nurse manager stated "those problems got missed", and the patient "was in isolation due to the infection".

2. Patient #11's, care plan was not complete for identified deficits in activity of daily living. A review of the patient medical record, nursing notes and physical therapy notes confirm a recent stroke symptoms and right sided weakness. The care plan did not address mobility, ambulation, or assistance with grooming.

Interview of the nursing manager was conducted concurrently with the record review. She stated that one would have to go to the therapy notes and the nursing notes to obtain a clear picture of what approaches are being conducted for this patient. A future electronic system will correct this care planning integration.

Based on observation, interviews and record review it was determined the facility failed to ensure drugs and biologicals were prepared and administered in accordance with Federal and State laws as evidenced by failing to ensure syringes were labeled as to strength and dosage, time drawn and initials of the preparer; and failing to date bottles of medications as to date opened or date of expiration.

The findings include:

During the tour of the labor and delivery suites conducted on 4/26/10 at 3:10 AM in operating room (OR) #3 the following were found:
Syringe labeled "anectine" and a syringe labeled "lidocaine Hcl" were found in the anesthesia cart with no strength, dosage or initials as to preparer.
An open bottle of topical lidocaine with no open date or date of expiration.
An open bottle of sevoflurane 250 cubic centimeters (cc) with no open date or date of expiration.

On 4/26/10 at 3:20 PM the following were found in OR#2:

A syringe labeled "anectine 2 grams/10 cc with no initials as to preparer with an illegible date.
An open bottle of benzoin 59 cc with no open date or date of expiration.
An open bottle of sevoflurane 250 cc with no open date or date of expiration.
An open bottle of isoflurane 100 milliliters (ml) with no open date or date of expiration.

On 4/26/10 at 3:25 PM the following were found in OR#1:
A syringe labeled "anectine" with no strength or dosage or initials as to preparer.
An open bottle of hydrogen peroxide with no open date or date of expiration.
An open bottle of povidone iodine 32 ounces with no open date or date of expiration.
An open bottle of Betadine 946 cc with no open date or date of expiration.

The nurse manager and the clinical manager both agreed the items should be labeled and dated.

On 4/27/10 at 9:10 AM the following were found in the anesthesia cart of the treatment room of the psychiatric unit:
Seven syringes labeled "labetalol" with no strength or dosage or initials as to preparer.
Nine syringes labeled "glycopyrrolate" with no strength or dosage or initials as to preparer.

The nurse manager agreed the syringes should be labeled.

The facility produced Policy #IPC 03-04 dated 3/16/10 stated that multi-dose medication/treatment solutions should be dated and initialed when opened (Addendum 1). An infection control policy dated May 16, 2006 for anesthesiology stated "all syringes into which drugs are drawn (filled syringes) will be labeled with the name of the drug it contains and the concentration of the drug, if diluted".

Based on observation, record review and staff interviews it was determined the facility failed to have a medical record service that has administrative responsibility for medical records. The facility failed to employ adequate personnel to ensure prompt completion, filing, and retrieval of records (refer to A0432). The facility failed to ensure that unauthorized individuals cannot gain access to or alter patient records (refer to A0442). The cumulative effect of these systemic problems resulted in the condition of participation not being met.

Based on observation, interviews and review of records it was determined the facility failed to employ adequate personnel to ensure prompt completion, filing, and retrieval of records as evidenced by failing to ensure that medical record personnel were employees of the hospital and allowing county employees access to the medical records.

The findings include:

During the tour conducted on 4/26/10 at 3:05 PM an open and unattended room was observed next to the triage area in Labor and Delivery (L&D). The room was full of hundreds of medical records in plastic milk crates. The nurse manager stated the room was usually locked and "the charts go back and forth between here and the outlying health departments. The charts are transported by county employees or Residents."

On 4/27/10 at 1:45 PM the Clinical Manager stated "the charts go back and forth to sixteen clinics in the AM and the PM" carried by county employees. She stated the bin is locked and taken down to the loading dock of the hospital. The Residents take the charts on occasion to the clinics if needed. The surveyor requested a policy and procedure addressing the transport of medical records by non-hospital employees.

