HospitalInspections.org

Based on record reviews and interview, the hospital did not provide nursing care as needed on two occasions for one of 23 inpatient records reviewed for care and services.. (Patient 2.)


The findings are:


On 12/5/2017 at 11:00 a.m., review of Patient 2's chart revealed the patient was admitted 12/3/2017 for Sepsis. Review of the physician orders dated 12/3/2017 at 10:58 a.m. revealed the physician ordered fingerstick bedside glucose monitoring every 4 hours. Review of the patient's labs revealed glucose monitoring was completed on 12/3/2017 at 10:51 p.m. and again at 12/4/2017 at 4:06 a.m. which was greater than every four hours. Review of the patient's labs for glucose monitoring every 4 hours revealed the patient's blood glucose was completed on 12/4/2017 at 7:39 p.m. and again at 12/5/2017 at 2:52 a.m. which was greater than every four hours. On 12/5/2017 at 11:00 a.m., Registered Nurse 2 verified the findings, and Director 2 stated, "We don't have tech's (nurse technicians) on the night shift."

Based on record reviews, interviews, and a review of the hospital's policy and procedures, the hospital failed to ensure patients receiving a procedure requiring conscious sedation at the outpatient pain management center had a full history and physical documented in the patient's record within a 30 day period prior to his/her procedure(s) for 1 of 1 in patient observed in the hospital's pain management outpatient clinic. (Patient #13) and 1 of 1 patient hospitalized. (Patient 3) The "Pain Management Procedure Form" used by the hospital's pain management outpatient facility as a short stay history and physical for outpatients did not include information related to the patient's medical history/past medical history, allergies, or major complaints as per hospital policy with a potential to affect all patients undergoing procedures in the hospital's outpatient pain management facility.

The findings included:

During an interview on 12/6/17 at approximately 1:45 p.m., Registered Nurse (RN) #12 indicated that Patient #13 was scheduled for a (Left Sided) Radiofrequency Ablation that afternoon. Review of Patient 13's electronic chart on 12/6/17 at approximately 1:50 p.m. with RN #12 revealed Patient #13 presented for a follow-up visit for low back pain on 10/17/17. Review of the follow up note revealed a focused history and physical examination documented on the pain clinic's "Pain Management Procedure Form" for the patient did not include a list of the patient's medications or allergies. A full history and physical had not been documented for that visit.

Review of the patient's chart with RN #12 revealed a hand written Pain Management Procedure Form for a Right Radiofrequency Ablation dated 11/22/17 that was more that 30 days past the follow-up visit dated 10/17/17. Review of the hospital's "Pain Management Procedure Form" for that visit showed, "The patient has been examined and the recorded history and physical reviewed: Admission Home Medication list reviewed, No changes in patient's condition". An entry stated to "Complete below if H&P(History and Physical) >(greater than) 30 days." Review of that section of the form revealed a physical examination that included the patient's vital signs, weight, height, and Oxygen saturation, and a review of the patient's systems and neurological status. The form did not include the patient's medical history, allergies, major complaints, impression, or the plan for the patient. When asked to review a current history and physical within 30 days for Patient #13, RN #12 stated that the last history and physical was dated 10/17/17, and indicated this was completed on the follow-up note. RN #12 stated they were not required to have a history and physical within 30 days of procedures at the pain center as long as they had an updated history and physical completed, which was documented on the Pain Management Procedure Form. When the surveyor asked to get a copy of the updated history and physical form for that day's procedure (12/6/17), RN #12 stated that the updated history and physical for that day would not be available for 48 hours since it had to be transcribed by medical records.

A review of the hospital's policy on 12/6/17, entitled, "History & Physical Examinations", reads, "...Short stay history and physical forms may be completed for outpatients, focused, limited, or patients visits less than 23 hours....Limited shall be defined as not requiring general anesthesia...Short Stay H &P (includes) Focused Medical History, Focused Past Medical History, Medication & Allergies, Focused Major Complaints, Focused Physical Examination, Focused Impression & Plan. At a minimum, all same day surgery (SDC) patients, patients having special diagnostic imaging, or patients having a procedure completed in....Endoscopy...pain center or other procedure require a short-stay history and physical examination (that) must be present on the patient record immediately prior to the patient having the procedure performed..."

