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Based on observation, interview and review of medical records, the Hospital failed to ensure that two Outpatients [Outpatient #11 and #12] in a total sample of 14 Outpatients had the right to make informed decisions regarding his or her care. Physician #3 failed to inform both Outpatient #11 and #12 that a corticosteroid was used off-label [not in accordance with the manufacturer's directions for use] during their procedures for two Outpatients from a total sample of 14 Outpatient records reviewed. Findings include:

A) Medical record review on 01/13/2014, indicated that Outpatient #11 presented to the Pain Clinic on 01/13/2014 for a left lumbar Facet/Medial Branch Block [the space between the covering of the spinal cord and vertebrae through which the nerve roots exit the spinal canal and the body was injected with an injection of a corticosteroid (Kenalog- a medication to reduce inflammation)]. Review of the Hospital Anesthesia Associates Pain Management Informed Consent failed to include the name of the corticosteroid administered or information indicating the Patient was informed that the medication was administered off-label [not in accordance with the manufacturer's directions for use].

B) Observation revealed that Outpatient #12 presented to the Pain Clinic on 01/10/2014, for a Left L3-4 transforaminal epidural steroid injection with digital subtraction fluoroscopy (injection of a dye and Kenalog into the spinal space to prevent sensory nerve impulses from reaching the central nervous system and causing pain). Review of the Consultation dated 01/10/2014 indicated that Outpatient #12 received triamcinolone (Kenalog, a corticosteroid with an anti-inflammatory action. According to the package insert, the drug was "not for intravenous, intradermal, intraocular, epidural or intrathecal use.") Review of the Hospital Consent and Release Form dated 01/10/2014 indicated that the name of the drugs injected and the procedure to be performed were not included on the document. The informed consent also did not indicate that the drug triamcinolone was used off-label.

Interview with Physician # 3 on 01/13/2014 at 1:15 P.M. Physician #3 said that he/she had used the drug for years and was not aware that the manufacturer reported that epidural use was considered off-label. Physician #3 said that he/she did not discuss this with patients during the informed consent process.

Please refer to A-510.

Based on observation, staff and patient interviews, the Hospital failed for 1 inpatient [#10] in a sample of 33 inpatients, to administer the medication Renvela [used to control phosphorus levels in people with chronic kidney disease who are on dialysis] on a timely basis as ordered by the physician and under the supervision of a nurse. Findings include:

1. Patient #10 was admitted to the hospital in 01/2014, with several diagnoses that included failed kidney transplant and kidney failure. The patient, who had a kidney transplant 21 years earlier, and now required hemodialysis treatments.

Review of the physician's, orders dated 01/04/2014, indicated that the patient was to receive 3,200 mg of Renvela with each meal.

On 01/6/2014 at 4:30 P.M., the Surveyor entered the patient's room and observed a medication cup with pills sitting on the patient's over-bed table. The patient was asked why the pills were sitting on the over-bed table. The patient said that the pills were his/her Renvela and he/she needed to take them with the supper meal.

The patient further stated that he/she had experienced a great deal of difficulty obtaining the Renvela and at times needed to eat a cold meal because the pills were late in arriving. The patient said that he/she had started asking for the medication at noon on that day, because he/she wanted to eat a hot supper.

Review of the Medication Administration Record (MAR) for 01/04/2014 to 01/07/2014, indicated the medication was not always delivered in a timely manner, so that the patient could take the Renvela with his/her meal. The Renvela was delivered as follows:
*On 01/04/2014, the supper tray was delivered at 4:35 P.M., but the medication was not delivered until 7:19 P.M., almost three hours late.
*On 01/05/2014, the breakfast tray was delivered at 7:35 A.M., but the medication was not delivered until 9:30 A.M., two hours late.
*On 01/05/2014, the lunch tray was delivered at 11:35 A.M., but the medication was delivered at 11:08 A.M. The patient had to hold the pills for approximately 30 minutes until the tray arrived.
*On 01/05/2014, the supper tray was delivered at 4:35 P.M., but the medication was not delivered until 5:30 P.M., approximately one hour late.
*On 01/06/2014, the breakfast tray was delivered at 7:35 A.M., but the medication was not delivered until 8:33 A.M., approximately one hour late.
*On 01/06/2014, the lunch tray was delivered at 11:35 A.M., but the medication was not delivered until 12:30 P.M., approximately one hour late.
*On 01/06/2014, the supper tray was delivered at 4:35 P.M., but the medication was delivered at 4:20 P.M. The patient had to hold the pills for 15 minutes until the tray arrived.
*On 01/07/2014, the breakfast tray was delivered at 7:35 A.M., but the medication was not delivered until 7:48 A.M., 13 minutes late.

