HospitalInspections.org

Based on record review and interview, the hospital failed to update/modify the plan of care and/or treatment plan to include a change in a patients condition as evidenced by failing to include documentation relating to the use of restraints during the provision of care to 1 of 1 patient (Patient #4) placed in restraints out of a total sample of 20 patients. Findings:

Patient #4: Medical record review revealed the patient was admitted to the hospital on 1/14/11. Review of the psychiatric evaluation revealed that Patient #4's Axis I diagnoses was "Bipolar Disorder with Psychotic Features Versus Schizoaffective Disorder". Review of the medical record revealed that Patient #4 was placed in 4 point physical restraints on 1/17/11 at 9:25 a.m. and released on 1/17/11 at 11:40 a.m. Documentation indicated that the patient was "verbally aggressive towards staff, unable to redirect. Using vulgar language & banging her head & hand on bedroom door. Pt also combative & threatening towards staff". Review of the plan of care/treatment plan revealed no documentation to indicate that the plan of care was updated and/or modified to include the use of restraints during the provision of care.

The acute care psychiatric unit charge nurse (S3) was interviewed on 1/18/11 at 10:20 a.m. S3 reviewed the medical record of Patient #4 and confirmed that Patient #4 was placed in 4 point restraints on 1/17/11 at 9:25 a.m. and remained in restraints until 1/17/11 at 11:40 a.m. S3 confirmed that the plan of care did not include the use of restraints on Patient #4.

Based on record review and interview, the hospital failed to ensure that the use of restraints was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient as evidenced by failing to ensure the authentication of an order authorizing the use of restraints during the provision of care to 1 of 1 patient (Patient #4) placed in restraints out of a total sample of 20 patients. Findings:

Patient #4: Medical record review on 1/18/11 revealed the patient was admitted to the hospital on 1/14/11. Review of the psychiatric evaluation revealed that Patient #4's Axis I diagnoses was "Bipolar Disorder with Psychotic Features Versus Schizoaffective Disorder". Review of the medical record revealed that Patient #4 was placed in 4 point physical restraints on 1/17/11 at 9:25 a.m. and released on 1/17/11 at 11:40 a.m. Documentation indicated that the patient was "verbally aggressive towards staff, unable to redirect. Using vulgar language & banging her head & hand on bedroom door. Pt also combative & threatening towards staff". Review of the medical record revealed verbal orders dated 1/17/11 at 9:25 a.m. to place Patient #4 in 4 point physical restraints. The restraint orders were not signed or authenticated by the physician or the licensed independent practitioner.

The acute care psychiatric unit charge nurse (S3) was interviewed on 1/18/11 at 10:20 a.m. S3 reviewed the medical record of Patient #4 and confirmed that Patient #4 was placed in 4 point restraints on 1/17/11 at 9:25 a.m. and remained in restraints until 1/17/11 at 11:40 a.m. S3 confirmed that the restraint orders were not signed or authenticated by the physician or the licensed independent practitioner.

Based on observation, record review, and interview the hospital failed to ensure Quality Indicators were selected and monitored for all departments/services provided by the hospital as evidenced by having no quality monitoring of the hospital's morgue. Findings:

Observations on 1/18/2011 at 10:00 a.m. revealed the temperature of the refrigerated cooler for the storage of bodies of deceased patients was 58 degrees Fahrenheit. This finding was confirmed by Quality Assurance Performance Improvement Director S1 and Safety Officer S6 at the time of the observation.

During a face to face interview on 1/18/2011 at 10:00 a.m., Safety Officer S6 indicated there had been no preventive maintenance performed on the morgue's cooler. Further S6 indicated he did not know what the appropriate temperature for storing bodies should be. S6 indicated the refrigerator cooler used by the hospital in the morgue was old and the hospital had no manufacturer's information on the cooler. Further Safety Officer S6 indicated there was no hospital policy that addressed the morgue to include no documentation as to how often the temperature of the cooler should be checked or what the acceptable temperature range should be. S6 indicated it had been the practice of the facility to only document the morgue's cooler temperatures at the time a body was placed into a cooler.

During a face to face interview on 1/19/2011 at 2:25 p.m., Director of Quality S1 confirmed there had been no Quality Indicators identified, monitored, tracked, or trended for the hospital's Morgue. S1 indicated she had not been aware that there was no policy to guide staff as to the proper temperature range for storing bodies, nor had she been aware there had been no ongoing monitoring of the cooler temperatures- outside of when bodies had been placed in the cooler. S1 indicated there should be a policy instructing staff on proper use of the morgue as well as Quality Indicators to monitor the quality of the services provided in the morgue.

