HospitalInspections.org

Based on observations and staff interview, the CAH failed to complete and accurately post patient census and number of nursing staff providing direct patient care as required per Vermont Statute 18 Chapter 42, 1854. Findings include:

Per observation on 5/21/12 at 11:20 AM, the "Direct Caregiver Full Time Equivalents" weekly sheets posted at the medical/surgical nurse's station were not completed for the dates 5/14/12 through 5/19/12. Vermont Statute Title 18, Chapter 42, 1854 requires the hospital to post the nursing full time equivalent (FTE) staffing per patient census per shift for the current date and the previous 7 days. There was no staffing posted on the special care unit and the birthing units. The failure to post the required nursing FTEs per patient per shift on each unit was confirmed with the unit clerk for the special care unit on 5/21/12 at 11:25 AM.
The Birthing Center Nurse Manager also confirmed, during interview at 2:05 PM on 5/23/12, that nursing FTE's was not currently posted on the unit, nor had it been posted for the 6 days prior to 5/23/12.

Based on observation and staff interview the CAH failed to assure all code carts where medications are stored were properly secured and/or monitored at all times. Findings include:

Per observation, during tour with the ED (Emergency Department) Nurse Manager at 8:14 AM on 5/22/12, the Pediatric Code Cart located in an exam room of the ED (Emergency Department) was found unsecured and unmonitored, providing access to the emergency medications stored within the cart. An RN (Registered Nurse) working in the ED at the time of the observation discovered the plastic seal used to secure the cart on the floor approximately 4 feet away from the cart and stated that housekeeping may have accidentally hit the lock when cleaning near the cart, causing the seal to break and fall off. S/he further stated that the seal had been broken off on previous occasions and s/he felt it was related to the location of the cart, which was in close proximity to the stretcher, providing opportunity for anyone walking by to accidentally hit the plastic seal and break it. The RN stated that although the seal had previously been found broken the cart had not been relocated nor had any other action been taken, to date, to resolve the issue.

Based on observation and staff interview, the facility failed to assure consistent and appropriate surgical attire was worn by perioperative staff in accordance with standards of practice as part of infection prevention and control. Findings include:

During a tour of the perioperative area on 5/21/12 at 1:45 PM a CRNA (Certified Registered Nurse Anesthetist) was observed wearing a hair covering that failed to completely cover their hair and jewelry. On 5/23/12 at 9:15 AM the anesthesiologist and other surgical staff observed in operating room #2 failed to cover their hair completely while a surgical procedure was being conducted. Per AORN (Association of periOperative Registered Nurses) Journal, January 2012 Vol 95 No 1 "Implementing AORN Recommended Practices for Surgical Attire " Perioperative nurses should not wear jewelry such as earrings, necklaces........that cannot be contained within surgical attire because of the risk of contaminating the surgical attire" AORN further states "All personnel should cover their head and facial hair when in the semirestricted and restricted areas. Hair coverings should cover facial hair, sideburns, and the nape of the neck. Perioperative nurses can help minimize the risk of surgical site infections by covering head and facial hair...." AORN further states " Skull caps are not recommended because they do not completely cover the wearers hair and skin; they fail to cover the side hair above and in front of the ears and the hair on the nape of the neck".

Per interview at the time of the observation on 5/23/12, the assistant nurse manager of perioperative services confirmed staff failed to maintain appropriate infection control standards of practice. Per interview on the afternoon of 5/23/12, the Chief of Anesthesia acknowledged wearing a skull cap during surgery did not provide sufficient covering of all hair.

Based on observation, interview and record review, nursing staff failed to conduct ongoing assessments of the needs of 1 patient to determine effectiveness of and continued need for specific interventions/treatment that had been implemented in response to an identified concern. (Patient #18). Findings include:

1. Per record review staff failed to provide assessments, in accordance with the facility's Restraint policy, to determine the ongoing need for use of soft wrist restraints for Patient #18 who was admitted on 4/6/12 for treatment of anaphylaxis (hypersensitive reaction to an allergen). The policy, last revised in March of 2012, stated, "1)Restraint orders are to be preceded by determination and documentation that other, less restrictive measures have been found to be ineffective to protect the patient or others from harm." and, the order for restraint must be, "8-d). Ended at the earliest possible time."

A Patient Progress Note, dated 4/7/12 at 7:46 PM, stated the patient had become agitated, combative, attempting to get out of bed, pulling at the IVs (intravenous lines) and continued to struggle and strike out at others for a period of approximately 45 minutes, resulting in the need to apply soft wrist restraints to protect the patient and others. The restraints were applied in accordance with a physician order, dated 4/7/12 at 7:00 PM, and they remained on the patient throughout his/her hospitalization, with brief periods of release for repositioning and/or ROM (Range of Motion) exercises, until discharge on the afternoon of 4/8/12.

Review of Patient Progress Notes indicated that during the 8 hour period between 11:00 PM on 4/7/12 and 7:00 AM on 4/8/12, the patient was asleep, "resting calmly" or "awake and appropriate....non-combative" with the exception of 1 period of restlessness, at 2:02 AM, that coincided with an episode of the patient's tongue swelling. In addition there was documentation that a 1:1 sitter remained with the patient until 11:30 PM at which time the Progress note stated; "nurse now providing constant monitoring from doorway." A Progress Note, at 6:17 AM identified that the patient was able to follow some commands and was non combative and stated "Restraints still in place at this time until patient is more alert and can assess demeanor." Although there was no evidence of reassessment to determine the need for continued use of the restraints during this time, nor any evidence of less restrictive measures employed, physician orders had been obtained, at 11:00 PM on 4/7/12 and again at 3:00 AM on 4/8/12, to continue the restraints for periods of up to 4 hours each.

During interview, at 2:40 PM on 5/23/12, the CNO (Chief Nursing Officer) agreed that bilateral soft wrist restraints had been continuously used on the patient and there was no evidence of reassessment or less restrictive measures employed prior to continued use of the restraints from 11:00 PM on 4/7/12 through 7:00 AM on 4/8/12.