During interview on 01/07/2014 at 8:20 A.M., Registered Nurse #17 said that she had been the patient's nurse on the previous day and had not administered the medication in a timely manner.

During interview on 01/07/2014 at 8:45 A.M., Registered Nurse #8 said that Hospital policy required an order from the physician in order for patients to self administer medications. Additionally, the nurse said that Patient #10 did not have an order to self administer medication and the medication should not have been left at the bedside.

Based on staff interview and observation, the Hospital failed to ensure that drugs were consistently stored according to the manufacturer's directions for refrigerated medications. Findings included:

The Surveyor toured the Anesthesia Workroom and interviewed Anesthesia Technician (AT) #1 at 9:35 A.M. on 01/07/2014. The Surveyor observed a medication refrigerator located in the Anesthesia Workroom. AT #1 said the staff would manually check and record the temperature of the medication refrigerator daily. AT #1 said if the medication refrigerator registered out of range, the refrigerator alarm was designed to sound an alarm. The refrigerator alarm was found to be in the off position thus disarming the alarm system. AT #1 said she/he was unaware that the refrigerator alarm was switched to the off position.

Based on staff interviews and review of medical records, the Hospital failed to ensure that patient safety, drugs and biologicals were distributed in accordance with acceptable standards of practice, consistent with Federal and State law. Findings include:

Interviews with Physician #3 on 01/13/2014 at 1:15 P.M. and the Pharmacy Operations Manager on 01/13/2014 at 3:05 P.M., indicated that both were not aware that Triamcinolone ( Kenalog - a corticosteroid with anti-inflammatory action), according to the manufacturer's directions, was "not for intravenous, intradermal, intraocular, epidural or intrathecal use."

Interview with Physician #3 indicated that he/she had used this medication for years and was not aware of the safety precautions for the medication. As a result, Physician #3 was using the medication for off-label use [not in accordance with the manufacturer's directions for use] and not informing patients during the informed consent process.

Based on interviews and medical record review, the Hospital failed to ensure that information related to drug interactions and information of drug therapy, side effects, toxicology, dosage, indications for use and routes of administration were available to the professional staff. Findings include:

Interviews with Physician #3 on 01/13/2014 at 1:15 P.M. and the Pharmacy Operations Manager on 01/13/2014 at 3:05 P.M., indicated that both were not aware that Triamcinolone ( Kenalog - a corticosteroid with anti-inflammatory action), according to the manufacturer's directions, was "not for intravenous, intradermal, intraocular, epidural or intrathecal use."

Interview with Physician #3 indicated that he/she had used this medication for years and was not aware of the safety precautions for the medication. As a result, Physician #3 was using the medication for off-label use and was not informing patients during the informed consent process.

Interview with the Pharmacy Operations Manager indicated that she/he was not aware of the changes the Manufacturer issued in June of 2011.

Based on observations and staff interviews, the Hospital failed to consistently maintain equipment or the patients' environment at an acceptable level of safety and quality. Findings include:

1. The Surveyor interviewed the Nurse Manager of the Intensive Care Unit (ICU NM) at 9:00 A.M. on 01/06/2014. The ICU NM said each of the ICU patient rooms were equipped with a Cardiopulmonary resuscitation (CPR) board that would be placed under a patient who required chest compressions. The CPR boards were constructed of wood and did not offer a surface that could be readily disinfected between patients.

2. The Surveyor toured the Intensive Care Unit (ICU) at 9:00 A.M. on 01/06/2014. The ICU had small walls between each movable set of patient room glass doors. The walls were consistently split, with the wall outside of ICU #6 lifted, revealing the plaster and mesh building materials visible down the length of the wall.

3. The Surveyor toured the Endoscopy Suite at 2:45 P.M. on 01/06/2014. Of the eight (8) defibrillator pads (used to facilitate the electrical current from the defibrillator machine to the patient, to eliminate an irregular heart rhythm) on the code cart, three (3) pads had expired in October, November and December, 2013.

4. The Surveyor toured the Day Surgery area and interviewed the Charge Nurse (CN) at 8:25 A.M. on 01/07/2014. The CN said the Day Surgery area could become warm and they used fans and a mobile air conditioner unit (Move 'n Cool) to maintain patient and staff comfort. The three fans and the mobile air conditioner unit were visibly soiled with debris on the fan blades and the mobile air conditioner unit output area.

