HospitalInspections.org

Based on review of medical records (MR), facility policies and staff interviews, it was determined staff failed to:

a) Document physician's ordered Intravenous (IV) Fluids as ordered.

b) Perform and document intake and output (I & O) as ordered.

c) Document wound assessments per policy.

This affected 3 of 18 inpatient records reviewed and did affect Patient Identifier (PI) # 12, PI # 13 and PI # 29.

This had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: # NUR 2006
Subject: Intake and Output (I & O)
Revised date: 01/18

"Purpose:
To provide specific guidelines in measurement of intake and output to gauge fluid balance of the patient.

Policy:
1. Patients that intake and output are measured include:
* dehydrated
* recent surgery
* foley catheter...
* Congestive Heart Failure (CHF)
* Kidney disease
* any other draining tube, catheter or continuous IV's or as ordered by the physician.

2. Intake and output is recorded each shift per Meditech...

4. Record the type and amount of fluids the patient has lost and the route. Those include urine, liquid stool, ..."

Facility Policy: # NUR 2801
Subject: Pressure Ulcer, Prevention and Treatment
Revised date: 09/17

"Policy
...5. All inpatients are assessed upon admission for pressure ulcers and staging is noted...

Treatment - Stage I
...2. Assess and measure length x (times) width and document.
...Treatment - Stage II
...2. Measure length x width x depth and document."

*******

1. PI # 12 was admitted to the facility on 2/28/18 with diagnoses including Colon Resection.

A review of a physician's order written on 2/28/18 at 11:00 AM revealed Lactated Ringers (LR) IV fluid at 125 cubic centimeters (cc) an hour (hr).

Review of the 2/28/18 Nursing documentation and I & O Summary form revealed no documentation of IV intake.

Review of the 3/2/18 physician's order written at 12:42 PM revealed LR at 125 cc/hr. D/C (discontinue) Foley on 3/3.

Review of the 3/3/18 physician's order written at 9:50 AM revealed "when taking PO (by mouth) well D/C (discontinue) IV to heplock".

Review of the 3/3/18 physician's order written at 12:31 PM revealed LR 1,000 ml IV as directed 30 ml hr start "3/2/18 at 1:15 PM."

Review of the 3/2/18 to 3/5/18 every 2 hour IV site check by nurses revealed no documentation of the type of IV fluid (IVF) infusing.

Further review of the 3/2/18 to 3/5/18 nursing notes revealed no documentation when the IVF was decreased from 125 ml to 30 ml hr or when the nurse discontinued the IVF to heplock only.

Observations were made on 3/5/18 at 11:20 AM with Employee Identifier (EI) # 17, Registered Nurse who performed wound care, EI # 25, Nurse Educator, was also present.

The surveyor observed the patient had a right arm heplock and 3 empty bags of IVF (LR, Normal Saline (NS), and Piperacillin). The surveyor asked the patient "Are you still receiving IVF?" He/she stated, "No, I'm not getting that anymore and I don't remember when it was stopped."

Review of the 2/28/18, 3/1/18, and 3/2/18 I & O Summary revealed no documentation of urine output for PI # 12 with a foley catheter.

In an interview conducted on 3/7/18 at 12:20 PM with EI # 9, Director of Post Anesthesia Care, confirmed the above findings.

2. PI # 13 was admitted the facility on 3/3/18 with diagnoses including Chronic Obstructive Pulmonary Disease.

Review of the 3/3/18 physician's order written at 11:20 AM revealed Levofloxacin 750 mg (milligrams) in NS 150 ml and Azithromycin 500 mg in NS 250 ml time.

Review of the 3/3/18 physician's order written at 3:50 PM NS 500 mg bag at 120 ml/ hr now.

Review of the 3/4/18 physician's order written at 3:18 PM revealed hold IVF.

Review of the 3/3/18 I & O Summary form revealed no documentation for IV intake.

Review of the 3/4/18 I & O Summary revealed documentation of only 220 ml IV intake.

The nursing staff failed to document the total IV intake in the medical record.

