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Based on observation and policy review, the facility failed to protect patient's rights to privacy by placing patient names in public view in four separate ICU's (Intensive Care Unit) and in the pre-surgical preparation area. The facility census was 245.

Findings included:

1. Review of the facility policy titled, "Patient's Bill of Rights (Adopted from the American Hospital Association) Patient's Responsibilities", revised 09/09, gave direction, in part, to include the following:"The patient has the right to every consideration of privacy."

2. Observation on 03/15/10, beginning at 3:35 p.m. in the four ICU's showed charts with patients' first and last names written on the chart binders. The binders were set on a counter between the nurses' station and the hallway so patient names were visible to visitors or anyone walking through the ICU areas. There were a total of 18 patients in the combined MICU (Medical Intensive Care Unit), SICU (Surgical Intensive Care Unit), CVU (Cardiovascular Unit), and CCU (Coronary Care Unit).


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3. Observation of the pre-surgical preparation area on 03/17/10 at 1:30 p.m. revealed three pre-surgical charts with patient's first and last names on a metal rack in a public corridor. Additionally, there was a white erase board found on the same corridor with seven patient's last names, their surgeon's name and the name of the scheduled surgical procedure in plain sight.

Based on policy, observation, and interview, the facility failed to ensure confidential patient information is stored in a secure manner. The hospital census was 245.

Findings included:

Review of the policy titled "Medical Records Located Outside Health Information Management", dated as revised 10/09, states in part the following: #3-Medical records maintained in clinical departments are kept in secured file cabinets and/or offices to protect patient confidentiality.

During an observation of the Pain Center on 03/18/10 at 10:20 a.m. patient medical records containing patient names, insurance information, social security numbers, medical history, and other patient identifying information too numerous to count were found in the Pain Clinic Registered Nursing Manager's office (staff MM), the Insurance Coordinator's office, and the physician's office.

During an interview on 03/18/10 at 10:30 a.m. staff MM said he/she does not think housekeeping cleans the staff offices, but acknowledged that even though the offices are locked at night, all door locks in the pain clinic offices are keyed the same and housekeeping has a key to those offices, as well as the medical records storage room where the majority of the patient records are stored.

During an observation of the Cardiac Rehabilitation patient area on 03/18/10 at 2:15 p.m. four boxes of folders with patient names on the outside of the folders, and full names, dates of birth, admitting diagnosis, and medical histories/major illness documented inside the folders, were found out on a table in the common rehabilitation area just inside the entry area.

Based on policy review, record review and interview, the facility failed to notify the physician of a one hour face-to-face evaluation for one patient (#3) of five restraint episodes reviewed. The facility census was 245.

Findings included:

Review of the facility policy "Restraint Management - Violent and Self Destructive Behaviors", last reviewed January 2010, showed in the Policy Statement #3, "The physician or licensed independent practitioner designee or a registered nurse specifically trained to conduct the face to face evaluation must see and evaluate the patient and the need for restraint use within one hour after initiation of the intervention. If the trained [Registered Nurse] conducts the face to face he/she will consult the attending physician or other licensed independent practitioner as soon as possible after the evaluation."

Review of current Patient #3 showed the patient entered the facility 12/23/09 for treatment of psychosis and violent behavior. Review of a physician's order dated 02/12/10 at 2:30 a.m. showed a telephone order to place Patient #3 in leather restraints due to disruptive behavior. However, review of the one hour face-to-face assessment dated 02/12/10 at 2:30 a.m. showed staff did not notify the physician of the need for a face-to-face evaluation.

During an interview on 03/15/10 at 4:00 p.m. the nursing director of psychiatric patient care services, staff D, confirmed staff did not notify the physician of the need for a one-hour face-to-face evaluation.

Based on facility policy, record review, and interview, the facility:

- failed to ensure one (Patient #7) of one patient reviewed for blood sugar testing received the testing as ordered by the physician;
- failed to medicate one of three patients for pain prior to dressing changes;
- failed to immediately document the identification of new pressure sores,
- failed to obtain treatment orders in a timely manner for the same patient (Patient #8);
- failed to relieve pressure from one patient's heels per physician's order for one of three reviewed with pressure sores (Patient #35); and
- failed to follow physician's orders to obtain daily weights for one patient (#55) of three patient records reviewed on the rehabilitation unit.

The facility census was 245.

Findings included:

1. Review of the facility policy titled "Medication Administration", revised 07/09, gave direction, in part, to include the following:
"Assess the patient for medication-specific data, prn (as needed). (For example...blood sugar prior to insulin [medication given to lower blood sugar level] administration.)"

2. Review of the facility policy titled "Bedside Glucose Testing", effective 12/31/06, gave direction, in part, to include the following:
"Enter glucose (blood sugar) results in hospital computer system on nursing floors...
NOTE: Patient results are not automatically entered into hospital computer by downloading meter."

3. Review of current Patient #7's medical record on 03/16/10 at 10:50 a.m. showed physician orders, written on 03/11/10 at 8:00 a.m., for the following:
"Fingerstick Blood Glucose Schedule (blood sugar test done by nursing) every 4 hours".

Further review of Patient #7's blood sugar record on 03/16/10 at approximately 2:00 p.m. showed the following:
- Testing was scheduled to be done at 4:00 a.m., 8:00 a.m., 12:00 noon, 4:00 p.m., 8:00 p.m., and 12:00 midnight.
- On 03/15/10 at 3:37 a.m., his/her blood sugar was 133 mg/dl.
- On 03/15/10 at 8:25 a.m. (almost five hours later), his/her blood sugar was 138 mg/dl.
- On 03/15/10 at 1:26 p.m. (five hours later), his/her blood sugar was 153 mg/dl.
- On 03/15/10 at 8:52 p.m. (three hours after previous test), there was no documentation of a blood sugar result. However, the patient received insulin.
- On 03/16/10 at 12:07 a.m. (three hours later), his/her blood sugar was 151 mg/dl.
- There was no blood sugar documented for 03/16/10 8:00 a.m. or 12:00 noon.

During an interview on 03/16/10 at 2:55 p.m., Registered Nurse, staff I, stated that the 8:00 a.m. blood sugar was 212 mg/dl. Staff I stated that the 12:00 noon blood sugar was 150 mg/dl. Staff I stated that neither results had been documented.

During an interview on 03/16/10 at 2:55 p.m., Clinical Director of ICU, staff II, and Patient Care Manager of ICU, staff UU, confirmed that Patient #7's blood sugar was not tested every four hours, that there was no blood sugar documented on 03/15/10 at 8:52 p.m. but that insulin was given.