The Surveyor toured the Central Medical (Reprocessing) Services (CMS) at 12:00 Noon on 1/07/2014. In the section of the CMS where the cleaned instruments were wrapped, there was a mobile air conditioner unit (Move 'n Cool) to maintain staff comfort. The filter on the side of the mobile air conditioner unit was visibly soiled.

The Surveyor interviewed the Facilities Manager at 10:10 A.M. on 01/09/2014. Despite the observations that the water reservoirs were not filled to capacity, the Facilities Manager said the mobile air conditioner units were not currently on a preventive maintenance program.


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5. Observations on Unit A3 at 10:30 A.M. on 01/06/2014, revealed the following:

a. The top shelf of the Code Cart was dirty with accumulated layers of dust;
b. A storage container on the Code Cart was laden with dust and debris;
c. The dial on the defibrillator was dusty;
d. The counters in Medication Rooms #1 and #2 were dirty, dusty, and contained tape residue (tape residue renders a surface uncleanable). Additionally, the counters were cluttered with clean and sterile supplies stored next to the handwashing sink;
e. The pill crushers (Silent Knight) in both Medication Rooms were dirty with dust and debris; and
f. A mortar and pestle (used to crush medications) on the counter in Medication Room #1, contained a powdery substance that was beige, pink and white in color, indicating that different medications were crushed in the bowl. The Unit A3 Nurse Manager said the mortar bowl should have been cleaned after each medication was crushed.

6. Observations on Unit B2 at 8:45 A.M. on 01/07/2014, revealed that the Medication Room counter was stained and dirty with tape residue. Additionally, the Silent Knight pill crusher was dirty with a black substance, in the well of the crusher.

Based on observations, staff interviews, and review of the Hospital's policies/procedures, the Association of periOperative Registered Nurses (AORN) Standards and Recommended Practices, the Hospital's Exposure Control Plan and manufacturer's directions for use (MDFU), the Hospital failed to consistently ensure an acceptable level of infection prevention practice related to adherence to infection control standards for 6 Inpatients (#8, #10, #17, #18, #19, #33) and 1 Outpatient (#2) from a total sample of 47 Patients (33 Inpatients and 14 Outpatients) reviewed. Findings included:

1. The Hospital failed to ensure that a high level disinfection (HLD) process (a cleaning process that should destroy all microorganisms, except for bacterial spores) followed the MDFU to reprocess semi-critical items (items that contact mucous membranes or non-intact skin) in the Endoscopy and Central Medical (Reprocessing) Service (CMS) Departments.

a. Interview with the Endoscopy Technician (Endo Tech) in the reprocessing area at 2:50 P.M. on 01/06/2014, the Endo Tech said HLD was done using an automated endoscope reprocessor (AER). According to the MDFU, the concentration of the HLD solution must be tested using a test strip before each cycle. The Endo Tech said she was testing the chemical reservoir prior to each use, but was only documenting the results in the log once per day.

b. During interview in the decontamination room, at 12:00 P.M. on 01/07/2014, the Manager of the CMS said the Hospital used manual HLD to reprocess the laryngoscope blades. After the disinfection process, the probes were not totally immersed in a large volume of fresh water for at least one minute, and repeated immersions in fresh water for a total of three separate rinses to ensure removal of chemical residue, in accordance with manufacturer's instructions. According to the CMS technician, the probes were only rinsed under running water.

2. The Hospital failed to consistently adhere to the Hospital's Exposure Control Plan (ECP), for transport of soiled equipment.

Review of the Hospital's Bloodborne Pathogen Exposure Control Plan indicated biohazardous labels must be affixed on containers/bags that transport blood or other potentially infective material. The soiled endoscopes or instruments were not transported in a manner that would comply with Hospital requirements to reduce the risk of exposure to employees or patients to equipment that has not been disinfected.

a. During interview at 2:40 P.M. on 01/06/2014, the Endoscopy Manager said Patient #17 was undergoing an Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure in the Imaging Department. The Endoscopy Manager also said the ERCP endoscope was returned to the Endoscopy decontamination room using a clear plastic container covered by a chux and lacked any biohazardous label as required by the Hospital's ECP.

b. Interview with the Manager of the CMS in the decontamination room at 12:00 P.M. on 01/07/2014, the Manager said the Hospital used large blue bins to collect the soiled instruments from the inpatient units. The Manager said the bins were returned to the decontamination area of the CMS for reprocessing. The bins lacked any biohazardous labels as required by the Hospital's ECP.