In an interview conducted on 3/7/18 at 12:30 PM with EI # 9, who confirmed the patient recieved IV fluids and the staff failed to document the IV intake per policy.



39098

3. PI # 29 was admitted to the facility on 3/2/18 with admitting diagnoses including Ascites, Cirrhosis, and Chronic Malnutrition.

Review of the physician documentation dated 3/2/18 at 2:06 PM revealed "Patient has grade 1 and grade 2 decubitus ulcers on his coccyx and buttocks."

Further review of the MR revealed a Nursing Admission Assessment dated 3/2/18 at 2:55 PM. The nurse documented "Two stage 2 wounds to coccyx." There was no documentation of the wounds' measurements per facility policy.

A review of the Registered Nurse (RN) Reassessment dated 3/4/18 revealed the following documentation: "Wound Location 1: Heels, Dressing Dry and Intact. Wound Location 2: Elbows, Dressing Dry and Intact." There was no documentation the coccyx area wounds were assessed.

An interview was conducted on 3/7/18 at 12:18 PM with EI # 15, Director Medical/Oncology, Dialysis, Infusion Clinic. EI # 15 confirmed the wounds were not measured per facility policy, and the documentation by the RN on 3/4/18 was an error in documentation, there were no wounds on the heels and elbows. EI # 15 provided the surveyor with written notes during the interview, which contained the following documentation by EI # 15, "One (wound) that was coccyx area probably not counted that was 2.5 cm (centimeter) x (times) 1 cm healed site white center, no drainage." EI # 15 confirmed the patient had 3 wounds, not 2, as documented by the RN.

Based on observation, review of medical records (MR), facility policy and interviews, it was determined staff failed to administer medications within time frames per facility policy.

This affected 1 of 14 medication pass observations and did affect Patient Identifier (PI) # 12 and had the potential to negatively affect all patients treated at the facility.

Findings include:

Facility Policy: # NUR 1703
Subject: Medication Administration Guideline
Revised Date: 10/17

Purpose
"To provide a plan for safe medication management, administration, and accurate documentation of the same...

Policy
A. Medications are given by the unit dose system whenever possible...

G. Transcription to Medication Administration Record (eMAR)...

Directions, Abbreviations with Times
BID (Twice a day) - 9:00 AM and 9:00 PM...
Daily - 9:00 AM

Preparing and Dispensing
A. Medication preparation sites will meet the following standards:..
4. Aseptic technique will be maintained...

E. Length of Use of Multi-Dose Vials:...
2. Multi-dose vials that are opened by personnel will be labeled with the date opened and the initials of the person opening the vial...

Administering...
D. Routine medications should be administered within 60 minutes of the designated time..."

*******

1. PI # 12 was admitted to the facility on 2/28/18 with diagnoses including Colonoscopy.

On 3/6/18 the surveyor was on the medical surgical floor at 7:45 AM to observe the morning (AM) medication pass with Employee Identifier (EI) # 17, Registered Nurse. EI # 17 stated the only medication left to give was a Lovonox subcutaneous (SQ) injection at 10:00 AM. The surveyor asked EI # 17, "Have the PO (by mouth) medications already been administered?" EI # 17 stated, "Yes, I gave them around 7:00 AM. I have a patient coming in."

The following medications were ordered for 9:00 AM and were administered at 7:02 AM: Klonopin 0.5 milligram (mg) every AM.
Norvasc 10 mg every AM.
Prinivil/ Zestril 40 mg every AM.
Protonix Packet 40 mg every AM.

The medications were administered to the patient 58 minutes prior to the acceptable times for administration. EI # 31, RN Charge Nurse, confirmed the RN administered the patient's medications too early.

In an interview conducted on 3/7/18 at 12:20 PM with EI # 9, Director of Post Anesthesia Care, confirmed the above findings.

Based on review of medical records (MR), facility policy, the Unit Issue/Transfusion Card, and interviews, it was determined the facility staff failed to check vital signs every hour during blood administration per policy. This affected 2 of 2 MRs reviewed of patients who received blood transfusions including Patient Identifier (PI) # 11 and # 27 and had the potential to negatively affect all patients who received blood transfusions at this facility.

