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Based on interview and record review, the hospital failed to ensure that their policy and procedure related telephone orders for the use of restraints were implemented as written, for 1 of 4 sampled patients (21). Multiple telephone orders for Patient 21's restraint use, for consecutive days and multiple nursing staff did not have documented evidence to show that the read back process was performed in accordance with the hospital's policy.

Findings:

Patient 21 was admitted to the hospital on 10/20/10 per the face sheet.

A review of Patient 21's medical record was conducted on 11/1/10 beginning at 3:18 P.M. Physician Order for Restraint Use dated 10/26/10, 10/27/10 and 10/28/10 were telephone orders obtained by registered nurses. Per the same orders, there was no documented evidence that the read back process was performed when these physician's orders for Patient 21's restraint use were obtained.

An interview and joint record review with the acute care manager (ACM) was conducted on 11/2/10 at 10:00 A.M. The ACM stated that the nursing staff was responsible for performing the read back process after a telephone order was obtained. She stated that all of Patient 21's Physician Order for Restraint Use should have had documented evidence that the read back process was performed in accordance with the hospital's policy.

A review of the facility's policy and procedure entitled "Verbal/Telephone Orders For Medications/Non-Medications; Authority to Transmit/Accept; Receipt of Order/Transcription" current effect date of 4/09 was conducted on 11/3/10. The policy stipulated that "The Authorized individual who receives a verbal or telephone order from an authorized prescriber will reduce the order to writing after receiving it (whenever possible), and read back (or repeat, if first reducing it to writing was not possible) the complete order to the prescriber to verify all components of the order, including patient identification, and indications for "prn (as needed)" medications, receiving confirmation that it was understood correctly. The recipient of the order is encouraged to document on the order that this process was performed, by any of the following methods, as appropriate to the facility, e.g. (example), writing "VORB" (verbal order read back), or making a checkbox on a preprinted or stamped "VO/TO (verbal order/telephone order) Read Back" order form element, or initialing/signing a preprinted or stamped "VO/TO Read Back" order form element."

Based on interview and record review, the hospital failed to ensure that the nutrition care plan and the fluid and electrolyte imbalance care plan were implemented as written, and in accordance with the physician's order for 1 of 6 patients (54).

Finding:

Patient 54 was admitted to the hospital on 4/14/10 with a diagnoses that included cellulitis (skin infection caused by bacteria)-finger and end stage renal (kidney) failure according to the Face Sheet.

On 11/2/10 at 1:30 P.M., the medical record for Patient 54 was jointly reviewed with the Clinical Nutrition Program Manager. According to the Clinical Nutrition Program Manager Patient 54 was on a 1800 kcal, low potassium renal diet with Nepro 4 oz TID (a nutrition supplement to be given three times a day), and on a fluid restriction of 1500 ml/day. In addition, there was a physician's order written on 10/26/10 that indicated, "If pt (patient) eats < 50% of meal, then give 1 can Jevity bolus via G-tube (a feeding tube that delivers nutrition into the stomach)."

According to the nursing care plan developed for nutrition, dated 10/3/10, an approach was to "Monitor & record po intake." Patient 54's medical record contained another nutrition care plan, dated 11/1/10, that indicated, "Need for enteral support ..., provide & monitor tolerance to TF (tube feeding)."

According to the nursing care plan developed for fluid and electrolyte imbalance, dated 10/3/10, an approach was to "Measure & record I & O (input and output)."

The Acute Care Flow Sheet under the heading of Nutrition on 10/27/10, and 10/28/10 had a note that indicated, "ref" (refused) for breakfast, lunch and dinner. There was no documentation on the Acute Care Flow Sheet, Input & Output record, medication administration record (MAR), or nursing notes that the care plan for nutrition, and that the physician's order for 1 can of Jevity bolus via G-tube when patient eats less than 50% of meals was carried out.

The Acute Care Flow Sheet indicated that Patient 54 consumed less than 50% of his meal for lunch and dinner on 10/29/10. There was no documentation on the Acute Care Flow Sheet, Input & Output record, MAR, or nursing notes that Patient 54 was provided with 1 can of Jevity bolus via G-tube for lunch and dinner on 10/29/10.

On 10/30/10, the Acute Care Flow Sheet did not contain any documentation for po (oral) intake, or G-tube intake for breakfast, or lunch on that day. There was documentation that Patient 54 refused his dinner on 10/30/10, but no documentation in the medical record about the 1 can of Jevity bolus via G-tube. According to the nursing care plan developed for nutrition, dated 10/3/10, an approach was to "Monitor & record po intake", which was not done.

