HospitalInspections.org

A. Based on observation and staff interview, it was determined that the Hospital failed to ensure patient safety and privacy were maintained while waiting for radiological services. This has the potential to effect all patients who receive radiological services.

Findings include:

1. During a tour of the Hospital, conducted on 1/30/12 at 10:15 AM with the Director of Performance Improvement (PI) and the Director of Emergency Department (ED), this surveyor was requested by the Life Safety surveyor to accompany the Life Safety surveyor. The Life Safety surveyor had observed a patient in a hospital bed residing in a recessed area on the corner of the Radiology/ ED hallway without a call light or ability to call for assistance. Upon return to the area approximately 5 minutes later, a radiology staff member was observed leaving the Radiology department, approached the patient, and took the patient into a room for testing. The Director of Radiology was interviewed at that time and verbalized that patients are placed in this area "briefly" while the technician goes into Radiology to do whatever errand needs to be done. Radiology then returns to the patient to do whatever procedure is ordered. There was no call light system observed for the patient to call for assistance if needed. The patient was visible to all visitors and staff who passed by in the hallway.

2. During a staff interview, conducted with the Director of PI on 1/31/12 at 3:00 PM, the above finding was confirmed.

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined in 1 of 2 (Pt. # 29) patients with restraints, that the Hospital failed to ensure all restraints were ordered per Hospital policy.

Findings include:

1. The Hospital policy titled, "Restraint and Seclusion," last reviewed 10/11 indicates : " F. Physician Orders 3. Orders for seclusion or restraint must never be written as a standing order or PRN order."

2. The clinical record of Pt. #29 was reviewed on 02/01/12. Pt. #29 presented to the Emergency Department (ED) on 02/01/12 with the chief complaint of drug overdose. Pt. #29 was combative and agitated. "Admission holding orders, For Floor Use Only" dated 11/20/11 at 6:00AM, indicated Pt. #29 was to be restrained "prn" which is not allowable per hospital policy. Restraints were not utilized when Pt. #29 was admitted to the floor.

3. The above finding was confirmed with Clinical Effectiveness Coordinator on 02/01/12 at 10:00 AM.

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined in 1 of 2 (Pt. # 29) patients with restraints, the Hospital failed to ensure each order for restraint did not exceed the 4 hour limit for an adult 18 years of age or older per Hospital policy.

Findings include:

1. The Hospital policy titled, "Restraint and Seclusion," last reviewed 10/11 indicates : "F1. b. Each written order for a physical restraint or seclusion is limited to 4 hours for adults 18 years of age and older..."

2. The clinical record of Pt. #29 was reviewed on 02/01/12. Pt. #29 presented to the Emergency Department (ED) on 02/01/12 with the chief complaint of drug overdose. Pt. #29 was combative and agitated. A restraint order sheet for Pt. #29, dated 11/20/11 at 4:19AM, indicated "Emergent: Restraints applied for irrational behaviors (to protect patient from self or to protect others)...May restrain patient for least restrictive time possible, not to exceed 24 hours." This order exceeds the 4 hour time limit for restraint orders per hospital policy. Pt. #29 was placed in soft wrist restraints on 11/20/11 at 4:19 AM and released at 6:24 AM.

3. The above finding was confirmed with Clinical Effectiveness Coordinator on 02/01/12 at 10:00 AM.

A. Based on a review of Hospital policy, medical record review, and staff interview, it was determined in 1 of 3 (Pt #10) medical records reviewed, in which the patient had Patient Controlled Analgesia (PCA), the Hospital failed to ensure monitoring was documented per the Hospital's PCA policy to ensure pain medication is administered in a safe and effective manner.

Findings:

1. The Hospital policy titled "Patient Controlled Analgesia Infusion System f/k/a PCA Plus II" (revision date 6/11) was reviewed on 1/31/12. It indicated "Z. Document PCA use/pain assessment appropriately in the medical record... 2. PCA monitoring and documentation should be performed at the following intervals: Every hour for the first 4 hours, then every 2 hours for 20 hours, then every 4 hours until the PCA is discontinued. 3. The monitoring will include: a. Respiratory Rate, b. Level of sedation / consciousness, c. Pain rating / intensity, d. Side effects, e. Pulse oximetry as indicated."

2. The medical record of Pt #10 was reviewed on 1/31/12. Pt #10 was admitted to the Hospital on 1/29/12 with the diagnoses Abdominal Pain, Gallstones, and Pancreatitis. On 1/29/12, there was a physician order "Intravenous (IV) Patient Controlled Analgesia (PCA) Orders: Meperidine 10 mg/ml..." Nursing documentation indicated the PCA was started by the nurse on 1/30/12 at 3:00 AM. PCA documentation failed include the required monitoring information and failed to follow the frequency for monitoring, as per policy.

3. During a staff interview, conducted with the Director of PI on 1/31/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of Hospital policy and procedure, medical record review and staff interview, it was determined that in 1 of 3 (Pt #30) medical records reviewed in which the patient utilized patient controlled analgesia (PCA), the Hospital failed to ensure the physician's order specified what PCA medication was to be administered.

