HospitalInspections.org

Based on observation and interview, it was determined that the hospital failed to ensure syringes were secure from unauthorized individuals and to prevent potential tampering, accidents or diversion.

Findings include:

Observation on 7/19/22 at approximately 10:00 a.m. on initial tour in the Emergency department revealed that a sharp's container was not attached or secured and could be removed by unauthorized staff or patients.

Observation on 7/19/22 at approximately 10:00 a.m. on initial tour in the emergency department revealed a unlockabke white 7 drawer mobile cart that can not be locked by room 2. Futher observation of the cart revealed multiple disposable syringes in the bottom draw.

Interview on 7/19/22 at the time of tour with Staff B (Patient Safety Manager) confirmed the above observation.

Based in interview and record review, it was determined that the hospital did not verify a physician's order for 1 of 2 resident's reviewed for closed death records. (Patient identifier is #1.)

Findings include:

Review on 7/21/22 of Patient #1's physician's orders revealed the following:
- On 1/22/22 an order for Do Not Resuscitate (DNR).
- On 1/25/22 an order for Full Code and Comfort Care. This was a "Verbal Order Read-Back".

Review on 7/21/22 of Patient #1's "Patient Expiration Record" revealed that the patient was pronounced deceased on 1/25/22 at 12:25 a.m.

Review on 7/21/22 of Patient #1's medical record revealed that no CPR (Cardio-Pulmonary Resuscitation) was performed to Patient #1.

Interview on 7/21/22 at 10:25 a.m. with Staff E (Nurse Leader Intensive Care Unit) revealed that patient's code status would be indicated on the patient's bracelet and in the electronic medical record.

Interview on 7/21/22 at 1:30 p.m. with Staff D (Registered Nurse, Quality) revealed that the nurse who wrote the 1/25/22 "Full Code" order had made a mistake when entering the comfort care order and that Patient #1 was a DNR (as per the 1/22/22 physician's order).

Interview on 7/21/22 at 1:45 p.m with Staff G (Registered Nurse, Quality) revealed that the nurse who wrote the verbal order for comfort care entered it along with the full code order which was a mistake. Staff G stated that when the chart was reviewed after death at a medical review, the mistaken full code order was missed as part of the audit.

Review on 7/21/22 of the facility's undated medical review for Patient #1 revealed that the patient was a DNR on admit, had been terminally extubated after a family meeting, and had been a witnessed cardiac arrest.

Review on 7/21/22 of the facility's "DNR (Do Not Resuscitate)" policy revised 1/2021 revealed, "...Procedure... D. Documentation - The responsible physician shall write the order, "Do Not Resuscitate" (DNR) in the doctor's orders portion of the patient's chart in advance of anticipated cardiac or respiratory failure... If the responsible physician determines that a change in the patient's medical condition or other relevant circumstances now justifies resuscitation, he/she should cancel the "Do Not Resuscitate" instruction with a written order..."

Based on interview and record review, the hospital failed to maintain completed closed medical records and follow the medical staff's rules and regulations for deficiencies in the delinquent chart documentation.

Findings include:

Review on 7/21/22 of the facility's "Delinquent Records - Delinquent Record List" from 7/2022 Thru 7/2022" revealed the following;
-There were a total of 47 medical records that were delinquent over 30 days;
-The oldest age of deficiency was 549.
-There were 27 records that were 100 or more days delinquent.

Review on 7/21/22 of the facility's policy "Rules and Regulations of the Medical Staff" revised 4/2021 revealed, "...Delinquent Records. 1. A medical record is considered to be delinquent when it has not been completed for any reason within (30) calendar days following a patient's discharge. HIM [Health Information Manger) will notify providers of incomplete electronic medical records on a weekly basis, with a final warning at 23 days from discharge of incomplete electronic medical records. When a medical staff member or individual with clinical privileges has failed to complete a medical record within the 30-day timeframe, his/her clinical privileges shall undergo automatic suspension until all of the individual's electronic medial records are completed... 3. Medical record delinquencies will be noted in the practitioner's credentials file..."

Interview on 7/21/22 at 11:25 a.m. with Staff F (Medical Records) revealed the above 47 records were still in process of being addressed, and that some of the physician's were no longer working at the hospital.

Interview on 7/21/22 at 1:10 p.m. with Staff F revealed that the facility does not add delinquencies to practitioner's credential files as per their policy. Staff F revealed that the above deficiencies should have been addressed.

