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Based on record review and interview the hospital failed to ensure the clinical records system was maintained in accordance with written policies and procedures as evidenced by failure to ensure medical records of patients were promptly completed as set forth in the hospital's policies for completion of medical records.

Findings:

Review of the hospital's policy titled Documentation of Health Information revealed in part:
Procedure: 7. All signatures should be on the chart within 30 days of discharge.
Procedure: 10. The Hospital conducts an ongoing review of records ...

Review of the hospital's Medical Staff By-laws, Policy 1 Medical Record Completion Policy revealed in part:
H. Minimum Content
1.15 Delinquent Medical Record:
Each group is assigned a week for completion of records. ...the assigned practitioner group will receive an Alert Letter from the Medical Records Department. If the member fails to complete the medical records within five (5) calendar days after receiving the warning, a temporary suspension ...shall be automatically imposed ...Temporary Suspension totaling more thirty-days (30) in one calendar year shall be deemed a voluntary resignation ...

Review of the hospital's Deficiencies by Provider and Days Incomplete report dated 1/31/18 revealed the following medical record deficiencies:

S15MD Physician: 31-60 days deficient: 2; Total deficient records: 2.
S16MD Physician: 31-60 days deficient: 1; 61-90 days deficient: 18; Total deficient records: 19.
S17MD Physician: 91 days or greater deficient: 3; Total deficient records: 3.
S18MD Physician: 91 days or greater deficient: 1; Total deficient records 1.
S19MD Physician: 61-90 days deficient: 1; 91 days or greater: 1; Total deficient records: 2.
S20MD Physician: 61-90 days deficient: 1; 91 days or greater: 1; Total deficient records: 2.
S21MD Physician: 31-60 days deficient: 15; Total deficient records 15.

During an interview on 1/31/18 at 2:45 S22CMO stated the facility has not issued any temporary suspensions and acknowledged the facility did not follow its policies and bylaws for completion of medical records.

Based on record review and interview the hospital failed to ensure the clinical records system was maintained in accordance with written policies and procedures as evidenced by failure to ensure medical records of patients were authenticated promptly by the ordering practitioner as set forth in the hospital's policy for physician orders.

Findings:

Review of hospital's policy, subject Physician Orders, revealed in part the following:
Procedure: F. All verbal or telephone orders shall be signed by the appropriately authorized person to whom the order was given...The responsible Practitioner shall authenticate within 10 days.

Review of patient R#2's chart with S2ADON failed to reveal the verbal order for Lasix 80 milligrams to be given intravenous (IV) on 1/1/18 at 6:00 p.m. was authenticated by the responsible reactionary.

During an interview at this time, S2ADON acknowledged the verbal order was not authenticated by the responsible practitioner.

Based on observation and interview, the hospital failed to ensure that unusable drugs were not available for patient use as evidenced by having a used single dose vial of sterile water stored in the medication room cabinet.

Findings:

Observation on 1/29/18 at 2:20 p.m. of the second floor revealed an open 10cc single-dose-use bottle of sterile water that was dated 1/14/18 and initialed with the letters KM on a shelf along with sealed bottles of Miralax in a cabinet located on the wall across from the Pyxis station in the medication room near the east side nurses station.

During an interview on 1/29/18 at 2:02 p.m., S7RN acknowledged the open single-dose-use bottle of sterile water and acknowledged the bottle should have been discarded and not kept for multiple use.

During an interview on 1/30/18 at 11:00 a.m., S13RN nurse manager stated they reconstitute some dosages of Solumedrol with sterile water on the second floor and acknowledged the sterile water they use are single-dose-use only and were to be discarded immediately after use.

Based on record review and interview, the hospital failed to ensure identified medication errors were documented in the patient's electronic medical record for 1 of 1 (Patient #18) hospital identified medication errors reviewed.

Findings:

Review of hospital's policy, Subject: Medication Errors revealed, in part, the following:
VI. H. The medication administered or omitted in error should be recorded in the patient care notes by the resposible staff member.

