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Based on record review and staff interview the Hospital failed to adhere to their policy related to verbal/telephone orders for three patients (Patients #18, #19 and #29) of thirty patients sampled.
Findings include:

The policy titled Telephone and Verbal Order Read and Repeat-Back, dated 6/16, indicated that telephone/verbal orders are to be used infrequently and should be used only to meet the care needs of the patient when it is impossible or impractical for the ordering practitioner to write the order or enter it into Computer Physician Order Entry (A computerized process which allows the physician to enter orders from computers located throughout the hospital).

1.) The Surveyor reviewed Patient #18 on 12/12/16. Patient #18's Physician Orders indicated that, at 1:20 P.M. on 11/30/16, a telephone order for TED (anti-clot) stockings and ambulation was received and transcribed. On 11/30/16 at 4:18 P.M., Patient #18's Physician Orders indicated that a telephone order to change the patient's status to observation was received and transcribed. On 12/2/16, Patient #18's Physician Orders indicated a telephone order to change the patient's status to inpatient was received and transcribed. On 12/3/16 at 4:35 P.M., Patient #18's Physician Orders indicated that a telephone order for medications and laboratory testing was received and transcribed. On 12/4/16 at 10:40 A.M., Patient #18's Physician Orders indicated a telephone order for laboratory testing was received and transcribed. On 12/4/16 at 2:25 P.M., Patient #18's Physician Orders indicated a telephone order for medication, laboratory testing and Bilevel Positive Airway Pressure (BIPAP) was received and transcribed. On 12/4/16 at 4:30 P.M., Patient #18's Physician Orders indicated a telephone order for imaging, treatment and laboratory testing was received and transcribed. On 12/4/16 at 6:00 P.M., Patient #18's Physician Orders indicated a telephone order for laboratory testing was received and transcribed. On 12/4/16 at 6:55 P.M., Patient #18's Physician Orders indicated a telephone order for BIPAP settings was received and transcribed.

The Surveyor interviewed Nurse Manager #1 at 2:30 P.M. on 12/12/16. Nurse Manager #1 said that telephone orders were to be taken only in emergency situations.


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2. For Patient #19, the Hospital failed to follow their policy in regard to receiving physician telephone orders.
Patient #19 was admitted to the Hospital 12/2016 for surgical repair of scoliosis.

On 12/12/16, review of the clinical record indicated the following physician's order, dated 12/7/16, to discontinue the following lab and intravenous(IV) orders: albumin, BUN, calcium, creatinine, magnesium, PT/INR, sodium, normal saline 80 milliters an hour (IV). This was received as a telephone order and transcribed by a nurse.


3. For Patient #29, the Hospital failed to follow their policy in regard to receiving physician telephone orders.

Patient #29 was admitted to the facility 12/2016 for spine surgery.

On 12/14/16, review of the clinical record indicated the following physician's order, dated 12/8/16, to give abilify (antipsychotic medication) 5 milligram by mouth, times one, now. This was received as a telephone order and transcribed by a nurse.

On 12/14/16 at 11:30 A.M., during interview, Nurse Manager #2 said that this patient was transferred from another unit and taking telephone orders is not the preferred method of obtaining physician orders.

Based on observations, records reviewed and interviews the Hospital failed to adhere to their policy and procedure and the manufacturer's recommendations for vaccine storage.
Findings include:

1.)The Hospital policy titled Refrigerator and Freezer Temperature monitoring, dated 6/16, indicated documentation of the designated medication refrigerator would be done daily.
According to the Centers for Disease Control (CDC) the desired refrigerator vaccine storage temperature is 36 °F- 46°F. Exposure to temperatures outside these ranges may result in reduced vaccine potency and increased risk of vaccine-preventable diseases.

The Surveyor observed the Supply Refrigerator in the Bond Center (the pre-surgical holding area) at 8:00 A.M. on 12/13/16. The Supply refrigerator contained various reagents and microbiology plates and two packages of influenza vaccine. The Supply refrigerator was not a dedicated medication storage area and the temperature log indicated the Supply Refrigerator had not been monitored since 12/7/16.

