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Based on tour of the facility, review of facility documentation, and interviews, the facility failed to ensure the LDRP unit was maintained in a safe manner to eliminate risk of newborn abduction. The finding includes:


On 10/06/14 at 9:45 hours, the surveyor along with a Supervising Nurse Surveyor and the Director of Facilities observed that the LDRP rooms were located on the first floor (ground level) and the windows were secured with Philips screws through window stops and into the window frame. The LDRP windows had been identified as a security risk for infant abduction during the survey ending 10/31/13 as the windows could be fully opened. Review of the plan of correction to address that concern identified that the plan for high security windows would be initiated on 11/24/13. Interview with the Director of Facilities on 10/6/14 stated the windows were reviewed with security staff and a glass vendor with a plan to replace the glass in the windows with "security glass", however, to date was not completed. Subsequent to these observations and discussion with facility administration, an interim measure of installing security screws (tamper resistant) were installed into the window stops and frames on 10/06/14.

Based on a review of clinical records and policy review, the facility failed to ensure that one of three patients' reviewed for restraint use (#59) had an order for restraints and/or documentation reflected behaviors that warranted the use of restraints and/or alternatives attempted prior to the implementation of restraints. The finding includes the following:

a. Patient #59 was admitted to the facilty on 9/14/14 with schizoaffective disorder. Review of Patient #59's monitoring flow sheet dated 9/17/14 identified that the patient was placed in four-point restraints at 3:15 PM. The order failed to direct the type of restraint to be applied, the behavior that necessitated the use of restraints and/or less restrictive interventions considered prior to the use of restraints. Review of the facility policy indicated that orders should include the date, time, behaviors of the patient, type of restraint and duration of use.

Based on a review of clinical records, interview and policy review, the facility failed to reduce and/or discontinue restraints at the earliest possible time for one of three patients' reviewed for restraint use (#59). The finding includes the following:

a. Patient #59 was admitted to the facilty on 9/14/14 with schizoaffective disorder. The clinical record indicated that the patient was placed in four-point restraints on 9/15/14 at 7:30 PM for biting, scratching and fighting. Review of the monitoring flow sheet during the period of 8:45 PM through 9:30 PM reflected the patient was "quiet", however, remained in four-point restraints. The facility failed to ensure that restraints were reduced and/or discontinued at the earliest possible time based on the behaviors exhibited. Interview with the ED Director on 10/9/14 at 11:00 AM stated facility policy directs the discontinuation of restraints when able and not to decrease based on behaviors. Review of the facility policy indicated that each restraint should be removed at the earliest possible time. The RN should assess the patient for behaviors to discontinue restraints.

Based on a review of clinical records and policy review, the facility failed to ensure that for one of three patients' (#59) reviewed for restraint use was monitored in accordance with facility policy. The finding includes the following:

a. Patient #59 was admitted to the facilty on 9/14/14 with schizoaffective disorder. Patient's #59 was placed in the four-point restraints on 9/16/14 at 10:00 PM for attempting to hit staff. Review of the monitoring flow sheet indicated that the facility failed to ensure that the patient's range of motion was monitored from 10:00 PM through 9/17/14 at 1:45 AM in accordance with facility policy. The policy directed that patient needs, (repositioning, fluid, nutrition, toileting and range of motion) should be addressed every two hours.

Based on a review of clinical records, review of Medical Staff Bylaws & Rules and Regulations, and interview, then hospital failed to ensure the history and physical (H&P) was completed prior to the procedure for one of three endoscopy patients' in accordance with hospital Bylaws. The finding includes:

Review of Patient #32's record identified that on 10/6/14, the patient underwent an upper endoscopy with the use of anesthesia medication. Review of the record failed to identify the completion of an H&P. During interview the VP of Patient Care Services on 10/7/14 at approximately 10 AM stated that the form had been redone within the last year to include the H&P, however, the updated form was not used in this case. Review of the Medical Staff Bylaw Rules and Regulations directed that outpatient procedures require a focused H&P based on a chief complaint with relevant history and the procedure being performed within thirty days prior to the procedure.

1. Based on a review of clinical records, interview, and policy review, for one of three records reviewed for blood pressure monitoring (Patient 337), the hospital failed to ensure that physician's orders were followed. The finding includes:

a. Patient #37 was admitted on 10/2/14 with depression and polysubstance abuse. Review of the physician admission orders dated 10/2/14 directed orthostatic blood pressures twice a day. Review of the clinical record failed to identify that orthostatic blood pressures were obtained on 10/3/14, and obtained once on 10/4/14.