Findings include:

1. The Hospital policy and procedure titled, "Physician's Orders" last reviewed date, 10/11, indicated under, "Policy Statement: No medication, treatment or diagnostic test shall be administered to a patient except on the written order of a member of the medical staff, a house staff member under supervision of a member of the medical staff , or allied health personnel with clinical privileges... Guidelines / Procedures, 12. The following are required elements of a completed order: ...12.1 Name of drug..."

2. The medical record of Pt #30 was reviewed on 2/1/12. It indicated Pt #30 was admitted to the Hospital on 1/31/12 with a diagnosis of Left Total Hip Arthroplasty. Documentation indicated that a PCA of morphine was started on 1/31/12 at 3:00 PM. It was discontinued on 2/1/12 at 7:30 AM. The document titled, "Orthopedic Post-Op Orders..." was reviewed. In the section titled, "Analgesia", directions are for the ordering physician to circle the medication of choice (Morphine or Demerol). Neither medication is circled. The only option box checked is for "Oxycodone 5mg, 1 or 2 tabs po (by mouth) every 4 hours PRN (as needed) for break through pain." There was no documentation to indicate what PCA medication was ordered.

3. During an interview with the Chief Nursing Officer, conducted on 2/1/12 at 10:55 AM, the above finding was confirmed.

B. Based on Hospital policy, medical record review and staff interview, it was determined in 1 of 15 (Pts #5) medical records reviewed, in which the patient presented to the Hospital thru the ED, the Hospital failed to ensure medication orders contained all the required elements to ensure a safe and effective dose was administered.

Findings include:

1. 1. The Hospital policy and procedure titled, "Physician's Orders" last reviewed date, 10/11, indicated under, "Guidelines / Procedures, 12. The following are required elements of a completed order: ...12.2 Strength of drug..."

2. The medical record of Pt #5 was reviewed on 1/30/12. Pt #5 presented to the ED on 1/3/12 with the CC, Victim of Violence. There was a physician order "Dilaudid 1/2 IV times one." It failed to include the dose of the medication to administer.

3. During a staff interview, conducted with the Director of PI on 1/31/12 at 2:00 PM, the above finding was confirmed.

A. Based on By-Laws Rules and Regulations, record review and staff interview it was determined that the Hospital failed to ensure 225 medical records as were completed within 20 days following discharge per Hospital By-Laws Rules and Regulations.

Findings include:

1. A review of the Hospital By-Laws Rules and Regulations, last reviewed 11/11, was conducted on 1/30/12. The By-Laws indicated under "25.3 Discharge Records a) Discharge records shall be completed within twenty (20) days of patient discharge."

2. A review of the "Delinquent Count-2012" for January 29, 2012 was reviewed on 1/30/12. Documentation indicated 225 medical records were past 20 days late following discharge.

3. During an interview with the Director of Performance Improvement on 2/1/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that the Hospital failed to ensure all controlled medications were properly secured potentially effecting all patient's safety.

Findings include:

1. The Hospital policy and procedure titled, "Medication Storage" last reviewed date, 11/10, was reviewed. It indicated under, "Procedure: 5.2 All medications are stored in locked containers or storage areas or are under constant surveillance."

2. During a tour of the Anesthesia area, conducted on 1/30/12, it was observed in the surgery preparation area, an unopened vial of Propofol, sitting on the top of an anesthesia cart was left unattended.

3. During an interview with the Chief Nursing Officer, conducted on 1/30/12 at 1:45 PM, the above finding was confirmed.

A. Based on observation, a review of Hospital policy, and staff interview, it was determined the Hospital failed to ensure single use vials were disposed of in accordance to Hospital policy.

Findings include:

1. During a tour of the Radiology Department, conducted on 1/30/12 at 11:00 AM with the Director of Radiology, the following were observed. In the Nuclear Medicine room, one 10 ml open vial of Normal Saline with no date as to when opened; two 5 mcg open single use vials on the counter with solution in them; and one open 5 cc syringe with a needle laying in the "hot box" area.

2. The Hospital policy titled "Medications, Reuse of Multidose and Single Dose Vials" (revision date 8/10) was reviewed on 1/31/12. It indicated "Procedure: 1.1 Single dose vials will be used once and discarded."

3. During a staff interview, conducted with the Director of PI on 1/31/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined the Dietary Manager failed to ensure dietary staff followed established Food Safety and Food Storage policies to ensure safe food storage, which has the potential to effect all patients.

Findings include:

1. The Hospital policy and procedure titled, "Food Safety" last review date of 11/09, was reviewed. It indicated "It is the policy of the department to maintain a food production and storage program that ensures the quality and safety of the food prepared. This program is based on HACCP (Hazardous Analysis of Critical Control Points)...The HACCP manual is up-to-date and exists in hard copy in the director's office and is available on the web-based SodexoNet. Specific food safety guidelines and references are contained in this manual..." Guidelines from the manual titled, "Food Safety Product Labeling & Dating Guide - U.S." was reviewed. It indicated under "Storing Prepared Food, Labels Required, Product storage label: Name of product (unless clearly identifiable, Date of preparation and/or use-by date..."