Based on record review and interview the hospital failed to ensure medical staff bylaws were enforced as evidenced by failing to suspend physicians for delinquent medical records as indicated in hospital policy and medical staff bylaws/rules and regulations for 7 of 7 physicians reviewed that met the criteria for suspension (S16, S17, S18, S19, S20, S21, S22). Findings:

Review of the hospital policy titled, "Medical Staff Suspension for Delinquent MR (Medical Records) # 661-309, last revised August 2009" presented by the hospital as their current policy revealed in part, "A delinquent medical record is any record not completed by the physician within thirty days following discharge. A notification of incomplete and delinquent medical records is sent via fax to the physician's office every other Tuesday. All delinquent records listed on the notification letter must be completed no later than midnight of the following Tuesday. Physicians who have not completed their records within the specified time frames shall lose their admitting privileges to the hospital until all delinquent records are completed. . . "

Review of Medical Staff Rules and Regulations revealed in part, "Medical records of discharged inpatients shall be completed within 30 days of discharge. . . Medical Records Department personnel will prepare a letter to each physician on the Wednesday in which records will become delinquent during the week ending on the following Tuesday. On the Wednesday after becoming delinquent the admitting privileges of the physician who has not completed these records will be suspended. . . "

Review of "Reminder Notices" regarding "Incomplete Records" revealed the following:
Physicians S17, S21, and S22 were provided notices regarding delinquent medical records on 12/21/2010.
Physicians S16, S17, S18, S19, and S20 were provided notices regarding delinquent medical records on 1/04/2011.

During a face to face interview on 1/19/2011 at 10:00 a.m., HIM (Health Information Manager) S10 indicated Physician S17, S21, and S22 should have been suspended on 12/30/2010. S10 further indicated Physicians S16, S18, S19, and S20 should have been suspended on 1/13/2011. S10 confirmed that the hospital had not followed their policy regarding suspension of physicians for delinquent medical records. S10 indicated the failure was a result of the holidays (Christmas/New Years).

During a face to face interview on 1/19/2011 at 1:50 p.m., Chief of Staff S14 indicated he had been aware that the policy regarding suspension of physicians had not been followed. S14 indicated he may need to consider revising the medical staff bylaws regarding suspensions in order to give physicians a few more days to complete delinquent records.

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Based on record reviews and interviews the hospital failed to ensure a registered nurse supervised and evaluated the care of each patient by : 1. failing to complete pain assessments prior to the administration of Morphine Sulfate for pain as ordered in the Post Anesthesia Care Unit (PACU) for 2 of 5 post anesthesia records reviewed out of a total sample of 20 patient records (#14, #15); 2. failing to complete the Suicide Assessment Documentation (SAD) for a patient stating he was suicidal upon entry to the Emergency Department as per policy for 1 of 3 emergency department psychiatric records reviewed out of a total sample of 20 patient records reviewed (#8), and 3. failing to ensure there was documented evidence the suicidal patients awaiting psychiatric evaluations in the emergency department were in visible view of an assigned ancillary staff/technician at all times for 2 of 3 emergency department psychiatric records reviewed out of a total of 20 sampled patient records reviewed, (#8, #20).
Findings:

1.
Patient #14
Review of PACU Orders dated 01/10/11 revealed the following orders:
2mg IV (intravenous) Morphine Sulfate for mild pain (1-3/10 on pain scale);
3mg IV Morphine Sulfate for moderate pain (3-5/10 on pain scale);
5mg IV Morphine Sulfate for severe pain (6-10/10 on pain scale).

Review of the PACU medication administration record dated 01/10/11 revealed the following medications documented as given:
Morphine 3.5mg IVP (intravenous push) given at 10:05 am;
Morphine 3.5mg IVP given at 10:08 am;
Morphine 3mg IVP given at 10:11am;
Morpine 3mg IVP given at 10:14 am;
Morphine 3.5mg IVP given at 10:17 am;
Morphine 3mg IVP given at 10:20 am.
Review of the entire PACU record revealed no documented evidence that the patient's pain level was assessed on a 0-10 pain scale prior to administering the Morphine Sulfate for pain.

Patient #15
Review of PACU Orders dated 01/11/11 revealed the following orders:
2mg IV (intravenous) Morphine Sulfate for mild pain (1-3/10 on pain scale);
3mg IV Morphine Sulfate for moderate pain (3-5/10 on pain scale);
5mg IV Morphine Sulfate for severe pain (6-10/10 on pain scale).