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3. For Inpatient #8, observations with the Unit A3 Nurse Manager, at 2:30 P.M. on 01/06/2014, indicated that Registered Nurse (RN) #5 failed to adhere to Hospital policy and Centers for Disease Control (CDC) Infection Control (IC) Standards for Hand Hygiene as follows:

In the Unit A3 Medication Room, RN #5 touched the automated medication dispenser (Pyxis) keypad to obtain Patient #8's medications. After removing the medication Heparin (prevents blood clots) from the Pyxis, RN #5 then reached into the box of clean alcohol prep pads and removed two prep pads. RN #5 then reached into the box of sterile syringes with attached needles and removed a sterile syringe. RN #5 failed to perform hand hygiene after documenting on the Pyxis keyboard and before removing the medication from the Pyxis and obtaining the clean and sterile supplies.

RN #5, then touched the keyboard to enter medication data into the portable medical record computer and took the portable computer, medications and supplies to the patient's room.

RN #5 then failed to perform hand hygiene after documenting on the computer keyboard and before donning gloves in order to prepare and administer the Heparin, by subcutaneous injection to the patient, as required by Hospital policy and CDC IC Standards for Hand Hygiene.

During the observation, the Unit A3 Nurse Manager said RN #5 should have performed hand hygiene prior to obtaining the clean and sterile supplies, preparing the Heparin for administration, and prior to donning clean gloves.

RN #5 failed to adhere to Hospital policy and CDC Standards.

4. During interview on 01/07/2014 at 10:00 A.M., the Contracted Hemodialysis Clinical Services Specialist (CSS) for Acute Hemodialysis Services said that dialysis staff were required to wear full personal protective equipment (PPE-gloves, impervious cover gown and faceshield), while administering IV (intravenous) medications through the dialysis tubing, during the dialysis procedure.

Inpatient #10 had a physician's order for Epogen (for anemia), 2 micrograms (mcg), IV.

For Inpatient #10, observations in the patient's room on 01/07/2014 at 9:05 A.M., indicated that the only PPE worn by RN #11 to administer the Epogen IV to the patient, was gloves. During interview at 9:10 A.M. on 01/07/2014, RN #11 acknowledged that full PPE was required for medication administration through the dialysis tubing. RN #11 failed to adhere to Dialysis policy.

Additionally, observations at 9:05 A.M. on 01/07/2014, revealed that RN #11 stored clean/sterile supplies (e.g., a container with sterile sponges, clean gloves, the patient's chart) and the patient's dialysis flow sheet on top of the dialysis machine. Because these items were made of paper and/or paper products, these items were not able to be disinfected at the end of the patient's dialysis procedure.

During interview with the Director of Inpatient Services and the Contracted Hemodialysis CSS on 01/07/2014 at 10:00 A.M., the Contracted Hemodialysis CSS said, because undisinfected dialysis machines were considered contaminated, clean/sterile items and/or supplies were not to be stored on top of dialysis machines.

During the above interview, the Director of Inpatient Services said that the patient rooms were small and lacked storage space to properly store clean/sterile supplies for dialysis.

5. For Inpatient #18, a patient receiving Hemodialysis, observations in the patient's room at 8:40 A.M. on 01/07/2014, revealed RN #10 stored uncleanable items (chart, box of clean gloves) on top of the dialysis machine. RN #10 failed to adhere to Dialysis policy.

6. For Inpatient #19, observations at 8:50 A.M. on 01/07/2014, indicated that RN #12 failed to adhere to Hospital policy and CDC Infection Control Standards for Hand Hygiene as follows:

In the Unit B2 Medication Room, RN #12 touched the Pyxis keypad to obtain Patient #19's medications. After removing the injectable medications Insulin (for diabetes) and Heparin, and multiple P.O.(oral) medications from the Pyxis, RN #12 then reached into the box of clean alcohol prep pads and removed three prep pads. RN #12 then reached into the box of sterile syringes with attached needles and removed two sterile syringes. RN #12 failed to perform hand hygiene before obtaining the clean and sterile supplies.

RN #12 then touched the keyboard to enter medication data into the portable medical record computer and took the portable computer, medications and supplies to the patient's room.

RN #12 then documented on the computer keyboard and adjusted Patient #19's bed and over-the-bed table. RN #12 failed to perform hand hygiene prior to and after contact with the patient's bed and over-the-bed table, although required by CDC IC Standards.

