HospitalInspections.org

Based on interview and record review, the hospital failed to have a signed physician order for restraints for one patient (19). Findings:

On 3/17/10 a review of Patient 19's clinical record indicated a telephone order for wrist and Posey restraints for safety reasons on 3/7/10. The order included the signature of the nurse who received the order and the nurse who noted the order but the area for physician signature remained blank.

A review of the Medical/Surgical Restraint Order and RN Assessment Sheet dated 3/7/10 indicated in bold type, "Physical Evaluation and Written Order are required within 24 hours of restraint initiation and minimally each calendar day for continuation". The section marked Physician Order was blank.

During an interview with the risk manager on 3/17/10 at 11:30 a.m., she stated it was the hospital's expectation for all restraint forms to be filled out and for verbal orders for restraints to be signed within 24 hours.

Based on documentation, the facility quality and performance improvement indicators failed to show measurable improvement for the year 2009. Findings:

On 3/16/2010 the hospital's quality assessment and performance improvement program was reviewed. During the review, it was noted that projects identified for study had virtually no improvement measured for the year 2009. For example, the emergency department conducted a study on "Stat" Troponin Timeliness. The goal was set at 95% with data being collected on a monthly basis. Throughout the year of 2009 the goal was never obtained and data remained static with no measurable improvement.

The hospital laboratory department had a study for "transfusion documentation" with a goal set at 100%. Data was collected on a monthly basis. Throughout the year of 2009 the goal was never obtained but data remained static at 98.2% per month.

There was no evidence the aggregated data for these two projects were analyzed in order to critique the lack of improvement for these projects.

Based on documentation, there was no evidence the hospital analyzed the quality indicators in the performance improvement program. Findings:

The hospital measures, assesses, and improves processes and outcomes related to patient care by implementing a quality improve program. This program includes a Quality Care Committee (QCC) that meets on a quarterly basis to review and analyze all the hospital quality projects. Performance indicators are submitted by each department to the hospital QCC. The committee reviews the indicators on a quarterly basis with results documented in the meeting minutes.

On 3/17/10 the QCC committee meeting minutes were reviewed. During the review, there was no evidence the committee analyzed any of the performance indicators submitted to them by various departments of the hospital. The minutes revealed that performance projects were only being done and not reviewed.

Based on documentation, the medical staff failed to enforce bylaws in regards to suspension of physician's privileges. Findings:

On 3/16/10, according to the medical record department, ten (10) physicians had failed to complete their patient records within the time frame set by the hospital's medical staff bylaws, rules and regulations. Page 13 of the rules and regulation Medical Staff Bylaws, Section 7.3-4 stated physicians with records that are incomplete 21 days after discharge, that require a history and physical, operative/procedure report, discharge summary and signatures, will automatically be suspended from all patient activities... The ten physicians who had failed to meet this requirement continued to practice at the hospital without restrictions.

Based on interviews and record review, nursing staff failed to complete assessments and initiate individualized care plans for 9 sampled patients (1, 2, 8, 9, 11, 12, 18, 20, and 24) with multiple medical diagnoses. Findings:

The interdisciplinary patient care plans were reviewed on 3/15/10 to 3/17/10. The generic interdisciplinary care plans had a section designating the patient's specific problem, a list of relevant interventions, and a space for individualized treatment goals. The chief nursing officer (CNO) and the directors of the particular patient care units were aware of the results of these reviews.

1. On 2/24/10, Patient 2 was admitted with diagnoses including an irregular heart rate and dehydration. On 3/15/10 at 11:30 a.m., the interdisciplinary patient care plans for cardiovascular dysfunction, high risk for falls, infection, nutrition and self care were reviewed. The forms required the nurse to check off, or circle, a problem, intervention or treatment goal. All sections had space to extend the problem, add interventions and establish and add measurable goals.

