HospitalInspections.org

Based on review of the hospital's quality assessment performance improvement (QAPI) data and interview, the hospital failed to ensure an active system was in place for the management of 2 of 3 adverse events reviewed for management.


The findings are:


On 12/11/14 from 9:30 a.m. to 11:30 a.m., review of the hospital's adverse events data identified adverse events dated 6/26/14 and 10/11/14 that had no documentation concerning identification of other areas in the hospital with similar processes that had the potential to be at risk for the occurrence of the same adverse event or the development and implementation of preventative actions with a plan for evaluations of those actions to eliminate or mitigate the risk of the adverse event in other areas of the hospital. On 12/11/14 at 11:45 a.m., the Director of Nursing verified the information provided was the only documentation of the adverse events.

Based on review of hospital personnel job description for the renal nurse manager and interview, the hospital's governance failed to ensure a qualified knowledgeable individual was responsible for the management, oversight, and monitoring of patient care processes on the dialysis unit.


The findings are:


On 12/9/14 at 10:10 a.m., a tour of the dialysis unit was performed with the Dialysis Nurse Manager (NM) 1. During the tour of the dialysis unit, Nurse Manager 1 revealed, "I was made the manager in this unit in January 2012, but I haven't actually taken care of dialysis patients since 2001. I will be honest with you, I would not run a patient on the hemodialysis machine. I would not feel comfortable in doing so. I cannot talk you through how to perform the Chlorine test because I don't run the machines. I guess I should know this." Nurse Manager 1 reported that he/she had not completed any type of annual dialysis competency training since appointed the Dialysis Nurse Manager. On 12/11/14 at 11:00 a.m., review of Nurse Manager 1's personnel file job description revealed, "Experience - Clinical experience in area to which assigned is mandatory."

Based on patient record reviews, interviews, and review of hospital policies and procedures, the hospital failed to ensure its staff had physician orders before performing procedures on patients that required physician orders for 7 of 30 patient records reviewed for care and services. (Patient 2, 10, 12, 21, 22, 24, and 26)


The findings include:


On 12/11/2014 at 9:50 a.m., review of patient charts on the medical surgical unit revealed Patient 26's was admitted on 11/29/2014 with physician orders for daily weights, but review of documentation in the patient's chart showed no daily weights were documented from 11/30/2014 to 12/11/2014. On 12/11/2014 at 10:05 a.m., the findings were verified with the unit Nurse Manager.

Review of hospital policies and procedures, titled,"...Policy/Procedure: Orders, Written and Verbal" reads, " ... Purpose: Providers communicate their plan for the patient by giving written or verbal orders. All orders for treatment must be documented in the medical record ... General A legible written record of all inpatient and outpatient diagnostic and therapeutic orders shall be maintained in the patient's medical record. A provider order is required to admit a patient, place a patient in observation, discharge (with the exception of AMA) or transfer a patient, move a patient to a different level of care and for all tests, therapies and procedures."




29886

On 12/10/2014 10:30 a.m., review of Patient 10's medical record revealed the patient had an intravenous needle, but there was no physician order for the placement of an intravenous needle. On 12/10/2014 at 10:30 a.m., the Supervisor of the Progressive Care Unit (PCU) verified the finding.

On 12/10/2014 at 2:00 p.m., review of Patient 22's medical record revealed the patient had an intravenous needle, but there was no physician order for the placement of an intravenous needle. On 12/10/2014 at 10:30 a.m., the Supervisor of the PCU verified the finding.

On 12/11/2014 at 10:15 a.m., review of Patient 24's medical record revealed the patient had an intravenous needle, but there was no physician order for the placement of an intravenous needle. On 12/11/2014 at 10:15 a.m., the Supervisor of the PCU verified the finding.






30011

On 12/09/14 at 10:40 a.m., review of Patient 2's chart revealed the patient was admitted to the hospital on 12/8/14 to the outpatient surgery department with the placement of an intravenous (INT) lock (venous access for administration of intravenous fluids). Review of physician orders dated 12/8/14 revealed there was no physician order placement of an intravenous (INT) lock. On 12/10/14 at 4:30 p.m., the findings were verified by the Center Coordinator.

On 12/10/14 at 2:50 p.m., review of Patient 21's chart revealed the patient was admitted to the hospital via the emergency room on 11/25/14 with the placement of an INT lock. Review of emergency room physician orders revealed there was no physician order for an INT insertion. On 12/10/14 at 4:25 p.m., the findings were verified by Nurse Manager 1. There was a physician order dated 11/30/2014 for neurological checks every 4 hours with the patient's vital signs, but there was no documentation that neurological checks were documented on 12/02/14 at 8:00 p.m., 12/04/14 at 7:30 a.m., 12/6/14 at 4:45 p.m., 12/7/14 at 12:30 a.m., 12/7/14 at 7:00 p.m., 12/7/14 at 8:50 a.m., 12/8/14 at 9:12 p.m., and 12/10/14 at 12:24 a.m..
On 12/10/14 at 3:15 p.m., the findings were verified by Registered Nurse 3.

