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Based on observation and interview, the facility failed to ensure the privacy of patients was maintained during medical evaluations in the Emergency Room (ER) for 3 unsampled patients.

Findings include:

On 7/5/12 at 1:40 PM, observed three patients sitting in an open area in the ER waiting to be examined. One male patient was sitting in the open area in front of the nurse's station, across from Bay 1 and Bay 2. Two female patients were sitting on the side of the nurse's station, directly across from each other, outside the triage room.

The male patient was being interviewed by the Nurse Practitioner (NP) regarding the patient's medical history and the reason the patient had come to the ER. The scribe was standing next to the NP documenting the information into the computer while the NP talked. The NP performed a brief examination of the patient and listened to the patient's heart using the stethoscope, on the patient's chest and back. There were no curtains or screens surrounding the patient.

After the brief examination, the NP went to one of the female patients and started interviewing her. The second female patient was sitting about 3 feet directly across from the first female patient.

On 7/5/12 at 1:55 PM, a laboratory technician drew blood from Female Patient #1 while the patient was still sitting in the open area. The patient verbalized "I'm very hard to draw blood from". Then while the technician drew the blood, the patient yelled "OOH, that hurts." Female patient #2 was still sitting directly across from Patient #1. There were no curtains or screens provided for the patient's privacy.

During this time, it was noted the triage room was empty from 1:40 through 1:50, and there was no patient in Bay 1.

On 7/5/12 at 2:00 PM, the Director of the ER (DER) was interviewed. The DER verbalized, in an effort to reduce the time patients remained in the ER, the hospitalist group had begun the new process of Rapid Medical Exam (RME). After a patient had registered, they were seen by the triage nurse. The patient was then seen by a physician, NP or PA (Physician Assistant) for the RME. Sometimes the patient was seen and examined in the Triage area. Sometimes the patients were seated outside the triage room by the nurse's station for the RME, as the patients were on this day. Usually Bay 1 was used for the laboratory (lab) draws or EKG's. The DER added Bay 1 was left open today just in case a patient arrived and the staff needed to do an emergent EKG (Electrocardiogram).

The DER indicated the staff and physicians did not believe there was an issue of the RME being done in an open area since the process reduced patients' time in the ER.

On 7/6/12 at 9:30 AM, the R.N. Charge Nurse of the ER was interviewed. The R.N. explained the process for the Rapid Medical Exam. He indicated usually patients were placed in Bay 1 or Bay 2 to be seen by the physician for a rapid screening. Then labs were drawn. This would decrease the total time patients were in the ER since the lab results would assist the physician in the assessment of the patient. Frequently, if no beds were available, patients were seated in front of the nurse's station or outside the triage room, to have the RME.

On 7/6/12 at 9:55 AM, the ER Physician was interviewed. The ER physician verbalized the process for the RME. He indicated, ideally Bay 1 would be used for the medical screening, examination, blood draws and EKG's. However yesterday had been an extremely busy day and patients were seen in the open areas around the nurses station so the screening process and lab draws would be quicker.

On 7/6/12 at 10:00 AM, the DER verbalized there had been bays available in the back of the ER on 7/5/12, where the patients could have been seen and examined.

Based on observation and interview, the facility failed to keep electronic clinical records confidential.

Findings include:

On 7/3/12 in the morning, two lap top computers were stationed outside patient rooms in the Intensive Care Unit (ICU). Patient information was easily visible on one screen while the second lap top screen was partially opened but was not logged off. The area in which the computers were located was a hallway next to double doors where staff and family entered and exited the unit. An irritated staff nurse walked from the nursing station to the computers and stated "It's ridiculous to log off every 5 minutes!"

On 7/3/12 in the morning, the ICU Manager confirmed it was not acceptable to have patient information left on the computer screen and staff should log off the computer when leaving the computer unattended.

On 7/5/12 in the afternoon, there was a lap top computer on the countertop of the nursing station in the Emergency Room (ER). The screen was facing the hallway area where staff and family walked by. On the screen was patient information. The staff nurse assigned to the computer was in another area of the ER.

Based on interview, record review, and policy review, the facility failed to ensure 1 of 30 sampled patients with restraints was seen by the physician timely and the order was authenticated timely (Patient #13).

Findings include:

Patient #13

Patient #13 was admitted 6/21/12 at 3:45 PM with a diagnosis of bilateral lower lobe pneumonia. The History and Physical Examination indicated diagnoses of acute respiratory failure, bilateral pneumonia, mild hypernatremia, history of seizure disorder, altered mental status, history of dementia, and leukopenia.