On 10/31/10, the Acute Care Flow Sheet indicated that Patient 54 consumed 30% of his breakfast, 50% of his lunch and that dinner was refused. The flow sheet indicated "Jevity 1 can bolus" during the breakfast hours, and "Jevity 1 can" during the lunch hours.

On 11/2/10 at 2:08 P.M., LN 55 reviewed the documentation on the Acute Care Flow Sheet for 10/31/10 and stated, "That means that one can of Jevity bolus was given at breakfast and lunch." LN 55 reviewed the Input and Output record for 10/31/10 and stated, "The Jevity via G-tube should have been on the I & O sheet." The I & O sheet did not contain any documentation that 2 cans of Jevity was given to Patient 54 on 10/31/10. According to the physician's orders, on 9/24/10 a physician wrote an order for "Fluid restriction 1500 ml/24 hours." Inaccurately documenting the intake and ouput of a patient on a fluid restriction could adversely impact a patient's medical status.

According to the nursing care plan developed for fluid and electrolyte imbalance, dated 10/3/10, an approach was to "Measure & record I & O." The I & O sheet was not completely filled out in accordance with the nursing care plan to measure and record input.

On 11/3/10 at 12:40 P.M., Staff 57, in the presence of Nursing Manager 56 and the Clinical Nutrition Program Manager, reviewed Patient 54's Acute Care Flow Sheets, Input and Output record, nursing notes and MAR from 10/26/10 to present. Staff 57 stated that it was the hospital's expectations for the nursing staff to document in the nursing notes if and when Patient 54 ever refused a feeding via his G-tube. Staff 57 stated the only documentation she found in Patient 54's medical record was on 10/31/10 that indicated, "Refused the jevity can in the morning and at dinner." Further, there was a discrepancy in the documentation in the nursing notes of 10/31/10, in accordance with the statement Licensed Nurse (LN) 55 provided in regard to what the documentation on the Acute Care Flow Sheet on 10/31/10 meant.

Based on observation and staff interview, the hospital failed to ensure that medical records were promptly completed, as evidenced by a backlog of processing recently discharged records.

Findings:

A tour of the Health Information Management Department was made on 11/2/10 beginning at 12:55 P.M. In one area, it was noted that there was a backlog of records awaiting analysis (the process which identifies reports that need to be completed or signed by physicians). The backlog dated back to 10/17/10. The surveyor requested a count of these records, which was provided the next morning and it revealed a total of 877 records (627 inpatient and 250 outpatient) records awaiting analysis. During another interview with the HIM Supervisor on 11/4/10 at approximately 9:40 AM, she stated that the goal to process/analyze records is within 5 days after the patient ' s discharge.

Based on interview and record review, the hospital failed to ensure that 2 of 20 sampled patients (11, 14) personal belongings were properly accounted for by itemized documentation in the medical record as required by hospital policy. The hospital failed to ensure that infants born in the hospital had an Admissions Agreement signed on their behalf in 1 of 2 records reviewed (62). Lastly, the hospital failed to ensure that all entries in the medical record were timed and authenticated in 6 of 8 closed records reviewed. (61, 63, 64, 65, 66, and 68)

Findings:

1. Patient 11 was admitted to the hospital on 10/27/10 with a diagnosis of lymphoma (cancer of the lymphatic system) according to the Admission Face Sheet.

A review of Patient 11's medical record was conducted on 11/1/10 at 2:00 P.M. According to the Patient Valuables/Belongings Sheet in Patient 11's medical record, Patient 11 was admitted to the hospital with a pair of glasses and a bible. There was no documentation on the Patient Belongings Sheet of the itemization and disposition of Patient 11's clothes.

According to the instructions on the Patient Belongings Sheet, the RN should "Update list as patient's valuables/belongings transfer in and out of the hospital."

The hospital's policy and procedure entitled "Patient Belongings" was reviewed on 11/1/10 at 2:05 P.M. The policy and procedure indicated that "If the patient consents to sending their belongings home and their belongings are given to family, document in the medical record a description of the item(s) and the name of the person to whom it was given."

An interview was conducted with the Lead Clinical Registered Nurse (RN) at 2:20 P.M. The Lead Clinical RN acknowledged that the hospital's policy and procedure had not been followed regarding the documentation and disposition of Patient 11's belongings.

2. Patient 14 was admitted to the hospital on 10/31/10 with a diagnosis of a fracture of the femoral condyle (lower end of the femur) according to the Admission Face Sheet.