Review of the PACU medication administration record dated 01/11/11 revealed the following medications documented as given:
Morphine 3mg IVP given at 12:27 pm;
Morphine 3mg IVP given at 12:30 pm;
Morphine 2mg IVP given at 12:35 pm;
Morphine 2mg IVP given at 12:40 pm;
Morphine 3mg IVP given at 12:45 pm;
Morphine 3mg IVP given at 12:50 pm.
Review of the entire PACU record revealed no documented evidence that the patient's pain level was assessed on a 0-10 pain scale prior to administering the Morphine Sulfate for pain.

Review of the hospital policy titled: "Analgesic Administration in Post Anesthesia Care Unit, Policy #646-35" revealed, in part, "II. Implementation- C. In assessing the patient's need for pain medication, the nurse should be alert to the time, drugs used, the amount of pre-op medication given, and the overall condition of the patient. The degree of pain and the alertness of the pain should also be considered". The policy failed to address documentation of the pain assessment on the PACU record.

2.
Patient #8:

Review of the medical record for Patient #8 revealed he arrived to the Emergency Department at 15:50 (3:50pm) on 1/13/11. Further review revealed the Triage Nurse, S23, RN documented the patient ' s chief complaint upon arrival to the Emergency Department was " Substance Abuse, (and) states he is suicidal " at 15:15 (3:15pm) on 1/13/11. There was no documentation of the completion of the screenings for Suicidal Assessment Documentation (SAD) and/or Behavioral assessments conducted by S23RN at 15:55 (3:55 pm) for the patient as per policy. Further review of the " 24 Hour Visibility Documentation Form " revealed there was no documented evidence #8 was in visible view of an assigned technician from 15:15 (3:15pm) to 1630 (4:30pm) on 1/13/11. There was no documented evidence in the medical record for #8 of an assigned technician's constant observation from 15:15 (3:15 pm) to 1630 (4:30pm) for about one (1) hour and fifteen (15) minutes on 1/13/11.

In an interview on 1/19/11 at 11:55 am, S23RN verified there Patient #8 stated he was suicidal at 1515 upon entry into the Emergency Department on 1/13/11. S23RN confirmed there was no documented evidence from 15:15 to 1630 (4:30 pm) the patient was assigned a tech to provide 24 Hour Visibility Monitoring for about one hour and fifteen minutes as per protocol. S23 verified revealed there was no documentation of the completion of the screenings for Suicidal (SAD) and/or Behavioral assessments were conducted by S23RN at 15:55 (3:55 pm) on for the patient on 1/13/11 as per policy. S23RN indicated there was no documented evidence the patient was in constant observation to an assigned technician from 3:15pm to 4:30pm for about 1 hour and fifteen minutes on 1/13/11.

An interview on 1/19/11 at 12:10 pm was conducted with S12 Emergency Room Director (ER Dir). S12 confirmed Patient #8 stated he was suicidal at upon entry into the Emergency Department on 1/13/11. S12 indicated there was no documentation of the completion of the screenings for Suicidal (SAD) and/or Behavioral assessments were conducted by S23RN at 15:55 (3:55pm) for the patient on 1/13/11 as per policy. S12 ER Dir confirmed there was no documented evidence the patient was in constant observation to an assigned technician from 3:15 pm to 4:30pm for about about 1 hour and fifteen minutes on 1/13/11 as per policy.

3.
Patient #20:

Review of the medical record for #20 revealed he arrived to the Emergency Department at 17:14 (5:14pm) on 1/13/11. Further review revealed the Triage Nurse, S25, RN documented the patient's chief complaint upon arrival to the Emergency Department was "thinking about jumping in front of a moving car", "ate a whole lot of clonipin Sunday" , and not taking psych (psychiatric) meds (medications) and taking street drugs at 17:14. Review of the "Emergency Department Physician Medical Record" dated 1/13/11 revealed the attending physician documented the patient with a diagnosis of "Suicidal Ideation". Review of the "Physician Emergency Certificate" dated 1/13/11 at 6:30 pm read patient is currently suicidal. Review of the "24 Hour Visibility Documentation Form" dated 1/13/11 revealed there was no documentation #20 was in visible view of an assigned technician from 17:14 (5:14pm) to 1900 (7:00pm). There was no documented evidence in the medical record #20 was in constant observation of an assigned technician from 17:14 (5:14pm) to 1900 (7:00pm) on 1/13/11.

In an interview on 1/19/11 at 11:25am, S23RN verified that Patient #20 had suicidal ideation upon admission to the Emergency Department at 5:14pm on 1/13/11. S23RN confirmed there was no documented evidence from 5:14pm to 7:00pm on 1/13/11 that the patient was in constant observation by an assigned ancillary staff/technician for about one (1) hour and forty-seven (47) minutes as per the suicidal policy and hospital protocol.

