HospitalInspections.org

33041


Based on record review, surveyor observation and staff interview, it has been determined that the hospital failed to obtain a physician's order relative to oxygen administration for 2 of 2 sample patients' (ID's #1 and 2) on oxygen.


Findings are as follows:

1) During surveyor observation on 7/24/2017 at approximately 2:00 PM, patient ID #1 was observed lying on the bed with oxygen being administered via nasal cannula.

Medical record review on 7/25/2017 revealed ID #1 was admitted to the hospital on 7/5/2017, with a diagnosis of acute respiratory failure with hypoxia. Further record review revealed no physician's order for oxygen.

2) During surveyor observation on 7/24/2017 at approximately 2:30 PM, patient ID #2 was observed lying on the bed with oxygen being administered via nasal cannula.

Medical record review on 7/25/2017, revealed ID#2 was admitted to the hospital on 7/17/2017 with a diagnosis of hypoxia. Further record review revealed no physician's order for oxygen.

During surveyor interview on 7/25/2017 at approximately 8:45 AM, the unit manager and advanced practice nurse manager stated both patients should have physician's orders and indications for use for the oxygen.

Based upon record review and staff interviews, it has been determined that the hospital's interventional radiologic services failed to meet professionally approved standards for safety for 3 of 4 sample patients (ID #'s 11, 12, & 13) who received radiological services.

Findings are as follows:

Review of the hospital's policy titled "Radiation Safety Manual; Patient Dose Monitoring During Fluoroscopically Guided Interventional Procedures", revised on 1/5/2016, under Procedural Guidelines, states, in part:

2. Monitor Patient Skin Dose.

2.1.3 For cases ending with CAK (cumulative air kerma) displayed between 5,000 and 14,999 mGy (milligray): "...Ensure recovery orders for extended fluoroscopy are followed and/or discharge instructions are given...".

1) Patient ID # 11 had an extended interventional fluoroscopy procedure done on 4/9/2017. The report form indicates the patient received 8,534 mGy. There is no evidence that recovery orders or discharge instructions relative to an entrance skin exposure exceeding (ESE) 5,000 was given to the patient.

2) Patient ID # 12 had an extended interventional fluoroscopy procedure done on 4/27/2017. The report form indicates the patient received 5,098 mGy. There is no evidence that recovery orders or discharge instructions relative to an ESE exceeding 5,000 was given to the patient.

3) Patient ID # 14 had an extended interventional fluoroscopy procedure done on 6/8/2017. The report form indicates the patient received 7,585 mGy. There is no evidence that recovery orders or discharge instructions relative to an ESE exceeding 5,000 was given to the patient.

When interviewed on 7/26/2017 at approximately 10:30 AM, the Director of Diagnostic Imaging was unable to produce evidence that recovery orders or discharge instructions were given per the hospital's policy.

Based upon record review and staff interview, it has been determined that the hospital failed to promptly correct radiological equipment that had been found to be in need of repair for 2 diagnostic imaging units.

Findings are as follows:

1) Review of the report titled "Landauer Medical Physics Survey Report Summary" with a survey date of 12/5/2016, of the portable x-ray unit (#CN24269) revealed failure of the Radiation Field Sizing - Table Image Receptor. The physicist recommended having service adjust the field size indicator.

2) Review of the report titled "Landauer Medical Physics Survey Report Summary" with a survey date of 3/22/2017, of the mobile C-arm unit (#CN28389) revealed failure of the x-ray field to image receptor alignment and fluoroscopic kVp accuracy tests.

When interviewed on 7/27/2017 at approximately 1:00 PM, the Director of Diagnostic Imaging was unable to produce evidence that the above failures were promptly addressed by the hospital's Biomedical Engineering Department.

Based on surveyor observation and staff interview, it has been determined that the hospital failed to comply with aspects related to the food service operation in accordance with their policy of daily management of dietary services.

Findings are as follows:

The following was observed in the main kitchen on 7/24/2017 at 9:30 AM.

* The storage racks in refrigerator #'s 3 and 4a had a visible accumulation of dried food debris and were sticky to the touch.

* 3 of the 4 sheet pan holding racks had a visible accumulation of dried food debris/matter.

* The fume hood over the cooking area had a visible accumulation of oil, which were droplets and streaks.

* At 11:25 AM during lunch service, 3 coffee cups were observed to have a dried brown film in the cup. Additionally, 2 soup bowls were observed with a white rim of pealing plastic on the inside of the bowls. The dietary aide was preparing to fill these cups and bowls.

On 7/25/2017 at 9:20 AM, a walk through of the kitchen was conducted in the presence of the Assistant Food Service Operations Manager where the above soiled items were again observed. The Assistant Food Service Operations Manager was unable to explain why the above items were not kept free of an accumulation of oil, dust, dirt, food residue, and other debris.

Additionally, on 7/24/2017 between 10:00 AM to 1:03 PM, observation of the nourishment kitchens on the hospital units revealed the following:

* 3 East - the refrigerator was observed to have dried matter/food debris on the shelves. The freezer was observed to have a heavy accumulation of ice.

* The microwaves in the nourishment kitchens on 3 East, 3A, 3 West, and 4 East were found to have an accumulation of dried food matter/debris on the inside.