During an interview on 03/17/10 at 9:25 a.m., Registered Nurse Educator of ICU, staff V, stated that he/she found information in the Accucheck (machine that analyzes blood for blood sugar result) and that Patient #7 had a blood sugar of 134 on 03/15/10 at 8: 16 p.m. Staff V confirmed that this information would not have been discovered if the surveyor had not looked at the medical record and found information to be missing.



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4. Review of Patient #8's History and Physical dated 03/08/10 revealed the patient was admitted that day with diagnoses of diabetes and peripheral vascular disease (both risk factors for developing pressure sores). The patient had recently undergone an above-the knee amputation on the left leg related to gangrene. Review of the Nursing Admission assessment revealed the patient did not have any pressure sores upon admission.

Review of facility policies entitled, "Maintenance of Inpatient Skin Integrity," reviewed 02/10/10, and "Nursing Documentation of Patient Care," reviewed 02/07, revealed the following:
a) A Braden score (a tool used to assess the potential for development of pressure sores) of "18" will cause pressure relief to be initiated. Any score below 12 is considered to be high risk. Heel elevation is imperative with scores of 14 and below.
b) Pillows, heel protectors, seat cushions are used to off-load bony prominences of concern.
c) Photographs will be labeled to include name, wound location, date and measurement.
d) Each significant skin alteration must be documented with a photo and Skin Assessment, with dated and timed photo.
e) Pain control should be treated as the fifth vital sign.

However, observation and interview on 03/16/10 from 8:46 through 9:43 a.m. revealed the patient had a Stage II (a partial thickness skin loss, appears as a shallow crater or blister) pressure sore on the upper coccyx (tailbone), measuring 1.0 centimeter (cm) by 1.0 cm, and the patient's rectal area was extremely excoriated (bleeding) related to continuous diarrhea. The patient screamed out in pain and threatened to hit the nurse when the rectal area was cleansed of bowel movement. The patient's left stump also caused the patient pain upon movement. The patient rated his/her pain at a "10," with "10" the worst pain. The Patient Care Technician (PCT), staff member J, told RN staff member L, the nurse responsible for the patient, that the patient needed pain medication; however, staff failed to administer the medication (Morphine 4 milligrams) until all wound treatments were completed. Nevertheless, review of the record on 03/16/10 revealed no documentation regarding the pressure sore on the coccyx.

During an interview on 03/16/10 at 10:40 a.m., SWAT staff member K said he/she identified the coccyx pressure sore two days prior on 03/14/10. Staff member K said the patient had been in a lot of pain on 03/14/10, too. Staff member K said the pressure sore measured 0.5 cm by 0.5 cm on 03/14/10, and she/he failed to document this until this day (03/16/10).

Review of physician's orders revealed no orders for treatment to the coccyx pressure sore until 03/16/10, two days after identification by staff K. Review of a facility-provided pressure sore list revealed Patient #35 had pressure sores on his/her heels and coccyx.

Review of Patient #35's admission orders revealed the patient was admitted on 02/25/10 with a diagnosis of breathing difficulty

Review of the patient's Braden scores from admission through 03/17/10 revealed scores from 8-12, all revealing a high risk for development of pressure sores.

According to the Agency for Health Care Policy and Research, Pressure Ulcer Treatment, devices that totally relieve pressure on the heels should be used, and review of Physician's orders dated 02/26/10 revealed the patient's heels were to be floated (elevated off any surface). However, observation on 03/17/10 at 11:00 a.m. revealed the following:
a) RN (Registered Nurse) staff members HH and GG uncovered the patient's feet and his/her heels were directly on a pillow, sustaining pressure. The pillow covering had drainage on it from the pressure sores on the patient's heels.
b) The patient had large areas of eschar (black, dead tissue) on both heels.
c) The right heel measured 5.0 cm by 7.0 cm, the left heel measured 9.0 cm by 5.0 cm, and the coccyx 5.5 cm by 7.0 cm (also eschar covered).

During an interview on 03/17/10 at 2:50 p.m., RN staff member confirmed that floating of heels meant to have the heels off any surface/pillow to totally relieve pressure.
Review of the patient's care plan revealed interventions to turn and reposition and consult a wound/skin specialist, but staff failed to include the intervention to float the heels as ordered by the physician.



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5. Record review showed current Patient #55 entered the facility on 03/14/10 for treatment of diabetes mellitus, uncontrolled hypertension, diarrhea, nausea, vomiting and chronic kidney disease with dialysis. Patient #55 received kidney three times a week. Review of the admission orders showed the physician ordered daily weights.

However, review of the vital signs form on 03/18/10 for Patient #55 showed no weight recorded for 03/16/10 and 03/17/10.

During an interview on 03/18/10 at 9:50 a.m. staff XX, the supervisor of patient care services for the rehabilitation unit, confirmed staff recorded no weight for Patient #55 on 03/16/10 and 03/17/10. On 03/18/10 at approximately 1:30 p.m. staff XX said the staff weighed Patient #55 on 03/17/10, but did not chart the weight until later in the day on 03/18/10.

Based on observation, record review, personnel file review, and interview, the facility failed to provide orientation to the nursing unit on which they worked for two of two agency nursing staff reviewed (staff I and staff YY). The hospital census was 245.

Findings included:

1. Review of the facility policy titled "Nursing Personnel/Patient Services - Outside Agencies", revised 12/09, gave direction, in part, to include the following:
"ICU (Intensive Care Unit) and ED (Emergency Department) Manager will interview the candidate and complete an orientation session specific to the area."
"Role of the Preceptor:"
"Review of general unit routines established for patient care and key aspects of care for assigned patients."

2. Observation on 03/16/10 at 9:20 a.m. in the Intensive Care Unit (ICU) showed Registered Nurse (RN), staff I, administer medications to Patient #7. Staff I took approximately 25 minutes to administer four medications and document his/her actions. The surveyor's escort, ICU Manager, staff II, had to assist staff I with documenting in the electronic medical record.

Review of Patient #7's medical record on 03/16/10 at approximately 2:00 p.m., showed that blood sugar testing and insulin (medication to lower blood sugar) administration had not been documented by staff I for 8:00 a.m. or 12:00 noon.

Review of staff I's personnel file on 03/17/10 at 3:45 p.m. showed no documentation of orientation to ICU.

During an interview on 03/16/10 at 2:10 p.m., staff II, stated that this was the first day that staff I had worked in ICU. Staff II stated he/she was not sure what orientation staff I received to the ICU.

During an interview on 03/17/10 at 4:40 p.m., ICU Educator, staff V, stated that agency nurses get one day of hospital orientation and no orientation specific to ICU. Staff V stated that staff I was assigned two ICU patients on 03/16/10.



