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Based on observation and interview, the hospital failed to ensure that they had all the necessary equipment and supplies available to conduct every type of life-saving procedures that may be required for all of the patient that seek consult at the Emergency Department (ED). The hospital's ED was not equipped with a fetal monitor (an electronic device that measures the fetal heartbeat as well as the mother's uterine contractions). This failure had the potential to contribute to the increased risk of harm to a woman and her unborn child who present to the ED for care with complaints of premature contractions or labor.

Findings:

An observation of the ED and a concurrent interview were conducted with ED Registered Nurse (RN) 2, on September 10, 2013, at 8:50 AM. It was identified that the ED's equipment did not include a fetal monitor. ED RN 2 stated that their ED was not equipped with a fetal monitor. ED RN 2 stated that if a laboring patient entered the ED, the hospital staff would use a Doppler (a small ultrasound device that uses specialized sound frequencies known as doptones to hear a baby's heartbeat) and if need be, they transferred the patient out to another hospital.

During an interview, on September 10, 2013 at 2 PM, with the Chief Nurse Officer (CNO), she stated that the ED was not equipped with a fetal monitor because they "did away with them because none of the staff are competent to read the monitors." She also stated that she was aware that the only way to see if a fetus was in distress was to place the mom on a fetal monitor. The CNO stated that the ED RNs use the Doppler to listen to the fetus heart tones and if needed, the patient would be transferred to a nearby hospital for higher level of care. According to the CNO, their ED had not seen a laboring patient in a long time and the ambulance drivers know not to take them to their ED because they do not have an Obstetrics Department.

A record review on September 10, 2013 at approximately 2:30 PM was conducted of the hospital "Scope of Current Services and Planned Services and Practices, revised January 27, 2012." The scope of service indicated that the hospital provided care to patients who required fetal and maternal assessment and stabilization and to newborns.

Based on interview and record review, the hospitals Governing Body failed to ensure that all members of the medical staff complied with hospital policies and with the hospital Medical Staff Bylaws Rules and Regulations. For 3 of 21 sampled patients (Patient 10, 11 and 12), in a universe of 3, the hospital failed to ensure that the prescribing physicians responsible for providing telephone and written orders, authenticated these orders with legible signatures, dates and times, as indicated in the hospital's policy (Telephone, Verbal and Written Orders for Medications and in the Medical Staff Rules and Regulations). This failure had the potential to contribute to medication errors which could increase the risk of patient harm due to use of medications that were not intended by the prescribing physician.

Findings:

1. A record review of Patient 10 and a concurrent interview were conducted with the Medical Record Clerk (MRC), on September 10, 2013, at 10:10 AM. The record review indicated that Patient 10 was admitted on July 3, 2013 with the diagnosis of Pancreatitis (an inflammation of the pancreas). A Physician telephone order provided to a Registered Nurse (RN), on July 3, 2013 at 9:40 PM, for a pain medication order, was authenticated on August 2, 2013 (30 days after the telephone order was received by the RN). The MRC stated that the physician who provided the telephone order should have signed it.

2. A record review of Patient 11 and a concurrent interview were conducted with the MRC, on September 10, 2013 at 11 AM. The record review indicated that Patient 11 was admitted on August 17, 2013 with diagnoses which included diabetes and altered level of consciousness (confusion). A Physician telephone order provided to an RN on August 18, 2013 at 1 AM for multiple medication orders contained an illegible physician signature (22 days after the telephone order was provided) and did not include the time when the order was signed by the prescribing physician. Another telephone order which included a medication order, provided to a RN, on August 19, 2013 at 8 AM, was not legible and did not include a date or a time. The MRC stated that she was unable to read the physician's signature but knew who it was. The MRC stated that the physician should have included the date and time when he signed the telephone order. Additionally, the MRC stated that in the past, the hospital had spoken to the physician about his illegible writing.