Findings include:

Policy: Blood/Blood Product Administration
Reference number: NUR 300
Revised Date: 8/17

Policy: "...9. Transfusion: Adult - A unit of blood should be transfused within 4 hours....
12. Vital signs: adult - Obtain a set of pre-transfusion vital signs, then fifteen (15) minutes after transfusion started and every one (1) hour during transfusion and one (1) hour after transfusion is completed, then routine."

*****

1. PI # 11 was admitted to the facility on 2/18/18 with diagnoses including Diabetic Ketoacidosis and Acute Blood Loss Anemia.

Review of the physician's order dated 2/28/18 revealed an order to "Type and Crossmatch 1 unit of PRBC (Packed Red Blood Cells), transfuse each unit over 4 hours with NS (Normal Saline)."

Review of the Unit Issue/Transfusion Card revealed the blood was started at 3:15 PM and ended at 7:30 PM. Vital signs were recorded under columns labeled "Before", "15 minutes", "After" and "1 Hour After". There were no documented times indicating when the vital signs under the labeled columns were taken. There was no documentation indicating PI # 11's vital signs were taken hourly during the 4 hour 15 minute transfusion as required by agency policy.

Further review of the physician order dated 3/3/18 revealed an order to "Type and Crossmatch PRBC (Packed Red Blood Cells), transfuse 1 unit PRBC now."

Review of the Unit Issue/Transfusion Card revealed the blood was started at 2:50 PM and ended at 6:15 PM. Vital signs were recorded under columns labeled "Before", "15 minutes", "After" and "1 Hour After". There were no documented times indicating when the vital signs under the labeled columns were taken. There was no documentation indicating PI # 11's vital signs were taken hourly during the 3 hour 25 minute transfusion as required by agency policy.

The facility staff failed to monitor vital signs every hour until 1 hour after the transfusion was completed per policy.

An interview was conducted on 3/7/18 at 12:15 PM with Employee Identifier (EI) # 1, the Director of Quality Management, confirmed the above information.

2. PI # 27 was admitted to the facility on 1/15/18 with a diagnosis of GI (Gastrointestinal) Bleed with Acute Anemia.

Review of the Unit Issue/Transfusion Card revealed PI # 27 received 3 units of PRBCs on 1/18/18.

The first unit of blood was started at 6:00 AM and ended at 8:45 AM on 1/18/18. Vital signs were recorded under columns labeled "Before", "15 minutes", "After" and "1 Hour After". There was no documentation indicating PI # 27"' vital signs were taken hourly during the 2 hour 45 minute transfusion as required by agency policy.

The second unit of blood was started at 2:20 PM and ended at 4:50 PM on 1/18/18. Vital signs were recorded under columns labeled "Before", "15 minutes", "After" and "1 Hour After". There was no documentation indicating PI # 27's vital signs were taken hourly during the 2 hour 30 minute transfusion as required by agency policy.

The third unit of blood was started at 9:35 PM and ended at 12:45 AM on 1/19/18. Vital signs were recorded under columns labeled "Before", "15 minutes", "After" and "1 Hour After". There were no documented times indicating when the vital signs under the labeled columns were taken. There was no documentation indicating PI # 27"' vital signs were taken hourly during the 3 hour 10 minute transfusion as required by agency policy.

The facility staff failed to monitor vital signs every hour until 1 hour after the transfusion was completed per policy.

In an interview 3/7/18 at 12:15 PM with EI # 1, confirmed the above information.

Based on review of medical records (MR), Medical Staff Rules and Regulations and interviews with administrative staff, it was determined the facility failed to ensure all orders were signed, dated and timed by the ordering physician for 1 of 2 sampled Obstetrical (OB) patients reviewed, Patient Identifier (PI) # 24, and had the potential to negatively affect all patients served by the facility.

