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Based on review of medical records and interview, it was determined that the facility failed to follow facility policy concerning restraint of a patient.

Findings were:

Facility policy entitled "Restraint and Seclusion" stated in part "'Restraint' means any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely ...Restraint is initiated only upon the order of a physician or other licensed independent practitioner ...Restraint orders must be dated and timed when signed by the physician and include: 1) criteria for release; 2) type of restraint used; 3) reason for restraint; 4) and specify duration of restraint order."

Facility policy entitled "Patient Rights and Responsibilities" stated in part that the patient has "The right to be free from restraints, of any form, that are not medically necessary or used as a means of coercion, discipline, convenience or retaliation by staff."

Facility policy entitled "Care of the Combative Patient" stated in part "It is the responsibility of this facility to promote safety and protection of in the care of a combative patient/hostile person and the staff and/or individuals at risk for harming themselves or others.
Procedure Steps:
Combative Patient/Person
1. Protect involved person from harm
2. Attempt to calm and reassure patient/person
3. Call for help. DO NOT LEAVE PATIENT/PERSON. CALL CODE STRONG 3333.
4. Contact physician if involving a patient
5. Document pertinent information.

Facility policy entitled "SPHN Emergency Codes" stated in part "Providence Memorial Hospital has established policies and procedures for a variety of potential disasters and emergencies. To expedite staff notification and response, the notification of external authorities, and to minimize public panic, emergency codes have been developed ...
Code Strong -Activates notification of staff and response personnel to a violent situation."

Patient # B1 was restrained on 12/02/14 @ 5:07 am. Nursing narrative note by Staff Member # B17 stated in part, "Pt.'s left arm grabbed by ****(Security Guard) and the right arm by ****(PCT), and his left leg by myself (RN)." While a Code "Strong" was called, patient's doctor was not alerted, nor was an order received for a personal hold/restraint.

In an interview with the Chief Nursing Officer on 12/2/14, it was confirmed that Patient # B1 was put in a brief personal hold/restraint. It was also acknowledged that the nursing staff failed to follow facility policy in regard to restraint of a patient.

Based on a review of medical records in the Post-Operative Care Unit (PACU) revealed that documentation was not completed for an updated history and physical examination prior to surgery for 2 out of 4 PACU patients.

Findings included:

Review of the medical records of 2 out of 4 patients, Patient #E6 and Patient #E7 in the PACU on 12/2/14, accompanied by Staff #2, Director of Surgical Services, and Staff #6, Risk Manager/Patient Safety Officer, the following was observed. For Patients #E6 and E7, the History and Physical examination was documented on 12/1/2014. The form entitled, "History & Physical Update" which stated, "Attach original H&P to this form" for documentation that the history and physical" (completed within the past 30 days) has been reviewed and the patient has been re-examined." was left blank. There was no documented evidence from the medical record provided to the surveyor to indicate the physician had reviewed and re-examined the patient prior to surgery.

Review of the Providence Memorial Hospital Rules & Regulations of Medical and Dental Staff, last revised 8/25/14, stated, in part, "2. A complete history and physical examination, performed by a practitioner member of or approved by the medical staff ...must be recorded in the medical record of all inpatients within 24 hours, and for all elective surgical inpatients and ambulatory (same-day) surgery patients at the time of admission and prior to the procedure ...a ... Inpatient H&P ....A physical examination and medical history must be done no more than 30 days before, with an appropriate up-dated assessment, or 24 hours after an admission for each patient by a doctor ...The H&P must be performed within 30 days prior to the hospital admission; and an appropriate assessment, which should include a physical examination of the patient to update any components of the patient's current medical status that may have changed since the prior H&P was performed or to address any area where more current data is needed."

The above findings were confirmed in an interview in the Pre-op area during the tour on 12/2/14 with Staff #E2 and Staff #E6.

Based on review of documentation and interview, it was determined that 1 of 19 nurses did not assess a patient and document findings per facility policy and job description.

Findings were:

Facility policy entitled "Daily Documentation (Nursing Notes)" stated in part "Nursing documentation will be done each shift with reassessments occurring at change of shift, change of caregiver, change in condition, prn or per physician's order."

Facility Job Description entitled "Licensed Vocational Nurse" stated in part "Under the guidance and supervision of an RN maintains up to date and accurate documentation of nursing care provided to assure the integration of information for use by the health care team, in order to assure quality care."