On 12/10/14 at 10:35 a.m., review of Patient 12's chart revealed documentation that a Foley catheter was inserted on 12/3/14 at 7:14 a.m. and discontinued by 12/9/14 at 6:57 a.m., but there was no physician order for insertion or discontinuation of the Foley catheter in the patient's chart. On 12/10/14 at 12:15 p.m., the findings were verified by Registered Nurse 7.

Facility policy/procedure, titled, "Orders, Written and Verbal", reads, "....Providers communicate their plan for the patient by giving written or verbal orders. All orders for treatment must be documented in the medical record....".

Review of hospital policies and procedures, titled,"...Policy/Procedure: Orders, Written and Verbal" reads, " ... Purpose: Providers communicate their plan for the patient by giving written or verbal orders. All orders for treatment must be documented in the medical record ... General A legible written record of all inpatient and outpatient diagnostic and therapeutic orders shall be maintained in the patient's medical record. A provider order is required to admit a patient, place a patient in observation, discharge (with the exception of AMA) or transfer a patient, move a patient to a different level of care and for all tests, therapies and procedures."

Based on record review and interview, the hospital failed to ensure the patient's plan of care was reviewed and/or revised every 24 hours by the nursing staff for 2 of 30 open patient charts. (Patient 12 and 20)


The findings are:


On 12/10/14 at 10:35 a.m., review of Patient 12's chart revealed the patient was admitted to the hospital on 12/01/14. Review of the patient's plan of care for the problem titled knowledge deficit revealed the hospitalization / disease process was not documented as reviewed daily on 12/2/14, 12/3/14, and 12/9/14. Review of the problem for fall prevention listed on the patient's plan of care revealed the problem was not documented as reviewed on 12/3/14. Review of the problem on the patient's plan of care for ineffective tissue perfusion showed the problem was not documented as reviewed on 12/2/14, 12/3/14, and 12/9/14. Review of the problem listed on the patient's plan of care for ineffective renal tissue perfusion revealed the problem was not documented as reviewed on 12/2/14, 12/3/14, and 12/9/14. Review of the problem on the patient's plan of care for knowledge deficit: Foley catheter revealed the problem was not documented as reviewed on 12/3/14, 12/4/14, 12/5/14, 12/6/14, and 12/7/14. On 12/10/14 at 12:15 p.m., Registered Nurse 7 verified the findings and revealed that the patient's plan of care is to be reviewed daily.

On 12/10/14 at 2:00 p.m., review of Patient 20's chart revealed the patient was admitted to the hospital on 12/04/14. Review of the problem listed on the patient's plan of care for knowledge deficit: hospitalization/disease process revealed the problem was not documented as reviewed daily on 12/9/14. The findings were verified on 12/10/14 at 3:00 p.m. by Registered Nurse 3.

Based on observations and interview, Registered Nurse (RN) 15 failed to disinfect the septum of a medication vial prior to connecting the intravenous tubing for administration of a medication for 1 of 1 Registered Nurse observed preparing intravenous medications in the outpatient infusion therapy center. (RN 15)


The findings are:


On 12/ 9/14 from 1:45 p.m. to 1:55 p.m., random observations in the outpatient infusion therapy center revealed RN 15 failed to disinfect the septum of a 5 mg (milligram) dose vial of Reclast. On 12/9/14 at 1:55 p.m., RN 15 revealed, "since I went straight in and flipped the top off that I don't have to wipe if off. If I had sat it down and done something else, then yes, I would have to clean the top".

Based on observations and review of hospital policy and procedures, the hospital failed to ensure expired medications were not available for patient use in 1 of 1 joint centers.


The findings are:


On 12/9/14 at 12:10 p.m., random observations in the joint center revealed the following expired medications on the crash cart: (2) Epinephrine 1:100 (one to one thousand) (1 mg (milligram)/ml (milliliter) expired October 1, 2014 and (2) Vasopressin injection 20 units/ml expired October 2014. On 12/9/14 at 12:10 p.m., the findings were verified by the unit Clinical Coordinator.

Hospital policy, titled, "Expiration date checking & removal process", reads, "....At least quarterly, expired medications are written up and returned by a "waste management company" for disposal and credit....All outdated, contaminated, improperly stored, or illegibly labeled medications will be considered outdated and stored in a separate area, so designated for outdates, until they can be returned to the manufacturer....crash carts are to be checked monthly....".