An interview on 1/19/11 at 11:55 am was conducted with S12 Emergency Room Director (ER Dir). S12 confirmed Patient #20 had suicidal ideations upon entry into the Emergency Department on 1/13/11. S12 ER Dir confirmed there was no documented evidence the patient was in constant observation to an assigned technician from 1714 to 1900 for about one (1) hour and forty-seven (47) minutes as per the suicidal policy and hospital protocol.

There was no policy for the CMT (electronic medical record system) used by only the Emergency Room RN for the completion of assessing a suicidal patient ' s screening for behavior, special alerts, SAD presented during the survey conducted from 1/18/11 through 1/19/11. In an interview with S7 Chief Operating Officer (COO) on 1/19/11 at 9:00am, she indicated the CMT was the electronic medical record system used to track only the Emergency Room patients. The CMT system is not used by any other department in the hospital. S7 COO reported there was no policy for the Emergency Room's electronic medical record system, CMT.

The policy titled, "Emergency Department Triage System", Number 649-301, Date Issued of November 1994, Date Revised of October 2009, Interrelated Department of Emergency Medical Services, with no reviewed date, and presented as the current "Emergency Department Assessments" policy was reviewed. The policy stated an experienced Emergency Department staff member, an RN or physician will perform an initial evaluation immediately upon the patient's arrival to the department. From the initial evaluation, appropriate services are provided in an organized and properly directed manner. The RN will initiate an initial Quick Look Assessment of the patient. The initial Quick Look Assessment includes the patient's chief complaint, and a brief evaluation/assessment is done are determined. Documentation of the patient's evaluation/assessment is part of the patient's medical record. The RN will initiate Quick Look immediately upon arrival of all patients who present to the Emergency Department. Completion of an assessment is performed by an RN who assesses the patient, obtains history which includes patient screenings for nutrition, function, behavior, special alerts and medication reconciliation are completed in the patient care area. All of this information will be documented in the EMR (electronic medical record) and the RN will initiate care. The RN will put the time on the assessment form that indicates the time that the RN initially assessed the patient in Quick Look. Quick Look notes will be started with the time the patient is seen by the RN. An assessment of the chief complaint. Document the information on the record. All continued assessments and observations in the treatment area shall be documented on the emergency department record (EMR). All assessments performed by an RN must include behavioral and special alert screenings.

Review of the policy titled, "Patient Awaiting Psychiatric Evaluation", Number: 649-1214; Date Issued of October 1999; Date Revised of June, 2007, August 2009, September 2010; with no review date, was presented on 1/18/11 at 2:35 p.m. as the hospital's current "Emergency Room Patient Awaiting Psychiatric Evaluation" policy. The policy read all Emergency Department patients who are determined by the staff to be a threat to themselves shall be deemed highest priority and specific interventions will be initiated to ensure their safety. The policy indicated the patient's safety will be maintained at all times. All patients in the Emergency Department holding and awaiting a psychiatric evaluation will have the following actions taken and documented:
1. Elopement Precautions will be implemented:
a. The patient will be under eye contact observation at all times.
b. Patient will be undressed and placed in a royal blue gown.
c. An RN will assess and document patient's elopement risk prior to allowing patient to
be escorted out of the lockeed area at any time.
2. Suicidal/Homicidal Precautions refer to Policy #640-S.2 Suicide/Homicide Precautions.
3. All belongings will be placed in a bag(s) and kept in a secure location.
5. Once Emergency Department physician has evaluated the patient and determined the
patient is a threat to self (PEC'd, CEC'd), the patient will require constant observation
by qualified staff.
6. Patient moved to the psych holding area, staffed with sufficient number of qualified staff,
once evaluated by the Emergency Department physician.
12. Assessment and documentation shall include but is not limited to:
a. Patient history
b. Patient complaint
c. Observation of signs and symptoms of mental, emotional behavior, or suspected
substance abuse
e. Documentation of behavior that is of potential danger to self.
f. Documentation of plans for suicide, suicidal ideation, etc.
h. Nursing assessment.

Review of the policy titled, "Suicide/Homicide Precautions", Number 640-S.2, Date issued of July 1996, Date revised of November 2009, Interrelated Department of Emergency Department, with no reviewed date, presented as the current "Suicide/Homicide Precautions" at 1:55 p.m. on 1/18/11. The policy indicated any patient admitted with a suspected or actual suicide attempt, with or without a PEC or CEC, shall have precautionary measures taken for the patient's protection. When a patient's behavior, or thought indicate the patient may be at risk of self-harm, there is a need for extra safety measures to be taken by the nursing staff. The need for precautionary measures is established before the patient is admitted and a "Suicide Precautionary Measures Checklist", (Form NUR127) is initiated. The form, "Precautionary Measures Checklist" documents the measures taken to prevent a patient from causing harm to self. Some of the precautionary measures implemented are to remove all sharps from the bedside cabinet and sharps containers in the room, search patient for sharps, and ensure the patient stays in bed and is restricted to their room. When the patient requires continuous observation, ancillary staff document on the "24 Hour Visibility Form", NUR129.