Facility Job Description entitled "Registered Nurse, Medical/Surgical" stated in part "Evaluates the identified problems, care provided and patient's responses are reassessed in order to meet patient and family needs to assure overall quality of care provided. ...Maintains up to date and accurate documentation of nursing care provided to assure the integration of information for use by the health care team, in order to assure quality care."

On 12/2/14 at 9:39 am, Staff Member # B25 (LVN) related to the survey team that he had completed his assessment of Patient # B1. He had not documented the assessment but stated that the patient had no edema on his lower left leg. Approximately one hour later, the survey team observed the same patient receiving dialysis treatment. The RN on duty had assessed the patient and had documented "pitting edema + 3" to Patient # B1's left lower leg.

On 11/17/14, Patient # B1 (a dialysis patient) received orders for daily weights. Review of the patient medical record on 12/2/14 revealed that no weights had been recorded for Patient # B1 since 11/29/14.

In an interview with the Director of Nurses on 12/2/14, the above discrepancies were acknowledged.

Based on medical record review, facility policy review, and staff interview, 2 of 19 nurses reviewed failed to follow the facility's policy in regards to administration of time-critical scheduled medications.

Findings were:

Medical record review for patient #B7 on 12/3/14 revealed the patient was ordered an anticonvulsant medication per patient's PEG tube. Medication was to be given every 12 hours. Medication was scheduled to be given at 9:00 a.m. and was given at 10:07 a.m. per PEG tube on 12/2/14. No documentation as to reason medication was given later than the scheduled time was documented.

Medical record review for patient #B21 on 12/3/14 at 10:35 a.m. revealed the patient was ordered an antibiotic IV every 12 hours to be given at 5:00 a.m. and 5:00 p.m. On 12/2/14 the patient received the IV antibiotic medication scheduled for 5:00 p.m. at 6:16 p.m.; and the dose scheduled for 5:00 a.m. on 12/3/14 was not documented as given (this was noted at 10:35 am on 12/3/14). No reason was given for the late administration of the medication on 12/2/14 or the missed dose on 12/3/14. There was no documentation in the patient medical record that the physician was notified of the missed dose of antibiotics.

Facility policy titled "eMAR Process (Medication Administration) states, in part: "When prescribed medication is not given, a reason is documented. If a scheduled medication is not administered; click on the medication task in the eMAR and select Chart Details. Click the "Not Given" box and select a reason from the drop down menu, comments may also be added. When documenting medications not given, a reason will be required and must be selected from a drop-down list. Free text may also be entered." "Time-critical scheduled medications, are those medications for which an early or late administration of greater than 30 minutes might cause harm or have a significant, negative impact on the intended therapeutic or pharmacologic effect. Examples of these medications or medication types are: Antibiotics; Anticonvulsants......" "All time-critical doses missed or not given, the physician will be notified."

In an interview with staff #B29 on 12/3/14 at 10:02 a.m. she stated there was no documentation in the medical record for patient #B7 to indicate the reason the anticonvulsant medication (a time-critical medication) was given greater than 30 minutes after the scheduled time.

In an interview with staff #B22 on 12/3/14 at 10:38 a.m. he could find no documentation why the medication was not given for patient #B21 and the medication was still in the patient medication box. He further stated there was no documentation the physician had been notified of the missed dose. He further acknowledged this was a time-critical scheduled medication.

Interview with staff #B1 on 12/3/14 confirmed the staff did not follow the facility policy on medication administration.

Based on a review of documentation and interview, it was determined that the facility failed ensure that food and dietetic services organization requirements were met, as evidence by failing to ensure that thermometers utilized in food preparation areas were appropriately calibrated per policy. The failure to calibrate thermometers used to measure the temperatures of food prior to serving could led to inaccurate temperature readings, increasing the potential for food borne illness.

Findings were:

Facility based policy and procedure entitled, "Thermometer Calibration" stated in part, "Temperatures of food shall be monitored using accurate thermometers. Thermometers should be accurate to +/-2 ? F ....
PROCEDURES:
To verify accuracy of thermometers: ...
? Complete Thermometer Calibration Sheet. If the Thermometer is recalibrated, the corrective actions column must also be completed; initial the entry."

A form in the Food and Nutrition Policy and Procedure Manual entitled, "Thermometer Calibration Sheet" stated, "All thermometers used in the department are calibrated weekly and documented on this form. The forms are kept on file for 3 months." The bottom of the form stated, "***Calibration of every thermometer is to take place once a week every week and form must be signed."