A review of Patient 14's medical record was conducted on 11/1/10 at 3:15 P.M. According to the Patient Valuables/Belongings Sheet, Patient 14's clothes were at the bedside.

An interview was conducted on 11/1/10 at 3:25 P.M. with the registered nurse (RN 14) assigned to care for Patient 14. RN 14 stated that she had mistakenly marked Patient 14's clothes as being at the bedside on the Patient Belongings Sheet. RN 14 further stated that Patient 14 actually had no clothes at the hospital because Patient 14's family had taken her clothes home with them. RN 14 was asked what clothes had been taken home. RN 14 replied that she did not know because she never looked in the patient belongings bag to identify the items of clothing.

A review of the hospital's policy and procedure entitled "Patient Belongings" indicated that "If the patient consents to sending their belongings home and their belongings are given to family, document in the medical record a description of the item(s) and the name of the person to whom it was given."

RN 14 acknowledged that she had not followed the hospital's policy and procedure.

3. Record 62 was reviewed on the morning of 11/2/10. There was no Admission Agreement found in the chart. During an interview with the Patient Access Services Manager on the afternoon of 11/3/10, he confirmed that the hospital had not been obtaining a signed agreement for any of the infants born in the hospital. This form ' s primary function is to document the patient ' s/legal representative ' s consent to hospitalization and routine services; and to document financial responsibility for payment of hospital charges for services rendered. The hospital ' s form, revised 6/09, did not contain a clause to cover an infant delivered while the mother was a patient of the hospital

4. Records 65, 66, and 68 were reviewed between 11/2- 4/10. The records contained a Graphic Chart and/or a Diabetes Flowsheet. These forms contained multiple entries over the course of several days documenting a patient ' s vital signs, intake and output, and blood glucose level. The forms did not contain any place for the entries to be authenticated, expect for a comment section on the reverse side of the Graphic Chart. This omission was confirmed by the CNO on 11/4/10 at 10:45 AM.

5. Records 61 and 64 were reviewed on 11/2 at 10:20 AM and 12:20 PM, respectively. The pre and post anesthesia orders and notes did not contain the time when the physician documented these entries. Record 65 was reviewed on 11/2/10 at 2:35 PM. The following entries were not timed when written: Pre-anesthesia evaluation/Physical exam; the post-anesthesia note; a Patient Controlled Analgesia order and a postoperative anesthesia order.

6. Records 63, 65, 66, and 68 were reviewed between 11/2-4/10. These records contained various forms such as the Anesthesia Record, Graphic Chart, Pre-Anesthesia Evaluation and Preoperative/Procedural Checklist that did not have any patient identifier (such as name and medical record number) on the back sides that contained documentation. Therefore, when the forms are photocopied/scanned, those pages cannot be linked to the patient. This finding was confirmed by the HIM Supervisor on 11/4/10 beginning at 9:55 AM.

Based on record review and interview, the facility failed to ensure that telephone orders and verbal orders were signed by the prescriber within 48 hours for 2 of 7 sampled patients (41, 42).

Findings:

On 11/2/10 at 9:15 A.M., the chart of Patient 41 was reviewed concurrently with Registered Nurse (RN) 41, RN 42, and Registered Pharmacist (RPh) 41. It was noted that an order for intravenous medications had been phoned in by Medical Doctor (MD) 49 at 1 A.M. on 10/27/10, which included Neosynephrine (a drug to maintain blood pressure), propofol (a drug used to cause sedation), protonix ( a drug used to reduce stomach acid production), and albumen 25% ( a drug used to stabilize blood pressure). At the time of the record review on 11/2/10, the order - phoned on 10/27/10 - had not yet been signed by the prescriber.
State Operations Manual 482.24(c)(1)(iii) indicates that verbal orders must be authenticated within 48 hours.


On 11/2/10 at 9:50 A.M., the record of Patient 42 was reviewed concurrently with RN 41, RN 42, and RPh 41. The following unsigned orders for Patient 42 were noted:

1. A verbal order phoned in by MD 41 for Patient 42 on 10/20/10 at 10:05 A.M. for Versed (an intravenous sedative) was noted to have no physician's signature.

2. A verbal order phoned in by MD 42 for Patient 42 on 10/20/10 at 10:15 A.M. to "decrease D10W" (an intravenous sugar solution) was noted to have no physician's signature.

3. A verbal order phoned in by MD 43 for Patient 42 on 10/20/10 at 9:30 P.M. to "Stop Golytely" (a laxative solution) was noted to have no physician's signature.