During an interview later that afternoon on 12/6/17, the Patient Safety Officer (PSO) reviewed the "Pain Management Procedure Form" dated 11/22/17 that was completed for the patient's procedure that day, the PSO verified the hospital's policy included the short stay history and physical form is to be completed for outpatients. The PSO reported that the hospital had revised the form to include updated physical examination information. During the interview, the PSO verified the short form completed for Patient #13 did not include information related to the patient's medical history or past medical history, and that he/she was unsure why the patient's current "Pain Management Procedure Form" completed for that day's procedure had not been available for review.

Prior to the survey team's exit on 12/6/17, a "Pain Management Procedure Form" dated 12/6/17 for Patient #13 was provided and revealed the procedure form did not include information as to the patient's medical history, allergies, or major complaint(s). The "Pain Management Procedure Form" used by the facility as a short stay history and physical for outpatients did not include information related to the patient's medical history/past medical history, allergies, or major complaints as per hospital policy


39463

On 12/5/2017 at 11:30 a.m., review of in Patient 3's chart revealed the patient was admitted on 11/15/2017 for Sepsis. Further review of the record revealed the patient's history and physical was not completed until 11/20/2017 at 8:15 a.m. On 12/5/2017 at 11:30 a.m., RN 2 verified the finding.

Based on observations, interview, and review of the hospital's policy and procedure, the hospital failed to ensure expired medications were removed from the patient care areas and medications and biologicals were marked with correct labeling when opened in the hospital's emergency department.

The findings are:

On 12/4/17 at 3:40 p.m., observations in the hospital's Emergency Department trauma room 1 Pediatric crash cart revealed 3- ten (10) milliliters (ml) saline flush syringes expired 10/2017, 10/2017, and 11/1/17. The findings were verified with Director 1 at the time of the observation who stated, "All of the expirations are supposed to be checked once a month on the fifteenth of each month." On 12/4/17 at 4:05 p.m., observations in the Emergency Department Fast Track Area revealed: 2- 20 mls vials of 1%(percent) Xylocaine that were not labeled when opened; 1- 20 mls vial of Sterile water (H2O) that was not labeled when opened; 2- 118 mls bottle of Betadine that were not labeled when opened; and 1- 118 mls bottle of Betadine expired 11/9/17.

On 12/4/17 at 4:10 p.m., observations in the triage cart revealed 1-118 mls bottle of Betadine that was not labeled when opened, and 1 - 250 mls bottle of 0.9% Sodium Chloride ( NaCl) that was not labeled when opened. The findings were verified with Director 1 at the time of the observations.

Review of the Hospital's procedure, titled, "Disposal of Expired Drugs", reads, "....1.. All outdated drugs will be removed from stock, whenever discovered...and separated from the active usable inventory....". Hospital procedure, "Disposal of Contaminated or Unusable Drugs", reads, "....Containers or medications having no labels are prohibited and contents shall be returned to the pharmacy for destruction....".

Based on observations and interview, the hospital failed to ensure a sanitary environment for in its kitchen and the hallways in the Endoscopy areas and other patient care areas.

The findings are:

On 12/4/17 from 3:05 p.m. to 3:55 p.m., during a tour of the hospital's physical environment with Director 6 and Assistant Director 2, observations revealed:
Water stains on ceiling tiles in the hallway outside of the Endoscopy lab and the finding was verified by Director 6 and Assistant Director 2 on 12/4/17. Observations in the hall way wall located between Room 382 and 384 had holes in the wallpaper. Observations in Room 243 showed the vent cover had layers of dust. On 12/4/2017 from 3:05 p.m. to 3:55 p.m., Director 6 and Assistant Director 2 verified the findings.










28883

Observations of the hospital's kitchen environment on 12/5/17 at 10:39 a.m. revealed 10 light covers that had a black substance or debris visible in or on the lighting fixture covers. Two of two recessed lighting fixtures in the kitchen did not have covers to prevent possible glass contamination of food in the event of the bulbs shattering or breaking. The findings were verified by Manager #2 at the time of the observations. According to Manager #2, s/he was unsure of when the covers had been cleaned last and indicated that building maintenance was responsible for the upkeep.

Observations on 12/4/17 at 2:53 p.m. of the dietary walk-in refrigerator revealed the following food items that had not been dated or labeled to ensure proper storage timeframe: 1 container of brown gravy, cut onions wrapped in cellophane, a container of chopped apples and onions, a container of rice, 4 pans of corn and green onion pudding, 1 pan of thawing collard greens, 1 container of Au Jus, and a container of cut purple onions covered with a paper towel. The findings were verified by Manager #2 at the time of the observation. During an interview on 12/5/17 at 4:15 p.m., Manager #2 stated there was no hospital dietary policy addressing the labeling of opened food items in the refrigerator, but there was a reminder posted that all items should be labeled with the prep date and the 3 day use date. A copy of the reminder for staff was provided to the surveyor.

