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Based on record review and interview, the provider failed to ensure its policy for consents was followed for 3 of 14 (1, 2, and 3) sampled patients who were admitted to the emergency room. Findings include:

1. Review of patient 1's consent to treatment and conditions of admission for an admission date of 7/20/10 revealed patient 1's name was electronically printed in the signature block. There were no other signatures or information included in the signature block to indicate there had been an attempt to obtain the patient's consent.

2. Review of patient 2's consent to treatment and conditions of admission for and admission date of 8/11/10 revealed the patient's name was electronically printed in the signature block. There were no other signatures or information included in the signature block to indicate there had been an attempt to obtain the patient's consent.

3. Review of patient 3's consent to treatment and conditions of admission for and admission date of 9/3/10 revealed the patient's name was electronically printed in the signature block. There were no other signatures or information included in the signature block to indicate there had been an attempt to obtain the patient's consent.

4. Review of the provider's revised May 2009 policy for rules-medical record documentation for medical staff revealed:
*An approved general consent form, signed by or on behalf of every patient admitted to the hospital, should have been obtained at the time of admission.
*The admitting officer was to notify the attending practitioner whenever the consent could not be obtained.
*In emergencies involving minors and unconscious patients where consent could not be obtained, consent was implied and essential treatment could have been included.
*Circumstances explaining why consent could not have been obtained should have been explained in the patient's medical record.
*Concurring documentation should have been obtained as soon as possible and entered in the patient's medical record.

Interview on 12/2/10 at 9:30 a.m. with emergency department director A revealed:
*She was aware of many instances where there was no signature on the consent to treatment and conditions of admission to document a consent had been obtained for emergency room treatment or admission.
*It was the duty of the emergency room associate to obtain the signatures for consent.
*If the patient was not able to sign the consent and no family members were present to consent, then two staff members were to sign the form.
*The emergency room associates were on duty from 7:00 a.m. to 12:00 midnight. When they were not on duty the emergency room nurses were to obtain the signatures for consent.
*The emergency department director was working on a procedure to ensure the consents were obtained.

Precepted by 26632
Based on observation and interview, the provider failed to ensure safe infection control practices were followed for one of two randomly observed patient (4) medications administered. Findings include:

1. On 12/2/10 at 8:50 a.m. registered nurse (RN) B administered patient 4's Cozaar 50 milligram tablet from a prepackaged plastic packet while the patient was in his bed. The RN opened the packet and tried to dispense the tablet into the patient's mouth. The tablet fell out of the packet onto the patient's gown. RN B then picked up the tablet with her ungloved hand and placed it into the patient's mouth. RN B had previously been in another patient's room and stated she had washed her hands before leaving that patient's room. She had not washed her hands in patient 4's room until after dispensing his medication.

Interview on 12/2/10 at 9:45 a.m. with RN B revealed she should not have touched the medication with her ungloved hand. When asked about using paper dispensing cups she stated they were sometimes used, but normally the medication was put into the patient's mouth or hand from the packet.

Interview on 12/2/10 at 9:55 a.m. with RN D revealed the paper medication cups were used if the medication needed to be placed in the patient's mouth. Normally the medication was placed into the patient's hand from the packet. RN D agreed medications should not have been touched with an ungloved hand and then given to the patient.

Interview on 12/2/10 at 10:20 a.m. with RN C revealed:
-There was no policy regarding the touching of medication by nurses with ungloved hands.
-Medications should not have been touched with ungloved hands and then given to a patient.

Based on record review, interview, and policy review, the provider failed to ensure all sampled medical record entries from different patient service areas were authenticated with either signatures, dates, or times. A sample of 228 medical record entries revealed 114 instances where either the signature, date, or time of the entry had not been recorded. Findings include:

1. Review of 115 written physicians' orders from all patient care areas revealed 2 were not signed, 11 were not dated, and 59 were not timed.

2. Review of 22 telephone physicians' orders from all patient care areas revealed 4 were not timed.

3. Review of 48 physicians' progress notes from all patient care areas revealed 2 were not signed, 4 were not dated, and 16 were not timed.

4. Review of 43 miscellaneous forms regarding physician contact with the patient from all patient care areas revealed 2 were not signed, 2 were not dated, and 12 were not signed.

5. Interview with the director of patient care services E at 3:50 p.m. on 12/1/10 revealed all physicians had been instructed regarding the need to date, time, and sign all medical record entries.

Interview with the vice president of patient care services F at 3:55 p.m. on 12/1/10 revealed she was aware of the regulation requiring all medical record entries to have been signed, dated, and timed. She further revealed the provider did not have a policy outlining the requirement for timing of those entries. She stated a change in the medical staff bylaws was needed in order to require physicians to time all medical record entries.

Review of the provider's revised May 2009 policy on rules-medical record documentation for medical staff revealed:
*All progress notes should have a date, time and signature.
*All orders for treatment, including verbal orders, must be dated, timed, and authenticated by the ordering practitioner.
*Entries in the medical record must be authenticated according to state and federal regulations.

