HospitalInspections.org

Based on document review and interview it was determined for 2 of 2 (Pt. #3 and #13) patients with hourly orders, the Hospital failed to ensure physicians' orders were followed as written.

Findings include:

1. Hospital "Bylaws, Rules and Regulations" included, "All orders for treatment shall be in writing."

2. The clinical record of Pt. #3 was reviewed on 11/16/15. Pt. #3 was a 61 year old male admitted on 11/13/15 with the diagnosis of severe abdominal pain. A physician's order dated 11/14/15 at 8:10 AM included, "Blood sugars every one hour for now." The clinical record lacked documentation of any blood sugars until 9:19 PM on 11/14/15.

3. During an interview on 11/16/15 at approximately 10:25 AM, the charge nurse (E#5) stated, "I am unable to find documentation of blood sugars for that time".

4. The clinical record of Pt #13 was reviewed on 11/16/15. Pt #13 was a 50 year old male admitted on 11/10/15 with a diagnosis of acute respiratory failure. Pt #13's clinical record contained a physician's order dated 11/10/15 at 1:12 PM that required Pt #13's intake and output (I&O) be monitored every hour. Pt #13's clinical record lacked documentation of hourly monitoring as required, on 11/16/15.

5. The manager of the Intensive Care Unit (ICU) stated during an interview on 11/16/15 at approximately 11:45 AM that the patient's intake and output were not monitored as ordered. She stated that hourly monitoring is not the standard that is followed in the ICU.

Based on document review and interview it was determined for 1 of 3 (Pt. #1) patients on 3 medical/surgical unit, the Hospital failed to ensure the patient's plan of care was individualized and revised daily as per policy.

Findings include:

1. Hospital policy titled, "Medical Records - Nursing Documentation (review date 11/10/15)" required, "...iv. The plan of care will be customized and prioritized based on the patient's current clinical condition and identified needs. ... vi. interdisciplinary plan of care will be updated every 24 hours."

2. The clinical record of Pt. #1 was reviewed on 11/16/15. Pt. #1 was a 63 year old female admitted on hospice (end of life care) 11/13/15 with the diagnosis of nausea and vomiting for one week. A nursing note dated 11/15/15 at 7:48 AM included, "Contact isolation - Productive cough with sputum ESBL (extended spectrum beta-lactamase - bacteria), please add mask to PPE (personal protective equipment). ESBL positive 11/9/15". A physician's progress note dated 11/15/15 at 8:14 AM included, "complains of persistent nausea/vomiting." The care plan dated 11/14/15 at 3:47 AM only included pain. The plan of care lacked documentation of updates to include the above problems/care (end of life care, cough/respiratory care, isolation or nausea/vomiting).

3. During an interview on 11/16/15 at approximately 11:30 AM, the clinical informatics nurse (E #6) stated, "The only item included on the plan of care is pain. No other problems are listed."

Based on document review, observation, and interview it was determined for 4 of 5 staff members (E#8-E#11) preparing food in the tray line, the Hospital failed to ensure adherence to the dress code policy for the kitchen. This potentially affected all patients on census, who received meals from the kitchen.

Findings include:

1. Policy entitled, "Personal Hygiene" (Reviewed 12/2014) required, "Procedure: 1.b. Hair nets and/or caps worn at all times.."

2. On 11/18/15 from 10:45 AM to 11:40 AM during the food line preparation, the following was observed:
-11:00 AM: Food Service Worker (E#8) was observed in the kitchen with an exposed beard and no beard guard;
-11:15 AM: Cook (E#9) was preparing salads in the designated "cold food preparation area" with exposed hair around the forehead from under the hairnet;
- 11:17 AM: Cook (E#10) was in the designated hot food preparation area wearing a hairnet with exposed hair around the ears.
-11:20 AM: Food Service Worker (E#11) was wearing a hairnet with hair exposed around the ears and neck.

3. On 11/18/15 at approximately 11:45 AM the findings were discussed with E#7 (Director of Dietary Services). E#7 stated staff have the option to either use a hair net or a cap to cover their hair completely while in the kitchen. E#7 stated the use of a beard guard is required in the kitchen if the staff member has a beard.

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 November 16-18, 2015, the surveyors find 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 a Full Survey Due to a Complaint conducted on November 16-18, 2015, the surveyors find the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies cited in the K-tags.

Based on document review, observational tour, and interview, it was determined, for 1 of 3 regular trash containers in the computerized axial tomography (CAT) area of the radiology department, the Hospital failed to ensure bloody waste was not placed in the regular trash, potentially affecting approximately 40 patients having CAT scans that day.

Findings include:

1. Hospital policy # II-06-3.13, titled, "Potentially Infectious Medical Waste", revised May 2011, was reviewed on 11/18/15 at 2:20 PM. The policy required, "Definitions... The following medical wastes are considered infectious: 1. Human Blood and Blood Products... Procedure... PIMW [Potentially Infectious Medical Waste] shall be discarded directly into appropriate containers or red plastic bags at or near the point of generation."

