HospitalInspections.org

Based on review of 1 of 1 medical records of patients with a current DNR (Do Not Resuscitate) in a total sample of 38, review of policy titled "No Code/No Cardiopulmonary Resuscitation" (reference #PR 15) and interviews, the hospital failed to follow their policy for DNR as evidenced by the failure of the attending physician to document who was involved in the decision making process to withhold cardiopulmomary resuscitation measures for patient #15. Findings:

Review of the open medical record for patient #15 revealed a physician order dated 7/20/2010 at 8:00 AM "Patient is No Code". A thorough review of the record failed to reveal who the physician discussed the DNR status with.

Review of hospital policy No Code/No Cardiopulmonary Resuscitation (effective date 1/1/07) revealed the physician should discuss the proposed No Code/DNR status with the patient and/or family members and write and sign the DNR order. The policy indicated the physician should document in the progress notes who was involved in the decision making to make the patient a DNR. In an interview on 7/26/2010 at 10:30 AM, S4 RN Nurse Manager 6th Floor Medical Surgical Unit, confirmed that the attending physician failed to document in the medical record that he had discussed the DNR with the patient or the patient's representative.

Based on record review and staff interview, the hospital failed to ensure the Housekeeping Department identified and tracked quality indicators as evidenced by the failure to include housekeeping in the hospital wide QA/PI program. Findings:

Review of the hospital QA/PI reports for the last 6 months (2/15/2010, 3/15/2010, 4/15/2010, 5/17/2010 and 6/21/2010) failed to reveal the housekeeping department submitted quality data to the QA/PI Coordinator. An interview was conducted with the Director of Plant Operations on 7/29/2010 at 1:55 PM who stated the Housekeeping Department is under Plant Operations, but that he does not track or submit quality indicators for housekeeping. In an interview on 7/29/2010 at 1:45 PM the QA/PI Coordinator confirmed that the Housekeeping Department does not report data to the QA/PI Committee.

Based on record review and interview the hospital failed to ensure the registered nurse (RN) assessed and evaluated the nursing care for 4 of 4 patients (patient #21, #22, #23 and #24) in a total sample of 38 by not having documented evidence that the nursing staff provided pertinent information regarding infection control practices to families of patients who were in contact isolation. Findings:

Review of the medical record revealed patient #21 was a 60 year-old admitted on 6/30/2010 at 2:21 PM with diagnoses of cellulitis of the right lower leg, nausea, vomiting and diarrhea. Review of 7/24/2010 lab results revealed the patient had a positive stool culture for C-difficile (causes diarrhea and requires contact isolation). Further review of the medical record failed to reveal documented evidence that the RN ensured the patient or family understood the purpose of contact isolation, or the precautions to prevent the spread of the infectious bacteria.

Review of the medical record revealed patient #22 was a 79 year-old admitted on 7/23/2010 with diagnosis of active TB (tuberculosis). Observation on 7/26/2010 at 9:30 AM revealed a sign on the door to the patient's room which indicated the patient was placed in respiratory isolation. On 6/27/2010 at 10:29 AM a family member was observed walking out of patient #22's room wearing a mask and she walked down the hallway toward the nurses station. At that time the QA/PI (Quality Assurance/Performance Improvement) Coordinator approached the family member and stated to her that she could not wear masks out of the patient's room. The family member stated to the QA/PI Coordinator "It's okay, I've only worn this mask two times" and went back into the patient's room. Further review of patient #22's medical record failed to reveal documented evidence that the RN provided information on infection control protocol to the patient or family members which included the importance of adhering to isolation precautions.

Review of the medical record revealed patient #23 was a 62 year-old admitted on 7/15/2010 with probable sepsis from an abdominal wound. Review of the 7/21/2010 lab report revealed the patient's sputum was positive for Methicillin Resistant staph aureus. Observation on 7/26/2010 revealed patient #23 was in droplet and contact isolation. Further review of patient #22's medical record failed to reveal documented evidence that the RN provided information on infection control protocol to the patient or family members which included the importance of adhering to isolation precautions.

Review of the medical record revealed patient #24 was admitted on 7/20/2010 at 3:48 PM with diagnoses of acute respiratory failure and pneumonia. Review of the 7/23/2010 lab reports revealed the patient's sputum culture was positive for Escherichia coli and was a multi-drug or pan-resistant organism. Further review of the medical record failed to reveal documented evidence that the RN ensured the family was provided with information on infection control practices and the importance of adhering to isolation precautions. RN S4 Nurse Manager confirmed in an interview on 7/27/2010 at 1:00 PM that the RN staff failed to have documented evidence that they provided infection control information and isolation precautions for the patient and family members of patients #21, #22, #23 and #24.