Patient 2's specific problems, interventions and treatment goals were not checked or circled. The problems related to his assessed cardiovascular dysfunction, fall risk, infection and self care, and the space for measurable treatment goals, remained blank from 3/11/10 to 3/15/10.

The nurses from days, evening and night shifts had signed off their review of these care plans from 3/11/10 to 3/15/10, but did not complete or individualize these care plans.

The chief nursing officer stated the care plans should be individualized, and either circled or checked. She also stated the twenty-four hour chart check should review and catch when care plans were not filled out properly.

2. Patient 1 was admitted to hospital on 3/13/10 with diagnoses including insulin dependent diabetes, an amputated toe, vomiting and bleeding problems. On 3/15/10 at 10 a.m., the patient stated he got sick after eating five-day-old beef stew.

There were no care plans developed with measurable treatment goals for his gastrointestinal problem, or to address the cause of his vomiting, his eating spoiled, leftover food, or the patient's diabetes.

3. Patient 9 was admitted with diagnoses including pneumonia on 3/15/10. The interdisciplinary patient care plans for patient problems: respiratory dysfunction, infection, and anxiety, were reviewed on 3/16/10. The patient was a 19 month old with a previous admission for asthma. None of the care plans included educating the family regarding the preventive care for the child's respiratory problems. There were no measurable treatment goals outlined for the above problems as required.

On 3/16/10, the registered nurse assigned to the patient stated the care plan was not developed as required, and that educating the family regarding the baby's respiratory problems should begin on admission.

4. On 3/16/10 at 10:45 a.m., Patient 12's record was reviewed. Patient 12 was admitted on 3/15/10 at 11:10 a.m. with diagnoses including stroke and end stage renal disease. Patient 12 arrived with complaints of left sided weakness and numbness. The interdisciplinary patient care plans for neurological dysfunction, cardiovascular dysfunction, infection, impairment of mobility and high risk for falls were not checked, or circled, as required

5. Patient 20 was admitted on 2/14/10 diagnosed with infection and a heart attack. On 3/17/10 the interdisciplinary patient care plans for cardiovascular dysfunction, infection, nutrition and respiratory were reviewed. The forms were not individualized, or completed as required.

6. Patient 8 was admitted to the neonatal intensive care unit on 3/5/10. The care plan did not address the use of breast milk as part of the baby's nutritional needs. The baby's mother was pumping breast milk at home. The breast milk was stored and warmed at the hospital before use.

On 3/16/10 the charge nurse was interviewed regarding the proper storage and use of expressed breast milk on the unit. The charge nurse stated staff use a pitcher filled with tap water to heat the milk and check the milk temperature against their own skin, using their sense of touch.

The hospital policy for Collection Storage and Use of Breastmilk did not specify what temperature the milk should be before administering to an infant. The current policy addressed how to collect, store, thaw the breast milk, but failed to assure the heated milk was at least body temperature (98.6 degrees Fahrenheit) and safe for the infant.



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7. Patient 11 was admitted to the hospital with diagnosis of appendicitis and had a laparoscopic appendectomy on 3/15/10.

During a review of Patient 11's clinical record on 3/16/10 at 11:15 a.m., the care plans for Infection and Pain indicated no interventions checked off, or circled, for infection, and no interventions or goals checked off, or circled, for pain.

During an interview with registered nurse A (RN A) on the same date and time, she stated the staff should circle the items on the care plan that are pertinent.

8. Patient 18 was admitted to the hospital with diagnosis of urosepsis (infection which includes a urinary tract infection with symptoms of a generalized infection).

During review of Patient 18's clinical record on 3/17/10 at 9:10 a.m., the care plans for high risk for falls, and communication, indicated problems listed but had no goals or interventions checked off, or circled. The care plan for Protection from Injury had written-in goals, but not other interventions checked off , or circled.

9. Patient 24 was admitted to the critical care unit in the hospital with diagnoses of acute gastrointestinal bleed and pneumonia.

