HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to implement acceptable standards of practice for two of four observed blanket/fluid warming cabinets located in the obstetric department and operating room (OR) suite. Findings include:

1. Observation on 9/4/13 at 7:10 a.m. revealed the Olympic warmette used for blanket warming in patient room 396 was set at 150 degrees Fahrenheit (F). Interview at the time of the observation with registered nurse (RN) G confirmed the above finding. RN G stated the warmette temperature should not have been higher than 120 degrees F or at a minimum in the green zone indicated on the temperature control dial. RN G stated she was not sure why the temperature had been set at 150 degrees F. RN G turned the warmer temperature down to 120 degrees F.

2. Observation on 9/4/13 at 10:05 a.m. in the OR revealed the Olympic warmette used for blanket and fluid warming had a temperature reading of 120 degrees F. Interview and review of the temperature log at the time of the observation with the OR director confirmed the temperature was too high for the intravenous (IV) bags in that warmette. She stated the warmer temperature for IV bags should not have been higher than 104 degrees F. warming in that warmer. A review of the policy attached to the door of that warmer revealed the temperature for IV fluids should not have exceeded 104 degrees F.

26180




23059




15036

A. Based on observation, interview, record review, and policy review, the provider failed to ensure:
*Physician's orders were obtained and followed to ensure the proper monitoring and care for one of one patient (35) with a chest tube.
*Physician's orders were clarified prior to delivery of ordered care for one of one sampled patient (41) with a gastro-intestinal bleed.
*Blood was administered in accordance with the provider's policy for one of one sampled patient (34) who received a blood transfusion.
*Nursing care plans reflected the patients' current status with appropriate nursing diagnosis, interventions, and goals for four of four sampled patients (6, 35, 36, and 37).
Findings include:

1. Review of patients 34 and 41's medical record revealed nursing care was not provided in accordance with acceptable standards of practice and the provider's care policies. Refer to C294, findings 1, 2, and 3; and C298, findings 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.

B. Based on observation and interview, the provider failed to ensure emergency medication required to treat a malignant hyperthermia (MH) crisis was available for use in one of one operating room suite. Findings include:

1. Observation and interview on 9/4/13 at 10:30 a.m. of the MH emergency cart with the director of surgery revealed:
*Only thirty-five vials of dantrolene sodium were available for use, but there should have been thirty-six vials.
*A phone call to pharmacy revealed they were not sure if additional dantrolene sodium was available in the pharmacy.
*The contingency plan for acquiring additional dantrolene sodium would have been to get it from another healthcare facility that was approximately one hour away.

Refer to C276, finding B1.

C. Based on observation, interview, and record review, the provider failed to ensure infection control practices were implemented in accordance with facility policy to prevent the potential cross-contamination of patients and patient care environments. Findings include:

1. Interview on 9/4/13 at 9:05 a.m. with the director of surgery revealed the wet contact time of ten minutes for the quaternary disinfectant solution was not met by staff when disinfecting patient care equipment and environmental surfaces.

Refer to C278, finding 1.

2. Interview on 9/4/13 at 3:20 p.m. with the director of surgery revealed the clinic staff in the surgical clinic, suite 501 did not mix the instrument pre-cleaning detergent in accordance with the manufacturer's directions for use to achieve the appropriate concentration.

Refer to C278, finding 4.

3. Physician staff and nursing staff failed to ensure appropriate hand hygiene was performed before and after completing patient care tasks.

Refer to C278, findings 5a, 5b, and 7.

4. Observation and interview on 9/5/13 at 3:11 p.m. in the endoscope storage area with the director of surgery revealed endoscopes were not secured from potential recontamination after terminal high-level disinfection.

Refer to C278, finding 6.

D. Based on interview and record review, the provider failed to ensure:
*Two of two radiology technicians (D and E) wore protective lead aprons during one of one patient's (35) portable chest x-ray.
*One of one nuclear radiology technician received training or skills testing for initiating intravenous infusions.
*Operating room staff that participated in surgical cases that required radiology support wore radiation badges to monitor their exposure.
Findings include:

1. Review of the provider's August 2012 Portable X-ray Services policy revealed "All operators of portable x-ray equipment must wear lead."