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3. Review of agency nurse staff YY's personnel file on 03/18/10 at 10:10 a.m. showed no documentation of orientation to the Rehabilitation Unit.

During an interview on 03/18/10 at 10:10 a.m., staff XX the supervisor of patient care services for the Rehabilitation Unit, said staff YY paired up with another night shift nurse for the first two shifts staff YY worked. Staff XX confirmed there was no documentation of unit specific orientation for staff YY.

Based on facility policy, record review, and interview, the facility failed to ensure medications were given as ordered by the practitioner and follows standard of practice references for the time over which the medication should be administered for three (Patient #7, #22 and #23) of six patients observed for medication administration. The facility census was 245.

Findings included:

1. Review of the facility policy titled "Medication Administration", revised 07/09, gave direction, in part, to include the following:
"Give medications when ordered; up to three hour prior to scheduled dose and up to three hour after scheduled dose.""Assess the patient for medication-specific data, prn (as needed). (For example...blood sugar prior to insulin [medication given to lower blood sugar level] administration.)...Utilize the six patient rights when administering medications."
"Right dose"
"Right time"
"Right documentation"
"Double-check high alert medication...insulin...Ensure this double-check is documented."
"Administer insulin after two RNs (Registered Nurse) have double-checked the order against the insulin type and the dose. Both must document the double-check on the order sheet or in the electronic medical record."
"Documentation: All medications should be recorded in MIS (Medical Information Systems [computerized charting]) (if not charted by Pyxis [medication distribution system]) by the authorized person administering the drug immediately after the drug is given."

2. Review of the facility policy titled "Bedside Glucose Testing", effective 12/31/06, gave direction, in part, to include the following:
"Enter glucose (blood sugar) results in hospital computer system on nursing floors...NOTE: Patient results are not automatically entered into hospital computer by downloading meter."

3. Review of current Patient #7's medical record on 03/16/10 at 10:50 a.m. showed physician orders, written on 03/11/10 at 8:00 a.m., for the following:
- "Fingerstick Blood Glucose Schedule (blood sugar test done by nursing) every 4 hours".
- "Hyperglycemic (high blood sugar) Correction Dose": (Instructions were written to administer the following doses of insulin based on the patient's blood sugar)
Less than 100 mg/dl (milligrams per deciliter) = 0 units of insulin
100 - 150 mg/dl = 3 units
151 - 200 mg/dl = 6 units
201 - 250 mg/dl = 10 units
251 - 300 mg/dl = 15 units
301 - 350 mg/dl = 20 units
- "All doses should be Novolog (insulin aspart [rapid acting insulin used to treat high blood sugar])"

Further review of Patient #7's blood sugar record and medication administration record on 03/16/10 at approximately 2:00 p.m. showed the following:
- Scheduled blood sugar and insulin times were 4:00 a.m., 8:00 a.m., 12:00 noon, 4:00 p.m., 8:00 p.m., 12:00 midnight.
- On 03/15/10 at 1:26 p.m. (five hours after previous test and insulin), his/her blood sugar was 153 mg/dl. The patient received 6 units of insulin as per the physician's order.
- On 03/15/10 at 5:52 p.m., his/her blood sugar was 146 mg/dl. The patient did not receive any insulin but should have received 3 units.
- On 03/15/10 at 8:52 p.m. (three hours later), his/her received 3 units of insulin but there was no documentation of the blood sugar result.
- On 03/16/10 at 12:07 a.m. (three hours later), his/her blood sugar was 151 mg/dl. The patient did not receive any insulin but should have received 6 units.
- On 03/16/10 at 4:10 a.m., his/her blood sugar was 204 mg/dl. The patient received 3 units of insulin at 4:44 a.m. and 6 units of insulin at 4:47 a.m., for a total of 9 units, but should have received 10 units.
- There was no documentation of the insulin type and dose being double-checked by a second RN for either of these insulin doses.
- There was no blood sugar or insulin documented for 03/16/10 8:00 a.m. or 12:00 noon.

During an interview on 03/16/10 at 2:55 p.m., Registered Nurse, staff I, stated that the 8:00 a.m. blood sugar was 212 mg/dl and he/she gave the patient 10 units of insulin. Staff I stated that the 12:00 noon blood sugar was 150 mg/dl and he/she gave the patient 3 units of insulin. Staff I stated that neither results had been documented in the patient's medical record.

During an interview on 03/16/10 at 2:55 p.m., Clinical Director of ICU, staff II, and Patient Care Manager of ICU, staff UU, confirmed that Patient #7's blood sugar was not tested every four hours, that there was no blood sugar documented on 03/15/10 at 8:52 p.m. but that insulin was given, that the patient's blood sugar on 03/15/10 at 5:52 was not treated, that the patient's blood sugar on 03/16/10 at 12:07 a.m. was not treated, and that the patient received an incorrect dose of insulin on 03/16/10 at 4:10 a.m.

During an interview on 03/17/10 at 9:25 a.m., Registered Nurse Educator of ICU, staff V, stated that he/she found information in the Accucheck (machine that analyzes blood for blood sugar result) and that Patient #7 had a blood sugar level of 134 on 03/15/10 at 8:16 p.m. so the patient received the correct dose of insulin. Staff V confirmed that this information would not have been discovered if the surveyor had not looked at the medical record and found information to be missing.


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4. Review of the facility policy titled "Transcription of Orders", revised 11/08, gave direction, in part, to include the following:
POLICY: To ensure patient safety through the accurate transcription of physician/nurse practitioner orders.
8.0 Transcription of Practitioner's Orders:
8.2 Orders will be transcribed by the clerical associate/licensed nurse.
8.5 After the order is entered in MIS, the Physician Order Sheet is removed from the chart and scanned through the Pyxis Connect Scanner. STAT (immediate) orders can be scanned to the top of the queue by marking the STAT box on the physician order prior to scanning.
8.8 The staff nurse is responsible for the completion and follow-through on all written orders.
8.9 All orders must be signed off including date time and licensed nurse signature in red ink.

However, observation during medication administration for patient #22 on 03/16/10 at 8:50 a.m. showed Registered Nurse, Staff X administer Pepcid (treatment for heartburn and/or ulcers) 20 milligrams (mg) Intravenous Push (IVP) over 1 minute 20 seconds.

Review of Micro Medex, the nurses' medication guideline reveals the following instruction "inject over a period of at least 2 minutes." Guidelines reveal medication given over shorter time frame may cause a drop in blood pressure.