Review of facility documentation revealed the following:
? The facility based form entitled "Trayline Temperature Monitoring Form" is utilized to document meal temperatures three times a day. At the bottom of the form a line stated, "WEDNESDAY ONLY: THERMOMETER CALIBRATION: place in ice water cup STD=32? F = ____?F."
? A review of the "Trayline Temperature Monitoring Form" for the main kitchen from January through May 2014, and October 2104 revealed no documentation of thermometer calibration. Review of the "Trayline Temperature Monitoring Form" for (the facility retail cafeteria) for October and November 2014 revealed no documentation of thermometer calibration.

In an interview with Staff member D #2, Food Services Director, on the afternoon of 12/02/14 in the facility conference room, she was asked if there was a form other than the "Trayline Temperature Monitoring Form" used to document the calibration of thermometers used for measuring food tray temperatures. Staff member D #2 stated, "No, this is the form on which we'd have the opportunity to document that. That ' s an area needing improvement."

Staff member D #2, they stated that the calibration of thermometers is not documented weekly per policy. Staff member D #2 stated that thermometer calibrations were not recorded consistently. They stated, "That's an opportunity for us to record that information. There are probably sporadic recordings of the thermometer calibration. That's an opportunity for improvement in this department."

The above findings were confirmed in an interview with staff member D #2 on 12/02/14.

Based on a review of facility documentation and staff interviews, the facility failed to ensure that dietary changes were ordered by a practitioner responsible for the care of the patient as required by facility policy for 1 of 3 patients with special diets.

Findings were:

A review of 3 records of patients on special diets revealed that the tube feedings for Patient #D6 were discontinued without a physician's order. Physician orders showed the following order:
"12/2/14 10:56:00 MST, Formula: Nephro, 10 mL/hr, Start Meal: Next Meal, Continuous..."
The Intake and Output form noted the patient received a tube feeding at 12:00 noon on 12/3/14 and then no further feedings. There was no order to stop tube feedings. A nursing progress note on 12/3/14 at 1:00 p.m. MST stated, in part, "TF (tube feedings) DC'ed (discontinued) by Dr. Fernandez. Orders received to connect OG to low continuous suction."

In an interview with Staff #D16, Unit Director, on the morning of 12/4/14 in the nurse's station of the ICU, she stated, "There should have been a verbal order to stop tube feedings. He [the physician] should have put them [the orders] in. Maybe he documented it in his progress note." When asked if the progress note would be considered a physician order, she stated, "Well, no. And a verbal order should only be given in an emergency. "

In an interview with Staff #D15, ICU RN, in review of the chart of Patient #D6 on the morning of 12/4/14 in the nurse's station of the ICU, she stated "Sometimes the physicians don't enter orders about resuming a patient's diet after a procedure. There's no order to stop the tube feedings here [indicating the physician orders contained in the electronic health record] so there was probably a verbal order." When asked if that meant the non-electronic patient chart contained a handwritten verbal order noted by the nurse, she stated, "Well, no. It's a problem. And if we enter the order in the system [as nurses] they'll [the physicians] get mad at us." When asked if this issue sometimes resulted in patients' diets not being stopped or resumed as necessary, she stated, "Yes."

Facility policy #O1, entitled "Physician Orders: Receiving, Transcribing," last revised 10/14, stated in part:
"RECEIVING ORDERS - TELEPHONE/VERBAL
1. Telephone orders are to be taken by licensed/registered personnel only. Verbal orders should be taken only in emergency situations...
4. Transcribe to the physician order sheet each order as received. Include the date and time.
5. Readback to the physician all telephone orders to verify accuracy and place nurse initials in the readback column for each order..."

Facility Patient Food Services policy #C002 entitled "Diet Orders," last revised 1/14, stated in part:
"Diets are ordered in Cerner by the responsible physician prior to the service of the diet ...
Physician
Writes/enters diet order in medical record/information system...
Writes a diet order for "NPO" when a patient is not allowed oral intake.
Writes new diet order to resume oral intake for patients who have been NPO..."

The above findings were again confirmed in an interview with the Interim Chief Operating Officer on the morning of 12/4/14 in the facility conference room.

Based on a review of facility documentation, a tour of the facility and staff interviews, the facility failed to maintain the overall hospital environment in a manner which assured the safety and well-being of patients.