Based on record review and interview the hospital failed to ensure an individualized nursing plan of care was developed for the potential for transfusion reaction for 2 of 4 sampled patients who received blood (#19, #20) in a total sample of 38. Findings:

Review of the medical record revealed patient #19 was a 91 year-old admitted on 7/20/2010 at 10:15 PM with diagnoses of lower gastrointestinal bleed and anemia. Further review revealed a 7/29/10 at 10:12 AM physician order to transfuse 2 units of PRBCs (packed red blood cells) and to administer Lasix (diuretic) 20 milligrams between units. Review of the patient's nursing care plan revealed the plan had not been updated since 7/21/2010 and that the nurse failed to formulate care plan approaches for the potential for transfusion reaction.

Review of the medical record revealed patient #20 was a 91 year-old admitted on 7/18/2010 at 11:23 PM with diagnoses of dehydration and acute renal failure. Further review revealed a 7/22/2010 physician order to transfuse 2 units of PRBCs but the nurse failed to modify the nursing care plan to reflect the potential for transfusion reaction.

I. Based on review of 2 of 6 open medical records of patients who had a surgical procedure (patients #13 and #15) in a total sample of 38, review of policy titled "Site Marking and Time Out Process" (no reference number, revised 1/2007) and staff interviews, the hospital failed to ensure each surgical consent was complete with date, time, and authenticated by the person responsible for providing or evaluating the services.
Findings:

1. Review of the medical record revealed patient #13 was admitted on 7/27/10 through ASU (ambulatory surgery unit) for an open right rotator cuff repair with insertion of a pain block pump. Observation on 7/27/2010 at 10:00 AM revealed the patient's surgery was completed, she had recovered in the post anesthesia care unit and was in ASU waiting for discharge. Review of the patient's informed surgical consent for the open rotator cuff repair revealed the physician had not signed the consent.

Interview with S1 RN, ASU pre-op nurse, on 7/27/10 at 10:30 AM revealed patient #13 was the first case scheduled for the day and that the patient's operative consent had been obtained at the surgeon's office. S1 RN stated she reviewed the patient's information in the pre-op unit and that she noted on the front of the patient's chart that the consent was not signed by the surgeon and then sent the patient to the holding area.

Review of form "Surgical/Procedural Verification and Time-Out" (time when the surgery team ensures all relevant documents are available and have been reviewed, all work ceases and all members of the operative/procedural team confirms correct patient, correct procedure, correct site and side, medications on the sterile field and availability of all items anticipated for the procedure to begin) record dated 7/27/10 revealed the RN in the holding area signed off that the informed consent was complete. Review of hospital policy titled "Site Marking and Time-Out" revealed "missing information or discrepancies must be addressed before starting the procedure and that the "time out " must involve the surgical team.

Interview with S2 CRNA, (Director of the operating room, ambulatory surgical unit, and post anesthesia care unit) on 7/27/10 at 10:35 AM confirmed patient #13 went to surgery and had a procedure performed without a physician's signature on the informed consent. S2 stated the operating room nurse depended on the nurse in the holding area to verify the medical record contained all pertinent information prior to surgery. S2 also confirmed the nurse in the holding area documented on the Time-Out record that the chart was complete.

2. Review of the medical record for patient #15 revealed a right femoral-popliteal bypass with toe amputation was performed on 7/24/10. Review of the informed consent failed to reveal which toe was scheduled for amputation. Interview with S3 RN on 7/27/10 at 10:45 AM confirmed the informed consent failed to indicate which toe would be amputated.


II. Based on review of 3 of 3 open medical records of patients in the geropsychiatric unit, review of policies and procedures and staff interviews, the hospital failed to develop a policy for the use of signature stamps. Findings:

Interview with S5, Director of Medical Records, on 7/26/10 at 9:00 AM revealed written or electronic signatures were the only signatures allowed in the medical record and that the hospital no longer allowed signature stamps on any medical record. S5 further stated there were some physicians whose signature was illegible and they were offered the choice of using a signature stamp to authenticate their signature after they signed the entry in the medical record, or they could print their name. S5 also stated if the physician chose to use the signature stamp, he was to keep the stamp on his person to prevent access to other individuals.