Review of Patient #22's physician orders shows on 03/14/10 at 1:15 p.m. the physician wrote an order #4 "DC [discontinue] IV Pepcid", but review of Patient #22's medication administration records shows that IV Pepcid was administered on 03/14 at 8:55 p.m., 03/15/10 at 8:55 a.m., 03/15/10 at 8:14 p.m. and 03/16/10 at 8:51 a.m., a total of 4 doses of medication after the physician had discontinued the medication.

Interview with Staff X after the medication administration revealed, "I did not look at the clock to see how long I gave the IV medication. I would say over 2 minutes."

Interview with Pharmacist, Staff ZZ on 03/16/10 reveals the order to discontinue the medication was not taken out of the computer system, so the medication continued to show up on the patient's medication administration record. The night nurse failed to catch the discontinued medication on the medication administration double check.

5. Observation during medication administration for Patient #23 on 03/16/10 at 9:23 a.m. showed Registered Nurse, Staff Y administered Protonix 40 mg (medication to treat heartburn) IVP over 45 seconds and Lasix (water medication, reduces swelling and fluid retention) 40 mg over 30 seconds.

Review of Micro Medex medication guidelines reveals the following instructions: for Lasix inject slowly over 1 - 2 minutes, for Protonix inject over a period of at least 2 minutes. Medication given over shorter time frames can cause a drop in blood pressure per guidelines.

Interview after medication administration with Staff Y revealed meds given over 1 - 2 minutes, didn't actually look at the clock, and, "Guess I need to give medication longer."

Based on record review and interview, the facility failed to ensure the physician signed the admission history and physical for one patient (#49) of four psychiatric records reviewed. The facility census was 245.

Findings included:

Review of current Patient #49's medical record showed the patient entered the facility 03/08/10 for treatment of confusion and Alzheimer's disease. The history and physical dated 03/10/10 was not authenticated by a signature of a physician.

During an interview on 03/17/10 at 3:40 p.m. the nursing director of psychiatric patient care services, staff D confirmed the handwritten history and physical does not have a signature of a physician. Staff D said he/she did not know which physician had written the history and physical.

Based on record review and interview, the facility failed to ensure the physician completed the history and physical within 24 hours of admission for one patient (#49) of four psychiatric records reviewed. The facility census was 245.

Findings included:

Review of current Patient #49's medical record showed the patient entered the facility 03/08/10 for treatment of confusion and Alzheimer's disease. However, the history and physical was dated 03/10/10, more than 24 hours following admission.

During an interview on 03/17/10 at 3:40 p.m. the nursing director of psychiatric patient care services, staff D, confirmed the handwritten history and physical has a date two days after Patient #49's admission.

Based upon review of facility policy, interview and record review, the nursing staff failed to document the intake of nutritional supplements. This applied to two (#9, 12) of two patients reviewed who were receiving supplements in the census of 245, which included a total sample of 59.

Findings included:

1. Record review for Patient #9, admitted 03/07/10, showed the patient to be receiving Suplena supplement (a low protein nutritional supplement specially designed for patients with limited kidney function) as a drink to be taken two times per day. The patient's medical record showed the supplement to have been provided to the patient, but the record failed to show the amount consumed from the time of order on 03/12/10 until the day of survey 03/15/10.

2. Record review for Patient #12, currently admitted since 03/05/10, showed the patient to be receiving Juvin (a specially formulated high protein nutritional supplement designed for patients with greater need for wound healing), as a drink to be taken two times per day. The patient's medical record showed the supplement to have been provided to the patient, but the record failed to show the amount consumed from the time of the order on 03/06/10 until the day of the survey 03/15/10.
During interview on 03/15/10 at 3:00 p.m., the Registered Licensed Dietitian (RDLD) (Employee R) and the nurse manager for the 10th floor, Employee WW, stated that the 'new' computer system did not have a good way to document the supplement intake. Documentation was better with the previous system.

Based on observation, interview and record review, the facility failed to have a system in place to:
- to perform monthly inspections on sample medications;
- to document receipt of sample medications;
- to document dispensed medications in the medical record for three of three patients sampled (#57, #58, & #59); and
- to ensure medications were dispensed according to a physician's order for three patients sampled (#57, #58, & #59) according to facility policy.

The hospital census was 245.

Findings included:

1. Review of the policy titled "Drug Samples", dated as revised 07/23/01, directs staff in part the following:
? All sample will be inspected monthly by Pharmacy personnel for outdates, storage and documentation compliance.
? Samples will be obtained, stored, dispensed or administered in compliance with all state and federal laws.
? All samples of legend medications dispensed or administered must be charted appropriately in the patient's medical record.
? Each area with sample medications shall maintain a "Sample Medication Dispensing Log" for each sample medication stored in that area.
? This log shall document the following for each transaction per dose form: Dispensing date; patient's full name; patient account #; product manufacture; product lot #; product expiration date; #doses dispense; and prescriber's signature.
? All samples of legend medications dispensed or administered must be charted appropriately in the patient's medical record.

However, review of the facility policy(s) related to sample medications does not show any specific policy on pharmacy oversight related to the receipt of sample medication directly to patient care units, responsibility of unit staff, or oversight related to the disposal of any unusable sample medications.

2. Review of the policy titled "Floor Stock Inspections", dated as revised 01/24/06, stated in part the following:
? Old, outdated or deteriorated drugs, when found, should be returned to the Pharmacy for proper disposition.

3. Review of the policy titled "Medication Administration", dated as revised 07/09 states in part the following:
? Medications and nutritional supplements require an order prior to administration.

4. During an observation on 03/19/10 at 10:00 a.m. the locked sample cabinet on the 3rd floor psychiatric unit is found to have too numerous to count Seroquel regular strength 300 milligrams (mg); Seroquel XR (time-released) (used to treat schizophrenia and bipolar disorder, also known as manic-depression) in strengths of 150 mg, 300 mg, & 400 mg; Cymbalta 30 mg (used to treat major depressive disorder, general anxiety disorder and fibromyalgia) & 60 mg; Zyprexa (used to treat the symptoms of psychotic conditions such as schizophrenia and bipolar disorder) 5 mg 15 mg & 20 mg.

5. Medical record review for patient #57, found the patient was discharged on 06/18/09 with a diagnosis of major affective disorder, depression, recurrent, with psychotic features. Review of the Medication Dispensing Log Mental Health entries (two) dated 06/18/09 showed Patient #57 received a total of 64 capsules of Cymbalta 30 mg. Additionally, the physician noted in the discharge orders dated 06/18/09 at 6:55 a.m. "Prescriptions in front of the chart". Review of patient #57's medical record showed no prescribers' order to dispense medication in the form of samples; no documentation the patient received sample medications, nor did the prescriber sign the Medication Dispensing Log Mental Health.