Interview on 9/4/13 at 7:45 a.m. with radiology technicians D and E revealed they should have worn protective lead aprons.

Interview on 9/4/13 at 10:00 a.m. with the director of surgery revealed operating room staff that participated in procedures that required radiology support did not wear film badges for monitoring radiation exposure. She was not aware the staff should have worn film badges to monitor their radiation exposure.

Refer to C283, findings 1, 2, and 3.

A. Based on observation, interview, and policy review, the provider failed to ensure:
*Home medications were properly stored and managed for one of one sampled intensive care patient (38) according to the provider's policy.
*Pourable sterile water used in the care of one of one sampled intensive care patient (38) was properly labeled with the opened date and time.
*A syringe used for one of one sampled patient (34) who received a blood transfusion was labeled according to the provider's policy.
*The security of medications in one of one pharmacy and one of one surgical area.
Findings include:

1. Interview on 9/3/13 at 3:00 p.m. with patient 38 revealed he:
*Had a history of a renal transplant and was currently having some breathing problems.
*Used a BiPAP (breathing assistance machine) whenever he was in bed.
*Used anti-rejection medications and kept them in his personal belongings in his room. He further stated he would take those medications and then make sure the nurse knew.

Observation on 9/3/13 at 3:15 p.m. of patient 38's room revealed a 1000 milliliter bottle of sterile water was in the corner of his room opened with no date or time on it as to when it had been opened.

Interview on 9/3/13 at 3:30 p.m. with registered nurse B revealed:
*The undated and untimed bottle of sterile water in patient 38's room was used to fill the humidity chamber of patient 38's BiPAP.
*She was not certain as to when the above bottle had been opened.
*She never dated and timed the pourable bottles of medical liquids as she was not aware they expired that fast.
*The provider did not carry the anti-rejection medications for patient 38, so the patient administered his anti-rejection medications he had brought from home.
*The patient self-administered his anti-rejection medications, and then she documented them in his medication administration record.

Interview and policy review on 9/3/13 at 4:30 p.m. with the director of quality regarding the above revealed:
*The provider had no policy related to the use of non-bacteriostatic pourable liquids.
*Non-bacteriostatic liquids should have been labeled with the date and time they were opened.
*Non-bacteriostatic liquids should have been disposed of within twenty-four hours of being opened.
*Patient 38's home anti-rejection medications had not been administered and stored according to the provider's August 2013 Medication Administration policy.

2. Observation on 9/4/13 at 11:50 a.m. of patient 34 in his room revealed:
*He was receiving a blood transfusion.
*A unlabeled ten milliliter syringe with three milliliters of a clear fluid in it was inserted into his intravenous blood tubing.

Interview on 9/4/13 at 11:55 a.m. with RN B and the director of quality regarding the above unlabeled syringe revealed:
*RN B had taken over the care of patient 34 while his primary nurse was gone.
*RN B was unable to tell this surveyor for sure what was in that syringe but thought it was normal saline.
*The director of quality confirmed that syringe should have been labeled per the provider's medication administration policy.

Review of the provider's revised August 2013 Medication Administration policy revealed the above syringe should had been labeled with its contents, dated, and timed.

3. Interview and policy review on 9/5/13 at 9:00 a.m. with the pharmacy director revealed:
*Five pharmacists including herself had keys to the main pharmacy. Those keys were taken home with the pharmacists every day.
*An unknown number of keys to the main pharmacy were kept in a drawer in the pharmacy for the pharmacy technicians to use during the day. No counts of those keys were ever done.
*All of the anesthesia personnel had keys to the medication areas located in the surgical area and took them home with them.
*The pharmacy and the surgical areas were not staffed twenty-four hours a day.
*She had not considered the possible unauthorized access to the provider's medications by the key carrying staff members. Nor had she considered the potential for key duplication once the key had left the facility.
*She had no policy related to the monitoring of the keys used to access the pharmacy or anesthesia areas.

Interview on 9/5/13 at 10:30 a.m. with the director of quality revealed she:
*Was not aware of the key use noted above.
*Agreed the above noted process for key security left the pharmacy and anesthesia medication areas subject to unauthorized access.



