HospitalInspections.org

Based on a review of facility policy and medical records (MR), observation and interview with staff (EMP), it was determined that the facility failed to adhere to their established policy for obtaining a physician order and informed consent prior to video monitoring patients for three of three medical records reviewed (MR31, MR32 and MR33).

Findings include:

A review on April 6, 2010 of facility policy: "Video Monitoring: Criteria and Procedure for Patient," last reviewed February 2010 revealed, "...Upon placement in room 360 MICU, room 3ES, or upon physician order in Administrative Telemetry Monitoring Center, a consent for video monitoring will be obtained from the patient or their responsible party. ..."

1) Observation on April 6, 2010, of the Progressive Care Unit monitoring room revealed three patients that were being video monitored.

2) A review on April 6, 2010, of MR31, MR32 and MR33 revealed that the medical records did not contain a physician order and/or a signed consent for the video monitoring.

3) An interview conducted on April 6, 2010, at 11:00 AM with EMP1 confirmed that MR31 and MR33 did not have a physician order and consent prior to video monitoring and MR32 did not have a signed consent for video monitoring.

Based on a review of facility policy, documentation and interview with staff (EMP), it was determined the facility failed to ensure that dialysis machines were disinfected according to the facility's established policy.

Findings include:

A review on April 6, 2010, of facility policy, Fresenius 2008H Machine: Acid Clean and Heat Disinfection: last reviewed January 2010 revealed, "...Chemical disinfection or heat disinfection must also be performed before treatment and any other time the machine has not been used for more than 48 hours. ..."

1) A review on April 7, 2010, of the Acute Treatment Log revealed that once in February 2010 and once in March 2010 the dialysis machine was not used for 48 hours and there was no evidence of disinfection prior to use.

2) An interview conducted on April 7, 2010, at 10:00 AM with EMP2 confirmed the facility could not provide evidence that the machines were disinfected prior to use when they had not been used for more than 48 hours.
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Based on observation and interview with staff (EMP), it was determined the facility failed to ensure all personnel were competent in using the automated external defibrillator (AED).

Findings include:

1) Observation on April 5, 2010, of the defibrillator on the medical surgical unit revealed the paper contained a red streak indicating the defibrillator was about to run out of paper. EMP4 and EMP6 were unable to insert a new roll of paper into the defibrillator.

An interview conducted on April 5, 2010, at 11:45 AM with EMP4 and EMP6 confirmed they did not know how to insert a new roll of paper in the defibrillator.

2) Observation on April 5, 2010, of the AED in the Cancer Center revealed EMP6 was unable to correctly apply the AED.

An interview conducted on April 6, 2010, at 1:45 PM with EMP6 confirmed that EMP6 did not know how to change the defibrillator paper or correctly apply the AED.

Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure that the contracted dialysis nurses followed physician orders for three of four medical records reviewed (MR35, MR36, and MR42).

Findings include:

A review on April 7, 2010, of Fresenius Medical Care (FMS) policy, "FMS Inpatient Services Administrative Guidelines" effective date May 21, 2008 revealed, "... The FMS Inpatient Services or apheresis services (a process of removing a specific component from the blood and returning the remaining components) must be ordered by an appropriate credentialed physician. Orders must be appropriately communicated and written on the medical record prior to treatment."

A review on April 7, 2010, of MR35 revealed on March 16 and 19, 2010, the physician ordered Heparin (prevents clotting of blood) "Min." The nurse's flow record documentation revealed Heparin 2,000 units was administrated without a physician order. A review of the physician orders of March 17, 2010, revealed an order to change the Potassium from a 2 to 3 millequivalent (meq) bath.

A review on April 7, 2010, of MR 35 nurse's flow record revealed the nurse documented with a check mark that Potassium was given. There was no documentation of how many meq. of Potassium was administered. There was no documentation that the physician was called to clarify the Heparin order or that a new order was obtained.

A review on April 7, 2010, of MR 36 revealed a physician's order written on March 15, 2010, for a total dialysis time of three hours and removal of two liters of fluid. The nurse's flow record documentation revealed the patient was dialyzed for two and one-half hours and 1.5 liters of fluid was removed. There was no documentation why the physician's orders were not followed or that the physician was notified of the change and a new order obtained.

A review on April 7, 2010, of MR36 revealed physician's orders written on March 17 and 18, 2010 for a blood flow rate of 400 to be maintained. The nurse's documentation revealed that on March 17, 2010, the blood flow rate was between 450 and 500 and on March 18, 2010, the blood flow rate was 500. There was no documentation that the physician was notified of the change and a new order obtained.

A review on April 7, 2010, of MR42 revealed a physician's order written on February 22, 2010, for a blood flow rate of 400. The nurse's documentation revealed the blood flow rate was 300. On February 25, 2010, the physician ordered a blood flow rate of 400. The nurse's documentation revealed the blood flow rate was between 250 and 450. A physician order on February 27, 2010, revealed "min" Heparin. The nurse's documentation revealed Heparin 2,000 units was administered. There was no documentation documentation that the physician was called to clarify the Heparin order or that new orders obtained.