The documented restraint forms indicated soft wrist restraints x2 and side rails x4 were implemented on 6/30/12 (8:00 AM), 7/1/12 (8:00 AM), 7/2/12 (8:00 AM), and 7/3/12 (8:00 AM). These restraint forms only documented the time of the nurse's entry, and did not have dates and times next to the physician's signature.

On 7/6/12 in the morning, the documented restraint form indicated on 7/5/12 at 8:00 AM the physician ordered the soft wrist restraints and the side rails x4, and the above date and time had already been written down next to the line for the physician's signature, although the physician had not signed it yet.

On 7/6/12 in the morning, the charge nurse on the 200 Hall indicated the physician should always document the time and date of his signature on the restraint forms. The Director of Clinical Education also verified it is the facility's policy to ensure an order for restraint is signed, timed, and dated by the physician within 24 hours of the order.

The facility's policy regarding restraints ("Restraint & Seclusion, policy number PCS:07:28", final approval date 5/18/12) indicated,

"Procedure: C. Initiation of restraint by order of an LIP (licensed independent practitioner) or Designee...Verbal/Telephone Orders for restraints must be authenticated within 24 hours for Medical Surgical Restraints...The order will be documented on the Restraint Order Form and must include: a. Clinical justification/reason for restraint to continue or discontinue; b. The type of restraints used; and c. The time limit of the order. Time limits: a. Medical/Surgical - Order must not exceed 24 hours..."

Based on observation, interview, record review, and document review, the facility failed to provide justification for the use of restraints for 1 of 30 sampled patients (Patient #11):

Findings include:

Patient #11

Patient #11 was admitted 6/23/12 at 8:59 PM with diagnoses including dehydration, renal failure, and acute kidney failure.

The restraint forms documented that on 6/25/12 and 6/26/12 / 8:00 PM that soft restraints x2, and side rails x4 were required. The nurse's progress notes indicated the patient had restless behaviors.

The restraint forms dated 6/27/12 indicated soft restraints x2, side rails x4, a posey vest, and tied mittens were required. However, there was no documented evidence of justification for the additional, more restrictive restraints (posey vest and tied mittens).

The nurse's progress notes dated 6/28/12 indicated the restraints used were the left and right soft wrist restraints, the posey vest, side rails x4, and left and right hand mitts. However, the restraint form for 6/28/12 / 12:20 PM indicated only soft restraints x2, side rails x4, and a posey vest were required. There was no documented evidence of justification for the use of the posey vest and the hand mitts for 6/28/12.

The restraint forms for 7/1/12, 7/2/12, 7/3/12, 7/4/12, and 7/5/12 indicated the soft restraints x2, side rails x4, posey vest, and hand mitts were required. There was no documented evidence in the clinical record for justification for the continued use of the hand mitts and the posey vest.

On 7/6/12 in the morning, Patient #11 was observed lying in bed with bilateral wrist restraints, a posey vest, and bilateral hand mitts applied.

On 7/6/12 in the morning, the Director of Clinical Education and the Quality Assurance Manager indicated there should have been documentation of a nurse's assessment indicating why the hand mitts and the posey vest were needed in addition to the side rails and the bilateral soft wrist restraints.

The facility's policy regarding restraints ("Restraint & Seclusion, policy number PCS:07:28", final approval date 5/18/12) indicated,

"Policy:..Patients will be restrained only when clinically justified to prevent the patient from causing injury to self or others in the therapeutic environment or to enhance medical healing and when alternative methods have proved unsuccessful...Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm. Each episode of restraint use considers the impact on the patient including: Bases use on patient's assessed needs...The order will be documented on the Restraint Order Form and must include: a. Clinical justification/reason for restraint to continue or discontinue; b. The type of restraints used; and c. The time limit of the order. Time limits: a. Medical/Surgical - Order must not exceed 24 hours...Renewal of Orders: a. If restraint use continues to be clinically justified beyond the time limits noted above, the LIP or his/her designee must issue a new time-limited order. b. The continuation of the restraints is based on the LIP's/designee's examination of the patient...F. Release From Restraints:...Clinical Justification Criteria: -No longer pulling at or interfering with Invasive Tubes/Lines; -No longer attempting to crawl out of bed and/or exhibiting disoriented/confused behavior resulting in potential injury to self; -No longer picking at surgical/wound site, in manner that hinders healing process."

Based on record review and interview, the facility failed to ensure a consent was properly signed for 1 of 30 patients (Patient #17).

Findings include:

Patient #17's diagnoses included diabetes, ulcer of the heel and midfoot, and transmetatarsal amputation. The patient was originally seen in 11/11 and currently was receiving daily outpatient hyperbaric treatments for the wound of the right foot.

The consent form for Hyperbaric Oxygen treatments included the statements:
- "(Pt Name), understands that my diagnosis is ______, and requires that I undergo Hyperbaric Oxygen treatments."
- I therefore consent to the procedure under the supervision of _____ (Hyperbaric Physician) and/or associates of the physician's choice."

