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Based on document review, observation, and interview, it was determined for 1 of 8 (Pt #25) emergency department patients observed for the ability to use a call light, the Hospital failed to ensure adaptive call light devices were provided, in accordance with patient needs. This has the potential to affect all patient receiving care in the emergency department with an average daily census of 166 patients.

Findings include:

1. The policy "Sensory Assistance Program" (revised 01/2021) was reviewed on 04/08/2021 at 11:15 AM. The policy noted "Department of Nursing i: Will assume primary responsibility for identification of patients for the Sensory Assistance Program through the admitting nursing assessment; staff nurses evaluate special needs based upon the level of sensory impairment. D. Assistive devices available are listed below. v. Breath call light system."

2. During a tour of the Emergency Department, conducted on 04/06/2021 at approximately 12:00 PM, Pt #25, in room #22, was observed to have a hand held call light for use in calling for assistance.
An interview was conducted with Pt #25 at the time of the observation. Pt #25 stated, "I'm paralyzed from the neck down since 2009 due to a fall and am unable to use a hand held call light. They usually give me a blow tube in order to notify staff for assistance."

3. During an interview on 04/06/2021 at approximately 11:30 AM, E#9 (Emergency Room System Administrator) stated, "We should have provided the patient with a different call system due to the patients' paralysis."

Based on document review and interview, it was determined for 1 of 1 (Pt #26) patient on the 4 east orthopedic unit, the Hospital failed to ensure the registered nurse supervised/ evaluated the provision of patient care, in accordance with physician orders. This has the potential to effect all patients on the Orthopedic Unit 4 E with a current census of 35 patients.

Findings include:

1. Pt #26 Start of Care (SOC): 4/3/2021
Diagnosis: Dementia. The record was reviewed on 4/6/2021 at approximately 3:00 PM. A physician order was entered on 4/3/2021 at 9:44 PM for "Daily Weights". The record lacked documentation of daily weights on 4/4/2021, 4/5/2021, and 4/6/2021.

2. During an interview on 4/6/2021 at approximately 3:30 PM, E#10 (Nurse Manager) reviewed Pt #26's record and verbally agreed the record lacked daily weights, as ordered.

Based on document review and interview, it was determined for 1 of 2 (Pt #1) patients records reviewed, the Hospital failed to ensure a plan of care was developed and maintained, to meet the patient's needs. This has the potential to affect all patients who receive care by the Hospital with an average daily census of 365 patients.

Findings include:

1. Pt #1 Start of Care:1/22/2021
Diagnosis: Heart Failure. The record was reviewed on 4/6/2021 at approximately 1:00 PM. The record noted soft restraint were applied on 2/3/2021 and removed on 2/5/2021. The record noted Pt #1 complained of a new onset of pain on 2/1/2021 and pain medication was administered daily until the patient expired on 2/6/2021. The record lacked a plan of care for the restraints or the new onset of pain.

2. During an interview on 4/8/2021 at approximately 10:30 AM, E#25 (Nursing Outcomes Facilitator) reviewed Pt #1's record and verbally agreed the record lacked development of a plan of care for the restraints and for the pain and the plan of care should have addressed both needs.

Based on document review, observation, and interview, it was determined the Hospital failed to ensure medications were administered, in accordance with its policy. This has the potentially to affect all patients receiving care on the Orthopedic 4 E Unit, with a current census of 35 patients.

Findings include:

1. The policy titled, "Administration of Medications" (revised March 2021) was reviewed on 04/08/2021 at approximately 11:45 AM. On page 4, under Procedure, the policy noted, "4 A. Medications may not be carried in pockets, pouches, etc, for administration at a later time."

2. During a tour of the 4 East orthopedic unit on 04/06/2021 at approximately 2:10 PM, E#12 (Register Nurse) was observed exiting room #426 with an intravenous (IV) bag of antibiotics (Zosyn) in the back pocket of E#12's uniform pants. E#12 then entered room #422 and exited. The IV antibiotic was observed to be labeled with the patient's name in room #436.

3. During an interview on 04/06/2021 at approximately 2:20 PM, E#10 (Nurse manager) stated, "The medication should have been kept in the medication room until it was going to be administered and not transported in the nurse's pocket."

Based on document review and interview, it was determined for 2 of 2 (Pt #6, Pt #42) patients records reviewed with LifeVests, the Hospital failed to ensure the LifeVest education forms were completed and in the medical record to communicate the necessary information to monitor the patient's condition. This has the potential to affect all patients who are discharged with a LifeVest, approximately 9 patients per month.