An interview conducted on April 7, 2010, at 10:00 AM with EMP2 confirmed that the physician orders were not followed and that there was no documentation in MR35, MR36 and MR42 that the physician was called and new orders were obtained.

Based on a Life Safety Code Validation survey, the Condition for Physical Environment is not met based on the results of the Department of Safety Inspection survey completed on March 31, 2010. See the Life Safety Code survey 2567 for the deficiencies.

Based on review of facility policy, documentation, observation and interview with staff, it was determined the facility failed to ensure a safe and sanitary environment.

Findings include:

1) A review on April 5, 2010 of facility policy, Ultrasound Department-Changing Cidex Filter, last reviewed 3/10 revealed, "The Cidex Filter will be replaced once every six (6) months. This is to be done by an Ultrasonographer."

Observation on April 5, 2010 of the log of filter changes in the Cidex Room revealed that the Cidex filter had not been replaced since 2008.

An interview conducted on April 5, 2010 at 1:30 PM with EMP9 confirmed that the Cidex filter had not been replaced every six months as required by policy.

2) Observation on April 6, 2010, of the Cancer Center revealed two vinyl patient chairs that had torn arms that exposed the padding.

An interview conducted on April 6, 2010 at 1:45 PM with EMP6 confirmed the two vinyl patient chairs in the Cancer Center had torn arms that exposed the padding.

3) Observation on April 5, 2010 of the dialysis unit revealed two vinyl patient chairs that had torn arms that exposed the padding.

An interview conducted on April 5, 2010 at 10:00 AM with EMP8 confirmed the two patient chairs in the Dialysis unit had two vinyl patient chairs with arms that were torn and exposed the padding.

4) Observation on April 6, 2010 of the Emergency room pediatric code cart revealed seven laryngeal mask airways (LMA) had expired; three expired August 2009, three expired February 2009 and one expired January 2010.

An interview conducted on April 6, 2010, at 10:10 AM with EMP6 confirmed the seven LMA's had expired.

5) Observation on April 5, 2010, of four north code cart revealed a respiratory box that contained a nasal airway that expired December 2008.

An interview conducted on April 5, 2010, at 2:50 PM with EMP5 confirmed the respiratory box contained a nasal airway that expired December 2008

6) Observation on April 6, 2010, of the Orthopedic cast room revealed a Wilson frame with torn vinyl that exposed padding.

An interview conducted on April 6, 2010, at 11:00 AM with EMP11 confirmed the torn vinyl covering on the Wilson frame.

7) Observation on April 6, 2010, of the surgical suite revealed the following rusty items: castors on case tables in operating room (OR) 1, 4, 5 and 6; on ring stands in OR 1, 2, 5 and 8; on kick buckets in OR 5; on IV/Bair Hugger stands in OR 8 and Orthopedic cast room; and on a Bovie stand in OR 8; on step stools in OR 5 and 6; base of surgeon's stools in OR 1; bases of one large and one small medical gas wheeled cart and exterior of a small CO2 tank in OR 5;

An interview conducted on April 6, 2010, at 11:15 AM with EMP11 confirmed the rusty castors on the OR equipment.

8) Observation on April 6, 2010, of OR 8 revealed two table positioners placed on the floor and OR 1 revealed a Bair Hugger with flexible tubing that was lying on the floor.

An interview conducted on April 6, 2010, at 11:30 AM with EMP11 confirmed the equipment was lying on the OR floors.

9) Observation on April 6, 2010, of OR 5 revealed three lead aprons lying wrinkled on OR counters.

An interview conducted on April 6, 2010, at 11:20 AM with EMP11 confirmed the lead aprons were wrinkled on the counters.

10) Observation on April 6, 2010, of substerile rooms 1, 2 and 4 revealed wooden doors connecting directly to the ORs that had holes at the bottom through the entire door.

An interview conducted on April 6, 2010, at 11:25 AM with EMP11 confirmed the doors to the OR's had missing pieces of wood and there were holes through the doors.

11) Observation on April 6, 2010, of substerile rooms 1 and 2 revealed floor mounted hoppers that contained water located immediately next to the Amsco sterilizers and water in mop buckets located in front of the sterilizers. Further observation of substerile room 7 revealed a red infectious waste container located between the Amsco sterilizer and the fluid warmer.

An interview conducted on April 6, 2010, at 11:30 AM with EMP11 confirmed the presence of the hoppers and mop buckets next to the sterilizers and the infectious waste container between the sterilizer and fluid warmer.

12) Observation on April 5, 2010, of the kitchen revealed two ceiling mounted Carrier heaters with thick layers of dust and dirt over the tray line and the cold food area.

An interview conducted on April 5, 2010, at 10:00 AM with EMP12 confirmed the presence of the dust and dirt on the ceiling mounted heating equipment.

13) Observation on April 5, 2010, of the retail restaurant revealed three holding cabinets with thick layers of dust on the overhead vents.

An interview conducted on April 5, 2010, at 10:30 AM with EMP12 confirmed the presence of the dust on the holding cabinet vents.