3. A record review of Patient 12 and a concurrent interview were conducted with the MRC, on September 10, 2013 at 11:30 AM. The record review indicated that Patient 12 was admitted on June 28, 2013 with diagnoses which included diabetes and gout (a form of acute arthritis that causes severe pain and swelling in the joints). A Physician order dated July 1, 2013 at 10 AM contained an illegible signature with no date or time. The MRC stated that she was unable to read the physician's signature and that it did not include a date or time when the physician wrote the order.

A record review was conducted on September 10, 2013 at various times, of the hospital policy titled, "Telephone, Verbal and Written Orders for Medication." The policy indicated, "...The prescribing practitioner must sign the written record of the verbal/telephone order within 48 hours of giving the order."

A record review was conducted on September 10, 2013 at various times, of the hospital "Medical Staff Bylaws Rules and Regulations, approved by the Governing Body on April 5, 2012." The bylaws indicated, "...The responsible physician shall authenticate, date and time verbal orders and telephone orders regarding medications within forty-eight (48) hours ..." Additionally, the bylaws indicated, "...The practitioner's orders must be written clearly, legibly and completely.."

Based on interview and record review, the hospital failed to implement their policy titled, "Pain Management," for 1 of 21 sampled patients (Patient 1), in a universe of 3. The hospital failed to ensure that Patient 1 was medicated after the patient had complained of pain. This failure contributed to patient harm by Patient 1 not having the right to be free from pain.

Findings:

A record review was conducted with the assistance of the Quality Assurance (QA) Director on September 9, 2013 at 3:30 PM of Patient 1. This patient was seen then discharged from the hospital's Emergency Department (ED). The record revealed that Patient 1 complained of chronic (persisting for a long time or constantly recurring) fibromyalgia pain (a chronic disorder characterized by widespread pain, fatigue and tenderness in localized areas). Nursing notes dated September 9, 2013 at 12:27 AM, indicated that Patient 1's pain level was reported as a 10 (pain intensity on a 0 - 10 scale where 0 means no experienced pain while a 10 means the worst pain ever experienced). The location and the duration of the pain were not documented. Additionally, aggravating (worsening) and alleviating (relieving) factors were also not documented. At 1:22 AM, Patient 1 was discharged from the ED. Documented evidence indicated that Patient 1 was not medicated for pain during her stay in the ED.

During an interview the QA Director, on September 9, 2013 at approximately 3:30 PM, she stated that after reviewing Patient 1's medical record, it was noted that there was no documentation to indicate that the patient was medicated for pain while she was in the ED.

During an interview with ED Registered Nurse (RN) 1, on September 9, 2013 at 4:10 PM, she stated that Patient 1 was probably not medicated because the patient had chronic back pain or that maybe she did not have a ride home and the staff did not want to administer a narcotic (a pain medication that can affect an individual's behavior or mood). Additionally, ED RN 1 stated that she was not sure why Patient 1 was not medicated because it was not documented in the medical record.

A record review was conducted on September 9, 2013 at approximately 4:30 PM of the hospital's policy titled, "Pain Management." The policy's "Assessment of pain" section indicated, "...Pain is whatever the experiencing person says it is, existing whenever he says it does." The policy also indicated, "All health professionals will assess each report of pain, including the nature of pain. The following characteristics...should guide the pain assessment: Words to describe pain ...Pain intensity on a 0-10 scale, 0 = no pain and 10 = worst pain imaginable...Location of pain, Duration of pain (presence or persistent and/or breakthrough pain), Aggravating and alleviating factors...A complete pain assessment will be done by nurses on admission and when pain is reported by the patient or recognized by the nurse...Pain Management: Various options for pain control will be available to patients, including both drugs and noninvasive treatment..."

Based on interview and record review, the hospital failed to implement its policy and procedure to ensure that the History and Physical (H&P) examination for 1 of 21 sampled patients (Patient 20) was completed within 24 hours of admission. This failure may result in an inaccurate and/or inadequate plan of care developed for Patient 20.