During a review of Patient 24's clinical record on 3/16/10 at 1:20 p.m., the care plans for bowel elimination and fluid volume deficit indicated problems but had no goals or interventions checked off, or circled. The care plan for pneumonia had no areas checked off, or circled.

Patient 24's initial nurse's assessment on the 3/14/10 indicated there were no skin issues except for pale skin. He was non-English speaking and understood a second language, not in his native language and a family member acted as an interpreter.

The nurse's notes on 3/15/10 indicated Patient 24 had a small blister near rectum on buttocks. The skin assessment in Patient 24's clinical record was blank.

During an interview with registered nurse B (RN B) on 3/16/10 at 2 p.m., she stated to see the care plans for communication and skin care in Patient 24's clinical record, but there were none. RN B stated the skin issue was at least a Stage II pressure sore and had been covered with a DuoDerm (skin dressing).

On 3/17/10, a review of the hospital's policy and procedure for Pressure/Ulcer/Prevention/Management dated 5/08 indicated to get thorough documentation of the pressure ulcer assessment, including photography, of all wounds at Stage II or above.

On 3/17/10, a review of the hospital's policy and procedure for Volume II- Assessment and Care of Patients dated 5/04 indicated, "The pre-printed plan of care is individualized to meet the patient's unique needs and expectations. This is noted by highlighting those interventions that are not applicable, or placing a check in the box indicating activation of an intervention".

Based on interviews and record reviews, the hospital failed to provide medication for one patient (Patient 53) in accordance with the accepted standards of practice and the prescriber's order. A registered nurse at the emergency department (ED) did not administer an anti-nausea medication as ordered by the physician. Findings:

On 3/16/10, a review of Patient 53's chart reflected he came to the ED with nausea, vomiting, and symptoms of alcohol withdrawal on 1/13/10. On the same day, the ED physician prescribed Zofran (an anti-nauseant) 4 mg (milligrams) to be taken orally along with other medications. All other medications were charted as acknowledged and given by the ED nursing staff except for the Zofran.

On 3/16/10 at 1:58 p.m., both the assistant director of the ED (DIR A) and the director of pharmacy (DOP) agreed that the Zofran was not given because there were no acknowledgement of the order and documentation as given in the patient's electronic record.

Based on documentation and interview, the hospital medical records department did not have enough staff to file patient care documents to ensure patient records were closed out in a timely manner. Findings:

On 3/16/10, the hospital medical record department was reviewed. During the review it was noted that a pile, approximately eight inches high, of patient documents had not been filed (loose filing). In the pile of documents, there were laboratory reports, test results, physician notes, etc. Three documents dated to early February 2010. According to the manager of the department, this was only one pile for this employee, and that other employees are assigned to file patient documents when they can. The manager stated they lost the clerk who would normally file these documents and other employees were given this additional work. The manager further stated she did not know how old the documents were, and how many had not been filed in the patient records.

Based on interview and record review, the hospital failed to properly fill out and have author identification for restraint assessments for one patient (18). Findings:

Patient 18 was admitted to the hospital with diagnoses including Alzheimer's disease, hypertension and congestive heart failure (impedes blood filling into the heart and produces fluid in the lungs). The Medical/Surgical Restraint Order and RN Assessment forms were reviewed for completion dating from 3/5/10 to 3/11/10.

The RN assessments were not completed consistently to identify the date, time, and identity of the nurse who was responsible for the assessments. The signature of the nurse completing the assessments was missing from the Medical/Surgical Restraint Order and RN Assessment forms on 3/5, 3/6 and 3/10/10 for Patient 18.

During an interview with the risk manager on 3/17/10 at 11:30 a.m., she stated it was the hospital's expectation that all restraint forms be filled out.

Based on observation, the hospital failed to prevent public access to confidential patient medical records on the medical surgical units for three patients (1, 21, and 22) Findings:

During the tour of patient care areas on 3/15/10 at 10 a.m. three patient records (Patients 1, 21, and 22) were observed stored in a rack at a counter accessible to the public. The records were located in a corner of the unit, across from room 346, where licensed staff were not present at all times.