Review of the hospital's medication variance reports revealed Patient #18 had received a dose of Vancomycin 1 Gram intravenous (IV) on 1/14/18 at 11:45 p.m. and the medication was supposed to be given on-call to the operating room.

During an interview on 1/30/18 at 2:30 p.m. S2ADON confirmed, after review of patient #18's medical record, the medication error was not documented in the patient's electronic medical record.

Based on record review, observation, and interview, the hospital failed to ensure the infection control officer developed a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:
1) failing to ensure the blood glucose meter was disinfected, immediately after patient use, per hospital protocol, during capillary blood glucose sampling for 1 (#R2 ) of 1 patients observed during capillary blood glucose sampling.
2) Failing to ensure equipment and other surfaces in a patient's room (#1) who was on contact precautions for positive wound cultures for MRSA (Methicillin-resistant Staphylococcus aureus) were not cross contaminated with soiled linens after they had been removed from the patient's bed for 1 (#1) of 2 (#1,#R1) patients observed who were on isolation precautions in the hospital's Intensive Care Unit.
3) failing to maintain a sanitary environment.

Findings:

1) Failing to ensure the blood glucose meter was disinfected immediately after use, per hospital protocol, during capillary blood glucose sampling.

Review of the hospital policy titled, "Designation of Clean and Dirty Patient Care Equipment" revealed in part: Shared patient care items such as blood glucose monitors should be cleaned after each patient use with either bleach wipes of a 1:10 dilution or Super Sani-Cloths. Further review revealed the disinfectant exposure time was for the meter to remain wet greater than or equal to 1 minute and to allow the device to air dry.

On 1/31/18 at 9:45 a.m. an observation was made of S5RN performing a fingerstick capillary blood glucose on Patient #R2. S5RN obtained the sample, performed the test, and discarded her gloves and sharps. S5RN was then observed picking up the glucose meter (which had not been disinfected), placing the glucose meter under her arm (contacting her scrubtop) to carry the device out of Patient #R2's room. S5RN then placed the meter on the counter of the nurses' station before obtaining a disinfectant wipe to clean the device.

In an interview on 1/31/18 at 11:20 a.m. with S2ADON, who had been present on the unit during the observation, she confirmed S5RN should have disinfected the blood glucose meter immediately after use. S2ADON also confirmed S5RN should not have carried the meter under her arm, (contacting her clothing) and should not have put the meter on the nurses' station counter prior to disinfecting the device.


2) Failing to ensure equipment and other surfaces in a patient's room (#1) who was on contact precautions for positive wound cultures for MRSA were not cross contaminated with soiled linens after they had been removed from the patient's bed.

Review of the hospital policy titled,"Guidelines for Isolation Precautions", reference #2009, revealed in part: Modes of transmission: There are 3 primary routes by which patients are exposed to microorganisms in health care settings: 1. Contact transmission: Direct and Indirect. Indirect: The most frequent mode of transmission; pathogens are transferred through a contaminated intermediate object or person.
Contact precautions: These precautions are to be used to reduce risk of transmission of resistant microorganisms by direct or indirect contact with a patient and/or patient's environment. Examples of the organisms that are MDROs (multiple drug resistant organisms) are MRSA and VRE (Vancomycin-Resistant Enterococci).

Review of Patient #1's medical record revealed the patient was on contact isolation precautions for positive wound cultures for MRSA (a MDRO).

On 1/31/18 at 9:50 a.m. an observation was made of Patient #1. The signage on the patient's room indicated the patient was on contact isolation precautions and an isolation supply cart was noted outside of the patient's room. .

On 1/31/18 at 9:55 a.m. an observation was made of S4RN changing the linens on Patient #1's bed. S4RN was observed touching the patient and the patient's linens with her gloved hands. S4RN was then observed placing a balled-up sheet that had been on the patient's bed on the keyboard of the in-room computer. S4RN was still wearing the same gloves. S4RN was then observed placing the soiled, balled-up sheet on the counter of the sink in Patient #1's room. S4RN cleansed the basin used to clean the patient and then placed the balled-up, soiled sheet in the biohazard linen hamper. S4RN failed to disinfect the computer keyboard and the counter of the sink in the patient's room after removing and discarding the soiled linens.