Based on observations and interview, the hospital failed to ensure proper storage of trash from the 1 of 1 laboratory departments by way of unconfined plastic bags of trash lying on the floor on the east side of the laboratory department.


The findings include:


On 12/09/2014 at 11:10 a.m., random observations of the laboratory department revealed 3 unconfined large plastic bags lying on the floor in the east side of the laboratory. On 12/09/2014 at 11:10 a.m., the Manager of the laboratory revealed, "...When they clean the rooms (environmental services) at night, they leave the trash here for pickup later in the day. The trash will sit here until late afternoon...".

Based on observations, interviews, and review of hospital policy and procedure, Registered Nurses(RN )1, 2, 5, 8, 9,10, 15, 16, and 28, and Certified Registered Nurse Anesthetist (CRNA) Student 1, and Dietary Aide 1 failed to follow standard infection control measures for gloving and performing hand hygiene when providing patient care to prevent potential cross contamination of infectious agents in the hospital setting.


The findings are:


On 12/9/14 at 1:45 p.m., observations in the Medical Surgical Unit revealed RN 2 donned gloves, administered a random patient's pain medication, and while wearing the same gloves, touched the computer's keyboard.

On 12/10/14 at 11:30 a.m., observations in Operating Room (OR) 3 revealed CRNA Student 1 dropped a spiked liter bag of lactated ringers (LR) onto the floor and then, picked up the intravenous fluid bag, hung the intravenous fluid bag back on the IV(intravenous) pole, without replacing the contaminated bag with a clean bag of intravenous fluid. On 12/11/4 at 11:13 a.m., CRNA Student 1 confirmed the findings, and stated,"I did drop it on the floor, but I thought since it was already spiked it was okay to keep using it." The Infection Control Officer who was present during the verification interview stated, "Anything below the table is a dirty area and has to be discarded."

Hospital policy, titled, "QSP-ICP-0019, Hand Hygiene", reads, "....I. Indications for hand hygiene: B. Your 5 Moments for Hand hygiene- 1. Before touching a patient; 4. After touching a patient; 5. After touching patient's surroundings....II. Hand Hygiene Technique: A. How to Hand rub (using hand sanitizer)- 20-30 seconds....B. How to hand wash (using soap and water)- 40-60 seconds....IV. Other aspects of Hand Hygiene: F. Remove gloves after caring for a patient. Decontaminate your hands after all glove removals....".

Facility policy, titled, "QSP-ICP-0004, Cleaning and Disinfection of Critical, Semi Critical and Non-Critical Patient Care Equipment", reads, "....BP Cuffs and portable machines- Visibly soiled- Immediately; When (routinely)- Daily if used on intact skin....Temporal thermometers- When (routinely)- Probe head: between every patient....Any equipment touched with a gloved hand- When (routinely)- Between each patient....".





31395

On 12/08/14 at 1:55 p.m., random observations in the emergency department triage room revealed RN 1, without donning clean gloves, placed a disposable blood pressure (BP) cuff on the patient, placed the non disposable pulse oximetry probe on the patient's left index finger, and pressed the button on the vital sign monitor to obtain the patient vital signs. Observation showed RN 1 removed and replaced the used equipment back on the monitor without cleaning and/or disinfecting the disposable and non disposable equipment after patient use. RN 1 exited the triage room to escort the patient to the assigned room, but failed to perform hand hygiene prior to exiting the triage room with the patient. On 12/08/14 at 2:05 p.m., RN 1 and Nurse Manager (NM) 3 stated that the BP cuff, the pulse oximetry, and the vital sign monitor are cleaned daily unless the equipment becomes visibly soiled.




25877

On 12/10/2014 at 3:45 p.m., observations on the sixth floor medical surgical unit revealed RN 8 administered medication to Patient 24. After administering Patient 24's medication, RN 8 performed hand hygiene for less than 5 seconds. On 12/10/2014 at 4:00 p.m., the finding was verified with RN 8.

On 12/10/2014 at 4:10 p.m., observations on the sixth floor medical surgical unit revealed RN 9 administered medication to Patient 25. After completion of the patient's medication administration, RN 9's removed the soiled gloves and donned a clean pair of gloves, but performed no hand hygiene. After adjusting the patient's bed and getting water for the patient, RN 9 removed the gloves but performed no hand hygiene before donning a clean pair of gloves. Before leaving the patient's room, RN 9 used hand hygiene with soap and water for less than 8 seconds placing the soap in her hands and immediately placing her hands under the water without lathering with the soap. On 12/10/2014 at 4:15 p.m., the findings were verified with RN 9.

On 12/10/2014 at 3:30 p.m., observations on the sixth floor medical surgical unit revealed RN 10 administered Patient 26's medication, but failed to perform hand hygiene before administering the patient's medication. On 12/10/2014 at 3:40 p.m., the finding was verified with RN 10.