Findings include:

1. The policy titled, "Care of a Patient Requiring a LifeVest" (dated 12/2020) was reviewed on 4/7/2021. The policy noted, "i... the... Patient Service Representative will review the device with the patient, fit the patient for appropriate vest size, provide the technical training, apply the LifeVest, and have the patient sign the education documents ("The Wearer Checklist")... will submit signed copies of the education documents to the nurse caring for patient... v. The signed patient education documents will be scanned into the medical record..."

2. Pt #6 Start of Care (SOC): 1/12/2021
Diagnosis: Heart Failure. The record was reviewed on 4/7/2021 at approximately 10:30 AM. The record lacked a scanned copy of the LifeVest education forms.

3. Pt #42 SOC: 2/17/2021
Diagnosis: Heart Failure. The record was reviewed on 4/8/2021 at approximately 9:45 AM. The record lacked a scanned copy of the LifeVest education forms.

4. During an interview on 4/8/2021 at approximately 10:30 AM, E#25 (Nursing Outcomes Facilitator) reviewed Pt #6 and Pt #42's records and verbally agreed the records lacked a scanned copy of the LifeVest education forms.

A. Based on document review, observation, and interview, it was determined for 1 of 1 crash cart observed on the obstetrics unit, the Hospital failed to ensure expired biologicals were not available for patient use. This has the potential to affect all patients who receive care by the Hospital with a current average daily census of 365 patients.

Findings include:

1. The policy titled, "Maintaining Integrity of Patient Care Supplies and Medications" (revised September, 2020 per facility) was reviewed on 4/9/2021 at approximately 10:20 AM. The policy noted, "...Procedure:...7. Outdated supplies... must be segregated and immediately removed from patient care... B. Outdated patient care supplies should be discarded..."

2. During a tour of the obstetrical unit on the 7th floor, on 4/6/21 from approximately 11:00 AM through 12:30 PM, with the Director of Nursing (E#29) and Nursery Manager (E#30 ), the crash cart was observed to have a multilumen CVC (central venous catheter) kit with an expiration date of 1/31/21.

3. During an interview on 4/8/21 conducted during the tour, E#29 verbally agreed the CVC kit was outdated and should not be in the crash cart.


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B. Based on document review, observation and interview, it was determined for 2 of 6 patient rooms (#610 and #612) on the 6 B cardiac unit, the Hospital failed to ensure one time use items were disposed of after a single use. This has the potential to affect all patients receiving care on 6 B cardiac unit with a current census of 22 patients.

Findings include:

1. The policy titled, "Administration of Medications" (dated 3/2021) was reviewed on 04/06/2021 at approximately 4:00 PM.
The policy noted, "single-patient, single use products, this is single use... Remaining content must be discarded immediately."

2. During a tour of the 6 B Cardiac Unit on 04/06/2021 at approximately 3:30 PM with E#11 (Nurse Manager), the following supplies were found to be opened and used:
a. Room #610 - a 1000 ml (milliliter) sterile water bottle, opened, with approximately 250 ml remaining;
b. Room #612 - a 1000 ml sterile water bottle, opened, with approximately 400 ml remaining without a lid;
c. Room #612 - a 500 ml sterile water bottle, opened, with approximately 40 ml remaining.

3. During an interview on 04/06/2021 at approximately 3:45 PM, E#11 stated "The bottles should have been discarded as they are considered single use."


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C. Based on document review, observation, and interview, it was determined for 1 of 2 offsite locations toured, the Hospital failed to ensure expired biologicals were not available for patient use. This has the potential to affect all patients who receive care in the spine works pain center with an average daily census of 10 patients.

Findings include:

1. The policy titled "Carts and Closets" (revised March 2021) was reviewed on 4/7/2021 at approximately 3:00 PM. The policy noted, "Closets: 4. If eye wash bottles are present the expiration date should be checked at least weekly and if out of date the bottles should be changed out".

2. During an observational tour of the spine works pain center, on 4/6/2021 between 3:30 PM and 4:30 PM, with the Registered Nurse (E #22), the eyesaline eye wash station located in the hallway closet, available for staff and/or patient use, was observed to have an expiration date of December 2020.

3. During an interview on 4/6/2021 at approximately 4:00 PM, E#22, verbally agreed the eyesaline eye wash bottles were outdated and should have been removed.

Based on document review, observation, and interview, it was determined in 1 of 2 off site locations toured, the Hospital failed to ensure dosimeter badges were stored appropriately when not in use. This has the potential to affect all patients who receive care in the spine works pain center with an average daily census of 10 patients.