2. During a tour of the Dietary Department, conducted on 1/30/12 at 10:00 AM, the following observations were made: In the deli cooler - 4 Jello and 2 fresh fruit cups without any type of dating/labeling; In the white freezer, 1 tray of sliced and plated angel food cake without any type of dating/labeling - In the cooks reach in freezer - 2 Styrofoam bowls of chili without labeling/dating. (A third bowl was dated but it had a broken lid) and 1 tray of brownies plated and Saran Wrapped with out any dating.

3. During an interview with the Dietary Manager, conducted on 1/30/12 at 10:30 AM, the above findings were confirmed.

B. Based on a review of Hospital policy and procedure, observation, and staff interview, it was determined that the Hospital failed to ensure there was an identifiable method to ensure first in first out (FIFO) rotation of the dry goods food stock per policy to ensure safe food storage, which has the potential to effect all patients.

Findings include:

1. The Hospital policy and procedure titled, "Proper Food Storage" with a review date of 2/11 was reviewed. It indicated under "Guidelines/Procedures: ...All stock is rotated so that older items are used first using the FIFO system." Guidelines from the HACCP manual titled, "Food Safety Product Labeling & Dating Guide - U.S." was reviewed. It indicated under "Receiving /Storing - Rotation System...FIFO system must be in place...Date cartons, cases, boxes, etc., with "date received..."

2. During a tour of the Dietary Department, conducted on 1/30/12 at 10:00 AM, it was observed in the dry goods storage area that there were no identification marks on any of the food containers that indicated when they were received. Therefore, there was no identifiable method to ensure all stock was rotated in accordance with FIFO.

3. During an interview with the Dietary Manager, conducted on 1/30/12 at 10:30 AM, the above findings were confirmed.

A. Based on observation, a review of Hospital policies, and staff interview, it was determined the Hospital failed to ensure infection control measures were followed, as per Hospital policy, which has the potential to effect all patients.

Findings include:

1. During a tour of the Hospital, conducted 1/30/12 thru 1/31/12, the following were observed: In the ED Triage 1 procedure cabinet, a cup of coffee was observed. A bag of specimen cups was observed under the ice maker in Triage 2. A patient care fan was observed under the sink in Triage 2. A patient suction canister was observed under the sink in Module C, Room 17. In the Sonography rooms, there were five 500 ml bags of 0.9% Normal Saline spiked and hanging from IV poles. There were 3 hanging in Sonography Room #1 and 2 hanging in Sonography Room #2. There was no date as to when they were spiked.

2. The Hospital policy titled "Food and Drink in the Workplace" (revision date 11/09) was reviewed on 1/31/12. It indicated "Guidelines/ Procedure: A. Eating, drinking, and applying... is prohibited in all patient care areas... B. Food and beverages must not be kept in refrigerators, freezers, shelves, cabinets, or on bench tops where blood or other potentially infectious or chemical materials are present."

3. The Hospital policy titled "Departmental cleaning" (revision date 11/09) indicates "Guidelines and Procedures:...3.4 Patient care items cannot be stored under sinks, only cleaning items."

4. During a staff interview, conducted with the Director of PI on 1/31/12 at 2:00 PM, it was indicated that "the Normal Saline bags are hung the night before in the sonography rooms so when patients come in they are ready for one time use to fill patient's bladder's and then are destroyed. They are typically dated when they are hung." It was further indicated that the bags of Normal Saline are not used for IV administration.

5. During a staff interview, conducted with the Director of PI on 1/31/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of the Respiratory Department refrigerator log, Hospital policy, and staff interview, it was determined the Hospital failed to ensure the Respiratory Department refrigerator was monitored in accordance to policy.

Findings include:

1. During a tour of the Respiratory Department, conducted on 1/30/12 at 11:10 AM with the Director of PI and the Director of Cardiopulmonary, the Respiratory Department refrigerator log was observed. It indicated "Refrigerator Temperature/ Room Temperature- 2 to 8 degrees/ 18- 25 degrees Celsius. Daily." There were 6 out of 31 days in December 2011 and 8 of the 30 days of January in which no refrigerator or room temperature were documented.

2. The Hospital policy titled "Blood Gas Laboratory Management System" (revision date 09/11) was reviewed. It indicated "9. Measurement and AQC (Automatic Quality Control) cartridges upon receipt are refrigerated between 2 degrees and 8 degrees Celsius. Wash/Waste Cartridges are stored in the department and the temperature area is monitored and maintained within the limits specified on the labels. Refrigerator and room temperatures are recorded daily..."

3. During a staff interview, conducted with the Director of PI on 1/31/12 at 2:00 PM, the above findings were confirmed.