On 7/27/2010 at approximately 10:00 AM review of the medical records for geropsychiatric patients #4, #5 and #6 revealed the medication orders were stamped with a signature stamp as well as signed by the attending psychiatrists. In an interview on 7/30/2010 at 9:45 AM S6 Unit Clerk stated she uses signature stamps for two of three staff psychiatrists and the stamps are kept at the nurses station. S6 further stated she only uses the signature stamp for medication orders she sends to pharmacy.

A second interview with S5 Director of Medical Records on 7/30/10 at 10:00 AM revealed the Medical Staff had discussed using the signature stamp, but a policy and procedure was not developed to address use of the stamp. S5 confirmed there was no documented evidence that physicians who chose to use the signature stamp to authenticate their signature accepted responsibility to keep the stamp on their person and to not allow anyone else to use the stamp.

Based on observation and interview the hospital failed to ensure outdated drugs were not immediately available for patient use by having expired medications in the adult and pediatric crash carts at the off-site ED (emergency department) located approximately seven miles from the main campus. Findings:

Tour of the ED at the off-site campus on 7/29/2010 at 9:45 AM revealed the following:

The crash cart (wheeled chest of drawers which contains all equipment necessary for emergency resuscitation) in Trauma Room #1 contained the following expired drugs:
1. 2 Naloxone 0.4mg with an expiration date of 1/01/10,
2. 3 Epinephrine 1:10,000 with an expiration date of 6/01/10,
3. 2 Epinephrine 1:1000 with an expiration date of 5/01/10,
4. 1 Amiodarone 150mg/3cc with an expiration date of 1/01/2010,
5. 1 Vasopressin 20units/cc with an expiration date of 6/10/10,
6. 2 Adenosine 6mg/2cc with an expiration date of 6/01/10,
7. 2 Lasix 5cc vials with an expiration date of 4/01/10,
8. 2 Verapamil 5mg/2cc with an expiration date of 1/01/10,
9. 1 Dopamine 80mg with an expiration date of 3/01/10,
10. 4 Lidocaine 2% 5cc with an expiration date of 3/01/10.

The pediatric crash cart at the nurses station contained 46 doses of medicines with expiration dates ranging from 1/01/10 to 7/01/10. An interview with the chief pharmacist on 7/29/2010 at 10:47 AM confirmed the medications were out of date and should not have been available for patient use.

I. Based on observations on the adult psychiatric wing and interview, the hospital failed to ensure the overall hospital environment is maintained in such a manner that the safety and well-being of patients are ensured. This was evidenced by: 1) utilizing 20 patient electric beds on the unit, 2) having locked doors to patient rooms and the seclusion and restraint room that were difficult to access, 3) having unlocked rooms which posed a safety hazard to any patient passing in the hallway, 4) having damaged mattresses for patient use, missing shower furnishing in patient bathrooms, and 5) poor lighting throughout patient rooms. Findings:

1. On 07/26/2010 at 9:30 AM, observations on the adult psychiatric wing of of the hospital revealed a 20 bed unit with electric beds in various raised positions. It was further observed that all the beds had approximately 8 to 10 feet of heavy gauged electrical cord connected to the bed frame with a type of plastic fastener.

2. On 07/26/2010 at 9:45 AM, observation of patient room a revealed the door was locked and that three different staff attempted, without success, to unlock the door with their facility keys. On 07/30/2010 at 10:15 AM, a staff RN could not open the locked door to patient room b with her facility key. On 07/27/2010 at 2:15 AM, observation of the locked seclusion and restraint rooms revealed that the DON, program director, and the charge nurse's keys would not unlock the door to the rooms.

3. On 07/26/2010 at 9:25 AM, observation of the adult psychiatric wing revealed that the soiled linen closet and the laundry room were unlocked, unattended, and accessible to patient passing in the hallway.

4. On 07/26/2010 at 9:30 AM, observation of patient rooms revealed the outer cover of 8 mattresses were torn, exposing the inside foam portion of the mattress. Further observation revealed that 2 rooms had missing shower curtains and rods.

5. On 07/26/2010 at 9:50 AM, observation of 10 patient rooms on the psychiatric adult wing revealed the lighting was dim in the rooms and could not be adjusted to provide adequate lighting. Further observation revealed patient room c had a purple colored bulb in the room.

On 07/28/2010 at 2:45 AM, interview with the DON and interim program director confirmed the above findings.