15036

B. Based on observation and interview, the provider failed to ensure emergency medication required to treat a malignant hyperthermia (MH) crisis was available for use in one of one operating room suite. Findings include:

1. Observation and interview on 9/4/13 at 10:30 a.m. of the MH emergency cart with the OR director revealed:
*There were thirty-five vials of dantrolene sodium available for use to treat a MH crisis.
*She was not sure why only thirty-five vials were available and would check with pharmacy.
*After a call to pharmacy it was confirmed thirty-six vials should have been on hand. Pharmacy was not sure if additional dantrolene sodium had been ordered.
*A contingency plan for acquiring additional dantrolene sodium would have been to get it from another healthcare facility that was approximately an hour away.
*MH was a medical emergency, if not treated death might occur, and dantrolene sodium was the medication treatment of choice during a crisis.
*Malignant hyperthermia was a rare genetic condition characterized by a severe increase in the body's metabolism, high body temperature, and muscle rigidity.

Review of the Association of periOperative Registered Nursing, Perioperative Standards and Recommended Practices, 2012 Edition, Denver, CO., revealed:
*Pages 621-662: Anesthetic agents were triggering agents for a MH crisis. "All patients undergoing general anesthesia should be screened for a family history of MH."
*Pages 621-623: "The use of dantrolene sodium, a drug specific for the treatment of MH" was one factor for a drop in the mortality rate from MH.
*Page 623: "Thirty-six vials of dantrolene sodium will allow for initial stabilization and treatment while more vials are being acquired to continue treatment."
*Page 634: The suggested contents for a MH cart included but was not limited to thirty-six vials of 20 milligram dantrolene sodium.

Review of the Lexi-Comp's Drug Reference Handbook, 12th Edition, 2007, under nursing implications revealed thirty-six vials were required for adequate hyperthermia therapy.

Based on record review, interview, and manufacturer's direction for use (DFU), the provider failed to ensure:
*The manufacturer's DFU for the quaternary disinfectant use was followed in three of three observed patient care areas (operating room [OR], endoscopy unit, and surgical clinic [suite 501])
*The manufacturer's DFU for pre-cleaning detergent was followed in one of one surgical clinic (suite 501).
*Staff did not hand carry a contaminated colonoscope into the hallway after pre-cleaning for one of one endoscopy unit.
*An appropriate cabinet was provided to store endoscopes for one of one endoscopic unit.
*The nursing staff identified an expiration date for the Cidex OPA test strips after opening in two of two patient care areas (OR and endoscopy unit).
*Nursing staff initiated one of one patient's (8) intravenous antibiotic medication without an infection control breach.
*Proper hand hygiene was performed by staff and physicians in two of two observed patient care areas (intensive care unit and operating room).
Findings include:

1. a. Observation on 9/4/13 at 9:05 a.m. in the OR revealed after patient 41's surgical procedure the staff members used a quaternary solution to disinfect the OR bed and environmental surfaces. The wet contact time for use of that disinfectant was not ten minutes as required by the manufacturer's DFU.

b. Observation on 9/4/13 at 3:20 p.m. in the surgical clinic, suite 501, RN I used Wet Tasks wipes saturated with a quaternary solution to disinfect the patient examination table and surfaces in a procedure room. The surfaces of the examination table and environmental surfaces remained wet for approximately two minutes with the quaternary solution but not for the full ten minutes as stated in the manufacturer's DFU.

c. Observation on 9/5/13 at 8:20 a.m. revealed surgical technician H used Wet Tasks wipes saturated with a quaternary solution to disinfect a table. That table had been used to transport a contaminated colonoscope from the procedure room. The top of that table was still wet from the disinfectant when she placed a clean towel on top of that surface to use at a later time.

d. Interview on 9/4/13 and on 9/5/13 at the time of the above observations with the director of surgery revealed:
*The staff were not following the manufacturer's DFU when using the quaternary disinfectant solution.
*The manufacturer's DFU required a wet contact time of ten minutes. She had requested the staff use additional Wet Tasks on the above listed surfaces after a review and discussion of the contact time with the surveyor.
*It was the provider's policy to follow the manufacturer's DFU when using the quaternary disinfectant.