6. Medical record review for patient #58 found the patient was discharged on 01/18/10 with a diagnosis of major depressive disorder, recurrent, severe, without psychotic features, and opioid dependence. Review of the Medication Dispensing Log Mental Health entry dated 01/18/10 showed Patient #58 received a total of 35 capsules of Cymbalta 60 mg. Additionally the physician wrote a prescription for Cymbalta to be given to the patient at discharge. Review of patient #58's medical record showed no prescribers' order to dispense medication in the form of samples; no documentation the patient received sample medications, nor did the prescriber sign the Medication Dispensing Log Mental Health.

7. Medical record review for patient #59 found the patient was discharged on 01/08/10 with a diagnosis of major depressive disorder, recurrent, severe, with psychotic features, and alcohol dependence. Review of the Medication Dispensing Log Mental Health entry dated 01/08/10 showed Patient #59 received a total of 28 capsules of Cymbalta 60 mg. Additionally the physician wrote a prescription for Cymbalta to be given to the patient at discharge. Review of patient #59's medical record showed no prescribers' order to dispense medication in the form of samples; no documentation the patient received sample medications, nor did the prescriber sign the Medication Dispensing Log Mental Health.

8. During an interview on 03/19/10 at 9:20 a.m. Registered Nurse Case manager staff TT said that he/she is responsible for managing the sample medications, has worked on the unit for about two years, and pharmacy has not come on the unit to check the sample medications for outdates. Staff TT said that there is only one key to the cabinet and he shares that key with a co-worker when he is not working.

Staff TT said the physician always meets with the drug company representative and signs for the acceptance of the medication. However, when staff TT was asked to provide one of the acceptance copies of verification received from the drug representative, he/she was unable to find the documentation. Staff TT said that he/she has all of the old receipts in the locked medication cabinet and has not sent any to the pharmacy. Staff TT said that sometimes the physician discharging the patient just gives a verbal order to dispense the samples to the patient, but he/she is not sure it is always written as an order in the patient's medical record.

9. During an interview on 03/19/10 at 10:05 a.m. the Manager of Mental Health Services, staff SS, said that sometimes staff says the physician may write orders to dispense sample medication and sometimes the physician may give a verbal order to the nurse to dispense. Staff SS said that best practice would be that when the physician tells the nurse what to dispense, it should be written as a verbal order in the medical record.

10. During a phone interview on 03/19/10 at 10:45 a.m., the Director of Pharmacy, staff QQ, said he/she thought the technicians were checking the sample area for monthly outdates. Staff QQ also said that independent consultants were onsite a while ago, but he/she is unsure of the time frame, and made suggestions regarding establishing a perpetual inventory sample log, but these suggestions have not been implemented by hospital staff.

Based on policy, observation, and interview, the facility failed to implement a system following hospital policies to identify opened medications with the date, time and initials of staff opening the medication and failed to removed outdated medications from immediate patient access. The hospital census was 245.

Findings included:

Review of the policy titled "Medication Administration", dated as revised 07/09, stated in part the following: #13-b. Label all multi-dose vials with the date and time opened and initials of staff opening. Discard within 28 days of date and time opened. Discard containers without preservatives and irrigating solutions with 24 hours of opening. Discard containers without preservatives and irrigating solutions (single use only containers) within 1 hour of opening.

However, observations on 03/17/10 from 2:55-3:10 p.m. found the following:
a. Operating Room #9, bottom drawer of the anesthesia cart:
? One bottle of Isoflurane, 100 milliliters (a multi-dose container of a liquid anesthetic inhalant), opened, exact quantity left unknown, unlabeled with opened date, time and initials.
? One bottle of Ultane 250 milliliters (a multi-dose container of a liquid anesthetic inhalant), opened, exact quantity left unknown, unlabeled with opened date, time and initials.

b. Operating Room #5, Cystoscopy Room (room used for kidney and urinary tract examinations), bottom drawer of the anesthesia cart:
? One bottle of Ultane 250 milliliters, opened, exact quantity left unknown, unlabeled with opened date, time and initials.

c. Operating Room #15, bottom drawer of the anesthesia cart:
? One bottle of Isoflurane, 100 milliliters, opened, exact quantity left unknown, unlabeled with opened date, time and initials.

During an interview on 03/17/10 at 2:55 p.m. Registered Nursing Director, staff JJ, said that anesthesia liquid inhalant medications should be dated, timed and initialed just like any other medication.

d. During a tour and observation of the Pain Clinic on 03/18/10 at 10:30 a.m. the following items are found in the third drawer of the medication storage cart located in the procedure room used to administer pain medication treatments:
? One vial sodium bicarbonate 8.4%, 50 milliliters, labeled as a single dose vial and dated as opened on 03/17/10.
? One vial of Omnipaque 240 milliliter/50 milliliter vial (x-ray dye), labeled as a single dose vial and dated as opened on 03/17/10.
? Lidocaine 1% with epinephrine 1:100,000 30 milliliter vial (local anesthetic) labeled as a single dose vial and dated as opened on 02/16/10.
? Bupivacaine 0.25% with epinephrine 1:200,000 30 milliliter vial (local anesthetic) labeled as a single dose vial and dated as opened on 02/24/10.

e. During an observation in the Endoscopy Unit on 03/17/10 at 3:37 p.m. the anesthesia cart in procedure room #4 is found to have one Lidocaine 1% 15 milliliter vial (local anesthetic) outdated 8/1/2008 and one Amiodarone 150 milligram/3 milliliters vial (cardiac medication) outdated 02/10.



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Based upon observation and interview, the director of food and dietetic services failed to consistently implement procedures to maintain safe and sanitary conditions for the preparation and service of foods for all patients in a current census of 245, including the sample of 59.

Findings included:

1. Observation of the Food Production Center and the kitchen within the hospital building, on 03/15/10 at 2:00 p.m. revealed the following:

At the Food Production Center:
-a cart of 4 trays of dished custard portions stored in the walk-in cooler without any cover on the dished custards (Refrigerator WRU #4).
-11 trays of finished chicken cooling without cover in Refrigerator WRU#5.
-the kitchen ceiling above the dishmachine had black speckles, predominantly over the area where clean dishes came through the dishmachine.
-the trash cans were uncovered at the cold food area and near the dry food storage.

During interview on 03/15/10 at 2:00 p.m., the Food Service Manager, Employee H, stated the stored food items were "supposed to have a plastic curtain cover over them."

At the kitchen #2 in the hospital building:
- the trash can near the cafeteria serving area did not have a cover.
-the food carts with meals on trays, kept for holding until re-thermalization, had the doors open for air flow; and the custard and fruit dishes were uncovered.