Observations on 12/4/2017 and 12/05/2017 revealed 3 of 3 male dietary aides and 1 of 2 Dietary Managers had facial hair that was not covered by a facial hair restraint. Observations in the kitchen on 12/4/17 between 2:37 p.m. and 3:30 p.m. revealed Dietary Aide #1, #2, and Manager #2 had either a mustache, beard, or both. Neither Dietary Aide #1, #2, or Manager #2 wore a facial hair restraint to prevent hair from potentially contaminating food or food prep areas. Observations on 12/5/17 at 10:35 a.m. in the kitchen revealed Manager #2 had a mustache and wore no facial hair restraint. Further observations on 12/5/17 at 10:56 a/a.m../ revealed Dietary Aide #1 stacking food on the tray line. Dietary Aide #1 had a mustache and beard and was not wearing a facial hair restraint. Observations on 12/5/17 at 1:05 p.m. revealed Dietary Aide #5 had a mustache and beard and was preparing dressing without donning a facial hair restraint. On 12/05/2017 at 1:05 p.m., Dietary Aide #5 reported the he usually does not wear a facial hair restraint because he usually keeps his beard trimmed. During an interview on 12/5/17 at 1:09 p.m., Dietary Aide #2 verified he had facial hair and had not been wearing a facial hair restraint. When asked about staff who had facial hair and facial hair restraints, Dietary Manager #2 stated on 12/5/17 at 1:10 p.m. that he didn't have any facial hair restraints available. During an interview on 12/5/17 at 1:32 p.m., Dietary Aide #1 verified he did not use a facial hair restraint. A review of the hospital's policy, provided by the hospital on 12/6/17, entitled, "Personal Hygiene", revealed, "Associates will practice good personal hygiene habits at all times while on duty". The purpose of the policy was "To prevent the spread of food borne illness". A note under the dress code policy included information that "Hairnets, and caps worn at all times...".

On 12/4/17 between 2:37 p.m. and 3:30 p.m., observation showed a no hands-free trash receptacle next to a handwashing sink in the kitchen. Upon entry to the kitchen and after the kitchen tour, Manager #3 rolled a large trash bin over so the paper towels could be disposed of. Observations on 12/5/17 at 10:21 a.m. revealed there was still no trash receptacle next to the handwashing sink in the kitchen. The surveyor performed handwashing and a staff member rolled the big garbage can close and removed the lid so the disposable towel could be thrown away. Observations on 12/5/17 at 10:49 a.m. revealed Cook #1 washed his/her hands. There was no hands-free trash receptacle next to the handwashing sink, but the large trash bin on wheels was close. Cook #1 lifted the lid of the trash bin so s/he could dispose of the paper towel and contaminating his/her hands with the trash bin's lid. Cook #1 donned gloves and proceeded to sanitize the thermometer and take the temperature of the gravy that was to be served for lunch. During an interview on 12/5/17 at 1:07 p.m., Cook #1 was asked about the observation of him/her touching the lid of the trash bin, contaminating his/her hands, after handwashing. Cook #1 verified the observation and stated that they usually had a trash can by the handwashing sink; but for the last couple of days it had been missing.

Observations in the kitchen on 12/5/17 at 10:35 a.m. with Manager #2, revealed dessert dishes stacked on a shelf. Nine of the dishes had drops of water on them when un-stacked. The dishes were not placed in a manner to allow air to circulate so they could air dry. During an interview at the time of the observation, Dietary Aide #4 reported the dishes are usually placed in a different rack where the dishes could air dry.