Findings were:

During a tour of the facility on 12/02/14 the following physical plant issues were noted:
- In the facility retail cafeteria a 3 inch x 2 inch area of tile was missing on the wall beside a shelf in the serving area. The magnetic door latch on the wall was dislodged exposing wires in the wall, allowing a potential entry point for pests
- In the Pediatric Unit cracked laminate was observed in a cabinet underneath the ice shelf, allowing for water penetration and the potential for bacterial growth. A 3 X 2 inch area of laminate was missing from a counter in the treatment room.
- In the Post-Partum Nourishment Area ? an inch of standing water was observed in the drain pan of the ice machine. It appeared that the drain was not properly functioning. The standing water creates a potential for bacterial contamination.
- Throughout the facility, there were old acoustic ceiling tiles that had holes, were crumbling or stained, had warped and thus were ill-fitting, and/or had never fit in the first place. These ceiling tiles served as entry points for dirt, dust and pests into the area below them. The stained tiles were indicated by staff to have been caused by previous water leaks. The deteriorating and/or ill-fitting tiles were found in a variety of areas, including areas which contained patient supplies and medications, as well as over patient beds. As examples:
o In the Day Surgery PACU, the ceiling tiles outside the bathroom over patient supplies did not meet and the resulting gap was approximately ?" by 2. '
o Outside the Labor & Delivery unit, in front of the elevator, a ceiling tile was warped and did not fit within the metal framing leaving a large gap where tiles did not meet. An attempt had been made to wire the tile to the ceiling framing.
o In the Pre-Operative area of the main OR over an area for a patient bed, there was an ill-fitting ceiling tile which left a significant gap in the ceiling which was difficult to measure due to the warp of the tile.
- A housekeeping closet on the Post-Partum unit contained an area of broken plaster along the baseboard that was approximately 3 " x 4 " which made cleaning impossible and allowed for entry of pests.
- In Dialysis Area missing areas of laminate were observed through on counters and cabinets. Exposing the wood beneath, preventing effective cleaning of these surfaces.

During a tour of the facility on 12/03/14 the following observations were made:
- In the Post Anesthesia Care Unit (PACU) several floor tiles were observed broken with depressions in the floor, preventing effective cleaning of the floor.
- In the Day Surgery Post Anesthesia Care Unit (PACU) an electric outlet was observed with a 2 X 1 inch area of plaster missing, creating a potential entry point for pests. In the nourishment area a cabinet was noted to have a drawer with visible rust present. There were chipped floor tiles by the sink, as well as an area of broken laminate approximately 18 " x 2 " on the front of the countertop. The sink cabinets had areas of broken wood down the side each approximately 3 " x 1 " which made cleaning impossible.
- In the Pediatric Intensive Care Step Down Unit a ceiling tile was observed to not be flush with the ceiling over a supply cart.
- In the Labor and Delivery Unit, Operating Room # 2, pieces of debris were observed on the floor, including plastic caps and an empty vial of medication. Operating Room # 1 and 2 had headboards stored on the floor. In an interview, the Director of the Labor and Delivery Unit identified these rooms as terminally cleaned.

In an interview with the Staff #D7, Director of Facilities, on the morning of 12/3/14, while touring the main OR pre-operative area, a warped ceiling tile was noted above an area for a patient bed. The warped tile had resulted in a significant gap in the ceiling. In a discussion of this tile, Staff #D7 stated, "This particular ceiling tile was probably warped from the weight of the light. So, it appears to have come out of the framing over the patient bed. A lot of these are crumbling and warping probably from age. When we move tiles and they hit a wire, it'll chip the tile. "

In an interview with Staff #D11, the Unit Director of Labor & Delivery, on the morning of 12/3/14, while touring the unit, she was asked if she had ever noticed problems with water leaking from the ceiling on the unit. She replied, "Anytime it rains everything pretty much leaks. We chase tiles daily, but this is one of the oldest parts of the hospital. And it doesn't matter if it's four drops of rain or a deluge." This was immediately confirmed by the Women's Services Administrator who was also touring.

In a second interview with Staff #D7, Director of Facilities, while on the tour on the morning of 12/3/14, he stated, "We had one elevator here that got completely flooded. But that elevator has since been replaced. We're gradually replacing the roof, so within the next few months this whole area will have a new roof." When asked if there was a facility policy which addressed general facility maintenance, or specifically several of the findings noted on the facility tour, he stated, "There isn't a policy like that. Maybe we should come up with one."

A review of the facility EOC (Environment of Care) Rounding Tools revealed the line for "Ceiling tiles intact and free from stains ..." was checked as "Not Met" for the following dates and areas:
8/21/14: Day/Main Surgery
8/22/14: NICU, ICU (Neonatal Intensive Care Unit, Intensive Care Unit)
8/29/14: Cath Lab
9/3/14: Post-Partum and Nursery
9/12/14: Labor & Delivery
9/25/14 & 9/26/14: NICU
10/23: Day PACU (Post-Anesthesia Care Unit)
10/24/14: CCU (Critical Care Unit)
11/18/14: ICU

Based on tour and interview it was determined the facility failed to ensure that alcohol based hand sanitizer rub dispensers were install in a safe manner, as evident by the presence of such dispenser near active electrical outlets, creating a fire hazard.