A. Based on random observation and interview, the provider failed to maintain the following items/areas in good/cleanable/durable condition:
* The folding table in the clean linen room.
* The countertop edges of the chemistry station in the laboratory.
* The mop board of the blanket warmer in emergency room 6.
* The corner wall of the treatment room in the emergency department (ED).
* The edges of a cabinet brace in x-ray room 2.
* The mop board on the wall in the freezer room of the orthopedic wing.
* The countertop under the ice machine in the clean supply room of the medical surgical wing.
* The east wall in the therapy department.
Findings include:

1. Random observation from 8:15 a.m. to 3:30 p.m. on 12/1/10 revealed:
a. The folding table in the clean linen storage room had chipped and scraped areas of varnish that exposed raw wood underneath the varnish. A clean table cloth had been placed over the table (photo 9). Interview with environmental services director G at the time of the observation confirmed that finding. She stated she had requested a new folding table due to the condition of that folding table. She stated they had to keep the table covered to make the surface clean for folding clean linen. She stated the table cloth would get tears, and they would tape the tears until they became uncleanable. Interview with the director of plant operations (DPO) I at 1:25 p.m. on 12/2/10 revealed he was not aware how bad the finish had chipped and cracked on the wooden folding table.
b. The chemistry station countertop in the laboratory was missing the laminate on the edges of the countertop (photos 1 and 2). Those edges measured 1 and 1/2 inches by 2 feet on each side and had exposed raw particle board that was not cleanable. Interview with the director of laboratory services H at the time of the observation confirmed that finding. She agreed those edges were not cleanable and should have been sealed. Interview with DPO I at 1:25 p.m. on 12/2/10 revealed he was not aware of the damage to countertop in the lab and had not received a work order for repairing the countertop.
c. The blanket warmer in emergency room 6 had the mop board missing from the bottom of the unit (photo 8). The metal area where the mop board had been attached had left dried and cracked old glue residue and created an uncleanable surface. Interview with environmental services director G at the time of the observation confirmed that finding. Interview with DPO I at 1:25 p.m. on 12/2/10 revealed he was not aware the mop board was missing from that blanket warmer. He stated he had not received a work order to reglue or replace the mop board.
d. The treatment room in the ED had two gouges and ripped wall paper on the corner wall by the door (photo 4). Those gouges were deep into the caulk of the gypsum board and measured 1 and 1/2 inches by 4 inches and 5 inches by 5 inches. Interview with environmental services director G at the time of the observation confirmed that finding. She stated she was not aware of the damage to the wall. Interview with DPO I at 1:25 p.m. on 12/2/10 revealed he was not aware of the damage to that wall and had not received a work order for repairing that wall.
e. Room number 2 in the x-ray department had a wall brace holding up the wall cabinet. That brace was one foot by two foot and had unfinished raw wood surfaces that were not cleanable (photo 5). Interview with environmental services director G at the time of the observation confirmed that finding. Interview with DPO I at 1:25 p.m. on 12/2/10 revealed he was aware of the brace that held up the wall cabinet in x-ray room 2. He stated he had glued and added more screws to the wall to hold up the heavy cabinet. DPO I stated he had told the x-ray technicians weeks ago to remove the brace when the glue had set.
f. The mop board in the freezer storage room in the orthopedic wing of the medical surgical unit was missing from about three feet of the wall (photo 7). Interview with environmental services director G at the time of the observation confirmed that finding. Interview with DPO I at 1:30 p.m. on 12/2/10 revealed he was not aware of the damage to that wall but would repair the mopboard.
g. The countertop under the ice machine in the clean supply room of the medical surgical unit had discolored circles and lines from the base of the old ice machine. Those circles and lines left by the old ice machine had eroded into the raw wood surface under the laminate top (photo 6). Interview with environmental services director G at the time of the observation confirmed that finding. Interview with DPO I at 1:30 p.m. on 12/2/10 revealed he was not aware of the damage to that countertop after the new ice machine had been installed.
h. The gypsum board on the east wall in the therapy gym was missing from an area one foot by four foot and two foot by three foot (photos 10 and 11). The missing gypsum board revealed the wall studs behind the wall. Interview with director of therapy J at the time of the observation confirmed that finding. She stated maintenance had removed the gypsum board, because the wall had been damaged from rain leaking into the building this spring and fall. She stated she thought maintenance was waiting to see if the wall leaked again before repairing the wall.
Interview with DPO I at 1:30 p.m. on 12/2/10 revealed he was aware of the hole in the wall in the therapy gym. He stated he thought they had stopped the leak and could repair the wall.