Findings Include:

Excerpt From the Medical Staff Rules and Regulations
Revised: 9/18/17

II. Medical Records

"Section 2.5 Medical Orders

(a). All orders, including verbal orders, must be dated, timed and authenticated no later than 30 days after discharge by the ordering physician or another practitioner who is responsible for the care of the patient ..."

1. PI # 24 was admitted to the OB Labor and Delivery (L & D) Unit on 3/5/18.

Review of the MR on 3/6/18 revealed three (3) telephone orders (TO) which included, L&D Admission Orders, L & D Medication Orders and Pitocin Protocol A documented by the Registered Nurse on 3/5/18.

Further review of the 3 TO's revealed there were no dates or times the physician signed the aforementioned orders as directed per the medical staff rules and regulations.

An interview was conducted on 3/7/18 at 12:02 PM with Employee Identifier (EI) # 10, Performance Improvement (PI) Coordinator, who verified the aforementioned findings.

Based on review of the medical records (MR), facility policy and interviews, it was determined the facility failed to ensure all necessary documentation was written and in the MR including:

A) Wound Care consult, as ordered.

B) Document pain assessment on admission.

C) Peritoneal Dialysis orders for fills/cycles, scheduled treatment frequency, and dwell time as ordered.

This affected 3 of 18 inpatient MR's reviewed and did affect PI # 29, PI # 30, PI # 32 and had the potential to negatively affect all patients served by the facility.

Findings include:

*******

Policy # NUR 1901
Subject: Pain Management
Date reviewed: 08/17

"...Guideline
Pain assessment is completed as part of the initial nursing assessment and occurs with each new report of pain focusing on identifying the cause of pain...

Management
A. On admission, the admitting nurse will assess pain... The admitting nurse will record this information in the electronic medical record."

********

1. PI # 29 was admitted to the facility on 3/2/18 with admitting diagnoses including Ascites, Cirrhosis, and Chronic Malnutrition.

A review of the MR revealed an order on 3/2/18 at 7:45 PM, for Wound Care consult. There was no wound care consult documented in PI # 29's MR at the time of record review on 3/6/18 at 10:00 AM.

During an interview on 3/7/18 at 12:18 PM with Employee Identifier (EI) # 15, Director Medical/Oncology, Dialysis, Infusion Clinic, the above findings were confirmed.

2. PI # 30 was admitted to the facility on 3/4/18 with admitting diagnoses including Chest Pain, and Hypertension.

A review of the Admission Assessment, dated 3/4/18 at 3:29 AM, revealed the patient answered "Yes" to "Pain in the last 48 hours?" There was no documentation to location, duration, character, length of pain, pain score, or associated symptoms.

During an interview on 3/7/18 at 12:15 PM, with EI # 3, Director of Education, it was confirmed the RN failed to assess the patient's pain according to facility policy.



37268

3. PI # 32 was admitted to the facility 3/2/18 with diagnoses including Left Femoral Neck Fracture.

Review of the physician's orders dated 3/2/18 at 5:02 PM revealed the following order: "Confirm CCPD (Continuous Cycling Peritoneal Dialysis) with home prescription dose (family knows)."

Review of the patient's home dialysis flow sheet dated 2/20/18 revealed the following CCPD order:

"Treatment Type: CCPD, PD (peritoneal dialysis) type: PD with cycler, ... Primary Access: PD Catheter - Left middle quadrant, ... Schedule: SU (Sunday), Mo (Monday), Tu (Tuesday), We (Wednesday), Th (Thursday), Fr (Friday), Sa (Saturday), Ca (calcium): 2.50, Mg (magnesium): 0.5, Dex (dextrose): varied, FX (frequency): Q (every) tx (treatment)... Total Fills: 5, ... Dwell time: 1 hrs (hour) 54 min (minutes)..."

Review of the Inpatient Automated Peritoneal Dialysis Orders dated 3/2/18 at 6:00 PM revealed no documentation for dialysis frequency schedule, dwell time, and fills/cycles. The RN failed to specify and document complete orders from the patient's home CCPD orders per physician order.

An interview was conducted on 3/7/18 at AM 12:09 PM with EI # 10, Performance Improvement Coordinator, who confirmed the above findings.