2.)The Hospital policy titled, Malignant Hyperthermia (MH is a rare life-threatening condition that is usually triggered by exposure to certain drugs used for general anesthesia), dated 2/16, indicted that refrigerated Normal Saline and Insulin were part of the MH protocol.

During tour with the Director of Surgical Services (DSS), the Surveyor and the DSS observed the Malignant Hyperthermia Cart in the Operating Room at 8:10 A.M. on 12/13/16. Because the Operating Room may be closed for extended periods of time, the refrigerator unit on the MH cart contained a specially designed temperature monitoring thermometer that contained a traceable memory feature that allowed the user to review the temperature history if the unit alarmed. The alarm on the unit was turned off thus circumventing this safety feature for the insulin and refrigerated saline.

The Hospital failed to educate staff about the availability of all Personal Protective Equipment (PPE) available to meet Centers for Disease Control (CDC) compliance for the Standard Precaution and consistently adhere to the Manufacturer's Directions for use for High Level Disinfection.

1.) According to the CDC, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, in all areas where healthcare is delivered, must provide supplies and equipment necessary for the consistent observance of Standard Precautions, including hand hygiene products and personal protective equipment.

The Surveyor interviewed RN #1 in the Intensive Care Unit (ICU) at 3:00 P.M. on 12/12/16. RN #1 was asked about the necessary PPE for a blood or body spill. RN #1 said she knew the Isolation Gowns were not impervious and she would need to call the supply room to obtain the impervious gown for a blood/body fluid spill.

The Surveyor interviewed Nurse Manager #2 at 9:00 A.M. on 12/14/16. Nurse Manager #2 said she would need to call Environmental Services to obtain an impervious gown.

Nurse Manager #1 brought the Isolation Gowns to the Surveyor at 10:00 A.M. on 12/14/16. The Isolation Gowns are designed as a barrier but do not provide impervious protection for staff.

It was later determined that all units had access to sterile impervious gown in their respective clean supply storage areas, but staff were not aware of this at the time of staff interviews.

2.) High Level Disinfection (HLD) is a process that eliminates all microorganisms in or on an instrument that is used between patients.

The Surveyor observed the HLD log at 1:30 P.M. on 12/13/16. According to the Manufacturer's Directions for Use the instrument must be submerged in the chemical high level disinfectant for twelve minutes in order to attain HLD and ready the instrument for use on another patient. The transesophageal echocardiogram (TEE is an alternative way to perform an echocardiogram) scope was high level disinfected on 12/12/16. According to the log the immersion time was eight minutes and not the twelve minutes required.

Based on review of the Hospital's policy and procedure for organ, eye an tissue donation and interview, the Hospital failed to ensure that all patient care staff were educated on donation issues.

Findings include:

The Hospital policy for Organ, Eye and Tissue donation, dated 6/2016, did not address the training/education of staff. The contract between the organ procurement organization and hospital, signed on 5/12/2010 and remaining in effect, indicated that the organ procurement organization would provide periodic in-service education programs on organ, tissue and eye donation.

On 12/13/2016 at 1:00 P.M., an interview was held with the Director of the Operating Room (OR) and the Nurse Manager of intensive care unit (ICU), who each said they were responsible for the hospital's organ procurement program. During the interview, the Director of the OR said that only the surgical nurses and the ICU nurses received mandatory annual training from the organ procurement organization educator on organ donation and the hospital's policies and procedures related to organ donation. The ICU NM said that only the ICU nurses attended such training and that other patient care staff did not receive this training and this training was not mandated by the Hospital for other patient care staff.

Based on observation, records reviewed and interview the Hospital failed to adhere to their policy for surgical attire.

The Policy titled Surgical Attire, dated 10/16, indicated that all persons entering the restricted area of the Operating Room should have jewelry totally confined within their scrub attire or removed.

The Surveyor observed Anesthesia Student #1 managing the airway of a patient in Operating Room #1 at 8:20 A.M. on 12/13/16. Anesthesia Student #1 was wearing earrings that were not contained within her surgical hat.

The Surveyor interviewed the Director of Peri-operatives Services at 8:25 A.M. on 12/13/16. The Director of Peri-operative Services said jewelry needed to be contained under the surgical attire.