Findings include:

1. The policy "Radiation Safety" (July 2019) was reviewed 4/7/2021 at approximately 3:00 PM. The policy noted, "A. In-service education is given annually to appropriate colleagues via lectures, Healthstream... 3. Other personnel who may come in contact with ionizing radiation may be furnished personnel dosimeters at the discretion of the Radiation Safety Officer".

2. During an observational tour of the spine works pain center on 4/6/2021 between 3:30 PM and 4:30 PM with Registered Nurse (E #22), a dosimeter badge belonging to Radiologist (MD #2) was observed laying/stored in a drawer in the procedure room.

3. During an interview on 4/6/2021 at approximately 4:00 PM, E #22 stated, "The doctor has been keeping it in here when (he/she) is not working".

3. During an interview on 4/8/2021 at approximately 9:00 AM, E#23 (System Director of Patient Safety) stated, "I have spoke with our Vice President of Ancillary Operations (MD #3) and Senior Medical Physicist (MD #4), and they agreed the dosimeter badges are not to be kept in the procedure room drawer in the procedure room".

Based on observation, document review, and interview it was determined the Hospital failed to ensure its Emergency Department labeled and/or processed laboratory specimens, in accordance with its policy. This has the potential to affect all patients requiring laboratory specimens acquired in the Emergency room with an average daily census of 166 patients.

Findings include:

1. The policy titled, "Specimen Collection Guidelines for Urine, Blood (Line Draw), and Blood Cultures" (revised September 2019) noted on page 1 and 4, "Staff members who collect specimens are required to label specimen containers at the bedside at the time of collection... sealed in a clear biohazard bag and placed in a pneumatic tube system carrier for transport to the laboratory."

2. During a tour of the emergency department on 4/5/2021 between 11:00 AM through 12:15 PM with E#9 (System Administrator of Emergency/Trauma Unit), the following laboratory specimens were observed, not labeled or processed per policy:
a) Room #11- unlabeled 30 ml (milliliter) urine sample on counter top (found 4/6/2021 11:20 AM);
b) Room #18- 2 blood culture specimens with blood samples and labeled with the patient's information were dated
4/6/2021 at 1:30 AM and were observed to be unprocessed on 4/6/2021 at 11:32 AM;
c) Room #19- 30 ml urine sample unlabeled on counter (found 4/6/2021 11:38 AM);
d) Restroom (DU 153) across from room #15- 30 ml unlabeled urine on bathroom sink (found 4/6/2021 11:52 AM)

3. During an interview on 04/06/2021 at approximately 12:00 PM, E#9 stated "The specimens should have been sent to lab or discarded."

Based on document review, observation, and interview, it was determined the Hospital failed to ensure dietary services adhered to its policies governing dietary services. This has the potential to affect all staff, visitors and patients with a average daily inpatient census of 365 patients.

Findings include:

1. The policy titled, "Sanitation Food and Nutrition Services" (revised 12/24/20) was reviewed on 4/7/2021. The policy noted, "... Bakery cleaning schedule: can opener/blade- daily, assigned to 'all... Food and Nutrition Services shall comply with recognized standards for sanitation to provide a sanitary environment to produce and serve a safe, quality food source."

2. The Daily Traditional Temperature Logs, dated 4/2/2021, 4/3/2021 and 4/4/2021, were reviewed on 4/6/2021. The log sheets noted, "If temp. (temperature) is out of range at next taking discard them. Hot food 135 (degrees) or higher. Cold food 41 (degrees) or below."

3. During a tour of the kitchen on 4/6/2021 between 11:00 AM and 12:30 PM the following were observed:
a) Two can openers in food preparation areas that were greasy;
b) Temperature logs lacked documentation of food temperatures on 3/30/21 at 2:30 PM and 4/4/21 at 6:30 PM;
c) "TradeEast Whole Peppercorn 18 oz spice" lacked documentation as to when it was opened;
d) The steak fries food temperature, checked at 12:00 PM, was observed to be 128 degrees (below range for hot food);
e) The pasta salad temperature, checked at 12:30 PM, was observed to be 48 degrees (above range for cold foods); and
f) A large chef salad temperature, checked at 12:30 PM, was observed to be 48 degrees (above range for cold foods).