Observations in the kitchen of the dish machine on 12/5/17 at 1:15 p.m. revealed Dietary Aide #3 rinsing and scrubbing dishes before loading the dishes into the dish machine. Observations of the dish machine revealed 4-5 racks of dirty dishes going through, but the dish machine final rinse temperature did not go over 140 degrees Fahrenheit (F). The dish machine was not working at the appropriate temperature to ensure proper sanitation and cleanliness of dishes. Dietary staff removed the dishes that had gone through the dish machine cycle and stacked the dishes on racks to dry. Observations revealed a sign on the dish machine that stated to run 3-4 empty racks through the dish machine first, and the dish machine's rinse temperature should be between 180 degrees and 190 degrees Fahrenheit. When notified of the concern that the dish machine's final rinse temperature had not gotten to 180 degrees Fahrenheit during the cycle, Manager #2 placed 2 empty racks through the dish machine with the temperature of the final rinse still not going over 140 degrees Fahrenheit. Manager #2 verified the dish machine was a high temperature machine and had no chemical method of sanitation. At 1:24 p.m., after putting another empty rack through the dish machine cycle, the final rinse temperature reached 183.9 degrees Fahrenheit. During an interview at 1:25 p.m., Dietary Aide #3 stated s/he had been working the dish machine for approximately 20 minutes. When asked how s/he monitors the dish machine cycle to ensure the final rinse temperature reached 180 degrees Fahrenheit, s/he stated that s/he had put 2 empty racks in the dish machine prior to washing the dirty dishes and the temperature had gotten up to 180 degrees (F).

A review of the Installation & Operation Manual for the Ecolab ES-6600 dish machine revealed the minimum wash temperature for hot water sanitizing was 160 degrees Fahrenheit, and the minimum rinse temperature was 180 degrees Fahrenheit. A review of the dishwashing machine temperature log on 12/5/17 at approximately 3:20 p.m. revealed the final rinse temperature for the lunch meal had been documented as 185 degrees Fahrenheit. Upon receipt of a copy of the dish log on 12/6/17, Manager #3 stated that the entry for the temperature for the dinner meal on 12/5/17 had been written on the wrong line.

Review of the hospital's policy, provided by the facility on 12/5/17 at 3:13 p.m., entitled, "Dish machine-Dishes and Silverware", revealed, "...The dish machine temperature must be taken three times a day and documented on the log to ensure that temperatures meet the established standards. If temps do not meet the standards below, stop using the machine so the booster heater heats the water up. Recheck the standards below. If it still does not meet the standard below, notify the supervisor/manager so the heat strips can be run through the machine. When the strips are used, write down the date and tape the strip to the back of the temp log. If the standards below still cannot be met, switch over to paper and call for service. Minimum acceptable temperatures for the dish machine are: Wash Rinse 160 F, Final Rinse 180 F." A review of the Installation & Operation Manual for the Ecolab ES-6600 dish machine revealed the minimum wash temperature for hot water sanitizing was 160 degrees Fahrenheit, and the minimum rinse temperature was 180 degrees Fahrenheit. A review of the dishwashing machine temperature log on 12/5/17 at approximately 3:20 p.m. revealed the final rinse temperature for the lunch meal had been documented as 185 degrees Fahrenheit. Upon receipt of a copy of the dish log on 12/6/17, Manager #3 stated that the entry for the temperature for the dinner meal on 12/5/17 had been written on the wrong line.







39463

On 12/5/2017 at 10:45 a.m., observations of the medication room on 2 Parish revealed the Sharps container was more than 3/4 full, lid locked, and had not been taken to the soiled utility room On 12/5/2017 at 10:45 a.m., RN 12 verified the finding, and stated, "Yes, that is the only Sharps container in this room."

Based on record review and interview, the hospital failed to ensure its governing body appointed in writing the individual acting as the hospital's Infection Control Officer.

The findings are:

Based on review of the hospital's infection control plan and governance data on 12/6/17 at 4:15 p.m., the hospital had no documentation for the appointment of its infection control officer in writing. In an interview with Patient Safety Officer(PSO) on 12/6/17 at 4:15 p.m., the PSO stated, "We cannot locate the appointment letter."

Based on observations, record reviews, interviews, and review of the hospital's policies and procedures, the hospital failed to ensure its staff followed accepted principles of infection control to prevent the potential cross contamination of infectious agents in the hospital setting for 2 of 2 Registered Nurses(RN) and 1 of 1 Respiratory Therapist(RT) in the provision of patient care. ( RN 1, RN 6 and RT1)

The findings are:

On 12/5/2017 at 9:58 a.m., observations in the Intensive Care Unit(ICU) revealed Registered Nurse (RN) #1 wearing a gown and gloves prepared medication for administration for Patient #6. Observation of a sign and isolation cart outside the patient's room door revealed Patient #6 was on contact isolation precautions. After assembling supplies onto the bedside table, the nurse removed his/her gloves, and without performing hand hygiene, put on a new pair of gloves. After removing the lid of a medication vial (Pepcid), the nurse inserted the needle to draw up the medication without first cleaning the vial's septum. After obtaining some alcohol pads from a staff member, RN #1 wiped the patient's Intravenous (IV) port and administered the medication. With the same gloved hands, RN #1 folded a towel and used it to prop the patient's head up. Without changing gloves or performing hand hygiene, RN #1 opened a package of intravenous tubing, removed the lid from a bottle of Propofol, and without cleaning the septum of the bottle, spiked the bottle with the intravenous tubing and primed the tubing with the medication. RN #1 took a pen and dated the new tubing, removed the old intravenous tubing from the pump, put in the new intravenous tubing and hung the new bottle of Propofol. Then, with the same gloved hands, RN #1 disconnected the old intravenous tubing from the patient and attached the newly primed intravenous tubing, set the pump, and charted on the computer. With the same gloved hands, RN #1 arranged the patient's blankets and tubing, opened some wipes, wet them, and wiped the patient's eyes, forehead, and cheek. RN #1 performed ET (Endotracheal suctioning) and oral suctioning using the same gloved hands. After removing his/her gown and gloves and throwing them in the trash in the room, RN #1 took the used Propofol bottle, sanitized his/her hands, and laid the bottle on the isolation cart outside the room.

During an interview, after the observation, on 12/4/17 at 10:14 a.m. with RN #1, he/she reported the patient was on Contact Isolation due to a history of a calf wound with MRSA (Methicillin Resistant Staph Aureus). When asked about the nurse's hygiene practices, RN #1 verified that s/he had either not changed gloves and/or failed to perform hand hygiene between tasks. RN #1 stated s/he does not change gloves with patient care unless they are soiled. RN #1 verified that s/he had not cleaned the septum of the medication vials prior to withdrawing/spiking the medication.

During an interview on 12/5/17 at 3:05 p.m., the Infection Control Officer stated gloves should be changed and hands disinfected before going from dirty to clean; and that hands should be disinfected anytime that gloves are removed. According the Infection Control Officer, the septum of vials or bottles of medications should be wiped with alcohol or another disinfectant before accessing the vials for administration.

Review of the hospital's policy on 12/5/17, entitled, "Hand Hygiene and Infection Control (Non-Patient and Patient Care Areas)", revealed, "...Proper hand hygiene is essential in preventing the spread of infections." Under "Procedure:" was listed "Guidelines regarding proper hand hygiene:" which included "...Hands shall be cleaned after removing gloves.....Hands shall be cleaned after handling any contaminated equipment or surfaces...". A review of the policy provided by the facility entitled "Injectable Medication Safety Practices" on 12/5/17 revealed, "...20. The rubber septum of all vials must be disinfected prior to each use: a. Chlorhexadine: scrub for 15 seconds, allow to dry (approximately 30 seconds) b. Alcohol: scrub for 30 seconds, allow to air dry...".






39310

On 12/5/17 at 11:59 a.m., random observations during medication pass for Patient #9 revealed Registered Nurse (RN) 6 transported the medication cart into the patient's room and failed to clean the medication cart after exiting the room. When RN 6 was asked if there was a hospital policy on cleaning medication carts, RN 6 stated, "We clean the cart if the patient is on contact precautions."

On 12/6/17 at 11:19 a.m., random observations in Room #263 with Patient #7 revealed Respiratory Therapist (RT) 1 failed to clean the stethoscope used to asses the patient prior to and after the patient's breathing treatment. Observations showed RT 1 transported the respiratory treatment cart into Inpatient #7's room, and failed to clean cart after exiting the patient's room. On 12/6/2017 at 12:00 p.m., RT 1 verified the findings.

Based on record review and interview, the hospital failed to document in the patient's medical record that a list of skilled nursing facilities (SNFs) that are available to the patient was presented to the patient or to the individual acting on the patient's behalf for 1 of 1 patient chart reviewed for requirements for discharge. (Discharged Patient 6)

The findings are


On 12/6/2017 at 2:30 p.m., review of discharged Patient 6's medical record revealed the patient was admitted on 11/15/2017 for Obstructive Urothapy and was discharged to a SNF. Further review of the record revealed there was no documentation including electronically of the list of Medicare-participating SNFs, and no documentation of rationale for providing only one option to the patient or to the individual acting on the patient's behalf. On 12/6/2017 at 2:30 p.m., Director 13 verified the findings, and stated, "Every patient being discharged to a SNF or Home Health Agency receives a vendor choice form so that families can go out and take a look at the facilities to choose one. The forms are scanned into the patient's electronic health record."