The patient's diagnosis and the name of the physician were left blank.

Patient #17's consent form did not include the date signed by the patient, or the signature of a witness.

On 7/6/12 in the morning, the nurse in the hyperbaric area was asked when Patient #17's consent was signed. The nurse verbalized there was no date documented but the consents have to be signed monthly.

The facility policy title Informed Consent dated 1/10 documented:
-"Completion of Forms
- 1. All dates, times, and signatures must be in ink, including signatures of witnesses...A witness should be eighteen years old or older and must be present when the form is signed...."

Based on interview and record review, the facility failed to properly monitor temperature levels where medications were being stored.

Findings include:

In the Pharmacy Department was a small refrigerator which stocked several different medications. Temperature checks were performed daily on the refrigerator.

The May 2012, Medication Refrigerator and Freezer Temperature Log for the narcotic refrigerator documented acceptable refrigerator levels in white unshaded squares. The acceptable ranges were 36 degrees Fahrenheit (F) to 46 degrees F. The following unacceptable temperatures were documented for May 2012:

5/12 - 34 F
5/13 - 32 F
5/16 - 33 F
5/23 - 35 F

There was no documented evidence temperatures were rechecked one hour after the unacceptable temperatures were documented.

On 7/3/12 in the morning, the Pharmacy Director indicated if a daily temperature is out of normal range then the temperature is retaken one hour later and documented. The Director indicated if temperature ranges were abnormal the refrigerated medications would be stored in another refrigerator which had normal readings.

On 7/3/12 in the morning, the July 2012 Medication Refrigerator and Freezer Temperature Log for the narcotic refrigerator did not document refrigerator levels on 7/1/12 and 7/2/12. The Pharmacy Director indicated temperature readings should have been taken daily.

Based on document review and interview, the facility failed to ensure that qualified personnel operated radiologic equipment.

Findings include:

On 7/6/12, Employee #5 and Employee #5 confirmed that Employee #7, one of eight radiology department employees whose personnel files were reviewed, did not have the required two years of experience prior to hire.

NFPA 101, 7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspection and tests shall be kept by the owner for inspections by the authority having jurisdiction.

This STANDARD was not met as evidenced by:

Based on staff interview and a review of maintenance records, annual 90-minute tests of battery-operated emergency lights were not being conducted.

Findings include:

On 7/3/12 the Director of Non-Clinical Operations volunteered that the battery-powered emergency lights (not connected to the essential electrical system) had not been subject to the required annual, 90-minute testing. A review of maintenance documents confirmed that there was no written documentation of such tests. Untested, light packs were observed in the Environmental Services structure (1 set) , the Main Conference Room (2 sets), and the MRI suite (3 sets). All of these locations were in Building 1 [construction type V (111)].

Based on observation, the facility failed to ensure that Alcohol Based Hand Rub (ABHR) dispensers were installed neither over, nor adjacent to, ignition sources. The two, noted deficiencies affected one of ten fire zones.

Findings include:

On 7/3/12 at 8:40 AM, it was observed that in Building 1 [single story, type V (111) construction], two ABHR dispensers were installed directly over two electrical outlets in the Intensive Care Unit (ICU) suite.

Based on observation, interview and document review, the facility failed to ensure infection control measures were followed to prevent the spread of infection throughout the facility.

Findings include:

During the survey from 7/3/12 through 7/6/12, several staff members were interviewed and observed regarding the process for cleaning glucometers.

On 7/3/12 at 1:30 PM, an L.P.N (Licensed Practical Nurse) in the Psychiatric Holding Area in the Emergency Room (ER) verbalized the glucometer was cleaned every 12 hours with a disinfectant wipe.

On 7/3/12 at 2:55 PM, a R.N. (Registered Nurse) in the Outpatient Postoperative Recovery Room verbalized the glucometer was cleaned every Monday using a Dispatch cleaning pad.

On 7/5/12 at 12:30 PM, observed a R.N. in the Hyperbaric Wound Care area perform an accucheck on a patient. The R.N. obtained the glucometer from a table. The R.N. did not clean the glucometer before performing the accucheck on the patient. After the test was completed, the R.N. returned the glucometer to the table, without cleaning the machine, and proceeded back into the office. Following the procedure, the R.N. was asked how often the glucometer was cleaned. The R.N. responded, the glucometer should be cleaned after each patient. The R.N.acknowledged she did not clean the glucometer as required.

On 7/5/12 in the afternoon, the Director of Quality Improvement (DQI) and the Infection Preventionist verbalized the glucometer should be cleaned between each patient. The DQI added staff had been trained in the process numerous times.