2. Based on a review of clinical records, interview, and policy review, for five (5) of five patient's reviewed (Patient #34, 35, 36, #37, and #59), the hospital failed to ensure safety assessments were accurately completed. The findings include the following:

a. Patient #34 was admitted to the facility on 10/3/14 with depression and suicidal ideation with a plan. Review of the daily nursing flowsheets with the Nursing Director identified a safety section that addressed the patients' risk factors on a scale of 1 (none) to 5 (severe) for suicidality, homicidality, violence, impulsive behaviors, elopement and falls. The record reflected that staff failed to accurately assess the patient utilizing the numeric scale but instead documented, "safe" and/or "remained safe".

b. Patient #35 was admitted to the facility on 10/1/14 with alcohol abuse. Record review with the Nursing Director failed to identify that staff accurately assessed the patient for suicidality, homicidality, violence, impulsive behaviors, elopement and falls utilizing the numeric scale but instead documented, "safe" and/or "remained safe".

c. Patient #36 was admitted on 9/30/14 with suicidal ideation with a plan. Record review with the Nursing Director failed to identify that staff accurately assessed the patient for suicidality, homicidality, violence, impulsive behaviors, elopement and falls utilizing the numeric scale but instead documented, "safe" and/or "remained safe".

d. Patient #37 was admitted on 10/2/14 with depression and polysubstance abuse. Record review with the Nursing Director failed to identify that staff accurately assessed the patient for suicidality, homicidality, violence, impulsive behaviors, elopement and falls utilizing the numeric scale but instead documented, "safe" and/or "remained safe".

e. Patient #59 was admitted on 9/14/14 after attempting to hurt self with a razor by cutting wrists. Record review with the Nursing Director failed to identify that staff accurately assessed the patient for suicidality, homicidality, violence, impulsive behaviors, elopement and falls utilizing the numeric scale but instead documented, "safe" and/or "remained safe".

Interview with the Nurse Director of the unit on 10/7/14 at 1:30 PM stated staff should be documenting the assessment utilizing the numeric scale and realized that form needed to be revised. The Director stated there is no policy related to the use of the form, however the form directs staff to document by using a numeric scale related to risk level.


3. Based on a review of clinical records, interview, and policy review, for one of two patient's reviewed for Pitocin therapy (Patient #47), the hospital failed to ensure that uterine resting tone was assessed in accordance with facilty policy. The finding includes the following:

a. Patient #47 was admitted on 10/5/14 at 6:52 PM for induction of labor. A physician's order dated 10/5/14 at 8 PM directed initiation of the Pitocin protocol. The clinical record identified that Pitocin was started per protocol at 8:19 PM. Review of the nursing flow sheets during the period of 7:44 PM on 10/5/14 through 7:51 AM on 10/6/14 failed to identify that nursing documented assessments of the patient's uterine resting tone while the patient received Pitocin. Review of the facility policy and interview with the Nurse Manager on 10/6/14 at 2PM identified that the resting tone should be assessed minimally every hour unless otherwise ordered by the physician.

Based on observation, interviews, and policy review, the hospital failed to ensure the technician followed procedure in preparation for sterile drug compounding activities. The finding includes the following:

On 10/7/14 at 1:32 PM, Pharmacy Technician #6 was observed to enter the compounding room and proceeded to don shoe covers, head cover, and face mask. The technician performed hand hygiene by washing hands for twenty (20) seconds, dried hands then donned a gown that allowed skin exposure (neck). Review of the compounding Personnel Hand Hygiene and Garbing Competency and interview with the Director of Pharmacy on 10/7/14 at 1:45 PM stated the Technician should have washed hands for thirty (30) seconds and prevent skin from being exposed.

Based on observation and interview, the controlled drug storage area at the Johnson Surgical Center failed to ensure security of drugs. The finding includes:

During tour of the Johnson Surgical Center on 10/10/14, observation of the locked safe for the storage of controlled medication identified a key locking mechanism. The keys utilized to lock the safe were stored in a desk drawer which was locked at the end of the clinical day, however, the key was kept on a hook in a cabinet adjacent to the desk. When interviewed on 10/10/14 at approximately 9:30 AM, about the security of the process, since other services were offered in that same building, the VP of Patient Care Services and the Charge Nurse identified that a locking format (i.e. the acudose medication machine) was a more secure option for storing the key when the surgical center was not occupied and initiated that procedure.

1. Based on observation and interview, the hospital failed to ensure that an anesthesia medication pump had a current biomedical status check and/or was pulled from use when the pump could no longer be cleaned effectively. The finding includes:

During tour of the endoscopy procedure room (#3) at the Surgical Center on 10/10/14, a medication pump utilized for the administration of anesthesia medication was observed to be lacking a biomedical sticker and the front face of the machine was dented and curled so that it could not be cleaned effectively between patients. During tour the pump was pulled from service to be reconditioned by the Manager of Peri-operative Services who stated that the pump should have been pulled earlier from service.

2. Based on observation, the emergency carts in the surgical center failed to be free and clear of obstacles. The finding includes:

Observation of the pediatric and adult emergency carts located at the Johnson Surgical Center, identified that their location was blocked by a large patient recliner which were adjacent to a patient recovery area. Although the recliner was empty, the recliner needed to be moved first before the emergency cart could be accessed. Subsequent to inquiry, the recliner was relocated to an adjacent area by the VP of Patient Care Services.