On 12/10/2014 at 4:30 p.m., observation on the sixth floor medical surgical unit revealed RN 9 administered Patient 28's medication and after administering the patient's medication, RN 9 removed one glove and donned a new glove, but no hand hygiene was observed. On 12/10/2014 at 4:40 p.m., the finding was verified with RN 9.

On 12/10/2014 at 12:00 p.m., observations on the sixth floor medical surgical unit revealed RN 5 administered Patient 28's medication. RN 5 performed hand hygiene for less than 6 seconds before administering Patient 31's medication. RN 5 left the room to get more supplies and after entering the patient's room, RN 5 performed hand hygiene for less than 5 seconds. Before leaving the patient's room, RN 5 performed hand hygiene for less than 3 seconds. On 12/10/2014 at 12:05 p.m., RN 5 verified the findings.






30011

On 12/9/14 from 11:45 a.m. to 11:55 a.m., observations in the joint center revealed Registered Nurse (RN) 28 obtained a glucose check of a patient but failed to perform hand hygiene after glove removal. On 12/9/14 at 11:55 a.m., RN 15 revealed, "we wash in and wash out. I guess I should have done it after removing the gloves as well".

On 12/9/14 at 11:55 a.m., observations in the joint center revealed RN 15 failed to disinfect the computer on wheels after use in a patient's room. On 12/9/14 at 11:55 a.m., RN 28 revealed, "the computers on wheels are only disinfected when visibly stained with blood".

On 12/9/14 from 1:35 p.m. to 2:00 p.m., random observations in the outpatient infusion therapy area revealed RN 15 obtained a blood pressure machine from the pre-operative area, obtained vital signs (blood pressure, pulse, and oxygen saturation levels) for two different patients without disinfection of the blood pressure machine from the pre-operative area or between the two patients. On 12/9/14 at 2:00 p.m., RN 15 revealed, "we don't clean the machines between patients, only the temporal probes".

On 12/9/14 from 2:35 p.m. to 2:55 p.m., observations in the wound center revealed RN 16 obtained six dry wash cloths from a cabinet and placed the wash cloths in the hand washing sink in the treatment room. RN 16 ran water over the wash cloths and placed some hand washing soap on (2) of the wash cloths and washed the patient's left leg wound times 2. The remaining wash cloths were removed from the sink and applied as a warm compress to the patient's left leg before a scab was removed.

On 12/10/14 at 2:10 p.m., random observations in the medical surgical unit revealed Dietary Aide 1 exiting a patient's room that had a sign posted that stated, "enteric contact precautions". Observations showed Dietary Aide 1 used hand sanitizer on the hands, exited the patient's isolation room, and proceeded to another patient who was not on isolation precautions. On 12/10/14 at 2:15 p.m., Dietary Aide 1 revealed, "we are only allowed to go to the curtains in the rooms, and anything past the curtains, we have to put on the equipment (personal protective equipment)".

On 12/10/14 at 3:30 p.m., review of facility policy, titled, "Enteric Contact Precautions", states, "Use of gown and gloves each time in the room. Wear full facial protection if a chance of spraying or spattering of infective material. Utilize the additional caution signs to remind staff and visitors to use soap and water to wash hands prior to leaving the room".

Based on review of the hospital's Organ Procurement training list and interview, the hospital failed to ensure that the appropriate patient care staff received training on Organ Procurement Organization (OPO) services.


The findings are:


On 12/10/14 at 12:40 p.m., review of the hospital's Organ Procurement training roster revealed that the only hospital staff members that received Organ Procurement Organization training were Registered Nurse (RN) RN 11, 12, 13, 14, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 29, and 30 and Director of Nursing (DON) 1 dated 08/29/13. On 12/11/14 at 10:20 a.m., Chief Nursing Officer (CNO) 1 revealed that only the Emergency Department and the Critical Care Unit nursing staff received training in Organ Procurement and other staff are prompted by the computer to notify the nursing supervisor for any imminent deaths.

Based on observations and interview, the hospital failed to ensure its operating room staff documented all the necessary components required on the hospital's operating room (OR) register.


The findings are:


On 12/09/14 at 12:35 p.m., review of the hospital's Operating Room Register revealed the Operating Room Register did not include the age of the patients or the pre and post diagnosis of the patients. On 12/09/14 at 1:55 p.m., Nurse Manager (NM) 4 reported that the patient's age and pre and post diagnoses is in the computer and accessible, if needed. On 12/09/14 at 4:35 p.m., Nurse Manager 4 presented a data sheet that contained all the components except for the patient age, and stated that the data was retrieved from the computer and placed on an excel spread sheet, but did not know why the patient's age was not listed on the sheet.