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Based on interview and record review, the hospital failed to show evidence that each patient (inpatient and outpatients) or patient representatives were informed of the patient's rights in advance of furnishing care and services for 3 of 3 surgical outpatient (1,4,5) records reviewed during the survey. Findings included:

All outpatients admitted to the Short Stay Surgical Center were not provided with written notification of patient's rights information either in the information mailing or on site prior to initiating the procedures.

During interview with Patient 1 on 1/5/10, at 8:20 a.m. prior to the surgical procedure scheduled that day, the patient could not recall receiving any written information regarding patients rights. The patient reported, "Maybe it was in the information they mailed me."

Patient 4 had a procedure and was then subsequently admitted to the hospital on 7-15-09. The patient did not receive patient rights information prior to the surgical procedure. The patient received the patient rights information in the inpatient admission packet upon admission to the hospital.

Patient 5 had a procedure and was then subsequently admitted to the hospital on 8-10-09. The patient did not receive patient rights information prior to the surgical procedure. The patient only received the patient rights information in the inpatient admission packet upon admission to the hospital.

During interview on 1-5-10 at 9:00 a.m. the Short Stay RN manager (RN-C) stated that printed patient rights information was not mailed or given to outpatients unless they were actually admitted as inpatients following a Short Stay procedure. RN-C stated the following pamphlets were given to patient prior to surgery. These were entitled, "Preparing for Outpatient Surgery," "How to Prevent Infections During Your Hospital Stay," and "Anesthesia." RN-C also reported the only place out-patients were able to access the patient rights information was to, " Read it on the wall poster" that was located adjacent to the surgical entrance area.

On 1/6/10 at 3:00 p.m. the Patient Care Services Administrator stated, "Our latest information was that the Resident Rights notice only had to be in posted in the area." She was not aware of any other requirements.

Based on observation and interview, the hospital failed to provide personal privacy for patients on the Dellwood unit 23 patients. Findings included:

During the tour on the Dellwood unit on 1/5/10, at 10:15 a.m. there were no privacy curtains noted in any of the rooms. The unit, which was for patients with adult substance abuse concerns, had a capacity of 23 beds and had approximately 12 patients on the unit. Some of these rooms were private but others had two and three beds in each room. Some of the rooms had tracks where privacy curtains had been at one point but were no longer there. The other rooms had no tracks for privacy curtains. When interviewed, two of the patients who shared the same room stated, "We dress and undress in the bathroom and if the other patient wants privacy we just leave the room." The nurse manager when interviewed on 1/5/10, at 10:15 am agreed there should be privacy curtains in every room. She further stated, "When we got the privacy curtains in the psych unit the patients loved them."

Based on policy review and interview, the facility's policy/procedures failed to assure physicians orders are obtained prior to the reapplication of a restraint. Findings include:

In review of facility's policy Seclusion and Restraint PC 149 it specified on page 10: "When restraint or seclusion is terminated before the time-limited order expires, the original order can be used to reapply the restraint or seclusion if the patient is at imminent risk of physically harming himself or herself or others, and nonphysical interventions are not effective. However, when the original order expires, a new order for restraint or seclusion is obtained from the Licensed Independent Practitioner primarily responsible for the patients's ongoing care, treatment, and services, or his or hers Licensed Independent Practitioner designee or other Licensed Independent Practitioner."

During interview on 1/710, at 8:45 a.m. the RN acknowledged the Seclusion and Restraint PC 149 policy was not correct and in accordance with the CMS (Center for Medicare and Medicaid Services) requirements.

This standard stipulates, "If a patient was recently released from restraint or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order would be required."

Based on interview and record review, the hospital failed to systematically release four-point locked leather restraints for 1 of 1 patient (6) whose restraint use was reviewed. Findings included:

P6 was placed in four-point leather restraints for a period of 21 hours, 45 minutes. Documentation was lacking to show the restraints were released and the patient allowed to exercise his limbs.

P6 was admitted to the hospital on 5/7/09 with substance abuse-related symptoms. The patient severely decompensated due to benzodiazapine (antianxiety) withdrawal after his admission, and he was transferred to the Specialty Care Intensive Care Unit (ICU) at approximately 10:00 a.m. He was described as severely agitated (thrashing about), hallucinating, and was confused. At 10:15 a.m. the four-point restraint order was received and Librium (antianxiety used to treat substance withdrawal symptoms) was initiated.

Documentation indicated at 12:00 noon the patient was anxious, confused, paranoid and attempting to climb out of bed. At 12:11 the patient was described as very restless, "does not know where he is or what was happening. The registered nurse (RN) assessed the P6 as uncontrollable and in need of the current four-point restraints. At 2:00 p.m. the patient was "asleep" for the previous two hours, however, woke up briefly for cares and continued confused and restless (the record was not clear if the restraints were released while cares were provided). At 3:00 p.m. the patient was asleep. At 4:41 p.m. the patient was restless, but sedated, and a notation was made to indicate the patient was up three times per request. Notations were made on the documentation flow sheets at 6:00 p.m., 7:00 p.m., and then not again until 12:00 a.m. (5 hours later). The patient was noted as vacillating between asleep and restless.