II. Based on observation of the labor and delivery unit and interview, the hospital failed to ensure that the physical environment is maintained in a manner that promotes the well-being of patients. Findings:

On 7/28/10 at 8:45 AM, observation of the newborn nursery with S13 RN, Nurse Manager, revealed 3 enclosed isolettes that had a build-up of dust and debris in the corners of the inside of the isolettes where the mattress rested. Further observation revealed an empty, clear plastic reservoir underneath the enclosed area on each isolette that had a thick white layer of dust inside and on top. Observation of the inside hinged edge of each isolette revealed a buildup of a black substance. Interview with S13 at that time revealed the isolettes were considered clean and ready for a newborn admission. S13 also confirmed there was a build-up of dust and debris inside the isolettes, underneath the isolettes, and that there was a buildup of a black substance inside the hinged edge. S13 confirmed that the isolettes needed to be cleaned.

On 7/28/10 at 9:15 AM, observation of rooms e, f, and g on the Labor and Delivery Unit revealed the splash guard underneath the delivery table was broken on each table. Interview with S14 RN, OB/GYN specialty coordinator, at that time revealed the splash guard was to prevent fluids from splashing under the table in areas that were difficult to clean. S14 confirmed the broken splash guards allowed fluids to get into areas that were difficult to clean and presented a breach in infection control practices.

Based on observation, review of policy titled "Daily Patient Isolation Room Cleaning" (Reference #5004), policy titled "Notification Procedure for Contact Isolation", form titled "Isolation Orders", and staff interviews, the infection control officer failed to ensure all staff adhered to infection control policies and procedures to prevent the spread of infections as evidenced by: 1) the lack of training for transport staff regarding infection control practices, 2) the failure of housekeeping staff to adhere to hospital policies and procedures for cleaning isolation rooms and 3) the failure of nursing staff to adhere to hospital policies and procedures for placing isolation carts outside patient rooms. Findings:

1. Observation on 7/26/2010 at 10:55 AM revealed patient #24 had a sign on the door of his room indicating that he was in contact isolation (patient's sputum culture was positive for Escherichia coli and was considered a multi-drug resistant organism). Further observation revealed an isolation cart in the hallway near the door of the patient's room. During that time housekeeper S7 was observed to sanitize her hands and then she removed a gown and gloves from the isolation cart. S7 put on the personal protective equipment, walked into the patient's room, removed the transparent trash can liner from the patient's room and placed it in a corner near the door. She (S7) took off her protective equipment placed it inside the trash liner, sanitized her hands with a alcohol base solution, put on another gown and gloves and went back into the room and used a dust mop on the floor of the patient's room. She sweep the trash up into the dust pan from the housekeeping cart, placed the debris into the trash can liner beside the door of the room, pulled off the gown and gloves, sanitized her hands and put on another set of gown and gloves. S7 took the wet mop from the housekeeping cart and mopped the floor in patient #24's room. After using the wet mop, S7 pulled off her personal protective items, placed them inside of the trash can liner, then placed the bag into the regular trash bin on her housekeeping cart and sanitized her hands.

After leaving patient #24's room, S7 pushed her housekeeping cart around the corner and down the hallway to room d and began cleaning the room. According to the isolation sign on the door to patient #24's room, S7 failed to wash her hands with soap and water after leaving the room. S7 failed to clean the supplies and equipment on the housekeeping cart, change mop heads, and label the trash she removed from the isolation room as infectious waste.

Housekeeper S7 stated in an interview on 7/26/2010 at 11:15 AM that she changes the mop water and cleaning solution every 3 rooms. She stated the only reason she would change the water more often was if she "cleaned up blood".

An interview was held with S10 on 7/27/2010 at 10:20 AM who stated that he was the director of the Housekeeping Department. He stated that isolation rooms should be cleaned last, at the end of the day. He also stated that after cleaning an isolation room the housekeeper should change the wet mop and dust mop heads, change the water, and clean the mop handles before cleaning another room.

2. Observation on 7/30/2010 revealed at 10:40 AM a sign was on the door indicating patient #36 was in contact isolation (patient's urine was positive for Enterococcus specie, a vancomycin resistant organism and the blood was positive for Enterococcus faecalis.). At this time CNA (Certified Nursing Assistant) S10 entered the room wearing gloves and held a gown sealed in plastic in her right hand (she never wore the gown). At 10:45 AM S9, transport staff came to the floor to transfer patient #36 for a diagnostic study. S9 was observed to drop his gloves on the floor in the hallway, pick up the gloves, put them on his hands and continue with the transport. S9 stated at that time that the hospital had not provided training or in-services to the transport staff regarding infection control practices.