Findings were:

Tour of the facility revealed that multiple alcohol based hand sanitizer dispensers were observed to be placed in close proximity to electrical outlets and plugs.

During a tour of the facility on 12/02/14, the following observations were made:
? In the Pre-Operative Holding area, patient bays 1 through 4 were observed to have alcohol based hand sanitizer dispensers beside or above electrical outlets and plugs. These hand sanitizer dispensers were observed within 2-4 inches of the electrical outlets.
? In a secondary Pre-Operative Area, one alcohol based hand sanitizer dispenser was observed 3 inches from an electrical outlet that was active with electric medical devices plugged in.

Staff E #2, Director of Surgical Services, confirmed the hazard presented by the location of the hand sanitizers.

During a tour of the facility on 12/03/14 the following observations were made:
? On the Medical Oncology Floor in the hallway between the exit door and room 401, an alcohol based hand sanitizer dispenser was observed located beside an electrical outlet.

In an interview on 12/03/14, staff member D #7 stated that the placement of the alcohol based hand sanitizer dispensed near electrical outlet was a result in miscommunication between various departments. Staff Member D #7 stated, "There was a breakdown. Now my guys are trained, now they know not to place them over outlets." Staff member D #7 stated the alcohol based hand sanitizer dispensers are supplied by housekeepers. "I think some units were just installing them themselves." The staff member also stated that, "The previous infection control nurse would put blue dots on the wall where she wanted them installed and my guys would go and place them without question."

Staff member D #7 confirmed that as of 12/03/14 alcohol based hand sanitizer dispensers throughout the facility remained in close proximity to electrical outlets, creating a fire hazard. Staff member D #7 stated the maintenance department was currently working to move them to appropriate and safe locations.

Based on review of medical records, staff interviews, patient interviews, and tour of the perioperative area of the hospital, the hospital failed to ensure that surgical standards of practice were followed as there were consent forms improperly documented, a patient without an emergency call light in reach, processes for disinfection not followed, and lack of proper labeling of IV fluids.

Findings included:

During a tour of the pre-operative the morning of 12/2/14, accompanied by Staff #E2, Director of Surgical Services, the following was observed:
? Review of the clinical record for Patient #1 at 8:55 am with Staff #E5, Pre-op RN, revealed the "Consent for Anesthesia Services" had not been signed by the patient (the line for "Patient's Signature/Other Legally Responsible Person" was blank), however the date, "12/2/14", and the time, "0905" was already handwritten on the form in the designated areas. The "Witness Signature" blank had already been signed by Staff #E5, despite there being no patient signature to witness. This was confirmed in an interview while reviewing the record with Staff #E5 and Staff #E2.
? During an interview with Patient #1 in the pre-op patient room, upon entering the patient room, the television was on and the volume was too high to converse. It was observed that the call light device, which also included the television controls, was inaccessible to the patient as it was hung out of reach on a hook on the wall above the patient's bed. Patient #E1 stated, "I can't even reach the call light or turn down the television." This was reviewed in an interview with Staff #E5 and Staff #E2 during the tour.
? In pre-op area, the surveyor noted children's activity toys mounted on the wall in the patient. In an interview with Staff #E16, Pre-op RN during the tour, she was asked by the surveyor how the children's activity toys were disinfected between patients. Staff #E16 stated, "I'm not aware that it happens ...I've never had the opportunity to do this." This presents a risk for cross contamination without performing thorough disinfection in the pre-op holding bays between patients.
? In the pre-op area, in the supply alcove IV solutions warmer, there was a sign posted on the front of the warmer which stated, "SOLUTION WARMING GUIDELINES IV SOLUTIONS WARMED TO 104 F (40 C) ARE GOOD FOR 30 DAYS PLEASE DATE ALL BAGS AND ROTATE SOLUTIONS APPROPRIATELY" Observation of the interior of the IV solution warmer revealed 16 one liter bags of IV solution in the warmer with labels which read, "in warmer Dec 07 2014, remove on Jan 2014". The "in warmer" date of 12/7/14 was observed during the tour on 12/2/14. There was no means of accurately determining when the IV solution had been placed in the warmer and the accurate 30 day removal or use by date of the solutions.
The above findings were confirmed in an interview with Staff #E2.