In an interview on 1/31/18 at 11:20 a.m. with S2ADON, who had been present on the unit during the observation, she confirmed S4RN should have discarded the soiled linens in the biohazard hamper immediately after removing them from the patient's bed. S2ADON agreed S4RN should not have placed the soiled linens on the computer keyboard and on the counter of the sink in the patient's room. S2ADON also confirmed S4RN should have disinfected the computer keyboard and the counter of the sink in the patient's room after removing and discarding the soiled linens.

3) Failing to maintain a sanitary environment as evidenced by failing to maintain radiology equipment, kitchen equipment, and equipment in patient care areas.

Findings:

I.

Review of hospital's policy Radiographic Contrast Material states in part:
B. ...Contrast will be drawn up in injector syringes and kept sterile by attaching the tubing that comes in the injector syringe package.

Observation on 1/29/18 at 1:18 p.m. revealed the CT injector syringe was left exposed to air on the flush side and a small fiber particle was in contact with the opening.

During an interview on 1/29/18 at 1:22 p.m. S11RadDir acknowledged leaving the injector open to air was a violation of the policy and an infection control issue.


II.

Observation on 1/29/18 at 3:30 p.m. of 3-compartment sink in the dish washing area of the kitchen failed to reveal a log book detailing the test strips results and the frequency of the tests results for the 3-compartment sink.

During an interview on 1/29/18 at 3:33 p.m., S9RD and S10DM acknowledged they did not keep a log of their chemical test strip results.

Observation on 1/29/18 at 3:38 p.m. revealed a 1.5 centimeter (cm) wide area of a black substance along the upper interior portion of the ice machine's door. Continued observation at this time reveal S10DM remove black substance by wiping the interior of the door with a clean towel.

During an interview on 1/19/18 at 3:40 p.m. S10DM acknowledged the black substance accumulated on the interior of the ice machine door was not sanitized and was an infection control issue.


III.

Review of hospitals policy Subject: Designation of Clean and Dirty Patient Care Equipment stated in part:
I. c. Only soiled equipment is stored in the soiled utility room.
II. Dedicated patient care equipment a. ...Clean, wrapped infusion pumps will be stored in clean patient care rooms or clean storage rooms.

During an observation on 1/30/18 beginning at 10:10 a.m., surveyor was accompanied on the second floor by S13RN Nurse Manager for general care areas and vacant hospital rooms during surveyor's entire observation

Observation on 1/30/18 at 10:10 a.m. revealed room 239 had a bed marked as clean with multiple particles approximately 1x 0.5cm on the surface of the mattress. S13RN acknowledged the findings and acknowledged this was an infection control issue.

Observation on 1/30/18 at 10:25 a.m. revealed a microwave in the Patient Nourishment room with dried food particles on every wall surface and the carousel plate of the microwave. S13RN acknowledged the findings and acknowledged this was an infection control issue.

Observation on 1/30/18 at 10:35 a.m. revealed room 223 revealed a dirty infusion pump on top of the bed which was marked as clean. S13RN acknowledged the findings and acknowledged this was an infection control issue.

Observation on 1/30/18 at 10:40 p.m. revealed room 228 had an infusion pump marked as clean that was soiled on the top with red/brown specks dried on the top surface of the pump and brown particles and a piece of Transpore tape on the left side of the pump. S13RN acknowledged the findings and acknowledged this was an infection control issue.

Observation on 1/30/18 at 10:45 revealed room 229 used for storage of patient equipment and the equipment labeled as clean was stored with the equipment not labeled as clean. Further observation revealed a chair with a 5cm tear to the seat cushion. S13RN acknowledged the findings and acknowledged this was an infection control issue.

Observation on 1/3/18 at 10:50 a.m. revealed room 230 labeled as clean with a dirty infusion placed for use. S13RN acknowledged the findings and acknowledged this was an infection control issue.