HospitalInspections.org

Based on observation and interview the facility failed to maintain the patents right to privacy as evidenced by posting of the patients full name on the outside of the patients rooms in the main hall way visible to all person including other patients and visitors . The names were posted on 9 out of 9 rooms observed during rounds on the medical unit. Release of patients names to the public is a violation of the patients right to privacy including release of their name without written informed consent.

On tour of the facility on 06/08/2010 at approximately 3:00 p.m., revealed the posting of the patient first and last name on the wall outside the patients room in a main hall way of the hospital. Tour of the unit revealed 9 out of 9 rooms observed all included the disclosure of the patients name.

Interview with staff # 2 on 06/08/2010 at approximately 3:00 p.m., confirmed that the facility posted all patients names outside the patients room in the main hallway of each unit. In addition staff # 2 confirmed the hospital did not obtain informed consent in order to post the names.

Based on record review, observation, and interview, the facility failed to follow its own policy in developing the plan of care for patients with falls in 5 out of 5 patients that were currently in the hospital, all charts reviewed contained a yellow dot verses a red dot as outlined in facility policy.


Review of the Hospital Policy #5-8 Identification and Management of Potential Patient Falls, on June 08, 2010, revealed that the policy states " a red dot is placed on the Kardex, and outside the medical record."

Review of patient medical records on June 08, 2010, of patient 2, 3, 4, 5, and 6 on the nursing units revealed the charts had a yellow dot on the outside of the record and on the Kardex, there was no evidence on any of the charts or kardex reviewed that they contained the red dot as required in the hospital policy. In addition review of the 5 patients medical record revealed the plan of care stated apply a yellow dot to the outside of the record, the staff failed to follow the facility policy in development of the patients plan of care.

Interview with staff # 8 on June 8, 2010 on the patient care unit , revealed she thought that a yellow dot was to be placed on the outside of the medical record and the Kardex. Staff # 8 accessed the policy on the hospitals computerized system and the policy # 5-8, Identification and Management of potential Patients Falls stated " a red dot is to be placed on the kardex, and on the outside of the medical record binder. " Staff # 8 confirmed the policy stated a red dot verses the yellow dots they were using.

Based on observation, record review and interview the facility staff failed to keep the crash carts which contained supplies and medication locked and secure in 6 out of 6 carts checked. These carts contained supplies and medication to be used during patient emergencies. These finding have the potential to cause harm to all patients, visitors and others by allowing free access to the medication that could result in tampering and diversion.

During tour of the unit on 06/08/2010 at approximately 3:30 p.m., a crash cart was observed sitting in a main hallway on the medical unit, the cart had the security lock in place but the locking device that secured the drawers containing supplies, needles, syringes and medications appeared to be unsecured. Surveyor pulled medication drawer lightly and the drawer opened easily. The security lock appeared to be placed on the cart incorrectly, allowing the drawer to open.

Interview with staff # 2 and 8 on 06/08/2010 at approximately 3:30 p.m., confirmed the carts were supposed to be kept locked and secured to prevent tampering and diversion.

A random check of 5 additional emergency carts on 06/08/2010 between approximately 3:30 and 3:45 p.m. revealed 1 cart on the pediatric/surgical unit located on third floor, 1 cart in the stress test area of the hospital, 1 cart in the cardiac rehabilitation area, 1 cart in the trauma cardiac room in the ED, and 1 pediatric emergency cart located in the hallway approximately five feet from the back exit door in the ED. All 5 carts were unsecured and accessible to the public.

Review of 3 policies on 06/08/2010 in the facility revealed, a policy titled crash cart
ER IV .18, last revised on 07/09, 1.0 stated "the cart should be checked each shift for cart seal integrity" and 3.0 stated "if there is no crash cart seal the entire cart contents will be inventoried and a new seal placed." Review of policy titled Code Blue # 9110.232 page 2 C 1.0 stated "all crash carts will be locked with a numbered locking ring and the integrity of the locking ring will be checked every 24 hours." Review of the page 5 of the policy revealed a list of fifteen emergency intravenous medication contained inside the adult emergency cart. Review of a policy titled pediatric crash cart last revised on 11/02 and last reviewed on 08/09, 3.0 stated " the pediatric medication box will be checked every day to insure integrity, page 2 of the pediatric policy contained a list of 15 intravenous medication including Demerol and Morphine" which are classified as narcotic medications requiring double locks to prevent tampering and diversion. Review of both the regular crash cart and the pediatric cart check lists revealed the carts had been checked as required by policy for the month of May through June 8, 2010 at approximately 3:30 p.m., and there was no evidence the staff had identified that the carts locking ring placement allowed the integrity of the cart to be unsecured until checked by the surveyor. The facility failed to follow it own policy.

Interview with staff # 2 on 06/08/2010 at approximately 3:50 p.m.., confirmed that the carts should have been secured and the staff should have found that the integrity of the lock allowed access to the contents inside the cart including supplies, needles, syringes and intravenous emergency medication and that the facility had no evidence the staff had identified and replaced the locks since May 2010.

Interview with staff # 2, 6 and 7, on 06/08/2010 in the pharmacy at approximately 3:50 p.m. revealed the pharmacy knew about the problem with the carts being unsecured. During the interview Staff # 6 stated " I had noticed the cart locks being applied incorrectly for some time when making rounds. " Staff # 6 stated "that the nurse were putting the locks on the carts wrong which allowed access to the contents inside the cart." When asked had he told anyone up the chain of command or done anything to ensure the carts were secured such as education of the staff he confirmed he had not. During this same interview time staff # 7 stated "that pharmacy was only responsible for stocking the cart and that nursing was responsible for applying the locks if they open it after the initial restocking.." When asked if the pharmacy was responsible for medication dispensing within the hospital and correcting unsafe medication security problems identified he confirmed they were. In addition Staff # 6 and 7 were asked to provided evidence the the locking problem had been identified and corrective action taken and they both agreed they could not provide evidence.

During the exit conference on 06/08/2010 at approximately 4:30 p.m., staff # 4 reported that they had identified that the pharmacy had not been taking responsibility for the pharmacy services and they hired a new pharmacist to oversee the department and he is in the process of reviewing the pharmacy Review of a policy titled pediatric crash cart last revised on 11/02 and last reviewed on 08/09, 3.0 stated " the pediatric medication box will be checked every day to insure integrity." polices and services.