1. Based on observation and interview, the hospital endoscopy suite (two rooms and a scope cleaning room between) failed to have a soiled to clean pathway for cleaning and movement of the scopes. The finding includes:

During tour of the hospital endoscopy suite on 10/8/14, it was identified that with two procedure rooms on either side feeding into the scope cleaning room (soiled) and the soiled sink located between two scope cleaning machines (clean), there failed to be a pathway of soiled to clean. Additionally, the cleaned scopes were hung in a closet in the soiled room. During interview with the Manager of the Endoscopy Suite on 10/8/14, the Manager stated that a new cupboard for the cleaned scopes was on order, however, no other plan was offered to correct the cleaning process.

2. Based on observation during tour, infection control practices failed to be implemented. The findings include:

a. During tour of the endoscopy room (#3) on 10/6/14, the scope cleaning room door (connecting to room #3) was observed to be propped open with a cart and miscellaneous supplies. The door located between the scope cleaning room and Room #3 had a round doorknob, failing to give access to the cleaning room that could be accessed by elbows when clinician's hands were full.

b. During tour of the surgical center, the soiled utility room failed to have a doorknob (lever) that allowed accessibly when clinician's hands were full. Additionally, this door did not self-close but remained open several inches.

c. Throughout the facility there was delamination of cupboard doors that inhibited cleaning of the environment.

Based on a review of clinical records, interview and policy, for four of six clinical records reviewed (#31, #33, #44 and 46), the hospital failed to ensure that post-anesthesia evaluations were conducted, and/or legible and/or complete. The findings include:

a. Review of Patient #31's record identfied that the patient underwent a colonoscopy on 10/6/14 and was medicated with 500 mg Propofol. The record failed to reflect that a post anesthesia evaluation was completed. During interview on 10/8/14 at 11:15 AM, the Chief of Anesthesia stated that although s/he was currently working on developing a policy, the expectation is for the outpatient to be evaluated prior to discharge.

b. Review of Patient #33's record identified that the patient underwent a right carpal tunnel revision on 10/6/14. Although the post anesthesia evaluation was completed, the document failed to be legible and thus it appeared that the patient was evaluated for anesthesia recovery prior to leaving the operating room.

c. Review of Patient #45's record identified that the patient underwent a right thoracotomy on 10/2/14. Review of the post anesthesia evaluation, while dated and signed, failed to be timed, ensuring the adequate recovery of the patient to participate in the recovery evaluation following general anesthesia.


d. Patient #46 was admitted to the hospital on 10/3/14 for an open reduction internal fixation (ORIF) of a right hip fracture. Review of the clinical record and interview with the Nurse Manager on 10/7/14 failed to reflect the time in which the post anesthesia evaluation was completed.


19952

Based on observation, review of hospital documentation, interviews, and hospital policy for patients receiving emergency care and services, documentation and interviews failed to reflect that adequate medical coverage was present in the Emergency Department (ED) as per policy. The finding includes:


Tour and observation in the ED on 10/6/14 at approximately 11:20 AM identified that approximately 20 patients were located in the department. An observation was made of the ED Medical Director being summoned to the Labor and Delivery Department for a possible neonatal resuscitation (Patient #48). Review of the ED Provider Schedule dated 10/6/14 identified that one Physician Assistant was present in the ED for medical coverage. Interview with the ED Medical Director on 10/8/14 at 12:20 PM identified that the ED physicians do have responsibilities outside the ED and that a hospitalist could be called for ED coverage if needed. Review of the Department of Emergency Standards for Staffing Policy indicated that physician coverage was provided 24-hours a day and additional coverage was provided 12 hours per day by midlevel providers (PA/APRN).

Based on a review of clinical records, interview, and policy review, for two of three records reviewed (Patient #42 and 43) , the hospital failed to ensure the referring physician authenticated the outpatient evaluation for therapy services in a timely manner in accordance with hospital policy. The findings include the following:


a. Patient #42 had a diagnosis that included CVA with hemiparesis. A physician's order dated 9/12/14 directed an Occupational Therapy (OT) evaluation. Although the OT evaluation was completed on 9/17/14, the record failed to reflect that the physician signed the evacuation. Interview with Physical Therapist #5 on 10/5/14 at 2:30 PM stated the process was for the secretary to fax the evaluation to the physician for signature and monitor for timely response. Subsequent to inquiry, the physician signed the evaluation on 10/6/14.


b. Patient #43 had a physician's order dated 7/28/14 for a Speech Therapy (ST) evaluation. Although the ST evaluation was completed on 8/8/14, the record failed to reflect that the physician signed the evaluation. Interview with Speech therapist on 10/6/14 at 2:45 PM reiterated that the secretary monitors the response and sometimes encounter difficulty with certain physicians. Subsequent to inquiry, the physician signed the evaluation on 10/7/14.


Review of the Referrals and Responsibilities policy identified that outpatient referrals are faxed to the referring physician within 24 hours of the initial visit for signature by secretarial staff. If the signature is not received within 14 days of faxing, secretarial staff will follow-up with a phone call to the physician's office at least every other day. If the signature is not received by the 25th day following the initial evaluation, the patient and physician will be informed that therapy with be terminated on the 30th day until the signature has been received.