The form titled, "Suicide Precautionary Measures Checklist", with no form number, was reviewed. Further review revealed the precautionary measures implemented by the ancillary staff are checked off of the form. The precautionary measures include the following: remove all sharps from the room, open the doors and blinds in the room, close the window in the room, place a stop sign on the door, remove all personal belongings, store all personal belongings in a designated place on unit, patient in full view of staff at all times, patient in stays in bed in room, no sharps are used by patient, and patient restricted to room.

Review of the form titled, "24 Hour Visibility Documentation Form", NUR129, 3/08 revealed the justification, time, location and behavior of the patient had sections to document the patient's continuous observation by the ancillary staff.

Based on record review and interview the hospital failed to ensure Post Anesthesia Care Unit (PACU) medication orders were complete by: 1. failing to order the total amount of Morphine Sulfate that may be administered in PACU for 2 of 5 post anesthesia records reviewed out of a total sample of 20 patient records (#6, #14); 2. failing to order the frequency for administration of Morphine Sulfate in the PACU for 1 of 5 post anesthesia records reviewed out of a total sample of 20 patient records (#6).
Findings:

1.
Review of the PACU orders for Patient #6 dated 01/13/11, revealed the ordering physician failed to write an order for the total amount of Morphine Sulfate to be administered in the PACU.

Review of the PACU orders for Patient #14 dated 01/10/11, revealed the ordering physician failed to write an order for the total amount of Morphine Sulfate to be administered in the PACU.

In interview on 01/18/11 at 3:05 p.m. S4 Anesthesia Clinical Supervisor, and S5 Surgery Director, confirmed that the PACU orders failed to include the total dose of Morphine Sulfate to be administered in the PACU.

2.
Review of the PACU orders for Patient #6 dated 01/13/11, revealed the ordering physician failed to write an order for the frequency for administration of Morphine Sulfate in the PACU.

In interview on 01/18/11 at 3:05 p.m. S4 Anesthesia Clinical Supervisor, and S5 Surgery Director, confirmed that the PACU orders failed to include the total dose of Morphine Sulfate to be administered in the PACU.

Review of the Hospital Policy titled: "Analgesic Administration in Post Anesthesia Care Unit, Policy #: 646-35" revealed, in part, "II. Implementation: A. The anesthesiologist caring for the patient will specify the amount, type and route of administration for the medication given in PACU, or may elect to follow the surgeon's post-operative medication orders".

Based on observation and interview the hospital failed to ensure medical records were properly filed in a manner to protect them from water damage if the hospital's sprinkler system were triggered. Findings:

Observations on 1/19/2011 at 10:00 a.m. revealed 7 movable filing cabinets with open shelves and two stationary cabinets with open shelves containing medical records in the hospital's Medical Record Department. Further observations revealed a sprinkler system was present above the medical record files.

During a face to face interview on 1/19/2011 at 10:00 a.m., HIM Director S10 indicated the movable files containing medical records were never moved. S10 indicated that two of the filing cabinets were originally radiology file cabinets. S10 indicated that moving the filing cabinets caused problems with the hospital's MRI (Magnetic Resonance Imaging) system and therefore they were never moved. S10 confirmed the medical records stored on open shelves would be subject to water damage were the hospital's sprinkler system to be triggered.

Based on record review and interview the hospital failed to ensure omitted respiratory treatments were reported to the patient's physician and the hospital wide quality assurance performance improvement department for 1 of 1 random sampled patients with omissions of respiratory treatments as ordered by the patient's physician (#R1). Findings:

Review of Patient #R1's Physician's orders revealed the following respiratory orders:
12/26/2010 at 2150 (9:50 p.m.): Ventolin (Albuterol) 0.5 in 5 cubic centimeters of Normal Saline every four hours; Mucomyst (Acetylcysteine) with Respiratory Treatment every four hours.
12/28/2010 at 9:53 a.m. : Decrease respiratory treatments to bid (twice per day) and PRN (as needed).
1/12/2011 at 12:00 noon: Increase aerosols with 0.6 milligrams Xopenex (Levalbuterol), mucomyst to tid (three times per day).