Based on review of the facility's policies, observations, and interviews it was determined the facility failed to ensure all medications available for patient use were not expired and opened multi-dose vials were labeled with date opened and the initials of the staff that opened the vial. This had the potential to negatively affect all patients served by this hospital.

Findings include:

Subject: Unusable Drugs and Devices
Policy Number: PHA 18-09
Revised Date: 08/2002

"Policy:

Unsuable drugs and devices shall be handled and disposed of in accordance with this policy...

Unusable drugs and devices include those that are:

expired (outdated)...

The pharmacy shall store unusable drugs and devices in special designated areas to prevent their distribution or administration and ensure they are disposed of safely. They shall not be returned to active pharmacy or patient stocks..."

******

Subject: Medication Administration Guideline
Policy Number: Nur 1703
Revised Date: 10/17

"Purpose:

To provide a plan for safe medication management, administration, and accurate documentation of the same...

Policy:

A. Medications are given by unit dose system whenever possible...

Preparing and Dispensing...

E. Length of Use of Multi-Dose Vials:

... 2. Multi-dose vials (containing a preservative) that are opened by personnel will be labeled with the date opened and the initials of the person opening the vial, with the exception of those medications controlled by pharmacy..."

******

1. A tour of the Pharmacy was conducted on 3/5/18 at 11:00 AM with Employee Identifier (EI) # 11, Director of Pharmacy and EI # 6, Registered Nurse (RN), Infection Prevention / Quality Manager.

The surveyor observed the following expired medications stored in patient stock:

Udderly Smooth Body Cream 12 oz (ounce), expired (exp.) 2/2018

10 % (percent) LMD (low molecular dextran) in 5 % Dextrose Injection, (9) - 500 ml (milliliter) bags, exp. 3/1/2018

Lidocaine HCL (hydrochloride) 2 %, (16) - (20 ml - multiple dose), exp. 2/1/2018

Deferoxamine Mesylate for Injection, (8) - 500 mg (milligram)/vial, exp. 2/1/18

Octreotide Acetate Injection, (10) - 50 mcg (microgram) / 40 ml, exp. 1/2018

Yervoy (ipilimumab) Injection 200 mg / 40 ml, exp. 1/2018

Yervoy Injection 50 mg / 10 ml, exp. 1/2018

Carbocaine Mepivacaine Hydrochloride Injection 1 %, 30 ml single-dose vial, exp. 2/1/2018

Mesna Injection 1 gram per 10 ml, (4) - 10 ml multi-dose vial, exp. 1/2018

Novolin R (Regular, Human Insulin) Injection, 100 units/ml, 10 ml vial, discard date: 3/4/18

Topotecan Hydrochloride for Injection 4 mg, exp. 1/2018

Azathioprine (Sodium for Injection), 100 mg / vial, exp. 2/2018

Phospha Neutral (Phosphorus Supplement) 250 mg tablet, (2) - tablets, exp. 2/28/2018

In an interview conducted on 3/7/18 at 1:00 PM with EI # 11 who confirmed the above mentioned findings.

2. A medication administration observation was conducted on 3/5/18 at 11:00 AM with EI # 27, RN on the PCU (Progressive Care Unit).

EI # 27 removed an opened vial of Novolog Insulin from the medication refrigerator to draw up 1 unit of insulin per sliding scale for an unsampled patient. There were no initials of the person that opened the vial documented per facility policy.

In an interview conducted on 3/7/18 at 1:24 PM with EI # 8, Director of Intensive Care / Progressive Care Unit, who confirmed the above mentioned findings.

Based on observation, review of facility policies and interview, it was determined the facility failed to:

1. Store food in a safe and sanitary manner.
2. Discard expired food.

This had the potential to affect all persons served by the facility.

Findings include:

*****

Policy: Food and Nutritional Manual
Policy #: FS-309
Date reviewed: 8/17

"Dry Storage
...Date and rotate items.
Remove from storage any item for which the expiration date has expired...
Refrigerated Storage
...Date and rotate items.
...Leftovers: cover, label, date...."