The facility policy titled Point of Care Testing dated 12/10 documented:
- "Disinfect the meter, after use with each patient, with 70% isopropyl alcohol, by wiping down the entire meter with alcohol. Note: For patients with C-Diff (Clostridium Difficile), wipe meter with Bleach Disinfectant Towellets right after each use. "

"CFR 42 482.43(c)(4): The hospital must reassess the patient's discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan."

Based on interview, record review, and document review, the facility failed to follow its policies and procedures by notifying the representative of an imminent discharge and ensuring the representative signed the discharge instructions for 1 of 30 sampled patients (Patient #29).

Findings include:

Patient #29

Patient #29 was admitted 3/26/12 with a diagnosis of acute psychosis. Patient #29 was discharged from the facility to a residential facility for groups 5/23/12 at 7:45 PM.

The History and Physical Examination dated 3/27/12 indicated a diagnosis of schizophrenia and a history including hypertension and chronic obstructive pulmonary disease.

The Case Management Notes (entered by the Nurse Case Manager (Employee #1) included the following:

-5/16/12: "Received a call from pt's (patient's) guardian. She requested GH (group home) eval (evaluation)...S/W (spoke with) (name of facility physician), he agreed to order GH eval..."

-5/17/12: "Per GH Liaison, she has accepting GH's. She will call pt's guardian to work out financial issues. CM (case manager) to f/u (follow up) later today for accepting GH's.

-5/23/12: "Called GH Liaison yesterday morning, she stated that (name of residential facility for groups) would come out to evaluate pt. (Name of administrator of the residential facility for groups) did evaluate and accepted pt pending guardian approval. Called pt's guardian, vmm (voice mail message) left informing her of the above. (Name of psychiatrist) was notified of above. Received a vmm from (name of guardian) at 1927 (7:27 PM) last night, she stated she will visit GH today at 1500 (3:00 PM). Pt was listed as discharged yesterday to GH...Transfer was arranged after CM (Case Management) office closed."

The Discharge Instructions indicated Patient #29 was discharged 5/22/12 at 1945 (7:45 PM) to a group home. The Discharge Instructions (Patient/caregiver Signature area) was signed by the Group Home administrator.

On 7/5/12, the Nurse Case Manager and the Lead Discharge Planner in the Case Management Department (Employee #4) were interviewed. The Lead Discharge Planner verified the guardian should have been given the opportunity to evaluate the residential facility for groups and should have been in agreement with the discharge prior to the actual discharge. The Case Manager also indicated the patient was prematurely discharged.

On 7/5/12, the Risk Management Specialist verified the facility did respond to a grievance from Patient #29's guardian regarding Patient #29's discharge, and acknowledged the facility discharged the patient on the evening of 5/22/12 without giving the guardian the opportunity to view the facility and approve it. The Risk Management Specialist indicated the grievance investigation confirmed Patient #29 was discharged to the residential facility for groups after hours (7:45 PM) on 5/22/12 prior to the guardian's evaluation and approval. In response to the question whether the discharge instructions should be signed by the patient or patient representative, the Risk Management Specialist indicated yes, if it was possible. If it was not possible, there should be documentation that the representative was contacted and was in agreement with the discharge.
The facility's policy and procedure, "Patient Choice at Discharge", revised 03/11 indicated, "Policy: Patients are to be discharged in a manner that meets their health care needs and protects their rights as patients. A member of the Case Management Team will inform the patient/patient representative of his/her legal right to be given a choice in their discharge plan of care..."

The facility's policy and procedure, "General Procedures for Discharge", final approval date 04/12/12 indicated, "Purpose: The purpose of this policy is to identify and facilitate: 5. Adequate and timely preparation of the patient, family, or patient's representative, thereby ensuring a smooth transition from one level of care to another."

The facility's policy and procedure, "Discharge Instructions", renewed 09/11, indicated, "Procedure: 3. The Discharge Plan/Instructions will be signed by the patient/representative and by the RN (registered nurse) providing the providing the review."

Based on a document review and interview, the facility failed to ensure that respiratory therapy personnel met the qualifications specified by the medical staff.

Findings include:

On 7/6/12, Employee #5 and Employee #6 confirmed that Employee #8, one of four respiratory employees whose personnel files were reviewed, did not meet the qualifications specified by the medical staff. Employee # did not have the required six months of experience prior to hire.

Based on a record review and interview, respiratory care services were not correctly documented in the patient chart.

Findings include:

On 7/6/12, Employee #5 and Employee #9 confirmed that on 6/29/12 at 1:47 AM, Employee #10 documented in Patient #31's electronic medical record that albuterol and atrovent were "Not Given: Clinical Decision." Employee # documented in a different area of the Patient #31's chart that the albuterol and atrovent were administered.