During interview on 03/15/10 at 2:00 p.m., the Chief Clinical Dietitian, Employee G, stated the meals are portioned to trays and kept from 11:00 a.m. until lunch the following day; and from 2:00 p.m. until supper the following day. These dishes would be uncovered in refrigeration holding for more than 24 hours.

Based upon record review, review of facility policy and interview, the facility failed to have therapeutic diets duly ordered by the practitioner responsible for the patient's care for two (#9, 12) of two patients reviewed for therapeutic diet orders. The current census was 245, and the total sample was 59.

Findings included:

1. Review of the facility policy, "Clinical nutrition Services, Clinical Privileges-Order Writing Policy (Policy #D028, issued 3/10)" found it stated in part, "This policy gives the RD/LD order writing privileges within his/her scope of practice as defined by the American Dietetic Association, the Missouri State Committee of Dietitians and the Missouri Division of Professional Registration. This policy also meets the criteria set forth by the Center for Medicare and Medicaid Services (CMS). Any order will be written in the physician order section of the patient medical record by the RD/LD."

Record review for Patient #12, currently admitted since 03/05/10, showed the patient to have ordered a Regular diet with Suplena supplement, 1 can BID (twice daily), ordered by the Registered, Licensed Dietitian.

Record review for Patient #9, currently admitted since 03/05/10, showed the patient to have ordered a Cardiac 4 gm Na+ (4 gram sodium) diet with Juvin, 1 packet 2 times per day, as ordered by the Registered, Licensed Dietitian.

During interview on 03/15/10 at 11:00 a.m., the RDLD Employee R, and the Chief Clinical Dietitian, Employee G, stated that the new policy allowed the dietitians to order diets and supplements for patients in the hospital.

Although the above referenced policy stated that the policy meets the criteria of the Centers for Medicare and Medicaid (CMS), it does not meet this regulation since the practitioner has not written an order for the dietitian to order the diet for a specific patient. Hospital policy, privileging, or other methods cannot abridge this regulation.

Based on observation and interview, the facility failed to administer enteral feeding (tube feeding) with proper regard to sanitation technique for one (Patient #7) of four patients observed with tube feeding and failed to administer and record intake of nutritional supplement as ordered for two patients (Patient #6 and #3). The facility census was 245.

Findings included:

1. Review of the facility policy titled "Feeding Tube: Weighted Enteral - Insertion Care and Use of Feeding Pump", reviewed 10/07, gave direction, in part, to include the following:
"Tube Maintenance...Change feeding bag and tubing every 24 hours."

2. Observation on 03/16/10 at 9:45 a.m. showed Patient #7 receiving a tube feeding. The label on the container showed that it was Opexa (liquid nutritional replacement) infusing at 40 milliliters per hour and hung at 03/15/10 at 4:00 a.m.

During an interview on 03/16/10 at 9:45 a.m., Manager of Intensive Care Unit, staff II, confirmed that the tube feeding, container, and tubing delivering it to the patient should have been replaced by 4:00 a.m. (almost 6 hours past due).



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3. Review of Patient #6's Medical Necessity Narrative dated 03/10/10 revealed he/she was admitted on 03/09/10 with diagnoses of breast cancer, depression, and failure to thrive.

Review of the patient's Physician's Orders revealed an order dated 03/09/10 for a nutritional supplement called Ensure, one can with each meal, at bedtime and more as requested.

Review of documentation regarding the Ensure provision and consumption from order to 03/15/10 revealed the Ensure had been provided three times over a minimum of four 24-hour periods, or a minimum of 16 opportunities for delivery. Staff failed to document delivery of 12 ordered supplements. Staff also failed to document consumption percentage for all 16 supplements.

During an interview on 03/15/10 at 2:23 p.m. Registered Nurse Manager staff member E said nurses deliver the supplements to patients and they had not been documenting the consumption percentage.

Review of Adult Assessments from admission through 03/18/10 revealed the patient had lost 1.4 kilograms (kg).

4. Review of Patient 3's History and Physical dated 03/08/10 revealed he/she was admitted on that date with diagnoses of diabetes, end-stage renal disease, breast cancer, and wound care.

Review of the patient's Physician's Orders revealed an order dated 03/09/10 for a nutritional supplement called Nepro, one can three times daily.

Review of documentation regarding the Nepro provision and consumption from order to 03/16/10 revealed the Nepro had been provided three times over a minimum of five 24-hour periods, or a minimum of 15 opportunities for delivery. Staff failed to document delivery of 10 ordered supplements. Staff also failed to document consumption percentage for 13 supplements.

Review of Adult Assessments from admission through 03/15/10 (about 7 days) revealed the patient had lost 3.19 kg, or approximately one pound daily.

Based on observation and interview, the facility failed to ensure two of two crash carts and one air intake vent were clean and free of dust and debris. The facility census was 245.

Findings Included:

1. Observation and interview on 03/16/10 at 3:00 p.m. revealed the top of the crash cart, located on the fourth floor, was covered with a moderate layer of dust, including the suction machine. Registered Nurse Manager staff T said the crash carts are supposed to be cleaned when restocked by the Central Purchasing Department. The last time the cart was restocked was 02/26/10.

2. Observation and interview on 03/17/10 at 9:02 a.m. revealed the top of the crash cart, located on the tenth floor, was covered with a moderate layer of dust, including the suction machine.


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3. Observation and interview on 03/16/10 at approximately 3:00 p.m. in the Emergency Department showed Trauma Room 3's intake vent covered with a thick layer of dust. Vice President, Patient Care Services, staff A, confirmed that the vent needed to be cleaned.

Based on observation and interview, the facility failed to maintain a clean and safe environment for patients receiving treatments and surgical procedures by ensuring that mattresses were free of holes, failed to remove outdated supplies from immediate access, and failed to monitor a patient food refrigerator daily for proper temperature. The hospital census was 245.

Findings included:

1. During an observation on 03/17/10 at 1:45 p.m. the pre-surgical preparation areas identified as room(s) #6, #8, & #9 are all found to have surgical stretcher mattresses with a dime size slit/hole exposing the foam core of the mattress. These holes may prevent appropriate cleaning and disinfecting of the mattress pad between use by different patients.

2. Observation of operating room identified as #15 on 03/17/10 at 2:37 p.m. showed the operating room table mattress pad to have tears in the pad and tears in the arm board exposing the foam core of the mattress. These holes may prevent appropriate clean and disinfecting of the mattress pad between use by different patients.