Based on documentation and interview, the hospital failed to complete patient medical records in accordance with its policy and procdedures. Findings:

On 3/16/10 the hospital's medical records department manager was interviewed. According to the manager, the hospital policy to complete records is 14 days after the patient was discharged. As of February 2010 there were 525 delinquent patient records. Of the 525 delinquent records, 37 required the patients history and physical, and 44 were operating room reports.

Based on interview and record review, the hospital staff failed to maintain accurate records of the disposition of controlled substances (CS) in the emergency department (ED) for two patients (51and 52) according the hospital's policy and procedures. Findings:

1. On 3/16/10 beginning at 10:25 a.m., a chart review during a visit to the ED reflected Patient 51 had an order for morphine (a highly controlled narcotic for pain) 10 mg (milligrams) to be given intramuscularly on 3/15/10 at 7:55 a.m. An ED nurse (Staff C) removed 12 mg of morphine (one vial each of 8 mg/ml and 4 mg/ml) from the Pyxis (the automatic drug dispensing cabinet) at 8:04 a.m. She documented that 10 mg was given to the patient on the electronic record. However, there was no documented evidence Staff C disposed of the excess 2 mg of morphine.

A review of another patient's (Patient 52) chart on 3/16/10 at 11:35 a.m. reflected Patient 52 had an order for morphine 2 mg to be given intravenously at 9:40 a.m. and again at 10:30 a.m. on 3/8/10. Staff C removed one vial of 4 mg/ml from the Pyxis at 9:44 a.m. and wasted 2 mg with another ED nurse as a witness. At 10:27 a.m., she removed another vial of morphine 4 mg/ml from the Pyxis. There was no evidence that wastage was done for the second dose of morphine. The patient's electronic record indicated 2 mg of morphine was given each time.

An interview with the assistant director of the ED (DIR A) was conducted on 3/16/10 at 1:58 p.m. She stated the nursing staff were expected to waste narcotics (controlled substances) via the Pyxis in the presence of another nursing staff witness. When shown that there was lack of evidence that Staff C wasted the morphine for Patients 51 and 52, DIR A stated, "She must have been busy and was sloppy and didn't waste it right."

On 3/16/10, the hospital's 7/08 policy and procedures on "Medication Policy: Controlled Substances, Wasting & Disposal of" indicated, "All waste of controlled substances must be witnessed, accurately documented, and destroyed in compliance with all Federal, State and local statues" and "Waste of partial doses of controlled substance medication in patient care areas (other than the OR) must be witnessed and documented in Pyxis by two licensed personnel."

Based on observations, interviews, and record reviews, the hospital failed to provide for patient safety in the control of drugs and biologicals when:

1. The pharmacist failed to capture and follow-up on an inappropriate medication override for a patient (Patient 50) during the retrospective review according to the hospital's policy and procedures.

2. The hospital's policy and procedures on controlled substance (CS) wasting did not address the time frame of when the wasting or disposal of CS should be done to ensure medication accountability and reduce potential for diversion in accordance with acceptable standard of practice (see ISMP).

3. One of one Malignant Hyperthermia (MH) cart in the operating room area did not contain calcium chloride solution as indicated by the hospital's policy and procedures and as recommended by Association of Perioperative Registered Nurses (AORN) standards.

Findings:

1. On 3/15/10 at 9:50 a.m., during an interview with the director of pharmacy (DOP), she stated the hospital revised the automatic dispensing cabinet override (Pyxis) process on 2/26/10. The revised procedure required the pharmacist and/or technician (with direct pharmacist oversight) to verify the appropriateness of the override activities. She stated daily retrospective review had been done daily to ensure there were documented orders and correct medications removed. Follow-up with appropriate nursing units would be done if inappropriate overrides were found.