*****

Sysco Product List for Food Storage
Date revised: 2/2017

"...BBQ (barbeque) sauce, opened, discard after 6 months.
...canned fruits and veggies (vegetables), unopened, discard after 1 year.
...oil, discard after 1 year.
...spices, discard after 1 year.

*****

During a tour of the Dietary Department on 3/6/18 at 11:00 AM, the following items were observed in dry storage:

2 - 28 oz (ounce) Diced Red Pimiento, no expiration date.
5 - 36 oz cartons Au Gratin Potatoes, no expiration date.

The following item was observed in the cooler, unit 1:
1 gallon Barbeque Sauce, opened, no expiration date.

The following item was observed in the cooler, unit 10:
9.5 oz tube squeeze garlic, opened, no expiration date.

The following items were observed on the Baker's table, lower shelf:
1 gallon corn syrup, opened, no expiration date.
1 pint Pure Lemon Extract, manufacturer's expiration date 7/15/16.
20 oz Poppy Seeds, manufacturer's expiration date 8/12/16.
16 oz Ground Nutmeg, opened, no expiration date.

The following items were observed on the wall shelf near fryers:
1 gallon Peanut Oil, opened, no expiration date.
16 oz White Pepper, opened, no expiration date.
23 oz Montreal Chicken seasoning, opened, no expiration date.
10 oz Parsley Flakes, opened, no expiration date.
8 oz Bay Leaves, opened, no expiration date.
2 - 30 oz Hot Peppers, opened, no expiration date.
0.12 oz Chives, opened, no expiration date.
0.6 oz Rosemary, opened, no expiration date.
1 lb (pound) box corn starch, opened to air, no expiration date.
2 oz Paprika, opened, no expiration date.
1 clear container, with red lid, containing white powder. No label to contents, or expiration date.
1 silver bag, stamped "Garden," no other label to contents, or expiration date.

During an interview on 3/6/18 at 3:00 PM, with Employee Identifier # 12, Director, Support Services, the above findings were confirmed.

Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety. This had the potential to negatively affect all patients served by the facility.

Findings include:

Refer to Life Safety Code violations

Based on observations, review of facility policy and procedure and interviews, it was determined the facility failed to ensure the staff followed the facility policy and procedure for proper hand washing.

This did affect Patient Identifier (PI) # 24, PI # 12, PI # 11 and unsampled patients and had the potential to negatively affect all patients served by this facility.

Findings include:

Facility Policy: # NUR 1100
Subject: Handwashing
Revised: 01/12

"Purpose:

To describe the correct procedure for effective cleaning of hands to decrease the risk of transmission of infection.

Policy:

Handwashing is considered to be the single most important strategy for preventing nosocomial infections...

Procedure:

A. Handwashing/Sanitizing Indications:

With exception of urgent situation in which handwashing cannot be done, personnel should always wash their hands:

...2. After removing gloves.

3. When hands are soiled.

5. Before medication preparation.

10. After touching ... objects that are likely to be contaminated..."

********

1. A medication pass observation was conducted on 3/6/18 at 9:05 AM with Employee Identifier (EI) # 16, Registered Nurse (RN) for PI # 24. EI # 16 applied gloves and cleaned the Computer on Wheels (COW) with Sani-Wipes. EI # 16 then removed his/her gloves and proceeded to retrieve oral medications from the medication cart (Pyxis) without performing hand hygiene as directed per facility policy.

An interview was conducted on 3/6/18 at 12:15 PM with EI # 10, Performance Improvement (PI) Coordinator, who verified the aforementioned findings.


34107


2. PI # 12 was admitted to the facility on 2/28/18 with diagnoses including Colon Resection.

During an observation of wound care conducted in the patient's room on 3/5/18 at 11:20 AM with EI # 17, RN, also present was EI # 25, Nurse Educator.