Review of Patient #R1's Medication Administration Record revealed "therapist busy" when Albuterol aerosols were scheduled for administration and omitted on 12/27/2010 at 2100 (9:00 p.m.), 12/28/2010 at 0100 (1:00 a.m.) and 0500 (5:00 a.m.). Further review revealed "RT (respiratory therapist) no notified of order change" when Levalbuterol aerosols were scheduled for administration and omitted on 1/12/2011 at 1500 (3:00 p.m.). Review revealed "therapist busy" when Acetylcysteine aerosols were scheduled for administration and omitted on 12/28/2010 at 0100 (1:00 a.m.) and 0500 (5:00 a.m.). Further review revealed "reason other" when Acetylcysteine was scheduled for administration and omitted on 12/27/2010 at 2200 (10:00 p.m.).

During a face to face interview on 1/19/2011 at 8:10 a.m., Director of Respiratory S9 confirmed the missed aerosol treatments as listed above for Patient #R1. S9 further indicated there was a log located in the Respiratory Department (confirmed with record review) where omitted medications were recorded. S9 indicated none of the missed aerosols as documented above for Patient #R1 had been documented in the Missed Aerosol Log in the Respiratory Department. S9 indicated it had not been the practice of the Respiratory Department Staff to notify the patient's physician of omitted medications or to document on an Incident/Occurrence Form.

During a face to face interview on 1/19/2011, Pharmacist S11 indicated he had no reports of missed aerosols from the Respiratory Department. S11 indicated that without having Occurrence Reports for missed medications, he would have no way to monitor, track, or trend medication errors made by the Respiratory Department. S11 indicated he had been unaware of any omissions of medications by the Respiratory Department and had never seen their Missed-Respiratory Treatment log. The Director of Quality Assurance Performance Improvement S1 was present during this interview and confirmed there had been no tracking and trending of medication omissions by the Respiratory Department.

Review of the hospital policy titled, "Patient/Visitor Incident Reporting, # 670-34C, last revised March 2004" presented by the hospital as their current policy revealed in part, "(Attachment) Medication Error Report: Physician Notified: Physician Name: Incorrect dose administered, Drug Given by incorrect route, Drug Omitted, Extra Dose of drug was administered, Drug administered to incorrect patient, Incorrect drug was administered, Drug administered to Patient with known allergy. . . When an incident/occurrence occurs, the employee witnessing the incident or becoming involved following the incident will complete the occurrence report. . ."

Based on observations and staff interviews, the hospital failed to ensure the hospital environment was maintained in a safe manner as evidenced by having dirty patient equipment in the Emergency Department trauma rooms " a " and " b " (sink facet rings, biohazard label, air conditioner vent, blood pressure cuffs ) and psychiatric holding area (sink).
Findings:


During a tour of the Emergency Department on 1/18/11 at 11:00am through 11:30am with S12 Emergency Room Director (ER Dir), trauma rooms " a " and " b " were observed with a grayish/whitish cached substances that surrounded the facet ring ' s outer surface area and cold and hot water facet ' s rings about one-fourth (1/4) inch. Further observation at 11:00am revealed trauma room " a " was noted with a file letter rack holder with five (5) slotted areas about two (2) inches in width with an orange discoloration on both sides of the slots about ? inch in width. Further observation of the rack holder revealed there were a total of about 20 sterile gloves ranging in sizes six (6) to eight (8) stored in the first four (4) rack holder. There were six (6) sterile drapes stored in the fifth (5th) rack holder. The 20 sterile gloves and 6 sterile drapes were removed from each of the 5 rack holders by S12 ER Dir at this time. Further observation revealed the orange discoloration noted on both sides of the slotted areas was touched when the sterile gloves and sterile drapes were removed from the rack holder by S12 ER Dir. At this time, S12 ER Director confirmed the above findings. At 11:20am, trauma room " b " the metal grooved sections of the air conditioner vent was observed covered with an orange discoloration. S12 ER Dir confirmed the metal grooved sections of the air conditioner vent were dirty at 11:20am. Further observation revealed there were adult -sized blood pressure cuffs, (maroon, tan) that had white debris covering the velcro area of the cuff at 11:30am. S12 ER Dir confirmed the adult-sized blood pressure cuffs were dirty with white debris at 11:30am.

A tour of the Psychiatric Holding Area with S12 ER Dir was conducted on 1/18/11 at 11:35am with S12 ER Dir and S7 Chief Operating Officer (COO). During this same tour, the aluminum sink was observed with a cached brownish/grayish/whitish substance along the back ledge of the sink about ? inch thick. Further observation revealed the paper towel holder had a white napkin dispensed. The left edge of the white napkin dispensed was touching the dirty ledge of the sink. S12 and S7 both confirmed the above findings. At 11:41am, S25 Housekeeping Director was observed removing the cached brownish/grayish/whitish substance from the back ledge of the sink with his ink pen. S25 indicated the sink ledge was dirty. S25 agreed the paper towel dispensing the white napkin onto the dirty sink ledge.