On the same day, during a tour to the pharmacy from 10 a.m. to 11:45 a.m., the DOP provided a ten-day override activity report, dated from 3/4/10 to 3/14/10.

A review of the override activity report reflected Patient 50 had an order for Coumadin (a blood thinner) 10 mg (milligrams) to be taken daily with "first dose now" at 12:50 p.m. on 3/5/10. Her nurse (Staff A) removed six tablets of Coumadin 2.5 mg (15 mg total) by Pyxis override. The patient's medication administration record (MAR) indicated she was given 10 mg that day. There was no documented evidence indicating such removal was inappropriate. When asked if the retrospective review of the override activity the next day captured the inappropriate removal of Coumadin, the DOP said she had to check with the pharmacist in charge of the override review on that day.

An interview with Staff A on 3/16/10 at 9:50 a.m. reflected she remembered giving the patient (Patient 50) only 10 mg of Coumadin that day and gave the excess amount (5 mg) to the pharmacy personnel whom she did not remember.

On 3/17/10 at 10:55 a.m., the DOP stated her conversation with the pharmacist in charge of the override review for the said patient reflected he had identified the inappropriate override withdrawal but failed to follow-up with the nursing staff.

The hospital's 2/10 policy and procedure, entitled "Pyxis: Medication Profiling and Override Access", indicated the override review was to monitor that correct medication was removed according to the doctor's order and "Inappropriate use will be immediately reported to the Unit Manager at the time of discovery."

2. On 3/17/10 at 9:30 a.m., a review of a patient's chart (Patient 54) with the DOP in the Medical/Surgical Unit reflected the patient had an order for morphine 3 mg to be given intravenously every 4 hours as needed for pain on 3/12/10.

A review of the Pyxis activity report reflected a morphine 4 mg/ml syringe was removed at 10:43 p.m. on 3/13/10 and 1 mg was wasted (with witness) at 11:23 p.m. (40 minutes later). Another syringe of 4 mg/ml morphine was removed at 8:19 p.m. on 3/14/10 and 1 mg was wasted at 9:01 p.m. (40 minutes later). The DOP said the partial wasting of morphine should be done at the time of removal of the medication from the Pyxis, before patient administration.

During an interview with the Med/Surg charge nurse (Staff D) on 3/17/10 at 10:30 a.m., she stated CS medication wasting should be done immediately at the time of removal. She stated the Pyxis had a prompt asking the user if the full dose of medication was being given. If the answer was no, the user would require a witness to waste the partial dose.

An interview with the director of the med/surg unit (DIR B) was conducted on 3/17/10 at 11:30 a.m. She stated, per hospital policy, she expected the CS wasting to be done "right then and there." She added, "Medication should be given to the patient right away, so wastage should be done when the med is withdrawn from the Pyxis."

In the Guidance on the Interdisciplinary Safe Use of Automatic Dispensing Cabinets (ADC) 2008, of the Institute for Safe Medication Practices (www.ISMP.org), the Institute recommended, "Security processes must be established to ensure adequate control of medications outside of the pharmacy and to reduce the potential for medication diversion from ADCs" and to ensure "policies exist and are followed that require the documentation and destruction of medication waste be done at the time of product removal."

On 3/17/10, the hospital's policy and procedures on "Medication Policy: Controlled Substances, Wasting and Disposal of" did not address how soon the partial dose wasting should be done. The DOP acknowledged that the policy did not address the time frame of when the disposal or wastage should occur.

3. On 3/15/10 at 2:10 p.m., the MH cart in the operating rooms area was inspected in the presence of the DOP and OR's charge nurse (Staff B). Staff B stated the hospital prepared the MH cart according to the AORN standards. The inspection of MH cart revealed it did not contain calcium chloride solution (for treatment of life threatening hyperkalemia associated with MH).

On 3/15/10, the hospital's 6/08 policy and procedure entitled "Management of Malignant Hyperthermia (MH)" indicated the inclusion of two vials of calcium chloride 10% vials.