The non-behavioral restraint policy (revised 12/08) provided by the hospital indicated patients were to be released from all wrist and ankle restraints for a minimum of ten minutes within a two hour time frame. For patients in four-point restraints, documentation was also required every fifteen minutes. Although some information was documented every two hours, no references were made in the notes or flow sheets to show P6 was actually released from the restraints every two hours for ten minutes. There was also no documentation of the patient's status every fifteen minutes when in the four-point restraints.

When interviewed on 5/6/09, at 4:00 p.m. the nurse manager was unable to provide further documentation to show the patient was released from the restraints every two hours for ten minutes or the patient's status was noted every fifteen minutes.

Based on observation, interview and record review the facility failed to follow dietary procedures which minimized the possibility of food borne illness. Findings include:

In the general tour of the kitchen on 1/5/10 at 9:55 a.m., the following observations were made:

The base of the tiled wall between the dish washing room and tray line food counter had an approximate 4 inch by 2 inch hole. The tile was broken with missing pieces which exposed sheet rock and metal reinforcement of the wall. There was rust like substance and sharp surfaces protruding out from the wall.

Eight dessert pans were found to be heavily scored and pitted. Food Service staff stated that they did not use any type of pan liner in these pans. These pans were stored in a cupboard that had an accumulation of visible dirt and dust on the shelves. The AM Cook Cleaning Schedule and Procedures for January 2010 indicated these areas were to be cleaned every weekend.

The plate lorator was noted to have three of five plates observed to have visible water on the surface. A stainless steel measuring cup which was stored in a drawer under the food surface prep area was found to have a small amount of standing water in it also.

The sugar bin had a approximate 3 inch hole in the cover. A blade for the Robo food processor had significant gouges in the surface. The director of nutrition stated the blade should be replaced.

In an interview at 1/5/10 at 10:15 a.m., with director of nutrition and food service manager she stated all food services areas were to be cleaned weekly and the equipment was to be inspected on a scheduled basis for the signs of wear. She also stated the facility dishwasher room had limited space which restricted the amount of time the dishes had to air dry properly. Efforts were being done to remedy the situation by cross stacking larger items like pans and trays. However, she acknowledged this method of cross stacking would not work for plates.

Based on observation, interview, and record review, the hospital was not found to be in compliance with the Condition of Participation related to the Physical Environment (42 CFR 482.41). The hospital failed to follow their fire safety practices and procedures to reduce the risk for surgical fires. In addition, the hospital failed to comply with the Life Safety Code requirements. Findings included:

FIRE SAFETY IN THE SURGICAL SUITES
Refer to findings at A 951 were there was no clear evidence that the policies for fire safety in the surgical suites were developed or being followed for the use of electro-surgery and other heart-producing devices in conjunction with use of alcohol-based skin preparations in anesthetizing locations. In addition, the surgeons were not placing the cautery tool in the sheath when not in use. This occurred for 1 of 1 surgical cases observed during the survey.

LIFE SAFETY CODE
The hospital was found not in compliance with the Condition of Participation related to the Physical Environment (42 CFR 482.41) as evidenced by deficiencies issued as a result of a Life Safety Code Inspection. The hospital was found not in compliance with Life Safety Code standards.

See the following K tags: K-018, K-029, K-038, K-062, and K-144 for additional information.

Based on observation, staff interview and record/policy review, the hospital failed to establish and follow appropriate policies and procedures to reduce the associated risk of fire in the surgery areas. Findings included:

There was no clear evidence that policies were developed or consistently followed for the use of electro-surgery and other heat-producing devices in conjunction with use of alcohol-based skin preparations in anesthetizing locations combined with the oxygen-rich environment. In addition, the surgical area lacked appropriate fire risk reduction measures as part of a systematic approach by the hospital to prevent surgery related fires that included policies related to preoperative preventative measures and intraoperative use of heat producing devices including electrocautery tools.

The Hospital position statement, "Patient Skin preparation for Surgical Procedures" dated 5/05 identified, "All alcohol-based surgical skin preparations must be used with caution by operating room staff following appropriate fire prevention precautions and procedures when electro-surgery, cautery and lasers are used."

The position statement also referenced the current "Tentative Interim Amendment to the National Fire Protection association (NFPA) for the Standard on Health Care Facilities (NFPA99)" and manufacturer's instructions included the recommendation for a "Policy for mandating a 'time out' period prior to the draping or use of electrosurgery to verify that the application site is dry prior to draping and use of heat-producing sources that pooling of solution has not occurred or has been corrected, and any soaked solution materials have been removed from the operating room suite prior to draping and use of heat-producing sources."