Findings:

During a record review for Patient 20 on September10, 2013 at 2:20 PM, it was noted that Patient 20 was admitted to the hospital on July 12, 2013 at 1:40 PM. The H&P was dictated on July 14, 2013 at 11:04 PM and was transcribed on July 15, 2013 at 9:53 AM. The H&P document was not completed within 24 hours, as per hospital policy.

During an interview with the HIM (Health Information Management) Director on September 10, 2013 at 2:30 PM, the HIM Director confirmed and stated that the H&P was dictated on July 14, 2013 at 11:04 PM and was transcribed on July 15, 2013 at 9:53 AM.

During a review of the hospital policy on "Admission History" (no date), stipulated that "Each patient admitted for inpatient care shall have complete admission history and physical examination shall be recorded by a qualified physician...within twenty-four (24) hours of admission."

Based on observation, interview and record review, the hospital's pharmacy department failed to ensure the following:

1. that an Isolation Box (Glove Box Isolation Chamber) was available in the area where compounding (mixing) of sterile (a germ free environment) products were being prepared.

2. that Patient 15's physician had written clear and well defined parameters when not to administer medications ordered for controlling the patient's high blood pressure condition when the blood pressure decreased to an unsafe level.

These deficient practices had the potential to increase the possibility of contamination of sterile products (medications) for all patients receiving medications prepared by the pharmacy department, and had the potential to affect 1 of 21 sampled patients (Patient 15's) health and safety when taking medications to control a high blood pressure condition.

Findings:

On September 10, 2013, at approximately 9:00 AM, it was observed during the pharmacy department inspection tour, that the work area for compounding sterile injectable drugs did not have a "Glove Box Isolator." Glove box isolators are essential pharmacy equipment for minimizing potential contamination (dirty substances) and exposure during compounding of sterile injectable (administered through the vein or into the muscle using a needle and syringe) drugs.

Glove Box Isolators have shoulder length impermeable (fluid cannot go through the material making it waterproof) sleeves with gloves attached. Pharmacy Technicians would insert their hands into the sleeves/gloves and manipulate (touch and handle) the compounding of sterile intravenous (IV - delivered through the vein) products.

On September 10, 2013, a review of the hospital's policy and procedure titled, "STERILE PRODUCTS-GENERAL", dated December 2009, it stipulated, "...Supply of IV medications are produced in a clean environment under a laminar flow (a constant flow of air pushing dirty particles out) hood minimizing the introduction of particulate matter..."

In section (B)(1)(b) of the policy, it stipulated, "...Use of laminar flow clean-air hoods, barrier isolators, and other contamination control devices must be used appropriate for the risk level. The frequency and amount of personnel access to the clean room or area should be restricted to minimize contaminants..."

On September 10, 2013, at approximately 10:00 AM, the Director of Pharmacy confirmed the finding that the pharmacy department did not have an isolation barrier or a glove box isolation chamber or other contamination control devices to minimize the potential for airborne contamination in the workspace according to hospital policy.

On September 11, 2013, at approximately 11:00 AM, the Director of Quality Assurance and Performance Improvement Program confirmed that active surveillance of the pharmacy's procedure for the preparation of sterile products had not taken place.

2. On September 10, 2013, a review of Patient 15's medical record was conducted. The Admitting Face Sheet revealed that Patient 15 was admitted to the hospital on June 7, 2013, with an admitting diagnosis of abdominal pain.

On September 10, 2013, a review of Patient 15's Physician's Order Sheet, dated June 7, 2013, at 10:30 PM, documented the following medication orders for controlling a high blood pressure condition:
a. Lisinopril (a medication given to decrease high blood pressure and treat heart failure) 20 milligrams P.O. (taken by mouth) every day.
b. Diltiazem (a medication given to decrease high blood pressure and treat heart failure) 120 milligrams P.O. every day.