2. Observation on 9/4/13 at 9:05 a.m. in the endoscopy unit revealed Cidex OPA was used as the high-level disinfectant for the provider's automated endoscopic processors. A review of the Cidex OPA test strip bottles in the procedure room and the decontamination room on that unit revealed both bottles of test strips were open and in use. The Cidex OPA test strip bottles did not have an opened date or a new expiration date on those bottles as required by the manufacture.

A review of the Cidex OPA manufacturer's DFU with ST H confirmed once a bottle of test strips had been opened, the test strips would have expired ninety days after opening. The date the test strip bottle had been opened and a new expiration date should have been documented on those bottles.

3. Observation and interview on 9/4/13 at 2:50 p.m. of patient 8's intravenous (IV) antibiotic set-up by RN J revealed:
*She had hung the IV antibiotic bag on an IV pole.
*To spike the IV bag with the IV tubing she held the IV bag with one hand and the IV tubing in her other hand.
*The end of the IV tubing that would have been connected to the patient's IV fell and landed on the floor.
*She started to spike the IV bag with the contaminated tubing and was stopped by the surveyor.
*She had stated she thought the IV tubing had only landed on the base of the IV pole not the floor.
*She retrieved another IV tube, spiked the IV bag, did not label the IV tubing with the date and time, and exited the patient room.
*When asked what the facility policy for labeling IV tubing and the time frame for reuse of that tubing was she stated she did not know.
*She agreed she should have labeled the IV tubing with an expiration date and time. The date and time would have indicated when staff should have discarded that tubing.

4. Observation on 9/4/13 at 3:20 p.m. in the surgical clinic, suite 501 revealed there were three procedure rooms. On the counter in the area used to pre-clean instruments was a bottle of ZolvStat cleaning detergent.

Interview on 9/4/14 at 3:20 p.m. with the director of surgery and RN I revealed:
*The clinic nurse used an undetermined amount of water and an undetermined amount of cleaning solution to pre-clean contaminated instruments prior to reprocessing.
*The ZolvStat cleaning detergent was from a pour bottle, it did not have a pump dispensing top that would have provided a measured amount of disinfectant into a measured amount of water.
*The clinic nurse did not have a process to measure the amount of water used to dilute the pre-cleaning detergent to ensure the appropriate concentration was obtained.

5. a. Observation on 9/4/13 at 8:40 a.m. of patient 41's surgical procedure revealed at the conclusion of the patient's surgical procedure the surgeon did not perform hand hygiene immediately after removal of his contaminated gloves. Surgeon K removed his contaminated surgical gown and gloves, and then charted in the patient's medical record. Surgeon K used hand sanitizer prior to exiting the OR.

b. Observation on 9/5/13 at 7:15 a.m. of patient 42's surgical procedure revealed surgeon L removed his contaminated surgical gown and gloves at the conclusion of the surgical procedure. Without performing hand hygiene he picked up the patient's medical record and exited the room.

c. Review of the provider's June 2012 Handwashing Policy revealed hand hygiene should have been performed after coming in contact with contaminated items.

Interview on 9/5/13 at 2:30 p.m. with the compliance officer revealed surgeons K and L should have performed hand hygiene after removing their contaminated surgical attire.

6. Observation and interview on 9/5/13 at 3:11 p.m. with the director of surgery in procedure room 8 located on the endoscopy unit revealed:
*An endoscopic storage closet inside procedure room 8 was used to store endoscopes after they had been high-level disinfected. There were twelve endoscopes that hung in the open from a wooden frame with pegs that had been secured to the wall.
*Stored on the window ledge in that closet was a stack of towels, gowns, and a bottle of pre-cleaning detergent.
*On top of an overbed table was stored a set of dilators in a blue cloth pouch.
*A step ladder was stored in that room for staff to use for hanging the endoscopes on the pegs.
*The storage closet door was opened and any attempt to close that door was prevented by a large gray trash bin.

Interview with the director of surgery at the time of the above observation revealed:
*The current method of endoscope storage did not prevent against potential contamination by staff members after being high-level disinfected.
*She was not aware of any other method of storage.
*The storage room door was prevented from closing by the large gray trash bin.




27457

7. Random observations on 9/4/13 from 7:05 a.m. through 9:00 a.m. of one of one intensive care unit during physician rounds revealed:
*Multiple unidentified nursing staff, ancillary staff, and rounding physicians were observed not performing hand hygiene prior to providing care and after providing care.
*Multiple unidentified physicians were noted going from patient room to patient room without performing hand hygiene.