The surveyor observed EI # 17 apply clean gloves and then remove the dirty abdominal dressing and dispose of the dirty dressing and gloves to the patient's trash can. EI # 17 then donned a clean pair of sterile gloves without sanitizing or washing hands. EI # 7 cleansed the dirty abdominal wound with peroxide and several gauze pads. After cleaning the wound, EI # 17 opened the sterile Telfa dressing to the patient's clean wound with the dirty gloves worn to clean the wound with.

EI # 17 failed to clean and sanitize hands before applying sterile gloves and change gloves after cleaning the wound.

In an interview conducted on 3/7/18 at 12:20 PM with EI # 9, Director of Post Anesthesia Care, confirmed the above findings.



39098

3. A Medication Pass observation was performed on 3/6/18 at 8:00 AM with EI # 28, RN. EI # 3, Director of Education, was also present. The oral medication was given to an unsampled patient.

Following the administration of the medication, EI # 28 removed his/her gloves, proceeded to document on the computer, and left the patient's room without performing hand hygiene.

During an interview on 3/6/18 at 1:45 PM, with EI # 3, the above findings were confirmed.

4. A Medication Pass observation was performed on 3/6/18 at 8:10 AM with EI # 29, RN. EI # 3 was also present. The medication was administered to an unsampled patient.

During the observation, EI # 29 changed gloves, and failed to perform hand hygiene after removing gloves. Following the administration of the oral medications, EI # 29 removed his/her gloves, and proceeded to document on the computer, without performing hand hygiene.

During an interview on 3/6/18 at 1:45 PM, with EI # 3, the above findings were confirmed.

5. An observation was conducted on 3/6/18 at 10:30 AM, to observe care provided by EI # 26, RN. EI # 3 was also present. EI # 26 started an IV (Intravenous) infusion on an unsampled patient.

EI # 26 rubbed a sterile Chlorhexidine swab on the back of her gloved hand until it appeared wet, then used the same swab to prepare the IV site on the patient's left forearm. During the observation, EI # 26 moved the garbage can twice with his/her gloved hand, then proceeded to prime and connect the IV tubing to the patient, without changing gloves. Following the procedure, EI # 26 removed his/her gloves and failed to perform hand hygiene.

During an interview on 3/6/18 at 1:45 PM with EI # 3, the above findings were confirmed.



37268

6. A medication pass observation was conducted on 3/6/18 at 9:05 AM with EI # 30, RN for an unsampled patient. EI # 30 sanitized his/her hands and applied gloves. EI # 30 administered the unsampled patient's oral medications. EI # 30 removed his/her gloves and donned cleaned gloves without performing hand hygiene per facility policy.

An interview was conducted on 3/7/18 at 1:23 PM with EI # 8, Director of Intensive Care / Progressive Care Unit, who verified the above findings.



39080

7. A Medication Pass observation was conducted on 3/5/18 at 11:26 AM with EI # 32, RN. Prior to medication preparation for PI # 11, EI # 32 donned non-sterile gloves and wiped his/her COW with several Sani-Wipes.

After wiping the COW, EI # 32 removed the gloves and no hand hygiene was performed after glove removal. The surveyor observed EI # 32 enter the medication cart to get insulin out of PI # 11's medication drawer but no hand hygiene was performed. EI # 32 then went into the clean supply room to retrieve an insulin syringe, no hand hygiene was performed. EI # 32 drew up the prescribed dosage amount in the syringe, no hand hygiene was performed prior to medication preparation.

An interview was conducted on 3/6/17 at 2 PM with EI # 10, who confirmed the above findings.

8. A Medication Pass observation was conducted on an unsampled patient in room 360 on 3/6/18 at 11:26 AM with EI # 34, RN. EI #34 donned non-sterile gloves to remove a nicotine patch from the unsampled patient's back. EI # 34 took off the gloves and then donned another pair of non-sterile gloves without performing hand hygiene in between.

An interview was conducted on 3/6/17 at 2 PM with EI # 10, who confirmed the above findings.

Based on review of the facility's policy, Medical Staff Rules and Regulations, medical records (MR) and interview, it was determined the facility failed to ensure the physician:

a) Completed and documented a medical history and physical (H & P) examination no more than 30 days before or 24 hours after admission or registration.

b) Completed and documented an updated examination of the patient within 24 hours after admission and surgical procedure.