The AORN established standards for drugs which were to be available in the event of an event of MH were reviewed on the same day. It recommended two 10 milliliter (ml) vials of 10% calcium chloride to be available. The hospital did not follow the AORN established guideline for MH carts (applicable standards of practice) when the MH cart did not contain calcium chloride solution.

During this inspection, both the DOP and Staff B agreed calcium chloride solution should be added to the MH cart.

Based on observation and record reviews, the hospital failed to follow the hospital's policy and procedure to dispose of one outdated medication and to properly label the open date on three other medications found in the anesthesia cart. Findings:

On 3/16/10 at 9 a.m. on a tour of the Room 3 operating room, which was being prepared for a surgery, a bottle of Atropine Sulfate (a medication which can decrease bronchial secretions) was observed with the expiration date of 1/5/10 on the label. An open bottle of Sensorcaine (a regional anesthetic), an open bottle of neostigmine methysulfate (a medication used to reverse the effects of muscle relaxants used in surgery) and an open bottle of glycopyrrolate (medication which reduces secretions and gastric acidity) were all found in the first drawer of the anesthesia cart. No open dates were observed on any of the three bottles.

On 3/17/10 a review of the hospital's Medication Policy: Expiration Dates dated 6/09, indicated all medications scheduled to expire during the next month shall be removed from stock and placed in the designated quarantine area until the product could be destroyed or returned. It was over two months from the expiration date on the bottle of Atropine Sulfate.

A review of the same policy indicated multi-dose vials should be labeled with the date opened and the initials of the health care professional first entering the vials. Expiration of opened vials was to be 28 days or less based upon the manufacturer's expiration date listed on the vial. All three multi-dose vials had no indication of open dates, therefore the expiration dates could not be determined.

Based on food service observation, staff interviews, and document review, the hospital failed to ensure safe food handling practices as evidenced by lack of established policies and procedures, safe foodhandling, multiuse utensil sanitation, and oversight of the volunteer food service operated in the hospital and serving potentially hazardous food. Findings:

On 3/15/10 at 11:00 a.m., the service league food service was observed. There were two volunteer cooks (VC1 and VC2) preparing potentially hazardous foods such as soup, tuna sandwiches, and breakfast with soft cooked eggs. One volunteer cook had a serve safe certificate posted in the kitchen area which verified food safety training. VC1 stated that the food they served could be taken to hospital patients by a visitor or family. The director of the hospital food and nutrition department confirmed that the service league operated this food service with no oversight by the hospital food service department. VC1 and VC2 confirmed they did not have any written policies addressing the safe food preparation or ware washing.

During observation VC1 washed a plastic container in one side of the two compartment sink with soap and rinsed and dried the container with a white towel. She then filled the unsanitized plastic container with salad greens (a ready to eat produce). VC1 stated they washed some containers and utensils in the sink and did not follow a wash, rinse and sanitize procedure.

The director of the food service stated the dirty containers and utensils were to be sent to the main kitchen for washing and sanitizing.

There was a soup product in a soup warmer in the serving area. One volunteer serving staff stated that the frozen soup was placed in the warmer and heated before being served. The soup "warmer" did not have manufacturer's directions to ensure the equipment had the capacity to heat the soup as required. The soup warmer was to function as maintaining soup at a safe holding temperature, and not to heat the food first. There were no policies directing staff to prepare the soup or follow the manufacturer's direction for the soup.

VC2 stated that the unpasteurized shell eggs she cooked could be prepared to over easy and not cooked thoroughly. The director of the hospital food service confirmed this was a potential for salmonella contamination if a patient were to receive eggs that were not pasteurized to kill the salmonella. This put the ill hospital patient at risk of food borne illness from salmonella.

There was a table meat slicer that had a significant amount of food debris under the equipment. VC1 stated she cleaned the top of the meat slicer, but could not lift the equipment to clean under the meat slicer.