Interview on 9/4/13 at 11:00 a.m. with the director of quality who also served as the provider's infection control nurse revealed she agreed the above hand hygiene observations in the intensive care unit were infection control breaches and had not met the provider's hand hygiene requirements.

Based on observation, interview, record interview, and policy review, the provider failed to ensure the proper nutritional assessments were completed for one of one sampled diabetic patient (41) who was NPO (without food). Findings include:

1. Review of patient 41's medical record revealed:
*She was admitted to the facility on 8/27/13 and was found to have a gastrointestinal lesion.
*Her physician had ordered on 8/27/13 to have a naso-gastric tube inserted and placed to suction. He also had ordered her to be NPO at that time.
*She remained NPO for fours days until she was placed on clear liquids, and then advanced to a regular diet just prior to discharge.
*No dietary assessments nor documentation were present except for the nurses initial assessment at the time of admission.

Interview and record review on 9/5/13 at 8:00 a.m. with the director of quality regarding patient 41's dietary care revealed she confirmed the above findings.

Interview and record review on 9/5/13 at 10:00 a.m. with the registered dietitian regarding patient 41's dietary care revealed she:
*Had not completed any dietary assessment of the patient.
*Was not able to explain why a diabetic patient who was also NPO was not monitored and assessed by dietary services.
*Agreed the patient was at significant nutritional risk and should had been assessed by her.

Interview on 9/5/13 at 10:45 a.m. with the director of nursing revealed she agreed nursing services should have noted patient 41 was at significant nutritional risk and should have made sure the registered dietitian was involved in the patient's care.

Review of the provider's April 2013 Admission/Discharge/Transfer of the Patient policy revealed that dietary assessment and consultation were required for patients with altered nutrition and diabetes.

Based on observation, interview, and policy review, the provider failed to ensure:
*Two of two radiology technicians (D and E) wore protective lead aprons during one of one patient's (35) portable chest x-ray.
*All staff that participated in surgical cases that required radiology support wore film badges to monitor their exposer to radiation.
*One of one nuclear radiology technician (F) received training or skills testing for procedures he or she was required to perform.
Findings include:

1. Observation on 9/4/13 at 7:35 a.m. of radiology technicians D and E in patient 35's room revealed:
*The two technicians positioned the patient for an x-ray in his bed.
*When the technicians took the x-ray both of them were within three feet of the radiation source and neither of them had protective lead aprons on.

Interview on 9/4/13 at 7:45 a.m. with radiology technicians D and E regarding the above observation revealed:
*They could not explain why they had not worn protective lead aprons during patient 35's x-ray.
*Both of them confirmed they should have worn their protective lead aprons.

Review of the provider's August 2012 Portable X-ray Services policy revealed "All operators of portable x-ray equipment must wear lead."



15036

2. Interview on 9/4/13 at 10:00 a.m. with the director or surgery revealed:
*Surgeons at times used radiology during surgical procedures.
*The staff participating in cases using radiology support did not wear film badges to determine accumulative radiation exposure.
*She was not aware OR staff should have worn radiation film badges during procedures that required radiology support to monitor radiation exposure.
*The OR did not have policies and procedures requiring the use of film badges by staff during those procedures to monitor radiation exposure.



26180

3. Interview on 9/4/13 at 3:30 p.m. with radiology technician (RT) F and the interim director of radiology revealed:
*The RT had worked in the radiology department for over twenty years.
*One of her responsibilities included inserting intravenous (IV) catheters for diagnostic imaging.
*Her training for the IV catheter insertion had occurred on-the-job.
*She had never had any formal training to complete that procedure.
*They had not done any skills testing to evaluate her competency for doing that procedure.

Review of the 2013 skills competency checklist of RT F revealed they had not evaluated her competency to insert an IV catheter.

Review of radiology technician F's employee file revealed:
*She had signed a job description upon her employment on 10/29/90.
*There was no record of any skill evaluation or training for inserting IV catheters.

Interview on 9/5/13 at 1:30 with the director of quality revealed they should have followed their standards for training of the RT in IV catheter insertion. They should have done skills competencies assessments.