4. A verbal order phoned in by MD 44 for Patient 42 on 10/24/10 at 3:45 P.M. for dopamine (an intravenous medication to maintain blood pressure) was noted to have no physician's signature.

5. A verbal order phoned in by MD 41 for Patient 42 on 10/24/10 at 4:20 P.M. to adjust SIMV (synchronized intermittent mandatory ventilation) 12 rate and PEEP (positive end expiratory pressure) (respirator settings for breathing support) was noted to have no physician's signature.

6. A verbal order phoned in by MD 45 for Patient 42 on 10/26/10 at 11A.M. for Albolene Cream (for dry skin) was noted to have no physician's signature.

7. A verbal order phoned in by MD 46 for Patient 42 on 10/26/10 at 3:30 P.M. to "hold tube feeding" was noted to have no physician's signature.

8. A verbal order phoned in by MD 46 for Patient 42 on 10/30/10 at 8:45 P.M. for "KUB" (Kidney, Ureter, Bladder - procedure for evaluation of the urinary tract) was noted to have no physician's signature.


RN 41, RN 42, and RPh 41, after the concurrent review of the record of Patient 42, all acknowledged that the orders listed above had not been signed by a physician within 48 hours after they were written.

Based on observation and document review, the hospital failed to ensure that manufacturer's recommendations were followed regarding the warming of intravenous fluids and irrigation fluids in the main hospital Operating Room (OR) and the Ambulatory Surgery Center (ASC).

Findings:

1. A general observation tour of the ASC was conducted on 11/2/10 at 9:15 A.M. 500 milliliter (ml) plastic bottles of Sodium Chloride for irrigation and 1000 ml. bags of Lactated Ringers intravenous fluids (IV) were found in the upper compartment of a warming cabinet located between two OR's in the ASC. The digital temperature device on the door of the upper compartment indicated that the current temperature for that warming cabinet compartment was 102 degrees Fahrenheit (F). The digital temperature device also indicated that the lowest temperature recorded was 101 degrees F and the highest temperature reached was 107 degrees F.

A review of the hospital's policy and procedure entitled "Solutions: Warming and Storage" indicated that "IV solutions in their over pouches may be warmed to a temperature not to exceed 104 degrees F ...Plastic irrigation solution containers may be warmed to a temperature not to exceed 104 degrees." The hospital's policy and procedure was based on manufacturer's recommendations.

An interview was conducted with the ASC Registered Nurse (RN) Manager on 11/2/10 at 1:15 P.M. The ASC RN Manager acknowledged that the temperature of 107 degrees that was reached inside the upper compartment of the warming cabinet exceeded the temperature recommended by the manufacturer.

2. A general observation tour of the main hospital's Operating Room (OR) was conducted on 11/2/10 at 1:30 P.M. A 1000 milliliter (ml) bag of Lactated Ringers intravenous (IV) fluid and a 1000 ml. IV bag of .9% Sodium Chloride were found in a warming cabinet in a room next to OR #7.

A review of the hospital's policy and procedure entitled "Solutions: Warming and Storage" indicated that "IV solutions in their over pouches may be warmed to a temperature not to exceed 104 degrees F for a maximum of four weeks and must be labeled with that 4-week expiration date." The hospital's policy and procedure was based on manufacturer's recommendations.

An interview was conducted with the Registered Nurse (RN) OR Manager on 11/2/10 at 1:55 P.M. The RN OR Manager acknowledged that there was no date on the bag of Lactated Ringers and the date on the IV bag of Sodium Chloride was smeared and not legible. The RN OR Manager stated that without a date on the IV bags it was impossible to determine when to remove the IV bags from patient use in accordance with hospital policy and manufacturer's recommendations.

Based on observation and document review, the hospital failed to ensure that one bottle of anesthetic gas was stored securely in the Operating Room (OR) when not in use.

Findings:

A general observation tour of the hospital's main Operating Room (OR) was conducted on 11/2/10 at 1:30 P.M. A 250 milliliter (ml) bottle of Sevoflurane (methyl isopropyl ether used for the induction and maintenance of general anesthesia) was found in the top drawer of the anesthesia machine in OR #7. The drawer was not locked.

A review of the hospital policy and procedure entitled "Drug Storage/Security" indicated that "Drugs shall be secured and accessible only to responsible personnel designated by the hospital."

An interview was conducted with the OR Registered Nurse (RN) Manager. The RN OR Manager stated that the Sevoflurane should be stored in a locked cabinet when it was not being used and that it was the hospital's policy and procedure to securely store all medications when the medications were left unattended.