On 4/27/10 at 4 PM the Director, Quality and Accreditation Quality Management stated she had reviewed the process. Shands information goes into the clinic records. The information is not secured in the county employees or residents' cars. The Privacy Office had reviewed the process a year ago but there was no change. The Director stated that the process was being changed immediately, no more would Shands records be in the clinic records. The hand carrying by Resident's would cease immediately. She stated the county employees would no longer have the combination to the door lock and that it had been changed. The hospital did not have a policy addressing the situation.

On 4/28/10 at 8:15 AM the Nurse Manager stated the medical record transfer process had actually "changed last year" but the Shands clerks had not alerted her to the change. She stated the Maternal and Infant Care Medical Director told her the county clerks scan information and place it in the files. The Nurse Manager stated that the county clerks had the combination to the door and that no one watched them while in the medical record room. The medical records contained Shands information. The Director of Nursing stated door lock was changed last night and now only Shands clerks have access.

On 4/29/10 the hospital produced a letter from the Maternity and Infant Care (MIC) Medical Director dated 4/28/10. The letter stated "MIC employs clerks to update the records housed in L&D" and the clerks print patient information (labs, clinic notes, patient vitals etc.) at the hospital and "the clerks take these records directly to L&D, on the same floor, and file them".

Based on observation, review of records and interviews it was determined the facility failed to ensure that unauthorized individuals cannot gain access to patient records as evidenced by allowing non-employees access to patient records, failing to secure said records, and failing to establish a system to protect the confidentiality of medical information.

The findings include:

During the tour conducted on 4/26/10 at 3:05 PM an open and unattended room was observed next to the triage area in Labor and Delivery (L&D). The room was full of hundreds of medical records in plastic milk crates. The nurse manager stated the room was usually locked and "the charts go back and forth between here and the outlying health departments. The charts are transported by county employees or Residents."

On 4/27/10 at 1:45 PM the Clinical Manager stated "the charts go back and forth to sixteen clinics in the AM and the PM" carried by county employees. She stated the bin is locked and taken down to the loading dock of the hospital. The Residents take the charts on occasion to the clinics if needed. The surveyor requested a policy and procedure addressing the transport of medical records by non-hospital employees.

On 4/27/10 at 4 PM the Director, Quality and Accreditation Quality Management stated she had reviewed the process. Shands information goes into the clinic records. The county employees had the combination to the door lock. The information is not secured in the county employees or residents' cars. The Privacy Office had reviewed the process a year ago but there was no change. The Director stated that the process was being changed immediately, no more would Shands records be in the clinic records. The hand carrying by Resident's would cease immediately. She stated the county employees would no longer have the combination to the door lock and that it had been changed. The hospital did not have a policy addressing the situation.

On 4/28/10 at 8:15 AM the Nurse Manager stated the medical record transfer process had actually "changed last year" but the Shands clerks had not alerted her to the change. She stated the Maternal and Infant Care Medical Director told her the county clerks scan information and place it in the files. The Nurse Manager stated that the county clerks had the combination to the door and that no one watched them while in the medical record room. The medical records contained Shands information. The Director of Nursing stated door lock was changed last night and now only Shands clerks have access.

On 4/29/10 the hospital produced a letter from the Maternity and Infant Care (MIC) Medical Director dated 4/28/10. The letter stated "MIC employs clerks to update the records housed in L&D" and the clerks print patient information (labs, clinic notes, patient vitals etc.) at the hospital and "the clerks take these records directly to L&D, on the same floor, and file them".

Based on record review and interview, the facility failed to ensure that all verbal orders were electronically entered into the hospital wide computer system for 3 (#36, #37, #38) patients out of 55 patients sampled.

The findings include:

1.) Record review for patient #36 revealed a telephone order written by the nurse on 4/22/10 which reads "May start Heparin drip as ordered". Review of the system computer, in which the physician countersigns on the next visit, did not reveal a telephone order listed in the system for the physician to sign.