Based on observation, record review, and interview the hospital failed to 1) ensure a policy and procedure was developed and implemented to ensure refrigeration coolers located in the hospital's morgue were maintained at the proper temperature and 2) ensure the functionality of all equipment in the crash cart on the acute care psychiatric unit. Findings:

1. Observations on 1/18/2011 at 10:00 a.m. revealed the temperature of the refrigerated cooler for storage of bodies of deceased patients awaiting funeral home receipt was 58 degrees Fahrenheit. This finding was confirmed by Quality Assurance Performance Improvement Director S1 and Safety Officer S6 at the time of the observation.

During a face to face interview on 1/18/2011 at 10:00 a.m., Safety Officer S6 indicated there had been no preventive maintenance performed on the morgue's cooler. Further S6 indicated he did not know what the appropriate temperature for storing bodies should be. S6 indicated the refrigerator cooler used by the hospital was old and the hospital had no manufacturer's information on the cooler. Further Safety Officer S6 indicated there was no hospital policy that addressed the morgue to include no documentation as to how often the temperature of the cooler should be checked or what the acceptable temperature range should be. S6 indicated it had been the practice of the facility to only document the morgue's cooler temperatures at the time a body was placed into a cooler.

During a face to face interview on 1/18/2011 at 11:15 a.m., Safety Officer S6 indicated he had located a copy of Louisiana Revised Statutes Title 37. Professions and Occupations Chapter 10. Embalming and Funeral Directors. Part 1. General provisions. which revealed in part, "If the body is to be held by the funeral establishment longer than thirty hours after the time of death, it shall be embalmed or the body may be refrigerated continuously at a temperature not to exceed forty-five degrees Fahrenheit.

Review of the hospital's "Morgue Log" from the date of 1/11/2009 through 1/18/2011 revealed a total of 24 deceased patients were placed in the morgue. Further review revealed the temperature of the cooler was documented as greater than 45 degrees as follows:
One body (Patient R4) placed in morgue on 2/14/2009 with temperature of cooler logged as 46 degrees. The body was picked up on 2/15/2009. There was no temperature recorded for the date of 2/15/2009.
One body (Patient #R5) placed in morgue on 1/12/2010 with temperature of cooler logged as 46 degrees. The body was picked up on 1/13/2010. There was no temperature recorded for the date of 1/13/2010.
One body (Patient #R6) placed in morgue on 3/03/2010 with temperature of cooler logged as 48 degrees. The body was picked up on 3/11/2010 (8 days after the patient died). There were no temperatures recorded for the dates of 3/04/2010, 3/05/2010, 3/06/2010, 3/07/2010, 3/08/2010, 3/09/2010, 3/10/2010, or 3/11/2010.
One body (Patient #R7) was placed in the morgue on 3/28/2010 with temperature of cooler logged as 46 degrees. The body was picked up on 3/29/2010. There was no temperature recorded for the date of 3/29/2010.
One body (Patient #R8) was placed in the morgue on 3/30/2010 with temperature of cooler logged as 46 degrees. The body was picked up the same day: 3/30/2010.
One body (Patient #R9) was placed in the morgue on 8/21/2010 with temperature of cooler logged as 50 degrees. The body was picked up the same day: 8/21/2010. These findings were confirmed by Safety Officer S6.

2. Observations of the acute care psychiatric unit were made on 1/18/11 between 9:50 a.m. and 11:45 a.m. The acute care psychiatric unit charge nurse (S3) and the hospital's chief nursing officer (S2) were present during these observations. When asked to test the equipment in the crash cart, it was noted that the Laryngoscope was not functioning as the light on the blade failed to illuminate when attached to the handle. S3 reported that monthly checks are done on the crash cart but did not believe the checks included testing the functionality of the Laryngoscope. S3 changed the batteries in the handle of the Laryngoscope and the equipment functioned properly after the batteries were changed. S2 indicated that the monthly checks should include testing the functionality of the Laryngoscope.

Based on record review and interview the hospital failed to develop an effective system for ensuring that all hospital credentialed physicians were free of tuberculosis upon appointment and annually thereafter for 47 physicians that failed to respond to the hospital's written request dated 10/07/2010 for compliance with TB surveillance. Findings:

Review of a list provided by the hospital of physicians that were non-compliant with screening for tuberculosis revealed the names of 47 physicians.