Next, RN #12 then failed to perform hand hygiene prior to donning clean gloves and preparing and administering Patient #19's Insulin and Heparin medications by subcutaneous injection.

RN #12 removed the gloves after administering the injectable medications and failed to perform hand hygiene, as required. RN #12 then donned a new pair of clean gloves, again failing to perform hand hygiene prior to donning the gloves.

Hospital policy and CDC IC Standards for Hand Hygiene required hand hygiene to be performed before and after contact with a patient and/or a patient's environment, before preparing and administering medications, prior to donning gloves, and after removing gloves. RN #12 failed to adhere to Hospital policy and CDC Standards.

7. For Outpatient #2, observations in Interventional Radiology at 2:50 P.M. on 01/07/2014, indicated that staff failed to adhere to AORN Standards and Recommended Practices as follows:

AORN Recommended Practice IV, Maintaining a Sterile Field read, "All items introduced to a sterile field should be opened, dispensed, and transferred by methods that maintain item sterility and integrity."

"All items should be delivered to the surgical field in a manner that prevents nonsterile objects or people from extending over the sterile field. Skin is a source of bacteria and scurf (the scales or small shreds of the top layer of skin that are continually exfoliated from the skin) shedding."

Observations with Infection Control Nurse(ICN) #2, in the Interventional Radiology Procedure Room, at 2:50 P.M. on 01/07/2014, revealed that Radiology Technologist (Rad Tech) #2 failed to wear proper surgical attire to set up the surgical field. Rad Tech #2 wore a surgical hat, mask and sterile gloves. However, Rad Tech #2's arms were bare from the top of the gloves to the sleeves of the scrub suit top. While setting up the sterile table, Rad Tech #2 reached over all areas of the surgical table with bare arms, to arrange the sterile instruments and supplies.

During the observation, ICN #2 said that Rad Tech #2 should have donned a sterile gown, in addition to the hat, sterile gloves and mask. After intervention by this Surveyor, ICN #2 instructed Rad Tech #2, to dismantle the surgical table and set up a new table, while wearing the proper surgical attire.



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8. For Inpatient #33, a patient admitted with a pressure area, observations at 9:45 A.M. on 01/13/2014, revealed RN #16 failed to adhere to CDC Infection Control Standards while administering a topical medication as follows:

Inpatient #33 had a physician's order for Miconazole (an antifungal agent) 2%, apply to buttocks, topical three times a day.

During treatment observation on 01/13/2014 at 9:45 A.M., RN #16 donned clean gloves to administer the topical medication. Prior to administering the topical medication, RN #16 used his/her gloved right hand to turn off the bed alarm at the foot of the bed. RN #16 proceeded to apply topical Miconazole to Inpatient #33's skin with the gloved hand that had been contaminated after contact with the control pad on the bed.

Based on observation, staff interviews and review of the Hospital's policy and procedure, the Hospital failed to ensure that policies governing surgical care were designed to assure the achievement and maintenance of high standards of medical practice and patient care and that services provided at the Oncology Outpatient center were consistent with established policy for one Outpatient, (Outpatient #13), out of 14 total outpatients. Findings include:

Observation 01/10/2014 at 1:00 P.M., indicated that Outpatient #13 presented to the Oncology Outpatient Center for a bone marrow aspiration (removal of a small amount of blood and tissue from the marrow cavities of spongy bone). Physician #2 was observed to prepare the surgical kit to perform the bone marrow aspiration and throw various items in the trash barrel. Observation revealed that the side of Physician #2's bare hand touched the inside of the lining of the trash can. Once the set up was complete, Physician #2 was observed to put on sterile gloves without first performing hand hygiene. This Surveyor commented on the lack of Physician #2 washing his/her hands. As a result of the intervention, Physician #2 performed hand hygiene before a new pair of sterile gloves were donned.

Review of the Hospital Policy for Bone Marrow Aspiration Biopsy, section on process, Part 3, A and B which indicated wash hands and put on sterile gloves (physician size).

Physician #2 was then observed to prepare to insert the trocar [sharp - pointed instrument fitted with a cylindrical tube that can be used to collect solid or liquid materials from a body cavity] into Patient #13 without confirming the Patient's name and date of birth and puncture side prior to performing the invasive procedure. Physician #2 and the Medical Assistant then performed a check of Patient #13 's identification and asked Patient #13 to state her name and date of birth out loud, after surveyor intervention.