Review of the provider's 2013 Injection of Radioactive and Diagnostic Agents policy revealed:
*"Statement of Purpose: To delineate who is allowed to inject radioactive and diagnostic imaging agents in the Medical Imaging Department under the supervision of the Radiologist. The presence of a physician or physician's assistant is required when contrast media is injected."
*It listed the names of technologists who were permitted to administer these agents.
*It had not addressed the training they had received.

Based on observation, interview, record review and policy review, the provider failed to ensure:
*Physician's orders were obtained and followed to ensure the proper monitoring and care for one of one sampled patient (35) with a chest tube.
*Physician's orders were clarified prior to delivery of ordered care for one of one sampled patient (41) with a gastro-intestinal bleed.
*Blood was administered according to the provider's policy for one of one sampled patient (34) who received a blood transfusion.
Findings include:

1. Observation and interview on 9/4/13 from 7:00 a.m. through 9:00 a.m. of patient 35 in his room revealed:
*He was alert and orientated to time, place, and person during interviews at 7:00 a.m. and 7:50 a.m.
*He had a chest tube inserted in his right chest. That chest tube had a large water seal leak (air leak).
*He had oxygen running at two liters nasally.
*He had no oximeter (machine that monitors oxygen) on.
*He had semi-labored breathing.
*He rated his pain at a ten (scale of one to ten with one the least and ten the worst)) at the 7:00 a.m. and 7:50 a.m. interviews. When asked where his pain was he held his hand over the chest tube site. When asked at 7:00 a.m. how long he had the pain like that he stated on and off since he had come to the hospital. When asked at 7:00 a.m. if he had told nursing staff about his past pain he stated yes.
*Pain medications were not obtained for the patient until this surveyor informed the nurse around 8:00 a.m.

Review of patient 35's medical record revealed:
*He was admitted to the facility on 8/30/13.
*He had the right chest tube inserted to try and re-inflate his right lung.
*He had no physician's order for his oxygen.
*He had no physician's order for continuous oxygen saturation monitoring (oximetry).
*He had physician's orders for incentive spirometry (breathing exercise) every two hours while awake. Those exercises had been documented as completed sporadically every four to twelve hours since his admission.
*His nursing care plan did not directly and comprehensively address his pain and respiratory status. Refer to F298, finding 6.
*He had multiple incidences of documented pain since admission. He rated his pain on most of those incidences to have been between five and ten. No evidence was found that nursing had contacted his physician to request increased pain medication doses or re-evaluation due to his reported high levels of pain.

Interview, record review, and policy review on 9/4/13 at 10:20 a.m. with the director of quality regarding patient 35 revealed:
*A physician's order had not been obtained for oxygen.
*Spirometry had not been carried out as ordered.
*Continuous oximetry should have been in place for a patient with a chest tube.
*The patient's pain had not been properly evaluated, addressed, and care planned for according to the provider's August 2012 Clinical Plan of Care policy.

2. Review of patient 41's medical record revealed she:
*Had been admitted on 8/27/13 and discharged on 9/3/13.
*Had a gastro-intestinal bleed.
*Had been without food for the first four days of hospitalization.
*Had a naso-gastric tube to suction for the first several days of her hospitalization.
*Had a physician's ordered for naproxen sodium (NSAID) 440 milligrams two times a day for pain after her naso-gastric tube was out.

Interview and record review on 9/5/13 with the director of quality regarding patient 41 revealed:
*She could not explain why the physician had ordered an NSAID at that dose for a patient with known gastro-intestinal problems.
*Nursing in conjunction with the pharmacist should have sought clarification of the above order prior to administration.
*She agreed that medication could cause further gastro-intestinal upset and possible bleeding.

Interview on 9/5/13 at 2:00 p.m. with the pharmacy director regarding patient 41 revealed she agreed with the above statements of the director of quality.

3. Observation on 9/4/13 at 11:50 a.m. of patient 34 receiving a blood transfusion revealed:
*The blood was being administered per a pump at 100 milliliters (ml) per hour.
*The blood was being administered through a 22 gauge intravenous catheter.