Based on observation, the hospital failed to ensure that irrigation fluids in the operating room (OR) were removed from patient use after the fluids had expired. In addition, the hospital failed to ensure that expired medications were removed from a difficult intubation cart. Three vials of expired lidocaine were found commingled with medications and medical supplies that were accessible for patient use.

Findings:

1. A general observation tour of the hospital's main operating room was conducted on 11/2/10 at 1:30 P.M. Two 2000 milliliter (ml) bags of Sterile Water for Irrigation were found in the equipment storage room of the OR. One irrigation fluid bag had an expiration date of April 2010 and the other had an expiration date of August 2010.

A review of the hospital policy and procedure entitled "Drug Storage/Security" indicated that "Drugs shall not be kept in stock after the expiration date on the label..."

An interview was conducted with the OR Registered Nurse (RN) Manager. The OR RN Manager stated that it was the hospital's policy to remove all expired medications and irrigation fluids from patient use upon expiration. The OR RN Manager acknowledged that the hospital's policy and procedure was not being followed.





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2. On 11/1/10 at 2:00 P.M., general observations with the managers of acute care and women's services were conducted. Three 4 ml (milliliters) syringes of Lidocaine Hydrochloride (local anesthetic for topical administration or local injection into the skin or mucous membranes) topical solution 160 mg (milligrams) were found in the difficult intubation cart with expiration dates that read "8/10."

A review of the facility's Difficult Intubation Cart (itemized list of cart's contents) was conducted on 11/1/10. The list indicated that there would be three laryngo-jet kits (disposable kit for producing rapid, effective topical anesthesia of the interior of the larynx and trachea which includes the Lidocaine Hydrochloride syringes).

An interview with the manager of women's services (MWS) was conducted on 11/1/10 at 2:25 P.M. The MWS stated that the nursing staff was responsible for conducting medication and medical supply audits every shift to ensure that there were no expired medications and medical supplies in the difficult intubation cart. She stated that the expired syringes of Lidocaine contained in the laryngo-jet kits should have been removed, as the difficult intubation cart contained medications and medical supplies that were readily accessible for patient use.

A review of the facility's policy and procedure entitled "Drug Storage/Security" current effect date of 4/09 was conducted on 11/8/10. The policy indicated that "Drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use."

Based on document review the facility failed to ensure that routine inspections of radiology equipment were complete and, that those inspections were documented.

Findings:

1. A review of radiology inspection logs from July 2009-November 2010 was conducted. Monitoring of the fluoroscopic kVp and mA was required to be done on a weekly basis on all fluoroscopic X-ray equipment in the facility. Monitoring records were not done correctly for all the fluoroscopic units located in the Cath Lab. The "weekly fluoroscopy check" did not include: 1) updated reference kVp and mA 2) the reference percent difference from the baseline was not determined and, 3) any evidence of re-measurement when the calculated dose was over 25 percent.

Based on food service observation, interview and record review, the hospital failed to ensure safe food handling practices as evidenced by: 1) Lack of dating system to ensure that a frozen juice product was used within 10 days, once thawed, per manufacturer's recommendations, 2) Uncooked thawed meat stored in a manner that could cause cross-contamination, and 3) A dietary staff did not wash hands after handling dirty pots and pans before proceeding to handle clean dishes.

Findings:

1. On 11/1/10 at 11:30 A.M., in the walk-in produce refrigerator, there was a large cardboard box that had a hand written date of "10/30". The box contained jello, along with approximately a dozen 4 oz.(ounce) containers of juice that were thawed. The cardboard box was not labeled with the product name of either the jello or the juice.

The juice box had pre-printed manufacturer's handling guidelines that indicated, "Keep Frozen, Thaw, Refrigerate and use within 10 days." When Dietary Staff 51 was asked what the "10/30" date meant that was written on the outside of the cardboard box she stated that is "probably" the date when the items were placed in the box. Dietary Staff 51 explained that she was unsure of the meaning of the date of "10/30" because dietary staff recycle the cardboard boxes. When Dietary Staff 51 was asked when the containers of juice expired, she stated, "I will have to ask [name] what the code date means."

On 11/1/10 at 11:35 A.M., Dietary Staff 52 stated that the 4 oz containers of juice were received frozen from the vendor, and then immediately placed into the refrigerator. Dietary Staff 52 was unable to determine when the thawed juice containers would expire in accordance with the manufacturer's recommendations.

Dietary Staff 52 acknowledged that there was not a dating system in place to ensure that the frozen juice product was used within the 10 day shelf life, once thawed.