2.) Record review for patient #37 revealed a telephone order written by the nurse on 4/22/10 which reads "NPO until AM, IVF D51/2 20KCL @ 70ml/hr". Review in the system computer, in which the physician countersigns on the next visit, did not reveal a telephone order listed in the system for the physician to sign.

3.) Record review for patient #38 revealed a telephone orders written by the nurse on 4/8/10 which reads "DC Levaquin start Cefepime 2 GM IV Q 8H", and "Azethreonam 2 Gms IV Q 8H, DC Cefepime". Review in the system computer in which the physician countersigns the orders on their next visit, did not reveal a telephone order listed in the system for the physician to sign.

Review of the facility policy reveals that the facility's Registered Nurse (RN) must be the one to take a verbal order from the physician. The nurse will read back the order to the prescriber to confirm the order. The transcribing clerk will then place the telephone order in the OAS Gold system, date and sign the order when the order is entered into the system. Orders are to be authenticated online by the prescriber within 48 hours (Core Policy).

Interview with Director of Nursing on 4/28/10 at 11:00 AM, revealed that the reason those telephone orders did not get countersigned by the physician, was that the transcribing clerk did not enter the orders into the OAS Gold system.

Based on observation, interview and record review it was determined that the facility's infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by failing to provide a functional and sanitary environment by failing to adhere to professionally acceptable standards of practice in the dialysis unit; in the outpatient bone marrow suite; and during medication administration.

The findings include:

1. On 4/26/10 at 1:45 PM observations were conducted of the Bone Marrow Transplant Clinic with the nurse manager. The triage room floor was observed to have garbage and (2) used syringes with needles on them. (One appeared to have blood in it and the other had a dark liquid). The garbage can and sharps receptacle were near the garbage. The manager stated "Miss [named individual] messy nurse worked today".

2. During observation of medication administration on 4/28/10 at 9:25 AM the Registered Nurse (RN) on the 5400 floor broke three potassium chloride tablets in half with his unwashed, ungloved hands. When interviewed the RN stated "I touch pills with my hands. I don't know the hospital policy." He acknowledged that he did not wash his hands. Another staff RN, when interviewed at 9:40 AM stated "I break pills with my bare hands".

During an interview conducted on 4/28/10 at 1:22 PM the Director of Infection Control stated "it's okay to handle medications with bare hands if the hands are washed" and "all medication carts have pill cutters".



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3. Observation during tour of the adult dialysis unit on 04/29/2010 at 8:15 AM revealed approximately 9 jugs utilized to mix dialysate were observed in the wall cabinet in the upright position. Observation inside of 3 jugs revealed that 2 of 3 jugs had small amount of a clear liquid still in the jug. Observation of the dialysis technician revealed that the jugs were taken from the cabinet and used to mix dialysate.

4. Observation during tour of the adult dialysis unit on 04.29.2010 at 8:15 AM revealed a container with tube clamps being decontaminated. Observation of the clamps revealed that the clamps were placed on theirs sides resulting in half of each clamp not being fully emerged in the disinfectant.


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5. A tour of the Dialysis Unit on 4/30/10 at 8:15 AM revealed five dialysis machines with a brown colored stain, like Betadine, on the tops of the machines.

6. There were four over bed tables in the Pediatric Unit that were stained, on the tops and the bottoms. One of the over bed tables was rusted at the bottom and was visible.

Based on interview and record review it was determined the facility failed to document in the patient's medical record that the list of home health agencies or skilled nursing facilities was presented to the patient or the individual acting on the patient's behalf.

The findings include:

Review of 55 clinical records between 4/26/10 and 4/29/10 failed to reveal any documentation in the records of discharged patients or patients soon to be discharged that a list of home health agencies or skilled nursing facilities was presented to the patient or the individual acting on the patient's behalf.

During an interview conducted on 4/28/10 at 3:30 PM the Director of Discharge Planning stated that such lists are presented to patients as part of the discharge planning process, but "we don't drill down to that level of documentation in the record. There is no documentation of the list being presented. We will change the process."