The Hospital Universal Protocol from the Corporate Peri-operative Council dated 2/2009 identified the process for the Time Out with the following requirements:
1. Correct patient identity.
2. Confirmation that correct side and site are marked.
3. Accurate procedure consent form.
4. Agreement on the procedure to be done.
5. Correct patient position.
6. Relevant images and results are properly labeled and appropriately displayed.
7. Need to administer antibiotics or fluids for irrigation purposes.
8. Safety precautions necessary based on patient history or medication use.

There was no component in the Pre-Procedure, Site Marking or Time Out sections of the Protocol that identified ensuring adequate drying of the area prior to draping or use of electrosurgery devices, nor that the protective sheath was available for use. The purpose of the Protocol was stated, "To eliminate the risk of an event involving the wrong site or side, wrong person or wrong procedure during an invasive procedure."

A review of the Hospital Electrosurgical Safety policy dated 6/1988 with revision 6/25/09 with purpose, "To ensure the safety of the patient undergoing surgical intervention" also did not identify any reference to preoperative or intraoperative procedures to ensure adequate drying of the alcohol preparation before use of the heat producing devices or placement of the electrocautery equipment when not actually in use, such as in a sheathing device.

During observation of a surgical procedure for septoplasty, turbinoplasty, uvelectomy (Patient 1) on 1/5/10 at 9:45 a.m., the surgeon was observed to place the cautery device on an instrument tray directly above the patients chest when it was not in use.

The Surgical Patient care manager (RN-A) was questioned regarding when a cautery sheath was used. RN-A verified the sheath was, "Used based on the anatomical area involved and surgeon's choice...Some put it on the chest, some put it in the sheath." RN-A also verified alcohol based preparation solutions were frequently used in a variety of cases and there were no specific procedures for use of the protective sheath in the Electrosurgical Safety policy.

During a tour of the Obstetric surgical area on 1-5-10 at 1:30 p.m., RN-A also verified to the surveyor, "The policy does not say to sheath it, typically they lay it on the body."

Based on staff interview and record review, the hospital failed to ensure each surgical patient received a post-anesthesia evaluation within 48 hours after surgery for 4 of 6 surgical patient (2,3,4,5) records reviewed during the survey. Findings include:

Electronic medical records of Patients 2,3,4 and 5 lacked evidence of completion of the post-anesthesia evaluation within the required 48 hour period.

The hospital policy, "Preoperative and Post-operative Assessments" dated 2/09 identified, "All patients will have a post-operative evaluation completed by an anesthesia provider. This evaluation will be done within 48 hours of surgery and can occur either in PACU, phase 2 recovery or by telephone after discharge."

Patient 2 and 3 received surgical services on 12/7/09. Patient 2 had a knee arthroplasty and 3 had a hip arthroplasty. Patient 4 received a shoulder surgical procedure on 7/15/09 and patient 5 received a surgical tendon repair on 8/10/09.

The electronic medical record was reviewed with the Surgical Patient Care Manager RN-A on 1/5/10 at 11:00 a.m. RN-A verified the post-anesthesia evaluation was not in the system for Patient 2,3,4 and 5 and reported, "It apparently is not always being done by those who provide the anesthesia." Nurse Anesthetist-A(CRNA) also verified during interview that at times the evaluation was not completed, "CRNA's who are off the next day do not always do it or call it in by phone."

On 1/6/09 at 9:15 a.m. the Manager of Surgical Services RN-B and RN-A reported they had conducted an additional audit for December 2009 and found 7 patients of 37 reviewed did not have a post-anesthesia evaluation completed, which should have been completed. RN-A verified the policy, "Preoperative and Post-operative Assessments" dated 2/09 that, "All patients will have a post-operative evaluation completed by an anesthesia provider...within 48 hours of surgery..." This was not completed consistently.

Based on observation, interview and record review the facility failed to ensure the required maintenance was performed on the respiratory therapy equipment. Findings include:

During the tour of the respiratory department on 1/6/10 at 8:40 a.m., one nebulizer machine was found to be missing a "PM" (preventative maintenance) label. The biomedical electronic technician stated the machine did not belong to the hospital as it did not have the hospital's label. He was uncertain where the machine came from and confirmed that it had not been checked for performance maintenance. In addition, a Portable Ventilator -Para Pac medic-machine, and a Smart vest,( a percussion machine) did not have a "PM" labels. The respiratory therapist explained this equipment was for educational purposes only. Further explaining that any equipment used for education would not have performance maintenance. However, neither the ventilator nor the percussion machine were labeled for education only and were located in the same area as the equipment which was used for therapy. The respiratory therapist acknowledge that because this equipment was not labeled for educational purposes only and because it was being stored in the same area as the other therapeutic respiratory equipment, it could be mistaken by other respiratory therapist for appropriate therapeutic equipment.

In an interview with the biomed electronic technicians on 1/7/10 at 9:20 AM they confirmed there wasn't a policy on the use of performance maintenance equipment which is used only for education purposes.