This affected 2 of 8 surgical chart reviews including Patient Identifier (PI) # 15 and PI # 16 and had the potential to negatively affect all surgical patients served by the facility.

Findings include:

Excerpt From the Medical Staff Bylaws and Regulations
Revised: 9/18/17

2.4 History and Physical

a) A pertinent history and physical examination shall be performed, documented in the patient's record within 24 hours of admission.

*******

Subject: Pre-op Criteria to the Operating Room
Reference # SUR 301
Revised date: 2/15

Policy

4. The time frame for History and Physical is defined as being completed or updated the day of the planned surgery. If dictated or written from 24 hours up to 30 days, a statement should be made to reflect any changes, and include informed risk and benefits.

*******

1. PI # 15 was admitted to the facility as an outpatient surgery patient on 2/14/18 with the diagnoses including Gastro-Esophageal Reflux Disease Without Esophagitis and Dysphagia, Unspecified.

Review of the MR on 3/6/18 revealed the physician failed to date and time the patient's history and physical prior to surgery.

An interview conducted on 3/6/18 at 1:05 PM with Employee Identifier (EI) # 20, Operating Room (OR) Nurse Manager, who confirmed the above mentioned findings.

2. PI # 16 was admitted to the facility as an outpatient surgery patient on 11/09/17 with diagnosis of Lumbar Radiculopathy Due To Lumbar Stenosis.

Review of the MR on 3/6/18 revealed the physician failed to sign, date and time the patient's history and physical.

An interview was conducted on 3/6/18 at 12:50 PM with EI # 20 who confirmed the above mentioned findings.

Based on review of medical records (MR), Medical Staff Rules and Regulations and interview, it was determined the outpatient therapy staff failed to ensure physician's orders were obtained and documented for continued care.

This affected 1 of 1 wound records reviewed for outpatient therapy, Patient Identifier (PI) # 36, and had the potential to negatively affect all patients served by the facility.

Findings include:

Excerpt From Medical Staff Rules and Regulations
Revised: 9/18/17

II. Medical Records

"Section 2.5 Medical Orders

(a). All orders, including verbal orders, must be dated, timed and authenticated no later than 30 days after discharge by the ordering physician or another practitioner who is responsible for the care of the patient ..."

*******

1. PI # 36 was admitted to Outpatient Rehab Wound Healing Center on 11/12/15 with the diagnosis of Wound to Right Medial Ankle.

Review of the 11/12/15 Physical Therapy Initial Evaluation note and physician's orders revealed the patient will be seen 2 times per week for up to 12 weeks. The patient's treatment will include outpatient wound care with debridement and dressing changes as appropriate. The patient will be instructed in home care of the wound.

The above mentioned orders were signed and dated by the physician on 11/18/15.

A tour of the Outpatient Rehab Department was conducted on 3/6/18 at 10:55 AM with Employee Identifier (EI) # 14, Director of Rehab Services and EI # 25, Nurse Educator. The surveyor observed 19 different plastic containers filled with wound care supplies including PI # 36 label revealed the admit date of 11/15/15.

The surveyor asked EI 14, "Has PI # 36 been receiving wound care since 11/15/15?" EI # 14 response was, "I have never seen this patient."

The surveyor was then introduced to EI # 19, Registered Physical Therapist, who stated, "The patient has been seen and discharged when the wound was healed and re-admitted when the wound had worsened."

Review of the MR revealed no physician's orders for care since 11/18/15 and no documentation of discharge and re-admission.

On 3/7/18 at 9:30 AM the surveyor was provided a letter dated 3/6/18 and signed by the physician stating, 'verbal orders for wound care have been given to the rehab staff for several years running.'

The surveyor asked EI # 14, Director of Rehab Services, "Do you have documentation of the physician verbal orders, referred to in the physician's letter?" EI # 14 stated, "No."

In an interview conducted 3/7/18 at 12:55 PM with EI # 14 who confirmed the above findings.