2. On 11/1/10 at 11:45 A.M., in the walk-in dairy refrigerator, there were six 18-20 lbs (pounds) thawed, uncooked roast beefs that were on three trays, on the lower shelf with the blood of the meat on the trays. Directly pushed up to the lower shelf that contained the trays of the thawed roast beefs were crates of unopened, gallon-sized milks. The crate that contained the milk had the blood from the thawed meat on it.

The General Manager Food and Nutrition Services acknowledged that the storage of the thawed meat in direct proximity to the dairy was not ideal and was a potential source of cross-contamination, and explained that there was a limited space issue.

According to the hospital's policy entitled PROCUREMENTS/STORAGE/INVENTORY/FLOOR SUPPLIES, the purpose of the policy was "To prevent contamination, and growth of disease-carrying organisms." The policy further indicated, "Raw protein foods must be stored separate from cooked foods."

3. On 11/1/10 at 1:45 P.M., Dietary Staff 53 handled dirty pots, pans and trays with gloved hands and then proceeded to handle clean cookware with the same gloves.

On 11/1/10 at 1:47 P.M., the General Manager Food and Nutrition Services acknowledged that Dietary Staff 53 should have washed his hands prior to handling clean cookware.

According to the hospital's policy entitled INFECTION CONTROL;HANDWASHING-AC-1013, "PURPOSE To prevent contamination and the transmission of disease-carrying organisms ..., The Food and Nutrition Services Department requires the employees to wash hands ...after handling soiled dishes or equipment."

The hospital's policy entitled Vinyl Gloves-AC-1012, "Gloves are not a substitute for hand washing. Change gloves in any situation in that you would wash your hands."

Based on interview and document review, the hospital failed to ensure that their policy accurately reflected a statutory regulation (California Senate Bill 1058) that was referenced in their policy. The hospital's policy did not clearly stipulate that the attending physician was responsible for notifying patient or patient's representative of a positive Methicillin-Resistant Staphylococcus Aureus (MRSA- an infection caused by a strain of staphylococcal bacteria that had become resistant to antibiotics commonly used to treat ordinary staphylococcal infections) test result in accordance with the statutory regulation.

Findings:

A review of the facility's policy and procedure entitled "Active Surveillance Testing For Methicillin-Resistant Staphylococcus Aureus" current effect date of 9/09 was conducted on 11/3/10. The policy stipulated that "Upon notification by the laboratory that the patient test is positive for MRSA, 1. The RN/LVN (Registered Nurse/Licensed Vocational Nurse) will notify the physician of the positive result 2. The patient will be notified or the positive test result and placed in Contact Precautions 3. The physician and/or RN/LVN will educate the patient and family."

An interview and joint document review with the Infection Control Practitioner (ICP) was conducted on 11/3/10 at 11:20 A.M. The ICP stated that she was aware of the statutory regulation (California Senate Bill 1058) requiring the attending physicians to notify patient or patient's representative of a positive MRSA test result. She acknowledged that the hospital's policy referenced the statutory regulation however, did not accurately stipulate that it was the attending physician's responsibility to notify the patient or patient's representative of a positive MRSA test result.

A review of the Senate Bill 1058 was conducted. The statute required the following from the hospital, "If a patient tests positive for MRSA, the attending physician shall inform the patient or the patient's representative immediately or as soon as practically possible."

Based on interview, record and document review, the hospital and the Infection Control Officer failed to ensure that two registered nurses (RN's) were knowledgeable regarding the hospital's protocol for disinfection of equipment used by patients with clostridium difficile (a bacteria that causes diarrhea and other intestinal disease). In addition, the hospital and the Infection Control Officer failed to ensure that the hospital's Active Surveillance Testing (AST) for methicillin resistant staphylococcus aureus (MRSA- an infection caused by a strain of staphylococcal bacteria that had become resistant to antibiotics commonly used to treat ordinary staphylococcal infections) was performed on a hemodialysis (a procedure for removing metabolic waste products or toxic substances from the bloodstream) patient in accordance with the hospital policy, for 1 of 7 sampled patients (26). The hospital and the Infection Control Officer also failed to ensure that the attending physicians notified patients and/or their representatives of a positive MRSA test result, for 2 of 7 sampled patients (22, 26).

Findings:

1. A general observation tour of the hospital's Medical Oncology Unit was conducted on 11/1/10 at 11:35 A.M. An interview was conducted with a staff RN at 12:00 P.M. The RN was asked what she would do to clean a wheelchair after it had been used by a patient with Clostridium Difficile (C-Diff). The RN stated that she would disinfect the wheelchair by cleaning the wheelchair with a Sani-wipe. The RN was asked to show the surveyor the disinfectant that she would use. The RN returned with a container of Cavi-wipes. According to the manufacturer's label on the Cavi-wipe container, the Cavi-wipes were only effective in destroying C-Diff vegetative cells but not C-Diff spores.