There was no documented evidence in the medical record that Patient 15's physician had written clear, well-defined parameters on when to hold (not to administer) Diltiazem and Lisinopril if Patient 15's blood pressure dropped below an unsafe level (normal blood pressure is considered 120/80 milliliters of mercury).

According to Mosby's Nursing Drug Reference, 22nd Edition, 2010, it stated, drug contraindications (when not to administer the medicine) for the medication Diltiazem exists when the patient's systolic blood pressure (high value of a blood pressure reading) is less than 90 milliliters of mercury or when the diastolic blood pressure (low value of a blood pressure reading) is less than 60 milliliters of mercury.

According to Mosby's Nursing Drug Reference, 22nd Edition, 2010, it noted that side effects of the medication Lisinopril, included, orthostatic hypotension (a decrease in blood pressure when abruptly changing position from lying flat on ones back to standing upright). This sudden change in position could cause dizziness, light-headedness, faintness, confusion or blurred vision and tachycardia (fast heart beat over 100 beats per minute, normal heart rate is considered 60 to 100 beats per minute).

On September 10, 2013, a review of the hospital's policy and procedure titled, "RANGE ORDERS FOR MEDICATIONS", dated December 2009 was conducted. There was no documented evidence in this hospital policy and procedure that specifically addressed parameters when to hold or when not to administer medications that were prescribed for treatment of high blood pressure in patients admitted to the hospital.

On September 10, 2013, at 11:30 AM, during an interview with the Chief Nursing Officer, she confirmed the finding that Patient 15's physician did not write specific parameters when not to administer Lisinopril and Diltiazem when the patient's blood pressure dropped below an unsafe level.

Based on observation, interview and record review, the facility failed to ensure that the Dietary Staff supervision of work and personnel performance was provided, resulting in the room temperature within the "Dry Storage" (Place where dry and canned food supplies were stored) area being maintained out of the expected temperature range for 40 days with no action taken to correct the issue. This has the potential to increase the risk of patient harm by hazardous food pathogen forming on the food and causing an infection when the food is ingested for a universe of three patients.

Findings:

During a record review of the Dietary Temperature Log forms on September 9, 2013 at 2:47 PM, it noted that the Dry Storage "Temperature Check Sheet" form had 40 days total of documented temperatures above 70 degrees Fahrenheit from August 1, 2013 through September 9, 2013 (acceptable range between 50-70 degrees Fahrenheit).

Further review of the "Temperature Check Sheet" form stipulated, "If out of range, notify EOC (Environmental of Care, the staff responsible for environmental maintenance) ASAP (as soon as possible)." The form also indicated to "Highlight any out of range. Notify Supervisor and EOC." The August temperature readings ranged from 72-78 degrees Fahrenheit, and for the September temperature readings ranged from 73-74 degrees Fahrenheit. There were no documentation that the room temperatures at the "Dry Storage" area were re-checked and that the EOC was notified when the temperature readings were above 70 degrees Fahrenheit.

During the Dry Storage Room observation on September 9, 2013 at 3:21 PM a wall thermostat was noted. The Chief Executive Officer (CEO) who was with this surveyor during dietary observation was observed to take the wall thermostat hanging from the wall and commented, "how accurate is this?"

During an interview with Dietary Staff 1 (DS 1) on September 10, 2013 at 10:44 AM, DS 1 confirmed that the temperature readings were out of range, and stated "I should have made a maintenace request."

During an interview with the Maintenance Director on September 11, 2013 at 9:40 AM, he confirmed that he was also the EOC. The Maintenance Director claimed that he was not made aware of the "Dry Storage" temperature readings when out of range until September 9, 2013 when the out of range temperature readings were brought to the Dietary Staff's attention.

During a review of the "Facility Agreement For Dietary Consulting" signed and dated on July 11, 2012, noted under "Services To Be Provided By Consultant" included, "Assist dietary personnel with menu planning, supply purchasing, proper storage..." and "Inspect dietary departments regularly to determine adherence to established policies and regulations."