4. During an interview on 4/6/2021 at approximately 12:30 AM, E #24 (Registered Dietician) verbally agreed with the above findings and stated the can openers should have been cleaned, the temperature logs should have had temperatures documented, opened dates should have been written on open food items, and food outside of temperature ranges should have been discarded.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on April 6 - 7, 2021, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on April 6 - 7, 2021, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review and interview, it was determined the Hospital failed to ensure refrigerator temperatures and fluid warmers were checked and monitored per policy. This has the potential to affect all patients who receive care by the Hospital with a current average daily census of 365 patients.

Findings include:

1. The policy titled, "Temperature Monitoring Policy" (revised February 2018) was reviewed on 4/8/2021 at approximately 11:00 AM. The policy noted, "... 2. Nourishment Refrigerators and Freezers A. Dietary refrigerator and freezer temperature are monitored 24 hours per day. Alerts are triggered when the unit is out of temperature range more than 2 hours... 4. Breast Milk Refrigerator/Freezer (Family Maternity Suites...) A. Breast milk refrigerators are monitored 24 hours per day. Alerts are triggered when the unit is out of temperature range of 4 hours... 5. Fluid Warmer (Family Maternity Suites) A... fluid warmer... will be monitored 24 hours per day. Alerts are triggered when the unit is out of temperature range. If the warmer is out for more than 30 minutes, an alert will be triggered..."

2. The temperature logs for the refrigerators, freezer, and fluid warmer were reviewed on 4/6/21 at approximately 2:00 PM. The following temperatures were recorded as out of range with no alerts and no corrective actions noted:
a) Newborn Nursery breast milk refrigerator for COVID 19 patients log:
February 2021 noted 2 days out of 28 days (greater than 4 hours)
March 2021 noted 1 day out of 31 days (greater than 4 hours)
b) Newborn Nursery breast milk refrigerator log;
March 2021 noted 1 day out of 31 days (greater than 4 hours)
c) Nourishment refrigerator log;
January 2021 noted 4 days out of 31 days (greater than 2 hours)
February 2021 noted 8 days out of 28 days (greater than 2 hours)
March 2021 noted 3 days out of 31 days (greater than 2 hours)
d) Fluid warmer log;
March 2021 noted 1 day out of 31 days (greater than 30 minutes)

3. During an interview on 4/8/21 at approximately 9:00 AM and 4/9/21 at approximately 9:00 AM, E#29 verbally agreed the temperatures mentioned above lacked alerts and corrective actions and should have been.

A. Based on document review, observation, and interview, it was determined the Newborn Nursery, failed to ensure all instruments were stored in order to prevent the potential for cross contaminations. This has the potential to affect all newborns who receive care by the Hospital.

Findings include:

1. During a tour of the Newborn Nursery on the 7th floor on 4/6/21 from approximately 11:00 AM to 12:30 PM with the Director of Nursing (E#29) and Nursery Manager (E#30), an unwrapped curved forceps was located in a cabinet in the Newborn Nursery and available for patient use.

2. During an interview on 4/6/21 conducted during the tour, E#30 verbally agreed the curved forceps should not have been in the cabinet unwrapped.

3. During an interview on 4/9/21 at approximately 11:20 PM, E#23 (System Director, Patient Safety) stated, "The curved forceps in the newborn nursery was used for loosening up intravenous (IV) connections and is sanitized after usage". During an interview at approximately 11:55 AM, E#23 stated, " There's no policy for the forceps being unopened but the protocol is the item should be sanitized in between uses and the practice of using the forceps for IV's is being stopped."


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B. Based on document review, observation, and interview, it was determined for 1 of 1 (Pt #41) patient observed in the special procedure department, the Hospital failed to adhere to infection control policy and procedures to reduce and/or prevent the spread and cross contamination of infectious organisms. This has the potential to affect all patients recieving care in an special procedure department which performs approximately 24 cases a day.

Findings:

1. On 04/07/2021 at 2:00 PM, the Hospital policy "Hand Hygiene" (revised May 2019) was reviewed. It read "Hand hygiene is to be performed AFTER: 3. Contact with inanimate objects in the room (equipment, food items, water, pitcher, doorknobs, personal belonging, linenes)".

2. On 04/07/2021 at 9:41 AM, while observing Anesthesiologist (E#17) intubate Pt #1 during a retrograde cholangiopancreaography, E #17 answered (his/her) cell phone with (his/her) gloved, right hand. After the call, E #17 place the phone on a cart, and ,without changing gloves and/or washing/sanitizing his hands, went over to the patient, opened a sterile, packaged endotracheal tube (ET), touched the tube with the same glove used to talk on the phone, and then handed the (ET) tube to the Certified Nurse Anesthetist (E#18). E #18 then intubated the patient with the same ET tube that E#17 touched with a dirty glove.