Review of the Hospital Policy for Bone Marrow Aspiration Biopsy, section on process, Part 4 indicated that staff must confirm patient's name and date of birth per policy, Patient Identification, #1560-CA.

Based on medical record review, patient and staff interviews, and review of Hospital Policy, the Hospital failed to obtain a properly executed consent for 6 of 10 inpatients undergoing invasive procedures (Patients #1, #10, #18, #20, # 23, #30) in a total sample of 33 inpatients. Findings included:

The Hospital's "Informed Consent Policy," Policy #1532-CA, dated 10/2011, read: "The Informed Consent Process. A signed confirmation of consent from the patient (or the patient's legal representative) must be obtained by the Attending Physician prior to the start of any major therapeutic and diagnostic procedures, including invasive procedures."

"According to the Hospital's current policy for Invasive Procedures, penetration of the skin or an orifice is considered an invasive procedure which requires a signed consent. This would include procedures including Hemodialysis."

Additionally, the Hospital's Informed Consent Policy also indicated that one of the essential elements that the physician was required to discuss with patients was "the person(s), if known, who would direct and provide care to the patient."

1. For Inpatient #20, the Hospital failed to obtain a properly executed consent for Hemodialysis.

Review of the medical record on 01/07/2014, indicated that Inpatient #20 was admitted to the Hospital in 10/2013, with a diagnosis of End Stage Renal Disease, hypertension and right ankle fracture. Further medical record review indicated the patient had received Hemodialysis on 10/28/2013, 10/30/2013 and 11/01/2013. On 11/01/2013, the patient was discharged to a rehabilitation facility.

Review of the patient's medical record on 01/08/2014, indicated that there was no written consent signed by the patient for Hemodialysis.

On 01/13/2014 at 1:45 P.M., Registered Nurse #15 said the Hospital did not obtain a written consent from Patient # 20 for Hemodialysis.


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2. For Inpatient #30, medical record review on 01/08/2014, indicated that Inpatient #30 had undergone a surgery requiring a team of three (3) surgeons.

The informed consent signed by Inpatient # 30, named two (2) but not the third surgeon who performed important surgical tasks for the procedure.


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3. Inpatient #10 was admitted to the hospital in 01/2014, with diagnoses including kidney disease. The patient had a kidney transplant 21 years earlier and now required hemodialysis treatments, due to failure of the transplanted kidney.

Review of the record indicated there was no informed consent for hemodialysis treatments.

During interview on 01/07/2014 at 8:45 A.M., Registered Nurse #8 said that there was no written informed consent in the medical record.


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4. For Inpatient #1, medical record review on 01/06/2014 indicated that Registered Nurse First Assistant (RNFA) #1 assisted the operating physician during the Patient's surgery. During the medical record review, the A3 Unit Nurse Manager said that RNFA #1 was listed on the Intraoperative Record as an assistant.

Further medical record review revealed that the surgical consent form titled 'Request for Surgical or Medical Procedures,' lacked documentation that RNFA #1 assisted with Patient #1's surgery.

During interview on 01/06/2014 at 12:05 P.M., Patient #1 said that he/she did not know who helped the Surgeon with his/her surgery. Patient #1 also said he/she didn't know if the Surgeon worked alone or had assistants during surgery.

5. For Patient #18, medical record review on 01/07/2014 indicated the patient had diagnoses that included of kidney failure, congestive heart failure (CHF), and pneumonia. Additionally, Patient #18 received hemodialysis three times a week, on Tuesdays, Thursdays, and Saturdays.

Continued review of the medical record indicated that Patient #18's record lacked a consent for hemodialysis. During interview on 01/07/2014 at 10:00 A.M., the Director of Inpatient Nursing said Patient #18 did not have a consent for hemodialysis.


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6. For Inpatient #23, the Hospital failed to obtain a properly executed consent for Hemodialysis.

Review of the medical record on 01/08/2014, indicated that Inpatient #23 was admitted to the Hospital in 01/2014, with diagnoses including End Stage Renal Disease, gastrointestinal bleeding and status post fall at home.

Further medical record review on 01/08/2014 indicated that the patient received Hemodialysis on 01/08/2014 as an inpatient.

Review of the patient's medical record on 01/08/2014, indicated that there was no written consent for the patient to receive Hemodialysis.

On 01/08/2014 at 11:50 A.M., RN #6 said that the Hospital did not obtain a written consent from Inpatient #23 for Hemodialysis.