Review on 7/21/22 of the facility's policy Parallon HIM "Order to File as Incomplete" reviewed on 10/29/21, revealed, "... Procedure: To provide the HIM Service Center (HSC) and Facility HIM Department with a standardized method of permanently closing medical records as incomplete. This policy pertains t medical records that have assigned deficiencies that cannot be resolved by the responsible provider or designee. Policy: It is the responsibility of the HSC to ensure that all patient records are complete and accurate. In the event that a physician is not willing or able to complete deficiencies assigned to him/her, following a through review a qualified member of the medical staff... can order the record(s) be permanently filed as incomplete..."

Based on observation, interview, and review of manufacturer's instruction, it was determined that the hospital failed to ensure safety and quality of glucose testing by monitoring the expiration dates of control solutions.

Findings include:

Review of manufacturer's instructions for the hospital's glucose meters control solution revealed the following directions

"Do not use if the expiration date has passed. Discard any unused control solution 90 days after first opening or after the expiration date."

Observation on 7/19/22 in the Emergency department at approximately 10:00 a.m. revealed the control solutions were undated therefore; unable to determine if it was greater than 90 days after opening.

Interview with the Staff A (Register Nurse, ED) revealed that the practice is to clean the glucometer after each use and return to the docking station.

Based on observation, interview, and record review, it was determined the hospital failed to ensure that patient care equipment could be properly cleaned and disinfected in the emergency department.

Findings include:

Observation on 7/19/22 of the Emergency Department at approximately 10:00 a.m. revealed that two pieces of patient care equipment (1 blood pressure machine, 1 glucometer) had tape adhered to them. Further observation revealed that the tape on the blood pressure machine had been wrapped around the equipment several times, and that the tape on the glucometer was not fully adhered, preventing thorough and effective cleaning and disinfection of these items.

Interview with the Staff A (Registered Nurse, Emergency Department) on 7/19/22 at approximatley 10:00 a.m. confirmed the above observation.

Interview with Staff B (Patient Safety Manager) on 7/19/22 at aproximatley 10:00 a.m. confirmed the above findings and confirmed that tape on equitpment would prevent effective cleaning and dsinfection.

Based on record review and interview, it was determined that the hospital failed to maintain record of adherence to professional standards for sterilization cycle verification monitoring for steam sterilization of surgical instruments for 2 out of 91 load records reviewed.

Findings include:

Standard:
Association of periOperative Registered Nurses. "Guidelines for Perioperative Practice." 2016 Edition. Denver, Colorado: AORN, Inc. 2016.
Page 841 - Sterilization and Disinfection.
"...Recommendation XX. A quality assurance and performance improvement process should be in place to measure patient, process, and system outcome indicators...XX.c. All physical, chemical, and biological monitoring results, including results from controls, should be interpreted by qualified personnel in the time frame specified by the manufacturer of the monitor and should be included in the sterlization records...Accurate interpretation and reporting of results promotes safe patient care."

Review on 7/20/22 of steam sterilization records revealed that the steam sterlization record dated 6/15/22 did not contain verification of a 3M Steam Chemical Integrator chemical indicator result and sterilizer printout for 1 out of 4 equipment loads (load number 1_3).

Review on 7/20/22 of steam sterilization records revealed that the steam sterilization record dated 6/17/22 did not contain verification of a Daily Air Removal Test (DART) Bowie Dick test sheet for 1 out of 1 sterilizers used.

Interview on 7/20/22 at approximately 11:40 a.m. with Staff C (Central Sterile Coordinator) confirmed the above findings. Interview further revealed that the procedure for verifiying sterilization records are complete is a daily review by staff and monthly supervisory review.

Review on 7/20/22 of hospital policy titled "Daily Air Removal Test (Dart) / Bowie Dick Guideline, 402," with revision date 8/2003, revealed the following: "...8. Retain DART test sheets and place in envelope along with loads cards and sterilizer printouts for the day."

Review on 7/21/22 of hospital policy titled "CSD Sterilization and Disinfection Guideline, 408," with revision date 4/2009, revealed the following: "...16. A sterilizer performance record includes the sterilizer identification number, sterilization date, cycle number, contents of each load, duration and temperature of exposure phase, identification of operator(s), results of biological tests and dates performed. The sterilizer computer sheet and/or time-temperature chart and any other test results will be included with this record."