Interview and policy review on 9/4/13 at 12:30 p.m. with the director of quality and patient 34's nurse (unidentified) revealed:
*Patient 34's nurse frequently used a 22 gauge intravenous catheter to administer blood. She did that because of a seminar that she had attended. She was unable to inform this surveyor what seminar that was.
*Patient 34's nurse administered blood starting at a rate of 75 ml per hour and then advanced it to 150 ml per hour after a half hour or so.
*The provider's February 2013 Blood Product Administration policy called for:
-An 18-20 gauge intravenous catheter to have been used when administering blood unless not possible.
-Blood was to have been administered at a rate of 125 ml through 250 ml per hour.
*The director of quality agreed patient 34's nurse had not used the appropriate gauge intravenous catheter for blood administration according to the above policy.
*The director of quality agreed patient 34's nurse had not administered blood at the flow rate outlined in the above policy.

Based on record review, interview, and policy review, the provider failed to ensure ten of ten sampled patients (6, 22, 23, 24, 25, 26, 35, 36, 37, and 41) reviewed had comprehensive care plans. Findings include:

1. Review of patient 25's medical record revealed:
*She had been admitted on 9/2/13.
*She had been discharged on 9/4/13.
*Her admission diagnosis had been pneumonia.
*Her patient progress note revealed she had constant pain related to a headache.
*There was not a care plan in her record.

2. Review of patient 26's medical record revealed:
*She had been admitted on 9/3/13.
*Her admission diagnosis was an upper respiratory infection/pneumonia.
*The 9/4/13 care plan only addressed altered respiratory function and had no interventions.
*Discharge planning had not been addressed.

3. Review of patient 24's medical record revealed:
*He had been admitted on 8/31/13.
*He had a fractured pelvis.

Interview on 9/4/13 at 10:40 a.m. with patient 24 revealed he was being discharged to home within the hour.

Review of patient 24's 9/3/13 problem activity report (care plan) revealed:
*They had identified the following problems:
-"Alteration in comfort - pain."
-"Impaired mobility related to a fractured pelvis."
*There were no interventions to address the above problems.
*Discharge had not been not addressed on the care plan.

Interview on 9/4/13 at 9:00 a.m. with the patient care coordinator revealed patient 24's care plan was not complete. It had not addressed any interventions.

4. Review of patient 23's medical record revealed:
*She had been admitted on 9/1/13.
*Her admission diagnosis had been gastroesophageal reflux disease (GERD).
*She also had a urinary tract infection (UTI).

Review of patient 23's 9/3/13 problem list revealed:
*The UTI had been addressed but had no interventions listed.
*GERD had not been addressed.

5. Review of patient 22's medical record revealed:
*He had been admitted on 9/3/13.
*His admission diagnosis had been bowel obstruction.
*The 9/3/13 problem list identified alteration in bowel and bladder and pain.
*There had been no interventions listed to address the above issues.



27457

6. Review of patient 35's medical record revealed:
*He had been admitted to the hospital on 8/30/13 and was still a current patient at the time of this survey.
*He had a right chest tube placed due to right lung problems and breathing problems.
*He had significant pain during his course of hospitalization.
*His chest tube had a significant water seal leak.

Review of patient 35's 9/4/13 care plan revealed:
*Nursing staff had identified activity intolerance and altered respiratory function related to infectious process as her priority nursing diagnoses.
*The interventions for the respiratory nursing diagnosis were to maintain oxygen saturations greater than 90 percent and avoid pulmonary complications.
*The interventions for the activity diagnosis were to report activity increase, participate in conditioning, and find alternate ways to maintain his activity level.

Interview and care plan review on 9/4/13 at 3:30 p.m. with the director of quality regarding patient 35 revealed:
*His care plan should have included pain monitoring.
*She could not explain how nurses would avoid pulmonary complications as outlined in the care plan.
*She could not explain how nursing staff could make sure the patient's oxygen saturations were maintained above 90 percent when he was not on continuous oxygen saturation monitoring.
*The activity nursing diagnosis was not pertinent.

7. Review of patient 41's medical record revealed she:
*Had been admitted to the facility on 8/27/13 and had been then discharged on 9/3/13.
*Had been admitted due to gastrointestinal bleeding.
*Had a history of diabetes.
*Had been placed on NPO (without oral food) status by her physician.
*Had a naso-gastric tube placed.