3. Operating Room Registered nursing educator, staff KK and Operating Room Registered Nursing Director, staff JJ, both confirmed the need to replace the mattress pads on 03/17/10 at 3:05 p.m. at the time of the tour. Staff JJ said that operating room #15 was used today.

4. During an observation of the Endoscopy (scope equipment used to visualize the digestive tract areas) examination area on 03/17/10 at 3:37 P.M. a stretcher used for procedures is found, near rooms #1 and #2, to have tears in the pad. Additionally, another stretcher was found near room #3 with a large tear in the pad. These holes may prevent appropriate cleaning and disinfecting of the mattress pad between use by different patients.

5. Observation on 03/16/10 at 2:50 p.m. in the Emergency Department (ED) Trauma room B, showed two stretchers for patient use. The stretcher on the right side of the room, when entering the room, had a large open area in the middle of the mattress. The hole was approximately seven inches long, exposed the foam core of the mattress, and had tape over it. There was a small hole on the side of the mattress. These holes may prevent appropriate cleaning and disinfecting of the mattress pad between use by different patients.

6. Observation on 03/16/10 at 2:55 p.m. in the ED Trauma room C, showed one stretcher for patient use. The mattress had a hole approximately one inch in length on the side and exposed the foam core of the mattress. This hole may prevent appropriate cleaning and disinfecting of the mattress pad between use by different patients.

7. Observation on 03/16/10 at approximately 3:15 p.m. in the ED area called "Northeast Express" showed a large room with 6 stretchers. Stretcher #3's mattress had several small cuts measuring approximately one inch or less that exposed the foam core of the mattress.

During interviews on 03/16/10 throughout the ED tour, Vice President of Patient Care Services, staff A, confirmed the need to replace these mattresses.

8. Outdated Supplies:

During an observation on 03/17/10 at 1:50 p.m.in the post-anesthesia recovery unit of a cart identified as anesthesia cart the following outdated supplies are found:
Drawer #1
? One-BD (brand) spinal needle #22 gauge by 3 1/2 inches long-outdated 08/09
? One-BD (brand) spinal needle #22 gauge by 1 1/2 inches long-outdated 01/08
? Three-BD Insyte Autoguard intravenous needles #24 gauge-outdated 11/07
? One-BD Insyte Autoguard intravenous needles #22 gauge-outdated 11/03
? Four-BD Insyte Autoguard intravenous needles #22 gauge-outdated 02/08
? Two-BD Insyte Autoguard intravenous needles #22 gauge-outdated 12/05
? Four -BD Insyte Autoguard intravenous needles #14 gauge-outdated 03/09
? Two -BD Insyte Autoguard intravenous needles #14 gauge-outdated 10/07
? Two-BD Insyte Autoguard intravenous needles #16 gauge-outdated 10/02
? One-BD Insyte Autoguard intravenous needles #16 gauge-outdated 10/06
? One-BD Insyte Autoguard intravenous needles #16 gauge-outdated 05/04
? One-BD Insyte Autoguard intravenous needles #16 gauge-outdated 01/06
? Three-BD Insyte Autoguard intravenous needles #16 gauge-outdated 07/02
? Four-BD Insyte Autoguard intravenous needles #16 gauge-outdated 04/09

Drawer #2
? One-#22 Regional Block Needle-outdated 07/07
? One-BD Insyte Autoguard intravenous needles #24 gauge-outdated 09/05

Drawer #3
? Four-hemodialysis Fistula Sets-outdated 05/08
? Six-Epidural Needles #18 by 6 inches long-outdated 07/04
? Six-Epidural Needles #18 by 6 inches long-outdated 03/06

Drawer #5
? One-Epidural Needles #18 by 6 inches long-outdated 03/06

Drawer #6
? Defibrillation/Pacing/Monitoring Electrodes-outdated 05/08

During an interview on 03/17/10 at 2:00 p.m. Anesthesia staff LL said that the cart is used once or twice per week. Staff LL said that there is not a regular schedule to check the cart for outdated supplies.

During an observation in the operating room #9 on 03/17/10 at 3:00 p.m. one small purple top tube used to collect blood samples is found in a small metal cart with supplies and was outdated 06/07.

During an observation in the operating room #15 on 03/17/10 at 3:00 p.m. two BD (brand) catheter tips used to adapt a syringe were found in a wall cabinet and were outdated 05/05 and 02/10.


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Observation and interview on 03/15/10 at 2:02 p.m. revealed a blood culture kit containing two bottles of BD Bactec 40 milliliters each, that had expired on 01/31 and 02/28/10. There were also three hypodermic Needle-Pro needles with Protection devices, 19 G x 1 1/2 inches, that had expired in 08/09. Both items were found in drawers in the medication area of the sixth floor. Registered Nurse (RN) Manager staff E said the nurses on the sixth floor don't draw blood cultures, so the kit doesn't belong in the medication room. The nursing supervisor or staff E monitor the medication room monthly for outdated supplies and medications.

Observation and interview on 03/16/10 at 3:00 p.m. revealed the Lifescan Glucometer high/low solutions (used to calibrate the blood sugar monitor) had expired in 01/10 and 02/10. A label on the bottles showed they were opened on 03/12/10, after they expired. RN Manager staff T said the glucometers were calibrated daily. The last time this glucometer was calibrated was 03/09/10 per history of the device.

Observation and interview on 03/17/10 at 9:02 a.m. revealed the patient food refrigerator on the tenth floor had not been checked daily for proper temperature. Review of the form utilized for documentation of temperatures revealed the refrigerator must be observed and recorded each day. There were eight days that the temperature had not been recorded, from 03/01-17/10. RN Manager staff W said this was a dietary responsibility.




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Based on facility policy, observation, and interview, the facility failed to perform hand hygiene using soap and water during the care of two patients (Patients #7 and #8) infected with c-diff and failed to follow facility standards of practice for isolation precautions (application of Personal Protective Equipment [PPE]) for Patients #27 and #28 observed with an infection and in contact precaution isolation. The facility census was 245.

Findings included:

1. Review of the facility policy titled "Hand Hygiene", revised 02/10, gave direction, in part, to include the following:
"Indications for hand hygiene; handwashing and hand antisepsis:"
"When caring for patients with diarrhea or known or suspected C. Difficile (a bacteria in the bowel) diarrhea; hand washing will be performed as the only option for hand hygiene."
"Before having direct contact with patients, upon entry into patient's room or patient's care/treatment/testing area."
"After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."
"Upon entry into and when exiting the patient's room or patient care area. This refers to the 'FOAM IN - FOAM OUT' program.
1) Upon entering the patient's room or care area the healthcare provider will perform one of the following options:
a. Wash hands with soap and water
b. Clean hands using the alcohol based hand disinfectant
c. Don gloves
2) Prior to exiting the patient's room or care area the healthcare provider will perform one of the following options:
a. Wash hands with soap and water
b. Clean hands using the alcohol based hand disinfectant
c. Remove gloves and perform option a) or b) above."