Further observation revealed housekeeper S8 entered patient #36's room at 10:48 on 7/30/2010 wearing a mask, gown and gloves and removed the bag of trash from the room and placed it in the trash bin on the housekeeping cart. S7 was then observed taking a wet cloth from the cart, wiping the furniture in the patient's room and then she wiped the outside of the door to the isolation room with the same wet cloth.

The housekeeper proceeded to dust mop the room, use the dust pan from the cart to collect the debris, and then empty the contents into the trash bin on the cart. S7 wet mopped the floor in the patient's room, placed the wet mop head in a plastic trash can liner, and sealed the bag. S7 failed to remove the dust mop head and place it in a storage bag. The housekeeper also failed to double bag the trash, label it as isolation, or place the trash liner in a biohazard bag before disposing it. In an interview at that time S7 confirmed that she did not label the trash before removing it from the isolation room. She stated that housekeepers are supposed to use red biohazard bags to store waste from isolation rooms.

Review of policy titled "Daily Patient Isolation Room Cleaning" revealed "When leaving Isolation Room, remove gown, mask and dispose of in trash liner. Do not remove gloves at entrance to room. Wash down supplies and equipment with germicidal solution. Bag the mop head and soiled linen. Dump out solution in bucket. Remove gloves and discard in trash liner. Double bag into liner outside of room. Tie off bag. All trash from that room is to be labeled infectious and disposed of as per standard infectious waste procedures".

3. On 7/27/2010 from 1:10 PM until 2:00 PM the survey team accompanied by RN S11, education staff, observed the Renal Unit on third floor. At that time no isolation carts or signs on the door to patient rooms were observed on the unit.

Review of the 7/28/2010 form titled "Isolation Orders" (list of patients in isolation) revealed patient #35's name was on the list which indicated the patient was in isolation. Review of the medical record revealed patient #35 was admitted on 7/23/2010 at 2:20 PM with diagnoses of end stage renal disease, and chronic obstructive pulmonary disease. Review of the 7/27/2010 lab report revealed the culture from drainage at the dialysis catheter site was positive for Proteus mirabilis and was a multi-drug organism which required contact isolation for the patient. Further review of the lab report revealed the results of the culture were called by lab to the nursing unit on 7/27/2010 at 8:34 AM and the isolation cart for the patient was ordered by nursing staff on 7/27/2010 at 8:39 AM. There failed to be a time documented in the medical record as to when contact isolation was initiated or when the isolation cart was placed outside the door to the patient's room.

4. On 7/28/2010 from 9:00 AM until 11:00 AM the survey team accompanied by RN S11, education staff, observed the Rehabilitation Unit on seventh floor. Observations at that time revealed there were no isolation carts and no signage on patient doors to indicate a patient was in isolation.

On 7/28/2010 at 9:00 AM observation revealed patient #37 was resting with the head of the bed elevated. The patient's speech was difficult to understand due to a cerebrovascular accident. While in the room RN S11 straightened the patient's linen.

Review of the 7/28/2010 form titled "Isolation Orders" revealed patient #37's name was on the list which indicated the patient was in contact isolation. Review of the 7/23/2010 lab report revealed the patient's had a positive urine culture for Escherichia coli and was a multi-drug resistant organism which required contact isolation. According to the lab report the culture results were called by the lab tech to the unit RN on 7/23/2010 at 11:15 AM. Review of the medical record revealed a request was made for an isolation cart on 7/23/2010 at 11:15 AM. Review of the medical record failed to reveal documented evidence that the isolation cart was placed at the bedside or that the isolation was initiated for the patient. The failure of the staff to initiate isolation precautions resulted in unnecessary exposure of staff and visitors to a virulent pathogen.

Review of policy titled, Notification Procedure for Contact Isolation (this was current policy provided to the survey team) revealed "Guidelines for notification of hospital staff/responsible care giver when an organism is identified requiring contact isolation. These organisms include multi-drug resistant organisms (eg. Enterococcus species VRE, Staph aureaus (aureus) MRSA, Acinetobacter, and other gram negative drug resistant bacteria) and Clostridium difficile". Further review revealed after the results of the cultures are received from the lab and are read back to the "technologist to verify correct communication and documentation" the "nurse will enter an order into CERNER (computer software system) to SPD (Sterile Processing Department) requesting an isolation cart" and "an isolation cart will be retrieved from SPD and placed outside the patient's room".

SPD Tech S12 stated in an interview on 7/30/2010 at 2:30 PM that when staff places a request for an isolation cart they don't always pick it up on time. He said sometimes the carts are "just sitting in here for days waiting on staff to pick them up".