Review of patient 41's 9/2/13 care plan revealed nursing staff had identified alteration in skin integrity and potential for injury related to a fall as her priority nursing diagnoses.

Interview on 9/5/13 at 7:50 a.m. with the director of quality regarding patient 41's care plan revealed:
*The above nursing diagnoses would not be the priority nursing diagnoses for the patient.
*Nursing should have focused on her main problem of alteration in nutrition and alteration in fluid volume based on diabetes and gastrointestinal bleeding.

8. Review of patient 36's medical record revealed he had been admitted to the facility on 8/2/13 for a diabetic reaction. He had not been discharged until 9/2/13.

Review of patient 36's care plans from the time of admission revealed his diabetes had never been addressed.

9. Review of patient 37's medical record revealed:
*She had been admitted to the facility as a trauma patient on 9/3/13, and then had been transferred to the medical floor for end of life care.
*No nursing care plan was present for that patient.

Review of the provider's August 2012 Clinical Care Plan policy required the nursing care plan:
*To be based on the patient's current status/assessment and to be continually updated.
*Be present for all patients beginning at the time of admission.
*To be focused on the comfort and dignity of all patients.



15036

10. Interview and review on 9/4/13 at 7:50 a.m. of patient 6's electronic and paper medical record with registered nurse G revealed:
*She had been admitted on 9/1/13 to the obstetrical unit and was still a current patient on that unit.
*There was no documentation of a discharge plan in her medical record or care plan.
*The nurse that had admitted the patient should have initiated and documented a discharge plan for the patient.

Based on record review, interview, and medical staff rule review, the provider failed to ensure one of one sampled patient (37) with end of life care had physician's progress notes to describe the care and services rendered. Findings include:

1. Review of patient 37's medical record revealed:
*She had been admitted to the facility as a trauma patient on 9/3/13. She had then been transferred to the medical floor that same day for end of life care after the family had requested she become a do not resuscitate patient.
*Orders for care were written by three physicians.
*No physicians' progress notes were present for that patient.

Review of the provider's November 2012 Medical Staff Bylaws revealed:
*"Pertinent progress notes be recorded at the time of observation, sufficient to permit continuity of care and transferability."
*"Each of the patient's clinical problems should be clearly identified in the progress notes and correlated with specific orders as well as results of tests and treatment."

Interview on 9/4/13 at 3:30 p.m. with the director of quality revealed she agreed the medical staff bylaws for progress notes had not been followed for patient 37.

Based on record review, interview, and policy review, the provider failed to ensure a comprehensive social services assessment had been completed on three of six sampled swing bed residents (29, 30, and 31). Findings include:

1. Review of resident 29's medical record revealed he had been admitted on 3/23/13 and had been discharged on 3/27/13. No social services assessment had been found on his chart.

2. Review of resident 30's medical record revealed she had been admitted on 4/15/13 and had expired on 4/17/13. No social services assessment had been found on her chart.

3. Review of resident 31's medical record revealed she had been admitted on 5/22/13 and had been discharged on 5/28/13. No social services assessment had been found on her chart.

4. Interview on 9/4/13 at 1:30 p.m. with patient care coordinator C confirmed no social services assessment could be found on the above records.

Interview on 9/5/13 at 1:10 p.m. with the licensed social worker revealed she visited all residents who had been admitted to the swing bed unit even if they had been a patient at the facility prior to admission. She stated she completed a new assessment or updated the assessment from the acute care stay. She confirmed there was no documentation any assessments had been completed on the above residents.

Review of the provider's revised May 2010 Swing Bed Social Service's policy revealed:
*A social service program would have been available for all swing bed patients.
*A qualified medical social worker or social services designee would have been responsible to identify the medically related social, physical, and emotional needs of the swing bed patient.
*Social services would have provided an intake interview to determine the needs, attitudes, feelings, and concerns of the patient.
*A social history would have been completed within five days.
*The social services director/designee would have visited the swing bed patient/family after admission and as needed to continually assess and assist the patient/family in adjustment.
*The psycho-social assessment and progress notes would have been kept in the resident's record.

Review of the provider's revised May 2010 Provision of Care and Services on the Swing Bed Unit policy revealed Social Services would visit each resident upon admission, and then as needed to identify their medically related social and emotional needs.