At 12:10 P.M. the Lead Clinical RN for the Oncology Unit placed a disinfectant labeled Dispatch on the counter. The Lead Clinical RN stated that the Dispatch contained bleach and that only bleach would destroy C-Diff spores.

A review of hospital protocol entitled "Germicidal Disposable Wipes" indicated that Dispatch was to be used for surface disinfection of rooms and equipment of patient's with C-Difficle.

2. A general observation tour of the hospital's Medical-Surgical Unit was conducted on 11/1/10 at 2:30 P.M.

An interview was conducted with the Lead Clinical RN at 2:35 P.M. The Lead Clinical RN was asked what she would do to clean a wheelchair after it had been used by a patient with Clostridium Difficile (C-Diff). The Lead Clinical RN stated that she would disinfect the wheelchair by cleaning the wheelchair with a Cavi-wipe. The Lead Clinical RN was asked to show the surveyor the disinfectant that she would use. The Lead Clinical RN returned with a container of Cavi-wipes. According to the manufacturer's label on the Cavi-wipe container, the Cavi-wipes were only effective in destroying C-Diff vegetative cells (cells that don't reproduce) but not C-Diff spores (cells that reproduce).

The Manager and Ambulatory Care and Ancillary explained to the Lead Clinical RN that it is the protocol of the hospital to use Dispatch to disinfect the surfaces of equipment used by patients with C-Diff because Dispatch contains bleach which is effective in destroying C-Diff spores.






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3. Patient 26 was admitted to the hospital on 4/14/10 with diagnoses that included end stage renal failure (severe malfunction of the kidneys) per the face sheet.

A review of Patient 26's medical record was conducted on 11/3/10 at 10:11 A.M. A History and Physical dated 4/15/10, indicated that on admission, Patient 26 had chronic renal failure and was on hemodialysis (mechanical process to filter waste products from the blood). A clinical lab report dated 6/17/10, indicated that a staphylococcus aureus culture was obtained from Patient 26 via nasal swab.

An interview and joint record review with lead clinical registered nurse (RN 21) was conducted on 11/3/10 at 10:30 A.M. RN 21 stated that according to the hospital's policy, hemodialysis patients were screened for MRSA on admission. She stated that she did not know why Patient 26 was not screened for MRSA on admission as the patient met the criteria for MRSA screening in accordance with the hospital's policy.

An interview with the Infection Control Practitioner (ICP) was conducted on 11/3/10 at 10:50 A.M. The ICP stated that all dialysis patients were screened for MRSA on admission because the hospitals were required to implement a process to test identified patient populations for MRSA within 24 hours of admission (California Senate Bill 1058 included in hospital's policy). She stated that the hospital generated a list of dialysis patients who were to be screened for MRSA on admission, Patient 26 may have not been on the list. She acknowledged that Patient 26 should have been screened for MRSA on admission, not 2 months after admission in accordance with the hospital 's policy.

A review of the facility's policy and procedure entitled "Active Surveillance Testing For Methicillin-Resistant Staphylococcus Aureus" current effective date of 9/09 was conducted on 11/3/10. The policy's purpose indicated that "To provide guidelines to comply with California Senate Bill 1058 which requires general acute care hospitals to implement a process to test identified patient populations for Methicillin-resistant Staphylococcus aureus (MRSA) within 24 hours of admission." Per the same policy, it indicated that "For all patients without a history of MRSA, AST will be performed within 24 hours of admission for the following patient population: ... 2. Patients undergoing hemo or peritoneal (within the abdominal cavity) dialysis ..."

4. Patient 22 was admitted to the hospital on 10/18/10 per the face sheet.

A review of Patient 22's medical record was conducted on 11/2/10 at 10:20 A.M. A clinical lab report dated 10/19/10, indicated that a staphylococcus aureus culture was obtained. Per the same report, it indicated that Patient 22 tested positive for MRSA on 10/22/10. There was no documentation in the medical record to show that the patient and/or patient's representative were notified of the positive MRSA result.

An interview and joint record review with the acute care manager (ACM) was conducted on 11/2/10 at 2:50 P.M. The ACM stated that Patient 26 and/or his representative were not notified by the physician and/or nursing staff of his positive MRSA test result in accordance with the hospital's policy.