3. On 04/07/2021 at approximately 9:50 AM, an interview with the Nurse Manager of the special procedure department(E#21) was conducted. E#21 confirmed that E#17 had contaminated the endotracheal tube used on Pt # 41and stated, "I saw the same thing."

C. Based on observation and interview, it was determined for 1 of 2 dialysis chairs, the Hospital failed to ensure that all dialysis chair surfaces were intact and free of tears, which prevented proper disinfecting/cleaning and prevent the potential spread and potentail cross contamination of infectious organisms. This has the potential to affect all patients receiving dialysis treatments from a department with an average census of approximately 15 patients.

Findings include:

1. On 04/07/2021 at 3:00 PM, a tour of the dialysis unit was conducted. One of the dialysis chairs was observed to have a tear in the material on the right arm rest, which prevented proper cleaning and disinfecting between patient use.

2. On 04/07/2021 at 3:10 PM, an interview with the Dialysis Department Manager (E #21) was conducted. E #21 confirmed the chair had torn material on the right arm rest and stated, "I didn't even see that. I will get it repaired."


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D. Based on document review, observation, and interview, it was determined for 1 of 1 laboratory technicians observed drawing blood for laboratory, the Hospital failed to ensure proper hand hygiene practices were followed. This has the potential to affect all patients receiving laboratory services by the Hospital.

Findings include:

1. The policy titled, "Hand Hygiene" (revised 05/23/2019) was reviewed on 4/7/2021 at approximately 3:30 PM. The policy noted, "Hand hygiene is to be performed AFTER:... removing gloves".

2. During a tour of the 6 B cardiac unit on 04/06/2021 at 3:30 PM, E#26 (lab technician) was observed in room #610 drawing blood for a laboratory sample. E#26 failed to perform hand hygiene after removing gloves and leaving the patients room.

3. During an interview on 4/6/2021 at approximately 3:35 PM, E#11 (Manager of 6 B Cardiac) verbally agreed E#26 did not perform hand hygiene after gloves were removed and should have been.

Based on observation, document review, and interview, it was determined the Hospital failed to ensure visitors followed the COVID-19 mask protocol. This has the potential to affect all patients, visitors, and employees of the Hospital.

Findings include:

1. The "COVID-19 PPE (personal protective equipment) Requirements per February 10, 2021 CDC (Centers for Disease Control) Guidelines" were reviewed on 4/7/2021 at approximately 9:30 AM. The guidelines noted, "Visitors will be provided a medical-grade mask upon entry."

2. During a tour of the orthopedic 4 E unit on 4/6/2021 between approximately 1:45 PM and 2:45 PM, a visitor was observed in room #417 (Pt #26) without a facial mask, as required by Hospital policy.

3. Pt #26 Start of care (SOC): 4/3/2021
Diagnosis: Dementia. The record was reviewed on 4/6/2021 at approximately 3:00 PM. The record lacked documentation education was provided to any family member or visitor related to COVID-19 or the required PPE.

4. During an interview on 04/6/2021 at approximately 3:15 PM, E#6 (Nurse Manager) stated, "It is really difficult to get family members to comply with wearing masks."

Based on document review and interview, it was determined for 1 of 2 (Pt #5) records reviewed for discharge planning, the Hospital failed to ensure all evaluations were conducted prior to discharge. This has the potential to affect all patients who receive care by the Hospital with an average daily census of 365 patients.

Findings include:

1. The policy titled, "Patient Discharge" (dated 7/2020) was reviewed on 4/6/2021. The policy noted, "6... A. Discharge Planning is the process by which health care professionals communicate, coordinate, and collaborate to ensure each patient has a plan for continuing care after discharge that meets his/her individual problems or needs."

2. Pt #5 Start of Care: 11/15/2020
Diagnosis: Corona Virus. The record was reviewed on 4/7/2021 at approximately 9:45 AM. The Care Transition Note- PCF (Patient Care Facilitator), dated 11/23/2020, noted the Physical Therapist recommended an Occupational Therapy (OT) evaluation, the physician was notified and confirmed Pt #5 was ready for discharge on 11/24/2020 and ordered an OT evaluation. The record lacked documentation the OT evaluation was conducted prior to discharge.

3. During an interview on 4/8/2021 at approximately 10:30 AM, E#25 (Nursing Outcome Facilitator) reviewed Pt #5's record and verbally agreed Pt #5 was discharged without an OT evaluation and it should have been conducted.