2. On 11/18/15 at 10:50 AM, an observational tour was conducted in the radiology department. Two bloody gauze pads and an intravenous catheter were observed in a garbage container lined with a clear plastic bag in a CAT scan room (room "16 slice"), not in a red hazardous waste bag.

3. On 11/18/15 at approximately 11:30 PM, an interview was conducted with the Administrative Director of Medical Imagery (E #13). E #13 stated bloody material should be disposed of in the hazardous trash.

Based on document review, observational tour, and interview, it was determined, for 1 of 1 crash cart in the computerized axial tomography (CAT) area of the radiology department, the Hospital failed to ensure defibrillator pads had not exceeded the expiration date, potentially affecting approximately 40 patients having CAT scans each day.

Findings include:

1. Hospital policy # I-03-2.3.5, titled, "Crash Carts, Emergency Carts, and AED Locations, Contents and Maintenance", revised 3/9/12, was reviewed on 11/19/15 at 9:00 AM. The policy required, "III. Maintenance of Supplies and Equipment for the Adult Crash Cart and the Broselow Pediatric Emergency Cart: A. Responsibility: 1. It is the responsibility of the Materials Management Department to ensure the availability and maintenance of the emergency supplies and equipment... All outdated supplies and equipment will be replaced..."

2. On 11/18/15 at 10:50 AM, an observational tour was conducted of the radiology department. Two of 4 adult defibrillator pads contained an expiration date of July 2015, and 1 of 2 pediatric defibrillator pads was labeled "use before 6/15", and were found on a crash cart in the Magnetic Resonance Imaging area available for use.

3. On 11/18/15 at approximately 11:30 PM, an interview was conducted with the Administrative Director of Medical Imagery (E #13). E #13 stated Material Management should have replaced expired supplies on the crash carts.

A. Based on document review, observation and interview, it was determined for 1 of 1 (MD #1) anesthesiologist observed, the Hospital failed to ensure the anesthesiologist disinfected the medication stoppers prior to accessing. This potentially affected all patients to whom MD #1 administered injectable medication.

Findings include:

1. Hospital policy entitled, "Safe Injection Practice," (review date 11/6/15) required, "...VI. Procedure: A...2...and the rubber septum should be disinfected with alcohol prior to piercing it."

2. During an observational tour in OR #9 on 11/18/15 at approximately 9:30 AM, MD #1 was observed preparing pre op medications by accessing the vial septum without disinfecting. Medications included: Fentanyl, Versed, and Propofol (all used in the anesthetic process).

3. The Director of Peri Operative Service was informed during an interview on 11/18/15 at approximately 10:45 AM that the medication vials were not disinfected prior to accessing.




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B. Based on document review, observational tour, and interview, it was determined, for 1 of 1 glucometer in the Emergency Department (ED), the Hospital failed to ensure the glucometer was cleaned after use, potentially affecting approximately 105 patient treated in the ED daily.

Findings include:

1. Hospital policy titled, "Blood Glucose Monitoring", revised 5/7/13, was reviewed on 11/18/15 at 2:15 PM. The policy required, "VI. Procedures: A. Infection Control: 4. The meter must be cleaned daily, and checked for cleanliness and cleaned when necessary before and after each patient test."

2. On 11/18/15 at 1:00 PM, an observational tour was conducted in the emergency department (ED). The glucometer in the medication room had dried blood on the area where the sample is inserted.

3. On 11/18/15 at 1:25 PM, an interview was conducted with the ED Director (E #12). E #12 stated the glucometer should have been cleaned after use.

Based on document review, observation, and interview it was determined for 3 of approximately 8 employees and 1 of 1 anesthesiologist ( E #1, 2, 3, and MD #1) observed in the surgical operating rooms (OR) 5 and 9, the Hospital failed to ensure adherence to the surgery department dress code policy.

Findings include:

1. Hospital policy entitled, "Surgical Attire," (revised 2/14) required, "...3. Head covers: Are worn by all personnel in the restricted and semi restricted areas. a. Head and facial hair must be covered with a hat or hood...4. Face Masks. a. Face masks must be worn by personnel in the operating room when sterile items and equipment are present..."

2. During an observational tour on 11/18/15 between 8:30 AM and 9:30 AM the following were observed:

In room #5 the circulating nurse (E #1) had facial hair uncovered and entered the room with his surgical mask untied. The certified registered nurse anesthetist (E #2) had approximately 1 inch hair exposed from beneath her head cover.

In room #9 the scrub nurse (E #3) had facial hair uncovered. The anesthesiologist (MD #1) had approximately 1 inch of hair exposed from the back of his head cover.

3. The Director of Peri Operative Services was informed of the above dress code issues during an interview on 11/18/15 at approximately 10:45 AM and stated, "Oh no."