The temperature of the soup in the soup warmer was taken and VC1 demonstrated the calibration of the stem dial thermometer. She placed the thermometer in the ice bath and confirmed the thermometer was calibrated when it read 38 degrees Fahrenheit (F). The correct calibration temperature of the thermometer was confirmed by the director of the hospital food service as 32 degrees F.

The two door reach-in refrigerator had torn and dirty door gaskets. The gaskets needed to be replaced to ensure proper temperature maintenance of the equipment.

There was a two compartment sink which the volunteer staff stated they used one side for washing the utensils and the other side for food preparation. There was no policy to ensure the safe food handling or safe utensil washing when there was not adequate and separate equipment for food preparation and utensil washing.

Review of the "Retail Food Facility Inspection Report" dated 11/4/08 showed the county inspection observed and cited the service league for not sanitizing the multiuse utensils in the kitchen.

Based on observation, the department of radiology moved the cleaning of ultrasound probes into an area that had not been deemed safe. Findings:

During a tour of the hospital's radiology department on 3/16/10, a room labeled "Housekeeping" contained equipment to disinfect and clean ultrasound probes. Staff stated the room was used to clean and disinfect ultrasound probes used by the radiology department. During the observation, it was noted that two probes were being processed in a disinfectant solution (Cidex OPA). The hospital had no permits to use the area for cleaning and disinfecting ultrasound probes, but had only been approved for housekeeping services (janitors closet).

Based on observation, interview and record review, the hospital infection control program failed to develop infection control guidelines for intravenous (IV) equipment. The hospital failed to assure hand sanitizers located in patient rooms, nurses stations and public hallways were dust and soil free. Findings:

1. During the tour of patient care areas on 3/15/10 at 10 a.m., an IV pole with two sets of empty medication bags with tubing were observed in Patient 1's room. Neither set of tubing was labeled with a start date or expiration date. Patient 1 was being discharged at 10:30 a.m.

Patient 1's record indicated the IV solution of normal saline with potassium was discontinued on 3/14/10.

The facility policy number 0156, reviewed on 3/17/10, indicated IV sites would be changed every 96 hours. The policy also indicated if multiple administration sets were used, each should be labeled so IV medication/solution lines could be identified.

During interview at 10:15 a.m., a staff nurse inspected the IV bags and stated the IV lines were not tagged with a dated red label to indicate expiration, as required. The policy did not mention the use of a red tag as part of the identification process.

The infection control nurse on 3/17/10 stated there was no specific written policy or procedure to ensure expired tubing was not used.

2. Multiple dusty and/or soiled hand sanitizer containers were observed secured to walls of patient rooms in the newborn nursery, intensive care unit and patient care unit hallways.

Based on interview and record review, the hospital failed to ensure a family member, or the receiving facility, received discharge instructions for one patient (18) who was diagnosed with dementia. Findings:

Patient 18 was admitted to the facility with diagnoses including Alzheimer's disease, hypertension and congestive heart failure (impedes blood filling into the heart and produces backup into the lungs). A review of her nursing assessment dated 3/3/10 indicated she was confused and disoriented.

On 3/17/10 at 9:10 a.m. during a review of Patient 18's clinical records, her discharge instructions dated 3/10/10, indicated the patient was unable to sign and no family was present. There was a notation the hospice nurse made a copy of information, and there was a signature of the nurse responsible for the discharge education. There was no indication of any family member or the receiving facility being given any discharge instructions.

A review of Patient 18's Patient and Family Educational Record indicated instructions given on 3/5/10 and listed the physical condition of Patient 18 as confused. There was no indication of family being present. The area for discharge instructions on the form was left blank.

During an interview with the case manager on 3/17/10 at 10:30 a.m., while reviewing the clinical record for Patient 18, she stated she was unable to find any documentation in the progress notes, nurse's notes, social service notes or discharge instructions of the family member or the receiving facility having been contacted to review discharge orders.