B. Based on observation, testing, and interview, the provider failed to maintain the hot water temperature in the main patient building at 120 degrees Fahrenheit (F) or less. Hot water temperatures in the medical surgical area were found at 124.1 to 129.9 F. Findings include:

1. Observation at 1:50 p.m. on 11/30/10 revealed the hot water in the women's bathroom in the administration wing was very warm to the touch. This surveyor could not hold her hands under the stream of water in the hand sink. Testing of the hot water at the time of the observation revealed the hot water tested at 126.5 F with a calibrated thermometer. Continued random observation and testing from 3:15 p.m. to 5:30 p.m. on that same day revealed the hot water temperature ranged from 124.1 F. to 129.9 F. throughout 14 patient access areas in the main building (patient bathrooms, patient bathing rooms, x-ray, and emergency rooms). Interview with charge nurse K at 5:40 p.m. revealed she was not aware of the hot water temperatures in the patient care areas. She stated she would call the on-call maintenance person immediately and have them return to the facility to adjust the temperature of the hot water. The surveyor relayed to the charge nurse and on-call maintenance person via written instructions to have the whirlpool tub and tub/shower filled with hot water three times and then drained after the new temperature was set on the hot water heater. That was to be done to assure the new set hot water temperature would regenerate at the new temperature. Interview with DPO I at 8:05 a.m. on 12/1/10 revealed he had received a call from his on-call maintenance person last night regarding the hot water temperature. He stated the main building had two hot water heaters, and one was normally used as a holding reservoir for the initial hot water heater. He stated the two water heaters were set at different temperatures. He stated he had set them for about 128.0 F, as he had thought the maximum temperature was 127.0 F. He stated he was not aware the maximum allowed hot water temperature was 125.0 F per state regulations and 120.0 F per federal plumbing regulations. DPO I revealed he had been testing the water temperature since 6:30 a.m. that morning, and the temperature was holding at about 120.0 F. He stated he had requested his maintenance personnel to test the water temperature every half hour this morning to see if the temperature would hold between the two hot water heaters. Continued interview with DPO I at 11:30 a.m. on that same day revealed the hot water temperature remained at about 120.0 F throughout the patient care areas.

Based on contract services review and interview, the provider failed to update contracts annually and maintain an adequate supply of potable drinking water for the facility. Findings include:

1. Review of the two contract letters for providing water to the facility revealed:
* A letter dated 10/18/85 from the fire chief /water superintendent at that time stated the city fire department would provide emergency water if needed. In that letter it stated the method of transportation might not be sanitary.
* A letter dated 8/21/98 from the city public works administrator stated the city would have enough storage to last two and one half days on gravity in the event of a total power outage. It also stated that should a line rupture near the hospital persons served in that area would be served temporarily through fire and garden hoses.

Interview with director of plant operations (DPO) I on 12/2/10 at 9:30 a.m. revealed he was not aware those contracts were outdated. He stated the provider had a contract with Culligan to provide drinking water on a regular basis but not on a emergency basis. DPO I revealed the provider did not have enough potable water on hand for patient needs for at least 24 hours nor up to three days.

A. Based on random observation and interview, the provider failed to maintain hand sanitizer within the manufacturer's specified timelines. Four of five in-use housekeeping carts had expired hand sanitizer. Findings include:

1. Random observation from 8:10 a.m. to 11:00 a.m. on 12/1/10 revealed four in-use housekeeping carts throughout the hospital had expired hand sanitizer. Interview with director of environmental services (DES) G at the time of the observations confirmed those findings. She revealed hand sanitizer was used by housekeeping staff between patient rooms and between changes of duties when they did not have direct access to a handwashing sink. DES G stated she was not aware the hand sanitizer had an expiration date and would have the housekeepers replace the hand sanitizer immediately.

B. Based on observation, interview, and policy review, the provider failed to disinfect the floors of the endoscopy room and seven of seven shared patient restrooms. Findings include:

1. Observation at 1:55 p.m. on 12/1/10 revealed a housekeeper with a mop bucket and housekeeping cart in the endoscopy room. Interview with DES G at the time of the observation revealed the housekeeper was completing a terminal clean on the endoscopy room. This surveyor questioned if the green sudsy substance in the mop bucket was cleaner or disinfectant. DES G replied the substance was a cleaner and not a disinfectant. She corrected the housekeeper at that time, and the housekeeper changed the solution at that time and remopped the floor.

2. Interview with DES G at 2:00 p.m. on 12/1/10 revealed a disinfectant was not used on the shared bathroom floors in the medical surgical unit. She stated she had not considered the fact that two patients shared the same bathroom and the same floor surface. She stated she would redirect her staff to use disinfectant on the bathroom floors immediately.

Review of the policy titled Cleaning of Treatment/Procedure Rooms, number HK316, dated 1/05, revealed "Procedure: 6. Sweep and mop the floor with germicidal detergent."

Review of the policy titled "Restroom Cleaning", number HK1802, dated 1/05, revealed "13. Wet mop the floor. b. Immerse the mop in the bucket of germicidal cleaner and wring it out. You want the mop wet enough to allow proper soil removal."

C. Based on observation and interview, the provider failed to use durable/cleanable containers for filled Vacutainer and specimen samples in the chest freezer in the lab. Cardboard boxes were used to hold the filled Vacutainer and specimen samples. Findings include:

1. Observation at 10:00 a.m. on 12/1/10 revealed three cardboard boxes were used to hold filled Vacutainer and specimen samples in the chest freezer in the lab (photo 3). Interview with director of laboratory services H at the time of the observation confirmed that finding. She stated she had not considered the fact the cardboard boxes were not cleanable and created an infection control problem.