2. Review of a facility policy entitled "Cohorting Patients on Isolation Precautions," reviewed 02/10, revealed hand hygiene in rooms where patients have diarrhea or suspected/confirmed C. Difficile illness is limited to hand washing.

3. Review of Patient #8's History and Physical dated 03/08/10 revealed the patient was admitted that day with diagnoses of diabetes and breast cancer. The patient had recently undergone an above-the knee amputation on the left leg related to gangrene.

Observation and interview on 03/16/10 from 8:46 through 9:43 a.m. revealed Registered Nurse (RN), Skin, Wound, Assessment Team (SWAT) staff member K entered Patient #8's room using antiseptic foam for hygiene. Staff member K said the patient was in contact isolation related to Clostridium Difficile (C-Dif) (a bacteria in the bowel which causes diarrhea). The patient had a Stage II (a partial thickness skin loss, appears as a shallow crater or blister) pressure sore on the upper coccyx (tailbone), measuring 1.0 centimeter (cm) by 1.0 cm and the patient's rectal area was extremely excoriated (bleeding) related to the continuous diarrhea. RN Staff members L and M entered the room and used foam antiseptic to cleanse their hands. Later, a physician entered the room and failed to wash his/her hands when entering the patient's room. The physician also failed to tie the isolation gown at the waist.

During an interview on 03/16/10 at 1:25 p.m. RN staff member U said according to the Centers for Disease Control, and their policy, staff was to wash hands with soap and water, rather than use the foam antiseptic for patients with C-dif. Physicians were also to follow this procedure. The nurse responsible for the patient is supposed to tape the foam dispenser off as a reminder to others to wash hands with soap and water as soon as the patient is identified as having C-dif.

4. Observation on 03/16/10 at 9:20 a.m. in the Intensive Care Unit (ICU) showed Registered Nurse (RN), staff I, administer medications to Patient #7. During this process, staff I left the room three times without performing hand hygiene when leaving the room or upon returning. The first time staff I left the room, he/she went to the medication supply area at the nursing station to get medicine cups. The second time staff I left the room, he/she crushed pills in order to give them to Patient #7. The third time staff I left the room, he/she got supplies. Three medications were then given through Patient #7's feeding tube and one medication was given as an injection.

During an interview on 03/16/10 at 2:10 p.m., ICU Manager, staff II, stated that the expectation is to perform hand hygiene upon entering a patient's room and when leaving the patient's room. Staff II stated he/she had observed staff I not perform hand hygiene as noted above.




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5. Review of the facility policy titled, "BJC Healthcare Isolation Precautions Policy ", revised 05/09, and gave direction, in part, to include the following:

E. CONTACT PRECAUTIONS
1. PURPOSE & INDICATIONS
Contact Precautions are intended to reduce the risk of transmission of epidemiologically significant microorganisms by direct or indirect contact.
Contact Precautions are indicated for patients known or suspected of being infected or colonized with organisms that are easily transmitted through direct contact or by contact with items in the patient's environment.

b) Personal Protective Equipment
1) Put on gown and gloves before entering a Contact Isolation area.

c) GOWNS
Protect clothing with a fluid repellent gown or plastic apron when it is likely that clothing will be soiled with body substances. Do not reuse gowns.

3. See Appendices B and C to view the isolation sign and the guidelines for use of the PPE.

Appendix C
Sequence for Donning personal Protective Equipment (PPE)
1. Gown
? Fully cover torso from neck to knees, arms to ends of wrists, and wrap around the back.
? Fasten in back of neck and waist.

However, observation on 3/16/10 at 3:10 p.m. showed Staff N, RN, in Patient #27's room. Patient #27 is on Contact precautions for Methicillin Resistant Staph Aureus (a germ that is resistant to penicillin and most other antibiotics) in the patient's sputum. Staff N did not have the isolation gown tied at the waist. Staff N was working at Patient #27's bedside in close contact with Patient's environment.

Staff AA, Respiratory Therapist, was observed in Patient #27's room at the same time. Staff AA did not have an isolation gown tied at the waist. Staff AA had contact with Patient #27's sputum.

Staff C, manager of risk management confirmed the observations of non-compliance with Isolation precautions, PPE application.

6. Observation on 3/16/10 at 3:15 p.m. showed Staff BB, RN, in Patient #28's room. Patient #28 is on Contact precautions due to diarrhea. Staff BB did not have isolation gown tied at the waist.

Staff CC, certified nurse assistant was also in the room, assisting with the patient care. Staff CC did not have isolation gown tied at the waist.

Staff C, manager of risk management confirmed the observations on non-compliance with Isolation precautions, PPE application.

Based on record review, policy review and staff interview, the facility failed to address the requirements in the Organ, Procurement Organization (OPO) agreement by failing to notify the OPO within one-hour of death for 2 (Patient #44, and #45) of 3 patient death records reviewed. The facility census was 245.

Findings included:

1. Review of the facility Organ and Tissue Recovery Agreement dated February 2, 2007 stated in part the following Responsibilities and services of the hospital:

4. Hospital will notify MTS, in a timely manner, of all individuals whose death is imminent or who have died in or before arrival at Hospital.
1) as soon as it is anticipated that the patient will meet, or within one (1) hour after the patient does meet, the criteria for imminent death and prior to removal from a ventilator, discontinuance of life support, deceleration of care and/or making an end-of-life decision;
2) in all other cases, before cardiac death and within one (1) hour after patient meets initial brain death criteria or, in the case of a single brain death examination, is declared brain dead; and
3) in circumstances where prior notification is not possible, within one (1) hour after the patient is pronounced dead.

2. Review of Patient #44's closed medical record on 3/17/10 showed Patient #44's date and time of death as 03/13/10 at 5:25 p.m. However, review of Expiration Checklist and Mortuary Release form shows no call placed to MTS.

During an interview on 03/18/10 at 8:25 a.m., Staff II, registered nurse, director of Critical Care said the OPO was not called.

3. Review of Patient #45's closed medical record on 3/17/10 showed Patient #45's date and time of death as 03/11/10 at 9:50 p.m. However, review of Expiration Checklist and Mortuary Release form shows call placed to MTS at 12:40 a.m. on 03/12/10, 2 hours and 50 minutes later.

Staff C, manager of risk management confirmed the notification time to the OPO on 03/18/10.