A review of the facility's policy and procedure entitled "Active Surveillance Testing For Methicillin-Resistant Staphylococcus Aureus" current effect date of 9/09 was conducted on 11/3/10. The policy stipulated that "Upon notification by the laboratory that the patient test is positive for MRSA, 1. The RN/LVN (Registered Nurse/Licensed Vocational Nurse) will notify the physician of the positive result 2. The patient will be notified or the positive test result and placed in Contact Precautions 3. The physician and/or RN/LVN will educate the patient and family."

5. Patient 26 was admitted to the hospital on 4/14/10 with diagnoses that included end stage renal failure (severe malfunction of the kidneys) per the face sheet.

A review of Patient 26's medical record was conducted on 11/3/10 at 10:11 A.M. A clinical lab report dated 9/28/10, indicated that an aerobic deep wound culture was obtained from Patient 26's right heel wound. Per the same report, a final report dated 10/2/10, indicated that Patient 26 tested positive for MRSA. There was no documentation in the medical record to show that the patient and/or patient's representative were notified of the positive MRSA test result.

An interview and joint record review with lead clinical registered nurse (RN 21) was conducted on 11/3/10 at 10:30 A.M. RN 21 stated that there was no documentation in the medical record that Patient 26 and/or his representative were notified of the positive MRSA test result in accordance with the hospital's policy.

A review of the facility's policy and procedure entitled "Active Surveillance Testing For Methicillin-Resistant Staphylococcus Aureus" current effect date of 9/09 was conducted on 11/3/10. The policy stipulated that "Upon notification by the laboratory that the patient test is positive for MRSA, 1. The RN/LVN (Registered Nurse/Licensed Vocational Nurse) will notify the physician of the positive result 2. The patient will be notified or the positive test result and placed in Contact Precautions 3. The physician and/or RN/LVN will educate the patient and family."

Based on observation, interview and document review, the facility failed to ensure that the laryngoscope (an instrument used to insert an endotracheal tube during cardio-pulmonary resuscitation) blades were compatible and functional with the laryngoscope handle in the Post Anesthesia Care Unit (PACU) crash carts of the main hospital and the ambulatory surgery center (ASC).

Findings:

1. During a tour of the PACU, on 11/1/10 at 12 P.M., the crash cart was inspected. A plastic laryngoscope blade from the crash cart was selected by the Lead PACU RN to connect to the laryngoscope handle from the crash cart to check that the laryngoscope was functioning as expected. The Lead PACU RN was not able to connect the laryngoscope handle to the blade; she stated that the blade did not fit the handle. She obtained another laryngoscope handle from another area of the PACU and the handle did fit the blade from the crash cart.

An interview with the Lead PACU RN was conducted on 11/1/10 at 12:05 P.M. She stated that central supply stocked the crash carts with the laryngoscope handles and blades. She acknowledged that the laryngoscope handle that was stocked in the crash cart was not compatible with the laryngoscope handles in the crash cart. She stated that some anesthesiologists preferred to use the laryngoscope handles that are not compatible with the plastic blades in the crash cart and perhaps that is why the non-compatible handle was placed in the crash cart by mistake.

A review of the facility's Policy and Procedure (P&P) titled "Code Blue, Code Pink, Crash Cart Checking and Crash Cart Emergency Medication" was conducted on 11/3/10 at 9 A.M. The P&P did not specify to staff that laryngoscope blades should be connected to the laryngoscope handle to ensure that the blades and handle are compatible and functional.

An interview with Director of Acute Care was conducted on 11/3/10 at 9 A.M. She stated that the facility has a P&P for Crash Cart checking and a crash cart contents list; however, she stated that the faculty did not have a P&P that specified to staff to connect the laryngoscope blades to the handle to check for laryngoscope blades being compatible and functional with the laryngoscope handle in the crash cart.

2. A general observation tour of the ASC was conducted on 11/2/10 at 9:15 A.M. The crash cart in the ASC's Post Anesthesia Care Unit was inspected at 10:05 A.M. Eight plastic laryngoscope blades and a metal laryngoscope handle were found in the crash cart drawer labeled #1. Several attempts were made to attach the laryngoscope blades to the laryngoscope handle unsuccessfully.

An interview was conducted with the ASC Registered Nurse (RN) Manager. The ASC RN Manager acknowledged that the metal laryngoscope handle stored in the crash cart was the wrong handle for use with the plastic laryngoscope blades.

A review of the daily crash cart check list revealed that it was not the hospital's procedure to check the function of the laryngoscope on a daily basis.