Review of a documented letter titled, "Important Notice" dated October 7, 2010, revealed in part, "Memo To: Medical Staff, Allied Health Staff. From: (Physician S14). Re (Regarding): TB (tuberculosis) Surveillance for the Medical/Allied Health Staff. In keeping with CMS regulations all members of the healthcare team must have annual TB tests. . . Please furnish the Medical Staff office with a copy of your current TB test results as soon as possible. It must have been done within the past 12 months. If you have not had a TB test in the past twelve months, please schedule an appointment with Employee Health. . . If you have had a positive TB test in the past please complete the attached TB surveillance form and return it to the Medical Staff Office."

During a face to face interview on 1/19/2011 at 2:25 p.m., Quality Assessment Performance Improvement Director S1 indicated she had not been successful in getting the cooperation of physicians for TB screening. S1 confirmed that the list provided to the surveyors containing the names of 47 physicians that had not complied with TB screening was an accurate account of physicians that had been non-compliant with the TB screening process.

Based on observation and interview the hospital failed to ensure steam indicators used for sterilization of surgical instruments were not expired by having 25 chemipack integrator test packs available in the sterile processing department that expired on 03/2010.
Findings:

Observation on 01/18/11 at 10:20 a.m., during a tour sterile processing department of the operating room, revealed 25 chemipack integrator test packs were available that expired on 03/2010.

In interview on 01/18/11 at 10:20 a.m., S5, Surgery Director, S6, Chief Operating Officer, and S15, Scrub Technician, confirmed that the chemipack integrator test packs were expired on 03/2010. S15 indicated that the operating room policy was to discard all expired items. S15 further indicated that the chemipack integrators are used for rapid sterilization of implants, such as screws and plates used for orthopedic surgery. The expired chemipack integrators were discarded by the hospital staff at the time of the observation.

Based on record review and interview, the hospital failed to assign an individual to be responsible for outpatient services as evidenced by: failing to have a single individual assigned to direct the overall operation of the hospital's entire outpatient services and failing to define in writing the qualifications and
competencies necessary to direct the outpatient services to include the directors necessary education, experience and specialized training consistent with State law and acceptable standards of practice. Findings:

In a face-to-face interview conducted on 1/19/11 at 2:05 pm, S7 Chief Operating Officer (COO) indicated there was no single individual assigned to direct the overall operation of the hospital's entire outpatient services. S7 COO further indicated there was no written documentation that clearly defined in writing the qualifications and competencies necessary for the director of the outpatient services.

Based on record review and interview the hospital failed to ensure respiratory treatments were administered as per physician's orders for 1 of 3 random sampled patients reviewed for respiratory treatment administration (#R1). Findings:

Review of Patient #R1's Physician's orders revealed the following respiratory orders:
12/26/2010 at 2150 (9:50 p.m.): Ventolin (Albuterol) 0.5 in 5 cubic centimeters of Normal Saline every four hours; Mucomyst (Acetylcysteine) with Respiratory Treatment every four hours.
12/28/2010 at 9:53 a.m. : Decrease respiratory treatments to bid (twice per day) and PRN (as needed).
1/12/2011 at 12:00 noon: Increase aerosols with 0.6 milligrams Xopenex (Levalbuterol), mucomyst to tid (three times per day).

Review of Patient #R1's Medication Administration Record revealed "therapist busy" when Albuterol aerosols were scheduled for administration and omitted on 12/27/2010 at 2100 (9:00 p.m.), 12/28/2010 at 0100 (1:00 a.m.) and 0500 (5:00 a.m.). Further review revealed "RT (respiratory therapist) no notified of order change" when Levalbuterol aerosols were scheduled for administration and omitted on 1/12/2011 at 1500 (3:00 p.m.). Review revealed "therapist busy" when Acetylcysteine aerosols were scheduled for administration and omitted on 12/28/2010 at 0100 (1:00 a.m.) and 0500 (5:00 a.m.). Further review revealed "reason other" when Acetylcysteine was scheduled for administration and omitted on 12/27/2010 at 2200 (10:00 p.m.).

During a face to face interview on 1/19/2011 at 8:10 a.m., Director of Respiratory S9 confirmed the missed aerosol treatments as listed above for Patient #R1. S9 further indicated there were times when Respiratory Therapist were busy with other patient needs and not able to provide treatments to other hospitalized patients as ordered by their physician. S9 indicated the department had a log for "missed treatments" however none of the above omissions had been recorded in the log. S9 indicated there was always one Respiratory Therapist scheduled for the hospital (59 bed hospital). S9 indicated there would be more than one Respiratory Therapist on duty when she was there during the day hours. S9 indicated the Respiratory Therapist would also cover emergencies in the Emergency Department. S9 further indicated there were only four patients located in the hospital with aerosol treatments and no patients on ventilators (1/19/2011). S9 indicated the number of patients with Respiratory needs located in the hospital were low and the therapist should be able to meet the needs of the patients with the exception of times when emergencies occupied the therapist.